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TRIAGE. Triage (from the French word "to sort"), is a system for assigning priority of care to the injured according to the degree of seriousness. Principles of triage are the same whether applied to the single victim with multiple injuries or to a group of injured victims. The goal is to maximize use of available resources and promote optimal outcome for all the trauma victims, and thus victims must be reassessed as often as possible, because their condition can deteriorate quickly (Chitwood, 1995). Principles of triage are that salvage of life takes precedence over salvage of limbs. The immediate threats to life are asphyxia and hemorrhage. There are various systems for assigning these priorities. Two systems are briefly described here – the Immediate, Delayed, Nonurgent system, and the START system (Grant, Murray, & Bergeron, 1990; Chitwood, 1995).
The simple triage and rapid treatment (START) system, is a triage system for rapid review of multiple victims at a trauma scene (Grant, Murray, & Bergeron, 1990; Chitwood, 1995). This triage system gets assistance flowing to the injured and facilitates their treatment as more professionals arrive on the scene. The victims are tagged and classified as immediate (highest priority of care), delayed (lowest priority of care), and dead (nonsalvageable). Immediate include those injured victims with respirations more than 30/min; respirations less than 30/min, no radial pulse, and those with adequate respirations and perfusion, unable to follow directions. Delayed include walking wounded, victims with respirations less than 30/min, radial pulse, and those with adequate respirations and perfusion, able to follow directions. Victims with no respirations are classified as death. All victims who can walk are directed to one area and categorized as delayed, and then respirations of each victim who cannot walk are checked, and necessary interventions are made. Thereafter both the immediate and delayed victims are checked for adequate perfusion, necessary interventions are made, and pressure to major bleeding sites is applied. If the victim has adequate respirations and perfusion, and is able to follow simple directions such as opening the eyes tag him or her as delayed, and if the victim has inadequate respirations and perfusion, and cannot respond tag him or her as immediate. Reassess victim as frequently as possible, because their conditions can deteriorate quickly. Note victims who are dead (nonsalvageable).
The "Field Triage Decision Scheme: The National Trauma Triage Protocol" (Decision Scheme) educational initiative was developed to help EMS providers, EMS medical directors, trauma system leadership, and EMS management learn about and implement the revised Decision Scheme. The emergency medical services (EMS) providers have a substantial input on the care of injured persons and public health. The Triage Decision Scheme is described in Chapter 6, Assessing the trauma patient.
Advanced Trauma Life Support (ATLS) program and courses are designed for doctors who care for injured patients. The training program has also been used in a modified form in the education of nurses and paramedics. Objectives are to:
Modified triage decision scheme (ABCDE) for management in situations of mass casualty/disaster (general principles of management).
| Secure vital functions | Airway Breathing Circulation |
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| Rapid methodical examination | Disability=Response when spoken to/stimulation Exposure=Head-to-toe survey
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| Decision/Priority | DECISION g ACTION f PRIORITY f |
Once the primary survey is complete, and life-threatening conditions affecting the airway, breathing, and circulation have been managed, a secondary survey is required. The survey should begin with an assessment of consciousness and vital signs and proceed systematically in head-to-toe order (see Chapter 6).
The American College of Surgeons (ACS), ("Resources for Optimal Care", 1990) has identified three phases of death due to trauma: The first peak is within seconds to minutes to injury. Invariably those deaths are due to lacerations of the brain, brainstem, upper part of the spinal cord, heart, aorta, or other large vessels. The second peak of deaths occurs within the first four hours after injury. These deaths are usually due to intracranial hemorrhage, hemopneumothorax, ruptured spleen, lacerations of the liver, fractured femur, or multiple injuries associated with significant blood loss. The third peak occurs days or weeks after the injury and most often is due to sepsis or multiple organ failure.
Survival rates in trauma patients are influenced by rescue actions taken in the first hour after injury. This concept was termed the golden hour by R. Adams Cowley. Most successful disaster rescues take place within the first 24 hours. In earthquakes most lives are saved by the immediate actions of survivors. In the situation of multiple casualties, such as a natural disaster, both victims and bystanders may react by becoming dazed, disorganized, or overwhelmed. When it comes to psychological triage the health care professionals need to figure out who most needs help and then deciding what will help most. Nurses need to evaluate on individual’s potential danger to self or others, and next knowing the symptoms of PTSD and the resources that are accessible to the people who need them (Nursing Spectrum, 2005). Elisabeth Kubler-Ross (Kubler-Ross, 1974) identified the five stages that most persons go through when confronted with a loss or potential loss; denial, anger, bargaining, depression and guilt, and the final stage acceptance. Trauma disrupts lives, and the order we cherish in our lives and throws us in to turmoil. Daily routine is disrupted, and may result in stress. Trauma after a disaster is a situation that results in crisis because it is a sudden, unanticipated event that affects both the person who experiences it and those concerned for that person. Crisis intervention is often necessary to help all concerned cope. The needs of the rescue team members are not to be overlooked after the injured patients are stabilized and the emergency phase has ended.
NURSING STRATEGIES AT THE DISASTER SCENE. The nurse’s primary tasks are to access the scene, including access and personal safety, set priorities, organize resources, classify victims according to severity of injury, give them qualified life-saving support and intervene as indicated, if possible stabilize the victims, and monitoring them while waiting for the arrival of transport to the most appropriate facility. The rescue team, nurses and other health care professionals should identify themselves and take command of the situation. They should assess victims as frequently as possible and be prepared to change their triage status and intervene if their condition has deteriorated.
The victims should not be left alone. Bystanders or walking victims can be assigned tasks according to their capabilities, for example to apply pressure to bleeding sites, comfort agitated patients, or call for assistance (Chitwood, 1995). Those who are not actively involved in the rescue should not be on the scene, because their presence can delay rescuers. Allow disaster victims to express emotions and feelings without fear of judgment. Reassure the victim that the disaster is over and that you are there to help. Answer the victim’s questions about family, loved ones, and friends as honestly as you can. Orient the victim to surroundings frequently, and offer support and empathy. If sedatives have been given they may mask important symptoms. Be aware of the psychological impact of a disaster, and accept your own limitations. Clergy or counselors are frequently called to a disaster scene or the receiving facilities to help both victims, rescuers, and bystanders cope with emotional reactions.
TREATMENT AREA MANAGEMENT. In most situations, the rescue team does not know exactly what will occur. They continually need to gather information about the disaster area, analyze options and make decisions, and take actions during the rescue process. Rescuers must always look first to their own safety, because dead heroes cannot save lives. Those at the scene most skilled in hazard control, usually the fire department, should be assigned to this possibility. The initial rapid assessment of the scene should also permit an evaluation of whether the number of responders is sufficient or whether more help is needed. One ambulance and at least two rescuers will be required for every seriously injured victim. One of the physicians should take charge as the medical triage team leader and wear a special vest (over his/her personal protective equipment) and a helmet in the same visible colors. The fire fighter leader has the responsibility to decide and inform about where the triage and treatment area can be established, and the care team can start their work. Several things need to be considered, such as need the electricity to be shut off in case of a railway emergency, and maybe the injured need to be decontaminated in case of a chemical accident, such as benzene, and sulfur mustard. With incidents involving WMD/T, the contaminated victims may appear for care before the hospitals have received information from the scene. The police officer in charge takes care of restrictions, lightning, and identification of victims at the disaster scene.
At least one vehicle should be specially equipped for disasters, containing all of the medical and other supplies necessary for initial treatment of large numbers of patients. This equipment should include individually packaged resuscitation kits, emergobelt, high-power lights, stretchers, and so forth. The triage and treatment area can for example consist of a parking lot, a railway station, a heated tent, or a mobile field hospital. It should be located between the site of the casualties and the evacuation vehicles, to ensure orderly triage and treatment before evacuation. People who have died should be separated from those victims that are injured. A numbered triage tag is affixed to the injured. The triage tag should be of a durable material, and should if possible contain the following information: identifying information, type and anatomic location of injury or illness, physical examination, treatment, and priority (colors and/or numbers). Graphic charts and diagrams might be used to monitor and control activities.
PROTECTING EMERGENCY RESPONDERS. The disaster team members must be adequately trained and equipped, and each team adequately staffed. They must be able to take care of themselves if a site become hazardous, wait for evacuation, and be fully prepared going in to a disaster site as to not add to the burden of an already overwhelmed infrastructure (Gaudette, Schnitzer, George, & Briggs, 2002). Disaster response may also call for the use of resources (such as specialty physicians, search dogs, tools for cutting through and lifting heavy reinforced concrete blocks, dialysis centers, laboratories to rapidly analyze hazardous chemicals or biological agents, radiation detection instruments, and hazardous materials response teams with appropriate protective gear, etc.) that are not commonly used in routine emergency responses or are in short supply (American Public Health Association, 2005, 2).
EVACUATION. When there are a sufficient number of evacuation vehicles to maintain a steady evacuation flow, the injured patients that are stabilized first are evacuated first. Sometimes the evacuation vehicle may leave the scene with a critically injured patient whose airways has been secured and who has received an intravenous infusion, and dressings, together with two "walking wounded", who required no treatment at the scene. Local hospitals and other health care services must have enough capacity in disaster situations. Alternative treatment facilities when any or all of these locations are closed must be available, and also possibilities for both routine and continuity of care for victims experiencing acute exacerbations of chronic medical problems. A relief agency should use local help and local resources and seek ways to develop local capabilities wherever possible.
Some hospitals have specialized teams comprising an anesthetist, surgeon, and nurses from the department of anesthesia or emergency care. Special equipment, such as emergency belt with medical disaster equipment and personnel protective equipment (for different temperatures) are used. Rescue personnel, fire fighters, and police are wearing special clothes and helmets in visible colors according to the responsibilities at the scene. The different units and the care team are alerted simultaneously by an emergency operation center, as well as the involved hospitals. Thereafter the departments begin to work according to their preparedness and response plan to be able to care for all injured victims. A disaster office is established at the hospital from which the activities are coordinated. Numbered disaster records (files) should be available, as well as id tags with a special color, referrals (lab, x-ray, blood), and strong bags for personal belongings and clothes. Information gathering and record-keeping is essential. Hospitals and police departments have information centers for patient tracking and registration of where victims might be located.
Treatment of serious physical injuries has priority, but emotional support and psychological treatment should not be overlooked (see Chapter 6, 7, 8, and 9). Circumstances that elevate risk for psychological trauma include bereavement, injuries, threat of life, separation from family (especially for youngsters), panic, horror, extensive loss of property, and relocation and displacement. The more exposures that people have experienced, the more likely they are to suffer psychological impairment (Norris, 2005). Most survivors will exhibit reactions to trauma, like anxiety, irritability, flashbacks, disbelief, hypervigilance, difficult sleeping, and nightmares. If the symptoms remain severe and impair the person’s functioning in 2 or 3 months, the person should seek help. There will also be people for whom the psychological symptoms will become permanent. There are several psychological treatment programs of exposure therapy (see Chapter 13).
In the event of a large-scale emergency, the American Nurses association (ANA) has drafted recommendations for nurses and other healthcare professionals to adopt when resources are scarce or care delivery occurs outside normal operating conditions. The ANA document is called "Adapting Standards of Care under Altered Conditions"