Co.Design

A Design History Of The Life-Saving Triage Tag

The simplicity of the triage tag has gone largely unchanged since the Cold War. Can it be upgraded for the War on Terror?

When a massive gas line explosion leveled two buildings in Harlem a few months ago, first responders found a scene of chaos. At least a few people had already been killed. Others still were in the process of dying, and needed immediate medical attention, but how to quickly identify them among the bedlam of 70 other victims, all scared, shell-shocked, and screaming?

The same problem unfolds in most mass casualty scenarios, whether a natural disaster or a terrorist attack. And if you look closely at the aftermath photos of these gruesome scenes, you will usually see a lanyard hanging around the necks of the wounded, with a color-coded strip of paper at the end. This simple invention is the Medical Emergency Triage Tag, or METTAG, and it's saved countless lives.

From the French verb trier, meaning to sift, the triage tag allows first responders to quickly categorize patients, directing medical attention to those most in need while channeling it away from the superficially wounded or already dead. It's essentially medical rationing, in scenarios of chaos and limited medical resources.

A "victim" is attended to at a triage center onshore during a mock rescue drill simulating a boating accident in waters off the coast of San Diego, California, March 5, 2014. Lifeguards, police, fire, and Coast Guard personnel joined together to assess their ability to respond and learn from the training exercise.Photo by Mike Blake, Reuters

The roots of triage extend as far back as the battlefield amputations of the Napoleonic Wars, but the simple, graphic design of the triage tag itself is a legacy of the Cuban Missile Crisis. It's the invention of an unheralded civil defense director from Jacksonville, Florida, who believed that nukes would be dropping on us at any second now. And while the War on Terror has inspired many redesigns, the triage tag has largely remains unchanged since the early 1960s.

As we enter the era of wearable health trackers that beam our biometrics into the cloud, it seems almost quaint that over the last 50 years the triage tag has largely resisted technological upgrades. But the METTAG is a lesson to anyone who develops human devices: the most timeless designs are often the simplest ones. And in the case of triage tags, that simplicity saves lives.

The Paranoid Origins Of The METTAG

On October 14, 1962, an American U-2 Aircraft scanning Cuba brought back reconnaissance photographs providing clear evidence that the Soviet Union had set-up medium and intermediate range nuclear missiles just 90 miles off the coast of Florida. For the first time, it seemed possible—even probable—that the atomic monster America had itself created just 20 years earlier could find its way home. As children huddled under under their school desks during drills, and air raid sirens blared across remote American towns, people scrambled to make sense of a new world in which even the most idyllic city square was just a launch code away from becoming a battlefield.

One of the implied ground zeroes of a nuclear strike was Florida. And that's where a Civil Defense Director named Robert F. Blodgett came up with the idea for the Medical Emergency Triage Tag, or METTAG. The simple, two-sided laminated card is hung around the neck of an injured person as a way to communicate to first-responders the severity of their need. It's designed to be usable in any language, without localization, featuring symbols representing concepts such as blood pressure, time, sex, date of birth, address, pulse and so on.

As an active member of The American Civil Defense Association (TACDA), an organization founded to promote emergency and disaster preparedness, Blodgett was the kind of guy who went around to local schools and taught students to duck-and-cover during the height of Cold War paranoia. Blodgett printed the tags himself and distributed them to local civil defense organizations throughout the 1960s.

In 1975, he gave the design to TACDA, which started selling bundles of METTAGs nation-wide in the pages of The Journal Of Civil Defense, a magazine dedicated to raising awareness about civil preparedness for both natural and manmade disasters

"People were setting up bomb shelters, and everyone was worried about civil defense, about what we would do if the Russians did attack," according to Janice Tyliczka, who worked for TACDA as Staff Coordinator throughout the 1970s. "They sold like hotcakes." In the heyday of the METTAG, TACDA might sell upwards of 100,000 tags every year to agencies around the world. METTAG sales alone kept TACDA afloat for many years.

"We had no competitors: no one had ever sold a simple triage tag before," says Tyliczka. "But they were obviously needed. If a plane crashed, just a handful of METTAGs on hand could save real lives. They were designed to be totally simple, so they could be used in any language without being translated, which is why we were able to sell them everywhere so easily. The METTAG's design was universal."

TACDA tweaked Blodgett's design only slightly, adding perforations to the colored strips at the bottom to make them easier to tear, but otherwise, the METTAG today is the same as the one Blodgett created in the early 1960s.

But the design of the tag is based in innovations that predate the Cold War by more than two centuries.

The Fathers Of Triage

A cannonball explodes through a regiment of soldiers, sending up clouds of broken limbs and spraying gore with each bounce. When the dust clears, a French private and a bourgeoisie lieutenant lie in the mud, side-by-side. The private holds his guts in with his hands, while the lieutenant has broken his leg. You are a doctor. Who do you treat first?

The was the question faced by the legendary French doctor Dominique Jean Larrey, the surgeon-in-chief of Napoleon's armies from 1797 to 1815. The usual answer, at the time, was that you prioritize the patient according to social class—the lieutenant would be treated first. Larrey had a revolutionary idea: he prioritized patients according to the gravity of their injury.

This seemingly obvious and egalitarian idea was born of practicality as much as humanitarianism. After spending a quarter of his life in the bloodiest military conflicts Europe had ever seen, Larrey—a master of the bonesaw—realized that a soldier whose life could be saved on the battlefield was a soldier who would live to fight again. And the Emperor needed as many soldiers as he could get.

Larrey established the first ground rules for the triage of war casualties. In his system, patients weren't just prioritized according to the seriousness of their injuries, but according to a doctor's reckoning of how quickly they could recover from those injuries.

Triage was imported to America during the Civil War. The Union Army was known to sort casualties chronologically, for example. "The men, whatever their condition, lie there, and patiently wait till their turn comes," wrote poet Walt Whitman, who worked as a wound dresser. But first come, first serve proved disastrous to the Union's mortality rate.

It was Jonathan Letterman, the medical director of the Army of the Potomac between 1862 and 1864, who refined the practice used by Napolean's armies. By incorporating Larrey's triage procedure with front-line medical care and ambulance services, Letterman was able to greatly decrease mortality rates in the Union Army.

Triage in World War I.

By the time the Great War came around, triage was a standard of battlefield medicine. Even so, the actual method used by battlefield surgeons to separate the critically wounded from the moderately wounded was informal. It could be a color-coded ribbon tied around someone's wrist, or even a cross drawn in lipstick on a patient's hand (an early form of triage tagging famously dramatized in a scene from Michael Bay's Pearl Harbor movie).

As long as mass casualties remained the exclusive domain of foreign battlefields, no one thought classifying the wounded for triage needed to be anything besides ad hoc.

Redesigning Triage Tags For The Age Of Terror

At 8:57 a.m a sunny spring day in 1995, a skinny, clean-cut Gulf War vet wearing a Semper Tyrannis t-shirt drove a Ryder truck packed with 4,800 pounds of explosive into the drop-off zone in front of the Alfred P. Murrah Federal Building in Oklahoma City. He then lit a five minute fuse, locked the truck, dropped the keys, and walked away. The Oklahoma City Bombing destroyed or damaged as many as 324 buildings in a 16-block radius; the explosion itself was heard as much as 55-miles away. It killed 168 people and wounded 680 more.

Dennis Ortiz was a captain in the Los Angeles Fire Department when the Alfred P. Murrah building exploded. Watching on-the-scene coverage of the bloody aftermath, Ortiz numbly realized he was living in a new age, the age of terror.

"I started asking myself, man, how do you handle something like that?" Ortiz says. "We'd never even dealt with the number of casualties we saw at Oklahoma. So me and my brother went to see what equipment the L.A. fire department had on hand to help us in case of a terrorist attack."

A triage tag from Tokyo, Japan modeled after the METTAG.

But when Ortiz and his brother checked out what Los Angeles County had on hand when it came to triage, they discovered warehouses full of antiquated METTAGs. "Picking them up, they literally started disintegrating in our hands," he remembers. The Ortiz brothers saw an opportunity: a triage tag designed for the age of terrorism.

Ortiz is now the co-founder of Disaster Management Systems (DMS), whose triage tags are made of resilient synthetic paper and include much more detailed information than the one Blodgett created.

Not only do they feature fields for radioactive and biological contamination, but diagrams indicating blast injuries, receipts for ambulance drivers, receipts for personal properties, tags for re-triaging patients whose injuries have been stabilized, patient wristbands, and more.

DMS's DMS-05420 All-Risk Triage Tag.

"More information has to appear on triage tags now, because of the rise of terror," argues Ortiz. "For example, a patient contaminated by radiation or biohazards needs to be treated totally differently than a patient who isn't contaminated." In addition, organizations often want sophisticated abilities to track patients who have been triaged, which DMS's tags provide.

But all of these features come at a cost: complexity. DMS's video tutorial showing how to fill out their most common triage tag is over four minutes long. In fact, by Ortiz's own admission, the company's tags have become so complicated that DMS actually needed to create a way for first responders to pre-triage patients. Before beginning the laborious process of filling out a DMS triage tag, the company now recommends that first responders tag patients with simple red, yellow, and green ribbons.

The problem with more complicated triage tag designs is that they make unrealistic assumptions of the ability of first responders to function normally in the fog of war, says Colin Smart, creator of the SMART Tag. As a medic in the jungles of Brunei in the 1980's, Smart saw the effects that multiple casualties had upon his abilities firsthand.

"The first thing you lose when you're in a mass casualty scenario is your motor skills," Smart says. "EMTs might see one or two of these events in their entire careers, with very little training, so if you suddenly drop them into that kind of scenario, the system needs to be foolproof. When dozens of people are screaming for help all around you, even tearing strips off of a tag might be too much for you to do reliably, let alone fill out a complicated form."

In design, the SMART Tag is not much more than a simple tri-folded card, almost like a restaurant menu. It's only when the triage tag card is unfolded that medical personnel can fill out other vital details. Otherwise, seen from afar, the SMART Tag conveys no more information than a color-coded triage priority: green, yellow, or red. This system also allows a patient to be brought back up the triage scale, if they have been stabilized.

Once folded, unlike other triage tags, the SMART loops around a casualty's wrist inside a simple plastic holder, so as to prevent exacerbating spinal injuries. And since the most important aspect of a triage tag is identifying and classifying the scope of injuries, the SMART Tag's design incorporates a glowing strip so that casualties can be identified, even in the dark.

To Smart—whose triage tags are used by over a quarter of all U.S. states, and are standard in Australia, Sweden, Holland, various European militaries, and Doctors Without Borders—more complicated triage tags like DMS's are a perfect example of bureaucracy-driven design bloat that does little to save lives. While Smart admits that in a post-9/11 environment, triage has become much more politically driven, there are ways to take what is politically driven and make it practical.

"The first job of a triage tag is tell an emergency responder at a glance, 'Where do I go and who do I treat first?'" says Smart. "If it's not doing that, it doesn't matter what other features it has."

Other efforts are being made to update the triage tag for the 21st century—new models include features such as embedded radio-frequencey identification (RFID) chips. But there is no evidence that more technologically sophisticated triage tags are any better at saving lives than the original METTAG.

"At the end of the day, you need a very simple tool that says that a patient is a priority," says Smart. "And I don't know that it will evolve much further."

A fictional, futuristic triage tag from the Warhammer 40,000A.D. strategy game.

Although the design philosophies of his company are very different from Smart's, Dennis Ortiz of DMS agrees. "We've played with RFID, because there are companies who want us to implement their technology into our patient tracking systems. But in the fog of war, when there's tons of chaos, you can't be waiting for an RFID reader to boot up, so we had to abandon it," he says. "Technology just isn't ready for it yet."

Perhaps a truly "smart" triage tag requires the Apple of medical technology to make it work. But in a plane crash, a nuclear strike, an earthquake or a terrorist attack, it is clarity of design—not technology or feature sets—that allows triage tags to save lives.

"When we were selling the first triage tags back in the 1970s, the reason everyone said it was great was because it was simple," says Tyliczka. "It was universal, and designed for speed and time. Even now, when we watch the news, it's really cool to see a METTAG. It's great to know that I was involved in something like that which, even decades later, is still saving lives."

That may be why triage tags have not evolved much since TACDA first unveiled the METTAG in the wake of the Cuban Missile Crisis.

Fears of nuclear onslaught died down by the late 1970s, but TACDA still sells METTAGs today. The organization itself has been absorbed by the Doctors for Disaster Preparedness (the DDP), a bizarre conservative nonprofit which has been linked to articles arguing that homosexuality is a mental aberration, that climate change isn't happening, that HIV doesn't cause AIDS, and that the Bible should be taught as literally true in schools. If supporting an organization like that doesn't sound like your cup of tea, though, no worries: the ideas of Blodgett's timeless design have been adapted and incorporated by many other companies with less onerous axes to grind.

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8 Comments

  • Bruce Curley

    What are your sources for that last paragraph? Any journalist worth his salt has at least two sources for any claims. You cite no sources yet make scurrilous attacks. Libel laws may not apply to the London Tabloids you grew up reading, but they apply here. I suggest you look up the case when National Enquirer wrote an article saying Carol Burnett was drunk at at reception. Carol Burnett sued for libel and won because she never touched a drop of alcohol because her parents had an issue with it. Your vicious allegations in that last paragraph have the same validity and will have the same outcome. Pity, really. The text above that paragraph is actually pretty interesting. What could have motivated you, Mr. Brownlee, to invent the lies in that last paragraph? I guess if "journalists" at the New York times and the Washington Post have done the same through blind ambition to advance their careers, maybe that has become the norm. The truth will win here, be assured.

  • You need to get your facts right "journalist." TACDA has never been associated with DDP. I'm curious as to where you created that lie. I'm on the TACDA board of directors and I've never heard of DDP. I find your last paragraph so full of lies, hatred, and politically correct baiting, I don't even know where to begin to respond. You need to take that last paragraph out and issue an apology stating that you created it in your head and it has no relation to truth. If not, we are prepared to take legal action against both you and Fast Company. I take no pleasure in that. I have followed Robert Scoble and Fast Company for years and never thought I would be in a legal issue with Fast Company, but your lies and vicious attacks leave me no recourse. You live at 19 Church Street in Boston with your parakeets. I grew up at 6826 N. 15th Street in Philadelphia. Those two facts are as related as you tying TACDA to DDP.

  • Jeff Lengyel

    Informative article but unfortunately the comments from Mr. Ortiz at DMS were taken out of context by the editor in that if Mr. Ortiz’s were to comment today (not 4 years ago) he would mention the fact that United States has adopted Ribbons (colored surveyor’s tape) as the national standard for initial triage and triage tags are utilized in the treatment areas for secondary triage and patient accountability. Ribbons represent a major recent evolution of triage in that they provide the fastest, simplest and most visible marking system available.

  • Bruce MacDonald

    While the secondary triage documentation is largely unchanged; pre-hospital primary triage in New Zealand utilises wrist wraps. The current introduction of the electronic patient report form may have some future influence upon the secondary triage material / documentation going forward but that's a little too early to predict at this time.

  • Dee Stanley

    The US Army used Casualty Cards in WWI to indicate the severity of the injury, track Chlorine Gas usage and for you to have a way to claim your veterans status for veteran's hospitals because at the time many people in Europe tried sneaking into allied hospitals for free care. I have a modern one from when I was MedEvac'd from Afghanistan.

  • Wonderfully informative article, I greatly enjoyed it!

    The off-topic and predjudicial jab at the end towards the DDP was unnecessary and unprofessional, however. That last paragraph really sullied an otherwise awesome article.