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Triage Scenarios

Triage Scenarios. Gary Davis MD. Scenario. The province of Itiah is under attack by Taliban forces. ANSF soldiers have been sent to protect an area controlled by the “friendly” side in the fighting.

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Triage Scenarios

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  1. Triage Scenarios Gary Davis MD

  2. Scenario • The province of Itiah is under attack by Taliban forces. ANSF soldiers have been sent to protect an area controlled by the “friendly” side in the fighting. • The opposing forces are mixed regular and guerrilla troops. The opposing forces have significant conventional weapons including light armor, and infantry. There is a confirmed report that they possess shoulder held anti-aircraft missiles. The rebel forces are determined, and also is known to possess fuel-air explosives (which can produce significant pure blast injuries and conventional destruction). • The province currently it is the rainy season. There is rain with 40(F) degree temperatures; colder at night. The terrain is very mountainous and wooded. Most of the roads in the country are unpaved and present a challenge to all but tracked vehicles during the rainy season. • Your group has been mobilized to provide medical and surgical support for the ANSF. Your unit has been assigned to a forward treatment facility near the perimeter of the area controlled by the friendly forces and ANSF forces. There have been a number of small skirmishes the last few hours and days on a front opposite the ANSF zone. There is intelligence that the rebel forces are planning an offensive, but because of the poor flying weather no solid information exists.

  3. Medical Facility • Your facility is made up of a triage area sufficient for twenty simultaneous casualties, one operating room, a post-op holding area with 4 patient capacity, and a ward for 20 patients. • Your equipment includes 2 ventilators (not counting the anesthesia machine), and supplies for 15 major general surgical operations without resupply. You have no X-ray nor ultrasound capability. • You have 20 units of packed cells (O-), and 30 of FFP. There is an unlimited supply of Lactated Ringers. There is no shortage of drugs for general purposes, but your antibiotics consist only of Ancef and Gentamicin, in unlimited supply. • Your personnel (besides you, the General Surgeon) are: • ·  one nurse anesthetist • ·  one orthopedist • ·  one general medical officer (as triage officer) • ·  one gynecologist (as surgeon, trained in basic wound debridement, closure of simple wounds, surgical assistant, etc.) • ·  two post-op nurses • ·  one Independent Duty Medical Technician (IDMT) • ·  three Med technicians • You are situated greater than 24 hours by ground (due to the seasonal conditions of the roads) and 30 minutes by air to the next level of care, which is the National Military Hospital in Kabul. Availability of air evacuation is subject to weather and the rebel forces’ possession of anti -aircraft missiles. • The security of your facility is excellent (no guerrilla activity, and the Rebel air force has not been seen within 50 kilometers). There is a Kandak of ANSF soldiers within two kilometers of your field hospital.

  4. Action • The anticipated rebel offensive has begun. It involves the combined rebel army, and guerrilla forces. There have been reports of use of rebel armor, and shoulder mounted anti-aircraft missiles. A helicopter has been confirmed shot down nearby by shoulder held rockets. • You have just received a report that there are a number of casualties (ANSF, friendly, rebel, and civilians) en route. They all arrive at once, and at the same time a number of other casualties come in on their own. Due to the large number of wounded, the obvious “walking wounded” (minimal casualties) have been pre-triaged by medics to a separate holding area. You will be receiving the more severely injured. • You must establish a triage category for each patient, outline a care plan for your GMO partner, and proceed to the OR to operate on the patients that you select. The GMO was recently eliminated from a radiology residency after his first year; he is able to perform immediate therapy maneuvers and to follow other instructions. • You have 30 minutes to accomplish these tasks for the entire group of casualties.

  5. Patient #1 • HISTORY: ANSF soldier with shrapnel wounds to abdomen and left lower extremity • VS: BP:100/70 P: 110 • PE: multiple wounds anterior abdomen with acute abdomen, left femur fracture with good distal pulses , lacerations to left lower leg

  6. Patient #2 • HISTORY: ANSF soldier with blunt trauma to the right chest • VS: BP: 100/- P:120 RR:30 • PE: Decreased breath sounds on the right, acutely tender on right lower lateral chest. Abdomen benign.

  7. Patient #3 • HISTORY: ANSF soldier with GSW right buttock, no exit site; pulseless lower extremity; no complaints of abdominal pain • VS: 120/80 P:80 RR:15 • PE: Bullet entrance with no exit • Non-tender abdomen and pelvis; pulseless right lower extremity

  8. Patient #4 • HISTORY: 2nd and 3rd degree burns involving the entire anterior body surface (chest, abdomen, and legs, excluding neck and face) sustained in an auto accident--not enclosed space; brief loss of consciousness, now alert and awake • VS: BP: 124/72 P: 100 RR: 20 • PE: clear airway; no singed nasal hairs/carbonaceous sputum

  9. Patient #5 • HISTORY: Near land mine explosion • VS BP:180/110 P: 60 RR: 10 • PE: left parietal scalp laceration; left dilated pupil; no eye opening/no motor response/no verbal

  10. Patient #6 • HISTORY: Stepped on landmine • VS: BP:90/70 P: 100 • PE: GCS: 15 incomplete amputation of right lower leg

  11. Patient #7 • HISTORY: Enemy soldier with high velocity GSW to Right lower extremity with no obvious fracture • VS: BP: 110/70 P:70 • PE: dirty wound transverse lateral right thigh; intact distal pulses and neurologic exam

  12. Patient #8 • HISTORY: ANA soldier inside bunker when large blast went off outside; can’t hear; complains of shortness of breath. Showered with glass at the time of the explosion. • VS: BP:130/90 P: 90 RR:22 • PE: ruptured TMs; Multiple superficial facial lacerations, including through-and-through laceration of right eyelid. Right pupil is asymmetric. No stridor or other evident difficulty with airway.Lungs clear, non-tender abdomen.

  13. Patient #9 • HISTORY: Young ANA soldier cut by glass in right antecubital fossa with history of spurting arterial blood • VS: BP: 86/palp P: 110 RR: 30 • PE: Deep laceration right antecubital fossa with minimal ongoing bleeding; no sensation in medial nerve distribution; no tourniquet or pressure dressing. Slightly delayed capillary refill, nail beds are pink. Radial pulse is barely palpable, definitely decreased in comparison to left.

  14. Patient #10 • HISTORY: Enemy middle age civilian with “neck injury”; speaks some English and complains weakly that he can’t breathe • VS: BP: 70/50 P: 60 RR: 36 and shallow abdominal breathing • PE: no sensation from sternal notch down; can only shrug shoulders; neck pain in high cervical area

  15. Patient #11 • HISTORY: ANP Colonel complains loudly, sobbing that can’t see and of pain in right forearm • VS: BP:118/78 P: 72 RR: 16 • PE: no obvious ocular/facial injuries, denies light perception, PERRLA; closed right forearm deformity with normal distal neurovascular exam(hysterical element)

  16. Patient #12 • HISTORY: ANA Soldier trapped in burning building during firefight; complains, hoarsely, that can’t catch his breath • VS: BP: 130/90 P:110 RR: 36 • PE: 3rd degree burns, involving circumferential chest, anterior abdomen, back, head and face, entire right leg, carbonaceous sputum and singed nasal hairs

  17. Patient #13 • HISTORY: ANA soldier in APC that was struck by rocket, victim escaped uninjured initially, but the vehicle caught fire, he went back in to attempt to rescue his friends and was inside the burning vehicle for prolonged time; ran back to aid station; now complains of shortness of breath • VS: BP:90/-- P: 120 RR: 38 • PE: cyanotic, burns to hands only; pink-tinged sputum; rales/ronchi bilaterally

  18. Patient #14 • HISTORY: ANA soldier accidentally shot by rifle grenade at close range; did not explode • VS: BP: 140/90 P:95 RR: 20 • PE: grenade round embedded in left calf

  19. Patient #15 • HISTORY: ANA soldier with bayonet wound to abdomen • VS: BP: 130/78 P:85 RR: 20 • PE: Anterior abdominal slash wound with small bowel evisceration, abdomen without peritonitis

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