DECONTAMINATION
START TRIAGE
The START triage system separates the injured into four groups.
The fi rst group are the expectant victims who are beyond help
The second group are the injured victims who can be treated and immediately transported to hospitals
The third group are the injured victims whose transport can be delayed, and
The fourth group are those victims with minor injuries who may need treatment less urgently, or have no apparent injuries, but were found in the incident area.
HAZMAT Team set-up Bracco Diagnostics
Communication of accurate information to all fi rst responders at the incident and hospitals in the vicinity of the incident is critical to the survival rate of the victims
Making a START Triage of victims, decontamination prior to treatment, and control of the total victim population can be one of the most challenging operations for a fi rst-responder incident commander. A review of 640 patients arriving at the emergency department at St. Luke’s International Hospital following the Tokyo Subway sarin attack in 1995 identifi ed 90% of the victims arriving at the hospital on their own and not by a fi rst responder or EMS ambulance. This same outcome could happen in the US and other countries, and places complex challenges to local hospitals as well as the fi rst responders on the scene of the incident. Domestic fi rst responders have been using
a triage system called START since the late 1980s. START is a Simple Triage And Repaid Treatment plan to manage mass incident victims. The START method is used by fi rst responders to eff ectively and effi ciently evaluate all of the victims during a mass casualty incident (MCI) - see box. The fi rst-arriving medical fi rst responders will use a colour-coded triage tag to categorise the victims by the severity of their injury. Victims are easily identifi able by a Red tag designating immediate care fi rst, followed by the Yellow tag designating delayed treatment, and Green tag identifying minor injured – that is, walking victims that can wait for treatment and be moved out of the incident area. There is a Black tag for dead victims or victims designated for the morgue.
Triage for CBRN Triage of CRBN victims is an entirely diff erent process. In many cases the victims cannot be taken out of the CWA-contaminated area (the hot zone) until they have been properly decontaminated fi rst. In these cases as in the above training scenario, many of
the victims that leave the hot zone on their own pose the greatest risk contaminating others - such as occurred in the Tokyo subway attack. Victim control is critical for fi rst responders.
The contaminated area must be contained and victims that are triaged in Red immediate- care designations must be able to complete the decontamination process using CWA neutralisers, as in RSDL fi rst, followed by a wash-and-rinse decontamination process in a portable decontamination tent or shower unit. After being fully decontaminated, the victim must receive a CWA medical antidote as soon as they are decontaminated. In some extreme cases a CWA automatic injection medical antidote may be given to a victim or fi rst responder in the hot zone.
Reaching the hospitals In the event of a large number of CWA- contaminated victims who leave the incident area, local hospital emergency departments must be informed immediately by the fi rst responders and the 9-1-1 Public Safety
Answering Point (PSAP) as soon as the incident is designated a CWA terrorist site. In addition to notifi cations, estimated numbers of victims need to be communicated to the hospitals, so that internal hospital CBRN and medical stockpile activations can be put in place for anticipated victim arrivals. The CBRN CWA domestic response
activation could take a considerable amount of time to deploy resources to the incident site. Containment of the incident hot zone area by only fi rst responders in appropriate CBRN CWA personal protection equipment (PPE) is critical in the safe naturalisation for the CWA exposed area(s) and victim(s). In addition, communication of accurate
information to all fi rst responders at the incident and hospitals in the vicinity of the incident is critical to the survival rate of the victims and non-exposed persons close to the incident. As the incident progresses into its higher levels of emergency response, key decision makers at the incident command post should make the notifi cation to the appropriate authorities to activate the SNS. RSDL is an appropriate CWA decontaminate
HAZMAT First Responder with RSDL Bracco Diagnostics
and neutraliser for domestic fi rst responders and is safe to use in pre-hospital and in- hospital operations. First responders should train and educate themselves responding to CWA incidents and know how their local governmental agencies can activate the CDC SNS in their communities. Please note that the US CDC SNS does not stock decontamination products as part of the SNS. It is recommended you check with your local Disaster Management Agency, or local hazardous material fi rst responders for appropriate decontamination products.
Dr Donald W. Walsh EMT-P is a retired Chicago Fire Department Deputy Chief (1976-2007) and President and CEO of International Emergency Medicine and Disaster Specialists, Chicago
62 | CHEMICAL, BIOLOGICAL & NUCLEAR WARFARE | 2012/02
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