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Sunday, August 8, 2010

Triage Systems for Crisis: Making the Hard Calls in Life or Death Situations, by Kathy S.

Wounded arriving at triage station, Suippes, F...Image via Wikipedia
While I have been searching the web for preparedness information I have yet to see much mentioned of the most emotionally and physically draining process of triaging the casualties produced during a crisis event.  While we are busy with our stockpiling of food and materials, weapons, and seeds, we seem to have left out some of the really horrific tasks we may be called upon to perform. Even if we are fully engaged as “preppers” we don’t take time to understand the implications that illness and injuries will have upon our lives in drastic times. Most of the general population has never been placed in a situation that requires triage, nor have been placed in a situation where they personally may need to make decisions quickly and efficiently. Those decisions may mean refusing medical assistance to victims. There may come a time when there are no emergency rooms, emergency response teams or 911 at our beckon call. Who will call the shots in a disaster?  Who decides who lives and who dies?  Could you manage a triage event within your own family?

In the general population, there are but a handful of trained medical personnel.  These are doctors, nurses, emergency medical technicians, police and fire personnel and even veterinarians.  In large scale events, such as earthquake, flood, and severe storms, these persons are usually at the forefront of helping others.  Remember too, that in any given scenario, some of these people will have been killed or are injured and will not be available to perform their duties. Others will be totally focused on their own families and will simply not respond to the calls for help.  In times of disaster, there are really very few heroes.
The act of triage will vary greatly depending on the type of incident and the scale of the disaster.  The larger the scale of the incident the smaller the circle of care the responder can provide. The assessment of the victims also becomes shorter and the criteria you use for estimating survival must become much more precise. You, as the responder, may have no more than a few seconds to view the casualty, make a determination of survival chances, and move on. The most important issue to remember is that in triage the victims are prioritized from the least to most sick or injured. This is exactly opposite of all of our usual thinking in respect to medical care, but is the only way to assure the survival of the largest number of victims.  This rule applies to a mass casualty event or dealing with your own family members.
At first glance, this may seem very cruel.  However, in a major disaster our thinking must turn to the fact that if we assist the extremely injured we will likely prolong their suffering while using medicine and supplies in an effort that is doomed from the beginning.
The type of event will determine the magnitude of the triage. There is a big difference in how you need to respond depending upon the circumstances you are facing. Most of the time, we are likely to find ourselves in a limited field of action such as a traffic accident, a localized fire or flood, or weather related event.  In a first responder situation you can make your initial reactions removing people from any immediate danger.  This you can apply to all the victims you encounter.  If you know that additional help is on the way then continue to provide comfort and emotional support but refrain from anything else but life saving techniques such as CPR or putting pressure on a major bleed. When help arrives, relinquish your role immediately. That, by the way, is not always easy to do as we can emotionally take ownership of a situation very quickly.
If you find yourself in a larger scale event you must switch your mind set to who can you help that will ensure the greatest return  (largest number of survivors helped) for your efforts. This is the area that requires you to do some advance mental planning. If you have never seen a casualty producing event, know that your senses will be assaulted at every turn. The cries for help will be in your ears constantly.  You may encounter violence from others as they demand you attend to their victims.  You must remain calm as self detached as you organize your mind.
There will be very specific issues that will help you prioritize your care.  First identify any others with any medical expertise.  If they are more prepared, relinquish authority to them and follow their orders.  If you are the one making the call, ask for help from any of the ambulatory persons in your immediate area. Assign them the task of separating the people into groups as you assign the victims a number beginning with the least injured and most responsive, as you categorize the victims. You will use the numbers one through five to determine level of survivability. If you have something to mark the victims like a ball point pen or marker of some kind take it with you.  If you must, you can mark the victim in their own blood. Make sure you have the victims out of any other harms way. As you encounter each person, visually scan for the following.  Are they breathing? Are the conscious?  Are there any large arterial bleeds going on?  You can tell if bleeding is arterial if the blood comes out in spurts instead of a constant flow. Are there large open or gaping wounds or extremities missing?  Can they move their extremities? A person is usually moribund (dying) is they are not breathing well, have weak irregular pulses, have mottled skin starting at the feet and legs, are cooling rapidly, and are not conscious or are losing consciousness, and or are bleeding out. These unfortunate folks receive the category five designations.  In all but extraordinary situations these folks are the least likely to survive for long. Place the designation number somewhere on their skin where it can be readily seen by others, usually the forehead. Move on.  The process continues for each victim.  Those assigned to move persons into the groups one through five should continue to do so.
 There will be a set of rules you can follow to help make decisions.  If breathing or cardiac function is severely compromised, there are obvious severe head injuries with loss of consciousness, brain tissue or spinal fluid coming from a wound, ears, or nose, or the inability to move body parts from the neck down, if there are chest wounds that make a sucking sound with each breath, or abdominal organs can been seen you must assume that these persons need more care than you can provide.

The next category four, the person will display some consciousness, is breathing on their own with some distress, have a irregular heartbeat, have bleeding that is likely to respond to direct pressure over a long period of time, have no organs visible but they complain of severe abdominal pain or have abdominal swelling and great tenderness, they can respond to you at least a little, can move at least some of their extremities upon command, or have broken bones protruding from the skin.  These people have a poor long term survival probability, but if advanced care should become available might survive.
 Category three will appear injured and may have multiple wounds, but they are conscious and can move upon command.  Breathing and heartbeat are not compromised, they may have broken bones, but they are closed fractures that help limit infection. If wounds are covered they will stop bleeding with pressure.  They do not complain of chest or abdominal pain. They may appear confused or combative.
The category two victims are alert and responsive, may have significant number of smaller wounds that respond to pressure dressings or splinting, but have no major compromise to breathing or circulation and can in most circumstances move by themselves.  They may be more physically and emotionally reactive due to their heighten adrenaline levels and may pose more danger to you or themselves because they really don’t understand they are significantly injured.

The highest survivability group, category one, will appear banged up or a little hyperactive due to adrenaline, but has no compromise in mobility or thought processes.  These folks may just need a little time to physically and mentally regroup before being able to move on their way.

Once the victims have been categorized, the process of treatment can begin.  The least injured are cared for, starting with category one and moving forward.  Patch folks up and move them to a more secured location if possible.  Try to keep them from the dead and dying, especially if they are agitated.  If family members are kept together they may be able to comfort one another, but if faced with a dying family member may pose a real problem with demands for care you can not provide.  They might have to be forcibly removed from the area. As you balance the care you give with the supplies you have, it may become necessary to re-score patients. People with significant internal injuries will deteriorate as their adrenalin levels become depleted. If water and food are not readily available even the moderately injured may fail more quickly. Always use your supplies working from least injured or sick to the worst.  It will not be easy and you will make mistakes.  Do your best and move on.

In the event of a medical disaster such as a pandemic, most of us will become more and more isolated as the contagion progresses.  The basic triage rules still apply.  Use what you have for the least sick, isolated the sick people from those who are not yet showing signs of illness.  Allow a limited number of caregivers to the ill. Remove the dead quickly and dispose of bodies rapidly.
Most of us will never face the prospect of a large regional disaster, but we should all have worked out plans in advance.  This includes care of the dead and dying.  Not all victims die quickly or easily.  If you have never seen a death, you may be horrified at what you experience.  As a registered nurse, I’ve witness many deaths and though there are similar physical traits that can be recognized as landmarks, the time it takes a person to actually expire varies greatly.  It will depend on the nature of the injury or illness, the physical strength of the individual, and the will to live.

For the most part, when we are mortally ill or wounded we separate from life in various stages.  Violent injuries and severe contagion may accelerate the process.  Severe loss of blood, injuries to the brain, lungs, or heart normally cascade through the death process more quickly.  A person who is dying will gradually begin to lose contact with people and surrounds through loss of consciousness. They may babble, groan, experience restlessness associated with air hunger.  They may sigh frequently or gasp.  The body begins to shut down vascular flow to the extremities in order to preserve the brain and core organs.  This will produce a blue or blue-black mottling of the skin on the arms and legs. A person may, for a while, go in and out of consciousness and question what is happening to them.  Be honest. Tell them that they are dying but that you are with them and will continue to be with them. Ask them if they want spiritual care.  Pray with them. As death approaches most people if told become more inward and self-oriented. Even if lied to about their status, most people know they are dying.  If lied to they become distrustful and fearful. Even if not easily roused, keep talking to the person, as hearing is the last physical sense to cease functioning and you can provide great comfort.
Once comatose, a person may display distressed breathing patterns.  The pattern called Cheyne-Stokes may occur.  It is a pattern of repeating periods of rapid breathing that slows and then stops momentarily then proceeds with a gasp for air. As this pattern worsens, the person may have a throaty rattle when they breathe.  During this time, it can be very distressing for the viewer, but remember the person is not aware in any way.  When death occurs, there may be some spasmodic movement of the extremities, the chest, or the throat. These are reflexive in nature and the person is not in distress.  When the heart stops, the person will likely have a bluish gray cast to the skin.  If the eyes are open, the pupils will dilate and become unresponsive to light and become cloudy.
The last important items to think about are the care of the dead body.  As we have seen in photos from Haiti, that in a regional event, the number of dead may preclude the normal death rituals a society performs.  As we saw bodies flung onto trucks and then unceremoniously dumped into mass graves, our spirits were assaulted. These sights will be all too common if mass disaster occurs.
The way to dispose of the dead in an attempt to prevent the spread of disease and those are cremation and mass burial.  In a SHTF situation we must understand that it takes energy to do either task.  If confronted with the responsibility what should you do?  How will you choose the method?  How much energy will you be able to expend?
If it is only one body, say of a family member or neighbor, a traditional ground burial is probably the most energy efficient and emotionally suitable. The body should be buried a minimum of four feet below ground, not within 150 feet of your ground water source.  The time it takes to dig a place big enough is measured in hours.  If in the winter it could be days depending on the weather and ground conditions. The more help you have the better and faster the job will go.  If you plan a cremation, you must have a large supply of wood.  But in a TEOTWAWKI event there might not be enough fuel to spare. [So cold storage, followed by burial after the ground thaws would be logical.]
We must be able to face the responsibilities of making hard choice of life and death. Our family’s survival may rely on our abilities to function in the most distressing situations with a calm head and prepared spirit. If you are called upon to triage an event remain calm, put your plan into work, and don’t look back. 

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