You are working the night shift in the emergency room. Four ambulances arrive at the admitting door at the same time. The attendants say they have gunshot wounds to the head. All four patients are critical. Which patient do you see first, second, third and last? This is the job of triage. There is not enough staff to see all four at the same time. In fact, you are so short staffed, only one patient can be seen at a time. How do you decide which one to see first? All have exactly the same medical emergency. All four are bleeding profusely from a gunshot wound to the head.

Patient number 1 is a four-year-old boy who was playing with his father’s gun.

Patient number 2 is a beautiful young woman. She had attempted suicide by shooting herself in the head.

Patient number 3 is an elderly man who was cleaning his gun and did not check to see of it was loaded first.

Patient number 4 is an elderly obese female who has been shot by an intruder in her home.

How do you decide the triage? Each patient has certain characteristics that influence decision making.

One characteristic is age. Many people will unconsciously consider a child more worth saving than an elderly person, so would choose Patient number 1 over Patients 3 and 4.

A second characteristic is gender. Many would treat males before females, seeing men as more important than women.

A third characteristic is attractiveness. Patient 2 would be seen before Patient 4 as a beautiful young woman is seen as more valuable than an obese elderly woman.

A more subtle choice is based upon a judgement about the victims responsibility for causing the gunshot wound.

Patient number 1, the little boy, was playing with his father’s gun, something I am sure he had been told not to do. So, the accident was self-induced. But children don’t really understand that actions have consequences.

Patient number 2 is a suicide and therefore the gunshot wound was self induced. She is totally responsible for her condition. Health professionals don’t really like people who commit suicide. After all, the health professionals job is to keep people alive, so suicide is contrary to their professional values.

Patient number 3 was being careless in his handling of his gun. Any gun owner would say he should have known better. He is seen as being responsible for his own gunshot wound.

Patient number 4 is totally innocent of causing her own wound. A stranger had broken into her home and shot her for no apparent reason.

Since the triage cannot be based upon the severity of the wound or time of arrival, which of these characteristics are the defining characteristics upon which the triage will based? Which is more important? Age? Gender? Responsibility for causality? Attractiveness? Gender?

The only way to answer this question would be to design a research project in which each of these patients is listed in a multiple-choice test. The sample would be different groups of professionals to rank order which patient will be seen first and which last. Their decisions will be made on their priorities based upon unconscious preferences.

Will the obese old lady be the one to wait to the end? If so, her obesity and gender override the fact that she was totally innocent of causing the gunshot wound. If it is patient number 2 who waits, then the suicide (responsibility for causation) is more important than age, attractiveness or gender.

As health professionals, we make unconscious valuations of patients all the time, and act on them. The important thing to stress here, is that health professionals need to be aware of their unconscious preferences and their reasons for them.

Studies such as this one are all part of the science of Patientology.