triage and sorting

Tuesday, May 22, 2018

Another week, another school shooting, this time in Santa Fe, Texas and another activation of a mass casualty response for the medical teams in the area. Aside from the police visible on the scene, the emergency medical response starts up. From first responders to paramedics and emergency department and operating room staff, people get ready to care for those who are injured. A successful response requires lots of players, but it all begins with triage and the unlucky soul who is the triage officer on scene.

There is a person, (sometimes a team depending upon the number of injured) whose job it is not to look after victims, but to decide about injury severity and survivability, and sort who is transported first to the hospital and who can wait. Remember M*A*S*H*? Hawkeye and Trapper/Hunnicutt would meet the arriving ambulances, pointing who needed to go to the operating room first. Now imagine having to see the victims in the field before the ambulances got there and deciding who needed to fly, go by ground or not go at all.

The triage doc’s job is to hand out color tickets that designate who is hurt and how badly, and whether survival is time sensitive. Poor sorting may cause a mismatch of resources. Trauma designated hospitals have staff and equipment geared up to care for the most injured, and that preparedness increases trauma survival rates compared to patients seen in community hospitals. Triage has to figure that out in just a minute or two at the victim’s side.

It’s not the triage doc’s job to care for people. It’s hard enough having the emotional strength to hand out the color tickets:

  • Red tags are used for the most critically injured whose survivability depends upon immediate transport and access to care.
  • Yellow are significantly injured and normally would be rushed back to an ER treatment bay for care if they showed up at the front door, but the victim is relatively stable…for now. They need to be watched closely as the first wave of helicopters and ambulances leave. Their yellow could turn red,
  • Green are the walking wounded. Though they may be in pain, cuts, scrapes, broken bones all can wait and often these patients are transported by buses to a community hospital for care.
  • White victims are fortunate. They aren’t physically hurt and don’t need care.
  • Black is bad. These patients have been killed or so severely injured that even with care, would not expect to survive.

There is some gestalt to triage but mostly, it’s assessing thvictom’s injuries and their vital sign:

Triage is hard. Tagging a patient and walking away to leave care to others is not what most medical people are trained to do. Triage is also fluid and patients are re-triaged, not only in the field if possible, but also when they reach the hospital. Literally in the ambulance bay, the Hawkeye/Trapper/Hunnicutt scene is played out and depending on the individual need, the patient is sent directly to the OR, the ER or ICU. Other parts of the hospital open for the expected walking wounded.

All this works well in urban areas where there may be an abundance of medical resources, but in rural area, where a small hospital. Remember the Humboldt Bronco hockey team bus crash in rural Saskatchewan that occurred at the intersection of two rural roads, 200 miles from major hospital. Distance from a large facility with all the bells and whistles, plus weather, plus patient stability will affect potential to survive.

Once up on a time, disaster drills were just drills and most hospital staff tolerated the inconvenience of having their routines disrupted to go through the response steps for an event that would never happen. It was all about preparing for plane crashes, factory explosions, and fires. The real world has changed that attitude. People in the trenches are paying attention. The shootings are real world disasters and the next one might happen next door.

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