Triage
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Image:Deconference-2002-triage-tag.jpg Triage is a system used by medical or emergency personnel to ration limited medical resources when the number of injured needing care exceeds the resources available to perform care so as to treat the greatest number of patients possible.
When performed in accordance with accepted medical practices, triage is recognized and sanctioned by law in most countries. Unfortunately in the United States, while triage in emergency rooms and at disaster sites is a commonplace event, the intentional withdrawl or witholding of care to patients during an emergency situation is not protected under most State or Federal law. Title 42, Chapter 6A, Subchapter X, Part B of the US Code requires that in order to receive federal funding for their trauma centers states must set standards for, among other things, triage, but there is no definition of triage and what it can entail. US States have created little to no legal protection should an individual choose to sue a hospital or medical professional over the withholding or withdrawl of care. During a national emergency such a hurricane Katrina or a terrorist attack, this could create a severe liability for medical professionals having to choose which patients should receive care and which do not.
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History
The word triage comes from the French word trier, which means "to sort".
Much of the credit for modern day triage has been attributed to Dominique Jean Larrey, a famous French surgeon in Napoleon's army who devised a method to quickly evaluate and categorize the wounded in battle and then evacuate those requiring the most urgent medical attention. He instituted these practices while battle was in progress and triaged patients with no regard to rank.
Types of 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 patients who can wait for help later. First aiders 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 person. 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 (Simple Triage and Rapid Treatment) 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 people should not receive care because they are unlikely to survive. The available care is then directed to those with some hope of survival. This clearly has ethical implications as treatment is intentionally withheld from some people with a small chance of survival so that others with a better chance are more likely to survive.
In the UK and the rest of Europe, the criteria used for this category of patient is a trauma score of consistently at or below 3 (<3). This can be determined by using the triage revised trauma score (TRTS), a medically validated scoring system incorporated in the Cruiform Triage Card orSmart Tag, two of the modern triage tags used by Ambulance services, prehospital doctors, hospitals, industry, in the UK.
The London bombings on July 7th 2005 saw the use of the Smart Triage Tag and Cruciform Triage Card and Smart Incident Command System, by London Ambulance Service and the receiving hospitals.
The Smart Incident Command System which provides a complete range of specialist triage and incident management solutions was at the front line of response in London. This System helped Paramedics onscene efficiently manage victims in the aftermath of the London bombings.
The adoption of a single Triage Card for use within the UK Ambulance Services is due to be announced shortly following working groups tasked including DH,HPA and the NHS following 7/7, the London Bombings.
The necessity of triage
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. Therefore, patients needing urgent surgical care need to be sent to a number of area hospitals including regional trauma centers 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 and would happen in the event of nuclear warfare. 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 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 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! In the UK and Europe, triage is similar to the USA, but the categories used are "DEAD", those who are pronounced as such by a medically qualified person or paramedics who is legally qualified to pronounce death, the "IMMEDIATE" category, who have a trauma score of 3 to 10 (RTS) and need immediate attention, the "URGENT" category, who have a trauma score of 10 or 11 and can wait for a short time before transport to definitive medical attention and "DELAYED" patients, who have a trauma score of 12 (maximum score) and can be delayed before transport from the scene.
- Some form of marking is very helpful to ration care. If you have triage tags—the right solution—immediately available, use them. If you have a marker or lipstick on your person, mark foreheads with "D" for deceased, "I" for 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 (9-1-1 throughout the United States and most of Canada, 1-1-2 throughout most of the European Union [but 9-9-9 in the UK and 18 in France], 101 in Israel and 000 for Australia).
- Triage 2: On each remaining person, check RPM—Respiration, Perfusion, and Mental state. For each person, follow this procedure:
- 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-wounded 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 may indicate 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 may 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 less 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 victim, 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 "IMMEDIATE".
Simple triage and evacuation
Simple triage identifies which persons need advanced medical care. In the field, triage also sets priorities 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 as they 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 are not evacuated 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, secondary triage is 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. In the UK, a dynamic triage tag like the "Smart Tag" is used, as this allows the patient categorisation to show improvement or deterioration. If immediate treatment is successful, the patient may improve (although this may be temporary) and this improvement may allow the patient to be categorised to a lower priority in the short term. Triage should be a continuous process and categories should be checked regularly to ensure that the priority remains correct. The difficulty with a triage tag with tear off sections, is that the patient is only shown to deteriorate; the dynamic card allows the priority to move up or down. The other advanced aspects of this card is that it enables sequential trauma scoring to be documented. This allows the trauma score (RTS) to be taken on a number of occasions so that a record over time is created. A trauma score is invariably taken when the victim first comes into hospital and subsequent trauma scores taken to see any changes in the victim's physiological parameters. If a record is provided back in time, the receiving hospital doctor can see a historical trauma score going back in time to the incident. This should allow more definitive treatment to be carried out earlier than might otherwise be the case.
Blue/ Expectant
They are 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); they should be taken to a holding area and given painkillers to ease their passing.
Red / Immediate
They require immediate surgery or other life-saving intervention, first priority for surgical teams or transport to advanced facilities, "cannot wait" but are likely to survive with immediate treatment.
Yellow / Observation
Their condition is 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
They will require a doctor's care in several hours or days but not immediately, may wait for a number of hours or be told to go home and come back the next day (broken bones without compound fractures, many soft tissue injuries).
White / Dismiss
They have minor injuries; first aid and home care are sufficient, a doctor's care is not required.
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.
The triage parameters can be understood more readily if reference is made to the Triage Sieve document contained in every "Smart Pac". This is a simple flow chart devised by medical personnel which is ideal for categorising victims, particularly in multiple victim scenarios.
Triage in France
In France, the triage in case of a disaster uses a four-level scale:
- DCD: décédé (deceased), or urgence dépassée (beyond urgency)
- UA: urgence absolue (absolute urgency)
- UR: urgence relative (relative urgency)
- UMP: urgence médico-psychologique (medical-psychological urgency) or impliqué (implied, i.e. lightly wounded or just psychologically shocked).
This triage is performed by a physician called médecin trieur (sorting medic). This triage is usually performed at the field hospital (PMA–poste médical avancé, i.e. forward medical post). The absolute urgencies are usually treated onsite (the PMA has an operating room) or evacuated to a hospital. The relative urgencies are just placed under watch, waiting for an evacuation. The involved are addressed to another structure called the CUMP–Cellule d'urgence médico-psychologique (medical-psychological urgency cell); this is a resting zone, with food and possibly temporary lodging, and a psychologist to take care of the brief reactive psychosis and avoid post-traumatic stress disorder.
In the emergency room of a hospital, the triage is performed by a physician called MAO–médecin d'accueil et d'orientation (reception and orientation physician), and a nurse called IOA– infirmière d'organisation et d'accueil (organisation and reception nurse). Some hospitals and SAMU organisations now use the "Cruciform" card referred to elsewhere.
Reverse triage
In addition to the standard practices of triage as mentioned above, there are conditions where sometimes the less wounded are treated in preference to the more severely wounded. This may arise in a situation such as war where the military setting may require soldiers be returned to combat as quickly as possible, a practice associated with the Russian military. Other possible scenarios where this could arise include situations where significant numbers of medical personnel are among the affected patients where it may be advantageous to ensure that they survive to continue providing care in the coming days especially if medical resources are already stretched.
Medical care during a disaster period
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
- first aid, wilderness first aid,
- emergency medical services, emergency medicine,
- battlefield medicine
- combat stress reaction
- Mass triage
- Mass decontamination