The quiet ones

In this episode, we explore a core challenge around triage, and how to identify the kind of support that each person needs.

When I was eight years old, way back in the late 1950s, I was sent away to boarding-school.

I can’t find any photographs from that exact age now, but you’ll get some sense of this in a photo from a few years before:

The boarding-house was quite a long way from the school itself - well over a mile, in fact - so the best way to get there was by bike. Most of the journey was safe enough - there was a wide sidewalk beside the main-road, and no-one minded us using it, so we didn’t need to ride on the road itself.

The only dangerous part was the final path down to the school-buildings. It was narrow, with loose dirt and gravel for the path itself, then a border on either side made of saw-edged brick, and tall, dark, deciduous trees looming above. It also had a sharp right-angled turn to the left just before the end. By late October, that first year at school, the mornings were dull, gloomy and damp, with soaking-wet autumn leaves strewn layer-upon-layer everywhere - especially down that track. It was dark enough that I needed the bike’s headlight - which didn’t work, of course. And cold too, especially in those school-uniform short-trousers. In a hurry now, to try to keep warm, I pedalled flat-out down the dark path - and remembered just too late about that steep left turn near the end. Yanking hard on the brakes while trying to do a sharp turn on top of autumn leaves that were slipperier than ice? - not a good idea…

Yeah, you can guess what happened next. A short, uncontrollable slide, then thrown full-tilt straight off the bike. My bare knee, with my full weight behind it, landing hard on that jagged-edged brick border at the side of the path.

Even in that dim morning light, I could see the yellowy-green colour of my kneecap beneath the ripped-through flesh.

Crying, I limped the last few yards into school. Where the school-nurse found me, cleaned all the other assorted abrasions and suchlike, and then took me off to hospital to get that knee stitched-up. Literally.

I still have that scar to this day. No real lasting damage, though.

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Later that day, the nurse called my mother to report on the incident. “I knew he was wasn’t badly hurt”, said the nurse, “because he was crying”.

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For many years after my mother had first told me about that, I’d felt angry about what the nurse had said. It had felt like just yet another sexist put-down - you know, the usual “Big boys don’t cry, so you must be a baby or a failure if you cry”. That kind of thing. I’d gone through a lot of that type of abuse throughout my childhood and beyond. Oh well.

So perhaps no surprise that it took me so long to realise that she’d actually been exactly right.

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When people are hurt, it’s usually one of three responses that we see, depending on how badly they’re hurt.

The first group is what we might call the small-criers. They’re often not all that badly hurt: scratches, bruises, maybe a few real lacerations, perhaps even a broken wrist. In a few cases, yes, they may actually be quite badly hurt. But whatever it may be, it’s still not a big deal for them: they know they’ll survive somehow or other. The younger ones might cry a bit, the older ones might whimper or even squeak if it really does hurt (try broken ribs sometime…), but often these ones wouldn’t see it as even worth the bother of crying about it. So they don’t.

By contrast, there are those that we might call the loud-wailers: the ones who make lots and lots and lots of noise about, well, often almost nothing, really. It’s the extreme end of that nurse’s comment: we know they’re not badly hurt, because they’re not so much crying, as yelling and yelling as loud as they can.

Instead, it’s the quiet ones that we need to worry about. The ones who are so badly hurt that they’ve no energy to spare on luxuries like crying.

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Okay, so here’s the problem.

When a range of people are hurt in some social context, we’ll need some kind of structured system to tackle it: some form of triage, for example. The aim would always be to tackle the issues in order - those most at risk first, those least at risk last, whoever they may be.

The ‘small-criers’ will accept all of that. They do follow the system; they do make room for others; and they do wait their turn. And they also do try to avoid creating any problems for anyone else. All that kind of thing, anyway. The only real danger there is that some may be a bit too selfless and stoic for their own safety - but a well-designed system of triage should be able to cope with that.

By contrast, the ‘loud-wailers’ will not accept any of that. They want attention, they want it right now, and they will not stop yelling until they’re given whatever it is that they say they want. So however trivial their own hurt might actually be, they will not follow the rules of the triage-system; they will not make room for others; and they will not wait their turn. (You’ll see a real-life example of that, playing out in a hospital emergency-room, in the earlier episode ‘There was a gap…’.) What they want is not just attention, but the only attention. They will not allow anyone else to come before them, no matter how urgent that other person’s needs may be. (Sadly, in some cases that attention-seeking can be less about getting their own needs met first, but about trying to ensure that others’ needs never do get served at all. We’ll see more about that in the next episode.)

In the case of the ‘quiet ones’, it’s the corollary of the school-nurse’s comment that would apply: “we know that they are badly hurt, because they’re not crying”. So yes, in a normal triage-system, they would naturally need to go first. The problem is that we first need to find them… which is hard, because not only do they not have enough energy to spare to call for our attention, but also because the ‘loud-wailers’ - whether intentionally or not - are distracting us so much with all their yelling that we can’t even hear the ‘quiet-ones’ anyway.

In practice, as soon as someone starts yelling like the ‘loud-wailers’ do, the fact that they can still yell at everyone tells us that they’re not badly hurt - which means that, by definition, they’re likely to be low-priority on the triage stack. Which means that yes, sure, we can maybe let them keep on yelling as much as they want to - but otherwise just ignore them - shut them out as best we can - until it is their turn on the triage-stack. Instead, we need to focus on how to find the ‘quiet-ones’ - and resolve their hurts before turning to anyone else.

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(In the next episode, we’ll continue to explore these themes and their big-picture implications.)

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