The concept of resource-based decision making would seem to be basic to the practice of medicine and especially emergency medicine and disaster medicine. Unfortunately the reality is that in the United States of America and, actually in most industrialized nations, medical care decisions are not resourced-based, they are emotionally-based. And this works in all but the most dire of circumstances.
Unfortunately more and more in a world now awakened to the dual threats of terrorism and natural disaster resource-based decision making, i.e., triage, is becoming a skill not only needed but oft found lacking.
Now in the short period of this article there is no way that I can describe the full process of integrated triage. Suffice it to say that triage is an ongoing event. It occurs repeatedly during the entire patient encounter; the entire time that a person is seeking and receiving medical care from the moment they first approach until the moment that they finally leave the care environment.
The first application of this continuous integrated triage approach occurred at the Louis Armstrong International Airport in New Orleans, Louisiana. At 1:38am on August 31, 2008 the governor’s order accepting federal disaster assistance for Louisiana was signed by then Governor Blanco. As part of a Disaster Medical Assistance Team (DMAT-FL3) attached to FEMA through the National Disaster Medical System I arrived to my duty station as part of the first contingent of medical providers to arrive at the airport in New Orleans. Intelligence reports had indicated that there were only a small number of evacuees sheltering at the airport, but when our advance team arrived, they were met by 5387 people awaiting assistance aided by a contingent of health department nurses and the staff of the airport. The advance team arrived before daylight and established five medical treatment areas and a command post in Concourse D. The remainder of the first medical contingent would arrive at 9:30am, unfortunately the helicopter flight line became active on order from the Louisiana State Emergency Operations Center at 7:00am. The flight line quickly blossomed to 3 aircraft wide and 5 rows of aircraft deep, delivering up to 540 people per hour.
When the remainder of the medical contingent arrived at 9:30am, we were assigned to various medical treatment area and the flight line. After only a brief time, I was reassigned to revamp triage at of the 5387 people inside the airport and the throngs arriving by air and ground.
The approach I introduced utilized a combination of MASS and START triage beginning with gross the observations,
Can the patient walk?
Do they follow commands?
Do they know who they are, where they are and why they are here?
I accomplished this by announcing, “If you can head the sound of my voice, follow these officers to Concourse A,” remember we were in Concourse D. Eighty percent of the evacuees walked to Concourse A. I then announced, “If you could not walk to Concourse A,
Progressing to basic physiology:
Are they breathing?
Do they have a pulse?
Can they follow commands?
And finally including more detailed information:
Why was the patient actually brought for care?
What happened to them?
What are their expectations?
Unfortunately most triage ends the first time that last question is asked. In the daily practice of triage in the emergency room and in medical practice the process stops here. Nobody goes back to ask the questions again. For triage to work the way it is intended, we must integrate it into our minds and into our moment-to-moment medical practice.
At first glance, this would seem to be a minor problem; something that can easily be corrected with a small amount of practice. Unfortunately that is far from the truth. In fact as integrated triage is taught around the nation we are discovering a disturbing trend.
While healthcare providers readily embrace the idea of continuously reassessing their patients (in fact nurses have done this for decades) the idea of re-categorizing patients, particularly those in the most dire of need, is still greatly emotionally laden.
There are reports now servicing of facilities that refuse to categorize any patient as anything less than absolutely critical until a full physical examination, laboratory evaluations and even CT Scans have been done. At these institutions the entire concept of triage, sorting the masses so that the most good can be done for the most people, has been lost. They are not performing triage. They are jumping straight into treatment.
Of even greater concern are a few isolated reports of facilities refusing to allow providers to bypass patients for whom there are not resources immediately available. It is always emotionally difficult for a healthcare provider to acknowledge that under different circumstances they could save. A life that today may be lost simply because there are too many people to care for. This one individual is too injured to save when compared to the good that can be done for so many more. Unfortunately, when victim counts soar, fatalities soar as well. This is the very decision that a disaster medicine professional must make. This is the decision that falls to the professional handling triage.
Most often referred to as “black tag” patients who are “expectant”, those who require more resources than are available and prudent to utilize for one person at this time. These expectant patients are often heartrending and more sadly for both patient and the provider under different circumstances are most often people who can be treated and saved. But on this day in these circumstances they must be “set aside”.
The problem comes in that healthcare professionals today do not understand that although set aside these patients are not abandoned. A “black tag” is not a death warrant. It is not a “Do Not Resuscitate” order. It is not an order to abandon all care. Expectant patients still receive comfort care, compassion, and human dignity. They are still continuously re-triaged and as resources come available. They are brought back into the treatment mix.
In the Louis Armstrong International Airport in New Orleans, following Hurricane Katrina during the first five horrendous days of triage and treatment of tens of thousands of patients and evacuees, only 38 individuals were placed in the expectant category. Of these 38, 36 were ultimately re-triaged, treated, stabilized and sent on to hospitals outside of the state of Louisiana. All 36 of these individuals survived those harrowing days in the airport. Two people did die. In both cases these individuals already had known terminal disease. They were in fact in hospice care before the hurricane. One of these brave souls even refused transportation to allow somebody who had a “better chance” to go ahead of them. These two “expectant patients” died in the airport. At the time that they died they were the only two people left in the expectant treatment area. They each had their own nurse provided by the responders at the facility. Each of them had family members at their bedside and local volunteers to sit with them.
In the case of each of these individuals, after they died their families commented that they had received better care in the Louis Armstrong International Airport following a hurricane than they would have received at home; not because hospice was in any way incapable but because in the airport they each had their own nurse. Doctors came and saw them four times a day. They each had their own volunteer and their family crowded around them.
The dreaded “black tag” given to the expectant patient is not a death warrant. It is an opportunity for the healthcare professionals and that patient to do the most human thing possible when part of an overwhelming situation, it is an opportunity to think about others first.