Donald S. MacMillan

Pilot Test of the SALT Mass Casualty Triage System

Introduction. No existing mass casualty triage system has been scientifically scrutinized or validated. A recent work group sponsored by the Centers for Disease Control and Prevention, using a combination of expert opinion and the extremely limited research data available, created the SALT (sort–assess–lifesaving interventions–treat/transport) triage system to serve as a national model. An airport crash drill was used to pilot test the SALT system. Objective. To assess the accuracy and speed with which trained paramedics can triage victims using this new system. Methods. Investigators created 50 patient scenarios with a wide range of injuries and severities, and two additional uninjured victims were added at the time of the drill. Students wearing moulage and coached on how to portray their injuries served as “victims.” Assuming proper application of the SALT system, the patient scenarios were designed such that 16 patients would be triaged as T1/red/immediate, 12 as T2/yellow/delayed, 14 as T3/green/minimal, and 10 as T4/black/dead. Paramedics were trained to proficiency in the SALT system one week prior to the drill using a 90-minute didactic/practical session, and were given “flash cards” showing the triage algorithm to be used if needed during the drill. Observers blinded to the study purpose timed and recorded the triage process for each patient during the drill. Simple descriptive statistics were used to analyze the data. Results. The two paramedics assigned to the role of triage officers applied the SALT algorithm correctly to 41 of the 52 patients (78.8% accuracy). Seven patients intended to be T2 were triaged as T1, and two patients intended to be T3 were triaged as T2, for an overtriage rate of 13.5%. Two patients intended to be T2 were triaged as T3, for an undertriage rate of 3.8%. Triage times were recorded by the observers for 42 of the 52 patients, with a mean of 15 seconds per patient (range 5–57 seconds). Conclusions. The SALT mass casualty triage system can be applied quickly in the field and appears to be safe, as measured by a low undertriage rate. There was, however, significant overtriage. Further refinement is needed, and effect on patient outcomes needs to be evaluated.

Pilot test of a proposed chemical/biological/radiation/ nuclear-capable mass casualty triage system

Introduction. Existing mass casualty triage systems do not consider the possibility of chemical, biological, or radiologic/nuclear (CBRN) contamination of the injured patients. A system that can triage injured patients who are or may be contaminated by CBRN material, developed through expert opinion, was pilot-tested at an airport disaster drill. The study objective was to determine the systems speed andaccuracy. Methods. For a drill involving a plane crash with release of organophosphate material from the cargo hold, 56 patient scenarios were generated, with some involving signs andsymptoms of organophosphate toxicity in addition to physical trauma. Prior to the drill, the investigators examined each scenario to determine the “correct” triage categorization, assuming proper application of the proposed system, andtrained the paramedics who were expected to serve as triage officers at the drill. During the drill, the medics used the CBRN triage system to triage the 56 patients, with two observers timing andrecording the events of the triage process. The IRB deemed the study exempt from full review. Results. The two triage officers applied the CBRN system correctly to 49 of the 56 patients (87.5% accuracy). One patient intended to be T2 (yellow) was triaged as T1 (red), for an over-triage rate of 1.8%. Five patients intended to be T1 were triaged as T2, andone patient intended to be T2 was triaged as T3 (green), for an under-triage rate of 10.7%. All six under-triage cases were due to failure to recognize or account for signs of organophosphate toxidrome in applying the triage system. For the 27 patients for whom times were recorded, triage was accomplished in a mean of 19 seconds (range 4-37, median 17). Conclusions. The chemical algorithm of the proposed CBRN-capable mass casualty triage system can be applied rapidly by trained paramedics, but a significant under-triage rate (10.7%) was seen in this pilot test. Further refinement andtesting are needed, andeffect on outcome must be studied.

Noninvasive fireground assessment of carboxyhemoglobin levels in firefighters.

Objectives. Carboxyhemoglobin (COHb) levels can be estimated by chemical analysis of exhaled alveolar breath. Such noninvasive measurement could be used on the fireground to screen both firefighters (FFs) andvictims. The purpose of this study was to assess the feasibility of using a hand-held carbon monoxide (CO) monitoring device to screen for CO toxicity in FFs under field conditions. Methods. Informed consent was obtained from all participants. Using a hand-held breath CO detection device, COHb readings were collected at baseline, andthen as FFs exited burning buildings after performing interior fire attack andoverhaul with self-contained breathing apparatus (SCBA) during live-fire training. Ambient CO levels were occasionally measured in interior areas where the FFs were working to assess the degree of CO exposure. Results. Baseline COHb readings of 64 FFs ranged from 0% to 3% (mean 1%, median 1%). One hundred eighty-four COHb readings were collected during training exercises. The mean andmedian COHb levels were 1%. The maximum value in a FF wearing SCBA was 3%; values of 14%, 5%, and4% were measured in instructors who were not properly wearing SCBA. Ambient CO readings during fire attack ranged from 75 to 1,290 ppm, andthe ambient CO reading for overhaul ranged from 0 to 130 ppm. When the device was used for interior CO monitoring, washout time limited its utility for COHb monitoring in FFs. Conclusions. A hand-held CO monitoring device adapted for estimation of COHb levels by exhaled breath analysis can feasibly be deployed on the fireground to assess CO exposure in FFs.

Is there a role for first responders in EMS responses to medical facilities

Objective: Emergency medical dispatch (EMD) protocols should match response resources with patient needs. We tested a protocol sending only a commercial ambulance, without fire department first responders (FR), to all non-cardiac-arrest EMS calls at a physician-staffed HMO facility. Study objectives were to determine how often FR provided patient care at such facilities andwhether EMD implementation could conserve FR resources without compromising patient care. Methods: All EMS dispatches to this facility in the 4 months before implementation of the EMD protocol and4 months after implementation were identified through dispatch records, andall FR andambulance patient care reports were reviewed. In the “after” phase, all cases needing ALS transport were reviewed to examine whether there would have been benefit to FR dispatch. Results: Of 242 dispatches in the “before” phase, BLS FR responded to 156 (64%), andALS FR to 117 (48%). BLS FR provided patient care in 2 cases, andALS FR in 17. Of 227 dispatches in the “after” phase, BLS FR responded to 10 (4%), andALS FR to 10 (4%); all but one were protocol violations. BLS FR provided care in one case, andALS FR in three. Review of the 93 “after” cases requiring ALS transport found none where FR presence would have been beneficial. Conclusions: First responders rarely provided patient care when responding to EMS calls at a physician-staffed medical facility. Implementation of an EMD protocol can safely reduce the number of FR responses to unscheduled ambulance calls at such a facility. Key words: emergency medical services; dispatch.

Model describing the effect of employment of the United States military in a complex emergency.

The end of the Cold War vastly altered the worldwide political landscape. With the loss of a main competitor, the United States (US) military has had to adapt its strategic, operational, and tactical doctrines to an ever-increasing variety of non-traditional missions, including humanitarian operations. Complex emergencies (CEs) are defined in this paper from a political and military perspective, various factors that contribute to their development are described, and issues resulting from the employment of US military forces are discussed. A model was developed to illustrate the course of a humanitarian emergency and the potential impact of a military response. The US intervention in Haiti, Northern Iraq, Kosovo, Somalia, Bosnia, and Rwanda serve as examples. A CE develops when there is civil conflict, loss of national governmental authority, a mass population movement, and massive economic failure, each leading to a general decline in food security. The military can alleviate a CE in four ways: (1) provide security for relief efforts; (2) enforce negotiated settlements; (3) provide security for non-combatants; and/or (4) employ logistical capabilities. The model incorporates Norton and Miskels taxonomy of identifying failing states and helps illustrate the factors that lead to a CE. The model can be used to determine if and when military intervention will have the greatest impact. The model demonstrates that early military intervention and mission assignment within the core competencies of the forces can reverse the course of a CE. Further study will be needed to verify the model.

Fireground use of an emergency escape respirator.

Abstract Introduction. Firefighters who become lost, disoriented, or trapped in a burning building may die after running out of air in their self-contained breathing apparatus (SCBA). An emergency escape device has been developed that attaches to the firefighters mask in place of the SCBA regulator. The device filters out particulate matter and a number of hazardous components of smoke (but does not provide oxygen), providing additional time to escape after the firefighter runs out of SCBA air. Objective. To field-test the device under realistic fire conditions to 1) ascertain whether it provides adequate protection from carbon monoxide (CO) and 2) examine firefighters’ impressions of the device and its use. Methods. A wood-frame house was fitted with atmospheric monitors, and levels of CO, oxygen, and hydrogen cyanide were continuously recorded. After informed consent was obtained, firefighters wearing the escape device instead of their usual SCBA regulators entered the burning structure and spent 10 minutes breathing through the device. A breath CO analyzer was used to estimate (±3 ppm) each subjects carboxyhemoglobin level immediately upon exiting the building, vital signs and pulse oximetry were assessed, and each firefighter was asked for general impressions of the device. Results. Thirteen subjects were enrolled (all male, mean age 42.5 years, mean weight 94 kg). The mean peak CO level at the floor in the rooms where the subjects were located was 546 ppm, and ceiling CO measurements ranged from 679 ppm to the meters’ maximum of 1,000 ppm, indicating substantial CO exposure. The firefighters’ mean carboxyhemoglobin level was 1.15% (range 0.8%–2.1%) immediately after exit. All pulse oximetry readings were 95% or greater. No subject reported problems or concerns regarding the device, no symptoms suggestive of smoke inhalation or toxicity were reported, and all subjects expressed interest in carrying the device while on duty. Conclusion. The emergency escape device provides excellent protection from CO in realistic fire scenarios with substantial exposure to toxic gases, and the firefighters studied had a positive impression of the device and its use.

O FFICER D OWN

At 9:18 PM on a June evening, a basic life support (BLS) first-responder engine company and a paramedic rescue unit were dispatched by the fire department communications center for a report of a police officer shot. The engine company arrived shortly before a commercial advanced life support (ALS) ambulance from the service that contractually provides emergency medical services (EMS) transport within the city. That ambulance had not been dispatched to this incident, but heard the call over a radio scanner and responded from the hospital a few blocks away. When they arrived at 9:19 PM, EMS personnel from both units found a 25to 30year-old man who was identified by on-scene uniformed officers as an undercover officer who was working a narcotics interdiction task force at the time of the shooting. The patient was lying unconscious and supine on the curb with his head in a flexed position. Because of the large throng of police officers surrounding the patient, the ambulance crew was able to gain only limited access to the patient and was unable to assess airway/breathing/circulation despite multiple attempts. As soon as the stretcher was removed from the ambulance, the wounded police officer was picked up by several other officers and placed on the stretcher without any direction from the senior medical responder. The ambulance crew was able to place a long board on the stretcher, but no cervical immobilization was performed despite attempts by the paramedic to do so. The patient was then placed in the back of the ambulance, again by police officers without direction by the senior medical responder. By this time (9:20 PM), the dispatched commercial ambulance and the fire department’s ALS rescue unit had arrived. A more thorough evaluation could now be performed by EMS personnel. The patient had what appeared to be a single gunshot wound (GSW) to the right infraorbital region. At this point, the first-arriving paramedic realized that the patient was his brother-in-law. The patient was stripped, his weapon was secured, and his ballistic vest was removed. The patient was pulselsess and apneic, and cardiopulmonary resuscitation (CPR) was begun by the first-arriving paramedic. The airway was controlled by positioning, and he was ventilated using a bag–valve–mask. Throughout the 3 minutes on scene, multiple police officers tried to get into the ambulance with the patient, further hampering resuscitative efforts. Throughout the evaluation and transport, the police officer accompanying the patient to the hospital pleaded with the paramedic not to let him die. Before departing from the scene at 9:22 PM, multiple police officers yelled and ordered the ALS transport and first-responder crew to leave for the hospital immediately. The total prehospital time, from dispatch of the initial assignment to arrival of the ambulance at the emergency department (ED), was 7 minutes. During the brief transport to the hospital, the patient’s condition did not change. Intravenous access and endotracheal intubation were not attempted, and formal vital signs were not assessed. No communication was made from the personnel in the patient compartment of the ambulance to the receiving hospital, although brief notification was made by the driver. On arrival at the trauma bay, the primary survey revealed a male patient with pulselsess electrical activity and a Glasgow Coma Scale score of 3. The patient was intubated, intravenous access was established, and epinephrine and atropine were administered with return of pulse. A large amount of blood was present in the oropharynx, requiring extensive suctioning before intubation. The patient’s cervical spine was immobilized with a Philadelphia collar during the initial resuscitation. Secondary survey revealed no other obvious injuries. The patient was taken to the computed tomography (CT) scanner, where a study of the head and neck revealed a maxillary sinus fracture, a slightly displaced left lamina fracture of C-1 with a bullet fragment in the adjacent prevertebral space, and associated soft tissue swelling. An arteriogram of the vertebral arteries was normal. During the initial evaluation, the trauma room became very crowded with city police officers. Despite placing two CASE CONFERENCE

Intracerebral Hemorrhage with Herniation in a Second-Trimester Pregnant Female

A 30-year-old woman, gravida 1, para 2, in her second trimester presented to the local emergency department complaining of an atraumatic headache described as the worst headache of her life. While undergoing evaluation, she became unresponsive with signs of herniation, including a blown pupil and bradycardia. Emergent imaging identified an intracerebral hemorrhage requiring immediate surgical decompression. The patient was transferred by helicopter to tertiary care. Upon arrival, the patient was taken directly to the operating room and underwent a decompressive craniotomy. This article reviews the considerations for transporting pregnant patients with intracerebral hemorrhage.