START

Document Sample
START Powered By Docstoc
					        Simple Triage and Rapid Treatment
                         Immediate




              Patients               Delayed




                         Deceased




John P. Frey, LP
                                 Objectives
                  Define START and MCI
                  Identify the need for START
                  Learn the START Algorithm
                  Learn how to effectively use START




           Immediate



Patients               Delayed



           Deceased
               What Problems Might We Find?




           Immediate



Patients               Delayed



           Deceased
                                 What is an MCI
                   An event that produces more patients
                       than you have medics
                   Produces minimal casualties but has
                       unusual events surrounding the
                       incident
                          HazMat, Rail, Aircraft, Marine

                   Effects local hospitals ability to
                       adequately treat patients
           Immediate



Patients               Delayed



           Deceased
           Elements of an Command System
                   Unified command
                   Limited span of control
                   Clear chain of command
                   Line and staff functions
                   Intelligence gathering
                   Flexibility


           Immediate



Patients               Delayed



           Deceased
            Incident Command System (ICS)

                  ICS is a system of establishing command
                  and control of an emergency incident

                                        Command



       Triage                    Treatment    Transport     Staging




           Immediate



Patients               Delayed



           Deceased
              Qualities of a Great Commander
                  All knowing
                  Forceful, yet sensitive
                  Totally calm under fire
                  Likes dogs and small children
                  Free of impure thoughts
                  Brave, clean, honest, trustworthy


           Immediate



Patients               Delayed



           Deceased
                                 So..Who’s In Charge?
                   First Responder
                   EMS
                   Supervisor
                   Line Officer
                   Chief
                   Governmental Official

           Immediate



Patients               Delayed



           Deceased
              First Responders Responsibility

               One member becomes
                   “Command”
               Other members starts the
                   Triage process
               Start calling for any additional
                   resources that you think you
                   will need

           Immediate



Patients               Delayed



           Deceased
                                    Triage


                    French for “sorting” or “to sort”
                    A process for determining who to
                        treat and transport first in the case
                        of a multi casualty incident (MCI)
                    Refined during the Vietnam
                        conflict by military medics


           Immediate



Patients               Delayed



           Deceased
                                 What is START?

                 START is an acronym for Simple Triage
                         And Rapid Treatment
                       It is a simple step-by-step triage and
                       treatment method to be used by the first
                       rescuers responding to a multi casualty
                       incident. It allows these rescuers to
                       identify victims at greatest risk for early
                       death and to provide basic stabilization
                       maneuvers
           Immediate



Patients               Delayed



           Deceased
                                 Why START?


                    Medically responsible
                    Easily learned
                    Easily remembered
                    Clear-cut decision process
                    Relies only on BLS skills


           Immediate



Patients               Delayed



           Deceased
                   3rd Law of the House of God


       In cases of cardiac arrest (or triage), the first
           thing you do is check your own pulse!




           Immediate



Patients               Delayed



           Deceased
                                 Your First Action

             If you can walk, go stand over there!

             All of Ya’ll, go over there! (Texas version )




           Immediate



Patients               Delayed



           Deceased
                                 The Next Step

                    Take a DEEP breath
                    Ensure that your scene is safe
                    Start to triage all patients that
                        were unable to move
                    Spend about 60 seconds/patient
                    Put triage tag on and note group
                    Move to the next patient
           Immediate



Patients               Delayed



           Deceased
    START Algorithm (Airway/Breathing)

                                 RESPIRATIONS/VENTILATIONS



                  NONE
                                                                  YES


                 REPOSITION AIRWAY

ASSESS RESPIRATIONS/VENTILATIONS



           NONE                     YES             > 30/MINUTE    <30/MINUTE
                                                                     ASSESS
    DECEASED                     IMMEDIATE           IMMEDIATE     PERFUSION
           Immediate



Patients               Delayed



           Deceased
                START Algorithm (Circulation)

                                             PERFUSION




                              <2 SECONDS                 > 2 SECONDS
                                ASSESS                    CONTROL
                             MENTAL STATUS                 BLEEDING

                                                          IMMEDIATE




           Immediate



Patients               Delayed



           Deceased
                   START Algorithm (Disability)

                                            MENTAL STATUS




                                  FOLLOWS                   FAILS TO FOLLOW
                                   SIMPLE                        SIMPLE
                                 COMMANDS                      COMMANDS

                                 DELAYED                       IMMEDIATE




           Immediate



Patients               Delayed



           Deceased
                                 Triage Tags (front)
                                   TRANSPORTATION OFFICER
                                   NAME______________________
                                   AMBULANCE _______________
                                   HOSPITAL __________________
                                   PRIORITY-1    2                    10945

                                   NAME

                                   AGE       MALE       FEMALE

                                   MEDICATION/TIME:

                                   ________________________________

                                   ________________________________

                                   ________________________________

                                   ________________________________

                                   ________________________________
                                                                      10945
           Immediate

                                         IMMEDIATE                    10945
Patients               Delayed

                                           DELAY                      10945
           Deceased
                                 Triage Tag (back)




           Immediate

                                    IMMEDIATE
Patients               Delayed

                                      DELAY
           Deceased
                          Other Triage ID Methods

                   Different tags
                   Bracelets
                   Duct tape
                   Survey tape
                   Marker on forehead



           Immediate



Patients               Delayed



           Deceased
                                 After Primary Triage


                    Move to secondary triage
                    Provide primary treatment
                    Complete triage tags
                    Call for necessary transport
                    Continue to reassess patients


           Immediate



Patients               Delayed



           Deceased
                                    Field Triage

                        Primary Triage (Triage)
                             Implement START
                             Immediate, life saving care

                        Secondary Triage (Treatment)
                             Document information on triage tags
                             Provide medical treatment

                        Tertiary Triage (Transport)
           Immediate         Transport patients

Patients               Delayed



           Deceased
                                 Example 1

                       57 year old female complaining of
                        chest pain. Respirations 24,
                        capillary refill 3 seconds,
                        responds to all verbal commands




           Immediate



Patients               Delayed



           Deceased
                                   Triage Tags
                                 TRANSPORTATION OFFICER
                                 NAME______________________
                                 AMBULANCE _______________
                                 HOSPITAL __________________
                                 PRIORITY-1    2                    10945

                                 NAME

                                 AGE 57    MALE       FEMALE X

                                 MEDICATION/TIME:

                                 ________________________________

                                 ________________________________

                                 ________________________________

                                 ________________________________

                                 ________________________________
                                                                    10945
           Immediate

                                     IMMEDIATE                      10945
Patients               Delayed



           Deceased
                                  Example 2

                   24 Year old male, with a 3’ pole
                       impaled through his abdomen,
                       respirations 28, capillary refill <2
                       seconds, responds to all
                       commands




           Immediate



Patients               Delayed



           Deceased
                                 Example 2 Tag
                                 TRANSPORTATION OFFICER
                                 NAME______________________
                                 AMBULANCE _______________
                                 HOSPITAL __________________
                                 PRIORITY-1    2                    10945

                                 NAME

                                 AGE 24    MALE X     FEMALE

                                 MEDICATION/TIME:

                                 ________________________________

                                 ________________________________

                                 ________________________________

                                 ________________________________

                                 ________________________________
                                                                    10945
           Immediate

                                     IMMEDIATE                      10945
Patients               Delayed

                                          DELAY                     10945
           Deceased
                                 Example 2 Tag (back)




           Immediate

                                      IMMEDIATE
Patients               Delayed

                                       DELAY
           Deceased
                                  Example 3


                       3 year old child with no obvious
                        injury. No respirations, capillary
                        refill 6 seconds, unconscious




           Immediate



Patients               Delayed



           Deceased
                                 Example 3 Tag
                                 TRANSPORTATION OFFICER
                                 NAME______________________
                                 AMBULANCE _______________
                                 HOSPITAL __________________
                                 PRIORITY-1    2                    10945

                                 NAME

                                 AGE 3     MALE X     FEMALE

                                 MEDICATION/TIME:

                                 ________________________________

                                 ________________________________

                                 ________________________________

                                 ________________________________

                                 ________________________________
                                                                    10945
           Immediate



Patients               Delayed



           Deceased
                                 Other MCI Concerns

                        What caused (or is causing) the
                         problem?
                        Medical Supplies
                        Communications
                        Transportation
                        Media Coverage
                        Crowd Control
           Immediate



Patients               Delayed



           Deceased
                 What’s Causing the Problem?


                    Was it an acute event?
                    Is it still occurring?
                    Are we in a safe area?
                    Is a chemical involved?




           Immediate



Patients               Delayed



           Deceased
                   Texas A&M Bonfire Collapse
                November 18, 1999
                2:30 AM bonfire stack collapsed
                150 people believed to be on bonfire site
                       at time of collapse
                As stack collapsed, all lighting was
                       pulled down leaving the area in total
                       darkness
                First Responders reported hearing
           Immediate
                       screaming in the darkness
Patients                Delayed



           Deceased
      First Responder Actions
 Immediate call for additional help
  with description of bonfire collapse
 Dispatch issued a MCI and paged all
  personnel as well as CSFD and BFD
  and Texas Fire Training Center
  resources. MCHD ambulances
  requested as well.
 Fire Department and TxDot light
  trucks were immediately called for
 Triage started by flashlight
             Triage Actions

 START was used immediately
 Separate Triage areas established
 early to isolate patients needing triage
 All site resources used the ICS system
 for unified incident command.
 Command was ultimately run by DPS.
 Texas Task Force 1 (FEMA) was
 mobilized for specialty rescue
 Mobile morgue was sent to site
As the Sun Came Up
              Final Outcome
 All recoverable patients triaged and
  transported in less than 1 hour
 Last bodies recovered about 20 hours
  after the collapse
 27 patients injured, 12 killed
 Investigative committees universally
  credited first responders with saving
  many lives
             So....How does this apply to me?
              Major incidents can occur
              First responders are generally involved in
                  these incidents
              Most responders face few large incidents
                  in their career
              Preparation is the key to successful
                  handling of these incidents


           Immediate



Patients               Delayed



           Deceased
                           START Card
WALKING WOUNDED - Walks               START Triage Steps:
and follows commands
                                      1. “If you can get up and walk,
                                      follow me”
IMMEDIATE - Respirations
greater than 30; capillary refill 2
sec's or longer; mental               2. Respiration
confusion or no response
                                             Perfusion
                                                       Mental Status
DELAYED - Cannot walk;
respirations less than 30; Cap
refill less than 2 sec's; responds
to questions                          3. “Thirty and two, can do”
DECEASED - Patient with no
respirations after one attempt to
manually establish an airway
              Front                                 Back
           Additional Resources

 The EMS Incident
 Management System,
 Christen/Maniscalco (Brady)
 START Training Manual
 Texas Department of Health
   http://www.tdh.state.tx.us/hcqs/
    ems/startman.exe
Questions