Page 70 - Journal of Special Operations Medicine - Spring 2016

Figure 3 Comparison of the MAP between the point-of- suggest that overall the triage system is fairly accurate at
injury reports and the Role II facility. sorting combat casualties. However, there remains some
A room for improvement. In particular, 15% of cases were
overtriaged and 6% were undertriaged. When resources
become limited, overtriage puts an increased and unnec-
essary strain on the medical system. In particular, it can
result in devoting resources to a patient when they are
not needed. In a robust environment, this may be less
of a concern, but in the setting of a less mature casualty
evacuation system, this could prove costly. Conversely,
undertriage can delay patients from receiving lifesaving
treatment.

B No formal military standards have been developed
for acceptable overtriage and undertriage rates. How-
ever, the American College of Surgeons Committee on
Trauma has recommended that the undertriage rate be
5% or less. This focus on undertriage accepts the fact
6
that decreasing undertriage paradoxically increases the
rate of overtriage, as demonstrated in a study by the
Western Emergency Services Translational Research
Network (WESTRN) investigators. The present results
7
show that military triage is near the civilian recom-
mendation for undertriage. Remarkably, this has been
Figure 4 Comparison of the respiratory rate between the achieved in an austere and sometimes resource-limited
point-of-injury reports and the Role II facility. environment, whereas numerous civilian studies op-
A erating in more robust environments have highlighted
difficulties in achieving this benchmark 7–10 or that it is
accomplished at the expense of an exorbitant rate of
overtriage. 11,12 While there is variability in the criteria
and indication for the triage at these civilian institutions
that may contribute to their individual results, these dif-
ferences may only serve to validate current approach to
combat triage.

Civilian triage criteria, such as the American College of
Surgeons Committee on Trauma Field Triage Decision
B
Scheme, are based on a combination of clinical findings
and the mechanism of injury. In contrast, US Army
13
doctrine relies upon the general gestalt of the treating
provider at the point of injury and not a predefined al-
gorithm. Relying on clinical gestalt allows for flexibil-
4
ity of the system and has been shown to be nearly as
good or better than algorithm-based triage. However,
14
we cannot exclude the possibility that some sort of al-
gorithm was being used at the point of injury. In fact,
Eastridge and colleagues published their Field Triage
Score for battlefield casualties based on an analysis of
Discussion
the Joint Theater Trauma Registry and it is plausible
15
The present study provides one of the first analyses of that this was being used to some extent. Future studies
battlefield triage during Operation Enduring Freedom. should seek to understand the heuristics and/or algo-
Point-of-injury triage was able to correctly identify 93% rithms being applied at the point of injury.
of the patients who required an urgent, life-saving surgi-
cal and/or medical intervention. The overall correlation The present study also demonstrates that MIST re-
between the triage and medical need showed a moder- ports are accurately reporting the number of casual-
4
ate correlation (k = .619). Taken together, these results ties, mechanism of injury, and region of the body that

54 Journal of Special Operations Medicine Volume 16, Edition 1/Spring 2016