**Chapter III**

**Disaster Medical OperationsPart 1**

***Introduction***

Most disasters are relatively unexpected, endanger lives and health, and
overwhelm existing emergency resources. These elements lead to some
basic assumptions about disaster medical operations:

 The number of victims will exceed local capacity for treatment.

 Survivors will assist others. They will do whatever they know how to
do, although it cannot be assumed that most people know lifesaving first
aid or post-disaster survival techniques.

The American College of Surgeons has described three phases of death due
to trauma:

 *Phase 1.* Death within minutes due to overwhelming and irreversible
damage to vital organs.

 *Phase 2.* Death within several hours due to excessive bleeding.

 *Phase 3.* Death in several days or weeks due to infection or
multiple-system failure (i.e., not from the injury per se).

Experts agree that over 40 percent of disaster victims in the second and
third phases of death could be saved by providing simple medical care.
CERT disaster medical operations personnel are trained to provide
treatment for life-threatening conditionsairway obstruction, bleeding,
and shockand treatment for other less urgent conditions. They are also
trained to **provide the greatest good for the greatest number of
victims** through principles of triage. Given the overwhelming nature of
disasters, the CERT members' training in medical operations can play a
critical role in disaster response.

***Introduction***

*(Continued)*

This chapter will introduce disaster medical operations and train you
to:

 Recognize and treat life-threatening conditions (i.e., open the
airway, control bleeding, treat for shock).

 Conduct triage evaluations.

Remember that the goal of disaster medical operations is to do the
greatest good for the greatest number.

Your instructor may present additional information not covered in this
Participant Handbook. Be sure to take notes during the classroom
presentation of this material.

***Recognizing And Treating Life-Threatening Conditions***

***Introduction***

In emergency medicine, airway obstruction, bleeding, and shock are
"killers"life-threatening conditions that can kill a patient if not
treated immediately. The first priority of medical operations workers is
to attend to these potential killers by:

 Restoring breathing.

 Controlling severe bleeding.

 Ensuring adequate circulation (treating for shock).

When working in a disaster with multiple casualties, the first goal is
Simple Triage And Rapid Treatment (START).

This section will train you how to recognize the "killers" by
recognizing their symptoms and their effects on body systems. It will
also provide you with practice in providing immediate treatment to
minimize disaster casualties.

***Opening The Airway***

An airway obstruction is anything that hinders or prevents the exchange
of oxygen and carbon dioxide through the body's respiratory system.
Through the respiratory system, we obtain oxygen by inhaling and rid
ourselves of carbon dioxide by exhaling. Once in the lungs, oxygen is
transferred to red blood cells and transported through the bloodstream
to nourish our cells. The major components of the respiratory system are
shown in Figure III-1.

***Opening The Airway** (Continued)*

![](media/image1.wmf){width="3.8048611111111112in"
height="3.6444444444444444in"}

**Figure III-1. Components Of The Respiratory System**

An unconscious or semiconscious victim may have an obstructed airway. If
the airway is obstructed, the victim cannot get oxygen, and the impact
is felt very quickly in the heart and brain. A victim with suspected
airway obstruction must be checked *immediately* for breathing, and if
necessary, the airway must be opened.

*Time is critical* when dealing with airway obstructions. Heart function
may be affected within the first few minutesand brain damage is
possible after 4 minutes without oxygen.

***Opening The Airway** (Continued)*

The most common airway obstruction is the tongue. In an unconscious
victim, especially one positioned on his or her back, the tongue relaxes
and may block the airway. This condition is shown in the figure below.

![](media/image2.wmf){width="5.741666666666666in"
height="4.352777777777778in"}

**Figure III-2. Airway Obstructed By The Tongue**

***Opening The Airway** (Continued)*

When the victim is not breathing, use the Head-Tilt/Chin-Lift method of
opening the airway. The Head-Tilt/Chin-Lift method involves following
the six steps shown in the table below.

  ------------ ----------------------------------------------------------
  ***Step***   ***Action***

  1            At an arm's distance, shake the victim by touching the
               shoulder and shout, "Can you hear me?"

  2            If the victim does not or cannot respond, place one hand
               on the forehead.

  3            Place two fingers of the other hand under the chin and
               tilt the jaw upward while tilting the head back slightly.

  4            *Look* for chest rise.

  5            *Listen* for air exchange.

  6            *Feel* for abdominal movement.
  ------------ ----------------------------------------------------------

**Table III-1. Head-Tilt/Chin-Lift Method For Opening An Airway**

If the victim does *not* start breathing using the Head-Tilt/Chin-Lift
method, try the procedure one more time. If the victim does not respond
the second time, move on to the next victim. Remember, the CERT team's
mission is to do the greatest good for the greatest number of victims
possible. Although it may be difficult to leave the victim, it is
necessary to do so under disaster circumstances.

If the victim begins breathing, the airway must still be maintained. Try
to get a volunteer to hold the head back to maintain the open airway, or
place something (such as a shoe or soft object) under each of the
victim's shoulders to slightly elevate the shoulders, which will keep
the airway open.

***Controlling Bleeding***

Uncontrolled bleeding initially causes weakness. If bleeding is not
controlled within a short period, the victim will go into shock
(described in the next section), and finally die. The average adult has
about 5 liters of blood. Because the loss of just 1 liter poses a risk
of death, it is critical that excessive bleeding be controlled in the
shortest amount of time possible.

There are three main types of bleeding. The type can usually be
identified by how fast the blood flows.

 *Arterial Bleeding.* Arteries transport blood under high pressure.
Therefore, bleeding from an artery is *spurting bleeding.*

 *Venous Bleeding.* Veins transport blood under low pressure. Bleeding
from a vein is *flowing bleeding.*

 *Capillary Bleeding.* Capillaries also carry blood under low pressure.
Bleeding from capillaries is *oozing bleeding.*

Use one or more of the procedures on page III-10 to control bleeding. If
you cannot control the bleeding using one method, try another, or a
combination of methods.

***Controlling Bleeding** (Continued)*

+-------------------+--------------------------------------------------+
| ***Method***      | ***Procedures***                                 |
+-------------------+--------------------------------------------------+
| Direct Local      |  Place direct pressure over the wound by        |
| Pressure          | putting a clean pad over the wound and pressing  |
|                   | firmly.                                          |
|                   |                                                  |
|                   |  Maintain compression by wrapping the wound     |
|                   | [firmly]{.underline} with a pressure bandage.    |
+-------------------+--------------------------------------------------+
| Elevation         |  Elevate the wound above the level of the       |
|                   | heart.                                           |
+-------------------+--------------------------------------------------+
| Pressure Points   |  Put pressure on the nearest pressure point to  |
|                   | slow the flow of blood to the wound. A pressure  |
|                   | point is a pulse point for a major artery. Use   |
|                   | the:                                             |
|                   |                                                  |
|                   | \- Brachial point for bleeding in the arm.       |
|                   |                                                  |
|                   | \- Femoral point for bleeding in the leg.        |
|                   |                                                  |
|                   | (See the figures on the following page for       |
|                   | illustrations of these pressure points.)         |
|                   |                                                  |
|                   | There are other pressure points that your        |
|                   | instructor may demonstrate.                      |
+-------------------+--------------------------------------------------+

**Table III-2. Procedures For Controlling Bleeding**

***Controlling Bleeding** (Continued)*

![](media/image3.jpeg){width="7.322222222222222in" height="5.2125in"}

+-----------------------------------+-----------------------------------+
| **Figure III-3.**                 | **Figure III-4.**                 |
|                                   |                                   |
| **Brachial Pressure Point**       | **Femoral Pressure Point**        |
+-----------------------------------+-----------------------------------+

***Controlling Bleeding** (Continued)*

An illustration of the three main methods to control bleeding is shown
in the figure below.

![](media/image4.wmf){width="4.2972222222222225in"
height="4.794444444444444in"}

**Figure III-5. Methods For Controlling Bleeding**

***Controlling Bleeding** (Continued)*

If none of the other methods for controlling bleeding is successful, a
tourniquet may be necessary. A tourniquet is *rarely* required and
should be used only as a *last resort*a "life or limb" situation.
Tourniquets are considered appropriate treatment for crushing-type
injuries and for partial amputations. Using a tourniquet can pose
serious risks to the affected limb, so it should not be used unless
*not* using it will endanger the person's life from excessive blood
loss. The most serious dangers in tourniquet use stem from:

 *Incorrect materials or application,* which increases the damage and
bleeding. If narrow materials are used or the tourniquet is too tight,
nerves, blood vessels, and muscles may be damaged.

 *Damage to the limb from a tourniquet.* Survival of a limb is almost
never possible after a correctly applied tourniquet is left in place too
long. Only a physician should remove a tourniquet. If you apply a
tourniquet, leave it in plain sight (don't bandage over it), and attach
an adhesive label to the victim's forehead stating the time the
tourniquet was applied.

**NOTE:** Detailed information on dressing and bandaging is provided in
Chapter IV.

Your instructor will demonstrate application of a tourniquet. Procedures
for using a tourniquet are illustrated in Figure III-6 on the next page.

***Controlling Bleeding** (Continued)*

![](media/image5.wmf){width="7.966666666666667in"
height="5.102083333333334in"}

**Figure III-6. Tourniquet**

***Recognizing And Treating For Shock***

Shock is a disorder resulting from ineffective circulation of blood.
Remaining in shock will lead to the death of cells, tissues, and entire
organs.

Initially, the body will compensate for blood loss, so signs of shock
may not appear immediately. It is important, therefore, to continually
evaluate and monitor the victim's condition. Observable symptoms of
shock to look for are:

 Rapid, shallow breathing (rate greater than 30 per minute).

 Cold, pale skin (capillary refill greater than 2 seconds).

 Failure to respond to simple commands, such as "Squeeze my hand."

To treat a person for shock, follow the steps in the table below.

+-----------+----------------------------------------------------------+
| *         | ***Procedure***                                          |
| **Step*** |                                                          |
+-----------+----------------------------------------------------------+
| 1         |  Lay the victim on his or her back.                     |
|           |                                                          |
|           |  Elevate the feet 6-10 inches.                          |
|           |                                                          |
|           |  Maintain an open airway.                               |
+-----------+----------------------------------------------------------+
| 2         |  Control obvious bleeding.                              |
+-----------+----------------------------------------------------------+
| 3         |  Maintain body temperature (e.g., cover the ground and  |
|           | the victim with a blanket).                              |
+-----------+----------------------------------------------------------+
| 4         |  Avoid rough or excessive handling.                     |
+-----------+----------------------------------------------------------+

**Table III-3. Procedures For Controlling Shock**

***Recognizing And Treating For Shock** (Continued)*

An illustration of correct shock position is shown in the figure below.

![](media/image6.wmf){width="8.991666666666667in"
height="3.3069444444444445in"}

**Figure III-7. Shock Position**

Do *not* give a victim who is suffering from shock anything to eat or
drink. People in shock may be nauseous and thirsty.

In a disaster scenario, you may have many victims requiring
attentionand few resources to use. The remainder of this chapter will
address the triage system for analyzing victim condition and
prioritizing treatment.

***Triage***

***What Is Triage?***

*Triage* is a French verb, meaning "to sort." Victims are evaluated,
sorted by immediacy of treatment needed, and set up for immediate or
delayed treatment. Military experience has shown that triage is an
effective strategy in situations where rescuers are overwhelmed, there
are limited resources, and time is a critical factor.

Triage occurs as quickly as possible after a victim is located or
rescued. Triage personnel evaluate victims' conditions and sort them
into three categories:

 *Immediate (I).* The victim has life-threatening (airway, bleeding, or
shock) injuries that demand immediate attention to save his or her life;
rapid treatment is imperative.

 *Delayed (D).* Injuries do not jeopardize the victim's life if
definitive treatment is delayed. Victim may require professional care,
but immediate treatment is not imperative.

 *Dead (DEAD).* No respiration after two attempts to open the airway.
(CPR is not performed in the disaster environment because resuscitation
of a person in full cardiorespiratory arrest takes a tremendous amount
of time and human resources.)

***What Is Triage?** (Continued)*

From triage, victims are taken to the designated medical treatment area
(immediate care, delayed care, or morgue) and from there are transported
out of the disaster area. The flow of patients is illustrated below.

**Figure III-8. Triage Patient Flow**

***Triage In A Disaster Environment***

Triage, like other disaster response efforts, begins with size-up. The
general procedure for triage in a disaster environment is as follows:

 *Stop, Look, Listen, and Think.* Before you start, stop and size up
the situation by looking around you and listening. Above all, THINK
about how you will approach the task at hand. Continue to size up the
situation as you work.

 *Conduct Voice Triage.* Begin with voice triage, calling out something
like, "Emergency Response Team. If you can walk, come to the sound of my
voice." Instruct those survivors who are ambulatory to remain at a
designated location, and continue with the triage operation.

 *Follow A Systematic Route.* Start with victims closest to you and
work outward in a systematic fashion.

 *Conduct Triage Evaluation.* Evaluate victims and tag them **I**
(immediate), **D** (delayed), or **DEAD**. Remember to evaluate the
walking wounded. Everyone must get a tag.

 *Treat "I" Victims Immediately.* Initiate airway management, bleeding
control, and/or treatment for shock for Category I (immediate) victims.

 *Document Results.* Document triage results for:

\- Effective deployment of resources.

\- Information on locations of victims.

\- A quick record of the number of casualties by degree of severity.

This will be very useful information for responders and transportation
units.

***Performing A Triage Evaluation***

Use the procedures below when performing triage.

+--------+-------------------------------------------------------------+
| ***S   | ***Procedures***                                            |
| tep*** |                                                             |
+--------+-------------------------------------------------------------+
| 1      | Check airway/breathing. At an arm's distance, shake the     |
|        | victim and shout. If the victim does not respond:           |
|        |                                                             |
|        |  Position the airway.                                      |
|        |                                                             |
|        |  Look, listen, and feel.                                   |
|        |                                                             |
|        |  Check breathing rate. Abnormally rapid respiration (above |
|        | 30 per minute) indicates shock. Treat for shock and tag     |
|        | "I."                                                        |
|        |                                                             |
|        |  If below 30 per minute, them move to Step 2.              |
|        |                                                             |
|        |  If the victim is not breathing after 2 attempts to open   |
|        | airway, then tag "DEAD."                                    |
+--------+-------------------------------------------------------------+
| 2      | Check circulation/bleeding:                                 |
|        |                                                             |
|        |  Take immediate action to control severe bleeding.         |
|        |                                                             |
|        |  Check circulation using the blanch test (for capillary    |
|        | refill).                                                    |
|        |                                                             |
|        | \- Press on an area of skin until normal skin color is      |
|        | gone. A good place to do this is on the palm of the hand.   |
|        | The forehead and nailbeds are sometimes used.               |
|        |                                                             |
|        | \- Time how long it takes for normal color to return.       |
|        |                                                             |
|        |  Treat for shock if normal color takes longer than 2       |
|        | seconds to return, and tag "I."                             |
+--------+-------------------------------------------------------------+
| 3      | Check mental status. Give a simple command, such as         |
|        | "Squeeze my hand." Inability to respond indicates that      |
|        | immediate treatment for shock is necessary. Treat for shock |
|        | and tag "I."                                                |
+--------+-------------------------------------------------------------+

**Table III-4. Triage Procedure**

If the victim passes all tests, then tag "D." If the victim fails one
test, tag "I." Remember that everyone gets a tag.

***Performing A Triage Evaluation** (Continued)*

The flowchart in Figure III-9 below illustrates the three triage steps
and the decisions that you will be required to make during a triage
evaluation.

![](media/image9.wmf){width="9.243055555555555in"
height="3.2284722222222224in"}

**Figure III-9. Triage Decision Flowchart**

**Note:** The blanch test (used in Step 2) is not valid in children.
Check mental status as the main indicator.

***Triage Planning***

There are several common problems in triage operations that can be
avoided through careful planning and preparation. These include:

 Inadequate medical size-up.

 No team plan/organization/goal.

 Indecisive leadership.

 Too much focus on one injury. (In a disaster, time is critical. You
cannot spend very much time with any single victim.)

 Treatment (rather than triage) performed.

Remember, triage is a process that needs to be *practiced.* Practicing
triage in disaster simulations as often as you can will help you avoid
these pitfalls.

***Summary***

***Introduction***

CERT members' abilities to restore breathing, control severe bleeding,
and treat for shock are critical to saving lives in the aftermath of a
disaster.

***Airway Obstructions***

Time is critical when treating a victim who has an airway obstruction.
The tongue is the most frequent obstruction. Breathing may be restored
using the Head-Tilt/Chin-Lift method. Once a victim's breathing has been
restored, take steps to keep the airway open.

***Excessive Bleeding***

There are three types of bleeding that can be identified by the flow of
blood:

 Arterial bleeding results in spurting blood.

 Venous bleeding results in excessive blood flow.

 Capillary bleeding causes oozing.

You can use one or more of the following methods to control bleeding:

 Placing pressure directly over the wound.

 Elevating the wound above the level of the heart.

 Putting pressure on the nearest pressure point to slow the flow of
blood.

***Excessive Bleeding** (Continued)*

In extreme cases, a tourniquet can be used. A tourniquet should be a
last resort. It is only used in a life-or-limb situation where other
methods have not controlled the bleeding.

***Shock***

Shock has symptoms that are readily observable. Shock requires immediate
treatment, or death can result. To treat for shock:

 Lay the victim on his or her back. Elevate the feet 6-10 inches.
Maintain an open airway.

 Control obvious bleeding.

 Maintain the body temperature.

 Avoid rough or excessive handling.

Never give a victim who is suffering from shock anything to eat or
drink.

***Triage***

Triage is a system of rapidly evaluating victims and prioritizing
treatment according to three categories:

 Immediate

 Delayed

 Dead

***Triage** (Continued)*

The procedure for performing triage involves:

 Checking the airway and breathing rate.

 Checking circulation and controlling severe bleeding.

 Checking mental status.

Triage operations require careful planning and practice. Practicing
triage in exercise situations can help avoid problems during an actual
emergency.

***Assignment***

Before the next session:

 Read and familiarize yourself with Chapter IV: Disaster Medical
OperationsPart 2.

Bring the following materials to the next session:

 Blanket

 1 box of roller gauze

 1 roll of adhesive tape (- or 1-inch)

 2 pieces of cardboard (approximately 4 inches  12 inches)

***Additional Reading***

The references below are available if you would like to know more about
the information in this chapter.

California Specialized Training Institute. [Disaster Medical
Operations]{.underline}. Sacramento, CA: Office Of The State Fire
Marshal, 1987.

Grant, Murry Jr., Bergeron, Brady. [Brady Emergency Care]{.underline},
Fifth Edition. Prentice Hall, Englewood Cliffs, NJ: 1990.

Heckman, James D. (Ed.). [Emergency Care And Transportation Of The Sick
And Injured]{.underline}, Fifth Edition. American Association of
Orthopaedic Surgeons, Park Ridge, IL: 1988.

[Reader's Digest Action Guide: What To Do In An Emergency]{.underline}.
Pleasantville, NY: 1988.

U.S. Department Of Mine Safety. [First Aid]{.underline}. U.S. Government
Printing Office, Washington, DC: 1986.

U.S. Department Of The Navy. [Self-Care/Buddy-Care]{.underline}. U.S.
Government Printing Office, Washington DC: 1988.

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  The American Red Cross also provides resources on this subject. Contact
  your local chapter for information.

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