DISASTER MEDICINE/EDITORIAL Mostly Dead: Can Science Help With Disaster Triage? Jonathan L. Burstein, MD From the Beth Israel Deaconess Medical Center, Harvard Medical School and Center for Public Health Preparedness, Harvard School of Public Health; and Massachusetts Department of Public Health, Boston, MA. 0196-0644/$-see front matter Copyright © 2009 by the American College of Emergency Physicians. doi:10.1016/j.annemergmed.2009.02.012 SEE RELATED ARTICLE, P. 424. [Ann Emerg Med. 2009;54:431.] “It just so happens that your friend here is only mostly dead. There’s a big difference between mostly dead and all dead. Mostly dead is slightly alive.” 1 In this issue of Annals, Schultz et al 2 report on the actual use and outcomes, after a train crash, of simple triage and rapid treatment (START) triage, a commonly used system of mass-casualty acuity- based patient sorting. They conclude that START triage substantially overtriages patients, and thus, although it may be useful in ensuring that the critically ill receive immediate care, it may be less helpful in preventing “flooding” of the medical system by an overwhelming number of casualties. This study is one of the few to examine actual use of a triage method after a real disaster, and as such its conclusions must be given great weight. To interpret this result, it may be helpful to review the purpose of disaster triage. Medical triage is a process of sorting patients by acuity, most familiar to emergency physicians as “sickest first.” It’s worth recalling, though, that the military medical purpose of triage is to ensure appropriate use of resources to return soldiers to duty, and civilian disaster triage has an analogous goal. That goal is to provide the greatest good for the greatest number of patients, forcing the triage officer to decide whether the chance of a patient surviving is so low in comparison to the burden such care would place on the medical system that the patient must be consigned to the “expectant” category (dying; little or no treatment). In a disaster, triage is not supposed to be the same as the everyday methods used in emergency departments. Nevertheless, it remains a characteristic of human beings that we are reluctant to abandon our fellow humans to death, even in the face of overwhelming odds. 3 The Schultz et al 2 data show that of the 22 patients triaged “red” or critically ill (the highest priority on START triage), only 2 of them actually met criteria retrospectively. Similar problems arise in the “yellow” (delayed care) and “green” (minimal care) groups. Only 1 patient, who was actually already dead, was triaged expectant at the scene. Overall, 79 of 148 patients (53%) were overtriaged to a level of care higher than they really needed. Although clearly it’s good to get everyone to needed care rapidly, if this train crash had actually overwhelmed local hospitals, it’s not clear that the START system would have been helpful in prioritizing care or in providing the greatest good for the greatest number of patients. It appears that the triage officers, acting as well- meaning human beings, were inclined to assume that people needed help, and that until the medical system collapsed, they would keep pushing victims of the disaster into it as fast as possible. “Red” triage did indeed get patients to the hospital nearly an hour faster than lower-acuity levels. This is individually laudable but may not be the right choice in a true mass disaster. As the study authors call for, any new work on triage systems must be sufficiently powerful to determine whether the proposed system works well as an abstract method and as used by actual emergency responders in the field. It is much harder to “write off” a dying person in front of you at a real disaster than it is to do so in a drill, and even a well-designed set of triage criteria may be inadvertently misapplied by concerned rescuers. Further detailed studies of triage methods are especially important because a new method, “SALT” (sort, assess, lifesaving, treat/transport) triage, is being proposed as a national standard by the Centers for Disease Control and Prevention 4 and should be subjected to rigorous evaluation as it is actually used. Supervising editor: Michael L. Callaham, MD Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article that might create any potential conflict of interest. The author has stated that no such relationships exist. See the Manuscript Submission Agreement in this issue for examples of specific conflicts covered by this statement. Publication date: Available online March 13, 2009. Reprints not available from the author. Address for correspondence: Jonathan L. Burstein, MD, Beth Israel Deaconess Medical Center, W/CC2, Boston, MA 02215; 617-667-1703; E-mail jburstei@bidmc.harvard.edu. REFERENCES 1. Act III Communications. The Princess Bride [motion picture]. 1987. 2. Kahn CA, Schultz CH, Miller KT, et al. Does START triage work? An outcomes assessment after a disaster. Ann Emerg Med. 2009;54: 424-430. 3. Heinlein RA. Starship Troopers. New York: GP Putnam & Sons; 1959. 4. Lerner EB. SALT mass casualty triage. NAEMSP News. January 2009;9 Volume , .  : September  Annals of Emergency Medicine 431