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• Accurate ethical triage
  Giles N Cattermole
  Published on: 29 April 2016

• Published on: 29 April 2016

  Accurate ethical triage

  • Giles N Cattermole, Assistant Professor

  Arbon and colleagues [1] helpfully demonstrate the differences between major incident triage as taught on courses such as MIMMS [2], and that practised ¡§in the real world¡¨. I have two concerns however.

  Firstly, the authors incorrectly suggest that the role of ¡§scanning and sweeping¡¨ before undertaking triage has been de-emphasised in current teaching. In the MIMMS course, the mnemonic ¡§CSCATTT¡¨ places the ¡...

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  Arbon and colleagues [1] helpfully demonstrate the differences between major incident triage as taught on courses such as MIMMS [2], and that practised ¡§in the real world¡¨. I have two concerns however.

  Firstly, the authors incorrectly suggest that the role of ¡§scanning and sweeping¡¨ before undertaking triage has been de-emphasised in current teaching. In the MIMMS course, the mnemonic ¡§CSCATTT¡¨ places the ¡§A¡¨ of assessment ahead of ¡§T¡¨ for triage and this is firmly reinforced in both the manual and the course. An estimate of the number and type of casualties, hazards and so on, before triage, is emphasised strongly in current teaching.

  Secondly, the authors conclude that a complex process of paramedic decision making expanding beyond physiological parameters is preferable to ¡§theoretical models¡K such as triage sieve and sort¡¨. When time is available, triage can and does involve elements such as mechanism and anatomy of injury, and the experience of senior clinicians. This is described in MIMMS as secondary triage, and is concerned with subsequent patient disposition. However, triage sieve (and the American ¡§START¡¨) are both simple, rapid, repeatable, objective primary triage systems that are performed in the initial few minutes when immediate life-threats must be identified and prioritised without delay.

  Physiological primary trauma systems are based on the best evidence available, despite the difficulty establishing robust evidence in mass casualty incidents. Until there is evidence that other factors predict imminent mortality better than physiology, it would be dangerous to add subjective elements to the critical process of initial life-saving triage.

  Whether one approaches triage ethically from a utilitarian or an egalitarian position, the strongest imperative is simply to save the most lives.[3] To do this, triage should accurately predict which patients need the earliest life-saving intervention. But it should also minimise any subjective bias on the part of the practitioner, especially bias according to gender, race, age, disability, social usefulness or past merit. If practitioners move ¡§beyond¡¨ triage systems which focus solely on immediate life-threat, and instead apply ¡§gut-feeling¡¨ or subjective experience there is a danger that triage will be both inaccurate and unjust.

  It is important to appreciate the differences between what is taught and what is practised, and understand the reasons for those differences, but we must not assume that departure from what is taught is a sign of good or mature practice. Effort should be made instead to explain the ethical and clinical importance of accurate triage so that practitioners understand the need to follow standardised and simple protocols that save the most lives, and research must continue to improve our methods of primary triage.

  References

  1. Arbon P, Zeitz K, Ranse J et al. The reality of multiple casualty triage: putting triage theory into practice at the scene of multiple casualty vehicular accidents. Emerg Med J. 2008;25:230-4.

  2. Advanced Life Support Group (2002). Major incident medical management and support: the practical approach at the scene (2nd ed). London: BMJ, 2002.

  3. Winslow GR. Triage and justice. London: University of California Press, 1982.

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  Conflict of Interest:
  None declared.

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