Triage for Responder Zero
If you are Responder Zero to a medical emergency, you may be placed in the position of having to decide who to help and in which order. While you may not possess the necessary medical skills, you can still make decisions that may positively impact the outcome of the scenario.
The purpose of this article is to help you with that decision making rubric. You’re likely not a medical provider, and maybe haven’t even taken a Stop the Bleed course. Don’t let that stop you from thinking you could be a helpful asset to the folks in need of aid.
It is not unrealistic that you’d be the first car to safely stop directly behind a 4 car pileup. You jump out and want to help. Where do you go first? Who do you help first? It’s a conundrum that can lead to many freezing with indecision. My hope is to help you square this circle.
Triage Defined and Redefined
"(in medical use) the assignment of degrees of urgency to wounds or illnesses to decide the order of treatment of a large number of patients or casualties."
That is the Oxford Dictionary's way of defining it. It is, of course, the correct definition. What it isn’t, however, is an insightful description. I’ll offer a definition that I think is a bit more helpful in both mindset and directive: Triage is doing the most good for the most people.
This is what I’ve found to be the most employable method in my time instructing triage. It is a process that requires one to embrace grey area. Optimal triage is a myth, and the first thing to do away with is hesitance or second guessing tendencies. I would often conduct an exercise with some medics and first aid students in which I’d propose 5 hypothetical patients with many various injuries. I’d ask them all individually to rank them in order of severity. In a class of 20 it wouldn’t be that uncommon to get 20 different lists. Which one was the correct list? That’s not a good question. Who got me a competent list the fastest? Now you’re asking the right stuff.
I would often allow 10 minutes to provide me the list. Folks with mild confidence and quick decision making skills were done within a minute usually. The perfectionist would utilize every last second. That is the mindset we wish to avoid.
Inaction is deadlier than sub-optimal. My old man used to tell me, “no decision was the decision."
I tell you this because I don’t want you to fret about your lack of medical knowledge. Your decision to be a helpful asset has already done more than anything else. You can let the Monday Morning Quarterback really get you down when you look back on a triage event, and while it may be a good feedback and learning point, it won’t do much to help your emotional stability. I’d much rather you help people in the wrong order than delay the help they need until you shore up the proper confidence to make a difference.
Prioritization by Convenience
I understand the term “convenience” connotes an idea that you’re helping only folks that it would be easy for you to help, as if you weren’t going that far out of your way. That’s not what I mean when I use this word.
What I mean is availability. Your decision for who to help first could be entirely determined by who the situation actually allows you to help. When EMT’s go through training, they learn of a concept called “scene safety.” You can’t help anyone if you become a casualty, too.
Remember that the goal is to do the most good for the most people. If you’re standing on the edge of some floodwaters, you might be able to help the nearest two people quickly. Perhaps there are another three people stuck on top of their car in the middle of the torrent. It would be extremely inconvenient for you to attempt to rescue them without copious support in terms of equipment and manpower. So you decide to do what is best for the most amount of people you can help, and you support the pair near the edge of the water flow that you can reach.
Four people are in a van and it slams into an oak tree. Three of the passengers are ejected from the vehicle and the last one needs extrication from the driver’s seat. There simply isn’t anything you can do for that last patient. So you can quickly move along to the ejected passengers to render as much aid as you can until emergency services arrive.
Prioritization by Proximity
If unfamiliar with medical procedures and vital signs, a method that can be as valid as any other is to simply help whoever is closest to you. If three cars all lose control on a bad patch of ice and find themselves in a ditch, there would be nothing wrong with you pulling over and running to the car closest to you and helping any way you can.
We can use the example from above about the van hitting the oak tree. You already know you can’t help the guy that’s still inside, but you can help the three outside. Which one do you help first? Well, with an ejection just finding the patient can be a task unto itself. For that reason you wouldn’t want to delay care for an individual because you spent a few minutes looking for the other two. No one would second guess your decision to start splinting the arm of someone unconscious on the side of the highway because he was the first person you were able to find and aid.
This isn’t just a method for the untrained, either. Sometimes it’s exactly the approach that a situation can dictate for professionals as well. When a building collapses during an earthquake, firefighters and EMT’s don’t delay care of those they have extracted until they’ve consolidated every patient and prioritized them. They treat everyone as they come and in the order they are freed.
The point is that as rudimentary and arbitrary as Prioritization by Proximity can seem on the surface, it’s still a useful rubric by which to ensure folks are treated quickly.
Prioritization by Severity
This is what most think of when you mention triage. In a situation in which the injured persons are consolidated and equally accessible in terms of convenience and proximity, you can survey the ailments and decide which ones to treat first.
This is not a perfect science. As I write this, I hesitate to want to offer any hard guidelines as things can change drastically from one scenario to the other. However, my goal here is to give you tools, not just reassurance. Here is how I would recommend deciding on a treatment order if you had to walk into a situation right now.
- Treat the major bleeds first.
- Treat those who can’t breathe second
- Treat anything else last
That’s as much detail as I'd be willing to go into. It’s a simple list, but I do that for a purpose. It will be easy to remember when the adrenaline kicks in, and it’s a proven system. In EMS the “ABC’s” were taught forever, and still are. The Military picked up HABC’s or MARCH a while ago, which are acronyms that start with the terms “hemorrhage” and “massive bleeds.” A person can be without air for 8-10 minutes before any lasting brain damage. A person with a severed artery can bleed out in as little as 2 minutes. This is the basic logic behind helping arterial, massive bleeds before helping those without air.
One must be careful. Not every bleed is a life threatening bleed. In my experience, the easiest tell is to just simply look at the person. Someone who’s “circling the drain” as we call it will be extremely pale, incoherent, and their wound will look grievous. Someone with a bleed that looks bad but isn’t immediately life threatening will be in pain, have flush skin, and likely be crying or yelling. That's a person that can wait until you’ve helped someone who can’t breathe.
This is not a perfect system. It’s not meant to be. It’s meant to give you the confidence to act when necessary, and eliminate any hesitation that hides in the back of your mind.
Too Many Cooks in the Kitchen
This is a quick aside, as the point of this article is to help Responder Zero. Very often with events that lead to mass casualties, however, you’ll have Responder Five, or even Responder Twelve. This can lead to a crowded and confusing situation.
As a Triage NCO part of my job was to bring order to the chaos. Just as often as I would delegate a task to someone, I would tell an extracurricular individual to get lost and quit cluttering up my area. If you’re the 7th or 8th person to stop and help a situation in which there are 3 injured folks, consider whether or not you’re helping the situation or hindering it. It could very well be that the best thing you can do for the injured is to clear the area so emergency services have one less parked car to navigate around.
Story time: I once saw a vehicle swerve in front of me in a panic from almost cutting someone off. It was a lifted 2-Door Jeep Wrangler with skinny tires at 70 mph. Not the choice environment for that vehicle. Being what it was, it toppled over to its passenger side and skidded down the road to a halt I stopped and so did the person behind me. There was a single driver, who unbuckled himself and climbed out. He complained that his back hurt. I helped him get into a position I knew the incoming paramedics would need him to be in order to get him nicely onto a spine board due to the high likelihood of back injury.
The other gentleman who stopped didn’t have any medical training. He asked the driver if he was okay. The driver said no. The good samaritan just stared at us, because he didn’t know what to do with that answer. I asked him if he had an emergency road kit, and he did. I then instructed him to turn on the hazard lights and pull the reflectors or flares out to mark the accident area. This cleared an ingress for the ambulance.
He felt a lot better being given a job that was useful, even if it wasn’t directly helping the injured man. The best thing he could do for the Jeep owner was to start clearing a path for the professionals to setup and get to the patient faster.
The rule of thumb I’d offer is that if you’re in a situation where it’s not immediately clear to you how you can be helpful, ask someone. If they don’t have an answer for you, then maybe there are just too many folks. You and your vehicle could just be an obstacle for people and other cars that could be helpful. Be honest with yourself and be objective with your analysis. I’m a trained medical technician who’s stopped at car crashes. 90% of the time I’d end up just sitting outside the car with the driver until the ambulance arrived. I usually left the moment the paramedics started talking to the patient. Even me, an experienced medic, is just in the way at that point.
I hope this article was helpful to you. Even if you forget everything you read in here, as long as you come away with a bit more confidence to act with more immediacy upon seeing an emergency (and determining that your safety wouldn’t be risked in helping), I’ll be happy. Odds are you’ll end up behaving in a way that’s similar to the recommendations I’ve given above.
ISG is a community of folks who want to be prepared and competent. Thanking you for willing to be Responder Zero may be preaching to the choir, but I offer the gratitude nonetheless. The paramedics can’t pull someone from a car with a gas leak if they’re not there. You can.
If you’re interested in bolstering your medical knowledge, the most pertinent skill you can have in the American landscape where our most dangerous killer is heart disease is a CPR certification. Not only is it good training, but it’s great legal liability protection to have that card. Next, a Stop the Bleed course is phenomenal training that I can endorse fully.
Again, thank you, and good luck.