6. Qualified and specialized medical aid.

The qualified medical aid appears by the qualified surgeons, therapeutists and doctors of other specialities in medical establishments and its aim is elimination of consequences of injuries, first of all, threatening the life of the victim, prevention of complications, struggle with the already developed complications and treatment till the final outcome. As optimum term of rendering of the qualified medical help the first 6-8 hours after the injury are considered.

The specialized medical aid is given by the physicians in the specialized hospitals or departments having special medico-diagnostic devices and equipment.

The rendering of the urgent medical help on temporary assembly points is carried out by teams of sanitary-medical personnel, doctor-nurse teams and other formations of a service of medicine of catastrophes.

At the first stage the casualties are given the urgent medical help according to vital signs.

The second stage (qualified and specialized medical help) can function depending on situation both in field conditions, and at the base of medico-prophylactic establishments of the disaster area.

The first aid to casualties in the focus of mass destruction may be conventionally divided into three phases (periods):

• The phase of isolation, which goes on from the moment of occurrence of accident till the beginning of the organized rescue measures, duration 0,5-6 hours. It is characterized by injury of the unprotected population with impossibility of help from outside. The range of damage can’t be evaluated. The problem of a survival is realized by rendering mutual aid. The duration of this phase defines to some extent the possibility of giving further effective first medical and qualified aid.

• The phase of rescue proceeding from a beginning of rescue work up to the end casualty evacuation, its duration is 6-12 hours. The assembly points of the first aid are organized in this period, they do assortment and concentration of injured, perform urgent surgery by the vital indications and evacuation. At this phase the diagnostics of state severity is performed by the simplest clinical signs and includes the evaluation of disturbance degree of consciousness, respiration, change of frequency and filling of pulse, pupil response, the presence and localization of fractures, bleeding, tissue compressions.

• The phase of rehabilitation, which is characterized from the medical point of view by realization of planned treatment and rehabilitation of casualties until the final outcome (0.5-90 days), i.e. the stage of the qualified or specialized medical help.

7. Medical sorting.

In an extreme situation there is always a discrepancy between the need of medical aid and opportunity of its rendering. It is necessary to take into account, that 25-30 % among the injured are in need of urgent medical measures, which are most effective just at the first hours after a trauma. There is a severe necessity of a choice, giving a priority first of all to badly-affected who have chances to survive. One of administrative measures in these conditions suggested by Н.И.Пирогов was the method of medical assortment.

Unfortunately, in tragical conditions of an extreme situation physicians become flustered and forget about this method. So, it was at a tornado in Ivanovo area (1984), at explosion at railway station Arzamas (1988) and at earthquake in Armenia (1988) and others. The poor organization of assortment of casualties was noted by the USA specialists at explosion of gas in a sports premises, where 54 men died on the spot and 374 were in need of medical help. The experience of work of the medical personnel in catastrophes confirms the importance of the time factor at rendering the medical help to the injured. While giving the aid to the first met victim or other victims without choice, the medical personnel causes irreparable harm, promotes the unreasonable death of those, who could have been saved. In this case nature itself does a cruel work of the doctor of assortment.

“The main task of the medical personnel in an extreme situation is to detect those whom timely medical aid is able to save as well as those who can’t be saved due to injuries incompatible with life and whose death is inevitable in the near future” (E.I.Smirnov).

Medical assortment is a method of division of victims into groups by a principle of need of homogeneous medico-prophylactic and evacuation measures depending on the medical indications and specific conditions.

The aim of assortment is to provide the casualties with timely medical help and rational evacuation. It is of particular importance in situations, when the number of those in need of medical aid (or evacuation) exceeds the possibilities of local (object, territorial) health services. The medical help is considered to be timely only then, when it rescues the life of the victim and prevents the development of dangerous complications. Medical assortment is a specific, continuous (the categories of urgency may change), repeating and successive process at rendering of all kinds of the medical help. It is done from the moment of giving the first medical aid on a place of catastrophe and in prehospital period beyond the zone of destruction as well as in admission to territorial, regional and other medical establishments to get full volume of medical aid and treatment till the final outcome. Medical assortment is performed on the basis of diagnosis and prognosis. It defines the volume and kind of the medical help.

At the focus of injury, at the place where the trauma was received, the simplest measures of medical assortment are carried out regarding the possibility of rendering the first medical help. After the arrival of the medical personnel (teams of first medical aid and teams of urgent medical aid) at the disaster area, the assortment is continued and deepened.

The experience of work in wars and catastrophes in peaceful time has shown, that the specific group of casualties during medical assortment changes depending upon a kind and volume of given medical help. In its turn the volume of the medical help is determined not only by medical indications and qualification of the medical personnel, but also mainly by conditions of the situation.

Depending on the solving tasks, it is expedient to distinguish two methods of medical assortment: intrapoint and evacuation-transport sorting.

Intrapoint assortment of casualties at stages of medical evacuation is done in order to divide them into groups depending upon a degree of danger to the surrounding people, character and severity of injury, to establish the necessity of rendering the medical aid and its sequence, and also determination of functional subdivision (medical establishment) of the stage of medical evacuation, where it should be rendered.

The evacuation-transport assortment is carried out to group the victims according to the order of priority in evacuation, the type of transport (automobile, plane, etc.); determination of position of the casualties in the transport means (laying, sitting; in the first, second, third circle), the destination-evacuation place. The condition, degree of severity of the injured; localization, character, severity of a trauma are taken into consideration. The solution of these problems is done on the basis of the diagnosis, forecast of a condition and outcome; without them the correct assortment is impossible.

We can’t single out other methods of assortment, for example, prognostic or by time of performing ("primary", "secondary", "final") or by qualification of the medical personnel conducting the assortment (premedical, medical, etc.). This way does not correspond to the aims and tasks of assortment. First of all the medical personnel of any degree of preparation and qualification is obliged to render the medical help to those who are in need of it, if there is a necessity of a choice (for example, several hardly injured persons were brought simultaneously). In case of mass catastrophe, in contrast to ordinary conditions of health services, a physician faces a bitter necessity of choice from the moral and ethical points of view.

Three main sorting signs are used as the basis of assortment:

• Danger for the surrounding people:

• - those who need special sanitary treatment;

• - those who are liable to temporary isolation;

• Medical signs:

• - the degree of need of medical help;

• - the degree of priority and place of its rendering;

• - Requiring the urgent medical help;

• - The help may be postponed (there is no need in urgent medical help);

• - those in need of symptomatic aid (terminal states, traumas incompatible with life);

• Evacuation signs:

• - the necessity and degree of priority of evacuation;

• - the type of transport and way of evacuation (laying, sitting);

• - the kind of medical establishment, where the evacuation is necessary.

For acceleration of assortment and rendering of the medical help there are many ways.

For example, there is a simple method of outcome evaluation in casualties with mechanic trauma at mass admission of victims. The method is based on evaluation of prognostic index in numbers:

visible injuries: head - 2, chest (spine) - 3, abdomen (pelvis) - 4, fracture of the femur-5, fracture of the calf, upper arm, forearm - 3 each.

The state of consciousness: loss- 5

Approximate (biological) age, elder than: 50 years - 2, 60 years - 5, 70 years – 7, 80 years - 10

Blood pressure is not taken, the severity of shock is not taken into account, as at a shock of the 3rd degree there is loss of (which is estimated by 5 marks).

Calculation of prognosis: at summation of the marks you will get prognostic index according to which the casualties are divided into three groups:

Sorting groups	Marks	Outcomes
		Prognosis	Mortality,%
1	More 15	Unfavourable	90
2	10-12	Doubtful	30
3	10	Favourable	10

Prognostic index of more than 20 indicates almost hopeless state, particularly in conditions of mass admission of casualties.

If besides a mechanic trauma the victim has a thermal trauma, then every 10 % of the body surface affected by burn (is defined by Wallace’s method of “nines”), are added as 3 marks to the prognostic index obtained in evaluation of a mechanic trauma.

The special attention should be paid to the victims with prognostic index of 10-20 marks.

Lecture №3

“Medico tactical characteristic of acts of nature”

THE PLAN OF LECTURE

1. Introduction. Characteristic of the main injury factors on catastrophes.

2. Characteristic of the amount and structure of population losses in catastrophes.

3. Medico tactical characteristic of natural disasters.

1. Flood.

2. Hurricanes and storms.

3. Earthquakes.

4. Snow avalanches, snow drifts and icings.

5. Lightning.

6. Fires.