#Baron Dominique Jean Larrey

[aquitainequeen]

Ridley Scott: I made a film about two rival officers constantly duelling throughout and in the aftermath of the Napoleonic Wars, and now I've actually done a film about Napoleon!

Me: Great! Could you also do a film about Baron Dominique Jean Larrey, a vital innovator in European battlefield surgery and triage, often considered the first military surgeon; who pioneered the ambulance volantes ("Flying ambulances") to quickly transport wounded men from the battlefield, effectively creating a forerunner of the modern MASH units; co-led the team that performed one of the first accurately recorded pre-anaesthetic mastectomies in Western medicine; was spotted helping wounded men while under heavy fire during the Battle of Waterloo by the Duke of Wellington who purposefully ordered for his soldiers not to fire in Larrey's direction; and when captured by the Prussians after the battle was about to be executed on the spot when he was recognised by one of the German surgeons, who pled for his life because he had saved the life of Field Marshall Blücher's son some years earlier?

Ridley Scott:

Ridley Scott: Um.

Me: Yeah. Didn't think so.

[senechalum]

I’m not sure if you’re taking requests still, but I’d rather ask and get ignored than not ask at all.

Could you possibly do one of Larrey or Frederik vi?

If you need references for either, just dm me, I’ve got plenty.

Hellooo !!

I'm still taking requests, yes, my job doesn't allow me to draw a lot but I'm doing my best to finally answer them all <3 This allows me to also try new things, new brushes, new coloring styles... !

Here's portrait of Larrey for you :) If you have references of Frederik VI, feel free to send me a private message and I'll try to draw him next month ! :D

[usergreenpixel]

No joke, an AU about Larrey sounds excellent!

Surgeons don’t get as much appreciation as they deserve!

I remembered your poster so…

“SOS! SOS! HELIUM POISONING DETECTED! SEND FOR DJ LARREY SPACE SURGEON! SOS!”

I wanted to draw something pulpy with these new things I downloaded, but how do?

HOW DID MY COMIC FOREBEARS LIVE?!

*slams fist on table* they didn't even have the undo button...

[armagnac-army]

OOC: The Napoleonic Askblog/Roleplay Scene Directory

Here's an Out Of Character post listing the blogs I'm aware of in the Napoleonic RPF Roleplay Scene! It's OOC because Lannes would want to make sarcastic remarks with typos.

If you want (or don't want) your blog on this list, message me and whether you want a main/other blog associated with your name or whether you want to be anonymised! Also happy to include non-Frenchmen and Frev folks.

Doubles or multiple versions of people are welcome, this is a varied afterlife. We all have our different ideas for what this afterlife is like as well.

Feel free to reblog or link to this!

And now we have a OOC discord server to chat about all of this! Feel free to join if you'd like!

The Marshalate

armagnac-army - Jean Lannes, Duke of Montebello - played by cadmusfly

murillo-enthusiast - Jean-de-Dieu Soult, Duke of Dalmatia, and ADCs - played by cadmusfly

@le-brave-des-braves - Michel Ney, Prince of the Moskva, Duke of Elchingen, and ADCs - played by @neylo

@your-dandy-king - Joachim Murat, King of Naples - played by @phatburd

@chicksncash - André Masséna, Prince of Essling, Duke of Rivoli, and others - played by @chickenmadam also playing as his ADC, with appearances from Marshal Augereau, the Cuirassier Generals d'Hautpoul and Nansouty, and the Horse Grenadier General Lepic

@your-staff-wizard - Louis-Alexandre Berthier, Prince of Neuchâtel and Valangin, Prince of Wagram - played by @chickenmadam, as above

@perdicinae-observer - Louis-Nicolas Davout, Prince of Eckmühl, Duke of Auerstaedt - played by @mbenguin

@bow-and-talon - Laurent de Gouvion Saint-Cyr, Marquis of Gouvion-Saint-Cyr

@france-hater - Jean-Baptiste Bernadotte, or Karl XIV Johan of Sweden, played by @deathzgf also includes the Duke of Wellington and Prince Pyotr Ivanovich Bagration

@simple-giant-ed - Édouard Mortier, Duke of Treviso, played by @isa-ko

@bayard-de-la-garde - Jean-Baptiste Bessières, Duke of Istria

@le-bayard-polonaise - Prince Józef Poniatowski of Poland

@oudinot-still-alive - Nicolas Charles Oudinot duc de Reggio, played by @spaceravioli2

@beausoleil-de-bellune - Claude-Victor Perrin, Duke of Belluno

@commandant-des-traitres - Auguste de Marmont, Duke of Ragusa

The Grande Armée

@general-junot - Jean-Andoche Junot, Duke of Abrantes - played by @promises-of-paradise

@askgeraudduroc - Géraud Duroc, Duke of Frioul, Grand-Marshal of the Palace - played by @sillybumblebeegirl, also with cameos from Marshal Bessières shared with your-dandy-king

@trauma-and-truffles - Baron Dominique-Jean Larrey, Surgeon to Napoleon and the Imperial Guard - played by @hoppityhopster23 who also plays his modern assistant

@generaldesaix - Louis Charles Antoine Desaix de Veygoux, most likely would have been a marshal if he lived - played by @usergreenpixel

@messenger-of-the-battlefield - Marcellin Marbot, aide-de-camp of maréchal Lannes - played by @a-system-of-nerds (Inactive)

@le-dieu-mars - Jean-Baptiste Kleber, General - played by @chickenmadam

@puddinglesablonniere - Charles-Étienne César Gudin de La Sablonnière, Gemeral of Davout's Corps

@francoislejeunes - Baron Louis-François Lejeune, ADC to Berthier, Artist and Engineer

@troboi1806 - Jacques de Trobriand, ADC to Marshal Davout

@cynics-and-cynology, Captain Elzéar Blaze

@thehussargeneral - General Antoine-Charles-Louis, Comte de Lasalle, played by upbeatmeeting

@pondicherry-pie - Charles-Rene Magon de Medine, Rear Admiral of the Combined Fleet at Trafalgar, played by chickenmadam

chanceux-et-perdu - Pierre-Charles-Jean-Baptiste-Silvestre de Villeneuve, Vice Admiral of the Combined Fleet at Trafalgar, played by cadmusfly

The Bonaparte Family

@carolinemurat - Caroline Murat née Buonaparte, Queen of Naples - played by @usergreenpixel

@alexanderfanboy - Napoleon Bonaparte, The Big Cheese

@frencheaglet - Napoleon II, also known as Franz, Duke of Reichstadt, played by @usergreenpixel

@rosie-of-beauharnais - Rose Beauharnais, also known as Josephine Bonaparte, once Empress of the French

@le-fils - Eugène Beauharnais, Prince of the Empire, Bonaparte's stepson, played by @josefavomjaaga

@jbonapartes - Jérôme Bonaparte, King of Westphalia, Prince of Montfort

@napoleon-bonapartee - Napoleon Bonaparte, The Head Honcho

Other Notable Personages

@askjackiedavid - Jacques Louis David, neoclassical painter - played by @sillybumblebeegirl

@lazarecarnot - Lazare Carnot, mathematician, military officer, politician and a leading member of the Committee of Public Safety

@serpentofotranto - Joseph Fouché, Duc d'Otrante, Comte Fouché, statesman and Minister of Police

@monsieurdetalleyrand - Charles-Maurice de Talleyrand-Périgord, Prince of Talleyrand, statesman and diplomat

Not French

Russians

@the-blessed-emperor - Tsar Alexander I (Inactive)

@loyal-without-flattery - General Aleksey Andreevich Arakcheev, who runs His Imperial Majesty's Own Chancellery (Inactive)

@misha-wants-to-go-home - Count Mikhail Andreyevich Miloradovich, played by @spaceravioli2

@catherinesucks - Tsar Paul I of Russia, father of Alexander I

@ask-tsaralexander - Tsar Alexander I, played by @goddammitjosef

British

@the1ronduke - Arthur Wellesley, Duke of Wellington, played by @spaceravioli2

@banasstre - Banastre Tarleton, Major-General

@pakenham-kitty - Catherine Wellesley, Duchess of Wellington

@britannias-god-of-war - Vice-Admiral Horatio Nelson, 1st Viscount Nelson, 1st Duke of Bronte

@lord-byrons-ghost - some Napoleon fan Lord George Gordon Byron, played by @vesseloftherevolution

Spanish

@headlessgenius - Francisco José de Goya y Lucientes, Painter and proud Spaniard

Prussians

@der-schnapsvater - Field Marshal Gebhard von Blücher

Original Characters and Friends

@the-adventures-of-lydia-brown - Lydia Brown, a jack of all trades and problem solver finding herself in this strange realm with all these dead Frenchmen

Hopster, trauma-and-truffles's modern time travelling assistant

Madam DuQuay, ADC who takes no nonsense, helping out chicksncash, your-staff-wizard and le-dieu-mars

[trauma-and-truffles]

After the Cake Incident with Marshal Lannes, My assistant, Mlle. Hopster has been telling me to make a blog myself. I finally gave into her pestering.

I'll probably make a better introduction at a later date, as by then I'll have a better gist of Tumblr.

I am Baron Dominique-Jean Larrey, Surgeon to Emperor Napoleons Imperial Guard. Feel free to ask whatever you like.

-Larrey

( This blog is run by @hoppityhopster23) (Disclaimers: This blog does not provide professional medical Advice, nor am i a professional historian. I'm just well read about the history of medicine and enjoy reading about Larrey) ------------------

Tags: Responses from the the Baron - answers to any asks.

Conversations with the assistant - Conversations with my time traveler assistant. shes the one who convinced me to create this. shes also young, sometimes foolish, and likes to give people bad ideas.

Portraits of the Doctor - Images of me.

Comments from the Assistant - self explanatory

-------------------

Fellow Soldiers and marshals, etc (personal notes below):

Marshals Other Military Staff Royals Other

@armagnac-army - My Dear Friend Lannes, Marshal of France, Prince of Siewierz, and Duke of Montebello.

@murillo-enthusiast - Jean-de-Dieu Soult, Marshal of France and Duke of Dalmatia. (I'm pretty sure he just tolerates me.)

@le-brave-des-braves - Michel Ney, Marshal of France, Prince de la Moskowa, and Duke of Elchingen. (He's very helpful, And I am grateful.)

@your-dandy-king - Joachim Murat, Marshal of France and King of Naples.

@chicksncash - Andre Massena; Marshal of France,  Duke of Rivoli, and Prince of Essling.

@your-staff-wizard - Louis-Alexandre Berthier, Marshal of France, Prince of Neuchatel, Valangin and Wagram, and technically my boss.

@perdicinae-observer - Louis Nicolas Davout, Prince of Eckmühl, Duke of Auerstadt.

@bow-and-talon - Laurent de Gouvion Saint-Cyr, Marquis of Gouvion-Saint-Cyr, and a man I respect for giving the us Medical staff needed in life.

@general-junot -  Duke of Abrantes, and General of the French army.

@askgeraudduroc - Also My good friend, Grand Marshal of the palace, Duke of Frioul, and head of the Emperors household.

@generaldesaix - One of my closest Friends. Unfortunately we didn't have a lot of time together in life. nut now we do.

@messenger-of-the-battlefield - Marcellin Marbot, an aide to an assortment of Marshals, and a man I met a few times in life.

@askjackiedavid - Jacques Louis David, neoclassical painter.

@carolinemurat - Caroline Murat, Queen of Naples, and sister of the Emperor.

@alexanderfanboy - Napoleon Bonaparte, Emperor of France.

@rosie-of-beauharnais - Josephine, the Empress of France.

@the-blessed-emperor - Alexander I, Tsar of Russia.

[le-brave-des-braves]

Bienvenue

you have reached my communication channel. I shall read through the letters as soon as one of my ADCs brings them to me, which might depend on the situation in the field.

You are welcome to submit any question, please be brief and go straight to the point. The love letters will be rejected.

If anyone has seen my family, please let me know.

Ney.

Prince de la Moskowa, Duc d’Elchingen, Maréchal d’Empire

The marshal is a busy man, and some inquiries might be answered by us, his staff:

General Baron Antoine-Henri Jomini, chief of staff of Marshal Ney and the strategy expert. and a traitor who should not even be here Author of multiple best-selling books on the matter.

Captain Octave Levavasseur, the most heroic aide-de-camp of Marshal Ney and author of the bestselling book of simping about Ney Memoir!

Colonel Pierre-Agathe Heymes, the adult one

Tags:

Les proclamations du Maréchal: announcements and official letter responses

Communication personnelle du Maréchal: Private communication

Les portraits du Maréchal: related art done either by @neylo or associates

Meine Adjutanten sind Idioten: The Aides-de-camp are responsible and upstanding officers except for the time when they aren’t

Disclaimer: This is rp/ask blog created for fun by @neylo. Please note that I am no Napoleonic historian and my only qualification might be that I also happen to be a redhead disaster with no concept of patience.

Didn't you have enough? Time to get to know the rest of the dead French squad!

@armagnac-army - Jean Lannes (he still didn't learn to spell)

@askgeneralduroc - Geraud Duroc and family (although he might be very busy since he is apparently a proud dad now)

@murillo-enthusiast - Jean de Dieu Soult (That loser who thinks he should be the king of Portugal. He should not.)

@your-dandy-king - Joachim Murat (and his terrible taste) - the KING OF ITALY

@chicksncash - André Masséna (you might miss your wallet after the conversation)

@general-junot - Jean-Andoche Junot (not even a marshal. He needs a therapist)

@trauma-and-truffles - Dominique Jean Larrey - Medical attention (More like amputation station)

@your-staff-wizard - Louis-Alexandre Berthier - The Prince of Paperwork

[snatching-ishidates-wig]

"Probably the outstanding surgeon was Dominique Jean Larrey (1766-1842), who was also an organizer, teacher, and inventor. He became surgeon-in-chief to the Imperial Guard, a baron, Commandant of the Legion of Honor, and Knight of the Order of the Iron Crown. Napoleon considered him the most virtuous man he had ever known. Practically his equal was Pierre François Percy, inspector general of military hospitals and surgeon-in-chief to the Army.

Both men hoped to make the Service de Santé an independent, self-sufficient organization with its own trains and full control over its hospitals. Sadly, some soldiers did not appreciate even their most devoted services. While Percy and his surgeons worked in the freezing cold at Eylau, stragglers stole their horses, swords, and baggage.

Swords Around A Throne, John R. Elting

[josefavomjaaga]

An apparently undated letter from Larrey to his wife, thought to be from the period of May to June 1807 (so during the Prussian/Polish campaign). Rough translation of the passages that are quoted in the sales description:

[...] you know in fact that my existence is attached to yours and that the fatal chisel that would cut the thread of your days would also cut that of your friend's. I don't know why, but I imagine that this intimate and strong sympathy was undoubtedly established by great causes, certainly it could only be your rare qualities, your graceful and expressive eyes when you transmit to them the sweet affections of your soul, your melodious and divine voice, your whole being at last animates my life and captures my heart, which yearns only for you and your Isaure, who seems to me to be another little Laville. How pleased I was by her letter, dear friend, especially when she told me that you had called me by the name of your little Larrey [...]. Why don't you give it to me more often? Why upset this unfortunate man who has only ever loved his Laville? Ha! if you only knew how much she occupies me even in the midst of my most important occupations! You would certainly love me more if you could read my thoughts: you would at least pay more attention to consoling this poor doctor who is constantly surrounded by the dead and the dying and by all sorts of vicissitudes [...]

While this is in total a very sweet declaration of love, I feel like there are also hints of tension, a long time before Larrey returned home and, as even his adoring biographer Triaire admitted, made his family suffer? According to the sales page, the passage translated above comes after Larrey has told his wife to only talk to him about domestic matters, never about politics. Did he and his wife not agree in political matters? I understand they did come from very different backgrounds which may have shaped their views of the world. But there's also at least a subtone of "you do not care enough about me!"

But most importantly: We have another wife calling her husband by his family name. "Mon petit Larrey". Though in this case, everything else would be astonishing, after all, the husband also called his wife by her family name "Laville".

[histoireettralala]

Older Larrey and the company he keeps.

Orientalism is in fashion, people support the Greeks in their struggle for independence against the Turks, Gérard de Nerval is preparing his trip to the East, Victor Hugo has published Les Orientales. Alexandre Dumas also seeks documentation because his editor of the Bureau de l'Echo des Feuilletons is anxious to publish the periodicals that his subscribers demand. Who moreover, better than Larrey, could inform him about the regions of the eastern Mediterranean?

{Alexandre Dumas, photography by Nadar.}

At Dumas’, the Larreys meet Baron Taylor, an informed art lover. Commissioner of the Théâtre-Français, he accepted that Hernani be staged and returned from Spain where he bought on behalf of the Louvre the Velasquez or Murillo paintings that Soult had not been able to appropriate to resell to the English. In 1836, he took part in the erection of the Luxor Obelisk on the Place de la Concorde.

{Le Baron Taylor}

Of the caliber of Vivant Denon, he is a man whom H. Larrey admires to the point of saying about him:

"One still listens to him when he doesn't speak anymore!"

There is also Franz Liszt, with his emaciated face, his long, already silver hair while he is not thirty years old. Famous for the power of his compositions, the virtuosity of his technique, he is also passionate about philosophy and human physiology and has found in Larrey an excellent interlocutor whom he can question at will.

{Franz Liszt in 1843}

When he stays in Paris, the prince of Metternich, the man who fixed in 1815 at the Congress of Vienna the destiny of Europe for one hundred years, seeks the company of Larrey because he prides himself on his knowledge of anatomy, cerebral in particular. [..]

In the salon of the Duchess of Abrantès as in that of Dumas, Larrey found by chance René de Chateaubriand, who attends only that of the resplendent Juliette Récamier in order to share their common passion. Gradually withdrawn from politics, the illustrious writer chairs the commission responsible for erecting a monument in memory of Junot. Composed of Maret, the former Secretary of State of Napoleon, the banker Laffitte, both ephemeral presidents of the Council of Louis-Philippe, David, Alexandre Dumas, it would be usefully completed by the presence of Larrey, says Chateaubriand. Although placed at political antipodes, both will find enough elevation of thought to forget the past, mutually respect each other's work and collaborate.

{Chateaubriand, by Girodet}

The only thing Larrey can neither forget nor forgive is betrayal.

During a reception given by the Comte de Rambuteau, Prefect of the Seine, Larrey sees a young officer whom he had known well in the wars of the Empire.

Endowed with a beautiful bass voice, he finishes his recital, leans nonchalantly on the piano before saluting a delighted audience. No one knows that with four other staff officers, he followed de Bourmont to pass to the enemy the day before Waterloo, white cockade on his hat, but in the early morning so as not to be seen.

Having distinguished Larrey among the guests, he crosses the room, walks towards him, a bewitching smile on his lips, hand widely extended:

"What! You don't recognize me, Mr. Larrey? I am ..."

Larrey, scowling, frowning, has taken two steps back, arms crossed, and interrupts him in an icy tone:

"The officer I knew by that name died at Waterloo!"

Then he ostensibly turns his back and leaves.

Jean Marchioni - Place à monsieur Larrey, chirurgien de la garde impériale

[microcosme11]

Baron Dominique Jean Larrey tending wounded on a winterly battlefield, in "Histoire de l'empire faisant suite a l'histoire du consulat" by Adolphe Thiers -1879

[count-lero]

Soooo I’m a little bit at a loss and just simply try to post… something, I guess??? 😂

Few drawings from the past year which I still adore!

The first one represents count Michail Andreevich Miloradovich, one of the bravest and most restless generals of the Russian Empire during Napoleonic wars. 🇷🇺🇷🇸🇺🇦 ✨

The second one shows Dominique-Jean baron Larrey, famous french field surgeon. 🇫🇷🩸

And in the third picture we have the one and only Armand Augustin Louis marquis de Caulaincourt, french general and diplomat who served twice as french ambassador in Saint-Petersburg. 🇫🇷✒️🗡

[elisabeth515]

Happy birthday Larrey!!!!!

I just realised that today is Larrey’s birthday and so I made this🌚 This is my first time drawing Larrey and I know I messed up

Baron Dominique-Jean Larrey was born this day in 1766. He was the chief surgeon of the Imperial Guard, also known for his humanitarian treatment of the wounded regardless of nationality and innovations in battle field medicine (such as battlefield ambulances). Napoleon was (very) fond of him.

Btw his son Hippolyte looks like old Speedwagon from Jojo goddamnit-

[senechalum]

Treasure ??

I didn’t buy it because I already spent too many euros in books this month. I’ll see if it’s still there at the end of the month !!

[deniscollins]

The Hardest Questions Doctors May Face: Who Will Be Saved? Who Won’t?

If you were a medical director and had 10 ventilators with 30 people needing the, thus can only save the life of 10 out of the 30, how would you determine who gets a ventilator by: (1) age (preference to young), (2) highest likelihood of survival, (3) most in need, (4) lottery, (5) first-come, first-served, (6) combination (if so, which ones), (7) something else (if so, what)? Why? What are the ethics underlying your decision?

The medical director of the intensive care unit had to choose which patients’ lives would be supported by ventilators and other equipment. Hurricane Sandy was bearing down on Bellevue Hospital in New York City in 2012, and the main generators were about to fail. Dr. Laura Evans would be left with only six power outlets for the unit’s 50 patients.

Hospital officials asked her to decide which ones would get the lifesaving resources. “Laura,” one official said. “We need a list.” After gathering other professionals, Dr. Evans checked off the names of the lucky few.

Now, she and doctors at hospitals across the country may have to make similarly wrenching decisions about rationing on a far bigger scale. Epidemic experts predict an explosive growth in the number of critically ill patients, combined with severe shortages of equipment, supplies, staffing and hospital beds in areas of the U.S. where coronavirus infections are surging, hot spots that include New York, California and Washington State.

Health workers are urging efforts to suppress the outbreak and expand medical capacity so that rationing will be unnecessary. But if forced, they ask, how do they make the least terrible decision? How do they minimize deaths? Who even gets to decide, and how are their choices justified to the public?

Medical providers are considering these questions based on what first occurred in China, where many sick patients were initially turned away from hospitals, and now is unfolding in Italy, where overwhelmed doctors are withholding ventilators from older, sicker adults so they can go to younger, healthier patients.

Choosing between patients “goes against the way we used to think about our profession, against the way we think about our behavior with patients,” said Dr. Marco Metra, chief of cardiology at a hospital in one of Italy’s hardest-hit regions.

In the United States, some guidelines already exist for this grim task. In an effort little known even among doctors, federal grant programs helped hospitals, states and the Veterans Health Administration develop what are essentially rationing plans for a severe pandemic. Now those plans, some of which may be outdated, are being revisited for the coronavirus outbreak.

But little research has been done to see whether the strategies would save more lives or years of life compared with a random lottery to assign ventilators or critical care beds — an option some support to avoid bias against people with disabilities and others.

Some commonly recommended rationing strategies, researchers found, could paradoxically increase the number of deaths. And protocols involve value judgments as much as medical ones, and have to take into account the public’s trust.

If hospitals withhold treatment by age, where do they draw the line? If they give lower priority to those with certain underlying health conditions, they may in effect be offering black Americans less treatment than white Americans. If physicians try to redirect resources — putting a patient on a ventilator for a few days, then giving it to someone else who appears to have better prospects — more people may die because few would get adequate treatment. And if many patients have a similar chance of survival, what fair way is there to make a choice?

The federal government, so far at least, is not providing national rationing guidelines for the coronavirus outbreak. Officials from various states, medical associations and hospitals are discussing their own plans, potentially resulting in very different decisions on life-and-death matters about which there are deep disagreements, even among medical professionals.

“You have to be really clear about what you are trying to achieve,” said Christina Pagel, a British researcher who studied the problem during the 2009 H1N1 flu pandemic. “Maybe you end up saving more people but at the end you have got a society at war with itself. Some people are going to be told they don’t matter enough.”

‘The Most Good’

Just before the coronavirus outbreak, Dr. Evans, the physician at Bellevue, moved across the country to direct the intensive care unit at the University of Washington Medical Center in Seattle. The city became one of the first areas in the United States to see community spread of the virus.

The hospital is doing whatever it can to prevent the need to ration — what Dr. Evans referred to as “an ethical obligation.” Like other institutions, it is trying to increase supplies, training staff to act in roles that may be outside their usual jobs and postponing elective surgeries to free up space for coronavirus patients. Some cities are racing to construct new hospitals.

Strategies to avoid rationing during the pandemic were published by the National Academy of Medicine. But hospitals across the country vary in their adherence to such steps. At the University of Miami’s flagship hospital, surgeons were told last Monday to cancel elective surgeries, but across the street at Jackson Memorial Hospital, they were “given wide discretion over whether to cancel or proceed,” according to an update sent to physicians.

Dr. Evans is working with health leaders in Washington State to figure out how to implement triage plans. Their goal, she said, would be “doing the most good for the most people and being fair and equitable and transparent in the process.”

But guidance endorsed and distributed by the Washington State Health Department last week suggested that triage teams under crisis conditions should consider transferring patients out of the hospital or to palliative care if their baseline functioning was marked by “loss of reserves in energy, physical ability, cognition and general health.”

The concept of triage stems from Napoleon’s battlefields. The French military leader’s chief surgeon, Baron Dominique Jean Larrey, concluded that medics should attend to the most dangerously wounded first, without regard to rank or distinction. Later, doctors added other criteria to mass casualty triage, including how likely someone was to survive treatment or how long it would take to care for them.

Protocols for rationing critical care and ventilators in a pandemic had their beginning during the anthrax mailings after the Sept. 11 attacks, but have not previously been implemented.

Dr. Frederick M. Burkle Jr., a former Vietnam War physician, laid out ideas for how to handle the victims of a large-scale bioterrorist event. After the SARS outbreak stressed Toronto hospitals in 2003, some of his ideas were proposed by Canadian doctors, and they made their way into many American plans after the H1N1 pandemic in 2009. “I have said to my wife, ‘I think I developed a monster here,’” Dr. Burkle said in an interview.

What worried him was that the protocols often had rigid exclusion criteria for ventilators or even hospital admission. Some used age as a cutoff or pre-existing conditions like advanced cancer, kidney failure or severe neurological impairment. Dr. Burkle, though, had emphasized the importance of reassessing the level of resources sometimes on a daily or hourly basis in an effort to minimize the need to deny care.

Also, the plans might not achieve their goals of maximizing survival. For example, most called for reassigning a ventilator after several days if a patient was not improving, allowing it to be allocated to a different patient.

But rapidly cycling ventilators might not give anyone enough chance to improve. When the coronavirus causes severe pneumonia, doctors are finding that patients require treatment for weeks.

In Canada, a study of H1N1 patients found that 70 percent of those who would have been withdrawn from ventilators after a five-day time trial if a rationing plan had been implemented actually survived with continued care.

Researchers at a British hospital had similar findings, concluding that “a new model of triage needs to be developed.”

A Score Card and a Lottery

Many of the original plans in the U.S. were developed exclusively by medical personnel. But in Seattle, public health officials gathered community input on a possible plan more than a decade ago.

Some citizens feared that using predicted survival to determine access to resources — a common strategy — might be inherently discriminatory, according to a report on the exercise. Citing “institutional racism in the health care system,” they were concerned that the metrics for some groups, like African-Americans and immigrants, would be skewed because they had not received the same quality of care.

There were similar findings in Maryland, where researchers at Johns Hopkins engaged residents across the state in deliberations over several years.

The researchers presented them with several options. Hospitals could assign ventilators on a first-come, first-served basis. Some thought that could disadvantage people who lived far from hospitals. A lottery struck other participants as more fair.

Others argued for a more outcome-oriented approach. One goal could be saving the highest number of lives, regardless of factors like age. A different goal could be saving the most years of life, a strategy favoring younger, healthier patients. Participants also considered whether those playing a valuable role in a pandemic, like medical workers who risked their lives, should be made a priority.

After the project ended, the Hopkins researchers designed a framework that assigns scores to patients based on estimated probability of short- and long-term survival. The latter was defined by whether the person had a pre-existing life expectancy of at least a year. Ventilators would be provided, as available, according to their ranking. The framework recommends a lottery for lifesaving resources when patients have identical scores. Stage of life may also be used as a “tiebreaker.” Decisions should be made by designated triage officers, not individual doctors caring for patients, and there should be a limited appeals process in cases of resource withdrawal, the protocol said.

The public input led the Hopkins researchers not to incorporate most exclusion criteria.

Dr. Lee Daugherty Biddison, one of the effort’s leaders, said that was because most participants were uncomfortable excluding patients with underlying health issues. Preconditions don’t always predict survival from respiratory viruses, and having chronic diseases like diabetes, kidney failure and high blood pressure often tracks with access to medical care. Rationing based on these conditions would be “essentially punishing people for their station in life,” Dr. Biddison said.

The Hopkins group published a description of the framework last year, and doctors from other Maryland hospitals are teleconferencing twice a day to prepare to implement the plan if conditions grow extreme. Dr. Biddison has also been sharing the recommendations with doctors across the country.

In Pennsylvania, Dr. Douglas B. White, chairman of ethics in critical care medicine at the University of Pittsburgh School of Medicine, is using the Hopkins protocol to help prepare hospitals in his state.

In Colorado, Dr. Matthew Wynia, a bioethicist and infectious disease doctor, is working on a plan that would also assign a score. In his rubric, the first considerations are odds of survival and expected length of treatment. He said there was wide agreement among planners “not to make decisions on perceived social worth, race, ethnic background and long-term disability status,” which some fear could happen if doctors had to make seat-of-the-pants judgments without guidelines.

He is also trying to ensure that patients on admission to Colorado hospitals are asked whether they would forgo a ventilator if there were not enough for everyone. “One thing everyone agrees on is that the most morally defensible way to decide would be to ask the patients,” Dr. Wynia said.

He supports the idea of reassigning ventilators in certain cases. “If things are clearly getting worse, it’s really hard to justify a stance of once you’re on a vent, you own it, no matter how many people have to die in the meantime,” Dr. Wynia said.

Unlike in Italy, where age has been used in rationing treatment, some people developing protocols elsewhere have de-emphasized it. “There are arguments about valuing the young over the old that I am personally very uncomfortable with,” Dr. Pagel, the British researcher, said, including that young people should be a higher priority because they have more life ahead of them.

“Where is your threshold? Is a 20-year-old really more valuable than a 50-year-old, or are 50-year-olds actually more useful for your economy, because they have experience and skills that 20-year-olds don’t have?”

A Right to Know

As Hurricane Sandy intensified outside Bellevue in 2012, Dr. Evans referred to New York State guidelines, since updated — which some hospital leaders have said they will follow if overwhelmed by the coronavirus — on how to allocate ventilators in a pandemic using a scoring system that tries to estimate someone’s chance of survival. She pulled together an ad hoc committee of doctors, ethicists and nurses. “Having a system and procedures gave us a sense we had some control of the situation,” she recalled.

For those about to lose electricity, she and her colleagues stationed two staff members at the bedside of all patients who relied on ventilators, preparing to manually squeeze oxygen into their lungs with flexible Ambu bags.

Looking back, Dr. Evans feels the patients and their families had the right to know that their machines would lose power, but in the crisis they hadn’t been told. The doctors also did not think to ask whether any patients or their families might volunteer to give up a power outlet so that it could be provided to someone else. “It wasn’t even on my radar,” Dr. Evans said.

In the end, it was improvisation that prevented tragic rationing at Bellevue. The generator fuel pumps failed, but a chain of volunteers hand-carried diesel up 13 flights of stairs. Dr. Evans’s patients were all maintained on backup power until they were transferred to other hospitals.

“I remember it really vividly,” she said of the experience. “It’s going to stay with me my entire professional career.”

[thiswaycomessomethingwicked]

Do you know how long an amputation would take to heal during the Napoleonic era? Above knee amputation, i mean.

Hello again! Your poor main character is in for a rough ride. 

As always, amputation was always a last resort. A sort of “you’ll die if we don’t, and you might die if we do so I mean your call.” That said, given the limited options at the time amputation was a life-saving operation in many cases. 

If you had a good surgeon the amputation itself would have been relatively quick although still painful and dangerous, especially without general anesthetic. Field surgeons and naval surgeons were very well versed in amputations and had it down to a science. As a soldier or sailor, for the act of amputation itself you were in good hands. If you were a labourer and an accident befell that necessitated amputation it would depend on your proximity to a large enough town that would have an experienced surgeon. Not that the local barber-surgeon wouldn’t be able to do it; they would! But the efficient removal of the limb might uh … not be efficient. For every surgeon who had it down to 30 seconds there is an equivalent horror story. 

According to Joseph Charriere in his 1712 treatise on surgery, it is recommended for surgeons to 'cut quick with a crooked knife (saw) before covering the stump with the remaining skin.’

Post-surgery they would stitch and bind the wound. The first four to five weeks would be spent with a very swollen leg and phantom limb-pain might begin to occur at this time. Not everyone experiences it; but it’s also not uncommon. 

In general, the healing process would vary depending on infection. Many didn’t survive amputation, either due to shock or gangrene. Lannes is one of the more famous cases of an amputee dying post-surgery due to gangrene having set in. If the amputation went poorly people would die anywhere from immediately after the amputation to upwards of seven to twelve days later.  

An account of Lannes’ amputation: 

Marshall Jean Lannes, a favorite of Napoleon and someone much admired by Larrey, who was hit by a three-pound ball during the battle of Essling on May 22, 1809, which shattered the left knee and also injured the right thigh, and left Lannes in extremis. Larrey was taken aback by the challenge of this situation. “How my situation was so difficult,” he later recorded. He wanted to offer hope to this brave leader, and yet he could see that the eventual outcome was at best questionable. Larrey knew and admired Lannes, who had been his great friend and his patient also in Syria and Egypt. “I swear that this was one of the most difficult circumstances of my life.” All agreed that an amputation was needed, but no one dared to try it, given the precarious state of the patient. Finally, Larrey quickly amputated the leg, taking less than 2 minutes, and this was well tolerated by Lannes. Lannes was to die at daybreak on May 30, 1809.

–David Welling, “The influence of Dominique Jean Larrey on the art and science of amputations,” Journal of Vascular Surgery, 2010. 

Presuming you’re a lucky one, have clean enough bandages and wound and no lingering infection, you could begin moving about around a month after surgery. There was no real concept of physical therapy in the modern sense of a strict program to retrain muscles after trauma but people absolutely made up their own version. 

To get back up to full speed it would take anywhere from six months to a year depending on how quickly the wound healed, rate of infection, and support from family and medical professionals. Amputation was a collective endeavour guided as much by communal concerns as by medical ones.

If you are wealthy enough to afford a prosthetic you could start practicing with one two to three weeks after the amputation, again, provided there’s been no infection. That said, custom made prosthetics took time to make so you might not have one to work with that quickly after surgery. 

Lingering after effects could possibly include continuous phantom limb syndrome as well as itching scar tissue. Numbness from damaged nerve endings. Increased stress on the cardiovascular system due to less space for blood to travel. Grief over the loss of a limb is also a common struggle. 

I hope this helps! 

Extra reading fun times (if you have $$ or university access): 

Hans De Boer, George Maat, “Survival time after fracture or amputation in a 19th century mining population at Kimberly, South Africa,” South African Archaeological Society Goodwin Series, 2013. 

Heidi Hausse, “Bones of Contention: The Decision to Amputate in Early Modern Germany,” The Sixteenth Century Journal, 2016. 

David Hillman, Carla Mazzio, The Body in Parts: Fantasies of Corporeality in Early Modern Europe, 1997. 

Joseph Charriere, Treatise on Surgery, 1712. 

David Welling, “The influence of Dominique Jean Larrey on the art and science of amputations,” Journal of Vascular Surgery, 2010. 

Panagiotis Skandalakis, ““To Afford the Wounded Speedy Assistance”: Dominique Jean Larrey and Napoleon,” World Journal of Surgery, 2006. 

Thomas Helling, “The Role of Amputation in the Management of Casualties: A History of Two Millenia,” The Journal of Trauma and Acute Care Surgery, 2000. 

Franck-Emmanuel Roux, Marion Reddy, “Neurosurgical work during the Napoleonic wars: Baron Larrey’s experience,” Clinical Neurology and Neurosurgery, 2013. 

[vincentdelaplage]

LE CHIRURGIEN LARREY (presque) FUSILLÉ POUR SA RESSEMBLANCE À NAPOLÉON Digne d'un film d'Hitchcock https://youtu.be/4DgE_Kwx4Pw Le baron Jean-Dominique Larrey, chirurgien en chef de l'armée impériale, "inventeur des ambulances chirurgicale mobiles, capable d'amputer un membre en une minute et à qui, tout au long des campagnes napoléoniennes, des milliers de soldats durent la vie. Séparé de ses hommes alors qu'il était en train d'organiser le repli de ses ambulances, le chirurgien est fait prisonnier par les troupes prussiennes. Trompés par sa petite taille, la capote grise qu'il porte, voire sa ressemblance physique avec Napoléon, les Prussiens pensent avoir capturé l'empereur des Français", écrit l'auteur de "Waterloo démythifié !" "Avant d'être conduit à un officier supérieur, Larrey est molesté, insulté, presque déshabillé." L'officier se rend compte qu'il ne s'agit pas de Napoléon, mais décide tout de même de faire fusiller le Français. Un peloton d'exécution est mis en place… et Jean-Dominique Larrey ne devra son salut qu'à l'homme qui était censé lui bander les yeux : "Chirurgien-major, l'homme le reconnaît. Et pour cause : il a jadis suivi ses cours à Berlin." Conduit auprès d'un général prussien, il est sauvé grâce à la réputation qu'il s'était faite "de soigner tous les blessés, qu'ils soient amis ou ennemis, hommes de troupes ou officiers supérieurs". Parmi ces blessés, le fils du général en question ! #leslumièresdeversailles https://www.instagram.com/p/Cia78_bMkZo/?igshid=NGJjMDIxMWI=