The notion of triage is somewhat problematic and debatable, as well as impregnated with difficult ethical and moral questions. During World War II, a battlefield nurse was given the responsibility of triage, i.e., dividing patients into three groups: patients with minor (non-life- or non-limb-threatening injuries) who do not need immediate attention, patients in critical condition who can mostly benefit from immediate care, and patients beyond hope who will not be treated (Frykberg 2002). Similar principles are applied in modern medicine for disaster triage, with emphasis on the fact that the essence of triage is to identify the few critically injured who can be saved by immediate intervention among the many others with non-life-threatening injuries, for whom treatment can be delayed.
The generally accepted principles of triage for mass casualty scenarios divide patients into four groups (Frykberg 2002; Jacobs et al. 1979).
1. Patients with life-threatening injuries requiring immediate and expeditious intervention in terms of the ABC care principles: airway compromise, breathing failure (tension pneumothorax, open chest wounds), and/or circulatory compromise from ongoing external hemorrhage.
2. Patients with severe but not life-threatening injuries, in whom treatment can be acceptably delayed, including fractures, vascular injuries of the limbs and soft tissue wounds.
4. The most severely injured patients, for whom treatment would require allocation of resources and time that would prevent other more salvageable patients from receiving timely care. These patients are expectantly treated and reevaluated when resources become available. This group generally includes patients with severe head injuries, open skull fractures, extensive open brain wounds and patients in cardiac arrest. There is no absolute definition for the patients composing this group, who will not receive treatment initially, because triage is always to be individualized according to the existing number and severity of casualties related to the available medical resources.
The triage concept is basically in contradiction with the day-to-day principles of care, dictated by the ultimate goal of providing maximal and optimal care for any individual patient. However, in mass casualty scenarios, triage becomes legitimate as the goal changes to that of providing the minimal acceptable treatment to the maximal number of salvageable patients. Triage should therefore be implemented only in extreme situations and only as a temporary process, until further re sources become available and the number of victims is clarified.
Stein and Hirshberg (1999) advocate a slightly different approach to triage by classifying victims into urgent and nonurgent groups. These authors advise against placing patients into the "expectant group" (unsalvage-able patients that receive no immediate treatment) unless the victim succumbs within minutes after arrival.
Normally, immediately after a disastrous event in a civilian area, during the immediate chaos phase, family members and bystanders evacuate 5 % -10% of the injured to the nearest hospital (Kluger 2003). Only subsequently, with the arrival of trained emergency medical services, is primary triage actually initiated on site with prioritized evacuation of the victims. Einav et al. (2004) described the importance of rapid primary triage, initiated within seconds or minutes after the event and conducted by experienced medical teams with minimal medical intervention and immediate evacuation to the nearest hospital. The preferred location for primary evacuation should be dictated by the condition of the patient and by the distance of each facility from the location of the event. However, there is an ongoing uncertainty in the literature regarding what is of higher priority: distance or expertise (Spira et al. 2006). While most patients will survive no matter where they are taken, there is a certain subgroup of severely injured victims who will benefit from being transferred to designated level I trauma centers (Stein 2006). Although no study showing improved outcomes in those level I centers is prospective and randomized, it seems that patients with severe head injuries and those with combined multisystem injuries will fare better there (Spira et al. 2006; Stein 2006).
The secondary and most important triage is performed at the trauma center or any other medical facility receiving the mass casualties. Almogy et al. (2004) and Kluger et al. (2004) described a model of "modern-day triage" implemented by the trauma system in Israel for terrorist bombing disasters. Accordingly, triage is performed by the most experienced trauma surgeon that does not take part in surgical or resuscitation procedures but exclusively triages patients according to the above-mentioned principles. Additionally, the same surgeon in charge is responsible for directing consultants from other specialties, urologists included, and assigning them as responsible for specific patients as dictated by their specific injuries. After all the victims have undergone triage, repeated reassessments are conducted by the senior surgeon and patients are relocated as needed. This secondary triage is intended to correct mistakes and the authors emphasize the importance of this repeated assessment in order to avoid un-dertriage resulting in catastrophic results, i.e., conditions such as blast lung injury that are not obvious within minutes of the explosion but eventually deteriorate to respiratory failure and death if not immediately treated by intubation and ventilation. On the other hand, overtriage, i.e., patients assigned for immediate care and eventually found not to have critical injuries, has negative and possibly disastrous implications in mass casualty events, as precious resources are misdirected and consequently the chances for survival of other critically injured casualties are eventually reduced. The early mortality of severe trauma shows a bimodal distribution with the first peak occurring within the 1st h (50 %) and resulting from airway and breathing problems, while the second peak is taking place 1-6 h after admission (18%) resulting from failure to control bleeding and the consequent physiological deterioration (Spira et al. 2006).
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