Triaging

[medicnick83]

Hi all,

Question;

You arrive at scene and your paramedic tells you to triage the patients (let's just assume there are quite a few!)
What 8 injuries would make them a P1 (Priority 1)

Go...

 

[Veneficus]

without knowing something about the patients and the resources, I am not sure this question can be answered intelligently.

 

[DesertMedic66]

Hi all,

Question;

You arrive at scene and your paramedic tells you to triage the patients (let's just assume there are quite a few!)
What 8 injuries would make them a P1 (Priority 1)

Go...

When I am triaging I am not looking at injuries. All I look for are resperations, cap refil, and mental status.

Over 30 resps per min = (P1) (Immediate in my system)
Not breathing at first but with a reposition of their airway start breathing = (P1) (Immediate)
Cap refil of over 2 seconds = (P1 Immediate)
Altered mental status = (P1 Immediate)

Anything else gets marked Delayed, Minor, or Morgue.

 

[Veneficus]

When I am triaging I am not looking at injuries. All I look for are resperations, cap refil, and mental status.

Over 30 resps per min = (P1) (Immediate in my system)
Not breathing at first but with a reposition of their airway start breathing = (P1) (Immediate)
Cap refil of over 2 seconds = (P1 Immediate)
Altered mental status = (P1 Immediate)

Anything else gets marked Delayed, Minor, or Morgue.

depending on the resources or the totality of other patients, the last 3 can instantly go from p1 to expectant

They may also be forced to become delayed.

 

[medicnick83]

without knowing something about the patients and the resources, I am not sure this question can be answered intelligently.

Bus accident (for example)

Your paramedic arrived first, maybe 30 seconds before you did, he is now telling YOU (BLS) to go and triage patients that are considered P1's

 

[DesertMedic66]

depending on the resources or the totality of other patients, the last 3 can instantly go from p1 to expectant

I must be a little out of it today. I don't understand what you said lol.

 

[Veneficus]

I must be a little out of it today. I don't understand what you said lol.

Depending on how sick your other patients are, obvious injuries which significantly amplify the morbidity of the last 3 criteria in your post, or a lack of responding/receiving resources, not everyone who meets your criteria may get to be priority.

Simple Example:

If you have 4 priority patients and 1 ambulance, it may work out where one or 2 instantly become delayed or expectant.

 

[medicnick83]

Depending on how sick your other patients are, obvious injuries which significantly

No, just give a break down what YOU think the 8 types of injuries would be to classify a patient being given the P1 status...

If we had to go on, I could say, more ambulances can be called... but ya... lol! :rofl:

 

[DesertMedic66]

They will still be under the P1 (immediate) even if we don't have the resources. We will transport the most critical of the P1s first.

For our system the classification of the patient does not change based on the number or resources. If we have a patient who can't maintain his own airway and a patient who is unresponsive but is breathing fine then they both get marked P1, but the patient with the breathing issue will be transported first.

If we have a P1 patient that we mark down to a P2 (Minor) that creates a problem for the hospital. We call the hospitals at the start of the MCI. The hospital tells us how many P1, P2, P3 patients they can take. If we send in a patient who we say is P2 but is really P1 by our standards then the hospital gets screwed and so do we.

 

[Veneficus]

No, just give a break down what YOU think the 8 types of injuries would be to classify a patient being given the P1 status...

If we had to go on, I could say, more ambulances can be called... but ya... lol! :rofl:

That is my point, if there are unlimited resources, then everyone is priority 1.

If there are limited resources, that changes who is priority 1.

I have been at this EMS game a while, triage is not an if:then criteria, there is an art to it.

There is a reason why in many use the convention that the most capable care provider be the person doing the triage.

 

[Veneficus]

They will still be under the P1 (immediate) even if we don't have the resources. We will transport the most critical of the P1s first.

Really?

So if you have an 86 y/o who can't maintain his own airway, has a GCS of 3, and has a delayed cap refil (because he is lying in a pool of his own blood)

Does that make him the most critical p1?

Because as far as I am concerned, he is dead in a mass casualty incident where I have to choose who gets sent to the hospital first.

 

[DesertMedic66]

Really?

So if you have an 86 y/o who can't maintain his own airway, has a GCS of 3, and has a delayed cap refil (because he is lying in a pool of his own blood)

Does that make him the most critical p1?

Because as far as I am concerned, he is dead in a mass casualty incident where I have to choose who gets sent to the hospital first.

He is marked as P1 If he is still breathing. If he stops breathing, and a head tilt chin lift (jaw thrust) doesn't make him start breathing again then he is marked as Morgue.

 

[mycrofft]

"Question;

You arrive at scene and your paramedic tells you to triage the patients (let's just assume there are quite a few!)
What 8 injuries would make them a P1 (Priority 1)

Go..."

Oh, about this long*.....:huh:

It isn't that simple. You have to think of these factors:
1. What are the victim's acute problems?
2. Know of any standing medical issues (meds, illness, allergies) of the victim?
3. How likely is it that this person will live through transport, if transport time is known? (If there is limited transport and distance/time is a factor).
4. Are there other victims who will survive that time/transport element but will succumb sooner than others?
5. And, as ongoing re-assessment is done, how is this victim doing?

SIDEBAR: 6. What can I do in the meantime to improve survivability and hence shift each victim's triage category?

Tests use simplified triage to try to impress how some conditions are more serious, all other things being equal and no other factors (never the case) , than others.




*Classic American koan:
Q: How long is a piece of rope?
A: About this long.
nyuk nyuk nyuk

 

[Shishkabob]

Priority 1 as in "Red" under START?

Does your agency not follow a uniform guideline, such as START?

 

[Medic Tim]

odd question. if you were a newbie first poster i would think it was a homework assignment you were looking for an answer to.

where I wor.k we use Start. so it depends on the pt not the specific injury for Red or P1.

 

[Veneficus]

If I can draw your attention to:

http://www.ncbi.nlm.nih.gov/pubmed/10159733

While this was initially meant for austere and major disaster type situations, I am sure I am not alone in discovering that in the modern state of healthcare, both in the US and abroad, total system resources are constantly stretched to maximum.

Most hospitals do not have substantial immediate surge capacity, like any other logistically challenging crisis, in order to mobilize in hospital resources it takes time.

There are also 2 aspects of MCI response that doesn't often occur to EMS providers.

First, the hospital must still deal with the the normal patient load that comes through the front door and is admitted by other physicians. (in various states of need)

Second, in disasters involving dozens of people or more, the victims do not all sit around and wait for EMS resources to properly triage them.

This really puts a hurt on hospital resources when there are a certain number of critical patients being delivered by EMS in the back door, with as many or more critical patients coming through the front door. (been there done that)

At the very least it takes a physician out of the mix to triage the disaster scene that has simply migrated from its origin to the hospital.

I have done some trsaveling in my healthcare career, I can tell you that most internal and external disaster plans for hospitals will not last even one second during an actual event before they completely break down.

They simply make assumptions or fail to account for realities. For example, equipment and facility access. EDs are usually closed departments, which means people without appropriate badges can't even get in. Once in, they have no idea where equipment is or procedures for taking care of emergent patients in an emergent situations. It basically turns these practicioners into extra hands or transporters. But at a cost of reducing the effectiveness of flow.

(that is just one example, but I could fill a book with them)

So when you show up at a scene as an EMS provider, you must be aware of the capabilities of the total system. What resources are where, how you utilize them, and most importantly, conserve them.

For example, it is pointless to send a red priority patient suspected of a head injury to a hospital with a CT scanner, but without a neurosurgeon. Even if that hospital claims they can take 5 red patients.

With system capabilities already taxed, the normal paperwork and requirements not practical, interfacility transport all but shuts down.

As if that were not enough, basic necessities of the people filling up the hospital become a problem. (restrooms, water, food, etc.) I can tell you I have not seen one hospital disaster plan that addresses this in any of my travels. Which means as time goes on into hours, people not cared for will get sicker, requiring higher levels of resources.

Another poorly thought out issue is hospital provider fatigue. When the pt surge goes away, the hospital returns to baseline patient load. Think of the consequences of that for a bit.

Also consider things like child care when whole families show up at the hospital with injured or ill parents but healthy children. Family members also like to go looking for each other at hospitals.

Remember, I am not talking about a major earthquake or something. Maybe 20-30 victims of various seriousness.

So when you send your red (priority) patient to the hospital, what are the likely resources needed? the ED? A surgical theatre? an ICU bed? All of those things?

What is the chance the patient will survive or even be permitted to begin their treatment?

In my earlier example, you think the 86 y/o unable to maintain airway, GCS 3, heavy blood loss guy is going to be taken to an OR? Blood equal to his volume or more expended on him? Will he make 30 or so days in the ICU after?

We are not even talking quality of life, just mere survival to downgrading.

Now I know many EMS providers live in their own little world, but regardless of the type of EMS agency you are, who owns or pays for you, EMS is part of the healthcare system.

The decisions you make, affect people and patients you may never see or hear about during normal operations, but especially in an MCI.

There is more to being professional than pay and status. It requires the ability to think about more than just your 1 patient at a time. It requires you to be part of the healthcare team.

Just as I encourage you not to be a simpleton with individual patient care, don't be a simpleton of MCI response.

Remember, large incidents are not mitigated by individual treatment, they are mitigated by logistics.

Be a part of the team and come play with the al- stars instead of the little league.

Think big. Master your system. Be more than a moron who only understands a 3 criteria color coding system for driving people around.

My 2 year old could probably assign color tags on who should go to the hospital first. (before you think that is an exaggeration, she has her own stethoscope, paramedic texts(so she doesn't trash the good books), and loves to look at the pictures in both my neonatal and pathology texts)

I expect more from EMS providers.

 

[DesertMedic66]

We use the START method with the terms "30-2-can do" to base all triage off of. This keeps it equal among providers as more arrive on scene. It takes out any personal bias or beliefs. If the patient is still breathing then they get a chance. What you see as a patient who may survive might be different then what someone else may see.

We have one hospital that will pretty much try to deny any trauma patient we bring them, so for normal days we don't take any kind of MVC patients there. If its an MCI then we don't have a choice and we will take them there. If we are on the edge of our response area then the closest hospital is 1 hour away. The next 2 closest hospitals are probably 20 mins apart. After that it's a drive before we can get to the next hospital.

We have had MCIs before and they all get treated the same way. It's not a perfect system but we work with it and make it work.

 

[Ewok Jerky]

We use START triage to determine priority but our protocols have us utilize med control for destination decisions....works very well for your average mci. But we also have a level 1, 3 level 2s, and a level 3 within 30 miles

 

[Veneficus]

It is things like this...

That remove any doubt that EMS will never be a profession in the US.

I know, you are just doing what you are told.

You probably even believe in it.

So I must...

We use the START method with the terms "30-2-can do" to base all triage off of. This keeps it equal among providers as more arrive on scene.

Yes, equal at the lowest common denominator. At that level of simplicity, all it means is transport everyone, you are not capable of triage.

It takes out any personal bias or beliefs..

No it doesn't. It only looks that way on paper. What's worse is that since not everyone always realistically has a chance, the shotgun approach takes away chances from people who do to waste resources on those who don't.

Absolutely nothing in START takes away provider bias out unless subsequent providers can retriage and downgrade patients.

With respirations as perhaps the most misinterpreted vital sign among providers, I also doubt its accuracy, and therefore usefulness.

If the patient is still breathing then they get a chance.

No they don't, they get a ride.

A ride and a chance are not the same thing. Especially from a hospital that doesn't normally take trauma.

That is the very reason trauma centers were developed. The community hospital that mandates a physician be current in ATLS doesn't make a trauma provider, much less expert.

The very crux of ATLS is to recognize the need and send a patient to an experienced provider who actually knows what they are doing.

It has long been known and taught in EMS that it is better to bypass the closest facility for the most appropriate. That very same principle is not lost in an MCI. If you take a patient that needs something specific to a place that doesn't provide it, all you did was waste that patients time and chance.

They would be no worse off tossed in a PD cruiser or POV than what your EMS system is doing for them. Amateurs...

What you see as a patient who may survive might be different then what someone else may see.

That is the point. Triage requires knowledge, skill, and experience. It means making a decision and acting on it. The person who makes the decision takes responsibility. That accountability is not simply pawned off as "procedure" or "giving everyone a chance," that is the belief of fools.

An appropriate and skillful triage provides the best care to the most people. Not the lowest possible care to all people.

We have one hospital that will pretty much try to deny any trauma patient we bring them, so for normal days we don't take any kind of MVC patients there. If its an MCI then we don't have a choice and we will take them there.

Why not just take them to a doctor's office?

When a facility tells you on a daily basis they don't have the expertise or resources to handle a certain patient population, what the hell would possess you to take those same patients there in a disaster?

"Better than nothing?"

Guess again. All you did was prolong them getting the help they need. Because it was too much of a burdon on your "system"

If your transport units clear the scene and the patients are still not getting the best care, requiring even more resources to fix the problem that you do not partake in, I hope you do not call that success.

That is another example of something that doesn't require paid or even volunteer EMS providers.

If we are on the edge of our response area then the closest hospital is 1 hour away. The next 2 closest hospitals are probably 20 mins apart. After that it's a drive before we can get to the next hospital.

Even more reason to have appropriate and effective triage ability and not some half-*** cookie cutter procedure.

We have had MCIs before and they all get treated the same way. It's not a perfect system but we work with it and make it work.

I am sorry to hear that. Truly.

Please don't think of this as a personal attack but as an outside look on an imperfect system that you are simply submitting to.

I know you didn't create it, from what I see here, I am confident you don't have much voice in shaping it, but I would caution you against true faith in those who did.

For they do not seek excellence. They seek only to be "good enough."

I offer such people no quarter or indulgence.

 

[EMSLaw]

If you have 4 priority patients and 1 ambulance, it may work out where one or 2 instantly become delayed or expectant.

Or all four, because quite honestly, the first ambulance on scene at a MCI isn't realistically transporting anybody anytime soon. That's what the other units responding will do.

Your example of the 86 y/o with severe bleeding does point out neatly where the START system breaks down. Even among your immediate/priority 1/red tag patients, there are some that are more likely to have a good outcome (let's define that as 'walk out of the hospital' for the time being) than others.

It's not a first-come/first-served proposition. We're supposed to be doing the most good for the most people with the limited resources at hand.

However, I will point out that START triage is designed to be applied by people with limited to no medical training - theoretically, I should be able to hand a firefighter or police officer a package of triage tags and send him to work. For what it's intended to do, it functions adequately. It probably isn't adequate for much beyond that.