“ORGANISATION OF MEDICAL EVACUATION OF THE
POPULATION IN EXTREME SITUATIONS”
THE PLAN
1.General principles of medical evacuation of the population in extreme
situations.
2.Kinds and volume of the medical aid
3.The first aid
4.Premedical aid
5.The first doctor’s aid
6.Qualified and specialised medical aid
7.Medical sorting
1. General principles of medical evacuation of the population in extreme
situations.
In catastrophe the losses usually arise suddenly and their quantity, as a rule,
exceeds the possibility of local and often territorial public health services in rendering
first aid in the shortest time to save lives and prevent dangerous complications.
Such situations occurred with regularity and prediction in the history of
mankind during wars. Therefore it is not accidental that for centuries it was military
doctors who dealt with giving first aid during emergency situations. They intuitively
realized and scientifically grounded (N.I. Pirogov, 1896), the special organization
principles with simultaneous change of tactics of doctor’s activity. Principles and
methods used in usual situations are ineffective in such situations. The analysis of
problems of rendering aid in extreme situations and catastrophes proves, that there is
no essential difference between principles of rendering of first aid in catastrophes of
both peaceful, and military time.
The organization of terms of urgent medical aid is the main index of work
efficacy of health services in extreme situations, since the outcome of many injuries
depends on the maximal reduction of time from the moment of getting a trauma till
the rendering of the first aid. To achieve this, a number of organizational measures
called «medical evacuation of the population in extreme situations (MEP)» are
suggested. The rescue of life of injureds and preservation of health of the population
in the disaster area depends on precise interaction of rescue medical forces of
immediate action, as well as exact organization of stage system of rendering of the
urgent medical aid to casualties. In the disaster area as a rule, the searching-rescue
1
work, reconnaissance, search, extrication of casualties, rendering of the first aid,
exporting them to temporary assembly points are not carried out by medical
personnel.
The essence of MEP is to organize timely and successive measures for giving
first aid and treatment to victims at the stages of medical evacuation with obligatory
transporting them from the center of destruction to medical establishments according
to character of the received damage, i.e. under the medical indications. This forced
division of the process of treatment in catastrophes resulted in necessity of
development of the unified concept of pathogenesis, diagnostics and treatment of
different injuries, obligatory for all medical staff. Its combination with uniform
classification and medical documentation provides continuity and sequence of
realization of medical measures at stages of medical evacuation.
Their timely fulfillment is achieved by fast intervention of forces and means of
health services, correct organization of their work and rational evacuation of injureds
beyond the disaster area. And the casualties are provided with all necessary kinds of
the medical help in succession: urgent, premedical, medical, qualified and specialized
medical help.
The term «a stage of medical evacuation» means forces and means of health
services organized on the way of medical evacuation and intended for reception,
medical sorting, rendering of the certain kinds of the medical help to the victims and
(if necessary) to prepare them to the further evacuation.
At present in natural disasters and catastrophes we use the two-staged system
of medical evacuation of casualties to the destination.
The first stage of medical evacuation is intended mainly for rendering urgent
and the first medical aid in the disaster area, is saved medical establishments, points
of the urgent medical aid organized by first aid teams, premedical and doctor-nurse
teams arrived at the center of catastrophe from nearby medical establishments and
medical points and doctor-nurse teams of military units, involved in conducting the
rescue works.
The second stage of medical evacuation is existing and functioning outside the
center of catastrophe, and additionally organized medical establishments intended to
give all kinds of medical aid-qualified and specialized, combined in a category of
hospital kinds of the medical aid, and treatment till the final outcome. This scheme of
organization of urgent aid in extreme situations is considered to be the most
expedient and efficient to fulfil its main task – to save the life of the maximal number
of the victims in the centers of mass injury of the population.
It is quite natural, that the given scheme is not a dogmatic assertion, but a
guide to action, as having got modern means of transportation and opportunities of
realization of medical measures in the process of evacuation, the organization of the
first stage of medical evacuation may not be necessary. On the other hand, depending
on real conditions of conditions of the extreme situation and opportunities of the
medical personnel, the rendering of first medical aid may be combined with the
elements of the qualified medical aid at the first stage of medical evacuation. We
should bear in mind that disregarding the size of the catastrophe and its kind, every
injured person must be given first medical aid at the place of getting injury as all
2
measures of this aid are directed at saving the life and prevention of development of
dangerous severe complications.
2. Kinds and volume of medical aid.
Medical and prophylactic measures at rendering medical aid at the stages of
medical evacuation are determined by a kind and volume of the medical aid.
The kind of the medical help is a definite complex of medical and prophylactic
measures given to a victim by a medical team of SMC in extreme situations. A
definite kind of the medical help is determined by qualification of the experts
rendering this help, presence of necessary equipment and place of its rendering.
The volume of the medical help is a totality of medical and prophylactic
measures within definite kind of the medical help.
The injured in extreme situations are given the following kinds of the
medical help:
3. The first aid.
It is a complex of the simplest medical measures given at the place of getting
the injury mainly as self- and mutual aid, and also by participants of rescue works,
with use of listed and improvised means.
The basic purpose of the first medical help is the elimination of the causes
threatening the life of the victim at the given moment, and to prevent the
development of severe complications. The shortest term of rendering the first medical
aid is up to 30 minutes after injury. In respiratory arrest this time is reduced to 5-10
minutes.
The main methods and ways of reanimation.
The condition of clinical death, which goes on not more than 3-5 minutes,
allows to restore heart activity and respiration by using urgent measures. Due to wide
educational work among the population, and teaching the reanimation methods of all
medical staff, we may count on conducting artificial ventilation of the lungs (AVL)
and close massage of heart in any surroundings, especially in conditions of mass
injury. The fulfillment of these measures allows to save the life of casualties, who
may have cardiac and respiratory arrest due to a trauma, exposure to electric current,
poisoning, sharp bleeding, obstructive disturbances of respiratory tract or other
causes.
Attributes of clinical death are:
 Absence of consciousness;
 Absence of pulse in the carotid or femoral arteries;
 Apnoe (absence of respiratory movements);
 Wide pupils and the absence of their reaction on light (comes in
1 minute after cardiac arrest).
3
In this case it is necessary to start cardio-pulmonary reanimation immediately.
It consists of the following stages:
1.
- to establish an adequate airway;
2.
- AVL by active inhalation of air (oxygen);
3.
- artificial circulation with the help of close cardiac massage;
4.
- introduction of medicines, ECG, defibrillation;
5.
- intensive therapy in the postresuscitation period directed on
maintenance and stabilization of vital functions of the organism.
The first three stages can be carried out by way of mutual aid and by
participants of rescue works.
For restoration of passableness of respiratory ways it is necessary: to place the
injured into the spinal position on a some firm surface, to throw back his head back,
to pull forward the lower jaw and to open his mouth. If jaws of the injured are tightly
squeezed, they should be opened by any flat subject or mouth dilator and a gause
padding is put between the teeth. After that examine the oral cavity with the finger,
which has been wrapped in a handkerchief or gauze, and remove vomiting masses,
mucus, blood, etc. Pressing your mouth to the mouth of an inured tightly and keeping
his nostrils closed exhale sharply into his mouth. If you can’t open the mouth, the air
is exhaled into the nose. The mouth and the nose off the injured may be closed with a
handkerchief or gauze.12 exhalations per 1 minute are done in adults and 15-18 – in
children.
If there are S-shaped airways, manual respiration apparatus, Ambou breathing
bag, you may use them, and automatic devices of AVL are used at the in-patient
department.
To maintain circulation, we use the closed cardiac massage by pressing the
heart between the sternum and the spine in pushing movements (1 time per one
second). Two straight arms are placed on each other by hands. Fingers should not
touch the chest. Hands are put on the lower third of the sternum. Press the sternum 35 cm in the direction of the spine and keep it in this position about 0,5 sec, then relax
your hands without taking them away from the sternum. In correct massage the blood
flow is kept at 20-40% of the normal, therefore the massage can be stopped only for a
few seconds. The chest should be pressed by using the weight of the body. To
children till 10-12 years the massage is done by one hand, and to newborns-by tips of
two fingers. The number of pushing movements in them is 70-80 and 100-200
correspondingly. The too energetic push can cause rib fracture. Pulse in the carotid
arteries in every pushing and narrowing of pupils indicate the effectiveness of the
massage.
Frequently it is necessary to combine AVL with cardiac massage. If it is done
by one man, two exhalations should be alternated by the following 10-15 pushes.
While doing by two persons, one exhalation is combined by 5 pushes. At the moment
of breathing in we don’t do pushes. To determine the moment of restoration of the
circulation massage is stopped for a few seconds every 2-3 minutes. If the pulsation
appears in the carotid arteries, massage is stopped, but AVL continues until the
restoration of one’s own ventilation is achieved.
4
During the reanimation the introduction of medicines is done intravenously,
intraarterially and intracardially.
The volume of the first medical aid:
 Temporary stop of external bleeding by all available means:
application of arresting bleeding tourniquet(standard and improvised),a
pressure bandage, finger compression of blood vessels;
 Elimination of asphyxia by removing mucus, blood, soil and
possible alien bodies from the upper respiratory tract, definite position of
the body (in tongue retraction, vomiting, profuse nasal bleeding) and
artificial ventilation off the lungs (mouth-to-mouth, mouth-to-nose
breathing, S-shaped tube, etc.);
 The closed massage of heart;
 Introduction of pain-killers with the help of a syringe - tube;
 Application of aseptic bandage to the wound and burn surface,
application of occlusive bandage in penetrating wounds of the chest by
using rubberized coating of the first aid pack;
 Immobilization of the injured area of a body in the simplest ways
by using listed and improvised objects;
 Putting on a gas mask while being in the contaminated area;
 Introduction of antidotes to the affected by toxic agents;
 Partial sanitary treatment;
 Antibiotics, sulfa drugs, antivomiting preparations, from
individual first aid pack-2.
4. Premedical aid.
Premedical (medical attendant’s) help is provided by personnel of medical
attendant teams and nurses of doctor-nurse teams. It is rendered in order to fight with
life-threatening consequences of injuries and prevent severe complications. It
compliments the first medical aid and includes:
 Elimination of asphyxia (introduction of air-way, artificial
ventilation of the lungs with the help of portable devices, oxygen
inhalation);
 The control of correctness and expediency of tourniquet
application at a proceeding bleeding;
 Repeated introduction of pain-killers, antibiotics;
 Application and correction of incorrectly applied bandages;
 Improvement of immobilization by using listed and improvised
objects;
5
 Warming up of the wounded, casualties, overcooled, extricated
from the water, giving them hot drinking (except the wounded into the
abdomen);
 Realization of partial sanitary processing by improvised means,
intake of radioprotective preparations, introduction of antidotes in acute
chemical poisonings.
5. The first doctor’s aid.
The first doctor’s aid is characterized by a complex of medico-prophylactic
measures carried out by the physicians at the first stage of medical evacuation and
directed on elimination or easing of consequences of life-threatening injuries,
prophylaxis of possible complications and preparation of casualties to evacuation.
Depending on real conditions and possibilities of the medical formation or
establishment, the measures of the first medical aid are divided into two groups:
- Urgent measures;
- Measures, which performance can be deferred.
The optimal term of rendering the first doctor’s aid are the first 4-6 hours from
the moment of injury. The increase of this time is directly proportional to the quantity
of lethal outcomes.
The urgent measures are be carried out in cases threatening the life of the
wounded and patients. They include:
 Control of external bleeding (tight tamponade of a wound with
application of skin sutures, suture of a vessel in a wound, clamping a
bleeding vessel, control of correctness and expediency of tourniquet
application, and tourniquet application by indications);
 Fight with a shock (introduction of pain-killers and cardiovascular preparations, novocaine blockade, transport immobilization,
transfusion of blood or blood-substitutes in severe shock or significant
blood loss, etc.);
 Elimination of acute respiratory insufficiency (sucking off the
mucus, vomiting masses and blood from the upper respiratory ways,
introduction of air-way, suture of the tongue, tracheostomy, excision or
suture of drooping flaps of the soft palate and lateral parts of the larynx,
artificial ventilation of the lungs, inhalation of oxygen, steams of ethyl
alcohol in lung edema, application of occlusive bandage in open
pneumothorax, puncture or thoracoscentesis in strained pneumothorax);
 The closed massage of heart;
 Transport immobilization (or its improvement) in bone fractures
and vast injuries off the soft tissues, application of sling-like transport
splint in jaw fractures;
6
 Excision of the extremity hanging on the flap of the soft tissues;
 Catheterization or capillary puncture of the bladder in retention
of urine;
 Urgent therapeutic aid (control of initial response to external
radiation, introduction of antidotes, etc)
 Introduction of antibiotics under the indications.
The measures of the first doctor’s aid which can be deferred includes:
 Remaking of bandages and improvement of transport
immobilization;
 Conducting of novocaine blockade and introduction of painkillers in injuries of moderate severity;
 Administrating of antibiotics, tetanus anatoxin, antitetanus and
antigangrenosus serums and other medicines, delaying and preventing the
infection in the wound;
The complete volume of the first doctor’s aid includes urgent measures and
measures, which realization can be deferred.
The reduction of volume of the first doctor’s aid is carried out at the expense
of measures of the second group.
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 medicoprophylactic 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
7
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).
8
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
9
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:
10
Sorting groups
Marks
1
2
3
More 15
10-12
10
Outcomes
Prognosis
Mortality,%
Unfavourable
90
Doubtful
30
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.
11