The Research
Koziel JR, Meckler G, Brown L, et al. Barriers to pediatric disaster triage: A qualitative investigation. Prehosp Emerg Care. 2015;19(2):279—286.
The Science
Training for disasters by EMS providers is focused on efficient and accurate triage of both adult and pediatric patients. The authors conducted pointed interviews of 34 paramedics following their participation in a 10-victim house fire simulation that required them to rapidly triage children with various trauma severity and special needs. Half of the paramedics were students with minimal experience and the other half had an average of six years on the job. The authors then categorized what they concluded to be barriers to pediatric triage in this simulated environment, including lack of familiarity with children and their physiology; challenges with triaging children with special healthcare needs; emotional reactions to triage situations such as a mother holding an injured or dead child; and training limitations such as poor simulation fidelity.
Medic Wesley Comments
Mass casualty incidents are always chaotic. Preparedness, planning and exercises make us familiar with the process, but are often like a video game–we know we can use a cheat code and come back to life. There’s always another game to improve our score.
The actual event of any true incident is overwhelming, even with sufficient resources. EMS response is tiered, with crews arriving at separate times trying to get caught up or filled in. That’s the reality. Add the most vulnerable patients–children–into the mix and all bets for order are off.
There are providers who can get through the situation, direct others who are stuck in indecision, and eventually gain control. There are others who will never get past the first pediatric patient.
There’s no practice or preparation for what our mind and memory holds in these cases. Having one triage system for adults and children has to be found, so the process is automatic. Until then it will only work on paper, even with extensive training. But once it’s real, there will always be stumbling blocks and barriers because we’re all individuals.
Add the most vulnerable patients–children–into the mix, & all bets for order are off.
Doc Wesley Comments
While this wasn’t a rigorous study and the number of participants was small, I applaud the authors for exploring what they term “barriers” to pediatric disaster triage. However, I’m going to go out on a limb and say these aren’t simply “barriers” that can be overcome by more education, training and fancier simulators as the authors suggest. Instead these are absolute roadblocks that will, in all likelihood, never be overcome.
We’re fortunate to live in a country where major disasters both natural and man-made are relatively rare and, when they do occur, often affect only a small percentage of EMS providers. Initial response at the scene is chaotic and fueled more by the desire to get everyone as far away as possible regardless of their supposed triage level of green, yellow or red. The greens all run and usually help carry the yellows and reds with them. Only those trapped are likely to require on-scene triage, and by that point the number of rescuers far outnumbers the injured. The priority then won’t be on who gets transported first but who can be freed the fastest.
I know my opinion won’t be popular by those who believe in the strict use of START (simple triage and rapid treatment), SALT (sort, assess, lifesaving interventions, treatment/transport), or some other triage scheme. I do believe in the value of unified command and the incident command system.
Unfortunately, there’s little evidence that hours of applying any triage criteria to mass casualties will improve their care. It’s simply theoretical. To ask an EMT to tag a dead child in their mother’s arms as black and walk on is to divorce oneself from the very essence of what drives us to do this job; our humanness. Instead, we need to invest in training that improves our emotional resilience so that we can endure exposure to such events. We need better ways to monitor our emotional health and acknowledge our fears and insecurities. No matter how well we think we may be able to apply some form of triage, our providers will always question their actions and lay awake at night wondering, “What if.”
