Ep 60: Trappings of Triage
Episode 60
Published Nov 20, 2023
Last updated Feb 18, 2026
Duration: 51:01
Episode Summary
Whichever triage system you use, it may not be enough in an Active Shooter Event. Today's topic is the Trappings of Triage and avoiding common mistakes in an Active Shooter Event.
Episode Notes
There is no standard triage system in the United States. S.T.A.R.T. is most common triage system in use, but there are many. Join Jill McElwee, Ron Otterbacher, and Bill Godfrey as the discuss common triage gaps, mistakes, and how things are different in Active Shooter Events. Don't miss the Trappings of Triage!
Watch this episode on YouTube at https://youtube.com/live/q9Q8meRzYbI
Transcript
Bill Godfrey:Welcome to the Active Shooter Incident Management Podcast. My name is Bill Godfrey, your podcast host. Joining me today is Jill McElwee from Fire-EMS side. Jill, welcome back in the studio.
Jill McElwee:
Thanks.
Bill Godfrey:
Along with Jill, we got Ron Otterbacher back in the house.
Ron Otterbacher:
Hanging out.
Bill Godfrey:
Hanging out, back on the law enforcement side. Jill and Ron, two of our instructors here within C3 Pathways. So thank you all for coming back in.
Jill McElwee:
Oh, we love it. It's fun.
Bill Godfrey:
Today's topic is going to be the trappings of triage. This ought to be some interesting discussions to see where all we go with this. So let me set the stage just a little bit, and then we'll jump right in. There's a number of triage systems in use in the United States. In fact, I think it's well over a dozen, in numbers closer to 20. The most common one in use is START triage, or at least that's what people tell us they use.
Jill McElwee:
Sure. We hear that most often.
Bill Godfrey:
Yeah. Then when you ask them to run through the algorithm, they're like, "Yeah. Uh, yeah." So we're not really using ... Well, that's a whole another thing. Okay, so START triage being the most common. There are a number of them. But one of the things that I want to make sure that we cover is what do you do after that? What do you do after that? Ron, I know it's been a minute since your paramedic days.
Ron Otterbacher:
A little bit.
Bill Godfrey:
Yeah, but you still remember this stuff. We're going to talk a little bit about some of our law enforcement stuff. So, in fact, let's just start there. When we're doing training with law enforcement officers that have no real specific medical training or background, tell us a little bit about what you think and what we teach them on basic triaging.
Ron Otterbacher:
The thing we do is we try to assess the situation while we're also assessing the patients. We call it a tactical triage. We'll have them go into a room, maybe a casualty collection point, maybe just a room they entered that's got a bunch of people, and we'll tell them, "Look, if you can hear my voice, move up against this wall." Anyone that moves up against the wall, we consider those green. Anyone else that hasn't moved, we consider them red.
Again, most law enforcement people don't have the medical knowledge to be able to assess whether it's a red, yellow, green, or even black. And so, we try and keep it simple. Then when the RTFs come in, they will reassess these people and re-triage them. They may identify certain reds as black, they may identify other ones as yellows, or they may take a green patient that was able to move up against the wall, but realize their injuries are more significant than the fact that they could respond to our directions.
So that's what we do. We just try to at least get an idea of what it is. Then when we put that information out to tactical triage and transport, at least we can give them a rough idea of what we're dealing with downrange.
Bill Godfrey:
Sure. So the basic idea is you come into the room, you get your uninjured out of the pile and moved off to one wall, whatever. Then for those that remain that are injured, you give them a verbal command to move to a specific location. The ones that are able to follow those instructions are greens, they're the walking wounded, and the others are red. Basically if they're hurt and you point a gun at them and tell them to move and they don't get to move, that's a red. We put them into those two buckets.
Now, Jill, for a second, I'm going to tangent to the science behind that, if you will. Yes, it's stripped down and it's a very, very basic way to split the C's, if you will, of people. But when you are bleeding, the first sign of shock is changes to levels of consciousness and is generally going to be demonstrated through confusion, failure to follow commands, things like that. And so, we're not just testing for whether they can walk or whether they can move, but what is their mental state.
Jill McElwee:
Absolutely.
Bill Godfrey:
You want to talk a little bit about that?
Jill McElwee:
Yeah. So what Ron just explained, there was a lot to that, just that simple act of asking someone that is wounded or not wounded to follow a simple command, the fact that they were able to hear you, comprehend what it is you wanted them to do. A very key component of what Ron said that is maybe looked over is when you ask them to move to a specific place. So there's some comprehension there as well. So those of us in the medical side, we've checked several boxes with that one simple act.
We talk about triage. Triage is not just a one and done thing. You're continually ... Triage is both ... It's a verb, like we're to triage a patient is to have them ... To assess their level of both comprehension, their mentation, as well as their physical condition. In the situation that we're going to use triage the most, we're looking for those ... Quickly identifying those life-threatening injuries. Just that one simple act, everyone that didn't move, wasn't able to move, couldn't move, then now we have ... Those are where we're going to focus our attention on.
Ron Otterbacher:
The other thing to add to that is while we're doing that, it seems like a simple task, but we're also assessing them to try to determine if they in fact are a threat to us also. So it's not just we're telling people to do things, we're also having them figure out who could be a threat, who may not be a threat. So it's a bunch of things going on in a simplified fashion.
Bill Godfrey:
Yeah, absolutely. I think one of the things, before we leave this and go into it a little bit deeper, I want to make really clear is that one of the common misunderstandings that we see within law enforcement who try to implement the red, green is they don't distinguish between the uninjured and injured. They'll sometimes ... Okay, we've got 14 greens. Well, 12 of those greens are uninjured. You have actually two greens. The uninjured don't get included in this triage count. That's just for the injured. And I think we've set the stage to talk a little bit more about the meat of this. So that's a simple system that we recommend law enforcement use. It requires very little training. It's very simple to understand. Jill, as you said, it checks off a bunch of boxes. So let's talk a little bit about START triage and some of the other triage systems because, interestingly, they have some of the same gaps.
Jill McElwee:
Yeah, sure. I think we're going to find that with most triage systems, and the fact that we're utilizing those triage systems that it's humans. There are first responders that we are going to ... Oftentimes we'll find ourselves, given whatever situation we're in, focusing, just laser-focused, on the things that we can do and we can fix.
And so, we'll focus on categorizing those injured and those wounded and trying to get so specific with categorizing them that we're forgetting the reason that we triage, the so what of triage. Why are we even triaging patients? Because we know that certain injuries kill people fast. Those injuries that we know, and especially in an active shooter incident, why do we triage? Why are we triaging anyway?
And so, that's the focus for me is identifying the system that you use. If I'm focused on counting respirations, I'm counting your pulse, I'm trying to ask you six or seven questions to tell what the state of your ... Your mental status is, I may skip the one thing I could do for you that's going to combat that clock that's just ticking, tick, tick, ticking, and could take your life.
Bill Godfrey:
Yeah. It's interesting the way you just said that. Why are we triaging anyways? I think it's important. We talked about this in an earlier podcast. If it's not a mass casualty incident, treat it as one. The basis for triaging is when you're overloaded with casualties.
Jill McElwee:
Right.
Bill Godfrey:
Now if you're one person, three people, where do you start? You need to triage them.
Jill McElwee:
Yeah.
Bill Godfrey:
But if there's two or three people injured and there's two or three of you, is there really a need to triage, or do you just go into your BATH assessment or whatever assessment process you use and do a detailed one? It's an interesting question.
Jill McElwee:
Yeah. Bill, we often get confused with triage and assessment-
Bill Godfrey:
Oh yeah.
Jill McElwee:
... like getting that terminology down. What is it that we're doing and why are we doing it?
Bill Godfrey:
Yeah.
Ron Otterbacher:
Again, we have to look at if I've got three red patients, which is the worst red out of the three? Which is the transportation priority? As we look at these situations and understanding that this one is worse than the other two, although they're both ... All three in critical conditions, which one do we have to take first to save a life?
Bill Godfrey:
Ron, that's exactly where I was leading this is to get into that. Before we go down that road, I want to make sure that we're clear. The bulk of these rapid triage systems, START being one of them, SALT another one, down the list you go, these systems are designed for broadly separating people into these categories. They take large swaths of things.For example, START. The only way you can be green is to elect to be green. Get up and move. Okay. Well, my back really hurts. I'm just going to sit here. I've just made sure that I'm going to at least be a yellow within the START system.
All of them are like that. So the very one that we try to teach law enforcement, that they're either red or green. There's one that FDNY uses that's very similar, interestingly, START, SALT, a lot of the others. It's a quick pass, put them in broad categories. In nearly all cases, those quick passes have very little basis in science. Some of them have a little more science than others, but none of them have any validation studies behind them. Once you've put them in these buckets, okay, great. We've got 12 injured. There is four green and eight red, to your point, Ron. Now what do we do?
Jill McElwee:
Now what? That's it. It's resource dependent, to Ron's point. How many transport units? How many ambulances do we have? What do we have on site that can assist this wounded person?
Bill Godfrey:
Yeah. So let's talk a little bit from the EMT and paramedic perspective. You do not have to be a paramedic to do an assessment and figure out how critical somebody is injured. So let's say you're the rescue task force that rolls into the casualty collection point and it's already been sorted by the law enforcement officers. They've got the uninjured out of the way. They've got the greens over on the left side of the room and the reds are where they lay in the floor. And so, okay, we're going to start with the reds. Now what, Jill? What do we do?
Jill McElwee:
Yeah. So you start where you are. Look at this patient. What we're looking for, again, are those life-threatening injuries, and we're going to fix ... If you find it, you fix it, and rapidly. It's a fix and find system. It should be because, again, why are we doing this? Because we're trying to stop the greatest damage to this person and try to save a life, because we're combating that clock. Typically with the active shooter incidents, we're looking at penetrating injuries. So we're looking at a loss of blood. That is the most preventable death that we have there, or situation we have, at an active shooter incident. The one thing that we can help prevent is stopping that bleeding. So if we can assess that rapidly, then we're going to do the greatest good.
Bill Godfrey:
It's interesting. I went through medic school. I remember going through the head-to-toe trauma assessment back ... Days of BTLS, PHTLS. The head-to-toe trauma assessment. When we started doing this over a decade ago, we started learning some things from some of the military guys about how they prioritize, like you were saying, some things differently. They don't look at airway first, they look at bleeding first.
Jill McElwee:
Right.
Bill Godfrey:
Then they look at airway, then tension pneumo, and then trying to correct from hypothermia. When you understand the why behind that, it really starts to make a little sense.
Jill McElwee:
Oh yeah.
Bill Godfrey:
Yeah.
Jill McElwee:
I mean even with the American Heart Association, it's about getting that blood pumping. Even in a cardiac incident, when we're talking non-trauma, the science has proven that it's getting that blood pumping. We pump hard and fast now. It's not spending the amount of time that we spent when we first became paramedics, all three of us. It's spending time getting that circulation. Well, translate that over to a trauma situation such as an active shooter. Blood needs to be circulating.
Bill Godfrey:
Sure.
Jill McElwee:
Well, blood doesn't circulate when it's on the floor. If it's not in the vessels, it's not circulating. So that's why bleeding is the number one priority for us in our scenarios.
Bill Godfrey:
Yeah, and I think that's part of it. Whether you use that military-style assessment, BATH assessment, which we probably ought to do a whole podcast just on talking about that a little bit.
Jill McElwee:
I agree.
Ron Otterbacher:
Yeah.
Bill Godfrey:
But whether you use that assessment or something else, we want to focus on knocking out the things that are the most life-threatening at that moment and, again, tuned for traumatic events. It's not like we're walking in there expecting to find somebody who's had a heart attack. I mean certainly that's possible, but that's not what's going on, traumatic offense. Find it and fix it, like you said, quickly. Control major bleeding, with a distinction between major bleeding and minor bleeding. Then take a look at the airway, figure out if you've got any chest involvement and deal with the tension pneumo.So whether you use that system or something else, have a system to use. But at the end of the day ... And I'm going to pose this to both of you. At the end of the day, you've got eight red patients in there. They're red. You've got some that have been shot in the head, some that have been shot in the chest, some that have been shot in the belly. Some of them have leg wounds, groin injuries, things like that. As a medic, how do you as use medical judgment to say this one needs to go first? Who wants to start on that?
Ron Otterbacher:
Go ahead, Jill.
Jill McElwee:
Okay, I'll take ... I'm the nurse in the room.
Ron Otterbacher:
Two amps of bicarb, one amp epinephrine.
Bill Godfrey:
Oh, now you might be dating yourself.
Jill McElwee:
All right, Johnny Gage.
Bill Godfrey:
Yeah.
Jill McElwee:
So for me, honestly, it's taking that patient assessment, if we're using that BATH assessment, and when you identify the patient. We know how much ... A certain amount given the person's size and blood loss, what it will do to that person. If you have someone with a greater blood loss from neck to navel, that's the area of our core, the core of our being, if we have a massive blood loss there or a massive blood loss maybe in an extremity, then we're going to identify the person who has the fastest trip to zero vital signs. For assessing those patients, that the first person you come to, this is a communication that we've got to have when we get to that ambulance exchange point, when we get to actually putting a body in an ambulance, is identifying what we're dealing with, looking at that total assessment, looking at what this person has as far as we know how much blood ... If we've only got about 10 units of blood that circulates around and how much blood loss we have. What is the impact to this airway? Has there been a penetrating wound to the chest that ...
Air gets sucked into that chest, and air should not be inside the chest if it's not ... That's not inside the lungs. So it will cause a rapid deterioration of a patient. So knowing those injuries that can cause that rapid deterioration. You have to identify which patients. Do I think we're going to get it right every time? Probably not. There may be a patient that we've loaded that might not have had the injuries or maybe the comorbidities that ... There's things we just will not know on a lot of these scenes. But for us, just having that simplified assessment that's going to tell us the potential deterioration of a patient is key.
Ron Otterbacher:
The things that we learned tragically throughout our times at war, we've improved every time on how we treat people. I tell you, a shooting victim in Mogadishu is no different than a shooting victim in Atlanta, Georgia. They have the same type of wounds. We need to treat them the same. We've done well at trying to improve how we assess them and how we triage them and how we transport them and how we prioritize them. We've come to the realization that some of these patients will not survive unless they see bright lights and cold steel, which we can't do in the field. But we've learned to better assess them and realize that, look, this one's got to go now. This is a right now, right now situation. This one we can wait. Or if we prioritize this one, are we going to lose three others on this side? So we've had to learn through our experiences both in the battlefield and on the streets of the United States that we have to treat things different. I think as professions, we've done a good job at advancing our skills through the learned experiences.
Jill McElwee:
Mm-hmm. There's things we'll be able to do in the field. You brought up a good point, Ron, that when it gets to where I can't stop this bleeding any longer, I've done everything I can, and they need that surgical center you were talking about, that cold steel is what's going to save most of the patients that are injured through an active shooter or some penetrating wound.
Bill Godfrey:
Yeah, I think that's right on target. For me, I think about it, and I don't know whether the right way to say this is pragmatic or not. But let me take them in three compartments, shot in the head, shot in the chest, shot in the abdomen. You're shot in the head. If it didn't kill you, then it is what it is. Head wounds tend to bleed very badly depending on the entry and potential exit point of the head wound. You could have some bleeding into the airway and some airway compromise. There's not a whole lot you can do. You can't really control that. You can't stop it. If you did, you would be creating a pressure problem on the brain anyways. So your best opportunity for them is to get them up on their side and let them try to drain out. In other words, if the head wound is not instantly fatal, there's not a whole lot that we can really do to make that a whole lot better. So to me, a head wound is going to come after somebody shot in the thorax, in the thoracic cavity.
Jill McElwee:
Great.
Bill Godfrey:
So the chest to me is an area of particular concern. You mentioned the lungs and the opportunity for tension pneumo or just a hemopneumo-
Jill McElwee:
Oh yeah.
Bill Godfrey:
... getting both blood and air into the chest cavity, which can cause us problems. You've got the heart there, your large vessels, your aorta, and your other vessels that are right up in the chest. That's a really bad area to get shot, number one. Number two, it's one of those areas where, as you said Jill, there's not a whole lot we can do. We can do a decompression if we think it's a tension pneumo. If you assess it correctly and you diagnose the correct side to actually decompress it ... I think we could do a whole podcast about tension pneumo.
Jill McElwee:
Oh, we should.
Bill Godfrey:
So great there. But the bleeding that's going on inside, if you've hit a major vessel, if it's hit the heart or part of the heart, again if it's ripped them apart, they're going to be done so quickly that they're probably already fatalities by the time we get to them. But to me, that shot in the thorax is probably my number one priority.
Jill McElwee:
For sure.
Bill Godfrey:
As we go down to the abdomen, yes, a lot of organs, a lot of things that can go wrong. However, the abdomen, we can do some bleeding control. You can do some pressure in most cases, depending on where it is and what's been hit. Now of course you've still got your aorta coming right down the center. And so, if you hit that, again, not a whole lot coming back from that. But the bulk of the injuries in the abdomen would, I think, be a lower priority than somebody shot in the chest. Now here's my question. With that as the background, where would you prioritize the head wound versus an abdomen? So somebody shot in the head, somebody shot in the abdomen, which one would you be inclined to push first?
Jill McElwee:
Well, I'll tell you, I'm going to answer that by not straight answering it, but kind of straight answering it, is that we used to have a terminology in the trauma center, that we'd have people that were going to be fatal fast, like, "This is a fatal fast coming in. We've got ... " And typically it was the chest. The chest because our thoracic cavity is designed like a well-built cabinet. Everything has a place.
Bill Godfrey:
Oh yeah.
Jill McElwee:
Everything is in its place. If something else comes in its place, that's where it wreaks havoc. That's with your respiratory center and your circulation, which we know are extremely important. And so, that area will kill you fast. Then we have those that'll ... Fatal later. So those are a little later. They can be fatal, but it's usually later. We've got some time. So with those abdomens, they need to be in surgery fast, because we've got to figure out what ... Especially when we start looking at our guts and having a penetrating wound there, the chance of infection.
So you want to address those super soon. Then that just requires a general surgeon opening them up. So now it's technical or getting on that second, third order for medical decisions. But that head wound, that's going to demand specialized surgeons and a specialized...So for me, I will go ahead and answer your question. I'm going probably abdomen next because I know they're my next priority at surgical center. You did hit it on the head, pun intended, for the wound to the brain, is that they're either going to die right then and there or we've got some time, and that's when we're going to monitor this patient. I mean continually monitoring, give resource ... And everything we say is-
Bill Godfrey:
Is resource-dependent. Yeah.
Jill McElwee:
... definitely dependent on what you have on scene. But as far as prioritizing patients, while there is a general category we can put patients in, or the injured in, it's not quite that simple always, because I can always come up with a but what if.
Bill Godfrey:
Oh yeah.
Jill McElwee:
So I have the what-ifs.
Bill Godfrey:
Yes.
Jill McElwee:
But in general terms, we're thinking ... And for me, if you want to come up with some simple codifier that will tell you how I should triage a patient, and when I'm doing my assessments, how do we triage, sort them, using triage for the word sort, is use the clock again. It's like my ... One of the things I always go back to, how am I going to be able to positively impact this person the best? Who can I have the most success positively by transporting them ahead of the others?
Ron Otterbacher:
Again, that time isn't ... We don't anticipate that time being an extended period of time.
Jill McElwee:
No.
Ron Otterbacher:
We anticipate it being-
Bill Godfrey:
A few minutes.
Jill McElwee:
Yeah, yeah, yeah.
Ron Otterbacher:
Yeah, absolutely. It's an instant. Yeah.
Bill Godfrey:
It's they're the next one out the door or they're the one out the door in three minutes or four minutes.
Ron Otterbacher:
Right.
Bill Godfrey:
Ron, what about you? Head versus abdomen, gunshot wound to the head, gunshot wound to the abdomen. Which one are you going to go with? Generally speaking. Generally speaking, which one and why?
Ron Otterbacher:
As I watch, not only my past life but my present life, even a lot of head injuries, they won't go in and do surgery immediately. They want to let some of the swellings ... And I'm not a doctor. I didn't stay at a Holiday Inn Express last night or anything. But they tend to handle it in a more methodical fashion. I'm not saying that patients that come in don't immediately go to surgery, because a lot of times they do. But there are times when they just wait a little bit. Even the abdominal wounds, they tend to take them right up and open them up so they can see the degree of injury. Okay, the spleen's blown up. We've got to address it right now.
Jill McElwee:
Yeah.
Ron Otterbacher:
So I would do the same thing Jill said.
Bill Godfrey:
Yeah.
Jill McElwee:
A good answer, Ron. Just kidding. But, hey, Bill, to your point, though, in all serious, a head injury? Are you kidding me? You're not going to take someone that's shot in the head first? I mean it sounds like you should, but that's where it demands. Unfortunately, we've all just been there and done that and seen the aftereffects of ... Appropriately is a strong word, but triaging in a sensible, scientifically based fashion, medically based.
Bill Godfrey:
I'm going to use that as an opportunity to tangent to the next part of this trappings of triage. What you just said, are you going to take ... Well, that isn't even the controversial part of this. How many people have you heard say, "Well, we're going to transport all the reds, and the greens can wait"?
Jill McElwee:
Oh yeah.
Bill Godfrey:
Yeah. I mean really? Okay, let's see how that's going to work. So here's the inherent problem. There's a couple of them. Number one, if you take all the reds to one hospital, you've overloaded that hospital and probably left them with a challenge. Now they might rise to the challenge, and they may still manage to save every saveable life depending on their system and their status, but that's not really what we are supposed to do as EMS. What we should be doing is spreading out those numbers to the available hospitals. So if there's two, three hospitals around your scene, you're spreading them out. But it's not just spreading out the numbers, it's also spreading out the severity.
Jill McElwee:
Yes.
Bill Godfrey:
In the back of an ambulance, there are some exceptions, but most ambulances are running with an EMT and a paramedic. The EMT is usually having to drive. And so, the paramedic is in the back by themselves, or if they happen to be lucky, maybe they've got one extra person riding with them. But they only have the equipment and the hands to deal with one critical patient, one red.
Ron Otterbacher:
Right.
Bill Godfrey:
And so, when we start talking about we've got some chest wounds, we've got abdominal wounds, we've got head wounds, and I'm going to send this chest wound with this yellow that's been shot in the leg, got a groin or a truncal injury that's ... We can't really quite control bleeding. But they're doing okay, they're yellow, so I'm going to move them out. Then I'm going to grab one of the green walking wounded and I'm going to load that ambulance with a red and a yellow and a green. People just want to lose their mind. But when you stop and think about the best interest of the patient, there's a limit to how much the medic can do. There's a limit to the amount of equipment they have, and, oh, by the way, if you send all your reds to one hospital, you overload them. You need to distribute that out.
Then I want you guys to pick it up here, but I want to tell this one story, anecdotal that it is. There was an active shooter event that occurred up in the northwest part of the country. There was a young lady that had been shot, walking wounded. The paramedic that was coming in said, "Well, what about her?" and the person that was with him said, "No, no, no. Walking wounded. Walking wounded. She's green. Walking wounded." For whatever reason, this paramedic looked at her and didn't like what they saw or wanted to check her. It turned out that she'd been shot in the back of the shoulder, except, unbeknownst to everybody, that bullet had done some bouncing around. While she was green and walking at that moment, the paramedic realized that she'd basically been shot in the chest and began to prioritize her and got her out on one of the first ambulances. She ended up coding in the ambulance, but survived.
You've got to wonder what would've happened if that young ... And this was a young paramedic. What would've happened if that young paramedic had just ignored her because she was a green? She was a "green". She can wait. That I think is the scariest part of the trappings of triage is this fallacy that the greens can wait, things like that. So with that, let's dive into a little bit of how you're loading your ambulances, the mixes of the yellows and the greens, how you can have somebody that's very severely injured be a green for a little while. Let's pick that up from there.
Ron Otterbacher:
We're talking about efficient transportation. If you're going to transport each red patient by themselves, how many ambulance do you have in your community? If you've got unlimited resources, then you might be able to do that, but most areas don't. So can you transport that red while you're putting the yellow right there next to them so someone can keep an eye on them? Then the green's up front. So as the driver's going, he's paying attention. Again, trying to do it as efficiently. This isn't a normal situation that we handle on a daily basis. These are the obscure type situation we respond to. So we don't handle them the same way we do on a day-to-day basis. We've got to get the most people to treatment as quickly as we can, and that tends to be the most efficient way to do it.
Jill McElwee:
Yeah. You hit on something that I want to ... Hopefully I'll remember to say later on. This is not a usual response. We all operated under guidelines, our standard operating guidelines, and guidelines are meant to give us law enforcement medic and to give us guidance on how. This is not a normal situation. So you're going to have to look at your resources. I'm going to try to unpack ... There was a lot that I wanted to unpack of the story you brought up. The first being just oversimplifying. Sometimes we want to keep is this triaging the green patients, the walking wounded, if you will. They have to be ... Just because they're put as walking wounded, immediately when resources, if there's just a few ... And many places across the country are very scarce in resources. So it may be two medics doing a lot of the triaging of the patients.
But other folks, which what's so important ... That's the first thing I wanted to unpack. It's so important that we bring in both our fire components and our law enforcement to assist with that. Just walk ... If I can just have somebody over, if I have six greens while I'm addressing the four or five reds, just talk to them. Just go talk, look and see if anyone has any wounds. Just find out what the wound ... I may not even need you to do anything to that, but just at least do some follow-on assessment by soliciting. And not just while having the other folks that have cleared the area out high-fiving and signing autographs, there's still life-saving that needs to go on, even with the walking wounded.
Addressing how we stack or…term, but how we put patients in the ambulance, that's a huge topic. Depending on what resources you have ... And not just resources on people, but on that rig, whatever your ambulance, however its outfit. How long of a drive do you have to your hospital? We've taught in some areas where their nearest facility is 20 miles away, and plus there's some truth ... Additions to that. How much treatment can you do in the back of that truck? What do you have on you with ... Because we know the physiology of the injuries, what's going to happen to the body with a penetrating injury. So you have to be smart, but getting them to treatment is still the priority. But getting them to treatment in an efficient and effective manner is just as important.
Bill Godfrey:
Right.
Jill McElwee:
They've got to be there effectively. The last thing I wanted to unwrap was hospitals, how we ... We tend to just get them off scene, get them off scene. We've got to break the record like we're at a pit crew or something. But transporting a large number of our categorized red patients, those with the severe life-threatening injuries, sending them all to just the closest hospital, we may not be doing the best for that patient.
Bill Godfrey:
Right.
Jill McElwee:
The one thing that we've talked about in many of our ... Or one aspect that we talk about in many of our podcasts is the importance of dispatch, utilizing dispatch for our triage, bringing them into that, making sure that we know what our hospitals are capable of at that moment, what their capacity is, and their capabilities are, and having-
Bill Godfrey:
You're talking about bed counts.
Jill McElwee:
Yeah. Yeah, yeah.
Bill Godfrey:
Capacity counts. How many reds, yellows, and greens can they take?
Jill McElwee:
vYeah. How many can you handle? Yeah. How many surgeons do you have on site? Because let's just be honest, the penetrating wounds, they're going to need surgeons. So we're looking at how many surgeons are available. That's when you call a hospital and they say, "Oh, we can take two reds, three greens." That's what they mean by that. This is at this point moment. Now might they have to take more because people drive up? Sure. That's the one thing we don't know in the field is there's a lot of walking woundeds that have happened in many of the active shooter incidents that we study on a routine basis, that a lot of the hospitals are getting those self-transports. So it's really important when we're delineating which patient goes to which hospital that we incorporate our dispatch, so that we have a solid answer and we're doing the best for the patient, if that makes sense.
Ron Otterbacher:
Yeah. I think what Jill said initially was something that we can't just mull over, is talking to the patients. How many times have we seen where a patient says, "I tweaked my back some," and that's all they think. They don't realize that they have in fact been shot.
Bill Godfrey:
Yeah.
Jill McElwee:
Yeah.
Ron Otterbacher:
It happens to law ... Trained professionals, soldiers. "Man, you're shot." "No, no." "Yes, you are." They don't realize because their epinephrine's going through the roof and everything in their body has gone into survival mode. So they don't realize it. I think that's key is make sure we talk to everybody. Again, we're taking care of the reds, but we're not negating the greens and the yellows or anything else.
Bill Godfrey:
I think what you just said, Ron, bears underlining and an emphasis point on them, and that is talking to everybody. I can't under ... Or overemphasize this enough, I guess I should say. It's so simple. But the first sign of shock is going to be an altered level of consciousness, which is almost always some instance of confusion. The most common thing is they start asking you the same question over and over again. "What happened?" "Well, this, this, and this." Then 30 seconds later, a minute later, "Well, what happened?" or some variation on theme of-
Ron Otterbacher:
Sure.
Bill Godfrey:
... "I just don't understand what happened." When you realize that a person you're communicating with is getting into that level of consciousness where they are confused, they're not clear, you've answered their question and they didn't comprehend it, and now they're asking the question again, that is a red flag, like showing up for a date and the father's sitting on the porch with the shotgun. This is an attention-getting red flag that you need to pay attention to. I have people sometimes that say, "I can't believe you're going to put a green," and your answer is that whoever's driving the ambulance should just talk to them. Well, yeah, because we're assessing level of consciousness.
Ron Otterbacher:
Right.
Jill McElwee:
Absolutely.
Bill Godfrey:
That's going to tell us when things have gone horribly wrong. I don't really know whether this young paramedic with this girl, whether in the conversation, he picked up on something and said, "No, wait a minute," she's going through asking the same questions over and over again. I don't really know. But he saved her life.
Jill McElwee:
I hope he was in one of my paramedic classes back in the day at the academy, because we teach young medics, be aware and be cautious of the person that's fine, that tells you, "Oh no, I'm fine. I'm fine. I'm fine."
Bill Godfrey:
Exactly.
Jill McElwee:
And you can see the mechanism of injuries or you see what's happening.
Ron Otterbacher:
Sure.
Jill McElwee:
The person that's fine ... Because denial is another big thing that you see people ... "No, I'm fine. I'm fine," because the tension is up. You don't want to believe it's happening. You think it's your back twinge.
Ron Otterbacher:
Right, right.
Jill McElwee:
Yeah. So be cautious of those as well.
Bill Godfrey:
Yeah, or the buddy that ... "No, my buddy's worse. Take my buddy first."
Jill McElwee:
Right.
Bill Godfrey:
You're holding your arm-
Jill McElwee:
The martyr, yeah.
Bill Godfrey:
... because you've been shot in the chest and your arm hurts when you move. When you hold it, you're fine.
Jill McElwee:
Yeah.
Bill Godfrey:
"Yeah, you had a bullet go in your chest, you're a priority." "No, no, I'm fine. My buddy. Take care of my buddy first."
Jill McElwee:
Right.
Bill Godfrey:
I just can't overemphasize that enough. You do not need to be medically trained to recognize when somebody starts to get confused.
Ron Otterbacher:
Sure.
Bill Godfrey:
You do need to know that that means they're going into shock. Now the caveat to that is they could also be in cognitive overload. They could also just ... Their brain can't process it and they're shutting down, and that can happen. But don't assume that. Assume it's a medical cause until proven otherwise is what I would say.
Ron Otterbacher:
Right.
Jill McElwee:
Right.
Bill Godfrey:
So what else on trappings of triage do you think we need to hit on for the greater good? I mean, from my perspective, it almost doesn't matter what system you're using. Use a system, but just know that that ain't going to get it done, because at some point you're going to end up with eight or nine reds, and who's going to go next? Now you're into medical judgment. So if you haven't taught your people how to do medical judgment, you need to get on that. But what else? What else is there that jumps out at you?
Jill McElwee:
I have one thing for triage that I try to focus on for myself and all of the responders I work with, is triage is not a one and done thing. Triage is a continual evaluation, a continual patient assessment and evaluation, because the condition is a continuum. So it's not once someone has been tagged or marked a certain level or acuity, if they're yellow, red, or green, that that means right now they are, that making sure we continue that, because oftentimes another trapping is medics, we tend to over ... Well, some medics tend to, I'll say some, overtriage, "Oh, everybody's red. If I just get them all off. Because if they're not here, I don't have to ... Let's just get them to the hospital fast, treat them with diesel."
So we're overtriaging and undertriaging of like, "Ah, you're fine. You're walking." We talked about that in a sense with our walking wounded, the undertriage. But there's also an over triage as well, making sure that we're cognizant on whatever system we're using. We know what our enemy is. It's the clock. So how can we best get this person with whatever their injury, wherever it is ... Knowing the physiology of the human anatomy and what a penetrating wound will do to that portion of the human anatomy should guide you into who needs to go next or who can safely go in if your resources are scarce, and we do need to send two wounded in one ambulance, or put the walking wounded that really does just have a scrape from running away. But putting them in that front seat so they can be evaluated. So those decisions are made very case-dependent, but it's a continual decision-making process.
Ron Otterbacher:
I go back to ... We assume, because we tell people they're going to triage, that they understand that it's the function of triaging the patients that you want them to do. If you've got cognitive overload and you tell them, "Hey, I want you to go triage," are they going to triage or are they going to the position of triage? We've got to make sure they understand clearly what their responsibilities are, and we're not ...But we do see that sometimes in certain situations people handle the stress differently. We've got to make sure that they understand that they're triaging the patients because ... Again, we go back to terms we talked about before. We use the same term for several things. Do they understand what the responsibility is? So it's something I've seen both in the fire service, where I've had senior lieutenants pull up on a big fire and lock up completely. It's just that cognitive overload that we've got to make sure that we clear, concise communication with confirmation. If we do that, then our chance of success is far better.
Bill Godfrey:
I think the last thing that I'd like to talk about as we wrap up on this one ... And I don't have any scientific evidence for this, just anecdotal observation. Of course, Jill, you're much younger than Otter and I.
Jill McElwee:
Much.
Bill Godfrey:
Yeah. Yes. But back in the day, when Otter and I were working in ambulances, we were the only medic within three or four ambulances around.
Ron Otterbacher:
Right.
Bill Godfrey:
It was commonplace, especially with multi-vehicle collisions and things like that, to need to go into mass casualty mode and to triage patients. I would say rarely would a week go by that you didn't have to manage multiple patients.
Ron Otterbacher:
Sure.
Bill Godfrey:
And so, by necessity, whether we were good at it or not, we had to do it and we had to use it. And so, if you weren't good at it when you got started, you figured it out underway. Today, it seems to be a very different environment. There are, in most communities, a plentiful number of medics. When we're faced with more than one patient, we call an equal number of rigs. Every medic gets their own patient, and they don't actually have to do multi-patient management. It seems that we've lost some of the art, if you will, of actually managing mass casualty incidents. We've lost some of that skillset because of how the environment has changed. I'm not seeing signs from the ... I mean it's not everybody, but the majority of people that are on the streets. I'm not seeing signs that that mass casualty incident module that they went through for two hours in school-
Jill McElwee:
Absolutely.
Bill Godfrey:
... really sunk in and that they've got good grasp of it. But, like I said, I don't have scientific evidence for that. It's just been my personal observations that we've got a disconnect. We have a generation of EMTs and paramedics that haven't needed to manage mass casualties on a regular basis. And when you don't do something frequently, you tend to lose the skillset at that. I'm not sure the training has picked up on that and prioritized it. I'm curious whether the two of you see it differently, see it the same, or don't see it at all. What's your thoughts?
Jill McElwee:
That's an interesting take, and I can see that. Not just in the fact that in many departments, especially major metropolitan departments, we find that everyone's a medic just about.
Bill Godfrey:
There's a lot.
Jill McElwee:
It's a lot of medics in a lot of our communities. For those communities, it could truly be a detriment because when we are triaging whose patient is in most need, well, it's going to be my patient. So it's the one I'm ... So there hasn't been a need for you to have to walk away from this patient to go to the next injured. There's a lot too walking away from one injured to go to another injured. So it's an interesting take on that. But I think the amount of ... If you take it to the ... EMS post-emergency medicine into the hospital, we are finding a lot of urgent care locations where we can take patients, where they can get some secondary care, like a tertiary care before needing the surgeon.
So we have almost saturated the field to where it's ... For a patient outcome, it could be very positive. But it's a situation that definitely warrants a nice deep dive on as to how we adjust our training for medics. How do we adjust the sorting of those patients and maybe utilizing all of those resources, both pre-hospital and the paramedics, and utilizing our hospital facilities that are maybe an ancillary standalone emergency room? So that's an interesting take, because I'm not quite as young as I'd like for you guys to portray that I am, and please continue, but I do remember the mass casualty training we had of old probably needs to stay there, I guess. Things have definitely changed.
Ron Otterbacher:
We should always be reflecting on everything we do. That's one of the areas that maybe it's time to circle back and reflect on that and see what we're doing, see what we're teaching. It's up to the people now. I'm not teaching anyone in the medical field anymore, but there are people that are and there are people that are very capable. So they're the ones that need to assess and see how they can improve.
Bill Godfrey:
Yeah, it'd be interesting. I'd also be curious, for our listeners out there, for the folks that are training officers, are you seeing this as an issue? Is mass casualty training for your EMS folks, whether that's fire-based EMS or whatever ... Are you seeing that as something that's worthy of spending time on because there's some gaps or not? We'd always love to hear the listener questions and doing that. Well, we are out of time on this one. Thank you both for coming in to talk about it.
Ron Otterbacher:
Thsnk you.
Bill Godfrey:
Jill, thank you very much.
Jill McElwee:
Of course.
Bill Godfrey:
I'd like to thank our producer, Karla Torres, as always, doing a great job behind the scenes. If you haven't subscribed to the podcast, please do subscribe and share it. Let your friends know about it. The more people that we can reach, the better chance we have of helping to save some lives and encourage better outcomes for these things. Until next time, stay safe.