What Happens When a Code Triage Sounds at a Level 1 Trauma Center?

At the region’s only Level 1 trauma center, the staff unites as something more than a team.

By Melissa F. Pheterson

Plane crashes, train derailments and chemical-plant fires are the kinds of mass-casualty events that trigger a Code Triage announcement at Westchester Medical Center and Maria Fareri Children’s Hospital, both members of the Westchester Medical Center Health Network (WMCHealth).

The alert signals that a large number of injured patients may be en route to receive care — whether due to a potential occurrence (a possible landing-gear failure on a nearby airplane) or a confirmed incident, such as the Metro-North Railroad train crash in Valhalla in 2015. As central components of the Hudson Valley’s only Level 1 Trauma Center, these Emergency Departments can provide care for burns, trauma and the most acute injuries. As in all triage situations, treatments have various levels of urgency. Most patients need near-simultaneous attention — and some may only have only minutes to live. At that point, dozens of clinical and non-clinical staff members mobilize to provide everything from heart monitors to hot meals.

“It’s an incredibly vast dynamic of moving parts, sort of like an orchestra,” says Garrett Doering, Director of Emergency Management, Life Safety & Security at WMCHealth. “Everyone has to master their instruments and play the tune right so nothing sounds amiss.”

That may mean gathering equipment, preparing meals, soothing parents or family members, directing traffic or clearing operating tables for those who most desperately need them. Here’s how they coordinate their efforts to produce a synergistic result:

Security directs traffic, including incoming and outgoing ambulances, emergency personnel, and even family members who are looking for loved ones. “Ambulances can get blocked in if we’re not careful, and they may need to go back to the scene to get more patients,” Doering says. To safeguard flow and avoid congestion, the department directs ambulances, staff’s cars and other vehicles to specified zones.

The Emergency Department staff relocates “stable” patients to make space for a new wave of wounded. “Nurses identify patients who can be moved to other floors and consolidate existing patients into available rooms,” Doering says. The Courier department escorts patients to nurses on other floors, then brings 30 to 40 stretchers and wheelchairs to assist the new patients.

 All Trauma surgeons report to the Emergency Departments to triage patients according to severity of injury. “Approximately 70 to 80 percent of patients have minor to moderate injuries; 15 percent have serious injuries; 3 to 5 percent have life-threatening injuries,” explains Doering. “Our trauma surgeons identify who needs surgical intervention within minutes and in what sequence they will get it.”

Each Intensive Care Unit (including cardiac, surgical, medical, pediatric and neonatal) sends a nurse to the Emergency Departments, for a target total of 15. “That protocol makes nurses available who have expertise in a wide range of issues for a broad age range,” Doering says. “In disasters, ages often range from babies to very senior adults.”

Equipment is key, with each department gathering its essentials. The Biomedical Department brings portable heart monitors and IV pumps. The Respiratory Therapy Department sends staff and extra ventilators to the Emergency Departments. The Materials Management Department brings disaster carts (with IVs, gloves, bandages and sutures) for trauma. Designated areas, like the Pediatric Emergency Department waiting room, become “surge spaces” for nurses and doctors to use the equipment and supplies to treat the “walking wounded.”

The Food Services staff prepares hot meals and delivers them to the Emergency Department or waiting room, along with snacks and water. “We know there will be anxious people standing around who haven’t eaten,” Doering says.

The Environmental Services team keeps on top of changing linens, replacing garbage bags and cleaning floors. “It needs to quickly ‘turn over’ rooms and address any immediate issues.”

Social Workers and Case Management staff work with clinicians to smoothly discharge patients who have received needed treatment while diffusing tension or anxiety in families. “When a pediatric population gets hurt, as in a bus accident, it generates all kinds of challenges,” Doering says. “Often, both parents rush into the hospital separately. Our social workers play a key role to verify the family situation and provide information as permitted.”

Pastoral Care offers counsel, support and a listening ear to meet the spiritual needs of patients and their families.

Child Life specialists assist the clinical staff by evaluating children, explaining events in terms they understand, mentally preparing them for procedures and reducing anxiety and stress for patients, parents and siblings alike.