Herding cats: ethics in prehospital triage

2.1 The historical basis of triage: differences between military and civilian triage

While this paper deals with the issue of civilian triage, discussing the philosophical premises of triage can offer clarity for its application. Triage originated from the French word “trier” that was primarily used in the context of military systems [9, 10, 11, 12, 13, 14]. Treating patients equally in all areas of medical practice is a fundamental ethical principle. The application of this basic principle to wounded soldiers on the battlefield is almost necessary and expected. Providing equal treatment is also more practical in a military setting because there are few overt differences between soldiers; they are mostly in the same uniform and approximately the same age. Notwithstanding, providing equal treatment is more challenging in civilian triage because of major demographic and cultural differences.

Another difference between military and civilian triage comes from the focus of triage criteria. Military triage focuses on maintaining the ability of the wounded to return to battle and duty [15]. In this way, the military perspective towards medical triage prioritizes the number of soldiers and their functionality. The one exception to where functionality does not apply is the advanced medical treatment needed for soldiers who are seriously injured on the battlefield. The logic of military triage is to “leave to die in dignity”, which is contradictory to the principles and logics that guide civilian triage [15]. Especially, it is a standard of practice for trauma surgeons to avoid spending time and resources on complex operations with low success rates [16].

From the standpoint of the facade discipline, soldiers who are more likely to return to combat are prioritized over soldiers who require greater resources and time for recovery. To this end, the triage of soldiers who are seriously injured or who require advanced medical intervention are evaluated to maximize the efficient use of limited resources.

The principle of “treating minor injuries first” is simple and easy to apply in the military perspective as well. This approach can also be referred to as “reverse triage”; however, this approach may lead to extreme consequences on humanitarianism. For example, in the 1982 Lebanon war, surgeons started operating on a soldier with a complex injury, only to have them executed by the commander because of the time and resources they would have taken for completing the treatment [17]. It should not be overlooked that the military triage system is basically “number focused” and this is in stark contrast with the principles that guide civilian triage.

2.2 The importance of triage

The military origins of triage have served as the foundation for civilian triage during mass casualty incidents. In situations where trauma threatens the lives of victims, triage can be a crucial way to provide efficient delivery of health care. Furthermore, triage can aid in providing timely and adequate prehospital emergency medical interventions, which may ultimately reduce the mortality rates of trauma patients [18].

The majority of trauma deaths occur in prehospital settings [19]. Some studies have reported that 15-21% of all trauma deaths are considered potentially preventable [20, 21]. In trauma-related injuries, death usually develops rapidly within six to 12 hours [22, 23]. In terms of the time of death, 50% of deaths due to trauma occur within the first few minutes [24, 25]. For this reason, prehospital triage is very important in trauma situations.

If triage is not applied adequately, undertriage puts patients at risk, whereas overtriage results in system strain. There is clear ethical conflict between two principles, beneficence and non-maleficence, that may affect the ethical distribution of health care services. Careful triage of trauma patients is pivotal in achieving optimum outcomes in patients. Mortality and morbidity can be reduced through effective management including identification, infield triage, and transport of injured patients to appropriate hospitals. However, in mass casualty triage, it is a reasonably difficult case due to two issues: minimizing the group’s overall morbidity and mortality and distributing patients to prevent overwhelming hospitals.

2.3 Ethical considerations in prehospital triage

While some ethical principles such as equality are particularly pertinent for the context of prehospital triage, a broader ethical discussion about mass casualties is highly relevant and needed [26]. In a mass casualty incident, there are two relevant ethical concepts. The first one is the individual virtues of the people who apply triage such as prudence, courage, justice, stewardship, vigilance, resilience, self-effacing charity, and communication [27]. The second concepts are the principles that the health service organization or emergency system advance, such as the organizational vision, mission, and values. The second one is a relatively slow but objective approach to disseminating corporate philosophy, such as preparing for disasters, eliminating technical and logistical deficiencies, and providing triage training to staff. The guiding principles of individual values are nourished as professional values, maintained by individual attitudes of staff, and can be partially changed by professional education [17, 28]. The key principle of both two concepts is beneficence.

Ethical inquiries in prehospital triage include issues of human rights, vulnerability, limited resources and options, justice, insecurity, urgency, instability, and decision-making in limited time. Due to these complexities, ethical approaches to decision-making during triage have generally been speculative, tentative and lacking, and remain an ongoing area of research [29]. However, triage is difficult to justify in terms of ethics on a daily basis in medicine. Triage must be replaced by other approaches in the allocation of health services for upholding human rights in routine medical practice [17, 30, 31]. Triage is only used in routine medical practice in situations where there are no other alternative courses of action.

There is a persistent ethical tension between two approaches or principles when discussing triage arguments [32]. One of these approaches is to maximize the “lives/benefits” of the greatest number of people; “do the greatest good for the greatest number of patients”. The other approach is to equip each patient with equal opportunity for receiving medical intervention. It can be said that the first approach is “results-oriented”, and the second approach is “intention-focused”. The philosophers of J. Bentham and J. S. Mill advocated for the biblical approaches, John Taurek (Should the Numbers Count?) and J. Harris (The Value of Life) promoted the intention-focused approach (equal chances) [13, 33, 34].

The first approach can be summarized as seeking to treat the greatest number of injured people with the quickest treatment methods. The first approach promotes the rapid assessment of patients who are easier to treat, and priority-setting and allocation in health service delivery and transport. So, in the military context, the measure of success in the first triage approach is the number of soldiers/people saved at the end of the battle. The majority of triage models applied in civilian settings are grounded in this basic philosophy since it emphasizes the treatment of the greatest number of people in a limited time frame.

The function the two basic approaches to triage discussed in this section is to guide practitioners and offer an ethical assessment of their values and principles. Each approach has critical aspects that practitioners must reflect on. These approaches broadly reflect Aristotelian virtues, Kantian duty-based (deontological) ethics, utilitarianism, communitarianism, or liberal approach [35]. Health care providers must be aware of the ethical discussions surrounding distinct approaches to triage, which may aid them in acting in an ethical manner.

Finally, according to some studies, there are three basic ethical values that are pertinent for the field of prehospital emergency medicine: social justice, utilitarianism, and moral rights [36, 37]. However, there is an important divergence between the values of health care professionals and the values prioritized by the ambulance system [36, 38]. When making decisions about health care, PECs emphasize social justice and moral rights, while ambulatory organizations advocate for utilitarianism. Notwithstanding, the examination of triage through ethical principles remains incomplete [39]; there is an opportunity to examine triage from the standpoint of other ethical approaches and theories such as humanitarianism.

2.4 Justice, equity, and equality

The way in which limited healthcare resources are managed and allocated is an ongoing discussion that involves invoking the ethical concept of distributive justice [40, 41]. In situations where there are limited health care resources, the principle of distributive justice is assessed on the issue of allocation/distribution of resources within ambulance services. In prehospital settings, distributive justice may be examined in light of the following three principles: equal chances, utilitarianism, and egalitarianism.

The principle of equal chances is similar to the phrase “first-come, first-served” in routine medical practice. However, the application of this approach is impractical in prehospital emergency medicine. Patients with minor injuries will likely arrive first to receive care because they are likely more physically capable of travelling to a health service organization. In this way, patients are not clinically equally and prioritizing patients who arrive first will rapidly consume health care resources before the arrival of patients with complex injuries that may require urgent medical interventions [42].

The utilitarian approach is an outcomes-focused approach that emphasizes “the greatest good for the greatest number of people”. This approach optimizes emergency care for the maximum number of patients. Disaster triage decisions are inherently utilitarian in nature [32], and despite the potential for injustice at the individual level, society may consider utilitarian theory as more appropriate for mass casualty incidents [41]. Yet, the main discussion is not exactly based on the concept of utilitarianism but egalitarianism. According to egalitarianism, emergency care resources would be directed to patients with the most severe injuries that require complex medical care. However, the challenge with egalitarianism is that it may use scarce resources on patients with complex injuries who may have a low survival rate; resources that could have been used to save patients with minor injuries have therefore been wasted (futility).

Furthermore, according to the principle of equality, PECs are required to adopt an attitude that opposes discrimination and injustice, and provide equal and accessible health care to all those in need, especially to vulnerable groups [43, 44]. This principle is also reflected in the emergency medicine code of ethics [44, 45]. Equality is the basic principle to guide medical practice; in triage, health care should not be distributed according to age, gender, nationality, political and religious beliefs as an election criterion [46]. The point at which ethics and medicine intersect is deciding the criterion for who receives emergency medical intervention.

2.5 Assessment and decision-making process

In the case of a large number of injured patients, PECs’ value system is the main facilitator of ethical decision-making, with many internal and external determinants affecting the situation [47]. Ethical decision-making is influenced by the subjective values of decision-makers which address ethical relativism; however, there is also a need to consider how decision-making affects other patients. In most situations, triage is an informal process where decisions are made ad hoc and implemented in a variety of ways [48]. Moreover, differences in ethical decision-making may arise not only among emergency health care professionals, but also between each professional group such as emergency technicians, nurses, and physicians [49, 50]. Therefore, the decision-making process emerges in the context of the individual as the result of eclectic thinking or preparedness rather than being the product of a totally single approach.

The general approach of medical ethics is to reference basic ethical principles and values in situations that require triage. Rather than tendering practical prescriptions applicable to each case, the basic ethically justifiable approaches to the topic were discussed in this paper, and the one to be preferred depends on the PEC. The main issue, however, in these situations occurs when there is a need for separate evaluation for each case to determine the most approach ethical approaches, values and principles. In medical education, triage is conceptualized as the process of coding and resource management. However, there is a need to develop appropriate selection and evaluation criteria for the ethical provision of health care.

2.6 Assessment criteria and slippery slopes

There is a compendium of prehospital emergency care systems used by countries around the world today [51]. Accordingly, there is no global acceptance of a particular triage system and no perfect triage algorithm exists. For these reasons, the issues related to triage in prehospital settings discussed previously vary across countries, cultures, health-education curricula, and community perceptions of the ambulance service. Since triage in prehospital settings is so dependent on a variety of perspectives, triage should be considered as more than a medical issue.

According to some authors, a sensitive and safe triage system should consider three parameters: physiological variables, anatomical structure, and the mechanism of injury [52]. Triage systems measure these variables using algorithms that assess circulation, respiration, the presence of abdominal trauma, motor response and speech skills, trauma urgency scores [5, 53]. There are also instruments that represent a combination of these algorithms in one measurement.

Furthermore, a significant amount of triage scales, indexes, scores, protocols, and systems have been developed for emergency services and departments. However, some research suggests that such systems impose unnecessarily rigid rules on triage decision-making; furthermore, these systems are essentially invalid because they are a product of “subjective” expert opinion [54]. Some authors suggest that the majority of these systems have a weak scientific base [55, 56, 57], lack studies with high-quality evidence supporting triage and treatment [58, 59].

Numerous triage models have been established for the purpose of rapidly sorting and categorizing of victims for prehospital settings [8, 60, 61, 62, 63, 64]. Though, there is insufficient evidence showing which prehospital triage systems/models are effective in achieving better health outcomes and quality of care [5, 57, 65, 66, 67, 68, 69]. Clearly, the quality of prehospital trauma triage depends on health care provider accuracy of and compliance with triage protocols and procedures [70]. Research shows that compliance rates to triage protocols vary from 21% to 94% for different procedures and process [71]. A recent review showed that different triage protocols were not capable in accurately discriminating between patients with simple and complex injuries [72]. Notwithstanding, the lack of evidence regarding the effectiveness of prehospital triage systems do not preclude their effectiveness. The uncertainty is a prime reason why triage and related issues serve as a slippery slope in prehospital emergency medicine and management.

2.7 The reliability of triage decisions/herding cats

Since the prehospital area is a more public and less controlled environment than the hospital environment [6], PECs must constantly keep their safety in mind [73]. Especially in cases of mass injuries and disasters, PECs rushing to help may inadvertently expose themselves to unexpected trauma. In triage decisions, emergency management is like the idiom of “herding cats”, which refers to managing or controlling the chaos and organizing people toward common goals. Triage is also related to a number of socio-cultural concepts like chaos management, communication skills, and a resilient organization. Unpredictable social reactions and the on-scene dynamics of the crisis make this field more complicated. PECs often deal with hostile patients and significant others alongside the intensity of the crisis. Thus, all PECs must first ensure that they are in a safe environment before beginning the assessment and treatment of patients.

Some research indicates that seniors are undertriaged while children are overtriaged [74, 75, 76]. However, a recent study found that neither of the four most popular triage systems for children worked with high accuracy, and each demonstrated an unacceptable amount of undertriage [77]. The challenge of reducing undertriage is also essential for maximizing the accuracy of mass casualty triage systems in the adult population in emergency services [78]. Ultimately, undertriage may cause a potential conflict in the accuracy of triage decisions when applied to different populations. On the other hand, some research has found that the individual characteristics of health care workers affect triage decision-making when physiological data of patients are used [79]. There are also a number of differences between how health care providers make triage decisions depending on their demographic and personal characteristics [47].

Other studies have achieved that similar result in this regard [80, 81, 82, 83, 84, 85]. For instance, one study found that more than half decisions were correct in emergency triage situations [81]. Moreover, in the same study, agreement between triage decisions made by different health professionals was very low. These observations raise the following question: do individuals characteristics and personal differences of health care providers have a greater influence on triage decisions than expected? The same questions pertaining to the adequacy and reliability of triage apply in the context of prehospital emergency medicine. For example, one study found that compliance of paramedics with triage guidelines to be below acceptable levels [82]. Another study reported that paramedics were not enough to make accurate decisions to reflect patient needs for emergency services [83]. Similarly, lower acuity patients who could have been treated in the community were not accurately identified by paramedics who lacked extended care training [84]. In another study, the overlap between the triage decisions within the same occupational groups is 47% for the 3-point scale and 45% for the 5-point scale [85]. Finally, significant differences with regards to insufficient or overtriage decisions between paramedics and emergency nurses were found for the 5-point triage scale [65].

Another challenge in the reliability of triage decisions is to use multiple triage systems. It is necessary to use the same triage system in hospital units and departments because using multiple systems - that might have distinct protocols and language - can worsen the patient’s prognosis [23]. However, using multiple triage systems is a challenge when health care providers use the “human factor”, or alternative methods guided by their professional norms to make triage decisions. Otherwise, it would be unrealistic to expect a professional contribution to the development of the profession from those who acted mechanically within a set of rules and obligations. Moreover, it may be considered ethical absolutism for a prehospital emergency system to insist on using a specific triage system.

Clinical findings in prehospital medicine and disaster management within the emergency department in terms of vital signs and emergency trauma scoring in patients may be different in some cases [86]. That is, the urgency index of the trauma patient may not always be accurately determined in the prehospital area. This observation shows that there is uncertainty in the triage process that requires clarification.

Patient vital signs are not always the key factor in triage decisions. One study found patient vital signs did not affect the triage decisions of the majority (92%) of the health professionals [87]. According to another study, PECs placed a significant emphasis on the speed of decisions, relying on initial impressions and immediately observable information, rather than the precise measurement of vital signs or systematic application of field triage criteria [88]. However, deciding on the most appropriate field triage criteria raises many questions as mentioned previously in this paper.

When deciding the medical condition of trauma patients, the main issue is to determine the severity of the trauma. One of the parameters used to assess trauma severity in prehospital settings is the respiratory rate. In any trauma case, it is relatively convenient to determine the patient’s respiratory rate on the scene; the respiratory rate can also help to make triage decisions that maximize providing medical attention to patients who need it immediately. However, some studies indicate that the respiratory rate of trauma patients does not provide reliable information about the patient’s oxygen saturation [89]. Therefore, using a less than ideal method to make triage systems will make the triage system invalid.

In many models, casualties are divided into four or more groups. Each patient is encoded with color-coded triage tags reflecting their casualty group. However, there are no international standards for triage tags. Since triage evaluation represents a continuum, there is always a possibility that an injury with a specific tag may receive a different tag at a future evaluation [7]. This possibility reduces the functional applicability of the encoding process. Furthermore, there is the question of the number of available triage tags in ambulances and how they can be used practically for each disaster situation.

Another criticism is that, in the case of a large number of injured patients during disasters, directing emergency health care professionals to the coding process will reduce attention to providing immediate medical attention in the ambulance. At the same time, who will use the triage coding? Is it for the other ambulance crews or emergency departments? It seems that the first thing in the evaluation of the patient is triage coding and not the treatment. Further, trauma triage is not a linear process, and assessments are not performed in a sequential fashion [88]. So, what will a PEC do when s/he comes to a patient with hemorrhage? Will she start immediately to hemorrhage control of current injured, or continue the triage assessment?

Finally, several decision support systems have been developed for prehospital settings in recent years which have great potential to augment triage decision-making. These support systems, such as artificial intelligence, raise significant ethical issues concerning triage, as well as humanity and compassion, and impact on society’s perceptions of medicine.