Medical Care during Disaster Situations

PATIENT IDENTIFICATION, REGISTRATION, AND CHARTING Documentation is limited to patient identification and charting of critical findings and treatments. Some plans call for the use of the prehospital disaster tag to record this limited information. Other plans include the preparation of kits containing the emergency department records, x-ray requests, laboratory slips and tubes, and wristbands, all prelabeled with a discrete disaster number. Medical records and laboratory computers accept these numbers, which are used for patient identification until full normal registration is possible. At that point the computer will search previous medical records to match disaster numbers with the records of victims who have been patients previously. Such a prelabeled kit system can be used during normal operations on unidentified critically ill or injured patients, so that all hospital departments are familiar with the concept. Admissions personnel are needed to log key information rapidly. Hours or days later they will be able to complete the registration process.

TRIAGE Triage is the prioritization of care based on severity of injury or illness, prognosis, and availability of resources. The triage personnel determine to which predesignated patient care area a patient should be sent based on priorities for care. For example, patients needing immediate decontamination or resuscitation are taken to decontamination and resuscitation areas. The dead are moved directly to the morgue. The severely but less critically injured are taken to the major illness/injury area. The walking injured are directed to the minor injury/primary care treatment area, often located in outpatient clinic areas.

A team consisting of an emergency physician or a surgeon skilled in triage, an emergency department nurse, and a medical records or admitting clerk should assess every patient. In extraordinary situations, several triage teams may be required to handle the casualty load. The physician performing hospital triage should be acknowledged as being in command in the triage area, should be clearly identified by a specially colored vest or other garment, and must understand all triage options.

Even though patients may have been triaged at the scene, they should undergo a second triage upon arrival at the hospital at the ambulance/triage entrance to the emergency department. Triage teams must remain at triage and cannot be diverted for patient care. Another team should be called to triage if immediate life support is needed. Only the most basic steps, such as opening the airway and applying pressure to active bleeding, should be done.

The triage team may need to communicate information on the number of casualties, severity of injuries, and need for additional resources to both the emergency department and the hospital Disaster Command center. Likewise, triage personnel need to be informed about the capability of the various treatment areas (e.g., major and minor injury) to handle additional casualties or special problems, such as eye injuries or burns. They also need to know about the establishment and location of patient overflow areas.

The admitting clerk's role as part of the triage team is to complete triage tags, attach them to victims, retrieve valuables and clothing for bagging, and maintain the triage area casualty log.

The approach to patient evaluation and treatment is quite different under disaster situations resulting in large numbers of casualties. While some principles of medical care are unchanged in a mass-casualty incident, other principles must be altered to achieve the best outcome for the largest number of patients rather than concentrating resources on a single patient. There is no role for advanced life support resuscitation at triage; care should be limited to manual opening of airways and control of external hemorrhage. Routine emergency department care is also modified: patients in cardiac arrest do not usually receive advanced life support and cardiopulmonary resuscitation in order that other seriously injured patients with a better chance of survival can be treated with available resources; radiologic and laboratory studies are used only if they will provide critical information; patients are hospitalized only when necessary; nurses have increased autonomy; and paramedics operate under standing orders without the need for on-line medical control.

The most common triage classification involves assigning patients to one of four color-coded categories (red, yellow, green, or black) depending on injury severity and prognosis (Tabie.5-4). In addition to taking into account the nature and urgency of the patient's condition, triage decisions should be sensitive to such factors affecting prognosis as age, general health, and prior physical condition of the patient.

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