Triage

Triage is the sorting of patients when the people needing help outnumber the available caregivers, treatments, or means of evacuation. In the Katrina crisis, the term described more than a clinical method: it named decisions about who would be helped first, who would wait, and whether anyone should be judged too ill to rescue. At Memorial Medical Center, staff devised an evacuation ranking under extreme conditions, without a governing protocol or a way to explain the resulting categories to patients and families. The contrasts with other hospitals and later efforts to plan for shortages show that triage is both a practical response to scarcity and a choice shaped by values, uncertainty, and power.

Origins and Competing Principles

Triage began as a way of sorting. The term had been used for sorting coffee beans before Napoleon Bonaparte’s chief surgeon, Baron Dominique-Jean Larrey, applied the idea to battlefield medicine. In his account of an October 1806 battle at Jena, Prussia, the guiding principle was to treat the most seriously injured first, while those with lesser injuries could wait. The method was later used in accidents and disasters when casualties exceeded the resources available to help them.

That familiar priority was not the only model. In 1846, British naval surgeon John Wilson added a category for patients whose operations were unlikely to succeed, withholding surgery from them. By 2005, some triage systems likewise allowed caregivers to forgo treatment or evacuation for people considered unlikely to survive with the resources at hand. Such a category was designed for exceptionally severe mass-casualty situations, such as a war-zone bombing with too few ambulances or medics. Its use carried a distinct danger: a mistaken prediction could consign a patient who might have survived to death without help.

The classification itself is not a reliable forecast. In a small study, experienced rescuers assigned widely different categories to the same patients, and some judged potentially survivable patients unsalvageable. Conditions can also change, as can the resources available. Once a label has been assigned, however, the need to reconsider it may be easy to overlook. Some experts therefore argued that patients thought to have little chance of survival should still receive treatment or evacuation after those needing immediate intervention, but before patients with significant injuries who could safely wait. The disagreement is not simply about the right ordering: it concerns how much uncertainty a system should tolerate before it stops trying to help someone.

Memorial’s Improvised Evacuation Ranking

At Memorial, the choices were made amid an evacuation crisis, not under a settled triage plan. Doctors had already established an exception to the usual priority of helping the sickest patients and those dependent on machines: patients with Do Not Resuscitate orders would be evacuated last. Four DNR patients were in the intensive care unit, including Helen Breckenridge and Jannie Burgess, an African American nurse who had once been able to care for patients in private hospitals where she herself could not receive care. Burgess’s history gave the category a particular weight: the person classified during the emergency had herself lived through unequal access to medical care.

The next morning, with more than one hundred Memorial and LifeCare patients still to evacuate, staff could not find enough official color-coded triage armbands. They improvised a three-group system as patients were brought downstairs. Patients in fairly good condition who could sit or walk were designated 1’s and prioritized first; patients who were sicker and needed more assistance became 2’s; very ill patients and those with DNR orders were assigned to the final group, the 3’s. The procedure gave the evacuation an order, but it also combined distinct judgments—mobility, illness, need for assistance, and DNR status—in a single sequence.

Pou and her colleagues had little, if any, training in triage systems and were not following a particular protocol. Pou regarded the sorting as heart-wrenching. In her view, the reversal from evacuating the sickest first to evacuating them last reflected the doctors’ sense that they could not save everyone. Yet those being ranked had no part in the decision: only medical professionals had a say in how patients were categorized, and no system was established to share the categories with the people most affected by them.

The practical and ethical difference between a DNR order and an evacuation decision emerged sharply when a nurse was told to leave a floor although no one had come for a DNR patient. Michelle Pitre-Ryals told the patient’s daughter that she could request discontinuation of the order. The daughter had approved the DNR for her ninety-three-year-old, oxygen-dependent mother on the understanding that she should not be resuscitated after cardiac arrest. She said that she had not meant for her mother to be left behind. Her distinction exposed the risk of treating a limit on resuscitation as if it settled a separate question about rescue.

Other Hospitals, Other Classifications

At Lindy Boggs Medical Center, patients were eventually divided into A, B, and C groups after firefighters began directing small boats to take patients to a nearby berm for helicopter pickup. Some doctors and nurses believed the most critical patients, the C’s, should be rescued first. The doctors and firefighters in charge decided to leave them until last, apparently concerned that medical care might not be available at the drop points. When a reporter asked for the reason, a firefighter offered little explanation beyond the assertion that this was how things were done. The labels thus organized the evacuation without resolving the underlying question of what the order was meant to achieve.

The markings themselves became a source of distress. Glenn Johnson, Lindy Boggs’s acting chief of staff, described writing letters on patients’ foreheads with permanent marker and compared the experience to people being marked like cattle. He changed one paralyzed patient’s C to an A after her husband offered to carry her, describing it as his act of mercy for the day. Staff carried patients down multiple flights of stairs in sheets. Firefighters withdrew before sundown for safety reasons, leaving critically ill, hospice, and long-term acute care patients behind; a small group of staff and rescuers returned on September 1 in a stolen flatboat, and other patients were evacuated the following day. Some staff later alleged that patients unable to say their names were denied IVs, and that patients marked black as too sick to move were not taken to the helipad. These reports show how categories could govern access to treatment and transport as well as the order of departure.

The account of Charity Hospital offers a striking contrast, although its circumstances were also dire. The public hospital flooded and lost power, plumbing, computers, telephones, and elevators; it had no helipad or corporate overseers, and its evacuation took until September 2. About twice as many patients were present across its two campuses as at Memorial, with fewer staff for each patient. Doctors said that employees continued caring for patients in their rooms through the crisis, despite reports of a nearby gunman, disruption to evacuation, more than a hundred psychiatric patients, and convoys attempting to reach the hospital being shot at and looted. Soldiers also brought ventilator-dependent patients there. Fewer than ten patients died. Charity’s leaders did not designate a group as too ill to rescue, and the sickest patients were evacuated first rather than last. The comparison does not make the hospitals’ circumstances identical; it does make clear that scarcity alone did not dictate a single triage order.

The Meaning of “Reverse” and “Battlefield” Triage

As the Memorial case moved toward possible trial, Anna Pou and her lawyer adopted the term battlefield triage for the controversial decision to help healthier patients before sicker ones. The phrase was intended to convey the conditions as Pou had perceived them, but the account notes that this was not typical battlefield practice. They also used reverse triage, a term that had occasionally described theoretical wartime situations in which the most able-bodied were treated first so they could return to the battlefield and help preserve the group. Neither label removes the difference between an abstract scenario and the actual patients waiting for evacuation at Memorial. The terminology framed the choice for a lay audience while leaving open whether that framework accurately described the practice.

The issue also entered the investigation in the form of vocabulary. Michael Morales kept a glossary of terms that included agonal breathing, double effect, euthanasia, palliative care, and triage. The special prosecutors, division chiefs, and attorney general used the glossary in their discussions; the Memorial case proceeded toward five charging conferences rather than the single conference typical of a case. Triage had become inseparable from questions about treatment, intention, and death, rather than remaining a technical label for sorting patients.

Planning for Scarcity and Public Values

Later disaster planning sought to prevent exhausted staff from inventing allocation rules in the middle of a crisis. Officials recognized that measures to expand ventilator availability would not be enough in the worst scenario: ventilators were costly, required trained operators, and consumed oxygen that could itself become scarce. The resulting rationing plans aimed to save as many lives as possible within an ethical framework. Planning criteria in advance was presented as a way to avoid placing front-line workers in the position faced by Memorial’s staff after Katrina, improvising decisions under intense pressure.

A Maryland committee offered one model for distributing that responsibility. Its organizer insisted that no single person should make the choices. The committee consisted of professionals who had no patients under consideration, so a patient’s primary doctor could continue advocating for that patient while a separate group considered broader factors under defined scoring guidelines. Doctors, ethicists, and nurses participated, but patients and their families were not represented. The design sought distance and consistency without making every stakeholder’s voice part of the process.

The larger question remains what the system is trying to maximize or protect. In a disaster, triage may aim to save the greatest number of lives, preserve years of life, account for quality of life, distribute help fairly, sustain social trust, or pursue other goals. Those priorities are matters of value as well as medical judgment, and a wider community may not share the priorities of a small group of professionals. The book’s accounts of families discovering what a DNR meant in practice, of patients marked for delayed evacuation, and of hospitals that chose different orders give that disagreement concrete stakes. Triage makes scarcity legible by sorting people, but the categories do not make the moral choices neutral.