Which of the following is a triage tag color you would allocate for a wounded patient who is unable to walk has absent respiration even after repositioning the airway?

PITFALLS

Most disaster scene triage decisions are predicated upon the application of the Simple Triage and Rapid Treatment (START) triage decision-making algorithm. This system is primarily based on the recognition of bodily injuries and the categorization of patients into categories of priority based on specific physiologic criteria, including airway, breathing, and circulation considerations. This is a system that is focused on the treatment and transport of the most emergent patients first, followed by those patients with injuries requiring less urgent attention. It involves a color-coded system that is used to rapidly triage patients into their respective injury status.

And although this triage approach works for the majority of mass-casualty situations, it needs to be adapted for use in air crash disasters, particularly those in which there has been a fire or explosion. Patients who may present with only mild throat irritations, without any other injuries, would likely be placed in the lowest transport priority group. However, such symptoms may be the harbinger of a more serious developing inhalation injury, either due to an explosion and fire through the passenger cabin, exposure to toxic fumes, or aspiration of water or toxic fluids in the event of a water ditching. Such patients must be automatically upgraded in response category and transported away from the scene in a more rapid manner. These patients may possibly benefit from early aggressive airway management if the index of suspicion of an inhalation injury remains high based on the assessment of the initial out-of-hospital care providers. This exemplifies the need for constant reevaluation and possible changes in triage and treatment status.

Post-Incident actions

1.

Establish and maintain scene safety.

Consider potential evacuation.

Identify hot, warm, and cold zones.

Don appropriate PPE.

Determine triage methodology.

Simple triage and rapid treatment (START)

SALT

Other

Establish prehospital triage categories for nontraumatic HF casualties.

Red: Victims in severe pain

Antidote (parenteral, aerosol) indicated

Yellow: Victims in moderate pain or with limited areas of TBSA contamination

Antidote (parenteral, aerosol) indicated

Green: Victims with little to no pain

Antidote (topical) indicated

Black: Absence of vital signs

No antidote indicated

Salvage and triage

POSTINCIDENT ACTIONS

Initial priority should be given to the extraction, triage, transport, and treatment of the victims. Remote railway locations can present difficulties in reaching the scene, necessitating use of aeromedical assets in addition to land-based responders. Once at the scene, it is vital to do the following: (1) perform a rapid assessment to identify any potential hazardous material spills and (2) establish an incident commander and command center in a secure location. If the potential for a hazardous material contamination has not been determined, the information regarding the contents on board the train should be available, along with their material safety data sheets from the managing railroad company.

On-scene triage of victims according to an established system, such as the Simple Triage and Rapid Treatment system, allows for prioritizing medical evacuation of victims back to the medical center according to severity of injury.5 The transportation of victims may include all traditional assets such as ground ambulances and aeromedical transports, as well as “lifts of opportunity” that may present themselves such as buses, police or fire vehicles, and military transport. Identification and tracking of the victims after their extrication and evacuation is vital and may be accomplished by triage tag number if no further identification is available on the scene. Definitive identification must be pursued at the time of presentation at the medical centers, for both the living and the deceased, to ensure all victims are recovered and accurately identified.

Early contact and coordination with state, regional, and national organizations such as the National Transportation Safety Board and the Federal Emergency Management Agency are essential in providing an appropriate response to a large-scale railway disaster. Local resources can rapidly be exhausted, thus necessitating outside aid such as from a National Guard unit or a disaster medical assistance team.

All railway disasters are potentially crime scenes and must be approached as such throughout the response. Extrication of victims is of paramount importance; however, attention must be paid to not destroy any potential evidence. In the case of a terrorist attack, there is also the potential for secondary devices targeted at the emergency responders.

Coordination of early statements and releases to the press should be handled through a single entity, whether it is the public affairs office of the hospital, the local police or fire department, or an outside agency; for instance, Amtrak manages all public affairs information and press releases for any accidents involving their trains.1

Response Scene Operations

The immediate concern of response organizations is the preservation of life. This not only includes actions directed at victims of the disaster—search and rescue, extrication, triage, scene treatment, transportation, and definitive treatment and rehabilitation—but also at preventing further risks to the community through containment of the disaster.

The disaster must be contained. This is relatively easy to envision in the case of a spreading hazardous materials incident, but the concept applies to any disaster. Containment can be both geographic (erecting levees for flood protection) or can be internal to the disaster area. These types of actions actually represent secondary or compound disasters. In the case of a progressive communicable disease outbreak (e.g., measles, influenza, or smallpox), containment of disease spread is the principal goal of public health. Failure to contain the disaster early on will result in significantly greater losses of life and economic resources.

All the actions one would think of to rescue and treat individuals directly affected by the disaster must take priority over salvage and property protection operations. Sequentially, these actions include the following:

Search and rescue: In a hazardous materials (HazMat) environment, up to an hour may pass before HazMat teams even arrive and enter the “hot zone.” Thus those minimally injured may self-extract and seek treatment well before those most severely injured, resulting in a bimodal presentation to area hospitals.

Triage of victims: This must be done at multiple stages of the operations. Classic triage is based on trauma, and this form of triage may not be the best for victims of chemical or biological incidents. Although most communities continue to use the simple triage and rapid treatment (START) methodology, a recent study indicates that other triage systems may be more accurate in predicting morbidity and mortality.10

Decontamination, especially in known HazMat incidents: A study conducted several years ago revealed that only 18% of victims of HazMat incidents who were treated at hospitals underwent decontamination before arrival.11 In the 1995 sarin attack in Tokyo, nearly 600 patients arrived at St. Luke’s Hospital within the first 45 minutes of the incident. None had been decontaminated (fortunately most did not require this). Still, a number of hospital personnel developed nerve agent exposure symptoms from treating and evaluating the victims.

On-scene treatment of victims: The majority of minimally injured victims do not stay at the scene long enough to receive prehospital triage and treatment. Those who remain on the scene are usually the most severely injured and are unable to escape the scene before the arrival of rescue assets. Also of interest, however, is that several studies have recently called into question the efficacy of victims waiting for responders.12 In one study, the morbidity and mortality of those who waited for EMS agencies were significantly higher than for those who were transported to community hospitals by the most expeditious method available.

Transportation of victims: This is also more complicated in a disaster situation. Although the nearest hospital might be the best equipped, if it has already been overwhelmed by the arrival of other critically ill victims, EMS will need to invoke “first-wave” protocols.13 This occurs when the most critically ill patients are distributed among potential receiving hospitals with little regard of proximity.

Retriage of victims and receiving fixed-site medical treatment facilities: Procedures and policies must be in place to handle this sudden surge of victims while still tending to already anticipated patients not involved in the mass casualty incident.

First responders will be overwhelmed in a true mass casualty incident. As mentioned, most first responders and EMS personnel have been trained in the START algorithm.14 This algorithm, which assesses mental status, respiratory effort, and peripheral perfusion, can be performed in as little as 30 seconds and allows only minimal treatment: repositioning of the head to decrease airway resistance and bandaging of gross hemorrhage.

Ambulance and vehicle control at the scene are important considerations. In the 1979 Avianca plane crash on Long Island, so many rescue vehicles arrived unsolicited that departing vehicles could not get on the one-lane road that provided the sole ground access to the scene. All arriving vehicles should be sent to staging areas out of the way, with at least one staff member remaining with the vehicle at all times.

Contaminated vehicles pose a risk to both patients and staff as a result of residual contamination or off-gassing from patients in the confined treatment compartment. In general, patients whose conditions are stable should undergo full decontamination at the scene before transportation. Patients whose conditions are unstable may undergo gross decontamination, which may entail removal of clothing only, and be placed in nonporous patient wraps for transport. Once a vehicle is used for a potentially contaminated patient, it should be considered contaminated until fully cleaned inside and out.

Disaster Triage

A disaster is an event that exceeds the capabilities of the response (e.g., the need is greater than the resources), resulting in disruption of normal function.41,42 In order to more concisely describe and reflect the degree (or stage) of disaster, the Potential Injury Causing Event (PICE) nomenclature has been developed.43

Triage during a disaster is different from ED triage. The purpose of ED triage is to identify critically ill patients and assure that they receive immediate resuscitation, while the principle of disaster management is to “do the most good for the most people.”1 It is possible during a disaster with limited response resources that, in order to maximize care for the majority of victims, some patients who have little or no chance of survival will not be not resuscitated.44 It is often a difficult concept for health care providers to ration resources and not expend efforts to resuscitate patients who are considered near death in order to save others. Comfort care should be provided to the dying patients when resources become available.

As with ED triage, there is no universally accepted standardized system for disaster or MCI triage, although several triage systems have been suggested. One MCI/disaster triage tool is the Simple Triage and Rapid Treatment (START) technique.45 This is based on a rapid assessment of respiration, perfusion, and mental status (RPM). Casualties who are ambulatory are asked to move away from the immediate area of the incident. These “walking wounded” are categorized as “green” or minor. The remaining patients are sorted into unsalvageable, immediate, and delayed (Fig. 155-2). If the patient has a patent airway and is breathing, by assessing the respiratory rate (>30 per minute or < 30 per minute), the radial pulse (present or absent), and the mental status (follows commands: yes or no), the patient can be categorized. Unsalvageable patients are patients who are not breathing even after positioning their airway and are classified “black” or deceased. “Red” (immediate) patients have an immediate threat to life or limb but, if given immediate care, will probably survive. Examples include a patient with altered mental status, labored respirations, or shock. “Yellow” (delayed) patients have significant injuries but can probably tolerate a 45- to 60-minute wait without undue risk.

This color-coded four-category system is probably the most common disaster/MCI triage system in the United States. “Red” casualties are the first priority and are “most urgent.” Patients classified “Yellow” are the second priority and are “urgent.” “Green” patients comprise the “walking wounded” or “nonurgent” and are the third priority. Dead patients and catastrophically injured patients with a negligible chance of survival belong to the “Black” triage category.

The MASS triage model has been used by the U.S. military in order to quickly assign large numbers of casualties into treatment categories.42 MASS triage incorporates the processes of “move, access, sort, and send.” Patients are grouped into four categories based on the “ID-ME” mnemonic: “immediate, delayed, minimal, and expectant.”42 Minimal patients are stable patients with minor injuries, such as contusions and minor lacerations, whose medical care could be delayed for days without any untoward effect from the delay. At the disaster or MCI scene, the triage officer should request that “Everyone who can hear me [the triage officer] and needs medical attention should move to the area with the green flag.” This will separate out the ambulatory “minimal” group or walking wounded.

The “delayed” patients need definitive medical care but will quickly decompensate if their care is delayed initially. Patients with open fractures, deep lacerations with pulses/distal circulation, hemodynamically stable abdominal injuries, or stable head injuries belong to the “delayed” category. To sort this delayed group of patients after separating out the ambulatory walking wounded, the “MOVE” command is to ask the remaining casualties to raise a hand (or leg) so that they can be helped.

After separating out the “minimal” and “delayed” groups, the rescuers proceed immediately to those who are left. These patients are in the immediate or expectant categories. The immediate patients are patients with an obvious threat to life or limb. These casualties generally have a problem with the ABCs, such as shock, respiratory distress, altered mental status, or a severe abdominal, chest, or head injury. These patients often need immediate life-saving care. The expectant patients are patients near death who probably will not survive no matter what treatment is rendered. A patient in traumatic arrest, a patient with a penetrating chest wound in shock, or a trauma patient who is not breathing would be classified as “expectant” since they are near death and have a minimal chance of surviving.

The Secondary Assessment of Victim Endpoint (SAVE) triage system was developed to identify patients who have the greatest possibility of benefit from care delivered under austere field conditions.46 SAVE is employed when patient transport to a definitive care facility is not available for days and treatment within the “golden hour” at a medical center is nonexistent.45 The three patient groups according to the SAVE triage are: (1) patients who will die no matter what treatment is rendered, (2) patients destined to survive whether or not care is given, and (3) patients for whom significant benefit will be obtained from “austere field interventions.” Casualties who would benefit most from early evacuation (e.g., a patient with intra-abdominal hemorrhage) are designated as “first out.”

JumpSTART is a modification of the START disaster triage for pediatric patients ages 1 to 8 years47 (Fig. 155-3) (see Chapter 152, Disaster Preparedness for Children).

Triage Protocols

The word triage comes from French word trier (to sort or separate), a military concept born on the battlefields of the Napoleonic wars. Today it is an integral part of most EDs around the country. Though military medicine has its own defined triage protocols, civilian triage of MCIs is somewhat different. In his memoirs, Dominique Jean Larrey, Chief Surgeon of Napoleon’s Imperial guard and the father of military and triage medicine, stated that “those who are dangerously wounded should receive the first attention, without regard to rank or distinction.”12 The basic purpose of triage still remains the same as Larrey envisioned, to risk-stratify patients and prioritize resource allocation, medical and nonmedical, to those who are likely to receive the most benefit. To paraphrase a famous quote, it is the “the greatest good for the greatest number.”13 An ideal triage system would be easy to understand, identify and deliver resources in a timely manner, be adaptive and evolve with the rapid change in surroundings, optimize resource allocation, neither underestimate the injuries of a critical patient (undertriage), nor divert unnecessary resources by overstating the patient’s condition (overtriage). Overtriage has been shown to actually worsen patient outcomes.14

No system is perfect, and triage protocols continue to advance. Many triage systems exist, some borrowed from the military like the North America Treaty Organization triage protocol,15 while others like the simple triage and rapid treatment (START) protocol were designed for use by untrained or minimally trained individuals for civilian use in an MCI.16 START and its pediatric version, JumpSTART, continue to be popular systems whereby patients are essentially distributed under a color coded scheme, red being the most urgent and black being those who are beyond saving (“expectant”) or already deceased.

Triage systems continue be region specific and operator dependent. These discrepancies are magnified during a large-scale catastrophe, and hence MCI triage guidelines are critical to future response scenarios. These criteria would include general considerations, global sorting, lifesaving interventions, and assignment of triage categories.17 In an effort to standardize and universalize mass casualty triage, an expert committee performed a detailed analysis and review of existing triage systems and proposed the SALT (sort, assess, lifesaving intervention, transport) system.18 This is one of the most exhaustive and detailed analyses of all existing triage systems in place. After much deliberation, the committee proposed the Model Uniform Core Criteria (MUCC) protocol for mass casualty triage. MUCC include 24 specific criteria that are detailed yet easy to implement, allow greater interoperator consistency, and permit further modifications. Most triage systems, including SALT, currently use 15 of these criteria. Though MUCC was well received in the disaster preparedness community, its formal acceptance and implementation nationwide remains a challenge. As of 2010, only 18 states in the United States had implemented statewide MUCC-compliant mass casualty triage protocols.19 SALT was conceived so as to make triage easy to understand across jurisdictions, avoid confusion, and improve outcomes. Although it appears effective in principle, further research needs to be undertaken to establish the efficacy of such a system in large-scale disasters. The National Disaster Life Support Foundation (NDLSF) offers training in SALT along with other methodologies for disaster preparedness.

In most hospital emergency departments, triage tends to be administered by an experienced nurse. During an MCI, triage ideally should be under the supervision of a trained physician; however, resources may not always permit this. Along with medical decision making, disaster triage also presents many ethical dilemmas, sometimes counterintuitive to the essence of being a physician. The sickest patients may not always get priority if they are deemed unlikely to benefit from the finite resources available. These people may be considered “beyond emergency care.” Such patients should be treated with empathy, dignity, and compassion and may benefit from sedation and analgesia.20

The concepts of “expectant” patients and “reverse triage” led to one of the most well-known cases of litigation in the aftermath of Hurricane Katrina. Dr. Anna Pou, a practicing surgeon, and her nursing team were assisting in the evacuation of critical patients from Memorial Medical Center. With no imminent help, resources, or guidance, her team decided to reverse-triage evacuees. Those who were unlikely to survive the process were given palliative care with sedation and analgesia. Although there were no specific guidelines to do so, Dr. Pou exercised her clinical judgment in these cases. Volunteer physicians are routinely asked to make such tough choices and expected to formulate, design, and implement such criteria or algorithms, placing an extra burden on them and their ability to care for patients.21 In one of its most controversial decisions yet, the Louisiana Attorney General’s office decided to pursue criminal charges against Dr. Pou and her team for administering palliative doses of sedatives and analgesics to expectant patients. Dr. Pou was a salaried employee, as were her nurses, and thus not considered a volunteer worker, which disqualified her from the legal shield of the Uniform Emergency Volunteer Health Practitioners Act (UEVHPA). (We discuss UEVHPA and other regulations in more detail below.) As stated previously, no laws exist to shield care providers from willful or negligible acts of malpractice. The case against Dr. Pou was subsequently dropped, although civil cases lingered until they were dismissed later. In response, Dr. Pou championed the cause of better protection for health care volunteers and physicians in the State of Louisiana,22 including salaried and paid workers participating in disaster care. Though such laws were later implemented and have brought better clarity and improved protection in Louisiana, the rest of the nation still lags behind.

Triage is the first step in disaster response and the most crucial. Having a well-executed plan that involves all agencies is the first step in effective triage. These plans must be implemented under controlled settings to identify deficiencies and pitfalls and must learn and evolve from mistakes. Having a dedicated Triage Committee is beneficial. Such a committee can routinely assess the effectiveness of current triage protocols, design and implement routine exercises for all responders and volunteers, liaise with local and state emergency planning committees, and maintain a vigilant review of MCI triage success and failures. Committee members themselves should attend workshops and seminars to keep abreast of the latest developments in this field. Such practices would not only ensure the best possible delivery of care but also mitigate risk management.

Medical treatment of casualties

Injury patterns seen in air show disasters are predominantly traumatic in nature, with a mix of blunt trauma, ballistic impact, and thermal injury. Scene safety issues in air show disasters are of particular importance due to the proximity of extremely flammable and explosive materials, in particular jet fuel and military ordinance. Refueling trucks should be immediately displaced to an area distant from the accident. After the scene is secured, triage of the victims is based on the locally agreed-upon method, such as the Simple Triage and Rapid Treatment (START) protocol.1 Care should be taken to move the victims to safer areas if there are continued issues of scene safety. Multisystem life-threatening injuries with blunt and penetrating trauma, burns, and amputations are common in aircraft crashes involving ground personnel. The sudden deceleration of the aircraft and ignition and disbursement of aircraft ordnance and fuel cause the majority of injuries. The field management consists of triage, stabilization, and transportation of victims to definitive care providers.12

Typically if aircrew are unable to eject, they will be killed by the initial impact despite advances in aircraft safety. The pattern of injuries relates to four specific types: thermal, blunt, penetrating, and deceleration-trauma. Thermal injury, particularly to flight crews, can be devastating despite the flame-retardant clothing they may be wearing. These injuries manifest as dermal-soft tissue burns, inhalational burns, and carbon monoxide inhalation. The blunt trauma can cause internal injuries as well as traumatic amputations, necessitating the rapid application of tourniquets. Intrusive injuries from the loss of occupiable space due to the intrusion of main rotor blades, propellers, trees, or wires are also common types of severe injury. Finally, impact and deceleration forces cause injuries based on the position during deceleration and the distribution of force over the body parts (Table 185-2). For example, a pilot who ejects before impact may survive but may sustain extremity fractures resulting from the violent extremity movements involved in a high-speed ejection.

Spectators on the ground experience thermal injuries, blunt and penetrating trauma, amputations, ocular injuries, and exposure to toxic materials. Air show disasters have a number of amputations, and recent experience has shown that the use of tourniquets will minimize blood loss and mortality in mass casualty events.15 Also in air show disasters, there will be a disproportionate need for burn units due to the number of burn injuries.16

Aircraft wreckage sites can have multiple hazards. Personnel involved in the recovery, examination, and documentation of the wreckage may be exposed to physical hazards posed by such things as hazardous cargo, flammable and toxic fluids, sharp or heavy objects, and disease. Hazardous materials, such as cartridge-actuated devices, tires, and oxygen bottles are major concerns. Explosive ordnance disposal personnel should target items such as pressurized bottles, hydraulic reservoirs, and canopy detonation cord to secure the scene and prevent further injury.17–21

Finally, once all injured or trapped victims have been cleared from the crash site, the area should be considered a crime scene. Wreckage and cargo should not be disturbed or moved except to the extent necessary for personnel safety. Arrangements should be made for security at the accident scene to protect the wreckage from additional damage and to protect rescue personnel and the public from injury.

Prehospital Arena

For formal incident scene triage, treatment, and transport, traditional fire/rescue/EMS and other first responder agencies will provide the necessary care. Informal triage and transportation will also be performed by bystanders and the casualties themselves. The formal resources can be supplemented with community teams, such as the Community Emergency Response Teams (CERTs). The CERT program is an all-risk, all-hazards training in which citizens may initially take actions on their own, and these actions can make a difference. The CERT program was developed by the Los Angeles Fire Department (LAFD) to engage citizen volunteer efforts to augment the response capacity before and during the department's response. In 1993, the Federal Emergency Management Agency (FEMA) made the concept and program available to communities nationwide. The Emergency Management Institute (EMI), in cooperation with the LAFD, expanded the CERT materials to make them applicable to all hazards. In January 2002, CERT became part of the Citizen Corps, a unifying structure to link a variety of related volunteer activities to expand a community's resources for crime prevention and emergency response. As of December 2004, 50 states, three territories, and six foreign countries were using the CERT training for a total of 1900 CERT teams.20

Because of the magnitude of a catastrophic event, such as an explosion, adaptations will be made as MCI operations are instituted. Triage will be abbreviated with use of systems such as the Sacco Triage Method or START (Simple Triage and Rapid Treatment Plan) method, which were both developed for use by rescuers with basic first aid skills to triage patients in 30 to 40 seconds or less. The Sacco Triage Method attempts not only to assign a level of acuity to a patient but also allows available resources to be assigned to the patient. Optimally, treatment will be limited and patients will be transported per MCI protocols.

Central collection points, such as portable triage shelters or the OST3C, can be staffed with personnel other than traditional first responders. Care at these intermediary centers is not expected to be a substitute for that provided in a traditional emergency department; staff should be able to provide, at a minimum, basic life support functions. Individual jurisdictions may decide to staff these centers with personnel who can provide a higher level of care if, for example, screening and dispensing of prophylactic antibiotics or vaccinations are to occur. Several models are offered for establishing a triage and dispensing site, optimizing personnel resources, and projecting the number of persons to be vaccinated or dispensed medicines.21,22 The Bioterrorism and Epidemic Outbreak Response Model (BERM)23 provides a computer model for determining the number and types of personnel necessary for such a clinic site and can be used for planners to provide adequate resources. Most dispensing site plans are based on the medical model and, therefore, provide for some degree of triage for ill patients. It is anticipated that these providers will be public health and community volunteers because hospital employees will be occupied in their respective facilities.

Additional resources available for “prehospital” arena care include those involved with volunteer corps, disaster medical assistance teams (DMATs), and the Metropolitan Medical Response System (MMRS). These resources allow for reliance on personnel responding directly to the emergency rather than staff required to report for duty at traditional facilities.

A federal DMAT, which is part of the National Disaster Medical System (NDMS), is a group of medical and support personnel designed to provide emergency medical care during a disaster or other unusual event at a location usually remote from the origin of the team. DMATs deploy to disaster sites with adequate supplies and equipment to support themselves for 72 hours and provide medical care at a fixed or temporary medical site. They may provide primary healthcare and/or augment overloaded local healthcare staff. DMATs are designed to be a response element to supplement local medical care until other federal or contract resources can be mobilized or the situation has resolved. Each DMAT deployable unit consists of approximately 35 individuals; however, teams may consist of more than three times this number to provide some redundancy for each job role. This ensures that an adequate number of personnel are available at the time of deployment. A team is composed of medical professionals and support staff who are organized, trained, and prepared to activate as a unit. Some states and regions are developing intrastate DMATs or Medical Reserve Corps. In a large-scale disaster, a DMAT's ability to provide local personnel surge capacity may be limited because these teams frequently draw on the same pool of professionals already expected to respond during the disaster.

The MMRS, directed by U.S. Department of Homeland Security and FEMA, directly supports enhancement of existing local first responder, medical, public health, and emergency management by increasing systematic, integrated capabilities to manage a weapons of mass destruction MCI until significant external resources arrive and are operational (typically 48 to 72 hours). The program provides training, supplies, medical caches, and coordination within a metropolitan jurisdiction. It does not supply additional personnel but provides an organizational structure and resources for response in a region. There are 125 MMRS operations in the United States.

Methods of triage

The simple triage and rapid treatment (START) system is among the most commonly used triage systems that APPs should be aware of (see Fig. 1). This triage system is very similar to the sort, assess, lifesaving interventions, treatment and/or transport (SALT) system, in which providers tag patients with stickers: black for dead, red for immediate, gray for expectant, yellow for delayed, and green for minimal.8 This is similar to the move, assess, sort, and send (MASS) system.

There are many different triage systems used, and APPs should keep in mind that there is no single standard triage system. When necessary, APPs should be adaptable with regard to triage.9,10