Triage at a Major Incident

Attack One responds to a motor vehicle accident with multiple casualties. The accident resulted from poor weather conditions, with a family van crossing the interstate median and striking a tractor-trailer head-on. There are at least 12 victims, and numerous fire units and EMS providers are involved and organized under Incident Command. The Attack One crew oversees triage. The van has been crushed, and two extrication crews are working opposite sides of the vehicle to effect rescue. The weather conditions involve rain and fog, with temperatures just above freezing.

Triage

Triage is rapidly organized. Victims freed from the wreckage include two persons from the tractor-trailer, both with moderate injuries. In the van, there were four adults and six children. Two children were ejected and have life-threatening injuries. Two children were removed by bystanders and have serious injuries. Two adults removed themselves and have serious injuries, and another adult has minor injuries. The remaining adult and two children are critically injured and will require extrication. Currently, about five transport ambulances are on scene, and it will be 10–15 minutes until another box alarm of five transport ambulances can arrive at the scene. More ambulances are available if needed.

The community’s hospitals are within 10–20 minutes away, and the trauma center is within 15 minutes. All hospitals are available to take patients.

Organizing Triage & Transportation

The Attack One crew does a rapid assessment of each of the 12 victims. The victims’ injuries and triage categories are summarized in the accompanying table. The crew meets with the EMS officer assigned to the transport sector. Treatment at the scene will be minimized, as cold, wet conditions will aggravate traumatic wounds, and helicopter transportation will not be an option. An adjacent area is designated as the transportation zone, and the EMS units are moved to that site. Victims already freed from the wreckage are moved to the area and then into the units as rapidly as possible.

The Attack One crew has designated the following order for transportation:

1) The two children who were ejected with red category life-threatening injuries;

2) The two children with red category serious injuries;

3) The two adults with red category serious injuries;

4) The two adults from the tractor-trailer with yellow category moderate injuries;

5) The three victims with red category critical injuries as they are extricated;

6) The adult with minor injuries.

The crew counts the number of transport units needed, and since there are ample EMS units available in the region, they assign each red category victim to an individual medic, and yellow or green category victims will be paired two at a time for transport. That means 11 transport vehicles will be activated for the victims, and one more to support the extrication. Transport sector personnel concur with this request, and Incident Command activates the regional box alarm system to obtain those units.

Abruptly, there is a scream in the extrication area. A hydraulic line on the extrication tool has ruptured and sprayed hot fluid on two of the firefighters. Both had goggles in place, but hot fluid sprayed onto the eyes, face and neck of one firefighter. The other injured his leg and burned his arms as the equipment recoiled. Immediately, the firefighter with the facial burns is pulled away and rinsed with cool water, but he has sustained significant burns to those areas, and he cannot open his eyes to assess for damage to them.

Attack One now has to add two more patients to the triage group and determine where these injured firefighters will fit into the transportation sequence. The injured crew members are added to the transportation list. A new group of extrication personnel is organized and utilizes a different hydraulic tool to remove the remaining victims.

Injured Children, Rescuers

There are good reasons to prioritize younger victims and members of the fire-rescue team for faster removal from an incident scene. Children who are acutely ill or injured have fewer reserves than adults, are more likely to be negatively affected by environmental conditions (particularly cold), and have a higher likelihood of complications from prolonged immobilization. Injured children and rescuers are much more likely to produce a stressful work environment for the remaining rescuers, and this distraction can prevent the ongoing rescue from progressing as effectively as it could. It is a good practice to prioritize these victims higher for transportation from the scene, provided that patient care is not compromised for those with threats to life or limb. For similarly injured children and adults, the child should be prioritized for earlier transportation.

The more-severely injured fire-rescue member has sustained burns and traumatic injuries. As discussed previously in this column, burn triage can be performed using no equipment. Partial-thickness burns produce intense pain, so remember, “quiet is bad.” This injured rescuer is very uncomfortable and has intense spasm of his eyelids, preventing him or the Attack One crew from determining the level of damage. He may have a problem that threatens his vision.

Personnel responsible for triage and transportation decisions should prioritize those patients having life threats first, then serious but salvageable wounds or illnesses. That is the purpose of the red/yellow/green triage classification system, and the basis for making transportation its own decision-making sector in the Incident Command System. To the extent possible, during triage and pre-transportation, all patients should be kept warm and appropriately immobilized, provided comfort and pain control, and then removed as soon as transport is available.

Organizing Patient Transportation

Many fire and EMS organizations use triage systems that result in patients being numbered in sequential fashion. The accompanying box depicts the results of that triage process. The crews have triaged 14 patients, and categorized them by compromise of the ABCDE body systems. The challenges in assigning victims for transport in this incident are 1) the need to place injured fire-rescue members and 2) the three victims who remain trapped. Their extrication will take an unknown amount of time and create additional victims in an unknown order.

Case Discussion

The crews in this case organized a difficult incident, found and triaged all patients, and then reorganized the scene following an accident with the extrication equipment. Cold weather made rapid transportation a priority. The two critically injured children, the two firefighters and the extricated patients (totaling seven patients) were removed to the trauma and burn center. The two serious pediatric patients were stabilized at the closest community hospital, then transferred to the regional pediatric trauma center. The two

serious adult patients were transported to the next-closest community hospital, stabilized and then later transferred to the trauma center. The same hospital cared for the three remaining yellow patients.

All victims were removed within 40 minutes of the Attack One crew arriving at the scene. The burned and injured firefighter had significant deep partial-thickness burns to the area around his eyes, but his goggles had prevented direct pressure injection of hot fluid into his eyes. His vision recovered shortly, and his other wounds healed well. The second firefighter recovered from a fractured lower leg and less-severe burns to his arms.

Later investigation revealed the hydraulic tool failed after the line lodged between two hot, sharp edges of the van.