Strategy Submission

This is a low fidelity simulation exercise that can be used to enhance content on mass casualties. This activity was originally noted as a simulation activity for the Kirkland Fire Department in Washington. Some nursing curricula cover this content in advanced Med/Surg, alongside emergency room content. Other programs place this content in a public health course. The necessary content to properly contextualize this activity focuses on the mass casualty ideas of: scene safety, incident command structure, triage choke points and allocation of resources (e.g. staff, supplies and transportation). The value of this learning activity is that it augments a theoretical, academic discussion with a hands-on, low fidelity simulation learning activity.

The necessary materials for this activity are a variety of stuffed animals that represent participants of a mass casualty. Although the activity is called “Triage Bears,” any kind of stuffed animal can be effective, and can convey the diversity of victims that might be the result of a mass casualty. Faculty have found it effective to include such diverse stuffed animals as teddy bears, stuffed snakes, gorillas, cats, dogs and tarantulas. Faculty aim to acquire one stuffed animal for every two students. Each of these stuffed animals represents a specific patient in a mass casualty situation. Faculty have found that worn and used stuffed animals work especially well. You can modify the appearance of the stuffed animal to match the nature of the injury (e.g. lipstick works very well as moulage blood on teddy bears, you can have a rip on the right arm to suggest a right arm fracture, etc…). Victims can also be grouped together as is appropriate (e.g. you can identify a family unit of a mother bear with two bear children, or bear siblings).

It is helpful in this exercise to have a wide representation of ages and injuries. Including medical emergencies such as cardiac concerns and disabled individuals (e.g. a victim who is blind, or paraplegic, or a child with Down’s syndrome) adds to the complexity.

Each stuffed animal has a tag that includes the following information: age, vital signs, and a brief description of the injury.

Students are divided into teams of two students. Each team assesses every stuffed animal. The students use the Lou Romig Start/Jump Start Algorithim (pdf file is attached) to determine whether the patient’s condition needs minor attention (green), delayed attention (yellow), immediate attention (red) or whether the patient is deceased or beyond reasonable resuscitation (black). Consistent with this well recognized algorithm, the students have 15 seconds to determine the color assignment of each stuffed animal. The goal of this activity is to have the students be working very quickly, but be systematic and focused in their determination of triage priorities.

Each team must keep track of how many victims end up in each color category per standard triage protocols. The team then provides an inclusive report to the site commander about the number of patients at the scene, the number in each category and the location of the victims that need priority attention. The scenario can be extended to include transport of bears to collection points, re-prioritizing those in each category, providing recommendations about how to organize care in a limited supply setting, and preparation for transport.

After the class has finished this work in teams of two, there can be a group debriefing. Some questions and pointers for discussion might include:

• How did you find making decisions alongside another nursing clinician?
• How did it feel to be making determinations about care in such a compressed timeframe? What was most difficult about the limited timeframe?
• What information did you wish had been provided to you that was not on the victim’s tag?
• What are your insights into each of the triage categories (green, yellow, red, black) that you gained from this experience?
• How would your assessment have been different if there were other team members working on the victims alongside you, such as respiratory therapists, physicians or EMTs?
• How would your care have differed if there were families hovering over your victims as you were trying to make these quick clinical decisions?
• What was most difficult about the inclusive report that you provided to the site commander?
• What did you learn about your communication style/effectiveness from working alongside another nurse, and reporting off to the site commander?
• Reflections on cultural bias can include impact of “saving” spiders and snakes, but not puppy dogs.