Intensive Care of Emergency Conditions - V. M. Zaporozhan 2006

Disasters. Organization of Emergency Medical Care

The history of humankind is a history of catastrophes. While minor events of everyday life have faded into oblivion, only grand catamisms resulting in massive human toll remain etched in our memory. Historically, these were predominantly triggered by natural phenomena (floods, typhoons, earthquakes, droughts), as well as wars and epidemics. With The Development of civilization, the frequency of such disasters has not diminished; rather, there has been a clear upward trend in various catastrophes directly tied to technological progress—specifically, numerous types of accidents.

The increasing likelihood of emergencies necessitates the establishment of specialized systems designed to maintain constant readiness to provide medical assistance to populations in disaster-affected areas. Given the scale of such events, the relative scarcity of regional medical personnel, and the vulnerability of the medical service itself to damaging factors, pooling the efforts of medical services at interregional, national, and even international levels became essential. This is how METABOLISM/2.html">THE CONCEPT OF "disaster medicine" was born.

As early as the beginning of the 1970s, the global community concluded that countries needed to join forces to improve emergency and disaster medicine services. In 1976, the "Mainz Club" was founded in the FRG, bringing together 10 of the world's most renowned anesthesiologists and intensivists under the chairmanship of Rudolf Frey. In 1983, this club evolved into the World Association for Emergency and Disaster Medicine (WAEDM), headed by American intensivist Peter Safar, and in 1989 led by British anesthesiologist and intensivist Peter Baskett. Multifaceted in nature, it unites practitioners from various specialties across five continents. Thus, numerous organizations dedicated to disaster relief emerged.

In the former USSR—a country exceptionally closed to outside information—people lived in ignorance of what was happening around them. Fires, railway accidents, floods, and earthquakes seemed to happen only abroad. And when a catastrophe was occasionally reported at home, the boilerplate Conclusion was always: "No casualties or damage reported."

With the advent of the "glasnost" era, alarming reports surged: the Chornobyl Nuclear Power Plant accident (1986), the true scale of which remains incompletely known to this day; the railway explosions in Arzamas and Sverdlovsk (1988); the train crashes caused by a pipeline explosion in Bashkiria (1989); the Armenian earthquake (1989); the accident at the Azot production association in Jonava (1989); mudflows and avalanches in the North Caucasus; the tornado in Ivanovo Oblast; floods in Primorye and Georgia; the sinking of the steamship Admiral Nakhimov and the accident aboard the nuclear submarine Komsomolets. Military conflicts in Baku, Karabakh, South Ossetia, Abkhazia, Transnistria, and Chechnya add to the list. This is an incomplete catalog of emergencies involving mass casualties, some of which transcended geographical boundaries to reach universal proportions.

Over a span of 5 years in Ukraine, more than 700 catastrophes occurred (according to a speech by the Deputy Minister of Health of Ukraine at the constitutive Plenum of "Extreme Medicine" in Luhansk, 1997) with a mortality rate of 16% among victims, whereas in England, similar disasters yield a mortality rate of 2.7%. In Germany, traffic accidents happen 20 times more frequently, yet result in 10 times fewer fatalities than in Ukraine. The frequency of transport accidents is rising, and a decline in the near future is unlikely.

In CIS countries, providing aid to victims of mass casualty incidents has traditions spanning over two centuries. As early as the mid-18th century, the foundations of military medicine were laid, later brought to life through the work of the Military Medical Academy. Mykola Pirogov became the world's first universally recognized pioneer of military field surgery. His organizational talent and creative approach, combined with exceptional surgical skill, saved the lives of tens of wounded soldiers during wars in the Caucasus, Crimea, Prussia, and Bulgaria.

Military medicine—specifically military field surgery as the core science studying the patterns of traumatic epidemics—developed particularly rapidly in the 20th century. Military medics gained invaluable experience from the numerous wars that this century proved so generous with.

V. S. Oppel (1917) placed immense emphasis on the Organization of Medical care for the wounded: "Just imagine for a single moment what hundreds of thousands of wounded soldiers mean, to immediately understand the state Significance of the proper Organization of surgical care for the wounded. It is enough to witness the scale of modern injuries—which often border on the limits of survivability—to grasp what the improvement of Surgical Treatment Methods means within the framework of a sound overall organization of wartime surgery." Contrary to THE PRINCIPLE OF "evacuation at all costs" prevailing since the days of M. I. Pirogov, he formulated The Doctrine of staged treatment for the wounded. All those who contributed to the advancement of military field surgery (M. M. Dieterichs, 1938; M. N. Akhutin, 1942; N. N. Elansky, 1950; S. I. Banaitis and A. N. Berkutov, 1955; P. A. Kupriyanov, et al.) noted that its primary distinction from peacetime surgery lies in the specific operational conditions for the surgeon, the necessity of establishing one's own operating environment, the sheer volume of those requiring aid, and the evacuation system. N. I. Zavalishin also specifically highlights climato-geographical and sanitary-epidemiological conditions.

During the Great Patriotic War, the Cold War, and the war in Afghanistan, certain theoretical tenets of military doctrine were revised, the organization and tactics of the medical service were refined, diagnostic and treatment methods were improved, and service equipment was modernized. Yet, the core mission of military medicine remained unchanged: the medical support of combat operations.

As for protecting the population against weapons of mass destruction, this task was primarily assigned to Civil Defense (CD), whose medical service (MS) bases its Operations on the principles of military medicine, while adapting to the distinct working conditions of CD and army medical services. However, CD medical services had another mission—one rarely mentioned, despite its potential to play a pivotal role in peacetime catastrophes. In practice, military medicine was frequently called upon to fulfill this role. According to E. A. Nechaev (1990), over the preceding 10 years, the Armed Forces medical service participated in mitigating the consequences of 130 disasters and accidents. Yet when CD medical formations were actually required to provide care in extreme situations (such as during the Chornobyl disaster or the Spitak earthquake), they proved largely unequal to the tasks assigned. This failure stemmed from the fact that CD medical units were structurally bulky, with excessively slow deployment times. The medical, sanitary, and logistical supplies of these units were typically stored far away in suburban zones in packed crates, significantly increasing the time required not only to retrieve them but also to render them operational. The arrival of medical units at disaster sites was further delayed by a lack of transport. Personnel lacked adequate equipment, gear, and apparatus for field operations, as well as systematic training, which negatively impacted their medical knowledge and practical skills. Consequently, even in the former USSR, the question arose of establishing a unified statewide system for the medical and sanitary Protection of the population during natural disasters, accidents, and mass outbreaks—modeled after the "national disaster medicine services" existing in many countries.

In Ukraine, the creation of such a system was officially initiated by Order No. 209 of the Minister of Health of Ukraine dated December 29, 1990. Under this order, emergency medical response centers for emergencies were established: at the national level based on the republican air ambulance station, at the regional level based on the emergency and planned-consultative care departments of regional hospitals, and at the municipal and district levels based on emergency medical stations and departments.

The challenges of disaster medicine were addressed at the 1st and 2nd Ukrainian Scientific and Practical Conferences on Emergency Care, held under the auspices of the WAEDM and the Emergency Care Society of Ukraine in Odesa in 1993 and 1994. In 1997, the 1st Constitutive Plenum of "Extreme Medicine" took place in Luhansk.

The Plenum advocated for the active involvement of rescue miners and anesthesiologists in solving this problem, viewing them as specialists whose core mission aligns organically with disaster medicine: saving the lives of as many victims as possible. This stems from the fact that at the earliest pre-hospital stage—which largely dictates the success of all disaster mitigation efforts—as well as at the initial medical facility receiving casualties, treatment per se is often secondary to non-specific interventions (applicable to trauma, poisoning, radiation exposure, and severe infectious diseases) aimed at supporting vital physiological Functions and preventing death. Disaster response operations have demonstrated that anesthesiologists, owing to their specialized training and experience with critically ill patients, are uniquely positioned not to panic under extraordinary circumstances.

By mandate of the President, the Cabinet of Ministers adopted a resolution in 1997 on organizing the disaster medicine service, and the Ministry of Emergencies was established. Nevertheless, during major catastrophes, success will depend heavily on the emergency preparedness level of physicians across all specialties mobilized to assist the population.

A disaster, in medical terms, is a sudden, rapid-onset event (barring slow-evolving ones such as droughts) that poses an extreme threat to human health and life.

The primary medical consequences of disasters include a massive influx of casualties, widespread psychological trauma, a complex sanitary-hygienic and epidemiological situation in the affected zone, the disorganization of local healthcare management, and diverse material and human losses. Consequently, a stark discrepancy arises between the acute demand for medical care and the capabilities of available medical forces and resources.

Often, alongside or instead of the term "disaster," the term "emergency" (nadzvychaina sytuatsiia) is used—denoting a situation that suddenly arises at a facility or within a specific territory (Water area) As a result of a catastrophe. In an emergency, it is imperative to protect the population from health hazards, conduct rescue operations, and deliver emergency medical care to victims. The territory (or water area) where an emergency has occurred, along with people, equipment, structures, and other objects exposed to damaging factors, is referred to as the disaster focus. Within it, zones typically form that vary by the degree and Nature of the threat to human life and production. Several foci constitute a disaster area—a collection of foci (homogeneous or heterogeneous in their impact character) that emerge across a vast territory and share a common causal origin.

According to their origins, A. E. Dubytsky and colleagues (1993) categorize disasters into:

— industrial disasters involving the release of energy—mechanical, chemical, thermal, radiological (with or without the release of radioactive substances [RS]);

— transport accidents—automotive, railway, aviation, maritime, including water management accidents;

— natural disasters—meteorological, topological, tectonic;

— social and specific events—wars, epidemics, public disorder, terrorism;

— ecological disasters—drying rivers and lakes, water body pathologies, global climate change.

Depending on their geographic scope, disasters can be classified as facility-level, local, regional, and global.

Based on the number of casualties, disasters are classified as small: 25–100 casualties, with 10–15 requiring hospitalization; medium: 101–1000 and 51–250, respectively; and large: more than 1000 and 250 casualties, respectively.

We believe that from the perspective of providing medical care to casualties, it is advisable to categorize disasters According to the nature of the prevailing pathology:

— trauma-related;

— chemical (or toxicological);

— radiation-related;

— epidemics.

Predicting the occurrence of a specific type of disaster in a given area, along with an estimated Assessment of the medical and tactical situation, the capabilities of the territorial health service, and objective preparedness for disaster relief, is extremely complex. Therefore, organizing an emergency medical response system that is constantly ready to act during any type of disaster is of paramount importance.

The doctrine of disaster medicine is defined as the provision of the earliest possible first aid, the most rapid evacuation of casualties to medical facilities closest to the disaster zone, and the widest possible coverage with skilled care.

K. Hell and M. Koscetti (1984) distinguish three phases of disaster response.

Phase I (Isolation) is characterized by casualties among the unprotected population where external assistance is impossible, and the scale of the disaster cannot be assessed. Survival depends on self-aid and mutual aid, including extrication from the danger zone, performing basic life support (cardiopulmonary resuscitation when indicated), bleeding control, bandaging, and limb immobilization for bone fractures. The duration of this phase varies significantly and largely determines the effectiveness of subsequent care.

Phase II (Rescue) is characterized by rescue operations conducted by teams arriving in the disaster area. Medical aid posts are deployed to triage and concentrate casualties, perform emergency life-saving interventions, and carry out evacuation. Diagnosis of injury severity at this stage is based on the simplest clinical signs, including assessment of consciousness, Respiration, pulse, pupillary reaction, presence and Location of fractures, Hemorrhage, and tissue compression.

Phase III (Recovery) is characterized by reconstructive and restorative treatment, as well as rehabilitation at the stage of skilled or specialized surgical care in a medical facility equipped with the necessary specialists.

Thus, it is evident that medical care must be delivered to casualties in several stages, keeping the number of stages to a minimum whenever possible.

The most effective treatment system for casualties is "on-site" care—that is, with a single evacuation stage: first aid at the scene followed by evacuation within 20–30 minutes to a medical facility where all necessary care and treatment are provided until full recovery.

This system is currently operational in urban settings in the absence of mass casualties. However, in the event of mass casualties where the number of ambulance crews is inadequate for the number of injured, it becomes necessary to break down the unified process of medical care and treatment into separate elements. For casualties in a state of Shock with massive bleeding, asphyxia, open pneumothorax, extensive Burns, and other critical conditions, emergency medical care to preserve life and restore transportability is provided at the disaster site and continued during transit. Other types of care and treatment are administered outside the disaster area.

The two-stage system has become the core principle in organizing the operations of emergency medical response units and facilities during disasters.

During the first stage (at or near the disaster site), medical triage, first aid, pre-medical care, and initial physician-led care are carried out, along with the organization of medical support for casualty evacuation, and sanitary-hygienic and anti-epidemic measures. In certain cases (when specialized medical teams are deployed to the disaster site), The Scope of care may be expanded to include skilled and elements of specialized care.

During the Second Stage (in existing inpatient facilities, and additionally deployed ones if necessary), skilled medical care is provided, along with a range of sanitary-hygienic and anti-epidemic measures in cooperation with the emergency anti-epidemic commission. In some cases, due to the exceptionally large scale of a disaster, some casualties may be evacuated to capital city centers or foreign countries for specialized treatment (as occurred, for example, following the earthquake in Armenia).

The scope of medical care at these stages is variable and depends on specific circumstances. The full scope of care is delivered when the number of casualties does not exceed the operational capacity of the response system. When a stage is overloaded, the scope of care is reduced.

First aid at the disaster site is provided during the isolation phase through self-aid and mutual aid, and later by firefighters, rescue workers (liquidators), traffic police officers, and other non-medical personnel. It includes:

— search and extrication of casualties from under rubble and from wrecked vehicles; after extinguishing burning clothing or substances on the body using dense fabric or earth, carrying the injured to a collection point in a safe area;

— putting personal protective equipment (such as gas masks) on casualties;

— basic life support (cardiopulmonary resuscitation);

— temporary control of external bleeding using basic means;

— applying an aseptic dressing to wounds and burn surfaces;

— immobilization of the injured limb using improvised means;

— careful evacuation of the victims (especially when a spinal fracture is suspected) to a collection point or an ambulance.

First-aid care in a disaster zone can be provided by arriving paramedic teams (nurses, feldshers from health posts, medical and sanitary units of the affected facilities, and local healthcare institutions). Supplementing first aid involves:

— insertion of an airway;

— artificial pulmonary ventilation using portable devices (bag valve masks, Ambu bags, etc.);

— oxygen inhalation;

— monitoring or application of a tourniquet in case of ongoing hemorrhage;

— application and adjustment of dressings;

— administration of analgesics;

— improvement of transport immobilization, including The Use of standard-issue equipment;

— warming and hot drinks in winter (except for victims with abdominal trauma) or cooling in hot weather;

— administration of cardiac medications as indicated.

Initial medical care is provided on-site, at the collection point, or in an ambulance by emergency teams arriving at the disaster zone. Its scope depends on the specific nature of the disaster:

a) for mechanical injuries (the specified scope of care is minimal and non-reducible):

— cardiopulmonary resuscitation at the advanced life support level (in a specially equipped "Ambulance-ICU" vehicle or similar);

— restoration and maintenance of airway patency via tracheal intubation, puncture tracheostomy, or conicotomy;

— cessation of external bleeding by vessel ligation in the wound or along its course, application of a clamp, monitoring and application of a tourniquet;

— intravenous infusion therapy;

— general and local anesthesia, including novocain blocks;

— puncture and drainage of the pleural cavity;

— catheterization or puncture of the Urinary Bladder;

— transection of a limb hanging by a soft tissue flap ("transport amputation"); however, if a microsurgery department is available in the region, it is advisable to preserve the limb for future replantation;

— Prevention of wound infection (Antibiotics, sulfonamides, tetanus toxoid);

b) for thermal burns:

— application or adjustment of dressings;

c) in acute poisonings:

— Urgent Detoxification;

— syndromic therapy;

— specific antidote therapy;

d) in radiation injuries:

— decontamination;

— prevention of radiation sickness (radioprotectors);

— syndromic therapy;

e) in bacteriological contamination:

— cardiopulmonary resuscitation;

— complete sanitary Processing;

— administration of therapeutic sera, gamma globulin, and broad-spectrum or targeted antibiotics once the pathogen is identified;

— vaccine prophylaxis.

Qualified care is provided in non-specialized hospital departments, such as general surgery departments, although elements of qualified and even specialized care may be delivered as early as The First stage by specialized emergency medical teams (anti-shock, toxicological, etc.).

Measures of qualified surgical care are divided into three groups:

The first group includes emergency measures performed according to vital indications, the omission of which threatens the victims' death within the next few hours:

— relief of asphyxia;

— definitive control of external and internal bleeding;

— comprehensive therapy for shock and Crush syndrome;

— surgeries for gas gangrene;

— surgical debridement and closure of wounds in open pneumothorax, thoracentesis in tension pneumothorax;

— laparotomy for injuries and closed abdominal trauma with internal organ damage;

— surgeries for intraperitoneal injury to the urinary bladder and rectum;

— amputation for traumatic avulsion and complete destruction of a limb;

— decompressive craniectomy for traumatic Brain injury with signs of brain compression.

The second group comprises interventions where untimely execution can lead to severe complications:

— creation of a suprapubic fistula for urethral injuries and a diverting colostomy for extraperitoneal rectal injuries;

— amputation in cases of ischemic limb necrosis;

— primary surgical debridement of wounds contaminated with toxic or radioactive agents, as well as those with extensive soft tissue damage.

The third group includes surgeries whose postponement, under antibiotic coverage, will not necessarily result in dangerous complications:

— primary surgical debridement of soft tissue wounds not contaminated with toxic or radioactive substances and lacking extensive tissue damage;

— primary management of heavily contaminated burns;

— application of plate sutures for flap wounds of the face;

— ligature fixation of Teeth for lower jaw fractures with substance loss.

Under favorable conditions, measures from all three groups are performed. Any reduction in the scope of qualified surgical care is implemented by postponing third-group Procedures; in extremely unfavorable circumstances and severe overload of the medical facility, second-group measures may also be delayed. It is critical that qualified care is delivered no later than 6 hours after wounding, as this plays a decisive role in achieving a favorable outcome.

Specialized medical care is provided by physician specialists possessing the necessary training, equipment, and working environment. Specialized care is considered the highest tier of medical care and must be comprehensive, significantly elevating the quality and outcomes of treatment. It is delivered in specialized medical institutions or non-specialized departments upon the arrival of designated standing readiness medical teams or specialized rapid-response and reinforcement medical teams equipped accordingly.

Practical actions to mitigate disaster consequences are carried out by the Emergency Medical Service (EMS). In Ukraine, the EMS is headed by the State Interdepartmental Commission on Emergency Situations under the Cabinet of Ministers of Ukraine, which includes the Emergency Operations Council. Regarding emergency medical matters, the respective services of three departments are subordinate to it: the Ministry of Health, the Ministry of Defense, and the Civil Defense Headquarters.

Territorial EMS branches have been established in every region. Their governing bodies include the operational headquarters and operational group under the regional emergency commission, while in cities and rural districts, they comprise service operational headquarters and public health operational groups under municipal (district) emergency commissions. The day-to-day management bodies of the regional EMS are the information and dispatch center at the territorial EMS center, and in cities and rural areas, the senior shift physicians and dispatchers of emergency medical service stations and departments.

The EMS in each region possesses specific forces and assets. For instance, in Odesa region, these include: the territorial EMS and Disaster Medicine Center; 115 EMS teams, including general (line) teams — 71; toxicological-therapeutic — 10; cardiological — 9; neurological — 3; psychiatric — 3; shock-trauma — 3; toxicological — 1; infectious disease — 2; obstetrical — 1; pediatric — 11; pediatric terminal — 1. There are also 17 standing readiness medical teams (SRMT) formed on The basis of city medical facilities and the regional SES, including 3 general surgery, 5 anesthesiology-resuscitation, 1 traumatology, 1 vascular surgery, 1 thoracic surgery, 1 toxicology, 1 burn care, 2 infectious disease, and 2 epidemiological-bacteriological teams. Furthermore, 9 specialized rapid-response and reinforcement medical teams (SRRRMT) have been established on the basis of the medical university and research institutes, including 3 otorhinolaryngology, 3 ophthalmology, and 3 maxillofacial surgery teams.

Territorial municipal and district EMS centers and EMS teams are organized in the cities and rural districts of the region.

When necessary for emergency assistance to disaster victims, the operational headquarters of the regional EMS center coordinates with the regional Civil Defense headquarters and its services for alert and communications, firefighting, public order maintenance, power supply and blackout, trade and catering, utility and engineering, animal and plant protection, human sanitation and clothing/footwear decontamination, the military medical service, the railway administration, the aviation detachment, and the emergency commission under the regional state administration, among others.

The EMS operates as follows: information regarding an emergency situation (ES) within the territory under the jurisdiction of an EMS center may reach the CEMC dispatcher from other CEMCs (cities, districts), the senior shift physician of EMS stations, the operational duty officer of the regional Civil Defense headquarters, or the HEAD of the regional CEMC.

In the event of disasters involving traumatic injuries:

— city and district EMS teams organize disaster site reconnaissance, provision of first aid, pre-medical care, and primary medical care at casualty collection points, evacuation to medical and prophylactic facilities located near the disaster site, and assistance during evacuation;

— upon receiving reconnaissance data indicating a mass-casualty disaster (more than 10 victims), preparation of SRMTs and SRRRMTs (general surgery, burn, traumatology, anesthesiology-resuscitation, maxillofacial, vascular, and thoracic surgery) begins immediately, bringing them to full readiness within 4 hours;

— within 2 hours, consultant physicians of the required specialties are dispatched to the disaster area to provide advisory assistance to local medical facility staff and to organize the reception and deployment of incoming teams;

— no later than 6 hours, the required number of SRMT and SRRRMT units are deployed to medical facilities located near the disaster zone;

— the operational headquarters of the regional CEMC coordinates with other services (Civil Defense, departments, Armed Forces Medical Service) to allocate transport for victim evacuation.

In the event of toxicological disasters:

— upon receiving information about a disaster—which may come from the Civil Defense operational duty officer (a "Chlorine" signal specifying the accident site, the direction of the contaminated cloud's spread, and the city districts falling within the contamination zone)—the regional CEMC dispatcher alerts and mobilizes the operational headquarters of the RCEMC, and if necessary, the entire center personnel within 15 minutes during working hours and 1.5 hours during non-working hours;

— within 30 minutes, emergency medical service (EMS) toxicosis-therapeutic teams conduct reconnaissance of the disaster zone, assess the scale of the catastrophe, and estimate the number of casualties who will need assistance;

— upon receiving data on the scale of the disaster, preparations immediately begin for mobile multidisciplinary emergency response teams (toxicology, anesthesiology-resuscitation), specialized medical nursing and rapid response teams (ophthalmology), and the mobile toxicological laboratory group of the regional Sanitary and epidemiological station (SES), bringing them to full readiness within up to 4 hours and deploying them to healthcare facilities outside the contamination zone;

— no later than 30 minutes, additional EMS teams, alongside toxicosis-therapeutic units and equipped with appropriate gear for primary medical care and the evacuation of victims, are dispatched to the disaster zone to temporary assembly points outside the contaminated area prepared for the inpatient treatment of toxicological patients;

— coordination with other services regarding transport for evacuation is organized;

— the operational headquarters of the regional emergency medical and disaster medicine center (REMDMC) organizes anti-chemical protection for medical personnel operating directly within or adjacent to the disaster zone;

— information exchange with neighboring regions is organized in the event of a potential threat of contamination to their territory.

In the event of radiation accidents:

— within 30 minutes, personal protective equipment is issued to medical personnel and drivers, and iodine prophylaxis is administered to all REMDMC personnel;

— after 30 minutes, data on the radiation situation are collected from the district SES;

— after 40 minutes, the toxicological mobile multidisciplinary team, the EMS toxico-therapeutic team, and the mobile radiological laboratory group of the regional SES are brought to readiness and dispatched to the disaster area;

— inpatient beds are re-profiled for patients with radiation injuries;

— a triage radiological team, formed by the mobile radiological laboratory group of the regional SES and the specialized medical rapid response team, is deployed at the edge of the disaster zone;

— the evacuation plan for healthcare facilities from the probable radioactive contamination zone is updated.

In the event of outbreaks of particularly dangerous infectious diseases:

— within 4 hours, the REMDMC operational headquarters collects data on the epidemiological situation arising in the territory based on reports from regional, municipal, and district SES;

— within 4 hours, the toxicological and infectious-epidemiological mobile multidisciplinary teams, as well as the mobile sanitary-hygienic laboratory of the regional SES, are brought to readiness;

— cooperation and information exchange with the regional anti-epidemic service are organized;

— upon the instructions of the head of the regional administration's healthcare department, the mobilized REMDMC forces are dispatched, and appropriate measures are taken to assist in eliminating the focus of the particularly dangerous infection and to organize quarantine, observation, and treatment measures.

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