4 ms·

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.

cperciva 9y ago
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.
- JshWright 9y ago
  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.
  - cperciva 9y ago
    "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?
    - JshWright 9y ago
      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.
      - cperciva 9y ago
        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.
        JshWright 9y ago
        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.
        cperciva 9y ago
        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?
        JshWright 9y ago
        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.
JshWright 9y ago
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.
- ncallaway 9y ago
  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=79529 https://www.medicinenet.com/script/main/art.asp?articlekey=7... Again, if you are experienced and knowledgeable in triage please disregard my understanding.
  - JshWright 9y ago
    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.
    - khed 9y ago
      This is not correct. https://en.wikipedia.org/wiki/Triage#Conventional_classifications https://en.wikipedia.org/wiki/Triage#Conventional_classifica...
      - JshWright 9y ago
        What do you mean by "this"?
deleted 9y ago
[deleted]
scoot 9y ago
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.
- khed 9y ago
  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.

cperciva 9y ago

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.

JshWright 9y ago
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.
- cperciva 9y ago
  "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?
  - JshWright 9y ago
    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.
    - cperciva 9y ago
      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.
      - JshWright 9y ago
        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.
        cperciva 9y ago
        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?
        JshWright 9y ago
        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.

JshWright 9y ago

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.

ncallaway 9y ago
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=79529 https://www.medicinenet.com/script/main/art.asp?articlekey=7... Again, if you are experienced and knowledgeable in triage please disregard my understanding.
- JshWright 9y ago
  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.
  - khed 9y ago
    This is not correct. https://en.wikipedia.org/wiki/Triage#Conventional_classifications https://en.wikipedia.org/wiki/Triage#Conventional_classifica...
    - JshWright 9y ago
      What do you mean by "this"?

deleted 9y ago

[deleted]

scoot 9y ago

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.

khed 9y ago
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.