I think he was talking about the first few car loads, while he knew there were a bunch of doctors inside with nothing else to do, he was not doing this the whole night?

This triage system is pretty standard, you can see the same triage armbands in this RNLI medical kit in the bottom right corner[0] (I couldn't find a standard UK ambulance kit image), but I am told that it takes a huge amount of mental discipline to follow this training to the letter in real life. It probably took a few people going through the system for him to get into the swing of it.

I can't imagine having to do this, this guy will be going back over the decisions he made that night for the rest of his life. I hope that in writing this article he has felt validated in himself because it sounds like he and his colleagues did an incredible job.

[0]https://twitter.com/TowerRNLI/status/593180062565924865

It's definitely hard. That's part of the reason the criteria is so clearcut. Not breathing = black tag.

From my reading of the article, he was the triage officer during the arrival of almost all the critical patients, and it was only after the acuity level started to drop off that he delegated to a nurse.

This is not my understanding of how to triage in MCI. ATLS definitely does teach the importance of deprioritizing people that will be hard or impossible to resuscitate in favor of prioritizing people that leads to a roughly utilitarian greatest good.

That said, I have never heard "black tag = not breathing = don't try to help"[1]. I know for a fact that the boundary for who to try to save immediately and who to deprioritize is very grey in many cases (it is why you should have an experienced doctor doing it). A common example why that equivalency is not taught in ATLS is the case of a boat capsizing in frozen waters. There may be many frozen victims who are not breathing but could still be very salvageable medically. If you chose to not help those who are not breathing in that case you would plausibly be found negligent without some extraordinary situation to justify yourself with.

Another example would be mass overdose on fentanyl, many are saveable but none would be breathing when you first see them.

1. https://en.wikipedia.org/wiki/Triage#Conventional_classifica...

Yes, those are two special cases where respiratory statues would not map well to expected outcomes. As far as I know, there was no capsize or mass opioid overdose involved...

I'm not sure where your understanding of triage comes from, but you're mistaken if you think respiratory status isn't the primary determining factor in black/expectant classification (in the US, there may be differences in other international systems I'm not aware of).

The vast majority of triage in US is done using the START system (or START-derived systems, like SALT).

Here is a graphical depiction of the START classification algorithm: http://citmt.org/Start/images/flowchart2.jpg

It seems like he just wanted a second opinion. Maybe he was just seeing too many people arriving to trust his own judgement about the black tag.

That sentence caught my eye too, and I would have commented on it if JshWright hadn't. "If the two of us ended up thinking that this person was dead, then I knew that it was a legitimate black tag." Sending them all back to the red-tag area doesn't get you a second opinion, it simply passes the responsibility to someone else.

A better explanation might by that by taking this approach, he was tiering the triage, in much the same way that the neurosurgeon in the article's comments mentioned that they were able to "neuro triage" patients sent to them.

I can't begin to imagine handling this type of situation.

There are a couple reasons why he might do this that I can think of.

1). He didn't know how many people were going to come in or how serious they would be. Triage in MCI does depend to a certain degree on what your facility is capable of and the expected volume and status of patients. If he underestimated the volume or criticality of the patients about to come in he might have put more into the red pod than he would have otherwise. Underestimating seems plausible in this case because this was the worst mass shooting in history in the US.

2). Medicolegally he might have a fear that he would be judged harshly if he didn't automatically try to save everyone.

This is what it sounded like to me; normally patients arrive slowly enough that he would have enough time to be absolutely certain about declaring one deceased, but under the circumstances he needed to make quick judgments and move on to the next arrival.

In a sense, he was correctly applying the rule of optimizing for the most critical resource -- except that in this case, the most critical resource was his ability to triage incoming patients.

There is a difference between "black tag" and "deceased". It wasn't his job to determine if anyone was deceased. It was his job to determine if they were worth expending any more effort on (given the limited resources). To qualify as a black tag, a patient would need to have no pulse, or to not be breathing (after positioning their airway in an "open" position). Those are both objective findings, not judgement calls.

I just want to reiterate though... This facility (and this doctor specifically) did a fantastic job. I look forward to the more in-depth case studies as an opportunity to further my own skills in EMS.

"No pulse" sounds objective... but how long do you look for one? On two occasions I've had doctors fail to find my pulse even while I was been alert and talking to them -- admittedly the pulse they couldn't find was radial, but the only circulatory issue I had was moderate dehydration.

Is it implausible that under these conditions someone would be uncertain whether there was no pulse or simply a weak pulse which they missed?

So, the actual criteria is is breathing. I'm throwing "pulse" in there because there's no way an ER doc isn't going to check for one.

You're absolutely right that finding a pulse can be tricky (though a carotid or femoral is a lot easier than a radial). There are a handful of good studies that show a fairly high degree of uncertainty, even among well trained providers (ER docs, paramedics, etc). This is why breathing is the "real" criteria, and should have been the decision making criteria used in this case.

Thanks for clarifying -- that makes more sense. Is it possible that casualties were arriving too fast for him to confirm that they had good airways? I have no idea how long that takes.

The goal is to take ~20 seconds. You position the head and neck in a position where the airway would be open (if someone is unconscious, they can't maintain their own airway, even if it would otherwise be fine). After positioning, take 10-15 seconds to observe for breathing. During this time you might as well check for a carotid pulse as well.

The article says that he triaged 150 patients in 30-40 minutes, or one every 12-16 seconds(!!!), so it sounds like not spending the 20 seconds it would take to check for breathing may have been the right call?

Some of them would have been a lot quicker than that, some would have taken a bit longer. In studies the mean is generally in the 15-20 second range, but some individual data points are just a couple seconds and some are >30 seconds.

That's not how triage works. It's literally an algorithm. If the patient doesn't have a pulse, or isn't breathing, they're a black tag. There is a fair bit of wiggle room between the other triage classifications, but dead is dead in triage.

My understanding (and this is from a limited amount of Googling, so if you have domain experience I'll gladly defer to your judgement) is that black tags are applied to those who are already thought to be deceased, _or_ to those who are thought cannot be saved with the given care available:

"Black tags - are used for the deceased and for those whose injuries are so extensive that they will not be able to survive given the care that is available."

https://www.medicinenet.com/script/main/art.asp?articlekey=7...

Again, if you are experienced and knowledgeable in triage please disregard my understanding.

Yeah, a black tag is someone who is going to be dead. That may be because they're already dead, or because they're beyond help (given the resources available).

The criteria used by all the major triage systems for a black tag classifications is a lack of respirations (and because he's an ER doc, he's going to reflexively check a pulse).

I don't think my experience is especially important (as you said, this is all googleable info), but I'm a paramedic with a little over a decade in EMS.

This is not correct.

https://en.wikipedia.org/wiki/Triage#Conventional_classifica...

What do you mean by "this"?

'The simplest definition of a "mass casualty incident" is when you need more resources than you have.'

This definition is an example of the logical fallacy called begging the question. Nobody would deny that an incident that brings 250 gunshot victims to one center is a "mass casualty." The brilliance of Dr. Menes's approach is that he did not immediately assume insufficient resources. He didn't say this, but it appears to me that he proceeded under the thought that with careful planning and ingenuity, they might have just enough resources. This redefines triage from a rigid algorithm to something like "the optimal deployment of available resources to maximize the utility for as many as possible."

They in no way had adequate resources to handle that event. Not even close. A hundred of those patients would have qualified as a trauma code on a "normal" day, and would have had the dedicated attention of a dozen people during their initial arrival and stabilization. In this case they were lucky if they got the undivided attention of a single person.

They made do with what they had (very efficient, and very effectively), but the scope of the incident vastly outsized the scope of the available resources.

Your description of triage is great. The algorithm (based on a fair amount of research) is one part of maximizing that utility (it doesn't stand in the way of accomplishing that).

> It is likely some outcomes were worsened by that waste of resources

I think the more interesting concept is the second look. Doctors are trained to be sensitive, then specific. Perhaps it would be easier to black tag people if you knew the next thing that would happen is they would go the red tag area for a second call of "black tag".