Triage

Definition

Triage is a dynamic system used for categorizing and sorting patients. This is done according to the severity of their injuries and prioritization for evacuation to definitive care, given the limitations of the current situation and available resources (time, equipment, supplies, personnel, and evacuation capabilities) (Auf der Heide, 1989; Szul, Davis, Maston, Wise, & Sparacino, 2004).  The goal is to afford the greatest number of casualties the greatest chance of survival by making the most efficient use of available resources.  There is no single, standard, or universal method of triage (Auf der Heide, 1989).  Various color codes, numbers, and symbols have been used to identify the categories of triage, identified by the use of a triage tag.  Practice with the particular system used by local responders is required to be successfully implemented. 

The START System

If not trained in managing a mass-casualty incident, arriving first responders can be overwhelmed by who to treat first.  The START System (Simple Triage And Rapid Treatment) can be a basic system to teach the triage process.  It is a color-coded system with either four or five triage categories using a commercial triage tag (METTAG) with strips that can be torn off the bottom, leaving the color of triage on the bottom.  The colors and their meanings are as follows (Auf der Heide, 1989; Deatly et al., 2003):

• Red/Immediate—First category.  Casualty is critical and is unlikely to survive without “simple” care interventions, such as maintaining an open airway so that the casualty may breathe on his/her own.  The casualty may/may not be conscious.
• Blue/Urgent—Second category (if used).  Casualty has suffered catastrophic injuries and is unlikely to survive without extensive or complicated care within minutes.  The casualty may not have a radial pulse, but one can be felt at the brachial or carotid artery.  The casualty may need to be focused in order to answer simple questions, such as where they are hurting.
• Yellow/Delayed—Third category (more often the 2nd category).  Casualty is likely to survive if “simple” care is given within hours.  The casualty has a palpable radial pulse and is comfortably breathing, with sufficient mentation to answer/ask questions.
• Green/Minimal—Fourth category (more often the 3rd category).  Casualty has minor wounds and is likely to survive even if care is delayed hours to days.  May be called the “walking wounded” or stretcher cases.
• Black/Expectant—Last category.  Casualty is either already dead or expected to be so before all victims can be evacuated, which can be most troubling to those not experienced in making such decisions.

Figure 2-2: START Triage System Flowchart

© 2006, Community Emergency Response Team (CERT) - Los Angeles. Used with Permission.

One problem associated with the use of this colored tag system has been the lack of availability of the tags at the incident site. Another problem has been responders' lack of familiarity with the tag system. This can be overcome with practice and training.

Categories of Triage

Military Triage

In the military, the ultimate goals of combat medicine are the return of the greatest possible number of soldiers to combat and the preservation of life, limb, and eyesight in those who must be evacuated (Szul et al., 2004).  Triage begins in the field, first with self-aid (placing your hand on your wound); buddy-aid (placing your hand on your buddy’s wound if he/she cannot); and then medical personnel (the medic replacing your hand with a pressure bandage).

Combat/Civilian Stress

Stress casualties are a concern both in the military and the civilian response efforts.  Repeated training builds the “muscle memory” needed to overcome a potentially shocking and overwhelming situation that can cause others to freeze in the response efforts.  If this is recognized, assigning the individual to focus on a specific, accomplishable task that requires a relatively short time frame for results can be the catalyst needed to reset the “muscle memory” of training.  Although individuals may believe themselves prepared for such an incident, until in the actual situation they will know their reaction.  Even seasoned responders have moments when they have to take a break to “reset” in order to resume their duties.

While there are situations when this stressful reaction can be anticipated, it is important to allow for unexpected aspects of a situation that cause extreme stress in individuals. For example, in 2007, a mother and her two young daughters were tortured and murdered in their CT house. The husband was badly beaten but was able to escape. In 2010, one of the two men accused of the atrocities went on trial for his crimes. The jurors heard days of graphic testimony and saw crime scene pictures that greatly affected them. Following the conviction, “Out of concern for the shell-shocked jury, Connecticut's Judicial Branch took the rare step of offering counseling services” (Melia, 2010). In another murder trial in NH, one of the jurors compared themselves to being “almost like we were a military unit that went through a battle. We survived it, and we all had that common traumatic incident to share” (Melia, 2010). These strong reactions reported by the jurors are important for 2 reasons:

1. Being involved in an emotionally trying situation can be difficult for more than just the people with boots on the ground and it is important to understand and be aware of how all the responders are coping.
2. For especially trying situations (the CT case was thought to be “exceptional” because it had factors including “multiple victims including children, sexual assault, graphic evidence and — as a capital case — the responsibility of deciding whether a defendant should live or die”), strong emotions can come from simply reliving the event through pictures and others’ testimonies.

EMS/Disaster Triage

Search and rescue (S&R) is often the initial contact with disaster victims.  An uncoordinated and confused operation can result in continued confusion and lack of coordination as those victims enter the EMS system. 

In traditional EMS, routine triage is directed more towards temporarily by-passing those with minor wounds (the “walking wounded,” or “green” casualties) and focusing more on stabilization of immediate life-threatening (“red” casualties) wounds for transport before attention is turned to those with less severe injuries (“yellow” casualties).  Therefore, triage establishes the order of treatment, not whether treatment is given, and is usually the responsibility of the most senior medical person on site.  In instances when medical treatment facilities have been damaged in a disaster incident, further triage may be necessary once evacuees arrive and resources or personnel are limited. This was the situation faced by the medical personnel in New Orleans after Hurricane Katrina struck, resulting in moral, medical utility, and ethical dilemmas that can haunt future planning efforts. (Triage During a Mass Disaster, 2005).  In a large-scale disaster, a person who would otherwise survive their injuries might—justifiably—not be treated and may even die as a result, since diverting the resources, manpower, and time necessary to treat the one might cost the lives of several patients who would otherwise be helped or are more likely to survive.  Withholding care is contrary to the fundamentals of medical training and can be quite stressful for medical personnel to implement if this ethical framework has not been included as part of a hospital’s disaster plan.

In the disaster incident, field care is limited to “simple” procedures, such as opening the casualty’s mouth/airway or placing an oral airway if one is available.  The responder can move from victim to victim in rapid succession, not taking more than 30 seconds to a minute per casualty rendering simple care and a triage status.  “Complicated” care would involve the use of artificial ventilation or CPR, requiring a more prolonged effort of life-saving and personnel involved on a single victim.  Field surgical or invasive procedures would be limited to placing intravenous access for fluids or emergency cricothyrotomies for those victims making spontaneous breathing efforts but who cannot support their upper airway even with an oral airway. Triage is not static; patients must be reassessed at short intervals to confirm that their original triage category has not deteriorated.

At this point, the victim may be placed in the “Expectant” or “black” category—those who are expected to die without further extensive interventions, such as surgical repair of ruptured organs requiring specialized hospital-based (civilian) surgeons, who may be located in facilities far from the incident site.  This triage category exists in some triage systems to guide responders to devote the time and resources necessary to save those who have less severe injuries.  Keep in mind these are situations potentially faced in the field disaster theater, and hopefully not in the hospital (if sufficient infrastructure exists) where it is generally agreed that all living casualties may be considered potentially salvageable.

Special Categories of Triage

Patients who do not easily fit into the above categories and casualties who pose a risk to other casualties, the medical personnel, and the treatment facility, may require special consideration.  These patients would be those who are contaminated by a biological and/or chemical agent, those who have unexploded ordnance contained within their body, or those who pose the threat of a secondary device on their bodies (such as a suicide bomber) or hostile intent, such as a desperate drug addict who has been cut off from his/her source (the snipers in New Orleans after Hurricane Katrina).

Problems Found in the Triage Process

Even those who teach mass triage can find shortcomings in their own self-confidence when faced with the desperate circumstances of a true disaster (Triage During a Mass Disaster, 2005). The presence of on-scene uniformed personnel can lead secondary responders to falsely assume that triage of victims has been done. Furthermore, lack of scene control allows those who are the “walking wounded” to walk or drive themselves to the nearest treatment facilities they know and trust, thereby bypassing the EMS system of triage and potentially overwhelming that facility. As a result, that facility may be unable to accept those more serious injuries remaining at the incident unless an effective hospital disaster plan exists to control such situations.  Keep in mind the difficulties of performing adequate triage when casualty distribution is dispersed over wide areas by natural disasters such as tornadoes and hurricanes.  

Adding to the problem is the natural tendency to load as many injured as possible into one vehicle and send them on their way, the belief being that this is a great way to quickly clear the incident scene of victims.  For these reasons, some disaster plans call for a delay in evacuation of victims from the scene, the intent on achieving an orderly and rational field stabilization and transport.  Also, the use of field first-aid stations needs to be widely broadcast as these can relieve the burden faced by receiving facilities and can address the desire of the “walking wounded” for prompt care.  As a result, the public will view positively the medical management of the incident, a benefit since public perception of “good emergency care” usually means the most rapid transportation possible to the hospital, not what is best for those needing medical care.

The triage process is one that takes practice, both internally and with other agencies comprising the response effort.  In this manner, participating agencies learn the shortcomings and capabilities of the partner response agencies, as well as confirming who is responsible for the identified tasks.  These practice sessions can assist with the needs assessment crucial in uncovering assumed responsibilities and non-available equipment.  A properly executed needs assessment can broaden limited perspectives and highlight those resources actually available during the disaster response as well as the funding or training needed to accomplish stated objectives. 

Non-local Responders

Control of well-meaning non-local responders is a difficult task to be handled with thought and advance preparation. These non-local organizations do not fall under the control of the local EMS system and can contribute to the lack of organized triage, especially those medical centers with helicopters located within aeromedical range (Auf der Heide, 1989).

Improving the Triage Process

Effective triage requires coordination and communication among medical and non-medical organizations at the disaster site and between the site and local hospitals (Auf der Heide, 1989).  Using common terminology, reducing the use of acronyms, joint planning, joint training, and testing all contribute to an improved response effort.  Jointly reviewing and approving procedures for cooperative communications, situation assessment, resource management, and integration of unexpected or unfamiliar responders are all applicable to organized triage (as well as decontamination) efforts.

Casualty Distribution Procedures

Disaster casualty distribution can be based on what is most practical depending on the size of the community, the number of area hospitals, and the difference in the capabilities of these institutions (Auf der Heide, 1989). 

In the simplest case, only one local hospital may be available to receive casualties.  The hospital may act as the triaging facility, stabilizing patients and then evacuating them to more distant facilities.  When there is more than one hospital available to receive patients, all with similar capabilities, ambulances may rotate dropping off their patient load in an effort to avoid over-burdening one particular facility (Auf der Heide, 1989).

Recovery

Recovery is a process of standing-down those resources no longer needed. This can be a phased process.  After-action reviews of the incident response can highlight the good, the bad, and the ugly, in preparation for the next time a response is mustered.