Mr. Editor:
The first part of the Kathy S. article was well done in describing potential scenarios and the medical problems with triage. I would take issue with her triage system and her method for establishing the categories. The standard civilian approach is that of Advanced Trauma Life Support (ATLS). It has been used and taught in the military. In a mass casualty situation, it requires establishing who has the best chance of survival within the constraints of time, manpower and materials. I am a retired Army physician (non-surgeon) who has been an ATLS instructor for many years prior to retirement. The military system uses ATLS but has the Special Operations Forces Medical Handbook as the gold standard for survival medicine. The 2001 edition was written by a friend who insisted that all of the specialist contributions use a common terminology so that the electronic version could be searchable. It has some exceptions to the ATLS model in special situations. It also has interesting information about how to do an appendectomy or to make jerky.
The first part of triage is the Primary Survey that establishes the basic medical points about a patient. These are the ABCDE’s as follows:
A—Airway (including cervical injury)—can the person talk or breathe? This is always priority one and sometimes is readily correctable and life-saving. Severe face injuries may obstruct the airway and be easily corrected. Sometimes tilting the neck back can open up the airway if no cervical injury is apparent (otherwise lethal). An emergency tracheotomy might be possible with little skill.
B—Breathing—is the chest moving and air being exchanged. Certain chest wounds could lead to a tension pneumothorax that identified could be readily corrected with a needle. It and cardiac tamponade might be difficult to distinguish without more advanced medical knowledge. Cheyne-Stokes respiration would indeed be a pre-terminal event.
C—Circulation—includes bleeding that may or may not be easily controlled. ATLS discourages tourniquets on the assumption of low velocity bullet wounds and access to advanced trauma care. The SOFMH allows for
tourniquets when those assumptions are not met. They should be loosened periodically to spare a limb. Abdominal bleeds require much more intensive time, manpower and supplies than might be available. IVs are needed to prevent shock if possible. Some use of oral water may help if it can be consumed without choking, vomiting or aspiration.
D—Disability (Neurological evaluation)—assessing level of consciousness would be difficult for most with little medical knowledge to assess but clearly deterioration could be noted. More advanced facilities would be required to treat, even acute epidural hematomas.
E—Exposure—covers environmental issues such as temperature, toxins, radiation, etc.
The triage system that I would favor would be a simpler one of I, D, and E. It would be a situational determination in part and can shift with changes in circumstances.
I—Immediate is the highest category within the resources available. An airway might be simple, quick and life saving.
D—Delayed is the category of salvageable people to be treated as time and resources permit. It would also include the walking wounded, those with minor injuries who should wait on others with more serious injuries. These should not be the top priority as Kathy S. suggested.
E—Expectant is a euphemism for those who cannot be helped in the given situation. They should be cared for humanely by people available who can comfort and be a human presence to those not likely to survive. This helps keep bystanders busy who want to help but keeps them out of way.
Obviously a lot of medical knowledge can quickly be required along with supplies. One needs this training and the supplies to deal with it. There is no easy way to cover all of these issues or all of the field expedients that might be helpful. The first key is the Primary Survey and the triage designation to be able to proceed. – Steve T., M.D.