On Your Mark, Get Set, Triage

Part 2 of “To Triage of Not to Triage? That is NOT the Question.”

Last week I took another dive into the world of triage- specifically focusing on some common questions and sticking points that were raised in RadioLab podcast entitled “Playing God.” As was mentioned in the previous blog post, we don’t think triage is really about playing god, rather about facing limited resources and making decisions. Last week we talked mostly about the value implications of such discussions of who lives and who dies. This week we’ll touch upon two other points. First, the reaction to not want to make triage decisions, and the second is the multitude of ways to triage and therefore the importance of RCTs in knowing which way is best in a given situation.

Which Blob should receive treatment first?

For a quick recap- the podcast hosts spoke to Sheri Fink, a reporter who has covered post-earthquake Haiti, interviewed doctors and nurses present at a hospital that suffered in the wake of Hurricane Katrina, and a more recent community conversation on triage led by Johns Hopkins doctors.

A common triage-related thread throughout the stories was a swift reaction to avoid the very decisions that needed to be addressed. This instinct is understandable. When some people inevitably will not receive full attention, life and death consequences create no-win scenarios. The hospital receiving patients after Hurricane Katrina had not developing a triage plan until crisis set in. Helicopters stopped coming regularly, generators were failing, and temperatures were reaching dangerous levels. At this point emotions are high, and resources are not being used as efficiently as possible. These factors don’t make triage any easier to conduct, and waste time and resources in an already dire situation.

Fink also learned from extensive interviews that doctors and nurses had different opinions about the best way to triage. At the end of the podcast—and despite firsthand observation and documentation of hundreds of interviews—Fink repeatedly insisted that she still didn’t know the best way to triage after the fact. We shouldn’t expect her to know the answers, even after such extensive exposure. Rather, her reporting reinforces that triage itself must be treated seriously as a subject of scientific inquiry. We should study its effectiveness and necessity in a variety of contexts—using RCTs of course—before formulating policies that can be effectively applied to dire situations.

Lastly, the sites covered in the podcast reveal a multitude of (seemingly) legitimate ways to conduct triage. The community discussion in Baltimore gathered people from varied walks of life, who all had, amidst a contentious political climate, respectful and honest dialogue about their preferred approaches to triage. Their reasons and conclusions varied. Some adopted a very utilitarian viewpoint: save the youngest, who will likely live longer than everyone else. Others thought the only way to triage fairly was to leave the decision to chance. The conversation often crossed into uncomfortable territory when it turned to identifying those who deserved saving, i.e., comparing one person’s potential longevity to another’s. The hospital in Baltimore ultimately incorporated a bit of these latter two suggestions. Health care providers would maximize life span in the first round of distributing care, and triage randomly for a second round.

As we touched upon in our last blog post, the necessity of triage within legal services is, unfortunately, here to stay. It’s therefore necessary to study triage and give ourselves the best information possible to make these tough decisions. According to Rebecca Sharpless, who has categorized triage in legal services “the central [c]hallenge for social justice lawyers,” given scarce resources, “they should prioritize their goals and methods to maximize positive social change” with an eye toward “practice visions to guide our allocation of scarce human capital.” Sharpless thereby places the triage question, with all of the attendant caveats and questions above, squarely before the legal community.

Regardless of the level at which triage occurs or the decision-maker involved, it is a decision point deserving of study in its own right. Typical client outcomes in the legal field might not always be as serious as the ones documented in the Radiolab episode. Nevertheless, who receives legal advice and in what dosage is as critical a question for lawyers as medical treatment choices are to doctors. So, engaging in triage is not claiming divinity. It’s an unavoidable, and understudied feature of our legal system that the A2J Lab is dedicated to improving through rigorous, randomized testing.

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