Sorting of Casualties

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Sorting of Casualties

Military Medicine and Triage

Book excerpt

By: U.S. Department of Defense

Date: 1975

Source: U.S. Department of Defense. Emergency War Surgery. Washington, D.C., 1975.

About the Author: The U.S. Department of Defense provides the country with the military forces needed to deter war and protect the national security. These military forces include the Army, Navy, Marine Corps, and Air Force—about 1.4 million men and women on active duty. In addition, about 1.3 million individuals belong to the Reserve and the National Guard. Under the President of the United States, the Secretary of Defense exercises authority, direction, and control over the department.

INTRODUCTION

Advances in medical knowledge and medical techniques often accompany wars. The number of casualties created by combat necessarily forces innovations in treatment and care. These innovations, rather than being abandoned at the end of a conflict, are incorporated into civilian medicine for the benefit of the general public. Emergency medical services and trauma care systems are two areas of medical care that have been greatly influenced by military medicine.

The term triage—from the French word trier, meaning to sort—originated about 1916 during World War I. It refers to a medical team's task of deciding which casualties to treat first. However, the sorting of casualties began during the American Civil War. At the first battle of the war, Bull Run in 1861, injured men were forced to find their way to safety on their own, or with only their comrades to help them. At the second Battle of Bull Run, 3,000 wounded were not picked up for at least three days and 600 remained on the field for a week.

After one fiasco in which men with minor illnesses, such as colds, were sent North ahead of men with life-threatening injuries, the Union reformed its system of medical care. The army set up an ambulance service and a systematic chain of evacuation to remove wounded men from the battlefield. Patients were triaged according to the severity of their wounds. Both the Union and Confederate armies gradually evolved a process whereby a secondary hospital was formed, further back from the battlefield. The wounded were examined at the regimental hospital, sent to this secondary hospital, and only days later evacuated to the system of general military hospitals.

By the turn of the twentieth century, medical organization had improved dramatically. In the twentieth century, each military conflict in which the United States has been involved has seen a progressive decline in mortality rates. The death rate for wounded American soldiers during World War I was roughly 8 percent; World War II was less than 5 percent; the Korean War was just over 2 percent; and the Vietnam War was 2 percent. The military's approach to trauma care helped to reduce wartime mortality rates. The same concepts and approaches that the military uses have been successfully adapted and applied to civilian trauma care, including field triage, patient packaging, radio communications, and rapid patient transport. By adapting these skills, there has been a decrease in civilian morbidity and mortality rates as well.

PRIMARY SOURCE

SORTING OF CASUALTIES

Sorting, or triage, implies the evaluation and classification of casualties for the purposes of treatment and evaluation. It is based on the principle of accomplishing the greatest good for the greatest number of wounded and injured men in the special circumstances of warfare at a particular time….

GENERAL CONSIDERATIONS

No task in the medical service requires more informed judgment than casualty sorting. The officer responsible for sorting has very heavy responsibilities. He must exercise sound judgment as he decides which patients need immediate resuscitation, which require resuscitation and surgery simultaneously, and which can tolerate delay in surgery. Of equal importance, after the initial surgery, sound surgical judgment is needed in deciding which patients should be evacuated to other hospitals.

The care of the wounded in any battle zone is always influenced by the prevailing tactical situation. These same considerations are reflected along the entire system of evacuation. They eventually affect the type of care rendered in even the generalized or specialized treatment hospital.

Military surgery, however, represents no crude departure from accepted surgical standards. A major responsibility of all military surgeons is to maintain these principles and practices as fully as possible, even under adverse physical conditions. Ideally, all the adjuvants of surgery, including whole blood, plasma, other fluids, chemotherapeutic and antibiotic agents, and anesthetic agents, are available well forward and should be employed in the same judicious manner as in civilian practice. In short, although certain compromises may be necessary, it is indefensible, even in forward areas, not to carry out correct initial measures. If this policy is not observed sedulously, later reparative surgery cannot be performed with the greatest possible benefit to the casualty….

The availability of rapid transportation by air does not alter in any way the necessity for the correct application of surgical principles. Speed in evacuation and comfort during transportation from the fighting front are highly desirable. Reduction in the timelag from wounding to initial wound surgery will almost always mean the salvage of life and limb, shortening of the period of recovery and rehabilitation, and reduction of functional disability….

SORTING AT THE BATTALION AID STATION

In the Vietnam conflict, the battalion aid station, for the most part, was bypassed with direct evaluation from the battlefield to clearing stations or definitive surgical hospitals. All efforts were expended to resuscitate the critically injured. No patient was immediately considered unsalvageable. After evaluation, only the most severe head wounds were placed in this category. If helicopter evacuation cannot be utilized directly from the battlefield to a definitive surgical hospital, the following criteria will apply:

Group 1. Those whose injuries are so slight that they can be managed by self-help or so-called buddy care. These casualties can be returned promptly to their units for full duty.
Group 2. Those whose wounds require medical care but are so slight that they can be managed at the battalion aid station or in the divisional area. These casualties can be returned to duty after being held for only a brief period.
Group 3. Those whose injuries demand surgical attention (a) immediately, (b) after resuscitation, or (c) as soon as practicable.
Group 4. Those mortally wounded or dead on arrival.

As a practical matter, sorting begins with the casualty himself. His wound may be such that he can elect to continue fighting or can walk to the aid station himself, or it may be so serious that he must summon aid….

At the battalion aid station, the casualty is examined by a medical officer or his assistant. Disposition of casualties in groups 1, 2, and 4 may be made quickly. The medical officer should spend most of his time with those in group 3, where treatment will most likely influence the outcome.

SORTING AT THE LEVEL OF INITIAL WOUND SURGERY

At this level, priorities for surgery must be decided. The primary decisions concern the urgency or permissive delay in the provision of supportive therapy and surgical care. These are decisions which cannot be delegated to inexperienced personnel. The officer who makes them must be familiar with the effects of anesthesia and surgery in the special wounds to be treated; with the patient's probable response to resuscitation and operation; with the optimal timing of this operation; and with the immediate postoperative problems….

PRIORITIES OF TREATMENT

With these considerations in mind, the following priorities for surgical intervention are recommended. Injuries not included in these listings are dealt with according to the indications of the individual case.

1. First Priority:

a. asphyxia, respiratory obstruction from mechanical causes, sucking chest wounds, tension pneumothorax, and maxillofacial wounds in which asphyxia exists or is likely to develop.
b. Shock caused by major external hemorrhage, major internal hemorrhage, visceral injuries or evisceration, cardiopericardial injuries, massive muscle damage, major fractures, multiple wounds, and severe burns over 20 percent. As shock is likely to occur in any of these injuries, it is well to institute treatment to forestall it before it develops.

2. Second Priority:

a. Visceral injuries, including perforations of the gastrointestinal tract; wounds of the biliary and pancreatic systems; wounds of the genitourinary tract; and thoracic wounds without asphyxia.
b. Vascular injuries requiring repair. All injuries in which the use of a tourniquet is necessary fall into this group.
c. Closed cerebral injuries with increasing loss of consciousness.
d. Burns under 20 percent of certain locations, for example, face, hands, feet, genitalia, and perineum.

3. Third Priority:

a. Brain and spinal injuries in which decompression is required.
b. Soft-tissue wounds in which debridement is necessary but in which muscle damage is less than major.
c. Lesser fractures and dislocation.
d. Injuries of the eye.
e. Maxillofacial injuries without asphyxia.
f. Burns of other locations under 20 percent.

SIGNIFICANCE

Injury, especially from accidents, is the leading cause of death and disability among children and young adults. Innovations in trauma care begun in military settings have reduced these numbers. While the emotional cost of trauma cannot be estimated, the financial costs include medical care, rehabilitation, and lost wages and productivity of those injured and killed. The sorting of injured persons by triage during a natural or manmade disaster also brings prompt, organized care that can maximize the number of lives saved. Besides those persons involved in military medicine, community physicians and nurses, along with police and persons working with aid organizations, such as the Red Cross, are often trained in the concept of triage.

There is no universally accepted system for categorizing a patient's injuries. Injury classifications are defined by the triage instruments used by the local system. Many systems use color codes, numbers, or symbols to denote the broadly defined medical needs of patients.

In the years since 1975, triage has expanded to a five-tier system. For patients with green or fourth priority, minor transport can be delayed since the patient is likely to survive even if care is delayed for hours or days. For patients with yellow or third priority, urgent care is needed but the patient is likely to survive if care is initiated within a few hours. For blue or second priority patients, their injury is catastrophic and they are unlikely to survive or will need complicated medical treatment within minutes. For red or first priority patients, their condition is critical and urgent care is needed to ensure survival. These persons are likely to survive if care is initiated. Black is the designation for persons who are dead at the scene or on arrival at the hospital. Triage mandates the proper allocation of resources and an integrated trauma system. Without an integrated trauma system, the ability of emergency medical services to provide for the needs of a community is greatly diminished. The military led the way in showing the importance of such organization.