Injury (1992) 23, (8), 507-510
Printed in Great Britain
507
Triage of war wounded: the experience of the International Committee of the Red Cross R. M. Coupland’, P. J. Parker2 and R. C. Gray ‘The International
Committee
of the Red Cross and ZNew Zealand Red Cross Society
The hospitals of the lntemational Commitfee of the Red Cross are often faced with situations in which fhe number of war wounded requiring surgical attention ovetwhelms the available facilifies. Hospiral organization, equipment and changes of aftitude necessary for health professionals are considered wifh respect to triage. Practical aspects of assessment and categorization of fhe wounded are considered in the light of a large ex.perience; relocafion and reassessment of those who do not warrant immediate surgery benefit patients and hospital staff alike. The importance of adherence to an emergency plan and respectfor the decisions of the person in charge of the hiage are emphasized. The dificulr and stressful nature of triage of war wounded should always be taken into account.
Introduction The International Committee of the Red Cross (ICRC) deploys surgical teams to care for war wounded in Africa, Asia and the Middle East; in 1990, more than 18 000 war wounded patients were treated in 13 hospitals in eight countries. Two of the largest ICRC hospitals are in Khao I Dang on the Cambodian border of Thailand and in Kabul, the capital of Afghanistan. Both of these hospitals have seen sporadic influxes of large numbers of both civilian and combatant war injured; the authors have considerable experience of situations where the number of patients requiring urgent surgery overwhelms the surgical facilities available. Most of the written material on this subject records military experiences of triage near the battle front (Walsh et al., 198% Peam, x990), or addresses theory and organization principles (Owen-Smith, 1978; Kirby and Blackbum, 1983; Bowen and Bellamy, 1988; Dufour et al., 1988; Ryan et al., 1990). This paper highlights the realities of triage of war wounded and documents a practical system which has been refined and tested in multiple locations. The ICRC hospitals are served by first aid posts from which the journey by ambulance may take several hours; those obviously severely injured have priority of transport. On the other hand, nearby hostilities may precipitate large numbers of admissions that arrive suddenly and spontaneously. This paper refers to triage of the wounded at the hospital, i.e. the site of the surgical facility as opposed to their triage for evacuation to hospital. The principle of achieving the ‘best for most’ is the essence of the triage plan. The plan, documentation and equipment should be as simple as possible, because anything 0 1992 Buttervvorth-Heinemann 0020-1383/92/080507-04
Ltd
resembling complexity is immediately forgotten or abandoned when the real situation arises. There should not be a manual to be read at the time.
The hospital The triage area should be near to, but should not obstruct, the entrance to the hospital. The area must be expandable in terms of patient capacity. When civilian casualties arrive it is very difficult to control who comes into the hospital; it is essential to have a guard on the hospital gate. His function is to keep away from the triage area those who rush to the hospital either to find their injured relatives or out of curiosity. The triage area should have a hard floor, water taps and ropes or wires running at 2 m height on which intravenous infusions can be hung. It should have a roof and in a cold climate be walled and heated. A simple shower is important for patients covered in mud or dust, such as victims of antipersonnel mines. Essential equipment is listed in Table la. Each item should be easily moved, easily unwrapped and easily located by anyone unfamiliar with the triage area. In addition, individual kits are made up in preparation for the event as listed in Table&. The number to be prepared will depend on an estimate of the number of casualties expected at any one time. Some items of equipment have been tried in the triage area and are not deemed necessary because they are never or very infrequently used. These are: pneumatic tourniquets; artery forceps; nasogastric tubes; endotracheal tubes and laryngoscopes. The authors recognize that elimination of the last of these could cause controversy. The triage area should be accessible to both radiography and the operating theatre(s). A nearby laboratory for haemoglobin estimation and the provision and crossmatching of blood for transfusion is necessary for the management of severe injuries (Eshaya-Chauvin and Coupland, 1992).
Personnel The staff should agree on the number of wounded arriving at one time that will determine when ‘triage is declared’ and the prepared equipment is used; this allows for familiarity with the system, documents and equipment in preparation
Injury: the British Journal of Accident Surgery (1992) Vol. 23/No.
508 Table la.
List of essential equipment for triage of war wounded
General Stretchers (at the hospital entrance). Suction machine and catheters. Tourniquets for venesection. Sphygmomanometer. Torch. Limb splints. Large sharp scissors for removing clothing. Large plastic bags for patient’s clothing. Small plastic bags for patient’s valuables. Sets of documents (at the hospital entrance). instruments Stethoscopes. Scissors. For treatment Intravenous fluids-electrolyte Giving sets. IV needles. Syringes. Needles
solutions/plasma expander.
Antibiotics. Antitetanus serum/tetanus toxoid. Gauze. Bandages. Sticky tape.
8
theatre first, inevitably occupy time and so add to the difficulty of maximizing the use of the surgical facilities. Fear for one’s personal safety also affects surgical decision making and technique. It is essential that one person is in charge of the triage of the patients. This person should be an experienced doctor or nurse, familiar with the type of wounds. In an ICRC hospital this role is usually undertaken by the head nurse. It should be understood that his or her decision about the patients’ triage is not questioned at the time. There is always disagreement about some decisions, but there is nothing more counterproductivti or undignified than clinical or ethical arguments in the midst of wounded patients. It is at this time that untrained and unqualified people arrive at the hospital asking if they can help; this may be a hindrance but is difficult to refuse. Some tasks can be delegated to them. Suggestions are: stretcher bearing; carrying specimens to or units of blood from the laboratory; filling syringes with penicillin. If possible, potential helpers should be identified and given instruction about such simple tasks beforehand. The relatives of civilians wounded in armed conflict place an enormous burden on the staff in the triage area. They may become aggressive in the hope of hastening treatment.
Chest drain sets. Documentation Triage cards. Cross-match forms. X-ray forms. Pens. Skin markers.
TableIb.
The following individual patient ‘kits’ are prepared Tublela in advance
from the items in
Intravenous needles (3). Intravenous fluid (1 litre). Giving set. Tape, already cut. Syringe (10ml).
for a larger influx. This number is small; it is generally agreed in the ICRC hospitals that when seven wounded patients arrive simultaneously they undergo triage. A situation in which there are multiple serious casualties is extremely stressful for all personnel involved. It is necessary to abandon the individual ‘contract’ that one normally has with the patient and to lower one’s expectations. This change of attitude to total responsibility for a group of patients is an intellectual challenge which arises when one is least able to face such a challenge. Simple clinical tasks become diIYicult and tempers become frayed. A contributing factor to the stress is that there is an obvious, large and urgent need for medical action but nothing appears to happen quickly enough. Despite this collective approach, the surgery is nevertheless administered on a one-to-one basis; once the patients are through the triage area, the surgery that they receive must still be adequate (otherwise the exercise is pointless.) Therefore, the surgical team must consider the group and yet must still focus their thoughts on each operation. The surgeon, therefore, must decide on the best management and must also decide how this management can be safely compromised. The more severely injured patients go to
Assessment, triage categories and clinica judgement A patient can only be assessed completely if all his clothing is removed. It is easy to miss a small but serious penetrating wound. He cannot be relied upon to locate all his wounds. The general condition of the patient rarely needs verification by careful measurement of the pulse rate, respiratory rate and blood pressure (note that this applies only to the triage situation). The briefest clinical assessment of central injuries involves: noting the level of consciousness in head injuries; feeling for surgical emphysema in neck and chest injuries; noting abdominal distension and tenderness with injuries of the chest, abdomen or buttocks Paraplegia from penetrating trauma is very easily overlooked; the patient should be asked to move his toes. In limb injuries the distal pulse should be felt although the diagnosis of vascular injury can be difficult in the presence of a compressive dressing and hypovolaemia. The ability to feel and move the distal extremity is important if the question of amputation arises. The triage categories used in ICRC hospitals are shown in TuableII. The patient’s admission number is marked on his arm in arabic numerals and his category is marked on his forehead (Figure I) in roman numerals. The objection to marking the patient with his category is that if becomes a permanent label and there is a reluctance to recategorize him
Table II. Triage categories used in ICRC hospitals Category I Those patients for whom urgent surgery is required and for whom there is a good chance of reasonable survival. Category II Those patients who do not require surgery. (This includes both patients with wounds so slight that they do not need surgery andthose who are severely injured and for whom reasonable survival is unlikely.) Category II1 Those who require surgery but not on an urgent basis.
Coupland et al.: Triage of war wounded
Figure 3. Photograph of a man who had a through-and-through bullet wound of the head. The entry is seen in the left temporal region; the exit was the same size in the right temporal region. He was unconscious on arrival at hospital and was allotted to category II (marked on forehead) because surgery was deemed inappropriate. He made a good recovery with non-operative treatment.
Figure2. The current ICRC admission/triage card. Note the meaning of each category is also marked. In the prepared pack (EzbleIb) the cards are folded along the line below ‘triage’. The cards can be perforated at one edge, reinforced with clear adhesive tape, for attaching string. The card is designed to accommodate the patient’s first 24 h in hospital, whatever the circumstances of admission.
509
Figure 3. Two of the former ICRC triage cards after their use in a triage situation. Note how they can become tom, detached from the string or rendered illegible by blood.
if his condition changes. At the time, it can be difficult to remember the categories; it is important that these also are on the cards (Figure 2). Wounded children bring new difficulties; they are frightened and may resist being marked or may throw away their cards. The card, because of its relative size, may have to be removed before radiography; the result is that the patient’s identification and documentation is then separated from him. This should be avoided. In spite of much discussion and experimentation, the Medical Division of the ICRC has not yet found the ideal triage card. Recurring problems are that they are easily separated from the patient, get damaged or rendered illegible by blood (Figure3). There is agreement that the triage card should be incorporated in the routine admission card (Figure2). It is frequently noted that handwriting becomes larger and illegible in a triage situation; this should be accounted for when designing the documentation. The majority of the patients are usually category III. The proportion of category I patients increases with rapid evacuation, as does the proportion of them who die after treatment has started. When the patients arrive by ambulance, those severely injured arrive first. Conversely, when they arrive having made their own way, those with small injuries arrive first and the survivors with more severe injuries follow. When the patients have undergone triage, they must, if possible, be moved to keep the triage area clear. Category II patients should be moved first to any area of low dependency; this facilitates processing of those who wil4 benefit from treatment. Under these circumstances, it is very difficult to allow a critically injured, young and previously fit patient a death with dignity. It is therefore important that a place with some privacy is set aside for those who are expected to die; grieving friends or relatives will then hinder less the processing of the potential survivors. Category III patients are then moved to the wards; it is not necessary for them to have their intravenous infusions or antibiotics started before they are moved. The category I patients are moved last and, if possible, to an area of higher dependency where they can await surgery. The triage staff must keep a record of where the patients have gone; it is surprisingly easy to lose track of them. The categorization of the majority of patients with penetrating wounds is straightforward when the site of the
510
Injury: the British Journal of Accident Surgery (1992) Vol. 23/No.
wound is obvious. For the more severely injured it is more complex; it involves estimation of the surgical time and task required and the prognosis. When multiple casualties present with blunt trauma, for example a road accident, severe injury is likely to be occult. Accurate assessment of the treatment required is impossible and, consequently, categorization is more difficult. A surgeon’s assessment is then helpful. Multiple bum casualties are more easily assessed clinically, but expectations of treatment based on experience of similar injuries in civilian practice make categorization difficult. They are not a great drain on the surgical facilities at first. Severe bums are disheartening, particularly for the nursing staff. At present, no trauma scoring system is used in the triage of war wounded in ICRC hospitals. The reason for this is their application to penetrating trauma remains unclear. It is hoped that wounds which commonly result in later loss of life or limb will be identified by retrospective review of records of patients whose wounds have been scored according to the Red Cross wound classification (Coupland, 1991, 1992).
It is important that patients are reassessed as soon as possible and, if necessary, recategorized. A perforated viscus may become apparent with time; review of radiographs may change the assessment. Patients left to die may survive for hours or days and so their initial reassessment must be questioned. The most important reassessment is that of category III patients as soon as they are moved from the triage area. Cultural or religious factors can also affect triage. In some situations, patients and their relatives are unwilling to give consent for amputation; this involves discussion and delay which can be frustrating. One should try to avoid rushing a patient to the operating theatre with a severe limb injury to find that it is necessary to amputate and that there is no permission to do so. The categorization of head injuries causes the most controversy. They are obviously life-threatening and may be the most disturbing for the inexperienced. It is necessary to consider both the chances of survival and the chances of go& survival. Most patients with large craniocerebral injuries die before reaching hospital, unconscious survivors are usually placed in category II. Conscious patients with smaller craniocerebral wounds rarely require urgent surgery (Coupland and Pesonen, 1991). Therefore, it is suggested that no patient with a penetrating brain wound undergoes urgent surgery in a triage situation unless a rapidly diminishing level of consciousness is thought to be due to an expanding, surgically accessible haematoma (which is rare). A similar process of natural selection takes place in patients with chest wounds; those with severe central chest wounds rarely survive to reach hospital, while many with peripheral thoracic wounds are treated initially by simple intercostal drainage. Therefore, chest injuries do not make much acute demand on the surgical facilities. Vascular injuries are not common. Urgent surgery is only required for those who have small associated wounds and are actively bleeding or have peripheral ischaemia. Large wounds involving major vessels are either fatal or render the periphery unsalvageable. The large majority of patients with abdominal wounds are category I because they stand a good chance of full recovery from life-threatening injury; they are justifiably expensive in terms of surgical resource. Therefore 1aparotom.y represents the majority of surgery on category I patients. The operating surgeon is not always the best person to be
8
involved in the triage, in spite of the fact that it is essentially a surgical assessment. While he may be able to give a more accurate estimation of the surgical task he may also ‘prefer’ cases that fall within his specialty or that he is familiar with. If inexperienced, he may have unrealistic expectations of the outcome for the severely injured patients. Both common sense and experienced clinical judgement are required to avoid operating upon patients who are unlikely to survive. It is difficult to recommend means to prevent many patients with simple penetrating wounds coming to the operating theatre unnecessarily as there is still controversy over which wounds need surgery (Fackler, 1989; Coupland, 1990; Haywood, 1991). Such patients are categorized II or III depending on the surgeon’s opinion. The triage nurse or doctor should know that patients with missile wounds of soft tissue only below a certain size (e.g. 1 cm) can go directly to a ward. At a later date it is beneficial to hold a meeting of personnel involved. Any difficulties should be discussed in preparation for the next incident. It is at this time decisions about clinical assessment, categorization and treatment are criticized. It is hoped that the recording of this experience will benefit anyone, including military medical personnel, who may have to deal with large numbers of war wounded with limited resources.
References Bowen T. E. and Bellamy R. F. (eds) (1988) Emergency War Surgery: Second United SfafesRevision of fhe Emergency War Surgery NATO Handbook. Washington DC: United States Government Printing Office. Coupland R. M. (1990) Letter. Br. 1. Surg. 77, 883. Coupland R. M. (1991) % Red Cross Wound Classjficafion. Geneva: The International Committee of the Red Cross. Coupland R. M. (1992) The Red Cross Classification of Wounds. World 1. Surg. 16 (in press). Coupland R. M. and Pesonen P. (1991) Craniocerebral war wounds: non-specialist management. Injury 23, 21. Dufour D., Kroman N., Jensen S., Owen-Smith M. et al. (1988) Surgeryfor Victims of War. Geneva: The International Committee of the Red Cross. Eshaya-Chauvin B. and Coupland R. M. (1992) Transfusion requirements for war wounded: the experience of the Intemational Committee of the Red Cross Br. J. Anaesfh. 68, 221. Fackler M. L. (1989) Letter. Br. J. Surg. 76, 1217. Kirby N. G. and Blackbum G. (eds.) (1983) Field Surgery Pockef Book. London: HMSO. Haywood I. R. (1991) Letter. Br. J Surg. 78, 123. Owen-Smith M. S. (1978) High velocity missile injuries. In: Hadfield J. and Hobsley M. (eds) &rent Surgical Practice, Vol. 2. London: Edward Arnold, 2~4. Peam J. H. (1990) The pivot: the first Australian Casualty Clearing Hospital at the Gallipoli beachhead. Med. 1. Awf. 153, 612. Ryan J. M., Sibson J. and Howell G. (1990) Assessing injury severity during general war. Will the military triage system meet future needs? J. R. Army Med. Corps 136, 27. Walsh D. P., Lammert G. R. and Devoll J. (1989) The effectiveness of Advanced Trauma Life Support system in a mass casualty situation by non-trauma-experienced physicians. J. Emerg. Med. 7, 175.
Paper accepted
19 March
1992.
Re+4esfs for reprints should be addressed to: Mr R. Coupland FRCS, Medical Division, The International Committee of the Red Cross, Av. de la Paix, CH 1202, Geneva, Switzerland.
Printed in Great Britain
507
Triage of war wounded: the experience of the International Committee of the Red Cross R. M. Coupland’, P. J. Parker2 and R. C. Gray ‘The International
Committee
of the Red Cross and ZNew Zealand Red Cross Society
The hospitals of the lntemational Commitfee of the Red Cross are often faced with situations in which fhe number of war wounded requiring surgical attention ovetwhelms the available facilifies. Hospiral organization, equipment and changes of aftitude necessary for health professionals are considered wifh respect to triage. Practical aspects of assessment and categorization of fhe wounded are considered in the light of a large ex.perience; relocafion and reassessment of those who do not warrant immediate surgery benefit patients and hospital staff alike. The importance of adherence to an emergency plan and respectfor the decisions of the person in charge of the hiage are emphasized. The dificulr and stressful nature of triage of war wounded should always be taken into account.
Introduction The International Committee of the Red Cross (ICRC) deploys surgical teams to care for war wounded in Africa, Asia and the Middle East; in 1990, more than 18 000 war wounded patients were treated in 13 hospitals in eight countries. Two of the largest ICRC hospitals are in Khao I Dang on the Cambodian border of Thailand and in Kabul, the capital of Afghanistan. Both of these hospitals have seen sporadic influxes of large numbers of both civilian and combatant war injured; the authors have considerable experience of situations where the number of patients requiring urgent surgery overwhelms the surgical facilities available. Most of the written material on this subject records military experiences of triage near the battle front (Walsh et al., 198% Peam, x990), or addresses theory and organization principles (Owen-Smith, 1978; Kirby and Blackbum, 1983; Bowen and Bellamy, 1988; Dufour et al., 1988; Ryan et al., 1990). This paper highlights the realities of triage of war wounded and documents a practical system which has been refined and tested in multiple locations. The ICRC hospitals are served by first aid posts from which the journey by ambulance may take several hours; those obviously severely injured have priority of transport. On the other hand, nearby hostilities may precipitate large numbers of admissions that arrive suddenly and spontaneously. This paper refers to triage of the wounded at the hospital, i.e. the site of the surgical facility as opposed to their triage for evacuation to hospital. The principle of achieving the ‘best for most’ is the essence of the triage plan. The plan, documentation and equipment should be as simple as possible, because anything 0 1992 Buttervvorth-Heinemann 0020-1383/92/080507-04
Ltd
resembling complexity is immediately forgotten or abandoned when the real situation arises. There should not be a manual to be read at the time.
The hospital The triage area should be near to, but should not obstruct, the entrance to the hospital. The area must be expandable in terms of patient capacity. When civilian casualties arrive it is very difficult to control who comes into the hospital; it is essential to have a guard on the hospital gate. His function is to keep away from the triage area those who rush to the hospital either to find their injured relatives or out of curiosity. The triage area should have a hard floor, water taps and ropes or wires running at 2 m height on which intravenous infusions can be hung. It should have a roof and in a cold climate be walled and heated. A simple shower is important for patients covered in mud or dust, such as victims of antipersonnel mines. Essential equipment is listed in Table la. Each item should be easily moved, easily unwrapped and easily located by anyone unfamiliar with the triage area. In addition, individual kits are made up in preparation for the event as listed in Table&. The number to be prepared will depend on an estimate of the number of casualties expected at any one time. Some items of equipment have been tried in the triage area and are not deemed necessary because they are never or very infrequently used. These are: pneumatic tourniquets; artery forceps; nasogastric tubes; endotracheal tubes and laryngoscopes. The authors recognize that elimination of the last of these could cause controversy. The triage area should be accessible to both radiography and the operating theatre(s). A nearby laboratory for haemoglobin estimation and the provision and crossmatching of blood for transfusion is necessary for the management of severe injuries (Eshaya-Chauvin and Coupland, 1992).
Personnel The staff should agree on the number of wounded arriving at one time that will determine when ‘triage is declared’ and the prepared equipment is used; this allows for familiarity with the system, documents and equipment in preparation
Injury: the British Journal of Accident Surgery (1992) Vol. 23/No.
508 Table la.
List of essential equipment for triage of war wounded
General Stretchers (at the hospital entrance). Suction machine and catheters. Tourniquets for venesection. Sphygmomanometer. Torch. Limb splints. Large sharp scissors for removing clothing. Large plastic bags for patient’s clothing. Small plastic bags for patient’s valuables. Sets of documents (at the hospital entrance). instruments Stethoscopes. Scissors. For treatment Intravenous fluids-electrolyte Giving sets. IV needles. Syringes. Needles
solutions/plasma expander.
Antibiotics. Antitetanus serum/tetanus toxoid. Gauze. Bandages. Sticky tape.
8
theatre first, inevitably occupy time and so add to the difficulty of maximizing the use of the surgical facilities. Fear for one’s personal safety also affects surgical decision making and technique. It is essential that one person is in charge of the triage of the patients. This person should be an experienced doctor or nurse, familiar with the type of wounds. In an ICRC hospital this role is usually undertaken by the head nurse. It should be understood that his or her decision about the patients’ triage is not questioned at the time. There is always disagreement about some decisions, but there is nothing more counterproductivti or undignified than clinical or ethical arguments in the midst of wounded patients. It is at this time that untrained and unqualified people arrive at the hospital asking if they can help; this may be a hindrance but is difficult to refuse. Some tasks can be delegated to them. Suggestions are: stretcher bearing; carrying specimens to or units of blood from the laboratory; filling syringes with penicillin. If possible, potential helpers should be identified and given instruction about such simple tasks beforehand. The relatives of civilians wounded in armed conflict place an enormous burden on the staff in the triage area. They may become aggressive in the hope of hastening treatment.
Chest drain sets. Documentation Triage cards. Cross-match forms. X-ray forms. Pens. Skin markers.
TableIb.
The following individual patient ‘kits’ are prepared Tublela in advance
from the items in
Intravenous needles (3). Intravenous fluid (1 litre). Giving set. Tape, already cut. Syringe (10ml).
for a larger influx. This number is small; it is generally agreed in the ICRC hospitals that when seven wounded patients arrive simultaneously they undergo triage. A situation in which there are multiple serious casualties is extremely stressful for all personnel involved. It is necessary to abandon the individual ‘contract’ that one normally has with the patient and to lower one’s expectations. This change of attitude to total responsibility for a group of patients is an intellectual challenge which arises when one is least able to face such a challenge. Simple clinical tasks become diIYicult and tempers become frayed. A contributing factor to the stress is that there is an obvious, large and urgent need for medical action but nothing appears to happen quickly enough. Despite this collective approach, the surgery is nevertheless administered on a one-to-one basis; once the patients are through the triage area, the surgery that they receive must still be adequate (otherwise the exercise is pointless.) Therefore, the surgical team must consider the group and yet must still focus their thoughts on each operation. The surgeon, therefore, must decide on the best management and must also decide how this management can be safely compromised. The more severely injured patients go to
Assessment, triage categories and clinica judgement A patient can only be assessed completely if all his clothing is removed. It is easy to miss a small but serious penetrating wound. He cannot be relied upon to locate all his wounds. The general condition of the patient rarely needs verification by careful measurement of the pulse rate, respiratory rate and blood pressure (note that this applies only to the triage situation). The briefest clinical assessment of central injuries involves: noting the level of consciousness in head injuries; feeling for surgical emphysema in neck and chest injuries; noting abdominal distension and tenderness with injuries of the chest, abdomen or buttocks Paraplegia from penetrating trauma is very easily overlooked; the patient should be asked to move his toes. In limb injuries the distal pulse should be felt although the diagnosis of vascular injury can be difficult in the presence of a compressive dressing and hypovolaemia. The ability to feel and move the distal extremity is important if the question of amputation arises. The triage categories used in ICRC hospitals are shown in TuableII. The patient’s admission number is marked on his arm in arabic numerals and his category is marked on his forehead (Figure I) in roman numerals. The objection to marking the patient with his category is that if becomes a permanent label and there is a reluctance to recategorize him
Table II. Triage categories used in ICRC hospitals Category I Those patients for whom urgent surgery is required and for whom there is a good chance of reasonable survival. Category II Those patients who do not require surgery. (This includes both patients with wounds so slight that they do not need surgery andthose who are severely injured and for whom reasonable survival is unlikely.) Category II1 Those who require surgery but not on an urgent basis.
Coupland et al.: Triage of war wounded
Figure 3. Photograph of a man who had a through-and-through bullet wound of the head. The entry is seen in the left temporal region; the exit was the same size in the right temporal region. He was unconscious on arrival at hospital and was allotted to category II (marked on forehead) because surgery was deemed inappropriate. He made a good recovery with non-operative treatment.
Figure2. The current ICRC admission/triage card. Note the meaning of each category is also marked. In the prepared pack (EzbleIb) the cards are folded along the line below ‘triage’. The cards can be perforated at one edge, reinforced with clear adhesive tape, for attaching string. The card is designed to accommodate the patient’s first 24 h in hospital, whatever the circumstances of admission.
509
Figure 3. Two of the former ICRC triage cards after their use in a triage situation. Note how they can become tom, detached from the string or rendered illegible by blood.
if his condition changes. At the time, it can be difficult to remember the categories; it is important that these also are on the cards (Figure 2). Wounded children bring new difficulties; they are frightened and may resist being marked or may throw away their cards. The card, because of its relative size, may have to be removed before radiography; the result is that the patient’s identification and documentation is then separated from him. This should be avoided. In spite of much discussion and experimentation, the Medical Division of the ICRC has not yet found the ideal triage card. Recurring problems are that they are easily separated from the patient, get damaged or rendered illegible by blood (Figure3). There is agreement that the triage card should be incorporated in the routine admission card (Figure2). It is frequently noted that handwriting becomes larger and illegible in a triage situation; this should be accounted for when designing the documentation. The majority of the patients are usually category III. The proportion of category I patients increases with rapid evacuation, as does the proportion of them who die after treatment has started. When the patients arrive by ambulance, those severely injured arrive first. Conversely, when they arrive having made their own way, those with small injuries arrive first and the survivors with more severe injuries follow. When the patients have undergone triage, they must, if possible, be moved to keep the triage area clear. Category II patients should be moved first to any area of low dependency; this facilitates processing of those who wil4 benefit from treatment. Under these circumstances, it is very difficult to allow a critically injured, young and previously fit patient a death with dignity. It is therefore important that a place with some privacy is set aside for those who are expected to die; grieving friends or relatives will then hinder less the processing of the potential survivors. Category III patients are then moved to the wards; it is not necessary for them to have their intravenous infusions or antibiotics started before they are moved. The category I patients are moved last and, if possible, to an area of higher dependency where they can await surgery. The triage staff must keep a record of where the patients have gone; it is surprisingly easy to lose track of them. The categorization of the majority of patients with penetrating wounds is straightforward when the site of the
510
Injury: the British Journal of Accident Surgery (1992) Vol. 23/No.
wound is obvious. For the more severely injured it is more complex; it involves estimation of the surgical time and task required and the prognosis. When multiple casualties present with blunt trauma, for example a road accident, severe injury is likely to be occult. Accurate assessment of the treatment required is impossible and, consequently, categorization is more difficult. A surgeon’s assessment is then helpful. Multiple bum casualties are more easily assessed clinically, but expectations of treatment based on experience of similar injuries in civilian practice make categorization difficult. They are not a great drain on the surgical facilities at first. Severe bums are disheartening, particularly for the nursing staff. At present, no trauma scoring system is used in the triage of war wounded in ICRC hospitals. The reason for this is their application to penetrating trauma remains unclear. It is hoped that wounds which commonly result in later loss of life or limb will be identified by retrospective review of records of patients whose wounds have been scored according to the Red Cross wound classification (Coupland, 1991, 1992).
It is important that patients are reassessed as soon as possible and, if necessary, recategorized. A perforated viscus may become apparent with time; review of radiographs may change the assessment. Patients left to die may survive for hours or days and so their initial reassessment must be questioned. The most important reassessment is that of category III patients as soon as they are moved from the triage area. Cultural or religious factors can also affect triage. In some situations, patients and their relatives are unwilling to give consent for amputation; this involves discussion and delay which can be frustrating. One should try to avoid rushing a patient to the operating theatre with a severe limb injury to find that it is necessary to amputate and that there is no permission to do so. The categorization of head injuries causes the most controversy. They are obviously life-threatening and may be the most disturbing for the inexperienced. It is necessary to consider both the chances of survival and the chances of go& survival. Most patients with large craniocerebral injuries die before reaching hospital, unconscious survivors are usually placed in category II. Conscious patients with smaller craniocerebral wounds rarely require urgent surgery (Coupland and Pesonen, 1991). Therefore, it is suggested that no patient with a penetrating brain wound undergoes urgent surgery in a triage situation unless a rapidly diminishing level of consciousness is thought to be due to an expanding, surgically accessible haematoma (which is rare). A similar process of natural selection takes place in patients with chest wounds; those with severe central chest wounds rarely survive to reach hospital, while many with peripheral thoracic wounds are treated initially by simple intercostal drainage. Therefore, chest injuries do not make much acute demand on the surgical facilities. Vascular injuries are not common. Urgent surgery is only required for those who have small associated wounds and are actively bleeding or have peripheral ischaemia. Large wounds involving major vessels are either fatal or render the periphery unsalvageable. The large majority of patients with abdominal wounds are category I because they stand a good chance of full recovery from life-threatening injury; they are justifiably expensive in terms of surgical resource. Therefore 1aparotom.y represents the majority of surgery on category I patients. The operating surgeon is not always the best person to be
8
involved in the triage, in spite of the fact that it is essentially a surgical assessment. While he may be able to give a more accurate estimation of the surgical task he may also ‘prefer’ cases that fall within his specialty or that he is familiar with. If inexperienced, he may have unrealistic expectations of the outcome for the severely injured patients. Both common sense and experienced clinical judgement are required to avoid operating upon patients who are unlikely to survive. It is difficult to recommend means to prevent many patients with simple penetrating wounds coming to the operating theatre unnecessarily as there is still controversy over which wounds need surgery (Fackler, 1989; Coupland, 1990; Haywood, 1991). Such patients are categorized II or III depending on the surgeon’s opinion. The triage nurse or doctor should know that patients with missile wounds of soft tissue only below a certain size (e.g. 1 cm) can go directly to a ward. At a later date it is beneficial to hold a meeting of personnel involved. Any difficulties should be discussed in preparation for the next incident. It is at this time decisions about clinical assessment, categorization and treatment are criticized. It is hoped that the recording of this experience will benefit anyone, including military medical personnel, who may have to deal with large numbers of war wounded with limited resources.
References Bowen T. E. and Bellamy R. F. (eds) (1988) Emergency War Surgery: Second United SfafesRevision of fhe Emergency War Surgery NATO Handbook. Washington DC: United States Government Printing Office. Coupland R. M. (1990) Letter. Br. 1. Surg. 77, 883. Coupland R. M. (1991) % Red Cross Wound Classjficafion. Geneva: The International Committee of the Red Cross. Coupland R. M. (1992) The Red Cross Classification of Wounds. World 1. Surg. 16 (in press). Coupland R. M. and Pesonen P. (1991) Craniocerebral war wounds: non-specialist management. Injury 23, 21. Dufour D., Kroman N., Jensen S., Owen-Smith M. et al. (1988) Surgeryfor Victims of War. Geneva: The International Committee of the Red Cross. Eshaya-Chauvin B. and Coupland R. M. (1992) Transfusion requirements for war wounded: the experience of the Intemational Committee of the Red Cross Br. J. Anaesfh. 68, 221. Fackler M. L. (1989) Letter. Br. J. Surg. 76, 1217. Kirby N. G. and Blackbum G. (eds.) (1983) Field Surgery Pockef Book. London: HMSO. Haywood I. R. (1991) Letter. Br. J Surg. 78, 123. Owen-Smith M. S. (1978) High velocity missile injuries. In: Hadfield J. and Hobsley M. (eds) &rent Surgical Practice, Vol. 2. London: Edward Arnold, 2~4. Peam J. H. (1990) The pivot: the first Australian Casualty Clearing Hospital at the Gallipoli beachhead. Med. 1. Awf. 153, 612. Ryan J. M., Sibson J. and Howell G. (1990) Assessing injury severity during general war. Will the military triage system meet future needs? J. R. Army Med. Corps 136, 27. Walsh D. P., Lammert G. R. and Devoll J. (1989) The effectiveness of Advanced Trauma Life Support system in a mass casualty situation by non-trauma-experienced physicians. J. Emerg. Med. 7, 175.
Paper accepted
19 March
1992.
Re+4esfs for reprints should be addressed to: Mr R. Coupland FRCS, Medical Division, The International Committee of the Red Cross, Av. de la Paix, CH 1202, Geneva, Switzerland.
