Moorgate to Katrina: the ethics of disaster triage

TRIAGE was barely necessary following London’s Moorgate train crash in 1975. The walking-wounded arrived first, covered in soot. Those with more serious injuries trickled in slowly over the course of the day as they were cut from the wreckage when they could be reached. And when, as a medical student shaken by my day’s experiences in the emergency department (ED), I rode home on the Underground that evening surrounded by commuters reading about the smash in the evening newspaper, I realised that for most of the residents of London the day was not very different from any other.

That was my training in disaster management.

So, when does a busy day at the office turn into a disaster for health care? When the number and complexity of casualties is greater than the capacity of the health care system to meet their health care needs according to contemporary standards and community expectations.

A one-car rollover can go almost unnoticed in Sydney or Melbourne, while the injuries from a smash in a remote location can overwhelm the skills and resources of the health workers who happen on the scene. Any one of us might find ourselves caring for the casualties of a disaster.

Wherever disasters occur, community leaders and health care managers activate their local disaster response plan (which I am sure you have all read).

However, while that support is being mobilised, and in the hours to days before it arrives, the health workers on the scene of the disaster must deal with the casualties as well as they can. The starting point for clinical decision making and the allocation of treatment in the midst of a disaster is widely known as triage. It should not be confused with the routine process of continuous sorting in ED that is also called triage.

Unfortunately, most of us have little idea what we might be expected to do were we to find ourselves suddenly having to lead triage in a disaster. The principles of triage (from the French verb trier, to sort) were formalised and refined during the Napoleonic and subsequent wars. The goal was to classify patients’ injuries so that treatment could be prioritised to achieve better outcomes.

Interestingly, since millions of years before we emerged from Africa, some species of ants have found success in an evolved pragmatic triage that supports the long term viability of their colony, although it is the injured ants that signal whether they should be rescued and the more seriously injured that do not do so (here and here).

What should we do when, at the scene of a disaster, the supply of resources does not match the demand and our decision making becomes far more complex than the dichotomous clinical task of separating those who can be saved from those who cannot?

Perhaps unsurprisingly, state-based and national disaster planning documents for Australia generally view disasters from the perspective of managers. They include extensive flow charts and tables for communication and organisation, including how to colour-code the casualties and what kinds of hard hats and identification vests rescuers must wear at all times.

Surprisingly, however, they contain little mention of the messy business of triage and death. For example, a search of the Queensland Health Disaster and Emergency Incident Plan includes the word death once and makes no mention of triage. The Queensland Health Mass Casualty Incident Plan includes the cryptic statement:

“Triage ensures that what may be limited patient management resources are directed at the principal of achieving the greatest good for the greatest number of people.” (p. 23)

However, the plan provides no guidance as what this might mean in flesh and blood practice. The Curriculum Framework for the Australasian College of Emergency Medicine, New South Wales’ Major Incident Medical Services Supporting Plan, and the Australian Government’s Department of Health and Ageing Emergency Triage Education Kit – Triage Workbook do not include discussion of difficult triage.

None of these documents acknowledges that clinicians may be overwhelmed by the numbers and complexity of sick or injured and dying patients. They provide no significant guidance about what to do while the clock ticks ever so slowly before the arrival from tertiary centres of the teams of disaster managers. They fail to describe the principles of resource-allocation disaster triage for first responders. Nor do they address the moral distress of clinicians who find their personal, professional and community culture of ethics and values confronted while they make resource-allocation decisions to set some patients to one side.

These are not hypothetical problems. For a greater understanding, I suggest reading the article about the chaotic aftermath of Hurricane Katrina in New Orleans (2005) published in The New York Times which provides an example of the challenges of dealing with a disaster. Staff at Memorial Medical Center triaged their patients for evacuation according to their proximity to death – with patients in critical care or with do not resuscitate orders left until last. For the staff as well as for those patients this had, and continues to have, major consequences.

Modern  day-to-day triage in high income countries, on site or in the ED, still requires the classification of patients into the minor casualties who can wait, those who would need to be treated now, and the dying who should receive palliative care. In routine practice, we clinicians can remain focused on the interests of our individual patients and leave the responsibility for the allocation of finite resources to politicians and managers.

However, when we find ourselves thrust into a situation in which we have become both the treating clinician and the person responsible for the allocation of insufficient resources, we are required to shift our frame of reference for decision making and engage in a different strategy.

“In a disaster situation, the focus of medical care shifts from the needs of the individual (autonomy) to the needs of the community as a whole (distributive justice) so that the ‘greatest good for the greatest number’ is the goal.”

Triage now becomes a value-laden cost–benefit resource-allocation exercise. We have no choice but to assess the supply of treatment, weigh up the various and competing interests of the sometimes-unknown numbers of individuals under our care and distribute finite resources to the optimum benefit of the community. In other words, because you can’t treat everyone, we have to decide not how to treat, rather, who to treat. Making these statements is the easy bit.

Unfortunately, most of us have little idea what we (as the most skilled person present) would be required to do were we to find ourselves suddenly having to lead triage in a disaster.

Disaster management plans should include candid descriptions of both the necessities of disaster triage and the duties of clinicians who find themselves in the unenviable position of engaging with its harsh realities. Clinicians reading such plans need to know that they will be supported by their community if they find that it has become their duty to walk away from some patients (and their families) in order to treat others.

While we can never know the nature and scope of disasters that may confront us in our future, we can learn the principles of leadership in complex clinical decision making. Our community can also learn to accept these necessities, but only if they are addressed openly in the numerous disaster and mass casualty plans prepared by governments.

The chaos of a disaster, whether a large or small crash, or a natural calamity, can come out of nowhere and happen anywhere, at any time. Perhaps we should each ask ourselves if we feel prepared to suddenly take on the casualties of a remote disaster such as a bus smash or a tsunami.

Most of us will never face such challenges. However, inevitably, sometime and somewhere, one of us will find ourselves confronted by the inescapably distressing realities at the centre of a disaster. Although we will probably feel overwhelmed, we will feel very grateful if, either at some point in our training or through self-directed learning, we have understood how to implement the core principles of triage in disaster management and our duty to our community founded on the principle of achieving the greatest good for the greatest number of people.

Dr Will Cairns OAM is on the verge of retirement from his medical career, first as a GP, and subsequently as a specialist in palliative medicine.

The statements or opinions expressed in this article reflect the views of the authors and do not represent the official policy of the AMA, the MJA or InSight+ unless so stated.