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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waiting to be seen

Sunday, November 15, 2015

Making the decision to visit the ER is never taken lightly. Aside from obvious injuries that need attention, think lacerations or broken bones, most other illnesses have the undercurrent of disaster. Is the chest pain a heart attack? Does my child have appendicitis? Is a tumor causing my headache? And worse yet, it’s the waiting, first in the waiting room and then finally being placed in an actual exam room, only to wait again. And then disaster strikes, but you don’t know about it.

Most hospital ERs, are staffed with doctors, nurses, lab and x-ray technicians, housekeeping and cleaning people, for the expected rush of patients that happens at different times of the day and different days of the week. Planning for the surge of patients on a weekend evening shift is no different that retail stores who prepare for Black Friday or Christmas Eve, expecting more customers. Hopefully, in the ER, the number of people working is enough to care for the number of patients walking in the door.

All that planning goes away when disaster strikes. In the Paris terrorist attacks, 129 people died (at the time of this column) and more than 350 people injured with almost 100 critically. These victims needed emergent care and many needed the services of a trauma team to provide care. But think of that number of patients. There are 13 hospitals in Paris, according to the Paris Tourism Office. Not all are capable of caring for these victims, but if each hospital took their fair share,  the “regular” emergency patients would be bumped and their wait to be seen extended. To be fair, hospitals have disaster plans and their whole staff would be mobilized to care for patients, both from the disaster and for those “routine” patients whose emergency visit was unlucky enough to happen at that same time.

People are very tolerant of waiting when a disaster happens. They see the carnage and they hear the news. Patients are less tolerant when waiting happens and they don’t know why. Many hospitals have waiting rooms that cannot see the ambulance bay and the steady stream of patients being dropped off. That said, arriving by ambulance does not necessarily let a patient jump the queue. Triage happens every time a patient gets touched, whether it is the person who walks in the ER door, or who arrives by ambulance, or who is found to be sicker than initially thought. First come, first serve is not the ER mantra.

A rush of patients doesn’t need to be the cause of the patient flow in the ER coming to a halt. It may be that the inpatient beds in the hospital are full and patients who need to be admitted from the ER have no place to go. They may be boarded in their ER bed, causing a logjam and the next patient up in the waiting room has no place to be seen. Or it may be there is one significantly ill patient that takes the time of many of the ER staff, leaving others to wait. Or it may be that a death has caused a doctor and nurse to spend time with a grieving family. Or that death caused the same doctor and nurse to take a few minutes to regroup emotionally for the next patient.

There is some sadness when hospital administration decides to use waiting times to lure patient to the ER by posting “real-time” waits on billboards or websites, or promising a patient will be seen within a certain amount of minutes. All those promises go away when a chest pain patient arrives at the door. To meet national standards of care, an EKG needs to happen within 10 minutes and if a heart attack (myocardial infarction) is happening, they need to be in the heart cath lab in less than an hour. If a stroke patient presents, they have less than 4 1/2 hours from onset of symptoms to get treatment and save their brain. Children with suspected meningitis need antibiotics immediately. A trauma patient who is in shock gets bumped to the head of the line. The waiting time listed on a website is old news if a disaster arrives before you do.

Waiting to be seen is difficult in the ER because of lack of control. There is the worry of the unknown about a headache or belly pain. There is the lack of choice as to what doctor or nurse will be providing care. And there is often a lack of information provided as to why the wait is happening in the first place. It is of little consolation to hear that somebody else is more sick or injured; there can be some perverse comfort in knowing that somebody else has it worse, but in the end, there is no joy in waiting.

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