How do you prioritize people?

There are many ways to prioritize people. In national frames, people often say we should prioritize the least among us, or that we should prioritize everyone equally. An emergency triage forces tradeoffs. Let’s say you have the following patients at a mass casualty event:

Alice, whose leg was cut off below her left knee

Bob, whose body has been completely separated below the waist, but he’s still breathing and looking around

Charlie, who is walking around without a hand

Daniel, who is stumbling around like he’s blinded, and is shouting for help

Eric, who’s on a wheelchair and wheezing

Who do you help first?

Something like “assist those most vulnerable” would suggest Bob. Something like “we must be fair” might suggest Eric, as it’s possible Eric has been disabled for a longer time than everyone else. A folk response might be “go where there’s the most blood”, which would be Bob again. Another common response might be “go to whoever is loudest”, which would lead us to helping Daniel first.

The method emergency medical personnel use to decide this today is downstream of Dominique Jean Larrey, a surgeon in Napoleon’s Army.

It asks, what outcome can you actually move? Of what you can do, which action would save the most life?

In the US Army, we had IDME.

Immediate: This person will die IF they are not treated, but may live with an intervention.

Delayed: This person may die tomorrow, or lose a limb, eyesight, or other functionality, but waiting an hour isn’t going to kill them.

Minimal: They’re walking around.

Black: The modal result strongly suggests this person will die, even with intervention.

With that, we would slap a tourniquet on Alice first. A leg amputation will usually lose more blood than a hand amputation, so that’s why Alice goes before Charlie. Charlie gets the second intervention. We get Eric talking while we’re looking at Daniel. If Eric is talking he’s fine for now. Then we cycle through Alice and Charlie again, stabilizing the interventions further. This is assuming you’re helping them alone.

If there are more people, you would be using the same prioritization, but acting as a control room instead, using other hands and feet. Let’s say we discover that Daniel was blinded by blood from a forehead cut. As soon as we get him seeing again, tag, you’re going to direct him to help you out.

After all this, we can look at Bob. Maybe get Daniel to pray with Bob, or give him company, sing with him, take any last words, etc. The focus is still on getting Alice and Charlie stabilized.

All the while, we’re getting everyone’s respirations per minute, heart rate, blood pressure, and so on, to see if anyone is deteriorating at a different pace. Let’s say Eric has gone from 20 respirations a minute to 8. Suddenly, this changes your focus. Check to see how Eric is getting air in and out.

Take that scenario. Imagine we had said that due to the privilege of our ableness, we should instead listen to the directions of Eric or Charlie. Sure, they might have useful information- but they’re not the ones with the clearest means to make any decision about how to allocate energy.

What if Eric tells you to help Bob, who is in the worst situation? You help Bob. Alice loses precious seconds. She dies within eight minutes. Twenty minutes later, despite going through a slew of interventions, Bob dies. And now Charlie passes out.

Death is fair, in that it comes for us all eventually.

Links:

Dominique Jean Larrey

Triage