The multiple casualty incident (MCI) plan for Emergency Medical Services is as strong as the weakest link. There are a lot of links in the chain, so it is critical that every member of the EMS organization develop skills to manage his/her role in a major incident.
Some agencies have developed a routine practice of triage skill testing using a defined period for use of process and props. This process is affectionately called "Triage Tuesday" in many communities.
The goals are several-fold. First, it allows EMS providers to use the basic tools of MCI management, like triage tags. Second, it gives providers the opportunity to discuss their patient evaluation skills with their officers, and importantly, the nurses and physicians at the Emergency Department. Third, it reinforces skills that will create confidence in the providers when the big incident needs to be managed.
The process of using "Triage Tuesdays" instills, and then cultivates, a culture of confidence in EMS providers and emergency department personnel.
Multiple casualty incident preparedness
EMS agencies and providers successfully use everyday operations to prepare for bigger incidents, including MCI events. The daily use of Incident Command Systems for incident management is one of the most important elements of preparedness.
Formal Incident Management System training is designed to prepare providers at all levels and in all disciplines for a multi-agency response. The use of patient triage principles occurs with each patient encounter, and is built around the use of ABCDE patient assessment (Airway Breathing Circulation Disability Exposure) and the differentiation of all types of patients around the basic decision of "sick" and "not sick."
But triage for multiple patient incidents requires another level of decision-making by emergency workers. Those incidents require the caregiver to determine who is sickest among a number of patients, and how sick are they versus the resources that are available to care for them. In the worst of MCIs, someone needs to be prepared to make decisions about who should or should not be resuscitated.
It is these decisions that can be developed using regular training like "Triage Tuesday."
Preparing EMS providers for multiple casualties
EMS providers accept that they practice patient assessment and determination of critical illnesses or injuries with everyday patient encounters. Many resist training for these incidents. There's a few reasons for this:
EMS providers don't like to practice. They often have a bias toward actual delivery, and feel that everyday care is difficult enough to prepare for a big incident.
It takes time and effort. It distracts from the most important role, which is day-to-day care.
EMS professionals don't like "pretend games" at all, and get callused by daily interactions with patients and providers that "play too many games."
When things don't go well in training exercises, it can be embarrassing.
It costs money to use those materials like triage tags, and other props.
So how can EMS agencies develop a regular and routine practice of triage skill testing? First, use a defined period for use of process and props, like "first Tuesday of every month." Second, work with hospital(s) providers to set mutual goals, like "we are testing and updating processes to prepare for MCIs in our area, for the mutual benefit of the patient." Third, establish a routine practice to communicate the results in each direction, as in "we are identifying areas of weakness in our practice only by accepting suggestions and concerns from your personnel, and hope your agency will do the same."
In the simplest models, the agency's triage tags are applied to each patient who is transported on a given day of the week (or month) before arrival at the hospital. The tag may or may not be used for simple documentation, in addition to the routine patient care report.
The Emergency Department personnel, advised about the process, accept the patient and confirm the accuracy of the patient triage classification, providing simple and immediate feedback to the EMS crew.
Emergency Department personnel may take advantage of the opportunity to test their own triage skills, become familiar with the tagging systems, and use the ED's disaster patient tracking system.
There are more opportunities to expand the training, or add elements once a month to enhance the experience. More props can be utilized, including vests, caps, signage, management boards, and technology enhancements.
Those items that were purchased are dug out of the cabinets and closets, and used for the day. Some agencies will designate the first Tuesday of the month to use the expanded set of tools, designate what type and volume of incidents will utilize the props (every auto accident, or every injured patient incident), utilize field and ED supervisors to provide additional options for testing and management, and produce reports on use of all of the tools.
When agencies are using new tools for MCIs, like bar code devices, the monthly designation allows more providers to develop the skills in using the technology, in the field and in the ED.
An important element of these designated days is to practice the communication scripts. The EMS providers will be asked to use the MCI props, and also to communicate with the patient/family/ED personnel what the props would accomplish in a major incident.
For example: "Mr. Jones, we take care of people every day, and expand those principles when we have big incidents or multiple patients. This is one of the tools we use for big incidents, and we are using it today on all of our patients. We are also doing our regular documentation that is part of your medical record."
In a few places, the supervisors will take the day's incidents and add some elements that give providers some practice in MCI management. At each incident where there is a moment or two where critical patient care is not needed, the supervisor may inject a couple virtual patient encounters to manage, or test the providers on what they would do if this patient encounter was part of a multiple casualty incident that is common for the area. That way a simple patient encounter can be made into a more complex incident for the providers to manage.
Simple and technology enhancements for MCI training
Triage Tuesdays allow the development of MCI skills without moulage, fake patients, and contrived scenarios. It is noted that the skills of MCI management are not developed by moulage administration. Don't waste the money. It is advantageous to expand on real patient encounters, rely on day-to-day patient assessments to train providers on what patients look like, and use simple patient descriptor cards to allow the providers to triage multiple simultaneous patients.
An EMS system could almost develop "baseball cards" that have a descriptor of patient injuries, and have the EMS providers practice going through the cards and making an accurate triage decision. A sample patient descriptor is listed below.
IT applications to Triage Tuesday are very appropriate. Some EMS systems and Emergency Departments have new IT applications that are being utilized, sometimes with new equipment, communication processes, and software.
These special tools require regular practice, especially near the introduction. Regular MCI drills allow practice using the tools, the hardware, and the software. It also helps define shortcomings and bottlenecks. It is likely to greatly benefit the staff of the EMS providers and the Emergency Department.
Regular drills, like Triage Tuesdays, enhance training for emergency providers. With that process, the EMS agency is taking care of people, to include your providers, your patients, and your support agencies. There is great benefit to having, practicing, and improving the EMS MCI plan. Having each member of the EMS agency and Emergency Department skilled in the props, process, and practice will benefit all of the appropriate elements, especially the rescuers.
Triage Tuesdays allow providers to use MCI props routinely. Vests, hats, signage all gets way too buried without regular use. So dust off the MCI kit, write and print a couple hundred patient descriptor cards, and take advantage of all special events. Understand what are high-risk events and use those as scenarios.
Sample MCI Patient Descriptor Cards Patient 101
Chris Farmley, born on 8/2/88, SS# 123-45-6789, complains of abdominal pain.
Jane Doe, approximately 13 year old Caucasian female with blonde hair, blue eyes, and a one inch scar on her left knee, is unconscious with no apparent injuries.
Cyanotic, cool, moist
Carotid pulse weak, irregular
Does not respond to verbal stimuli; pupils dilated, react slowly
About the author
James J Augustine, M.D., is medical advisor for Washington Township Fire Department in the Dayton, Ohio, area. He is director of clinical operations at EMP Management in Canton and a clinical associate professor in the Department of Emergency Medicine at Wright State University. He formely served as Deputy Chief-Acting Medical Director for Washington, DC Fire EMS. He has served 27 years as a firefighter, and was the first Chair of the Ohio EMS Board. Contact him via email at James.Augustine@FireRescue1.com.
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