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Triage

Triage is a system used by medical or emergency personnel to ration medical help when the number of injured needing care exceeds the resources available to perform care. Triage, when performed in accordance with accepted medical practice, is recognized and sanctioned by the law in most countries.

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Simple vs. Advanced Triage

Simple triage is used at the scene of a mass casualty incident to choose patients who require immediate transport to the hospital to save their lives as opposed to casualties who can wait for help later. First aid persons performing field triage on the battlefield or at a disaster site usually do not need to assess resources until transportation becomes available.

In most field situations, the walking wounded are numerous. For each particular injury, a lightly-injured person can be deputized to perform a particular first-aid action for a particular severely-injured persons. For example, the first aid person might say "You. Put your hand on this wound, and press so hard that the blood stops. Like this. (demonstrates) Thanks." The START system presented below is one system used by prehospital responders and trained volunteers at the scene of a mass casualty incident.

In advanced triage, doctors may decide that some severely injured persons should not receive care because they are unlikely to survive, and the available care must be rationed to those person who have some hope of survival. This situation is extreme, and of interest in ethics because people with some mathematical chance (however small) of survival are deprived of that chance so that others are more likely to live.

Why Triage Is Necessary

Some injuries require immediate medical care. Trauma patients in particular require a surgeon within one hour of injury, the so-called "Golden Hour" of emergency medicine. A surgeon can only treat one person at a time. A typical hospital has only a few surgeons available and would be overwhelmed if presented with several casualties all requiring immediate surgical care. So persons needing surgical care need to be sent to a number of area hospitals to "even out the load," especially because some victims will "self-transport" to nearby facilities which are most likely to be overwhelmed (as well as possibly damaged in the disaster.)

This is where START saves lives -- at the scene, people requiring surgical care are sent by helicopter or ambulance to faraway hospitals which have been warned to expect victims requiring immediate surgery and are ready to shoulder the load. This is preferable to rushing them to the "nearest" hospital which is overloaded and unable to help.

Advanced triage may become necessary when medical professionals determine that the medical resources available are insufficient to treat all the people who need help. This has happened in disasters such as earthquakes, tsunami and civil defense situations including nuclear attack. Consider that the detonation of a nuclear weapon may inflict tens of thousands of immediate casualties, some percentage of which will die regardless of medical care due to burns and/or radiation exposure but will live for a few hours or days. Others will live given immediate medical care, but will die without it.

In this extreme case, any medical care given to people doomed to die is care taken away from people who might live if they had been given it. It becomes the unpleasant task of the disaster medical authorities to set aside some victims (especially burn victims) because it would take a staff of several professionals ten days to save their one life at the expense of several dozen other lives.

START (Simple Triage and Rapid Treatment)

START (Simple Triage and Rapid Treatment) is an expedient triage system that can be performed by lightly trained lay and emergency personnel in emergencies. It is not intended to supersede or instruct medical personnel or techniques. It may serve as an instructive example, and has been (2003) taught to California emergency workers for use in earthquakes. It was developed at Hoag Hospital in Newport Beach, California for use by emergency services in Orange County, California. It has been field-proven in mass casualty incidents such as train-wrecks and bus accidents, though it was developed for use by CERTs and firemen[?] after earthquakes.

Triage separates the injured into four groups: The DECEASED who are beyond your help, the injured who can be helped by IMMEDIATE transportation, the injured whose transport can be DELAYED and those with MINOR injuries; the walking wounded, who need help less urgently. Other regions may use different designations. Use the designations of your area.

Only perform triage for two or more injured persons. For a single injury[?], always perform first aid!

Some form of marking is very helpful to ration care. If you have triage tags immediately available, (the right solution) use them. If you have a marker, or lipstick on your person, mark foreheads[?] with "D" for deceased, "I" for severely "Immediate," "DEL" for delayed or "M" for "minor injuries." Unmarked or untagged persons should be considered unevaluated. If you cannot mark or tag, proceed anyway.

Triage 1: Loudly and authoritatively ask the group to get up and walk to a safe area that you designate. Do not ask them to walk to the sound of your voice. Designate a particular close area. Anyone who can walk does not need immediate life-saving help in a mass casualty situation. However, people can change categories, and the walking wounded are usually the largest category of victim. A person in shock, for example, might start an incident able to walk, and then faint in the walking-wounded area.

Those with minor injuries are your human resources to perform first aid. You will tell them what to do.

If you have not called for help, point at a particular person, and forcefully ask them to call for help. Make eye-contact, and get them to promise to do it. Say, "You! Get help, and get back to me! Will you do that?" Ask them to call for help using the local emergency telephone number.

Triage 2: On each remaining person, check RPM, that is, Respiration, Perfusion, and Mental state. For each person, follow this procedure:

Triage 2R: If a person is not breathing, adjust their head and clear their airway. If that does not restore their breathing, they are beyond your ability to help. Tag them as DECEASED. Do not start CPR as several other persons may die while you are trying to save just one.

If a person is breathing, check the rate. If it is more than twice as fast as yours, (more than 30 inhale, exhale cycles per minute) they are entering shock. Mark them IMMEDIATE; have a person with minor injuries lay them down, elevate their feet, and warm them with a blanket or jacket. As soon as you have instructed the walking-counded care-giver, move on.

Triage 2P: If a person is breathing, but less than 30 cycles per minute, check their perfusion (blood circulation) by pressing and releasing a fingernail, or the ball of a finger, and seeing if it turns pink within two seconds. Use the ball of the finger if they have nail polish. If it's dark, use your flashlight, if you have one on your person. If it's dark and you have no flashlight, you may check for a pulse at their neck. If they are not perfused, tag them as IMMEDIATE.

Checking the fingernail is both faster and more reliable than checking the pulse, if the light permits, and this means you are less likely to mismark a person as "IMMEDIATE."

Triage 2M: If they are breathing and perfused, check their mental state[?]. Ask them their name, and what happened. If they cannot reply, or say something unrelated, ask again, and tell them that you are testing to see if they are mentally confused. If they are confused, it probably indicates a brain injury[?], which is beyond your ability to help. Tag them as "I" or IMMEDIATE for immediate transportation.

If the person is not confused, mark them DELAYED to indicate that they are stable. and their transportation to the hospital can be delayed.

Now quickly check the person for bleeding. If a large wound is arterial bleeding, determine the first aid method of treating it, and ask the victim (if they are rational) or a particular person ("YOU, yes YOU...", not "Somebody") with MINOR injuries to perform the care.

Now, go back and repeat the process for the next person. Using this process, a trained responder can evaluate most injuries in les than thirty seconds. Remember, do not give care yourself. Give the care-giving tasks to walking wounded on the scene, so you can be free to evaluate other people.

Triage 3: Evaluate the IMMEDIATE injuries to prescribe first aid. Deputize people with MINOR injuries and bystanders to perform first aid operations, by telling them what to do for each person. There are almost always enough people to perform the needed first aid when given instruction.

Triage 4: Evaluate the DELAYED injuries to prescribe first aid. Recruit the victim to self-treat, or people with MINOR injuries to perform the first aid operations, by telling them what to do for each person.

Triage 5: Train one of the persons with MINOR injuries to watch the other MINOR injuries for signs of shock. As time permits, examine the victime, including the MINOR injury patients for shock. Look for very rapid breathing, more than twice as rapid as yours, and confirm by touching their skin. If they are clammy or cold, or the breathing is sufficiently rapid, they are entering shock. Have them sit down. If they are sitting, have them lay down. If they are lying down and you have no reason to suspect spine injury, have them raise their legs. The object is to raise the blood pressure to their inner organs to prevent oxygen starvation of major tissues - which is one way that shock kills. If possible, try to keep shock victims dry and warm to reduce their need for oxygen. If you have oxygen, and know how to administer it, do so. As you have time, tag walking wounded as "WALKING" and upgrade shock victims to "INJURED."

Simple Triage and Evacuation

Simple triage identifies which persons need advanced medical care. In the field, triage also sets priorites for evacuation to hospitals. In START, persons should be evacuated as follows:

  • DECEASED are left where they fell, covered if necessary; note that in START a person is not triaged "DECEASED" unless they are not breathing and an effort to reposition their airway has been unsuccessful

  • IMMEDIATE priority evacuation by MEDEVAC if available or ambulance need advanced medical care at once or within 1 hour.

  • DELAYED Can have their medical evacuation delayed until all IMMEDIATE persons have been transported.

  • MINOR do NOT evacuate until all IMMEDIATE and DELAYED persons have been evacuated. These will not need advanced medical care for at least several hours. Continue to re-triage in case their condition worsens.

Advanced Triage

In advanced triage systems, typically implemented by paramedics, battlefield medical personnel or by skilled nurses[?] in the emergency departments of hospitals during disasters, injured people are sorted into five categories. "Tear-off" tags are sometimes used for this purpose.

Black / Expectant so severely injured that they will die of their injuries, possibly in hours or days (large-body burns, severe trauma, lethal radiation dose), or in life-threatening medical crisis that they are unlikely to survive given the care available (cardiac arrest, septic shock); taken to a holding area and given painkillers to ease their passing

Red / Immediate require immediate surgery or other life-saving intervention, first priority for surgical teams or transport to advanced facilities, "cannot wait" but likely to survive with immediate treatment

Yellow / Observation condition stable for the moment but requires watching by trained persons and frequent re-triage, will need hospital care (and would receive immediate priority care under "normal" circumstances)

Green / Wait will require a doctor's care in several hours or days but not immediately, may wait for a number of hours or told to go home and come back the next day (broken bones without compound fractures, many soft tissue injuries)

White / Dismiss minor injuries, first aid and home care sufficient, doctor's care not required ("Go home!")

Note that this scale is much more complex than with simple triage. Medical professionals should refer to professional texts and training references when implementing advanced triage; this listing is only for a layperson's understanding.

Some crippling injuries, even if not life-threatening, may be elevated in priority based on the available capabilities. During peacetime, most amputations may be triaged "Red" because surgical reattachment must take place within minutes -- even though strictly speaking, the person will not die without a thumb or hand.

If you present yourself for medical care during a disaster, please understand that the quality of care will be much lower than usual for persons whose lives are not in danger. You may have to wait several hours. Once you get to the front of the line, the care you receive may be cursory and brief and you may be asked to come back in several days.

See also emergency medical services first aid and wilderness first aid.

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