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When preparing our departments and personnel for the next terrorist event, a new concept has emerged that needs to be addressed before the event happens. This is the concept of "acceptable losses." What are the ramifications of this idea, and how does it relate to the fire service?
During military battles, field commanders are prepared to accept the loss of up to 33% of their troops during combat. A percentage is really ambiguous, and this needs to be put in proper perspective. For lack of better words, one out of every three soldiers, Marines, airmen and sailors are considered written off when considering battlefield casualties. During World War II, the United States in its bombing raids over Europe on the average incurred these losses, and sometimes even more.
I just completed a class called "Emergency Response to Terrorism" at the University of Miami School of Medicine. This was a pilot course and several command officers and company officers throughout the greater Miami-Dade County area were asked to evaluate and give input so it could be improved. This was like many other courses I have taken on this subject, except this one had a very hands-on approach. On the last day, all participants took the role of rescuers, then changed roles to victims in an attempt to learn what victims might feel in these types of events.
During the first day's lectures, "acceptable losses" were discussed. How does this term impact the fire service? In a terrorist attack of some magnitude there will be many victims. The first-arriving units will be greeted by myriad sick, injured and dying patients. This will become a mass-casualty incident (MCI). Triage procedures from that point on drastically change, as we all know. Instead of the worst being treated first, the firefighters, EMS workers and other first responders must now look at all patients and treat the most viable first. Those patients who in all probability will die must be written off so that the rescuers can attend to patients who might have a chance to survive with immediate treatment.
Most fire departments have adapted a system of rapid triage using MCI triage cards with perforated ends that are color coded - black indicates dead, red means immediate treatment and transport, yellow is for delayed treatment and green is assigned to the walking wounded or "walking well," using the new terminology. Initially, first responders will walk among the victims and tag them according to their probable survivability.
Some departments have adopted a rapid triage method called START (Simple Triage And Rapid Treatment) in which three criteria are used for rapid evaluation: Respiration, Perfusion and Mental status, or RPM. An algorithm printed on a card the size of a business card is given to every firefighter to help in remembering this technique. Basically, it says you examine the patients; if they are not breathing, you open the airway; if they still aren't breathing, they become non-salvageable and you move to the next patient. If they begin breathing, you assess the rate and categorize the patient, and go to the perfusion criteria. Further categorization takes place and you move to the mental status category, examine further and make the last category selection. Each examination should take no more than 30 seconds.
To make the process even faster, each unit has several spools of colored ribbons. The tags are placed on the victim's in the secondary triage station. Colored ribbons are tied around a patient's extremities, and an extrication group comes in and removes these patients in the order of urgency using this system.
To understand this system and how it works, a fire department at the very least should practice these techniques in an MCI drill with many patients. In Miami, for example, area nursing schools allow us to use their students as "victims." Our training division moulages the "victims" and tells them what signs and symptoms to display.