Medical Director Message August 2023

MCI- Week 1: Improving our Response to Mass Casualty Incidents

Continuous quality improvement is the key to improving EMS. This can be achieved in numerous ways such as- comparing the treatment we provide to existing protocols and standards, reviewing patient outcomes to the treatment provided, and studying the results of larger research studies. This ultimately guides changes to training and/or protocols. These improvements can have an effect on our medications, equipment, and procedures. For instance, many of you can remember administering Bretylium or escalating a dose of Epinephrine. In fact, some medications that used to be standardly administered are one of the following:

• no longer available

• have been proven ineffective

• simply replaced by better options

One recent observation is that our mass casualty incident (MCI) procedures that we’ve used for over 40 years aren’t as effective as we need them to be. The steps you learned in your basic EMT class generally work well with classic MCIs, such as transportation incidents or carbon monoxide emergencies. These “static” events are defined as those that are not evolving, less chaotic, and generally confined to one area. However, “dynamic” events such as an active shooter or bombing are not managed as effectively with conventional techniques. These scenes can evolve as we try to manage them, and many times we see that a victim’s first concern is to flee the scene, not sit on a colored tarp.

The movie theater shooting in Aurora, Colorado resulted in 70 people injured, with 17 of those critical. Fifteen of those critical patients were transported to the hospital by law enforcement, and never triaged or treated by EMS. Undoubtedly this saved lives, but most patients treated and transported by ambulance had less severe injuries. The Boston Bombing resulted in 3 deaths and 264 injuries (16 with traumatic amputations), but very few were given triage tags. Tags weren’t readily available, and many patients were instead treated at the medical tent or immediately transported. News footage of the shooting at LAX airport showed EMS setting up red, yellow, and green tarps several hundred yards away from where the patients were brought out. No patients were moved to triage. 

In no way can we blame first responders for not following the textbook on these events. The books were not written with dynamic events in mind, and the sheer size of these incidents makes them impossible to completely manage. But this is where quality improvement is used to examine what happened and identify potential options to help on the next MCI. Should we try to treat and transport as many critical patients with Advanced Life Support (ALS) as possible- or have law enforcement transport? Are triage tags important- or should we just eliminate them? Are tarps or flags with color identification even needed? In other words- can we design a system for dynamic events that can save more lives? Possibly the best way to answer these questions is to review the changes we have already made in our response to dynamic events. Consider the evolution of Stop the Bleed (STB), Rescue Task Force (RTF), and Tactical Emergency Casualty Care (TECC), to name a few.

The time has come to create two MCI procedures, one for static and one for dynamic. Each should offer the best suggestions for incident management regarding the triage, treatment, and transport of victims. These techniques can help save lives and flow seamlessly from RTF/TECC and feed directly into ALS. The new protocol will be introduced this month and finalized by the end of this year. Rather than requiring EMTs or paramedics to take mandatory actions during a mass casualty, it will instead provide more tools to choose from. It will use lessons learned from other national events and introduce different techniques such as sifting and sorting and directional level two-staging. We will cover the new state tracking system (EM track) to ensure our triage and transport techniques feed directly into hospital tracking systems and, ultimately, a county family reunification plan.

This project involved numerous shareholders throughout northeastern Ohio, including hospital systems, EMS committees, and county emergency management agencies. Hopefully, this new system will provide you with more tools to assist you in saving the most lives.

MCI- Week 2: Triaging Efficiently and Effectively 

One of the most important components of managing a mass casualty incident is to perform effective triage. The present word has many roots, including: to thin out, categorize, and sort by threes (tri). The French army created a system of triage which debuted at the Battle of Jenna in 1806. Injuries were categorized into three grades of severity- dangerously wounded, less dangerously wounded, and slightly wounded. Over time, these categories would be assigned the colors of red, yellow and green to ensure the system was as easy as possible. 

But while Napoleon Bonaparte’s system ensured the most severely injured would be moved to a medical tent first, it would be nearly 150 more years before triage would involve helicopter evacuation, an additional 25 before EMS would provide advanced life support, and another decade before hospitals started receiving trauma designations. We continue to evolve in our treatment and procedures even today. For example, we’ve accepted the incorporation of life-saving interventions (LSI’s) as a part of Rescue Task Force (RTF). Gone are the days of ABCs for trauma assessment, and we now use Major Hemorrhage, Airway, Respiratory, Circulation and Hypothermia/Head Injury (MARCH). BLS MARCH is conducted in the warm zone, and feeds directly into ALS MARCH at the casualty collection point (CCP) or in an ambulance. Modern systems also dictate that patients are transported to appropriate facilities. The most severely injured would ideally be sent to a trauma center by helicopter, and minor patients would be transported to smaller non-trauma hospitals. But one of the most important rules is to never overrun one hospital with a flood of patients.  

Start triage has been our go-to technique for prioritizing patients for nearly 30 years. Many county and EMS organizations have MCI plans or procedures which suggest the use of simple, triage and rapid transport, (START).  

• START step 1: Ask patients to move to a specific area, which identifies them as green, or walking wounded.  

• Next, the rescuer checks a patient’s respirations, pulse and mental status (RPM) to categorize them as either red or yellow. It’s been the most popular technique for triage and is generally effective for static events such as a transportation accident. Unfortunately, it doesn’t work as well for dynamic events. These types of events are those that are violent, evolving, and patients who have a desire to flee the scene. (ie: active shooters, terrorist attacks or bombings.) These scenes also necessitate LSIs such as chest seals, tourniquets, and needle decompression.  

Start triage simply doesn’t address those needs. Conceivably, a patient could be shot in the chest, but when assessed by Start be designated green (able to walk and follow commands), yellow (RPM is in normal parameters), or red (RPM outside normal guidelines). Obviously, that patient should be assigned red. It’s not that Start triage should be discarded, it’s just that we need to understand when to use it.   

Salt (Sort, Assess, Life-saving Interventions, and Treat/Transport) triage is a different format that is more effective for sorting victims of dynamic events. Patients who follow commands and can be directed to the CCP are the last to be assessed, but cannot be assumed green. Those who do not respond to you are checked first, followed by those who wave or call for your help. When approaching a victim, life threats are immediately identified, followed by any appropriate LSI’s(Life Saving Interventions). After that, they are assessed using RPM to determine which color they will be assigned. Salt is not any quicker than Start, but it does provide a better template for grouping your patients from a dynamic scene.  

For substantial dynamic events where there are numerous victims with severe injuries, sifting and sorting may provide you a quicker way to begin the process of triage. Rather than initially sorting by color, patients receive any LSI’s which are marked with a Black/White ribbon (deceased), or an Orange ribbon (injured and needs to be evacuated). This method allows a rescuer to quickly move through a field of injured patients quickly, similar to the movement of RTF. The addition of the ribbons prevents duplication of efforts, and guides the next crews to who needs to be littered (carried or dragged), and who is now part of the crime scene.  

Regardless of the triage method you choose, the goal is to decide who is Unstable (red), Stable, (yellow), or Ambulatory, (green). This is easily remembered as USA. You might choose to use START, SALT, or even your own experience to prioritize them. Regardless, triage is the first step in ensuring your MCI can be managed effectively. 

MCI- Week 3: Tagging for Success

 Mass casualty incidents (MCI’s) are one of those high risk, low frequency events that can really test emergency responders. Many of us will never respond to one in our career, and even fewer will be called upon to manage one. But effective management is the real key to saving lives. Consider, for a moment, how we manage our average EMS call. It’s not uncommon that we respond with more than one vehicle, assessing and treating patients with a 2:1, 4:1 or maybe even a 6:1 caregiver to patient ratio. Although some patients require the involvement of the entire crew, many times there are adequate responders to carry equipment and assist in transferring the patient to an ambulance. MCI’s simply do not have this luxury. The ratio is more like 1:2, 1:4 or 1:6 caregivers to patients. This span of control problem is best addressed using both the incident command system and solid MCI procedures.

One of our main objectives in MCI procedures is to perform effective triage. By ranking our patients in order of severity, it establishes our order of transport, method of transport, and destination. For instance, red (unstable) patients would ideally be transported first, in a helicopter or ALS squad, to a trauma center. Greens (ambulatory) would be the last to leave the scene, possibly on a bus, to a more remote non-trauma hospital. Proper triaging has the potential to save lives, but is ineffective if the patients aren’t easily identified with their severity color. This process can be completed using surveyor’s ribbon, but is best accomplished with a triage tag. 

The MCI triage system in most EMS textbooks has been in place for decades. Although it always relied on the key component of using triage tags, numerous companies have created different tags and built systems around their use. There is presently no standard for how to use them, and each tag has its own advantages, disadvantages, and capabilities. Although tags are commonly used for education and mass casualty drills, they are rarely utilized for real world events. In some cases, tags weren’t readily available. Other times, rescuers simply forgot to use them. For an MCI to be effectively managed, tags must be used.

In an effort to improve triage tag use in Northeast Ohio, University Hospitals has partnered with other hospitals to create better education, equipment, and procedures for response to MCI’s. This project also included developing a new triage tag to make the process easier for emergency responders. The tag requires less patient information, allows for re-triaging, and includes a hospital wristband to assist in patient tracking. As we roll out the new tags into 2024, some medical directors will encourage their use by having “tag days,” when all patients transported will be given a triage tag. The goal is to make the tags more commonplace both in their storage location, and their use.

We encourage all EMS personnel to review their MCI equipment, especially the triage tags their agency uses. Reviewing the use and application of the tags will surely assist you in managing patients in an MCI.

MCI- Week 4: Tracking your Victims

Since the mass evacuation of the gulf coast from Hurricane Katrina in 2005, efforts have been underway nationally to improve patient tracking during mass casualty incidents (MCI’s), as well as family reunification. As you can imagine, locating family members after an incident must be a high priority in the goals of any system. Our EMS plans for triage, treatment and transport must feed hospital patient tracking systems, which ultimately results in successful county family reunification plans. Although EMS has many responsibilities in managing an MCI, patient tracking only overlaps our duties twice.

The first has been there since the inception of the incident command system (ICS). MCI organizational charts originally included a transport sector, responsible for assigning the transport of patients to appropriate facilities and tracking who went where by whom. As ICS morphed into the national incident management system (NIMS), terminology was cleaned up and the duties became part of the transportation group, led by a supervisor. As with all NIMS assignments, any job not assigned becomes the duty of the incident commander (IC). Therefore, an MCI with no transportation group supervisor puts the duties of tracking the destination of each patient and ambulance squarely on the IC. Obviously, one of the first assignments at an MCI should be in transportation.

The second time EMS is involved with patient tracking is by linking a patient with a unique identifier. Normally this would be a patient’s name, but we know some of them won’t be able to provide that information to us. In single patient EMS calls, this is not a big deal. Family members, friends, or even a driver’s license may clear things up. If not, we have systems in place at hospitals to treat a John Doe. But with multiple Jane Doe’s at an MCI, how does EMS track the destination of someone or a family member find their loved one? Facial recognition may someday provide this unique identifier, but the technology and laws are simply not there yet. For now, our best option is a bar code. Most cell phones and tablets have the capability to scan a bar code. Bar codes are really just a visual representation of a number, so if a scanner was not available, EMS could simply record the number on the bar code.

This is exactly why triage tags have evolved with bar codes. If patients are appropriately triaged by their severity of injuries, tagged with an identifying color code, and the tags contain a unique identifier like a bar code, the system is complete. EMS really only has two responsibilities for patient tracking. First, put a tag on every patient which assigns them a unique identifier. Second, record that bar code number for a reference to where the patient was transported, and by what ambulance. In an effort to make your job a little easier, our new tags include numerous peel-off labels with the bar code and number on them so they can be peeled off a triage tag and stuck to a transport log form, scanned to a device, or uploaded to the state tracking system.

The state system is called EMTrack by Juvare, and can be downloaded as an app. It replaces the old OHTrack system, and offers some improvements. It starts with the creation of an MCI in the system, which notifies hospitals to prepare them. According to the Ohio Department of Health (ODH) website, “The intent is for incidents to be generated in the field to provide notice to healthcare facilities, (but) it is the responsibility of the receiving healthcare facility to create an incident if not already done so, and to track patients related to the incident.” Once an incident has been created, EMS agencies and hospitals can easily attach patients to the incident using the barcodes. Ultimately, that number can be used by organizations assisting with family reunification.  

We are in the process now of batch loading ambulances in northeast Ohio with usernames and pins.  If you have more questions about EMTrack or how to get a login and password, feel free to check the ODH website, contact your EMS coordinator or send your questions to: donald.zimmerman@uhhospitals.org 

https://www.jems.com/operations/ambulances-vehicle-ops/how-to-operate-and-manage-the-mci-transportation-group/

https://odh.ohio.gov/about-us/offices-bureaus-and-departments/bhp/resources/bed-availability-and-patient-tracking