Disaster Triage System and Educational Strategies

Introduction

Triage is a French word that means "to arrange and choose from" [2-1]. In other words, it is the process of determining the priority of patients' treatments based on the severity of their condition, time and the possibilities. The term triage may have originated during the Napoleonic Wars from the work of Dominique Jean Larrey, Napoleon's doctor, in order to determine the order and priority of emergency treatment. [3]

One of the responsibilities of medical team is to assist the casualties of a disaster, arrange the emergency transport and administer treatment. [4]

The authorities' logical and constant demand of medical team is to decrease injured soldiers and casualties in a battlefield. In fact, the mission of military medical team is to assist and empower the soldiers who are involved in the war [1].

The philosophy of triage is to categorize the victims who require immediate medical care; moreover, this dynamic method is to manage the order and priority of emergency transport. When medical and emergency personnel deal with arranging wounded, rationing resources, taking care of human resources, equipments and physical environment, they will need to apply special strategies.

When classification is based on and in accordance with accepted medical standards and regulations, it would be an accepted law in most countries [6]. [b1] Triage is the process of active decision-making that determines the patients' treatment priority [1, and 7].

Some problems would be obviated through triage, such as: patients who have arrived earlier, who scream more, those who express more needs, or ones who have more retinue should be treated in advance. Triage is used only in mass casualty; therefore, the doctor who does triage should have some special traits and have experiences other than the ones in emergencies. The doctor who does triage should not have emotional look and attitude toward children, women, elders, youth, girls and boys. The purpose of his/her job is to save more lives, he is not supposed to help the wounded with critical injuries, even the doctor might leave them to save more casualties.

Doctor who does triage should have great knowledge about psychology and sociology in order to perceive the situation and conditions, and make decisions. He/she should recognize the conflicts and provide the solutions while they are under pressure. Moreover, the morality is important in the job. How is the doctor that does triage trained and prepared through one's own moral and virtues, reading, attending classes, listening or via gaining experiences? 

If we have a logical and purposeful look at realities, we will realize that triage trainings are possible only in disasters and terrible catastrophe. In order to have more skilled practitioners in this field, the doctors who have had trainings should participate in disaster triage. The question is that why there are not enough definitions and contents in maneuvers and training courses of triage. The reply is obvious although education and practice would help to learn skills and principles of triage, the huge gap between practice and reality would not be covered unless gaining experiences in real situations.

It should be accepted that the mental conditions, anxiety and stress in a disaster does not allow the doctor to use his knowledge appropriately. It would be very nice if we could have other doctors in real situations to teach experiences and skills of triage. This action is not immoral, we should have fresh look and take care of future. Along with experienced doctors who are in disaster, the inexperienced doctors should participate, as well, in order to gain skills and learn triage thoroughly [8].

Triage involves multiple levels including cooperation, coordination and decision making. This is an appropriate relationship that should be provided [9].

Taking care of the wounded and casualties has been developed since war. Different kinds of medical equipments, quick treatment, quick transfer, care flight, various methods of care, and etc have expanded. People and the authorities expect the medical system to enhance medical treatment, especially triage [10].

The members of triage team should have high knowledge and intelligence so that they can keep calm in disasters and provide the services. Without doubt, doctor of triage should have managerial skills in order to control and lead the personnel (paramedics, nurses and other medical team members), and patients appropriately. 

Methods

Delphi technique was used in this method.  Firstly, a number of questions were framed and sent to experts of different majors including Emergency Medicine, Pulmonary Disease, Forensics, Eyes, Skin, and Nurses, Pharmacologists and Toxicology. They were asked to express their opinions about triage and its issues. Finally, 18 people replied the questionnaires. The questions and answers were provided based on different and accessible resources.

The questionnaires were collected and analyzed. The opinions were categorized and feedbacks were provided. An invitation was sent to them to participate in a meeting in order to discuss about the categorized opinions. In the meeting, the issues that were raised in the questionnaire were debated; the meeting continued for hours and recorded. Then, the issues were categorized.

In the following table, the data related to triage categorization, symptoms of casualties with different factors, and the required treatment and cure are presented schematically:

Results

The results of the study reveal that the triage team is weak in three educational subjects of chemical casualties including:

1. The recognition of chemical poisoning symptoms,
2.  The necessity to teach caring and curing methods while dealing with special factors that cause symptoms and disorders in different parts of the body,
3. And the control of stress and anxiety of casualties in disasters.

For the first issue about 80% agreed and their opinions were collected. In the second one, 90% believed that instructions should be devised for care and treatment. The last issue was discussed in the meeting and 70% agreed that the medical team is under pressure because of disaster, explosion, the high number of casualties, and etc; they become anxious and stressful and should control themselves.

Discussion

Nowadays, non-compliance with ethical issues in totalitarian regimes and superpowers has made troubles for the countries that are looking for freedom and independency. The terrorists use chemical, biological, nuclear and explosive weapons which lead to terrible disasters. Therefore, the countries should program to reduce the number of casualties [11]. It is recommended that the programming be done according to the research results. 

Triage system categorizes and specifies treatment resources for patients. The determined factors of triage in emergencies sound little or far-fetched. Therefore, there is imbalance between degraded environment and the medical team that might not be able to provide the required services and ask for foreign and international help [12].

In medical ethics, it is important to control the patients' stress and anxiety; moreover, it is mentioned in our religious teachings. The mission and philosophy of the prophets had been to improve ethics among human. Therefore, scientific development should be ethical. Professionalism without ethics is not sufficient for human. This is similar in medicine.

Attempting to save human's lives, improve their health, relieve their pain, survive generation and make the environment healthy are ethical values in medical community. The way that doctor treats patient is very crucial; they should have ethical, emotional, friendly, respectable and with dignity behavior. What are the red lines in commitment and law? How far should we continue to save the ethics? These are some questions debated in medical community. However, the replies for some of them are simply obvious and the medical community should pay attention to them [13]. 

Mahebinia has written an article named "Triage decision-making in disasters". It is concluded that appropriate and on-time decision-making is necessary in triage. The priorities in triage and treatment experiences have been done for hundreds of years.

In order to have influential triage, the very first step is to be virtuous.Stability in thinking based on ethical principles is the problem that personnel of emergency deal with. This function might be because of getting used to scenes of disasters.

Understanding this concept is the preparation for doing triage in disasters. The results could be used to train the triage team after the disaster, as well. Furthermore, implementing difficult decisions, made by doctors, is vital in triage that should be based on ethics. Abstract thinking and judgment development of an empirical function could be determined according to the professionalism of caregivers. Further studies should be conducted on this field and the development of criteria to enhance experience levels and decision-making skills. In order to provide appropriate answers for triage in emergencies, the art and science of triage should be developed [14].

One of the major differences between normal and critical conditions in triage is that in critical one usually the victims are classified in three groups and the doctors are supposed to do the triage, and because of limitations in resources they cannot divide equally. At this moment the criterion is the effect not fairness. So, respecting ethics is different in critical conditions [15].

Ethical principles in disasters have not been devised thoroughly and internationally yet; and there are no special principles in state related to the issue. There are medical ethics for normal and usual conditions, to some extent, called Childress and Beachamp that include beneficence, autonomy, non maleficence, and justice. However, these principles are for normal situations and could not be applied in disasters. They have been developed to protect the society and could not be generalized [16].       

Since decision-making in disasters would save casualties' lives, it is very crucial that design the triage program logically and scientifically.

In some countries like United States, there are special educations for emergency technicians, emergency medical technicians, nurses, dentists and psychologists to prepare them for disasters. They are taught and prepared to save peoples' lives in disasters [17].

Our country deals with different natural disasters like flood, earthquake or other types of disasters like war or terrorism. Therefore, special educational programs should be provided for emergency doctors, emergency medical technicians, nurses and psychologists. It should be conducted based on needs assessment and the classification of disasters. They should be trained for different situations to deal with, whether in the place of disasters or at the hospitals.