Day 8: Triage in Disaster

Triage in French means: to sort. Triage is the sorting of patients into categories of priority to rationally allocate limited resources; it is proverbially, to do “the greatest good for the greatest number”.

In normal circumstances, triage uses all available manpower and supplies. The resources are used to focus on saving one’s life. However, in mass casualty situation, in which the number of injured exceeds the ability to treat in normal manner; the resources are used to focus on saving as many lives as possible. Patients are prioritized based on ‘survivability’.

Triage fails in one of two ways:

Undertriage – undertriage represents a failure to identify the casualties who could benefit from scarce medical resources such as the serious casualty whose life would be saved decisively with rapid evacuation and prompt emergency surgery. In terms of test characteristics, undertriage means poor sensitivity to those who would get the most benefit from the medical resources available.

Overtriage – overtriage occurs when casualties who, do not benefit from a scarce resource nonetheless receive that resource. Overtriage signifies a sorting system with low specificity. Noncritical patients who receive immediate care even though they could safely wait (at the expense of more serious, saveable casualties) constitute one form of overtriage. It can also occur when expectant, sick patients, so sick with little chance of treatment success are provided with precious medical resources.

Triage following disaster is not a single processing step; rather triage underlies all aspects of the response, including on-site rescue, evacuation, receiving hospital activities, decontamination, and so on. Because all these steps evolve throughout the time-course of the response, response priorities are important. Triage is what we can call, a dynamic process.

Triage in disaster is difficult to handle due to the large number of casualties, in which case there are more patients than available resources. Victims who are ‘beyond rescue’ are given a black tag. Example: patient with no pulse and not breathing are considered ‘black’.

START Triage system

The most common used triage classification is the S.T.A.R.T (Simple Triage And Rapid Transport). It is the common four-level system and it is a well-known civilian classification method:

• GREEN – least severe injuries, little or no care needed (often referred to as ‘walking well’)
• YELLOW – delay care (must wait), injury not life-threatening
• RED – immediate priority care for life-threatening situations
• BLACK – no care, mortal injuries, cannot be saved, poor prognosis

START flow chart

[People responding to international disasters should be aware of all the triage classification by the host country and by the other responding agencies]

A slightly more complicated five-level system makes a distinction between patients who will not survive (colour-coded BLACK) and those who are gravely injured to receive limited resources (sometimes colour-coded BLUE). But if enough resources become available, blue-coded casualties can then receive care. If given a choice between red and black for gravely injured patients who are not dead yet, it might be emotionally difficult for responders to apply a black tag, even though resources would be wasted on the casualty with a very poor prognosis.

Triage kit includes:

Triage Tag

• Tape to create triage areas
• Patient triage tags
• Clipboards
• ID vests

[The smart tag is a dynamic, high visibility, triage tag. Its unique folded design means that effective triage is quick and simple]

• It must attach securely to each casualty’s body
• It must be easy to write on
• It must be weather-proof
• It should permit the documentation of the patient’s name, gender, injuries, interventions, care-provider IDs, casualty triage score and an easily visible overall triage category.
• It must also permit changes to be made (because triage is dynamic)

Who will be the Triage Officer(s)?

In short, a triage officer needs the experience, disposition and judgement to act as an able leader under incredible pressure. The designated triage officer (can be at the field and/or receiving hospital) needs a deep understanding of emergency medical treatments, what outcomes are likely for various casualties and what resources are necessary for treatments. It may be advantageous to have a physician for this role.

Where will casualties from each triage category be cared for? And who will staff each area?

Geographic triage means assigning casualties to different locations based on severity. Initially, casualties can be brought to a collection point. From there, the triage officer can determine the appropriate triage category (green, yellow, red or black), and then the casualty can be moved to a triage category-specific collection point for further on-site treatment and/or transportation. The walking wounded (green) are readily separated from the more seriously injured casualties and most of them will be taken care of in an urgent care center, clinic or private physician offices. It has been suggested that dead victims should be moved to an isolated location. 

The triage officer must make a determination as to whether in the environment of the specific disaster and the availability of resources; a patient has a significant probability of survival or does not. If it is the latter, disaster triage principles mandate that care be given to the patient with a higher likelihood of survival. This basic disaster triage principle can have a profound psychological impact on the care provider. As a physician, one is trained to render care to the sick and to not leave the side of a needy patient. To deny care to a critically ill or injured patient can be one of the most anxiety-provoking tasks a disaster medicine specialist performs.




REFERENCES:

1. Disaster Medicine, 3rd Edition; Mosby Inc., 2006
2. Module 3: Triage System [ Sorry, I can't find the author's name... =( ]