Triage = French = Sorting (sorting out). From Fr. verb Trier = To sort.

Introduction

Every modern British soldier in a current war is virtually assured of prompt medical assistance and evacuation in the unfortunate circumstance of being wounded, or falling sick, in combat. This is clearly understood by all concerned as an important element in maintaining good fighting spirit and morale. A good case in point is the Falklands Islands conflict in 1982, when no British casualty who arrived at a medical treatment facility alive, subsequently died.

When the enormous casualties from the Western Front battles of 1914, and afterwards, overwhelmed the military casualty collection and clearing apparatus, the Royal Army Medical Corps (RAMC) was required to evolve some sort of disciplined and rationale sorting out of the casualties as they streamed in from the combat zone.

Historical background

During the Napoleonic Wars, in the first two decades of the 19th Century, the limited medical resources of the French Army had to deal with the heavy casualties that ensued. They were forced to ration the dispensation of medical care by prioritisation. Accordingly, Napoleon's Chief Surgeon, Baron Dominique-Jean Larrey, devised a system of prioritisation on the battlefield which he called Triage. Essentially, he defined it as follows:

  • Determine the number of cases needing medical care.
  • Evaluate the resources available to give medical care.
  • Separate the cases by priority of care excluding the consideration of military or social rank. (Presumably very senior officers were excluded from this stricture).
  • Ensure that the most serious, but viable, life threatening cases are treated first.
  • Continuously appraise the situation so that the greatest number of cases possible that can be treated are treated and that disproportionate time is not spent on a few really serious cases to the disadvantage of many other more viable cases.

Relevant to this process, it may be recalled that it was in the Napoleonic Wars that the amputation of war-injured limbs became a relatively common practice.

Thereafter, the practice of triage was adopted by many armies in the field and was taken over to France by the RAMC in 1914 as a working principle within BEF.

Casualty clearing on the Western Front

The first level of casualty care in the British Front Line was the Regimental Aid Post, (RAP) under the charge of the RAMC Regimental Medical Officer (RMO) with his two medical orderlies and the regimental stretcher bearers (SB). This was located in dugout or suitable ad hoc building. Here the RMO and his aides would filter out the minor injuries of the so-called Walking Wounded (WW) and treat them on the spot and send them back to their unit. The remaining wounded and sick would be transported on by the regimental stretcher-bearers or proceed under their own steam. Before a casualty was evacuated, the RMO would prepare an evacuation sheet detailing the case and any first aid given.

Behind the RAP, but close to the Front Line, at the Division level, were the medical care centres of the RAMC Field Ambulance - 10 officers and 224 men strong. Here a chain of treatment and evacuation facilities existed. The closest unit to the Front Line that was run by the RAMC Field Ambulance was the Casualty Collection Point (CPP) for onward transmission by ambulance to the Advanced Dressing Station (ADS). At the ADS more of the Walking Wounded were treated and returned to their unit in due course under the supervision of the Royal Military Police. They would also take care of any Walking Wounded enemy prisoners of war (POW's). (At times when there were large numbers of Walking Wounded, or Gas cases, separate units - Walking Wounded Collecting Posts (WWCP) and Gas Centres (GS) - would be set up to deal with them). The more seriously wounded, or ill, would be given drugs, dressings applied, or changed, as necessary, and then moved onto the Main Dressing Station (MDS).

At this point the wounded and sick men left the care of the RAMC Field Ambulance unit and were transferred to a medical unit at the Corps level, the Casualty Clearing Station (CCS) with a nominal capacity of 150 beds; although the number of cases greatly exceeded this when big battles were on-going. This was the point where the triage principle was most rigorously applied. From here, the less serious cases were further transferred to an Advanced Convalescent Depot and the more serious cases to a General Hospital at the Army level with around 1,000 beds.

The final steps in this chain of referral sent patients requiring less than 30 days in-treatment to a Base Convalescent Depot (BCD) and the others, via a hospital train and hospital ship to the UK. Here long-term care and rehabilitation was undertaken both in military and civilian hospitals. The major British Military Hospital - the Royal Victoria Hospital (also see WFA website article NETLEY) - was located at Netley, near Southampton, in southern England.

Once honed by experience and organisational pressure, what seems to be a very long and complicated chain of decision and referral, generally worked very well - it could be short-circuited if conditions so demanded. It allowed the continuous movement of the casualties away from the Battle Zone whilst reducing the risks that bottle necks would build up. It also permitted the patients to be given supportive treatment en route and, where feasible, recycled back to their respective combat units without choking up the flow of patients to an appropriate level of referral.

As the war progressed and treatment regimens became more sophisticated and refined, the CCS became more like self-contained receiving and treatment centres carrying amputations and treatment of bullet trauma wounds. Camps of Nissen type corrugated huts and tents were created for this purpose. More substantial buildings such as chateaux, civic buildings, churches and schools were also used when available.

On this basis of selection and referral, the medical officers, or at times of extreme pressure of battlefield casualties, senior medical aides, would perform a triage based on the following general principles:

  1. Those with injuries unlikely to respond to treatment at the CCS and/or survive onward referral to the next level of care. (These cases would be heavily anaesthetised with morphine and removed to a holding area. Most would not survive, but the few that did could be brought back into the care system).
  2. Those with injuries that could not be treated at the CCS but were expected to withstand the trauma of referral up the treatment chain. (These cases would be given the first aid care that would make them fit for the journey. In the early part of the war, many of this category were categorised as having the so-called 'Blighty Wound' or 'Blighty One' were repatriated to hospitals in the UK. As the war wore on, many more were treated in rear area hospitals to give an overall UK referral rate of about 50%).
  3. The so-called 'Walking wounded' who could be treated at the CCS and returned to their unit. (At times of crisis on the battlefield, the selection criteria for 'fit for duty' tended to be a bit more flexible).

Of course, the classification of the Category 1 cases was the most stressful to the medical officers and nursing staff and many felt it was a bit too much like 'Playing God' for their taste. But it was a job that had to be done and each person had to come to terms with it as best they could.

Anecdotal reports indicate just how expert these triage decision takers became. One personal anecdote relates how a senior female nurse claimed she was able to determine with uncanny reliability the certainty of ensuing death by the 'look' on the face of the wounded man allied with the feel of the touch of the back of her hand on his cheek. Presumably, her ability was related to the signs of the Severe Shock Syndrome.

Conclusion

Unfortunately, the nature and of the trench warfare on the Western Front meant that many soldiers who were wounded in No man's land, or fell into enemy hands, were largely outside the reach of the RAMC Field Ambulance and suffered accordingly. Never-the-less, the wounded that were recovered received increasingly efficient and effective care in the hands of the RAMC, the female nurses of the Queen Alexandra's Imperial Military Nursing Service (QAIMNS), and the staff of various voluntary organisations - such as the Red Cross - that also participated along the chain of medical care.

In this process of the provision of appropriate and speedy medical care under the conditions of total war, the Triage System played a vital and, essentially, a humane part.

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