April 1 2020
tri·age
/trēˈäZH/
noun
(in medical use) the assignment of degrees of urgency to wounds or illnesses to decide the order of treatment of a large number of patients or casualties.
verb
verb: triage; 3rd person present: triages; past tense: triaged; past participle: triaged; gerund or present participle: triaging
assign degrees of urgency to (wounded or ill patients). "victims were triaged by paramedics before being transported to hospitals"
Origin
early 18th century (in the sense ‘the action of sorting items according to quality’): from French, from trier‘separate out’. The current sense dates from the 1930s, from the military system of assessing the wounded on the battlefield.
There are definitely no “death panels” in the United States, or the rest of the world. Triage is a standard procedure which is applied to people needing medical help when they arrive to emergency rooms, or any other type of urgent care facility. The essence of triage is to allow doctors treating those who are most likely to survive.
There is no doubt: we want to save everyone but, if one is in heart failure, dying from cancer, or chronic lung disease, doctors must make a choice in favor of saving ones who are salvageable. This is the reality. The ONE and ONLY way to avoid the need to triage is to have abundance of resources, e.g. medications, beds, ventilators, and last but not least - doctors, nurses and support personnel. When and if such abundance exists, we can attend immediately and without delay to everyone in need of care.
We are now learning that our (the US) healthcare system is short on beds, doctors, nurses, ventilators, and lacks personal protection equipment, as simple as masks, while the POTUS is touting a machine to sterilize the masks and reuse them up to 20 (twenty) times. See a separate blog in the subject.
The best and the most straightforward triage rules are adopted by military around the word.
The United States Army “Mass Casualty and Triage” guidelines spell out: “A mass casualty event overwhelms immediately available medical capabilities to include personnel, supplies, and/ or equipment”. Does this sound familiar: overwhelmed hospitals and the lack of ventilators?
“The decision to withhold care from a casualty who in another, less overwhelming situation, might be salvaged is difficult for any physician, nurse, or medic. Decisions of this nature are unusual, even in mass casualty situations. Nonetheless, the overarching goal of providing the greatest good to the greatest number must guide these difficult decisions. Commitment of resources should be decided first based on the mission and immediate tactical situation and then by medical necessity, irrespective of a casualty’s national or combatant status”.
Triage Categories
Triage is performed at each echelon of care. Traditional categories of triage are immediate, delayed, minimal, and expectant.
Immediate: This group of injured requires attention within minutes to 2 hours on arrival to avoid death or major disability.
Delayed: This group includes those wounded who will require surgery, but whose general condition permits delay in treatment without unduly endangering life, limb, or eyesight.
Minimal: Patients comprising this group have relatively minor injuries (eg, minor lacerations, abrasions, fractures of small bones, and minor burns) and can effectively care for themselves or be rendered minimal medical care.
Expectant: This group has injuries that overwhelm current medical resources at the expense of treating salvageable patients.
Special Triage Considerations
Patients who do not easily fit into the standard categories or who pose a risk to other casualties, medical personnel, or the treatment facility may require special consideration.
Wounded contaminated in a biological and/or a chemical battlefield environment: These casualties must be decontaminated prior to entering the treatment facility. Prehospital care may be provided outside of the medical facility by appropriately protected medical personnel prior to decontamination.
Retained, unexploded ordnance: These patients should be segregated immediately and treated last. See Chapter 1, Weapons Effects and War Wounds, which describes the special handling of these wounded.
Noncombatant local or third country nationals: Due to the asymmetric nature of modern warfare, these individuals may be brought into the military trauma system for care during a mass casualty event that may or may not include United States or allied forces.
Enemy prisoners of war/internees/detainees: Although treatment is based on medical necessity, it is essential that the threat of “suicide bombers” and “human booby traps” be prevented by carefully screening and disarming all casualties prior to moving into treatment areas, including the triage area.
US, allied, and third nation contractors: Although these individuals will also receive care based on mission, tactical situation, and medical necessity, it should be recognized that less stringent predeployment health assessments or requirements may permit a population with significant chronic health co-morbidity to enter a theater of war as a population at risk.
Combat stress: Rapid identification and immediate segregation of stress casualties from injured patients will improve the odds of a rapid recovery.
Resource Constraints
Triage decisions are influenced by multiple factors. Areas to consider include:
External factors: The surgeon/medic may have limited knowledge of and no control over external issues.
Internal factors: These issues are known to all medical personnel and should be factored into triage decisions.
Medical supplies: These supplies include equipment, drugs, oxygen, dressings, sutures, sterilization capability, blood, etc.
Space/capability: This category includes the number of OR tables and intensive care unit (ICU) beds (holding capacity and ward capacity), the available diagnostic equipment - ultrasound, radiograph, computerized tomography (CT) - and laboratory tests.
Personnel: This includes knowing the professional capability (type and experience of individual physician/ nurse/medic), and the emotional stability, sleep status, etc, of your personnel. This perishable resource must be preserved; for example, 24 hours of continuous operation may exhaust your only OR crew and may necessitate diversion of casualties to another facility.
Stress: Soldiers, including medical personnel, are affected by the consequences of war; individual and unit capabilities are degraded during sustained operations. The personal impact of military triage on the medical team cannot be overemphasized. It is extremely emotional, and measures should be undertaken to minimize these effects.
WHAT IS THE MAIN RULE OF TRIAGE? The most experienced physicians must be in charge, Not a nurse, resident, fellow, or a junior faculty but the PROFESSOR!