Operational medicine in disasters.

There are many similarities and differences between operational and disaster medicine. Over the past several years, there have been increasing requirements for the use of military and tactical law enforcement operational medicine in disaster, humanitarian assistance, and terrorist settings. Many of the TEMS techniques have a direct application to disaster medicine.

Refining prehospital physical assessment skills: a new teaching technique.

Physical assessment is a critically important skill in the prehospital setting, the performance of which is complicated by adverse environmental conditions. Emergency medical technicians (EMTs), paramedics, and others providing out-of-hospital emergency health care frequently receive training that does not adequately prepare them to perform an appropriate physical assessment. This is particularly true for such providers who support special operations as combat medics, wilderness EMTs, winter emergency care technicians, or EMT-tacticals. We describe a new training technique that emphasizes tactile sensory inputs rather than visual and auditory cues. The training strongly reinforces the importance of conducting a systematic survey.

Cervical spine immobilization of penetrating neck wounds in a hostile environment.

Current guidelines concerning trauma suggest that cervical spine immobilization be performed on all patients with penetrating wounds of the neck. This study was undertaken to examine the risks and benefits likely to be found when such care is provided in a hazardous environment, such as the battlefield, or the scene of a terrorist attack or domestic criminal action. Data for casualties from the Vietnam conflict were reviewed to determine the potential benefit of cervical spine immobilization on the battlefield. In this population, penetrating cervical cord injury was always fatal and usually immediately so. Only 1.4% of all casualties who were candidates for immobilization might have benefitted from the care. However, the risk of performing immobilization in a hazardous environment is substantial since about 10% of casualties are incurred while helping other casualties. Mandatory immobilization of all casualties with penetrating neck wounds sustained in an environment hazardous to first aid providers has an unfavorable risk/benefit ratio.

Absence of a tachycardic response to shock in penetrating intraperitoneal injury.

The belief that tachycardia is an early and reliable indicator of shock has recently been challenged. We examined 144 battlefield casualties with penetrating intraperitoneal injury to determine whether patients in shock presented with pulse rates that were significantly more rapid than those in patients not in shock. No differences in mean pulse rates were found when using objective operational definitions of shock. In contrast, the only pulse rate difference was noted when shock was defined on the basis of the surgeon's subjective clinical impression and this was attributed to selection bias. The absence of a tachycardic response in battlefield casualties with penetrating abdominal wounds cannot be taken as an indication that serious injury and significant intraperitoneal bleeding have not occurred. Caution should be exercised when using this parameter as a guide for therapeutic interventions, and further study is indicated to determine whether a similar pattern is seen in civilian practice.

Airway management: a new look at old models.

Two methods for modifying standard orotracheal intubation models, in order to teach and practice special airway management skills, are described. Using these quick and inexpensive manipulations, an intubation manikin can be modified for use as a teaching model for standard nasotracheal intubation techniques as well as both orotracheal and nasotracheal intubation with a lighted stylet.

Epidemiology of trauma: military experience.

Battle injuries sustained in conventional warfare are more likely to be lethal than are injuries sustained by civilians. Depending on the tactical situation, mortality may range from 20% to more than 80% of all casualties. The American experience indicates that about 90% of the total mortality occurs on the battlefield. Such casualties, those classified as killed in action, die before reaching medical care. More than 90% of all battle injuries (morbidity) are caused by penetrating missiles. Exsanguination from wounds of the heart/great vessels and penetrating/perforating wounds of the skull cause the majority of battlefield deaths. The frequency distribution of injury severity appears to be bimodal. A large peak occurs at low injury severity and indicates a population of casualties with relatively benign soft tissue wounds. A smaller peak at high injury severity represents those killed in action.

New concepts in triage.

The triage process is a valid concept in the initial approach to multiple casualties. Triage tags are, in theory, a reasonable adjunct to the process, but have proved to be a failure in practice. Based on the historical perspective and on the authors' experience with approximately 180 mass casualty drills and incidents, it is recommended that the "daily routine doctrine" be applied and that conventional, color-coded triage tags be replaced by a process of "geographical triage." A valid model for disaster planning is needed, and organizers must conduct drills that are based on the actual threat to the community in order to determine the most efficacious way to manage medical response.