Military Surgery with Emergency Surgery - V.Ya. Bilyi 2004

Organization and Content of Surgical Care in Peacetime and Wartime Emergencies

Definition of emergencies. During peacetime disasters and wartime catastrophes, the healthcare system operates under extreme conditions. The Nature of these conditions, their specific features, and the measures implemented to organize adequate medical care depend on the circumstances in the combat zone, industrial disaster area, or disaster site; the hazards affecting people; and the scale of the event. The disruption of normal living and working conditions for people in a facility, territory, or Water area—caused by an accident, disaster, natural calamity, or other hazardous event that has led (or may lead) to the impossibility of the population residing or conducting economic activities in that area, human fatalities, and/or significant material losses—is officially designated as an emergency (EM).

Each state possesses its own unique set of geographical, demographic, and economic living conditions, as well as historical experience, which determines the most probable and severe emergencies for that country. To unify the measures for mitigating the consequences of specific emergencies, the Cabinet of Ministers of Ukraine adopted its own emergency Classification system via Resolution No. 1099, 'On the Procedure for Classifying Emergencies,' dated July 15, 1998.

In our country, emergencies are classified according to their ROOT causes, territorial spread, and the scale of actual or anticipated economic damage and human casualties.

Depending on the causes leading to their occurrence, emergencies in Ukraine are categorized into technological, natural, socio-political, and military emergencies.

Technological emergencies include transport accidents, fires, unprovoked explosions or the threat thereof, accidents involving the release of hazardous chemical, radioactive, or biological agents, sudden structural and building collapses, accidents on utility networks and life-support structures, and hydrodynamic accidents at dams, levees, etc.

Natural emergencies encompass hazardous geological, meteorological, hydrological marine and freshwater phenomena, wildfires, Changes in the air basin condition, infectious diseases among humans and agricultural animals, changes in water resources and the biosphere, and so on.

Socio-political emergencies are situations associated with unlawful terrorist and anti-constitutional acts, such as terrorist attacks (armed assaults, seizure and occupation of critical facilities, nuclear installations and Materials, hijacking or destruction of vessels, hostage-taking, etc.).

Military emergencies are situations linked to the consequences of using weapons of mass destruction or conventional weapons, which generate secondary hazards to the population due to the destruction of nuclear and hydroelectric power plants, depots and storage facilities for radioactive and toxic substances, waste, petroleum products, explosives, transport and engineering infrastructure, and similar facilities.

Depending on territorial spread, actual or expected economic losses, and the number of people injured, killed, or whose living conditions have severely deteriorated for a prolonged period, emergencies are classified into four levels: national, regional, local, and facility-based. Let us examine the Structure/97.html">Definitions of these emergency levels based on territorial extent, casualty numbers, and significant deterioration of living conditions.

National-level emergencies are situations that develop across the territory of two or more regions (the Autonomous Republic of Crimea, the cities of Kyiv and Sevastopol) or threaten transboundary spread, or require resources exceeding the operational capacity of a single region to resolve; they result in over 300 casualties (temporarily or permanently disabled), more than 5 fatalities, or a severe, long-term deterioration of living conditions for over 3,000 people.

Regional-level emergencies are situations that develop within the territory of two or more administrative districts (or cities of regional significance), or require resources exceeding the capabilities of an individual district to resolve; they result in 50 to 300 casualties (temporarily or permanently disabled), 3 to 5 fatalities, or a severe, long-term deterioration of living conditions for 300 to 3,000 people.

Local-level emergencies are situations that extend beyond a potentially hazardous facility or threaten to spread the emergency or its secondary consequences to the environment and neighboring populated areas, or require resources exceeding the capabilities of the hazardous facility itself; they result in 20 to 50 casualties (temporarily or permanently disabled), 1 to 2 fatalities, or a severe, long-term deterioration of living conditions for 100 to 300 people.

Facility-level emergencies are situations that do not fall under higher-level emergency definitions, resulting in up to 20 casualties (temporarily or permanently disabled), no more than 1 fatality, or a severe, long-term deterioration of living conditions for up to 100 people.

Emergencies arise As a result of accidents, disasters, and hazardous natural phenomena.

An accident is a hazardous technological event that causes human fatalities or poses a threat to human life and health at a facility or within a specific area, leading to the destruction of buildings, structures, equipment, or vehicles, disrupting production or transport processes, or causing environmental damage.

A disaster is a large-scale accident or other event resulting in severe consequences.

A hazardous natural phenomenon is an event of natural origin or the result of natural processes which, due to its intensity, spatial scale, and duration, can harm humans, economic assets, and the environment.

Medical and tactical characteristics of emergencies threatening Ukraine. The territory of Ukraine covers 603.7 thousand square kilometers, with a population of about 48 million people. In terms of its size, population, educational level, and scientific-technical potential, Ukraine ranks among the largest states in Europe. The physical and geographical features of Ukraine's territory, along with its high concentration of chemical-, explosion-, and fire-hazardous facilities, create preconditions for virtually all types of emergencies. Preconditions for technological emergencies in our country include a well-developed infrastructure across all transport modes (aviation, water, rail, road) and energy transmission systems; a developed and extensive energy supply and power generation complex; and the presence of powerful industrial giants in metallurgy, chemical production, mechanical engineering, and the construction industry. The country operates 1,703 industrial facilities utilizing more than 300 thousand tons of toxic substances, including 10 thousand tons of chlorine and 190 thousand tons of ammonia. Nearly half of the electricity is generated by 4 nuclear power plants comprising 13 Reactor units. An extensive network of ammonia pipelines, the 'Druzhba' oil pipeline (1.5 thousand km), the Prydniprovsk trunk oil pipelines (2.3 thousand km), gas pipelines (35 thousand km), and railway tracks (22.3 thousand km) run across our territory. Artificial cascades of reservoirs on the Dnipro, Dniester, and Bug rivers have created zones of potential catastrophic flooding that encompass many major cities (including Kyiv).

An indication of potential overall population losses during technological disasters is provided by the consequences of the Chernobyl Nuclear Power Plant reactor accident in 1986 in Ukraine. As a result of this disaster, 3,420 square kilometers of Ukrainian territory were radiologically contaminated, hundreds of thousands of our compatriots received radiation doses above acceptable limits, and the initial victims among the accident liquidators—firefighters—required surgical care for mechanical trauma and Burns compounded by acute radiation sickness. The problem of population losses from large-scale technological disasters becomes clear when one calculates that from minor accidents and accidents alone, injury and poisoning fatalities in our country were: in 1987 — 8.37 per 10,000 population; in 1991 — 11.73; in 1995 — 15.06; and in 2001 — over 19 per 10,000 population (for comparison: in England, it is 2.7). In absolute numbers, 60,000 people died in 1991, nearly 80,000 in 1999, and over 90,000 in 2001.

Probable population losses under technological emergencies are subject to calculation for each emergency category and specific high-risk facility. To estimate the scale of these losses, consider the following figures: in aviation accidents, casualties can exceed 500 people (1985, Japan, a Boeing 747 crashed into Mount Osaka, 520 fatalities; 1996, Zaire, Kinshasa, a Russian cargo plane crashed into a market during takeoff, 350 casualties. As a result of the Su-27 fighter jet crash on July 27, 2002, at the Sknyliv airfield in Lviv during an aviation sports event, 241 people were injured, including 83 minors. Seventy-six people died or succumbed to their injuries, 27 of them children); in railway and water transport accidents, a similar scale of casualties is possible (the railway disaster caused by a product pipeline explosion near Ufa in 1989 resulted in 871 casualties, including 339 deaths; the sinking of the steamship 'Nakhimov' near Novorossiysk caused 450 casualties, including 424 deaths); the largest known population losses from an industrial chemical disaster occurred in Bhopal, India, in 1985, with over 300,000 casualties, including about 3,000 fatalities.

Preconditions for natural emergencies in our country include, first, the seismic hazard of its territory, indicating the possibility of earthquakes. Earthquakes are subterranean shocks and surface vibrations caused by natural forces. Severe earthquakes disrupt soil integrity, damage structures, disable power grids, and cause significant human casualties. Geophysicists state that virtually all regions of Ukraine are seismically active, with major earthquakes probable not only in the mountainous areas of Crimea and the Carpathians—which are situated in the most unfavorable geological conditions where earthquakes up to 8–9 points are possible. In Kyiv, ground motion intensity could theoretically reach up to 5.5 points; in Odesa Oblast, up to 7; Izmail and Bolhrad, up to 8; Chernivtsi Oblast, up to 7; Zhytomyr Oblast, up to 6; Kirovohrad Oblast, up to 7; Chernihiv, Sumy, and Zaporizhzhia oblasts, up to 5; Kharkiv and Donetsk oblasts, up to 7 points, and so on. Even the Chernobyl NPP is located in a lithospheric fault zone, where earthquakes exceeding 6 points are possible. Regarding maximum casualties from earthquakes, Examples include the 1976 earthquake in China, which claimed 242,769 lives, and the 1989 earthquake in Armenia, where the death toll reached 24,542 people. Globally, nearly 60,000 earthquakes occur annually, of which about 800 are of medium to significant magnitude. Three earthquakes in 1999 (in Turkey, Greece, and Taiwan) prompted serious reflection on the threat this phenomenon poses to our country. For instance, close to Ukraine, a powerful earthquake measuring 6.7–7.8 on a 9-point scale struck Turkey on August 17, 1999. The destruction zone spanned 30 thousand square kilometers and was located in the most densely populated part of Turkey. Several cities and tens of thousands of buildings were destroyed, claiming about 15,000 lives and injuring roughly 45,000 people.

Floods pose a major hazard to Ukraine. Floods are temporary inundations of significant land areas by water resulting from natural forces. In Ukraine, floods are associated with rising water levels in water bodies due to multiple causes: rapid seasonal snowmelt with substantial runoff; intensive precipitation (rain, snow); ice jams in riverbeds; wind-driven water surges in reservoirs and river mouths; and the failure of dams and levees. Preconditions for flooding include numerous rivers changing their character along their course (from mountain to plain, and vice versa); and the presence of cascading hydro-schemes with large reservoirs. Floods are accompanied by the inundation of vast territories, destruction of housing and roads, and the prolonged paralysis of living and economic activity in flooded areas. They cause massive economic damage and human casualties. In terms of frequency, affected area, and material damage, floods rank first among natural disasters in Ukraine. Virtually every year, the country battles floods in Transcarpathia and other regions. Globally, floods account for 40% of all natural disasters, ranking first in frequency and second in casualties (after earthquakes).

Other natural disasters potentially threatening our country include landslides, mudflows, storms, hurricanes, tornadoes, and wildfires. Casualties from potential natural disasters are calculated using modern methodologies for each region and disaster type. The expected scale of population losses can be illustrated by major disasters of the past century: for example, a flood caused by a tropical cyclone in the Bay of Bengal in 1970 and the cyclone itself resulted in over 300,000 deaths in Bangladesh; the deadliest river flood of the century occurred in China along the Yangtze River basin in 1911, claiming 100,000 lives; a tornado near Ivanovo in Russia in 1984 injured 873 people and killed 69; a mudflow in Uchcunava, Peru, in 1970 caused 21,000 fatalities; and an avalanche in Tyrol resulted in 3,500 deaths.

Characteristics of casualties in peacetime emergencies. During peacetime emergencies—both technological and natural—liquidators and affected populations are (or may be) exposed to mechanical, thermal, radiation, chemical, biological, and psycho-emotional hazards.

Mechanical hazards refer to the direct dynamic impact on The Human Body of air or hydraulic Shock waves; the dynamic and static impact of various solid objects set in motion by collapsing structures, machinery, environmental items, explosions, earthquakes, or transport accidents and disasters. An air blast wave generated by explosions of various origins injures the human body through overpressure on specific body parts and propels individuals, causing mechanical trauma during falls. A hydraulic shock wave additionally submerges the injured person in liquid, causing drowning. The dynamic impact of flying debris and fragments injures the human body, causing open and closed trauma, penetrating wounds, and other injuries depending on the object's speed, mass, and shape. The static pressure of building elements and soil on a person trapped in rubble causes Crush syndrome. Mechanical hazards are present in virtually all technological and natural emergencies.

Thermal damaging factors refer to high or low temperatures affecting the human body. High temperatures impacting the human body typically occur during fires, as a result of thermal radiation from nuclear explosions, or during thermal equipment failures. They cause burns and general hyperthermia of the body. Low temperatures affecting the human body during technological emergencies in winter, meteorological natural disasters, natural and man-made hydrotechnical or hydrological catastrophes, cause general hypothermia and frostbite.

Radiation damaging factors—specifically radiation exposure affecting individuals during accidents at radiation-hazardous facilities—cause radiation sickness, radiation burns, and complicate the condition of victims with mechanical trauma.

Chemical damaging factors, represented by highly potent poisons, occur during chemical accidents and industrial accidents involving toxic substances in their technological cycles. They cause acute poisonings that constitute independent pathologies and, when accompanied by mechanical trauma, significantly complicate the patient's condition.

Biological damaging factors—such as toxins and harmful microorganisms—arise from accidents at bio-hazardous facilities, cause infectious diseases among the population, and create an unfavorable epidemic situation within the emergency zone.

The human body can be simultaneously affected by various factors, as well as identical factors of varying intensity. Focusing on the surgical aspect of care, the following sections discuss injuries that require surgical intervention. Damaging factors can result in injuries to various anatomical regions. Depending on the type of damaging factors and the Nature of the victim's injuries, they are classified as isolated, multiple, Polytrauma (combined), and mixed injuries.

Isolated injuries refer to damage to a single internal organ within a single cavity or a single anatomical and functional structure of The Musculoskeletal System (e.g., a Femur fracture).

Multiple injuries are mechanical damages to two Organs within the same anatomical region (cavity) or the musculoskeletal system in several locations (e.g., a fracture of both the femur and the humerus).

Polytrauma (combined injuries) refers to mechanical damage to two or more organs located in different cavities, involving elements of different anatomical and functional systems (e.g., traumatic Brain injury combined with a lung rupture).

Mixed injuries are damages to organs and elements of anatomical and functional systems caused by two or more different damaging factors simultaneously (e.g., a lower leg fracture combined with a chest burn).

Casualties among emergency response personnel and the civilian population resulting from injuries are divided into irretrievable and sanitary losses. Irretrievable losses include those who died at the moment of the emergency, died before receiving medical assistance, or went missing. Sanitary losses include those who sustained injuries (and survived), as well as those who fell ill during or as a result of the emergency.

The ratio of irretrievable to sanitary losses, as well as the type and severity of sanitary losses, depends on numerous factors: the scale and nature of the emergency, the Location (population density and urban development characteristics), time of day, readiness of responders and the public to react to emergencies, season of the year, etc.

During earthquakes, for instance, 20 to 45% of injuries are caused by the structural collapse of buildings. At night, the death toll in an earthquake zone is twice as high as during the day. Earthquake-related injuries are typically severe. For example, following the earthquake in Armenia, shock and acute Blood loss occurred in 25% of the victims, and over 87% sustained open injuries. Approximately 25,000 people died, and about 31,000 were hospitalized.

According to calculations by Russian researchers (Ryabochkin, 1996), based on the average diagnoses of hospitalized patients during peacetime emergencies, HEAD injuries accounted for 32.5% of victims, neck injuries for 0.7%, chest injuries for 12.5%, abdominal injuries for 4.7%, spine injuries for 5.9%, pelvic injuries for 2.4%, and extremity injuries for 41.3%.

The percentage of victims with isolated trauma ranged widely from 2.5 to 33.3%; multiple trauma ranged from 28.0 to 97.5%; and polytrauma ranged from 23.6 to 63.0%.

Mixed injuries can result from emergencies involving multiple damaging factors. Fires occurring simultaneously with explosions lead to A large number of casualties with complex injuries. During the pipeline explosion near Ufa in 1989, nearly 31% of the victims suffered Skin burns combined with respiratory tract burns, 15.2% suffered mechanical trauma combined with skin burns, and 16.9% suffered a combination of mechanical trauma with skin burns and concurrent respiratory tract burns.

Characteristics of wartime sanitary losses. When estimating expected wartime sanitary losses, it is advisable to separately determine the sanitary losses among the civilian population in the rear and frontline zones, and the sanitary losses among military personnel. Civilian sanitary losses comprise casualties resulting from the direct action of weapons, including weapons of mass destruction, as well as casualties resulting from secondary damaging factors caused by the destruction of nuclear and hydroelectric power plants, storage facilities for radioactive and toxic substances, waste, petroleum products, explosives, transportation and engineering infrastructure, etc. The magnitude and structure of sanitary losses from direct weapon effects are similar to military sanitary losses, whereas sanitary losses from secondary damaging factors resemble those seen in technological disasters.

To estimate the scale and structure of sanitary losses among military personnel caused by conventional weapons, open generalized data from the Analysis of the Great Patriotic War of 1941–1945 and modern military conflicts can be utilized. Average daily sanitary losses during the Great Patriotic War of 1941–1945 accounted for 0.8–1.5%, whereas during modern military conflicts they reached 2.2–3.4% of the personnel participating in combat operations. Surgical casualties constitute approximately 85% of total sanitary losses.

For the Medical Service of the Armed Forces of Ukraine, the experience gained in providing medical care to the wounded during the war in Afghanistan is of particular significance. It demonstrated that the improvement of "conventional" types of weaponry has led to a significant increase in their lethality and substantially impacted The structure of combat sanitary losses. Consequently, compared to World War II, the proportion of severe shock-inducing combat trauma has increased from 10–12% to 25–40%, which corresponds to the structure of combat injuries predicted for the deployment of weapons of mass destruction.

Concept of Active systems for eliminating medical and sanitary consequences of emergencies in peacetime and wartime. The terms "accident," "catastrophe," "natural disaster," and "emergency situation" do not always accurately reflect the extraordinary nature of the healthcare system's response in eliminating their consequences. Therefore, medical literature introduces METABOLISM/2.html">THE CONCEPT OF a "public health emergency," defined as a sudden circumstance in which the capabilities of healthcare authorities and institutions to prevent and eliminate the medical and sanitary consequences of emergencies are inadequate and require the engagement of additional forces and resources or a substantial reorganization of daily working Methods and practices. Under normal conditions, a developed public healthcare system proves incapable of adequately responding to sanitary losses during modern catastrophes. In the disaster zone, there is typically a shortage of medical personnel, Pharmaceuticals, and medical equipment. To provide timely medical care during a catastrophe, well-trained medical personnel equipped with modern facilities, appropriate means of patient transportation to medical facilities, and a sufficient number of hospital beds must be deployed to the disaster site. Therefore, every state establishes its own specialized systems for managing the medical and sanitary consequences of peacetime and wartime emergencies. In addition to directly organizing medical care for victims, the core Functions of such systems include preliminary emergency response planning; determining the forces and resources to be involved in disaster relief; training medical personnel and building up reserves of pharmaceuticals and medical supplies; and establishing the legal, regulatory, and normative framework necessary for the deployment and functioning of these systems.

In our country, the responsibility for mitigating the peacetime medical and sanitary consequences of emergencies is assigned to the State Disaster Medicine Service of Ukraine (SDMSU), while in wartime it falls to military medicine and the civil defense medical service.

The SDMSU is a specialized state emergency rescue service whose primary mission is to provide free medical assistance to victims of man-made and natural emergencies, rescue workers, and individuals participating in emergency relief operations.

The SDMSU was established in accordance with Resolution of the Cabinet of Ministers of Ukraine No. 343 dated April 14, 1997, "On the ESTABLISHMENT OF THE State Disaster Medicine Service." It comprises specially designated medical forces, resources, and Treatment-and-prophylactic institutions regardless of their departmental subordination or sector, including entities from the Ministry of Health of Ukraine, the Ministry of Emergencies, the Ministry of Defense, the Ministry of Internal Affairs, the Ministry of Transport, the Council of Ministers of the Autonomous Republic of Crimea, as well as regional, Kyiv, and Sevastopol city state administrations.

The SDMSU operates at two levels: central and territorial.

At the central level, the SDMSU is organized within the System of the Ministry of Health of Ukraine; at the territorial level, it is organized within the systems of the Ministry of Health of the Autonomous Republic of Crimea and the healthcare departments of regional, Kyiv, and Sevastopol city administrations. The STRUCTURE OF THE SDMSU encompasses governing bodies, operational units, and institutions.

Leadership of the SDMSU during the mitigation of medical and sanitary emergency consequences is vested: at the central level, in the Ministry of Health of Ukraine; at the territorial level, respectively, in the Ministry of Health of the Autonomous Republic of Crimea and the healthcare departments of regional, Kyiv, and Sevastopol city administrations.

Since the Ukrainian Disaster Medicine Service (UDMS) comprises medical institutions under various departments, its activities in emergency situations are coordinated by:

at the national level: the central coordination commission established by the Cabinet of Ministers of Ukraine;

at the territorial level: territorial coordination commissions established, respectively, by the Council of Ministers of the Autonomous Republic of Crimea, as well as regional, Kyiv and Sevastopol city state administrations.

The main headquarters and operational facilities of the UDMS are designated as follows:

at the national level: the Ukrainian Scientific and Practical Center for Emergency Medical Care and Disaster Medicine;

at the territorial level: territorial emergency medical care centers.

UDMS units at the central and territorial levels include: mobile hospitals, detachments, as well as first- and second-line permanent readiness medical and specialized teams.

UDMS institutions include medical facilities (treatment and Prevention facilities, Sanitary and epidemiological facilities, emergency medical care services, research and practical centers, educational institutions, supply bases, etc.) which, regardless of their departmental subordination, are designated in accordance with the established Procedures of the Ministry of Health of Ukraine as part of the state or territorial levels of the disaster medicine service. The only permanent staff institutions of the UDMS are the Ukrainian Scientific and Practical Center for Emergency Medical Care and Disaster Medicine and the territorial emergency medical care centers. Other institutions are functionally subordinated to the UDMS.

By agreement with the relevant central executive authorities, the central-level UDMS units include 571 first-line permanent readiness medical teams, 190 second-line permanent readiness specialized teams, and 14,659 specialized hospital beds based at medical facilities of ministries, departments, and administrative-territorial management bodies.

First-line UDMS permanent readiness medical teams are primarily emergency medical care teams (general and specialized) that routinely operate within the public health emergency medical service system. Second-line specialized permanent readiness teams are formed on The basis of UDMS centers and institutions (at the territorial and central levels) to reinforce stationary and mobile medical treatment facilities of the Second Stage of medical evacuation, which provide casualties with qualified and specialized medical care.

The legal and regulatory framework for the development and functioning of the disaster medicine service comprises the Laws of Ukraine "On Emergency Rescue Services" (1999) and "On Protection of the Population and Territories from Technogenic and Natural Emergencies" (2000), as well as dozens of resolutions of the Cabinet of Ministers and orders of the Ministry of Health of Ukraine.

Throughout its existence, the UDMS has accumulated considerable positive experience: UDMS units have participated in mitigating virtually all medical and sanitary consequences of national and regional emergencies in Ukraine (including in Transcarpathia, Mykolaiv Oblast, etc.);

UDMS units have taken part in numerous international programs, such as the IAEA RER International Project on Nuclear Accident Emergency Preparedness, the American International Health Alliance (AIHA) "Partnership" and "Rough and Ready" programs, and joint NATO exercises;

the mobile hospital of the Ministry of Emergencies of Ukraine, staffed by teams from the Ukrainian Scientific and Practical Center for Emergency Medical Care and Disaster Medicine as part of the UDMS, successfully operated during the aftermath of earthquakes in Turkey, India, and Iran. In Turkey (1999), the hospital provided emergency care to disaster-affected populations for 21 days, delivering qualified medical care to 5,432 patients and casualties. In India (2001), the hospital provided qualified medical care to 5,558 casualties, including 1,053 children, performed 216 surgeries, and delivered 13 babies.

Given that the UDMS operates at two levels (central and territorial), medical care during local and facility-level emergencies is typically provided by emergency medical service structures, which comprise about 1,040 facilities (stations, substations, and emergency departments), 3,390 field teams, over 7,000 physicians, and approximately 21,000 mid-level medical personnel. Annually, the emergency medical service carries out about 1 million responses to provide care for accidents and injuries. Stationary medical care in such cases is provided by hospitals within the regional public health system.

Units and formations intended to provide medical care to military contingents include: battalion medical aid stations, separate brigade medical companies, and frontline specialized medical service units and institutions. Field specialized medical units and institutions include separate medical detachments, army medical reinforcement detachments, specialized medical care detachments, and mobile field and evacuation hospitals. Naturally, during combat operations on national territory, stationary medical facilities of the Ministry of Defense, as well as those of the Ministry of Health, other departments, and the mobile hospital Base of the civil defense medical service, can be utilized for treating military personnel.

The legal and regulatory framework for the development and functioning of the Civil Defense Medical Service is formed by the Laws of Ukraine "On Civil Defense of Ukraine".

Organization of surgical CARE IN EMERGENCIES

Emergency surgery is a clinical discipline that studies human body injuries resulting from emergency situations, along with the organizational principles and Specific features of delivering surgical care.

Military surgery is a clinical discipline that studies modern combat surgical trauma, as well as the Specifics of organizing and treating the wounded and sick under various operational-tactical (medical) conditions in wartime and peacetime.

Modern medical support for casualties in peacetime emergencies and the wounded in combat is based on a staged treatment system with evacuation to designated destinations.

Timely and high-quality surgical care at medical evacuation stages (MES) is one of the primary conditions for saving lives and preventing severe complications in wounded and injured persons during peacetime, disaster relief operations, peacekeeping missions, and wartime.

In conditions of a mass influx of wounded personnel to an MES, it is particularly important to select the specific organizational model of surgical care that is optimal for the given situation.

Medical evacuation is a set of measures involving the extraction and removal of casualties, wounded, and sick from the emergency zone or combat area to a medical evacuation stage to ensure they receive timely and comprehensive medical care. Ensuring the medical evacuation of the wounded and sick encompasses a broad range of organizational, medical, and technical measures.

A medical evacuation stage refers to the medical service forces and assets (medical aid stations and field treatment facilities) deployed along the evacuation routes of casualties, wounded, and sick to provide them with medical care.

At all medical evacuation facilities (MEFs), medical triage is a mandatory element of treatment and evacuation measures.

Medical triage is the sorting of casualties, wounded, and sick into groups based on their need for uniform preventive, treatment, and evacuation measures. It is carried out in accordance with medical indications, the actual volume of medical care available at a given stage, and the established medical evacuation procedure.

Medical triage must be continuous, specific, and consecutive.

There are the following types of medical triage:

Intra-unit triage: the sorting of casualties, wounded, and sick at a medical evacuation stage into groups for dispatch to the appropriate functional subunits of that stage in a prescribed sequence.

Diagnostic triage: the sorting of casualties, wounded, and sick According to the Diagnosis of injury or disease, taking into account the urgency, nature, scope, and priority of the required medical care.

Prognostic triage: the sorting of casualties, wounded, and sick according to the probable outcome of the injury or disease and the estimated duration of treatment.

Evacuation-transport triage: the sorting of incoming casualties, wounded, and sick into groups according to their evacuation destination, priority, methods, and means of further evacuation.

Scope of medical care: the total volume of treatment measures performed at a given stage, which may increase or decrease depending on the combat situation, the number of wounded, placement conditions, distance from the battlefield, as well as the staffing and equipment of the MEF.

Type of medical care: a unified process of providing medical care that depends on the equipment and qualifications of medical specialists. In peacetime, it is provided in a single medical institution, whereas in wartime, it is divided into separate treatment and prophylactic measures that may be carried out in multiple locations and at different times.

These include: first aid, pre-medical care, first medical care, qualified medical care, and specialized medical care.

Each type of care is characterized by its scope, specific tasks, a list of standard treatment and preventive measures, the qualifications of the medical personnel, and equipment. Each MEF corresponds to specific types of medical care.

Principles of surgical care in peacetime and wartime emergencies (military-surgical doctrine)

1. The organization of surgical care in peacetime and wartime emergencies, The Scope of surgical care, and the Selection of treatment methods are determined by the magnitude and structure of casualties, the combat and operational-tactical situation, the number of surgical formations and teams, the level of medical support, and the treatment-diagnostic tactics at the MEF.

2. Improving the quality of surgical care and, consequently, treatment outcomes is achieved by maximizing the proximity of surgical care to mass casualty sites, the maneuverability of medical service forces and assets, the objectification and prognosis of injury severity, the Implementation of Modern achievements in medical science, and the maximum utilization of modern evacuation means.

3. First medical care can be performed in either full or reduced scope.

The full scope consists of emergency surgical measures of first medical care and deferred measures.

The reduced scope consists of emergency surgical measures of first medical care.

4. Qualified surgical care can be performed in emergency, reduced, or full scope.

The emergency scope consists of emergency measures of qualified surgical care.

The reduced scope consists of emergency and urgent measures of qualified surgical care.

The full scope consists of emergency, urgent, and delayed measures of qualified surgical care.

5. Specialized medical care can be provided in emergency and full scope.

The emergency scope consists of emergency measures of specialized surgical care.

The full scope consists of emergency and delayed measures of specialized surgical care.

6. Every wound is considered initially contaminated. The primary measure for preventing and treating infectious complications in wounds is primary surgical debridement (PSD), potentially followed by repeated surgical debridement and delayed primary closure.

7. The scope, extent, and number of surgical wound debridements depend on the severity, nature, and localization of the injuries.

8. Prevention of traumatic and burn shock in injured persons begins with the provision of first aid, while subsequently, along evacuation routes and at medical treatment facilities (MTF), the primary focus shifts to the prevention and treatment of Traumatic shock (TS).

9. The structure of surgical services must be mobile and flexible, remaining ready to provide medical care under any conditions. Achieving this requires the continuous improvement of knowledge in military surgery, disaster medicine, and military medical training, as well as the enhancement of material resources, increased mobility of formations, and standardization of surgical care assets.

10. The principles of surgical care delivery must be unified for both emergency and military surgery.

TYPES OF MEDICAL CARE AND SPECIFICS OF THEIR PROVISION IN EMERGENCIES DURING PEACETIME AND WARTIME

First aid (FA) is a type of care comprising actions taken by the injured person or bystanders immediately after injury to preserve the victim's life. FA is provided as self- and buddy-aid by rescuers, as well as by orderlies or other medical personnel within the emergency zone (and beyond it), at the incident site, among casualties, and on the battlefield.

The scope of FA is fixed and includes simple measures accessible to a trained rescuer or combat medic.

The content of FA includes: halting the action of the damaging agent; temporary control of external Hemorrhage using a tourniquet (see insert, Fig. 1); relief and prevention of asphyxia; basic life support (CPR); application of an occlusive dressing for open pneumothorax and aseptic dressings; administration of analgesics; transport immobilization and prevention of additional injuries; infection prophylaxis; protection of the wounded from adverse weather conditions, alleviation of thirst; and evacuation of the wounded from the battlefield and contamination zones or areas of immediate danger.

Pre-medical care (PMC) is a type of medical care that includes a set of measures aimed at preserving life and health, provided by mid-level medical personnel (medical assistant, paramedic) at the scene of the incident or during transport.

The scope of PMC is fixed and includes simple measures accessible to a trained medical assistant or paramedic.

The content of PMC includes: checking and adjusting improperly applied dressings, splints, or tourniquets, or applying them anew; supplementing FA measures aimed at maintaining vital body functions and preventing shock; temporary arrest of external hemorrhage; administration of Antibiotics and analgesics; artificial pulmonary ventilation (APV); intravenous crystalloid infusion in shock; prevention of severe complications; warming the wounded in winter and alleviating thirst (except for those with abdominal wounds); and preparing the wounded for evacuation.

First medical care (FMC) is a type of care that includes a set of measures aimed at preserving the life and health of the wounded, as well as eliminating and preventing severe injury complications, provided by physicians with basic anesthesiological and surgical training using standard-issue equipment.

Considering that, according to WHO data, 30% of casualties who do not receive timely FA die within one hour after a catastrophe, 60% within 3 hours, and 90% within 6 hours, and given that delays in providing FMC lead to a rapid increase in the frequency of complications among the wounded, FA in emergencies is provided concurrently with rescue operations, which are conducted round-the-clock throughout the entire disaster area. At the same time, radiation and chemical conditions must be taken into account, which in some cases requires The Use of personal protective equipment (respirators, gas masks, skin protection gear, etc.).

In the disaster zone, the provision of medical care to casualties can conventionally be divided into three periods (phases):

- the isolation period, lasting from the moment of the catastrophe until THE START OF organized rescue operations;

- the rescue period, lasting from the beginning of rescue operations until the completion of casualty evacuation outside the zone;

- the recovery period, from a medical standpoint, characterized by planned treatment and rehabilitation of casualties until complete recovery.

The duration of the isolation period can range from several minutes, as was the case in Sverdlovsk and Arzamas (1988), to several hours during the earthquake in Armenia (1988). Given this, it must be emphasized that the entire population should know the rules of conduct in emergency situations and, in particular, methods of providing FA through self- and buddy-aid.

The rescue period begins with the arrival of the first emergency medical teams and specialized medical-nursing emergency teams from healthcare facilities located near the zone. During this period, the work of medical personnel is focused on emergency medical measures based on vital indications and preparing casualties for evacuation to medical facilities.

The capabilities of FA are expanded through the extensive use of standard medical supplies and the participation of mid-level medical personnel.

The optimal timeframe for providing FA is one hour post-injury.

An important task is assigned to the medical personnel who are first to arrive at the disaster site. They must determine the scale and nature of the catastrophe, the number and severity of the injured, and inform public health authorities.

FMC at the pre-hospital stage is provided During the first hours (within the first 24 hours). The optimal timeframe for providing this type of medical care is the first 4-6 hours from the moment of the catastrophe, since the majority of fatalities from severe injuries occur within the first day—accounting for 50-80% of all deaths. Death is predominantly caused by severe head, abdominal, and chest injuries.

The scope of FMC includes emergency interventions as well as measures whose implementation can be deferred.

Content of LLS: elimination of factors directly threatening the wounded; maintenance of vital organ functions; prevention of severe complications; preparation of the wounded for further evacuation.

1. Urgent LLS measures: monitoring of tourniquets and temporary cessation of external bleeding by applying a clamp or ligating a vessel; relief of all types of asphyxia; tracheostomy or conicotomy for injuries to the neck, Larynx, jaws, and chest with continuous bleeding into the Trachea; necrotomy for circumferential chest burns with signs of Acute Respiratory Failure (ARF); pleural puncture or drainage of the pleural cavity for tension pneumothorax in the 2nd intercostal space at the midclavicular line; monitoring or application of occlusive dressings for open pneumothorax; catheterization or puncture of the Urinary Bladder for Acute Urinary Retention; intramuscular administration of analgesics; anti-shock measures and infusion therapy for grade III shock; amputation of a limb hanging by a skin-Muscle flap; correction of transport immobilization deficiencies in traumatic shock; administration of prophylactic antibiotic doses; subcutaneous administration of 0.5 ml of tetanus toxoid; special measures for combined radiation and chemical injuries.

2. First medical care measures that may be postponed out of necessity: correction of transport immobilization defects threatening The Development of shock; novocaine blockades for limb injuries without pronounced signs of shock; administration of antibiotics around the wound; infusion therapy; administration of analgesics.

Qualified surgical care (QSC) is a type of medical care that includes a set of measures aimed at preserving the life and health of the wounded person, creating favorable conditions for specialized treatment, preventing the development of complications, and preparing for further evacuation, provided by surgeons using special equipment in stationary, mobile, or field medical facilities.

Content of QSC: performance of operative and non-operative interventions aimed at saving life and preventing life-threatening complications; prevention and treatment of complications from mechanical, thermal, radiation, and combined injuries; creation of conditions for the fastest possible recovery; achieving the most favorable anatomical and functional results.

According to the scope, qualified surgical care is divided into: emergency care (10%), abbreviated care (25%), and full-scale care (50-60%).

Emergency QSC (10%) is provided for injuries that directly threaten the life of the wounded.

These include: definitive cessation of external and internal bleeding of various localizations; relief of asphyxia and maintenance of pulmonary ventilation; comprehensive differential therapy for traumatic and burn shock; correction of Homeostasis disorders; necrotomy for deep circumferential burns of the neck, chest, and limbs; surgical correction of open and tension pneumothorax; thoracotomy for Heart injuries and destruction of the chest wall; temporary shunting of major Arteries in case of their damage with signs of decompensated limb ischemia; laparotomy for injuries to Internal Organs of the Abdominal cavity; operations for anaerobic infection; decompressive craniectomy for progressive brain compression.

Abbreviated QSC (25%) consists of emergency (10%) and urgent (15%) measures of qualified surgical care.

Urgent measures (15%) are those that can be postponed for a certain period and are aimed at preventing life-threatening complications.

These include: primary amputations for decompensated ischemic necrosis of limbs; primary surgical debridement (PSD) with significant destruction of soft Tissues contaminated with toxic agents; temporary fixation of the sternocostal flap in casualties with signs of ARF; creation of a suprapubic fistula for injuries to the extraperitoneal section of the urinary bladder; creation of a colostomy for extraperitoneal INJURIES OF THE rectum.

Full-scale QSC (50-60%) consists of emergency, urgent, and delayed measures of qualified surgical care.

Delayed measures (25-35%) include procedures whose implementation does not cause severe complications, but the risk of their occurrence can be reduced by preventive measures.

These include: PSD of wounds as indicated; necrotomy for deep circumferential burns of the neck, chest, and limbs that do not cause respiratory and Circulatory Disorders; toilet of heavily contaminated burns; treatment of facial wounds in flap injuries with plastic suturing; ligature bonding of Teeth for mandibular fractures.

Elements of specialized surgical care (SSC) are measures that can be performed by general surgeons to provide comprehensive medical care at the QSC stage to casualties who quickly return to duty and the wounded who can be evacuated to the territorial base hospital (10%).

These include: decompressive craniectomy; thoracotomy for unaddressed pneumothorax and clotted hemothorax; definitive fixation of the rib flap; application of a lateral vascular suture; osteosynthesis of bone fractures using external fixation devices.

Specialized surgical care (SSC) is a type of surgical care that includes a complex of diagnostic, surgical, resuscitation, and rehabilitation measures provided by surgical specialists using complex methods, special equipment, and gear in accordance with the nature, profile, and severity of the injury in medical institutions: emergency hospitals, regional, district, and city hospitals with traumatology departments, primary and territorial base hospitals, and is aimed at the final elimination of the consequences of trauma.

SSC is primarily required by severely wounded patients with multiple and polytrauma: penetrating injuries to the head and spine, closed injuries to The Skull and brain, spine and Spinal Cord, penetrating chest injuries with signs of massive blood loss and severe respiratory failure, penetrating abdominal injuries, severe fractures of long tubular bones and the pelvis, and damage to major Blood Vessels. This category also includes trauma victims with severe isolated injuries.

Content of specialized surgical care: performance of operative and non-operative interventions aimed at providing comprehensive surgical care to eliminate the consequences of severe injuries, rehabilitate, and return the injured to duty.

Depending on the operational and tactical situation, SSC can be provided for emergency indications (10-15%) in casualties and in full scope (80%).

Emergency SSC (10-15%) is a type of specialized surgical care provided by surgeons using special equipment for emergency indications.

It includes: circular vascular suture (manual or mechanical); osteosynthesis with external fixation devices for combined pelvic and limb trauma; repeated surgical interventions for complications after Operations on the skull, chest, abdominal, and pelvic organs; primary urethral suture for injuries to the pendulous part; thoracotomy for massive clotted hemothorax, Gangrene of the lung, and Pleural Empyema; decompressive laminectomy, surgical wound management, and spinal stabilization for spinal cord compression syndrome; decompressive craniectomy with primary surgical debridement of the brain wound; placement of guiding sutures for ruptures and avulsions of eyelids and auricles with large tissue defects; closure of penetrating Eyeball wounds; PSD of wounds with extensive facial and jaw defects.

Full-scale SSC (85%) is provided by surgical specialists using special equipment to deliver comprehensive surgical care to the wounded.

Full-scale SSC consists of emergency and delayed specialized surgical care measures.

Objectives of SSC: treatment of wounds of various localizations; treatment of wound complications; restoration of the Structure and function of damaged tissues and organs; medical rehabilitation.

By type, specialized surgical care varies as follows:

- specialized surgical care for the lightly wounded (24%);

- specialized surgical care for the wounded with head, neck, and spinal injuries (13%);

- specialized surgical care for the wounded with chest, abdominal, and pelvic injuries (10%);

- specialized surgical care for the wounded with injuries to long Bones and joints (20%);

- specialized surgical care for burn casualties (5%);

- specialized surgical care for the wounded with Nervous system injuries (4%).

Subspecialized surgical care is a type of surgical care provided by surgical subspecialists focusing on a specific organ or body system, utilizing specialized equipment in specialized medical facilities or territorial hospital bases.

It includes:

- specialized otorhinolaryngological surgical care (2%);

- specialized ophthalmological surgical care (2%);

- specialized maxillofacial surgical care (3%);

- specialized urological surgical care (4%);

- specialized gynecological surgical care (1%).

In major administrative centers, highly qualified subspecialists and specialized equipment are concentrated to provide specialized medical care to casualties and establish specialized clinical centers of a specific profile. Thus, in the event of disasters, specialized facilities and clinical centers will play the primary role in organizing emergency medical care for casualties.

Highly specialized surgical care is a type of surgical care provided by specialized surgical physicians within a single organ or body system using advanced equipment and high technologies in medical facilities and main hospitals of the Armed Forces of Ukraine.

Early-returnable casualties (ERC) are casualties with a high potential for return to duty—including light, moderate, and severely wounded—who can receive qualified and specialized surgical care provided by the medical service forces and means at the First Hospital Base (Mobile Field Hospital), with projected treatment durations of 30–60 days.

Surgical care for ERC is a type of qualified, specialized, and highly specialized surgical care provided to victims with varying degrees of injury severity and treatment durations defined in the guidelines of chief specialists (30–60 days).

The division of medical care into qualified, specialized, and highly specialized is somewhat conventional; however, these types of care must be integrated into the echeloned treatment system across different medical evacuation stages: mobile units and hospitals of the Emergency Medical Service of Ukraine, mobile field hospitals, and the first hospital bases of the Armed Forces of Ukraine; specialized care is provided in hospital base medical facilities, as well as stationary medical facilities of the Ministry of Defense, Ministry of Health, and Academy of Medical Sciences.

Qualified surgical care during a stay in hospital base medical facilities for casualties and wounded who have not received it previously is generally provided simultaneously with specialized care.

The procedures and timeframes for providing specialized surgical care are established by the chief surgical specialists of the Emergency Medical Service of Ukraine and hospital base administrations for each medical facility. The ORGANIZATION OF WORK, profiling of stationary medical facilities, hospitals, or their departments, the scope of qualified and specialized medical care therein, as well as treatment durations, are determined by specific working conditions, the Size and Structure of casualties during peacetime emergencies, and in wartime, by the availability of hospitals, the nature of military operations, and the operational-tactical situation.

It should be noted that to provide casualties with qualified and specialized medical care during emergencies, the healthcare system must implement measures to prepare medical facilities for the mass intake of victims and create mobile formations capable of maneuvering their forces and resources to provide prompt and high-quality medical care to victims at the second stage of medical evacuation.

The periods of non-transportability for injured patients are as follows:

- by motor transport: head (spine) - 14–21 days; ENT organs - 7–10 days; chest - 10–15 days; abdomen - 10–15 days; large joints and pelvis - 7–10 days; burns - 10–15 days;

- by air transport: head (spine) - 2–3 days; ENT organs - 2–4 days; chest - 2–3 days; abdomen - 3–4 days; large joints - 3–5 days; burns - 2–3 days.