CERTEMERGENCY

MEDICAL OPERATIONS

Part 1

Whatcom County Division of Emergency Management

OBJECTIVES

1. Identify “killers”

2. Apply techniques for opening airways, controlling serious bleeding, and treating shock

3. Conduct triage under simulated disaster conditions

DISASTER MEDICAL OPERATIONSAssumptions

• The number of victims will exceed local capacity for treatment

• Survivors will assist others

PHASES OF DEATH FROM TRAUMA

Phase 1: Death within minutes

Phase 2: Death within several hours

Phase 3: Death after several days or weeks

• Experts agree that over 40%40% of disaster victims in the second and third phases of death could be saved by providing simple medical care

• CERT members aim to “Do the greatest good for the greatest number”

CERT REMINDER!

CERT members MUST take care of themselves before caring for others

• Gloves

• Mask

• Goggles

• Pocket Mask

THE “KILLERS”

• Airway Obstruction

• Bleeding

• Shock

AIRWAY

OBSTRUCTED AIRWAY

• 4-6 minutes until brain death

• Heimlich– Conscious– Unconscious– Most common obstruction is the tongue

HEAD-TILT/CHIN-LIFT

• Step 1 Can you hear me?

• Step 2 One hand on foreheadOther hand under chin

• Step 3 Lift the jaw while tiltingthe head backwards slightly

• Step 4 Look, Listen, Feel for signs ofbreathing (Chest Rise, Air

Exchange, Abdominal Movement)

Pad under shoulders to maintain an open airway

WHAT IF. . .

• The person doesn’t breath after opening the airway?– Try one more time then move on.– Remember the CERT Mission.

• The person does start breathing but you need to move on to other patients?– Walking wounded.– Recovery position - consider neck injury.

PRACTICE TIME

• IC break class into teams.• Medical Group Leader make victim and

rescuer assignments.– Patient to breathe normally.– Rescuer to assess breathing.– Practice Head-Tilt/Chin-Lift.– Position patient in recovery position.

BLEEDING

• Uncontrolled Bleeding is a “Killer”!

• Three types– Arterial high pressure, spurts– Venous low pressure, flows– Capillary low pressure, oozes

BLEEDING CONTROL

• Direct Pressure– Brachial– Femoral

• Elevation– Local pressure combined with elevation

will address 95% of bleeding.– Can take 5-7 minutes to work.– Get help from the patient, walking

wounded, pressure bandage.

BLEEDING CONTROL

• Pressure Dressing• Pressure Points

May be combined. Not a tourniquet.

TOURNIQUET

• Rarely necessary except– Crushing injury– Partial amputation

• Use when willing to “sacrifice a limb to save a life”

• Leave it in plain sight - no bandage

• Time/Day written on patient’s forehead

CERT REMINDER!

• One CERT function is to collect and record information. Pencils, markers, and tape are important items for the disaster preparedness kit.

• The marker can be used for non-traditional purposes, such as marking a forehead.

PRACTICE TIME

• IC break class into teams– Medical Group Leader assign

victims/rescuers– Practice making a pressure dressing– Practice slipping a square knot

– Additional Skills• Vital Signs (BP, HR, RR)• EpiPens

SHOCK - THE SILENT KILLER

• Ineffective circulation of blood (which carries oxygen)

• Will lead to the death of cells, tissues and entire organs

• Adults compensate differently from children

• Early recognition is essential

• Slightly increased rate of breathing - Breaths may be shallow

• Slightly increased pulse - pale and cool skin - Capillary refill of >2 seconds

• Restlessness, anxiety, irritability, apprehension, inability to follow simple commands

Compensatory Stage

Earliest Signs of Shock

Compensatory Stage

CERT GOAL:Watch for subtle signs of early shock

• Slightly increased rate of breathing

• Slightly increased pulse - pale and cool skin

• Restlessness, anxiety, irritability, apprehension

Increased, irregular, shallow breaths

Increased, irregular, weak pulse

Cool, moist, blue or pale skin

Dilated pupils Listlessness, apathy

Progressive Stage

(uncompensated)

This patient will die!

We must do what we can to prevent the condition from progressing to this point!

Irreversible Stage

SHOCK ASSESSMENT

• R Rapid and shallow breathing - (Respirations/airway)

• P Capillary refill of greater than 2 seconds - (Pulse)

• M Follow simple commands, such as “Squeeze my hand” -

(Mentation)

CERT TREATMENT

Face Pale - Raise TailFace Red - Raise Head

• Elevate feet 6-10 inches - Watch the airway• Control bleeding• Maintain body temperature• Avoid rough or excess handling• Give nothing to eat or drink - Expect the

patient in shock to be nauseous or thirsty

DISASTER MEDICAL OPERATIONSOrganization

TriagerTranscriber

TRIAGE

Litter bearers

TRANSPORT

DelayedTX leader

ImmediateTX leader

TREATMENT

SecurityIdentification

MORGUE

MEDICALGroup Leader

TRIAGE

• French for “to sort”• Evaluated and sorted by the

immediacy of treatment needed• Used when

– Rescuer(s) are overwhelmed.– There are limited resources.– Time is critical.

TRIAGE PRIORITIZATION

• GREEN - Minor/Walking Wounded• Patient may require professional care.• Life not jeopardized by delay in treatment.

• RED - Immediate• Life-threatening injuries demand immediate attention.• Treatment may save a life.

• YELLOW - Delayed• Needs care as soon as people and materials are

available.• Treatment is essential.

• BLACK - Dead• Not breathing after two tries to open the airway.• Massive trauma or major medical condition which

exceeds available resources.

BEFORE CHARGING IN . . .

• 1ST - Stop, Look, Listen, Smell, Think– Dangers to CERT?– Where to set up staging/supply/treatment and

morgue areas?

• Voice Triage - Identify “walking wounded”– Whistle.– “If you can walk, come to my voice.”– Label as GREEN - Reassess later.– Get information from them

• Stage them with a CERT member• Use as needed.

PERFORMING TRIAGE

R Respirations/Airway– Position.– Look, Listen, Feel.– Greater than 30 = Immediate/Red.– Treat for shock and move on.– Not breathing after 2 attempts = Dead/Black

EXCEPTION: Give children 15 breaths andreassess before placing them in the Black category

Begin with the first patient located

DEAD

Still not breathing

Check respirations

< 30/min.

Treat for shock

> 30/min.

If breathing, check pulse

Reposition Airway

NO YES

R - RESPIRATIONSAssess & Position Airway/Check Breathing

VOICE TRIAGE FIRST

Step 1

PERFORMING TRIAGE

P Pulse/Bleeding

– Capillary refill greater than 2 sec. = Immediate/Red.

– Control bleeding, treat for shock, and move on.

Triage & quickly move to the next patient.

Only immediate life-saving treatment is given during triage.

Step 2

Check Mental Status

< 2 seconds

Treat for Shock

> 2 seconds

Perform the Blanch TestCapillary Refill

P - PULSECheck Circulation & Control Bleeding

PERFORMING TRIAGE

M Mental Status

– Ask the victim to follow a simple command, such as squeezing your hand.

– No response or inappropriate response = Immediate/Red.

– Treat for shock and move on.

Step 3

TREAT FOR SHOCK

Fails to Follow Simple Commands

May become a Red or a Green on re-evaluation

Follows Simple Commands

M - MENTATIONCheck Mental Status

PRACTICE TIME

Turn to your neighbor and perform a “shock assessment”. Look for normal

R RespirationsP Pulse/Capillary RefillM Mentation

TRIAGE - DETAILS

• Everyone gets a tag

• Keep a count of numbers in each color

• Triage is sorting - transportation does not start until triage is completed

• Time is critical in a disaster

AFTER TRIAGE - THEN TRANSPORT TO TREATMENT

• Immediate - RED• Delayed- YELLOW

– Most qualified rescuers.– Majority of medical equipment.

• Minor - GREEN– Walking wounded may already be in the treatment

area.– May be able to help with Red and Yellow patients.– Record keepers.

• Dead - BLACK– A different location - morgue.– Consider sanitation/safety issues.

CERT REMINDER!

• Triage Pitfalls– Inadequate medical size-up.– No team plan, organization or goal.– Indecisive leadership.– Too much focus on one injury.– Treatment rather than triage.

PRACTICE TIME

You are at the scene where a bus has been overturned as the result of an earthquake. No other emergency services will be able to reach your location for several hours, at least, and likely much longer.

Use the worksheet to identify the category you will triage each of the following patients into. You will have 15 seconds to read the information and make a decision.

What’s your call? 1

• A young school aged boy is found lying on the roadway 10 ft from the vehicle.

• Respiratory Rate 10/min.• Capillary Refill is 2 seconds.• Groans to painful stimuli.

What’s your call? 1

• A young school aged boy is found lying on the roadway 10 ft from the vehicle.

• Respiratory Rate 10/min.• Capillary Refill is 10 seconds.• Groans to painful stimuli.

R- Slow for a childP- OKM- Unable to follow command

What’s your call? 2

• An adult kneels at the side of the road, shaking his head. He says he’s too dizzy to walk.

• Respiratory Rate is 20.• Capillary Refill is 2 sec.• Obeys commands.

What’s your call? 2

• An adult kneels at the side of the road, shaking his head. Says he’s too dizzy to walk.

• Respiratory Rate is 20.• Capillary Refill is 2 sec.• Obeys commands.

R - OKP - OKM - OK - but couldn’t walk

What’s your call? 3

• A school aged girl crawls out of the wreckage. She’s able to stand and walk toward you crying.

• Jacket and shirt torn.• No obvious bleeding.

What’s your call? 3

• A school aged girl crawls out of the wreckage. She’s able to stand and walk toward you crying.

• Jacket and shirt are torn.• No obvious bleeding.

• R - Crying• P - No obvious bleeding• M - Able to obey command

What’s your call? 4

• A toddler lies with his lower body trapped under the vehicle.

• Not breathing with modified jaw thrust and after 15 ventilations.

What’s your call? 4

• A toddler lies with his lower body trapped under the vehicle.

• Not breathing with modified jaw thrust and after 15 ventilations.

R - noP - noM - no

What’s your call? 5

• Adult female driver, trapped by her lower legs under caved-in dash.

• Respiratory Rate 24.• Capillary refill 4 sec.• Moans with verbal stimulus.

What’s your call? 5

• Adult female driver, trapped by her lower legs under caved-in dash.

• Respiratory Rate 24.• Capillary refill 4 sec.• Moans with verbal stimulus.

R - fastP - slowM - no

What’s your call? 6

• A toddler lies among the wreckage.• Respiratory Rate 50.• Capillary refill > 2 seconds.• Withdraws when touched.

What’s your call? 6

• A toddler lies among the wreckage.• Respiratory Rate 50.• Capillary Refill > 2 seconds.• Withdraws when touched.

R - fastP - delayedM - inappropriate

What’s your call? 7

• A woman is carrying a crying infant. She is able to walk.

• Respiratory Rate 20.• Capillary Refill 2 sec.• Obeys commands.

What’s your call? 7

• A woman is carrying a crying infant. She is able to walk. Obeys commands.

• Respiratory Rate 20.• Capillary Refill 2 sec.

R - okP - okM - ok

What’s your call? 8

• An infant is carried by mother.• He’s screaming but the woman quiets

him. He focuses on mom. • Respiratory Rate of 34.• Capillary refill < 2 seconds.• No obvious significant external injuries.

What’s your call? 8

• An infant is carried by mother.• He’s screaming but the woman quiets him.

He focuses on mom. Respiratory Rate of 34. • Capillary refill < 2 seconds.• No obvious significant external injuries.

R - okP - okM - ok

What’s your call? 9

• School aged boy props himself up.• Respiratory Rate 28.• Capillary refill in hands and feet < 2 sec.• Answers question and commands.• Obvious deformity of both lower legs.

What’s your call? 9

• School aged boy props himself up.• Respiratory Rate 28.• Capillary refill in hands and feet < 2 sec.• Answers question and commands.• Obvious deformity of both lower legs.R - okP - okM - ok

What’s your call? 10

• A school aged girl lies among the wreckage.

• Respiratory Rate 40.• Capillary Refill is 5 seconds.• Pushes rescuers away.

What’s your call? 10

• A school aged girl lies among the wreckage. Pushes rescuers away.

• Respiratory Rate 40.• Capillary Refill is 5 seconds.

R - fastP - delayedM - questionable

What’s your call? 11

• A screaming infant is found among the bushes at the side of the road. Partial amputation of the foot without active bleeding. Reaches for you.

• Respiratory Rate 38.• Capillary Refill < 2 seconds.

What’s your call? 11

• A screaming infant is found among the bushes at the side of the road. Partial amputation of the foot without active bleeding. Reaches for you.

• Respiratory Rate 38.• Capillary Refill < 2 seconds.R - okP - okM - ok

What’s your call? 12

• An adult male lies at the water’s edge.

• No Breathing.• Continues to not breath with jaw

thrust.

What’s your call? 12

• An adult male lies at the water’s edge.• No Breathing.• Continues to not breath with jaw thrust.

R - noP - noM - no

What’s your call? 13

• A youngster is up and walking around but is limping.

• Alert, crying hysterically for his mother.

• Capillary Refill is immediate.

What’s your call? 13

• A youngster is up and walking around but is limping.

• Alert, crying hysterically for his mother.

• Capillary Refill is immediate.

R - CryingP - okM - ok

What’s your call? 14

• A school aged boy lies close to the road.• Respiratory Rate 36.• Capillary refill is 2 seconds.• Slowly looks at you when you talk to him.

What’s your call? 14

• A school aged boy lies close to the road.• Respiratory Rate 36.• Capillary refill is 2 seconds.• Slowly looks at you when you talk to him.R - fastP - okM - delayed

What’s your call? 15

• Teen girl lies next to vehicle, crying for someone to help her. A man with her says she needs her wheelchair. Minor cuts and bruises. Alert.

• Respiratory Rate 22.• Capillary Refill is 1 second.

What’s your call? 15

• Teen girl lies next to vehicle, crying for someone to help her. A man with her says she needs her wheelchair. Minor cuts and bruises. Alert.

• Respiratory Rate 22.• Capillary Refill is 1 second.

R - okP - okM - ok

What’s your call? 16

• An adult male lies on the ground.• Respiratory Rate 20.• Capillary refill is 2 seconds.• Obeys commands but cries that he

can’t move his legs.

What’s your call? 16

• An adult male lies on the ground.• Respiratory Rate 20.• Capillary refill is 2 seconds.• Obeys commands but cries that he

can’t move his legs.R - okP - okM - ok

OR

What’s your call? 17

• An older school aged child is found lying against a tree. Groggy, confused but slowly follows commands.

• Respiratory Rate 28.• Capillary refill is 2 seconds.

What’s your call? 17

• An older school aged child is found lying against a tree. Groggy, confused but slowly follows commands.

• Respiratory Rate 28.• Capillary refill is 2 seconds.

R - okP - okM - slow

It can be confusing - but it’s ok to change your mindthe second time through.

Next Class

• Search & Rescue

Next Class

• Public Health Considerations• Disaster Medical Operations

– Establishing Treatment Areas– More Indepth Patient Evaluations– Bandaging– Splinting