Saturday, September 03, 2005

The Nature of Triage

Check out this article by Rabbi Marc Gellman, who is one of my all-time favorite columnists. His articles are always articulate, profound, and inspiring.

In our ski patrol training, we are trained in triage, but it's one of those skills that you really hope that you will never have to perform.  It is a terrifying responsibility, and the people who are making the tough calls about who to evacuate first deserve our support and recognition for their efforts and their courage.

As I see the news coverage of the hurricane this week, I have been frustrated and outraged to hear stories about people shooting at and threatening MedEvac helicopters, police, and other rescue personnel, because every helicopter that gets pulled out of service, and every police officer who turns in his badge, and every National Guard who is assigned to protect agaist looters, murderers, and rapists is one less resource that is available for the people who most desperately need immediate help to ensure their health and survival.  It breaks my heart to think that people who legitimately need aid are being deprived of if by the selfish and criminal acts of others. I have also been frustrated by the lack of evidence of people stepping up to help each other, rather than just demanding to be helped by government agencies.  Maybe that's happening, but it's sure not making it into the news, and it's rapidly eroding my faith in humanity.

But I think that Rabbi Gellman says it best:

The reason for triage decisions is the fact of limited resources. Now there is much to say about why lifesaving resources are limited in this catastrophe, but only a fool or an abject ideologue cannot grasp the fact that when the strongest possible storm hit the most vulnerable possible city, death, devastation and chaos were sure to follow in its wake no matter what the preparations for the storm. Yes, more could have been done, and nothing I say or believe ought to be construed in any way as justifying any possible malfeasance of what public officials could have or should have done ahead of this killer storm. I am particularly bewildered and outraged at the length of time it has taken to get food and water to the starving, suffering people in the convention center. As I write this on Friday, they are still in harm’s way and still suffering from the lack of the only lifesaving resource that should never be rationed and that is hope. It is a disgrace that even in the context of necessary triage decisions, they still wait in fear, hunger and thirst way too long for the time of triage to end.

However, in the end I simply refuse to blame the rescuers more than the storm that caused the need for rescue. It is not merely naive but profoundly foolish to have expected that 100,000 troops with water and food and patrol vehicles and helicopters and busses and trains and showers and shelters and electricity and bulldozers and levee-repair crews and mobile kitchens and tent cities and psychological services and identity checkers and employment services and construction crews and electrical linemen and mechanical and structural and civil engineers and architects and water-control experts and animal-removal experts could have all been set up somewhere out of the storm path but close enough to swoop in and pluck the soaking victims out of harm’s way despite the collapsed bridges and levees the minute the winds stopped blowing and minute the tide subsided without missing a heartbeat. Where have we gleaned the arrogant belief that if we suffer from a natural disaster, it must always somebody’s fault? We must all face the grim but inescapable fact that there are some times and some places where the need you face is simply greater than the resources you have at that moment or even days after that moment or even weeks after that moment, and thus agonizing decisions must be made. Triage is a way to make those decisions on the allocation of scarce lifesaving resources that does not stop the tears, but at least it stops the feeling that you did not just throw up your hands and give up.

In medical triage training, there are actually four color-coded levels that are assigned to victims of a disaster:

  • Green - The "walking wounded" who are affected, but who are at least capable of temporarily taking care of themselves.

  • Yellow - Those with significant, but not life-threatening, injuries.

  • Red - People with life-threatening injuries who need immediate attention to ensure their survival.

  • Black - People who are dead or likely to die even with aggressive medical attention. Resources are not be assigned to these victims, because you are more likely to have an impact on the outcome of the critical "reds" and "yellows" with limited resources.

If a triage system works effectively, it allows aid to reach the critical "Reds" first (i.e. premature babies and hospital patients and the people trapped in their attics surrounded by toxic water) then the "Yellows" (i.e. sick and disabled, young children and babies) and finally the "Greens" (i.e. the thousands of people who will need help rebuilding their homes and lives in the coming months). In the case of this hurricane, many of the the "Greens" are folks that self-evacuated before the hurricane hit, but there are also lots of able-bodied people who just no longer have access to any means of transportation. In triage, it is often necessary to ask "Green" patients to help provide assistance with the "Yellows" and "Reds", and I suspect that in this case there are plenty of people who could be helping their fellow evacuees instead of complaining about why no one is helping them.

I also think that anyone caught committing a crime that injures or endangers other people or causes precious resources to be diverted away from true victims of this disaster-- by threatening rescue workers, destroying property, looting (of non-survival-essential goods), murdering, or raping-- should immediately be designated as a "Black" level for triage, meaning that no resources whatsoever should be wasted on evacuating them. They should be left in the flooded city to fend for themselves without food, water, or shelter. If triage is an efficient way of administering aid, it may also be an efficient way of administering justice.