Chapter 4 TRIAGE Frederick M. Burkle, Jr. , MD ...

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emergency room physician assumes the triage officer role until relieved by the .... ed by the Advanced Trauma Life Support (ATLS) course of the. American ...
Chapter 4 TRIAGE Frederick

M. Burkle, Jr. , M. D. , M. P. H. I. TRIAGE

Triage is a French word meaning to pick out or sort. It was first introduced into the English language during World War I as a military process of classifying casualties. The modern definition has two major components: (1) sorting of victims according to severity of injury or illness, and (2) assigning priorities of treatment. The civilian definition of triage over the years has become somewhat clouded. Triage in a modified form is carried out daily and automatically in physicians' offices, clinics, and emergency rooms, primarily by nursing personnel. An office physician may be interrupted from a scheduled consulting appointment to evaluate briefly and treat an unexpected asthmatic patient. Patient rescheduling or delays are common daily occurrences. Emphasis, however, is on efficient and excellent care to ALL patients. A triage situation is defined as a temporary prioritizing of critical care. For example, one emergency medicine physician who has a limited nursing staff in a rural hospital and is faced with two critically injured patients will be in a triage situation until on call assistance arrives. Triage situations are often anticipated and planned for in hospitals and emergency care systems. The triage situation can be nullified immediately with the addition of as few as one or two health care professionals to the scene. This chapter addresses mass civilian or military disasters where triage is performed under circumstances of stress when the number of patients exceeds the normal capabilities and resources for a prolonged period of time. Triage is the first of three principles of mass casualty care: 1. Triage 2. Evacuation (see Chapter 8) 3. Standard procedures (see Chapter 6, and addendum this chapter)



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The Organization

56

of Disaster

Medicine

will determine the efficient flow of care from one priority and triage round to another. The triage officer's supervision, leadership, and clinical judgment is of critical importance in the efficiency of this process. Triage rounds may be completed from several seconds to 15-30 min depending on the number and severity of first and second priority patients.

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4. Tagging in the Field Tagging is critical to continuity of care. Several varieties of triage tags exist. The most useful are those which are easy to read and also give clear instructions (Figures 4-2 and 4-3A B C). ' , Triage tag information should include: a) Patient identification by name or number. Alphabet identification may be confused with patient's initials and should never be used. b) Sex. c) Injuries. Main problems only, using accepted abbreviations (i, e. , cpd fx of femur, mult lac). d) Any procedures or medications provided. e) Paramedic's name. This is essential to medical documentation, disaster care critique, and tracing of circumstances leading to patient identification. f) Ambulance number. g) Tags should be attached to the large toe. If toe is not available, attach to the wrist. Never attach to clothing or shoelaces.

if U. S. GOVERNMENT PRINTING

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1967-245-

357

BACK

Figure 4-2. Military triage tag. (Reprinted with permission, Washi ngton , D. C., U. S. Government Printing Office, 1967245-357. ) 5. Evacuation Priorities The field paramedic is faced with two priorities: priority of care and priority of evacuation. A patient stabilized after requiring immediate airway opening may require a less immediate priority of evacuation as shown in Table 4- 2. Color-coded

58

The Organization

of Disaster

Medicine

Triage

59

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Figure 4-3A.

0

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Civilian triage tags.

METHOD OF REMOVAL

B.

Nonentrapped patients: 1. Red 2. Yellow 3. Green Entrapped patients 1. Red 2. Yellow 3. Green

_

1Ai__ ,__ 0 _

Uncorrected Respiratory Problems Cardiac Arrest Severe Blood Loss Unconscoious Severe Shock Open Chest or Abdominal Wounds Burns Involving Respiratory Tract Several Major Fractures

tagging is commonly used (Figure 4-3). Inappropriate color codes are detached leaving the appropriate evacuation color code at the bottom of the tag. Internationally recognized codes now correspond to the color sequence in traffic signals: red, yellow, green. A field triage plan utilizing color codes was developed for Montgomery County, Maryland32 as follows:

A.

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Deceased

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Figure 4-3B. Civilian disaster triage tags. (Repr-inted with permission from METTAG, P. O. Box 910, Starke, Florida 32901, U. S. A. ) 4. Nonentrapped gray 5. Entrapped gray RED TAG

Removed first

A. B.

Uncorrected respiratory Cardiac arrest *

problems

*Never provide CPR in those situations where a casualty is a doubtful survivor or while others more salvageable are allowed to deteriorate.

The Organization

60

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Priority of Transportation 3

TIME

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Table 4- 2. Field Priorities

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of Disaster

Patient 1. Dyspnea, stridor, UNC 2. Abrasions, mod. hysterical 3. Bleeding profusely from neck laceration 4. Grossly deformed FX leg, FX mandible, and blood loss 5. Elderly PT, FX arm, substantial pain, dyspnea

Priority of Care 1 5

5

2

1

4

4

3

2

*Reproduced with permission: Hughes, J. H.: Triage. graduate Medicine. Vol. 60, No.4, Oct. , 1976.

Post-

YELLOW TAG

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I

II

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II

III

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III

A. B. C. D.

Severe burns Moderate blood loss (1-2 pints) Back injuries with or without spinal cord damage Conscious with serious head injuries

GREEN TAG o

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Figure 4-3C. Civilian disaster triage tags. (Reprinted with permission from Honolulu County Medical Society, HMA Disaster Committee, Honolulu, U. S. A. ) C. Severe blood loss (2 pints or more) D. Unconscious E. Open chest or abdominal wounds F. Several major fractures G. Severe shock H. Burns (complicated by respiratory tract injury)

A. B. C. D.

Minor fractures Other minor injuries Minor burns Obviously mortal wounds in which 'death appears certain

reasonably

GRAY TAG A. Without pulse or respiration for 20 min B. Injuries make CPR effort impossible Where tags are not available, a system using crosses marked on the forehead with indelible pens is acceptable19 (Figure 4- 4). 6. Fatal Injuries Fatalities should be immediately identified and labeled "deceased. " Time and per sorssel are often wasted reconfirming

62

The Organization

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Medicine

Triage

63

E. TRIAGE SITE 2 System

used

to severity

for of

marking

injury

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in jury:

xx

x Minor

foreheads

Serious but

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some

delay

Serious

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Requires

in treatment

immediate

possible

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Figure 4-4. Rapid triage identification method. (Reproduced with permission: Moorgate tube train disaster. Br Med J, Vol. 3,1975.) death. Portable monitor paddles to confirm heartbeat are easily passed from one casualty to another. 17 The remains, with all personal effects, are covered appropriately with sheet or body bag and removed as soon as possible to designated morgue or mortuary. The remains may be placed in a polythene tube bag with 200 cc of 4 % formaldehyde injected intraperitoneally and an additional 200 cc placed in the bag itself. Decomposition will be delayed by this process for up to two weeks. 20 Identification of the deceased may take equally as long in large disasters where severe burns or disfigurement occurs. 7. Community Physician's

Obligation in the Field

Invariably, physicians or other health professionals will be present or will arrive quickly at the scene of a disaster. Paramedics will be following standardized triage and treatment protocols which have been developed by local EMS agencies. Health care providers should not interfere or intervene in this process. Accepted guidelines for these professionals are as follows: a) Identify yourself to the person in charge, i. e. , the triage officer. Briefly state your qualifications for care (e. g. , "I am an internist. "). b) Ask how you can assist and accept assignment willingly unless you do not possess such skills. c) Stay away from nonfamiliar procedures, e. g. , extrication.

1. Prior disaster planning will have designated the hospital antrum, emergency room, or other suitable entrance as Triage Site 2. The designated triage officer and assistants remain in this area until completion of triage tasks. The triage tags are rapidly reviewed by the triage officer. Examination of the ABC status is made and further resuscitation is provided. Tasks are assigned to assistants by the triage officer. The triage officer does not stop to treat patients. A similar primary survey is undertaken as new loads of casualties arrive. If field triage has proceeded well, the hospital triage officer will make contact with the most critical patients in the first evacuation to the hospital. Attention, however, is given to every casualty. Patient status may shift rapidly. Misdiagnosis in the heat of field triage is common, and ABC stabilization is never certain. Retagging and alteration in treatment priorities will, therefore, occur. Triage tagging is accurate approximately 70% of the time. The new tag is placed over the original tag, which is never removed. The triage officer allocates a nurse, medical student, paramedic, or student nurse to each patient. 2. The triage officer must be kept informed of all data critical to the triage decision-making: Type of disaster Number injured Distance in time from hospital Special circumstances, e. g. , severe weather, elementary school bus accident Number of health care providers available for assistance: phys i cians and specialty Laboratory and blood bank availability Surgical teams availability Presence in the hospital of department chiefs and disaster team members Evacuation capabilities Available acute care beds Simplified diagrams of triage flow of patients Easy access to communication system both internal and external Available runners and clerical assistants 3. At Triage Site 2, all p$tients are assigned to one of four treatment categories:21

The Organization

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of Disaster

Medicine

Triage

65 Examples21

Qualifications

Ambulatory treatment Immediate treatment Delayed treatment Expectant treatment

Injuries or illnesses not requiring immediate hospitalization

F. TRIAGE SITE 3 1. Designated Areas Areas are designated for each treatment category. The principle of categorization is the length of time needed to carry out treatment, not the severity of the injury or illness. Triage is a continuous process to be repeated in all areas of the hospital. Patients are constantly being changed from one treatment category to another as justified by shifting circumstances of available resources. a) Immediate Treatment Area (ITA): Usually resuscitation area of established emergency room. Larger institutions may have separately designated acute burn, shock, and fracture treatment areas. Qualifications (1) Minor injuries requiring brief treatment not appropriate to ambulatory treatment area (2) Severe injuries that r equir-e brief lifesaving procedures

c) Delayed Treatment

Select third degree burns of less than 15% BSA; lacerations of soft tissue requiring only cleansing and dressing; fractur es that permit ambulation; patients exposed to radioactive contamination

Area (DTA): Examples21

Qualifications (1) Casualties where some delay in treatment will have little effect on final result (2) Patients with serious or multiple injuries needing time-consuming intensive care

Examples21

Disposition

Easily correctable airway defects; hemorrhage from easily accessible areas, incomplete amputations of extremities: burns 15-40% of BSA; open fractures of major bones, uncomplicated major soft tissue wounds

(1) Patients receive supervised IV stabilization with frequent vital signs (2) Patients triaged to ICA as openings occur d) Expectant Treatment

Closed lower extremity fractures; severe eye injuries; fractures of pelvis and spine

Area (ETA):

Qualifications

Examples21

Disposition (1) (2) (3) (4) (5)

Surgery ICU CCU Acute care wards 1-4 often via x-ray

b) Ambulatory Treatment Area (ATA): Patients are treated and discharged to provide space for other casualties.

Casualties nosis

with a poor prog-

Disposition (1) Receive supervisory custodial care (2) Analgesics and sedation as required for pain

Severe multiple injuries requiring more care than resources available; less severe injuries but with poor prognosis from age or other debilitating illness; massive radiation exposure

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The Organization

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Medicine

2. Laboratory

services

or experienced

Expectations: a) Extended laboratory services are required for 2- 5 days before many casualties are stabilized and evacuated. b) Laboratory triage office must report all blood and colloid availability to the triage officer-in-charge. c) Laboratory should be prepared to provide the following:22 immediate availability of low titer "0" whole blood 5-min capability for group and type specific whole blood 20 min for 4 units or less of fully cross-matched blood22 d) Contingency plans to organize a community "walking blood bank" must be anticipated and put into effect. e) Limit and streamline lab requests. Results must be simplified in anticipation of those values most critical to clinical decisions. -t

translated

to

CBC Electrolytes Urinalysis Urine function tests Glucose Arterial blood gases

-t

Actual Need Rct, Rgb Sodium, potassium Specif'tc gravity, presence of blood BUN Finger dextrostix Adequate ventilation; PC02

a) X-r ay examinations should be discouraged. 17 A barometer of good disaster management is an underutilized x-r ay department. Treat all suspected fractures as fractures. No xrays will be done before resuscitation. Known compound fractures require x -r ays only after surgical correction. b) Examination requests should be streamlined to those views most critical to necessary clinical management. Suspected hemothorax should receive a lateral decubitus view alone. 23 This view will identify as little as 15 cc of fluid in the chest. Routine AP and lateral views are not necessary to the clinical decision to vent the hemothorax. c) Military-type canvas litters serve as splints; x-r ays are easily taken through canvas portion preventing unnecessary patient movement. 24 Pitfalls: a) Requests for x-r-ay examination may come from various sources and thereby confuse priorities. Be attentive to requests from the immediate care area. Requests from ambulatory, delayed, and expectant care areas should receive strict scrutiny and decisive refusal. b) Physicians, either out of anxiety over a complex multiple-injured case or during a lull in the care of stabilized patients, tend to react by hasty and often inappropriate ordering of x-r ay examinations.

4. Surgery Department

Pitfalls:

Triage Officer:

Large blood volume request will cause a bottleneck. Limit requests for crossmatches to 2-4 units at anyone time.

Expectations:

3. Radiology Department Triage Officer:

67

Expe ctati ons:

Triage Officer: Chief of laboratory chief technician.

Normal Request

Triage

Senior radiologist

Senior surgeon or designate

a) Triage critical and serious cases around available surgeons, surgical nursing teams, and anesthetists/ anesthesiologists. b) Critical unstable cases requiring brief but definitive surgical correction come first. c) Serious stabilized cases must have their vital signs, fluids, and blood closely monitored by critical care nurses or nonsurgical phys i cians. Atl.] evidence of instability must be

68

The Organization

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Medicine

communicated to the surgical triage officer. Many abdominal wounds awaiting surgery can be successfully stabilized for 3-4 hrs on crystalloids alone. d) Specialty surgeons (ophthalmologist, urologist, obstetrician-gynecologist, plastic surgeons, etc. ) are utilized by the surgical triage officer to close major surgical wounds in order to allow general, thoracic, and orthopedic surgeons to work on the next priority case. Pitfalls: a) Inattentiveness to the priority of delayed secondary closure in many disaster or battlefield wounds. b) Surgeons may not be familiar with the characteristics of devitalized muscle and the requirements for debridement. c) Contaminated or poorly debrided smaller wounds treated by physicians in the Ambulatory Care Area may return with wound infections. Few minor wounds necessitate immediate closure. 25 Proper early debridement, wound immobilization, extensive drainage, and delayed closure in 5-7 days are the fundamental principles. d) Allowing low priority surgical cases to arrive in surgery to be operated on immediately, without attention to the posstbrlity that more severe cases requiring immediate definitive sur- . gical intervention are at that moment being stabilized in the Immediate Care or Resuscitation Areas. 5. Acute Nursing Units Triage Officer: Nursing supervisor

or director

of nursing.

Expectations: a) Discharge or transfer noncritical patients to home or alternate care facility. In any major hospital nationwide, at least 50 patients can be safely discharged to home on an immediate basis. Hospitals vary from 30- 60% clearance ability of noncritical patients. b) Staff critical care units with appropriate nursing personnel. Practical nurses, nursing students, medical students, paramedics, or experienced community volunteers may be ~tilized to staff noncritical nursing units or to supplement nur smg requirements on acute care units. c) Disaster plans should be reviewed to determine the feasibility of utilizing one ward or block beds on individual wards for disaster victims. utilizing one ward may provide for

Triage

69

more efficient staffing and critical care, nursing staff is limited in number. 26

especially where

Pitfalls: Acute care beds must be planned for up to 5 days. Staff fatigue, exhaustion, and equipment limitations may necessitate early triage to another facility. Inattention to this may lead to delayed morbidity and mortality of otherwise properly cared for victims. 6. Medical Department Internists and pediatricians provide critical triage in the following areas:27

responsibilities

to

a) Fluid and electrolyte consultation (1) Early recognition and treatment of crush-related hyperkalemia and renal impairment. (2) Nutritional and electrolyte requirements of victims of prolonged entrapment. (3) Dialysis requirements associated with severe trauma. b) Infectious disease consultation (1) Treatment of sepsis secondary to complications of trauma and contaminated wounds. (2) Anticipation of outbreaks of communicable disease associated with postdisaster phase. c) Radiation, Chemical, and environmental casualty care consultation (1) Evaluation, treatment, and follow-up of casualties in these areas fall primarily to the internist, pediatrician, or generalist. (2) Consultation with military, federal, state, or university experts in these areas of care must be obtained early in the course of disaster care. 7. Predischarge

Areas for Ambulatory Patients

The predischarge area should be a quiet, easily accessible gathering area removed from the original triage entry poi nt. Triage tags, records, and identifi cation procedures are completed and collected. All patients should be: a) Instructed in the management of their condition. b) Provided with a brief description of the treatment. c) Provided with a brief des cr iption of their condition and information for follow~"&p.

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The Organization

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Medicine

VI. COMMUNITY PHYSICIAN'S OBLIGATION TO IN-HOSPITAL TRIAGE A. B. C. D.

Identify your presence to triage officer-in-charge. Accept assignment. Know standard procedures (see Chapter 5). Resist temptation to change from locally accepted standard procedures. E. Examine minor cases and discharge them rapidly. (There is a tendency for medical staff to stand by and await the "really big cases. ") VII. MILITARY TRIAGE

The objective of mass casualty triage is to accomplish the greatest good for the greatest number in the shortest time. In the stark reality of com bat, the major obj ecti ve of battlefield triage is to determine who can be returned to the front immediately, treat them, and move them back to duty. Quick treatment and evacuation of the more seriously injured is an important but a secondary objective. The process conducted on the battlefield where medical facilities are limited involves the unpleasant but necessary military decision to evacuate first those with the best chance of survival and leave for later evacuation those who have no chance of survival. An improvement in survival of casualties was seen when triage principles were applied in the Korean War. Further improvement in survival rates of casualties was noted during combat activities in Vietnam where sophisticated triage and evacuation practices were performed. 5,28,29 Table 4-3 illustrates this improvement. Table 4-3.

71

Triage Table 4-4.

Mortality

WWII Korean War Vietnam War

4.7% 2.0% 1.0%

Contributing factors to the 1% mortality rate in the Vietnam War include: immediate helicopter evacuation, well equipped and staffed hospitals , rapid triage and treatment, and limitation of enemy weaponry. z9 Casualties are sorted at every medical installation in the chain of evacuation and hospitalization (Figure 4- 5). A. FIELD SITUATION30 The corpsman in the field is prepared to sort and treat casualties rapidly and efficiently. 1. Corpsman maintains a position in the immediate proximity of the front lines. 2. The casualty is first removed from the direct line of fire. Corpsman must have knowledge of

UNIT (BATTALION/SQUADRON)

CORPSMENIN THEFIELD

LEVel:

lID STUION

DIVISION

LEVEL:

---I-IO-S-Tl-TIO-NS---~I--1

CL!IRING SlITIONS

I -----'

,....-----..,

Time of Wound to Definitive Care28 CORPS

WWI WWII Korean War Vietnam War

12-18 6-12 2-4 1-2

hrs hrs hrs hrs*

*Nine out of 10 consecutive laparotomies started within 70 min of the wound.

LEVEL:

COMMUNICA liONS

110 SlITlONSjOlSPENSlRlES

SUPPORTClEIRING SlIIIDNS

110 STIT10NS/DISPENSIRIES

ZONE lEVEL:

performed were

Mortality rates have dropped significantly II. This decrease is shown in Table 4-4. 28

TYPICAL MILITARY FIELD TRIAGE OPTIONS AND SUPPORT FACILITIES AT LEVELS OF THEATER OPERATIONS

since World War Figure 4- 5. Medical operations in combat. (Reproduced with permission: Department of'gefense, Washi ngton , D. C. )

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The Organization

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Medicine

a) field of fire b) type or ordnance encountered c) protective features of the terrain 3. A corpsman never exposes himself recklessly to reach a casualty. 4. The squad or platoon leader provides protective fire coverage. 5. When the casualty has been removed to an area of relative safety, first aid measures are carried out. 6. The responsibility of the initial sorting of casualties falls to the first corpsman who attends to the casualty. Decision must be made as to: a) Need for evacuation b) Urgency of evacuation c) Advisability of returning the soldier to duty 7. Battlefield triage involves three categories of casualties. The corpsman's evaluation is essential in assisting the military commander on the scene who will pass through air request channels for MED-EVAC assistance if necessary. a) Emergency: Critical wound, illness, or injury; immediate evacuation is a matter of life or death. b) Priority: Serious wound, illness, or injury. Requires early hospitalization but not immediate evacuation, e. g. , minor multiple wounds; muscle damage which is less than major; thoracic wounds without asphyxia; dislocation and lesser fractures; and injuries of the eyes. c) Routine: Wound, illness, or injury of a minor nature. These should be handled by the corpsman immediately and the soldier returned to duty, e. g. , minor cuts, abrasions, superficial shell fragments, sprains and strains, mild headaches, toothaches, diarrhea, and constipation. Evacuation is not warranted. (1) Routine category is used through air channels when applied to the evacuation of the deceased as well as transfer of patients between medical facilities (see Chapter 7). (2) If an injury is routine but will prevent the military unit from accomplishing its mission, it should be upgraded to priority to hasten MED-EVAC. B. INITIAL ORGANIZED TRIAGE FACILITY These may be mobile aid stations close to the battle area or, somewhat more removed, casualty clearing stations. These areas are used when evacuation is primarily performed by foot or limited military vehicles.

Triage

73

These open facilities may be manned by one clinically experienced medical officer, veterinarians, dentists or nurses, and eight corpsmen. 33 Tri -Service (Army, Navy, Air Force) Combat Casualty Care Courses (C-4) presently provide all military health care professionals with instruction in emergency resuscitation and triage procedures. Nonphysician health professionals are critical in manning these facilities under battlefield priorities. Evacuation to second echelon triage facilities or field hospitals is performed by armored personnel carriers. Helicopters may evacuate casualties from field or initial triage facilities. Where field helicopter MED- EVAC is utilized, the initial triage facility is usually overflown and bypassed in favor of the second echelon triage facility. C. SECOND ECHELON TRIAGE FACILITY Usually no more than 20-30 minutes from the initial triage facility by vehicle. This facility may represent a casualtyreceiving hospital ship where coastal evacuation by helicopter is an organized entity. These facilities are manned by organized teams of general medical officers, anesthetists or anesthesiologists, general and orthopedic surgeons; several specialty surgeons if the facility warrants this; and nurses, corpsmen and nonmedical support personnel who assist in supply, evacuation, and recordkeeping duties. Many of the principles and objectives discussed under Section V (Civilian or Community Disaster Triage) are applicable to Military Triage. The efficiency of sorting which was discussed under triage rounds is critical to any echelon level (Figures 4-6 to 4-10). VIII. MEDICO-LEGAL ASPECTS OF TRIAGE IN CIVILIAN DISASTERS A. Assessment of liability will take into consideration the various circumstances surrounding the disaster situation. Major factors include: 1. Availability of physicians to treat disaster 2. Reasonableness of the triage procedure

victims

Paramount to this is the presence in the community of a specific disaster plan; the presence of trained triage officers who act in the reasonable fashion expected of their duties; and the provision of services by. health care professionals working ,,""

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The Organization

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Medicine

Figure 4- 6. Triage bunker, Delta Medical Company, 3rd Division' Vietnam, 1968. Separate numbered stations were manned by one physician and two to three corpsmen. Hung IVs will r-e-' main sterile for 2-3 days. to the best of their abilities them.

with the resources

Triage

75

Figure 4-7. Soldiers triaged and tagged during military conflicts (Vietnam, 1968). Conditions warranted that casualties be stripped to allow for full view of all injuries. This is more critical where casualties are unable to provide information due to injury or language barriers.

available to

ADDENDUM TO CHAPTER 4 (TRIAGE) ST ANDARD OPERATING PROCEDURES FOR TRIAGE PERSONNEL Primary care providers may find themselves assigned to treat, evaluate, and monitor trauma victims in various stages of shock. Providers will be asked to stabilize these victims and maintain stabilization until resources (i. e. , operating room or evacuation) for definitive treatment become available. Providers may find themselves sitting on a potential time bomb of a patient. The waiting period may seem endless. The provider must monitor the stabilization and notify the Triage Officer immediately if it appears stabilization can no longer be maintained. It will be the responsibility of the Triage Officer to either upgrade the victim to an immediate place in the operating room, recommend an alternate stabilization method (i. e. , auto transfusion) or possibly reroute the victim to the Expectant Treatment Area.

Figure 4- 8. Treatment of heat casualties expedited by common Showering by means of hose. Unfortunately, personal privacies are often compromised by the demands of disaster care (Vietnam, 1968).