Medicosnext
September 08, 2025 saw the GenZ revolution in Kathmandu, heart-wrenching scenes where innumerable casualties were brought to the emergency departments of the Civil Hospital and Trauma Centre where doctors and nurses put incessant efforts in saving young lives.
As the neurosurgeon on call in Upendra Devkota Memorial Neuro Hospital (UDM-NINAS), Bansbari I was busy with a “99 call”, trying to save the life of a young girl who had a stab injury onto her heart. The scenarios in the emergency departments were, however, different.In our emergency, a cardio-thoracic surgeon, neurosurgeon, two anaesthesiologists, a neurosurgical registrar, two medical officers and numerous nurses, around 10–12 medicos were working to save a single life. In the other emergencies, however, the doctors and nurses were not just running to help the first person they saw; they were performing a critical process called “triage”—a major process during disasters and mass casualties.So what exactly is triage? It is a concept that can seem confusing or sometimes even unsettling, but understanding it is key to appreciating the incredible work our emergency medicos are performing during the time of crisis and disasters.
What is Triage?
In simple terms, triage is “a sorting system.” It comes from the French word “trier,” meaning “to sort.”
In a mass casualty event, where there are more patients than there are resources (paramedics, ambulances, hospital beds), first responders must make quick, difficult decisions about who to treat first. I would like to take you all to the movie scene from the movie Pearl Harbour where the Americans are taken by surprise by the Japanese attack, probably the first time I saw “triage” in its true sense.
The goal is not to treat the seriously injured, but to “do the greatest good for the greatest number of people.” It’s a strategy to save as many lives as possible.
Why can’t the doctors and nurses just help the most injured first?
This is the most common and heartfelt question. Imagine a single medico (doctor, nurse, paramedic) arriving at a scene with ten injured people. One is unconscious and not breathing, another has a severe leg wound and is bleeding heavily, and eight others have various injuries.
If the medico spends 20 minutes trying to resuscitate the first person, who has a very low chance of survival (as in the Neuro Hospital emergency—12 medicos working to save a single life for more than an hour), the second person might bleed to death, and the eight others would receive no care at all. Triage helps the medicos quickly identify:
- Who is in immediate, life-threatening danger?
- Who can wait a short while for treatment?
- Who has minor injuries and can help themselves or others?
- Who is beyond help?
By answering these questions, they can direct their limited resources where they will have the most impact.
The Color-Coded System: The “Traffic Light” of Triage
To make this sorting process fast and universal, first responders use a simple color-coded tag system. We at Neuro Hospital, Bansbari, and most hospitals in Nepal follow the Simple Triage and Rapid Treatment (START) system. Each color represents a different priority level.
- RED (Immediate): This person has life-threatening injuries but a high chance of survival if they get treatment quickly. Examples include severe bleeding, breathing difficulties, or signs of shock. These patients are treated and transported first.
- YELLOW (Delayed): This person is seriously injured, but their condition is stable enough to wait for a short time without immediate risk of death. Examples include a broken bone without severe bleeding or a deep wound. They will be treated after the “Red” patients.
- GREEN (Walking Wounded): These individuals have minor injuries—sprains, cuts, bruises. They are able to walk and can often help themselves or even assist others. They are asked to move to a safe area and will be treated last. This group of patients may be demanding urgent treatment. The medicos may need to tell a small lie here—“people wanting quick treatment, please follow me.” The walking wounded would follow the medico to the green zone, hence relieving the chaos for proper identification and treatment of patients requiring urgent treatment.
- BLACK (Deceased/Expectant): This is the most difficult category. It is used for individuals who are not breathing and cannot be resuscitated, or whose injuries are so catastrophic that they are not expected to survive given the available resources. This allows responders to focus their efforts on those who can be saved. Triaging a patient as black is a heartbreaking but necessary decision about resource allocation during an extreme situation.
What This Means for You and Your Family
Knowing about triage isn’t just academic; it can help you and your loved ones in an emergency.
- If You Are Able (Green Tag): If you can walk and your injuries are minor, follow instructions. Move to the designated safe area. This clears the scene for responders to reach the more critically injured. You may be asked to provide basic help, like applying pressure to a wound.
- Stay Calm and Wait Your Turn: If a first responder assesses you and moves on, it does not mean you are abandoned. It likely means you have been categorized as “Yellow” or “Green.” They know you are there and will return. Panicking or calling out can distract them from saving a life.
- Help Responders Help You: If you are conscious, try to be calm and answer questions clearly. The information you provide helps them make an accurate triage decision.
SMART T
Triage is a system born of necessity, not choice. It is a protocol designed to bring order to chaos and hope to a dire situation. It requires first responders to make calm and logical decisions under immense emotional pressure.
The SMART triage system was first developed by the Newport Beach Fire Department and the Hoag Hospital, California in 1983. The following flowchart is used by any paramedic for a standard categorization of patients within 30 to 60 seconds.
Preparedness is the key for proper management of disasters. We have a hospital disaster management plan in place in UDM-NINAS and so do all major hospitals worldwide. During major accidents, natural disasters, or an act of violence leaving dozens or hundreds injured, in the chaos, with sirens wailing and people crying for help, a team of first responders move with urgent purpose and a carefully designed strategy with one ultimate goal: to save as many lives as humanly possible.
Hence, triage is a profound and difficult responsibility, one that deserves everyone’s understanding and respect.
Dr Pratyush Shrestha
He is a senior consultant neurosurgeon at Upendra Devkota Memorial National Institute of Neurological and Allied Sciences where he commits himself to provide the best quality and technologically advanced neurosurgical services as envisioned by his mentor Prof Upendra Devkota.
As the Academic Director of the Institute, he is responsible for the quality of the academic activities and for ensuring that his team is informed about the latest evidence generated internationally. This is important in keeping abreast with the ever-changing technological landscape of neuroscience.
His interest lies in brain tumours and spine surgery, where he incorporates the latest advancements not just in saving lives but also in preserving functionality of his patients. He is an Associate Professor of Neurosurgery of Kathmandu University.
