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ACEP Now: Vol 34 – No 07 – July 2015

The NTSB Go Team arrives on the scene of the Amtrak train No. 188 derailment in Philadelphia, Pennsylvania.

KK: You said they were trying to decompress the ED. Tell me some of the things you and your colleagues did to decide which patients needed to go upstairs immediately without a workup and which did not need to be seen in the ED at all.

AK: We have a medicine chief and a night chief on overnight, and they did a great job sending me down residents to make sure that admission orders were written for everyone who needed to go upstairs. Everyone who needed to go upstairs was out of there in two to two and a half hours of our disaster plan implementation. Anyone else who had a minor workup already in progress was dispositioned; most of them were sent home. Our neurology resident actually cleared out the neurology step-down unit so that we would have extra step-down beds if needed. Everyone was being very judicious about assigning levels of care. A patient who was being intubated while I was on the phone with the administrator on call went right up to the medical intensive care unit as soon as his chest X-ray was shot.

KK: Based on your ability and your skills, did any patients appear less injured than they really were?

AK: One patient came in walking with her family assisting her. I flagged down the senior resident and said, “Please make sure you take a really good look at her.” There was a language barrier, and she was clearly distraught, in pain, and not really ambulating on her own power. It turned out that she had three cervical spine fractures, and so she went to the surgical intensive care unit.

Dr. Klimke (right front) with her Pennsylvania Task Force 1 medical team during Superstorm Sandy.

KK: What percentage of patients do you think were ultimately upgraded for whatever reason?

AK: About 20 percent. Twenty percent is even on the low end of the disaster literature, but I say that’s right about where we were. Over-triage is more acceptable than under-triage, which is definitely something that you need to be aware of. Again, triage is very fluid, an ongoing process.

KK: Tell me if you agree with this: Although you could do it, it’s very ill-advised to downgrade somebody’s triage status. Unless it was completely erroneous, someone may have seen something that you aren’t seeing now. What are your thoughts about whether you should downgrade people or not?