Emergency War Surgery NATO Handbook: Part III: General Considerations of Wound Management: Chapter XII: Sorting of Casualties

Facility Design

United States Department of Defense

To facilitate efficiency and optimize triage, evaluation, and definitive care under mass casualty conditions, certain features should be incorporated into the combat hospital's physical plant. The design should promote smooth casualty flow through all areas of the facility. At no time should the normal progression of care or casualty flow be allowed to have a reverse direction. A casualty should not be carried off to X-ray and then returned from whence he came. Traffic should not enter and exit through the same portal. Flow against the grain must be held to an absolute minimum. These principles should apply regardless of the nature of the construction whether it be Quonset, tentage, or modification of already existing permanent structures. Figure 21 illustrates this concept.

Figure 21

Heliport. Ideally, the helipad should be close enough to the hospital's receiving area to preclude the need for intermediate motorized surface transport.

Decontamination Areas. A decontamination area should be set up under shelter, and provided with temperaturecontrollable water and drainage away from the hospital. If prevailing winds exists, this area should be downwind from the hospital. A separate area nearby is required for the collection and disposal of contaminated uniforms, equipment, weapons, and personal items.

Triage Area. Adequate space in this area is of the utmost importance. Overcrowding contributes to confusion and unacceptable noise levels, and detracts from careful casualty evaluation. Each patient station must be accessible from all sides. Multiple stations consisting of litters placed on sawhorse frames should be in place and ready. Shelving or cabinets should be installed along the walls to supply the required consumable supplies: IV fluids, administration sets, venipuncture sets, tetanus toxoid, antibiotics, dressings, evaluation forms, identification tags, etc. There should be an ample supply of IV poles or an overhead cable or rail from which to suspend IV solutions and blood.

Each casualty should pass into the decontamination and triage areas one at a time. It is a mistake to have two or more helicopters discharging casualties simultaneously, although this is sometimes unavoidable when tactical aircraft assist in the evacuation. This leads to confusion and competition among litter bearers for doorways and stations, and a critical casualty may pass by the triage officer unnoticed.

Those deemed urgent and requiring resuscitation should be taken to thatspecific area equipped for their evaluation and management. Type O-negative or O-positive low-titer blood should be available, as well as airway management equipment, suction, and closed thoracotomy setups.

Each litter station is attended by one medical officer, usually a surgeon, and one nurse Here the casualty undergoes evaluation, fluid administration, tetanus toxoid injection, and assignment of an appropriate priority of care by the triage officer. When appropriate, the immediates will pass through X-ray and into the preoperative area, where they are further triaged and assigned to operating teams. This cycle is repeated until all casualties have been operated. When the number of patients exceeds the bed space, convalescing patients are triaged for further evacuation to make beds available

To ease congestion and confusion, ambulatory casualties should be evaluated in a separate area designated for minimal care If the triage area needs to be cleared for new arrivals, wards should be made available to receive the spillover. The delayed casualties are often held in designated wards until the preoperative area is clear of the more seriously injured. One must remember that triage is a dynamic process. The initially-assigned priority may change as the individual's condition changes or with the receipt of additional casualties.

Above all, the dead must not be introduced into the triage area. Not uncommonly, a casualty will expire enroute, and, not infrequently, a unit commander will demand that his dead be evacuated in air ambulances along with the wounded. In either case, the litter bearers must halt outside and request guidance or pronouncement from the triage or some other medical officer.

Operating Rooms. The surgical suites are most often configured with operating tables in a single large room. The arrangement functions very efficiently, in spite of an increased noise level.

Personnel. After the initial notification of the anticipated large influx of casualties, a timely alert is passed along the chain of responsibility, and the triage officer insures that all stations and services are prepared. Personnel should be well drilled in their responsibilities and remain at their stations unless otherwise directed.

The triage area will rapidly develop into the site of greatest activity, usually attended with some degree of initial hyperexcitability and confusion among the staff. Access to this area should be restricted to the assigned medical officers, nurses, corpsmen, litter bearers, and those administrative personnel required to assist with patient identification, custody of personal belongings, and registration. Overcrowding with nonessential personnel is common and can become an impediment to efficient progress. Once the litter bearers discharge their patient, they should revert to the pool for further assignment. The tendency is to stand around in an observer status. All hospital personnel, no matter how well intentioned, should stay clear of the active areas unless their presence is requested.

Triage Officer. The triage officer, usually the Chief of Surgery, must be the most experienced of the surgeons, and must exercise absolute authority in all decisions involving the sorting and assignment of casualty priorities. He must continually monitor each patient's status while simultaneously managing and committing his resources. He will direct the activities of the evaluating teams in the triage room and the preoperative holding area, and the eventual movement and priority of patients proceeding into the operating room. He will designate the number of operating teams necessary and will mobilize pools of medical officers and other personnel as necessary to assist in the total effort. He must continually reassess the hospital's ability to sustain momentum while simultaneously providing routine care to patients already hospitalized. When his resources are all committed, he must request the diversion of additional workload to some other medical treatment facility.

As the exercise proceeds, the triage. officer must continually evaluate and reevaluate the status of his resources, fatigue level of his personnel, bed availability, and the surgical- backlog. Not infrequently, a patient in the delayed category will deteriorate and require more immediate -attention. Once those in the initial immediate category have been operated and stabilized, others from the delayed category are funneled- into the surgical treatment channels on a prioritized basis.

The Final Phase. As the casualties finally clear the operating room suites, the pace will slow for the surgeons. The recovery room and intensive care units will become crowded, nursing shifts will have to be extended, and fatigue will rapidly become a hospital-wide factor. Numerous authors state that after the first 24 hours of a mass casualty ordeal, the activities of the personnel must be decreased by one half to allow for rest for the participants, and a new rotation must be established to sustain a modified but continuous effort.

Once the press is over, personnel must be encouraged to rest rather than to socialize. Rest must be enforced since the entire scenario may recur at any time.

Commanding Officers Responsibility. The medical facility commanding officer must be kept informed of the tactical situation, the likelihood of extended combat in his area, the security of his hospital, and the possible need to divert patients to other medical facilities. He must know the status of his resources and must support or modify the activities of the triage process depending on the reserves within. his hospital, the threat from without, and the capacity of his personnel. He must have knowledge and control of all the support activities involved in the effort, including such services as feeding those unable to adhere to the standard schedule; resupply of urgently needed items, such as blood, plaster, or medications; and the status of his staff. His wisdom may be required when wounded prisoners are introduced into the triage situation, not an uncommon situation in Vietnam. During such episodes when his unit is under maximal stress, his role should be one of total involvement and his primary concern should be to provide an environment in which his surgeons, nurses, and support personnel can function at the maximal level of productivity.

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Operational Medicine 2001

Health Care in Military Settings

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