Decision-making in limited resource settings

Triage Systems - Sorting the Chaos

• Goal: "Do the most good for the most people" in Mass Casualty Incidents (MCI) by categorizing casualties based on urgency.
• Common System: START (Simple Triage and Rapid Treatment).
  • 🔴 Red (I): Immediate. Life-threatening but salvageable. E.g., shock, airway threat.
  • 🟡 Yellow (II): Delayed. Serious injuries, but can wait. E.g., stable fractures.
  • 🟢 Green (III): Minor. "Walking wounded."
  • ⚫ Black (IV): Expectant/Deceased. Unlikely to survive.

⭐ In pediatric triage (JumpSTART), if an apneic child has a pulse, give 5 rescue breaths. If breathing starts, tag as Red. If not, tag as Black.

Scoring Systems - The Numbers Game

• Objective tools for triage & predicting prognosis; guide resource allocation.
• SIRS Criteria: Sensitive but not specific for sepsis.
• qSOFA: Bedside tool to identify patients with suspected infection likely to have poor outcomes. A score of ≥2 is critical.
• SOFA Score: Assesses organ dysfunction in the ICU; more comprehensive than qSOFA.
• NEWS/NEWS2: Broader scores for detecting clinical deterioration.

⭐ qSOFA (quick SOFA) assesses three criteria: Respiratory Rate (≥22/min), Altered Mental Status (GCS <15), and Systolic Blood Pressure (≤100 mmHg). A score of ≥2 suggests a high risk of poor outcome.

Ethical Frameworks - The Moral Compass

• Core Four (Principlism):
  • Beneficence: Act in the patient's best interest.
  • Non-maleficence: "First, do no harm" (Primum non nocere).
  • Autonomy: Respect patient's right to decide (informed consent).
  • Justice: Fair distribution of resources (distributive justice).
• Utilitarianism: Greatest good for the greatest number; guides public health & triage.
• Deontology: Duty-based ethics, focusing on moral rules and duties irrespective of outcomes.

⭐ In resource-limited settings, the principle of distributive justice often overrides the "Rule of Rescue" (our impulse to save one identifiable life at any cost), shifting focus to maximizing population-level benefit.

Resource Allocation - Dividing Scarcity

• Primary Goal: Maximize benefit for the largest number of people (Utilitarianism).
• Triage: Cornerstone of emergency resource allocation. Prioritizes patients based on severity and survivability.
  • Key Systems: START (Simple Triage and Rapid Treatment), SALT (Sort-Assess-Lifesaving Interventions-Treat/Transport).

⭐ In resource-limited ICU settings, the SOFA (Sequential Organ Failure Assessment) score is often used to predict mortality and guide allocation decisions, prioritizing patients with a higher likelihood of survival.

• In CCS, treat first what kills first; prioritize immediate life-saving interventions over complex diagnostics.
• Systematically follow the ABCDE (Airway, Breathing, Circulation) approach to manage emergencies.
• In mass casualty incidents, employ triage principles to maximize survival for the greatest number.
• Opt for cost-effective, high-impact treatments available within the limited resource setting.
• Continuously re-assess the patient's status, as clinical conditions can change rapidly.
• Base decisions on resource availability-staff, beds, and essential supplies.