Triage in the Emergency Care of Patients
Triage in the Emergency Care of PatientsDisclaimer: This paper was written for the Master Rank requirements of a Healer at SouCon™ MUSH and with the intent that it could be used for Role Play purposes only. Though many of the sources was taken from real life medical sources this document should to be used to learn how to perform triage outside the confines of the Role play environment.
Triage is defined as a "system used by medical or emergency personnel to ration limited medical resources",1 especially when the number of injured patients exceed the available resources. This is done so that the greatest numbers of patients receive treatment.
Triage is used to divide people into four major groups, the Deceased or those who are beyond help, those who can be saved by immediate attention and/or transportation to the Healer Hall, those who's treatment and/or transportation can be delayed and those with minor injuries - the walking wounded. Only perform Triage when there are two or more wounded. For a single injury, always perform first aid.
Triage is normally brought into play when the healer is at a scene of a mass casualty of some type. In most situations the "walking wounded", or those with minor injuries are numerous and many of these can be drafted to assist the healer until more help arrives. For example you might be able to tell a person to hold a bandage over another persons wound, apply pressure to staunch the bleeding. In advanced triage a Master may have to make a decision that some people who are severely wounded not receive care, because they are unlikely to survive, in order to allow the treatment of someone who has a hope of survival.
Four Stages of Triage
First, or during Triage one, loudly and authoritatively tell everyone to move to a safe area that you have designated. Do not tell them to walk toward you. Most wounded who are able to move on their own will not need immediate medical attention.
Second, for those who remain, check their RPM (Respiration, Perfusion, and Mental State). If they are not breathing, make sure that the airway is clear. If it is and they are still not breathing you need to move on to the next patient. If they are breathing, check the perfusion by pressing a fingernail and seeing if it turns back pink within two seconds. If the patient has some form of nail coloring, check for a pulse at the wrist. If they are breathing and perfuse, check their mental state by asking their name, if they know where they are, and/or what happened.
Third, try to recruit those who are bystanders and/or moderately wounded to assist you with first aid. Most people are able to perform the first aid needed when given proper instructions, such as "apply pressure here until the bleeding stops. If the blood soaks through put on another dressing and don't remove this one" or "keep this patient lying down and talk to them, assuring them and telling them where they are", etc.
Fourth, as time permits reassess everyone checking for shock by checking for rapid respirations and checking to see if the skin is clammy and cold. If you judge that they might be entering shock, have them sit down. If they are sitting have them lie down and elevate their legs as much as possible. The goal here is to raise the blood flow to the inner organs to prevent oxygen starvation of the inner organs and major tissues.
Normal Diagnostic Signs
When performing triage, a rapid but accurate examination of the patient is critical for proper medical care. Knowing exactly what is wrong with the patient isn't necessary since the pulse, respiration, body temperature, skin color, reaction to pain, ability to move and reaction of the pupils of the eyes can usually tell the Healer what needs to be done for the patient. For the purposes of this paper, I will cover what to look for in relation to the pulse, respiration, skin color and eyes.
Pulse
The pulse is the pressure wave along the arteries that is generated when the heart beats. In a normal, healthy adult, the pulse ranges between 60 and 80 beats per minute, while the pulse of a child is usually between 80 and 100 beats per minute. The pulse can be felt anywhere an artery passes over a bone. The most common place to palpate the pulse is at the base of the thumb over the wrist. If the pulse cannot be felt there, you can check the pulse at the neck or depending on the size of the patient, in the groin. If a pulse cannot be felt at any of these places, place your ear directly over the chest of the patient and listen for a heartbeat. A rapid, weak pulse is generally caused by shock and/or loss of blood. A rapid, bounding pulse is present when the patient is frightened or can be a sign of hypertension. If there is a lack of a pulse, could mean that the artery is blocked or the heart has stopped beating.
Respiration
Normal breathing is painless, not labored and usually lies between 12 and 20 breaths per minute but can be significantly lower for athletes or those in exceptional physical health. They should not be unusually shallow or unusually deep. If the breathing is rapid and shallow, this could be a sign of shock, while deep and labored breathing could indicate airway obstruction. Frothy sputum with blood at the nose and mouth, especially of accompanied by coughing, could indicate lung damage. This could be caused by broken ribs that have punctured the lung or that a foreign body had penetrated the chest cavity and damaged the lung.
Skin Color
The color of the skin depends primarily on the pigmentation on the presence blood circulating in the subcutaneous blood vessels. The primary colors of medical importance are red, white and blue. In deeply pigmented people, these colors may be obscured but color changes may be apparent in the fingernail beds, the sclera of the eyes or under the tongue. A red color may be present with someone who has high blood pressure, sunstroke or certain stages of carbon monoxide poisoning. Someone who has severe high blood pressure may also appear purplish in color.
Patients with insignificant circulation may display pale, white, ashen or grayish skin. This could indicate shock or someone who is suffering from a heart attack. This coloration is caused because there is not enough blood circulating in the skin.
If the patient's skin color is bluish, this indicates that the patient is not receiving enough oxygen and steps need to be taken to assist with breathing. A common cause of this is either an airway obstruction or a heart attack.
Pupils of the eyes
Normally the pupils of the eyes are roughly the same size, equal in size and reactive to a light that is shined directly into them. Changes and variations in the size of one or both of the pupils are important sings in emergency care. If the pupils are constricted (smaller in size than normal) the person could be suffering from either a drug overdose or could be suffering from some illness that affects the central nervous system. Dilated or enlarged pupils could indicate a relaxed or unconscious state. Such a dilation usually occurs rapidly after a heart attack, though the presence of drugs or a head injury could keep the pupils in a constricted state. Pupils that are uneven could indicate a head injury or someone who has had a stroke. Ordinarily the pupils contract when a light is shined on them. Failure of the pupils to react to light could indicate a head injury, poisoning, or drug overdose.
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Written by Master Xavier, SouCon MUSH
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