Thursday, November 16, 2006


In a mass casualty situation one of the most critical operations is triage. The most skilled medic doesn't work treatment, he or she is assigned to triage. He does a quick primary survey, cursory secondary survey, as much as needed, no more and drops a tag- Red, Yellow, Green, or Black- then moves on.

The treatment medics follow up, Red patients first.

I want to go into detail here, because Triage is a critical and cold-hearted business. The ones who make the most noise or are in the most pain aren't necessarily the ones who need to be treated first. The ones who tug at your heart, especially the children, can't influence the decision. Time is critical and the time it takes to ease the pain of a Yellow tag may make the difference between a Red and Black tag for someone else. But that would be an aside, I want to write about something else.

The Categories: Immediate (Red- we can save the casualty if we act quickly enough); Delayed (Yellow- he won't die if we spend an hour or so on the Reds); Minimal (Green- the patient will be okay and can probably help with treating others); Expectant (Black- don't waste the resources, he's going to die).

The Black category gives a lot of people, including medical professionals, trouble. People who have trained their entire adult lives to save people have a really hard time turning away, and no one deep down really believes in a hopeless case. It's made even harder because in practical experience, there is almost no such thing as an Expectant case. As long as there is any sign of life, and sometimes even beyond, ER surgeons and trauma teams and paramedics in the field will move heaven and earth to keep tissues oxygenated and nodes firing. Even in cases of advanced and inoperable cancer the hospice system gives help and medication to ease the pain of the last days.

Although I think that is going too far when a dying eighty year old man wants a steak and a slug of bourbon and his nurse says it's bad for his heart. Ahem.

The Black tag means that you are moving on and leaving the person to die.

It may sound horrible, but it's even worse than that, because the triage model is driven as much by resources as it is by injury. With medevac and an operating theater available an abdominal perforation might not even rate a Red tag. Ab wounds are bad, but if there's not much bleeding the person can live for hours. Remove the medevac and make it a twelve hour stretcher carry to an LZ and the patient gets the Black tag.

With unlimited resources there are no Expectant patients. As resources dry up or numbers of caualties increase, things that could have been Red or Yellow become Black.

The Triage Officer has to know all this and has to be able to make these decisions, even if the decisions suck. If someone is going to die anyway, do you give them morphine to ease their pain? Only if you have morphine to spare, otherwise it goes to someone who has to remain still for an operation.

This is another thing about life- about letting go, about following the military maxim not to reinforce failure. There is a delicate balance in what I'm trying to say here. Medical triage exists in a place of limited time and limited resources and great demands. Most of your life doesn't. If you are willing to make the plan and do the work, you can amass almost any resources that you will ever need to make something happen.

But sometimes not. Sometimes in friendships that have turned to something else, sometimes in public policy, sometimes in trying to help someone who doesn't want to be helped, you have to drop the Black tag and move on.


  1. Anonymous11:27 PM

    Thank you for putting this into organized words for me. This is something I need to work on.