Disaster Medicine and Public Health Preparedness is dedicated to the engagement of the disaster community in an ongoing dialogue that examines challenging matters of utmost importance within our field. This special issue, entitled Triage: Implications for Mass Casualty Response, is therefore dedicated to the examination of issues surrounding the theory and practice of triage, with particular emphasis placed upon their population-based and individually based applications. This discussion expands upon the practical and ethical issues relevant to both the traditional sorting of casualties and the allocation of scarce medical resources in disaster situations. A framework for the equitable and efficacious rationing of scarce resources has been addressed in our journal by Tia Powell and colleagues (“Allocation of Ventilators in a Public Health Emergency”Reference Powell, Christ and Birkhead1). This framework has proven beneficial in enabling our community to inform the development of ethical and legal guidelines for disaster triage practices, yet further discussion is clearly warranted.
The establishment of treatment priorities in mass casualty situations has received a great deal of attention to date and has spawned a robust body of scientific literature that addresses multiple approaches to civilian and military triage. This special issue of the journal reviews this body of research to help establish the framework for an evolving discussion and development of a triage rationing system for establishing care priorities and making rationing decisions under a broad spectrum of potential scenarios. Ultimately, such systems must be grounded in science and informed by ethical theory, and most important, must allow for a concept of population or public triage that is complementary to the casualty-based systems with which we are most familiar.
Our discussion begins by providing a historical context on triage that examines the elementary philosophical foundations of disaster triage. From this point, articles are included that review the current body of medical literature on traumatic victim mass casualty triage and that propose a new standardized triage model called SALT (sort, assess, lifesaving interventions, treatment and/or transport), which is offered as a model for building a consensus-based approach to policymaking. This issue also examines the unique, and often underappreciated, considerations specific to the care of geriatric and chronically diseased populations.
We also provide an article that examines the contextualization of triage protocols in terms of a continual and systemic process occurring at distinct levels within the health care system, under the hypothesis that the triage process must be effectively integrated at all stages to avert or mitigate excess morbidity and mortality. Moreover, we analyze the application of triage principles in the I-35W Minneapolis bridge collapse mass casualty incident.
This issue additionally contains an article that specifically addresses the potential shortcomings of prevailing mass casualty traumatic triage models. Such models are intended for use at the individual level and therefore remain inherently limited in their application to population-based models, in which the public good may compromise individuals' personal interests. These incompatibilities must be addressed appropriately within our community because disasters implicitly constitute events that affect the overall community and may necessitate the use of ethical constructs that diverge from traditional conceptualizations of medical ethics. The reconciliation of discrepancies between the population-based ethic of the public health approach and the patient-centric ideals of traditional medical ethics will be essential as our community looks to address issues inherent to the containment of infectious disease outbreaks, including the continuing threat of pandemic influenza. The tacit tensions between these divergent constructs is well characterized by Tabery and colleagues as requiring a switch “from standard medical ethics with the primary focus on the individual autonomy of patients to an ethics of public health with a primary focus on the health of the community [which] may pose a conflict between the health of the community and the health of the individuals who make up that community.”Reference Tabery and Mackett2
I believe that the weight of the materials presented here and elsewhere compels us, as members of the disaster response community, to provide a priori guidance to our medical and public health colleagues, and further ensure that all guidelines are both grounded in ethics and supported by law to protect all responders as citizens and professionals. The development of a systemic disaster medical response system is essential to ensuring effective health security for our nation. Such a system must be driven by valid, objective, and equitable triage models. This issue provides targeted and broad discussions of those topics that are enriched through accompanying editorials. These documents are ultimately intended to encourage a constructive dialogue among our readers regarding the enduring evolution of appropriate disaster triage protocols. On behalf of the DMPHP staff, I propose that the articles contained within this special issue will enhance the disaster community's understanding of triage-related issues and precipitate continuing research and discussion on related matters.
