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Triage is a system used by medical or emergency personnel to ration limited medical resources when the number of injured needing care exceeds the resources available to perform care so as to treat the greatest number of patients possible.
When performed in accordance with accepted medical practices, triage is recognized and sanctioned by law in most countries.
The word triage comes from the French word trier, which means "to sort".
Much of the credit for modern day triage has been attributed to Baron Dominique Jean Larrey, a famous French surgeon in Napoleon's army who devised a method to quickly evaluate and categorize the wounded in battle and then evacuate those requiring the most urgent medical attention. He instituted these practises while battle was in progress and triaged patients with no regard to rank.
Simple triage is used at the scene of a mass casualty incident to choose patients who require immediate transport to the hospital to save their lives as opposed to patients who can wait for help later. First aiders performing field triage on the battlefield or at a disaster site usually do not need to assess resources until transportation becomes available.
In most field situations, the walking wounded are numerous. For each particular injury, a lightly-injured person can be deputized to perform a particular first-aid action for a particular severely-injured persons. For example, the first aid person might say "You. Put your hand on this wound, and press so hard that the blood stops. Like this. (demonstrates) Thanks." The START system presented below is one system used by prehospital responders and trained volunteers at the scene of a mass casualty incident.
In advanced triage, doctors may decide that some severely injured people should not receive care because they are unlikely to survive. The available care is then directed to those with some hope of survival. This clearly has ethical implications as treatment is intentionally withheld from some people with a small chance of survival so that others with a better chance are more likely to survive.
Some injuries require immediate medical care. Trauma patients in particular require a surgeon within one hour of injury, the so-called Golden Hour of emergency medicine. A surgeon can only treat one person at a time. A typical hospital has only a few surgeons available and would be overwhelmed if presented with several casualties all requiring immediate surgical care. So persons needing surgical care need to be sent to a number of area hospitals including regional trauma centers to "even out the load," especially because some victims will "self-transport" to nearby facilities which are most likely to be overwhelmed, as well as possibly damaged in the disaster.
This is where START saves lives—at the scene, people requiring surgical care are sent by helicopter or ambulance to faraway hospitals which have been warned to expect victims requiring immediate surgery and are ready to shoulder the load. This is preferable to rushing them to the "nearest" hospital which is overloaded and unable to help.
Advanced triage may become necessary when medical professionals determine that the medical resources available are insufficient to treat all the people who need help. This has happened in disasters such as earthquakes, tsunami and civil defense situations including nuclear warfare. Consider that the detonation of a nuclear weapon may inflict tens of thousands of immediate casualties, some percentage of which will die regardless of medical care due to burns and/or radiation exposure but will live for a few hours or days. Others will live given immediate medical care, but will die without it.
In this extreme case, any medical care given to people doomed to die is care taken away from people who might live if they had been given it. It becomes the unpleasant task of the disaster medical authorities to set aside some victims (especially burn victims) because it would take a staff of several professionals ten days to save their one life at the expense of several dozen other lives.
START (Simple Triage and Rapid Treatment) is an expedient triage system that can be performed by lightly-trained lay and emergency personnel in emergencies. It is not intended to supersede or instruct medical personnel or techniques. It may serve as an instructive example, and has been (2003) taught to California emergency workers for use in earthquakes. It was developed at Hoag Hospital in Newport Beach, California for use by emergency services in Orange County, California. It has been field-proven in mass casualty incidents such as train wrecks and bus accidents, though it was developed for use by CERTs and firemen after earthquakes.
Triage separates the injured into four groups: The DECEASED who are beyond help, the injured who can be helped by IMMEDIATE transportation, the injured whose transport can be DELAYED, and those with MINOR injuries—the walking wounded who need help less urgently. Other regions may use different designations. Use the designations of your area.
Simple triage identifies which persons need advanced medical care. In the field, triage also sets priorites for evacuation to hospitals. In START, persons should be evacuated as follows:
In advanced triage systems, typically implemented by paramedics, battlefield medical personnel or by skilled nurses in the emergency departments of hospitals during disasters, injured people are sorted into five categories. "Tear-off" tags are sometimes used for this purpose.
They are so severely injured that they will die of their injuries, possibly in hours or days (large-body burns, severe trauma, lethal radiation dose), or in life-threatening medical crisis that they are unlikely to survive given the care available (cardiac arrest, septic shock); they should be taken to a holding area and given painkillers to ease their passing.
They require immediate surgery or other life-saving intervention, first priority for surgical teams or transport to advanced facilities, "cannot wait" but are likely to survive with immediate treatment.
Their condition is stable for the moment but requires watching by trained persons and frequent re-triage, will need hospital care (and would receive immediate priority care under "normal" circumstances).
They will require a doctor's care in several hours or days but not immediately, may wait for a number of hours or be told to go home and come back the next day (broken bones without compound fractures, many soft tissue injuries).
They have minor injuries; first aid and home care are sufficient, a doctor's care is not required ("Go home!").
Note that this scale is much more complex than with simple triage. Medical professionals should refer to professional texts and training references when implementing advanced triage; this listing is only for a layperson's understanding.
Some crippling injuries, even if not life-threatening, may be elevated in priority based on the available capabilities. During peacetime, most amputations may be triaged "Red" because surgical reattachment must take place within minutes—even though strictly speaking, the person will not die without a thumb or hand.
In France, the triage in case of a disaster uses a four-level scale:
This triage is performed by a physician called médecin trieur. This triage is usually performed at the field hospital (PMA–poste médical avancé, i.e. advanced hospital). The absolute emergencies are usually treated onsite (the PMA has a surgical room) or evacuated to a hospital. The relative emergencies are just placed under watch, waiting for an evacuation. The involved are adressed to another structure called the CUMP–Cellule d'urgence médico-psychologique (medical and psychological emergency unit); this is a resting zone, with food and possibly temporary lodging, and psychologist to take care of the brief reactive psychosis and avoid the post-traumatic stress disorder.
In the emergency room of a hospital, the triage is performed by a physician called MAO–médecin d'accueil et d'orientation (reception and orientation physician), and a nurse called IOA– infirmière d'organisation et d'accueil (organisation and reception nurse).
In addition to the standard practices of triage as mentioned above, there are conditions where sometimes the less wounded are treated in preference to the more severely wounded. This may arise in a situation such as war where the military setting may require soldiers be returned to combat as quickly as possible, a practice associated with the Russian military. Other possible scenarios where this could arise include situations where significant numbers of medical personnel are among the affected patients where it may be advantageous to ensure that they survive to continue providing care in the coming days especially if medical resources are already stretched.
If you present yourself for medical care during a disaster, please understand that the quality of care will be much lower than usual for persons whose lives are not in danger. You may have to wait several hours. Once you get to the front of the line, the care you receive may be cursory and brief and you may be asked to come back in several days.
See also: first aid, wilderness first aid, emergency medical services, emergency medicine, battlefield medicine
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