Triage for the Neurosurgeon
Triage for the Neurosurgeon
Triage for the neurosurgeon is a misnomer. The neurosurgeon's role within a mass-casualty situation is one of a subspecialist surgeon instead of a triage officer. Unfortunately because of the events of September 11, 2001, civilian neurosurgeons and other medical specialists have been questioning their role within a mass-casualty situation or, worse, a situation created by biological, chemical, or nuclear weapons. There is no single triage system used exclusively within the United States, and different systems have differing sensitivities, specificities, and labeling methods. The purpose of this article is to discuss varying aspects of triage for both military personnel and civilians and suggest how the neurosurgeon may help shape this process within his or her community. Furthermore, the effects of biological, chemical, and nuclear weapons will be discussed in relation to the triage system.
The title for this article is somewhat of a misnomer. If the neurosurgeon is performing general triage in a mass-casualty situation, something is gravely wrong. For the general neurosurgeon, understanding the principles of triage, why decisions are made and where he or she fits into the system is beneficial and essential for the effective treatment of the neurologically injured. As a limited medical asset, neurosurgeons can best serve patients by performing triage and subsequent surgery in head-and spine-injured victims and not by trying to perform general triage of all patients in a mass-casualty situation. In light of the events of September 11, 2001, many within the medical field have more fully analyzed their roles within a mass-casualty situation both in regard to blast-and missile-induced wounds from terrorist acts and potential acts of biochemical terrorism. In their examination of 220 terrorist bombing incidents, Frykberg and Tepas indicated that injury to the central nervous system is frequent. They noted that head injury was the most common cause, 71.4 and 52%, respectively, of both immediate and late fatality. The neurosurgeon will obviously play a key role in a terrorist-related mass-casualty situation, but that role will not likely be at "ground zero."
Triage comes from the French word trier meaning "to sort" and was anglicized after the Napoleonic wars. The proper practice of triage "...creates a situation whereby the greatest good for the greatest number can be accomplished," states Colonel C. Cloonan of the Uniformed Services University of the Health Sciences. Much of modern day triage methods can be traced to the pioneering work of Baron Dominique Jean Larrey. As a surgeon in Napoleon's army, Larrey developed a system to evaluate rapidly the wounded and evacuate salvageable patients needing the most urgent care. He instituted these principles while battle was still in progress and triaged without regard to rank. Principles of triage were further practiced during the American Civil War and World War I. In World War II the United States Army Medical Corps developed a tiered triage system. Portable field hospitals were used, and medics initiated treatment in the field. This system is credited with contributing to the survival of more patients with abdominal wounds in World War II than any other single factor. During the Korean War, the military began using the four-tiered triage system described in the Military Triage section of this paper. This system led to a significant improvement in survival of patients who sustained casualties. As transportation methods improved, time from injury to treatment decreased significantly, and correspondingly mortality rates also improved. In World War II time from injury to definitive treatment was approximately 12 to 18 hours. This interval decreased to fewer than 2 hours during the Vietnam War largely because patients could be transported by helicopter. Kennedy and associates indicated that mortality rates decreased from 4.7 to 1%, in part, due to the advances in rapid triage and transport.
Ultimately the goal of triage is to ensure that the available medical resources are used to treat the greatest number of patients in need of those resources. In standard triage patients at either end of the extremes of care should be identified. Resources can then be diverted from those whose death is imminent or who will recover regardless of care to those who are critically ill. After an attack involving WMD, the number of cases will likely overwhelm the resources of area hospitals. In a study performed by Wetter and associates, they found that the majority of urban and rural Pacific Northwest emergency departments would have difficulty responding to the effects of a biochemical attack. In a questionnaire emergency department officials were asked about their capabilities after a sarin gas attack or an anthrax exposure affecting 50 patients. Questions addressed the supply of medications, availability of indoor isolation rooms, water containment systems, and personal protective equipment. Only 29% of hospitals stocked enough atropine to treat 50 chemical casualties, and no hospital had enough pralidoxime. Sixty-four percent of hospitals had enough ciprofloxacin to treat 50 anthrax cases for 2 days. Twenty-one percent of hospitals had isolated ventilation units and water containment systems while 25% had no systems. In light of these statistics, the hypothetical situation proposed by Kaufmann and associates is even more disturbing. These authors estimated that if anthrax spores were released up-wind of large suburban area, approximately 50,000 cases of anthrax contamination would occur, resulting in 32,000 deaths. This defines the mass-casualty situation in which the number of casualties quickly overwhelms the available resources. Resources must be allocated to provide the best care to the most patients possible, with the knowledge that some patients will receive no care. This scenario is in contrast to a multiple-casualty situation in which resources are available to treat the large number of patients involved.
Weapons of mass destruction attacks also require efforts to ensure the safety of medical and rescue personnel. Careful staging of patient arrival and decontamination must be preplanned. The process by which an individual patient is decontaminated should ideally take 15 to 30 minutes. If a hospital is situated within a "contaminated region," medical personnel should initiate standard treatment required for the particular inciting agent and then transfer the patient to a region where decontamination and follow-up treatment can be provided. Unfortunately, in a mass-casualty situation involving chemical or nuclear agents, it cannot always be assumed that the hospital designated to treat these casualties is not itself within a contaminated area. Preplanning within a medical region must deal with contingency plans. Furthermore, planning must assume that all patients exposed to a WMD attack will need to undergo decontamination and treatment (that is, atropine injections for even mild nerve gas exposure). These are significantly larger numbers of patients than the 10 to 15% severely injured casualty case load that would be expected to require care after a terrorist attack.
Triage for the neurosurgeon is a misnomer. The neurosurgeon's role within a mass-casualty situation is one of a subspecialist surgeon instead of a triage officer. Unfortunately because of the events of September 11, 2001, civilian neurosurgeons and other medical specialists have been questioning their role within a mass-casualty situation or, worse, a situation created by biological, chemical, or nuclear weapons. There is no single triage system used exclusively within the United States, and different systems have differing sensitivities, specificities, and labeling methods. The purpose of this article is to discuss varying aspects of triage for both military personnel and civilians and suggest how the neurosurgeon may help shape this process within his or her community. Furthermore, the effects of biological, chemical, and nuclear weapons will be discussed in relation to the triage system.
The title for this article is somewhat of a misnomer. If the neurosurgeon is performing general triage in a mass-casualty situation, something is gravely wrong. For the general neurosurgeon, understanding the principles of triage, why decisions are made and where he or she fits into the system is beneficial and essential for the effective treatment of the neurologically injured. As a limited medical asset, neurosurgeons can best serve patients by performing triage and subsequent surgery in head-and spine-injured victims and not by trying to perform general triage of all patients in a mass-casualty situation. In light of the events of September 11, 2001, many within the medical field have more fully analyzed their roles within a mass-casualty situation both in regard to blast-and missile-induced wounds from terrorist acts and potential acts of biochemical terrorism. In their examination of 220 terrorist bombing incidents, Frykberg and Tepas indicated that injury to the central nervous system is frequent. They noted that head injury was the most common cause, 71.4 and 52%, respectively, of both immediate and late fatality. The neurosurgeon will obviously play a key role in a terrorist-related mass-casualty situation, but that role will not likely be at "ground zero."
Triage comes from the French word trier meaning "to sort" and was anglicized after the Napoleonic wars. The proper practice of triage "...creates a situation whereby the greatest good for the greatest number can be accomplished," states Colonel C. Cloonan of the Uniformed Services University of the Health Sciences. Much of modern day triage methods can be traced to the pioneering work of Baron Dominique Jean Larrey. As a surgeon in Napoleon's army, Larrey developed a system to evaluate rapidly the wounded and evacuate salvageable patients needing the most urgent care. He instituted these principles while battle was still in progress and triaged without regard to rank. Principles of triage were further practiced during the American Civil War and World War I. In World War II the United States Army Medical Corps developed a tiered triage system. Portable field hospitals were used, and medics initiated treatment in the field. This system is credited with contributing to the survival of more patients with abdominal wounds in World War II than any other single factor. During the Korean War, the military began using the four-tiered triage system described in the Military Triage section of this paper. This system led to a significant improvement in survival of patients who sustained casualties. As transportation methods improved, time from injury to treatment decreased significantly, and correspondingly mortality rates also improved. In World War II time from injury to definitive treatment was approximately 12 to 18 hours. This interval decreased to fewer than 2 hours during the Vietnam War largely because patients could be transported by helicopter. Kennedy and associates indicated that mortality rates decreased from 4.7 to 1%, in part, due to the advances in rapid triage and transport.
Ultimately the goal of triage is to ensure that the available medical resources are used to treat the greatest number of patients in need of those resources. In standard triage patients at either end of the extremes of care should be identified. Resources can then be diverted from those whose death is imminent or who will recover regardless of care to those who are critically ill. After an attack involving WMD, the number of cases will likely overwhelm the resources of area hospitals. In a study performed by Wetter and associates, they found that the majority of urban and rural Pacific Northwest emergency departments would have difficulty responding to the effects of a biochemical attack. In a questionnaire emergency department officials were asked about their capabilities after a sarin gas attack or an anthrax exposure affecting 50 patients. Questions addressed the supply of medications, availability of indoor isolation rooms, water containment systems, and personal protective equipment. Only 29% of hospitals stocked enough atropine to treat 50 chemical casualties, and no hospital had enough pralidoxime. Sixty-four percent of hospitals had enough ciprofloxacin to treat 50 anthrax cases for 2 days. Twenty-one percent of hospitals had isolated ventilation units and water containment systems while 25% had no systems. In light of these statistics, the hypothetical situation proposed by Kaufmann and associates is even more disturbing. These authors estimated that if anthrax spores were released up-wind of large suburban area, approximately 50,000 cases of anthrax contamination would occur, resulting in 32,000 deaths. This defines the mass-casualty situation in which the number of casualties quickly overwhelms the available resources. Resources must be allocated to provide the best care to the most patients possible, with the knowledge that some patients will receive no care. This scenario is in contrast to a multiple-casualty situation in which resources are available to treat the large number of patients involved.
Weapons of mass destruction attacks also require efforts to ensure the safety of medical and rescue personnel. Careful staging of patient arrival and decontamination must be preplanned. The process by which an individual patient is decontaminated should ideally take 15 to 30 minutes. If a hospital is situated within a "contaminated region," medical personnel should initiate standard treatment required for the particular inciting agent and then transfer the patient to a region where decontamination and follow-up treatment can be provided. Unfortunately, in a mass-casualty situation involving chemical or nuclear agents, it cannot always be assumed that the hospital designated to treat these casualties is not itself within a contaminated area. Preplanning within a medical region must deal with contingency plans. Furthermore, planning must assume that all patients exposed to a WMD attack will need to undergo decontamination and treatment (that is, atropine injections for even mild nerve gas exposure). These are significantly larger numbers of patients than the 10 to 15% severely injured casualty case load that would be expected to require care after a terrorist attack.
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