To Triage or Not to Triage: Knowing Our Limits as Health Care Providers Overseas

by Erin Mullan

While working in the developing world, I found myself in many situations where I either witnessed or fell victim to trauma where proper healthcare was unavailable. I interpreted the overwhelming sense of responsibility I felt, as my calling to medicine. I am now back home in Canada, one year from receiving my Doctor in Medicine. As I learn new skills, I often reflect on the cases I witnessed in the developing world and it is a fulfilling method of study. There is one situation however that I replay over and over, and still cannot decide on how to best respond. 

There was an overcrowded bus speeding on a main road, which lost control and flipped over multiple times before landing 500 meters off road. Seatbelts in this country were a luxury so one could imagine the injuries sustained. When my friend and I approached in the taxi, there were over 50 people, many of them covered in blood, lying on the side of the road. Others were running around flagging down cars, as the closest doctor was two hours away and there was no ambulance. We were approached by a very authoritative man who told us about two muzungus (white people) who needed our help. During his instructions, we spotted two topless coloured men piled in the car, holding their blood drenched shirts over the multiple lacerations on their head and neck. Their eyes were scared yet thankful. The man in charge began yelling at our new passengers in an unknown dialect and pulled another couple towards us. Then we spotted one very anxious white woman who had sustained no visible injuries and her husband, whose race was indistinguishable due to a layer of blood which was pouring from his head. The look on the coloured men’s faces as they were told to leave the taxi was a heartbreaking mixture of fear, confusion, defeat and humiliation. Next thing I knew we were driving away from the accident with the “muzungu” couple. 

Thinking about that moment and the look in the eyes of those left behind, will haunt me forever. Did I condone a purely race based decision? Or was the triage appropriate? I have spent a lot of time justifying the decision. The couple we took were the only foreigners on the bus and were unable to communicate with the others on the scene; the man was quite sick and the woman was being emotionally disruptive. I often wonder what a good physician would have done in my shoes. Would he or she have obeyed the person in charge? Or taken the reins and done their own triage? The answer must be something in between but it raises an interesting point. No matter how skilled a physician is, it is a challenging history when you don’t speak the language and it is difficult to triage when you are unfamiliar with the region. Moreover passerby physicians without gloves, masks, and other medical equipment are much less helpful, not to mention the risks of liability, licensing, and insurance issues in a foreign country. Medical students and doctors interested in international travel and work should be educated on these issues so they are more prepared if and when problems arise.