Medical Aspects of Chemical Warfare (2008) - The Black Vault

Medical Aspects of Chemical WarfareINTRODUCTIONThe term “triage” has come to have different meaningsdepending on the situation in which it is used.Derived from the French word trier, meaning to sort,categorize, or select, its initial use is thought to havebeen in reference to the sorting of crops according toquality. Triage soon became used on the battlefield asthe sorting of casualties into three groups: (1) thoseneeding immediate care, (2) those who could waitfor treatment, and (3) those not expected to survive.Military triage has certain definitions codified indoctrine and policy. The term also refers to the initialscreening and prioritization process in emergencydepartments.Triage is one of the most important tools in the handlingof mass chemical casualties. Triage criteria mustbe relevant to the available medical units’ capabilities,and triage process should be planned in advance andpracticed. In general, triage is performed at naturallyoccurring bottlenecks, where delays in medical caremay occur, and when medical requirements exceedcapabilities or resources, which may cause a breech inthe standard of care. The ultimate goal of triage is tooptimize the use of available medical resources to providethe best medical care possible by identifying thecorrect priority of patients. 1 This chapter will focus onthe process of triage in chemical agent mass casualties.Specific chemical warfare agent classes, current triagesystems, and classifications of triage will be reviewed,with discussion of issues specific to the battlefield andinstallation setting.TRIAGE PRINCIPLES AND PROCESSESIn a mass casualty situation, whether in peacetimeor on a battlefield, triage is carried out to provideimmediate and appropriate care for casualties withtreatable injuries, to delay care for those with lessimmediate needs, and to set aside those for whomcare would be too timely or asset-consuming. Triageensures the greatest care for the greatest number andthe maximal utilization of medical assets: personnel,supplies, and facilities. To effectively triage a givenpopulation, a triage officer should know the followingessential information:• The current environment and potential threat,course, and harm. Situational awareness mustinclude current tactical goals and conditions,the potential evolution of hazardous materialsor conditions, and the impact these mighthave on the patients and providers.• The ongoing medical requirements, includingthe number and type of current casualties andpotential population at risk.• The medical resources on hand.• The natural course of a given injury.• The current and likely casualty flow.• The medical evacuation capabilities.• The decontamination requirements in a chemicalincident.According to FM 8-10, Health Service Support in aTheater of Operations, 2 the triage officer should be ahighly experienced medical provider who can makesound clinical judgments quickly. Ideally, a surgeonexperienced with combat trauma would be used inthis capacity; however, once casualty flow progresses,surgeons must spend time in the operating suite, andtheir available time to perform triage will be limitedbeyond the initial efforts and between operations.Additionally, the expertise of surgical triage appliesto traumatic injuries, and may not be as applicable tochemical incidents. Commonly, the most experiencedcombat medic performs triage; however, other physicians,dentists, or nurses with appropriate training andexperience can also accomplish this arduous task.Part of the triage process is the evaluation of thebenefit that immediate assistance will provide. Thisevaluation is based, in part, on the natural course ofthe injury or disease. For example, dedicating medicalassets to a casualty with an injury that will either healor prove fatal no matter what immediate care is givenwould be of little benefit. Another part of the process isconsidering the overall tactical mission requirements,which may change rapidly in the battlefield setting.The ultimate goal of combat medicine is to return thegreatest possible number of soldiers to combat and thepreservation of life, limb, and eyesight in those whomust be evacuated. 3Setting aside casualties who are in need is unpopularamong medical care providers, and poses an ethicaldilemma on how to provide the ultimate care for eachpatient. The Hippocratic Oath is not helpful in thissorting process, because the modern interpretation ofthe Oath states that the duty of physicians and nursesis to protect and promote the welfare of their patients.Furthermore, according to the Oath, caregivers mustfocus their full attention on that patient until thepatient’s needs are met, before turning their attentionto another patient. Additionally, in peacetime, everypatient who enters the hospital emergency room512