Editing Triage (section)

== Modern history of triage ==
[[File:Larrey's Flying Ambulance.jpg|thumb|Larrey's "flying ambulance" design.]]

=== Napoleonic triage ===
Modern triage grew out of the work of [[Baron Dominique-Jean Larrey]] and [[Pierre-François Percy]] during the reign of [[Napoleon]]. Larrey in particular introduced the concept of a "flying [[ambulance]]" (flying in this case meaning rapidly moving) or in its native French, [[History of the ambulance|Ambulance Volante]].<ref name="Robertson-Steel_2006" />

=== World War I ===
In 1914, [[Antoine Depage]] developed the five-tiered ''Ordre de Triage'', a triage system which set specific benchmarks on evacuation, described staged evacuation.<ref>{{Cite web | author = WSJ com News Graphics |title=World War I Centenary: Triage |url=https://online.wsj.com/ww1/triage |access-date=2023-05-26 |website=The Wall Street Journal |language=en}}</ref><ref name="Pollock-2008">{{cite journal | vauthors = Pollock RA | title = Triage and management of the injured in world war I: the diuturnity of antoine de page and a belgian colleague | journal = Craniomaxillofacial Trauma & Reconstruction | volume = 1 | issue = 1 | pages = 63–70 | date = November 2008 | pmid = 22110790 | pmc = 3052731 | doi = 10.1055/s-0028-1098965 }}</ref> [[France|French]] and [[Belgium|Belgian]] [[physician|doctors]] began using these concepts to inform the treatment of casualties at [[aid station]]s behind the front.<ref>{{Cite web | vauthors = Thompson G |title=Battlefield Medicine: Triage-Field Hospital Section |url=https://www.kumc.edu/school-of-medicine/academics/departments/history-and-philosophy-of-medicine/archives/wwi/essays/military-medical-operations/triage-field-hospital-section.html |access-date=2023-05-26 |website=Kansas University Medical Center |language=en-us}}</ref><ref name="Pollock-2008" /> Those responsible for the removal of the wounded from a battlefield or their care afterwards would divide the victims into three categories:<ref name="Iserson_2007">{{cite journal | vauthors = Iserson KV, Moskop JC | title = Triage in medicine, part I: Concept, history, and types | journal = Annals of Emergency Medicine | volume = 49 | issue = 3 | pages = 275–281 | date = March 2007 | pmid = 17141139 | doi = 10.1016/j.annemergmed.2006.05.019 }}</ref><ref>{{cite journal | vauthors = Chipman M, Hackley BE, Spencer TS | title = Triage of mass casualties: concepts for coping with mixed battlefield injuries | journal = Military Medicine | volume = 145 | issue = 2 | pages = 99–100 | date = February 1980 | pmid = 6768037 | doi = 10.1093/milmed/145.2.99 }}</ref>

* Those who are likely to live, regardless of what care they receive;
* Those who are unlikely to live, regardless of what care they receive;
* Those for whom immediate care may make a positive difference in outcome.

From that delineation, aid workers would follow the ''Ordre de Triage'':

==== First Order of Triage ====
[[File:A ward in the 2nd Australian Casualty Clearing Station near Steenvoorde.jpg|thumb|Casualty Clearing Station as described in the Second Order of Triage]]

In the first order of triage, the injured would be evacuated to clearing stations in the night, when darkness offered maximum protection from the [[German Empire|German forces]].<ref name="Pollock-2008" /><ref name="Lewis-2013">{{Cite web | vauthors = Lewis CH |date=2013-12-15 |title=Triage and Trauma Medicine in United States Military History – Health & Medicine in American History |url=https://lewiscar.sites.grinnell.edu/HistoryofMedicine/uncategorized/triage-and-trauma-medicine-in-united-states-military-history/ |access-date=2023-05-26 |language=en}}</ref>

==== Second Order of Triage ====
Once at a casualty clearing station, wounds were dressed,<ref name="Lewis-2013" /> and anyone requiring immediate surgical intervention was placed in a cart and brought immediately to an ambulance pickup area. If the wounded could wait, they would be evacuated by ambulance during the night.<ref name="Pollock-2008" />

==== Third Order of Triage ====
Ambulances, driven by [[YMCA]] and [[American Red Cross]] trained drivers then removed the casualties to [[Mobile Army Surgical Hospital|mobile surgical centers]], called ''postes avances des hospitaux du front'' or outposts of the frontline hospitals.<ref name="Pollock-2008" /><ref name="Lewis-2013" />

==== Fourth Order of Triage ====
At the mobile surgical hospitals, the most severe cases were treated, specifically those who were likely to die before reaching a permanent, more equipped hospital. Anyone who could survive the trip was transported to a farther away, often costal, hospital.<ref name="Pollock-2008" /><ref name="Lewis-2013" />

==== Fifth Order of Triage ====
Upon reaching a permanent hospital, casualties received appropriate care to treat all of their injuries.<ref name="Pollock-2008" /><ref name="Lewis-2013" />

=== World War II ===
By the onset of World War II, American and British forces had adopted and adapted triage, with other global powers doing the same.<ref name="www.sciencemuseum.org.uk">{{Cite web |title=Medicine in the war zone {{!}} Science Museum |url=https://www.sciencemuseum.org.uk/objects-and-stories/medicine/medicine-war-zone |access-date=2023-05-26 |website=www.sciencemuseum.org.uk |language=en}}</ref><ref name="Katoch-2010">{{cite journal | vauthors = Katoch R, Rajagopalan S | title = Warfare Injuries: History, Triage, Transport and Field Hospital Setup in the Armed Forces | journal = Medical Journal, Armed Forces India | volume = 66 | issue = 4 | pages = 304–308 | date = October 2010 | pmid = 27365730 | pmc = 4919805 | doi = 10.1016/S0377-1237(10)80003-6 }}</ref> The increased availability of airplanes allowed rapid evacuation to a hospital outside of the warzone to become a part of the triage process.<ref name="www.sciencemuseum.org.uk" /><ref name="Katoch-2010" /> Although the basic practices remained the same as in World War I, with initial evacuation to an aid station, followed by transitions to higher levels of care, and eventual admission to a permanent hospital, more advanced care was provided at each stage, and the mindset of treating only what was absolutely necessary fell away.<ref>{{cite journal | vauthors = Baker MS | title = Creating order from chaos: part I: triage, initial care, and tactical considerations in mass casualty and disaster response | journal = Military Medicine | volume = 172 | issue = 3 | pages = 232–236 | date = March 2007 | pmid = 17436764 | doi = 10.7205/MILMED.172.3.232 | s2cid = 44317599 | doi-access = free }}</ref> Although triage almost certainly occurred in the days after the [[atomic bombings of Hiroshima and Nagasaki]], the pandemonium caused by the attack left records of such action non-existent until after the fifth day, at which point they are largely without historical use.<ref>{{cite book | vauthors =  Leaning J | collaboration = Institute of Medicine (US) Steering Committee for the Symposium on the Medical Implications of Nuclear War | chapter = Burn and Blast Casualties: Triage in Nuclear War |date=1986 | chapter-url = https://www.ncbi.nlm.nih.gov/books/NBK219175/ | title = The Medical Implications of Nuclear War |access-date=2023-05-26 |publisher=National Academies Press (US) |language=en | veditors = Solomon F, Marston RQ }}</ref> 

=== The Texas City disaster (1947) ===
[[File:Txcitydisaster5storybuilding.jpg|thumb|A destroyed rubber factory from the Texas City Disaster]]

In 1947, the [[Texas City Disaster]] occurred when the SS ''Grandcamp'' exploded in [[Texas City, Texas]], killing 600 people and injuring thousands more.<ref>{{Cite web | vauthors = Barnes M |title=Texas history: A witness to one of America's worst human-made disasters |url=https://www.statesman.com/story/news/history/2020/04/17/texas-history-witness-to-one-of-americas-worst-human-made-disasters/1335171007/ |access-date=2023-05-26 |website=Austin American-Statesman |language=en-US}}</ref> The entire fire department was killed in the blast, and what followed was a massive informal triage of the victims.<ref name="Wall-2015">{{Cite journal | vauthors = Wall BM |date=2015 |title=Disasters, Nursing, and Community Responses: A Historical Perspective |journal=Nursing History Review |language=en |volume=23 |issue=1 |pages=11–27 |doi=10.1891/1062-8061.23.11 |pmid=25272474 |s2cid=219207043 |issn=1062-8061|doi-access=free }}</ref> Drug stores, clinics, and homes were opened as makeshift triage stations. As the city has no hospital, they had to evacuate casualties to area facilities, including those in [[Galveston, Texas|Galveston]] and [[Houston]],<ref name="Wall-2015" /> with at least one doctor relying on skills he had learned in World War II to inform care decisions.<ref>{{Cite web | vauthors = Barnes M |title=Texas history: Readers relive the horrors of the 1947 Texas City Disaster |url=https://www.statesman.com/story/news/history/2020/05/08/texas-history-readers-relive-horrors-of-1947-texas-city-disaster/1227001007/ |access-date=2023-05-27 |website=Austin American-Statesman |language=en-US}}</ref>

=== The Korean War ===
The [[Korean War]] saw the advent of the tiered triage, wherein care providers sorted people into categories defined ahead of time.<ref name=":1">{{Cite journal |last1=Nocera |first1=Antony |last2=Garner |first2=Alan |title=An Australian Mass Casualty Incident Triage System for the Future Based Upon Triage Mistakes of the Past: The Homebush Triage Standard |date=August 1999 |url=http://doi.wiley.com/10.1046/j.1440-1622.1999.01644.x |journal=ANZ Journal of Surgery |language=en |volume=69 |issue=8 |pages=603–608 |doi=10.1046/j.1440-1622.1999.01644.x |pmid=10472920 |issn=1445-1433}}</ref> These categories, immediate, delayed, minimal and expectant are still the basis for most triage systems today.<ref name=":1" /> The time period was also marked by improvements in medical understanding, including shock, which allowed effective interventions to be administered earlier in the Triage process, which in turn significantly improved outcomes.<ref name=":2">{{Cite journal |last=Mitchell |first=Glenn W. |date=September 2008 |title=A Brief History of Triage |url=https://www.cambridge.org/core/product/identifier/S1935789300001270/type/journal_article |journal=Disaster Medicine and Public Health Preparedness |language=en |volume=2 |issue=S1 |pages=S4–S7 |doi=10.1097/DMP.0b013e3181844d43 |pmid=18769265 |s2cid=11093773 |issn=1935-7893}}</ref> At the same time, [[Mobile Army Surgical Hospital]]s (MASH) were introduced along with helicopters for evacuation. These helicopters, however were used for evacuation only, and care was not provided in the air during the evacuation.<ref name="United States Marine Corps" /> These advances reduced fatalities for injured soldiers by up to 30%, and changed the nature of battlefield medicine significantly.<ref name=":2" />

=== The Vietnam War ===
The conditions of the [[Vietnam War]] drove further development on the concepts created during the Korean War. Advances in helicopters allowed the introduction of the first helicopter medics, who were able to provide [[fluid resuscitation]], and other interventions mid-flight.<ref name=":2" /> This made it so that the average time from injury to definitive care was less than two hours.<ref name="United States Marine Corps" /> This evolution also flowed into the everyday life, with air ambulances emerging in the civilian world by the mid-1960's.<ref name=":2" /> The use of triage in emergency departments and ambulance services also quickly followed.<ref name="United States Marine Corps" />

=== The World Trade Center bombing (1993) ===
In 1993, the north tower of the [[1993 World Trade Center bombing|World Trade Center was bombed]], in a plot with a similar intended outcome as the later [[September 11 attacks|September 11th attacks]].<ref>{{Cite web |title=February 26, 1993 Commemoration |url=https://www.911memorial.org/connect/commemoration/February26-1993 |website=9/11 Memorial & Museum}}</ref> While search, rescue and triage operations immediately following were ordinary, the attack itself represented one of the first terrorist attacks affecting the United States directly. The fact that the U.S. was no longer seen as untouchable, along with the later [[Oklahoma City bombing]] in 1995, and the September 11th attack lead to long term changes in triage practices to be more focused on operational safety and the risk of secondary attacks designed to kill care providers.<ref>{{Cite journal |last=Eckstein |first=Marc |date=August 1999 |title=The Medical Response to Modern Terrorism: Why the "Rules of Engagement" Have Changed |journal=Annals of Emergency Medicine |language=en |volume=34 |issue=2 |pages=219–221 |doi=10.1016/S0196-0644(99)70232-5|pmid=10424924 |doi-access=free }}</ref>

=== Matsumato sarin attack (1994) ===
In June 1994, emergency crews began responding to calls related to symptoms of toxic gas exposure in a neighborhood. Without proper [[personal protective equipment]], more than 253 residents were evacuated and 50 were hospitalized.<ref>{{Cite journal |last1=Kulling |first1=Per E. J. |last2=Lorin |first2=Henry |date=March 1999 |title=KAMEDO — A Swedish Disaster Medicine Study Organization |url=https://www.cambridge.org/core/product/identifier/S1049023X0002851X/type/journal_article |journal=Prehospital and Disaster Medicine |language=en |volume=14 |issue=1 |pages=25–33 |doi=10.1017/S1049023X0002851X |pmid=10537595 |s2cid=12078694 |issn=1049-023X}}</ref> 20 vehicles were called to the scene, and a mobile operating center was setup nearby, likely within the zone of contamination. Unaware of the presence of Sarin, triage was performed following the standard system of the time, which ultimately resulted in eight care givers experiencing mild sarin poisoning, and an unknown amount of additional staff experiencing general malaise.<ref name=":3">{{Cite journal |last1=Okudera |first1=Hiroshi |last2=Morita |first2=Hiroshi |last3=Iwashita |first3=Tomomi |last4=Shibata |first4=Tatsuhiko |last5=Otagiri |first5=Tetsutaro |last6=Kobayashi |first6=Shigeaki |last7=Yanagisawa |first7=Nobuo |date=September 1997 |title=Unexpected nerve gas exposure in the city of Matsumoto: Report of rescue activity in the first sarin gas terrorism |url=https://linkinghub.elsevier.com/retrieve/pii/S0735675797902011 |journal=The American Journal of Emergency Medicine |language=en |volume=15 |issue=5 |pages=527–528 |doi=10.1016/S0735-6757(97)90201-1|pmid=9270397 }}</ref>

At the time, no decontamination procedures or gas masks were available for incidents involving contaminants. In response, the [[Japan Self-Defense Forces]] created a decontamination team, which was then instrumental to the response of the Tokyo subway sarin attack which occurred only seven months later.<ref name=":3" />

=== Triage in the present day ===
As medical technology has advanced, so have modern approaches to triage, which are increasingly based on scientific models. The categorizations of the victims are frequently the result of triage scores based on specific [[physiological]] assessment findings. Some models, such as the [[Simple triage and rapid treatment|START]] model may be [[algorithm]]-based. As triage concepts become more sophisticated, and to improve patient safety and quality of care, several human-in-the-loop decision-support tools have been designed on top of triage systems to standardize and automate the triage process (e.g., eCTAS, [[NHS 111]]) in both [[hospitals]] and the field.<ref>{{cite web| url = https://hospitalnews.com/digital-tools-and-virtual-care-in-emergency-services/| title = Digital tools and virtual care in emergency services| date = 25 September 2020}}</ref> Moreover, the recent development of new [[machine learning]] methods offers the possibility to learn optimal triage policies from data and in time could replace or improve upon expert-crafted models.<ref>{{cite arXiv | vauthors = Buchard A, Bouvier B |eprint=2003.12828 |title=Learning medical triage from clinicians using Deep Q-Learning  |date=2020 |class=cs.AI }}</ref>