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Triage: military and civilian experience
Current Anaesthesia and Critical Care (1998) 9, 48-51
© 1998 HarcourtBrace & Co. Ltd
Focus on: Prehospital and e m e r g e n c y t r a u m a care in disaster medicine
Triage: military and civilian experience
M. G. Mezzetti
Introduction
Purposes of triage
The word 'triage', now internationally accepted and diffused, is a French term meaning 'choice', or 'selection', introduced in military medicine by Baron Jean Dominique Larrey during Napoleonic campaigns, and only later adopted in prehospital and emergency medicine. Triage is a part of the medical rescue chain, crucial in order to minimize the potential morbidity and mortality that follow a mass-casualty event in peacetime or a battle in war. 2 Providing simultaneously effective care to disaster victims is often impeded by the massive flow of victims that creates a disproportion between the availability of resources and the number of injured patients requiring immediate or delayed care. The massive inflow of victims is a phenomenon typically observed after a disaster, either isolated (e.g. a road traffic accident) or repetitive (e.g. during a war)) The basic goal of triage is to give to rescue staff a method of assessing the disaster, the extent of injuries to the victims and the degree of priorities both in treatment and in evacuation from the scene. 4 The application of triage is a 'dynamic' need, which could disappear when the massive flow of victims has ceased or has been controlled; however, it remains one of the basic responses to a disaster, independent from the environmental conditions, and the pre-existing levels of care delivered. Moreover, in a context often burdened by panic, a sense of insecurity, and disorganization, the need to sort patients depending on the severity of their injuries represents the only ethical response, passing from the daily performed 'individual' to the unusual, but indispensable, 'mass' medicine.
The aim of triage is based on the principle of accomplishing the greatest good for the highest number of wounded and injured people in the special circumstances of a war or a disaster, by separating the victims into different classes for purposes of treatment and evacuation. 5 Triage protocols are different depending on the purposes and the experience of the teams involved in rescue operations, but generally four levels, or degrees, of priority are considered: 1. Absolute priority: a patient suffering from life-threatening injuries and requiring immediated treatment (e.g. asphyxia, tension pneumothorax, haemorrhagic shock); 2. Potentially critical: a patient actually stable, but at risk of developing life-threatening lesions (e.g. all vascular injuries in which the application of a tourniquet is required, closed head trauma with decreasing Glasgow Coma Scale score) 3. Delayed treatment: a patient suffering from injuries compatible with a long wait (e.g. burns under 15%, minor fractures, minor soft tissue injuries) 6 4. Deceased/will die: a patient who is either dead or suffering from mortal injuries from which death is reasonably certain (e,g. severe head trauma with brain exposed, unwitnessed cardiac arrest) Every triage protocol has its own definitions; in many cases the term 'absolute' (priority) is interchangeable with 'immediate', or 'first', and 'potentially critical' is interchangeable with 'secondary'. Usually, the triage team is not in charge of therapeutic goals, so immediate resuscitation teams, emergency surgeons and other specialists (e.g. trauma anaesthesiologists) must be immediately available for delivering adequate care after assignment of a patient to his or her level or priority]
Marzio G. Mezzetti, Consultant, Departmentof Anaesthesiaand Critical Care, Health Centre 'Mater Domini', Castellanza, Varese,
Italy_ 48
MILITARY AND CIVILIAN TRIAGE
49
Triage and stages of disaster response
Composition of a triage team
Disasters generally have different stages, during each of which specific responses and different protocols of triage should be adopted; for the purposes of this chapter the 'classical' four temporal stages are considered: 8'9
Triage is an activity that must be performed by a team, or unit, of skilled physicians, nurses and administrators, trained in working together under the supervision of a leader. TM Ideally, a triage team should be composed of at least: 19
1. Immediate phase (within seconds/minutes): initial emergency care is provided by bystanders, survivors or victims with minor injuries; triage is simply based on survivor/non-survivor~° 2. Early phase (within minutes/hours): emergency care is provided by professionals, resuscitative interventions are possible; tnage is based on predefined protocols 3_ Stabilized phase (within 4-6 hours): emergency care is provided by professionals. Stabilization of victims is performed on scene in order to evacuate them; triage protocols are valid in case of 'delayed rescue' (e.g. entrapped victims) 4. Late phase (within 1-7 days): triage is not needed. In this phase, public health authorities have a detailed assessment of the disaster and only rarely emergency teams are recalled on scene. In cases of major disasters (e.g_ earthquakes, volcanic eruptions, floods) involving wide or densely populated areas, the duration of each phase increases but the criteria for applying the triage protocols are the same. In fact, particularly if the disaster area is remote from essential resources, the immediate rescue and first aid are provided by bystanders or survivors; only after the arrival on the scene of skilled and properly equipped medical teams triage can be started and a higher level of care delivered.
How the ATLS doctrine can be applied to triage In the recent past, the ATLS has become the most important method of evaluation and treatment of trauma patients in the USA, Canada, the UK and some European countries; this new approach also involves the criteria used during the phases of triage. 11'1z The applicability of ATLS to field and military medicine has been studied by several authors and practically evaluated during the operation Desert Storm and recently in others operations of peace-keeping in eastern Europe. 13'14With few differences, the prevailing opinion is that the ATLS primary survey is practically inapplicable during triage after a disaster, or in cases of mass casualties at the advanced medical post, but could be adequate when health resources are sufficient to care for all the victims, as in intermediate (field) or definitive hospitals. ~5Also, in military triage, the surveys of ATLS are not always sufficiently specific for evaluation and description of typical lesions from the battlefield, particularly at the level of the battalion aid station. 16However, in the author' s experience, ATLS is a very useful method for the treatment of trauma patients, and will probably constitute the common basis for the future of trauma surgery and prehospital and emergency medicine. 17
• One triage team leader, the most skilled triage officer, acting as supervisor of all the activities (usually a trauma surgeon or a trauma anaesthesiologist) 2° • Three triage officers, experienced emergency physicians who perform the primary survey of victims in order to assign their priority of treatment • Six triage assistants, experienced nurses who cooperate with the triage officers, particularly in exposing and positioning the victims before and after physical examination, filling in patients' triage tags and collecting identification data • Two administrative personnel to compile the list of victims examined at the triage area and assign a suitable hospital destination for each victim; such a list often represents a very important medico-legal document (e.g. after a terrorist bombing or an air crash).
Logistic aspects of triage Triage is a medical activity requiring only a few instruments, but appropriate areas are needed in order to perform the correct procedure, z' In field hospitals, the triage centre is usually hosted under tents or shelters. With urban disasters, experience shows that even in a busy town it is possible to adapt appropriate spaces in order to perform the triage. The very basic equipment required in a triage centre is: za • Examination tables: three tables for each triage officer; alternatively, stretchers can be placed over two sawbucks • Lamps • Wastebins • At least one table for administrative purposes • Posters or large coloured bands, for easy identification of the area and its different parts; coloured spray, or self-adhesive tapes on the walls works well as an alternative. The 'ideal' triage area should have the following requisities: ~3 • • • • • • • • •
Placed near the disaster core, but in a safe zone Accessible from main streets Separate doors for entry and exit Air conditioning Electric power supply Current water supply No internal stairs Near (or not too far from) a helipad Adequately indicated in order to organize the turnover of ambulances.
50 CURRENT ANAESTHESIA AND CRITICAL CARE In urban areas it is quite easy to find a space adaptable as a triage centre (e.g. pub, underground station, school) and the experiences of many authors show that the creation of a triage centre starting from a public hall is relatively simple. Triage tents are specially conceived for this activity and fulfil all the above listed requirements; triage sheltered units are not very popular .among disaster medicine specialists because of the lack of space that typically occurs in such units. Each member of a triage team should be easily recognizable and equipped with a minimum of instruments: 24 • • • • •
Scissors (or tailor's shears) Stethoscope Inflatable pressure cuff Pocket lamp Portable radio.
Differences between military and civilian triage Triage was born under war circumstances, and only later has been adapted to civilian mass casualties. The basic need is the same, but some notable differences exist between civilian and military practice_ z5 Firstly, the victims during a war are mainly soldiers, i.e. young and healthy people, physically able to sustain fatigue and stress. In civilian triage the victims are completely different, ranging from newborn to very elderly. The past medical history of civilian patients is unknown to triage officers, but it could become important in the immediate future, particularly in order to avoid late complications (e.g_ infections, transmissible diseases). Secondly, triage protocols in military practice consider mainly lesions determined by war and terrorism (e.g. gunshot wounds, fragment bullets, landmines, blast), and this kind of injury is not always comparable to the lesions observed in peacetime. 26 Thirdly, triage is also performed in order to determine the priority of evacuation; in peacetime, evacuation could be performed on a 24 h/day, 360 ° basis, usually in a short time. In military practice, evacuation is not always possible and should never be performed according to the same criteria adopted for civilians; in fact, in times of war, medical needs generally take a second place to the dictates of the strategic situation. Fourthly, military triage, particularly in times of war, is also aimed to reducing the number of disabled soldiers; from this point of view, particularly for medicolegal and humanitarian reasons, the civilian protocols of triage are more detailed.
Triage tags and alternative methods Triage tags or other methods of patient identification represent an essential instrument for the triage team: after the visible confirmation of assignment of a victim to a degree of priority, it becomes easier to deliver the appropriate level of care. The diffusion of the principles of triage among both civilian and military physicians determined the creation
of several triage tags; in fact many experts decided that their own organization or department needed a well-done or exhaustive triage tag. This proliferation of different methods is quite harmful and overall useless, and now most specialists are using one of two kinds of tags: the 'immediate' tag (e.g. Mettag, Perth casualty triage tag) or the 'classical record'. Both of these triage tags present advantages and limits: immediate tags are in some circumstances too concise and do not provide sufficient information, particularly for seriously injured patients. Classical records, mainly adapted from pre-existing anaesthesia or critical care transport records, are, on the contrary, often too complicated for non-critical victims, In the author's opinion, the most important limit of immediate tags is their non-reversibility: a victim started as 'red' (haemorrhagic patient) could be changed to 'yellow' (haemodynamically stable vascular wound) after an appropriate treatment, but, particularly in long chains with multiple steps (e.g. military 'echelons of care'), it becomes quite difficult to modify the original tag because the colour corresponding to the actual physical status has been cut previously or removed) 7 Nevertheless, excellent triage tags are nowadays in use in various organizations. A classic example is the Swiss Green Cross triage tag, composed of an external holster in PVC, acting as a cover, with a progressive number and the patient data, a transparent pocket for an immediate tag; in the holster there is a very simple data record where it is possible to indicate the clinical parameters and administered drugs, and also a PVC bag for used vials and ampoules of administered drugs. When triage tags were not available, alternative methods have been used in order to mark with the appropriate colour a victim assigned to a definite class; the cheapest, and probably the simplest, is to put on a visible part of the body (generally the front or the wrist) a bit of adhesive tape corresponding to the colour assigned to the patient's class_ Coloured clothes-pegs or spots of spray paint have also been used. 2s
Triage under special circumstances Triage protocols are standardized in order to reduce the possibilities of errors. Some special circumstances require an adaptation of protocols or the application of special criteria. Burns
The triage of burned victims is generally performed by following two criteria: the percentage of burned surface _+ the age of the victim. If the burned surface is over 40%, death is probable, depending on the immediacy of care, but death is almost certain if the victim is under the age of 18 months, or over 60 years. In cases of burns between 15 and 40% of total body surface, hospitalization must be attempted. Second- and third-degree burns under 15%, or first-degree burns under 20% of total body surface could be treated on scene, except in cases of circumferential or facial burns. 29'~°
MILITARY AND CIVILIAN TRIAGE
Irradiation In cases o f m a s s c a s u a l t i e s after irradiation, a n e v e n t p o s s i b l e b o t h in n u c l e a r w a r a n d in c i v i l i a n disasters, triage a s s u m e s a c r u c i a l r o l e b e c a u s e m e d i c a l r e s o u r c e s are h i g h l y l i k e l y to r u n o u t q u i c k l y , a n d all the h o s p i t a l s will b e s a t u r a t e d b y i r r a d i a t e d v i c t i m s . In p e r f o r m i n g triage, p h y s i c i a n s s h o u l d c o n s i d e r t h e a s s o c i a t i o n o f c o n v e n t i o n a l l e s i o n s w i t h i r r a d i a t i o n , a n d f r o m this p o i n t o f v i e w t h e triage s h o u l d b e m o d i f i e d as f o l l o w s : 31 N o irradiation: refers to c o n v e n t i o n a l t r i a g e p r o t o c o l s I r r a d i a t i o n u n d e r 150 rads: g o o d r e c o v e r y , i m m e d i a t e evacuation I r r a d i a t i o n o v e r 4 0 0 rads: m i n i m a l p o s s i b i l i t y o f survival, d e l a y e d t r e a t m e n t .
Developing countries D i s a s t e r s o c c u r r i n g in d e v e l o p i n g c o u n t r i e s are c h a r a c terized by a chronic lack of medical resources (limited o x y g e n , b l o o d a n d c l e a n w a t e r supplies, p o o r s a n i t a t i o n facilities, m a l n u t r i t i o n ) , w h i c h will b e e x a c e r b a t e d b y t h e event. T h u s , t h e i m m e d i a t e t r e a t m e n t o f m a s s c a s u a l t i e s b e c o m e s p a r t i c u l a r l y i n a d e q u a t e d u e to a l a c k o f t r a i n e d m e d i c a l p e r s o n n e l a n d e q u i p m e n t . In t h e s e situations, communicable diseases may increase exponentially and p r o b l e m s o f s h e l t e r i n g will w o r s e n the r e s c u e o p e r a t i o n . C o n v e n t i o n a l triage p r o t o c o l s s h o u l d b e a d a p t e d to suit t h e i m m e d i a t e l y a v a i l a b l e facilities, w a i t i n g for a s e c o n d a r y r e l i e f o p e r a t i o n f r o m n e i g h b o u r i n g a n d intern a t i o n a l c o m m u n i t i e s . 32
References 1. Favre R. L'homme et les catastrophes. Paris: France SElection 1969. 2. Caroline N. Emergency care in the streets. Boston: Little, Brown, 1981. 3. Adler J. Evacuation et soins des blesses pendant la guerre d'octobre 1973. Rev Int Sev Sant~ Arm 1973; 52:11. 4_ Champion H R, Sacco W J. Triage of trauma victims. In: Trunkey D D, Lewis F R, eds. Currem therapy of trauma. Philadelphia: Decker, 1986. 5. Champion H R, Morean M M, Gainer P S Assessment and triage. In: Baskett P J F, Weller R M eds. Medicine for disasters. London: Wright, 1988. 6. Born C T. Delayed identification of skeletal injury in multisystem
51
trauma: the 'missed' fracture. J Trauma 1989; 29: 1643. 7. Rund D, Trausch T. Triage. St Louis: Mosby, 1981. 8. Goddard G_ Triage and vital signs (lett). Am J Emerg Plays 1977; 6: 224. 9. Moore W S. A new classification system for disaster casualties. Hospitals 1967; 41: 66. 10. Safar P. Stages of resuscitation and life support in disasters. In: Frey R, Safar P, eds. Disaster medicine, resuscitation and life support relief of pain and suffering. Heidelberg: Springer, 1980. 11. Palmer I P, Baskett P J, McCabe S E. A new chart to assist with advanced trauma life support. J R Army Med Corps 1992; 3: 118. 12. Walsh D P, Lammert G R, Devoll J. The effectiveness of the advanced trauma life support system in a mass casualty situation by non-experienced physicians: Grenada 1983. Am J Emerg Med 1989; 7: 175. 13. Rudland S V. An audit of resuscitation and anaesthesia during Operation 'Safe Haven'. J R Nav Med Serv 1992; 3: 133. 14. Wiedeman J E, Jennings S A. Applying ATLS to the Gulf War. Mil Med 1993; 2: 121. 15. Thomas F, Clemmer T P, Orme J F Jr. A survey of advanced trauma life support procedures being performed by physicians and nurses used on hospital aeromedical evacuation services. Aviat Space Environ Med 1985: 12: 1213. 16. Backer M S. Advanced trauma life support: is it adequate standalone training for military medicine? Mil Med 1994; 9: 587. 17. Greenslade G L, Taylor R H. Advanced trauma life support aboard RFA Argus. J R Nay Med Serv 1992; 1: 23. 18. Walsh M. Disasters: current planning and recent experience. London: Arnold, 1989. 19. De Angelis C. The effectiveness of various health persons as triage agents. Community Health 1977; 2: 286. 20. Grande C M. Trauma anesthesia and critical care: the concept and the rationale for a new subspecialty. Cat Care Clin 1990; 6: 1. 21. Thomas G I. Le triage entra-hospitalier. Ann Anesth Franc 1978; 1: 93. 22. Thomas G I. R~gles de triage en cas de catastrophe. Converg Mdd 1983; III: 211. 23. Thomas G L. Le triage des blesses. In: Soins urgentes en situation de catastrophe. Paris: Hermann, 1981. 24. Noto R, Huguenard P, Larcan A. MEdicine des catastrophes. Paris: Masson, 1989. 25. Tighe S Q, Rudland S V, Loxdale P H_ Resuscitation in northern Iraq. Injury 1992; 7: 448. 26. Coupland R M, Howel P R. An experience of war surgery and wounds present after 3 days at the border of Afghanistan. Injury 1988; 19: 259. 27. Cowan M L, Cloutier M G. Medical simulation for disaster casualty management training. J Trauma 1988; 28: 178(S). 28. Koslowsky D F. Die triage in katastrophensituazion. Katastr Med 1969; 12: 669. 29. Editorial. Les secours mEdicanx aprEs l'attentat d'Orly. Converg MEd 1983; V: 458. 30. Editorial. Mexico: explosion de gaz ~tSan Juan Iuxthapetec le 19 novembre 1984. Converg MEd 1985; I: 23. 31. Galeano A. La section sant6 des forces ten'estres en operation. In: AA V V. M6mento de chirurgie de guerre. Paris: Ami Editeur, 1984. 32. Dufour D. Surgery for victims of war. Gen6ve: International Committee of the Red Cross. 18(1)
© 1998 HarcourtBrace & Co. Ltd
Focus on: Prehospital and e m e r g e n c y t r a u m a care in disaster medicine
Triage: military and civilian experience
M. G. Mezzetti
Introduction
Purposes of triage
The word 'triage', now internationally accepted and diffused, is a French term meaning 'choice', or 'selection', introduced in military medicine by Baron Jean Dominique Larrey during Napoleonic campaigns, and only later adopted in prehospital and emergency medicine. Triage is a part of the medical rescue chain, crucial in order to minimize the potential morbidity and mortality that follow a mass-casualty event in peacetime or a battle in war. 2 Providing simultaneously effective care to disaster victims is often impeded by the massive flow of victims that creates a disproportion between the availability of resources and the number of injured patients requiring immediate or delayed care. The massive inflow of victims is a phenomenon typically observed after a disaster, either isolated (e.g. a road traffic accident) or repetitive (e.g. during a war)) The basic goal of triage is to give to rescue staff a method of assessing the disaster, the extent of injuries to the victims and the degree of priorities both in treatment and in evacuation from the scene. 4 The application of triage is a 'dynamic' need, which could disappear when the massive flow of victims has ceased or has been controlled; however, it remains one of the basic responses to a disaster, independent from the environmental conditions, and the pre-existing levels of care delivered. Moreover, in a context often burdened by panic, a sense of insecurity, and disorganization, the need to sort patients depending on the severity of their injuries represents the only ethical response, passing from the daily performed 'individual' to the unusual, but indispensable, 'mass' medicine.
The aim of triage is based on the principle of accomplishing the greatest good for the highest number of wounded and injured people in the special circumstances of a war or a disaster, by separating the victims into different classes for purposes of treatment and evacuation. 5 Triage protocols are different depending on the purposes and the experience of the teams involved in rescue operations, but generally four levels, or degrees, of priority are considered: 1. Absolute priority: a patient suffering from life-threatening injuries and requiring immediated treatment (e.g. asphyxia, tension pneumothorax, haemorrhagic shock); 2. Potentially critical: a patient actually stable, but at risk of developing life-threatening lesions (e.g. all vascular injuries in which the application of a tourniquet is required, closed head trauma with decreasing Glasgow Coma Scale score) 3. Delayed treatment: a patient suffering from injuries compatible with a long wait (e.g. burns under 15%, minor fractures, minor soft tissue injuries) 6 4. Deceased/will die: a patient who is either dead or suffering from mortal injuries from which death is reasonably certain (e,g. severe head trauma with brain exposed, unwitnessed cardiac arrest) Every triage protocol has its own definitions; in many cases the term 'absolute' (priority) is interchangeable with 'immediate', or 'first', and 'potentially critical' is interchangeable with 'secondary'. Usually, the triage team is not in charge of therapeutic goals, so immediate resuscitation teams, emergency surgeons and other specialists (e.g. trauma anaesthesiologists) must be immediately available for delivering adequate care after assignment of a patient to his or her level or priority]
Marzio G. Mezzetti, Consultant, Departmentof Anaesthesiaand Critical Care, Health Centre 'Mater Domini', Castellanza, Varese,
Italy_ 48
MILITARY AND CIVILIAN TRIAGE
49
Triage and stages of disaster response
Composition of a triage team
Disasters generally have different stages, during each of which specific responses and different protocols of triage should be adopted; for the purposes of this chapter the 'classical' four temporal stages are considered: 8'9
Triage is an activity that must be performed by a team, or unit, of skilled physicians, nurses and administrators, trained in working together under the supervision of a leader. TM Ideally, a triage team should be composed of at least: 19
1. Immediate phase (within seconds/minutes): initial emergency care is provided by bystanders, survivors or victims with minor injuries; triage is simply based on survivor/non-survivor~° 2. Early phase (within minutes/hours): emergency care is provided by professionals, resuscitative interventions are possible; tnage is based on predefined protocols 3_ Stabilized phase (within 4-6 hours): emergency care is provided by professionals. Stabilization of victims is performed on scene in order to evacuate them; triage protocols are valid in case of 'delayed rescue' (e.g. entrapped victims) 4. Late phase (within 1-7 days): triage is not needed. In this phase, public health authorities have a detailed assessment of the disaster and only rarely emergency teams are recalled on scene. In cases of major disasters (e.g_ earthquakes, volcanic eruptions, floods) involving wide or densely populated areas, the duration of each phase increases but the criteria for applying the triage protocols are the same. In fact, particularly if the disaster area is remote from essential resources, the immediate rescue and first aid are provided by bystanders or survivors; only after the arrival on the scene of skilled and properly equipped medical teams triage can be started and a higher level of care delivered.
How the ATLS doctrine can be applied to triage In the recent past, the ATLS has become the most important method of evaluation and treatment of trauma patients in the USA, Canada, the UK and some European countries; this new approach also involves the criteria used during the phases of triage. 11'1z The applicability of ATLS to field and military medicine has been studied by several authors and practically evaluated during the operation Desert Storm and recently in others operations of peace-keeping in eastern Europe. 13'14With few differences, the prevailing opinion is that the ATLS primary survey is practically inapplicable during triage after a disaster, or in cases of mass casualties at the advanced medical post, but could be adequate when health resources are sufficient to care for all the victims, as in intermediate (field) or definitive hospitals. ~5Also, in military triage, the surveys of ATLS are not always sufficiently specific for evaluation and description of typical lesions from the battlefield, particularly at the level of the battalion aid station. 16However, in the author' s experience, ATLS is a very useful method for the treatment of trauma patients, and will probably constitute the common basis for the future of trauma surgery and prehospital and emergency medicine. 17
• One triage team leader, the most skilled triage officer, acting as supervisor of all the activities (usually a trauma surgeon or a trauma anaesthesiologist) 2° • Three triage officers, experienced emergency physicians who perform the primary survey of victims in order to assign their priority of treatment • Six triage assistants, experienced nurses who cooperate with the triage officers, particularly in exposing and positioning the victims before and after physical examination, filling in patients' triage tags and collecting identification data • Two administrative personnel to compile the list of victims examined at the triage area and assign a suitable hospital destination for each victim; such a list often represents a very important medico-legal document (e.g. after a terrorist bombing or an air crash).
Logistic aspects of triage Triage is a medical activity requiring only a few instruments, but appropriate areas are needed in order to perform the correct procedure, z' In field hospitals, the triage centre is usually hosted under tents or shelters. With urban disasters, experience shows that even in a busy town it is possible to adapt appropriate spaces in order to perform the triage. The very basic equipment required in a triage centre is: za • Examination tables: three tables for each triage officer; alternatively, stretchers can be placed over two sawbucks • Lamps • Wastebins • At least one table for administrative purposes • Posters or large coloured bands, for easy identification of the area and its different parts; coloured spray, or self-adhesive tapes on the walls works well as an alternative. The 'ideal' triage area should have the following requisities: ~3 • • • • • • • • •
Placed near the disaster core, but in a safe zone Accessible from main streets Separate doors for entry and exit Air conditioning Electric power supply Current water supply No internal stairs Near (or not too far from) a helipad Adequately indicated in order to organize the turnover of ambulances.
50 CURRENT ANAESTHESIA AND CRITICAL CARE In urban areas it is quite easy to find a space adaptable as a triage centre (e.g. pub, underground station, school) and the experiences of many authors show that the creation of a triage centre starting from a public hall is relatively simple. Triage tents are specially conceived for this activity and fulfil all the above listed requirements; triage sheltered units are not very popular .among disaster medicine specialists because of the lack of space that typically occurs in such units. Each member of a triage team should be easily recognizable and equipped with a minimum of instruments: 24 • • • • •
Scissors (or tailor's shears) Stethoscope Inflatable pressure cuff Pocket lamp Portable radio.
Differences between military and civilian triage Triage was born under war circumstances, and only later has been adapted to civilian mass casualties. The basic need is the same, but some notable differences exist between civilian and military practice_ z5 Firstly, the victims during a war are mainly soldiers, i.e. young and healthy people, physically able to sustain fatigue and stress. In civilian triage the victims are completely different, ranging from newborn to very elderly. The past medical history of civilian patients is unknown to triage officers, but it could become important in the immediate future, particularly in order to avoid late complications (e.g_ infections, transmissible diseases). Secondly, triage protocols in military practice consider mainly lesions determined by war and terrorism (e.g. gunshot wounds, fragment bullets, landmines, blast), and this kind of injury is not always comparable to the lesions observed in peacetime. 26 Thirdly, triage is also performed in order to determine the priority of evacuation; in peacetime, evacuation could be performed on a 24 h/day, 360 ° basis, usually in a short time. In military practice, evacuation is not always possible and should never be performed according to the same criteria adopted for civilians; in fact, in times of war, medical needs generally take a second place to the dictates of the strategic situation. Fourthly, military triage, particularly in times of war, is also aimed to reducing the number of disabled soldiers; from this point of view, particularly for medicolegal and humanitarian reasons, the civilian protocols of triage are more detailed.
Triage tags and alternative methods Triage tags or other methods of patient identification represent an essential instrument for the triage team: after the visible confirmation of assignment of a victim to a degree of priority, it becomes easier to deliver the appropriate level of care. The diffusion of the principles of triage among both civilian and military physicians determined the creation
of several triage tags; in fact many experts decided that their own organization or department needed a well-done or exhaustive triage tag. This proliferation of different methods is quite harmful and overall useless, and now most specialists are using one of two kinds of tags: the 'immediate' tag (e.g. Mettag, Perth casualty triage tag) or the 'classical record'. Both of these triage tags present advantages and limits: immediate tags are in some circumstances too concise and do not provide sufficient information, particularly for seriously injured patients. Classical records, mainly adapted from pre-existing anaesthesia or critical care transport records, are, on the contrary, often too complicated for non-critical victims, In the author's opinion, the most important limit of immediate tags is their non-reversibility: a victim started as 'red' (haemorrhagic patient) could be changed to 'yellow' (haemodynamically stable vascular wound) after an appropriate treatment, but, particularly in long chains with multiple steps (e.g. military 'echelons of care'), it becomes quite difficult to modify the original tag because the colour corresponding to the actual physical status has been cut previously or removed) 7 Nevertheless, excellent triage tags are nowadays in use in various organizations. A classic example is the Swiss Green Cross triage tag, composed of an external holster in PVC, acting as a cover, with a progressive number and the patient data, a transparent pocket for an immediate tag; in the holster there is a very simple data record where it is possible to indicate the clinical parameters and administered drugs, and also a PVC bag for used vials and ampoules of administered drugs. When triage tags were not available, alternative methods have been used in order to mark with the appropriate colour a victim assigned to a definite class; the cheapest, and probably the simplest, is to put on a visible part of the body (generally the front or the wrist) a bit of adhesive tape corresponding to the colour assigned to the patient's class_ Coloured clothes-pegs or spots of spray paint have also been used. 2s
Triage under special circumstances Triage protocols are standardized in order to reduce the possibilities of errors. Some special circumstances require an adaptation of protocols or the application of special criteria. Burns
The triage of burned victims is generally performed by following two criteria: the percentage of burned surface _+ the age of the victim. If the burned surface is over 40%, death is probable, depending on the immediacy of care, but death is almost certain if the victim is under the age of 18 months, or over 60 years. In cases of burns between 15 and 40% of total body surface, hospitalization must be attempted. Second- and third-degree burns under 15%, or first-degree burns under 20% of total body surface could be treated on scene, except in cases of circumferential or facial burns. 29'~°
MILITARY AND CIVILIAN TRIAGE
Irradiation In cases o f m a s s c a s u a l t i e s after irradiation, a n e v e n t p o s s i b l e b o t h in n u c l e a r w a r a n d in c i v i l i a n disasters, triage a s s u m e s a c r u c i a l r o l e b e c a u s e m e d i c a l r e s o u r c e s are h i g h l y l i k e l y to r u n o u t q u i c k l y , a n d all the h o s p i t a l s will b e s a t u r a t e d b y i r r a d i a t e d v i c t i m s . In p e r f o r m i n g triage, p h y s i c i a n s s h o u l d c o n s i d e r t h e a s s o c i a t i o n o f c o n v e n t i o n a l l e s i o n s w i t h i r r a d i a t i o n , a n d f r o m this p o i n t o f v i e w t h e triage s h o u l d b e m o d i f i e d as f o l l o w s : 31 N o irradiation: refers to c o n v e n t i o n a l t r i a g e p r o t o c o l s I r r a d i a t i o n u n d e r 150 rads: g o o d r e c o v e r y , i m m e d i a t e evacuation I r r a d i a t i o n o v e r 4 0 0 rads: m i n i m a l p o s s i b i l i t y o f survival, d e l a y e d t r e a t m e n t .
Developing countries D i s a s t e r s o c c u r r i n g in d e v e l o p i n g c o u n t r i e s are c h a r a c terized by a chronic lack of medical resources (limited o x y g e n , b l o o d a n d c l e a n w a t e r supplies, p o o r s a n i t a t i o n facilities, m a l n u t r i t i o n ) , w h i c h will b e e x a c e r b a t e d b y t h e event. T h u s , t h e i m m e d i a t e t r e a t m e n t o f m a s s c a s u a l t i e s b e c o m e s p a r t i c u l a r l y i n a d e q u a t e d u e to a l a c k o f t r a i n e d m e d i c a l p e r s o n n e l a n d e q u i p m e n t . In t h e s e situations, communicable diseases may increase exponentially and p r o b l e m s o f s h e l t e r i n g will w o r s e n the r e s c u e o p e r a t i o n . C o n v e n t i o n a l triage p r o t o c o l s s h o u l d b e a d a p t e d to suit t h e i m m e d i a t e l y a v a i l a b l e facilities, w a i t i n g for a s e c o n d a r y r e l i e f o p e r a t i o n f r o m n e i g h b o u r i n g a n d intern a t i o n a l c o m m u n i t i e s . 32
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