The sorting of patients to determine the order of medical treatment is known as triage, a fundamental process in modern healthcare. Triage is a system that attempts to maximize the number of survivors when the demand for medical resources exceeds the available supply. While the concept of prioritizing the injured likely extends back to ancient warfare, the formalized, systematic approach originated in military history. This modern framework, developed under the pressures of mass casualty events, transitioned from the battlefield to become the standard for emergency response today.
Defining the Core Concept
The term “triage” is derived from the French verb trier, which means “to sort,” “sift,” or “select.” In a medical context, triage is the rapid process of assessing and categorizing patients based on the urgency of their conditions. This categorization determines the sequence and type of medical intervention they will receive. The underlying philosophy is to achieve the greatest good for the greatest number of people, especially when resources are severely limited. Priority is given to those with life-threatening injuries who have the highest probability of survival with immediate care, meaning the most severely injured are not always treated first.
The Birth of Formalized Triage
The formalized system of modern medical triage was established in the late 18th and early 19th centuries by Baron Dominique Jean Larrey, chief surgeon of Napoleon Bonaparte’s Imperial Guard. Before his reforms, wounded soldiers often lay on the battlefield for a day or more, with evacuation and treatment typically delayed until fighting ceased, causing many deaths from treatable injuries. Larrey developed his system during the French Revolutionary Wars, notably during the French campaign in Egypt and Syria. His innovation was the creation of ambulance volante, or “flying ambulances,” which were light, horse-drawn wagons designed to rapidly transport the wounded directly from the front lines to field hospitals. Crucially, he instituted a three-tiered system for sorting casualties based solely on medical urgency and probability of survival, fundamentally changing battlefield medicine.
Evolution in Modern Conflict and Civilian Use
Following Larrey’s work, the principles of triage were adopted in subsequent military conflicts. During World War I and World War II, the scale of casualties and the complexity of weapons necessitated more structured sorting. Medical personnel began to use specific tags and categories, often including a category for the “expectant” or mortally wounded, who would receive comfort care rather than resource-intensive treatment. This refinement helped manage massive numbers of injured individuals over long evacuation chains.
The transition of triage principles from the military to civilian settings began in the mid-20th century. As emergency departments (EDs) became more crowded, the need for a systematic way to prioritize patients based on acuity became clear. The first systematic descriptions of civilian ED triage in the United States were published in the 1960s. Today, triage is a standard component of emergency medicine, disaster response, and mass casualty incident preparedness worldwide.
Modern Triage Systems
Modern medical systems rely on standardized protocols to ensure rapid and consistent sorting. For mass casualty incidents in the field, the Simple Triage and Rapid Treatment (START) method is widely used, allowing lightly trained personnel to assess patients in approximately 60 seconds each. This system uses a color-coding scheme to categorize patients into four main groups:
- Red is assigned to those who require immediate intervention to survive, such as those with severe bleeding or breathing difficulties.
- Yellow tags indicate a delayed priority for patients who are seriously injured but stable enough to wait a few hours without risk of death.
- Green is reserved for the “walking wounded” with minor injuries.
- Black is used for those who are deceased or have injuries so severe that survival is unlikely given the available resources.
For daily use in hospital emergency departments, the Emergency Severity Index (ESI) is a common five-level scale that helps nurses determine the patient’s acuity and the number of resources the patient is expected to require.