Last time, we described a mass casualty incident scene with 20 victims and told you about initial considerations before beginning START (Simple Triage and Rapid Treatment). In our scenario, you ended up with 10 victims on the ground, 8 walking wounded, and 2 relatively uninjured but unskilled victims that volunteered to help. You moved the walking wounded to a separate area and are now ready to quickly triage the remaining 10 victims.
Primary Triage Categories
To review the primary triage 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)
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)
And here are your triage evaluation parameters (RPMs):
Respirations: Is your patient breathing? If not, tilt the head back or, if you have them, insert an oral airway (Note: in a MCI triage situation, the rule against moving the neck of an injured person before ruling out cervical spine injury is, for the time being, suspended) 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.
What is Perfusion and CRT
Perfusion:Perfusion is an evaluation of how normal the blood flow or circulation is. Check for a radial pulse and/or press on the nail bed (I sometimes use the pad of a finger) firmly and quickly remove. It will go from white to pink 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 (“open your eyes”, “what’s your name”)? If the patient is breathing and has normal perfusion but is unconscious or can’t follow your commands, tag red. If they 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.
Remember this: 30 (respirations) – 2 (CRT) – Can Do (follows commands). Here’s a flow chart that will help:
Your 2 uninjured helpers are an able-bodied man and woman. The woman knows how to take a pulse. You have no medical equipment with you other than some oral airways and triage tags to work with.
Begin with the nearest victim (from our list in the last article):
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 has 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 (level of forearm), 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.
You initially think this child is deceased, but you follow protocol and reposition his airway by tilting his head back. 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, including the ICU nurse that you contacted initially. You are no longer the most experienced medical resource at the scene, and you are relieved of Incident Command. The nurse begins the process of assigning areas for yellow, red and black tags where secondary triage and treatment can occur. Stick around, she needs 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. 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 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.