Is civilian hospital triage illegal?

Factual Questions
21

There is something odd about the list of bullet points that constitute the casualties. Something about badly burned patients being the one glaring point.

Something tells me that doctors wont be the ones that make that decision, if there happens to be a sizeable contingent of doctors still alive to do so.

[ul]
[li]viral pandemic[/li]
Govt institutes martial law and orders population to stay indoors, bring out your dead

[li]concurrent mass casualty event[/li]
Nuclear war threshold level casualties, multiple citys
[list]
[li]the old ,young , infirm, will already be dead[/li][li]casualty levels may be higher than the available supply of pain killers , euthanasia via bullets was perscribed by the british home office , in the event of a nuclear war[/li][/ul]
[li]local hotspot[/li]
[ul]
[li]Casualties would be farmed out to other cities[/li][li]Mash units would arrive, govt would be the determiner[/li][/ul]
[/list]

Triage is what happens when you cant treat everyone, so its just an allocation of resources. As to who gets what and when , depending on the event, lawyers and economists might be concidered expendable, while ditch diggers are worth their weight in gold.

As well , that assumes that you have taken no precautions of your own, should you fall into one of the groups that would probably be left disapointed at a primary aid center.

While I wont put much thought into what a heroin addict might go through, someone who needs insulin and does not get it because of triage would be a tradgedy.

Declan

22

Time is rationed. Medical personnel only have so much time to spend. There are only 24 hours in a day and all that. Patients will die if untreated. The time to help them must be rationed.

"We’ve only got so much time [to treat x numbers of patients], some people are not going to get any [time to be treated] and are therefore going to die.

23

Things like organs are rationed too - there are obviously quite literally only so many donor hearts, so many donor livers, so many matches for bone marrow, etc.

24

Presumably this is not hypothetical. Doctors have to do this whenever there is a serious accident (e.g. train crash, building collapse, even a big multi-vehicle accident) that temporarily overwhelms nearby ER rooms, and presumably don’t suffer to terrible legal consequences.

Has anyone’s family sued after their loved ones were “black tagged” ?

25

It’s not a Jack Bauer situation, though: at the end of that 24 hour day, there’s another 24 hour day ready to get started. I understand what you’re saying, but if all you’re talking about is time and staff resources, then it’s still a question of prioritizing, not rationing. It’s not like a surgical team will only work on one patient and then they say, “well, it’s time to go home now, the rest of you are S.O.L.” Even when the surgical team is exhausted, presumably in such a situation, their relief team would be coming in to take over, right?

26

Yes, but a badly injured person cannot wait indefinitely. If you have 15 people who need an operation that takes 3 hours to perform, and each of them will die if the operation is not started within the next 5 hours, and you only have 6 surgeons available for the next 24 hour period, 3 people are going to die.

27

Conceded.

28

What do you find odd about it? Severe burns are difficult to survive and require intensive treatment. Under our protocols, we won’t even attempt resuscitation on someone with extensive 3rd degree burns.

29

In extreme cases, prioritizing is rationing. Time is a critical resource, and some injuries can’t wait.

30

Cite?

31

From the things I’ve read about the report, I don’t think it goes far enough, and I do think there needs to be some legal exemptions put in place. Let me give you an example of a situation that will guaranteed happen some day in the US…

So, I live in a suburb of Seattle and at some point in the future the area will be hit with a massive regional earthquake that will cause extensive damage. I belong to a local CERT team that has been trained to help out the local fire department in that kind of situation. Here is a scenario of how things might play out in my town and how the triage structure is expected to work (best case scenario, mind you). Image a massive regional quake happens during the work day. There is wide-spread damage, fires, building collapses, etc. The first several hours after an event are the most critical and our training (and the city’s plan) is to save the lives of the most possible people. Roughly estimating, there are probably 10,000 people in or within a several mile radius my towns downtown core during the day. There are maybe 10 policeman and 40 firefighters and paramedics. There is no hospital in my town, but if you total up all the doctor’s offices there are maybe 40 MDs, and maybe 100 if you include dentists, nurses, even veterinarians… anybody that has been to Med school or has training.

Traditional first responders won’t be doing triage at all. They are tasked with other things. Police are for continuity of services and security (making sure major roads are clear for firemen, no looting, running local command centers and communicating regionally). Paramedics are for transporting injured to the hospital (and obviously some major injury triage). Firemen are for responding to major things (big fires or building collapses, making sure large buildings downtown are safe, checking schools, etc.) There is no regional help since all the neighbouring towns are in the same situation. And the majority of severely injured people will have died long before any national help arrives.

All that being said the majority of people will be triaged in the following manner. CERT teams will come across some injured people and since we are not medically trained besides just stabilizing injured people, the only people we are supposed to black tag are people that are dead. Anybody else is tagged according to the START method listed above. Our next task is to try to get the critical (red tag) people to a place they can get help as fast as possible. If able to transport, Injured people are supposed to be taken to the main firestation, where presumably some paramedics and doctors mentioned above have gathered. There the injured are triaged again by medical staff, and this is where this document comes into play and where solid recommendations would be helpful. Mind you, these are not ER doctors that are used to dealing with these kind of situations. These are local family practice doctors that are years away from medical school and ER residency. So, imagine the scenario where an ambulance pulls up to the main triage location and has room to take one injured person to the hospital (for a subsequent further triage and potential treatment). There is a 50 year old family practice MD whose day to day business is dealing with little kid’s sniffles and prostate exams is now looking at 5 injured people:

  • a 30 year old father of two with a crushed pelvis and possible internal bleeding
  • a pregnant woman that has almost catastrophic injuries, but not quite
  • a 65 year old man that just suffered a heart attack
  • a 16 year old with severe bleeding
  • a 7 year old with a head injury that is about to go into shock

His job is to pick the person that gets to go in the ambulance knowing that by the time the next ambulance arrives, 2 of the remaining four will probably be dead. Who do you pick? That is where a document like this is invaluable: to help a stressed out person make the best possible decision for all involved in a bad situation. That’s why I think the document needs to go a little farther than the things I have read about it. It is fairly obvious (though controversial to see it published publicly) that severe burn victims, the elderly, etc. will have to wait, but some more guidance for how to deal with people in the meaty part of the bell-curve would be welcome.

As far as legality question in the OP, what I’ve been told is that there is no exemption/immunity for anyone’s personal actions in these type of situations. Usually the “Good Samaritan” clause will cover private citizens trying to help, but MDs that have to make the tough choices described above are held to a higher standard and can get sued after the fact. And the fireman we got training from said they would expect a barrage of lawsuits about their actions after an event that was large enough to call up CERT teams. I assume it would be worse for medical staff. Hopefully, this working group and this document are a first step towards granting some legal immunity for MDs in these type of situations if they followed published procedures.

32

Missed the edit window… but let me clarify my own point on a re-read.

Policemen, firemen, and paramedics will absolutely be doing triage in a situation like this. My (poorly stated) point was that they can’t triage everyone, can’t be everywhere at once, and in a big event, they have other things to worry about. So a large part of initial triage will fall to other people like local doctors and CERT teams.

33

Not sure if it’s what Magiver meant, but sometimes, treatment will be denied to obese people or smokers because it will not be effective. Joint replacements for seriously obese people may mechanically fail, for example - in which case the operation will not even be attempted.

34

I don’t know about Declan, but to me, a pandemic is the widespread outbreak of a disease. What kind of disease causes severe burns? I realize they’re also talking about catastrophic events (i.e. “acts of God”) in the article, but the emphasis really is on a disease outbreak. Though I suppose if there was a super-flu epidemic and a modern-day Triangle Shirtwaist Factory fire at the same time, then doctors would still have to perform triage.

35

Thats exactly what I meant. I suppose tho, what actually happened was some reporter cherry picked situations and did not connect the dots.

Declan

36

On the other hand, a pandemic could well come along with riots, stupid accidents (remember how many of the fires in San Francisco after the earthquake were started by people who should have known better?) and general havoc. Then again, it could be perfectly peaceful and calm.

37

I thought the idea was that if there were a major pandemic that required the full attention of all the nation’s health providers, they wouldn’t have time to spare for the usual steady trickle of burn victims and trauma cases that hospitals normally treat.

But the more I think about this, the more questionable it seems to be formulating a plan like this without reference to the specific type of disaster being considered. In the case of a flu pandemic, for example, what exactly would doctors be doing for flu patients that would take up so much of their time and resources? Influenza isn’t very treatable, after all. People with very advanced and severe cases of the disease would probably be “black-tagged” and people with mild cases wouldn’t need labor-intensive treatment.

38

And all of these situations, we have to pass laws about common sense.

This whole thing has come about because it is all about me, for everyone. It is fear of the legal system, the inability of people to think of the greater good and their pathological need for all the tough decisions to apply only to others. Our greed and fear have be allowed to run rampant for so long now that we are incapable of doing the right thing without this sort of zero decision making. See zero tolerance in schools, courts etc.

As long as we act as we do now and allow it from others, no amount of law or list will really work because when it is over, if civilization still stands, we will go for the the money and as we will be on the juries, we will give it to them because we want them to do the same when it is our turn.

If you can’t stand in front of you spouse, child or parent today, while this is only a maybe happen, and tell them that in one of these situations that you will let them die for the greater good, then you are part of the problem.

YMMV