National Registry Paramedic Exam: Trauma - Incident Management and Triage

Incident management and triage often are the paramedic's responsibility. On a scene with multiple patients, or the potential for multiple patients, the paramedic must employ a system of response, treatment, and transport to maximize the greatest number of casualties surviving the incident with the least long-term deficits. This can be accomplished by using the National Incident Management System (NIMS) to help guide responses and effective, rapid triage on scene to help identify the most life-threatening conditions among the casualties. This section will provide an overview of both systems and highlight the areas commonly tested.

Incident Command System
NIMS provides for the overall structure guidelines for the effective running of a situation. If all responders are familiar with the system and how to operate within it, the casualties will suffer the least long-lasting ill effects, and the providers will be able to operate in a safe environment.

The  incident command system has the following components:

- Command structure
- Preparedness
- Resource management
- Communications and information management and dissemination

Incident Commander
The incident commander (IC) on a scene will be the person in charge of the overall operation of the scene. In many cases, this is the local fire chief, fire marshal, or other designated officer. Rarely is it a person from EMS. The IC, like the chief executive officer of a small business, is responsible for scaling up or scaling down the operation depending on needs and resources. He or she assigns the necessary roles to arriving personnel or as they become necessary. Any roles not assigned are inherently retained within the role of the IC.

There are 2 types of command systems:

- Unified Command System. A system of command where the possibility of a major incident is planned well ahead of time with the anticipated agencies that will be involved with the primary wave of response. For example, agencies in the area of a nuclear power plant will plan and practice, often at least annually, for a fire or meltdown situation. During this drill, they will practice establishing triage and evacuation procedures, among many other procedures. It gets the name unified because each agency knows the role it would play in the event of an actual incident.
- Single Command System. In this system, one person is in command of the operation. These are often medium- to large-scale incidents that could not be anticipated, such as a multiple vehicle crash on a major highway or a natural disaster. The IC, as in the unified command system, should be well identified both on his or her uniform and the location from which he or she will operate.

Finance Sector Chief
The finance sector chief will be responsible for all costs associated with a large-scale incident. This is particularly essential when multiple agencies are responding. The finance sector chief often is part of a unified command structure, and the expenses are tallied well in advance of the event.

Logistics Sector Chief
Logistics is planning, so the logistics sector chief is responsible for procuring and distributing supplies to be delivered directly to a scene. The supplies include not only medical supplies but also food, water, fuel, and lodging for the providers on scene. This person does not have any direct responsibility for the transport destinations of patients.

Operations Sector Chief
The operations sector chief is responsible for the operation of the scene and all tactical operations. This includes all branches related to patient care. The branch leaders report to the operations sector chief. Usually there is only 1 operations sector chief, but multiple officers may report to the operations sector chief. The tactical operations branch officers who report to the operations sector chief are as follows:

- Triage Officer. Responsible for the team of personnel triaging each patient from the scene or area that they have been tasked by the operations sector chief.
- Treatment Officer. This person is responsible for the care delivered in the triage area. He or she will have several providers assigned to each triage area to provide care and remain accountable for the patients in that area. This officer also is responsible for ensuring that his or her personnel record any patients who refuse care or transportation so that individuals involved in the incident are accounted for.
- Transport Officer. Responsible for assigning patients from the triage and treatment area to ambulances, busses, or wheelchair-accessible vans for transport to the hospital or other temporary housing. The transport officer should keep track of where the patients were sent so that they may be reunited with scattered loved ones after the incident is over or winding down. This individual also is responsible for keeping track of those patients who could not be resuscitated.
- Staging Officer. This individual is responsible for maintaining an ongoing list of available transport-capable units as they arrive to the scene and as they are called away by the transport officer. These units include not only ambulances but also busses and wheelchair-accessible vans for noncritical transports from the scene.
- Extrication Officer. This individual is responsible for overseeing rescue operations. This person often bridges the EMS and fire operations on a scene because he or she responsible for the successful extrication of patients (fire) and for getting the patients to the triage sector (EMS). With this in mind, the extrication officer usually functions under the EMS branch but often (ideally) is cross trained in both extrication and EMS knowledge.
- Rehabilitation Officer. The rehabilitation officer is responsible for the care and well-being of the providers on scene. This includes the fire and EMS branches, although this person operates under the EMS operations. He or she has the ability to remove a provider from the operation for medical reasons or to ensure adequate sleep.

Planning Sector Chief
The planning sector chief is responsible for solving issues as they arise during an operation that are unrelated to treatment or transportation. This individual, for example, may be tasked with finding temporary housing for displaced individuals who are not otherwise hurt and not in need of medical care. He or she may need to work on getting supplies to the scene. Ultimately, this person works closely with the logistics sector chief and the IC to ensure smooth operation of the scene.

Command Staff
The IC may need to rely on several individuals to work with the public, media, and other sector officers on especially large-scale incidents, such as natural disasters.

- Safety Officer. This individual is responsible for the provision and maintenance of safety throughout the operation for any condition that may become a problem for providers. Under the safety officer’s authority, the entire operation may be stopped, if a threat to providers is recognized, and not restarted until the problem is resolved.
- Public Information Officer. Under the direction of the IC, the public information officer provides information to media outlets about the state of the ongoing operation. This person is assigned later in the operation and is positioned well away from the operation, both to keep the members of the public and media safe and prevent or minimize distractions on the scene.
- Liaison Officer. Disseminates information among the members of the command structure to ensure all providers are up-to-date with the latest information and the status of the operation.

Triage
Triage is a system of sorting patients at an MCI in a manner that ensures that the patients with the most life-threatening conditions receive the fastest care. This system allows a small team of rescuers to do the greatest good for the vast majority of patients.
Primary triage takes place as soon as the patient arrives at the triage sector. This is the first and arguably cursory evaluation of the patient. Often performed by the triage officer or a designee, once triaged, the patient is assigned an initial triage category. This category often is of a higher priority than the patient’s condition may warrant after a more detailed assessment.
When the patient arrives at his or her primary triage area as assigned during primary triage, the patient is reevaluated during the secondary triage process. This better reflects where the patient should be and, by extension, the priority with which the patient can be transported. The patient is assigned Green, Yellow, Red, or Black colors that designate the severity and priority of the patient’s condition.

- Green. Low priority, non-life-threatening injuries. These patients will remain on scene longer in most cases and may receive transport to a hospital by a means other than an ambulance.
- Yellow. Delayed transport, moderate injuries not likely to be life threatening. Patients in this category may have visible fractures of distal extremities or spinal injuries with or without paralysis. These patients will not have severe impairments to respiratory or cardiovascular systems. In addition, they will not have a known apparent change in mental status.
- Red. Immediate transport, life-threatening or potentially life-threatening condition. These patients have known and apparent changes in mental status or derangement in respiratory or cardiovascular systems. This can include patients with chest pain and respiratory distress independent of the injury. Patients who regain spontaneous respirations with an airway adjustment or adjunct or who have spontaneous respirations after being given 5 rescue breaths are tagged red; if these fail, they are tagged black. Patients experiencing a severe psychiatric emergency, whether directly related to the incident or not, may be given a red tag so that they are removed from scene more quickly, thus minimizing their impact to the scene. Injured rescuers should be transported immediately off scene to minimize the morale impact on the remaining rescuers.
- Black. Deceased or unsalvageable patients. Patients garner a black tag when they have signs inconsistent with life, such as cardiac arrest or severe chest or head injuries. Patients in respiratory arrest with a pulse get a black tag if manual adjustment of the airway (head tilt/chin lift or an oral pharyngeal airway) does not result in spontaneous, life-sustaining respiratory effort on the part of the patient.

START Triage
START triage is the recommended primary triage guidelines for a disaster response. Following this 6-step approach will allow the triage officer or a designee to rapidly evaluate all accessible patients on a scene and direct them to the treatment areas.
The first step is to get all the walking wounded off the immediate area of the scene. These will all be tagged green and sent to the treatment area.
The next steps involve an evaluation of breathing for each patient remaining on the scene. If the patient is not breathing, reposition the airway and reevaluate. If with the repositioning the patient begins to breathe spontaneously, he or she is tagged red; if the patient fails to begin breathing, he or she is tagged black.
If the patient is breathing, is the estimated respiratory rate between 10 and 30? If outside this range, the patient is tagged red and sent to that treatment area for secondary triage. If the patient is breathing, move to the next evaluation point, circulation.
Does the patient have a strong radial pulse? If so, move to the next evaluation step of mental status. If the patient does not have a strong radial pulse, and it is found to be either weak, irregular, or absent, the patient is tagged red and sent to that treatment area.
If the paramedic makes it this far in the triage process on any patient, the patient is essentially hemodynamically stable, and the final evaluation point is the patient’s mental status. If the patient is able to follow commands, he or she is tagged yellow and sent to that treatment area. If the patient is unable to follow commands, he or she is tagged red and sent to that treatment area.

START Triage Principles
 

This process can be completed in under 30 seconds for every patient, and it is cohesive if more than one person is completing the primary triage of each patient. Obviously, it is likely that a lot of patients will be triaged to the red category, many of whom will be overtriaged. Once to the red treatment area, the personnel there can do a more in-depth assessment of the patient and choose to either keep the patient in that category or reduce the patient’s priority to yellow or green if appropriate.

Special Triage Considerations
Lightning strikes required a significant alteration to these triage guidelines. Patients in cardiac arrest from a lightning strike need to be triaged in what is known as reverse triage. This means that the victim of a lightning strike in cardiac arrest will receive a red tag instead of a black tag in all triage situations. This decision is because such patients often will recover from the event with rapid appropriate treatment, whereas most other trauma patients in cardiac arrest will not.
Patients involved in an incident involving hazardous materials—either chemical or biological—will need to be decontaminated before going to the triage sector. This is to prevent contamination of the triage area, treatment area providers, ambulances, and equipment. Once decontaminated, these patients can be triaged as usual.
As mentioned earlier, certain patients should be triaged higher than their conditions may otherwise indicate. Injured or ill rescuers should be transported immediately. Individuals on scene who are exhibiting signs of psychiatric illness, including hysteria and aggression, should be removed as soon as possible. This kind of behavior is contagious and could lead to the situation getting out of control quickly.