03 - The Long Way ‘Round

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Introduction:

The Working Group developed a MUCC (Model Uniform Core Criteria) for mass casualty incident triage. The MUCC is to serve as a template upon which triage systems must adhere. The MUCC was comprised of 24 core criteria the working group agreed upon based off their internal research. The process used to develop the MUCC did not include field testing, resulting in concepts that may not be practical in the real world.

The Critical Missing Component:

The Working Group relied solely on research papers and committee consensus to develop the MUCC. In doing so, they neglected to consider the primary purpose of triage in their process - to obtain and report a patient count, by acuity, as quickly as possible. Instead the Working Group identified patient care as the primary purpose of triage - hence SALT’s emphasis on LSI, and more pertinent, its assessment prioritization process.


This critical omission led to a global sorting and assessment prioritization process that quantifiably increases the time for obtaining the acuity count, therefore proportionally delaying the information set needed by the Incident Commander and MedComm to begin the ordering up of ‘greater good’ resources.

The Working Group’s MUCC.

The Global Sorting Criteria:

In an attempt to provide LSI to those that theoretically need it most - patients that are still or have obvious life threatening injuries - SALT employs a Global Sorting Process that sets the priority of how patients are encountered and triaged. Unlike the familiar ‘start where you stand’ process used in START, SALT requires that responders bypass patients of one type as they make their way to patients of another. In practice this process has inherent inefficiencies and is prone to subjectivity. A number of questions come to mind:

At what point from his starting position does a responder stop seeking out still patients or those with life threatening injuries before making his way back to the ones he passed along the way?

How do other responders know where the first responder left off since there is no ribbon or tag trail identifying patients he bypassed.

‘Obvious Life Threatening’ is a visual assessment. A responder would need to be within 10’ of a patient in daylight and 5’ at night to make that determination and even at that range life threatening injuries, such as a GSW hemorrhage under clothing, would not be detectable. Is it practical for a responder who is 5’ from a patient to not just take 2 steps, check pulses and tie on a count ribbon as opposed to walking by and coming back later?

All dead patients will be still. Is wandering around until all the dead are confirmed dead practical?


The Time Detriment:

The above questions may have plausible answers but what cannot be avoided in the SALT assessment prioritization process is speed reduction in acuity count. Backtracking inherently means more steps which means more time. In randomly created casualty fields used in SALT drills the distance responder needed to travel under SALT was on average 60% longer than under START, equating to a proportionately longer time to complete triage. (See diagram)

After the call for the walking wounded, START requires that the operator use ‘start where you stand’ to methodically make their way through the casualty area using a logical path, ensuring no patients are bypassed.


SALT’s global sorting requires that patients with purposeful movement that do not have obvious life-threatening injuries be assessed after patients that are still or have obvious life-threatening injuries. This means patients are bypassed and re-encountered later.

Total Distance Traveled (line length)

                START = 220ft

                SALT = 360ft

SALT travel time is over 60% longer than START.

Hypothetical:

10 minutes to reach all patient under START

16 minutes to reach all patient under SALT


*Actual time to triage patients not included as it can be assumed both SALT and START take the same amount of time by a qualified operator unless decompressions are used for SALT in which case the time would be proportionately longer.

< Try it Yourself:
Download the Triage Travel Game. Cut out the cards and drop them on the floor. Count your steps as you use START and SALT to get a rapid count.

triage_travel.pdf

SALT’s Global Sorting Matrix.