[Unit 3: Disaster Medical Operations---Part 1]{.smallcaps}

In this unit you will learn about:

-   **Life-threatening Conditions:** How to recognize and treat an
    airway obstruction, bleeding, and shock.

-   **Triage:** Principles of triage and how to conduct triage
    evaluations.

# Unit 3: Disaster Medical Operations---Part 1

+-----------------------------------------------------------------------+
| # Introduction and Unit Overview                                      |
+-----------------------------------------------------------------------+
| The need for disaster medical operations is based on two assumptions: |
|                                                                       |
| -   The number of victims will exceed the local capacity for          |
|     treatment.                                                        |
|                                                                       |
| ```{=html}                                                            |
| <!-- -->                                                              |
| ```                                                                   |
| -   Survivors will assist others. They will do whatever they know how |
|     to do. They need to know lifesaving or post-disaster survival     |
|     techniques.                                                       |
+-----------------------------------------------------------------------+
| There are three phases of death from trauma:                          |
|                                                                       |
| -   [Phase 1]{.underline}: Death within minutes as a result of        |
|     overwhelming and irreversible damage to vital organs              |
|                                                                       |
| -   [Phase 2]{.underline}: Death within several hours as a result of  |
|     excessive bleeding                                                |
|                                                                       |
| -   [Phase 3]{.underline}: Death in several days or weeks as a result |
|     of infection or multiple-system failure (i.e., complications from |
|     the injury)                                                       |
+-----------------------------------------------------------------------+
| Peter Safer's research after earthquakes in Chile, Peru, and Italy    |
| indicated that more than 40 percent of disaster victims in the second |
| and third phases of death from trauma could be saved by providing     |
| simple medical care.                                                  |
+-----------------------------------------------------------------------+
| CERT personnel are trained to provide:                                |
|                                                                       |
| -   Treatment for life-threatening conditions---airway obstruction,   |
|     bleeding, and shock---and for other less urgent conditions.       |
|                                                                       |
| -   The greatest good for the greatest number of victims by           |
|     conducting simple triage and rapid treatment.                     |
|                                                                       |
| In a disaster, there will be more victims than rescuers and that      |
| immediate help will not be available. CERTs must be able to function  |
| quickly and efficiently to save lives.                                |
+-----------------------------------------------------------------------+

+-----------------------------------------------------------------------+
| # Introduction and Unit Overview (Continued)                          |
+-----------------------------------------------------------------------+
| ## Objectives                                                         |
+-----------------------------------------------------------------------+
| At the end of this unit, you should be able to:                       |
|                                                                       |
| -   Identify the "killers."                                           |
|                                                                       |
| -   Apply techniques for opening the airway, controlling bleeding,    |
|     and treating for shock.                                           |
|                                                                       |
| -   Conduct triage under simulated disaster conditions.               |
|                                                                       |
| The goal of disaster medical operations is to do the greatest good    |
| for the greatest number. In a disaster with many victims, time will   |
| be critical. CERT members will need to work quickly and efficiently   |
| to help as many victims as possible.                                  |
|                                                                       |
| This unit will introduce you to the "three killers" and the           |
| principles of triage. Throughout the unit, you will have              |
| opportunities to practice the treatment techniques and, at the end of |
| the unit, you will have the opportunity to conduct triage evaluations |
| in a simulated disaster.                                              |
+-----------------------------------------------------------------------+
| The first section will deal with treatment for life-threatening       |
| conditions: Airway obstruction, excessive bleeding, and shock.        |
+-----------------------------------------------------------------------+

+-----------------------------------------------------------------------+
| # Treating Life-Threatening Conditions                                |
+-----------------------------------------------------------------------+
| In emergency medicine, airway obstruction, bleeding, and shock are    |
| "killers." The first priority of medical operations is to attend to   |
| those potential killers by:                                           |
|                                                                       |
| -   Opening the airway.                                               |
|                                                                       |
| -   Controlling excessive bleeding.                                   |
|                                                                       |
| -   Treating for shock.                                               |
|                                                                       |
| This section will train you to recognize the "killers" by recognizing |
| their symptoms and their effects on the body.                         |
|                                                                       |
| Always wear safety equipment: Helmet, goggles, gloves, mask, and      |
| boots. A timesaving technique is to wear latex gloves under your work |
| gloves. Then, when you find a victim, you can remove your work gloves |
| and are ready to work with the victim.                                |
+-----------------------------------------------------------------------+
| ## Opening the Airway                                                 |
+-----------------------------------------------------------------------+
| ![](media/image1.wmf){width="3.013888888888889in"                     |
| height="2.8854166666666665in"}                                        |
+-----------------------------------------------------------------------+
| ######### Components Of the Respiratory System                        |
|                                                                       |
| **Components Of the Respiratory System, showing the pharynx, nasal    |
| air passage, larynx, trachea, bronchus.**                             |
+-----------------------------------------------------------------------+
| The respiratory system includes airways, lungs, and muscles.          |
+-----------------------------------------------------------------------+

+--------------+-------+------------------------------+----------------+
| # ![](media  |       |                              |                |
| /image2.wmf) |       |                              |                |
| {width="3.38 |       |                              |                |
| 541666666666 |       |                              |                |
| 65in" height |       |                              |                |
| ="2.57291666 |       |                              |                |
| 66666665in"} |       |                              |                |
| Treating Lif |       |                              |                |
| e-Threatenin |       |                              |                |
| g Conditions |       |                              |                |
|  (Continued) |       |                              |                |
+--------------+-------+------------------------------+----------------+
|              |       |                              |                |
+--------------+-------+------------------------------+----------------+
| #####        |       |                              |                |
| #### Airway  |       |                              |                |
| Obstructed B |       |                              |                |
| y The Tongue |       |                              |                |
+--------------+-------+------------------------------+----------------+
| The most     |       |                              |                |
| common       |       |                              |                |
| airway       |       |                              |                |
| obstruction  |       |                              |                |
| is the       |       |                              |                |
| tongue. In   |       |                              |                |
| an           |       |                              |                |
| unconscious  |       |                              |                |
| or           |       |                              |                |
| s            |       |                              |                |
| emiconscious |       |                              |                |
| victim,      |       |                              |                |
| especially   |       |                              |                |
| one          |       |                              |                |
| positioned   |       |                              |                |
| on his or    |       |                              |                |
| her back,    |       |                              |                |
| the          |       |                              |                |
| to           |       |                              |                |
| ngue---which |       |                              |                |
| is a         |       |                              |                |
| muscle---may |       |                              |                |
| relax and    |       |                              |                |
| block the    |       |                              |                |
| airway. A    |       |                              |                |
| victim with  |       |                              |                |
| a suspected  |       |                              |                |
| airway       |       |                              |                |
| obstruction  |       |                              |                |
| must be      |       |                              |                |
| checked      |       |                              |                |
| immediately  |       |                              |                |
| for          |       |                              |                |
| breathing    |       |                              |                |
| and, if      |       |                              |                |
| necessary,   |       |                              |                |
| the airway   |       |                              |                |
| must be      |       |                              |                |
| opened.      |       |                              |                |
+--------------+-------+------------------------------+----------------+
| When an      |       |                              |                |
| airway       |       |                              |                |
| obstruction  |       |                              |                |
| is           |       |                              |                |
| suspected,   |       |                              |                |
| CERT members |       |                              |                |
| should clear |       |                              |                |
| the airway   |       |                              |                |
| using the    |       |                              |                |
| Head-Ti      |       |                              |                |
| lt/Chin-Lift |       |                              |                |
| method.      |       |                              |                |
+--------------+-------+------------------------------+----------------+
| #########    |       |                              |                |
| Head-Tilt/Ch |       |                              |                |
| in-Lift Meth |       |                              |                |
| od for Openi |       |                              |                |
| ng an Airway |       |                              |                |
+--------------+-------+------------------------------+----------------+
|              | **S   | **Action**                   |                |
|              | tep** |                              |                |
+--------------+-------+------------------------------+----------------+
|              | 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 the    |                |
|              |       | palm of 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     | Place your ear over the      |                |
|              |       | victim's mouth, looking      |                |
|              |       | toward the victim's feet,    |                |
|              |       | and place a hand on the      |                |
|              |       | victim's abdomen.            |                |
+--------------+-------+------------------------------+----------------+
|              | 5     | *Look* for chest rise.       |                |
+--------------+-------+------------------------------+----------------+
|              | 6     | *Listen* for air exchange.   |                |
+--------------+-------+------------------------------+----------------+
|              | 7     | *Feel* for abdominal         |                |
|              |       | movement.                    |                |
+--------------+-------+------------------------------+----------------+

+-----------------------------------------------------------------------+
| # Treating Life-Threatening Conditions (Continued)                    |
+-----------------------------------------------------------------------+
| ## Exercise: Opening the Airway                                       |
+-----------------------------------------------------------------------+
| **[Purpose]{.underline}:** This exercise allows you to practice using |
| the Head-Tilt/Chin-Lift method on each other.                         |
|                                                                       |
| **[Instructions]{.underline}:** Follow the steps below to complete    |
| this exercise:                                                        |
+-----------------------------------------------------------------------+
| 1.  Work in pairs---one person will be the victim and the other       |
|     person the rescuer.                                               |
|                                                                       |
| 2.  Victims should lie on the floor on their backs and close their    |
|     eyes.                                                             |
|                                                                       |
| 3.  The rescuer should use the Head-Tilt/Chin-Lift method on the      |
|     victim to open the airway.                                        |
+-----------------------------------------------------------------------+
| 4.  After the rescuer has made two or three attempts at using the     |
|     Head-Tilt/Chin-Lift method, the victim and the rescuer should     |
|     change roles.                                                     |
+-----------------------------------------------------------------------+

+-----------------------------------------------------------------------+
| # Treating Life-Threatening Conditions (Continued)                    |
+-----------------------------------------------------------------------+
| Part of your mission is to do the greatest good for the greatest      |
| number of people. For that reason, if breathing is not restored on    |
| the first try using the Head-Tilt/Chin-Lift method, CERT members      |
| should try again using the same method. If breathing cannot be        |
| restored on the second try, CERT members must move on to the next     |
| victim.                                                               |
+-----------------------------------------------------------------------+
| If breathing has been restored, the airway still must be maintained.  |
| One option is to use a volunteer or walking wounded to hold the head  |
| in place. The airway also can be maintained by placing soft objects   |
| under the victim's shoulders to elevate the shoulders slightly and    |
| keeping the airway open.                                              |
+-----------------------------------------------------------------------+
| ## Controlling Bleeding                                               |
+-----------------------------------------------------------------------+
| Uncontrolled bleeding initially causes weakness. If bleeding is not   |
| controlled, the victim will go into shock within a short period of    |
| time, and finally will die. An adult has about five liters of blood.  |
| Losing one liter can result in death.                                 |
|                                                                       |
| There are three types of bleeding and the type can usually be         |
| identified by how fast the blood flows:                               |
|                                                                       |
| -   [Arterial bleeding]{.underline}. Arteries transport blood under   |
|     high pressure. Bleeding from an artery is [spurting]{.underline}  |
|     bleeding.                                                         |
|                                                                       |
| -   [Venous bleeding]{.underline}. Veins transport blood under low    |
|     pressure. Bleeding from a vein is [flowing]{.underline} bleeding. |
|                                                                       |
| -   [Capillary bleeding]{.underline}. Capillaries also carry blood    |
|     under low pressure. Bleeding from capillaries is                  |
|     [oozing]{.underline} bleeding.                                    |
+-----------------------------------------------------------------------+
| There are three main methods for controlling bleeding:                |
|                                                                       |
| -   Direct pressure                                                   |
|                                                                       |
| -   Elevation                                                         |
|                                                                       |
| -   Pressure points                                                   |
+-----------------------------------------------------------------------+

+---+-------------------+------------------------------------------+---+
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+---+-------------------+------------------------------------------+---+
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| g |                   |                                          |   |
+---+-------------------+------------------------------------------+---+
|   | **Method**        | **Procedures**                           |   |
+---+-------------------+------------------------------------------+---+
|   | Direct Pressure   | -   Place direct pressure over the wound |   |
|   |                   |     by putting a clean dressing over the |   |
|   |                   |     wound and pressing firmly.           |   |
|   |                   |                                          |   |
|   |                   | -   Maintain pressure on the dressing    |   |
|   |                   |     over the wound 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. Use the:                  |   |
|   |                   |                                          |   |
|   |                   | ```{=html}                               |   |
|   |                   | <!-- -->                                 |   |
|   |                   | ```                                      |   |
|   |                   | -   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   |   |
|   |                   | > the Instructor may demonstrate.        |   |
+---+-------------------+------------------------------------------+---+

+-----------------------------------------------------------------------+
| Direct pressure combined with elevation will address most bleeding.   |
| Demonstrate the procedure for controlling bleeding through direct     |
| pressure:                                                             |
|                                                                       |
| -   [Step 1]{.underline}: Place direct pressure over the wound by     |
|     putting a clean dressing over the wound and pressing firmly.      |
|                                                                       |
| -   [Step 2]{.underline}: Maintain pressure on the dressing over the  |
|     wound by wrapping [firmly]{.underline} with a pressure bandage.   |
+-----------------------------------------------------------------------+
| Direct pressure and elevation can take 5 to 7 minutes to stop the     |
| bleeding completely. The use of a dressing and pressure bandage       |
| allows the rescuer to move on to the next victim.                     |
|                                                                       |
| A pressure bandage should be tied with a bow, so that it can be       |
| loosened---rather than cut---to examine the wound, and then retied.   |
| This procedure helps to conserve supplies and saves time.             |
+-----------------------------------------------------------------------+
| Bleeding can also be controlled through elevation: Elevating the      |
| wound above the level of the heart. Elevation is used in combination  |
| with direct pressure.                                                 |
+-----------------------------------------------------------------------+
| There are also pressure points that can be used to stem the flow of   |
| bleeding.                                                             |
+-----------------------------------------------------------------------+

+-----------------------------------------------------------------------+
| # Treating Life-Threatening Conditions (Continued)                    |
+-----------------------------------------------------------------------+
| The pressure points most often used are the:                          |
|                                                                       |
| -   Brachial point in the arm.                                        |
|                                                                       |
| -   Femoral point in the leg.                                         |
|                                                                       |
|     Get victims to help themselves, whenever possible.                |
+-----------------------------------------------------------------------+
| ![](media/image3.jpeg){width="6.1930555555555555in"                   |
| height="4.41875in"}                                                   |
+-----------------------------------------------------------------------+

+-----------------------------------------------------------------------+
| # Treating Life-Threatening Conditions (Continued)                    |
+-----------------------------------------------------------------------+
| ![](media/image4.wmf){width="2.977777777777778in"                     |
| height="3.4319444444444445in"}                                        |
|                                                                       |
| ######### Methods For Controlling Bleeding                            |
|                                                                       |
| **Methods For Controlling Bleeding by using direct pressure on wound, |
| elevation, and pressure points.**                                     |
+-----------------------------------------------------------------------+

+-----------------------------------------------------------------------+
| # Treating Life-Threatening Conditions (Continued)                    |
+-----------------------------------------------------------------------+
| ## Exercise: Controlling Bleeding                                     |
+-----------------------------------------------------------------------+
| **[Purpose]{.underline}:** This exercise allows you to practice the   |
| techniques for controlling bleeding.                                  |
|                                                                       |
| **[Instructions]{.underline}:** Follow the steps below to conduct     |
| this exercise:                                                        |
+-----------------------------------------------------------------------+
| 1.  Work in pairs again -- one person will be the victim and the      |
|     other the rescuer.                                                |
|                                                                       |
| 2.  Victims should lie on the floor on their backs and close their    |
|     eyes.                                                             |
+-----------------------------------------------------------------------+
| 3.  The rescuer should use direct pressure to control bleeding from a |
|     simulated wound on the right forearm just below the elbow. The    |
|     rescuer should:                                                   |
|                                                                       |
| -   Apply a pressure bandage.                                         |
|                                                                       |
| -   Elevate the arm.                                                  |
|                                                                       |
| -   Repeat these two steps.                                           |
|                                                                       |
| -   Repeat the two steps for speed.                                   |
+-----------------------------------------------------------------------+
| 4.  After the rescuer has made at least three attempts at using each  |
|     technique, the victim and the rescuer should change roles.        |
+-----------------------------------------------------------------------+
| Bleeding must be controlled as quickly as possible so as not to       |
| endanger the victim's life from blood loss.                           |
|                                                                       |
| You should always wear your rubber gloves, goggles, and a mask as a   |
| protection against blood-borne pathogens, such as hepatitis and HIV.  |
+-----------------------------------------------------------------------+

+-----------------------------------------------------------------------+
| # Treating Life-Threatening Conditions (Continued)                    |
+-----------------------------------------------------------------------+
| ## Recognizing and Treating Shock                                     |
+-----------------------------------------------------------------------+
| Shock is a disorder resulting from ineffective circulation of blood.  |
| Remaining in shock will lead to the death of:                         |
|                                                                       |
| -   Cells.                                                            |
|                                                                       |
| ```{=html}                                                            |
| <!-- -->                                                              |
| ```                                                                   |
| -   Tissues.                                                          |
|                                                                       |
| ```{=html}                                                            |
| <!-- -->                                                              |
| ```                                                                   |
| -   Entire organs.                                                    |
|                                                                       |
| The body will initially compensate for blood loss and mask the        |
| symptoms of shock. Therefore, it is important to continually evaluate |
| patients for shock and monitor their condition.                       |
+-----------------------------------------------------------------------+
| The main signs of shock that CERT members look for are:               |
+-----------------------------------------------------------------------+
| -   Rapid and shallow breathing.                                      |
|                                                                       |
| -   Capillary refill of greater than 2 seconds.                       |
|                                                                       |
| -   Failure to follow simple commands, such as, "Squeeze my hand."    |
|                                                                       |
| -   Changes in skin color.                                            |
|                                                                       |
| Capillary refill is how long it takes for the color to return. This   |
| is called the "blanch test."                                          |
+-----------------------------------------------------------------------+

+--------------+-------+------------------------------+----------------+
| #            |       |                              |                |
| Treating Lif |       |                              |                |
| e-Threatenin |       |                              |                |
| g Conditions |       |                              |                |
|  (Continued) |       |                              |                |
+--------------+-------+------------------------------+----------------+
| Although     |       |                              |                |
| victims who  |       |                              |                |
| are          |       |                              |                |
| suffering    |       |                              |                |
| from shock   |       |                              |                |
| may be       |       |                              |                |
| thirsty,     |       |                              |                |
| they should  |       |                              |                |
| [not]        |       |                              |                |
| {.underline} |       |                              |                |
| eat or drink |       |                              |                |
| anything,    |       |                              |                |
| because they |       |                              |                |
| may also be  |       |                              |                |
| nauseated.   |       |                              |                |
+--------------+-------+------------------------------+----------------+
| ######       |       |                              |                |
| ### Procedur |       |                              |                |
| es For Contr |       |                              |                |
| olling Shock |       |                              |                |
+--------------+-------+------------------------------+----------------+
|              | **S   | **Action**                   |                |
|              | tep** |                              |                |
+--------------+-------+------------------------------+----------------+
|              | 1     | -   Lay the victim on his or |                |
|              |       |     her back.                |                |
|              |       |                              |                |
|              |       | -   Elevate the feet 6-10    |                |
|              |       |     inches above the level   |                |
|              |       |     of the heart.            |                |
|              |       |                              |                |
|              |       | -   Maintain an open airway. |                |
+--------------+-------+------------------------------+----------------+
|              | 2     | -   Control obvious          |                |
|              |       |     bleeding.                |                |
+--------------+-------+------------------------------+----------------+
|              | 3     | -   Maintain body            |                |
|              |       |     temperature (e.g., cover |                |
|              |       |     the ground and the       |                |
|              |       |     victim with a blanket if |                |
|              |       |     necessary).              |                |
+--------------+-------+------------------------------+----------------+
|              | 4     | -   Avoid rough or excessive |                |
|              |       |     handling unless the      |                |
|              |       |     rescuer and victim are   |                |
|              |       |     in immediate danger.     |                |
+--------------+-------+------------------------------+----------------+

+-----------------------------------------------------------------------+
| ## Exercise: Treating Shock                                           |
+-----------------------------------------------------------------------+
| **[Purpose]{.underline}:** This exercise allows you to practice the   |
| steps for treating shock.                                             |
|                                                                       |
| **[Instructions]{.underline}:** Follow the steps below to complete    |
| this exercise:                                                        |
+-----------------------------------------------------------------------+
| 1.  Work in pairs of victim and rescuer.                              |
|                                                                       |
| 2.  The victims should lie on the floor on their backs and close      |
|     their eyes.                                                       |
+-----------------------------------------------------------------------+
| 3.  The rescuer should treat the victim based on the scenario given   |
|     by the Instructor.                                                |
+-----------------------------------------------------------------------+
| 4.  The victim and the rescuer should then switch roles.              |
+-----------------------------------------------------------------------+

+-----------------------------------------------------------------------+
| # Triage                                                              |
+-----------------------------------------------------------------------+
| [Triage]{.underline} is a French term meaning "to sort."              |
|                                                                       |
| During triage, victims are evaluated, sorted by the urgency of the    |
| treatment needed, and set up for immediate or delayed treatment.      |
+-----------------------------------------------------------------------+
| Triage was, in fact, initiated by the military and experience has     |
| shown that triage is an effective strategy in situations where:       |
|                                                                       |
| -   There are many more victims than rescuers.                        |
|                                                                       |
| -   There are limited resources.                                      |
|                                                                       |
| -   Time is critical.                                                 |
+-----------------------------------------------------------------------+
| Triage occurs as quickly as possible after a victim is located or     |
| rescued.                                                              |
+-----------------------------------------------------------------------+
| During triage, victims' conditions are evaluated and the victims are  |
| prioritized and labeled (tagged) into three categories:               |
|                                                                       |
| -   [Immediate (I)]{.underline}: The victim has life-threatening      |
|     (airway, bleeding, or shock) injuries that demand immediate       |
|     attention to save his or her life; rapid, life-saving treatment   |
|     is urgent.                                                        |
|                                                                       |
| -   [Delayed (D)]{.underline}: Injuries do not jeopardize the         |
|     victim's life. The victim may require professional care, but      |
|     treatment can be delayed.                                         |
|                                                                       |
| ```{=html}                                                            |
| <!-- -->                                                              |
| ```                                                                   |
| -   [Dead (DEAD)]{.underline}: No respiration after two attempts to   |
|     open the airway. Because CPR is one-on-one care and is            |
|     labor-intensive, CPR is not performed when there are many more    |
|     victims than rescuers.                                            |
|                                                                       |
| The CERT program goal is to do the greatest good for the greatest     |
| number.                                                               |
+-----------------------------------------------------------------------+
| From triage, victims are taken to the designated medical treatment    |
| area (immediate care, delayed care, or morgue). (Note: If you have    |
| labeled your medical treatment areas using "I," "D," and "Morgue,"    |
| you can tell spontaneous volunteers to take the "I" victims to the    |
| "I" treatment area, etc.)                                             |
+-----------------------------------------------------------------------+

+-----------------------------------------------------------------------+
| # Triage (Continued)                                                  |
+-----------------------------------------------------------------------+
| ## Triage in a Disaster Environment                                   |
+-----------------------------------------------------------------------+
| The general procedures for conducting triage are:                     |
|                                                                       |
| -   [Step 1: Stop, Look, Listen, and Think]{.underline}. Before you   |
|     start, stop and size up the situation by looking around and       |
|     listening. THINK about your safety, capability, and limitations,  |
|     and decide if you will approach the situation and how.            |
|                                                                       |
| -   [Step 2: Conduct voice triage]{.underline}. Begin by calling out, |
|     "Emergency Response Team. If you can walk, come to the sound of   |
|     my voice." If there are survivors who are ambulatory, instruct    |
|     them to remain at a designated location, and continue with the    |
|     triage operation. (If rescuers need assistance and there are      |
|     ambulatory survivors, then these survivors should be asked to     |
|     provide assistance.) These persons may also provide useful        |
|     information about the location of the victims.                    |
+-----------------------------------------------------------------------+
| -   [Step 3: Start where you stand, and follow a systematic           |
|     route]{.underline}. Start with the closest victims and work       |
|     outward in a systematic fashion.                                  |
|                                                                       |
| -   [Step 4: Evaluate each victim and tag them]{.underline} **"I"**   |
|     (immediate), **"D"** (delayed), or **"DEAD."** Remember to        |
|     evaluate the walking wounded.                                     |
|                                                                       |
| -   [Step 5: Treat **"I"** victims immediately]{.underline}. Initiate |
|     airway management, bleeding control, and treatment for shock for  |
|     **"I"** victims.                                                  |
+-----------------------------------------------------------------------+
| -   [Step 6: Document triage results for]{.underline}:                |
|                                                                       |
| ```{=html}                                                            |
| <!-- -->                                                              |
| ```                                                                   |
| -   [Effective deployment of resources]{.underline}.                  |
|                                                                       |
| -   [Information on the victims' locations]{.underline}.              |
|                                                                       |
| -   [A quick record of the number of casualties by degree of          |
|     severity]{.underline}.                                            |
|                                                                       |
| The rescuer's safety is paramount during triage. Wear proper          |
| protective equipment so as not to endanger your own health.           |
+-----------------------------------------------------------------------+

+---+---------+-----------------------------------------------------+---+
| # |         |                                                     |   |
|   |         |                                                     |   |
| T |         |                                                     |   |
| r |         |                                                     |   |
| i |         |                                                     |   |
| a |         |                                                     |   |
| g |         |                                                     |   |
| e |         |                                                     |   |
|   |         |                                                     |   |
| ( |         |                                                     |   |
| C |         |                                                     |   |
| o |         |                                                     |   |
| n |         |                                                     |   |
| t |         |                                                     |   |
| i |         |                                                     |   |
| n |         |                                                     |   |
| u |         |                                                     |   |
| e |         |                                                     |   |
| d |         |                                                     |   |
| ) |         |                                                     |   |
+---+---------+-----------------------------------------------------+---+
| # |         |                                                     |   |
| # |         |                                                     |   |
|   |         |                                                     |   |
| P |         |                                                     |   |
| e |         |                                                     |   |
| r |         |                                                     |   |
| f |         |                                                     |   |
| o |         |                                                     |   |
| r |         |                                                     |   |
| m |         |                                                     |   |
| i |         |                                                     |   |
| n |         |                                                     |   |
| g |         |                                                     |   |
|   |         |                                                     |   |
| a |         |                                                     |   |
|   |         |                                                     |   |
| T |         |                                                     |   |
| r |         |                                                     |   |
| i |         |                                                     |   |
| a |         |                                                     |   |
| g |         |                                                     |   |
| e |         |                                                     |   |
|   |         |                                                     |   |
| E |         |                                                     |   |
| v |         |                                                     |   |
| a |         |                                                     |   |
| l |         |                                                     |   |
| u |         |                                                     |   |
| a |         |                                                     |   |
| t |         |                                                     |   |
| i |         |                                                     |   |
| o |         |                                                     |   |
| n |         |                                                     |   |
+---+---------+-----------------------------------------------------+---+
| # |         |                                                     |   |
| # |         |                                                     |   |
| # |         |                                                     |   |
| # |         |                                                     |   |
| # |         |                                                     |   |
| # |         |                                                     |   |
| # |         |                                                     |   |
| # |         |                                                     |   |
| # |         |                                                     |   |
|   |         |                                                     |   |
| T |         |                                                     |   |
| r |         |                                                     |   |
| i |         |                                                     |   |
| a |         |                                                     |   |
| g |         |                                                     |   |
| e |         |                                                     |   |
|   |         |                                                     |   |
| P |         |                                                     |   |
| r |         |                                                     |   |
| o |         |                                                     |   |
| c |         |                                                     |   |
| e |         |                                                     |   |
| d |         |                                                     |   |
| u |         |                                                     |   |
| r |         |                                                     |   |
| e |         |                                                     |   |
+---+---------+-----------------------------------------------------+---+
|   | *       | **Procedures**                                      |   |
|   | *Step** |                                                     |   |
+---+---------+-----------------------------------------------------+---+
|   | 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, then 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).                              |   |
|   |         |                                                     |   |
|   |         | ```{=html}                                          |   |
|   |         | <!-- -->                                            |   |
|   |         | ```                                                 |   |
|   |         | -   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 nailbeds are          |   |
|   |         |     sometimes used.                                 |   |
|   |         |                                                     |   |
|   |         | -   Time how long it takes for normal color to      |   |
|   |         |     return.                                         |   |
|   |         |                                                     |   |
|   |         | ```{=html}                                          |   |
|   |         | <!-- -->                                            |   |
|   |         | ```                                                 |   |
|   |         | -   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."                        |   |
+---+---------+-----------------------------------------------------+---+

  -----------------------------------------------------------------------
  If the victim passes all tests, his or her status is "**D.**" If the
  victim fails one test, his or her status is "**I.**" Remember that
  [everyone gets a tag]{.underline}. All victims tagged "I" get airway
  control, bleeding control, and treatment for shock.

  -----------------------------------------------------------------------

+-------------+-------------+-------------+-------------+-------------+
| # Triage    |             |             |             |             |
| (Continued) |             |             |             |             |
+-------------+-------------+-------------+-------------+-------------+
| ## Documen  |             |             |             |             |
| ting Triage |             |             |             |             |
+-------------+-------------+-------------+-------------+-------------+
| ####        |             |             |             |             |
| ##### Sampl |             |             |             |             |
| e Triage Do |             |             |             |             |
| cumentation |             |             |             |             |
+-------------+-------------+-------------+-------------+-------------+
| ###         | #####       |             |             |             |
| #### Status | ## Location |             |             |             |
+-------------+-------------+-------------+-------------+-------------+
|             | **A**       | **B**       | **C**       | **D**       |
+-------------+-------------+-------------+-------------+-------------+
| ####### I   | 1           | 2           | 0           | 1           |
+-------------+-------------+-------------+-------------+-------------+
| **D**       | 0           | 2           | 5           | 3           |
+-------------+-------------+-------------+-------------+-------------+
| **Dead**    | 3           | 7           | 1           | 0           |
+-------------+-------------+-------------+-------------+-------------+

+-----------------------------------------------------------------------+
| # ![](media/image5.wmf){width=                                        |
| "5.998611111111111in" height="2.658333333333333in"}Triage (Continued) |
+-----------------------------------------------------------------------+
|                                                                       |
+-----------------------------------------------------------------------+
| ######### Triage Decision Flowchart                                   |
|                                                                       |
| **Triage Decision Flowchart, showing the three steps in the triage    |
| process. Step 1: assess and position the airway and check breathing;  |
| Step 2: Check circulation and control bleeding; Step 3: Check mental  |
| status.**                                                             |
+-----------------------------------------------------------------------+
| Time will be critical in a disaster. You will not be able to spend    |
| very much time with any single victim.                                |
+-----------------------------------------------------------------------+
| Take advantage of local exercises as a means of maintaining your      |
| triage skills and to avoid the triage pitfalls.                       |
+-----------------------------------------------------------------------+
| Triage pitfalls include:                                              |
|                                                                       |
| -   No team plan, organization, or goal.                              |
|                                                                       |
| -   Indecisive leadership.                                            |
|                                                                       |
| -   Too much focus on one injury.                                     |
|                                                                       |
| -   Treatment (rather than triage) performed.                         |
+-----------------------------------------------------------------------+

+-----------------------------------------------------------------------+
| # Triage (Continued)                                                  |
+-----------------------------------------------------------------------+
| ## Exercise: Conducting Triage                                        |
+-----------------------------------------------------------------------+
| **[Purpose]{.underline}:** This exercise is intended to allow you to  |
| practice conducting triage in a high-pressure situation.              |
|                                                                       |
| **[Instructions]{.underline}:** Follow the steps below to complete    |
| this exercise:                                                        |
+-----------------------------------------------------------------------+
| 1.  Work in 6-person groups. In each group, three participants will   |
|     act as victims, and three will act as search and rescue team      |
|     members (two rescuers and one runner).                            |
|                                                                       |
| 2.  The "victims" should select a card from the Instructor and tape   |
|     it to their shirts.                                               |
|                                                                       |
| 3.  The victims should arrange themselves within the designated       |
|     "disaster" area.                                                  |
+-----------------------------------------------------------------------+
| 4.  The three "rescuers" will have 5 minutes to:                      |
|                                                                       |
| -   Conduct triage on each of the victims and determine how each      |
|     should be tagged and treated.                                     |
|                                                                       |
| -   Document the number of victims in each category of triage         |
|     (immediate, delayed, dead).                                       |
+-----------------------------------------------------------------------+

+-----------------------------------------------------------------------+
| # Unit Summary                                                        |
+-----------------------------------------------------------------------+
| The key points from this unit include:                                |
|                                                                       |
| -   CERT members' ability to open airways, control bleeding, and      |
|     treat shock is critical to saving lives.                          |
|                                                                       |
| ```{=html}                                                            |
| <!-- -->                                                              |
| ```                                                                   |
| -   Use the Head-Tilt/Chin-Lift method for opening airways.           |
|                                                                       |
| -   Control bleeding using direct pressure, elevation, and/or         |
|     pressure points.                                                  |
|                                                                       |
| -   If there is a question about whether a victim is in shock, treat  |
|     for shock.                                                        |
|                                                                       |
| ```{=html}                                                            |
| <!-- -->                                                              |
| ```                                                                   |
| -   Triage is a system for rapidly evaluating victims' injuries and   |
|     prioritizing them for treatment. The procedure for conducting     |
|     triage evaluations involves checking:                             |
|                                                                       |
| ```{=html}                                                            |
| <!-- -->                                                              |
| ```                                                                   |
| -   The airway and breathing rate.                                    |
|                                                                       |
| -   Circulation and bleeding.                                         |
|                                                                       |
| -   Mental status.                                                    |
|                                                                       |
| Disaster medical operations require careful planning, teamwork, and   |
| practice. Take advantage of participating in community-wide disaster  |
| exercises whenever they are scheduled.                                |
+-----------------------------------------------------------------------+
| ## Homework Assignment                                                |
+-----------------------------------------------------------------------+
| Read and become familiar with Unit 4: Disaster Medical Operations---  |
| Part 2 before the next session.                                       |
|                                                                       |
| Bring a blanket, roller gauze, adhesive tape, and cardboard to the    |
| next session.                                                         |
+-----------------------------------------------------------------------+