Welcome to the presentation, Triage Considerations in the Occupational Health Setting. I am Melanie Hallman. My background relevant to this presentation is influenced by my work as a nurse practitioner provider of occupational healthcare and many different healthcare related roles within emergency services, both pre-hospital and hospital-based. I have no conflicts to disclose related to this presentation. The intent of this presentation is to immerse learners in content relevant to basic triage principles. It is my hope that the presentation will assist learners to apply knowledge gained within occupational settings. So, what is meant by the word triage? For the most part, triage simply means to sort and assign a value or a priority to individuals being sorted. Triage has a different meaning and intent depending on the setting in which it is performed. Triage in the pre-hospital setting is known as field triage and it is usually performed by first responders and emergency medical services professionals. The intent is to identify patients who have sustained serious injuries and to link those patients to the most appropriate level of care or trauma center that is required for their particular injury or injuries. Goals for pre-hospital care are to provide life-saving interventions while preventing more injury and to efficiently transport the patient to a facility that matches their physical needs. This may be the closest location to further stabilize the patient before transfer to a higher level of care at another healthcare facility. In the emergency department setting, triage involves treating the most life-threatening condition first. Patients are triaged into categories by one of several common triage systems. Generally, triage ranges from the most life-threatening to the least life-threatening condition. Triage during mass casualty incidents and disasters is quite different. Triage in these settings is based on the principle that during disasters, entire communities are affected and resources required for the community are greater than the resources available. Therefore, the goal in disaster triage is to prioritize so that the greatest number of people receive the services needed and is dependent on the number of available resources at any given time. The clinical status of patients, the prognosis of their diseases and their condition immediately following a disaster are given consideration and also given consideration are resources at the time, and all of this weighs into determining the triage category in which they will be placed. So, in disasters, patients with life-threatening conditions that are not likely to survive do not receive first priority because available resources are to be used to achieve the best outcome for the greatest number of people in the community and not exhausted on those requiring excessive resources that could have been shared among multiple affected survivors. Triage as we know it today has evolved over centuries, mostly improving due to deficiencies that were noted during wars. Triage used during wars can be traced all the way back to a surgeon in Napoleon's Imperial Guard in the early 1800s. The surgeon noted that great numbers of men were injured and unable to receive care quickly due to having no organized system to remove them from the battlefield until the battle had actually ended. He saw that many of the injured could have survived their wounds if they had received early medical care. This led to development of an organized system of treatment by teams of soldiers that sometimes included surgical intervention and then movement from the battlefield to mobile hospitals by wagon or other means. So, this was really the first ambulance transfer. Ultimately, a medical professional who is skilled at triaging should be able to get a good first assessment by looking at a person as they approach them. If the patient is stable enough, a rapid focused exam can be accomplished within just a few minutes and a starting priority can be assigned that will in turn establish how the patient's care will proceed from there. In work settings and clinic settings, the focused assessment helps to determine if early transport to a higher level of care should be initiated or if there's time for further assessment, if it is safe to do that, to be continued at the initial site. Relationships within work sites and with those in the surrounding community is of the utmost importance in managing occupational emergencies. We should all be aware of the makeup of our work communities and establish key relationships early on. We should also know of any established company procedures that may dictate where employees are to receive their care. The relationship between the healthcare practitioner and patient is key to appropriate triage and assessment. It's important to know the worker mix in regard to job types, age variance, and primary languages. Knowing the risk potential and most common injuries for different jobs within a workplace is of primary importance. Spending time getting to know the workforce and letting them get to know you is a great way to survey your population. When emergencies arise, this can prove to improve the confidence between the worker and the caregiver. You should also get to know the plant manager and shift supervisors as well as safety officers at your work site. You will likely be working very closely with them. Make it a point to connect with the local emergency medical services providing coverage in your area. Learn what resources they have available to care for your particular workforce and communicate in the layout of your work site and on-site clinic if your setting provides this service. In the same manner, you need to build relationships with law enforcement agencies. Take time to meet with emergency leaders at trauma centers and other hospitals most likely to receive your community of workers. Exchange phone contact details before an emergency arises and the need for urgent communication occurs. It's also important to know if the company has predetermined specialists for their employees to be referred to. If so, meet those providers. And let me also suggest being sure that an eye specialist and a dental professional are included in your referral list. Triage may differ depending on whether you are responding to the site of an injury or illness or if they are brought to you for care in a clinic. Triage at the scene of an accident will follow more closely to pre-hospital triage principles and triage within the clinic will be more like emergency department triage. There are numerous methods of triage for the field and within hospitals. Let's take a look at a few of the more common methods of triage. Field triage usually requires four sequential steps in descending order to determine the severity of injury and the level of trauma care the patient will need. In steps one and two, consideration of physiologic and anatomic factors occurs. If these factors are present, the patient should be transported to the highest level of trauma care available. Step three focuses on the mechanism of injury and step four reviews any special variables or considerations that may be present. The details gained from assessing steps three and four will determine the level of trauma care that the patient needs. The patient may not require the highest trauma care but instead need a lower level of trauma care or a more specialized care such as burn care or eye care. These may be available and best managed at a specific hospital instead of the trauma center itself. Advanced trauma life support is a product of the American Trauma Society and usually applied once a patient reaches the emergency department setting. So this is where your trauma team may respond and use those down lines from ATLS to resuscitate a patient. The concept of ATLS is to treat the most life-threatening condition before anything else. So airway, breathing, and circulation must be intact before moving forward in assessment or treatment. ATLS works systematically by a structured algorithm that allows for rapid assessment and treatment and is not dependent on a detailed history or arriving at a definitive diagnosis during stabilization of the patient. The Emergency Severity Index or ESI is the five-level scale most commonly used by emergency departments in the United States. The Canadian triage and acuity scale is also a common triage scoring tool that you may encounter. The makeup of these two scales are different but the desired outcome for each is the same. To rapidly determine the severity of a patient's illness or injury and to categorize how rapidly they need to be evaluated and treated. The ESI model of emergency department triage evaluates the physiologic stability and risk for decline in patients. It's a method to apply a triage acuity algorithm to evaluate how severely a patient is injured or the severity of illness and what resources will be needed to care for them with a category of care assigned using levels one through five with level one requiring the most resources and level five needing the fewest resources. This determination also directs where the patient should be moved to for further evaluation and care. At the work site, this can be applied to determine if a patient can receive care at the work site or the company clinic or if rapid transfer to a higher level of care is appropriate. The tool is only meant for triaging and not for when the patient has been assessed by a provider. Beyond this point, the patient's status should be evaluated by ongoing reassessment with timing based on the patient's most recent findings, condition, and treatment interventions. The ESI was acquired by the Emergency Nurses Association in 2019, and they continue to actively research and improve the scoring system. The Canadian Triage and Acuity Scale or CTAS is another ranking tool that's used nationally and internationally and assists caregivers when determining requirements for patient care. The tool allows caregivers to assess patient flow and works well with other resource measures such as workload and case mix measures. The system is very detailed, assisting to remove some of the subjectivity that's native to triaging. Patient category levels are determined by acuity, risk potential, and resources that they will require. A comprehensive list of modifiers is included for each body system. There are three steps in the CTAS process that will eventually take you to five levels of risk levels, basically, for triage or triage scores. Step one is to select the chief complaint by category. Step two is to choose from a list of complaint-specific modifiers. And step three requires selection of a first-order modifier from lists of more defined symptoms by body systems. Overall, the patients who are the sickest and at the highest risk for deterioration receive care first. Ongoing reassessment is an expectation of this triage scoring tool and all other triage scoring tools. This particular tool has been adopted uniformly for all Canadian emergency departments and is used in a few United States-based emergency departments at this time. The most important thing to consider if you go into the actual work site as a provider is first to make sure that the scene is safe because if you go into an area that is not safe, you may become a victim yourself, and that's not going to do anyone any good. So you need to be aware when you first assess from a distance what is going on, what the conditions are, is there excessive heat, is it excessively cold, or is there dust or fire involved, do you smell chemicals, has an explosion occurred, are you in a confined space? If you go in to see this patient, are you in a confined space? Think about these things. You want to know if there's any moving equipment or objects that you might come in contact with or that may make the scene definitely unsafe, and if there are moving things, then those should be shut off before you go into the area. Also want to know is there any electrical activity, not just in the things that are moving, but, you know, are there any signs that there may be wires down or something or liquids on the floor, anything that might make you have a potential for being electrocuted, and is that actually what might have happened to the patient you're about to see? You want to have on the proper PPE yourself for going in that area. So whatever that PPE is that the workers are wearing, you really should have that on as well. This might include safety glasses, closed-toe shoes, and at a minimum, you need gloves to go into the area to protect your hands. So the point for going to the scene is to stabilize the patient as best you can to minimize further injury, but you have got to be safe for this activity. It's got to be safe as possible for both the patient and the caregivers, and when you must, you can remove and treat the patient elsewhere or call 911 so that you can have proper assistance to take care of the situation. So in review, scene safety consists of assessment of what the layout is before you enter the area where the patient is located, to do anything that's needed to decrease risk before you enter the area, and to notify appropriate personnel, be it the worksite personnel, be it a power company, 911 for emergency services. You must notify whoever is appropriate for the scene that you see that you're entering so that you have the assistance that you need and the best chance for the highest level of safety for everyone. Since triage definitely has associated subjectivity, it is so important that we're aware that the risk for under-triage or over-triage does exist and that we take measures to avoid the occurrence of both of these while triaging. Under-triage is the term that's used when the degree of sickness or injury is not realized. This can result in delay of treatment and can impact patient survival. Over-triage is when the degree of illness or injury is determined to be much greater than it actually is. Over-triage results in placing a patient whose need is actually lower at a higher priority for care and is particularly important when more than one patient is involved and need for care is actually greater for the other patient whose care will be delayed waiting for the over-triage patient to be cared for with inappropriate use of limited resources. And these resources include staff, stuff, or space. Basically, a risk for worsened outcomes may be created for patients falling in lower priority to an over-triage patient. Established protocols usually exist for providing first aid in each workplace. So, it's important that you know what your first aid protocols are very well. If triage reveals that a worker only needs first aid, then allow them to administer their own first aid as appropriate for the injury. It is important, though, that we provide them with enough instruction to adequately apply and accomplish effective first aid measures. Determination of whether the worker can return immediately to duty or requires further evaluation or follow-up must also occur. All patients need verbal and written instructions for care and any follow-up instructions. Sometimes during initial triage following an injury at the work site, a rapid decision must be made about whether it's safe to move the patient or not. If you see that they cannot be moved without worsening their condition, it is best to call 911 to allow providers that are skilled at packaging patients for transport to complete that task. In the meantime, you should provide on-site emergency care that is safe and necessary for best patient outcomes. Communication should be early and ongoing when managing an on-site injury or illness that requires a higher level of care than what is available at the work site. Continue to reassess for scene safety, patient condition, and response to treatment while you're caring for injuries or illnesses at work sites. There are two phases to triage, as well as primary and secondary surveys for trauma and medical emergencies. The initial triage or phase one of the process should take no longer than five minutes. Preferably, it should be completed in two. You will be gathering information about mechanism of injury or onset of illness with goals to gather, achieve complaint, preferably from the patient if at all possible. And if it's not possible, then get that from the bystanders or coworkers who may have witnessed the event. Suspected injuries, clinical symptoms, and an initial set of vital signs should be completed during the triage process. Gather focus subjective and objective data. You need to apply a triage rating, and when appropriate for the situation, you will document thoroughly. Remember that ongoing reassessment is an expectation of the triage process and getting the patient from triage to provider assessment or further provider assessment. When it's necessary and only if the scene is safe, you should begin resuscitation or other emergency treatments such as hemorrhage control and call 911. So, remember what we've said about scene safety. It is of utmost importance. If you are not safe, then no one has got the provider that they need to assess them and take care of them because you will find yourself potentially injured as well. During phase one, you have gathered a rapid yet focused exam. You've gotten enough information to determine if 911 should be summoned immediately or if there's time and it's appropriate to further evaluate the patient and provide treatment in a clinic setting. During phase two, you will go back through the process of evaluating from head to toe so that you can gather more detailed information and determine what diagnostics or treatment is needed for the patient. There are some symptoms that warrant an immediate 911 call and those would include any mechanism of injury that could cause significant trauma, choking episodes, syncope or disorientation, hemorrhage, perhaps difficulty balancing or a new onset gait disturbance. That's definitely a 911 call. If there's significant skin dryness in conjunction with hot skin and you have dehydration or heat illness as a suspect, then that is one that 911 would be needed for. In the particular case, it's really thinking more beyond just a baseline heat illness, it's looking at the potential for heat stroke to have occurred. Seizures are something that you would want to call 911 for, that's not appropriate to be treated at the site. And then shortness of breath and complaints of chest pain should really be taken for evaluation at a higher level of care. If a patient is sweating profusely and there's no explanation for that and they look very ill, call 911. And then if there is significant abdominal pain, if they are writhing in pain or they have other symptoms that accompany the abdominal pain that make you alert to needing to call 911, please do. Baseline is this, if your gut simply tells you that this may be an emergency or this is an emergency, call 911. As nurses and nurse practitioners or any provider that is experienced, we are blessed with a gut and that gut is for something is not right here. And you know what that gut is because you have one. When it's something is not right here, it's going through your head and you feel it, call 911. Better safe than sorry for the patient and you too. The intention of phase two of the evaluation is to address any injuries that may not have been appreciated during phase one. Reassessment begins during this phase and treatment is started for non-life-threatening conditions. Make sure to document along the way to avoid missing data that's important to the situation. If you see that the patient is improving, you can decrease the triage level as appropriate. Now let's move on to applying concepts of triage in primary and secondary surveys. The first thing you should do on entering a room or scene of illness or injury is ask yourself, what do I see, what do I hear, and what do I smell? The initial assessment for potentially serious injuries and conditions will be completed in less than five minutes, but this is your opening phase or opening to the phase, the beginning initial assessment. You've made sure that your scene is safe and then you're approaching the patient and taking in what you see, hear, and smell. The purpose of the primary survey is to quickly identify and treat immediate life-threatening conditions and to begin resuscitation or other emergent care that's warranted. First, you need to assess the patient's ABCs, and we know that's airway, breathing, and circulation. So those things have to be intact or you're not gonna be able to move forward in the process. If they don't have an airway, if they're not breathing or oxygenating, and if they don't have circulation present, you've got to deal with that before moving on. If there are any significant injuries, those would be identified following making sure that the ABCs were in place. So when you go through the initial triage pieces, then you would move on to looking for any significant injuries. And you need to manage anything that would cause the patient to deteriorate immediately. So just like ABCs, you're looking for disability, and that would be an example of that would be hemorrhage. If the patient is hemorrhaging, you've got to stop and manage that right then because if you don't, they're not gonna be able to circulate and oxygenate, et cetera, and so they're gonna deteriorate and not be able to be resuscitated. So you've got to manage hemorrhage right away. Once you've accomplished all of this, you wanna begin the secondary survey. And that is where you will complete a more thorough head-to-toe examination. Once the survey is completed, then you will move on to your diagnostic testing if the patient is going to stay with you or therapeutic interventions based on your medical decision-making. Afterwards, you want to give clear, specific education to the patient. And if they are being transferred, they receive education in that process too about what you're going to be doing with them and why. If they are going to be discharged home but have to follow up with an appropriate specialist or if they're supposed to go or come back to your clinic for follow-up, et cetera, you have to be very clear about that. Make sure that you give them valuable and written instructions. Typically, if a patient has been injured or been through something very stressful, we know that they're not gonna be able to retain much of anything that we tell them. But if you give them verbal and written discharge instructions, it allows them to go and calm down and recap and be able to take in what it is that you wanted them to have from your instructions. Look at your patient and the surrounding area. Is there only one patient or are there more? Is there airway patent? If not, manage it. What is the respiratory rate? Is it too fast? Is it too slow? Are they gasping? Are there obvious signs of distress? If so, manage it. Do you see any external bleeding? Are they hemorrhaging? If so, manage it. Is the patient awake? Are they alert? Can they speak to you? If they are able to speak, is it comprehensible? Are they making any noise at all? Are they in obvious pain and protecting a body part, for instance? What is the color of their skin? Are they pale red, blue? Is there any injury to the skin? Are obvious deformities noted? Are there any amputations? Certainly if there's amputations, you have to worry about them exsanguinating depending on the size of the limb, for instance. So you would need to manage that. If they're hemorrhaging, manage it. Are they standing, sitting or lying? And what is their body position? Can they walk? Is their gait normal? Or are they off balance? Are they favoring an extremity? What is their behavior? Are they distressed? Are they calm? Do they look stunned? Are they acting irrationally? What does their clothing look like? Is it neat, wet? Is it torn or burned? What does the immediate area around them look like? Does it appear that an explosion has occurred, for instance? Is it neat? And nothing is obviously out of place or affected. These are all part of, what do I see? Now, what do you hear? You wanna listen carefully and note exactly what you hear. Or if you don't hear something you expect you should hear. Note the patient's speech, sound and pattern. Is it clear or muffled? Is it too fast? Is it sluggish? Is their speech splinted? Is their voice raspy? Do they have hoarseness? Or is there a hot potato sound like you would hear with excessive throat or tongue swelling? Are there unusual airway sounds like strider or wheezing that are apparent? Now, what do you smell? Do you smell feces or the musty smell of urine? If so, the patient may have been recently incontinent. Do you smell vomit or alcohol? Do you smell ketones or acetone? This is described by some as a fruity smell and sometimes associated with the breath of a person who has hyperglycemia. Is there a smell of infection? Most of us will never forget what Pseudomonas smells like. Other infections have their own particular scent. Cigarettes, marijuana, chemicals, are those in the air? Do you smell those on the patient or in the area? Is there a strong smell of body odor or sweat present? Gathering a focused history from the patient or witnesses will usually give you the valuable information about circumstances that led up to an injury or illness. Specific details related to common injuries like motor vehicle or equipment crashes, distance of falls from heights, chemical exposures, to guide retrieval of MSDS sheets and treatment, or other environmental exposures like excessive heat or cold can be critical to rapid treatment. Any preexisting chronic or current medical conditions may play a role in the patient's illness or injury. It's critical to know. Don't forget to ask about cardiac and respiratory disease early on, as well as whether or not the patient is currently or recently pregnant as appropriate. Asking about medications, both prescriptive and over-the-counter, especially steroids, beta blockers, and anticoagulants, may clue you into an expected response to injury that you should be monitoring for. We know that if they're on anticoagulants, they will likely bleed more profusely than they would if they were not on anticoagulants. That certainly varies patient by patient and drug by drug, but it is something to consider. No matter how bad the scene may be, just stay calm. Watch your facial expressions, your voice, your tone, your body language, because you have to be that patient's rock as you interact and assess them. It's especially important to gather the chief complaint in the patient's own words or that of the witness or witnesses if the patient is unable to communicate. Use a mnemonic like old cards when you gather your history of present illness or injury. If we gather the history of present illness or injury in the same manner for each patient, it becomes automatic and allows pertinent positive and negatives to stand out. It works for me. I'm sure it works for you, too. It also helps us to avoid leaving a part of the history out or the evaluation. It works the very same way when we carry out our focused exams. Of course, we need to obtain a more focused history in emergency situations. Signs and symptoms, timing and progression of symptoms is must have data to gather. When you are completing a pain assessment, it's helpful to use a mnemonic such as P, Q, R, S and T. And that stands for provocation, palliation, quality, radiation, severity and timing. Using this mnemonic or any mnemonic for pain assessment regularly. It's useful for remembering all of the components of pain assessment. I love mnemonics. I think you know that by now. But I use them in my nurse practitioner practice all the time and they make a great deal of difference in making sure that I don't leave anything out. Here is another useful mnemonic, AMPLE, A-M-P-L-E. And this allows you a great way to gather specifics related to allergies, medications, past medical history, the patient's last meal time and what they ate, medications, the date of their last menstrual period and the events and environment related to the illness or injury and it is oh so helpful. Remember, you start with a focused assessment initially and the components of the assessment are based on the brief history you have obtained. Don't forget a set of early vital signs. Get them now if you have not yet. Mechanism of injury is crucial in making a decision to treat or transport and for having a pretty good idea of what injuries you should be suspecting. For instance, if the mechanism of injury is a direct blow to the medial clavicle, then you should suspect a posterior sternoclavicular dislocation. If the patient has had a fall landing on an outstretched arm or with the elbow beneath their body, then you should suspect a fracture of the radial head. Another example is if a patient has landed flat on their feet from a height, then it's possible that they have a calcaneus fracture, a tibial plateau fracture, an acetabular fracture or maybe vertebral compression fracture and that would usually be lumbar in this case. Another is ankle inversion force. If they have this, then a fracture of any of the three malleolus or a fracture of the base of the fifth metatarsal should be in your suspicion. If the patient has experienced a sudden stop from a crash or striking their head on an object on the ground, for example, then you should be suspicious at a minimum that they have sustained a concussion and perhaps a more serious traumatic brain injury. Expect a coup, contrecoup brain injury with most head trauma of any force. Another example of mechanism of injury is that of inhalation injuries. If smoke or chemicals have been inhaled, you should not only be suspicious of lung injury, but also consider that the tissues of the nose and from the mouth to the lungs may be injured and potentially swelling rapidly and that the patient may quickly lose patency of their airway. Now let's take a few minutes to look at some select medical symptoms. And we're basically looking for some of the key things to be looking for during triage or early assessment for any of these complaints. For each of the different conditions that we're going to review now, I have put the basics of what you need to consider in triaging these patients or whether you want to keep them at your clinic or site to take care of them or if it's someone that needs to be transferred quickly or a higher level of care. Syncope is something that we see on and off. It's not unexpected. In the work setting, it might be something that happens from a vasovagal episode. It could be someone who is dehydrated maybe. It could be that they have underlying cardiac or pulmonary issues. One of the key things that it can be from in somebody that was doing just fine and there's no other explanation for it is that they may have thrown a pulmonary embolus. So that has to be in the back of your mind for patients that there's no other explanation. Bottom line is, you know, this is something that is most likely you're going to want to go ahead and transfer right away for further evaluation. There's a lot of risk with it and there are diagnostics that need to be done. And I'm sure a head CT is going to be one of those. So they're going to go to a higher level of care, but I do want to mention that they, you know, they might've had orthostatic hypotension and that would go along with someone who is dehydrated. And dehydration happens on the job for a lot of folks. So basically with this syncope, you want to, in your history, ask them if they have had any history of heart or lung disorders. Are they prone to having syncopal episodes? Have they ever had a pulmonary embolus or have they ever had a blood clot? You can ask them that way. In their lower legs, for instance, those would cue you in that this could very well be a pulmonary embolus. And so you're still going to go through the whole process of doing your ABCs. You've gotten a cheap complaint, done your ABCs, and you're going to decide, do I need to go ahead and send them home? Can I move them from here safely? And, you know, you got to consider, or did they fall when they passed out? Did they, were they sitting? Were they standing? Did they hit their head? You know, can you obviously say that they have swelling or bruising from the fall? Because the older the person, the more likely that they could have a bleed and it can happen to young people too. But we know that the older we are, the more likely that it is that we could have a bleed from relatively simple head contusions. Some of the differential diagnoses that go with this particular condition, syncope, would be that the patient might have had a seizure. It could be that they've had a stroke. They could have a low blood sugar. They may have a head bleed like a subdural or an epidural or a subarachnoid hemorrhage. They may have hyperventilated and actually had syncope result from that. And, you know, there's lots of other horrible things that it could be. So this is something that once you've assessed the patient, if they've fallen and struck their head and it's not someone that just slumped in a chair, then you're gonna wanna be sure to let the EMS that come to pick this patient up know that they did strike their head or they did fall from a standing position or something other than just slumping in a chair and that they really need to be packaged. They'll need to have a cervical spine precautions and a Philadelphia collar or whatever they use to stabilize the neck. Having a patient in the work setting that is confused can be, or even in the emergency department, confusion is very concerning. There are a lot of different things that could cause confusion, but if they are lethargic or stuporous or they seem to have a cloudy consciousness or a stupor, then that is a problem with the central nervous system that you're looking at, or actually it's a brain issue. So it's important to know how easily if the patient has, for instance, had syncope and then they are confused or they were found down and then you're assessing them, trying to figure out what's going on and they seem to be confused, how hard were they to arouse? Are they able to speak? Can they follow a conversation? Do they make sense? And most patients that have an altered level of consciousness and confusion that goes with that really have difficulty doing these things. So some of the things that you want to think about with patients that are found down and then they're confused is that you don't wanna assume anything. You wanna do a good examination and in your triage, you want to get a neurological exam in there for sure and make sure if the person has passed out, just like with syncope, that C-spine precautions are taken if there's no clear mechanism for what happened. And you don't want to delay this patient in getting seen by a higher level of care because what, it could be a stroke even. So some mnemonics to help you in ruling out what you think might have occurred in helping you make your triage decisions would be A-E-I-O-U and that would be, A would be alcohol or acidosis or arrhythmias. The E could be electrolytes, encephalopathy, which if this patient has been at work or this worker has been working and then they have this episode and they're confused, it's not likely that it would be encephalopathy but it's not saying that it cannot be. So that, anyway, these are things that the E would stand for just to consider. Are they hypo or hyperglycemic? So the I stands for insulin. Is it an overdose? Are they withdrawing from a drug? Are they depleted of oxygen? Are they hypoxic? Are opiates the problem? Urania is what the U stands for. So that can cause confusion. Have they had a trauma? Maybe they had something happen before they got to work and they actually fell or bumped their head. So trauma can cause confusion. You could have someone with carbon monoxide poisoning and I guess it would depend on the type of work they were doing and if they were in an enclosed space but you do have to think about that. It could be some sort of toxidrome. Maybe it is a chemical exposure that's done this. They also, you have to think about increased intracranial pressure from maybe an infection like a meningitis. These are far-fetched, I know, in the work setting but not really because you in your care for workers are basically sometimes in a clinic sort of setting with them. Sometimes it's an emergency setting or an urgent setting. So you do have to have these things in the back of your mind. So this patient, you would wanna take care of any needs with first aid. So if they've had a head contusion or whatever, maybe you could apply ice to the site while you wait for the transfer or transport. And definitely if there's question about the security of their neck, you would want to keep them in alignment for their cervical spine and protect their neck until they have a proper P collar applied. We know that patients with chest pain need to be evaluated quickly and there are lots of causes for chest pain but you have to be concerned for the cardiac chest pain or a pulmonary embolism that's causing chest pain among and you could have an aortic aneurysm. There's so many different things. So these people definitely need to go to a higher level of care. Some of the things that you want to ask about besides your typical timing, et cetera, that go with chief complaint and the initial history, you would want to ask them in addition to the basics, you want to know if they have a prior history of any coronary artery disease, if they had a heart attack before, did they smoke, did they have high blood pressure or high cholesterol, did they have diabetes? You want to know if they have a family history of any of those things or anyone in their family had a myocardial infarction before age 60. That's very important information that needs to be passed on when they go to the higher level of care. You would check for pulses and listen to their heart. You want to note if there's any diaphoresis, if there's any unusual behavior, what their color is, are they very hot or very cold? So what the temperature of their skin is. You would also want to listen to their lungs and make sure that they are equal bilaterally, that they have good expansion to the bases. If there's any repetitious sounds, you would note that. So these are all things that we all do for regular evaluations, but this would require a heart and lung exam and even an abdominal exam if they were in your clinic or in an emergency department. So those are things that you can do quickly. And you would also want to check to see if there's chest wall tenderness, because it may be a pleuritic pain or it may be that it is musculoskeletal pain. So, and also check for epigastric tenderness and note if there's any nausea or vomiting involved. But this is one that needs to go rapidly to a higher level of care. Shortness of breath may be a complaint that a patient has. And if you do your ABCs and they're stable, then you might be able to take extra time to figure out, has this person just done something that was very taxing, pushing heavy loads, or have they walked a long distance or done something strenuous basically. So when you get to the history, right? So you make a choice if this is one that's gonna stay or go quickly. So if they are stable, then you have time to do the rest of your exam, your focused exam, to make your determination of whether they should stay or go. And you want to be sure, in addition to doing a pulmonary exam, as we always do with all of the listening, looking, feeling for that, you also want to get a pulse ox out there and check and see what their oxygenation is and note if their respiratory rate is getting better possibly as they rest. Are they sweating? Are they dry? Is this possibly a heat-related issue or even a cold-related issue? And does this person have underlying asthma or other respiratory condition like COPD? Have they ever done this before? Is this someone who has had recent travel? Have they been traveling on a plane for a long time in a car, et cetera, because you have to be suspicious again that they might have a pulmonary embolus that's causing shortness of breath. I know I'm on the pulmonary embolus, but that is a sneaky something that we always have to have in the back of our mind for lots of different complaints, but especially shortness of breath or chest pain. So basically, you're trying to determine is this person stable enough? Is their respiratory rate way out there? Or is this something that is getting better as I'm assessing them? Because it may be that they can be moved on over to the clinic area. If you have a clinic area, they are transferred to a clinic area. But if they are significantly short of breath and there's not a good explanation for it, please go ahead and get them transferred to a higher level of care. This is another one that you just don't want to hang around too long for them to decompensate on you. And for them to get a chest X-ray, you might do in your clinic area, if you have one that is there at the work site or they're brought into you with shortness of breath, but they very likely will need to have some other imaging done that you would not usually have available at a occupational health clinic or a work site. Seizures account for about 5% of all 911 calls and they need to be managed aggressively. If the person has a history of seizures, then that is definitely good to know, but you want to know if they've had a head trauma or had any exposure to chemicals at work. There are a lot of different things that could cause someone to have a seizure. So you need to ask a really good focused history to look for any underlying causes that might've played a part while you call 911 because seizures must go for further evaluation. This is not one that you could just take care of in the clinic on the site, because they're gonna need lots of diagnostics that might not be readily available at your location. Some of the things that might cause seizures that they could have a headache or a tumor, if they do not have an underlying history of seizures, these things need to be considered. They could have a low blood sugar, hypoglycemia may be present. They may have some kidney disease or renal disease that's the underlying problem. But in your differential diagnosis, you're gonna have to consider, was this caused by a syncopal episode or following a syncopal episode? Was this part of a dysrhythmia? Do they have some sort of infection going on? And could it be that there are drugs or alcohol involved or other chemicals that might've caused the seizure? If a patient presents with stroke-like symptoms, they're going to go by 911 to a higher level of care. If they've had a sudden onset of numbness or weakness or difficulty speaking, if their vision has changed suddenly, if they become uncoordinated where they were actually very coordinated before. And even if these things have improved or resolved, they need to go immediately for evaluation for stroke. And then here is a mnemonic that you can use for the signs and symptoms. So it's BEFAST, B-E-F-A-S-T. And that is for balance. So you're looking at gait or balance issues. You're looking at their eyes. Do they have nystagmus or diplopia? Do they have asymmetry of their face? A is for if there's a drift of their arms. Did they have slurred speech? So S in BEFAST is for speech. Or do they have aphasia? And then you want to look at time of symptom onset. For patients that have facial swelling, you have to consider first, do they have a patent airway? So take a look at their airway and make sure that they are able to maintain a safe airway. If it looks like they're beginning to swell, this person needs to go right away by 911 to the emergency department for further evaluation. If they work around chemicals or other substances that are known to cause allergic reactions, or if this person has a history that you find allergic reactions to particular substances that they might inhale or come in contact with, you have to be suspicious that that might be maybe a contact dermatitis that has occurred or it is an allergic reaction or a reaction to that substance. So this person needs to be watched to be sure that they've got a patent airway, need to listen to their lungs, make sure there's no adventitious sounds, there's no stridor present. And then you've got to make a determination if this is someone that goes by 911, is this someone that has a history, might be able to self-medicate and take Benadryl or whatever, but this is a judgment call based on your triage and what the vital signs are doing because if it's a systemic reaction, they may have a low blood pressure, for instance, and so that person needs to go on to the emergency department. So facial swelling, you really want to try to figure out quickly what might be the underlying problem, but it's all determined by how stable is this patient and about moving them on if they go by ambulance, I would say that that would be the better way to send them and not by private auto, and not meaning their private auto, but by plant transfer, I think that it would be best to consider calling 911 and get them to evaluate the patient too. So this is, can they safely wait? I don't know, let me assess them further, but if you have any doubt, they need to go 911 right away and get further care. The main thing to remember with acute abdominal pain is this something that came on slowly and maybe they're bloated or having an achy pain and they're prone to that, or is this something that came on acutely? Is this a quick onset? Is there nausea and vomiting associated with this? Is this person writhing in pain? Is it sharp and tearing? If they have significant abdominal pain, you want to go ahead and transfer them out and to a higher level of care so that they can have the diagnostics and imaging done necessary to make sure that this is not an issue with an aortic aneurysm or tear, that they don't have other life-threatening abdominal conditions that are developing or in progress. So again, you're gonna do your ABCs, you're gonna get your vital signs, and if this person has not had a trauma to the abdomen and they're running a low pressure, you definitely want to call 911 for them, but this person in significant acute abdominal pain needs to be evaluated further with diagnostics that are not usually available in a world setting. Heat-related illness is something that is very tricky. You may have someone that is just having some mild heat exhaustion. Their blood pressure may not be very, very low. Their heart rate may not be running very, very high. So it's like, is this something that we can treat on-site? Have they been working in a hot area? We need to cool them off. We need to give them, you know, if they can tolerate drinking, then you'll be able to help them with heat exhaustion if it's mild on-site. But if they have any of the symptoms of heat stroke, if they're excessively hot, not sweating at all, and they have a rapid, very strong bounding pulse, if they've had syncope associated with their symptoms, and if they have had a headache and confusion, you really need to go ahead and call 911 for them because if a heat stroke is taking place, that is life-threatening. So make sure that you consider that and get them a higher level of care. If you think it is mild heat exhaustion by the symptoms and the history, and they don't have underlying medical problems that you're concerned about, you might be able to begin doing some rehydration and cooling on-site, and then if they are not getting better quickly, then this is someone who's gonna need to be evaluated as a potential for heat stroke if they are not rebounding. We also have to take consideration of hypothermia that might occur at a work site or during work. And so if you have a patient who is very confused and if they have got too high or too low of a pulse, definitely too low would be something that this is a 911, get them out of there. You don't want to dunk them in hot water if they're extremely cold though, that needs to be a slower warming, but do what you can to remove them from the area that has produced the hypothermia and then begin slow rewarming as you call 911 to come and get them. If they are way, way too cold, the possibility of them going into cardiac arrest does exist, so you should be prepared to provide CPR until 911 gets there or use, if you use an AED on a hypothermia patient that had not been warmed yet, it's not gonna be very helpful. So it just depends on the degree of hypothermia that's present. But the point here is that this is someone that first aid is not gonna be appropriate for if they are confused and or have lethargy and their vital signs are showing other than the fact that they're extremely cold. Like if you have someone that is less than 97 degrees, I would get them evaluated. If they get down 96, 95, you're in trouble, like beyond trouble. So please have these people checked if they cannot be slowly rewarmed and it's not just mild hypothermia or mild coldness. If this person actually is showing signs of hypothermia, have them evaluated at a higher level of care. Be aware of what transport options that you have available to you at your work site. Some of us working in occupational health are in remote settings and that will change possibly the way that your patient can be transferred in an expedient manner. It may be that this is going to have to be a helicopter transport, for instance, instead of an ambulance. But you do have to make in your disposition of the patient a determination of how they'll be transported if they are going to leave you and go to a higher level of care. So just be mindful of that and take time to take courses like advanced trauma life support or trauma nurse core course or basic trauma life support and additional education just to get down an algorithm or method to the way that you triage medical and trauma patients or injured patients so that you have a system. It's systematic, it's natural, and you are able to go through those steps in an organized manner and it will help you to face whatever situation that you need to in your occupational health setting. I appreciate your time and I hope that you enjoy your work in occupational health. I know I certainly have. Have a great evening.

triage considerations

occupational health

field triage

emergency department

mass casualty incidents

triage systems

Emergency Severity Index

Canadian Triage and Acuity Scale

under-triage

over-triage