The Sorting - Life-or-Death Decisions on the Scene

Triage is a French word meaning to sort or the sorting. In the context of medical care it describes the process of sorting patients into groups in accordance with the severity of their injuries or illnesses in order to allow a judicious prioritization of care – and thereby maximize the survival of as many patients as possible by not making those wait who will not survive without intervention. In pre-hospital care there are two principal points where triage comes into play – system entry, and at the bed side. When requests for aid overwhelm the resources available, whether the medical situation occurs in a small town or a big city, life-or-death decisions must be made – immediately, in many cases – about which patient receives immediate help and who waits. During day-to-day operations triage is largely a function assigned to the 9-1-1 call center. The alternative to prioritization is to answer calls sequentially. Unfortunately, although a first-come-first-served model works well when ordering eggs or waiting in a ticket line, adherence to this same democratic model in medical situations would mean that a seriously injured patient could bleed to death waiting while others with the sniffles are taken to the hospital. Under the “call triage” model, often termed emergency medical dispatch (EMD), the caller answers brief questions that allow the most seriously injured or ill patients to be given priority over those with relatively minor non-life-threatening conditions. On scene, triage is performed by the emergency medical technicians (EMTs) and/or paramedics present, who have both the experience and the training needed to prioritize patients at the site of a mass-casualty incident (MCI) so that those with the most life-threatening conditions receive care and transportation first; those who have lesser injuries are delayed. It sometimes happens, regrettably, that those who have little or no chance of survival may receive no care. 

Special Provisions for Special Circumstances 

The definition of MCI assumes that the on-scene EMS resources available are not sufficient to care for the patients on scene. This generic definition allows the car accident with four patients involved to be ified as an MCI in a jurisdiction with Those with the most life-threatening conditions receive care and transportation first; those who have lesser injuries are delayed only two ambulances available, but requires a higher threshold to be used for a better-resourced system. While triage at an MCI is a concept well understood within the EMS community itself, the image of EMS staff walking away from some patients and treating others is distressing enough to the general public that it is incumbent on the EMS agency or policy-writing body with jurisdictional oversight to make special provisions for such situations, not only to provide legal protections for the EMTs involved but also to educate everyday citizens about the extraordinarily complex decisions involved in a true triage situation. Similarly, the documentation standards followed while operating under triage conditions should be worded to reflect the goal of stretching the EMS resources on scene to deal with the overwhelming medical needs facing the limited staff present. Many systems use documentation standards during MCIs, in fact, that require forwarding only the minimum essential information needed by downstream medical providers and, if necessary, leaving out much of the information usually provided on a standard EMS report. Larger disasters – i.e., events that rise above the MCI level and might overwhelm a larger region (and/or involve multiple locations) – may well require the use of specially prescribed disaster procedures even at the 9-1-1 call-taking level. An important factor to be considered in this context is that many states already have enacted legislation requiring that EMS agencies respond to all calls for medical assistance. However, complying with that mandate under disaster conditions may sometimes be impossible. Revised policies must therefore be written and in place, ahead of time, that permit the system to decline calls for minor ailments and injuries and, in certain well-defined circumstances, respond to life-threatening problems only. Those who must develop and enact these policies should be provided with clear guidance and legal protection, if only because experience has shown that – if the policies required are not clearly enunciated and well publicized – unacceptable problems will develop, and criticism, recriminations, and perhaps even lawsuits will follow in short order.


Links for additional information:

PreHospital Treatment Protocols General Operating Procedures

Military Style Triage (focus on putting troops back on the line)

Joseph Cahill
Joseph Cahill

Joseph Cahill is the director of medicolegal investigations for the Massachusetts Office of the Chief Medical Examiner. He previously served as exercise and training coordinator for the Massachusetts Department of Public Health and as emergency planner in the Westchester County (N.Y.) Office of Emergency Management. He also served for five years as citywide advanced life support (ALS) coordinator for the FDNY – Bureau of EMS. Before that, he was the department’s Division 6 ALS coordinator, covering the South Bronx and Harlem. He also served on the faculty of the Westchester County Community College’s paramedic program and has been a frequent guest lecturer for the U.S. Secret Service, the FDNY EMS Academy, and Montefiore Hospital.



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