Medical Aspects of Chemical Warfare (2008) - The Black Vault

Triage of Chemical Casualtiesreceives the full attention of all personnel needed toprovide optimal care. For these reasons, the thoughtof setting aside a critically sick or injured patient maywell be repugnant to someone who has not been in amass casualty situation or who has given little thoughtto such situations. 4In addition to knowing the natural course of thedisease or injury, the triage officer should also beaware of current medical assets, the current casualtypopulation, the anticipated number and types of incomingcasualties, the current status of the evacuationprocess, and the assets and casualty population at theevacuation site. Committing assets to the stabilizationof a seriously injured casualty in anticipation of earlyevacuation and more definitive care would be pointlessif evacuation could not be accomplished withinthe time needed for the casualty’s effective care, orif the assets at the evacuation site were already committed.The officer might also triage differently if, forexample, he or she knew that the 10 casualties presentwould need care in the next 24 hours, or, on the otherhand, that those 10 casualties were to be followed by50 more within an hour. 5 In an unfavorable tacticalsituation, another consideration may arise: casualtieswith minor wounds, who otherwise may be classifiedminimal, might have highest priority for care to enablethem to return to duty. The fighting strength thuspreserved could save medical personnel and casualtiesfrom attack.Levels of CareTriage is a dynamic rather than a static process,in which casualties are periodically reevaluated forchanges in condition and retriaged at various levelsof medical care, ranging from the battlefield to thebattalion aid station to the combat support hospital.The first triage is done by the corpsman, medic, or unitcombat lifesaver in the field. The medic first evaluatesthe severity of injury and decides whether anythingcan be done to save life or limb. If the answer is no,the medic moves on, perhaps after administering ananalgesic. More commonly, the medic decides thatcare is indicated. Can the medic provide that care onthe spot to return the service member to duty quickly?Can the care wait until the battle is less intense or anambulance arrives? Or must the care be given immediatelyif the casualty is to survive? In the latter case,the medic ensures that the casualty is transferred tothe medical facility if possible.A casualty is triaged once more upon entry into amedical care facility, followed by repeated triage withinthe facility as circumstances (eg, the casualty’s conditionand the assets available) change. For example, acasualty set aside as expectant (see Triage Categoriesfor Chemical Casualties, below, for definitions ofclassification groups) because personnel are occupiedwith more salvageable casualties might be reclassifiedas immediate when those personnel become free.On the other hand, a casualty with a serious but notlife-threatening wound, initially classified as delayed,could suddenly develop unanticipated bleeding and,if treatment assets were available, might be retriagedas immediate.Even in the most sophisticated medical setting, aform of triage is usually performed (perhaps not alwaysconsciously): separation of those casualties whowill benefit from medical intervention from those whowill not be helped even by maximal care. However, inmost circumstances in a large medical facility, care isadministered anyway; for instance, an individual witha devastating head injury might receive life-supportmeasures. The realization that in some settings assetscannot be spent in this manner is an integral part oftriage. 6DecontaminationAt the first level of medical care, the chemical casualtyis contaminated, and both the casualty and the triageofficer are in protective clothing (mission oriented protectiveposture [MOPP] level 4 or Occupational Safetyand Health Administration level C). Furthermore, thefirst medical care given to the casualty is in a contaminatedarea, on the “hot” or dirty side of the “hotline” atthe emergency treatment station (see Chapter 14, FieldManagement of Chemical Casualties). This situation isin contrast to any level of care in which casualties werepreviously decontaminated, and to a conventionalsituation with no contamination involved. Examinationof the casualty is not as efficient or effective as itmight be in a clean (not contaminated) environment,and very little care can be given to a casualty in theemergency treatment section in the contaminated area.In a chemically contaminated environment, in contrastto other triage situations, the most experienced medicalstaff work in the clean treatment area, where they canprovide maximum care.It is extremely unlikely that immediate decontaminationat the first level of medical care will changethe fate of the chemical casualty or the outcome of theinjury. Various estimates indicate that the casualtyusually will not reach the first level of care for 15 to60 minutes after the injury or onset of effects, exceptwhen the medical treatment facility (MTF) is close tothe battle line or is under attack and the injury occursjust outside. The casualty is unlikely to seek care untilthe injury becomes apparent, which is usually long513