BOOK 2

MASCAL

CHAPTER 6

THE MASS CASUALTY INCIDENT

J ust now, you read about conducting a physical examination. Although most of these exams will be routine and unhurried, occasionally, you must make hasty decisions. The "golden hour"—the first hour following the victim's injury, when his or her likelihood of survival is greatest—is significant to remember in cases of major trauma. If a sufferer is not treated within that hour, their chances of survival substantially drop. Every thirty minutes that go by without attention causes it to get worse.

Typically, the healthcare professional will be attending to one sick or hurt person at a time. But there might come a time when you're faced with an emergency where several people are hurt. It's known as a mass casualty incident (MCI).

Any incident resulting in high casualties and severe injuries is considered a mass casualty incident. MCIs can manifest in a variety of ways, and they might include any of the following:

       Doomsday scenario occurrences like nuclear explosions

       Terrorist acts, such as those committed on September 11th or in Oklahoma City

       Repercussions of a disaster, like a tornado or a hurricane;

       Repercussions of civil disturbance;

       A mass transit accident (train derailment, plane crash, etc.)

       An automobile collision, for instance, in which three people suffered serious injuries, but only one ambulance was present

Any of the occurrences above must be accurately and swiftly triaged for medical intervention to be effective. Triage, which means "to sort" in French, is the procedure by which medical professionals may quickly assess and prioritize several injured patients, thereby providing the best care for the greatest number of people. I did not state, "Provide each victim with the greatest care available."

 

Analysis of an MCI Scene

Your first moves at the scene of an MCI could affect how the emergency response plays out. The five S's of appraising an MCI situation are as follows:

 

1. Safety evaluation. The employment of primary and secondary bombs by terrorists in the Middle East is a cunning tactic. The second bomb is timed to go off or is detonated right when the medical and security professionals arrive, while the primary bomb causes the majority of victims.

Many medical professionals cringe when I mention not approaching the injured in a hostile environment. Remember that as a medic, your top priority is your survival; maintaining the health of the medical staff will probably save more lives in the long run.

Ensure there is no ongoing threat as soon as you get on the scene. Wait until it is obvious that you and your helpers are safe before entering.

 

2. Assessing the situation. Consider the following inquiries for yourself:

• What is the circumstance? Is there a mass transit crash here? Did a burning building crumble?

• How many wounds were there, and how bad? Are there a few or many victims? Exist other people who can assist?

• Are the victims gathered in one place or dispersed over a large area?

• Where could injured people be transported and treated locally?

• Are there any sites that could be accessed by vehicles to assist in transporting victims?

 

3. Requesting aid. Call 911 and report a mass casualty occurrence involving a multi-vehicle auto accident at the crossroads of Hollywood and Vine if contemporary medical treatment is available. At least seven injured individuals will need medical care. One vehicle is on fire, and people may be trapped inside other vehicles.

You have told the authorities that a mass casualty incident has happened, what kind of event it was, where it happened, an estimated number of patients who may need care, and the kinds of care or equipment that may be required—all in the space of three phrases.

If you're the only person there, grab your phone or another form of communication, and let people know what's going on and what resources (people and goods) you'll need. Contact the group medic if you don't have any medical training. The incident commander is the medical professional with the most experience.

 

4. Setup. Identify potential areas for additional assessment and treatment of patients with varying levels of disease (see below). Also, if there are any medical facilities, decide where the victims should enter and leave if they require immediate transport.

 

5. Start Primary triage. It or the initial round of triage, should be quick (30 seconds per patient, if possible), and injuries should not require significant care. It should concentrate on determining each patient's triage level. Quick assessments of breathing (or lack thereof), perfusion (adequacy of circulation), and mental status make up most of the primary triage evaluation. Aside from stopping major bleeding and clearing airways, only a very small amount of treatment is administered during the first triage.

Triage levels are typically based on color, albeit there is no universally accepted method for doing so:

Immediate (red tag) - The victim needs urgent medical attention and won't live without it (for example, a major hemorrhagic wound or internal bleeding). The priority is on this guy.

A delayed victim (yellow tag) needs medical attention within 2-4 hours. If injuries are overlooked, they could become life-threatening (for instance, an open femur fracture without significant bleeding), but they can wait until patients with red flags are treated.

Minimal (green tag)—Usually ambulatory and stable (the "walking wounded") but may require some medical attention (for example, broken fingers, sprained wrist).

The victim is marked as expecting (black tag) if they are either dead or not anticipated to survive (for example, open skull fracture with brain damage or multiple penetrating chest wounds).

Caregiver's understanding of the urgency of a patient's situation is made simple by knowledge of this patient tagging system. It should go without saying that many red and even some yellow tags will turn black in a power-down scenario without access to modern medical treatment. Without surgery, it will be impossible to save someone internally bleeding severely.

As an example, let's examine a mass casualty incident and discuss how triage tasks ought to be carried out.

 

First Priority: MCI Scenario

Here is our fictitious example: As you proceed down the street, an explosion is audible. You are the only person at the scene and the first to arrive. Roughly twenty people are injured, and blood is all over. How do you behave?

Assuming you have already assessed the scene's safety and applied the five S's, let's go on to the next step. There seems to have been an explosion from a bomb. As you can determine, there are no hostiles close by, and there is no sign of approaching ordnance. As a result, you and the other responders think that no one is in danger. The victims are gathered in one location, and the injuries are severe.

There are entrances and exits because the incident occurred on a major road. Your request for assistance and description of the scenario has prompted responses from multiple group members, including a former intensive care unit (ICU) nurse who communicates with all other group members who have medical training. Since the area is very open, you can designate sections for different triage categories. You can now begin.

You will shout, "I'm here to help everyone who can get up and walk and needs medical attention, get up and move to the sound of my voice," as loudly as you can. Follow me if you can help and are unharmed.

You're fortunate since thirteen of the twenty people, largely from the blast's outskirts, managed to sit up or at least attempt to. Eight moves to the place you specified for walking wounded, and the remaining ten can stand. These individuals are hobbling, have wounds and scrapes, and one has broken arms. Two tough but battered individuals join you. By recognizing the walking injured (those with green tags) and obtaining some urgent assistance, you have made your job as interim incident commander easier through communication. There are still eleven victims left.

Then you head to the victim lying on the ground closest to you. Start where you are as you move from one victim to the next. Triaging in this method will be quicker and more efficient than determining who needs help the most at a distance or by moving randomly.

Suppose you have "SMART" tags in your pack as a little cheat. SMART tags are practical tickets that let you identify a patient's triage level on the fly. After determining a victim's triage level, you cut off a piece of the tag's end until you reach the right color, then wrap it around the patient's wrist.

The victims' foreheads could be marked with colored markers or numbers as an alternative. If you utilize numbers, code them as follows:

       Priority 1: Urgent/red

       Priority 2: Llate/yellow

       Priority 3: Low-impact/green

       Priority 4: Dead, pregnant, or black

Keep in mind that you are triaging rather than treating. Only major bleeding will be stopped, airways will be opened, and legs will be elevated in cases of shock as the only therapies in START. Keep your cool and let the patients know who you are and that you are there to help as you move from one to the next. You want to determine who will want assistance most immediately (red tags). You will evaluate the patient's breathing, blood flow, and mental state (RPM).

Are they breathing? Is your patient? If not, tilt the head back or, if one is accessible, place an oral airway. (Note: In current emergency treatment, the rule that the neck should not be moved until a cervical spine injury has been ruled out is temporarily disregarded in an MCI triage situation.) A victim is marked as black if they are not breathing but have an open airway. Tag red if the victim breathes after their airway has been reopened or if they are breathing more than 30 times per minute. Move to perfusion if the victim is breathing regularly.

Perfusion: Evaluate the blood flow or circulation's normalcy. (Wrist or neck) Pulse: Check for a pulse. Alternately, firmly push on the finger's pad or nail bed and immediately remove it. If there is adequate perfusion, it will change from white to its usual hue in less than two seconds. The term for this is "capillary replenishment time" (CRT). Tag red if there is no pulse or if it takes more than two seconds for the color to change back to pink. Checking the patient's mental status comes next if there is a pulse and the CRT is normal.

Mental state: Is the patient capable of responding to simple questions like "What's your name?" or "Open your eyes." Tag red if the patient is unconscious or confused but is still breathing and has normal perfusion. Patients should be marked with a yellow or green tag if they can understand and follow instructions but cannot stand up. Keep in mind that some victims might not be able to hear you clearly due to the explosion.

If you just think "30-2-Can Do," it might be simpler to recall everything: Can Do: 30 (respirations), 2 (CRT) (Commands).

Always use the red triage level for the greatest priority if there is any question about the category. If you have substantial bleeding to stop, tag the patient as triage level red and move on to the next patient as soon as possible. The victim is marked red for each RPM check that does not adhere to the 30-2-Can Do criteria. For instance, tag red and stop the further investigation if the patient is not bleeding if they were not breathing but started breathing after you realigned the airway. If you detect shock, elevate the legs before moving on to the next patient.

Let's go back to our mass casualty incident now. Eight walking wounded have been located, and you've moved them to a specified spot. Two healthy helpers, a man and a woman are at your disposal. She is capable of taking a pulse. Let's assume that the only medical supplies you have with you are some oral airways and triage tags. Following are instructions on how to treat your ten victims in order of proximity.

Victim 1 is a male in his forties who complains of discomfort in his left leg, which is broken. His breathing is 24 breaths per minute, his pulse is strong, and his CRT is 1 second.

Pulse and CRT are normal, and respirations are within a reasonable range (less than 30). Since the patient expresses pain by complaining about it, their mental state is likely normal. This patient is marked yellow, meaning that they will still survive even if there is a reasonable (2-4 hour) wait. Pass on.

Victim 2: A woman in her fifties with bleeding mouth, nose, and ears. You try to sit up but cannot do so; your breathing rate is 20, your pulse is present, and your CRT is 1 second.

Despite having a serious head injury, the subject remains stable regarding breathing and blood flow. Tag red because she is damaged mentally (immediately). Pass on.

Victim 3 is a teen girl profusely bleeding from her right thigh; her respirations are 32, her pulse is thready, and her CRT is 2.5 seconds. She complies with orders.

One of the reasons to treat this patient at triage is that they are hemorrhaging quite a bit. High respirations and poor perfusion are present. You instruct your inexperienced male aid to apply pressure to the bleeding area while wrapping it with his shirt or a bandana. Mark red. You don't need to determine the patient's mental state because they are already marked red. You and your female assistant continue.

Another adolescent girl, victim #4, claims she cannot move her legs and has a minor cut on her forehead. Twenty breaths per minute, a robust pulse, and a one-second CRT.

The spinal injury is likely, but otherwise, stable and able to communicate. Yellow tagging Pass on.

Male in his twenties, victim number 5, with a head wound and no breathing. Repositioned airway, no improvement in breathing.

You will adjust his head and place an airway if he is not breathing. This does not revive his breathing. This patient is no longer alive. Black is tagged; continue.

Sixth victim: a 40-year-old man with burns to his face, chest, and arms. Twenty-two respirations, a 100-beat heartbeat, a 1.5-second CRT, and compliance with orders.

Despite having severe burns covering a substantial portion of his body, the victim is breathing normally, and his blood flow is normal. You tag yellow and continue since your mental health is unimpaired.

The seventh victim is a teenage male with several scratches and scrapes but is not bleeding. He claims he can't breathe, his respirations are 34, his radial pulse—the radial artery pulse—can be felt at his wrist, and his CRT is 2.5 seconds.

Although the victim doesn't appear to be in too much pain, she has poor perfusion and difficulty breathing. Although his mental state is unaffected, he probably has additional problems, including internal bleeding. Your red tag (due to respirations greater than 30 and impaired perfusion). Pass on.

Victim 8 is a woman in her twenties with burns on her neck and face. She has 22 respirations per minute, a heartbeat, and a CRT of one second.

This young lady is hurt, but she is otherwise stable and speaking. She can walk by herself and can stand up with assistance. She becomes Tag Green, another one of the wandering wounded. Move on and point her at the other green victims.

Victim 9 is an elderly woman who has had her right arm amputated below the elbow; she is bleeding heavily, breathing at a rate of 36, has no pulse in her other wrist, and her CRT is three seconds.

The victim is obviously in terrible shape, so you apply pressure on the bleeding area while using your shirt as a tourniquet. Tag red, then proceed.

Male toddler, victim number 10, many piercing wounds, no respirations. Repositioned airway; breathing begins. There is no radial pulse, a two-second CRT, and no response.

Despite your first concern that the infant is dead, you follow protocol and tilt his head back to clear his airway. Normally, you would be hesitant to do this due to the risk of a neck injury. One of the few situations where you can assess a patient without worrying about cervical spine injuries is when they have an MCI. You designate him red when, to your astonishment, he begins to breathe even without an oral airway. You apply pressure and wait for the additional help you initially sought to arrive if he is bleeding profusely from his wounds.

In less than 10 minutes, you just finished performing triage on twenty people, including the walking wounded. The ICU nurse who you initially phoned is among the first to come with assistance. You are relieved of incident leadership since you are no longer the medical resource with the most experience on the spot. For victims with yellow, red, and black tags, the nurse starts allocating locations where further triage and treatment can occur.

The casualties who require the most immediate care have been identified, but more must be done. Modern medical facilities typically arrive on the scene with ambulances, trained employees, and a wealth of equipment. But many of the victims have a poor prognosis in an off-grid environment. See who you believe would survive without access to modern medical care by looking through our list of victims. There would be a significant risk of death from their wounds for many of the red tags and even some of the yellow tags.

 

PATIENT TRANSPORT

 

Stabilize the patient as much as possible before deciding whether to move them. This includes putting an end to any bleeding, splinting any orthopedic wounds, and checking the patient's breathing. If you can't guarantee this, think about having a group member obtain the things the patient needs before you relocate them. Have as many people as you can at your disposal to help you. The most crucial thing to remember is that you want to conduct the evacuation with as little stress on you and your patient as possible.

A stretcher is a crucial medical item to have in this situation. Although many high-quality commercially created stretchers are available, it is not very difficult to assemble improvised stretchers. Even an ironing board can function as a useful transportation tool. If possible, roll a person with a spinal injury onto a stretcher without bending their neck or back.

Another method is to use two long rods or poles with coats or shirts inserted through them to support the victim's weight. A rescuer could have their coat pulled off if they hold both poles. The coat is immediately shifted onto the poles as a result. Another method for creating a strong stretcher is to crisscross lengths of rope or paracord.

If you must drag someone to safety, take hold of their coat or shirt with both hands at the shoulders, letting their head rest on your forearms. Another option is to throw a blanket underneath the patient, grab the end of it close to their head, and pull. Again, try to avoid bending the torso or neck during transport if you are unsure of the severity of any spinal injuries.

If your patient can be carried, there are several options. The "fireman's carry" keeps the victim's torso steady and level. This procedure is much simpler if the patient is placed carefully, so they are lying on their stomach while asleep. By "hugging" the victim under their arms and supporting them with your dominant leg placed between their bowed legs, you can lift them. Then, with your left hand, you would take hold of your right wrist and place it over your right shoulder. Put your right hand between their legs and around the right thigh while maintaining a straight back. They should end up with their body over your back and their right thigh resting on your right shoulder after you lift using your leg muscles. If you've done it well, their left arm and leg will hang behind your back. To put the least load on you, adjust their weight.

The "pack-strap carry" is an additional choice. Take hold of both arms and cross them on the front of your chest with your patient behind you. When squatting, keep your back straight and elevate the victim with your legs and back muscles. Lift the individual off the ground by bending a little so that they are resting their weight on your hips.

If you have the luxury of a helper, you might think about putting your patient, if they're conscious, on a chair and lifting them by the chair's back and front legs. This counts as a "sit-stretcher." One rescuer wraps their arms around the victim's torso from behind, while the second rescuer (facing away from the patient) holds the patient's legs behind each knee. This is another two-person carry. The patient is raised by crouching down and using the muscles in the legs.

When dragging or carrying a person, it's crucial to keep in mind the abbreviation B.A.C.K., which stands for the following:

Straight back. When the back is straight, greater weight may be safely supported by the muscles and discs.

Do not twist. Twisting can cause harm to joints.

Near the body, Reaching to pick up a burden puts greater tension on your muscles and joints, so avoid doing it.

Hold steady. Pressure on the discs and muscles increases with rotation and jerks.

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