You’re the first-arriving ALS unit at a scene where a man opened fire into a crowd with a handgun. The shooter is taken into custody, and the scene is secure. You grab your triage tags and begin to triage and tag.
You find seven patients: Patient #1 is unconscious, has a massive gunshot wound (GSW) 1" above his left eye and stops breathing as you’re assessing him. Patient #2 was hit in the chest and is gasping for air. Patient #3 was hit in the left femur and is bleeding profusely. Patient #4 is dead. Patients #5 and #6 have GSWs to their abdomens. Both are in severe pain and apparent shock. Patient #7 has a small laceration on her chest from a ricocheted bullet fragment, is hysterical and is breathing 30 times a minute.
Sounds easy enough; you were taught to use a triage algorithm that places patients with certain vital signs and presentations into nice, neat triage categories. However, as you start to place red tags on multiple patients, you realize you’re in a rural area, your other units are tied up on different calls, and dispatch reports that the next ambulance won’t arrive for at least 15 minutes. Now what? Nobody ever taught you that you might have to adjust your triage decisions based on resource limitations and time delays.
The fact is many systems teach triage via algorithms and matrix-riddled triage tags. They don’t teach triage as a multivariable process, which necessitates that, during assessment and tagging of patients, you consider what resources are available and how long your patients are going to be delayed before being transported.
I teach “RAT Triage” (resources and time factors of triage). RAT is a mnemonic that’s short and easy to remember, and it’s useful to remind you to adjust triage decisions according to resources and time parameters.
Time and location are important factors because, despite your best efforts and resources, if time isn’t on your side, some patients won’t survive. If you’re in a rural area and have two patients bleeding out from massive abdominal (internal) wounds, like patients #5 and #6 above, you have to factor at least 20 minutes for triage/transport into each triage decision. This is because it usually takes us about 20 minutes (on a good day) to get patients like this assessed, treated, packaged, loaded and off to the hospital. And, if you add in travel time, it’s not unusual to find total time from first contact to hospital arrival of 60 minutes from MCI locations.
So, before you decide on a triage priority and tag the patient, you should ask yourself, “Can this patient survive for 60 minutes knowing what I know about the resources available, the patient’s condition and time to get them to definitive care?”
If ambulances aren’t yet on scene and a patient’s vital signs are already lousy, making decisions based on multiple variables also helps you proceed with tagging them as “delayed,” or shipping out the more salvageable patients first.
Resource consideration is equally important, because you’ll miss opportunities to save some patients if you use only algorithm and assessment parameters to triage patients, failing to consider the depth and availability of your resources. Many triage schemes would have you “write off” a patient as non-salvageable if they have a severe head wound and stop breathing, no matter what the setting. However, if you’re deep with resources and can get the patient to a trauma center in less than 10 minutes, that patient may have a chance of survival.
Such was the case when John Hinckley, Jr., fired a handgun into a crowd in Washington, D.C., on March 31, 1981, and inflicted a massive head wound on former President Ronald Reagan’s press secretary, James Brady. Because EMS resources were immediately available, Brady, critically wounded and lapsing into respiratory arrest, was treated and transported, and he survived. In many systems he would have been black-tagged and allowed to expire.
A similar triage “save” occurred in Oklahoma City after the April 19, 1995, bombing of the Alfred P. Murrah Federal Building. An EMS Authority (EMSA) crew found a patient with a severe laceration and crushed trachea to the rear of the structure, away from most triage activity. The patient stopped breathing as they were assessing him.
In many systems, this patient would have been tagged dead; however, because of abundant EMS transportation resources and limited patients early in the incident, the EMSA crew was allowed to “work” the patient and saved his life.
I hope I’ve been able to provide a different perspective on the concept of triage. I also hope that the next time you’re confronted with multiple patients and have to make important triage decisions, you’ll “RAT them out” by adding consideration of time, distance and resource availability into your triage process. JEMS
This article originally appeared in May 2010 JEMS as ‘Rat’ Race:
You must factor resources and time to your triage formula.