triage and sorting

Tuesday, May 22, 2018

Another week, another school shooting, this time in Santa Fe, Texas and another activation of a mass casualty response for the medical teams in the area. Aside from the police visible on the scene, the emergency medical response starts up. From first responders to paramedics and emergency department and operating room staff, people get ready to care for those who are injured. A successful response requires lots of players, but it all begins with triage and the unlucky soul who is the triage officer on scene.

There is a person, (sometimes a team depending upon the number of injured) whose job it is not to look after victims, but to decide about injury severity and survivability, and sort who is transported first to the hospital and who can wait. Remember M*A*S*H*? Hawkeye and Trapper/Hunnicutt would meet the arriving ambulances, pointing who needed to go to the operating room first. Now imagine having to see the victims in the field before the ambulances got there and deciding who needed to fly, go by ground or not go at all.

The triage doc’s job is to hand out color tickets that designate who is hurt and how badly, and whether survival is time sensitive. Poor sorting may cause a mismatch of resources. Trauma designated hospitals have staff and equipment geared up to care for the most injured, and that preparedness increases trauma survival rates compared to patients seen in community hospitals. Triage has to figure that out in just a minute or two at the victim’s side.

It’s not the triage doc’s job to care for people. It’s hard enough having the emotional strength to hand out the color tickets:

  • Red tags are used for the most critically injured whose survivability depends upon immediate transport and access to care.
  • Yellow are significantly injured and normally would be rushed back to an ER treatment bay for care if they showed up at the front door, but the victim is relatively stable…for now. They need to be watched closely as the first wave of helicopters and ambulances leave. Their yellow could turn red,
  • Green are the walking wounded. Though they may be in pain, cuts, scrapes, broken bones all can wait and often these patients are transported by buses to a community hospital for care.
  • White victims are fortunate. They aren’t physically hurt and don’t need care.
  • Black is bad. These patients have been killed or so severely injured that even with care, would not expect to survive.

There is some gestalt to triage but mostly, it’s assessing thvictom’s injuries and their vital sign:

Triage is hard. Tagging a patient and walking away to leave care to others is not what most medical people are trained to do. Triage is also fluid and patients are re-triaged, not only in the field if possible, but also when they reach the hospital. Literally in the ambulance bay, the Hawkeye/Trapper/Hunnicutt scene is played out and depending on the individual need, the patient is sent directly to the OR, the ER or ICU. Other parts of the hospital open for the expected walking wounded.

All this works well in urban areas where there may be an abundance of medical resources, but in rural area, where a small hospital. Remember the Humboldt Bronco hockey team bus crash in rural Saskatchewan that occurred at the intersection of two rural roads, 200 miles from major hospital. Distance from a large facility with all the bells and whistles, plus weather, plus patient stability will affect potential to survive.

Once up on a time, disaster drills were just drills and most hospital staff tolerated the inconvenience of having their routines disrupted to go through the response steps for an event that would never happen. It was all about preparing for plane crashes, factory explosions, and fires. The real world has changed that attitude. People in the trenches are paying attention. The shootings are real world disasters and the next one might happen next door.

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when you have to wait

Sunday, April 8, 2018

There is no word to describe the photo. Three survivors of the bus wreck that killed 14 of their Humboldt junior hockey teammates and their coach, holding hands while waiting to be helicoptered to a larger hospital in Saskatoon. Did they know that so many had died? Did they see the bodies, or did somebody tell them while they lay on the stretchers in the hospital? And who was that somebody? Who was there to help them hold hands while they waited. Teenagers with no family at their bedside.

Every hospital is required to have disaster drills that includes triage at the front end, sorting victims, and then making certain the hospital staff shows up at their designated spot. Like a life boat drill on a boat, once everybody gets to their spot, it’s over, everybody congratulates themselves on a drill well done and the day goes on. There is no part of the drill that involves breaking news to three teenagers about their friends and who lived and who died. And there is no drill that looks after those who cared for the victims.

Looking after patients who are extremely ill or injured is why most people work in the ER, providing critical care and making a difference in the first few minutes is what defines emergency medicine. There is a ying-yang to the adrenaline rush that comes during a patient resuscitation. Win the battle, the patient survives and the team celebration can last for the rest of the shift; lose and the patient dies, but there is no time for remorse or grief. The family now needs care and there is a waiting room full of patients, all waiting, some not so patiently. Winning makes it easier to deal with a frustrated waiting room but losing makes it much harder.

When the ambulance radio goes off with a trauma notification, everybody’s ears perk up. The trauma nurses hand off their patients to others to ready for battle in the resuscitation room. The ER docs try to plan care for their other patients when they will be drawn away to look after the soon to be arriving victim. The team gathers (lab, x-ray, respiratory therapy, pharmacy) and starts to prepare. But in the back of their minds, they want to know…where is the ambulance coming from… how old is the victim… and where is my family? Just checking.

Even with the best of care, some people die. Bodies are too damaged or too diseased, and death may be declared quickly, or it may take hours of care. The options for people at the bedside to process the unexpected death are limited. One can pretend that the victim wasn’t a real person becoming numb to events, or they may not be able to let go and disconnect the death they have just witnessed from their own life. When it’s a child who dies, it can sometime become overwhelming for the staff. The ability to pause for a few minutes and process what just happened is an important need for hospital workers, but that never gets practiced in a drill and not commonly in the real world. Time for reflection rarely happens because of the pressure to see a continuously filling waiting room.

Patients and family get frustrated when they have to wait, especially when they don’t know why. Newer hospital architectural designs insulate the waiting and treatment areas. In older buildings, people could see ambulances arriving, staff running to meet them and the noise of the care provided. Now, sitting in a quiet waiting room, the patient can only imagine doctors and nurses staff working at a leisurely pace with the urgency that they expect.

After a busy shift, and a less than polite patient or two, the ER staff have been known to gripe over a beer…the time to pause sometimes comes later than it should…and say things that they never would in front of a patient.

  • Can you believe the guy who complained that he had to wait for two hours? Doesn’t he have a clue?
  • We’re sorry that you had to but be glad that we thought you could wait. It means that somebody else was more damaged.
  • You had to wait because the doc was looking after a teenage trauma victim, and even though we did everything that we could for 45 minutes, he died.
  • The nurse and the doc had to tell family and sit with them until the chaplain came. The nurse stayed behind to talk about organ donation, while the doc talked to medical examiner and then had to go in back to change scrubs and coat because of blood contamination.
  • Meanwhile, housekeeping had to clean up the mess in the room. Central supply and pharmacy had to come down and restock so it would be ready for the next trauma patient.
  • So yeah, you had to wait and you’ll be seen when the doctors, nurses, techs and everybody else who makes the ER run, gets their heads together about what just happened because they have feelings and emotions too.
  • Welcome to the ER. now do you want to fill out your satisfaction survey?

By the way, there are three boys holding hands waiting for a helicopter, and somebody has to tell them that their teammates and coach are dead.




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