Triage

[mobey]

I know it is bad ju-ju to ask for opinion on a subject that has lots of literature available, but I would like to know what triage successes and failures you have experienced.

Me.... I have never been part of a major disaster, however, I have been to many scenes with >3 patients and only 1 unit. I guess you could say a small scale MCI but when backup is not readily available things can go for ca-ca pretty quick.

Anywhoo.... I look forward to some solid advice and shared experience.

[fiznat]

I have been to several scenes that could be considered legitimate "MCIs." I have learned that these calls don't happen as frequently as people sometimes think, and it isn't a rare occurrence that providers (myself included) aren't quite sure what to do right away. The failures I have seen have been mostly related to lack of coherent leadership on scene, organization of incoming resources, and patient prioritization. It never goes as smooth as the triage advice seems to suggest it should, and often we are happy to simply have got through it without any major blunders.

One lesson I learned the hard way - even though it seems obvious - is that the first provider in to an MCI should be the last one out. That means if you are the first truck to arrive on an "oh shit" call, your job isn't the same as it is on other calls where you focus on getting to the patient's side. Your primary job as the first arriving is to count patients, get resources rolling, and start delegating responsibilities. Patient care is secondary. That's a tough lesson to learn, especially when you are used to treating patients.

[FireMedic65]

I have been involved in situations where they went really well, and really horrible.

What made a difference you ask? TRAINING! Everyone must be on the same page and follow the chain of command. The officers in charge of their delegated duties must know what they are doing, otherwise things will fall apart. Sure, you can have a triage officer screw up, or a treatment officer get overwhelmed, but if you had done proper planning these people won't be alone in their designated areas and have help. The command officer though, has a very hard job and hopefully knows what they are doing.

If you have untrained people trying to handle the situation, it's a disaster. You don't want that. We ran a mock scenario here awhile back. It was for a haz-mat. It was a complete mock up. Department response, patient actors, a vehicle leaking something nasty, etc etc. The first go around, they had untrained people try to handle it. I don't mean newbie firefighters or anything like that. I am talking people who have been doing the job for awhile. They were relatively untrained and grossly unprepared to handle it. From fire, to EMS, to PD. It fell apart. No one really know what to do as a whole. Everyone was trying to do their own thing to assess the situation and work through it. It failed big time.

After that, it was discussed with the EMA people, then it was done all over again. This time with the people in the departments who were trained to handle it. It went much more smoothly, but still had it's problems. After that, people got the hint for the need to train for such things that almost never happen. Hopefully more people get the hint.

[AnthonyM83]

I've found that in mini-MCI's the whole START Triage usually isn't used. Responding unit just goes through and decides who's "critical", who's "ALS", and who's "BLS".

I haven't been on any of the large-scale MCI's here in LA, but from speaking to several who have, it seems the START Triage and the whole NIMS program has worked very well. The key, of course, is having resources to practice as a whole (rather than just studying your Triage sheet)... actual drills/simulations are required.

[HERBIE1]

Triage is only a part of the overall response to mitigating an incident, and in a smaller scale incident, it's usually done on a limited basis. It's also simply not practical to adopt a full blown START triage system all the time.

Training is key and everyone(police, fire, and EMS) needs to know their roles and must practice them. The biggest problem on ANY MCI- and even on a smaller scale- communications and interoperability between agencies. If you can't talk to other agencies, at any level-things go south quickly. In every MCI I have been involved with, in the after action critiques, by far the single most common problem stated by everyone involved is communications.

The problem is, too often these things turn into turf wars- who's in charge, who is making decisions, and who is notified when these decisions are made. Everyone wants to protect their own little domain and is more worried about looking bad than in working together. In large scale incidents, each agency establishes their own command center and although there may be a central command location, too often the decisions are made outside this command center. NIMS, if properly implemented- is an ideal way provide a format for everyone to work together and get on the same page. It starts at the top- the providers will do exactly what they are told if the powers that be adopt the command structure.

Unfortunately, the only way to improve is to have more incidents, and each time, use NIMS type command structures in every possible situation. Training is fine, but we all know that 2 incidents never unfold in the same way and our response is never exactly the same. Practically, there is not enough time to establish a unified command structure in anything but large scale, longer term incidents, but the more they are implemented, the more they become second nature.

In the end, I think the most important issue is the establishment of a unified command structure and the communications needed to make an MCI efficient. The nuts and bolts of triage, treatment, transport, etc- mitigation- will all occur more smoothly as long as the command framework is in place.

[Richard B the EMT]

FDNY EMS policies are, if an incident either has generated 5 or more patients, or potentially can generate 5 or more patients, it's an MCI. Figure it this way: If it is one more patient than can be handled by one tech or medic per patient, and the capabilities of the 2 personnel on 2 ambulances, it's an MCI.

I need refresher on some aspects of an MCI, but if what I do remember is still current policy, any and all sectors of an MCI are both expandable, and collapsible regarding the incident size.

[CBEMT]

I've found that in mini-MCI's the whole START Triage usually isn't used. Responding unit just goes through and decides who's "critical", who's "ALS", and who's "BLS".

Large ones either. The after-action review of the Station nightclub fire noted that no EMS provider interviewed stated they used triage criteria for assessing patients, and not a single triage tag was placed on a patient.

That said, 186 patients were transported by EMS. All reached a hospital alive, and only 4 died later (in some cases over a week later).