When was triage invented

Surprisingly the next chapter involves the Russians. The great Russian surgeon, Nikolai Pirogov, came to the Crimea and, with the help of Grand Duchess Helena Pavlovna, he established hospitals and developed a system of sorting battle casualties. He divided the casualties into four groups in order of care priority. The mortally wounded were assigned to the care of the Sisters of Mercy. The seriously wounded who required urgent surgery received it at the emergency dressing station.

The less seriously wounded were transferred for surgery the next day. Those who had minor wounds were treated and returned to their units. Hospitals were established and nursing care was under the care of the Sisters of Mercy, a nursing order started by Grand Duchess Helena Pavlovna.

Wounded at Savage Station, VA, Courtesy of the Library of Congress. The term is in none of the many surgical manuals of the time or in the Medical and Surgical History of the War of the Rebellion. None of the many published letters and diaries of surgeons and nurses from the Civil War ever used the word.

Brinton, serving in the west at Fort Henry and Fort Donelson in early , described some sorting of the wounded while under fire, with the less gravely wounded being removed to the rear. Confederate Surgeon J. Chisolm discussed the role of the surgeon, stating that all of the wounded must undergo a thorough exam. Chisolm also described the duties of the assistant surgeon on the battlefield stating that he must look at all wounds, do hasty dressings, and place men on the litter, but not do surgery.

He further stated that at the field hospital the wounded were not treated in the order in which they arrive but that the more severely wounded would always receive the earliest attention. Its first known medical use was in World War I, when the French used it to apply to the sorting of casualties. It was rapidly adopted by the British who assumed only three levels of classification: minimally wounded; seriously wounded but treatable; and mortally wounded.

Triage stayed in the international medical lexicon and is still widely used. Because it is popularly believed that triage had its origin in the Civil War, it is necessary to look at the developments in handling casualties in that war. At the outset of the war, no system of medical evacuation existed and no ambulance corps or effective use of ambulances was present. With the disarray in casualty handling at the First Battle of Bull Run, it became obvious to many that a system had to be devised.

As recently as , the Union Army had had no ambulances. The war began with a mix of two-wheeled and four-wheeled ambulances, predominated by the two-wheeled variety.

These would prove inadequate for the terrain and the number of casualties. Even worse, the ambulance drivers were not only untrained, they were not in the army but were civilian workers responsible to the Quartermaster Corps. The hospital system that existed was still that of the pre-war army, with the major focus on the regimental hospitals. The first line of care was at the regimental level, and the sick and wounded that could not readily be returned to battle were sent to the regimental hospital.

They remained there as long as possible, hoping for recovery and a return to duty. Those that could not be adequately treated at this level were ultimately sent to the general hospitals. Wounded at Fredericksburg, Efforts were made beginning in the summer of to create an ambulance corps with personnel, wagons, and horses under the direct control of the Medical Department.

Union Surgeon Charles Tripler made such a recommendation soon after becoming Medical Director for the newly formed Army of the Potomac. Surgeon General Clement Finley rejected this proposal, as did the higher military staff and the Secretary of War. Such a proposal was also made early by the newly-formed United States Sanitary Commission.

This later proposal also went nowhere. Another early source agitating for the creation of an ambulance corps was the Boston surgeon, Henry Bowditch, whose son had suffered from lack of care at the First Battle of Bull Run. Tripler also began record keeping within the regiments regarding the sick, the wounded, and their treatment and disposition.

Only prearranged transfers were allowed. He directed that the newly created brigade surgeons give regular help and instruction to the regimental surgeons. Unfortunately Tripler received little support from Surgeon General Finley in any of his efforts. Tripler had great difficulty obtaining supplies, tents, blankets, and, of course, ambulances. When the spring offensive began in , only a small percentage of the requested, required, ambulances and supplies were available.

It did not begin to improve until after the arrival of his replacement, Jonathan Letterman. In August , Letterman attempted to solve the ambulance problem by creating, within the Army of the Potomac, an ambulance corps with officers, men, ambulances and horses all under the control of the Medical Department. This proposal was sent to the Surgeon General, who endorsed the system; but the proposal was again rejected by the senior army staff and therefore by the Secretary of War.

Nevertheless, Letterman persisted and obtained approval from the Commander of the Army of the Potomac, Major General George McClellan, who happened to be a friend of his. McClellan may well have been receptive to this idea because he had been one of the official observes the Army had sent to the Crimean War, and would have seen the problems caused by the lack of coordinated care.

It would be re-instituted in September when the entire Army of the Potomac was returned to the command of McClellan, on the way to the battles of South Mountain and Antietam. Many of the units in the new army had never been trained in the system, so it was only partially effective in these battles. In October , Letterman, with approval from the Surgeon General and the army commander, re-organized medical care, thus creating a medical evacuation system.

Medical care would start with an assistant surgeon and attendant at the edge of the battle who provided the first level of care. Those lightly wounded were sent back to battle and those who could benefit from medical care were sent to the field hospitals located beyond cannon range where urgent care would be given.

Most amputations took place in these field hospitals. For example, the Royal Prussian Field Hospital Regulations of gave information on classifying various degrees of severity of injured people, and triage was used in the Coalition Wars, i. It is also known from abandoning ships.

The captain is the last to disembark, and women and children first. Because they are said to be the weaker ones who may not be able to stay afloat in the sea for so long. This is a bit like triage.

Angetter: We have to consider that even civil rescue organizations like the Red Cross or the Malteser were very much integrated into military medicine until the end of the monarchy. They were trained by military doctors so that they could support the military in the event of war. This also applied to the Teutonic Order, i. It was only with the collapse of the monarchy that a rescue service, as we know it today, slowly established itself, much of which was carried out on a voluntary basis, as with the Red Cross or the Arbeiter-Samariter-Bund.

After the Second World War, the triage system grew more and more into the civil sector. To decide who is treated quickly is an ethically very difficult task for triage doctors today. In the past, the seriously injured simply remained lying on the battlefield.

Angetter: Especially in preclinical emergency medicine, i. If the operation has been going on for a while, then of course more emergency vehicles follow. Angetter: Triage is set up according to the prioritization of rescue, treatment, and transport. What is the diagnosis of the injured person? How urgent is surgery? Can the operation be carried out on site or is it better to stabilize the patient and transport them quickly — and to which hospital?

As well as immediate treatment and transport, there is also palliative care for those patients who unfortunately have a very low chance of survival. If the severity of the injury is so great that it would tie up too many forces to resuscitate the patient or treat multiple traumas, this patient must wait until enough emergency personnel or paramedics are on site to take care of them.

To decide who is left unattended and who is treated quickly is of course an ethically very difficult task for triage doctors today. In the past, the seriously injured simply remained lying on the battlefield or in a military hospital.

Angetter: Yes. More recently, an algorithmic decision support tool called the Toowoomba Adult Triage Trauma Tool TATTT was developed to address the need for consistency in triage assessment and categorisation; these were found to be lacking when the ATS was applied Hegney et al, This supportive tool, while limited to trauma cases, provides a standardised assessment approach to aid in the triage decision process Hegney et al, The goal of this triage system was to standardise the process and duration of triage within the EC and show the benefit of nurse triage within the EC when based on consensus opinion Cooke and Jinks, These triage systems represent only a few of the major ones used throughout Europe, with potentially more being used in local contexts that are less known or published.

Even though triage has been used there for decades, there was no nationally accepted triage system in Canada until the s Ng et al, In addition, CTAS classifies patients in descending order of acuity which has emerged to be a more sensitive, accurate and reliable technique for safe, rapid patient assessment Beveridge et al, Currently, hospitals in the United States use a variety of triage systems; the most widely used and dispersed being the Emergency Severity Index ESI , which has been in existence since the end of the s Rutschmann et al, This five-level triage system was designed and validated in the EC setting using a variety of patient presentations Gilboy et al, The ESI categorises patients, taking into consideration both priority and resources, to rapidly assess patients.

However, its effect has not been measurably established White et al, The START programme complements standard EC triage with a team of clinicians who initiate the diagnostic process and selectively accelerate the time to treatment of a patient subset White et al, The reason for choosing the CTAS model was its demonstrated excellent inter-rater reliability Hamamoto et al, The TTS is a four-level triage system based on concise criteria for major presentations or conditions Ng et al, However, these studies highlight the various shortcomings and limitations of the TTS to accurately determine patient acuity and resource utilisation Chi and Huang, ; Ng et al, The SATS assigns triage with decreasing priority, using physiological parameters such as vital signs and clinical presentations within a two-stage approach Gottschalk et al, This adaptation was required after the un-adapted MEWS was found to be unsuitable as a unified triage scoring system for both medical and trauma cases within the South African EC context Gottschalk et al, The MEWS was deemed unsuitable based on patient presentations in South Africa that have a different physiological profile than Europeans; trauma is predominant, and the disease profile differs substantially.

The SATS was the first of its kind to delineate such a prominent focus on vital sign parameters, and resulted in a system that could even be used by entry-level healthcare providers Twomey et al, Most triage systems focus on the evaluation of acuity based on adult findings; however, specific paediatric indicators have been developed in conjunction with well-known triage systems that incorporate their physiology as part of the assessment Doyle et al, The MTS, with its 52 flowcharts, was designed with 49 of the 52 charts applicable to paediatrics van Veen et al, Triage systems have come a long way since the 18 th century; however, most of the innovation occurred over a year period between and Multiple systems have developed throughout the world as evidenced by the 13 triage systems presented in the current paper.

It does however appear from the literature that development has reached a plateau. The latest research endeavours focus on refining and improving existing triage systems, instead of formulating bespoke approaches. Using triage to manage EC patient volumes has resulted in countries around the world using different approaches based on their local needs and available resources.

Although these systems use different principles of acuity stratification and resource allocation, it is most notable that all of them take into consideration three main aspects: patient presentation, vital sign parameters, and time to treatment. Given that these considerations are the fundamental pillars of a triage system, it was apparent that a plateau of combinations would be reached at some point.

In the 21 st century, there is a push for improved global health and the sharing of literary resources that would aid in healthcare innovation. The availability of a range of triage system approaches makes it easier for countries to adopt and adapt a current system to their needs than to develop one from scratch. After the literature review on triage systems by Fry and Burr in , at least six more were developed and numerous research studies conducted to evaluate and improve existing systems.

The questions are: what is the perfect triage system, and will we ever achieve such a system?