Prepping Trauma Medicine

8.] Triage


Note: for informational purposes only. This level of medical response takes time and specific training.

In emergent medicine with more patients than medical supplies, you must implement some system of triage. Over time and through necessity a fourth portion has been added to the Latin “Tri” for Triage (a French word for picking out and sorting.)

Triage is the process of sorting through a mass-casualty situation to identify patients that need immediate life-saving help, and to prioritize resources accordingly (both personnel and medical supplies).

A situation requiring Triage would be rare, and that’s why you need a plan ahead of time. A number of years ago there was a 30+ car pile-up on a mountain pass in Wyoming. The pass was foggy, icy, and snowy and it happened very quickly. In a situation like that, in addition to managing injuries, you also have to plan to avoid being hit by the 31st or 32nd vehicle coming over the pass, and also to treat against hypothermia. Hypothermia risk goes up if the patient has lost blood or has burns on a large portion of their body. I usually carry at least one “space blanket” but there are better insulated, packable blankets that don’t rip easily. Anyways, imagine that scenario, you’re with your family and you have some medical training. Remember the acronym M.D.I.E. or “Men DIE” – Minimal, Delayed, Immediate, Expectant. Here they are in more detail:

The four categories of Triage (They should call it Quattrage) and their purposes are:

Minimal (Color Green): “Walking wounded,” they are able to treat themselves or help you with others. No severe loss of blood or altered state of consciousness (concussion, etc). Their injuries may look like small burns, lacerations/cuts (easily bandaged), or small fractures (e.g. broken finger).

Delayed (Color Yellow): These have more serious wounds or injuries like long bone fractures (need to be immobilized to prevent damage to large blood vessels), deeper serious cuts, or impaled objects. These patients are hemodynamically stable, meaning they don’t need active fluid resuscitation…which means they’re not bleeding out right in front of you, but they do need to be treated for pain, etc. until help arrives. You can enlist the people in the Green category to help with these while your most qualified medical crew move on to more serious injuries.

Immediate (Color Red): Require immediate life saving intervention. You need to find and treat these patients NOW. Chest penetrating trauma, injury to airway, typically unconscious and losing blood rapidly. These get the tourniquet, airway intervention either an OPA or NPA (Oral Pharyngeal Airway or Nasal Pharyngeal Airway) and IV fluids if you have them.

Expectant (Color Black): Patient survival unlikely. They should be given comfort measures. For example, they sustained Severe internal bleeding you can’t stop, a severe injury to any vital area (e.g. a piece of rebar protruding from their upper left chest perhaps). In a vehicle accident, possibly if someone snapped their seatbelt and was thrown from the vehicle, that level of injury is so severe they may be dead before you get to them. Severe blunt head trauma and lack of a pulse in their wrist are a good sign you need to rush to the next patient who needs you to save them.

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Patient Assessment Steps

Scene Safety: First verify you’re not going to become another casualty before you rush out and try to help anyone.

Situation Dependent:

Vehicle Collision: Can you get to the patient without being hit by oncoming traffic? Is the vehicle on fire or about to burst into flames? Identify sharp edges, move carefully, be alert.

Shooting Incident: In a civilian mass shooting, quickly identify Distance, Direction, Description, i.e. How close are you to the shooter, what direction is the shooting coming from, identify how many assailants there are and what they’re shooting (e.g. pistol, rifle, crossbow, etc) In combat medicine this is where we have a different mindset and skillset than civilian trauma responders. We shoot back. In combat, the best medicine is superior firepower. Now if you just have a pistol and going up against someone with a rifle then you have to be very careful. Always move from cover to cover. Cover = a barrier that hides your body AND will stop the bullets coming in. This is a very bad situation, and there are volumes of things you need to be able to process in your OODA loop (Observe, Orient, Decide, Act). For this example, we’ll assume the rampage has ended, and the gunman has taken his own life. I can’t teach you how to take down a shooter in a blog very well but I suggest you look up ReadyMan, Vigilance Elite and follow them for advice on combat training. There are others, but I would recommend learning from Green Berets, SEALs, MARSOF (marine special operations), and Army Rangers. NRA courses are fine for basic marksmanship, but leave the react to contact training to men who’ve made an art form out of this.

There are many other situations that could come up that are more common but to list them all would be a full chapter in a book. So to shorten this, just maintain your personal safety when helping people. Step back and look at the big picture, identify the hazards, and quickly come up with solid solutions before trying to be a hero. If there’s an electrocution, for instance, a good solution would be to shut off the power before going in to help. Another thing to think about is who is around who can help you. Acting alone can be risky, you should get someone to watch your back.

ABC’s of Patient Assessment:

ABC stands for Airway, Breathing, Circulation. In order of things that will kill an injured person first, Airway is Numero Uno.

Airway/Breathing: I think of these two in one step. When I approach a patient, I’m talking to them noting quickly if they’re conscious or unconscious. If unconscious, put them in the best position to breath on their own, which is usually on their back and by doing a head tilt/chin lift

If you see the chest rising and falling, and can hear breathing noises move on to checking their pulse. If they’re not breathing, begin CPR immediately. You can learn how to do this easily and I recommend you take a CPR class.

Circulation: You want to do this quickly, if you don’t wear a watch, start wearing one. Because when you check a pulse, you can quickly do this by holding the correct position to feel the pulse, and count the number of heartbeats in 6 seconds, then multiply that number by 10 to get a good enough measurement to quickly establish an idea what’s going on with the patient. An unconscious patient laying down will likely have a pulse around 80. If there’s loss of blood, the pulse will easily be up around 120 to compensate for loss of blood. If there’s no pulse, begin CPR immediately.

In addition to pulse, I think of Circulation also in terms of finding/stopping the bleeding. Bright Red Spurting blood is Arterial Blood. If you see this, you need to control that first. This will end the patient’s life quickly if not treated. Apply direct pressure to stop the bleeding. Fashion a tourniquet or a pressure dressing to keep pressure on the artery and stem the flow of blood. A tourniquet should always be followed with a pressure dressing if possible. In the case of an accident you weren’t prepared for, you can use a piece of cloth, tying the knot directly over the wound and wrapping again tightly to press the knot into the wound. I’ll do a full post on handling bleeding. I also recommend you buy an Israeli Trauma Dressing. These are great pressure dressings that also have a chemical compound that will help the blood clotting process.

Treating patients where they are can quickly slow down the Triage process so remember this: You need to quickly assess all the patients in the shortest amount of time possible, to identify who needs Immediate help. Treat first the patients who are Immediately in danger of dying. Whether you have a lot of people injured (Mass-Casualty) or just one or two, get help, establish a casualty collection point (CCP). Have someone Call 911 Immediately. Have your other helpers bring the patients to you. Even better, have multiple people pair up and go out to collect the patients. If they come across someone who’s unconscious and not breathing, check the airway, assert that there is no Arterial Bleeding, and have your helpers start CPR and stay with the patient until Emergency Medical Services Arrive. Since they’re going to be busy with that patient, enlist other helpers to continue the process of collecting patients and bring them to the CCP.

Casualty Collection Point:

This should be in a safe area, if possible sheltered from the weather, and not too far from the accident site. It may just be in the field right next to the highway or road where the large accident occurred. It needs to be SAFE, and visible from the road. Don’t lay patients in red ant hills, for example. Think. Stay Calm. Assemble resources such as helpers, blankets, towels, rags, anything to use as medical supplies. This also begs the point, you should have a bag of medical supplies in your vehicle. I’ll go over a solid medic bag in the future. Something that doesn’t require a lot of training to use, but will have adequate supplies to handle things from cuts and scrapes, to impaled objects and full on amputated limbs. All this can fit in a backpack or small duffle bag.

Triage shouldn’t be seen as heartless or cold.

Yes, you do need to be able to leave someone who’s dying right then, to save someone who will die in a few minutes. The key is to have a plan, act fast, and worry about the emotional part afterwards. Do your best, save as many as you can. If you do this, you will have no need to feel guilty later when you find out how many didn’t make it.

It helps if you have people helping you. They will also feel guilt, and you need to remind them you all did all you could, and you saved some that would have surely died. You need others to help you go through patients as quickly as possible. Tell them to check for massive bleeding, and if they see it, apply direct pressure immediately and call you over. If they have a tourniquet they should apply it immediately if there is an injury requiring it.

Another thing your helpers will do is bring patients to YOU at the “Casualty Collection Point.” This will streamline things extremely well. They are to carefully bring patients to you, as they bring them by classify them to the 4 categories, stopping to apply lifesaving procedures on the Immediate patients as soon as you get them.

Now you may be thinking that you could never be the lead triage person. After all, you’re not a combat medic, or a doctor. Well the trauma medicine that’s required to stop bleeding, and add basic assistance to the airway is basic first aid. We’re talking direct pressure on the wound, and “get me a rag or towel!” kind of simple. If they have penetrating injuries anywhere above the belly button or below the chin, put a flat smooth plastic seal over the area to prevent air from getting in their chest cavity and causing a collapsed lung. These immediate things will give the patient a little more time, for the professionals to get there.

Remember the 4 Categories: Minimal, Delayed, Immediate, and Expectant. Review this chart and study it carefully:

To leave you with some practical examples, I’ll tell you a story of why in triage you need to look at every patient and not get distracted or develop “Tunnel Vision”.

I learned that you have to force yourself to look and think beyond the outward blood and screaming scared people and think about who’s the worst off so you can prioritize and treat the ones who need it FIRST:

There was a car accident in front of my house in North Carolina. Two vehicles collided. A white ford pickup was rear-ended by a mini-van with 4 people in it. I ran and grabbed my aid bag, someone else called 911. I was a very new medic but I knew all kinds of fancy trauma medic tricks but hadn’t been through a Triage class yet. The mini-van was closest to me so I stopped there and Holy Smokes! Blood and loud fast talking stole my attention from the big picture. There was a mentally ill teenager with a bloody nose. He was conscious and making quite a racket. The others in the car were very much riled up, talking quickly and loudly due to the adrenaline. I didn’t even go to the truck that was rear-ended but instead grabbed some gauze and checked the bloody nose for any sign of spinal fluid (fancy trick, but totally unnecessary because he was still conscious and jabbering away, a good sign that he was not hit hard enough to cause spinal fluid to leak into his nasal passage. There would most likely have to be a blow to the head so severe he would be out like a light, and be showing signs of trauma to the brain (seizure, limbs rigidly protecting his mid section or rigidly splayed outward). Anyways, the fire-rescue crew showed up during this and those professionals immediately went to the first vehicle because they noticed the truck didn’t have head rests on the seat (it was an old ford with just a bench seat) and the guy in there wasn’t moving. The professionals weren’t thrown off by the raucous bloody nosed group, but went first to the man who sat quietly bearing his pain. He had most likely broken his neck. They applied a neck brace, and carefully extracted him out of the vehicle and onto a hard back board and were off to the hospital in a flash of lights.

So remember that next time you’re in or around a car accident. Slow down, take a breather and take in the whole scene. What happened, who’s being noisy talking and yelling, and who’s sitting quietly looking off into space and may be going into shock. Call 911 immediately. I won’t explain Shock fully here, but Shock will kill someone so you need to monitor them, keep them conscious if you can. It would be good to have them lay down and put their feet up. I know this is a lot to think about, and there’s no way you’ll learn all this from a blog post. Hopefully you’re at least better informed than you were before. You know some of the simple, fast, life saving steps you can take, in the proper order. Just having the idea in your head will give you something to do when the time comes, and that may just be enough. I suggest if you want to go further down this road, find some first aid classes. Hands on training is best. In the meantime, look over the chart above and maybe go watch some videos on this to plant the idea firmly in your mind. Triage does require special training, and I don’t expect you to coordinate an effective triage after this. The best I can hope for is you will be a good helper and that God willing, there is someone with extensive training to take the lead in a situation like this should you ever be unfortunate enough to experience it. I pray you never have to use it, but if you do you’ll be a better leader or at least a well informed assistant when required. Stay sharp. Aquire more skills, “So that others may live.”


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