November CME Journal

November Journal CME Article
From Larrey to the Present Day
It was over two hundred years ago when Napoleon’s chief surgeon, Dr. Dominique Jean Larrey,
suggested that not all patients on the battlefield should be treated the same. Dr. Larrey, who is also credited with
developing the concept of the ambulance, felt that some patients stood a better chance of surviving if they were
delivered promptly from the field to a medical facility, some patients could wait, and others were so severely
injured that they were certain to die even with prompt care. What he needed was a way to identify patients as
belonging to one of these categories and to facilitate their care accordingly. And so he suggested that medical
providers should be able to sort (in French, “triage”) patients according to the severity of their injuries.
“Those who are dangerously wounded should receive the first attention, without regard to rank
or distinction. They who are injured in a less degree may wait until their brethren-in-arms, who
are badly mutilated, have been operated and dressed, otherwise the latter would not survive
many hours, rarely until the succeeding day.” – D.J. Larrey, MD (1797)
In the centuries that have passed, this concept has been refined, its military use has been improved, and it
has been adopted for use in the civilian sector, including the development of such formalized triage programs as
START. And while these programs have improved our ability to rapidly classify patients as ambulatory,
moderately or severely injured or moribund, we have all experienced the patient who just doesn’t quite fit.
At the steam pipe explosion in Midtown, the only immediate fatality initially would have been
appropriately categorized as a green tag since she walked away from the scene despite her complaints of
shortness of breath. Isn’t there a better way to fit her into our triage and transport algorithms?
What do you do with the asthmatic who is too short of breath to walk, in moderate distress, yet has a
respiratory rate less than thirty (30)? Should she really be listed as a yellow tag and placed side-by-side with the
ankle injuries? What about the older male who is pale, cool, diaphoretic, and complaining of chest pain? What
about the child who has a pulse but has just stopped breathing?
November 2009 – Journal CME Newsletter page 6 of 15
The difficulty with most triage systems is that they focus on the very types of patients that Dr. Larrey first
focused on during the Napoleonic wars – the “dangerously wounded.” Triage focuses on the most common
emergencies during mass casualty incidents – the wounded – but it typically lacks the flexibility to deal with the
medical emergencies that are also a common part of any disaster. And it focuses on adults, while pediatric
patients may easily be involved in the incident.
For some time, the Office of Medical Affairs (led by Dr. David Prezant and Dr. Dario Gonzalez) has been
working with EMS Operations, the Bureau of Training, REMAC / REMSCO, pediatric disaster experts, and
others to develop a way to appropriately deal with such patients while holding to the basic principle of triage – to
provide the best care to the most patients in the setting of limited resources.
In this month’s article, we will review the principles that are being added to our triage algorithms,
describe the logic behind these changes, and provide examples of how these new concepts will impact upon onscene
operations at the scene of an MCI. Then, in this month’s CME drill and in other training sessions that will
follow, these concepts and the tag that will accompany them will be incorporated into our practice.
Let’s START with a Review
The Simple Triage and Rapid
Transport model of prehospital triage
utilizes four categories into which patients
are classified: green, yellow, red, and black.
This triage model (Figure 1), which has
been used by the FDNY and countless
other EMS agencies around the world, has
the advantage of using very simple, easy to
determine physical assessment findings to
direct patients into one of these four
categories.
Those patients who are able to walk
from the scene are classified as green tags.
The idea is that these patients will have
minimal injuries or complaints and that they are able to wait for a significant period of time before receiving
more definitive medical care. During very large events, this may even include being transported to distant
hospitals to keep from overwhelming facilities closer to the event.
With the green tags having removed themselves from the mix, patients now require a simple physical
assessment, beginning appropriately with the ABCs.
Figure 1: START Triage Algorithm
November 2009 – Journal CME Newsletter page 7 of 15
For those patients who are not breathing, one attempt to open their airway is made. Though they may still
have a pulse, the fact that they cannot maintain their own airway and ventilation would require the use of
resources that just are not available. Therefore, if this one attempt to open their airway is not sufficient to cause
them to start breathing, they are categorized as black.
Patient who are breathing or those who begin breathing after their airway is opened should have their
breathing assessed. Respiratory rates greater than thirty (30) are considered to be signs of critical illness or injury,
and these patients are categorized as red.
Spontaneously breathing patients with respiratory rates less than thirty (30) must then have their
circulation assessed. Remembering that the presence of a radial pulse is an indicator of a systolic blood pressure
of ~80mmHg or higher, patients without a palpable radial pulse are considered to be critically hypotensive and
are categorized as red.
Finally, those patients for whom the assessment of the ABCs does not suggest a critical condition (they
have a patent airway, respirations of 10-30 per minute and a palpable radial pulse) are assessed for significant
neurologic compromise. Patients who despite having intact ABCs cannot follow simple commands are
categorized as red.
And everyone who is left is classified as yellow. This means that this category, by default, includes
patients with non-life threatening injuries, non-ambulatory patients with medical conditions, and pediatric
patients who are unable to walk.
“Overtriage”
One of the recognized problems with the large variety of patients who end up being categorized as yellow
is that the providers who initially triage or later care for these patients often recognize the severity of their
injuries or illness in spite of their having met the criteria for a “yellow tag” or even “green tag.” To deal with this
problem, providers often feel the need to “uptriage” the patient in order to ensure their transport before patients
with less serious conditions.
The act of “uptriage” is certainly well-intended – the provider is trying to ensure that a patient who seems
to be in need of more rapid treatment and transport receives it by moving them into a “higher” category. But the
downside to this act is that the number of patients in that higher category increases – a result known as
“overtriage.”
The problem with overtriage is that, by increasing the number of patients in this higher triage category, it
is likely that the patients who were properly assigned to this category will suffer delays in transport and/or
treatment as the system works to deal with the larger number of patients in this category. And this could result in
further injury or even death among these patients.
This issue was one of the findings in a 2002 article that analyzed the triage of patients in a series of ten
terrorist bombings that occurred between 1969 and 1995. The authors found that overtriage resulted in increased
November 2009 – Journal CME Newsletter page 8 of 15
mortality (death) among the most critically injured patients because the limited resources were devoted to caring
for a larger number of patients: "…overtriage could be as life-threatening as undertriage because of the
inundation of overwhelmed medical facilities with large numbers of critical casualties all at once which may
prevent the timely detection of that small minority with critical injuries who need immediate treatment and
jeopardize their survival." (Frykberg – 2002)
Not Little Adults
As we have discussed in past articles, there are a number of
anatomic and physiologic differences between adult and pediatric patients.
And while a common practice among any of us who have had to triage a
child is to simply “uptriage” them, we have already mentioned why this
may not be the most appropriate act when you consider the overall event.
Where the START triage particularly fails to address pediatric
needs is in its initial steps. Remember that one of the primary causes of
death among pediatric patients is airway obstruction. But the START triage
algorithm would suggest that a child who is not breathing should have their
airway opened and, if they do not spontaneously breathe, they should be
triaged as black. And it is too easy to recall any number of events where
not trying to “at least try something” for a critically injured or dying child
was not a decision that a provider was willing to make (Figure 2).
For these reasons, there have been products developed to specifically address the challenges of pediatric
triage. One of the most popular of these is a product called JumpSTART, a modification to the START triage
algorithm that takes into account the issue of airway obstruction, uses vital signs that are specific to pediatric
patients, and changes the mental status assessment to account for the stranger-anxiety, fear, and language issues
that may prevent a child from “following commands.”
While such products are considered by many to be useful for the triage of a large number of pediatric
patients, these products are also thought to be of limited use when the incident includes a large number of patients
of varying ages. What is needed for such events is a simple-to-use algorithm that will take into consideration the
issues that we have mentioned here while not contributing to the stress and disorder of the scene by requiring
providers to use a variety of different algorithms depending on the age of each patient.
New Triage for New York City
As mentioned in the introduction, the Office of Medical Affairs has been working with a number of
individuals and organizations to improve upon our triage process while maintaining the fundamental principle
that must remain central for any useful triage algorithm: doing the most good for the greatest possible number of
Figure 2: Provider carries a mortally injured
child from the rubble of the Alfred P. Murrah
Federal Building in Oklahoma City, OK
November 2009 – Journal CME Newsletter page 9 of 15
patients. This process included the review of available triage concepts and products, discussions of the issues of
“overtriage” and the reasons behind it, age-specific issues for pediatric patients and issues that are specific to our
City. And just as importantly, the concepts that were developed were then shared with providers such as yourself
in order to receive critical feedback regarding the changes and whether they were felt to be of use in improving
the triage process and addressing providers’ concerns about our current process.
The result of these efforts is a new triage algorithm that we will be teaching throughout the Department,
beginning with this article. Further training will include this month’s skill drill and agency-wide trainings that
will occur as a part of grant funding that the Department received to enhance its disaster preparedness.
But the training cannot stop there, because it is not only FDNY providers who will be providing triage at
the scene of MCIs in this City. So the training materials that are developed will be shared with other EMS
agencies in the City and will be incorporated into multi-agency drills to be held in the future. And this training
will be extended beyond the City limits in order to include those providers who may assist us in the event of a
true disaster, including agencies that may respond as part of mutual aid agreements from surrounding counties
and states.
Enhanced START Triage
What is important to remember about this new triage process is that it is intended to build upon what you
have already been doing for your entire career. The START process forms the foundation of what will now be
Figure 3: Enhanced START Triage Algorithm for New York City
November 2009 – Journal CME Newsletter page 10 of 15
our triage program. And to that process two simple but critical concepts have been added – improved pediatric
triage and a new, intermediate category to address the concept of “overtriage.” With the addition of these two
steps, the new triage algorithm that we will use is as shown in Figure 3 and, as you can see, it is very similar to
START except for those two, very important changes.
While this algorithm may look like it is much more complex, it is so similar to START that there are
really only two changes. This means that your triage process will begin in the exact same way – getting anyone
who is ambulatory to remove themselves from the scene by directing them to a safe area. This will help to
eliminate some of the on-scene confusion and allow for more efficient triage of the remaining victims, will
minimize those moving about the scene other than rescuers, and will prevent further injury to these patients and
even providers.
With the “green” patients removed from the scene, the next priority is to identify those patients for whom
medical care and/or transport would likely be futile. And because of the issue of pediatric airway obstruction that
was mentioned above, this is the first place where an improvement has been added.
Begin by assessing each patient’s respirations. If none are noted, make one attempt to reposition the
patient’s airway. If the patient continues to be apneic (no spontaneous ventilations), they should be categorized as
“black” except for those who are children.
If the patient is a child (which is simply defined as a person who “looks like they are a child”) and
remains apneic after opening the airway, provide five artificial ventilations via bag-valve-mask. There are
certainly children for whom this simple act may be enough to stimulate spontaneous ventilations and, if so, they
should be triaged as “red.” For those children who do not respond to the five ventilations, having provided them
with the treatment for the most likely and reversible cause of death, they should be classified as “black.”
Just as in START triage, the next step is to assess the respiratory rate of all patients with spontaneous
breathing. If the respiratory rate is greater than 30, the patient should be categorized as “red.”
Now remember that the normal respiratory rate of an infant (less than one year of age) is thirty (30) to
sixty (60) breaths per minute. This means that infants are likely to all be categorized as “red.” Though this is an
example of the “overtriage” that was mentioned earlier, the very small number of infants involved in any mass
casualty incident combined with the difficult task of quickly assessing an infant makes this likelihood acceptable.
For those patients with spontaneous respirations at a rate of thirty or less, you should next assess their
radial pulse. If it is absent, they are assumed to be significantly hypotensive and therefore categorized as “red.”
For those with a radial pulse, their mental status should be assessed by asking them to follow a simple
command. Those who cannot are categorized as “red”, while those who can are categorized as “yellow.” But this
is where the second improvement occurs.
All of those patients who should be categorized as “yellow” that you may have previously been tempted
to “uptriage” to “red” now have a new category into which they can be placed. This category is meant to provide
November 2009 – Journal CME Newsletter page 11 of 15
an appropriate category for patients who do not meet the criteria for a “red tag” but whose injuries and/or medical
condition suggests to the on-scene providers that they are in need of more rapid treatment and transport than most
“yellow” patients.
The new “orange” category is meant to include both pediatric and adult patients who are unstable (but not
“red”), potentially unstable, or rapidly deteriorating. Most of these patients will be the medical patients
(respiratory distress, chest pain, asthma exacerbations, children with significant respiratory distress as evidenced
by respiratory rates less than twelve breaths per minute, etc) that would have otherwise been grouped with the
patients whose injuries prevented them from walking. And this category may include patients who would
otherwise be categorized as “yellow” or “red,” at the discretion of the on-scene providers.
And this is probably one of the most potentially exciting and useful parts of this new category – it is not
bound by vital signs or other strict criteria. It allows you to take those patients that you may have been tempted to
“uptriage” to the “red” category and appropriately assign them to a category that will speed their treatment and
transport without “overtriaging” into the “red” group of patients.
New Tag
This new approach to triage obviously would not work if we were to continue to use the same triage tag
that we have been using as part of the standard START triage process. We need a tag with an “orange” category,
at the very least.
The Department has been working to develop such a tag, but also one that allows for rapid documentation
and communication of other relevant information on the scene of a mass casualty incident or disaster. This
information includes initial treatments provided such as the number of nerve agent kits (Duodote or Mark I kits)
administered to the patient and other such useful information. These tags will be introduced as these other
training exercises are put into place in the coming weeks.
Conclusion
Appropriate triage is an absolutely essential component for the management of any mass casualty incident
or disaster scene and has been shown to improve the outcomes of the patients involved in such an incident. Its use
ensures that the limited resources that are available for any such incident are appropriately utilized to provide the
best possible care to the greatest number of patients. And with the addition of the two changes described in this
article, the ability of each and every one of you to ensure that this occurs during such events will increase
dramatically.
Written by: John Freese, M.D. Dario Gonzalez, M.D.
Medical Director of Training / OLMC Borough Medical Director – Manhattan and Bronx
Director of Prehospital Research Medical Director for Rescue / HAZTAC
November 2009 – Journal CME Newsletter page 12 of 15
NOVEMBER 2009 JOURNAL CME QUIZ
1. Which patient is not appropriately categorized “red” under the new triage algorithm to be used in NYC?
a. patient with spontaneous respirations but no palpable radial pulse
b. patient who begins to spontaneously breathe only after having their airway opened
c. child who begins to spontaneously breathe after receiving five artificial ventilations
d. child who is breathing less than thirty times per minute
e. patient who is breathing less than 30/min, has a radial pulse, and cannot follow commands
2. All of these patients may appropriately be categorized as “orange” except:
a. a forty-five year-old patient with orthostatic hypotension and chest pain.
b. a nineteen year-old patient experiencing a moderate asthma exacerbation.
c. a six year-old patient with normal V/S who is able to follow commands with a significant head injury.
d. a twenty-one year-old patient who begins to spontaneously breathe after their airway is repositioned.
e. an eleven year-old with normal V/S, able to follow commands, with inspiratory / expiratory stridor.
3. Whifcih of the following is true of pediatric triage?
a. No programs have been developed to specifically address the issues of pediatric triage.
b. Because children are really no different than adults, there is no need for pediatric-specific triage.
c. JumpSTART is an example of an adult triage program that does not consider pediatric needs.
d. There is no need to adjust vital sign parameters as pediatric vitals signs are similar to those of an adult.
e. The new approach to triage in New York City will provide five ventilations to an apneic “child.”
44. AAs part of the new triage algorithm to be used in New York City, which of the following is the correct
a. age <18 c. looks like an infant e.
b. age <21 d. looks like a child
age <14, consistent with
REMAC protocols
5. The first descriptions of a triage process date back to:
a. the Napoleonic wars c. WWI e. the Vietnam War / Conflict
b. the American Civil War d. WWII
6. The normal respiratory rate for an infant is:
a. 12-20 c. 20-30 e. 30-60
b. 15-25 d. 30-40
7. The result of placing patients into triage categories higher than those to which they should rightfully be
a. overflow c. overload e. overspread
b. overtriage d. overweighing
8. Which of the following is true regarding the initial development of the modern day triage process?
a. It was developed by one of Caesar’s physicians, Dr. Larrey.
b. The physician credited with developing the idea of triage also developed the idea of the ambulance.
c. The concept of triage was designed to ensure that the richest patients were treated first.
d. The concept of triage was designed to ensure that the highest ranking patients were treated first.
e. Triage is the French word term for “bring out your dead.”
9. One of the most common and yet reversible causes of death among pediatric patients is:
a. airway obstruction c. head injuries e. vascular compromise
b. asthma d. myocardial infarction
10. The concept of START triage stands for:
a. Simple Treatment after Rapid Triage d. Sample Triage and Rapid Transport
b. Simple Triage and Related Transport e. Sample Treatment allows Rapid Transport
c. Simple Triage and Rapid Transport
November 2009 – Journal CME Newsletter page 13 of 15
Based on the CME article, place your answers to the quiz on this answer sheet.
Respondents with a minimum grade of 80% will receive 1 hour of Online/Journal CME.
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• for all other inquiries.
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November 2009
CME Quiz
1.
2.
3.
4.
5.
Required for
BLS & ALS
providers
6.
7.
8.
9.
10.
Required for
ALS
providers only
November 2009 – Journal CME Newsletter page 14 of 15
Citywide CME – N