Supplies
Extensive commitment of public funds is needed for very rare potential disaster episodes, such as prepositioning large supplies of nerve agent antidote or antibiotics against biological attacks, all of which will expire over time.
It is diffi cult to know where to pre-position supplies to provide for the optimal use.
Scalability is defi ned as the ability to increase the positive response to a disaster situation in order to optimize citizen safety and attempt to oper-ate within community assets. Absence of scalability threoper-atens secondary issues, such as cholera outbreaks following earthquakes.
Triage
Numerous triage methods are found through EMS-provider training (see Fig. 13.2).
There is a linear relationship between ineffective triage and bad patient outcome. Recent CDC work on unifying triage of patients through the
“SALT Triage” plan may help alleviate this disparity in training (Fig. 13.3).
MASS triage (Move, Assess, Sort, Send) is an effective method of sort-ing large numbers of victims in preparation for the individual assessment of victims.
Triage tags may not be available, and rescuers must be prepared to physically record documentation of triage category on the patient, typi-cally the forehead, using a marking pen.
Types of conditions
Bio-weapons can produce symptoms that are extraordinarily diffi cult to diagnose until the situation is understood. Hours to days may pass from the onset of the outbreak until the causative agent is identifi ed.
Chemical exposures will likely produce areas inaccessible to EMS per-sonnel until cleared by HazMat perper-sonnel. Working in the fi eld in protec-tive suits (such as Level A protection) makes patient care very diffi cult and places the EMS provider at risk for injury.
Personnel
In a disaster, the EMS providers reporting to work will likely go to their full-time job. EMS agencies depending on part-time provider assistance will sustain personnel shortages, which will increase response times.
Employees scheduled for regular duty shifts may not show up because of personal issues that the disaster has caused at home. Preparations for employee no-shows should be expected.
Exposure of EMS providers to elements of the disaster may well injure the responders themselves.
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Measure vital signs and level of consciousness Glasgow Coma Scale < 14 or
Systolic blood pressure < 90 or
Respiratory rate < 10 or > 29 (< 20 ininfant < one year) YES
Take to a trauma center. Steps 1 and 2 attempt to identify the most seriously injured patients. These patients should be transported preferentially to the highest level of care within the trauma system.
NO
Assess anatomy of injury
• All penetrating injuries to head, neck, torso and extremities proximal to elbow and knee
• Flail chest
• Two or more proximal long-bone fractures
• Crushed, degloved, or mangled extremity
• Amputation proximal to wrist and ankle
• Pelvic fractures
• Open or depressed skull fracture
• Paralysis YES
Take to a trauma center. Steps 1 and 2 attempt to identify the most seriously injured patients. These patients should be transported preferentially to the highest level of care within the trauma system.
NO
Assess mechanism of injury and evidence of high-energy impact
Falls
• Adults: > 20 ft. (one story is equal to 10 ft.)
• Children: > 10 ft. or 2-3 times the height of the child High-Risk Auto Crash
• Intrusion: > 12 in. occupant site; > 18 in. any site
• Ejection (partial or complete) from automobile
• Death in same passenger compartment
• Vehicle telemetry data consistent with high risk of injury Auto v. Pedestrian/Bicyclist Thrown, Run Over, or with Significant (> 20 MPH) Impact
Motorcycle Crash > 20 MPH YES
Transport to closest appropriate trauma center, which depending on the trauma system, need not be the highest level trauma center.
NO
Assess special patient or system considerations
Age• Older Adults: Risk of injury death increases after age 55
• Children: Should be triaged preferentially to pediatric-capable trauma centers Anticoagulation and Bleeding Disorders Burns
• Without other trauma mechanism: Triage to burn facility
• With trauma mechanism: Triage to trauma center Time Sensitive Extremity Injury
End-Stage Renal Disease Requiring Dialysis Pregnancy > 20 Weeks
EMS Provider Judgment YES
Contact medical control and consider transport to a trauma center or a specific resource hospital.
NO
Transport according to protocol
When in doubt, transport to a trauma center.
For more information, visit: www.cdc.gov/FieldTriage
Figure 13.2 Field triage decision scheme: the National Trauma Triage Protocol.
Source: Centers for Disease Control and Prevention
DILEMMAS IN PREHOSPITAL DISASTER PREPAREDNESS
101
Patient load
EMS systems typically operate at high-volume levels of response and trans-port during normal times. A disaster in a community will drastically over-load the emergency response system with patients, requiring alternative transport methods and destinations.
Standard EMS case types will predictably increase in volume. For exam-ple, particulate releases could increase the likelihood of chronic respiratory illness exacerbation. Such patients also rise to a high triage level for emer-gent management and transport.
Communications
Emergency response systems will be overwhelmed by callers in a major disaster. Emergency communications may not sustain the impact of a major environmental disaster, preventing calls from reaching responders.
Step 1 –Sort:
Global Scrting
1
2
Step 2 –Assess:Individual Assessment
BreatingYes Yes
Yes
Yes Any NO
Likely to survive given curent resources
• Control major hemorrhage
• Open airway (if child consider 2 rescue breaths)
• Chest decompression
• Auto injector antidotes
NO EXPECTANT LSI*:
IMMEDIATE DELAYED
MINIMAL
NO NO
DEAD
AI Minor Injures Only?
Walk Assess 3rd
Wave/Purpossful Movement Assess 2nd
Still / Obvious Life Threat Assess 1st
• Obeys purposeful movement?
• Has peripheral Pulse?
• Not in respiratory distress?
• Major hemorrhage is controlled?
Figure 13.3 SALT triage scheme.
Source: Centers for Disease Control and Prevention.
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Conclusion
The emergency medical services teams in a geographic area provide a criti-cal arm in community preparedness for disasters, victim rescue, patient care in the fi eld, resuscitative maneuvers, and, most importantly, transport of the acutely ill and injured to appropriate destinations. These teams must play an integral role in the creation of operational clinical response to provide the best available outcome in the event of a disaster.
Suggested readings
American Medical Association (2007). MASS triage. Advanced Disaster Life Support. http://www.
ama-assn.org/resources/doc/cphpdr/ndls_brochure.pdf
Bass R (2009). History. In Cone D, O’Connor R, Fowler R, eds. Emergency Medical Services: Clinical Practice and Systems Oversight, 4th ed. National Association of EMS Physicians, Vol 2:3.
Centers for Disease Control and Prevention (2009, January). CDC guidelines for the triage of injured patients. Retrieved December 29, 2010, from http://www.cdc.gov/mmwr/pdf/rr/rr5801.pdf Lerner B, Schwartz R, McGovern J (2009). Prehospital triage for mass casualties. In Cone D,
O’Connor R, Fowler R, eds. Emergency Medical Services: Clinical Practice and Systems Oversight, 4th ed. National Association of EMS Physicians, Vol 4(2):11–15.
National Academy of Sciences (1966). Accidental death and disability: The neglected disease of modern society, Washington, DC: National Academy Press. Retrieved December 29, 2010, from http://www.nap.edu/openbook.php?record_id=9978&page=R1
National Highway Traffi c Safety Administration (2007, February). National EMS Scope of Practice Model. DOT HS 810 657. Retrieved December 29, 2010, from http://www.nhtsa.gov/people/
injury/ems/EMSScope.pdf
Pepe P, Copass M, Fowler R, Racht E (2009). Medical direction of EMS systems, In Cone D, O’Connor R, Fowler R, eds. Emergency Medical Services: Clinical Practice and Systems Oversight, 4th ed. National Association of EMS Physicians, Vol 2:22.
White J (2009). Radiological and nuclear response for emergency medical personnel. In Cone D, O’Connor R, Fowler R, eds. Emergency Medical Services: Clinical Practice and Systems Oversight, 4th ed. National Association of EMS Physicians, Vol 4(5):46–57.