THE CURRENT STATE OF AFFAIRS
REGARDING TRIAGE TAGS
IN THE EUROPEAN UNION
A thesis submitted
in partial fulfilment of the
requirements for the degree of
by
Demetrios G. Pyrros, MD
To be approved by :
Dr. Michel Debacker
Chairperson of Supervisory Committee
Academic Year 2000 - 2001
THE CURRENT STATE OF AFFAIRS
REGARDING TRIAGE TAGS
IN THE EUROPEAN UNION
by
Demetrios G. Pyrros, MD
A thesis submitted
in partial fulfilment of the
requirements for the degree of
European Master in Disaster Medicine
Centro Europeo per la Medicina delle Catastrophy CEMEC
(European Centre for Disaster Medicine, Republic of San Marino)
Universita del Piemonte Orientale “Amedeo Avogardo”
(University of Eastern Piedmont “Amedeo Avogardo”, Novara, Italy)
Universitaire Ziekenhuizen Leuven
(Catholic University of Leuven, Leuven, Belgium
Academic Year 2000 - 2001
To be approved by :
Dr. Michel Debacker
Chairperson of Supervisory Committee
Date : 31 December 2001
TABLE OF CONTENTS
TABLE OF CONTENTS ..........................................................................I
LIST OF FIGURES................................................................................. V
ACKNOWLEDGMENTS .....................................................................VI
PREFACE................................................................................................. 1
INTRODUCTION .................................................................................... 1
TRIAGE .................................................................................................... 4
INTRODUCTION........................................................................................ 4
MILITARY TRIAGE................................................................................... 7
CIVILIAN TRIAGE................................................................................... 11
NUCLEAR, BIOLOGICAL AND CHEMICAL TRIAGE.................................... 16
COMMERCIALY AVAILABLE TRIAGE TAGS ............................. 18
CASUALTY HANDLING SYSTEM CHS TM POUCH ...................... 20
CRUCIFORM EMERGENCY DOCUMENTATION SYSTEM .... 22
DMS TRIAGE TAG............................................................................... 24
OVERALL DESCRIPTION :........................................................................ 24
TRIAGE TYPE......................................................................................... 24
INFORMATION ON CARD ........................................................................ 25
MEDICAL EMERGENCY FIELD TRIAGE TAG (STANDARD) .. 26
SIMPLE TRIAGE AND RAPID TREATMENT (START) TRIAGE
TAG......................................................................................................... 28
OVERALL DESCRIPTION :........................................................................ 28
TRIAGE TYPE......................................................................................... 28
INFORMATION ON CARD ........................................................................ 29
SMART TAG.......................................................................................... 30
PRESENTATION OF TRIAGE TAGS PER EUROPEAN UNION
COUNTRY.............................................................................................. 32
AUSTRIA ..................................................................................... 33
OVERALL DESCRIPTION :........................................................................ 33
TRIAGE TYPE......................................................................................... 33
INFORMATION ON CARD ........................................................................ 34
BELGIUM .................................................................................... 35
OVERALL DESCRIPTION :........................................................................ 35
TRIAGE TYPE......................................................................................... 36
INFORMATION ON CARD ........................................................................ 36
DENMARK.................................................................................. 37
OVERALL DESCRIPTION :........................................................................ 37
TRIAGE TYPE......................................................................................... 37
INFORMATION ON CARD ........................................................................ 37
FINLAND..................................................................................... 38
FRANCE....................................................................................... 39
A) FROM “D EPARTEMENT DES BOUCHES DU RHONE”............................ 39
OVERALL DESCRIPTION :........................................................................ 39
TRIAGE TYPE......................................................................................... 39
INFORMATION ON CARD ........................................................................ 39
B) FROM “UNITE DE S ECURITE CIVILE NO 7” FROM BRIGNOLES ............ 40
OVERALL DESCRIPTION :........................................................................ 40
TRIAGE TYPE......................................................................................... 41
INFORMATION ON CARD ........................................................................ 41
C) FROM “SAPEURS POMPIERS”............................................................. 42
OVERALL DESCRIPTION :........................................................................ 42
TRIAGE TYPE......................................................................................... 42
INFORMATION ON CARD ........................................................................ 42
GERMANY.................................................................................. 43
A) THE GERMAN RED CROSS REGISTRATION CARD FOR INJURED /SICK
PERSON (A NHANGEKARTE FUR VERLETZTE/K RANKE) .......................... 43
OVERALL DESCRIPTION :........................................................................ 43
TRIAGE TYPE......................................................................................... 44
INFORMATION ON CARD ........................................................................ 44
B) THE GERMAN ASSOCIATION OF PROFESSIONAL FIRE DEPARTMENTS IN
NORDRHEIN-WESTFALEN (ARBEITSGEMEINSCHAFT DER LEITER DE
BERUFSFEUERWEHREN )......................................................................... 45
OVERALL DESCRIPTION :........................................................................ 45
TRIAGE TYPE......................................................................................... 45
INFORMATION ON CARD ........................................................................ 46
ii
GREECE ...................................................................................... 47
OVERALL DESCRIPTION :........................................................................ 47
TRIAGE TYPE......................................................................................... 47
INFORMATION ON CARD ........................................................................ 48
IRELAND..................................................................................... 49
ITALY........................................................................................... 51
A) FROM U.L.SS NO 6 “VICENZA ” SERVICIO URGENZA EMERGENZA
MEDICA 118.......................................................................................... 51
OVERALL DESCRIPTION :........................................................................ 51
TRIAGE TYPE......................................................................................... 52
INFORMATION ON MODIFIED METTAG CARD ....................................... 53
B) FROM BOLOGNA SOCCORSO 118....................................................... 53
OVERALL DESCRIPTION :........................................................................ 53
TRIAGE TYPE......................................................................................... 53
INFORMATION ON CARD ........................................................................ 54
OVERALL DESCRIPTION :........................................................................ 56
TRIAGE TYPE......................................................................................... 56
INFORMATION ON CARD ........................................................................ 57
THE NETHERLANDS ............................................................... 59
OVERALL DESCRIPTION :........................................................................ 59
TRIAGE TYPE......................................................................................... 59
INFORMATION ON CARD ........................................................................ 60
PORTUGAL................................................................................. 61
OVERALL DESCRIPTION :........................................................................ 61
TRIAGE TYPE......................................................................................... 62
INFORMATION ON CARD ........................................................................ 62
SPAIN ........................................................................................... 64
OVERALL DESCRIPTION :........................................................................ 64
TRIAGE TYPE......................................................................................... 64
INFORMATION ON CARD ........................................................................ 65
SWEDEN................................................................................... 66
OVERALL DESCRIPTION :........................................................................ 66
TRIAGE TYPE......................................................................................... 66
INFORMATION ON CARD ........................................................................ 66
iii
UNITED KINGDOM .................................................................. 68
A) THE METTAG CARD ....................................................................... 68
B) THE “CRUCIFORM ” CARD ................................................................. 68
C) THE “SMART MEMOS” CARDS.......................................................... 68
OVERALL DESCRIPTION :........................................................................ 68
TRIAGE TYPE......................................................................................... 69
INFORMATION ON CARD ........................................................................ 69
CONCLUSIONS .................................................................................... 70
BIBLIOGRAPHY..................................................................................... 1
BOOK REFERENCES ............................................................................ 1
iv
LIST OF FIGURES
Number
Page
Figure 1.CHS pouch and its content (from CHS Internet site) ..............................................21
Figure 2.Checklist for Triaging Officer in German by CHS (from CHS
Internet site)............................................................................................................21
Figure 3. "Cruciform" unfolded front and back ....................................................................23
Figure 4. DMS Triage Tag (from DMS Internet site)............................................................23
Figure 5. METTAG Triage Tag both sides...........................................................................27
Figure 6. START Triage Tag both sides ...............................................................................27
Figure 7 Folded Smart Tag ..................................................................................................31
Figure 8 Smart Tag unfolded ...............................................................................................31
Figure 9 Smart Tag unfolded (other side) .............................................................................31
Figure 10 Austrian Triage Pouch System..............................................................................34
Figure 11 Belgian METTAG Triage Tag..............................................................................36
Figure 12 Triage Tag from “Departement des Bouches du Rhone” in France.......................40
Figure 13 Triage Tag from “Unite de Securite Civile No 7” from Brignoles,
France.....................................................................................................................41
Figure 14 Triage Tag from French Fire Department “Sapeurs Pompiers”.............................42
Figure 15 The German Red Cross registration card for injured/sick person
(Anhangekarte fur Verletzte/Kranke) ......................................................................45
Figure 16 The German Association of Professional Fire Departments in
Nordrhein-Westfalen (Arbeitsgemeinschaft der Leiter de
Berufsfeuerwehren) .................................................................................................46
Figure 17 Modified METTAG Triage Tag from Greece.......................................................48
Figure 18 Triage Tag of the ‘cruciform” type from Ireland ...................................................50
Figure 19 Double Triage Tagging system from U.L.SS no 6 “Vicenza”
Servicio Urgenza Emergenza Medica 118 in Italy .....................................................53
Figure 20 Triage Tag from Bologna Soccorso 118, in Italy....................................................55
Figure 21 Triage Tag from Luxembourg ..............................................................................58
Figure 22 The Triage Tag from The Netherlands .................................................................60
Figure 23 The "Cruciform" from Portugal ...........................................................................63
Figure 24 The modified Smart Tag from Spain ....................................................................65
Figure 25 The Swedish colour coded Triage Tags.................................................................67
v
ACKNOWLEDGMENTS
First, I would like to express my sincere appreciation to Professor Francesco
Della Corte for getting me onboard for this most interesting experience of
the European Master in Disaster Medicine. Dr. Michel Debacker was kind
enough to be my tutor and make a lot of interesting observations and for that
I would like to thank him. Professor Herman Delooz has listened very
closely when I was presenting the concept of this Thesis for the first time in
San Marino and he also had interesting observations.
Special thanks are in order to Dr. Michalis Tzagarakis , President of the
Administrative Council and Dr. Dimitris Bilalis, President of the Scientific
Committee of the National Centre of Emergency Care (EKAB) in Greece for
providing the necessary support for this undertaking. Dr. Vasilios
Theodorou, President of the Road Safety Committee of the Ministry of
Health and Welfare in Greece was always there for giving advises.
Thanks are also in order to Mr. Takis Alevantis and Mr. Dick Fundter for
their input, as well as to the other members of the Core Group for the
European Union Major Project in Disaster Medicine.
In addition, I would like to thank all the members of the master class of
2000-2001 for their valuable input, Dr. E.G. Pavlakis for many of the
pictures, as well as, the individuals mentioned in the thesis for providing
valuable information along with Mr. Kobi Peleg.
Sincere thanks also to Dr. Frederick M. Burkle for sharing references and
personal communiqués.
Last but not least, I would like to thank my wife Effie for keeping the world
spinning while I was away in body and/or mind and my son George for his
hugs when I was almost ready to give up.
vi
PREFACE
The first time I encountered Triage Tags used in an exercise was back
in 1980 at Binghamton, N.Y., U.S.A. I was then a young volunteer at
Harpur’s Ferry Student Volunteer Ambulance Service Inc. at the State
University of New York at Binghamton (SUNY-B) and participated in
the exercise as one of the victims of a road traffic accident.
The collision, according to the exercise scenario, was between a bus full
of students and a truck carrying low radiation materials within the
university campus grounds. I was properly briefed to be one of the
students-victims inside the bus. (It was also my first exposure to an
exercise involving radiological materials but that is an entirely different
story!).
The exercise was a full-scale one, involving the Ambulance Services and
the Hospitals of the area, but also Police and Fire Brigade. I remember
very well that the Triage Officer on site put a Triage Tag around my
neck and left me at the same position I was lying at the front of the bus
near the stairs. I was a code red! It took them too much time to
transport and treat me and, according to the scenario I was given, I was
supposed to die, so I played dead before arriving at the Hospital. When
I arrived at the Emergency Room I was transported, the doctor, after
attempting to revive me for about 5 minutes pronounced me dead
saying: Well, we can’t win them all!
But that was not the triggering factor for this thesis.
1
The theme for this thesis came as an actual question I have posed, first
to myself and then to colleagues, some years ago. The original question
was: Are Triage Tags really used for what they are supposed to be used?
I think it first occurred to me at the World Conference on Disaster
Medicine (WCDEM) in 1997 in Mainz, Germany, organized by Prof.
Dick on behalf of the World Association of Disaster and Emergency
Medicine (WADEM). It was there, at a stand of one of the commercial
manufacturers of Triage Tags, that it first occurred to me that what I
was looking in front of me would be very difficult to be used in real
emergencies. However, it looked very professional as a tool and it had
all the right colours, pockets, notes, drawings etc. to attract the attention
of the eye of the ambulance professional.
At that time I had already some experiences from real emergencies
around the world.
I had spent one full year in 1990, as the Dispensary Physician of the
United Nations Dispensary in Kabul, Afghanistan and three tours of
about three months duration each, as a United Nations Medical Officer
in Monrovia, Liberia in 1991, 1993 and 1996. I also had the short term
but intense experiences from the Leninakan, Spitak earthquake in
Armenia in 1998 (approximately 35.000 dead) and the Aegion
earthquake in Greece in 1995 (157 dead).
The above covered a wide spectrum of both man-made and natural
disasters of non-insignificant proportions and duration. Between them I
had experienced events ranging from a “coup d’etat” to rocket attacks
and from collapsed buildings of all shapes and sizes to major road
traffic accidents and from cholera outbreaks to hordes of malnourished
2
children. However, I had not encountered Triage Tags been used in any
of the situations mentioned above.
On the other hand I had also participated in a number of exercises and
trainings around Europe (Finland, France, Germany, Greece, Italy,
Sweden). Every time at the practical exercise the Triage Tags were at
centre stage. However, almost always it was a different size and shape
and usually each one was praised for its merits against the others!
So the original question was changed as follows: Are Triage Tags
actually used for triaging patients in real emergencies?
3
Chapter 1
INTRODUCTION
In the beginning of 1999 I was introduced as a trainee to the Major
Project in Disaster Medicine of the European Union. I was again going
to get myself involved with Triage Tags but I was not aware of that in
the beginning.
The project was launched by the Civil Protection Unit of the
Directorate General of Environment of the European Commission in
the context of the Civil Protection Action Programme. The first project
(1998-1999) was co-ordinated by the Ministry of the Interior and
Kingdom Relations of the Netherlands and a core group of
representatives from Austria, France, Germany, Portugal, Spain and
Sweden.
From that project I participated in the following activities
• “Workshop on Disaster Relief Medicine”. A survey followed by a
workshop to identify Disaster Medicine structures, definitions and
sociological, psychological, legal and financial aspects of Disaster Medicine
(10-12 February 1999, Nainville les Roches, France, at the Institut National
d’Etudes de la Sécurité Civile).
• “Preparatory meeting for the pilot course for teachers and instructors in
Disaster Medicine”. A workshop on the analysis of training needs in the field
of Disaster Medicine (6-9 April 1999, Linköping, Sweden, at the University of
Linköping).
• “National Training Programme of Medical Assistance and Disaster
Management”. A large scale exercise with three scenarios in which the
medical chain was practised (3-5 September 1999, Chalon sur Saône , France,
organised by the Institut National d’Etudes de la Sécurité Civile and the Fire
Brigade of Saône et Loire, France).
• “Pilot EU-course in Disaster Medicine” A pilot course for trainers in
Disaster Medicine (18-22 October 1999, Linköping, Sweden at the University
of Linköping).
1
During those workshops, exercises and training sessions it became once
again apparent to me that there is a lot of confusion about triaging even
within the limited number of participants/ representatives from all
European Countries who were amongst the “experts” in the field of
Disaster Medicine in Europe. When it comes to Triage Tags the subject
is either avoided, brushed off or people have very strong views that
want to support to the end. This was also reflected in the Final Report
of the project. The word Triage is mentioned 24 times during the 68
page report but Triage Tags were not mentioned even once.
Among the paragraphs the Triage is mentioned in the final report it is
worth noting the following ones:
First Paragraph of General Conclusions:
In 1999 and in the context of the major project, much progress has been made in key
areas of Disaster Medicine. The workshops have contributed to a deepened insight in the
problems encountered during Disaster Medicine operations, have opened discussions
focused on the use of many different Disaster Medicine systems, and have lead to
international attention given to difficulties confronted with in triage procedures,
bottlenecks and opportunities in training and exercise, psycho-social care and many other
subjects.
From the analysis of the conducted survey in the French contribution to the
report:
The glossary showed variations of concepts, for old words (catastrophe) as well as new words
(triage). For example, the terms care and triage need to be specified since they do not
seem to cover the same categorisations of victims nor the methods to treat them.
From the conclusions and recommendations on the issue of Ethics and
Triage from the report by the Netherlands of the 8 Workshops conducted in
Amsterdam on “Operational Chances and Restraints in Disaster Medicine” as
part of the International Conference on Disaster Management and Medical
Relief:
- -Triage is a dynamic process, a continuing process and a progressive process. Therefore
triage in disaster situations is not identical to triage in daily Emergency Medical
Systems;
- - There is a need for clear definitions of triage;
- - Triage has two aspects: a technical aspect (the right person has to receive the most
appropriate therapy) and an ethical aspect (the common human rights and medicalethical codes should be respected);
- - To enhance the capabilities of triage, triage procedures need to be standardized;
2
- - To facilitate ethical aspects an international declaration of human rights during
triage should be established;
- - Education and training in triage is needed;
- - Training in ethics does not exist. Ethics lie in the heart of every person and consists of
moral values that we all share. As such mutual respect between all persons and
parties involved in disaster medicine is in essence the good basis for triage.
When the project was extended under the same name for the period of
2000 to 2004 I was honoured by the call to become a member of the
core group. After all I was struck from the beginning by the long-term
goal of the project:
«Struck by a large-scale accident or disaster, people living or
travelling in European Union Member States should receive the
same high quality medical care»
as well as the main goals:
•
•
•
cross-border mutual assistance between member states
psycho-social care
preparation for major accidents and disasters
It was then that I started considering that the issue of Triage and Triage
Tags should be addressed under both the “preparation for major
accidents and disasters” as well as “cross-border mutual assistance
between member states” I was not alone. Other members of the core
Group were of the same mind. It was also the time that I had to decide
of a Thesis for the European Master in Disaster Medicine.
The title came almost immediately: “The current state of affairs
regarding triage tags in the European union”
3
Chapter 2
TRIAGE
Most who write scholarly articles on the subject have never practiced triage, or even witnessed
it!
Col. Kenneth G. Swan, MC USAR
Introduction
Nothing can be said about Triage Tags before having a clear picture of
what the term Triage means. So let us start from the beginning: It is
agreed by most that the term Triage is derived from the French verb
trier, meaning to sort. Combining the new and the old it was possible to
find in the Internet the definition of triage from the 1st edition of the
“Dictionnaire de L'Académie française” in 1694 as follows:
Triage. s. m. Choix. Il signifie & l'action par laquelle on choisit, & la chose choisie. Faire
le triage. voila un beau triage.
Today the term Triage is also described as follows in the electronic
form of the Merriam-Webster’s Collegiate Dictionary:
Main Entry: tri·age Pronunciation: trE-'äzh, 'trE-"
Function: noun
Etymology: French, sorting, sifting, from trier to sort, from Old French -more at TRY Date: 1918
: the sorting of and allocation of treatment to patients and especially
battle and disaster victims according to a system of priorities designed
to maximize the number of survivors; broadly : the assigning of priority
order to projects on the basis of where funds and resources can be best used
or are most needed
- triage transitive verb
Also, the American Heritage Dictionary offers the following definition
online:
4
triage SYLLABICATION: tri·age PRONUNCIATION: tr -äzh , tr äzh
NOUN:
1. A process for sorting injured people into groups based on their need for
or likely benefit from immediate medical treatment. Triage is used in
hospital emergency rooms, on battlefields, and at disaster sites when
limited medical resources must be allocated.
2. A system used to allocate a scarce commodity, such as food, only to
those capable of deriving the greatest benefit from it.
3. A process in which things are ranked in terms of importance or priority:
“For millions of Americans, each week becomes a stressful triage between work and
home that leaves them feeling guilty, exhausted and angry” (Jill Smolowe, Time
May 6, 1996 Volume 147, No. 19).
TRANSITIVE VERB: Inflected forms: tri·aged, tri·ag·ing, tri·ag·es
To sort or allocate by triage: triaged the patients according to their symptoms.
ETYMOLOGY: French, from trier, to sort, from Old French.
The term is also defined in the medical literature as the:
“ranking of medical problems in order of priority”
Perrin P. “War and Public Health”
1996 International Committee of the Red Cross
“classification of victims, according to the seriousness of the injuries
sustained”
de Boer J. “Order in Chaos”
“sorting of patients based on the need for treatment and the available
resources to provide that treatment”
American College of Surgeons, Committee on Trauma, “ATLS ”
“evaluation or assessment process of the medical condition of victims
and categorisation of victims into gravity classes according to sustained
injuries, vital and functional prognosis”
Ciancameria G. Triage in “Handbook of Disaster Medicine”
5
Going back to the original meaning of Triage in the French language, it
is easy to assume that it was used mainly in the market place in order to
sort different goods according to quality and price. This is a very
important point since in its original use it is evident that it was meant as
a one time process with no need to be repeated since material goods
sorted could not change their qualities. Triaged products could remain
in the category they were sorted until sold. There was no need for
sorting them again. Of course, there was an obvious exception to the
rule. Live, delicate products like vegetables and fruits that could change
their qualities (i.e. become ripe or rotten). Then even at the setting of a
market place there was a need for re-triaging.
The previously mentioned exception became obviously the rule in its
current meaning, when traumatized human beings are “sorted”, since
their “qualities” regarding their injuries can and do change from
moment to moment and therefore there is a constant need for reevaluation. That added characteristic to the meaning of triage, specific
for dealing with the nature of living creatures involves the parameter
time in a way that it becomes of paramount importance.
So let us see how the parameter time is incorporated into the current
practise of Triage: There is a universal agreement in the literature that
Triage is a dynamic process. One can claim that theoretically Triage is
already outdated the time it is finished since it is certain that some
parameters have already changed and therefore the priorities could have
changed as well. And since changing priorities means different
allocation of treatment the significance is self-evident.
6
Trying to give yet another definition of Triage incorporating the
parameter of time and the fact that it is a skill neither easily described
nor easily taught, the following definition was reached:
Triage is the skill of assigning and re-evaluating priorities
between disaster survivors during all echelons of treatment and
transport, based on the science of emergency medicine, in order
to minimize loss of life or limb.
Currently there are three distinct triage categories: Military Triage,
Civilian Triage and Nuclear Biological and Chemical Triage or NBC
Triage, (Terms also found in literature include Trauma Triage,
Conventional Triage etc). The third category of Triage mentioned
above, although very important it had attracted very little attention and
it was mainly mentioned when discussing the possibility of a nuclear
accident or a nuclear war. The tragic events of the 11th of September
2001 in New York city and the subsequent anthrax attacks inside the
United States changed all that It was only then that the world focused
for the first time at a global level at the biological and chemical threat
and the term NBC disasters became a household name.
Returning back to the origins of Triage in its current meaning most
agree that triage was first introduced as a military medicine term.
Military Triage
Military Triage is practised in the context of military medicine.
“"Military Medicine" is an academic discipline supported by extensive
literature and scholarly activities with broad applications across the spectrum
of medical specialties. Armed forces physicians generally recognize that there
is a body of knowledge peculiar to the medical problems and needs of military
units and that this knowledge base is different from that required in ordinary
medical practice. The practice of medicine by uniformed physicians in fixed
military facilities does not differ greatly from the above-mentioned "ordinary
7
medical practice." However, Military Medicine involves risk ("threat")
assessment, prevention, medical dispositions (evacuations), and the clinical
management of diseases and injuries resulting from military occupational
exposures. …
Besides having technical competence in general medicine, the Military
Medicine specialist must have additional skills and knowledge in the specialty
areas of preventive medicine, trauma management, behavioral sciences,
environmental medicine, and tropical infectious diseases. ….”
What is Military Medicine? By Craig H. Llewellyn, MD, MPH
Uniformed Services University
Various military medicine scholars site numerous examples of Triage
been practised in the battlefield long before the term was used in that
context. One of the famous examples was sited is that of the Surgeonin-Chief of Napoleon’s Grand Army in the Russian Campaign, Baron
Dominique Jean Larrey (1766-1842). He was famous for insisting on
treating casualties, including any captured enemy, in order of severity
ignoring rank. The following is sited as an anecdote in “Larrey: Surgeon
to Napoleon’s Imperial Guard” by Richarson R.:
"Who is that bold fellow?" asked the Duke of Wellington.
"It's Larrey," someone answered.
"Tell them not to fire in that direction; at least let us give the brave man time
to gather up the wounded."
And so saying he doffed his hat.
"Who are you saluting?" enquired the Duke of Cambridge.
"I salute the courage and devotion of an age that is no longer ours," said
Wellington pointing at Larrey with his sword.
From World War I and onwards, the term Triage was used to signify a
process of classifying battlefield casualties.
Triage is the most important of the three elements contributing to
success in combat casualty care. The other two are wound debridement
and limb salvage.
8
The major objective of triage from a military point of view is to
determine who can be treated and returned to the front lines as soon as
possible and the preservation of life and limb in those who cannot be
returned. It also means an effort to make casualty care as efficient,
humane and successful as circumstances permit.
In military medicine, Triage is regarded as one of its cornerstones and
therefore, there have been a large number or papers, reports etc
regarding the application of triage in combat situations including resent
ones, such as the Falklands War and the Persian Gulf War. There is also
a clear standardization process through major international
organizations with military scope, such as NATO, regarding the triage
method applied. This standardization is supposed to be applied by all
member countries military forces.
The current conventional NATO triage classification is as follows:
T1:Immediate
Surgery to save life or limb
Short operating time
Good quality survival
T2: Delayed
Time-consuming surgery
Life not endangered by delay
Effects of delay minimized by stabilization
T3: Minimal
Minor injuries
Managed by untrained staff
T4: Expectant
Serious and multiple injuries
Treatment complex or time-consuming
Consuming personnel or resource demands
9
However, papers coming even from military medical personnel of the
United States Armed Forces express reservations about the
effectiveness of the current standards mentioned above and even
suggest different methods and categories of triage. Emphasis in those
papers is put on analysis of the experiences of actual battle conditions
in various combat fields since Vietnam and incorporation of the lessons
learned into modern combat casualty resuscitation, triage and
transportation to definitive care structures. Time and again it is
mentioned that a lot of valuable lessons learned in combat are quickly
forgotten.
Regarding the person who should practise Triage (i.e. the “Triage
Officer”), F.M. Burkle states the following characteristics as desirable:
1.
2.
3.
4.
Surgically experienced
Easily recognized and respected by medical staff
Good judgment and leadership qualities
Unflappable under stress: ability to practice suppression and handle
unpopular criticism
5. Decisive
6. Knowledgeable: familiar with resources, staff skills and limitations,
equipment, and evacuation potential
7. Sense of humour (his important quality assists in maintaining leadership
and staff relaxation at a time of considerable stress.)
8. Imaginative and creative: ability to make decisive and creative decisions
under stress, especially when resources and equipment dwindle over a
period of time (e.g. using leg elevation with ACE wraps in lieu of
expended MAST suits; hose showering rather than individual soaks for
numerous heat casualties)
9. Availability: closeness to hospital (All essential personnel should be
available within 5-15 min of summons)
10. Anticipate type of casualties: ability to plan from anticipated categories
of patients (e.g. aircraft disaster: multiple injuries and burns; hotel fie:
smoke inhalation, burns, psychological stress; earthquakes: crush
injuries)
10
Apart from the above list, there is almost uniform agreement within the
military medicine literature that the most appropriate triage officer-incharge should be a senior surgeon. The emphasis is put on the skills
and the expertise that such a person should have as mentioned above.
However, it must be noted that there are reports about dental officers
from the Royal Army Dental Corps of Great Britain being trained in
Triage and filling their roles with great success in the Falklands war.
There is extensive literature regarding Triage in military conditions. It is
felt that it is outside the scope of this thesis to further discuss the issue.
What is important to point out is that through the acceptance of a
common NATO classification comes uniformity in the Triage Tags
used in the militaries of the “western world”, including European
Union countries, which is hardly the case for Civilian Triage.
Civilian Triage.
Civilian Triage is practised in the context of disaster medicine. In turn
disaster medicine is obviously practised during a disaster. Defining
disaster is almost as complex as dealing with one.
‘From a medical point of view an incident can become a disaster when two
elements are present. First the incident must generate casualties and secondly
the medical response capacity of the affected area must be insufficient. Thus a
disaster is characterized not only by the extent and severity of the incident but
above all by the disproportion between the medical response capacity and the
actual medical resources available in order to manage the casualties. This
disproportion can be due to a quantitative or qualitative shortage of resources
both in manpower and equipment but also to medico-organizational
problems.
Dr. Michel Debacker: Disaster Medicine.
In: Concepts and Developments in Emergency Medicine, Leuven, 1992
The above definition is but one of the 46 definitions sited by the same
author of the term Disaster by various entities and from various
11
perspectives. In turn the term Disaster Medicine has only 3 definitions
sited and they are:
‘Disaster medicine can be defined as the kind of medicine that will manage in
a disaster situation the disproportion between the immediate health needs and
the actual available resources in the affected community in order to save the
highest possible number of casualties. It consists of medical care with adapted
technical procedures and medico-organizational managerial aspects including
preventive measures and restoration of the health status of the affected
population’.
Debacker M.
‘The study and collaborative application of various health disciplines, eg
pediatrics, epidemiology, communicable diseases, nutrition, public health,
emergency surgery, social medicine, community care, international health – to
the prevention, immediate response, and rehabilitation of health problems
arising from disasters, in cooperation with other disciplines involved in
comprehensive disaster management.
Gunn SWA
‘Disaster medicine is the most appropriate kind of medicine to respond in a
coherent and adapted way to the destructive effects experienced by a social
group after a catastrophic event’.
Noto R
It is a fact that Disaster Medicine evolved out of Military Medicine
principles and practices that migrated to civilian environment. For that
it is considered by de Boer and others that Military Medicine is the old
pillar of Disaster Medicine. By the same authors the new pillar of
Disaster Medicine is considered to be the rather new discipline of
Emergency Medicine. Irrespective of the definition of Disaster, Triage
is the corner stone of its practise. As a matter of fact it is regarded as
the first of three principles of mass casualty care, followed by standard
procedures and evacuation.
12
In civilian triage, the role of triage officer is assigned to personnel with
different types of training and background, ranging from the ambulance
crew to the experienced surgeon.
One of the reasons behind this is that Triage is practised in
environments with different pre-hospital care systems. The pre-hospital
care system used almost defines the person that will be performing
Triage. One can divide the pre-hospital systems in 3 categories:
1. Pre-hospital system with no doctor involved in the pre-hospital
care at all.
2. Pre-hospital system with no doctor involved in the day-to-day
pre-hospital care but involved in case of major incidents or
disasters.
3. Pre-hospital systems with dedicated pre-hospital emergency care
doctors involved in both day-to-day operations as well as in
cases of major incidents or disasters
The systems that do not utilize at all medical doctors in the pre-hospital
setting are usually systems relying heavily on protocols for the delivery
of advance as well as basic life support that are validated by hospital
doctors and applied in the field by specifically trained personnel. In
such systems medical doctors are simply not available to perform
Triage and therefore the Triaging in the field should be adapted to this
reality by using triaging methods that do not require the expertise of a
doctor.
There are also systems where, although a doctor is not involved in the
everyday delivery of pre-hospital care, doctor are getting outside their
13
hospital doors in cases of major incidents and disasters and deliver prehospital emergency care. In such systems there is usually a first Triage
designed for non-doctors followed by a medical triaging system both
being applied at the pre-hospital setting.
In the third category the doctors are in the field on a day-to-day basis
and usually can be at the scene in a very short period of time. In that
case Triage at a medical level can be initiated immediately.
In all cases the experience of the Triaging officer is very important as
well as the characteristics of the person. The characteristics stated for
military triage officers apply here as well.
Another reason behind the variety of backgrounds of the Triage officer
is that Triage is not practised in one environment or setting, but at least
three sites can be identified in any civilian disaster situation:
1. On site
2. Emergency room entry
3. In-hospital triage
It should be noted that there is also an additional site in many disaster
plans between sites 1 & 2 above: the so called in the French literature
“PMA” or “Post Medical d’Avance” translated usually as Forward
Medical Post. In France AMP is even been ruled by ministerial decree
since 1989! The basic rational behind it, is that using this step we avoid
bringing the disaster into the Hospital thru the Emergency Room.
There are also additional instances where Triage should be performed
more that once in each step or site. For example one person involved
could be triaged more than once on the disaster site if there is a large
14
number of patients and there are posts for primary treatment and
transport set at different places within the site and the movement from
one post to the other is a long one. So long that priorities could change
in the meantime for a large number of casualties.
Another reason for the above mentioned diversity of backgrounds of
persons performing Triage in civilian life is that there are many Triage
systems utilized that require different levels of expertise and knowledge
in order to be able to perform them.
A large number of methods such as the Trauma score, the Revised
Trauma Score, the CRAMS (circulation, respiration, abdomen, motor
and sensory) score, the Pre-Hospital Index, the Revised Trauma Index,
the Trauma Triage Rule, the Injury Severity Score (ISS) and the
Abbreviated Injury Score (AIS) are mentioned in the literature. All of
the above-mentioned methods require medical expertise and cannot be
performed by non-medical personnel.
There are also methods for Triaging that require very little medical
expertise and can be performed by non-medical personnel. Such
methods are the S.T.A.R.T. method, the C.E.S.I.R.A. protocol and the
Triage Sieve.
An additional important factor for the Triage is the actual setting of the
major accident or the disaster. It is clear that there should be a different
approach to the scene in an urban setting than in a hinterland.
Ideal trauma triage criteria should direct severely injured patients to
trauma centres, while distributing patients with minor injuries to
community hospitals. However, in order for this ideal to be achieved
different approaches should be used in the urban and the rural settings.
15
Another parameter is the quality of triage performed at the scene. It is
often assessed through measurement of overtriage and undertriage.
Overtriage results in the arrival of relatively mildly injured patients to
high-level trauma centres.
Undertriage happens when severely injured victims are taken to lowlevel trauma centres often not capable of providing the indicated
management.
Nuclear, Biological and chemical Triage
It is clear from the literature that conventional Triage could not cope
with such incidents where the factor of contamination adds a new
dimension to the disaster. If in conventional Triage we use as a
paramount factor the safety of the personnel it is clear that in any NBC
accident or premeditated act this factor is compromised from the onset.
W. Gunn in a personal communiqué has even suggested a number of
years ago yet a third category of disasters in the common classification
of natural or man made disasters by adding the “man conceived”
disasters.
In cases of exposure it is very difficult to actually apply any of the
Triage systems mentioned above in military or civilian Triage. As far as
regular Triage Tags of the same systems it is very clear that they are not
even relevant although many Triage Tags have lately added ways of
identifying contaminated individuals and putting them in a separate
category.
It is therefore suggested by F.M. Burkle to apply an epidemiological
approach in such cases. Specifically for the Bio-terrorist event a
16
different Triaging system is suggested with Triage Tag categories
ranging from the Susceptible to the Exposed to the Infectious to the
Removed and finally to the successfully Vaccinated (SEIRV). Such an
approach also takes into consideration not only inclusion criteria, which
is usually the case for conventional Triage but also exclusion criteria.
Regarding any nuclear incidents there are also very specific factors that
need to be taken into consideration such as mass distribution of iodine,
evacuation of population from large areas and confinement of others.
All three categories of NBC share the decontamination factor of the
individuals and materials exposed. Although there are a lot of specific
details for each one category the overall exercise of decontamination
posses a lot of challenges to the responding units.
Needless to say there is very little actual experience regarding biological
or chemical terrorism and the questions raised from such incidents have
yet to find the complete answers.
Clearly this subject is very specific and needs to be dealt separately,
especially taking into consideration the events on the 11th of September
2001 as well as the events from the anthrax exposure that precipitated
from that.
17
Chapter 3
COMMERCIALY AVAILABLE TRIAGE TAGS
Triage Tags are available through out the world both as commercially
available products as well as institutional productions from Authorities
of Health Services, Civil Protection Agencies, Fire Departments or
Counter Disaster Units.
Although this thesis concentrates on the Triage Tags used in the
European Union countries alone, it became evident that it was also
important and worth researching the commercially available products
that are offered within the same region but also worldwide
Searching for Triage Tags one soon realizes that what is usually
available in the market are actually Triaging Systems instead of plain
Triage Tags that use as one of the tools a specific tag or other device
for placing persons affected into distinct categories. Most of the
commercially available products claim endorsement by various
government or academic institutions.
Some of the products are also available as training tools in packages that
allow training either during filed exercises or at table top ones. Finally,
some of them are obviously modified versions of previously available
products while others are prototypes.
The commercially available products located in the Internet after
exhaustive search are (in alphabetical order):
18
Ø Casualty Handling System CHS TM pouch by Risk
Management Consulting of Austria.
o http://www.ispub.com/sponsors/risksponsor.htm
Ø Cruciform Emergency Documentation System by CWC
Services of U.K
o http://www.cwc-services.com/
Ø DMS Triage Tag by Disaster Management Systems, Inc.
of California, U.S.A.
o http://www.triagetags.com/triagetags.html
Ø Medical Emergency Field Triage Tag (Standard) by
METTAG Products, Inc. of Florida, U.S.A.
o http://www.mettag.com/products.asp?SN=MT137
Ø Simple Triage and Rapid Treatment (START) Triage Tag
by the Newport Beach Fire Department of California,
U.S.A.
o http://www.start-triage.com/index.html
Ø Smart Tag by Smart Memos by TSG Associates of U.K.
o http://www.smartmemos.demon.co.uk/smarttag.html
A description of all the above follows:
19
Casualty Handling System CHS TM pouch
by Risk Management Consulting of Austria
This bright orange pouch is in use in Austria as the standard Triaging
System and the company claims that hospitals, companies and other
entities in Germany, Austria, Slovenia and Switzerland are also using it.
It is worth noting that it is actually used in some hospitals in their daily
ER routine for unknown individual patients and by ambulance services
for regular ambulance patients. More than a Triage card it is a pouch
that includes papers inserted in the pouch with detailed records
regarding treatment and identification and it is extensively described
below under the Austrian section.
It has provision for marking radioactive, biological or chemical
contaminated patients and objects in the form of yellow reflecting
triangles. The triangles are attached to the pouch and objects and allow
identification of contaminated objects even under flashlight conditions.
Along with the pouch come additional checklists for Disaster Relief
Personnel with separate cards for the emergency doctor, the paramedic
and the Triaging officer (doctor or paramedic).
There is no standard training programme directly associated with the
CHS pouch by the Risk Management Consulting
20
Figure 1.CHS pouch and its content (from CHS Internet site)
Figure 2.Checklist for Triaging Officer in German by CHS (from CHS Internet site)
21
Cruciform Emergency Documentation System
by CWC Services of U.K
This Tag takes its name from the cruciform shape it has when
unfolded. It is used by various health entities in the UK, in Portugal and
in France. The company claims industry, oil & gas rigs, ships and even
the elite Special Air Service (SAS) of the British Army also use it
It is extensively described below under the Portugal section. It is in use
for the last fifteen years. One unique characteristic is the possibility of
dividing the Green category into four sub groups by folding the two
top corners of the Green Tag in order to show “flashes” of another
colour. The four categories of “Delayed/Green label” are:
Green (victims with Trauma Score 12 and no obvious significant injuries)
Green with Red “flashes” (Trauma score consistently at 3 or below.
“Expectant” patients –those expected to die soon)
Green with yellow “flashes” (Trauma score of 12. no obvious significant
injuries but awaiting special transport, due to suspected infection, infestation
or contamination)
Green with white “flashes” (victim considered to be dead by rescuers,
awaiting definitive pronouncement of death by legally qualified professional.
Trauma score of 0)
An additional feature is the sheet with self-adhesive labels for
identification of the patient and other related items. The record keeping
modules give ample space for record keeping and other information.
There is no standard training programme directly associated with the
“cruciform” but there are notes for use including basic instruction and
guidance on priority assessment and the Revised Trauma score
parameters including definitions.
22
Figure 3. "Cruciform" unfolded front and back
Figure 4. DMS Triage Tag (from DMS Internet site)
23
DMS Triage Tag
by Disaster Management Systems, Inc. of California, U.S.A.
This Triage Tag has as a prominent feature a long side strip marked
with the word “decontamination” and is also uniquely made from
synthetic paper.
The card is part of an overall Triaging System from Disaster
Management Systems. A Rapid Response Kit, a Treatment Area
Identification Flag kit and a DMS MCI Decon Mesh Stretcher are some
parts of the system. Tabletop training kits as well as a school command
kit is the training components of the system.
This Triage Tag was not encountered in Europe and therefore a
description follows:
Overall description:
Plastic card with two strips to be cut-off at the top, one for evidence or
for personal property collected and one for transportation, four colourcoded strips to be cut-off at the bottom of the tag for triaging and one
long side strip at the left marked with the words Contaminated and
Evidence. All tear-off parts, as well as the main part, have a unique
seven digits number printed on them and a bar code. Apart from those
seven-digit identification code, only pictograms present on both sides
of the card. Info on the card is in English only.
Triage Type
Possibility of triaging only once with this tag, if it is to downgrade the
patient, whereas, if it is to upgrade the patient, you can do it by tearingoff the lower part. Categorization and colour codes used: GREEN
24
Minor, walking wounded YELLOW Delayed, serious but not life
threatening RED Immediate, life threatening injuries BLACK
Morgue.
Information on card
Front side: Space for recording gross as well as secondary
decontamination and to the side, both sides of a human body to record
injuries and space to register sex and age. Below there is space for
taking four sets (time, blood pressure, pulse and respirations) of vital
signs and recording four different medications given with info about
time, drug solution and dose.
Back side: All the information on the method of triaging suggested
called Triage Flow Chart starting from respirations (red if over 30 per
minute or finding respirations only after positioning the airway
properly. Morgue if no respirations even after positioning the airway
properly) going to perfusion if respirations are under 30 per minute by
checking either radial pulse or capillary refill (red if no radial pulse or
capillary refill more than 2 seconds) and then metal status if there is
radial pulse or capillary refill under 2 seconds (red if it is not possible to
follow simple commands, yellow if it is possible). Space below to
register the three parameters mentioned above and below space for
recording personal info: name, address, city, state, phone, religious
preference and comments.
25
Medical Emergency Field Triage Tag (Standard)
by METTAG Products, Inc. of Florida, U.S.A.
Probably the oldest and most well recognised product. The company METTAG stands for Medical Emergency Triage Tags and Supplies claims wide spread use by various US Federal, State and local response
units while the copyright of the product belongs to The American Civil
Defence Association (TACDA) a non-profit, non-political association.
In Europe it is used in Belgium as well as in other countries such as
Italy, UK, Ireland and Greece in various modified forms
It is actually but one in a range of products ranging from the Standard,
to the Airport Emergency Triage Tag and to the Emergency Room
Patient Triage/Tracking tag. Additional products include the Controlled
Mass Evacuation Tags and the Controlled Access and Identification
Tags.
The tag is extensively described below in the Belgium section. A
limitation of this tag is that a patient once Triaged to a high category
(i.e. red) can not be Triaged again to a lesser one since the Triage is
done by tearing off the colours of the other categories.
There is no specific training offered by the company for the use of this
Triage Tag only suggestions for use.
26
Figure 5. METTAG Triage Tag both sides
Figure 6. START Triage Tag both sides
27
Simple Triage and Rapid Treatment (START) Triage Tag
by the Newport Beach Fire Department of California, U.S.A.
This Triage Tag is specifically designed to accommodate the S.T.A.R.T.
system of Triaging and design wise it is a modified METTAG Triage
Tag. The Hoag Hospital and the Newport Beach Fire Department in
California, U.S.A, developed the S.T.A.R.T. system. A personal
communiqué with one of the developers revealed the names of the
original developers. They are Dr. Greg Super, Emergency Director at
Hoag Hospital, Dr. Steve Groth, emergency physician, Tom Arnold,
Deupty Chief NBFD, and Ms. Vickie Cleary, Emergency Services
Manager, NBFD. The California Fire Chief’s Association solely
distributes the Tag.
This Triage Tag was not encountered in Europe and therefore a
description follows:
Overall description:
Water resistant card with four colour-coded strips to be cut-off at the
bottom of the tag and two yellow “ears” to be cut-off at the top. A
reinforced by metal grommet hole at the top centre of the tag attaches
to a string. All tear-off parts, as well as the main part, have a six digits
number printed on them. Info on the card is only in English with no
pictograms.
Triage Type
Possibility of triaging only once with this tag, if it is to downgrade the
patient, whereas, if it is to upgrade the patient, you can do it by tearingoff the lower part. Categorization and colour codes used: GREEN
Minor YELLOW Delayed RED Immediate BLACK Deceased
28
Information on card
Front side (Part 1): Information on proper categorizing patients into the
four categories: Green (Minor) Move the walking wounded, Black
(Deceased) No respirations after head tilt, Red (Immediate) if
respirations over 30 per minute, capillary refill over 2 seconds or mental
status unable to follow simple commands Yellow (Delayed) if
otherwise. Space below to record major injuries, Hospital destination, if
oriented, disoriented or unconscious and 3 sets of vital signs with time,
pulse, blood pressure and respirations.
Back side: Space for free text regarding medical complaints/ history,
allergies and notes. There is also space for writing patient medications
taken with time drug solution and dose and personal information with
name, address, city, telephone number, sex, age and weight.
29
Smart Tag
by Smart Memos by TSG Associates of U.K.
This laminated four-fold card in a pouch is in use in UK and Spain and
it is part of the Smart Incident Management System (SIMS) Equipment
as well as the SIMS Training.
It is worth noting that has no tear off parts so it is actually reusable. The
card when folded shows one of the three categories in one side while
the other side is standard. It has no fourth category for the deceased but
incorporates an additional single white card for them marked DEAD.
The card is extensively described below under UK.
The tags are offered from small packages of 5 or 20, to a valise or even
a in bag in order to adjust to the needs from the first personnel on
scene through to the incident commander. The systems also include
additional parts like the incident sketch and the adult triage sieve.
There is standard training material for the Smart Tag. In the SIMS
training modules, the packages contain lectures on:
Ø
Ø
Ø
Ø
Defining a Multiple Casualty Incident.
Multiple Casualty Scene Management
The Why, When and How of Triage.
Triage Equipment.
30
Figure 7 Folded Smart Tag
Figure
8 Smart Tag
unfolded
Figure
9 Smart Tag
unfolded
side)
(other
31
Chapter 4
PRESENTATION OF TRIAGE TAGS PER EUROPEAN UNION
COUNTRY
Information about the Triage Tags utilized from civilian organizations
for all 15 European Union Countries were obtained. The Triage Tags
used by the military was out of the scope of this Thesis. The
information collected was provided from professionals directly involved
in the fields of emergency medicine, disaster medicine or civil
protection through direct contact. The contact details of all
professionals that were used as sources of information are provided in
the beginning of each country section.
A total of 17 seventeen Triage Tags were obtained Unfortunately it was
not possible to collect Triage Tags from 4 countries (Denmark, Finland,
Ireland and Luxembourg), although detailed information about the
Triage Tags used were obtained from 3 of them (Denmark, Finland and
Ireland). When more than one type of Triage Tags are used in one
country every effort was made to collect at least two types of Triage
Tags and in 2 cases there were 3 collected. In another 2 cases only one
Triage Tag was obtained although more than one Triage Tags are used
in the country.
The countries are presented in alphabetical order from their English
names.
32
Austria
Source of information:
Mr. Rudolf Christoph,
Chief Executive Office for Rapid Relief and Aid Programmes
City of Vienna
Rathausstraße 1
A - 1082 Vienna
Austria
Tel: +43-1-4000-75232
Fax: +43-1-4000-7174
email: [email protected]
In Austria there is only one type of Triage Tags used under one
Triage system. The Austrian system is published under the title “ Das
Osterreichische Patienteleitsystem”.
Overall description:
The size of the card is: 27cm x 11,5cm
Bright orange plastic pouch with elastic band attached to a hole at the
top of it. The Tag has info written on both sides and it is to be filled
(ticks and text by permanent marker. The Tag has at the bottom two
parts that can be cut off. It also has one large pocket containing two
different colour cards (pink, light blue) for filling treatment and
identification additional info. All parts have the same 6 digit unique
number. Additional labels with the same number are available within
the pocket. Info on the card in German and pictograms
Triage Type
Room for triaging twice and record it on the face of the tag
Categorization used:
33
T1
T2a
T2b
T3
area)
T4
immediately (emergency operations on the spot)
early (immediately transport)
retarded (second priority for transport)
minimal (slightly injured persons/minimum treatment at the damage
wait (hopeless patients)
Information on card
Front side: Diagnosis info including ABC, and Human body front and
back for marking injuries and pupil sizes. There is space for doing triage
twice and writing patients name. Stub for the Hospital includes only ID
number and stub for transport includes ID number Hospital Name and
Patients Name
Back side: Space for Therapeutic measures performed including Airway
measures, circulation measures, medications given, decontamination
and transport position with pictograms
Inside: Two cards (one pink, one light blue) for record taking and
additional self-adhesive labels (with the same unique number on the
tag)
Figure 10 Austrian Triage Pouch System
34
Belgium
Source of information:
Dr. Geert Seynaeve,
Belgian Ministry of Public Health
RAC Vesaliusgebouw 448
1010 Brussels,
Belgium
Tel: +32.210.48.25/26
fax: +32 2 210.48.66
email: [email protected]
In Belgium there is one type of Triage Tags and one disc used under
one Triage system. The Ministry of Health to all Mobile Medical
Teams and Disaster Units officially distributes them. The Triage Tag
used by Medical Doctors is a commercially available product by
METTAG. The plastic discs (called "triageschijf" in Dutch, and
"macaron de tri" in French) used by 'ambulanciers' for preliminary or
sweeping triage and are to be hanged around a patients neck
Overall description:
The size of the card is: 20,5cm x 10,5cm
Water resistant card with four colour-coded strips to be cut-off at the
bottom of the tag and two yellow “ears” to be cut-off at the top. A
reinforced by brass grommet hole centre attaches to a string at the top
of the tag. All tear-off parts, as well as the main part, have a unique
letter and six digits number printed on them. Apart from those seven
digit identification code, only pictograms present on both sides of the
card. Info on the card is only in pictograms.
35
Triage Type
Possibility of triaging only once with this tag, if it is to downgrade the
patient, whereas, if it is to upgrade the patient, you can do it by tearingoff the lower part. Categorization and colour codes used: III GREEN
Emergency transportation is not considered necessary at this time. II
YELLOW Injuries are serious, but transport can be delayed until
after "Red" priority victims. I RED Victim's condition is critical,
and in need of immediate care and transport. 0 BLACK Victim is
dead and should be moved to the designated morgue area.
Information on card
Front side: Pictograms indicating time and date, sex, name, full address
including city and state, and any other info the patient can give. At the
bottom space for writing the name or initials of the person performing
the triage.
Back side: Human body, front and back, to mark injuries and
pictograms to indicate vital signs (blood pressure, pulse and
respirations) and the time they were taken with space for 3 sets. Also
pictograms for I.V. and I.M. medications given and the time
Figure 11 Belgian METTAG Triage Tag
36
Denmark
Source of information:
Freddy Lippert, MD
Course Director, Chief Emergency Physician Course
Trauma Centre and Major Incident Command Centre
Copenhagen University Hospital, Rigshospitalet
Blegdamsvej 9, DK-2100 Copenhagen, Denmark
Phone: +45 3545 3474
FAX: +45 3545 2950
E-mail: [email protected]
www.dasaim.dk
In Denmark there is only one type of Triage Tags used under one
Triage system utilized in the country. They are standardized for the
entire country
Overall description:
4 individual plasticized colour coded cards. Info on the card is in
Danish.
Triage Type
One has the possibility of changing priorities many times with those
tags. Categorization and colour codes used: 1 RED Life Threatening, 2
YELLOW Can wait, 3 GREEN Shall wait 0 White with black stripe
Dead.
Information on card
Only the colour, the number of categorization and the given priority as
above are in the card. No other info is recorded.
37
Finland
Source of information:
Dr. Matti Mattila,
Anaesthesiologist
Past President of the Finish Society of Disaster Medicine
Puolukkatie 11
70280 Kuopio
Finland
Tel &Fax+358 (71) 36405388
Email: [email protected]
In Finland there are several different manual patient charts in use for
accidents and emergency situations under many Triage systems. Each
emergency group from different hospitals is using their own type, and
the emergency services another, more uniform type.
It was not possible to obtain any Triage Tags from Finland.
38
France
Source of information:
Dr. Thierry Prunet
Méd. Chef du SDIS 30
335 rue chalet
F-30000 Nîmes, France
tel.: +33 4 6663 3600
fax: +33 4 6676 6090
email: [email protected]
In France there are several types of Triage Tags used under many
Triage systems. Three of them were obtained. A) from “Departement
des Bouches du Rhone” B) from “Unite de Securite Civile No 7” from
Brignoles and C) from “Sapeurs Pompiers”
A) from “Departement des Bouches du Rhone”
Overall description:
Size of the card: 24,5cm x 17cm
Not a card but a single face, 4 self carbon copy papers with information
with a lot of space for free hand writing. A hole at the centre attaches to
a string at the top of the tag. The card is exposed to climatic conditions.
Info on the card is only in French.
Triage Type
Categorization: 3 categories used: UA, UR, DCD
Information on card
Front side (only): Space for information indicating time and date, sex,
age, name and surname and a printed id number. At the bottom space
for writing the bilan de l’avant, categorization, and space for free text
39
and name of doctors performing the triage. Each page has additional
room for writing specific info of the function area that will keep the
page: Admission, regulation, transport, and patient.
Figure 12 Triage Tag from “Departement des Bouches du Rhone” in France
B) from “Unite de Securite Civile No 7” from Brignoles
Overall description:
The size of the card is: 31cm x 21cm
Not a card but a single face, 5 self carbon copy papers with information
with a lot of space for free hand writing. A hole at the centre attaches to
a string at the top of the tag. Info on the card is only in French.
40
Triage Type
Categorization: 4 categories used: UA (red), UR (yellow), IMPLIQUE
(green), DCD (black). Possibilities for triaging twice
Information on card
Front side (only): Space for information indicating time and date, sex,
age, name and surname and a printed id number. There is also space for
clinical data. At the bottom space for writing treatment, observations,
categorization, and space for free text and name of doctors performing
the triage. Each page has additional room for writing specific info of
the function area that will keep the page: Admission, regulation,
transport, and patient.
Figure 13 Triage Tag from “Unite de Securite Civile No 7” from Brignoles, France
41
C) from “Sapeurs Pompiers”
Overall description:
The size of the card is: 25cm x 16cm. The size of pouch is: 28cm x
20cm
A plastic pouch with zipper including 4 self carbon copy papers for
collecting information and a self-adhesive paper with 20 stickers with
the same unique id number. The pouch on the front side has non
transparent red colour that covers all info except basic info about triage
categorization and evacuation and is clear on the back side There is a
hole at the centre of the pouch that attaches to an elastic band at the
top. Info on the card is only in French.
Triage Type
Categorization: 3 categories used: UA, UR, DCD. Possibility for
triaging once only
Information on card
Front side (only): Space for information indicating name of PMA time
and date, sex, age, name and surname and an id number. Below there is
space for clinical data and comments. At the bottom space for triage,
treatment and evacuation orders. Each page has additional room for
writing specific info of the function area that will keep the page:
Figure 14 Triage Tag from French Fire Department “Sapeurs Pompiers”
42
Germany
Sources of information:
Dr. B.M. Schneider,
FICS Surgeon / Emergency
Medicine
medical Informatics
(AWWT)=Akademy for Sicence,
Technology and Economics
University Ulm c.o.
Rektoramt Universiy Ulm
Robert Koch Str. 6
89081 Ulm
phone: 0731- 502-4913
FAX: 0821 - 48 47 12
Hdy: 0172 - 82 73 64 2
oder über RLST Augsburg
Tel: 0821 - 3249998
Dr.med. Heiner P.Woltering
Orthopäde - Rettungsmedizin
Mühlenmathe 41
D-48599 Gronau
phone +49 2562 4088
fax +49 2562 81205
GMS +49 171 2111 797
GMS fax +49 171 218 4011
e-mail [email protected]
homepage http/www.vitalpark.de
In Germany there are several types of Triage Tags used under many
Triage systems. Two of them were obtained. A) The German Red
Cross registration card for injured/sick person (Anhangekarte fur
Verletzte/Kranke) and B) The German Association of Professional
Fire Departments in Nordrhein-Westfalen (Arbeitsgemeinschaft der
Leiter de Berufsfeuerwehren)
A) The German Red Cross registration card for injured/sick person
(Anhangekarte fur Verletzte/Kranke)
Overall description:
The size of the card is: 23cm x 15cm. The size of the pouch is: 33cm x
16cm
A clear pouch plastic with two different size pockets with a reinforced
brass grommet hole with an elastic band. In the larger pocket of the
pouch 3 unequal sized carbon copy papers and in the smaller pouch a
43
single folded paper with all four-colour codes for Triage and the
respective numbers. Info on the card is in German, English French and
pictograms.
Triage Type
Possibility of triaging 4 times with this Triage Tag by folding the paper
with the colour codes in a different fold and proper space for writing.
Categorization and colour codes are: I Red, II Yellow, III Green, IV
Blue, The Categorizations used in some regions in Germany are
assigning different meaning in Red and Yellow than most. Red means
immediate treatment and yellow means immediate transport. While
green means no treatment, no transport and black of blue dead.
Information on card
Front side on all 3 carbon copies: name, surname, date of birth,
residence address, place of finding, destination, patient nr, sex, religion,
nationality, no of ID disk, date, time, whereabouts. Additional info on
3rd copy only: Place for 4 different triaging with space for writing time
and name of person performing the triage as well as the category
assigned. At the bottom pictograms with Transport instructions (lying,
sitting, under supervision, helicopter, isolation)
Back side of 3rd copy only: Human body, front and back, to mark and
space to write injuries burns, diseases, intoxication, excessive radiation
and psychic conditions. Space to write vital signs 3 times and
pictograms to indicate treatment (injectables, IV) and the time they
were taken. At the bottom free space for doctor’s notes
44
Figure 15 The German Red Cross registration card for injured/sick person (Anhangekarte fur
Verletzte/Kranke)
B) The German Association of Professional Fire Departments in
Nordrhein-Westfalen (Arbeitsgemeinschaft der Leiter de
Berufsfeuerwehren)
Overall description:
The size of the card is: 25cm x 17cm.
A clear plastic pouch with a hole in the top centre. Inside 5 different
colour cards: white, red, yellow, green and black. Info on the card is in
German and pictograms. Categorizations criteria at the back of clear
pouch as we;; as a sticker with info on triage to be attached on the
patient
Triage Type
Possibility of triaging many times with this Triage Tag by using the
relevant colour tag. Categorization used I (red) Serious danger,
immediate transportation, problems with breathing RR 100, no pulse,
45
not responsive. II (yellow) no serious danger, transportation within 46 hours to hospital, no breathing or pulse problems , to be kept under
observation. III (green) not injured or slightly injured, no problems.
IV (black) dead.
Information on card
Front side free fields for writing down: date, name, loacation (where the
person was found first) Triage, Triage at PMA entrance, Triage at PMA
exit, Special transportation-aim, by car, by helicopter etc
Figure 16 The German Association of Professional Fire Departments in Nordrhein-Westfalen
(Arbeitsgemeinschaft der Leiter de Berufsfeuerwehren)
46
Greece
Source of information:
Author of the thesis
In Greece there is only one type of Triage Tags used under one
Triage system. The Triage tag used is a modified METTAG card
produced by the National Centre of Emergency Care (EKAB), which is
the nationwide ambulance service.
Overall description:
The size of the card is: 21,5cm x 10,5cm
Water resistant card with four colour-coded strips to be cut-off at the
bottom of the tag and two white “ears” to be cut-off at the top. A hole
at the centre attaches to a string at the top of the tag. All tear-off parts,
as well as the main part, have a unique four digits number printed on
them. Info on the card are in Greek and in pictograms.
Triage Type
Possibility of triaging only once with this tag, if it is to downgrade the
patient, whereas, if it is to upgrade the patient, you can do it by tearingoff the lower part. Categorization and colour codes used: 3 GREEN
Emergency transportation is not considered necessary at this time. 2
YELLOW Injuries are serious, but transport can be delayed until
after "Red" priority victims. 1 RED Victim's condition is critical,
and in need of immediate care and transport. 0 BLACK Victim is
dead and should be moved to the designated morgue area.
47
Information on card
Front side: Pictograms indicating time and name, sex, place of incident,
hospital referred, time and date, signature of triage officer, description
of injuries and care provided.
Back side: Only a human body, front and back, to mark injuries
Figure 17 Modified METTAG Triage Tag from Greece
48
Ireland
Source of information:
Mr. Patrick G. Callaghan
Chief Ambulance Officer Mid-Western Health Board
Dooradoyle, Co. Limerick
Ireland
tel.: +353 61 228583
fax: +353 61 482493
email: [email protected]
In Ireland currently there are more than one Triage Tags used with
many Triage systems. The country was reported to be in a transition
period in order to introduce a single type of Triage Tags under one
Triage system. The uniform triage tag to be implemented is of the
commercially available “cruciform” type.
The “cruciform” Triage Tag from Ireland was obtained.
A detailed presentation of this type of tag is in the section of
commercially available Triage Tags above and in the Portugal section
below.
It should be noted that the “cruciform” Triage Tag from Ireland has no
carbon copies in any of the modules.
49
Figure 18 Triage Tag of the ‘cruciform” type from Ireland
50
Italy
Source of information:
Dr. Federico Politi
Coordinator EMS
Servicio Urgenza Emergenza Medica (S.U.E.M. 118)
U.L.SS no 6 “Vicenza”
Viale Rodolfi, 37
S.Bortolo Hospital
Vicenza
Italy
Tel. +390444993411
fax: +39 0444 927567
Cell. Phone +39 348-6707385
email: [email protected]
In Italy there are several types of Triage Tags used under many
Triage systems. Two of them were obtained. A) from U.L.SS no 6
“Vicenza” Servicio Urgenza Emergenza Medica 118 and B) from
Bologna Soccorso 118
A) from U.L.SS no 6 “Vicenza” Servicio Urgenza Emergenza Medica
118
Overall description:
The size of the modified METTAG tag is: 17cm x 10cm. The single
colour tag size is: 15cm x 10,5cm
Not a single card but a double card Triage Tagging system.
The first card is a single colour card (red, yellow, green,) with only the
name of the Emergency service and a serial 6 digit number with a string
attached from a reinforced hole at the top centre.
51
The second card is a modified METTAG card. Water resistant card
with four colour-coded strips to be cut-off at the bottom of the tag and
two white “ears” to be cut-off at the top. A hole at the centre attaches
to a string at the top of the tag. The top tear-off parts, as well as the
main part, have a unique four digits number printed on them. Info on
the second card is in Italian and pictograms.
Triage Type
Possibility of triaging a number of times with this double tagging
system.
The first single colour tags are for swiping triage performed not by
medical personnel but by Ambulance personnel using the START
method (Simple Triage And Rapid Transport).
Second and subsequent Triage is to be performed by the modified
METTAG triage card. Again with the modified METTAG card you
can triage only once with this tag, if it is to downgrade the patient,
whereas, if it is to upgrade the patient, you can do it by tearing-off the
lower part.
Categorization and colour codes used: III GREEN (non grave)
Emergency transportation is not considered necessary at this time. II
YELLOW (grave) Injuries are serious, but transport can be delayed
until after "Red" priority victims. I RED (molto grave) Victim's
condition is critical, and in need of immediate care and transport.
BLACK (deceduto) Victim is dead and should be moved to the
designated morgue area.
52
Information on modified METTAG card
Front side: Space for three lines of free text. At the cut-off ears there is
space for time and hospital information.
Back side: Human body front and back, markings for conscious or
unconscious state and haemostasis as well as pictograms for time, pulse,
blood pressure, respirations and drugs given with space for 3 sets of
vital signs.
Figure 19 Double Triage Tagging system from U.L.SS no 6 “Vicenza” Servicio Urgenza Emergenza
Medica 118 in Italy
B) from Bologna Soccorso 118
Overall description:
The card size is: 21cm x 15cm.
A plane paper card with information on both sides. Only the front side
has space for triaging twice, transport info and vital signs. The backside
has info on two triaging protocols. Info on the card are in Italian and in
pictograms.
Triage Type
Possibility of triaging twice with this tag. Categorization and colour
codes used: Red, yellow, green, and blue. There is the possibility of
53
triaging using two systems with the categorization criteria written at the
back. The first is strictly for non-medical personnel with no possibility
for categorizing in the blue (dead) category while the second is the
START protocol with possibility for triaging in the 4 categories since it
is for medical personnel.
The first protocol is called C.E.S.I.R.A. and has the following criteria:
Green: if the person can walk, Red: if the person is unconscious, in
shock, with external haemorrhage, and respiratory insufficiency and
Yellow: if there are fractures, dislocations or other ailments.
The second protocol is the S.T.A.R.T. and is taking the following
questions into consideration a) can the person walk (if yes green, if no
go to next question) b) Is the person breathing (if no blue, if yes with
difficulty red and if yes go to next question. c) does the person have a
radial pulse (if no red, if yes go to next question) d) can the person
follow simple commands (if no red, if yes yellow)
Information on card
Front side: Space for bar-code-label, name sex and time. Space for first
and second Triage, vital signs, treatment and principal problems, as well
as transport instructions Back side: The info for the two triage
protocols as described above
54
Figure 20 Triage Tag from Bologna Soccorso 118, in Italy
55
Luxembourg
Source of information:
Mr. Bley Guy
Ministry of Interior
Direction of Civil Protection Unit
1, rue Robert Stümper
L-2557 Luxembourg
Tel:+352 49.771-305
email: [email protected]
In Luxembourg there is only one type of Triage Tag (called
Evacuation Tag) used under one Triage system. All emergency units
are using the same Triage Tags. Mr. Fred Speltz who is an officer of the
Fire Brigade in Luxembourg developed the Tags.
Overall description:
The card size is: 28cm x 16cm. The clear plastic cover is 28,5cm x
16,5cm
A two-page carbon copy Evacuation Tag with a third plasticized card
with information and instructions and a clear plastic cover in front.
Only the front side has space for triaging and priority info, as well as
information regarding care given and destination. A unique number is
printed on the top left corner and in the bottom left detachable corner.
The lower part of the first copy with information about evacuation and
destination is also detachable. Information on the Evacuation Tag part
is in English, while the information and instructions on the plasticized
card are some in French and some in English.
Triage Type
Possibility of triaging twice with this tag. Categorization instructions in
the back of the plasticized card is U1 (red) for immediate transport and
56
continuous observation, U2 (yellow) for no necessity for continuous
observation after primary care, U3 (green) for need of basic care only
and I (no colour code) for implicated persons but with no apparent
problem. The Evacuation Tag has no colour coded area or detachable
part for assigning priority. The priority is hand written on two
designated areas of the Evacuation Tag.
Information on card
Evacuation Tag pages: Name, first name, age, sex, hair, clothes and
time. Space for first Triage includes space for recording fractures,
wounds, burns and bruises or amputations per body area (skull, face,
neck, spine, thorax, back, abdomen, pelvis, right arm, left arm, right leg,
left leg). Also space for Glasgow coma scale, respirations, blood
pressure and heart rat recordings. Separate space for clear marking of
principal or life threatening injury.
Separate space is provided for the initial therapy with space for writing
the Dr.’s name and care provided (fluids, drugs, O2, intubation,
ventilation, thorax drain, tourniquet or clamps), as well as, evacuation
instructions (medicalised or not, specific destination, position of patient
and reassessed priority). The bottom part is reserved for destination
instructions including type of transport to be used, hospital arrival time
and admission number.
The info on the front of the plasticized card is a modified Glasgow
coma scale called Glasgow-Liege (GLS) which is the GCS with the
addition of a category of reflexes of the CNS. This category gives a
maximum of 5 points and minimum of 0 so the range of the scale is
from 3 to 20. (Bibliography referred in the card is: J.D. Born et al.
Neurosurgery, 1985, 16, 595-601). The back is filled with possible
57
injuries and their respective categorization as described above as well as
a legend for the acronyms used in the evacuation tags.
Figure 21 Triage Tag from Luxembourg
58
The Netherlands
Source of information:
Mr. Dick Fundter
Project Officer Disaster Medicine
Crisis Management and Fire Services Department
NL Ministry of the Interior & Kingdom Relations
tel.: +31 70 426 7011
fax: +31 70 426 8244
email: [email protected]
In the Netherlands there is one type of Triage Tags used under one
Triage system. The Triage Tag used is the official Triage Tag for all
medical disaster units issued by the Ministry of Health / Home Office
Overall description:
The size of the card is: 21,5cm x 11cm.
Plain hard paper card with four colour-coded oval strips to be cut-off at
the left side of the tag and two yellow “ears” to be cut-off at the top
and bottom right side of the card. Two reinforced holes at the centre
top and bottom to be attached to a string. The main part of the tag has
a 5 digit identification number. Info on the card is in Dutch and
pictograms.
Triage Type
Possibility of triaging only once with this tag. Categorization and colour
codes used: I RED Victim’s condition is critical, and in need of
immediate care and transport. II YELLOW Injuries are serious, but
transport can be delayed until after "Red" priority victims. III
GREEN Emergency transportation is not considered necessary at
59
this time. IV BLACK Victim is dead and should be moved to the
designated morgue area.
Information on card
Front side: Pictograms indicating sex, and space for name, date of birth,
address, place, place where found, date and time at casualty post, and
for arrival and departure at medical post. Pictograms for assigning
destination to: Hospital, morgue or home. Also pictograms for
positioning patient during transportation in prone, recovery, abdominal,
semi-prone and sitting. The two yellow cut-off tabs are with pictograms
for Transportation and Hospital with space to add name.
Back side: A human body front and back, to mark injuries. as well as
space for describing the injured area. Additional room for recording at
least 3 sets of vital signs (respirations, blood pressure, pulse) as well as
reaction to pain and reaction to speech. Additional space for writing IV
infusion and injectables given.
Figure 22 The Triage Tag from The Netherlands
60
Portugal
Source of information
Dr. M.T. Pinto (Teresa)
Instituto Nacional de Emergência Médica
Rua Infante D. Pedro 8
P-1799 Lisboa Codex
Portugal
tel.: +351 21 792 9279 (792 9100)
fax: +351 21 797 5426 (793 7124)
email: [email protected]
In Portugal there are several types of Triage Tags used under several
Triage systems. The National Institute of Emergency Medicine
(INEM) has adopted a commercial Triage Tag, “the Cruciform” but
other entities like the Red Cross are having their own. The cruciform
type was the only one obtained.
Overall description:
The size of the card (folded) is: 23cm x 15cm. The size of the pouch is:
26,5cm x 17cm.
Plain hard paper card with four colour-coded ears in one side, that
when unfolded create a cross. There are also two self carbon copy
papers in two of the sides, for the casualty assessment module and for
the category 4 victims side.
The entire card along with a single sheet with unique numbered
adhesive labels is in a clear plastic bag for weather protection. A hole at
the top centre attaches the card to an elastic band.
The card is divided in 5 modules:
61
a) Colour module
b) Casualty Assessment module
c) Casualty details module
d) Trauma score module
e) Additional observations / Treatment given / comments
module.
Info on the card is in Portuguese.
Triage Type
Possibility of triaging many times with this tag since the way to triage is
to fold the four colour coded sides so that only ones shows.
Categorization and colour codes used: 1 RED Immediate, 2
YELLOW Urgent, 3 GREEN Delayed and 4 WHITE Dead. The
Triage Tag also includes the possibility of Triaging according to the
Revised Trauma score. An additional feature is that the Green
category can be divided into four sub categories. (see above at the
description of the commercial product)
Information on card
Front side (or inner side when unfolded):It has the info for the 3 of the
5 modules: Casualty details module, Trauma score module, Additional
observations/Treatment given/comments module It includes Notes on
Use, Revised Trauma Score Operational Definitions, Space for
recording Revised Trauma Score, Glasgow Coma Scale and Oxygen
saturation up to 12 times, Casualty Details (name, surname, address,
sex, DOB, age, Type of incident details – incident location date,
location of casualty, position when found, time found, found by -,
particulars of casualty, state of body, ambulance call sign, police names,
immediate care, nurse and other rescuers) and free space for additional
observations, treatment given and comments
62
Back side: (or outer side when unfolded): It has the info for the other 2
of the 5 modules Colour module and Casualty Assessment module. The
Casualty Assessment Module includes a primary survey with ABCD
assessment, a human body front and back, to mark exposures and/or
injuries. as well as space for comments. Also space for observations
about respiratory rate, oxygen saturation, blood pressure, and pulse rate.
Also secondary survey with eye opening, best verbal response, motor
response and pupils, Primary Management (Airway, Breathing,
Circulation) and Secondary Management (Analgesia and Splinting)
Figure 23 The "Cruciform" from Portugal
63
Spain
Source of information
Dr. Nelly Habed Lobos
C/ Costa Rica 24,
28016 Madrid,
Spain
tel.: + 34 91 3599551/+34 609 11 6611
email: [email protected]
In Spain there are many types of Triage Tags used under many
Triage systems. In the Madrid region alone there are 3 different
emergency services with 3 different Triage Tags. Only the one from the
“S.A.M.U.R. Proteccion” of the “Ayuntamiento de Madrid”.was
obtained. This tag is actually a modified tag from the commercially
available system from “Smart Memos”.
Overall description:
The size of the card (folded) is: 15cm x 10cm. The size of the plastic
pouch is: 22cm x 11,5.
A plasticized single paper folded 4 ways within a clear plastic bag. The
four sides used for colour coding and four sides for writing info. The
plastic bag has a hole at the centre top for an elastic band. There is
always one side visible with an id number while the other one is the
colour coded one. Info on the card is in Spanish.
Triage Type
Possibility of triaging many times with this tag since the way to triage is
to fold the card so only one colour coded sideshows. Categorization
and colour codes used: Priority 1 RED Immediate, Priority 2
64
YELLOW Urgent, Priority 3 GREEN Delayed and Priority 0
BLACK Dead.
Information on card
The always-visible side: Sex, estimated age, and number. Airway,
respiration, circulation and Glasgow Coma Scale information as well as
date and time
Other sides: a) space for recording 4 times GCS, respirations and blood
pressure as well as sum and time. b) casualty clearing station info
including time, priority, vehicle and destination and notes. c) secondary
assessment with a human body front and back for marking injuries,
treatment information including time, doses and description as well as
notes
Figure 24 The modified Smart Tag from Spain
65
Sweden
Source of information
Dr. Thore Wiklstrom
Acting Professor of Disaster Medicine and Traumatology
University of Linkoping
S-581 85 Linoping
Sweden
tel.: +46 13 222000
fax: +46 13 222910
email: [email protected]
In Sweden there is only one type of Triage Tags used under one
Triage system. They are standardized for the entire country
Overall description:
The size of the card is: 14cm x 10cm.
4 individual plasticized colour coded cards. Info on the card is in
Swedish.
Triage Type
Possibility of changing priorities many times with those tags.
Categorization and colour codes used: 1 RED Life Threatening, 2
YELLOW Can wait, 3 GREEN Shall wait 0 White with black stripe
Dead.
Information on card
Only the colour, the number of categorization and the given priority as
above are in the card. No other info is recorded
66
Figure 25 The Swedish colour coded Triage Tags
67
United Kingdom
Source of information:
Dr. Andrew Mason
3 Matts Hill Road
Sittngbourne, Kent
UK
tel.: +44 1634833974
email: [email protected]
In the United Kingdom there are many types of Triage Tags used
under many Triage systems. From the information collected it is
apparent that the majority of the Hospitals use the METTAG tag. The
“cruciform” is also used as well as the “smart memos” one. All three
cards, which are the original commercially available products, were
obtained from the UK.
A) The METTAG card
The original METTAG card has been described as the card used in
Belgium.
B) The “Cruciform” card
The original “Cruciform” card has been described as the card used in
Portugal.
C) The “Smart Memos” cards.
Overall description:
The size of the card (folded) is: 15,5cm x 10cm. The size of the plastic
bag is 18,5 x 11cm.
A plasticized single paper folded 4 ways within a clear plastic bag. The
three sides used for colour coding Red, Yellow and Green) and five
68
sides for writing info. The plastic bag has a hole at the centre top for an
elastic band. There is always one side visible with a written id number
while the other one is the colour coded one. There is an additional
separate white card for the dead. Also included is a plasticized card with
info about “The Adult Triage Sieve” and space for counting the
persons triaged into the different categories. Info on the card is in
English.
Triage Type
Possibility of triaging many times with this tag since the way to triage is
to fold the card so only one colour coded sideshows. Categorization
and colour codes used: Priority 1 RED Immediate, Priority 2
YELLOW Urgent, and Priority 3 GREEN Delayed. As mentioned
before Priority 0 WHITE Dead is a separate card.
Information on card
The always-visible side: Patient information like sex, approx age,
location found, and number. There is also space for recording Airway,
Airway management, Breathing, Circulation and Disability information
as well as date and time.
Other sides: a) space for recording up to 5 times GCS, respirations and
blood pressure as well as the sum and time. Also assigning priorities
according to sum total. b) casualty clearing station info including entry
and exit time, priority, ambulance call sign, destination and notes. c)
Secondary assessment with a human body front and back for marking
injuries, treatment information including time, doses and description as
well as notes.
69
Chapter 5
CONCLUSIONS
Everything that can be invented has been
invented. (!)
–
–
Charles H. Duell, Commissioner,
–
U.S. Office of Patents, 1899
in English D., Slipping the Surly Bonds:
Great Quotations on Flight,
McGraw-Hill 1998
The major objective achieved by this thesis was that information from
all European Union countries were obtained by individuals who could
all be called experts in this field. All persons acting as sources of
information are very knowledgeable and have first hand experience on
the issue of Triage Tags.
However, it was not possible to collect Triage Tags from all countries.
More specifically Triage Tags were not collected from two out of
fifteen countries, namely, Denmark and Finland.
It was also not possible to collect more than one Triage Tag from
Portugal and Spain although both countries have more than one Triage
Tag in use.
Concluding this thesis it is important to state that the work is not over.
There are a lot of interesting issues regarding the Triage Tags in the
European Union that need to be further explored.
Among them the issue of the actual use of Triage Tags in major
incidents and disasters remains a thorny one. It was not possible to
70
collect data in a systematic way regarding this issue. From anecdotes
from the various sources used for this Thesis it is derived that in some
countries the Triage Tags have been used for major incidents but not
for disasters.
It seems that a limiting factor for not using the Triage Tags is the lack
of daily use of them. Because of that, it is not part of the routine in
handling patients and it becomes very difficult to be incorporated into
the job when disasters strike.
On the other hand, it was clearly established by all sources that the
Triage Tags are used extensively as a training tool for all kinds of
exercises, from table top to full scale all over Europe.
Regarding the content and made, it is very clear that the commercial
products have influenced the Triage Tags of the majority of the
countries either by adapting a commercial product or when creating
there own. They have also found their way even as single products
applied on a countrywide basis.
It is also hoped that with some effort a consensus can be achieved
within the European Union for a single type of Triaging method in the
field and therefore a single Tagging method to be used in the field. The
quotation at the top of the chapter has to be proven wrong!
Finally it is recommended that the Triage Tags should either be
incorporated as a tool used on a daily basis if they are to be actually
used. Otherwise they should remain only a very good training tool on
handling patients in a disaster.
The compilation of the information collected follows:
71
Info
collected
þ
þ
þ
þ
COUNTRY
Austria
Belgium
Denmark
Finland
Single
Tag
þ
þ
þ
No. Tags
Smart
Collected METTAG* Memo*
1
þ
1
ø
ø
France
þ
3
Germany
þ
2
Greece
Ireland
þ
þ
Italy
þ
Luxembourg
The Netherlands
Portugal
Spain
Sweden
þ
þ
þ
þ
þ
United Kingdom
þ
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BIBLIOGRAPHY
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