Triage

There are two forms of triage, triage sieve, which is a primary triage system and triage SALT which is a secondary triage system. At the scene, we are only probably doing primary triage until the casualties are cleared to a casualty-clearing point or casualty-clearing station. There is a standardised algorithm for this but may still need to be adopted depending upon the situation.

• Are the casualties walking? If the answer to that is yes, they are priority three casualties.
• Does the casualty have any catastrophic haemorrhage? By catastrophic haemorrhage, we do mean pumping, splurting blood from an artery or limb, in which case you need to stop that catastrophic haemorrhage by applying a tourniquet and they become a P1 casualty.
• Is the casualty breathing? Actually, we have this gentleman here, who doesn't appear to be breathing. Simply opening the airway, by either doing a head-lift chin tilt.
• Does the casualty start to breathe? If the answer to that question is no, then in a major incident scenario, the casualty is dead. That does not apply to normal incidents where you would actually start basic life support and other forms of resuscitation but when you have a large number of casualties, we don't invest in that. If we open the airway, the casualty doesn't breathe, the casualty is dead. If the casualty does breathe and he's unconscious, we need to move him to a recovery position, if it's possible to do so and he becomes a priority one patient. If the casualty is unconscious, or not unconscious, we are going to look at the respiratory rate. And if it's below 10 or above 30, we are going to consider that abnormal and they are going to become a P1 patient. Now, this is a technical point. You don't need to take the pulse for the full 60 seconds. It's often done better by just assessing the breathing for 15 seconds timing by four to give you the respiratory rate nor does it need to be exact in some cases. If this casualty was really breathing rapidly, and you can tell at first glance that it was rapid breathing, it was probably over 30 then that's a perfectly acceptable way of doing it when you're dealing with primary triage. If the respiratory is between the two, in other words between 10 and 29, we are going to consider that normal we are going to move on and we are going to look at the casualty's circulation in terms of their pulse rate. If the pulse rate is over 120, we are going to consider that abnormal, making them a P1 casualty. If it's under 120, we are going to consider that to be a P2.

So as you go through the algorithm, which is set out and is now a national standard for most ambulance services, well, all ambulance services in the United Kingdom, it's a very easy thing to follow. It doesn't really matter how good a clinician you are, the easiest thing to do is take your triage algorithm out, put your finger on it, follow it and when it comes to a conclusion, stop. Label the casualty up appropriately and then move on to the next patient. You shouldn't be spending much more than 90 seconds at a time on each casualty in a major incident scenario when you are doing primary triage, which will have included the tourniquet or any other essential interventions that have to be carried out as dictated by the algorithm. Sometimes you won't have access to the casualty. We can see here that we have a couple of boots sticking out and we have a couple of arms sticking out. So we have got casualties entrapped and we cannot see the whole casualty. So, it is very difficult to apply this algorithm to these patients. If you are close enough and you can reach, you can probably take a pulse and what you are actually looking for here is are they alive or are they dead?

Because if there is no pulse, then there is no point in wasting any more time. Now you need to move on and find the next live casualty. If you cannot get access to them, let's say these were higher up in the rock face when actually there are other methods of triaging. So, a thermal imaging camera borrowed from the fire brigade will give you heat recognition. And clearly, if there is no heat recognition, then the casualty is dead, you do not need to worry that you can move on and find other casualties. So triage may have to be adopted despite the fact that we have a national standard for doing it. And you are going to have to work out what is going to be the best for your scenario. One of the reasons I like to go in and say, "If you are injured and you can walk, come to me," is actually am clearing those people who are able to move out of my way as quickly as possible, because actually, it is the people that can move and can talk which will be the biggest nuisance to you on the scene. So actually it is easy to get them away, corral them somewhere else, get them treated. So you can then concentrate on the people that are in fact, the higher priority as left behind in terms of the entrapped P1s and P2 casualties.