Triage in a resource-rich environment
Triage ought to be conducted in a simple, straightforward, and experienced manner. Triage should be prognostic with a view toward singling out those among the burned who are likely to survive.25 The two most important aspects of triage have to do with who will perform triage and where. The initial triage will most likely be at the site of a burn disaster by bystanders followed shortly thereafter by other first responders. The triage area is an important consideration. Because of the nature of some burn disasters, it is important to establish triage stations somewhat removed from an immediate scene.16 This would be in response to hazards to the rescue and triage personnel such as bomb threats and potential explosions, interference by a crowd, or simply the fact that better facilities for triage are nearby and available. A safe triage area must be secured so that additional burn victims are not created because of lack of scene safety. The lobby of a hotel might serve as a good triage area, since it has good access and egress, appropriate space to work, and serves as a known location to all rescue workers and medical personnel.20 Sorting should, ideally, be performed at the site by an expert in burns.13,84,92 Expert triage may minimize the requirement for specialized burn beds.31 Few casualties with burn wounds of 30–70% TBSA (14% of those admitted) were encountered following fire disaster.31 Since bed availability in specialized centers is limited, it is clear that accurate triage is essential.31 With lack of sophistication at the scene, burn victims may be taken to the nearest hospital emergency department or accident ward for triage16 before they are transported to tertiary verified burn centers.16,58,83,84,93–95 The rapid evacuation of casualties to nearby hospitals is a realistic aim for all but the most isolated locations, aided by the fact that most burn victims are themselves initially mobile and cooperative50 (see Figure 5.4).
The organization of salvage work is affected by the number of casualties, the seriousness of their injuries, and the general conditions of a disaster.25 The actual triage of patients will be influenced not only by the total number of casualties and bed availability but also by such factors as depth and locations of wounds, complications such as inhalation injury, and extremes of age.31,52 With effective triage, the demand for care in a specialized burn center can be minimized for small minor burns. In the case of the Ramstein air disaster, the triage sites formed de novo where large numbers of patients were encountered, medical personnel congregated naturally, and supplies could be obtained for initial resuscitation. The patients were then carried a short distance to staging areas for helicopter pick up or for ambulance or bus loading. In the Ramstein disaster, complete triage on the scene was not possible. The triage response of emergency services at the air base was criticized,35,82,83 mainly because most of the victims were transported by a ‘load and go’ system to nearby hospitals who were use to patients being treated in the prehospital setting by trained anesthesiologists.
Patients must be triaged into categories for systematic referral to appropriate facilities. The triage category is based on the severity of injury and the potential for salvage. The overall goal is to do the most good for the most people. In general, when resources are unlimited and a disaster plan incorporates additional resources, even the most severely injured burn victim will receive optimal care if the triage is accomplished in the most favorable manner. Where resources are limited, triage may require a method for selecting casualties on a true priority basis. It may mean developing an expectant category for those so severely injured that they are not likely to survive (Figure 5.5).
The problem of triage can be simplified and facilitated by a flexible adaptation of certain formulas. The gravity of burns can be expressed in terms of the extent of TBSA burned and age of the patient. In Czechoslovakia, the sum of age and extent of burn that is greater than 90 has established an empirical 50% chance of survival. By flexibly bringing this number up or down, depending on the overall situation, one can extend or narrow the number of burn casualties who ought to be transported first.25 Immediate triage is essential in the presence of large numbers of burned patients. It has been observed that if a long period elapses before rescue teams can start triage and resuscitation, most of the severely injured die and many of the initially moderately injured develop serious complications.35 Triage may identify five important groups for victims of burn disasters13,59 (Table 5.6).