Sorting It All Out: Triage, CERT, and EMS

The ideal groups to handle any mass-casualty incident (MCI) affecting any community are the existing emergency medical services (EMS) agencies and other medical/healthcare resources available in that community. Unfortunately, though, there are disasters every year that overrun these resources. The federal government has sponsored a number of programs to address that problem, among them the CERT (Community Emergency Response Team) program, which recruits and trains everyday citizens to assist the response community in times of crisis.

Triage, French for “the sorting,” is a process wherein multiple patients are quickly prioritized for healthcare treatment and, in that context, can be thought of as a filter. The first and usually only filter in a non-disaster triage situation is the question “Who gets treated first [to maximize the number of survivors]?” The triage sorting carried out at the scene of a multi-casualty disaster is different, though. The first filter in an MCI context is a more difficult but unavoidable question: “Are they [a group of patients suffering from what seem to be extremely severe injuries] likely to die without immediate and resource intensive care?”

If the answer is “Yes,” those patients usually will receive no care until other patients with a greater chance of survival have been treated. This emotionally difficult structure seeks to avoid using scarce medical resources to help one or two patients who have a low likelihood of survival rather than using those same resources to care for a larger number of patients with a better chance for survival.

True Life-or-Death Questions

Once the decision is made to treat a patient, though, urgent life-saving care is rendered immediately. The second screen in the disaster triage process, therefore, is yet another question: “Among those deemed savable, who gets treated first [again, to maximize the number of survivors]?” The answer to that question, of course, is used to determine the priority list.

Triage is obviously one of the most important components of the standard on-line training provided to CERT team members. Among the other key components of that training are instructions in life-saving processes such as airway management and bleeding control, both of which help prepare CERT members to render the type of care prescribed during the triage sorting.

CERT members also are trained in disaster operations, and in this training are introduced to the Incident Command System (ICS). This allows them to interface with emergency responders in a way that promotes a unity of action and command. Partly for that reason, CERT team members are probably the best option available to on-scene decision makers to use for triage operations during a mass-casualty event.

The ABCs of Successful Triage

Probably the hardest part of training medical staff and first responders to perform triage is getting them past what they already know. First responders and medical staff have not only thoroughly trained reflexes but also an innate desire to do something for the patient, no matter what that “something” is. Their motivation is simple: they want to help people get better, and they have confidence in their own skills and knowledge.

Disaster triage is actually fairly simple in its structure. It typically follows the “ABCs” of cardiopulmonary resuscitation, or CPR: Airway, Breathing, and Circulation. The first strictly medical questions asked in a triage situation are: “Is the individual victim’s airway clear, and is he or she breathing?” If the answer to either of those questions is “No,” the provider makes a quick attempt to remedy the problem – and, if successful, moves on to the “C” of the ABCs. If unsuccessful, that victim is determined to be unlikely to survive, and the provider moves on to the next patient.

The “C” of the ABCs is addressed primarily by checking to determine: (1) if the patient has a heartbeat; and (2) if he or she has any major bleeding. Major bleeding is then stanched – but, again, if the patient has no heartbeat, the provider moves on.

The combination of these three training foci prepares the CERT member to take on the responsibility of carrying out triage within the framework of a carefully developed and medically sound response process. It is important, though, also to have medical professionals such as EMS personnel in the mix as well – both to provide guidance and oversight, and to step in when more advanced definitive care is indicated.