Now that we have discussed the importance of defining exactly what a MCI is in comparison to your available resources, let’s get to work!
The passenger of the first arriving ambulance takes triage:
As we mentioned in the previous article, having seat assignments can help to eliminate confusion, reduce time-to-task and improve overall communication. Building scene momentum is something we want to achieve early in the MCI. Remember, the actions we take in the first 5 minutes will often dictate how smoothly things go for us throughout the rest of the event. Don’t get hung up on level of training – triage responsibilities can be more than adequately handled by any level of EMS certification. The reason why we chose to assign this important role to the ambulance instead of the fire apparatus is to account for the likelihood that the first arriving engine or truck will be faced with multiple competing demands (fire, smoke, extrication, haz-mat, technical rescue needs, etc.).
By “choreographing” the process of our first arriving resources, the incident commander can be assured that the ambulance crew will automatically assume responsibilities for Triage and Transportation, leaving the engine or truck free to address all of the other scene related challenges. This procedure also assures that a formal triage process will actually be performed on every MCI, avoiding the common MCI pitfalls of no triage being performed, competing methods of triage being performed or no tags being distributed.
Realizing that there are now multiple methods of triage being talked about in the trade journals and at national conferences, this article will focus on the use of the START Triage method. START is what we decided to use in our system. Ultimately, it doesn’t matter which method you use – just pick one, train everyone to it and use only that method on scene!
Getting your arms around the incident:
Imagine showing up to a motor vehicle collision on the highway, it is larger than you expected. Carnage everywhere you look! Broken glass, jagged metal, people ejected & bleeding on the ground, people trapped in their vehicles, others wandering around the incident yelling for help, or on their cell phones. One of the vehicles is on fire. Where the hell are you supposed to begin? How are you and your partner supposed to make any sense of this mess? The first principle of the Simple Triage and Rapid Treatment (START) process is that you START where you stand! (Cute huh?). Calling out, you ask all those that can walk to come to the sound of your voice (or to a location of your choice). Congratulations, you just effectively triaged all of the “Green” patients. With START, patients categorized as “Green” are the lowest priority. Disaster research tells us that low priority or “walking wounded” patients can typically go for many hours if not days before receiving medical attention and not have any negative outcomes as a result of delayed care. From a triage standpoint, those that cannot get up and walk to you are either “Yellow”, “Red” or Dead (“Black”).
The START method has a rapid assessment trick to help the Triage Unit Leader rapidly categorize the patients that remain – it’s called RPM;
– Is the patient breathing? (Yes or No)
No? – Open their airway, if the patient begins to breathe stuff a basic airway adjunct in them and tag them “RED”. You don’t need to do anything else, move on to the next patient! If they do not begin to breathe after opening their airway, then they will likely not survive – tag them “BLACK”(dead or expectant) and move on to the next patient!
Yes? – How fast are they breathing? If they are breathing greater than 30 breaths per minute, tag them “RED” and move on to the next patient! If they are breathing less than 30 breaths per minute, then move on to the next level of assessment…
A word of caution: This early part of the assessment contains the hardest decision we may be faced with making during an MCI, “Red” or Dead. Don’t fall into the trap of committing resources that are already overwhelmed to attempting to resuscitate someone found not breathing. You are there to help as many people as possible and committing resources to someone that will not survive may lead to preventable deaths due to delayed care… Trust the process, make the decision quickly and move on to the next person that really might benefit from your care.
NOTE: This portion of the assessment allows for checking either capillary refill (2 seconds or less is considered normal) or a distal pulse. There are many factors that can alter cap refill, making this method not as reliable or accurate as feeling for a pulse. Since the Triage Unit Leader is medically trained, our system recommends using the distal pulse as the deciding factor.
– Does the patient have a distal pulse? (Yes or No)
No? – Tag them “Red”, perform a quick scan for any signs of profuse bleeding – if present, stop the bleed or have the patient or a bystander control the bleeding and move on to the next patient!
Yes? – Move on to the next level of assessment.
Wait, if the patient is found without a distal pulse, aren’t they dead? Shouldn’t we be tagging them “Black” and moving on? Remember, you’ve already checked their respirations and you found that they were breathing within normal limits. The fact that the patient does not have a distal pulse is telling you that their perfusion is poor and their blood pressure is likely very low – making them a “Red” or priority patient.
– Can the patient answer simple questions or follow your commands? (Yes or No)
No? – Tag them “Red” and move on to the next patient!
Yes? – Tag them “Yellow” and move on to the next patient!
Hold on. If they’re respirations are within normal limits, they have a distal pulse and they have a normal mental status – why aren’t they “Green”? The simple answer is that you’ve already triaged the green patients – this patient was unable to get up and walk to you. Using START, the best category they will receive is “Yellow” or delayed.
Most of us were introduced to the START triage algorhythm at least once during our career. The RPM process is meant to be completed in 30 seconds or less. Much like our primary survey (ABC’s), in fact, just like our primary survey! RPM is ABC- just a different way of packaging it.
Using the tags:
There are also multiple styles of triage tag to choose from. For your MCI to run smoothly, it is important that only one style of tag is used. Multiple kinds of tags will certainly lead to confusion. Once you have chosen the style of triage tag for your system. It is important that all of your people (including hospital ED & trauma staff) know how to navigate and interpret the tag. For the purpose of this series of articles, we will be talking about the “MET-TAG” triage tag.
Suffice it to say that the triage unit leader only has to tear the color coded tabs at the bottom of each tag to the category they chose and affix the tag to the patient. They don’t have to write anything on it and they don’t have to tear anything else off! We’ll talk in greater detail about using all of the tag features in part three of this series.
NOTE: a trick of the trade is to make sure you save the tags that you tear off. Don’t throw them away. You’ll need them later. (Part three).
An important choice for the Triage Unit leader to make upon their arrival:
In order for the process of triage to be fast and effective, the triage unit leader must immediately decide how they will perform triage upon their arrival at the incident. Will they move to each patient and triage them on the go, or will they create a “triage funnel”? A triage funnel implies that the triage unit leader will pick a stationary location and others will bring the patients to them to be triaged. For the triage funnel to be useful it requires stretcher bearers (or shuttle teams) to move the patients to the funnel and there should be a casualty collection point established directly behind the funnel. As the patients are triaged, they are then gathered in areas based on their category (color coded tarps, flags, cones or tents can be used to mark the areas). It is important to understand that the triage funnel and the CCP rely upon each-other. They are NOT mutually exclusive. If you think you need one, you will need the other as well in order to adequately manage the incident.
So, it seems like the triage funnel is complicated and may serve to slow forward progress. I would actually suggest the opposite! If you are faced with a large number of patients covering either a geographical stretch or packed into a confined area (like a school bus), trying to go mobile and attempt to make contact with every individual will ultimately slow things down and in some cases, we may never find you again! While it will seem painfully slow initially, the triage funnel is a much more efficient way to organize the incident. It breeds consistency, reduces unnecessary duplication of effort and speeds the gathering of patients by their category. It also minimizes the likelihood that patients will be missed.
A quick note on stretcher bearers or shuttle teams:
Initially, you will not have enough people or equipment to do all of the things you want to do. Gathering teams of people for moving patients from the scene to the triage funnel is essential to creating the scene momentum that I keep mentioning. As with everything else we do in our profession, we are only limited by our creativity. Think about who could serve in that role until additional resources arrive. By the way, two-person teams are not safe or effective, think three or four person teams. More on this topic as well in part three.
Common triage mistakes:
The START method has been criticized by others for being very subjective. In other words, two medics using START may categorize the same patients differently. I believe that this subjective tendency is partially due to lack of practice. If your people don’t train regularly and practice the process, when suddenly placed under time pressure and other situational stressors, they will fall back onto old habits or simply make their own rules for triaging patients.
– Don’t base your triage decisions on “mechanism of injury”. Thankfully, we’ve changed how we consider mechanism in our day to day assessments. While mechanism is a piece of the pie, it is NOT the whole pie and it has nothing to do with how we initially categorize our patients in a MCI.
– Don’t base your triage decisions on how “ugly” their injuries are. Bad looking wounds are distractors NOT indicators of priority.
– Don’t base your triage decisions on the location of their injuries. It is natural or intuitive to consider injuries to the core of the body more serious than injuries to the extremities. That is a consideration for the treatment unit leader, NOT the triage unit leader.
– Just because they’re really young or really old doesn’t automatically make them a “Red” patient. Yes, it is true that the pediatric or elderly patient can be at a higher risk of severity due to their age. Leave that for the treatment unit leader to worry about. Age is NOT a factor during initial triage.
Triaging patients is about their physiological condition in the moment, NOT what it might be in the future. You are trying to build forward progress and get things moving. Trying to consider too many what-ifs or potentials is crystal ball nonsense that you can’t afford when the number of patients overwhelms your resources. Triage does not have to be perfect. It does have to be fast. Also remember that triage is not static, it is dynamic. Triage should occur throughout the event, not just once. Re-triaging patients during each step of an MCI will account for changes in their physical condition and the potential need to adjust their priority.
– Avoid the temptation to assign triage responsibilities to multiple responders. I’m not saying that this should NEVER be a consideration. However, in most circumstances multiple people doing triage on one incident usually breeds confusion and opens the door to subjectivity. If it makes sense to assign multiple people, it should be done under the direct supervision of the single Triage Unit Leader (unity of command).
– Avoid the temptation of creating more than one triage funnel or more than one casualty collection point (CCP). In our line of work, we never say never. In circumstances that cover a large amount of geography (AKA, the world trade center, etc.) you may have no choice but to create more than one place to gather patients. Keep in mind that multiple triage funnels & CCPs will require exponentially more people and resources to successfully manage. If the decision is made to create more than one CCP or triage funnel, you may want to consider managing it as an “area command” – essentially like an incident within an incident. Review your ICS-300 & ICS-400 materials for a refresher on “area commands”.
Necessary Materials for the Triage Unit Leader:
– Our system uses a small “triage bag” that contains triage tags, basic oral and nasal airway adjuncts, tourniquets and basic first aid materials for bleeding control – that’s it, you don’t need anything else!
– Triage Unit Leader vest. Remember that a common MCI pitfall is confusion created by not knowing who has been assigned key positions in the event. Wearing the vest is critical in visibly marking the person responsible for this important role in MCI management. Our system utilizes vests that are also ANSI rated for roadway safety.
– There is no shame in using quick reference materials. Position specific quick reference cards are located in all of our MCI vests. A quick reference card specific to the triage unit leader is also placed inside the triage bag. It is not uncommon to lose your train of thought during a complex incident. When you realize that you have gone “off the reservation”– take a peek at the quick reference card and right your course!
1. The passenger of the first arriving ambulance assumes the role of triage unit leader, grabs the “triage bag”, puts on the vest and goes to work!
2. The triage unit leader should use the pre- approved method of triage as well as the pre-approved triage tags. Do NOT allow multiple methods of triage or multiple styles of triage tags on your MCI.
3. The triage unit leader should choose whether or not to triage every patient one-by-one while on the go, or to set up a triage funnel and have shuttle teams bring the patients to them for triage. Remember that the triage funnel and the casualty collection point go together like peas and carrots. (ref. Forest Gump)
4. Don’t be afraid or ashamed to use quick reference materials. Checklists are used with great success in many industries that utilize high risk / low frequency procedures.
NOTE: The next article (Part Three) will discuss the role of the Transportation Unit Leader and how Triage and Transport units work together to bring the situation to a safe and positive conclusion.