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Triage and the Lost Art of Decoding Vital Signs: Restoring Physiologically Based Triage Skills in Complex Humanitarian Emergencies

Published online by Cambridge University Press:  21 April 2017

Frederick M. Burkle Jr.*
Affiliation:
Harvard Humanitarian Initiative, Harvard University, and Harvard T.C. Chan School of Public Health, Cambridge, Massachusetts Woodrow Wilson International Center for Scholars, Washington, DC; Captain, Medical Corps, USNR (Ret)
*
Correspondence and reprint requests to Frederick M. Burkle, Jr., MD, Harvard Humanitarian Initiative, c/o 452 Iana Street, Kailua, Hawaii 96734 (e-mail: [email protected]; [email protected]).

Abstract

Triage management remains a major challenge, especially in resource-poor settings such as war, complex humanitarian emergencies, and public health emergencies in developing countries. In triage it is often the disruption of physiology, not anatomy, that is critical, supporting triage methodology based on clinician-assessed physiological parameters as well as anatomy and mechanism of injury. In recent times, too many clinicians from developed countries have deployed to humanitarian emergencies without the physical exam skills needed to assess patients without the benefit of remotely fed electronic monitoring, laboratory, and imaging studies. In triage, inclusion of the once-widely accepted and collectively taught “art of decoding vital signs” with attention to their character and meaning may provide clues to a patient’s physiological state, improving triage sensitivity. Attention to decoding vital signs is not a triage methodology of its own or a scoring system, but rather a skill set that supports existing triage methodologies. With unique triage management challenges being raised by an ever-changing variety of humanitarian crises, these once useful skill sets need to be revisited, understood, taught, and utilized by triage planners, triage officers, and teams as a necessary adjunct to physiologically based triage decision-making. (Disaster Med Public Health Preparedness. 2018;12:76–85)

Type
Original Research
Copyright
Copyright © Society for Disaster Medicine and Public Health, Inc. 2017 

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References

1. Beecher, HK. Resuscitation and Anesthesia for Wounded Men: The Management of Traumatic Shock. Springfield, IL: Charles C. Thomas; 1949.Google Scholar
2. Burkle, FM. Triage. In: Burkle FM, Sanner PH, Wolcott BW, eds. Disaster Medicine. New York, NY: Excerpta Medica Publications/Elsevier Press; 1984:145.Google Scholar
3. Burkle, FM. Advances in the methodology of the triage of disaster medicine casualties. Kyukyu-Igaku [Japanese Journal of Acute Medicine]. 1991;15:1767-1772.Google Scholar
4. Burkle, FM Jr, Newland, C, Orebaugh, S, et al. Emergency medicine in the Persian Gulf War--Part 2. Triage methodology and lessons learned. Ann Emerg Med. 1994;23(4):748-754. https://doi.org/10.1016/S0196-0644(94)70310-8.CrossRefGoogle ScholarPubMed
5. Jauhar, S. The demise of the physical exam. N Engl J Med. 2006;354(6):548-551. https://doi.org/10.1056/NEJMp068013.CrossRefGoogle ScholarPubMed
6. Knox, R. The fading art of the physical exam. NPR: Science. http://www.npr.org/templates/story/story.php?storyId=129931999. Published September 20, 2010. Accessed 1, November 2016.Google Scholar
7. Welch, S. Death of the physical exam. ACEP Now. 2014;(February):30-31.Google Scholar
8. Guly, HR, Bouamra, O, Spiers, M, et al. Vital signs and estimated blood loss in patients with major trauma: testing the validity of the ATLS classification of hypovolemic shock. Resuscitation. 2011;82(5):556-559. https://doi.org/10.1016/j.resuscitation.2011.01.013.CrossRefGoogle Scholar
9. Kahn, CA, Lerner, B, Cone, DC. Triage. In: Koenig KL, Schultz CH, eds. Disaster Medicine: Comprehensive Principles and Practices. 2nd ed. New York: Cambridge University Press; 2016:208-218.Google Scholar
10. Complex Humanitarian Emergencies. Center for Disaster Philanthropy website. http://disasterphilanthropy.org/issue-insight/complex-humanitarian-emergencies/. Accessed January 16, 2017.Google Scholar
11. Brennan, RJ, Nandy, R. Complex humanitarian emergencies: a major global health challenge. Emerg Med. 2001;13(2):147-156. https://doi.org/10.1046/j.1442-2026.2001.00203.x.CrossRefGoogle ScholarPubMed
12. Sambanis, N. What is Civil War? Conceptual and empirical complexities of an operational definition. J Conflict Resolut. 2004;48(6):814-858. https://doi.org/10.1177/0022002704269355.CrossRefGoogle Scholar
13. Cockburn, P. Tomgram: Patrick Cockburn, an endless cycle of indecisive wars. TomDispatch.Com. http://www.tomdispatch.com/blog/176158/tomgram%3A_patrick_cockburn%2C_an_endless_cycle_of_indecisive_wars. Published June 28, 2016. Accessed May 1, 2016.Google Scholar
14. Quinn, JM. Notes from the field: the humanitarian crisis in Ukraine. Journal of Human Security. 2015;11(1):27-33. http://www.librelloph.com/journalofhumansecurity/article/view/johs-11.1.27/html.CrossRefGoogle Scholar
15. Council on Foreign Relations. Global Conflict Tracker: Updated 10 November 2016. http://www.cfr.org/global/global-conflict-tracker/p32137?goal=0_aa18ea5b4e-ff3d9e77cf-#!/. Accessed November 10, 2016.Google Scholar
16. Hervey, A. The Decline of War. https://medium.com/@angushervey/the-decline-of-war-8760f9a5b5ce#.jagyj163g. Accessed June 1, 2016.Google Scholar
17. Countries in Conflict: 1975-2015. Uppsala Conflict Data Program. Department of Peace and Conflict Research. Uppsala University, Sweden. http://www.ucdp.uu.se/?goal=0_aa18ea5b4e-ff3d9e77cf-. Accessed November 10, 2016.Google Scholar
18. Roser, M. War and Peace after 1945. OurWorldInData.org. https://ourworldindata.org/war-and-peace-after-1945/. Accessed November 10, 2016.Google Scholar
19. Physicians for Human Rights. Anatomy of a Crisis, a Map of Attacks on Health Care in Syria: Findings as of June 2016. https://s3.amazonaws.com/PHR_syria_map/findings.pdf. Accessed October 1, 2016.Google Scholar
20. World Health Organization. Mass casualty management systems: strategies and guidelines for building health sector capacity. Health Action in Crises, Injuries and Violence Prevention. 2007. http://www.who.int/hac/techguidance/MCM_inside_Jul07.pdf. Accessed June 2, 2016.Google Scholar
21. Burkle, FM Jr. Population-based triage management in response to surge-capacity requirements during a large-scale bioevent disaster. Acad Emerg Med. 2006;13(11):1118-1129. https://doi.org/10.1111/j.1553-2712.2006.tb01634.x.Google ScholarPubMed
22. Klein, KR, Burkle, FM Jr, Swienton, R, et al. Qualitative analysis of surveyed emergency responders and the identified factors that affect first stage of primary triage decision-making of mass casualty incidents. PLoS Curr. 2016 August 19:8. doi: 10.1371/currents.dis.d69dafcfb3ad8be88b3e655bd38fba84.Google Scholar
23. Winslow, GR. Triage and Justice. Berkeley, CA: University of California Press; 1982:1-23.Google Scholar
24. Domres, B, Koch, M, Manger, A, et al. Ethics and triage. Prehosp Disaster Med. 2001;16(1):53-58. https://doi.org/10.1017/S1049023X00025590.CrossRefGoogle ScholarPubMed
25. Military Health System Echelons of Care. War Surgery in Afghanistan and Iraq: A Series of Cases, 2003-2007. Nessen, SC, Lounsbury, DE, Hetz, SP, eds. Washington, DC: Department of the Army, Office of the Surgeon General, Borden Institute; 2008:3-6.Google Scholar
26. MSF Analysis. Conflict medicine: a manifesto. http://msf-analysis.org/conflict-medicine-manifesto/. Published October 26, 2016. Accessed October 28, 2016.Google Scholar
27. Rasmussen, TE, Kellermann, AL. Wartime lessons - shaping a national trauma action plan. N Engl J Med. 2016;375(17):1612-1615. https://doi.org/10.1056/NEJMp1607636.CrossRefGoogle ScholarPubMed
28. Raynaud, L, Borne, M, Coste, S, et al. Triage protocol: both undertriage and overtriage need to be evaluated. J Trauma. 2010;69(4):998. https://doi.org/10.1097/TA.0b013e3181ec4e1d.Google ScholarPubMed
29. Frykberg, R. Triage: principles and practice. Scand J Surg. 2005;94(4):272-278. https://doi.org/10.1177/145749690509400405.CrossRefGoogle ScholarPubMed
30. Sasser, SM, Hunt, RC, Faul, M, et al; Centers for Disease Control and Prevention (CDC). Guidelines for field triage of injured patients: recommendations of the National Expert Panel on Field Triage, 2011. MMWR Recomm Rep. 2012;61(RR-1):1-20.Google Scholar
31. Mass Casualty & Triage: Chapter 3. Emergency War Surgery, 4th U.S. Revision. P.3.1-3.10. https://quizlet.com/123921745/emergency-war-surgery-4th-us-revision-chapter-3-mass-casualty-triage-4-aeromedical-evacuation-flash-cards/. Accessed 12 May 2016.Google Scholar
32. Hick, JL, Barbera, JA, Kelen, GD. Refining surge capacity: conventional, contingency, and crisis capacity. Disaster Med Public Health Prep. 2009;3(2)(suppl):S59-S67. https://doi.org/10.1097/DMP.0b013e31819f1ae2.CrossRefGoogle Scholar
33. Hanfling, D, Alevoght, BM, Viswanathan, K, et al. Crisis Standards of Care: A Systems Framework for Catastrophic Disaster Response. Volume 1: Introduction and CSC Framework. Committee on Guidance for Establishing Crisis Standards of Care for Use in Disaster Situations; Institute of Medicine. Washington, DC: National Academies Press; 2012.Google Scholar
34. Heffernan, DS, Thakkar, RK, Monaghan, SF, et al. Normal presenting vital signs are unreliable in geriatric blunt trauma victims. J Trauma. 2010;69(4):813-820. https://doi.org/10.1097/TA.0b013e3181f41af8.Google ScholarPubMed
35. World Health Organization. Classification and Minimum Standards for Foreign Medical Teams in Sudden Onset Disasters. UN Health Cluster. Geneva 27 Switzerland. http://www.who.int/hac/global_health_cluster/fmt_guidelines_september2013.pdf. Accessed January 2, 2008.Google Scholar
36. Gerhardt, RT, Mabry, RL, De Lorenzo, RA, et al. Mass-casualty-incident management. In:. Fundamentals of Combat Casualty Care. Lenhardt MK, Savitsky E, Eastridge B, eds. Falls Church, VA: Office of the Surgeon General, Department of the Army; 2012.Google Scholar
37. Emergency War Surgery. Fourth United States Revision, 2013. Borden Institute, US Army Medical Department Center and School, Falls Church, VA: Office of the Surgeon General.Google Scholar
38. Sobrino, J, Shafi, S. Timing and causes of death after injuries. Proc Bayl Univ Med Cent. 2013;26(2):120-123.CrossRefGoogle ScholarPubMed
39. Cripps, MW, Kutcher, ME, Daley, A, et al. Cause and timing of death in massively transfused trauma patients. J Trauma Acute Care Surg. 2013;75(2)(suppl 2):S255-S262. https://doi.org/10.1097/TA.0b013e31829a24b4.CrossRefGoogle ScholarPubMed
40. Redmond, AD, Redmond, CA, Jones, JM, Hillier, V. The significance of patient appearance in predicting severity of injury. Injury. 1994;25(2):81-82. https://doi.org/10.1016/0020-1383(94)90106-6.CrossRefGoogle ScholarPubMed
41. Bouzoukis, JK. Shock. Prim Care. 1986;13(1):193-205.CrossRefGoogle ScholarPubMed
42. Dillon, AR, Hankes, GH, Nachreiner, RF, et al. Experimental hemorrhage in splenectomized and nonsplenectomized dogs. Am J Vet Res. 1980;41(5):707-711.Google ScholarPubMed
43. Xiong, Y, Mahmood, A, Chopp, M. Animal models of traumatic brain injury. Nat Rev Neurosci. 2013;14(2):128-142. https://doi.org/10.1038/nrn3407.CrossRefGoogle ScholarPubMed
44. Poulton, TJ. ATLS paradigm fails. Ann Emerg Med. 1988;17(1):107. https://doi.org/10.1016/S0196-0644(88)80538-9.CrossRefGoogle ScholarPubMed
45. Sarti, A, Savron, F, Ronfani, L, et al. Comparison of three sites to check the pulse and count heart rate in hypotensive infants. Paediatr Anaesth. 2006;16(4):394-398. https://doi.org/10.1111/j.1460-9592.2005.01803.x.CrossRefGoogle ScholarPubMed
46. Jahangir, E. Blood pressure assessment. Medscape: http://emedicine.medscape.com/article/1948157-overview. Accessed October 11, 2016.Google Scholar
47. Burkle, FM, Geiling, JA. Decoding vital signs during triage: pulse pressure in children. Lancet. 2016;387(10033):2091-2092. https://doi.org/10.1016/S0140-6736(16)30541-4.CrossRefGoogle ScholarPubMed
48. Duke, T. New WHO guidelines on emergency triage assessment and treatment. Lancet. 2016;387(10020):721-724. https://doi.org/10.1016/S0140-6736(16)00148-3.CrossRefGoogle ScholarPubMed
49. WHO. Updated guideline: Paediatric Emergency Triage, Assessment and Treatment. Geneva: World Health Organization; 2016.Google Scholar
50. Nhan, NT, Phuong, CVT, Kneen, R, et al. Acute management of dengue shock syndrome: a randomized double-blind comparison of 4 intravenous fluid regimens in the first hour. Clin Infect Dis. 2001;32(2):204-213. https://doi.org/10.1086/318479.CrossRefGoogle Scholar
51. Share, L. Role of peripheral receptors in the increased release of vasopressin in response to hemorrhage. Endocrinology . 1967;81(5):1140-1146. https://doi.org/10.1210/endo-81-5-1140.CrossRefGoogle Scholar
52. Morales, MD, Madigan, J, Cullinane, S, et al. Reversal by vasopressin of intractable hypotension in the late phase of hemorrhagic shock. Circulation. 1999;100(3):226-229. https://doi.org/10.1161/01.CIR.100.3.226.CrossRefGoogle ScholarPubMed
53. Errington, ML, Rocha, M, Silva, E Jr. The secretion and clearance of vasopressin during the development of irreversible hemorrhagic shock. Proc Phys Soc. 1971;23:43-45.Google Scholar
54. Davis, JW, Davis, IC, Bennink, LD, et al. Are automated blood pressure measurements accurate in trauma patients? J Trauma. 2003;55(5):860-863. https://doi.org/10.1097/01.TA.0000092686.91877.DE.CrossRefGoogle ScholarPubMed
55. Pickering, TG, Hall, JE, Appel, LJ, et al. Recommendations for blood pressure measurement in humans and experimental animals: part 1: blood pressure measurement in humans: a statement for professionals from the Subcommittee of Professional and Public Education of the American Heart Association Council on High Blood Pressure Research. Circulation. 2005;111(5):697-716. https://doi.org/10.1161/01.CIR.0000154900.76284.F6.CrossRefGoogle Scholar
56. World Medical Association Statement on Medical Ethics in the Event of Disasters. World Medical Association, Adopted by the 46th WMA General Assembly, Stockholm, Sweden, September 1994 and revised by the 57th WMA General Assembly, Pilanesberg, October 2006. http://www.wma.net/en/30publications/10policies/d7/. Accessed January 20, 2017.Google Scholar
57. Burkle, FM Jr, Martone, G, Greenough, PG. The changing face of humanitarian crises. Brown J World Aff. 2014;XX(11):25-42. https://www.brown.edu/initiatives/journal-world-affairs/sites/brown.edu.initiatives.journal-world-affairs/files/private/articles/Burkle_GALLEY.pdf. Accessed October 22, 2014.Google Scholar
58. Burkle, FM Jr, Orebaugh, S, Barendse, BR. Emergency medicine in the Persian Gulf War-Part 1: preparations for triage and combat casualty care. Ann Emerg Med. 1994;23(4):742-747. https://doi.org/10.1016/S0196-0644(94)70309-4.CrossRefGoogle ScholarPubMed
59. Burkle, FM Jr, Newland, C, Meister, SJ, et al. Emergency medicine in the Persian Gulf War--Part 3: battlefield casualties. Ann Emerg Med. 1994;23(4):755-760. https://doi.org/10.1016/S0196-0644(94)70311-6.CrossRefGoogle ScholarPubMed
60. Bernard, V. A price too high: rethinking nuclear weapons in light of their human cost [editorial]. Int Rev Red Cross. 2015;97(899):499-506. https://doi.org/10.1017/S1816383116000321.CrossRefGoogle Scholar
61. Dallas, CE, Bell, WC, Stewart, DJ, et al. Nuclear war between Israel and Iran: lethality beyond the pale. Confl Health. 2013;7(1):10. https://doi.org/10.1186/1752-1505-7-10.CrossRefGoogle ScholarPubMed
62. Burkle, FM, Dallas, CE. Developing a nuclear global health workforce amid the increasing threat of a nuclear crisis. Disaster Med Public Health Prep. 2016;10(1):129-144. https://doi.org/10.1017/dmp.2015.125.CrossRefGoogle ScholarPubMed
63. Hauer, JM. Preparing the country for Nuclear terrorism. Bulletin of the Atomic Scientists. http://thebulletin.org/preparing-country-nuclear-terrorism9985. Published October 7, 2016. Accessed October 25, 2016.Google Scholar
64. Coleman, CN, Koerner, JF. Biodosimetry: medicine, science, and systems to support the medical decision-maker following a large scale nuclear or radiation incident. Radiat Prot Dosimetry. 2016;172(1-3):38-46. https://doi.org/10.1093/rpd/ncw155.CrossRefGoogle ScholarPubMed
65. Hanfling, D, Altevogt, BM, Gostin, LO. A framework for catastrophic disaster response. JAMA. 2012;308(7):675-676. https://doi.org/10.1001/jama.2012.8171.CrossRefGoogle ScholarPubMed
66. Kassem, DF, Hoffmann, Y, Shahar, N, et al. Multidrug-resistant pathogens in hospitalized Syrian children. Emerg Infect Dis. 2017;23(1):166-168. https://doi.org/10.3201/eid2301.161204.CrossRefGoogle ScholarPubMed
67. Teicher, CL, Ronat, JB, Fakhri, RM, et al. Antimicrobial drug-resistant bacteria isolated from Syrian war-injured patients, August 2011-March 2013. Emerg Infect Dis. 2014;20(11):1949-1951. https://doi.org/10.3201/eid2011.140835.CrossRefGoogle ScholarPubMed
68. Burkle, FM Jr, Burkle, CM. Triage management, survival, and the law in the age of Ebola. Disaster Med Public Health Prep. 2015;9(1):38-43. https://doi.org/10.1017/dmp.2014.117.CrossRefGoogle Scholar
69. Burkle, FM. Operationalizing public health skills to resource poor settings: is this the Achilles heel in the Ebola epidemic campaign? Disaster Med Public Health Prep. 2015;9(1):44-46. https://doi.org/10.1017/dmp.2014.95.CrossRefGoogle ScholarPubMed
70. Levine, AC, Shetty, PP, Burbach, R, et al. Derivation and internal validation of the Ebola prediction score for risk stratification of patients with suspected Ebola virus disease. Ann Emerg Med. 2015;66(3):285-293.e1. https://doi.org/10.1016/j.annemergmed.2015.03.011.CrossRefGoogle ScholarPubMed
71. Moschos, SA. Ebola check: delivering molecular diagnostics at the point of need. Hell J Nucl Med. 2015;18(suppl 1):144.Google ScholarPubMed
72. Velimirovic, B. Plague in South-East Asia. A brief historical summary and present geographical distribution. Trans R Soc Trop Med Hyg. 1972;66(3):479-504.CrossRefGoogle ScholarPubMed
73. Burkle, FM Jr. Plague as seen in South Vietnamese children. A chronicle of observations and treatment under adverse conditions. Clin Pediatr (Phila). 1973;12(5):291-298. https://doi.org/10.1177/000992287301200512.CrossRefGoogle ScholarPubMed
74. Hick, JL, Hanfling, D, Cantrill, SV. Allocating scarce resources in disasters: emergency department principles. Ann Emerg Med. 2012;59(3):177-187. https://doi.org/10.1016/j.annemergmed.2011.06.012.CrossRefGoogle ScholarPubMed
75. Altevogt, BM, Stroud, C, Hanson, SL, et al. Guidance for Establishing Crisis Standards of Care for Use in Disaster Situations, A Letter Report. Board on Health Sciences Policy. Washington, DC: Institute of Medicine, The National Academies Press; 2009. https://www.nap.edu/read/12749/chapter/1#ii. Accessed May 2, 2016.Google Scholar
76. Health and Medical Care Delivery in a Mass Casualty Event. Archive: Agency for Healthcare Research and Quality. US Department of Health and Human Services. https://archive.ahrq.gov/research/altstand/altstand2.htm. Accessed May 1, 2016.Google Scholar
77. Levin, D, Cadigan, RO, Biddinger, PD, et al., on behalf of the Joint Massachusetts Department of Public Health–Harvard Altered Standards of Care Working Group. Altered standards of care during an influenza pandemic: identifying ethical, legal, and practical principles to guide decision making. Disaster Med Public Health Prep. 2009;3(Suppl 2):S132-S140.CrossRefGoogle Scholar