Sean Brayford-Harris Profile picture
Oct 18, 2022 28 tweets 9 min read Read on X
A proud day at #TraumaCare22 where the ‘Ten Second Triage’ tool has been officially launched

Recommended as first line triage tool for all incidents

/1
TST is designed as a pan-emergency service early scene triage tool, actively confronting the challenges experienced by tools that have come before it (none of which were good enough)

Signed off for:
Amb & Military

Recommended for:
Police & Fire
(sign off likely imminent)

/2
TST rapidly filters walking patients

Especially relevant for initial responding police officers who are likely to control ‘walkers’ robustly

Training will include a caveat for those who are walking with critical injury - you there, sit down

/3
It does not rely on physiological measurements:

We know that such measurements are irrelevant in the emerging phase of an incident

Theory ≠ Real World

Try finding any alive casualty with a pulse below 100 or even 120 immediately post explosion or during a marauding attack

/4
Try reliably finding a pulse if you are an incredibly stressed police officer, firefighter or paramedic in ballistic/CBRN PPE

Try finding a first responder who legitimately & accurately quantifies resp rate in the immediate assessment of GSW victim

Me = Lots, some or none

/5
TST utilises a nuanced response check

Talking is proxy for adequate cerebral perfusion. In the world of AVPU it may feel non clinical but is useful across the spectrum of responders and is sensitive for critical injury

‘Talking’ also P1 safeguards children too young to talk

/6
It prioritises unconscious casualties and encourages immediate essential airway management.

TST is not prescriptive and is adaptable, allowing for local interpretation of ‘airway management’ for those who may carry additional airway adjuncts

/7
TST is designed to be pragmatic and is reflective of the gold standard, real world actions of any police officer or ambulance responder to the victim of a stabbing or gunshot

/8
I want a police officer to prioritise the victim who is on the floor

I want them to aggressively arrest external haemorrhage

I want them to assess a responsive casualty for central injury in order to report accurately, enabling appropriate enhanced care support

/9
I want a police officer to prioritise the victim who is on the floor

I want them to aggressively arrest external haemorrhage

I want them to recognise reduced levels of consciousness and intervene with airway management or resuscitation as required

/10
I use police officers in this example because if I’m bleeding to death, I don’t care who applies my tourniquet or packs my junctional injury

I also don’t care what brand of tourniquet or type of dressing

The measure of success is effective haemorrhage control

/11
This is what we want our initial responders to do for single patients… and under pressure it is what they’ll do for multiple

TST is a structure that can be overlaid on ‘real world’ high threat care and provide triage categories in order to aid what happens next

/12
TST is pragmatically based on real world actions rather than suggesting staff should measure physiology, actioning a complicated, unwieldy and rarely practiced system

On a bad day, we know people will revert to what they know (and what they know is right!)

/13
TST prioritises external haemorrhage

The primary cause of preventable death

/14
TST prioritises central penetrating injury

Neck, Chest, Back, Axilla, Abdomen, Groin, Buttocks

This is a new consideration

This is the injury pattern I lose sleep over as it’s the one we know we cannot effectively manage out of hospital

/15
If I’m bleeding to death from a non compressible injury I now do care about what uniform you are wearing!

The inclusion of ‘P1 - Central Injury’ is huge, it builds in a bias to action for these patients. The same group we aim for ‘minimum on-scene times’ for every other day

/16
TST allows for all responders to identify those not breathing, using an objective assessment of respiratory effort through an open airway

The following actions are scenario dependent

‘Dead’ is not the simple decision as perhaps we’ve trained it, almost enforcing futility

/17
The tactical scenario can change

The resourcing scenario can change

Traumatic Cardiac Arrest is not always futile

Impact Brain Apnoea should not be fatal

Resuscitation should occur where possible

Decisions regarding ‘death’ should be handled with appropriate gravity

/18
TST is an important cog in the mass casualty response machine

Policing has been historically focussed on threat confrontation

Healthcare has been historically delayed by threat mitigation

TST allows for concurrent, collaborative clinical activity

/19
TST allows any activity before formal healthcare to be truly meaningful

Priorities should always include enabling access, but there will be scenarios when this is impossible

TST provides structure for policing to start a casualty management plan compatible with formal NHS

/20
It prevents duplication of effort and allows healthcare resources to hit the ground running instead of starting from scratch, triaging patients that have been with the police for x amount of time already

What an opportunity for marginal gains!

/20.5
Casualty flow, or more importantly the lack thereof, has been a challenge in practically every mass casualty incident

Providing police officers a structure that can enable flow in scenarios where healthcare cannot access a scene is crucial

/21
If you can’t get health care in… get patients out

/22
The Ten Second Triage sieve looks to address many of the challenges presented by high threat mass casualty management

It’s pragmatic

It’s faster

It’s effective in the hands of police officers, ambulance staff and FRS

It’s sensitive where other systems have failed

/23
I’ve been very lucky to have been a part of the development of this tool, from initial concept, evolution through to final testing

Rolling out in Spring 23

Huge thanks and kudos to @ClairePark01, @NARU_org and @NHSEngland and all others involved
What started as a local idea for the streets of London gained traction far beyond what I thought possible

@ClairePark01 has led and driven the piece phenomenally

The team @NARU_org & @NHSEngland Phil Cowburn, Jamie Vassallo, Jason Smith and Dave Bull have given it wings
What started off as a scribble in a notebook in wintery wales a number of years ago has been developed by the team into something that I believe is capable of improving outcomes in mass cas incidents

Hearing Phil & Claire announce it in its current guise is a career highlight!
The enormity of the challenge to bring us to this point; the amalgamation of multiple other streams of work, including some alternative models across the country can’t be overlooked

I humbly applaud all of those involved who have made it happen

/end

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More from @SeanHarris999

Apr 24, 2023
⚠️ TEN SECOND TRIAGE ⚠️

england.nhs.uk/publication/cl…

@NHSEngland have published the key training materials for #TenSecondTriage / #TST and MITT on their website (or sent it to your trust EPRR department)

🧵
/1 Image
Users will be divided into:

Clinical Responders
🚑 🚁 🏥

or

Non-Clinical Responders
🚓 🚒

With specific materials available for each. The tool remains the same, but there are some subtle training nuances relevant to the various responsibilities of each user group

/2
Materials include:
1) High Res versions of the tool itself
2) PowerPoint presentation
3) Supplementary training material (acts as a trainer guide/presenter notes)

And this introductory video:



/3
Read 28 tweets
Oct 19, 2021
After an extended virus-led hiatus, this weekend I was finally able to return to the @ATACCFaculty and the #ATACC course

The build up felt similar…
An email from @WestCorkRR informing me that I could have ‘my’ lectures if I wanted*

/1
*not necessarily ‘mine’, but I’ve delivered variances of the initial Roadside to Critical Care talk for a while. I didn’t expect to have them back… but it was amazing to slot back in. I asked to completely change Batons, Blades, Bullets & Blasts… “go for it”

/2
Weeks before I’m even in Lincoln, before the first bag was packed… months and months since I was last there… boom. Engines on! Burners lit!

There’s something incredible about being enabled, trusted and supported to just do what you do.

/3
Read 14 tweets
Apr 14, 2020
The Paramedic experience of COVID-19 is completely counter to what I initially expected

Not to discredit the work of our incredible in-hospital colleagues, but the prehospital management of COVID feels ‘simple’

Well enough to stay*?
Sick enough to go?
How much O2?

*caveats
/1
We have some pretty robust decision making guidelines and though it’s been dynamic and changing daily, I feel pretty confident about the clinical decisions being made and the core ‘ambulance work’ that we’re doing... which is actually what I feared being difficult

/2
The challenges are human

They are moral

They are ethical

They are harder wearing PPE (albeit safer)

/3
Read 16 tweets
Nov 26, 2019
I haven’t been terrified at work for a very long time. I remember brand new experiences as a student being ‘scary’; but with time, education, exposure & experience, they became more infrequent

Alas, I can categorically assure you, it still happens!

A thread

/1
[Details altered and only the minimal will be discussed. This isn’t theatre and you’ll understand why]

Cat 2: 7yr F - Chest Pain / Breathing Diff (Known Asthmatic)

OA:
Atonic, GCS3, RR10 grunting, minimal chest movment, silent on auscultation

Uncle futilely trying inhaler

/2
With those CAD details - the mental rehearsal en route was a “routine” asthma exacerbation

Calm and de-escalate
Peak flow
10 puffs of own
Maybe some nebulisers

...like the hundreds before it

/3
Read 25 tweets
Nov 9, 2019
Practical thoughts on #SpontaneousResponders

It's important to acknowledge that the first people to respond to any incident will often be the lay person who uses their initiative; the relative, the work colleague, the fellow commuter

Day to day, this can be the difference

/1
We will all meet / have met a patient who was saved by a non-uniformed #SpontaneousResponder

Perhaps via public access defibrillation or good first aid

This is the system working! Amazing projects like @GoodSamApp/@ThecitizenAID show us how

/2
But what about when the incident is less 'routine'

Think big

Explosions, terrorist attacks & major incidents all come with a #TherapeuticVacuum. A clinical void where formal incident response is delayed by ongoing threat / due to the demands of co-ordination prior to access

/3
Read 17 tweets

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