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Useful Notes / Triage

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Simplified Triage tags. Real Life ones are far more comprehensive.
Triage is a system where in a mass casualty event such as an earthquake, hurricane, nuclear accident/attack, major military attack, disease outbreak, chemical release, etc. that causes enough casualties to overwhelm the available medical facilities, medical personnel divide patients into classifications in order to make the best use of the limited resources available to save as many lives as they can. The word, derived from the French verb trier, means "to separate." The broad goal is to sort patients into three categories:

  • Those who are likely to live regardless of care they receive;
  • Those who are unlikely to live regardless of care they receive;
  • Those for whom available medical care will make a difference in ultimate outcome.

Analysis of the nuances and variations between different countries and emergency services as well as the different criteria used by military and civilian medical units is beyond the scope of this article (see The Other Wiki [1]), so by necessity this is a basic description. Hospitals in particular may use a half-dozen codes or more once specialty codes (i.e. children) are included. The coding used here is for a mass casualty incident following the START system that is widely recognized in the United States.

Mass casualty triage (e.g. disaster or major terrorist attack) and ordinary hospital triage (e.g. medical dramas) are not the same thing. Under normal circumstances, medical decisions are "most seriously injured" = "treated first". In a mass casualty event, this can increase the number of deaths by allocating too many resources to one person, so a different set of criteria is used. The ethical consideration is that futile care in such a situation is the exact same thing as consciously withholding care from people with better survival prospects.

One more thing that is important to understand for mass casualty triage is that, unlike a hospital assessment, it is intended to be conducted by minimally trained individuals. It's one of the first things that has to happen at a mass casualty event, so the people making life-or-death judgments do not have diagnostic equipment and are not necessarily paramedics. They may be the first police officer on the scene, the relatively uninjured infantry soldiers after a post was hit with an airstrike, or even civilian CERT volunteers. Since this sorting can literally mean "life or death," there is a strong bias to "overtriage" (Yellow or "expectant" Black as Red) rather than "undertriage" (Red as anything else), often put as an order of magnitude where a 25-50% overtriage rate is acceptable to keep undertriage to less than 5%. The former is not ideal, but can be fixed later; the latter almost certainly means someone dies.

Casualty Types

  • Green / Minor - These are patients who require medical treatment, but are not in danger of death or major complications, and can be instructed to go to a safe area, manage their injury, and return the next day for actual treatment, or return to the treatment area if their condition significantly worsens. E.g. Simple broken bone, deep cut that has stopped bleeding but will require stitches, first degree burns. This can also be thought to include people who are shaken up or have only superficial injuries, as the point of triage is to quickly decide who needs resources most; Greens will not receive detailed examination. In some cases they may be asked to help around the hospital, for instance carrying people who can not walk by themselves.
  • Yellow / Delayed - These are patients who need major medical attention to either survive or have a reasonable quality of life in the future, but are stable enough to wait until Reds are treated. They would be transported to the hospital by ambulance and be a high priority in the emergency department in normal circumstances. On the START tag, yellow is "delayed." E.g. Compound fractures, head/eye injuries, single gunshot or flying debris wound that can be controlled.
  • Red / Immediate - These are patients who need major medical attention immediately because they are not stable enough to wait, but have a good chance of survival if such care can be delivered. These people will very likely die within the hour if not stabilized, or if mislabeled as "Yellow". Casualties may move back and forth between Red or Yellow, as the difference is mainly how badly someone needs treatment at that moment, not that they do ultimately need major help. E.g. Hemorrhage, traumatic amputations or crush injuries, unresponsive but with pulse, severe difficulty breathing, extensive but survivable burns.
  • Black and/or Blue / Dead/Expectant - Dead or "expectant" (no level of care will help, pain medication only). In a triage situation, anyone with no pulse/no breathing after checking the airway is tagged as "Black", even if under normal circumstances it's possible they could be revived— resuscitation takes a lot of resources, has a minimal success rate outside a hospital, and even in the best case, the injury that caused loss of pulse is likely catastrophic and still exists. Includes casualties with injuries so severe as to be incompatible with life— decapitation, severe brain trauma, evisceration, etc. In some situations, people still living might be coded this— if they were suffering from a condition that, while not immediately fatal, is untreatable and will result in death, e.g. acute radiation dose exceeding lethal levels, symptomatic rabies.

While rare or unheard of on large scale in the modern world, "untreatable" can also apply to "required resources are destroyed or not plausibly accessible." Major internal injuries/hemorrhage without access to a hospital, extensive 3rd degree burns in a nuclear war, that sort of thing. Many, many large-scale disaster movies and novels implicitly get into this territory even if not depicting a Apocalypse How. At a level beyond that are decisions such as "prioritize those under 55 in good overall health."

Under normal (i.e. non-mass casualty) circumstances, triage is practiced routinely in emergency departments and by EMS personnel; accurate medical or police/EMS dramas should have this. It's worth noting that these two systems do not always mesh with each other. EMS in North America use a three-tier priority system, whereas nearly all hospital emergency departments worldwide use a five-tier system. However, practically everyone everywhere can agree on the following:

  • Priority 1 / Code 3: Life threatening emergency. These can range from CPR in progress, to active heart attack, respiratory failure or stroke, to major trauma.
  • Priority 2: Emergencies that are not life threatening... yet... but will be if not treated ASAP. Examples include sepsis (a laundry list of deadly bloodstream infections), severe head pain, most traumatic injuries, and severe respiratory disease that hasn't yet progressed to failure.
  • Priority 3 / Code 2: Emergent, but not deadly. Most abdominal pain and chest pain complaints— unless they're of the Hollywood Heart Attack variety, in which case see Priority 1.
  • Priority 4 / Code 1: Urgent but not emergent. Lacerations, orthopedic injuries (breaks, dislocations, sprains/strains), and minor complaints. For liability reasons, Priority 4 / Code 1 is the lowest typically assigned priority code in emergency medical care.
  • Priority 5: Non-emergent. Suture removals, medication refills, drug and alcohol tests (by court order) for police, and pregnancy tests (yes, people really do go to the Emergency Department for a test you can do yourself at home for less than $5.00) fall into this category.

Obviously, this is a Cold Equation that requires hard decisions by medical personnel— it's not easy to follow dispassionate criteria like these when you have people all around you screaming for help, but it's a necessary evil. Many times, particularly following a disaster, triage comes down to a cold, often brutal calculation based on the available resources— what Sir Terry Pratchett called "the dreadful algebra of necessity". Triage professionals have The Needs of the Many down to an art form. It is Truth in Television that non-objective considerations (e.g. parents of badly injured child, high levels of personal involvement or resource investment in a now deteriorating case, casualty is a fellow first responder or doctor) will make this more difficult.

Works where Triage (or its equivalent) are present:

  • In The Belgariad, during the Battle of Thull Mardu, as casualties mounted, only soldiers with some chance of survival were treated— the mortally wounded were given a infusion of herbs to ease their pain and left to die.
  • In The Day After, those who have received lethal doses of radiation from the fallout are given black ribbons even while they are still living, to mark them as being "treatment for this person is useless."
  • Code Black hammers home the brutality of field triage in the two-parter "Black Tag"/"The Fog of War", including a rather hair-raising discussion of what happens when medical personnel break these rules trying to save someone who is too far gone.
  • Triage is a war drama with Colin Farrell.
  • In Tokyo Magnitude 8.0, a character is left in critical condition after receiving a injury. We don't learn their exact fate until a couple of episodes later, in which we see in a flashback a doctor giving him a black triage tag.
  • The series finale of Flashpoint is a two-part episode involving a serial bomber. The team of emergency responders gets to one of the bomber's targets too late to stop the bomb, and arrive in chaos and confusion as smoke, debris, and injured people are everywhere. The team leader tells the team to prepare, and they all pull out triage tags of various colors before starting to move through the area.
  • Triage comes up frequently in M*A*S*H when a large number of wounded arrive at the same time and the doctors have to prioritize which ones need to go into surgery first. Often one or two of the doctors will organize the triage while the others start prepping for surgery.
  • Trauma Team: In Maria Torres's gameplay segments, triage tags are used to determine patients' current vital levels. Green (III) represents patients with high vitals, yellow (II) represents patients with depleting vitals, red (I) represents patients with critical vitals, and black (0) represents deceased patients. With this information, players must juggle providing first response treatment to multiple patients.
  • The novel The Dorset Disaater has people being triaged after a nuclear power plant explosion. The less sick are separated from the severe cases so the severe but still treatable cases can be flown to hospitals that can accommodate them.