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History of Triage - The indispensable tool in emergency medicine

Triage- a tool used in emergency medicine to classify patients into different categories to determine what kind of care they immediately need. 

RED Immediate Chance of survival with urgent intervention
YELLOW Observation Possible re-triage, not in immediate danger of death
GREEN Wait “walking wounded”
WHITE Dismiss Do not need a doctor’s care
BLACK Expectant Pain management only

Between the years 1797 and 1801, Napoleon Bonaparte, the iconic Frenchman whose military and political conquests are marveled at the world over, had travelled to Syria and Egypt on a military expedition. The French Revolution of 1789 resulted in the creation of the First Republic- and also the conscription of thousands of soldiers to the military, many of whom were already from poor, disadvantaged backgrounds. 

Napoleon and his troops made the journey to Syria but were prevented from direct entry by a British blockade. The army was forced to enter Syria through an alternate route, further deprived by diminished supplies and medicine. It is said that on arrival in Akko (also known as Acre, in Israel, a point along the Mediterranean Sea), Napoleon laid siege to the land, but lost nearly one fifth of his army due to poor sanitation, weather and plague- which may have been avoided had the British not intervened.  It is here that the concept of primary triage came to be - as a method to salvage soldiers who could be useful in further battles and to ‘discard’ those who would not - heartless as it seems.

The word triage itself has many roots. Initially, the word was used in 17th century Britain to describe the sorting of coffee beans. It has its origins in French - trier, the verb form of triage, dates back to the term triare, which has a combined meaning of three and crushing. The French then began to use the word triage to sort out or to thin down a group of objects. Essentially, it means to categorize. 

It is here that we must differentiate two very similar concepts. There lies an important difference in the current day triage and the triage used in Napoleon’s conquests (Napoleonic triage). Napoleon invested the system in order to lessen military loss and to strengthen prowess on the field. The aim to quickly and methodically divide patients into groups based on their need for medical assistance was formed through the course of many years, and by the insistence of philanthropic and dedicated doctors- not by Napoleon Bonaparte himself.

Let me now introduce to you the physicians who birthed the concept of triage: Pierre-François Percy (1754-1825) was a professor, and revered as an authority on medicine in Paris during the monarchy. Dominique Jean Larrey (1766-1842) was also involved. He was 12 years younger than Percy, and initially did not find favor with Napoleon on many issues. 

Percy began to develop the concept of triage with his formation of “ambulance volantes” – the ‘flying ambulances’. These included around 340 men in 3 divisions, each division with 12 light and 4 heavy horse drawn carriages. A first class surgeon-major commanded the whole unit, which also included an apothecary, a farrier, a saddler, a bootmaker, "a bearer of surgical instruments with a trumpet" and "a lad with a drum carrying surgical dressings."[1]The idea itself was revolutionary- the team of ambulances would watch with expectancy, ready to tend to the first man who fell from his injuries. However, in reality, the picture was not as rosy. Percy and his ambulances were deployed mainly to assist high ranking military officials and those who were out rightly in favor of Napoleon and his principles. The other soldiers, who may have been in dire need of attention, were seen to last. It was all based on military ranking, with actual attention to patient condition being secondary. 

This is where Dominique Jean Larrey comes into play. Percy may be credited with the idea of the triage system, but it was Larrey who perfected it. Larrey’s humanitarian disposition was instrumental in shaping the triage system into the successful operation it is today. It was only after the early 1800s that Larrey came to occupy a position of power within the French military.

In the Battle of Jena in 1806, between France and Prussia, the French army used Larrey’s system of triage. Wounds were classified into 3 categories-

  1. Dangerously wounded
  2. Less dangerously wounded
  3. Slightly wounded

Larrey’s attention to detail is evident here - if there was a fourth category, he assumed that there would be difficulties in separating grades 2 and 3, and thus evacuating soldiers with these grades would be difficult. It is interesting to note that Larrey was the first physician to perform an amputation at the hip. Reports from that time even say that the Duke of Wellington allowed the French ambulances to work by relocating his line of fire. 

Although the early triage was a work in progress, there was a significant improvement in the soldier mortality and even a better morale amongst those in the army. The triage paved the way for aid stations and formal military ambulances, which were further advanced as motor vehicles were invented. Advancements in surgery, development of the tetanus toxoid vaccine, civilian participation in form of the Red Cross and countless other innovations in the medical discipline have lead to the triage system being indispensable not only in war fields but in our day to day practice in emergency outpatient services. 

In the present day, mass casualties are where the typical triage is in play. Research is ongoing in the development of improved and efficient triage- for example, theChemical Hazards Emergency Medical Management Intelligent Syndromes Tool (CHEMM-IST) to combat chemical, biological, radiological, or nuclear (CBRN) threats and emerging infectious diseases. Mobile medical applications, electronic triage tags, such as eTriage, and devices for mobile diagnostic programs, such as the Joint Biological Agent Identification System for infectious diseases are all steps forward in the efficient and successful management of mass casualties.