08 - The Subject of Subjectivity.


An ideal triage system contains no subjectivity. In other words the decision process used to determine an acuity class is void of assumption. Not only does removing subjectivity from the process ensure all patients are triaged equally, it allows the results of the triage to be accurately measured to test processes used and the competence of the user. This data set is valuable to identify training deficiencies and to further improvement of the triage system. SALT’s inherent subjective process negates these benefits.

Framed for the Future:

We can’t but marvel at the foresight the designers of START possessed. They were truly visionaries. Over three decades ago, with virtually no science available, they derived at an algorithm for mass casualty triage that has withstood the test of time. Akin to our founding fathers framing the constitution, they knew it would need to evolve and built in provisions for modifications to occur with ever so gentle disruption to our training. It accepted science from the field and allowed for us to improve it.
The designers also did something equally amazing. Something most of us either take for granted or do not realize. They knew the human decision-making process was inherently flawed by subjectivity and that such subjectivity would result in different outcomes, thereby skewing the data we would need to identify weaknesses in our training and necessary improvement to the algorithm. They also knew subjective decision making would slow the triage process. So they constructed START to have no subjectivity. At no point can an incorrect assessment be made without breaking the rules. There is no ambiguity. Either your respirations are over 30 or they are not. Your pulse either is palpable or it isn’t and you can either mentate or you can’t. All answers are either right or wrong. There is no murky middle-ground. This allows START to yield true data.

This is the hidden jewel of START and should be a required component of any triage system to ensure it can evolve and improve.

Knowledge is Power:

Most of us have been remiss in utilizing this feature of START. Think of the power from a training perspective alone. By using a triage system with no subjectivity during training drills we can know, without a doubt, who is conducting triage correctly, and who is not, by comparing how the patient was triaged vs. what was written on the casualty card. Some forward-thinking states have not neglected this important component of START and actually have an area on the tag used for secondary triage to record how a responder initially triaged a patient.

If this process becomes second nature in drills it could be extended into real-world events with nominal disruption to patient care. This would enable us collect data on how well algorithms are applied in high-stress environments. Real science in real time. Knowing this do we want to adopt something that, by nature, does not have this capability?

Hoag Hospital, Newport Beach. Circa 1990 - Photo by D Ramey Logan

Florida triage tag data-collection section.

Subjective by Design:

SALT is inherently subjective in numerous ways and would prevent any usable data collection with respect to personnel aptitude in applying the algorithm in training or measuring the algorithm’s performance in actual events:

1. Visible Life Threat: In the minds eye we see walking by a patient making purposeful movement easy to visually assess for life-threatening injuries. In reality this is not the case. ”A happy trauma patient is a naked trauma patient” as we say, and for good cause, but that is not an option in an MCI. Sometimes ideal lighting or fair weather are not options either. Many of our less experienced responders would not know what to look for. Even the best of us could get it wrong. Without a physical RPM test of some sort it is purely speculative as to if a life-threat exists or not. If it is left up to the user to decide it is subjective. START forces the user to make non-subjective yes or no findings. In SALT it is a best guess. Throw in cold-weather clothing or a mud-rich environment and that best guess just became a coin toss. No science can be derived from it either way.

A Word on Accuracy:

Putting the argument of over-triage and under-triage aside (all the ‘studies’ we found on the subject are deeply flawed) we can make a conclusion as to the accuracy of SALT and START. Accuracy in the sense that the individual conducting the triage correctly derives the proper patient acuity category based off the algorithm’s requirements. Taking SALT’s ‘Minor Determination’ out of the equation and assuming exact Resources are known at the time of triage, both systems are 100% accurate. This is because the problems with austere triage are not with the instrument used but with the people using them. Training is what is essential to ensure any algorithm is properly applied. By collecting data that is not subjective we can ensure our training is optimized.

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3. Resource Dependent: Because there is a likelihood individual triage members teams will not know the resources stacking up behind them in real-time it must be an assumption of available resources that is used when assigning a patient to either an Immediate or Expectant category. Regardless of the hypothesized benefits a resource dependent algorithm provides, the data it yields has no value as the derivative is assumption based. Couple that with the fact that multiple individuals will be operating of varying resource data sets and the result is not just bad data but variability and inconsistency in the entire triage process. START circumvents these issues and ensures accurate data is generated by requiring consistency.

4. Minor Injury Determination: What constitutes a minor injury is by nature a subjective call. To inexperienced responders, such as a green EMT or CERT, something as benign as severed toes could rate a Delayed category. Without a clear guideline to follow any categorization of Minor will require subjectivity.

START’s Minors (Greens) are always those that can walk. The only time a Minor is in the non-ambulatory triage area is when they voluntarily stay to render aid.

5. Respiratory Distress: Purely subjective and fully dependent on the medical skill set of the responder and personal opinion. Highly prone to error for novice responders. No meaningful data can be derived from this.

6. Control Major Hemorrhage: If taken literally, a responder would need to deviate from the SALT rules in order to control life-threatening blood flow that is not in the form of a major hemorrhage. This may not have direct impact the data set but it is another instance where subjective decision making is necessary under SALT.

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The best way to explain it is to show it. We’ll pick up where we left off in our cold-shooter scenario in white paper four. You’re in the boots of the responder. See if the questions he asks and the decisions he makes are similar to what you would do given the same situation and SALT.

2. The Sorting Process: Tightly bound to the ‘visible life threat’ is SALT’s sorting criteria. It may look good in black-and-white but put into real-word practice it suddenly turns an ugly shade of gray.
It’s subjectivity is only surpassed by its unworkability.

SALT’s Sorting Matrix.