Managing Chaos (MCI Scenario Experience)

RedAirplane

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I did an extended MCI drill and was impressed.

There's one aspect of the exercise I completely bombed. The secondary triage / ambulance loading area.

You and your three other EMTs walk up to a tennis court full of about 50 moulaged patients. They were supposedly triaged by first responders, but we soon found that the tags were all wrong (or status had changed). Re-triage gave most people red tags.

The first time through I was one of the "heads down" EMTs and it was chaos. Going around trying to "start where you stand" and re-triage / seal chests / put TQs on. Completely lost all of my triage tag stubs trying to stop major bleeding leading to accountability problems later.

The second time through I was the leader. I had a list of five hospitals and how many beds they had for each color. I had to direct triage, order resources, and coordinate transport. I felt about as effective as an invisible traffic cop at an intersection.

Even though I was supposed to be tracking pt destinations, ambulances, etc, I quickly became overwhelmed and ordered a supervisor from the ambulance company and delegated this to him. I focused on trying to get the most sick people out (at this point they were all Red or Green). I was taught to delegate so I asked one of the walking wounded to tag all of the green people and give me all of the stubs. They all vanished, including my stubs, when the bus arrived, so I had no idea where the bus went and how many people it took.

As far as the Reds... I was taught "not all reds are equal" so I was trying to get the sickest out first. I shouted to my team to bring the worst of their patients towards the ambulance loading area, which of course, backfired, because everyone thought the patient in front of them was the sickest, leading to a choke point where ambulances couldn't get in because of a pile up of people.

Enter a bunch of paramedics with gurneys and backboards running around, scooping up people, and vanishing, and I had no idea what I had. I was supposed to collect receipts etc from all patients but was so overwhelmed.

The thing here is: the ambulance company supervisor was able to articulate to me which tag numbers went in each ambulance, what their acuity was, and where the ambulance went. He assigned the destinations based on the MedCom list I gave him.

How did he / how would you manage all this communication and organize such a chaotic situation? I think I could do better with it now that I have been through the training, but I am not comfortable enough to be throw in to a situation of 50 major patients with only 3 EMTs assisting and make order out of chaos.

Thanks for your input.
 
Sounds like you were initially tasked with two jobs initially; med comm and transport coordinator. I'd say you did right delegating. But I'd of delegated first thing if I had the manpower. I don't think I'd waste time redoing triage. Get the triaged to the treatment area. When a treatment person saw the need to upgrade do it then. But redoing all triage wastes time.

I'd you're med com I'd try to stay out of the mix away from people but be within reach of transport so you can relay what beds are available without having to do so over the air.

I find large binder clips for triage tags works fairly well. You can fan them out are little so you can see the tag number and kinda keep track.

It's always going to be chaos when there's that many patients. It'll never run perfectly, there's just too many working parts. I'd say just focus on being calm and collected and not rush.
 
Grammar and punctuation does not exist when I do this on my phone, so English Nazis just relax.
 
The second time through I was the leader. I had a list of five hospitals and how many beds they had for each color. I had to direct triage, order resources, and coordinate transport. I felt about as effective as an invisible traffic cop at an intersection.
That's a tall order for a single provider with 50 patients. Each of those jobs is a relatively discreet role.

If it's just you and you're partner, you might start with all roles, but you'll need to pawn those off. Fortunately, the first thought is to probably request more resources. Once the next unit gets on scene, they can set up some rough staging and coordinate transport. You don't need bed statuses to triage, and that is of course the priority.

How did he / how would you manage all this communication and organize such a chaotic situation? I think I could do better with it now that I have been through the training, but I am not comfortable enough to be throw in to a situation of 50 major patients with only 3 EMTs assisting and make order out of chaos.

Thanks for your input.
It's a rare line provider that could manage that period.
 
As far as the Reds... I was taught "not all reds are equal" so I was trying to get the sickest out first. I shouted to my team to bring the worst of their patients towards the ambulance loading area, which of course, backfired, because everyone thought the patient in front of them was the sickest, leading to a choke point where ambulances couldn't get in because of a pile up of people.
You could use the revised trauma score (RTS) to objectively further triage people. I would only do this if I am waiting for transport, there are a lot of people in a single category/group, and if it is not detrimental to the system. If we started to choke then I would discontinue this and focus on just getting people out loading them into the ambulance in order of who is physically closest to the ambulance in that group similar to you triaging people in order of who is physically closest to you and work your way towards the end in START triage. It sounds like you were overwhelmed so I don't know if I would have done this in your scenario, but it is also possible that you could have delegated this job to another person if the resource was available or that this could have made it less overwhelming for you maybe. I also find RTS difficult to memorize so I wouldn't exactly recommend it without some sort of physical chart being available on scene for each person participating in this secondary triage that way you don't have to memorize it and try to do math* in your head during this stressful time.

* I wouldn't use the weighted score that it mentions at the bottom of the wikipedia page. Just simply add up each point for the GCS, SBP, and RR 0-12 and use that number. Simple addition. Nothing more.
 
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You could use the revised trauma score (RTS) to objectively further triage people. I would only do this if I am waiting for transport, there are a lot of people in a single category/group, and if it is not detrimental to the system. If we started to choke then I would discontinue this and focus on just getting people out loading them into the ambulance in order of who is physically closest to the ambulance in that group similar to you triaging people in order of who is physically closest to you and work your way towards the end in START triage. It sounds like you were overwhelmed so I don't know if I would have done this in your scenario, but it is also possible that you could have delegated this job to another person if the resource was available or that this could have made it less overwhelming for you maybe. I also find RTS difficult to memorize so I wouldn't exactly recommend it without some sort of physical chart being available on scene for each person participating in this secondary triage that way you don't have to memorize it and try to do math* in your head during this stressful time.

* I wouldn't use the weighted score that it mentions at the bottom of the wikipedia page. Just simply add up each point for the GCS, SBP, and RR 0-12 and use that number. Simple addition. Nothing more.

The proctor got on my case for a few things:

-- All red patients are not created equal. Send the sickest first.
-- I didn't have complete and accurate paperwork.
-- Scene safety (choke point, patients everywhere).

I think just sending the patients in the order they were closest to the ambulances (since they were all RED) would have simplified matters considerably and freed my EMTs to do other tasks, which would then have allowed me to actually have an overview picture of who is going where, how many patients, how many ambulances, etc.

In all the training videos, they show well-marked areas with tarps and EMTs treating each acuity category, separate triage area EMTs, and separate people working the transport arena. It's kind of hard to do all that stuff with so few people, but I guess I now know that "overwhelmed resources" means in the MCI definition.

Overall it was an excellent learning experience.
 
I totally understand the all red patients are not created equal and that's why I brought up are RTS. I don't know what other people use, if that is even standard, but that's something I would consider using to re-triage or further triage people. In scenarios I've participated on, we only re-triage to make sure their status was the same or move them to a more appropriate status eg a yellow became a red using RPM from START triage. We did not use RTS. That is something I've mentally considered before (but I was considering it for smaller scale MCI that I would respond to where I'd get 4 patients all immediate/red, no yellow, no green, etc). I do feel it could be applied to larger scale, but would be much better if there was a chart or something so you don't have to memorize it. I wouldn't be against trialing it, but if overwhelmed, I would abandon the idea and just revert to what is easiest (even though it would probably be best for the sickest to go first). My comment was primarily towards the all red patients are not created equal.

I don't have much too add to your other problems. The other two issues are gonna require practice I think. Don't people do MCI drills so we can practice the logistics and motion of an MCI? The last MCI drill I participated in, we had the same problem with paperwork and we didn't have a choke point problem because the drill only had 7 patients with 4 of them requiring transport, lol. What's funny is I don't even feel like our drill was realistic because we changed the drill to make it easier for us eg patient didn't need to be decon for us, but then they were treated as if they needed decon at the hospital. Your drill sound like a much larger scale. I imagine we would have had the same problems if our drill was a larger scale.

I did participate in a large scale MCI drill like 2 years ago and we had problems with incorrect triage and paperwork. We did not further triage people. Some people did get re-triaged/reassessed, but most of them did not. It was very chaotic.
 
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