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An Australian Mass Casualty Incident Triage System for the Future Based on Mistakes of the Past: the Homebush Triage Standard

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An Australian Mass Casualty Incident Triage System for the Future Based on Mistakes of the Past: the Homebush Triage Standard An Australian mass casualty incident triage system for the future based on mistakes of the past: The Homebush Triage Standard Introduction injuries into slight, serious and fatal and The combined effects of an aging popu- by Dr Antony Nocera, FACEM & Dr Alan described a system of treatment priority lation, the trend towards day and mini- directed towards the control of life Garner, FACEM, NRMA CareFlight mally invasive surgery, plus the increasing threatening hemorrhage, To a serious cost pressures upon hospitals have Westmead New South Wales bleeding everything must of necessity at significant implications upon the avai- once give way, and the vessel be secured lability of health resources during a mass Dr Wilson advocated the treatment of casualty incident (MCI) There are no those with fatal injuries be restricted to a the end of battle The wounded were then universal definitions of what constitutes stimulus, an opiate, a proper easy position evacuated and treated according to rank either a disaster or a MCI within Australia (Wilson 1846) including the removal of dead nobles A disaster is said to have occurred when In the Second World War the procedure taking priority over wounded common normal community and organisational of patient triage was regarded as the biggest soldiers (Hamby 1967) arrangements are overwhelmed by an single factor contributing to survival Dominique Jean Larrey, Surgeon Gene- event and extraordinary responses need following abdominal wounds in the US ral to Napoleons Army of the Rhine, to be instituted (Emergency Management Army (Welch 1947) In the Korean War the introduced a major revolution in combat Australia 1995) application of a four tiered triage system, casualty care When available medical resources are (immediate, delayed, minimal and expec- Larreys philosophy was to rescue overwhelmed by casualties, transport and tant) lead to a striking improvement in casualties during battle, with a dedicated treatment priorities need to be assigned casualty survival (Hughes 1976) The corps using purpose built wagons, the to individuals to ensure limited medical combination of triage, advanced resus- ambulance volantes, and rapidly trans- resources are used efficiently The term citation and rapid helicopter evacuation port them to a central collection point triage was transposed from French into of casualties in the Vietnam War contri- Here the most seriously wounded would the English language during the First buted to reducing mortality rates down to be operated on, without regard to rank World War to describe the process of 1%, compared to the 47% observed during or distinction, by either the Surgeon-in- sorting casualties for treatment priority World War Two (Kennedy et al 1996) Chief or a competent surgeon under his by the American Army Medical Corps direction (Richardson 1974) In 1792 Goals of MCI triage (Rutherford 1989) Casualty triage is the Larrey personally lead his ambulance The primary objective of military triage most important medical function during volantes to treat wounded French soldiers was to identify those wounded soldiers a mass casualty incident (MCI) and in the field and transport them from the who could be treated rapidly and retur- accurate triage a major determinant of front line during the battle against the ned to the battlefield (Kennedy et al 1996) an individuals survival (Rutherford 1989; Austrian Army near Königsberg (Leroy- In civilian practice, the triage process Waeckerle 1991; Fryberg et al 1988) Dupré 1862) attempts to achieve the greatest good for This study reviews the evolution of In 1807 at the Battle of Eylau against the the greatest number of patients (Emer- triage, and factors that can potentially Russian Army, Baron Larrey, now gency Management Australia 1995; Ruth- interfere with the triage process and Surgeon-in-Chief to Napoleons Grand erford 1989; Waeckerle 1991; Fryberg et al compromise the medical response to an Army, gave treatment based on medical 1988; Burkle 1984) Traditional individual MCI These are then used to synthesize a need but with priority to the wounded of doctor-patient relationships are over- triage system to provide a common Napoleons Imperial Guard over other ridden by a collective medical respon- platform so that patient priorities at the wounded French soldiers (Dible 1970) In sibility to the group of casualties (Wae- incident site can be interfaced with those spite of Larreys pioneering example, ckerle 1991; Burkle 1984; Llewellyn 1992) arising within receiving hospitals during the American Civil War in 1862, In general there is no role for cardio- Historical perspectives MCI triage three thousand wounded Union soldiers pulmonary resuscitation during an MCI The advent of gunpowder and the were left virtually unattended and un- (Emergency Management Australia 1995) development of the rifle forced infantry treated for three days after the second except in cases of lightening strikes into linear battle formations As battle- battle of Bull Run (Adams 1952) involving multiple individuals Here fields became larger it became increa- In 1846 British Naval surgeon Dr John medical efforts should be directed at those singly more difficult to locate wounded Wilson described the principles of MCI victims in cardio-respiratory arrest, since soldiers who were left where they fell until triage Dr Wilson classified combat the majority of other victims will make a Winter 2000 41 good recovery (Myers et al 1977) Normal triage priorities may be reversed for Injury High evacuation and Low evacuation and casualties involved in highly toxic hazar- treatment priority treatment priority dous material exposures where decon- Penetrating abdominal Individuals who can access Survival after 12 hours tamination and treatment priority should wounds definitive surgical treatment without operative care be directed at the uninjured and even within 6 hours of injury asymptomatic patients (Kirk et al 1994) The success of the triage process as a Major vascular injury Individuals who can achieve If vessel reconstruction cannot in an extremity vessel reconstruction within be achieved within 10 hours means of minimising preventable deaths 10 hours of injury direct ligation of the vessel will during an MCI depends upon being able result in limb loss in 50% of cases# to rapidly identify those casualties at the extremes of care Medical resources are Penetrating head injuries Unstable patients with Individuals who are stable, conscious diverted from those who will either die, evolving neurological signs with either no deficit or moderate paresis or hemianopia can survive for or recover irrespective of the medical care 36 hours without neurosurgical care they receive, and concentrated on those with appropriate fluids, wound care critically ill casualties with a reasonable and antibiotics probability of survival (Emergency Management Australia 1995, Waeckerle Table 1: triage considerations for single practitioners in isolated locations 1991, Kennedy et al 1996, Burkle 1984) Problems with MCI Triage warning before an emergency medical systems (Burkle 1984; Coupland et al 1992; During an MCI, triage is approximately system (EMS) response has been initiated Caro et al 1973; Hodgetts et al 1995; Lumley 70% accurate (Burkle 1984) with a (Caro et al 1973) In addition, large et al 1996; Mac Mahon 1985; Miller 1971; tendency to under estimate injury severity numbers of casualties may be transported Baskett et al 1988) along with differing This underscores the need for triage to directly to the hospital from the incident triage tag designs to document casualty be viewed as a process of repeated scene by EMS (Anderson et al 1977) or triage status (Coupland et al1992; Finch casualty reassessments until the patient they may simply overwhelm established et al 1982; Hodgetts et al 1995; Lumley et al receives definitive care The difficulties EMS field triage & treatment posts, and 1996; MacHahon 1985; Baskett et al 1988) in making rapid value judgements based then move en masse to the nearest have been developed The crash of a upon relative percentage survival proba- hospital (Maningas et al 1997) Boeing 737-400 in 1989 at Kegworth in bilities (Kennedy et al 1996; Hughes 1976; The hospital triage process has to be the United Kingdom occurred on the Wardrope et al 1991) adds to the emotional fluid as well as continuous and capable of boundary of three different counties stress upon the individual attempting to dealing with incidents where the major whose respective ambulance services perform casualty screening assessments casualties are medical rather than surgical used different systems of MCI triage This in a hostile environment during an MCI (Myers et al 1977; Wardrope et al 1991; incident highlights the avoidable con- (Spengler 1995) Buerk et al 1982) During an MCI hospitals fusion that can arise when responding Triage accuracy is also adversely have to integrate casualty triage with the personnel attempt to use different triage affected by other factors including, the triage of normal daily emergency presen- systems and triage tags during an incident physiological ability of the young to tations (De Lorenzo et al 1996) In (Barton et al 1991; Malone 1990) compensate for hypovolaemia, altered addition, there may be an increase in Experience has shown that the key perceptions of pain in high stress situa- normal daily emergency presentations operational principle for an efficient tions (Beecher 1946) and neuropsychia- from ischaemic heart disease or exacer- disaster response is to ensure
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