a final paper / scholarly paper (essay)

– The topic of the paper is : Information management and information technology in mass casualty incident (MCI) or disaster. (What does the team need? How do you provide redundancies? What role does IT – including social media – play?) – Paper length should be approximately 3000 words, but substance is more important than volume. Use recent articles from peer-reviewed journals as well as textbooks. Texts are often out of date soon after published. Expect to use no fewer than 10 references.- I have done the most of the work (2100 words), but I sent it to the writing lab and the Doctor of the course, they both comment on it, so basically you just adjust what did they it needs to be fixed. Note that I have not write the conclusion. – You just need to write a conclusion, and edit what the lab and the doctor said that it need to be edited. ( everything is being writing on the margins) – Attached 1- grading rubric for the paper.2- Example of how the paper should look like 3- writing lab review of what I have done.4 – Doctor’s review of my work. –
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Paper Rubric – 20 points
Point
value
Content
Max
16
Key elements of the assignment are substantive. See detail of
assignment.
Points
Earned
Comments
Includes all applicable areas for
a scholarly paper and focuses
on what you need to say.
5
It is not uncommon for students to ignore the assignment and write about something
completely different!
Introduction: purpose of the paper identified; introduction provides
sufficient background on the topic; major points in the introduction
match the assignment; author creates a focus and context for the
subject; author previews the content
1
Note that APA does NOT use an Introduction heading. The first paragraph or two after
your title are the introduction.
Body of paper: ideas are consistent and flow in logical sequence; major
points are organized using appropriate headings; points are supported
with appropriate research and references; ideas are stated clearly and
concisely; transitions are used to bridge topics
EVERY paper needs an
introduction. Remember, in APA
you don’t use the heading
Introduction. The first few
paragraphs of your paper will be
considered the introduction.
Briefly tell us what you are
going to tell us.
3
APA has specific requirements for headings. Your paper should be readable. Try reading
it out loud. There should be a story that makes sense.
Conclusion: flows logically from the material presented; insights are
drawn from summarized major points
2
Every paper needs a conclusion.
Tell us what you told us. Don’t
include any NEW information in
your conclusion. The conclusion
should start with a level 1
heading called CONCLUSION.
2
Assignment length 2500-3750
words (7-10 pages – NOT
counting title page, abstract, or
references). YOUR PAPER =
XXXXX
The Introduction says “here is what I am going to tell you”, the conclusion should say
“here is what I told you”. The intro and conclusion should be in alignment. Don’t add
new material, references, or thoughts in your conclusion.
Organization of ideas:correct and varied sentence structure; paragraphs
well structured with logical and effective transitions; paper reviews
relevant concepts and creates a coherent theoretical framework for the
subject
Assignment specifies 10
references: YOUR PAPER =
XXXXX
Scholarship: research adequate and timely; appropriate depth and
quality of research (scholarly literature); research presented objectively
3
Assignment specifies that a
majority of your references be
within the last 5 years.
Concentrate on scholarly, peer
reviewed journals. Avoid the
popular press and general web
sites.
Search for as much current support (within last 5 years) as possible. Try to tell BOTH
sides of every story, and present conflicting research when it exists.
Mechanics, Readability and Style
Max
This is an aggregate grade that includes all areas below.
4
Points
Earned
Comments:
Transitions from section to section and paragraph to paragraph are
present and logical.
Grammar: subject-verb agreement; proper voice (active vs. passive) and
person used; pronouns are unambiguous and congruent; plurals correct;
appropriate hyphenation of terms.
Turn on your grammar checker in MS Word. It isn’t always correct, but you need to pay
attention to anything that it points out. If you still haven’t learned basic punctuation, it is
time to start.
Sentences: complete, clear, and concise and do not contain
redundancies and excessive complex words; do not contain hidden
verbs, wordy phrases or clichés; sentence transitions are present and
maintain the flow of thought
APA frowns upon colloquialisms and trendy terms. Don’t try too hard to sound smart.
Language usage: language appropriate for the audience; nonbiased
language used; contractions avoided; colloquial expressions, slang and
jargon avoided; language clear, concise, precise and unambiguous;
parallel construction; proper word choice; tone appropriate to the
content and assignment
Sentence and paragraph structure: sentence well constructed,
consistently strong and varied; paragraphs well constructed and contain
a minimum of three sentences
The “three sentence rule” is not set in stone, but many scholars consider a paragraph of
less than 3 sentences to be underdeveloped.
Other style issues: appropriate use of personal pronouns; paper neat and
well presented; ellipsis points used properly to indicate omitted
material; text does not contain widows or orphans.
Text: Times Roman 12-point font used; document double-spaced
throughout; margins at least 1 inch on all sides and ragged right edge;
paragraphs indented 5-7 spaces; headings and subheadings properly
formatted; no end-of-line hyphenation; only one space after
punctuation; no bold type used for emphasis; italics used instead of
Be careful about extra spaces
between words.
underlining
If you don’t have an APA template, set one up. There is no reason that you should be
using manual tabs or spaces to indent your paragraphs.
In-text citations: all outside ideas properly cited; citations complete and
properly formatted; electronic sources properly cited; personal
communications cited in text only; page numbers included for direct
quotations; indirect or secondary sources properly cited
Reference list: references in correct alphabetical order with author’s
initials; electronic references properly cited and formatted; format of
references conforms to APA requirements; in-text and reference list
citations correspond
.
Punctuation: used correctly; the word “and” and the ampersand are used
correctly; punctuation correctly placed with quotation marks
Spelling is correct: misspellings or typos are not acceptable in graduate
work. USE YOUR SPELL CHECKER BEFORE SUBMITTING WORK.
Total
Total 100 Percent
20
100
Running Head: Disaster Triage for Mass Casualty Incidents
Disaster Triage for Mass Casualty Incidents:
Present Status and Future Implementation
Carlyn M. Christensen-Szalanski
Philadelphia University
Disaster Triage for Mass Casualty Incidents
2
Abstract
The author surveyed literature about disaster triage systems for managing the chaos of mass
casualty incidents (MCIs) and concluded that no system is yet sufficiently validated, reliable, and
accepted as an official standard for disaster triage. Effective disaster triage rapidly identifies
which victims require immediate resuscitation, which victims can safely wait for treatment, and
which victims require so many resources to survive that they receive medical help last, rather
than first. In disasters, needs surpass resources, so the paradigm of disaster triage differs from
that of triage at an emergency department with plentiful resources; there, the most severely
injured or ill patients receive treatment first, not last.
In the United States literature three disaster triage systems predominate: START (Simple Triage
And Rapid Treatment) and its pediatric variant, JumpSTART; the Sacco Triage Method, and
SALT (Sort, Assess, Lifesaving intervention, Triage/Transport). Little research exists about the
use of disaster triage in actual MCIs, largely because first responders have not systematically
used disaster triage and documented their use of it. Researchers have often evaluated these
systems retrospectively with “singleton” paper victims listed in a trauma registry and less
commonly in MCI disaster drill scenarios. Most researchers lament the lack of data from reallife use of disaster triage systems in actual MCIs. The author describes these three disaster triage
methods, their strengths, weaknesses, and reported use. The author briefly discusses training
bystanders to triage victims and the importance of EMS responders using disaster triage
routinely to become better prepared for future MCIs.
Key words: disaster triage, mass casualty incidents(MCIs)
Disaster Triage for Mass Casualty Incidents
3
The three major endeavors of initial mass casualty and disaster management for medical
providers are medical triage, transport, and definitive medical care. Effective disaster medical
triage gives responders the best opportunity “to do the greatest good for the greatest number” of
victims in a mass casualty incident (MCI). Multiple proposed systems of disaster triage have
emerged over the past 30 years, all variants of the task to sort surviving disaster victims into at
least three groups: those who need immediate help, those who can wait for help, and those who
are “beyond help” – all because their needs exceed the resources in a disaster. This approach
runs counter to the usual model of triage for urgent and emergency care facilities.
Three disaster triage systems predominate the ongoing discussion in the US literature of
which are more valid and reliable. Researchers have usually evaluated the validity and reliability
of these consensus-based systems by applying their approach to “singleton” trauma victims from
historical registries or pretend victims in MCI disaster exercises. These experimental
circumstances do not encompass the overwhelming chaos and danger of an actual MCI or the
fear and other vulnerabilities of responders acting as triageurs. The author sought definitive
evidence in the literature that one triage system is superior, but found none.
Few articles exist about the use of disaster triage in actual MCIs, largely because first
responders have not systematically used disaster triage and documented their use of it.
Implementing the metrics of a disaster triage system is not yet a universally practiced,
“automatic” skill of the disaster responders. This paper briefly mentions training first responders
and others to practice using disaster triage in routine circumstances to prepare better for MCIs .
Disaster Triage for Mass Casualty Incidents
4
Brief Overview of Disaster Triage
Triage comes from the French verb “trier” meaning to sort. Disaster triage is an important
tool to use in sorting the victims of a mass casualty incident when needs for medical care outstrip
the resources available. This type of triage differs from routine medical triage when resources are
sufficient to meet every need, as in a well-equipped urban Emergency Department. Historically
disaster triage originated on the battlefield. Two hundred years ago Baron Dominique Jean
Larrey, the chief French surgeon with Napoleon’s Grande Armée, first established a disaster
triage system where soldiers (independent of their rank) received initial medical treatment on the
field before their transport via his “flying ambulances” (ambulances volantes) to a field hospital
(also his idea). Some military leaders used triage to increase their combatant manpower by
treating preferentially the soldiers with minor injuries. Others recommended that the most
seriously wounded should receive treatment first, since they were most likely to benefit (Foley,
page 337).
In the past century, military medicine dramatically improved its capability for rapid transport
and evacuation by air-ambulances to sophisticated surgical field units. It also devised field triage
decision rules, paralleling progress in civilian systems for individual trauma victims. (Mitchell,
2008, pp. S4-S6) The MASS (Move-Assess-Sort and Send) triage system was used in the
military setting for many years. Since the 1980s, other disaster triage systems have evolved.
Most disaster triage sorts victims into four categories:
Priority 1~ Immediate~ Red: Victims whose lives are in danger who require immediate
treatment to improve their survival.
Disaster Triage for Mass Casualty Incidents
5
Priority 2~Delayed~Yellow: Victims whose lives are not in immediate danger who can
safely wait for urgent care.
Priority 3~Minimal~Green: Victims with minor injuries that will eventually need
attention.
Priority 4~Expectant~Black: Victims who are either dead or whose injuries are so
devastating that they will probably die since only limited resources are available.
The main hazards of using a triage system are “undertriage” and “overtriage”. Undertriage is
underestimating the severity of a victim’s injury, such that the victim may not get help soon
enough to survive. Overtriage is overestimating the severity of the victim’s injury, resulting in
unnecessary crowding of noncritical victims at the receiving medical center (Foley & Reisner,
pp. 339-341). The double check on this system is secondary triage at the receiving hospital,
where a physician may note deteriorating vital signs. Hence researchers often assess the validity
of a triage system by its rates of undertriage (sensitivity) and overtriage (specificity).
Three Disaster Triage Systems
This paper focuses on three disaster triage systems which US researchers have examined for
their validity and reliability: START /JumpSTART, the Sacco Triage Method, and SALT.
START/JumpSTART Triage
In the early 1980s the Newport Beach Fire and Marine Department and Hoag Hospital
developed the START (Simple Triage and Rapid Transport) triage system (Kahn, Lerner &
Cone, p. 209). Initially triageurs ask victims who can walk to move to another area. These
Disaster Triage for Mass Casualty Incidents
6
walkers are the Priority 3 ~ Minimal ~Green victims. Triageurs later reassess the Green victims
after evaluating other victims by their breathing, circulation and mental status. As they rapidly
sort them by this simple process, triageurs tag them with identifying information and move them
to three colored areas according to their status. Triageurs tag Black victims who have died.
Triageurs also tag Black the victims whose injuries are so devastating that they likely cannot
survive with the relatively scant resources available. Triageurs may later reassess these living
“Expectant” victims after assessing all others. Until then they receive only comfort care.
In 1995 Dr. Lou Romig developed the pediatric variant JumpSTART, noting that the START
algorithm was designed for people weighing at least 100 pounds who could walk (the first
decision point of START). She addressed physiologic differences of children so that normal
Disaster Triage for Mass Casualty Incidents
7
younger children would not be triaged as an Immediate because of their respiratory rate.
Intended for children younger than 8, Dr. Romig advised, “If the victim looks like a child, use
JumpSTART. If the victim looks like a young adult, use START” (Romig, 2002, pp.54-63).
START (and JumpSTART) triage has been the most commonly used civilian disaster triage
system in the United States since the 1980s.
Strengths of START/JumpSTART.
The potential strengths of the START/JumpSTART algorithms are their simplicity, rapid
assessment of each victim, and availability of materials. The Newport Beach Fire Department
and Dr. Romig offer free of charge their triage algorithms and all other files on their START and
JumpSTART websites. Numerous other triage system variants are based on START.
Weaknesses of START/JumpSTART.
One criticized weakness of START is overtriage. To decrease the rate of overtriage in using
START triage, the New York City Fire Department (NYFD) added a fifth category, “Orange”,
between Red and Yellow. This more reliably prioritizes a subgroup of delayed non-critical nonambulatory patients (Yellow) who do not need the immediate lifesaving resuscitation of the most
critically injured (Red), but are not stable enough to wait as long to receive medical intervention
as a typical Yellow patient (Arshad, et al., 2015).
A second criticized weakness of START is undertriage. Cross, Petry & Cicero (2015) noted
from their retrospective application of START to patients of a trauma registry, older age was the
primary predictor for undertriaging. They recommended that triageurs upgrade the severity
especially for adults older than 75. Farris (2015) also reported that START triage undertriaged
Disaster Triage for Mass Casualty Incidents
8
the elderly. Viewing this undertriage as a phenomenon larger than just START triage, she
recommended developing a separate triage system for the elderly, paralleling JumpSTART’s
variation for the pediatric population. These criticisms are not based on triage in actual MCIs.
A third potential practical weakness of START is the relative lack of mandated life-saving
interventions. This triage algorithm focuses on triage, not treatment. For adults, triageurs open
airway to reassess breathing, and for children they also give five rescue breaths. The NYFD
modified the JumpSTART algorithm to accommodate the importance of ventilatory support for
pediatric victims by expediting the off-site transport of all Red and Yellow pediatric victims
(Cooper, Foltin, Tunik & Kaufman, 2012, p. 94).
Use of START/JumpSTART Triage.
Experience using triage in actual events is invaluable. The NYFD noted from actual
experience (Kaufman et al., 2013) that
“infants at a mass-casualty incident tend to be difficult to accurately assess and even
when in a low-priority triage category occupy a disproportionate amount of EMS
resources. By immediately categorizing infants with red tags, we strive to quickly
transport them from the scene. Although this may be an overtriage for the infant’s
medical condition, it allows maximum efficiency for the overall scene management and
is therefore consistent with the overarching goal of saving the most lives.”
Several reports exist about using START triage in actual MCIs. Hogan, Waeckerle, Dire &
Lillibridge(1999) reported on the response to the Oklahoma City bombing in 1995 by examining
Disaster Triage for Mass Casualty Incidents
9
all available disaster triage tags and hospital medical records for 388 patients. They reported that
at least ninety (23.1%) had documentation of prehospital EMS triage and transport. Hogan et al.
(1999, p.164) commented, “Unfortunately documentation of the process behind the triage
decisions made in Oklahoma City was practically nonexistent, similar to other mass casualty
disasters.”
Kahn, Schultz, Miller & Anderson (2003) evaluated the successful performance of START
triage at a 2002 head-on train collision in California, reviewing 148 records of victims. They
hypothesized that START would 1) ensure that the most critical patients would be transported
first and 2) achieve at least 90% sensitivity and 90% specificity for each triage level. They found
that START did prioritize well the transport of the most critically injured, but that no triage level
met both levels that they hypothesized. Nonetheless the sensitivity of the Red triage was 100%
and the specificity of Green was 89.3%. The National Transportation Safety Board stated “the
emergency response to this incident was timely, effective, and appropriate to the incident.
(National Transportation Safety Board, 2003).”
Kaplowitz, Reece, Hershey, Gilbert & Subbarao (2007) reported on the successful START
triage and transport of 25/26 victims to rural regional hospitals after the Virginia Tech active
shooter mass casualty event of 2007. After two tactical medics ensured scene safety, additional
EMS providers from two different Rescue Squads assisted with triage and transport and treated
the mobile Green victims at the scene. The one Green victim who bypassed triage arrived first at
a hospital — via public transportation. EMS providers transported most Red and Yellow victims
to the level III trauma center ED three miles away where a triage officer directed Green and
Disaster Triage for Mass Casualty Incidents
10
Yellow victims to the waiting room and Red victims to an operating theater where a code team
reassessed them. They transferred three Red victims to the closest level 1 Trauma center, 45
miles away. The over-triage rate was 69% (11/16). Only one victim was under-triaged; ED
secondary triageurs noted a bullet entry wound in his flank so he was retriaged as Red instead of
Yellow. Kaplowitz et al. (2007, p. S12) emphasized that this was a “rural health system response
with signific …
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