Following a significant avalanche in a backcountry ski area, a mountain rescue team has been activated due to reports of buried skiers. A hasty team is at the base of the avalanche, and within minutes a rapid transceiver check and probing have identified three patients. Despite this rapid response and identification, sadly, all three have injuries incompatible with life. “All responding units cancel their response,” the hasty team leader orders over the radio. “Every patient is Black ”. Citizens in the community hear this over scanners. Immediately social media posts appear about racist operators on the mountain rescue team. As those posts go viral and international, a formal complaint is filed with the county. County leaders ask for a meeting with the mountain rescue team to discuss the case.
Words matter. In medical care generally and wilderness EMS particularly, we try to make our language as precise and functional as possible to avoid medical errors or miscommunication.
It’s past time to apply that principle to our triage categorizations as well.
One can easily see how triage color categories, despite being commonplace in medicine, could be misunderstood in common dialogue. The commonplace replacement of patient names with symbols (“Room 16”, “John Doe”, “your trauma patient”) by medical personnel exacerbates this situation. While we are quite familiar with the practice, we need to remember what it sounds like to people listening in our conversations. And in the modern world, almost everything is accessible, especially over radios or in public spaces where recording devices are now ubiquitous. Moreover, labels can have a dehumanizing effect—this is why person-first language is emphasized in modern medical language, such as referring to a “patient with diabetes”, not a “diabetic”.
It’s time to retire color categorizations in triage that have dual meanings in our society with skin color and “race”.
Race itself is a socially constructed term that is largely based on observed, subjective characteristics like skin color. Since triage categories are also based on observed characteristics, it is all too easy for observers to replace one set of observations with another. A common convention is to capitalize race, but an observer hearing that resuscitation efforts are being stopped because a patient is “black” can easily misunderstand this to be resuscitation cessation because a patient is “Black”.
Numerous all-hazards triage systems such as the Simple Triage And Rapid Transport (START) algorithm continue to utilize the categorization of deceased or expectant patients as “black”. Nor is this an esoteric system: START may be the most frequently utilized triage system in the US. This situation is particularly problematic because, by definition, triage systems prioritize patients, and black-categorized patients receive the lowest priority and lowest level of care (if they receive care at all). This corresponds all too closely with evidence that Black patients in the United States also receive diminished levels of care.
Unfortunately, modern avalanche triage systems have perpetuated the front-country black categorization. For example, Bogle et al’s Avalanche Survival Optimizing Rescue Triage (AvSORT) algorithm, introduced in 2010 in Wilderness & Environmental Medicine, categorizes expectant and “assumed deceased” patients as “black”, with a prescribed treatment plan of “no further treatment unless resources and time permit”.
It’s only made worse that COVID-era evidence suggests that triage principles in general can exacerbate racial disparities.
Both theory (linguistic anthropology) and practice (operational teaching) recognize that codes are only useful if they compress complex considerations into rapidly accessible packets and facilitate communication. This can be a powerful communication tool, but it needs to be used in appropriate ways and only when it does facilitate rather than complicate communication. Some triage categories accomplish the same triage process without verbal codes. For example, the 2023 clinical practice guidelines for on-site treatment of avalanche victims from the International Commission on Alpine Resuscitation Medical Committee (ICAR MedComm) convey the same information as prior triage systems without utilizing color codes or “black” to indicate reduced care. Other alternatives include using colors not correlating with a skin color, such as the movement of some companies to replace black with zebra as a triage category.
An appeal to remove colors that correspond to skin hues from WEMS triage systems could be seen as overkill or politicization of a medical or operational process. But it is important to remember that, like race, triage categories are also a socially constructed concept. There is no inherent meaning in them except that which we create. If we choose to create, or perpetuate, the use of symbols and codes that have the potential to cause unnecessary confusion, the results are unforced errors. In the hypothetical scenario described earlier, wouldn’t it be preferable to have the county leadership praising the (accurately) exceptional response time and operational scene management, rather than investigating the (inaccurate) allegation of racism and operational discrimination?
One counterargument to this would be the ways other codes—colors or any arbitrary system—could run afoul of cultural associations. Do we need to reconsider all codes in light of their potential misinterpretation? I would say yes. Within reason, which is true of all WEMS practices, if we feel a need to encode our language, we do so in a way that avoids misinterpretation and considers cultural values and implications. Applied anthropology offers a pathway to this and should be much more widely applied in our operational considerations.
There is no reasonable benefit to perpetuating unnecessarily confusing codes in WEMS triage, and every reason to change. And it’s time for that change.