Emergency Medicine News:
Dr. Janson is an emergency physician at Lawrence General Hospital in Lawrence, MA. He is the author of a novel, Mal Practice, and a children's book, The Child in Our Heart, both available on http://pauljanson.com/.
The transport and triage of the sick and injured has probably been a part of medicine since the beginning of medicine. The Bible speaks of the sick being carried on litters, and Hippocrates advised physicians against treating those patients who had no likelihood of benefiting from their treatment. Carts were used to transport the sick, but these seem to have been used to remove the insane or contagious persons, such as lepers, from the community.
Public service, not treatment, motivated these efforts. Those injured on the battlefield were left until the battle was over, and their treatment was often administered by a camp follower who before the battle was washing clothes and cooking meals. The ambulance and triage system that we know today began with Napoleon and his surgeon-in-chief to the imperial guard, Baron Dominique Jean Larrey. Caring for the sick and injured was not given a position of much importance before 1792.
Figure. An ambulance...Image Tools
But Larrey became concerned that the wounded were not being promptly evacuated and that little regard was paid to the severity of their injuries. He convinced Napoleon that a better system was necessary, and then he developed it. Napoleon may have been motivated by humanitarian concerns as Larrey did or possibly he saw his soldiers as valuable human resources that would fight again if they could be treated more quickly. He also may have realized that his troops might be more willing to fight and chance being wounded if they saw that they would be treated well.
Whatever the reason, Larrey set about developing the system that is the basis for our modern EMS and triage. The ambulance was probably a stretcher carried on the battlefield. Various adaptations included a stretcher with wheels. The exact origin of the term “ambulance” is not clear, and the original use may have been applied to the field or “walking” hospital. Whatever its origin, the ambulance soon became the transportation of the wounded.
A horse-drawn vehicle, the ambulance volante or flying ambulance, was developed. The mixing of these two meanings suggests that treatment was initiated in the vehicle, but Larrey clearly sided with those who advocated rapid transport of the injured rather than treatment at the scene. The fact that the scene for Larrey was a battlefield may have influenced his views. Discussion continues on this point, though today's emphasis is usually on rapid transport.
The origin of triage is clearer. The word comes from the French trier, meaning to select or sort, and it was also developed by Larrey. Three levels were used, those who would recover regardless of treatment, those who would die regardless of treatment, and those who were likely to benefit from prompt treatment. Variations notwithstanding, this is the basic system we use today.
Larrey's system was obviously designed to be used in a disaster — the battle — but now it is used routinely. This may be true because medicine is always in a chronic disaster situation, and the wait times in our emergency departments and the boarding of admitted patients there support this view. It may be, however, that the system is being used for a different purpose: to prevent the delivery of care.
The delay in care is becoming so onerous for many of our patients that it amounts to no care. They choose not to wait for care, sometimes for very serious illnesses. It does no good to triage if the purpose is to deny people care. Triage is an exercise for the benefit of the system, not the sick, if we have nowhere to treat people because the ED is crowded or full of boarded patients. Triage no longer has any purpose if our patients cannot receive treatment because they have been triaged to a crowded waiting room.