Triage – a horror scenario?

Since the beginning of the COVID pandemic, there has been a word that has haunted the media that makes medical laypeople (most of the people) feel uncomfortable and that one would rather not experience in reality. We are talking about “triage”.

The reason for this is simple: during the first COVID wave in spring, countless pictures and reports from Bergamo (Italy) and New York that came from totally overburdened clinics often made media consumers very concerned. The pictures showed countless seriously ill COVID patients on ventilation machines in intensive care units, completely exhausted doctors, totally overtired nurses and desperate relatives, all of whom apparently no longer knew what to do.

In the reports it was mentioned repeatedly and almost daily that the doctors would now have to use so-called triage measures due to the overloading of the clinics in order to bring the situation under control. But hardly anyone in the media  could describe exactly what “triage” actually means. Individual attempts at explanation fizzled out or were only perceived selectively, the impression remained: triage always has something to do with bottlenecks, emergencies, rationing and resource limitation and leads to life-threatening situations.

For the readers, viewers and social media activists, the fear-inducing impression arose in the spring that triage would mean that because of the countless COVID sufferers, some of these patients could not be offered treatment and that these poor people would then perish miserably and without care.

The lonely “suffocation at the end of the hospital corridor” became a horrific vision and the corresponding creepy-cruel associations solidified in the audience. This mood was immediately exploited by politicians: “We don’t want conditions like in Italy” was a standing sentence of the government politicians in March and the idea of ​​triage was therefore ultimately the decisive factor that led to the first lockdown or made it possible relatively easily. (Although, for the sake of honesty, one also has to say that we knew much less then than we do today. At the beginning of the first lockdown, for example, masks were still considered unnecessary and only useful for the medical staff).

But – what is this ominous triage really? Is it a horror scenario or is it simply an instrument that physicians can use for quick orientation, in order to be able to use more targeted and meaningful relief measures when things get haywire or the rush of patients is so great that one could lose the overview and no more know where to start?

Of course, triage is the second: It is a technique for prioritizing and using medical help in the best possible and most beneficial way. To begin with, “triaging” means nothing more than classifying the patient after the patient has been examined and determining who needs help immediately and who can wait. Of course, triage also includes the need to identify which patients can no longer be helped. But that definitely does not mean that the unsaved patients will not be cared for.

The simplest example of triage is the operation of an emergency ambulance: Anyone who is admitted there bleeding profusely, unconscious or in poor general condition, has an immediate answer, regardless of whether 20 or 30 people with minor injuries or moderate complaints are waiting for their treatment there.

In other words: The sprained ankle from the day before yesterday, who comes to the emergency room at the same time as the emergency helicopter has just brought a seriously injured person, is naturally put back and has to wait until the life-threatening injured person has been treated.

Another everyday example: every time an acute pain patient is brought forward to the dentist, it is already a form of triage. Doctors always treat those patients who need help most first. Every waiting time is ultimately a form of triage, as acute patients who need quick help and are therefore preferred to those already waiting there always appear in every ordination and in every outpatient department.

So-called triage systems, specially designed for ambulances, have long been in existence for better management of these situations. The best known of these is the Manchester Triage System (MTS), which is also used in a number of Canadian hospitals. The MTS works according to an urgency scale and, depending on the type of illness / injury, the patients are given a color code that shows how acute they need to be treated. These levels of urgency are determined by specially trained doctors or specially trained nursing staff. The scale ranges from red (immediately) to orange (very urgent), yellow (urgent), to green (normal) and blue (not urgent).

In any case, the situation is reassessed regularly and it may be the case that, for example, a “yellow” becomes “orange” after a certain period of time and has to be brought forward because it is worse off. It can also happen that a “blue” does not come up until the next day, because red and orange have priority and if their number is very high on a day, the not acute ones are postponed or sent away. This is everyday life.

The much more delicate and naturally the most challenging type of triage for doctors is when it comes to life or death and this need for decision-making arises from resources that are always and everywhere limited. This can be the case if, after a major accident, suddenly a few or even dozen injured people need to be cared for (e.g. after a bus or train accident) and initially only one emergency doctor and his team arrive at the scene of the accident – the doctor must then with his paramedics triage as quickly and efficiently as possible and first help those patients who need his help most urgently.

In most cases, such a situation will soon ease as further emergency services will of course be called in and, depending on the location and type of the accident, it will not take too long for the other helpers to arrive. Nevertheless, it is essential for the first responder or the injured that the vitally threatened are diagnosed as quickly as possible and that they get help immediately, because it often takes a few minutes (e.g. because of severe bleeding, chest injuries, etc.). As hard as it sounds: you shouldn’t waste time with the unsaved, because this time is lost for those who can be saved. A doctor who has to treat several unconscious seriously injured people has to decide to the best of his knowledge and belief and the initial diagnosis who to help first – accepting the death of another patient.

A special form of triage and the “ultra posse nemo tenetur” situation can arise in intensive care units (ICU) if, in the course of a pandemic, which for example causes a large number of patients with severe pneumonia requiring ventilation or with multiple organ failure, more and more intensive care patients have to be cared for than the ICU concerned can supply.

In such a case, those responsible must first exhaust all possibilities of inpatient intensive care and contact other ICUs in nearby hospitals in order to be able to offer the necessary care to as many patients as possible. In such a situation, it is also possible, for example, to move lighter cases from the ICU to the normal ward and monitor vital parameters (pulse, blood pressure, oxygen saturation) there using portable monitors and devices. This also happens in “normal times” when, for example, an ICU is overloaded with too many patients for a short time. Every hospital usually has these reserves.

If the absolute (and from today’s perspective completely unlikely) COVID-related worst-case scenario occurs and ALL available intensive care beds throughout the country are occupied or there are no more staff available to adequately care for all seriously ill patients, then a triage must be carried out in which the doctors must assess and determine according to the existing clinical criteria which critically ill patients who are on the ventilator have the comparatively best chances of survival. These patients will continue to be offered “high care” (maximum medicine including artificial ventilation if required) and they will be given appropriate care.

Those patients who, from a medical point of view, are already in such a bad condition that their chances of survival are only assessed as very low or are diagnosed as irreversible, receive a so-called “palliative setting” and are taken over by palliative care professionals: Infusions and any medication that takes away pain, anxiety, shortness of breath and thirst.

That means: NOBODY remains unsupervised and, even with the greatest possible bottleneck, it is always ensured that all patients receive medical and nursing care. Other, more easily ill people have to accept being downgraded or even released into home care, if this is medically justifiable.

We have to be aware that even without a pandemic, doctors have always made decisions about life and death every day, which in principle correspond to those of triage: Every day in hospitals a decision is made as to whether maximum therapies are to be continued or continued for the incurably and irretrievably critically ill or seriously injured or canceled. It is even ethically correct to end a medically senseless maximum therapy, because the patient no longer has any chance of survival due to his illness (such as with metastatic cancer in the end stage or with therapy-resistant multi-organ failure).

However, it is ethically and medically imperative in every single case to provide palliative care for unsaved patients. Every professionally carried out triage is therefore not a horror scenario, but an aid to find out the best possible therapy option for the respective patient as quickly as possible and then apply it individually.

Categories: Opinion

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