Current Anaesthesia and Critical Care (1998) 9, 45-47
© 1998 HarcourtBrace & Co. Ltd
Editorial
Prehospital and emergency trauma care in
disaster medicine
Disaster medicine implies large numbers and usually
involves trauma_ Trauma, both civil and military in
orgin, has always been an integral part of medical prac-
tice. The lessons, in terms of management both of popu-
lations and of individuals, have been learned and
relearned, painfully, over the centuries. While the injury
type may change, particularly with the rapid pace of
military developments, the fundamental principles
remain the same. We can plot some of the historical
milestones in the development of these principles.
Presumably, many of the ancient civilization had
shamans or doctors who dealt with traumatic injury, but
the first extensive documentation that has survived
comes from the Egyptians. The ancient Egyptians wrote
of the management of trauma, in both warfare and indus-
trial accidents during building and quarrying. An advan-
tage of trauma over other areas of medicine, then as now,
is that the cause and effects are often obvious. Profound
hypothetical discussion is needed neither for cause nor
indeed for effect. The Egyptians had a methodical
approach to diagnosis and examination, and they mapped
out areas of trauma and types of injury. Curiously, they
went further and had descriptive methods for 'intention
to treat', Illness and injuries are defined in terms of
'an ailment which I will treat, an ailment with which I
will contend and an ailment not to be treated.' This
concept is easily recognizable as triage and to some
extent prognostication.l
The management of trauma underwent developments
and refinements through the periods of Greek and then
Roman civilization. Presumably, some forward and
others backwards, as is the nature with most branches of
medicine. Galen contributed significantly to the under-
standing of injury from his dealings with gladiators. It
was the Roman Legions who introduced the concept of
field hospitals, with tents set aside to look after the
wounded. This was a recognition of the need for facili-
ties to treat the injured. The fundamental role of war in
the development of the art of medicine and, in particular,
surgery can be illustrated by a Hippocratic aphorism,
'He who wishes to be a surgeon should go to war'.
45
Throughout the ensuing centuries, war was the focus
from which many developments arose. A myriad of text-
books on the management of traumatic injury, such as
the Feldbuch der Wundartzney by Gersdorff (circa
1500), were written from field experiences. Classical
descriptions of how to deal with wounds were described
by surgeons like Ambroise Pare, who had a wealth of
experience with treating wounded soldiers. He described
five facets to his practice, 'To remove what is super~
fluous, to restore what has been made dislocated, to sepa-
rate what has grown together, to reunite what has been
divided and to redress the defects of nature'. Those
comments still stand. He also had the distinction of
performing the first clinical trial when he compared the
use of boiling oil to the use of a turpentine salve in
treating gunpowder wounds. To be fair, this was done
out of necessity as he had run out of oil, but he observed
that those treated with the salve did better and he thus
became an advocate of this approach: the first evidence-
based medicine_ Other breakthroughs followed, including
the use of ligatures to stop bleeding. However impressive
these innovations appear, it would be wrong to imply
only surgical techniques were addressed. These doctors
were involved in all aspects of care for their patients, but
it was, presumably, in the individual treatment of injuries
that they could meaningfully have influence. Some did
have an impact in other directions.
Dominique Jean Larrey, a surgeon with Napoleon,
realized that many soldiers injured during a protracted
battle would lie in pain dying slowly from exsanguina-
tion. He developed a field ambulance service to evacuate
them much earlier than had previously been possible_
Light and fast, two horse carriages were used to retrieve
soldiers from the front line during the battle rather than
waiting until afterwards_ Presumably, many were salvaged
who would otherwise have exsanguinated at the site of
injury. Through this, mass evacuation of casualties
became a reality and, as a result, so did the problems of
dealing with hundreds of critically-ill patients at one
time_ Larrey records a rate of one operation every 7 rain
at the Battle of Borodino. 2 The benefits must have been
46 CURRENT ANAESTHESIA AND CRITICAL CARE
immediately apparent as was, presumably, the fact that
his innovation effectively overwhelmed his surgical
resources.
There were other important landmarks in disaster
medicine which had greater impact than specific surgical
techniques but which were dependent on the facilities
being available. Prior to Lister's work with hygiene and
anti sepsis, whatever the surgeons were achieving in the
field was all too often lost in the septic aftermath.
Figures from the Franco Prussian war suggested that
during that conflict approximately 13 000 limbs were
amputated. It has been suggested that approximately
10 000 of these patients subsequently died from infec-
tion. The introduction of Lister's methods fundamentally
changed the late outcome of trauma surgery. Comple-
mentary to these developments were the efforts of
Florence Nightingale at Scutari in the Crimea and
Dorothesa Dix in the American Civil War, both of whom
instituted high standards of both hygiene and nutrition in
their respective military hospitals. The crucial role of
nursing in these circumstances was established.
As mankind progressed the scale of conflict has
increased considerably. This introduces the other far-
reaching consequences of war. Social disruption and loss
of all the normal environmental infrastructure. Whole
countries and massive populations are placed at risk.
Poor water supplies, often linked with waste disposal and
in association with inadequate food and shelter, predis-
poses to the explosive spread of disease. There is good
reason to believe this was always a consideration
throughout history, and it is only the potential scale of
the problem that has changed in recent times. During
conflicts such as the American Civil War and the
Russian Revolution, more died from disease than from
the weapons of war.
From this historical perspective it is easy, therefore, to
see that the approach to the management of major disas-
ters has to be at several different levels but also need to
be integrated. The ability to treat an individual surgically
is only useful if the patient is safely transported to and
from the surgeon, if the facilities for surgery are
adequate, if the aftercare does not undo the good work
and if the environment to which the survivor returns does
not subsequently kill them. Given all of these considera-
tions, the overall plan for management of a disaster has
to apply to the local situation. Both the nature of the
problems and the resources likely to be available are very
different if you compare a major European city with the
situation in a country like Rwanda or a city in the middle
of a civil war.
Dealing with a disaster starts with the communication
system that informs of the event, and when and whom it
informs. Providing assistance as rapidly as possible is
important but may be logistically difficult, for example
access to some recent air disaster. Whether to evacuate
patients from the site of injury or provide immediate
care on site, or maybe use a combination must be con-
sidered. 3'4 The type of transport to and from the site is
determined by a variety of factors including geography
and numbers involved. The relevance and role of teams
sent to disasters is important and, in particular, deter-
ruing what can and cannot be achieved on site. 5 Dealing
with individual patients provides potential problems.
Knowledge of the nature of injury is important, espe-
cially if it is a type of injury that one is unaccustomed to
seeing, such as a blast injury. With large numbers
involved effective triage is essential. 6 The methods of
triage should be understood by those using them, rele-
vant to the injuries and easily communicable. 7"gProvision
of adequate resources to deal with large numbers of
casualties and sensible allocation of patients to resources
and vica versa must be considered. For example, using
several available hospitals within a certain distance of a
disaster may be preferential to sending all the casulties to
one hospital. There is of course the issue of the type of
hospital receiving trauma cases. 9 That requires city-wide
or area-wide planning prior to the event. In large-sale
emergencies where social infrastructure is non-existent
either because of war or disaster, provision of the funda-
mental requirements to sustain life and limit the potential
for disease is as, or more important than the management
of the individual. In all, a major disaster, even in the
most sophisticated environment, requires the integrated
activity of a range of services, of which the medical team
is but one part.
How does this all influence us in Europe. Throughout
most of Europe we have enjoyed many years free from
war. The major source of trauma experience is from road
accidents, which do not usually present very large
numbers of casualties. Nevertheless, the potential for
major disaster, whether aircraft, industrial or terrorist, is
always there. Few of us have experienced major disasters
and even those that have do not necessarily have a wealth
of experienced tQ fall back upon. The fundamental prin-
ciples are relatively simple but need to be known. There
must be knowledge not just of the appropriate surgical or
anaesthetic method for a particular problem, but also on
understanding of how the available resources are being
utilized so that each individual knows their role. There
should be an integrated plan, but while there almost
always is a plan, in-depth knowledge of the plan by those
expected to implement it is often lacking. It is a fact that
the less exposure one has to a problem the more effort
one needs to make to keep up to speed on how to deal
with it, This is classically the case with major disasters
which are, fortunately, infrequent, but when they do
occur without warning they readily identify all the weak-
nesses in the system. It is incumbent on all of us to be au
fait with all aspects of emergency care and not just our
own area of personal interest. In the articles that follow
most of these areas are covered and should provide the
basics. Having read the articles it might be wise to read
through your own institution's 'Major Disaster Plan'.
References
1. Nunn J. Ancient Egyptian Medicine. London: British Museum
Press, 1996.
 PRE-HOSPITAL AND EMERGENCY TRAUMA CARE IN DISASTER MEDICINE
2. Porter R. The Greatest Benefit to Mankind. London: Harper
Collins. 1997.
3, Hedges J R, Feero S, Moore B, Shultz B, Hover D W, Factors
contributing to paramedic on scene time during evaluation
and management of blunt trauma. Am J Emerg Med 1988;
6(5): 443-448.
4. Baxt W G, Moody P. The impact of advanced prehospital
emergency care on the mortality of severely brain-injured patients_
J Trauma 1987; 27(4): 365-369.
5_ Compton J, Little M. Role of the intensive care ambulance in
the transport of accident victims. Aust N Z J Surg 1983;
53(5): 435-438.
47
6. Boyd C R, Tolson M A, Copes W S. Evaluating trauma care: the
TRISS method. Trauma Score and the Injury Severity Score.
J Trauma 1987; 27(4): 370-378.
7. Bowyer G W, Stewart M P, Ryan J M. Gulf war wounds:
application of the Red Cross wound classification. Injury 1993;
24(9): 597-600.
8. Bowyer G W. Afghan war wounded: application of the Red
Cross wound classification. Journal of Trauma 1995;
38(1): 64-67.
9. Anderson I D, Woodford M, de Dombal F T, Irving M.
Retrospective study of 1000 deaths from injury in England and
Wales. Br Med J Clin Res Ed 1988; 296(6632): 1305-1308.