Triage is a terrifying word when you actually think about it. Most of us first heard it in a crowded ER or maybe while binge-watching Grey’s Anatomy, but the reality is much grittier than television. It’s the process of deciding who lives who dies when the resources—the doctors, the oxygen, the physical beds—simply aren't enough to go around. It’s a math problem where the remainder is always a human life.
We like to think medicine is about saving everyone. It isn't. Not always.
In a crisis, medicine becomes an exercise in cold, hard utility. During the peak of the COVID-19 pandemic, specifically in places like Northern Italy or New York City in early 2020, "Crisis Standards of Care" weren't just theoretical documents gathering dust in a hospital administrator's drawer. They were active scripts. Doctors had to look at two patients and one ventilator and make a choice. It sounds like a horror movie. Honestly, for the people in those rooms, it was.
The History of the Sorting Hat
The concept of triage—French for "to sort"—didn't start in a sterile hospital. It started on the muddy, blood-soaked battlefields of the Napoleonic Wars. Baron Dominique-Jean Larrey, Napoleon’s chief surgeon, realized he couldn't save everyone. Before Larrey, the rule was usually "save the highest-ranking officers first" or "save the guys who look like they might actually get back to the front line today."
Larrey changed the game. He decided to treat people based on the severity of their wounds, regardless of rank.
Think about that for a second. In the early 1800s, suggesting a private deserved a surgeon's time before a captain was radical. It was the birth of modern medical ethics. Today, the system is more refined, but the core remains the same. We use things like the START (Simple Triage and Rapid Treatment) protocol.
First, you check if they can walk. If they can, they're "Green." They wait.
Then you check breathing. If they aren't breathing and a quick airway adjustment doesn't fix it, they’re "Black." Deceased or expectant.
Red means immediate. Yellow means delayed.
It’s a color-coded system for human value in a moment of absolute chaos.
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The Ethical Math of Who Lives Who Dies
When we talk about who lives who dies, we’re usually talking about Utilitarianism. That’s the "greatest good for the greatest number" philosophy.
Bioethicists like James Childress or Ruth Faden have spent decades arguing over how to actually apply this. Is a 20-year-old’s life worth more than an 80-year-old’s? Most triage protocols say yes, but they don't use those exact words. Instead, they use "Life Years Saved."
If you save the 20-year-old, you are potentially saving 60 years of life. Save the 80-year-old, and you might be saving five. In a resource-depleted environment, the 20-year-old gets the bed.
The SOFA Score and Objective Cruelty
Doctors try to take the emotion out of it by using the SOFA (Sequential Organ Failure Assessment) score. It’s a point system. It looks at your lungs, your liver, your cardiovascular system, and your kidneys.
- High score? Your organs are failing.
- Low score? You’re relatively stable.
The paradox? In a total collapse, the person with the lowest score might not get the treatment because they’ll survive without it. The person with the highest score won't get it because they’re likely to die anyway. The resources go to the middle. The people who are sick enough to need help but healthy enough to recover.
It’s a narrow window of "worth saving."
What Happens When the System Breaks?
Let’s look at a real-world example: Memorial Medical Center during Hurricane Katrina. Dr. Anna Pou and her staff were trapped in a hospital with no power, 100-degree heat, and rising water. They had to decide who lives who dies among patients who couldn't be evacuated.
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The investigation that followed was a nightmare of legal and ethical questions. When the "system" fails—when the government doesn't come and the helicopters don't land—the burden falls on the individual. We found out that day that humans are remarkably bad at playing God under pressure.
In 2026, we’re seeing more of these "black swan" events. Climate-related disasters, localized infrastructure collapses, or new viral strains. The conversation has shifted from "if" we need triage to "how" we make it fair.
The Myth of the "First Come, First Served"
We love the idea of a queue. It feels fair. But in medicine, "first come, first served" is actually considered unethical by most major medical boards, including the AMA.
If a billionaire rolls in with a mild cough and takes the last ICU bed right before a mother of three arrives with a massive pulmonary embolism, the system hasn't worked. It has failed. Wealth, status, and timing shouldn't dictate survival.
Yet, we know they do.
Social Determinants of Health (SDOH) play a massive role in who lives who dies long before they ever reach the hospital. If you live in a food desert or a zip code with high pollution, your SOFA score is likely already higher. You’re starting the race with a lead weight tied to your ankles. True triage doesn't just happen in the ER; it’s happening in city planning and insurance boardrooms.
Survival is Often About Logistics
Sometimes the answer to the survival question isn't medical at all. It’s boring stuff. Like supply chains.
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In the 1960s, when dialysis was first becoming a thing, there were "God Committees." These were literally groups of people—doctors, a housewife, a lawyer, a minister—who sat around a table in Seattle and decided which kidney patients got the limited number of dialysis machines.
They looked at "social worth." Did the person have a job? Did they go to church? Were they "productive citizens"?
We look back at that now and cringe. It’s horrifying. But it highlights the core problem: when you have a scarcity of life-saving tech, some criteria must exist. If we don't use medical data, we end up using our own biases.
Moving Toward a More Resilient Future
We can't solve the "who lives" dilemma entirely, but we can change the odds. Resilience isn't just about having more beds; it's about having better systems for distribution.
- Advance Directives are Non-Negotiable: If you haven't told your family what you want in a crisis, you're leaving your life up to a stranger's SOFA score. Write it down. Be specific about intubation and "heroic measures."
- Public Health as Infrastructure: Think of health like the power grid. If we only fix it when it breaks, people die. Investing in baseline health for the most vulnerable populations lowers the "surge" during a crisis.
- Transparency in Triage: Hospitals need to be open about their protocols before a disaster strikes. Families deserve to know how decisions are being made.
The reality of who lives who dies is that it’s rarely a single, dramatic choice made by a hero in a white coat. It’s a slow accumulation of policy, luck, biology, and available oxygen. Understanding the mechanics of that choice doesn't make it any less scary, but it does make us better prepared to face it when the lights go out.
To take control of your own place in this equation, ensure your medical legal documents—specifically a Durable Power of Attorney for Healthcare—are updated and accessible digitally. Check your local hospital's "Standard of Care" policies if you live in a high-risk disaster zone. Knowing the rules of the game is the first step in surviving it.
Next Steps for Individual Readiness:
Check your state's specific Crisis Standards of Care (CSC) guidelines, which are often published by the Department of Health. These documents outline exactly how resources will be allocated in your region during a declared emergency. Additionally, ensure your "ICE" (In Case of Emergency) info on your smartphone includes your blood type and any chronic conditions that would impact a SOFA assessment.