The multiple casualty incident (MCI) plan for EMS is only ever as strong as the weakest link. There are a lot of links in the chain, so it is critical that every member of the EMS organization develop skills to manage his/her role in a major incident.
Jump into "Triage Tuesday"
Some agencies have developed a routine practice of triage skill practicing and testing, often coordinated with surrounding EMS agencies and destination hospitals. This process is affectionately called "Triage Tuesday" in many communities.
The goals of Triage Tuesday are several-fold. First, it allows EMS providers to become confident in the location and use of the basic tools of MCI management, such as triage tags. Second, Triage Tuesday gives providers the opportunity to discuss their patient evaluation skills with their officers, and importantly, the nurses and physicians at the emergency department. Third, Triage Tuesday helps EMS field providers, supervisors, regional coordinators and hospital staff work together to identify problems and opportunities to improve the local MCI response process before a major incident like a mass shooting, terrorism incident or building collapse.
The process of participating in Triage Tuesdays instills, and then cultivates, a culture of confidence in EMS providers and emergency department personnel.
Multiple casualty incident preparedness
EMS agencies and providers successfully use everyday operations to prepare for bigger incidents, including MCI events. Regular use of the Incident Command System for incident management is one of the most important elements of preparedness.
Formal Incident Management System training is designed to prepare providers at all levels and in all disciplines to work with providers from many different agencies, many of whom they do not normally come in contact with, but the core principle of ICS/IMS can and should be practiced on daily or routine calls.
In a similar way, EMS personnel perform patient triage — the sorting and prioritizing of medical problems — to some degree with each patient encounter. For non-MCI patient calls this is typically built around the use of ABCDE patient assessment — airway, breathing, circulation, disability and exposure — and the differentiation of all types of patients around the basic decision of "sick" and "not sick."
But triage for multiple patient incidents requires another level of decision-making by emergency personnel. Those incidents require the caregiver to clearly sort patients by determining who is sickest among them and how best to deploy the available resources to care for patients. In the worst of MCIs, someone needs to be prepared to make decisions about who should or should not be resuscitated, as well as transported.
Comfort and confidence with emergency skills like these can be developed using regular training like "Triage Tuesday."
Preparing EMS providers for multiple casualties
EMS providers feel more confident when they practice patient assessment and determination of critical illnesses or injuries with everyday patient encounters. Yet many EMS providers resist hands-on training specific to MCI incidents. There are a few reasons for this reluctance to practice:
- EMS providers don't like to practice while they’re working. They often feel that everyday care is difficult enough and doesn't allow time to prepare for a big incident.
- On-duty training takes time and effort. It distracts from the most important role of being an EMT or paramedic — day-to-day patient care.
- Many EMS professionals don't like pretend games and get callused by daily interactions with patients and providers who "play too many games."
- When things don't go well in training exercises, it can be embarrassing.
- Triage training costs money to use materials like triage tags and other props.
Regular and routine triage practice
So how can EMS agencies develop a regular and routine practice of triage skill testing" First, use a defined period for use of process and real-world tools or props like triage tags, pediatric triage reference tapes and cards and patient tracking and incident management boards. While there is some cost to use disposable triage supplies, the benefit in real and tangible preparation is well worth the cost of a few tags.
Second, work with receiving hospitals and their clinicians. Collaborate during planning to set mutual goals, such as, "we are testing and updating processes to prepare for MCIs in our response area, for the mutual benefit of the patient."
Third, establish a routine practice to communicate the results of Triage Tuesday in each direction, as in "we are identifying areas of opportunity in our practice only by accepting suggestions and concerns from your personnel and hope your agency will do the same." EMS providers will appreciate feedback on alignment of the triage decision with the patient's disposition and are more likely to continue participation if hospital personnel find the triage information valuable to patient care.
In the simplest Triage Tuesday models, the agency's triage tags are applied to each patient who is transported on a given day of the week or month before arrival at the hospital. Triage practice can be done on any day of the week. Picking days other than Tuesday might allow more personnel — EMS and hospital — to participate. The tag may or may not be used for simple documentation, in addition to the routine patient care report.
The emergency department personnel, advised about the triage practice process, accept the patient and confirm the accuracy of the patient triage classification, providing simple and immediate feedback to the EMS crew.
Emergency department personnel may take advantage of the opportunity to test their own triage skills, become familiar with triage tagging systems used by different EMS agencies and use the emergency department's disaster patient tracking system.
There are more opportunities to expand the training or add elements once a month to enhance the experience. More props can be utilized, including incident management vests, caps, signage, management boards and technology enhancements such as smartphone triage apps, barcode scanners, automatic blood pressure cuffs or RFID tags.
When agencies are using new tools for MCIs, like barcode devices or smartphone apps, practicing monthly allows more EMS providers to develop the skills in using the technology, in the field and in the ED.
An important element of these designated triage practice days is to rehearse the communication scripts. The EMS providers will be asked to use the MCI props, and also to communicate with the patient, family or emergency department personnel what the props would accomplish in a major incident.
For example: "Mr. Jones, we take care of people every day, and expand those principles when we have big incidents or multiple patients. This is one of the tools we use for big incidents, and we are using it today on all of our patients."
Some services will also have their field supervisors respond to non-critical incidents and add some elements that will still allow providers additional MCI management practice. At each incident the supervisor may inject additional information that would turn the non-critical patient into a critical one or add a virtual patient encounter to manage. The field supervisor might test the providers on what they would do if this patient encounter was part of a common or likely MCI. That way a simple patient encounter can be made more challenging and effective for the providers to manage.
Simple and technology enhancements for MCI training
Triage Tuesday allows for the development of MCI skills without moulage, fake or simulated patients and contrived scenarios. The skills of MCI management are developed, like any cognitive or kinesthetic task, through regular practice and repetition. Expand on real patient encounters by adding simulated patients with simple patient descriptor cards. This allows the EMS providers to triage multiple patients.
Triage Tuesday is also a perfect time to practice the use of emergency technology. Some EMS systems and emergency departments have new IT applications that are being utilized, sometimes with new equipment, communication processes and software.
These high-tech tools require regular practice, especially at the time of implementation. Regular MCI drills allow practice using the hardware and software tools. Practice, before an actual incident, also helps define shortcomings and bottlenecks. It is likely to greatly benefit the staff of the EMS providers and the emergency department.
Additional MCI training
EMS training officers and educators can easily create opportunities for additional triage and MCI response training. A small tabletop exercise can clarify how the incident management system functions, and the roles and responsibilities of EMS positions in triage, treatment and transport during MCI response.
A tabletop exercise can also show EMS personnel how triage, treatment and transport come together to move MCI patients constantly forward — away from the incident which is causing harm to or generating patients — and towards the destination hospitals providing definitive care. Here is a method to create a simple to use, low tech and reusable tabletop exercise with envelopes and index cards.
- Use mailing envelopes to represent local EMS units — BLS and ALS ambulances, supervisor’s vehicles.
- Create individual patients with small index cards. On each card, write a visual general impression — what first-arriving rescuers will see — on one side and patient details and vital signs on the other side of the card.
- Create individual EMS providers, also with index cards, with details about their level of training, incident role or ICS position and their primary gear, such as stretcher, ALS or BLS bag.
- Place the patient index cards, general impression facing up, on a tabletop scene. The first responding unit — an envelope with index cards for ALS/BLS providers and their gear — will arrive and establish the incident management system and begin triage.
- Triage the patients following the department's preferred triage method.
These materials can be reused to run the tabletop exercise for different combinations of personnel. After triage is complete discuss the providers' reasons for assigning patients to different categories, the interventions applied during triage and likely additional treatments for each patient. The transportation destination, based on the patient's problem and local hospital capabilities can also be discussed.
A tabletop exercise is another good time to review the tools of MCI management. All providers need to know where supplies are kept and how they work. During the exercise communicate on real radios — on private talk-around channels — to practice the communication discipline that is necessary to properly coordinate a complex MCI scene which involves moving patients to ambulances and those patients to the best-available receiving facilities.
Practice with a likely real-world MCI scenario, such as a mass shooting or school bus rollover. Avoid highly unlikely though theoretically possible scenarios like a "hurricane causes a multiple school bus collision with haz-mat release.”
Straight forward scenarios allow providers to build their confidence in how the incident management system works, how effective triage helps move the right patients forward or from the scene first, and their role in MCI response and management. Seeing how real patients, providers, gear and vehicles interact emphasizes the importance of incident management before clinical care in a multiple casualty incident.
Lifesaving care during triage
Most triage methods direct rescuers to assess for patient breathing and scan for severe bleeding. If the patient is not breathing a few maneuvers can be attempted. The patient's airway can be manually opened, including insertion of an oropharyngeal airway. Rescuers, if directed by protocol, may also assess for an open chest wound and apply a chest seal.
If a rescuer observers severe bleeding from extremity hemorrhage a tourniquet should be applied proximal to the wound. The rescuer may direct the patient, a bystander or another rescuer to apply and monitor a tourniquet.
Hemostatic dressings are an additional consideration for bleeding control during an MCI. The application of hemostatic gauze and wound packing is likely best performed in the treatment area or by teams moving patients from the triage area to the treatment area.
Tourniquets and chest seals are likely used as infrequently as triage tags in most EMS systems. EMS personnel should be given regularly opportunities to review tourniquet and chest seal application. Consider using online training videos, case reviews and hands-on practice sessions with a field supervisor or training officer to maintain skill competency.
Triage and MCI supplies on every vehicle
Triage and MCI supplies should be available on every ambulance and quick response vehicle. Triage is often initiated by the first arriving EMS unit. Work with your department's supply officer to equip each vehicle with a specially marked MCI bag. The bag should contain ten or more triage tags, two or more tourniquets and at least one chest seal. Also consider including a triage officer vest, triage officer job action sheet and other supplies required by your department's MCI response protocol.
Regular drills, like Triage Tuesday, enhance training for emergency providers. With that process, the EMS agency is taking care of people, to include your providers, your patients and your support agencies. There is great benefit to having, practicing and improving the EMS MCI plan. Having each member of the EMS agency and emergency department skilled in the props, process, and practice will benefit all of the appropriate elements, especially the rescuers.
Triage Tuesday allows providers to use MCI props routinely. Vests, hats and signage all gets buried in response vehicles and mass casualty trailers without regular use. So dust off the MCI kit, write on a few envelopes and index cards and help everyone in your EMS service better prepare themselves to be the first unit arriving at an MCI, better coordinate with their EMS and health care partners and improve your department's entire MCI management process.
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