Triage: This might be one of the most stressful things that an individual responder may be asked to do during a Mass Casualty Incident and will become a defining moment in their career in one way or another. Proper triage of patients is going to set the tone for how well and how quickly that Mass Casualty Incident is resolved.
Because you make life or death decisions for a group of people, making that decision over and over again every ~30 seconds. Was that decision made correctly? In the aftermath, that second guessing that goes on could be the difference between someone who sleeps soundly at night or someone who loses sleep, becomes irritable with family, gets a divorce, becomes an alcoholic, commits suicide. Stress is real. Listen to the radio traffic from any Mass Casualty Incident that’s posted on YouTube and you’ll hear the stress in the voice of the one who gets assigned triage.
The Status of Triage
Most organizations in the CONUS utilize START triage. There are many resources out there as a guide for START triage, so we will give a quick overview. The mnemonic to utilize for START triage is 30/2/Can Do under the RPM method.
Ask “who can walk? Walk to me/over here.” These patients are tagged Green
Assess Respirations. Apnic? Open the airway and reassess. Continued apnic patients are Black. If they have return of spontaneous respirations they are Red.
Respirations >30? Red
Respirations less than 30? Check pulse or cap refill.
Radial pulse absent? Red. OR Cap refill >2 seconds? Red
Radial pulse OR cap refill < 2? Check mental status
Follows simple commands? No: Red. Yes: Yellow
If a patient earns a color somewhere, assign it and move on. The remainder of the algorithm does not need to be completed.
But that’s a lot to remember…
In teaching TECC classes all across the country, I’ve asked students many times if their department uses START triage. When they say ‘yes,’ I then ask them to recite it and it gets botched one way or another. This is something they are going to be called to do during a stressful event but they have trouble doing it in the classroom setting. If the pressure of being put on the spot in front of the class is too much to recall START triage, then looking down at someone who’s severely injured will be much less stressful…
Why is it so difficult to remember? Because it only gets used in those once-a-career calls. Mass Casualty Incidents don’t occur often. Those that make CNN happen even less frequently. The San Bernardino, Orlando, Boston, Blacksburg, Binghamton, Newtown, Ft. Hood and Nice, France events all had more than 10 patients. These are events that have happened in the last 10 years. Additionally, the patient count and frequency of events has increased over the last 16 years according to the FBI study on Active Shooter Incidents.
So we are going to utilize two tools to help ensure these situations are resolved as best as possible.
The first tool gets borrowed from another industry: the airline industry. Ever watch a pilot? They won’t drink coffee without a checklist. There is quite literally a checklist for everything. Something they do every day such as assessing the airworthiness of the plane has a checklist. Engine failure? Checklist. Engine on fire? Checklist. Smoke in the cockpit? Checklist… and you can’t leave the cockpit until you’ve gotten to that step on the checklist. The airline industry has a less than 1% incident rate for accidents/incidents. Medicine has a larger incident rate for medical errors than the airline industry. In some instances, hospitals are now taking this same checklist method to make sure the wrong limb isn’t amputated…
So how do we apply this to triage? There are flow charts created for START triage. Some of these commercially made flow charts may be a little pricy, but it can be as simple as an index card with the proper flow chart written down. I’d recommend if a low cost option is going to be utilized that it is laminated, as Murphy’s Law tells us that if you have a simple paper flow chart, it will be raining when you want to use it. Hole punch a corner if you want to and you can tie some string/paracord to a corner and tie a small clip to the other end. If you deploy your card, clip it to a belt loop so it’s easily accessible and you don’t lose it. Real fancy? Drop a sharpie marker in your pocket and you can keep track of your casualty count on the back. Use the flow chart for every patient. Every patient. Every single one.
This is going to prevent any freelancing or forgetfulness. A group of doctors created this algorithm, so it isn’t something that was just created for fun. Thought and reasoning went into the classifications, so relying on this method helps reduce the variability of triaging patients. The responder who has to triage 20 patients can definitively say it was done correctly because they used their flow chart.
So what’s the second tool?
Of the incidents listed earlier, the smallest incident had 17 patients. If you are to look in any triage kit on an ambulance or fire truck, how many triage tags will you find? Typically the most that are carried are 10 in prepackaged commercial kits. Our next step is we must ration the triage tags. This method needs to be easy enough that another responder following behind us can easily identify what color each patient is.
So here we go:
Green patients don’t get triage tags on the first pass. They can be given a piece of 3 inch tape initially, and when a second ambulance arrives we can utilize additional triage tags. We separate them from the remainder of the patients right off the bat by having them walk towards us. Thus further incoming responders know these are green patients because they can walk and are huddled around an ambulance.
Black patients are placed in the “Fallen Angel” position. This is where the patient’s arms and legs are crossed over each other and the patient’s shirt is pulled up over their head as if they had been covered by a sheet. This is an unnatural position for someone to just fall to the ground and end up in, so further responders will know this patient has been triaged and has been tagged black. No treatment will be done for these patients, so documentation on a triage tag is unnecessary. While these patients can also be considered part of a crime scene, some movement of the body is required as patient care and assessment comes first. Moving the patient to the “Fallen Angel” position will help minimize the need for additional responders to come over to assess that patient, potentially disturbing the crime scene further.
This leaves red and yellow patients who are lying on the ground unable to walk. We differentiate our patients at this point by giving all red patients a triage tag. All red patients will be easily identifiable because they are the only ones with a triage tag. All yellow patients will be easily identifiable because they don’t have a triage tag. As further responders come into the area, they can move directly to patients who have triage tags to evacuate them to the triage/treatment area. If there are enough triage tags, or when the second ambulance arrives with triage tags, yellow patients can get tags.
By the time our patients have arrived at the triage area, we should have additional ambulances/fire trucks that have triage tags. Every patient in the triage area should get a triage tag before departing as this helps the command element track patients. Also, for patients in the triage area for any length of time, this provides a method of documentation. Many times patients will be left alone (briefly) and the next responder who comes to provide care can read the documentation and seamlessly pick up where the last responder left off. They then document their findings/treatment and the cycle repeats.
In the end, triage can be a stressful assignment during any Mass Casualty Incident. Responders need to be prepared with tools to address these scenes. The use of a checklist/algorithm takes the stress off trying to recall the exact steps, and a deliberate rationing of triage tags in a large scale event can still be effective at marking which patients are which color after they have been triaged.