Sorting though Disaster: Triage and 9/11

As a tribute to the upcoming ten year anniversary of 9/11, I thought it would be nice to have our resident ER doc write about triage.

Where were you on 9/11? Please, leave a comment today.

Most people over the age of twenty probably have some memory burned into their mind of the fire consuming the World Trade Towers and their ultimate collapse and destruction.

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I had just flown in from Chicago the night before. I remember waking up to the incessant ringing of our phone. Tired from the previous night, I was adamant about letting the machine pick it up. It became clear after about five minutes of solid ringing that perhaps it was an emergency. I answered and a good friend of mine was on the other end blubbering, crying—nonsensical. I remember fragments of her words—“planes crashed” , “New York”, “Thank God you’re back!”--“Just turn on your TV!”

I think I sat on the couch watching the tragedy unfold for the next three days.

A good friend of mine was working as a nurse at the time of the attacks. She’d just gotten off the night shift and was getting settled into sleep when the events broke. Immediately, she hustled back out of her apartment to go back to the hospital.

Upon her arrival, they were setting up for multiple victims, beginning to formulate a plan of how they would triage the patients.

Here’s triage from the ED doctor’s perspective: Dr. Edwards.

Some extraordinarily difficult decisions have to be made when you're dealing with a mass casualty situation. Unless you have unlimited resources to treat everyone, victims will have to be triaged.  Triage comes from the French verb trier--meaning to sort--and classically we think of three triage categories: 1) those victims so gravely injured they will not survive regardless of what you do; 2) those who can probably be saved if the right things are done quickly; and 3) those with lesser injuries who may be in distress but who can obviously wait (i.e., the walking wounded). 

 Battlefields have always been the crucible of innovations in trauma care, and indeed the modern concept of triage dates to the Napoleonic Wars of the late eighteenth and early nineteenth centuries.  The individual credited with inventing it (as well as field hospitals and fast-moving ambulances manned by trained individuals) was Dominique Jean Larrey, the French emperor's surgeon-in-chief. 

 Partly in response to 9/11, disaster medicine is now an actual specialty unto itself, with post-graduate fellowships and board exams.  Because of this, triage grows into more of a science each year as we evolve ever more sophisticated rating scales based upon injuries and vital signs to help providers make those fateful decisions about whom they will race to save.  

 The person assigned to triage duty must be trained to rapidly differentiate hopeless cases from those who might be saved, Typically, that individual will attach a color-coded tag alerting the rest of the team to the patient's category, and will also perform immediate life-saving maneuvers including the control of external bleeding, needle decompression of pneumothoraces (collapsed lungs), the insertion of mechanical airways, the initiation of field IV fluid resuscitation.  But more often primary triage involves deciding who must be transported to the hospital first. 

 When a mass casualty event occurs, hospitals switch into "disaster mode."  Carefully worked out plans involving the assignment of crisis team roles and the mobilization of additional staff--all practiced in regular drills, lest we become complacent--are activated.  Hallways and lounges become triage and treatment areas.  Larrey would have been impressed.

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Frank Edwards was born and raised in Western New York.  After serving as an Army helicopter pilot in Vietnam, he studied English and Chemistry at UNC Chapel Hill, then received an M.D. from the University of Rochester.  Along the way he earned an MFA in Writing at Warren Wilson College.  He continues to write, teach and practice emergency medicine. More information can be found at http://www.frankjedwards.com/.