(DR. BONES SAYS: The frequency of mass casualty incidents from shootings have been very high recently, culminating in the shooting at Los Angeles International Airport being reported at present. This is part 2 of my series on mass casualty incidents written in response to the Boston Marathon Bombing. Stay safe.)
The Boston Marathon Bombings: Mass Casualty Incident
We now know that the Boston Marathon bombings were caused by pressure cookers filled with nails and other shrapnel. There were 2 bombs; this is not uncommon as a tactic of terrorists. It is my suspicion that the idea was that the larger bomb was supposed to go off first, then followed by a second bomb to get the first responders. It didn’t turn out that way, but many of those who came to help might have been killed if the bombs went off in the manner I’m describing.
Given the horrific events, we all have to realize that we are not safe, and may never be in today’s world. This article is part 2 of 2 of what you, the non-medical professional, need to know when you face the worst case scenario. Thanks to all those who picked up the flag and assisted in this tragic event, and our prayers go to the victims and their families. I was originally going to make this three articles, but have compressed it in view of the urgency of sharing this information.
Last article, we discussed the 5 “S”‘s of successful triage for a mass casualty incident (MCI). If you missed it, here’s the link:
Now we are ready to S.T.A.R.T. (Simple Treatment And Rapid Triage)
The effective medical management of an MCI requires rapid and accurate triage. If you missed the last article, Triage comes from the French word “trier” (to sort). It is the process of rapidly evaluating and sorting casualties by the severity of injury and the level of urgency for treatment. We will use the following categories:
Immediate (Red tag): The victim needs immediate medical care and will not survive if not treated quickly. (for example, a major hemorrhagic wound/internal bleeding) Top priority for treatment.
Delayed (Yellow tag): The victim needs medical care within 2-4 hours. Injuries may become life-threatening if ignored, but can wait until Red tags are treated. (for example, open fracture of femur without major hemorrhage)
Minor/Minimal (Green tag): Generally stable and ambulatory (“walking wounded”) but may need some medical care. (for example, 2 broken fingers, sprained wrist)
Expectant (Black tag): The victim is either deceased or is not expected to live. (for example, open fracture of cranium with brain damage, multiple penetrating chest wounds)
If you don’t have triage tags or you’re color blind, you can simply take a pen and mark the victim’s forehead with a 1, 2, 3 or 4. 1 is highest priority (RED), 2 is delayed (YELLOW), 3 is minimal (GREEN) and 4 is dead or expected to die (BLACK). This method is used in some other countries.
So let’s take a hypothetical situation. You have witnessed an explosion, and there are twenty people down; there is blood everywhere. What do you do?
We have made our assessment (the 5 “S’s”) of initial MCI scene evaluation. From that, let’s say that you have already determined the SAFETY of the current situation and SIZED UP the scene. There appears to have been a bomb that exploded. You believe that you and other responders are not in danger. The injuries are significant (there are body parts) and the victims are all in an area no more than, say, 30 yards. The incident occurred on a main thoroughfare, so there are ways in and ways out. You have SENT for help by calling 911 and described the scene, so help is on the way. The area is relatively open, so you can SET UP different areas for different triage categories. Now you can START (Simple Triage And Rapid Treatment).
You will call out as loudly as possible: “I’m here to help, everyone who can get up and walk and needs medical attention, get up and move to ______ (pick an area). If you are uninjured and can help, follow me.”
You’re lucky, 13 of the 20, mostly from the periphery of the blast, sit up, or at least try to. 10 can stand, and 8 go to the area you designated. These people have cuts and scrapes, and a couple are limping; one has obviously broken an arm. 2 beaten-up but sturdy individuals join you. By communicating, you have made your job easier by identifying the walking wounded (GREEN) and getting some immediate help. You still have 10 victims down.
You then go to the closest victim on the ground. Start right where you are and go to the nearest victim. In this way, you will triage faster and more effectively than trying to figure out who needs help the most from a distance or going in a haphazard pattern. You will take no more than 30 seconds to evaluate each patient.
You don’t have triage tags, but you have a pen. You can write red, yellow, black, green on a patient’s forehead or quicker 1,2,3,4 to identify priorities.
It is important to remember that you are triaging, not treating. The only treatments in START will be stopping massive bleeding, opening airways, and elevating the legs in case of shock. As you go from patient to patient, stay calm, identify who you are and tell them that you’re here to help. Your goal is to identify who will need help most urgently (red tags). You will be assessing RPMs (Respirations, Perfusion, and Mental Status):
Respirations: Is your patient breathing? If not, tilt the head back and jaw forward or, if you have a good medical pack, insert an oral airway In a MCI triage situation, the rule against moving the neck of an injured person (not breathing, remember) before ruling out cervical spine injury is, for the time being, suspended until help arrives. If you have an open airway and no breathing, that victim is tagged black. If the victim breathes once an airway is restored or is breathing more than 30 times a minute, tag red. If the victim is breathing normally, move to perfusion.
Perfusion: Perfusion is an evaluation of how normal the blood flow or circulation is. Check for a wrist or neck pulse and/or press on the nail bed (I sometimes use the pad of a finger) firmly and quickly remove. It will go from blanched white to normal skin color in less than 2 seconds in a normal individual. This is referred to as the Capillary Refill Time (CRT). If no radial pulse or it takes longer than 2 seconds for nail bed color to return to pink, tag red. If a pulse is present and CRT is normal, move to mental status.
Mental Status: Can the victim follow simple commands and questions (“open your eyes”, “what’s your name”)? If the patient is breathing <30 times/minute and has normal perfusion but is unconscious or can’t follow your commands, tag red. If your breathing, normally perfused victim can follow commands, tag yellow if they can’t get up or green if they can. Remember that, as a consequence of the explosion, some victims may not be able to hear you well.
It might be easier to remember all this by just thinking: 30 (respirations) – 2 (CRT) – Can Do (Commands)
If there is any doubt as to the category, always tag the highest priority triage level. Not sure between yellow and red? Tag red. Once you have identified someone as triage level RED, tag them and move immediately to the next patient unless you have major bleeding to stop. Any one RPM check that results in a red result tags the victim as red. For example, if someone wasn’t breathing but began breathing once you repositioned the airway, tag red, stop further evaluation if not hemorrhaging and move to the next patient. Elevate the legs if you suspect shock.
Use this flow chart for the hypothetical situation that I’m going to place you in:
These are your 10 patients on the ground, in order. Begin with the nearest victim, don’t try to figure out who is hurt worst at a distance or go in a haphazard manner. Read the descriptions and decide the primary triage level; remember you have two unskilled helpers following you.
Here’s what you find:
1. Male in his 30s, complains of pain in his left leg (obviously fractured), Respirations 24, pulse strong, CRT 1 second, no excessive bleeding.
Respirations are within acceptable range (less than 30), pulse and CRT normal. Complains of pain, and is communicating where it hurts, so mental status probably normal. This patient is tagged YELLOW: needs care but will not die if there is a reasonable (2-4 hour) delay. Move on.
2. Female in her 50s, bleeding from nose, ears, and mouth. Trying to sit up but can’t, respirations 20, pulse present, CRT 1 second, not responding to your commands.
This victim may have a significant head injury, but is stable from the standpoint of respirations and perfusion. As her mental status is impaired, tag RED (immediate). Move on.
3. Teenage girl bleeding heavily from her right thigh, respirations 32, pulse thready, CRT 2.5 seconds, follows commands.
This victim is seriously hemorrhaging, one of the reasons to treat during triage. Respirations elevated and perfusion impaired. You use your unskilled male helper to apply pressure by placing his hands on the bleeding and applying pressure, preferably using his shirt or bandanna as a “dressing”. Tag RED. As the patient is already RED, you don’t really have to assess mental status. You and your female helper move on.
4. Another teenage girl, small laceration on forehead, says she can’t move her legs. Respirations 20, pulse strong, CRT 1 second.
Probable spinal injury but otherwise stable and can communicate. Tag YELLOW. Move on.
5. Male in his 20s, head wound, respirations absent. Airway repositioned, still no breathing.
If not breathing, you will reposition his head and place an airway. In this case, this fails to restart breathing. This patient is deceased for all intents and purposes. Tag BLACK, move on.
6. Male in his 40s, burns on face, chest, and arms. Respirations 22, pulse 100, CRT 1.5 seconds, follows commands.
This victim has significant burns on large areas, but is breathing well and has normal perfusion. Mental status is unimpaired, so you tag YELLOW and move on.
7. Teenage boy, multiple cuts and abrasions but not hemorrhaging, says he can’t breathe, respirations 34, radial pulse present, CRT 2.5 seconds.
This victim doesn’t look so bad but is having trouble breathing and has questionable perfusion. Mental status is unimpaired, but he likely has other issues, perhaps internal bleeding. You tag RED (respirations over 30, impaired perfusion) and move on.
8. Female in her 20s, burns on neck and face, respirations 22, pulse present, CRT 1 second, asks to get up and can walk, although with a limp.
Obviously injured, this young woman is otherwise stable and communicating. With assistance, she is able to stand up, and can walk by herself. She becomes another of the walking wounded, tag GREEN. Point her to the GREEN area you previously assigned and move on.
9. Elderly woman, bleeding profusely from an amputated right arm at the elbow, respirations 36, pulse on other wrist absent, CRT 3 seconds, unresponsive.
Obviously in dire straits, you use your shirt as a tourniquet and sacrifice your remaining helper to apply pressure on the bleeding area. Tag Red, move on.
10. Male child, multiple penetrating injuries, respirations absent. Airway repositioned, starts breathing. Radial pulse absent, CRT 2 seconds, unresponsive.
You initially think this child is deceased, but you follow protocol and reposition his airway by tilting his head back. As previously mentioned, a Mass Casualty Incident is one of the few circumstances where you don’t worry about cervical spine injuries in making your assessment. He starts breathing even without an oral airway, to your surprise, so you tag him RED. If he is bleeding heavily from his injuries, you apply pressure and wait for the additional help you requested on initial survey of the MCI to arrive.
You have just performed START triage on 20 victims, including the walking wounded, in 10 minutes or less. Help begins to arrive. You are no longer the most experienced medical resource at the scene, and you are relieved of “Incident Command”. The emergency medical pros begins the process of assigning areas for yellow, red and black tags where secondary triage and treatment can occur. Stick around, they’ll need your help to treat and transport.
There is still much to do, but you have performed your duty to identify those victims who need the most urgent care. You have done the most good for the most people.
In a normal situation, your modern medical facilities will already have ambulances and trained personnel with lots of equipment on the scene. In a collapse situation, however, the prognosis for many of your victims is grave. Go over our list of victims and see who you think would survive if modern medical care is not available. Many of the RED tags and even some of the YELLOW tags would be in serious danger of dying from their wounds.
In times of trouble, it is wise to always carry some form of individual kit to deal with medical issues you may be confronted with. Nurse Amy and I constantly research, develop and tweak medical supplies to tailor them to collapse scenarios. We are always learning and improvising, and it would serve you well to do the same.
Joe Alton, M.D. aka Dr. Bones