Triage

In the world we live in there are usually two answers to any question: the simple one, and the real one.

Politicians only seem to have time for the simple one.

Partially, that is because the modern media has trained them to talk to the public in sound bites. So any concept too difficult to fit into a sound bite, such as the real answers to most questions that the government should be addressing, doesn’t get talked about. Now, if you’re a politician and mostly concerned with getting re-elected, why spend time on something you’re not going to talk to the public about?

So the simple answers tend to be the only ones that get into legislation.

“But Federal laws are enormous! Thousands of pages! Surely they can’t be simple?”

Wrong. The basic concept that the law is based on is often quite simple.

The basic concept of Obamacare, for example, is that everyone should have healthcare. Simple concept. Easy to say, easy to defend on an emotional level.

Problem is, not one bit of that enormous bill with its simple concept answered the question of ‘how do we make healthcare better?’

To see why, let’s talk about triage.

If you provide a paramedic (or a doctor, but let’s talk about paramedics since I am one) with one patient, they treat that patient. Healthcare or no healthcare, we treat that patient. We do our best to collect their healthcare information so they can be billed later (because that’s where we get the money that allows us to treat the next patient), but bottom line is whatever healthcare they have or don’t have, we treat the patient.

If you provide a paramedic with ten patients, they treat none of them.

Wait, what?

Yup, you read that right, NONE OF THEM get care. Because our lone paramedic is going to do something called ‘triage’. He’s going to assess each patient and put them in one of three or four (depending on exact protocol) categories. These are color coded, and the colors are often used as shorthand even outside of triage. Exact definitions vary by region, circumstances, and a few other factors, but more or less they break down as:

Red: requires immediate care, but with immediate care can probably be saved.

Yellow: requires care, but not immediately.

Green: does not require care. Note that this doesn’t mean uninjured: someone with a paper cut is injured, but they’re going to get better on their own (OK, if they’ve got a couple of rare blood disorders or if they swoon from the sight of blood and fall down the stairs they won’t get better, but those are extraordinarily rare and triage is all about playing the odds).

Black: probably cannot be saved even with immediate care. Again, note that this doesn’t mean they’re already dead, or that we wouldn’t treat them if they were the only patient. If we’ve got one patient with no pulse we treat them (we do that quite often in fact). If we’re passing out triage tags someone without a pulse gets a black tag.

Let’s talk about those green and black tag patients a little more. Again, a green tag doesn’t mean you’re just going to be sent home. Triage is done quickly, which means that it can miss things. Someone who feels, and looks, fine may have internal injuries for example which are actually very serious. So some of the available medical resources watch the green tags. They’re watching a much larger group, so they’re providing little to no actual care. Then the black tags. Most people don’t respond well to being told “sorry, you’re going to die, please go sit in the corner over there so your blood doesn’t create a slip hazard.” In civilian triage we seldom reach the stage where we black-tag people who are still conscious, of course, but it does happen. In the military a large dose of morphine is often applied to solve the consciousness problem. On the civil side someone is often assigned to cover the bodies. Again, they aren’t giving care, or at least not care that is going to save anyone.

The bottom line is that as you increase the number of patients the amount of care given starts to drop. If you flood a medical unit (hospital, ambulance company, whatever) with minor to moderate cases the amount of care given will drop sharply. If the unit is not well managed or if the crisis is prolonged, effective care can approach zero. This doesn’t happen in the US, where there are numerous methods in place for temporarily overwhelmed units to get temporary support and providers are generally well trained and equipped. It happens all the time in the third world. It happens in Europe on a fairly frequent basis.

All clear? Good, stick a pin in that key point and let’s move on.

ERs and ambulances spend most of their time treating people who would be ‘yellow’ or ‘green’ in a triage situation. We complain about it on a regular basis. Sometimes these people know they aren’t really seriously ill but want the attention. Still, most people who aren’t actually that badly off don’t seek emergency medical care. They, in effect, self-triage themselves as green or yellow and don’t clog up emergency services with their problems. Another key point: people without insurance self-triage better than those with. Someone who knows they’ll have to pay for their care is much more likely to take some over-the-counter medication and hope they get better. Another key point: most people DO get better on their own given some time and a little self-treatment. Sometimes, of course, they diagnose themselves incorrectly and wind up being red. And yet another key point: just about everyone who winds up being red gets treated whether they have insurance or not.

See where I’m going? The higher the portion of the population that has insurance, and thus a great reduction in their immediate cost for getting emergency care, the more low-priority cases the emergency medical system has to deal with… and eventually the less efficient it gets at providing care.

Now to me the obvious solution is that if you think you’re close to a capacity problem (which the rapidly rising cost of health care and the generally crowded state of emergency rooms leads me to believe we are) the logical thing to do is increase the capacity of the medical system. How do you do that? Train more doctors. Train more nurses. Medical technicians of all types. Pharmacists. Lab techs. Build or expand medical facilities while you’re at it, and maybe buy a few more ambulances.

On the surface, this solution ought to be very appealing to politicians – after all, that’s a lot of JOBS, the majority of which pay at least a living wage. Two problems: one, that takes a lot of time. It takes the better part of a decade to turn someone into a doctor who is a net provider of care (interns actually reduce the care provided since they have to be so closely supervised, and in some branches junior residents aren’t much better). That’s bound to be an election away whatever office you hold, so no politician really has an interest in pushing for it. Second, how do you train more doctors? Uh… teach them? Yes, but how do you increase the pool of people who are willing AND capable of becoming doctors? That’s a VERY complicated problem – and one that we’re not only not solving, that is becoming worse. The only thing that is keeping the US medical profession growing are the addition of non-clinical positions (usually as the result of government legislation) and the importation of providers from overseas. That’s right folks, a LOT of doctors are trained in India or the UK (to give two examples) and then work in the US. While this is just fine from a temporary prospective (most of those doctors are just as good as the ones we train in the US), it hardly seems sustainable. The domestically-trained pool of nurses is graying fast, and nursing schools are shrinking. Paramedic training is healthy last I heard, but the drop-out rate in EMS is appalling.

So at the same time our glorious leader has ensured medical care for all, the pool of providers is shrinking. Further, as discussed above, as the ratio of patients to providers rises, the amount of care drops. Can anyone say “negative feedback” and “descending spiral”?

I’ll be fully frank and honest: I don’t know how to solve the healthcare problem in the US, and yes we most certainly DO have a problem. The long term trend is especially bad. On the other hand, I do know what we need, and what we don’t need. We need more providers. We need fewer lawsuits over claimed malpractice. We need less well-meaning but ignorant government legislation (HIPPA was the crowning example when I was active, but was neither the first nor the last – what do you call someone who goes to the hospital every three days with the same problem? A Medicare patient). We need, as we need so desperately in so many fields in the US, to think about the long term.

But most importantly I don’t know any way to make actually solving our healthcare problem appeal to politicians, because I don’t know any way to compress this post into a sound bite that will help them get votes.