Citation
International Orthopaedics (SICOT) (2013) 37:1433–1438
DOI 10.1007/s00264-013-1961-y
ORIGINAL PAPER
Triage of mass casualties in war conditions: realities
and lessons learned
Sylvain Rigal & François Pons
Received: 6 May 2013 / Accepted: 28 May 2013 / Published online: 23 June 2013
# Springer-Verlag Berlin Heidelberg 2013
Abstract
Purpose The authors made a retrospective analysis of three
triage situations of war wounded in Chad and Rwanda in which
mass casualties overwhelmed available medical facilities.
Methods The triage classification is based on the waiting
period for surgery. The categories are: extreme, first, second
and third emergencies, expectant, walking wounded.
Results In Chad, 23 wounded adults were received in 24 hours,
and 19 were operated up on within 48 hours. In Rwanda 1, 94
wounded were received in two hours, of whom 68 were
operated upon, 23 on the first day. In Rwanda 2, 59 wounded
were received in 12 hours, treatment of extreme and first
emergencies required 48 hours, while second and third emergencies were treated during the three following days.
Conclusions These episodes were very different when considering the setting, the number of casualties, the type of
wounds, the logistical and medical difficulties. The authors
report the difficulties faced and the lessons learned.
“Il faut toujours commencer par le plus douloureusement
blessé sans avoir égard aux rangs et aux distinctions.”
You must always begin with those who are most seriously wounded without regard to rank or other distinction.
Baron Larrey (1766–1842), surgeon to Napoléon’s
Imperial Guard [1]
S. Rigal
Clinic of Traumatology and Orthopaedics, Percy Military Hospital,
Clamart, France
S. Rigal : F. Pons
Department of Surgery, French Military Medical Academy, École
du Val-de-Grâce, Paris, France
Keywords Triage . Mass casualties . War . Waiting period
Introduction
The concept of triage is essential in the management of
soldiers’ and civilians’ wounds in war or in natural disasters.
Triage is used when the medical care system is overloaded,
meaning there are more people who need care than there are
available resources to care for them. It allows the rational
utilisation of resources in order to benefit the greatest number.
The French definition is “draw or choose, after examination.” Triage is a process of sorting the casualties
according to the severity of injury and the prioritisation
of treatment.
The need to sort war casualties rose dramatically in the
19th century during the Napoleonic wars. Dominique Jean
Larrey was the first to organise triage in the field [1, 2]. He
also described the echelons of care that characterise modern
military surgery.
The French army medical service is frequently engaged in
treating servicemen or civilians injured in armed conflict or
natural disasters. Our surgical teams have experience from
many military and humanitarian missions. Many times in
recent years, field surgical teams have used triage to the
benefit of French soldiers and combatants from other countries (2004 Ivory Coast; 2008 Kosovo; 2008 and 2012 Afghanistan; 2013 Mali).
The authors, with a Forward Surgical Team (FST) had to
cope with three episodes of triage of war wounded in 1994 in
Chad and Rwanda. This article reports the difficulties faced
and the lessons learned.
F. Pons
Clinic of General and Thoracic Surgery, Percy Military Hospital,
Clamart, France
Materials and methods
S. Rigal (*)
Service de Chirurgie Orthopédique, Traumatologie et Chirurgie
Réparatrice des Membres, 101 avenue Henri Barbusse, 92140,
Clamart, France
e-mail: s.rig@libertysurf.fr
This is a retrospective analysis of the management of three
mass casualties in Chad and Rwanda in 1994. FST of the
French Medical Corps is a small facility (Table 1). The first
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mission was to support the French Armed Forces and provide the initial medical support abroad for all military and/or
humanitarian operations. The wounded were not supposed to
stay in the FST. In the three reported experiences the unit had
no ability to evacuate the wounded.
International Orthopaedics (SICOT) (2013) 37:1433–1438
FST was rather more a small MASH than a simple FST. The
organisation of triage was well planned in this hospital because mass casualties of Chadian soldiers had been received
once or twice a year.
Rwanda, July 1994
Triage system
The French classification is based on one criterion only—the
waiting period for surgery. Classifications are reported in
Table 2. The third column shows a few examples of the
wounded for each category.
Environmental constraints
Chad, January 1994
Since 1986, one FST has been based in N’djamena to provide
surgical support for the French troops and for French citizens
and foreigners. The FST took care of Chadian soldiers and
some Chadian civilian people. In this case the FST was not
housed in tents but in a building with two well equipped
operating rooms, X-ray equipment and laboratory. There were
also a large number of ancillary personnel. In addition to the
FST there were regimental medical officers, one chemist, laboratory technicians, and nurses. There were also some Chadian
employees, who were very useful as translators. N’djamena
The same FST was sent to Rwanda in June 1994 with the
French troops during the “Operation Turquoise”. Its goal was
to try to stop the massacre of Tutsis people. The FST was
based in Goma, a city on the border between Rwanda and
Zaire. The FST’s organisation was basic. The FST was
planned for the emergency surgical treatment of French
soldiers before an early evacuation to France. Because of
an unexpected flood of refugees to Goma, the FST had to
take care of the civilian population as well. More than 500
patients were received within two months. We performed
more than 300 surgical procedures and coped with two mass
casualty situations.
Results
Mass casualties in Chad (Fig. 1). Twenty three wounded were
received within 24 hours. All were male adults. They
sustained 21 gunshot wounds and two blunt traumas. Categorisation was nine U1, ten U2 and four ambulatories (Fig. 2).
Table 1 Composition of a forward surgical team
Forward Surgical Team (FST) of the French armed forces military medical service
Category
Description
Mission
1. Treat wounded and after stabilisation quickly
evacuate them to the rear
2. Treat wounded civilians in humanitarian operation
Three physicians (one general surgeon, one orthopaedic
surgeon, one anaesthetist)
Five nurses (two anaesthetists, one operating room, one
for the ward)
Four corpsmen
Two tents: one operating room and one 12 bedroom
Equipment for the treatment of all surgical emergencies
(abdominal, thoracic, neurosurgical and orthopaedic)
Operational within one hour of arriving at location.
Ten to 12 procedures/day
Theoretical triage capacity: 100 wounded per day
Capable of working independently in 48 h
48 h (including water, food, gas for generating set, drugs,
surgical material)
30 red packed cells units, resupplied every three weeks
X-ray equipment, laboratory
5137 kg, 30 m3
Composition
Infrastructure
Equipment
Treatment capacity
Limits of independence
Basic supplies
Shipping size
International Orthopaedics (SICOT) (2013) 37:1433–1438
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Table 2 Triage categories
Category
Time to surgery
Example
EU/Extreme emergency
Immediate resuscitation
and/or intervention
U1/First emergency
6h
U2/Second emergency
U3/Third emergency
18 h (or more)
Massive haemorrhage
Respiratory distress
Abdomen
Limbs (tourniquet, major wounds)
Head (neurological signs)
Burns>15 %
Limbs
Head
Facial wounds, ophthalmology
Chest
Eclopés/Walking wounded
Potential emergency
No surgery
No surgery. Constant
reassessment and updating
No surgery
U4/Expectant
Nineteen wounded were operated upon within 48 hours. The
priority of treatment was first the face wounds, second the
thoracabdominal wound, and third abdominal and perineal
wounds. There was no mortality.
The first instance of mass casualties in Rwanda (Fig. 3)
occurred when thousands of refugees fled from the massacres.
The most severely injured were brought to the FST by helicopter. Ninety-four wounded were received within two hours.
Survivors were seen days or weeks after wounding. Thirty
percent were children and 20 % were women. Seventy percent
sustained machete wounds and 30 % gunshot wounds.
Triage was performed during the night in front of the
tents. Identification of the wounded was a difficult task. Most
of them did not speak French and we did not have translators.
Some children were too young to communicate with and
were frightened without their parents. For registration we had
to write a number on the forehead or the wrist of the patient.
Sixty eight out of 94 were operated upon. The delay between
wounding and arrival was so long that we did not face any
extreme or first level emergencies. All wounded were classified
Fig. 1 Distribution of injuries
in Chad
Multiple small wounds of the trunk :
penetration?
as second level emergencies (Fig. 2). Twenty-three patients
were operated upon within the first day. Priority was given to
head wounds because we feared cranio-cerebral injuries. Then
we treated perineal injuries and finally limb wounds. Many of
these injuries were infected with early gangrene. When children and adults presented with similar injuries, children were
treated first.
The second instance of mass casualties in Rwanda (Fig. 4)
occurred ten days later where one million refugees were
settled around the airport near the FST. They were targeted
by mortar attacks. Fifty nine wounded were received within
12 hours. Thirty percent were children, 70 % sustained
fragment wounds and 30 % gunshot wounds.
Triage was performed in daylight, most logistical problems
had been solved after the first triage, and translators were
available. Categorisation was such that there was one extreme
emergency (cardiac wound in a French officer) and three
patients were classified “expectant” (severe cranio-cerebral
wounds and coma). Nearly 50 % were classified extreme emergency or first emergency. The choice of priorities of treatment
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International Orthopaedics (SICOT) (2013) 37:1433–1438
Fig. 2 Categorisation in the three triage situations in Chad
had to be made for patients classified in the same category.
We therefore treated abdominal wounds before patients with
seriously damaged limbs.
Treatment of extreme and first emergency required 48 hours
of continuous work. Second and third level emergencies were
treated during the three following days. Some of them were
operated upon more than 20 hours after wounding, when they
should have been treated within six hours according to category. Thirteen patients died: three expectants, three while
waiting for surgery (one hip joint wound, two upper limbs
with severe injuries) and seven after surgery (one head, four
abdominal with associated injuries including three children,
two severe upper limb).
During the postoperative course we were forced to keep
these refugees in the FST because of the same lack of social
organisation and the impossibility of early evacuation. A
major cholera epidemic worsened the situation. Thousands
of refugees died from cholera. More than 150 patients stayed
under our tents and about 20 suffered from cholera but only
one died.
Discussion
These three episodes were very different when considering
the setting, the number of casualties and the types of wounds.
Fig. 3 Distribution of injuries during the first episode in Rwanda
Fig. 4 Distribution of injuries during the second episode in Rwanda
The logistical and medical difficulties were also different,
but they both shared the complete inability to transfer
wounded to a higher level of medical care.
A situation in which the number of casualties overwhelms
the medical resources is uncommon. For management of
many casualties we can distinguish two different situations.
First is multiple casualties, where the number does not exceed available medical resources. In this case, the triage
permits every patient the appropriate medical treatment without delay. Triage delivers “the right patient to the right place
at the right time” [3]. Second is mass casualties that overwhelm available medical facilities. Some patients simply
cannot be treated in a timely manner. The goal of triage is
to ensure the best possible chance of survival for the largest
number of people. Triage imposes a process which delivers
“the greatest good for the greatest number” [4] or “the best
for the most” and not “everything for everyone” [5].
Triage in Chad could be viewed as “easy”. This was a well
organised and trained facility where medical staffing was
adequate, equipment was sufficient, and the social context
was good. Families could help feed and provide the patients’
nursing. The triage was easy because there were a relatively
small number of casualties and the flow of victims did not
exceed capacity in any single day. Finally, because of a long
delay, the most severely injured died before arrival, making
decisions about the remaining priorities easy.
During the first mass casualty situation in Rwanda medical
problems were limited because of the very long delay before
arrival. Logistical problems were serious. Indeed major difficulties have to be expected when a small surgical facility is
coping with mass casualties over such a short period of time.
The organisation of the reception centre was difficult, e.g. for
registration, identification and translation with patients, especially for civilians and children. This has been reported by
several authors [6]. It is even more difficult when refugees are
without relatives to help them, when there is no possibility of
evacuation. Furthermore in overcrowded tents the monitoring
of patients is very difficult.
International Orthopaedics (SICOT) (2013) 37:1433–1438
Second mass casualty situation in Rwanda. The logistic
problems were solved or improved after the first mass casualties incident. The medical problems were very different. Sorting
was very difficult because of the high rate of seriously wounded, e.g. near 50 % were classified EU or U1 (the anticipated rate
during a standard conflict is about 30 %) [7]. The treatment of
those patients only required 48 hours. Some of them were
operated upon more than 20 hours after wounding, when they
should have been treated within six hours according to the
category. The perioperative mortality rate was high (22 %).
In the Red Cross classification, the priority seems to be
given to abdominal wounds [8, 9]. In the NATO classification stable patients with abdominal wounds seem to be
treated after the major limbs wounds. In our experience the
abdominal wounds were treated before the limbs wounds.
But in Rwanda some patients with major limbs wounds died
before surgery. We believe that some of them should have
been operated upon before the patients with abdominal
wounds. The large mortality in patients suffering from upper
extremity major injury is probably due to associated pulmonary blast with pulmonary and/or myocardial contusion.
Some patients died while waiting for surgery and some
others after surgery. One can wonder whether triage was
judicious. If we had operated earlier on those who died
before surgery or if we had decided not to operate on some
of those who died after surgery, maybe we could have saved
one or two more wounded.
We would like to highlight three points: logistic, medical
and ethics. In the ICRC hospitals it is generally agreed that
triage is declared when seven (or more) patients arrive simultaneously [8]. For an FSU as soon as the number of casualties
exceeds ten wounded, triage becomes very difficult to organise.
To identify the civilian casualties without ID is very hard. The
translator’s role is very important. Operating records should
also be classified in real time. Every team member should know
in advance his proper place and task during a mass casualty
situation. The decisions of the triage officer must be accepted
without discussion. During conflict involving a civilian population, secondary evacuation is usually impossible. We would
like to underline a very important point. Without evacuation
triage and treatment can be different and surgical procedures
must allow for simple postoperative monitoring.
There are a variety of defined triage systems used. It is
inherently difficult to investigate and compare disaster protocols
by using an evidence-based approach [10]. There is no definitive
data on which disaster triage technique would save the largest
number of victims. Each organisation has its own variation. In
every system three main categories are proposed—first, patients
to operate upon; second, patients not to operate upon because
they do not need surgical treatment; and third, patients not to
operate upon because they are too seriously injured and they
are unlikely to survive. The important points are that the
categorisation should be perfectly understood by every member
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of the team and members of the team should be regularly taught
and trained about the classification used.
Triage is a medical task that requires moral responsibility.
The triage officer needs internal stability and external authority [11, 12]. In the past he was the most experienced surgeon.
Nowadays the triage officer is the anaesthetist–intensivist
[13]. However, we must consider that both are complementary. The surgeon probably better evaluates the length of the
surgical procedure. The anaesthetist–intensivist has a better
expertise in resuscitation. Application of effective and accurate triage is a team-based multidisciplinary activity.
These three aspects of triage bring us to a discussion of two
key ethical problems, i.e. the notion of expectant and the neutrality of the choice. It is very hard to think of “expectant”, whereby
two types of wounded may be classified into this category. The
first variety is not difficult to classify as they are the extremely
wounded patients. However, it is very hard to classify the second
group, which comprises patients who might be saved after
prolonged surgical treatment and major resuscitation.
Could we sort patients using only medical criteria?
According to Dominique Larrey [1] and the Geneva convention [14] one should triage regardless of nationality, race, sex,
religion, rank, etc. The only criteria used for triage should be
the medical status. A classification using criteria other than
medical principles is a violation of human rights [11]. However, wounded children in a war mass casualties situation are
uncommon for military teams. For civilian patients in the
same category we believe that priority must be given to
children, because they are weaker. If we sort children we could
classify some of them as “expectant”. But such a decision
seems to be very difficult, or even impossible. However
because of the high postoperative mortality of children with
abdominal wounds and associated lesions we think that some
of them should have been classified “expectant”. It is absolutely necessary that each member of the medical team thinks
about this particular category beforehand.
Conclusion
For the majority of surgeons, triage is an abstract concept.
They never have to use it in their daily practice. Triage in war
or disaster conditions is a complex process with no direct
civilian medical equivalent. Each medical unit must be prepared to participate in a realistic triage practice.
Theoretically the medical team of a forward surgical team
knows the principles of the triage. However, we have been
surprised by the number of casualties and the resulting logistics problems, by the issues of prioritisation, by the presence
of a large number of children and by the issue of when to
apply the expectant category.
Battlefield surgery, because it sometimes deals with mass
wounded, requires a replacement of “individual ethics” with
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the ethics of doing “the greatest good for the greatest number” [4].
Conflict of interest The authors declare that they have no conflict of
interest.
The views expressed are solely those the authors and do not necessary
reflect the official policy or position of the French army medical service.
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