Sunday, May 18, 2008

Delegating and Prioritizing In A Disaster

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Okay, this is a much needed informational blog that I put together to explain the difference between internal, natural and external disasters. The NCLEX is focusing a lot on this due to the advent of 9/11/2001 and the changing times we live in.
What is meant by Internal Disaster was when the buildings actually started emploding [collapsing upon themselves] killing and/or trapping thousands of people inside. This is your INTERNAL DISASTER. You know more than you can handle will be hurt and or dead. What do you do? You are the head of the INTERNAL DISASTER MANAGEMENT TEAM. When a disaster happens INSIDE and enclosed place with lots of people, you help the people that are least hurt first. The reason being, so that they can possible help you, with the other survivors or you have very little time and you know you can move the victim and they have a chance to survive. In an INTERNAL DISASTER help and survival are KEY.

How does this differ from a disaster from which they are now coming to your hospital? Now, we take all the people from the World Trade Center and now, they are start coming to your hospital. Of course, now you are over loaded. It is up to you as the triage nurse NOW to see the most traumatized person FIRST. The rest can wait. Once they are at their destination of medical care, the gear shifts, you help the more tramatized patient first to ensure their chances of survival.

An EXTERNAL DISASTER can also be known as a NATURAL DISASTER in some cases. This involves a disaster that occurs outside the hospital as well such as a plane crash, or a train wreck ect. To summarize the three types of disasters: an INTERNAL DISASTER is a large number of people wounded/hurt/dead in an enclosed place be it inside or outside. [ie: 9/11 with the explosion of the twin towers in New York or the Pentagon in Washington]. An EXTERNAL DISASTER is a disaster away from a medical center and it is "man made". [ie: Plan crash, train wreck or casualties of war].

In a NATURAL DISASTER, say the San Diago Bridge collapses or there is a giant volcano ect. Still use the same rule as in the 2001 ect above. Help the people off the bridge [the least wounded] before the bridge collapses. The goal here is to save lives. You can not do anything about the people whose cars have already fallen into the ocean or for the people to whom the fire has already engulfed. Once, you get the people into a save distance, then you do the whole triage thing helping the most wounded.

Does that make it any clearer? Please continue to ask your questions. This is an important area of discussion. My goal personally, is not to answer the actual questions. You will never pass the nclex memorizing questions. We must understand CONCEPTS to pass the NCLEX.

Now, let us move on to delegating in terms of triage:

How do you prioritize in a disaster? Remember the word T-R-I-A-G-E. Trauma, R=respiratory, Intracranial pressure & mental status, An infection, GI-upper, Elimination-lower. In that order. Prioritizing, starting with trauma first and lower GI injuries last. You will not need to know how to tag for the nclex but I place this here so that you can understand the concept.

Triage is a French verb that means "to sort". The goal of triage is
to do the greatest good for the greatest numbers of individuals. This
is accomplished by having a system to quickly assess each patient,
categorize and prioritize them according to their needs. Be sure to
evaluate the hazards before entering an area to perform triage.
Triage should be initiated whenever there are more injured persons
than rescuers.

The four (4) triage categories and a description of their meanings

• Green is the lowest priority and is used for walking wounded or
patients who may not need to go to the hospital. Patients in this
category may have minor musculoskeletal or soft tissue injures. They
can wait for treatment and/or transport until all other patients have
been removed from the scene.

• Moving up the tag, yellow is the next category and is used for
patients who definitely need to go to a hospital, but not
immediately. These patients have injuries that are serious but not
life-threatening, such as burns without airway problems, major or
multiple bone or joint injuries, and back injuries without spinal
cord damage. These patients will be treated and transported after the
critical (or red-tagged) patients have been taken to trauma centers
or hospitals.

• The highest priority is red, and it is used for critically-injured patients with treatable life-threatening injuries or illnesses. This
might include airway and breathing difficulties, decreased mental
status, and uncontrolled bleeding. These patients will be treated and
transported from the scene first.

• The final category is black and it is used for dead and
unsalvageable patients such as someone in cardiac arrest. These
victims will be removed from the scene, but only after all of the
living/salvageable patients.

METTAGs in hand, you now begin the tremendous responsibility of
organizing the chaos. Simple Triage And Rapid Treatment, or START, is
a triage system that was developed in California in the early 1980s. It is simple and fast, requiring less than sixty seconds for each patient. It does not require any special assessment or diagnostic tools. EMTs do not need a blood pressure cuff, a stethoscope or even a penlight. The system provides for rapid life saving stabilization such as airway control and bleeding control, but excludes CPR.
A word here about cardiopulmonary resuscitation: CPR is not performed
in these situations because two or three rescuers would be required
to treat a single patient whose probability of survival (in the
chaos) is zero-to-none. On the other hand, those same two or three
rescuers could play an important role in treating five, ten, or maybe
even more patients.

How to Start
The first (and easiest) thing you must do is separate the walking
wounded from the other victims with more severe injuries. This can be
done by shouting slowly and clearly or using a bullhorn. Designate an
area for walking wounded and instruct anyone who can walk to get up
and move to that area. (Note: Some victims may be unwilling to leave
their friends or family members who are ill or injured; permit them
to stay as they can help you with managing the patient.) The theory
here is that if a person can walk, he does not need immediate medical
care. Green-tagged patients will not be ignored. Rather, they will be
further assessed and treated when all of the red and yellow patients
have been treated and/or transported and resources become available
to take care of them.

All of the patients in this area are considered to be "green tags."
Later you will return to the "green" area and "officially" tag them
but only after you have triaged the red and yellow victims. With this
green group in a separate (safe) location, you are well on the way to
being organized.

Evaluating the Remaining Victims
The next step is to triage the remaining victims. By evaluating
respiration, perfusion and mental status, you sort and separate them
into three categories which give the greatest priority to those
victims who are most critically injured, and have the greatest chance
of survival. Let's quickly review our color-coded tags:

• Red Tag: those victims whose injuries are life-threatening and
must be immediately treated and transported.

• Yellow Tag: those whose injuries will allow for delayed
treatment and transport.

• Black Tag: those who are dead or unsalvageable.

How do we make that determination? RPM.

R = Respirations

The first assessment is for presence and rate of respiration (RPM).
Is the victim breathing? If there is no respiratory effort,
reposition his head and reassess. If there is still no respiratory
effort, the victim is considered "dead/non-salvageable." Apply a
black tag and move on to the next victim.

What if he is breathing? Assess the rate. If the rate is above 30
breaths-per-minute, the patient is critical and requires immediate
care. (Remember from your EMT-B class that a respiratory rate above
30 and below eight breaths-per-minute (BPM) is not adequate to meet
the body's needs and may quickly progress to cellular death.) As
triage officer, however, you do not stop to ventilate this patient!
He is given a red tag and you move on to the next victim. You do not
need to complete any other components of the START assessment on this

If the patient requires simple airway maintenance (e.g. manual head
positioning), you will need to assign someone to this task. If no
emergency service personnel are available, remember that you have a
pool of human resources in the green tag area. If no one there is
available, you will need to improvise by placing something under the
patient's head/neck to keep the airway open. It should also be
noted here that airway maintenance might need to be done without standard
cervical spine precautions.
If the respiratory rate is less than 30 breaths-per-minute, move on
to the next part of the assessment process.

P = Perfusion

The next step is to assess for Perfusion (RPM). As you may remember
from your EMT-B course or core refresher, perfusion is the
circulation of blood within an organ or tissue in adequate amounts to
meet the cells' current needs. If the body lacks adequate
or circulation, cells, tissues, and organs will die.

How do we assess perfusion in victims at an MCS? Check for the
presence of radial pulses. However, note that we are not concerned
with a pulse rate at this time. If the patient has no radial pulses,
he is critical and in immediate need of care. You apply a red tag to
the patient and move on to the next patient.

If there are no radial pulses, there is no need to check for carotid
pulses. Why not? If the patient does not have a carotid pulse, then
he will also have no respiratory effort, and therefore, would have
been triaged as dead/non-salvageable in the previous step. Recall
also that the presence of a radial pulse correlates to a systolic
blood pressure of at least 80 to 90 mmHg. If radial pulses are
present, move onto the next assessment.

There is one other assessment-finding related to perfusion status
which must be mentioned here: severe bleeding. Uncontrolled bleeding
is potentially life threatening and must be treated when found.
Again, you may have to improvise by using the cleanest piece of cloth
around which may not be sterile.

Do not forget your human resources available in the green area.
Delegate someone to maintain direct pressure on the wound and move on
to the next victim. Your job remains triage.

M = Mentation

The third and final assessment is for Mentation (RPM) or mental
status. A patient who is either unconscious, or conscious but unable
to follow directions, is critical and requires immediate care. You
will apply a red tag to this patient and move on to the next victim.
If the patient has a normal level of consciousness and can follow
directions, he is not in immediate need of care and is triaged as

As soon as a patient meets any one of the criteria for triage as
critical/immediate, you should apply a red tag, delegate someone to
provide rapid treatment (e.g. maintain an airway or control
bleeding), stop any further assessment and move on to the next

Any patient who makes it through all three assessments, without any
findings that would result in triaging as critical/immediate, is
given a yellow tag. No triage system is 100% fail safe. It is,
however, reasonable to assume, that a patient who cannot walk, but is
maintaining his own airway, breathing at a rate less than 30 breaths-
per-minute, perfusing radial pulses, has no sign of uncontrolled
bleeding and follows commands, is in need of medical attention at the
hospital, but can wait until all of the critical/immediate (red tags)
are removed from the scene.

Secondary Triage

Let's quickly review how START integrates with the METTAG system.
• Anyone who gets up and walks to the designated area is given a
green tag (may not even require hospital care).
• Anyone who is not breathing is given a black tag (dead/non-
• Anyone who fails one of the RPM assessments is given a red tag
• Anyone who cannot walk but passes all of the assessments is
given a yellow tag (delayed).

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