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September 21, 2005

Triage for Fun and Profit
Posted by Jim Macdonald at 09:19 AM * 114 comments

The concept of “triage” has been much in the news. Since emergency medicine is one of my hobbyhorses, I’ll ride it for a while.

Triage is a French word that means “sorting.” It comes into play any time your resources are overwhelmed.

In any emergency involving casualties there will be some who will get better even if you do nothing, and some who will die even if you do everything. Between those two extremes there will be a number who will get better if you do the right things right now but will die if you don’t. The purpose of triage is to find those people so your limited resources can go to them.

Before we begin — the Tags. These are literally, physically, tags, with string to tie ‘em to the patient’s clothing, or wrist, or big toe:

Green — Minor. This person can wait.
Yellow — Delayed. Is treated ahead of Green tags.
Red — Immediate. Treat and ship these people right now.
Black — Deceased. No treatment required or desired.

The tags have colored strips on the bottom with perforations. If you don’t tear anything off, the bottom is green. Tear off that strip, the tag becomes yellow. Then red. Then black. You see the progression?

First step. There you are, a sole rescuer, facing a scene of disaster. Turn to a bystander, look directly into his eyes, point to him, and say “You! Call 9-1-1 now. Get help. Come back and tell me when you’ve done it. Okay?” When that person says “Okay!” and trots off… you go to step two. (If there is no bystander, call it in yourself. Nothing you can do else is more important than getting more help rolling.)

Now: with lungs of iron and a voice of brass, shout “Yo! Listen up! Everybody go to [name and description of safe area nearby]!”

Everyone who moves to that area is a Green Tag. They’re the walking wounded. You’ll get to them when you can. (Note: They’re also a resource.)

Now, if and only if it is safe to do so, enter the area where the rest of the casualties are. (If it isn’t safe there’s no point in going in. All it’ll mean is one more casualty and one less responder. You’ve made the situation worse.)

Go up to each person who didn’t walk out. You’ll be spending about 30 seconds with each one.

1. Is the person breathing? Yes/No. If Yes, go to step 3.

2. If the person is not breathing, open their airway. (Tilt head, jaw thrust, scoop out foreign material, as appropriate.) Is the patient breathing now? If yes, Red Tag. If no, Black Tag. Move on.

3. Is the patient breathing more than 30 times per minute? If yes, Red Tag. Move on. If no, go to 4.

4. Squeeze the patient’s fingernail until the nailbed blanches. Let go and count how long it takes to darken again. If greater than two seconds, Red Tag. Move on. If less than two seconds, go to 5.

5. Ask the patient his/her name and what happened. If the patient does not reply or answers inappropriately, Red Tag. If the patient answers appropriately, Yellow Tag. Move on.

That’s it! Keep a tally of how many and what kind you have and where they are. If you have triage tags, that’s great. If not, and you can mark them in some other way (strips of colored cloth, colored surveyor’s tape) that’s great. Or, you can take your Sharpie Marker and write the Roman numeral I on the forehead of your Red tags, II on the foreheads of your Yellow tags, III on the foreheads of your Green tags (if they stand still for it) and the Arabic number 0 on the foreheads of your Black tags. If you can’t do any of those things — when help arrives tell the person is charge what you’ve found.

If a patient is going into shock, you can direct a bystander or a Green tag to treat that person for shock (elevate feet, keep warm). If a patient is bleeding heavily, you can direct a bystander or a Green tag to control the bleeding (direct pressure). Don’t stop or delay to do these things yourself. You have more important things to do.

If you enter a building, draw (spray paint or Magic marker) a diagonal line on the wall beside the door where you entered. When you come out cross that diagonal line with another to form an X, and write on the wall the number of patients who are inside. Later rescuers, when they arrive, will know if they see a single diagonal line that someone went in but hasn’t come out. If they see an X, they’ll know that the room has been searched. If they don’t see any mark they’ll search the room themselves.

When more help arrives, go to the senior person, inform that person of what you know, and ask for an assignment.

Copyright © 2005 by James D. Macdonald

I am not a physician. I can neither diagnose nor prescribe. This post is presented for entertainment purposes only. Nothing here is meant to be advice for your particular condition or situation.

Creative Commons License
Triage for Fun and Profit by James D. Macdonald is licensed under a Creative Commons Attribution-Noncommercial-Share Alike 3.0 United States License.

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Comments on Triage for Fun and Profit:
#1 ::: Ken MacLeod ::: (view all by) ::: September 21, 2005, 10:56 AM:

Great post, but it would be a lot clearer if the tag colour codes were given before they're referred to.

#2 ::: Daniel Martin ::: (view all by) ::: September 21, 2005, 10:57 AM:

Did anyone else notice that this post has somehow gotten itself wrongly linked together with neighboring posts so that if you foolow the "Forward to Next Post" links, you get stuck in a loop of the latest three James Macdonald posts?

Forward links:
Arrr! -> The Enfield
The Enfield -> Today's Lesson(3)
Today's Lesson (3) -> Triage
Triage -> The Enfield

Backwards links:
The Enfield -> Arrr!
Today's Lesson (3) -> The Enfield
Triage -> Arrr!

#3 ::: Daniel Martin ::: (view all by) ::: September 21, 2005, 10:57 AM:

And wouldn't you know it, it's fixed now. Maybe the bug depended on there being no comments.

#4 ::: Ian Ireland ::: (view all by) ::: September 21, 2005, 11:00 AM:

One part of step-the-first bears emphasizing. Having your caller come back and tell you once they've called increases the chances that they'll actually make the call, and saves you from wondering if the call has actually been made.

#5 ::: Patrick Connors ::: (view all by) ::: September 21, 2005, 11:13 AM:

Wow. That's much more concise than the way they taught it to me in EMT school back in the Moderately Dark Ages (1989).

Would you if I format that down to reference card size and post it as a PDF?

#6 ::: Fernmonkey ::: (view all by) ::: September 21, 2005, 11:15 AM:

I didn't know that was the etymology of triage.

I thought it was something to do with dividing the living into three groups. (I first heard the word in an emergency-room context, where most people sitting there waiting are alive.)

Learn summat new every day...

#7 ::: mayakda ::: (view all by) ::: September 21, 2005, 11:22 AM:

What does #4 signify? (What does it mean if it takes more than 2 seconds for the nailbed to get back to it's usual color)?

#8 ::: Patrick Connors ::: (view all by) ::: September 21, 2005, 11:27 AM:

#4 is a quick estimate of blood circulation. If it's diminished, that's bad.

#9 ::: James D. Macdonald ::: (view all by) ::: September 21, 2005, 11:40 AM:

Excellent suggestion, Ken. It shall be done.

Patrick C.: This isn't my system: it's a standard. This system is called "START" for "Simple Triage and Rapid Treatment" -- it's what's in all the books now. I'm sure it exists in the form of laminated wallet cards already.

The squeeze-the-fingernail trick is called checking for capillary refill. If the circulatory system is working well, the nailbeds will fill back up in under two seconds. If it isn't (and it isn't your job right at that time to figure out why, just that it isn't) -- it gives you a rough guestimate. If the patient is wearing nailpolish you can do the same trick on the back of the hand. If you can't get to the patient's hands, you can do it on the center of their forehead. That's tricker with patients who have lots of skin color, but doable.

"Triage" is a French word for the same reason "ambulance" is a French word. The French (specifically Napoleon's army) came up with both concepts in the course of developing battlefield medicine.

#10 ::: Patrick Connors ::: (view all by) ::: September 21, 2005, 11:52 AM:

Thanks for the pointer. Googling "START triage" will take you to several more detailed sources, none of which include the term "lungs of iron and a voice of brass". Poetry in disaster.

Note that, which will appear first in the list, is slow and possibly buggy Java.

#11 ::: fidelio ::: (view all by) ::: September 21, 2005, 12:04 PM:

Ignorance in action here, but surely the fingertips or palm would be better than the backs of the hands, since the palmar surfaces usually have less pigment, even in extremely dark-skinned individuals?

#12 ::: Naomi Kritzer ::: (view all by) ::: September 21, 2005, 12:06 PM:

"...And come back and tell me when you've done it." What a good idea. When I took Red Cross CPR in the 1980s I remember that the drill went like this: "{To Unconcious Victim} Are you okay? Are you okay? {Look up and shout} Help! YOU! {Point at specific bystander} CALL 911!" I have a friend who took the training more recently who learned it as, "YOU, YOU, and YOU {picking out three specific bystanders} GO CALL 911!"

What interesting to me is that this is the piece of the training that has MOST stayed with me: the ability to direct people to useful activity in an emergency. And that's good, because in my (thankfully limited) experience, ordering bystanders to call 911 and helping the injured person to stay calm have been the most critical things to do.

#13 ::: James D. Macdonald ::: (view all by) ::: September 21, 2005, 12:14 PM:

The reason you go for the backs of the hands rather than the palms is you have to be fairly close to a bone to get the blanching. Anything you do, though, any surface you can reach -- is right. This is rough sorting, not a detailed assessment. You're trying for a count on how many patients you have and a general idea of how bad off they are. The phrase "quick 'n dirty" was coined for situations like this.

#14 ::: Julia Jones ::: (view all by) ::: September 21, 2005, 12:23 PM:

Paraphrase of St John's Ambulance "first aid at work" course, 1990s:

"You, go and call 999, stay on the line until they tell you that you can leave, and then come back and tell me that you've done it and if they have any instructions for me."

They were *very* hot on stop, think, and check the area for hazards before going in, lest you become a casualty yourself. They had lots of gruesome stories to demonstrate why, but there was one from my own workplace that could have resulted in several fatalities -- it was the third person who saw the unconscious people in the work pit who went and phoned for help. The first two went rushing into the pit to help, and joined the collection of people learning that argon is heavier than oxygen...

#15 ::: James D. Macdonald ::: (view all by) ::: September 21, 2005, 12:42 PM:


News from this morning, or Why You Fucking Do Not Fucking Put a Fucking X on a Fucking Door Unless You Personally Have Fucking Gone In and Fucking Looked:

Y'all remember the photo of the emaciated man being rescued in New Orleans the other day? Patrick sidelighted it, and here's the post he linked to again: Just One Photo

Okay. New Orleans. The hurricane had hit twenty-three days before. And yesterday afternoon...

When they [ATF agents Charles Smith and Sam Cohen] got to the house in the Mid-City section, they thought the couple might be safe. The door was marked with the bright orange "X" that indicates a patrol had already been through.

"I saw that 'X' and thought it would be OK," Smith said. "It had been checked."

A closer inspection showed this one was dated September 13, and that the house was not entered because it was locked. It also bore a zero and the letters A and D -- no one alive, no one dead. The same day, the SPCA had taken a dog from the other side of the duplex.

Okay. X on the door. Dated 13 September. Zero dead, 0 alive. That's seven days before.

Only guess what! There really were two people in there. One dead, one alive. And guess what else? The dead one only died five days before. That means that when that building was supposedly searched and cleared, there were two live people in it, and one of them had been able to hold out another two days.

Did anyone search? Nope. But how the fuck would someone know there was no one dead inside to write "0 D" if they didn't look?

The lesson: Do not go and say you've searched if you haven't. Maybe a subsequent team would have gone in if the building hadn't been marked as having been cleared. Lots of maybes. But know something? Someone who didn't have to be dead is sure-enough dead right now.

Because someone fucked up.

#16 ::: Terry Karney ::: (view all by) ::: September 21, 2005, 12:59 PM:

I'll point out that capillary refill takes longer in tissues other than the nailbed.

Double-checking this I find that on my (skinny) knuckles, it takes about twice as long to get evident color, and more for full refill.

My only question in this method is what does one do with obvious problems which can't wait, things like copious bleeding?


#17 ::: Erik V. Olson ::: (view all by) ::: September 21, 2005, 12:59 PM:

Why You Fucking Do Not Fucking Put a Fucking X on a Fucking Door Unless You Personally Have Fucking Gone In and Fucking Looked:

... And Fucking Come Out Again, unless you think dying in a building that you were searching, and nobody comes to get you because you labled it as "searched" is a good idea.

As you noted -- one slash for "searching", two for "searched." And, of course, DATE THAT X. Sometimes, shit happens twice, and if I'm seeing 08-Nov tags in February, those buildings aren't searched.

Finally -- I really, really, REALLY, hate using I, II, III for triage codes. For one thing, a little smudge magically upgrades your patient. Since changing tags doesn't actually fix problems, this isn't helpful.

Arabic numerals are better -- the only likely confusion is a quickly scrawled 2->3 and visa versa. Even better is 1, 2, "NOW" and 0 -- none of which are likely to confuse, and when the cavalary arrives, it's not hard to figure out what to do with a guy who has "NOW" written on the forehead, but even 1,2,3,0 has far less failure modes than I,II,III,0.

#18 ::: James D. Macdonald ::: (view all by) ::: September 21, 2005, 01:11 PM:

For obvious problems that can't wait like copious bleeding -- have the patient hold direct pressure on himself. Have a bystander hold direct pressure. Have a Green Tag hold direct pressure. But ... right now what you're doing, triage on the remaining patients, is more important than treating this one patient.

The important things are:

Take charge. Make decisions.

Get more help rolling.

Do what you can while you're waiting for backup.

#19 ::: TomB ::: (view all by) ::: September 21, 2005, 01:12 PM:

Excellent post. It leads me to think that we need to train activists on how to perform political triage.

#20 ::: James D. Macdonald ::: (view all by) ::: September 21, 2005, 01:18 PM:

As long as we're Having Fun with Sharpies:

If you give a patient epinephrine, write E and the time (24 hour clock) on their forehead. If you give the patient morphine, write M and the time on their forehead. If for some reason that I can't imagine you lost your senses and put a tourniquet on a patient write the letter T and the time on their forehead.

Here's a slick trick if you're going to be with a patient longer-term. Feel their arm. Is there a place where the arm stops being warm and starts being cold? If so, put a line there with your Sharpie. Now do your interventions. Check for that warm/cold line again, and draw with your Sharpie on its new location. If the new line is higher up the arm, you're losing. If the new line is lower down the arm, you're gaining.

#21 ::: Terry Karney ::: (view all by) ::: September 21, 2005, 01:25 PM:

Jim: That's what I'd do (since leaving the salvable to die doesn't strike me as good triage) but I wondered what the system did for that.

The E for Epi is new to me. The other thing I'd do for a tourniquet patient is make certain the tourniquet is visible.

Then again, the army has trained me to be very specific in how I apply various bandages so the medics can, at a glance, know how serious the bleeding underneath is.


#22 ::: Annie G. ::: (view all by) ::: September 21, 2005, 01:48 PM:

coming out of lurkdom to ask: I thought there were injuries for which a tourniquet was an appropriate treatment? Granted, my first aid training is limited to a couple of Red Cross sessions a while ago, so I'm probably way off-base.

#23 ::: Laurie Mann ::: (view all by) ::: September 21, 2005, 01:50 PM:

Jim, don't you have the problem that a "green" untrained-in-first-aid person might do the injured person more damage than no care at all?

Also, isn't there a danger with only using color-coded tags? What if some of the later responders are colorblind?

Otherwise, I think what you said makes lots of sense.

I was in a train accident in 1968 - 1 killed, 8 injured, and a bunch of others with minor injuries including my brother. We were lucky - the landslide that derailed the train happened about 200 yards from a road. If the landslide had happened a further on in our journey, we would have been in the middle of nowhere in the Canadian Rockies. The RCMP (but on busses, not on horses) to the rescue! There was no formal triage as the major injuries were all in the car hit by the landslide, and everyone else was ambulatory.

#24 ::: James D. Macdonald ::: (view all by) ::: September 21, 2005, 01:55 PM:

Okay -- if you use an untrained person to do basic first aid (treat for shock/control bleeding) and they screw it up, the patient is dead. If you don't use anyone at all, the patient is dead.

If, on the other hand, the person does okay (and holding direct pressure isn't all that tough) the patient may live.

One way the patient has a chance. The other way ... he doesn't. Give him the chance.

And the color codes -- the color strips are also printed with numbers, and with little graphics for people who don't know their numbers. It's pretty well covered.

#25 ::: Charlie Stross ::: (view all by) ::: September 21, 2005, 01:58 PM:

"Epinephrine"? That would be adrenalin, wouldn't it?

(Are you guys still using non-internationally-standardized names for such basic stuff? Isn't that, like, potentially dangerous? (I'm thinking specifically about multi-national efforts here -- not relevant to New Orleans, quite possibly very relevant to, say, military forces in Middle Eastern countries beginning with "I".))

#26 ::: Leigh Butler ::: (view all by) ::: September 21, 2005, 01:58 PM:

I love learning about shit like this. Seriously.

Sometimes I feel a little egotistical assuming that, in an emergency situation, I should be the one to take charge.

Though if there were someone with actual medical/emergency training on hand, I wouldn't be, of course. But I've heard enough stories about how people tend to go into frozen-deer-in-headlights mode at such times that it only makes sense to prepare to deal with the possibility.

#27 ::: Paula Helm Murray ::: (view all by) ::: September 21, 2005, 02:08 PM:

Charlie, following is from Wikipedia. It's a naming issue.

The basis for the name epinephrine in the United States was out of necessity—the name adrenalin (without a final "e") was registered as a trademark by Parke, Davis & Co. In other countries where this trademark was not registered, the name adrenaline was adopted at the insistence of the British pharmacologist Henry Hallett Dale. Resistance to the adoption of epinephrine has even resulted in some dispute as to the validity of the name (Aronson, 2000).

The monograph name in the European Pharmacopoeia remains adrenaline, despite the adoption of INN names for all other agents, and European Union (EU) countries continue to use either adrenaline or dual-labelling of both names on products. This is because of the confusion that the name epinephrine would cause to patients in EU countries, and resistance to the perceived Americanisation.

#28 ::: ElizabethVomMarlowe ::: (view all by) ::: September 21, 2005, 02:16 PM:

I have a dumb question. Are medical bracellets helpful to EMTs? Are necklaces better? I suppose it depends on what it says and what the disease/disability is, but I'm just curious.

#29 ::: Beth Meacham ::: (view all by) ::: September 21, 2005, 02:18 PM:

A cross-species FYI: with horses, you do the capillary refill check on the gums. I presume this would work with people too....

#31 ::: Erik V. Olson ::: (view all by) ::: September 21, 2005, 02:23 PM:

Are you guys still using non-internationally-standardized names for such basic stuff

Uhh, epinephrine is the standard name, in particular, it is the INN. As is often the case (see "UTC") the Brits are the ones whinging about how the INN is chock full of American Names, which Aren't Right™), thus, they insist on using adrenaline -- never mind the great number of INN compounds that are, in fact, based off the British name -- see "paracetamol" as an even more common example.

Normally, I'm with you on "USA, suckitude thereof", but this is one case where you and the BMA need to Shut The Fuck Up™. Indeed, you passed legislation explicitly saying that everything would henceforth be INN -- except, of course, adrenaline.

#32 ::: P J Evans ::: (view all by) ::: September 21, 2005, 02:26 PM:

As someone who wears a bracelet, I hope the EMTs will read it, but I've heard stories of non-EMT medical people not reading them even on in-patients in hospitals (which is something I can't understand: did they think it was decorative?). Fortunately someone raised a fuss before the medical people did something really wrong, and the patient survived.

For small children: if the bracelet tends to come off, it's probably too large. In an emergency, use safety pins to fasten it more securely (pin the chain to make it shorter, or pin it to clothing). Mine isn't that easy to remove single-handed, so I doubt that children could do it.

#33 ::: James D. Macdonald ::: (view all by) ::: September 21, 2005, 02:38 PM:

When I'm in the field you betcha I look for bracelets and necklaces with that lil ol' Star of Life (TM) on it. (I'm checking your neck and wrists for other stuff anyway, so I might as well -- and sometimes it's Really Useful Info(like Allergic to Iodine).

(If you're unconscious you betcha I'm going to start an IV on you. And I use iodine in the course of doing it. Unless you have a bracelet that says otherwise....)

We also look in your refrigerator for a Vial of Life.

(No, the EMTs are not looking for a beer. Even if it is a very hot day.)

#34 ::: Zoe ::: (view all by) ::: September 21, 2005, 02:41 PM:

And if anyone wants to have a look, here's the site with details of the legislation Eric V. Olson mentioned

#35 ::: P J Evans ::: (view all by) ::: September 21, 2005, 02:52 PM:

Jim: Mine has a staff with one snake. In red. (Two snakes around a staff: see if you've got Signal Corps.) I've worn out two bracelets already; this is the third. They only last about ten years before the jump rings take out the end loops - stainless steel is soft.

#36 ::: Michelle K ::: (view all by) ::: September 21, 2005, 02:53 PM:

This is a serious question. Can you still get Red Cross training if you are extremely squeamish?

I've (I'm sad to admit) never gotten CPR training, because the idea of mouth-to-mouth recussitation REALLY freaked me out.

But the idea of not knowing what to do in an emergency ALSO really bothers me.

#37 ::: Carrie ::: (view all by) ::: September 21, 2005, 02:56 PM:

Re: calling 911. When I worked in a bookstore, a man came up to me at the info desk and said, "There's been a bad car accident outside." I immediately went, "Oh gosh, here's the phone, call 911." He said, "I don't want to be the one to call." And just stood there. So I called, and what happened was absolutely predictable. The operator asked me for specific info, and I had to ask the man who'd actually seen the accident, then get back to the operator. An extra, time-wasting step that wouldn't have happened if he'd just made the call himself.

Have you emergency medical types ever had this happen, where you tell someone to call 911 and that person says, "No." ???

#38 ::: clew ::: (view all by) ::: September 21, 2005, 03:02 PM:

Would doing CPR on a plastic dummy bother you, Michelle? It's pale and wan, but not otherwise icky.

#39 ::: Terry Karney ::: (view all by) ::: September 21, 2005, 03:08 PM:

Carrie: I've had that happen. What I did was wait until the operator got on the line, and then said, "Yes, here he is," and handed him the phone.

At which point he took it, because "someone in authority" had asked for him.


#40 ::: Naomi Kritzer ::: (view all by) ::: September 21, 2005, 03:12 PM:

What is a Vial of Life?

Leigh Butler wrote, Sometimes I feel a little egotistical assuming that, in an emergency situation, I should be the one to take charge.

Four years ago this Saturday, my sister was in a really bad car accident. During morning rush hour, driving on a highway, she suddenly lost control of her car; it skidded off the highway and rolled 360 degrees before coming to rest at the bottom of an embankment. We think it was caused by a tire blowout. When her car first went out of control, Abi thought she was going to die. When it came to rest, she was in severe pain from a broken arm, but was also convinced that she needed to find her cell phone or get out and flag down a car because she knew she needed an ambulance. Her own door was inoperable so she scrambled across the passenger seat and out into the wet grass before collapsing to her knees. At that point, the other drivers who'd stopped to help her came running down the embankment shouting to her that they had called 911 and that she shouldn't try to move, help was on its way.

One driver, a carpenter on his way to a construction site, had a blanket in his car. He brought it down and draped it gently around her, then talked to her to keep her calm until the paramedics arrived. That's all he did -- treated for shock, reassured her, and kept her company.

When the paramedics arrived, they put a collar on her, strapped her to a backboard, and took her to the hospital. Where they determined that she had two fractured cervical vertebrae -- C2 (the one Christopher Reeve broke) and C7. She spent three months in a halo vest so that her broken neck could heal. But thanks in part to the people who stopped, her spinal cord was never injured and she is not paralyzed. She made a full recovery.

I am so grateful to the strangers who stopped to help her. You don't need a great deal of knowledge in order to make a huge difference, if you're the first one on the scene.

#41 ::: fidelio ::: (view all by) ::: September 21, 2005, 03:15 PM:

Michelle, when I did my CPR training, we were given little plastic gizmos to use for mouth-to-mouth "in those situations where it might be warranted". I don't know if they still do that or not.

Given the format of the training, you'd be putting your mouth on a dummy, rather than a human, if that's any help. It's worth it, because any training at all helps overcome the urge to panic or dither. You know what to look for, and what to do next, and when not to do anything at all. The Red Cross trainers have seen every level of squeamishness among their students--you won't be the first.
Many employers are willing to pay for their workers to take first aid/CPR training; check and see, because it'a always worth knowing the basics, no matter where you live or what you do. If nothing else, you'll know how to be useful if things are really bad.

It is better to be trained, and never need it, than to need it, and not know what to do.

#42 ::: Lexica ::: (view all by) ::: September 21, 2005, 03:16 PM:

Michelle, I'd guess that I was the most squeamish person in the room when I took the first aid/AED training at work, and I had very little trouble with it. (I started to feel a bit woozy when the instructors were discussing eye injuries, but was fine up to that point, including practicing CPR on the dummy.)

For me, the added confidence of knowing what to do increased my comfort level far more than my usual squeamishness decreased it.

#43 ::: jennie ::: (view all by) ::: September 21, 2005, 03:33 PM:

Leigh Butler,

Sometimes I feel a little egotistical assuming that, in an emergency situation, I should be the one to take charge.

It's not egotistical, as long as you don't assume it's inevitably and always you.

If I, with my out-of-date lifeguard training, show up at the scene of an incident, and everyone else is standing around gawking, I take charge, substituting my teacher voice for the voice of brass (gotta get me one of those sometime). If James D. Macdonald shows up, I'm more than likely to fill him in, and defer to his vastly superior expertise.

You may not be the ideal triage manager, but you're almost certainly better than no triage manager.

#44 ::: Terry Karney ::: (view all by) ::: September 21, 2005, 03:41 PM:

Leigh: The person who knows best, or has the most presence, will be in charge. Usually knowing best will lead to presence (I've taken over accidents where people who didn't know were doing their best, which including moving a victim from the car; no fire, so smell of gas, and no risk of secondary collision, so I stopped them trying to get the driver out).

Calm demeanor leads to people giving you authority in such circumstances (this may be why military types get credit in wrecks, and the like, we get lots of training putting off reaction; the now matters more than the thing, and the horrid gets put off until later). Knowing is better than not knowing, and since needs must when the Devil drives, you'll do what you know how to do and be squeamish later.

I've seen people who were so squicked at having given someone mouth to mouth that they went into a bush and puked, after the person came round.

#45 ::: Michelle K ::: (view all by) ::: September 21, 2005, 03:42 PM:

It's actually the idea of putting my mouth on anything that bothers me. The rest of it I'm okay with I think. Maybe.

And my last job actually offered certification, but I didn't do it because I chickened out.

I know. I should do it. Maybe I should go look it up right now.

#46 ::: mayakda ::: (view all by) ::: September 21, 2005, 03:52 PM:

The CPR class I went to (a couple of years ago), the trainer said that if you didn't have one of those plastic thingies to put between your mouth and the victim, then just do the chest compressions at least. (If the person's not breathing and you've checked/unblocked the airways). I don't remember much -- obviously time for a refresher.

#47 ::: Debra Doyle ::: (view all by) ::: September 21, 2005, 03:55 PM:

Michelle -- these days, they make plastic face masks that provide a barrier between you and whoever you're giving CPR to. They come in in all sizes, from fancy ones in hardshell cases to little bitty compact ones that go on a keychain.

#48 ::: John M. Ford ::: (view all by) ::: September 21, 2005, 04:37 PM:

Disposable CPR faceshields, in a number of different designs (they all work) cost a few bucks, and in addition to preventing contact help establish a proper airway. The one I have costs $7.40 in its base, polybagged model; mine is in a little Cordura bag with a "key chain" snap hook, that also has room for a pair of gloves. (Remember that you may need to clear your subject's airway, and your fingers are the likeliest tool to, uh, hand.)

I don't carry a kit, but I have the CPR mask and a couple of 4x4 gauze pads in my everyday bag; I figure the things I am most likely to run across on the street that equipment will help are CPR or a serious bleeder. (And when I'm downtown I'm usually within seven blocks of the Level 1 center anyway.)

#49 ::: Wendy Bradley ::: (view all by) ::: September 21, 2005, 05:28 PM:

I'm pretty squeamish about most things too (almost passed out the first time I had my blood *pressure* taken ) but I've been thinking it would be a Good Thing to have some first aid training. But doesn't the argument that "a little knowledge is a dangerous thing" come into play? My colleague bashed her head last week and was bleeding copiously from her scalp, but the first aider was a terrible drama queen who enjoyed every minute of the limelight, hurt her fiddling with the bandages, and then wouldn't let the paramedics into the room! (They thought he was a neurotic husband and treated him with kid gloves, while she was wishing they'd just deck him and come help her)

So I guess I'm saying, is it better to have a bad first aider, or no first aider?

And if I suspect I might be a bad first aider, should I stay well clear of anything except following your excellent triage instructions and praying someone competent comes along before it becomes germane that I have no idea how to do the nail bed thing????

#50 ::: Jasper Janssen ::: (view all by) ::: September 21, 2005, 05:54 PM:

Being squeamish doesn't make you a bad first aider. Worst comes to worst, you can tell someone else what to do. Being a drama queen might qualify you as a bad first aider, especially if it involves not giving over control of the situation to truly competent authorities like the paramedics. Even then, a scalp wound is not a life threatening injury, even if it bleeds a lot. He might have been less of an ass if it was serious.

#51 ::: fidelio ::: (view all by) ::: September 21, 2005, 06:04 PM:

For me, the question I ended up asking myself was: Is it more important to be able to help someone in dire need than to indulge my own feelings? (whether those feelings might be Ick--that's gross! or Here is my chance to SHINE! I leave up to you all.) I decided that if I was serious about helping, I would A. Get trained and B. Keep in mind this was about the person in need, and not me. These are the two things to know--what to do, and that it's not your party. Wendy's drama queen first aider had mislaid part B, because if he'd kept it in mind, he'd know--once the Real Experts are there, you're chopped liver. If it's bad enough, you'll be grateful to be chopped liver, too. Likewise, the EMT crews are generally glad to turn things over to the ER staff. It's not about them--it's about the patient.

We had an elderly physician collapse from an episode of cardiac arrhythmia one day here--one of the other Old Doctors was an anesthesiologist, and immediately did CPR--and when the paramedics arrived, with the oxygen tank, and all the other tools of the trade, he stood aside, and was glad to do so, because they were set up to do some serious intervention, and he was just set up to do CPR, despite all his experience.

#52 ::: Andrew Gray ::: (view all by) ::: September 21, 2005, 06:53 PM:

I read this and remembered this, from Random Acts of Reality a year or so ago - the London Ambulance Service's procedure for handling a "major incident", including a brief description of their triage system (with handy flowchart).

(It omits the "call 911" step, since the existence of an ambulance on scene implies that something like that happened already, but does include a "first, scream loudly for backup" part - same principle, writ large)

May be of interest as a comparison, though it's not specified how the triage method differs from that generally used at other incidents.

#53 ::: Laurie Mann ::: (view all by) ::: September 21, 2005, 07:36 PM:

Giving someone CPR or artificial respiration I don't think would bother me too much. I think I'd be OK with closed fractures and abrasions. I freak out over adults vomiting and lots of blood, so I probably wouldn't be that good in an emergency involving major injuries.

Laurie Mann
Whad'Ya Know?

#54 ::: xeger ::: (view all by) ::: September 21, 2005, 09:45 PM:

I've been amused to find that the reaction of a person/group of people to my pulling latex gloves out of my bag is a good general measure of how accustomed to dealing with incidents of various sorts the are.

The accustomed say "thanks" and get on with whatever task requires the gloves. The rest come up with a variety of odd blathered questions, often starting with "Why do you have -those- in your bag?"

#55 ::: Kayjay ::: (view all by) ::: September 21, 2005, 09:56 PM:

As a substitute teacher, I've come to appreciate readily available disposable gloves (and hand sanitizer, but that's another story) as there is a lot more exposure to bodily fluids in this job than I'd ever imagined. However, I always make sure to buy non-latex gloves--vinyl or nitrile generally--because so many people have latex allergies. Not everyone wears an alert tag, and sometime they won't be in a position to tell you.

#56 ::: Christopher Davis ::: (view all by) ::: September 21, 2005, 10:21 PM:

A thought on all of this: first responders are great folks. However, any of us may suddenly become zeroth responders (by analogy to the Zeroth Law of Robotics) without warning, so we should at least try to have what preparedness we can.

#57 ::: Azure Lunatic ::: (view all by) ::: September 22, 2005, 06:01 AM:

It looks like the crowd around here is largely the choir, so I'll avoid preaching to it. As far as people who "don't want to get involved" are concerned, if any of them are reading this, there isn't generally much "involvement" to making a 911 call in response to an injury, at the very least.

The last-but-one 911 call I made was because of a car wreck at midnight in front of my apartment's balcony. It was a noisy crash, and when I opened my blinds to see what the matter was, there was already a crowd gathering. I knew my running down to help would serve nothing; I let my previous phone conversation go with a "Car crash, gotta call 911" and called.

I wasn't asked my name. I was asked the location of the crash, and pertinent details like the number of injured, the number, color, and general type of vehicles involved, and then questions about the injured like:

Are they breathing?
Are they bleeding?

I got the impression that the 911 operator was glad to have a coherent person on the line, but that she was used to asking the right questions to get the right information, and saying the right things to calm down someone in a panic.

I have the lungs of iron and the voice of brass. I was on a balcony with a commanding view of the accident. I relayed information between the zeroth responders on the scene and the emergency operator, by dint of bellowing the questions I couldn't answer myself down to the people standing down by the accident. I think at some point I bellowed, "I'm on the phone with 911!" so everyone would know that 911 had been called, that help was on the way, and that the questions I was asking weren't just me being a nosy bystander, it was 911 asking through me. I must admit that I was trembling, terrified of telling others what to do, of speaking to complete strangers, but more terrified of what could happen if I didn't.

And it's amazing how people who don't know what to do in a crisis will listen to someone who does know what to do, or at least acts as if they do. They take their cue from the leadership they're given. If the Person Acting Like They're In Charge is calm, the people observing or involved in the emergency will be calmer than they otherwise might. If any perceived leaders are in hysterics or suchlike during the emergency, people who don't know what's going on are going to assume that it's worse than they think, and panic themselves...

Training oneself into a calm and helpful response to an emergency is possible. I see so many people in the comments here who treat responding calmly to life-threatening emergency situations as a matter of course, and it might be easy to think that either you're born with the ability to react coolly in an emergency or you're not. But that's not the case. The first crucial factor is knowledge of what to do in an emergency, and what to expect -- first-aid classes, instructions like this triage training here. The second one is practice. After a few rounds calling 911, after dealing with more than one co-worker having an asthma attack or shock set in, you know how to react. And it's not such a big deal.

And it means the world to the person you help, even if all you did was call for medical aid and sit there with them being calm or holding pressure on a wound.

#58 ::: James D. Macdonald ::: (view all by) ::: September 22, 2005, 11:31 AM:

That link over at Random Acts of Reality is wonderful.

What I really enjoyed was the CHALET report format:

If I'm first on scene at a Major incident, then if I am the attendant I need to run around the scene to do a quick bit of reconnaissance, I'm not there to treat anyone. I then get back in the ambulance and radio in a "CHALET" report. This is...

C - Casualties (number and severity). H - Hazards on the scene. A - Access, meeting points, vehicle parking area. L - Location, the map reference and best directions to get to the parking area. E - Emergency services required. T - Type of incident.

"Casualties (number and severity)" is what you've just learned from doing your START triage.

That strongly reminds me of the SALUTE report that we had when running around in various jungles, on making contact with enemy forces. The report you radioed back:


Both of those reports are designed so that if the transmission is cut or garbled, what you've already sent is the Most Important Stuff for the guys back at command and control to know what sort of response is most appropriate. (Uniform there is whether they're wearing uniforms, and if so, what kind.)

#59 ::: James D. Macdonald ::: (view all by) ::: September 22, 2005, 11:40 AM:

And it means the world to the person you help, even if all you did was call for medical aid and sit there with them being calm or holding pressure on a wound.

In a Wilderness rescue, one official position in the rescue team is "Patient's Buddy." This is one individual who has no other duty than to stay beside the patient and talk to him the whole way out. While you're going to be switching through a lot of folks doing the carrying (three miles into the backcountry and figure you're going to need twenty-one individuals switching in and out as bearers) the Patient's Buddy walks by his head, just chatting, telling him what's going on around him, determining the patient's wants and needs, explaining stuff, and incidentally keeping an eye on the patient's level of consciousness. While other folks hand off their assignments, the Patient's Buddy is with the patient the whole time, which could be hours or days. One face, one voice, right the way to definite treatment.

#60 ::: Xopher (Christopher Hatton) ::: (view all by) ::: September 22, 2005, 02:30 PM:

Wow, this is really useful stuff, all of it.

Jim, one question. If someone isn't breathing after you open their airway - and you got there really fast after the incident, suppose it was a bombing or something - why do you tag them black? Isn't it possible to get them started breathing again?

You wouldn't spend the time if there were other people who might start breathing on your own...but isn't there room for circumstance here? If you can tell by a visual that everyone else is yellow or red, for example?

Almost all of this information was new, but it all made sense to me except that bit. Can you clarify?

#61 ::: James D. Macdonald ::: (view all by) ::: September 22, 2005, 02:51 PM:

If someone isn't breathing -- and you have other patients -- that person would take too many resources. If you open the airway and the patient still isn't breathing....

Well, four to six minutes without oxygen and they're probably going to be braindead anyway. Resuscitation is a labor-intensive activity.

Some people, in triage situation, might throw an oral airway into the non-breathing patient and give two breaths with a bag-valve mask (if you have the oral airways in your pocket and you have the BVM in your hand). But after that, time's up. You have other, more important, things to do right then.

When you're doing triage you aren't doing treatment. You are looking at an overwhelming task. Break it down into smaller parts that you can do. Get a system; use it.

(BTW, when I go out, I carry an 8cm oral airway in the lower left pocket of my jacket. Your 8cm airway is the most common adult size.)

#62 ::: James D. Macdonald ::: (view all by) ::: September 22, 2005, 03:44 PM:

If you can tell by a visual that everyone else is yellow or red, for example?

If you have someone who is breathing 30+ times a mintute, and someone else not breathing at all ... the guy breathing at 30+ needs just as much help, but has a far better chance of living if you do something right now.

#63 ::: Xopher (Christopher Hatton) ::: (view all by) ::: September 22, 2005, 04:07 PM:

OK, that makes sense. And by the time help arrives, black is REALLY black...different decisions if the nonbreather is your only patient, of course.

Wow, I really feel the need to get some training in this stuff...I should try to find out where I can get some.

#64 ::: fidelio ::: (view all by) ::: September 22, 2005, 04:44 PM:

Xopher, you can start with the Red Cross chapter in your area. Check with your company's HR office as well--they may have arrangements to get their people trained, the same way many companies arrange to have blood drives on premises. Sometime churches sponsor training classes as well--check the one where you sing in the choir.

Also, the Red Cross will send trainers to any place where you can assemble a group interested and willing to pay the fees. I'm not sure what the minimum number is.

#65 ::: Terry Karney ::: (view all by) ::: September 22, 2005, 04:55 PM:

SALUTE has changed.


On the subject of attitude, and being calm:

There are a host of other drills, like the 9-line medevac (which tells how many, in what condition, where, how to approach, hazards to navigation, etc.).

The 8-step method of evaluatiing a casualty, the 9-signs of minor nerve-agent poisoning, and the 11 for major, acronyms for all sorts of things, instructions on the four lifesaving steps (open the airway, stop the bleeding, bandage the wound, treat for shock) are on the wrapper for the field dressing, and a host of others, are all meant to make it rote, or at least familiar.

That's to teach you to be calm: "To keep your head when all about are losing theirs."

And that, I have found, is often the only thing that matters, someone keeping calm.


#66 ::: NelC ::: (view all by) ::: September 22, 2005, 05:04 PM:

So, we've got an airway and latex gloves. What other useful items do people carry with them in case of emergencies?

The only vaguely useful things I carry are a mobile phone and a selection of pens.

#67 ::: Stefan Jones ::: (view all by) ::: September 22, 2005, 05:36 PM:


What kind of emergencies? That's a question that can be answered in many ways.

I'm not an EMT or vaguely like one. What's in my car's trunk:

Blanket(s). Tarp(s). Rain poncho. Bottle of cheap aspirin. Rope. Hatchet. A few cans of food (stew, fruit). Dog food. Flashlight. Flares.

I will probably add a waterproof box with some matches.

I've occasionally wondered, given that one of the area's failure modes is a volcano going off, if a spare air filter might be a good thing to keep around.

#68 ::: Xopher (Christopher Hatton) ::: (view all by) ::: September 22, 2005, 06:18 PM:

Stefan, since the aspirin is cheap...replace it regularly. Old aspirin gets nasty properties. Not just less effective, but I can't remember what goes wrong with it. My mom (a nurse) told me about it, but it was 30 years ago.

#69 ::: Stefan Jones ::: (view all by) ::: September 22, 2005, 06:36 PM:

Good point.

I'm sure there's a best-by date on the bottle.

General FYI:

Walgreen's regulary has $.39 or "2 / $1.00" sales of handy first aid items like hydrogen peroxide, isopropyl alchohol, 100 bottles of aspirin, etc.

When I had to empty out my "use it or lose it" medical savings account last month, I bought a ludicrous amount of first aid gear and over-the-counter remedies. My immediate family members are all getting first aid kits for Christmas.

#70 ::: Graydon ::: (view all by) ::: September 22, 2005, 07:19 PM:

Nel C --

This time of year, the only things I carry around that are for emergencies, in that sense, are the teeny first aid kit that lives in the belt pouch, the small first aid kid that lives in the bike rack pack, and the sorta medium first aid kit that gets tossed in if I'm going on a significant cycling trip.

Well, ok, possibly the umbrella counts as an emergency thing, too, because it's the umbrella for bringing when rain isn't expected.

The pens, LED lights, spirit level, whistle, thermometer, antiacid, lighter, utility knife, diamond hone, ceramic hone, flint and steel, glasses retaining strap, optics cleaning cloth, and glasses repair kit live in the belt pouch (along with my wallet, change purse, PDA, work ID badge, and a couple of 2 meter nylon web straps) because I feel like a complete moron if I want them and haven't got them.

Pockets get the Swiss Army knife, another LED light, the 3 foot measuring tape, the utility cord, the Space Pen, the transit pass, the business card holder, and my keys.

That's the sort of minimal 'might be useful' set of stuff; no compass, no water containers, no ability to filter or purify water, no fuel, no food, no spare clothing or rain gear or shelter materials, no ax, all of which I'd consider pretty much basic for actual survival in any emergency dire enough to make me worry about survival issues in the middle of Toronto.

In the winter, I've got IceWalkers (cleated sandals that go over your boots), a survival bag (like a blanket but a bag), a spare hat, a couple of survival blankets, and a lot more implements.

For inter-urban bus travel, mostly, yes. The Lady of the Ice has a very limited conception of mercy.

#71 ::: Thena ::: (view all by) ::: September 22, 2005, 07:53 PM:

Stefan Jones -

I'm told by friends who lived in Portland, OR during Mt. St. Helens' 1980 explosion that an old air filter is better than a new one during an ash fall - just pull it out of the car, whack it on the ground to knock the ash loose, and put it back. Ash particles are tiny enough to get through the mesh of a perfectly new filter, but an old half-clogged one will block them.

#72 ::: Terry Karney ::: (view all by) ::: September 22, 2005, 09:35 PM:

My walking out of the house stuff.

On my belt, all the time:
Buck knife.
Gerber Multi-tool.

In a bag, which gets dropped into whatever I'm carrying:
Airways (one adult, one child)
A couple of Army Field Dressings (6"x7" sterile, with long tails to keep the badange from shipping dirt, can be modified to pressure dressing or tourniquet, and with the wrapper can be used to treat a sucking chest wound).

random things of similar nature in the camera bag, the knapsack and the camelback.

If I'm heading out with the horses, or hiking, etc. I have a bunch of bandaids, more dressings (including a couple of really large ones meant for open abdominal wounds), cravats (for splints, and (God forbid I should need to build one myself, a traction splint for broken leg) slings and making compresses, burn salve, neosporin, gauze, ace bandages, scalpel, tweezers.

The last time I had to use it was to treat a pair of mule-foals who had stepped in a cattle-guard.

There are somethings, meant to be used for horses and cows, which one might want to get for people bags, like vet-wrap, and the like.


#73 ::: jennie ::: (view all by) ::: September 22, 2005, 10:43 PM:


This is the list of things that fit into the tiny, girly wallet-onna-string that I always carry. Unlike some folks, if I had all sorts of useful stuff in a belt pouch, I wouldn't ever have the thing with me, 'cause it would look silly on me (looks perfectly reasonable on other folks, sure, but not on me), and I know myself. Also, I don't usually have pockets.

Since I don't have a car, I don't keep things in the trunk (though I did put together pretty decent emergency kits for my brothers' cars as a Christmas gift).

In the girly bag:

Swiss Army knife
Cell phone
Sharpie marker (soooo useful for so many things)
Alcohol prep pads
Hand sanitizer, when I remember to put it there
Lightdays sanitary napkins (they're small, they're individually wrapped, and they absorb all manner of things)
Gauze pads in sterile wrappers

This, in addition to the stuff I use more frequently:
Lip gloss (it is a girly bag)
Business cards

And the one non-useful thing:
Photo of cat

I should stuff some nitrile gloves in there, too.

There's more useful stuff in the bike bag, but the girly bag is the stuff I'm never without.

#74 ::: Xopher (Christopher Hatton) ::: (view all by) ::: September 23, 2005, 12:18 AM:

The Lady of the Ice has a very limited conception of mercy.

I think it was Gwydion who wrote:

Now the Leprous-White Lady
Leads her train of the Lost
Leads her spirits through glade and wood
And goodly fields of frost.
Not quite time for that yet, of course. But it's coming!

#75 ::: Scott Lynch ::: (view all by) ::: September 23, 2005, 04:20 AM:

As a companion to (or replacement for) flares, I recommend chemical light sticks, the "snap and shake" kind. They have quite a few advantages:

A. They're extremely cheap and readily obtainable;

B. You can use them at an accident site where there might be a danger from spilled fuel or other combustible chemicals, because they won't ignite anything;

C. You can tuck them in a pocket or elsewhere on your person without worrying about burning yourself;

D. You can secure them to physical objects (trees, signs, etc.) with duct tape for instant attention-getters. You can even secure them to yourself (chest, back, back of a hat) to increase your visibility at night; and

E. Even small children can handle them without getting burnt.

For those interested in this topic but freaking out a bit at the thought of it all-- just remember that you do not need to carry a Batman utility belt on your person at all times. Too much stuff on hand can be confusing and time-wasting if you don't drill with it regularly.

Last month, I asked a fellow firefighter for a spanner wrench (basic FF tool used to loosen and tighten hoses). He dug through three pockets on his gear, and accidentally tossed me six pairs of loose nitrile gloves and a packet of aspirin along with the wrench. Too much stuff.

A pair of nitrile gloves* and a CPR barrier mask will take up about as much space as a checkbook, if that. And if you're still averse to carrying stuff like this because you just don't think you could ever possibly use it (squeamishness, nerves, infirmity, whatever), kudos to you for your honesty, but who says you'd be the one to use it? Carry it around in a purse or glove compartment, and you might just be able to pass it on to someone who can.


*These suckers aren't just gloves, they're multi-tools. They can be tied around a limb (up to a certain size) as an emergency tourniquet. They can be used to tie hair back. Fill them with ice and they become little ice-packs. You can stick them on things as markers-- "We had to leave two people who couldn't move in the room on the second floor with the glove on the doorknob! Please hurry!"

It only sounds dorky until all hell breaks loose around you.

#76 ::: Stefan Jones ::: (view all by) ::: September 23, 2005, 01:03 PM:

"These suckers aren't just gloves, they're multi-tools."

And for certain exotic transhumans, they're dandy condoms!

#77 ::: James D. Macdonald ::: (view all by) ::: September 23, 2005, 02:05 PM:

Most of the year I wear a parka on runs.

What I carry:

In a belt holster: radio, flashlight, shears, gloves.

In lower-left patch pocket: 8cm oral airway
In lower-right patch pocket: more exam gloves
In upper right zippered pocket: combo seatbelt-cutter/oxygen tank wrench
In upper left zippered pocket: nothing. It's where I put my radio when I'm working.
In slit/handwarmer pockets: heavy leather gloves
On belt: Buck folding hunter knife, Leatherman multitool.
In left cargo pocket of trousers: CPR mask + gloves (in the same case)
Right cargo pocket of trousers: Notebook and pen

During the part of the year when I'm not in a parka, I'm in a three-season jacket. Oral airway and seatbelt cutter in left pocket, extra gloves in right pocket.


See my emergency kit page for the contents of my wilderness bag and my first aid kit.

(The Wildnerness bag is when it comes across the scanner, "Fish and Game is looking for a search party for a lost hunter. Gather in the school parking lot." Throw that into my normal backpack. The first aid kit is for when I don't have the ambulance with me.)

#78 ::: Terry Karney ::: (view all by) ::: September 23, 2005, 07:07 PM:

My only comment on Chem-lights is they expire. They are good for about a year, tops, in a place like a trunk, rucksack, etc.

For the car I'd make sure to have both, and use the old Chem-lights as party decorations at Hallowe'en.

#79 ::: John M. Ford ::: (view all by) ::: September 23, 2005, 07:37 PM:

Anybody else remember The Human Glove? (He wasn't, actually -- more of a gadgeteer -- but "Nitrile Man" confused too many readers.) I think his last appearance was in Crisis on Infinite Crises, in an alternate-world version called Manefisto. Gosh, comics have changed.

#80 ::: David Goldfarb ::: (view all by) ::: September 24, 2005, 07:02 AM:

Mike Ford: DC Comics is in fact very shortly starting a crossover event called Infinite Crisis. Be afraid.

#81 ::: Vassilissa ::: (view all by) ::: September 24, 2005, 10:57 AM:

give two breaths with a bag-valve mask (if you have the oral airways in your pocket and you have the BVM in your hand).

Holy colliding initials! My immediate mental unpacking of BVM was not 'bag-valve mask' but the Blessed Virgin Mary. Probably also good to have on-hand in an emergency.

#82 ::: Lila ::: (view all by) ::: September 24, 2005, 11:18 AM:


Vassilissa, I have a similar problem whenever I see the World Taekwondo Federation's initials (I do taekwondo, but not at a WTF-affiliated school).

#83 ::: Bruce Arthurs ::: (view all by) ::: September 24, 2005, 12:24 PM:

I don't think anyone responded to the question uptopic, whether a tourniquet wasn't suitable in some circumstances.

Back in the battlefield first-aid parts of my Army basic training (early 1970's), the instructor drilled us newbies, over and over, that the first step in treating an injury was "clear the airways".

So he gives an example of a typical battlefield injury. "What do you do?" "Clear the airway, Sergeant!" we respond.

He gives another example. "What do you do?" "Clear the airway!"

He tells us: "An artillery round lands near you. You see your buddy's legs have been blown off above both knees. What do you do?"

"CLEAR THE AIRWAY!!" we all shout in reply.

"WRONG, YOU IMBECILES!* By the time you clear his damned** airway, he'll have bled out and died! Jeezus, did your mamas drop you all on your heads?!***"

So, in a traumatic injury with massive bleeding, yep, a tourniquet is called for. (If I recall correctly, if the lower limb is still attached, you loosen the tourniquet for one minute out of ten, to try and keep some bloodflow t the lower limb, and possibly stave off the need for later amputation.)

*"imbeciles" was not the word he used

**that wasn't the word he used, either

***what he said our mamas must have done with us was much more colorful

#84 ::: Vassilissa ::: (view all by) ::: September 24, 2005, 12:34 PM:

Lila, that's great! Now I want WTF affiliation, and I don't even do Taekwando.

#85 ::: James D. Macdonald ::: (view all by) ::: September 24, 2005, 12:40 PM:

The sergeant was an idiot. He's also wrong.

If the man with both legs blown off also isn't breathing, he's dead anyway.

If the man with with both legs blown off is breathing, talking to you, screaming, he's got an airway.

If he doesn't have an airway what you do with his legs doesn't friggin' matter. And it takes approximately one second to open an airway.

Where'd this guy get spawned?

Anyway -- if you put on a tourniquet, and you loosen it -- all you're doing is putting cold, dead blood full of lactic acid and carbon dioxide back into central circulation. Good job, chief, you just killed your patient.

If you use a tourniquet you've just decided that the man is going to lose that limb. Period.

But, I can't really think of an injury to a limb that doesn't respond to direct pressure, elevation, and pressure points. It's possible, with a large crush injury, to not be able to figure out where to put the direct pressure. Here's a trick: Sluice it out with water. See where the bleeding starts. That's where to put the pressure.

#86 ::: Bruce Arthurs ::: (view all by) ::: September 24, 2005, 01:20 PM:

Well, that was over thirty years ago, Jim. IIRC, the "loosen the tourniquet" instructions were fairly common back then, in the real world as well as the Army.

And the sergeant did say that the airway should be cleared as soon as the gushing stumps were tied off.

#87 ::: Larry Brennan ::: (view all by) ::: September 24, 2005, 01:47 PM:

Someone asked this way upthread, but what the heck's a "Vial of Life"? Sounds like a treasure object from D&D. Or the contents of the One True Grail.

#88 ::: Larry Brennan ::: (view all by) ::: September 24, 2005, 01:52 PM:

JMF: Anybody else remember The Human Glove?

No, but I do remember The Human Ton (and Handy) from The Tick.

"Now that was an Oedipal moment!"
[crickets chirp]
"Oedipus Rex?!"
[more crickets]
"Read a book!"

#89 ::: Lis Riba ::: (view all by) ::: September 24, 2005, 03:16 PM:

Handy fond memory:
"Sulking in his tent like some guy from Chile?"

#90 ::: Madeline F ::: (view all by) ::: September 24, 2005, 03:59 PM:

I work in a lab, and the end of last year I started trying out all types of different nitrile gloves. The best ones I found of like 11 different varieties were Fisher nitrile gloves with aloe. They slip on easily, they don't have any nasty powder on them, they don't leave your hands smelling stanky and gross, they're thin enough that it's not an effort at all to move your fingers, they're strong enough that you can pry things apart without ripping holes in them, and the aloe part means you can wear them for hours on end without your hands getting all messed up.

If you're looking to buy gloves, the Fisher nitrile with aloe are the best of any disposable gloves I've ever worn. Now everybody in my lab uses them. My brother-in-law who changes car batteries for Sears says they're the longest-lasting he's found... The small size seems to map to "tiny, child-sized or woman under 100 lbs", medium is "most women", large is "most men", XL is "men with big hands."

As for WTF, one of the guys in my kali class was talking about a taekwondo tournament he went to watch, and how it seemed stultified with rules... "They can't punch?" "No, WTF rules!" "They can't kick for the legs?" "WTF!" "They can't scoot around to the side?" "WTF!" :)

#91 ::: Terry Karney ::: (view all by) ::: September 24, 2005, 04:41 PM:

I think tae kwon do, as a general rule, is a wonderful dance for and a good way to stay in shape, but that's about it.


#92 ::: Lila ::: (view all by) ::: September 24, 2005, 04:54 PM:

Terry: it also comes in handy fairly often if you work in a bar, as my instructor and several classmates do.

#93 ::: Dave Bell ::: (view all by) ::: September 24, 2005, 05:35 PM:

Thena, there are different grades of dustmask.

The basic grade doesn't protect against the mould spores that can cause farmer's lung. Tou can get finer filters. Instead of being s sort of moulded fibrous paper they have some thickness, with extra filtering layers.

Anyway, that sort of rigid disposable mask maybe isn't so easy to pack, whatever filtering level they give.

It does depend what you're expecting to need protection against.

#94 ::: Lenore Jean Jones ::: (view all by) ::: September 24, 2005, 08:50 PM:

Larry Brennan: Someone asked this way upthread, but what the heck's a "Vial of Life"? Sounds like a treasure object from D&D. Or the contents of the One True Grail.

I don't actually know, but I'm guessing it may mean insulin.


#95 ::: P J Evans ::: (view all by) ::: September 24, 2005, 10:27 PM:

Larry Brennan: Someone asked this way upthread, but what the heck's a "Vial of Life"? Sounds like a treasure object from D&D. Or the contents of the One True Grail.

I think it's a storage vial with medical history, kept in the fridge as a standard location. (I vaguely remember hearing about this sort of thing.)

#96 ::: James D. Macdonald ::: (view all by) ::: September 24, 2005, 10:37 PM:
The Vial of Life Program is designed to speak for you when you are unable to speak for yourself. The information contained within the vial will provide pre-hospital and hospital providers with essential details that will aid in providing appropriate medical treatment. You may have a separate vial for each member of the household. When more than one vial is used, be sure to place the persons name on the outside of each vial.

Vial of Life:

This is a pill bottle, which you keep in your refrigerator, that contains a sheet with your medical information on it.

Here's AARP's description:

How the Vial of Life Program works:

* The Vial of Life puts important instructions in the hands of Emergency Responders and Physicians when it is needed most—during the first minutes of critical illness or accident in your home.

* Emergency Medical Personnel in the community have been notified to look for your special Vial of Life magnet.

* Simply complete the medical record forms with the assistance of your doctor or a family member.

* Ask your Pharmacist to add any new prescription to your medical record.

* Tightly roll up the completed forms, include your Living Will or Advanced Medical Directive, place them into the Vial of Life and put the cap on the Vial. Attach the Vial of Life under the top shelf of your refrigerator on the right hand side with a twist-tie or scotch tape.

* The second Medical Record is for your personal use and could be taken with you when you travel.

* Place your Vial of Life magnet on the front of your refrigerator.

Here are some links:

Santa Clara County FD

UNM Health Sciences Center

Alameda County FD

My Precious Kid (includes a form and labels)

The National Exchange Club


Get stickers and magnets here. (Among many other places.)

#97 ::: Katherine ::: (view all by) ::: September 24, 2005, 10:38 PM:

Vial of Life:

It's medical information for EMTs, stuck to the fridge where it's easy to find.

#98 ::: Larry Brennan ::: (view all by) ::: September 25, 2005, 12:48 AM:

Thanks for the explanation.

It sounds like a pretty good idea. Of course, a standard smartcard that could hold one's medical records and be read and updated by all hospitals, doctor's offices, pharmacies and first responders would be better. But this is America, and such a system would require government to set a standard, and government is (apparently) un-American.

Pardon my off-topic display of bile.

#99 ::: Mark ::: (view all by) ::: September 25, 2005, 09:17 PM:

Excellent - Thanks. I'm printying thios out and adding it to my earthquake kit.

#100 ::: Bruce Arthurs ::: (view all by) ::: September 25, 2005, 10:43 PM:

Larry Brennan wrote:
"Of course, a standard smartcard that could hold one's medical records and be read and updated by all hospitals, doctor's offices, pharmacies and first responders would be better."

Except that using "a standard smartcard" is only useful if the responders have a machine handy to read the smartcard. With the hardcopy tucked inside a pill bottle (though with my wife's medical issues, she'd probably have to use a mayonnaise jar or something equivalent), the responders only have to be literate.

(Yeh, a card reader might eventually become standard equipment. In how many years?)

#101 ::: Brad Hicks ::: (view all by) ::: September 26, 2005, 07:32 AM:

My cousin, an undercover police officer, has had one and exactly one occasion to use a tourniquet. But it was a freakish circumstance. A car bomb had completely severed both of the patient's legs and almost completely severed one arm while throwing him clear of the wreck. My cousin used his own belt to tie off one leg, used a bystander's belt to tie off another leg, and used direct pressure to stop the arm bleeding.

He didn't use the bystanders to apply pressure to the femoral arteries because none of the few people who were around were willing to approach the patient that closely. Some of them were too busy freaking out, but the it turns out the rest knew something my cousin didn't: the victim was the brother of a mob boss. Hence the car bomb.

(And when the mob boss sent a $5,000 thank-you check to my cousin, boy, wasn't THAT awkward for him, for the department, and come to think of it probably for the mob family.)

So yeah, as far as I know, the only remaining reason to use a tourniquet is if the limb is doomed anyway and you don't have enough hands available to apply pressure to all the spots on all the people who are bleeding.

(Caveat: I am SO not an expert. I am, however, as someone with a neurological disorder that usually prevents me from outwardly expressing recognizable emotional expression, always apparently calm during emergencies. So I've studied up a bit, since people keep PUTTING me in charge during emergencies.)

#102 ::: Kate Nepveu ::: (view all by) ::: September 26, 2005, 10:03 AM:

Brad Hicks: So what did your cousin do with the thank-you check?

#103 ::: P J Evans ::: (view all by) ::: September 26, 2005, 11:31 AM:

Larry: It isn't that government is (apparently) un-American; it's that now competent government is (apparently) un-American.

After all, you have to make sure all your college friends, and their friends, have jobs.

#104 ::: Terry Karney ::: (view all by) ::: September 26, 2005, 02:39 PM:

Lila: In what way? Moving through the crowds?

Or quelling disturbance?


#105 ::: Oskar ::: (view all by) ::: September 27, 2005, 12:57 PM:

Talking about triage - Here is an excellent analysis about the triage that took place in New Orleans, and how it was to serve the Bush administration to avert the political disaster. With success, I might add.

(I apologize if quoting this in its entirety is bad netiquette)
But What About the Snipers?

All the vaguely sane world understands that the poor of New Orleans, whether because of their race or their class, got the worst of it. But, someone might say, what about the snipers? Looting food, ok, looting stores, well, that's a crime against property, not people, but shooting at rescue helicopters? Blocking public hospital evacuations? Could anything be lower?

Poverty isn't known to bring out the best in people, and the worst in people can, of course, weaken sympathy for them. Should we sympathize with some poor victims of New Orleans, but not others? Are there Good Victims and Bad Victims? Can you tell who's who?

Without damning or excusing people we know nothing about, it might be worth looking at possible reasons for their actions. Sniping is quite unlike like robbery or rape in that the sniper doesn't get anything from it. This isn't ordinary crime. The last thing a robber or rapist or junkie would want to do is shoot at hospital evacuation helicopters, something guaranteed to bring more police and troops into the area. In short, criminals ordinarily don't want to call attention to themselves.

What actually happened? The rescue professionals found themselves utterly incapable of saving everyone. As all their training requires, they decided to practice that favorite of hospital shows, triage. Normally, triage means saving the very worst off first, and hoping to save the others later.

In this case, it turned out to mean leaving the others die, and saving some of the very worst off: there were likely others, dying in attics, unknown and unheard, just as badly off. It meant saving, for instance, critically ill hospital patients, people whose condition and location were known, and who had to be among the worst off.

The rescuers workers could feel they were doing good, but their efforts were not solving the problem. That you can't make a serious attempt to help 80,000 victims with a few helicopters, winching up one person at a time, this was nothing the rescuers could affect; it was not worth thinking about.

But the other people, the ones the helicopters had to pass over, the abandoned, I'll bet they were thinking about it. Maybe - oh, very likely - they were wondering what to do.

So, again, what actually happened? Because there was shooting, the hospital patients could not be evacuated. Though the efforts of the rescuers were heroic, the scale of the rescue was pathetic, and on the way to becoming more pathetic still. One thing, I think, was certain and obvious. The people who really could help, the Federal Government and Bush's bureaucrats, at least some of those people with their formal requests and their triage procedures and their professionalism, and some of the rich, some of the powerful - these people wanted the helicopter evacuations to work. This half-ass effort was their only demonstration of compassionate competence. If the rescues failed, those responsible would have nothing, not one little bit of success, to show the world. There would be no containing the outrage, no damage control. The humanitarian disaster would produce a political disaster.

Now suppose you were a pissed-off thug living in filthy water, with the dead floating by, with crying, dying, frightened, hopeless victims all around you. You might fire on a helicopter just to make it clear that being left to rot was not acceptable. Or, if you were calm enough to think things through, you might ask yourself: what leverage do I have? What do those who have power over thousands of helicopters and rescue craft, over hundreds of thousands of rescuers - those smug assholes asleep at the wheel - what do they want that I can deny them?

Just one thing, to me anyway, comes to mind: the snipers could deny Bush and his minions their face-saving operation, their little bit of success, their triage. The federal authorities would do anything to save some people. They would even get off their asses and send in troops, massive military convoys, not fast, because it was too late for that, but finally. And with those convoys would come - this too was clear, wasn't it? - massive aid, massive rescues, a massive effort to save, not a few victims, not the cosmetic cases, but everyone. Or at least, from the standpoint of an ignored victim, blocking the helicopter evacuations was the only thing that might bring this result. If there was anything any lone thug up to his knees in filthy water could do, this would be it. Let the helicopter evacuations proceed, useful to a very few, and what could reasonably be expected? That real massive help would take much longer to come, because there would be less outrage, less desperation, from the comfortable people deciding who should live or die. The choice of the Bush administration was to save a few, to keep their own peculiar sense of proportion: moving heaven and earth to kill Arabs is one thing, moving heaven and earth to save a bunch of welfare cases is quite another. Triage was a part of business as usual, what Maureen Dowd described as "a chilling lack of empathy combined with a stunning lack of efficiency".

The choice of the snipers was to undo this triage, this business as usual: all would be saved, or none. Maybe the victims thought they too should have some say in who lived and who died. Maybe they thought that triage was only as legitimate as the need for it: was this really the best that America could do?

Would this make you take aim at a rescue helicopter? You don't know; you weren't standing in that water. Were any of the snipers thinking anything like what I've suggested? And if they were, would that be any kind of excuse? You don't know and neither do I.

I do know the shootings loomed large among the reasons that the troops finally got moving, bringing with them the first massive relief operations. If anyone adopted the strategy I imagined, it seems to have worked. I also know that much is permitted to people fighting for their lives, and the lives of others.

#106 ::: Clark E Myers ::: (view all by) ::: September 27, 2005, 01:12 PM:

It sounds like a pretty good idea. Of course, a standard smartcard that could hold one's medical records and be read and updated by all hospitals, doctor's offices, pharmacies and first responders would be better. But this is America, and such a system would require government to set a standard, and government is (apparently) un-American.
A decent description of smart dogtags which I understand are a coming standard and also perhaps a solution in search of a problem - see the current cross-checking of medical insurance records against job applications and consider the privacy implications. I wonder how many of the people who read this know they can and perhaps should check their "public" insurance medical records data base equally as they track their credit status when applying for jobs and perhaps housing.

#107 ::: Lis Riba ::: (view all by) ::: September 27, 2005, 01:12 PM:

Given the other myths being debunked about Katrina, were there actually snipers?

I can't help wondering if some of the gunshots reported might not have been intended as the equivalent of shooting off flares. Sending a message of "Hey, I'm over here!" rather than actually trying to harm rescue workers...

#108 ::: Nathan E. Rasmussen ::: (view all by) ::: October 10, 2005, 01:01 PM:

Regarding tourniquets: A good friend of mine is a hemophiliac. He instructs his first-aid-minded friends to put a tourniquet on him in the event of massive bleeding (except maybe from a head wound, because, well, yeah). In his case, direct pressure just doesn't work. What you are doing is condemning the limb to save the trunk, and that's true of any tourniquet.

#110 ::: Tom Whitmore ::: (view all by) ::: June 17, 2011, 01:39 AM:

Really useful perspective for all sorts of incidents, IMO (including planned ones like conventions). Thanks!

#111 ::: Paul A. sees spam ::: (view all by) ::: June 28, 2011, 11:58 AM:

Puzzlingly, it doesn't appear to be appearing on the Recent Comments page.

Check the view-all-by as well -- there's more by this author.

#112 ::: Jim Macdonald ::: (view all by) ::: July 28, 2013, 10:27 PM:

From our good friends the Australian Government, an Emergency Triage Education Kit.

#113 ::: Nonie ::: (view all by) ::: July 31, 2013, 06:51 PM:

I'm seeing a lot of dead links to medical information in Jim McD's EMT pages here, especially in the comments.

And that's normal with older posts anywhere, but since some of the information could be lifesaving, it might be a good idea to update the links where possible

Would one of the admins consider replacing the links with current ones, especially if the original writers (when possible) could help them hunt down the current URLs?

(I'd volunteer to hunt 'em down myself, but in most cases I can't tell what site I'd be looking for.)


--Newbie Nonie

#114 ::: Cal Dunn ::: (view all by) ::: March 03, 2014, 01:38 AM:

Jim Macdonald @112 / Nonie @113: The Department of Health seems to have reorganised its website (this is a deleterious side-effect of Australian elections).

New link to the Australian Emergency Triage Education Kit

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