The concept of resource-based decision making would seem to be basic to the practice of medicine and especially emergency medicine and disaster medicine. Unfortunately the reality is that in the United States of America and, actually in most industrialized nations, medical care decisions are not resourced-based, they are emotionally-based. And this works in all but the most dire of circumstances.
Unfortunately more and more in a world now awakened to the dual threats of terrorism and natural disaster resource-based decision making, i.e., triage, is becoming a skill not only needed but oft found lacking.
Now in the short period of this article there is no way that I can describe the full process of integrated triage. Suffice it to say that triage is an ongoing event. It occurs repeatedly during the entire patient encounter; the entire time that a person is seeking and receiving medical care from the moment they first approach until the moment that they finally leave the care environment.
The first application of this continuous integrated triage approach occurred at the Louis Armstrong International Airport in New Orleans, Louisiana. At 1:38am on August 31, 2008 the governor’s order accepting federal disaster assistance for Louisiana was signed by then Governor Blanco. As part of a Disaster Medical Assistance Team (DMAT-FL3) attached to FEMA through the National Disaster Medical System I arrived to my duty station as part of the first contingent of medical providers to arrive at the airport in New Orleans. Intelligence reports had indicated that there were only a small number of evacuees sheltering at the airport, but when our advance team arrived, they were met by 5387 people awaiting assistance aided by a contingent of health department nurses and the staff of the airport. The advance team arrived before daylight and established five medical treatment areas and a command post in Concourse D. The remainder of the first medical contingent would arrive at 9:30am, unfortunately the helicopter flight line became active on order from the Louisiana State Emergency Operations Center at 7:00am. The flight line quickly blossomed to 3 aircraft wide and 5 rows of aircraft deep, delivering up to 540 people per hour.
When the remainder of the medical contingent arrived at 9:30am, we were assigned to various medical treatment area and the flight line. After only a brief time, I was reassigned to revamp triage at of the 5387 people inside the airport and the throngs arriving by air and ground.
The approach I introduced utilized a combination of MASS and START triage beginning with gross the observations,
Can the patient walk?
Do they follow commands?
Do they know who they are, where they are and why they are here?
I accomplished this by announcing, “If you can head the sound of my voice, follow these officers to Concourse A,” remember we were in Concourse D. Eighty percent of the evacuees walked to Concourse A. I then announced, “If you could not walk to Concourse A,
Progressing to basic physiology:
Are they breathing?
Do they have a pulse?
Can they follow commands?
And finally including more detailed information:
Why was the patient actually brought for care?
What happened to them?
What are their expectations?
Unfortunately most triage ends the first time that last question is asked. In the daily practice of triage in the emergency room and in medical practice the process stops here. Nobody goes back to ask the questions again. For triage to work the way it is intended, we must integrate it into our minds and into our moment-to-moment medical practice.
At first glance, this would seem to be a minor problem; something that can easily be corrected with a small amount of practice. Unfortunately that is far from the truth. In fact as integrated triage is taught around the nation we are discovering a disturbing trend.
While healthcare providers readily embrace the idea of continuously reassessing their patients (in fact nurses have done this for decades) the idea of re-categorizing patients, particularly those in the most dire of need, is still greatly emotionally laden.
There are reports now servicing of facilities that refuse to categorize any patient as anything less than absolutely critical until a full physical examination, laboratory evaluations and even CT Scans have been done. At these institutions the entire concept of triage, sorting the masses so that the most good can be done for the most people, has been lost. They are not performing triage. They are jumping straight into treatment.
Of even greater concern are a few isolated reports of facilities refusing to allow providers to bypass patients for whom there are not resources immediately available. It is always emotionally difficult for a healthcare provider to acknowledge that under different circumstances they could save. A life that today may be lost simply because there are too many people to care for. This one individual is too injured to save when compared to the good that can be done for so many more. Unfortunately, when victim counts soar, fatalities soar as well. This is the very decision that a disaster medicine professional must make. This is the decision that falls to the professional handling triage.
Most often referred to as “black tag” patients who are “expectant”, those who require more resources than are available and prudent to utilize for one person at this time. These expectant patients are often heartrending and more sadly for both patient and the provider under different circumstances are most often people who can be treated and saved. But on this day in these circumstances they must be “set aside”.
The problem comes in that healthcare professionals today do not understand that although set aside these patients are not abandoned. A “black tag” is not a death warrant. It is not a “Do Not Resuscitate” order. It is not an order to abandon all care. Expectant patients still receive comfort care, compassion, and human dignity. They are still continuously re-triaged and as resources come available. They are brought back into the treatment mix.
In the Louis Armstrong International Airport in New Orleans, following Hurricane Katrina during the first five horrendous days of triage and treatment of tens of thousands of patients and evacuees, only 38 individuals were placed in the expectant category. Of these 38, 36 were ultimately re-triaged, treated, stabilized and sent on to hospitals outside of the state of Louisiana. All 36 of these individuals survived those harrowing days in the airport. Two people did die. In both cases these individuals already had known terminal disease. They were in fact in hospice care before the hurricane. One of these brave souls even refused transportation to allow somebody who had a “better chance” to go ahead of them. These two “expectant patients” died in the airport. At the time that they died they were the only two people left in the expectant treatment area. They each had their own nurse provided by the responders at the facility. Each of them had family members at their bedside and local volunteers to sit with them.
In the case of each of these individuals, after they died their families commented that they had received better care in the Louis Armstrong International Airport following a hurricane than they would have received at home; not because hospice was in any way incapable but because in the airport they each had their own nurse. Doctors came and saw them four times a day. They each had their own volunteer and their family crowded around them.
The dreaded “black tag” given to the expectant patient is not a death warrant. It is an opportunity for the healthcare professionals and that patient to do the most human thing possible when part of an overwhelming situation, it is an opportunity to think about others first.
Griffin Works offers Pawsitive Interactions with Service Dogs During Response Operations©, an audience-customized training that breaks down barriers by offering hands-on handling training and demonstrations with working service dogs for fire departments, EMS agencies, and public safety organizations.
Part of the National Domestic Preparedness Consortium and home to the National Emergency Response and Recovery Training Center, TEEX has been leading homeland security training since 1998. The major TEEX programs include fire and rescue, infrastructure and safety, law enforcement, economic and workforce development, and homeland security. As a member of The Texas A&M University System, TEEX is unique in its ability to access a broad range of emerging research and technical expertise. Beginning with course design and development all the way through hands-on instruction and national certification testing, TEEX delivers comprehensive training through both classroom and hands-on instruction and as online courses.
The National Child Traumatic Stress Network (NCTSN) was created by Congress in 2000 as part of the Children’s Health Act to raise the standard of care and increase access to services for children and families who experience or witness traumatic events. This unique network of child-serving professionals, caregivers and young adults, researchers, and national partners is committed to changing the course of children’s lives by improving their care and moving scientific gains quickly into practice across the U.S. The NCTSN is administered by the Substance Abuse and Mental Health Services Administration (SAMHSA) and coordinated by the UCLA-Duke University National Center for Child Traumatic Stress (NCCTS).
The Emergency Management Institute (EMI) is part of the Department of Homeland Security’s Federal Emergency Management Agency (FEMA). The EMI provides national leadership in developing and delivering training to ensure that individuals and groups having key emergency management responsibilities possess the requisite skills to effectively perform their jobs.
The High Alert Institute maintains a list of reviewed courses provided by governments, universities and professional organizations. This list is geared towards the non-emergency management person who participates in disaster planning, preparedness, response, recovery or mitigation as part of their job responsibilities.
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Koi need forever homes, too! For pond enthusiasts, freshwater exotic and ornamental fish may not be available through pet stores or rescues in their area. The High Alert Institute Aquatic Pet Shelter Rehoming Program will be happy to assist you in stocking your new pond or adding a new finned friend to your school. Coming soon – when you adopt a Koi from the High Alert Institute Aquatic Pet Shelter Rehoming Program, we can arrange for delivery to your door anywhere in the continental United States.
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Dumping of freshwater non-native species and exotic aquatic pets into wild habitats is a man-made disaster that is truly preventable. The Institute’s Aquatic Pet Welfare Partnership works to raise awareness and reduce the impact on healthy ecosystems through education, as well as rescue and rehoming. Joined by champions of animal welfare and environmental stewardship, this association of aquatic pet rescue operations and aquatic pet shelters across the United States aims to save our finned friends and preserve our waterways together.
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Disasters are defined as situations in which needs exceed or overwhelm available resources. Some disasters affect an entire community, while other disasters impact individuals and families. Crises of physical or psychological health can be very personal disasters.
The therapeutic value of pets during illness, trauma, and recovery is well established. And Koi fish may be well suited for people who are not able to provide verbal pet commands or physically care for pets like dogs and cats. Koi ponds are also a source of beauty and peace, providing an ideal setting for quiet reflection or meditation.
We are working to partner with pond installers and aquatic pet rescues/shelters to offer free or reduced-cost ponds with rehomed Koi fish to people seeking this type of pet therapy.
Disasters disrupt life and impact our sense of personal, family, and community safety. Survivors and responders alike often are not aware of the emotional, psychological or spiritual challenges that they may face from disaster onset through recovery. With two decades of experience training responders and communities to prepare for the behavioral health aspects of disasters, we will continue to provide education and a curated list of resources to groups or individuals.
Non-medical factors that impact overall health are termed Social Determinants of Health or SDoH. Noise pollution, poor air quality, and poor water quality are three environmental factors known to have a strong link to overall health. And the same environmental factors that impact humans impact their pets and other animals in their care. We continue to assist in advocacy, education, and technology development to mitigate the impact of SDoH on humans and animals alike.
Our efforts in shelter and rescue are the main focus of our environmental stewardship, reducing the environmental impact of non-native aquatic animals being dumped into public waterways. The High Alert Institute also assists innovators with the design, development, and evaluation of green and renewable energy technologies. Reducing the carbon footprint associated with disaster preparedness, response, and recovery furthers our continued mission to mitigate risk and improve resilience.
We partner with public and private organizations, sharing resources and fostering partnerships to improve disaster preparedness, response, and recovery, and mitigation.
The High Alert Institute team has over a century of combined research experience in medical, nursing, behavioral health, and disaster sciences. Our team provides support to researchers and technology developers through comprehensive literature searches and reviews, as well as failure mode database searches and adjudicated reviews.
When disaster strikes, most aquatic pet owners have limited options to secure the safety of their pets. Sheltering in place may not be possible if there is no power to provide aeration and “pet-friendly” shelters do not include ponds or aquariums. Our goal is to provide an option for aquatic pet owners in need of rescue and shelter for their finned friends.
Our goal is to share our two decades of disaster readiness experience with animal welfare organizations, shelters, caretakers, and pet owners, as they implement contingency plans for natural and manmade disasters.