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Medical Science Publication No. 4, Volume 1



The experience on which my address is based is that of 19 months onthe eastern front in Korea during 1951-53. This experience provided primarilyan opportunity to study the casualties from the time of injury to the timeof definitive surgical care and secondarily, an opportunity to study andto follow personally a few patients through the evacuation hospitals inKorea, the Army hospitals in Japan and on back to hospitals in America.

During most of 1952-53 the front lines were stable and the flow of casualtieswas generally small. One might think that triage was unnecessary, but triagewas employed in the management of every casualty.

The term, triage, was derived from the French, trier,meaning to cull. It was the term used to designate the separation of thecoffee beans from the refuse or in Biblical terms, to "separate thewheat from the chaff." Triage might, therefore, be defined as an evaluationand classification of casualties for the purpose of treatment and evacuation.It involves the evaluation of a single casualty or many casualties. Itinvolves decisions as to emergency therapy, the lack of need of therapy,the hopelessness of therapy, and the priority of therapy and evacuation.What more important life-dependent decisions are ever to be made by a medicalofficer?

We speak of importance of triage. Importance to whom? To the woundedsoldier, to the unwounded soldier, and to the American people. Here morethan anywhere else in the field Medical Corps we must define our purpose,for decisions in triage may necessitate that even among those already woundedsome must make additional sacrifices for the common good.

The purpose of the Medical Corps in support of a combat army is firstto help win the war-to support the health and morale of the fighting troops.The second responsibility is to support the wounded casualty.

Included in triage, therefore, must be the separation of the woundedinto two groups: first, those able to continue combat and, second, thoserequiring evacuation further to the rear. No definite criteria

*Presented 19 April 1954, to the Course on Recent Advances in Medicine and Surgery, Army Medical Service Graduate School, Walter Reed Army Medical Center, Washington, D. C.


can be outlined by which this decision can be made as the criteria mustvary in order to fulfill our primary purpose of supporting the combat troops.There have been times when any man able to fire a gun had to be returnedto duty.

Triage involves primarily decisions regarding the urgency or permissivedelay in providing supportive and definitive therapy. It therefore restson our knowledge of the wound, of the patient's response to the wound,and the relationship of these antagonistic forces to the lapse of time.Such a concept might be summarized as follows:

    1. The battle wound is dynamic. It results in a defect which producesa continuing, sometimes increasing, deleterious effect. The most urgentfeatures of the wound are blood loss and mechanical defects. This continuingdeleterious effect must be minimized by hemostasis, operative débridementand transfusion.

    2. Following injury, the body responds to correct the defects. Thisis a continuing response of every organ and system which has been studied.This response may be lifesaving. Since this response involves the utilizationof the body's reserve, the casualty, like the Army, has committed his reservesand is then quite sensitive and susceptible to further trauma or to thepassage of time before relief.

    3. Anesthesia or analgesics block part of the patient's response and,therefore, at least for the moment, may further the injury.

It is upon this background that triage should be based.

Let us re-examine the framework of triage in the Korean experience.Triage begins with the casualty himself. Will he continue fighting, summonaid, or walk to the aid station? Next the corpsman participates in triage.Will the casualty walk or be carried to shelter? Does he require immediatetreatment for relief of pain or control of hemorrhage?

In Korea, triage centered to a great extent at the battalion aid station.Here the medical officer evaluated the injured soldier as to whether heshould return to duty or be evacuated. He determined whether the man neededemergency care and whether he could be safely evacuated by ambulance orwhether a helicopter should be called for rapid, smooth transportationto the surgical hospital. If the man was injured at night, should he beevacuated by ambulance or held until morning and moved by helicopter? Inthe standard chain of evacuation, the final decision that the injured manshould leave the control of the infantry division and go to the surgicalhospital was the responsibility of a field-grade officer at a clearingcom-


pany. In Korea, the junior medical officer at the battalion level could,for practical purposes, make this decision by requesting direct helicopterevacuation of the more seriously wounded to the forward hospital, thusbypassing collecting and clearing stations. This privilege was not abused,but, to the contrary, resulted in the saving of many lives. Thus in Korea,when the casualty load was light, the battalion surgeon was the key manin triage.

It is at the battalion level, the combat level, that the vast majorityof deaths occur. It is here, therefore, that we should center our attentionin the future. Since most of the deaths occur prior to medical treatment,marked improvements may not result from extending our present therapy.Nevertheless, a determined effort to evaluate and solve the problems shouldbe made by organizing a unit of mature surgeons to work as battalion surgeons.This is a real opportunity for the future which we cannot afford to overlook.

We were approaching the problems of triage and evacuation toward theend of the war by accompanying the injured from the combat area to theforward hospital and recording our observations during the various phasesof movement and treatment.

The notes on such patients prove instructive:

While on patrol a 20-year-old private suffered a traumatic amputationof the foot and many soft tissue injuries when he stepped on a land mine.The accompanying medical corpsman controlled the hemorrhage with a tourniquetand returned the man to the aid station via litter. He was injured at 0200hours and reached the aid station at 0500 hours. He was examined immediately.External hemorrhage had been adequately controlled. His blood pressurewas 125/75, pulse rate 96, his skin slightly pale. Plasma expanders wereavailable but the blood volume deficit did not appear dangerous. He wasgiven penicillin and tetanus toxoid. His pain was not intense at the momentand morphine was avoided. He left the aid station via ambulance along withfour other casualties at 0600 hours. At collecting station, 0630 hours,his blood pressure was found to be still approximately 125/75 but his pulserate had risen to 110. There was little or no external bleeding. When hemoved to a sitting position during examination, his pressure dropped to80/40 and he became pale and nauseated. After he was again placed in supineposition, his pressure gradually returned to the previous level. Aftera long, slow, bumpy trip to the clearing station, he arrived, at 0800 hours,with a blood pressure of 90/60, pulse rate 124. He was given 500 cc. ofblood, which was often available there and his pressure returned to 120/75.Finally on admission to the surgical hospital, at 0930 hours, 71/2hours after injury, his pressure was 80/40, pulse rate 132. External bleedingwas minimal.


Following subsequent transfusions, his leg was reamputated. His coursewas uneventful and his wound remained clinically uninfected.

His record was selected for it indicates some of the points on whichthe medical officer must make his decisions as to treatment and evacuation.The primary fact, as pointed out by the workers in the Mediterranean Theater,is that with major injury blood is lost. It continues to be lost untilthe wounds are débrided and, as will be presented by Dr. Prentice,it continues to be lost even though it may not be obvious by signs of externalbleeding. The second fact is that any casualty with a reduced blood volumehas spent his reserve and tolerates poorly movement, changes in position,morphine, and often the passage of time. A man may leave the battalionaid station apparently in good condition and reach the hospital a desperateproblem in resuscitation.

There is no true "golden period" today. The wound continuesto exert a deleterious effect until it is débrided (Beecher). Allwounds need débridement as early as possible. With antibiotics,open treatment of wounds and tetanus prophylaxis, men rarely died frominfection in Korea, particularly not infected wounds of the extremities.They died from hemorrhage and injury to vital organs. The "goldenperiod" is therefore a relative term and, in terms of mortality, shouldbe directed toward the time required to obtain hemostasis and correct theblood volume deficit. Infection is, without doubt, a contributing causeto the mortality in abdominal wounds and these patients deteriorate morerapidly with the prolonged passage of time before correction of their circulatoryand visceral defects.

Triage rests on the premise that the greatest good must be accomplishedfor the greatest number under the varying conditions of warfare.

In establishing guide posts for officers performing triage, certainprinciples should be kept in mind: first, the purposes of the Medical Service,to support the fighting soldiers and to provide every conceivable supportfor the seriously injured casualty; second, the principles of care of thewounded man.

The principles involved in the care of the individual casualty includethe following:

    1. Life takes precedence over limb, function over anatomical defect.

    2. Mechanical defects may occur which threaten life or limb.

    3. Hemorrhage is the chief cause of death once a casualty reaches medicalattention. Casualties with a reduced blood volume tolerate movement poorly.When possible, hemorrhage must be controlled and transfusion institutedbefore the patient is evacuated.


    4. Serious infections develop slowly in the face of antibiotic therapyexcept in casualties with bowel perforations.

    5. The undébrided wound continues to increase in size (infectionand fluid extrusion) and continues to exert a deleterious effect on theentire body. This effect can only be reversed by débridement. Naturedébrides all wounds as a slough but requires weeks to do so.

    6. At the division level, therapy and evacuation must go hand in hand.Movement prior to transfusion or control of hemorrhage may be fatal. Suchdecisions are basic in the therapy and practice of triage.

With these principles in mind, let us establish our priorities for triageand surgical intervention. These may be listed as follows:

Priorities of Triage and Surgical Intervention

Top Priority: Mechanical correction of defects which immediatelyendanger life.

    1. Control of external hemorrhage.
    2. Relief of intracranial pressure.
    3. Closure of sucking chest wound or tension pneumothorax.
    4. Control of internal hemorrhage.
    5. Relief of respiratory obstruction.
    6. Relief of cardiac tamponade.
    7. Shock, coma, or evisceration places any casualty in this group as regardspriority of medical attention.

Second Priority: Correction of defects which ultimately endangerlife.

    1. Relief of progressive spinal cord pressure.
    2. Definitive repair of perforations of gastrointestinal tract, genitourinarytract, or biliary-pancreatic tract.
    3. Débridement of cerebral wounds.
    4. Exploration of wounds of mediastinum.
    5. Surgical amputations following traumatic amputation (to control bleedingand prevent sepsis).

Third Priority: Correction of defects which immediately endangerlimb or organ.

    1. Repair of major arterial wound.

Fourth Priority: Correction of defects which ultimately endangerlimb or organ.

    1. Exploration of ocular injuries.
    2. Immobilization of compound fractures and reduction of dislocated joints.

Fifth Priority:

    1. Débridement of soft tissues.
    2. Realignment of fractures.


Sixth Priority: Delayed operation: Restoration of function.

    1. Closure of soft tissue wounds.
    2. Repair of peripheral nerves.

These priorities are self-explanatory and are based on the above principles.Life takes precedence over limb, function over anatomical defects.We must always repair the defect which is the most serious first. Thuswhen we were studying arterial injuries we found a sharp increase in theamputation rate after a lag period of 8 hours. Nevertheless, when a casualtyis admitted with a perforated bowel and a perforated popliteal artery,the bowel injury must be repaired first as severe shock may interrupt theoperation prior to completion and life must be protected before limb.

Specialty centers, neurosurgical and renal failure, were establishedin Korea and functioned well. Patients were taken to these centers by air.The paradox existed in both cases that the patients were in their bestcondition for transportation early. With the passage of time, both groupsbecame less transportable.

Triage does not end with early definitive therapy. I should like tosee it extended to cover a concept not only of secondary evacuation tospecialty centers but to include the concept of selective evacuation followupso that the results of early treatment might be appreciated and made knownto the Army surgeon and thereby to the forward surgeons while the specificneed for the knowledge still existed. Thus, as we did with the arterialrepairs, there could be selective management and followup of colon injuries,hepatic injuries, joint, facial or hand injuries. Mistakes could thus beappreciated and corrected within a matter of months and field medicinewould progress at a tremendous rate. This is a magnificent opportunitypresented only to the Armed Forces. It should be planned at this time.Better field records should be a part of the plan.

In conclusion, triage is the evaluation and classification of a casualtyor casualties for purposes of therapy and evacuation. There is no moreimportant or difficult task in the Medical Service. Triage is one of theresponsibilities of the divisional medical officer. It is at the divisionallevel that most casualties are dying. This position, therefore, requiresjudgment, hard work and courage. The Medical Service and the civilian medicaleducators must re-emphasize this opportunity for service. In time of war,the infantryman is drafted and placed in the front lines by indirect orderof the American people. His injury, deformity, or death is not of his choosing,but in defense of and by order of the American people. No higher honorcan come to an American physician than that of caring for these combatcasualties as a medical officer at the forward divisional level.