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The purpose of this article is to discuss various factors associated with successful handling of mass casualties in the field with special reference to the airborne military operations. Various limitations specific to airborne operations are highlighted. Stress is laid on the importance of variables as they effect medical support and planning. Various analgesics, both opiates and non opiates including role of subanaesthetic doses of ketamine are discussed. Adequate knowledge and experience in wide ranging field techniques including improvisations is stressed. The facts are placed in a specific, original context through which new insight can be derived. The feasibility of incorporating light weight modern equipments in field anaesthesia are also brought out.
Anaesthesia and resuscitation in a mass casualty situation in a field set up always poses a challenging task for the anaesthesiologist. The problems are further compounded in an airborne military operation due to its obvious factors and limitations. Needless to say that efficient handling of war casualties in such situations has tremendous morale boosting effect on the fighting troops. In a war scenario, at times help from civilian medicos is also sought to meet the crisis. It is therefore imperative that all of us are well conversant with the problems and techniques in such disaster situations in difficult terrains. It is rather unfortunate that the recent editions of text book on anaesthesiology are ignoring this aspect of anaesthesia, which should still remain an important chapter for the developing countries.
The lethality of the modern battlefield has been extensively documented in the US (Army's) literature [1, 2]. Quick strike with all modern weapons in a highly stressful and confusing environment can generate heavy casualties. This drastically affects combat power and its psychological impact has potential demoralising effect on the remaining forces. With the increasing risk of nuclear, biological and chemical warfare the problem seems to be further compounded for which even the most advanced countries may not have a solution. It will be quite practical to assume that 40% of the wounded casualties who would otherwise survive, die before reaching a medical aid post .
Dominant factors in airborne operations are flexibility, light weight, mobility, quick reaction time, physical robustness, mental alertness and high degree of motivation. Efficiency of medical cover in airborne operations tends to decrease due to certain limitations as follows:
Modern warfare is highly skilled and technologically advanced, leading to mass casualties. Situation during war differs from other mass casualty situations in many aspects as discussed above. Efficient medical cover depends more on training, skill and adaptability than on availability of expensive and complicated equipments. Anticipation and improvisation are the key words.
For effective medical cover, prior planning and training, timely evacuation by ground and air resources, coordination, effective communication system and administration are the main factors. Periodic rehearsals and review of plan is important to ensure that the personnel with the key responsibilities are familiar with the various drills. Meticulous packing and cushioning of equipments during airborne operation is important to prevent damage during para drop. Adequate stock of pneumatic splints, MAST and light patient carrying equipment like paraguard stretchers, scoop stretchers etc, should be catered for.
First aid training for all ranks is the foremost important factor in view of mass casualties and limited medical resources. Adequate realistic and practical training in basic life support measures during peace time will go a long way in salvaging many lives and limbs. This should not be a problem in the modern set up due to better educational standard of soldiers.
Adequate analgesia and safe and timely evacuation to the nearest FSC remains the foremost aim at the remote battle field. This may have to be provided by the paramedical/trained comrade in the scattered areas. Use of a single disposable syringe with multiple disposable needles for different casualties is quite practicable in the field. Availability of multidose vials will be added advantage for packing and administration, compared to ampoules. Some of the analgesics which can be used are:-
With the growing menace of world-wide abuse of opioids, medical personnel are equally vulnerable. So there is a requirement to find suitable alternative. It is unlikely that NSAIDS can completely replace opioids in severe pain. But since they exert effect by different mechanism, combination of lower doses of opioids with injectable NSAIDS can achieve optimum analgesia with lesser side effects [13, 14]. Advantages over opioids include reduction in side effects like respiratory depression, nausea and vomiting, absence of tolerance or addiction potential and less sedation. They do not constrict the pupils and can also be given in patients with head injury and in whom opiods are not recommended. The potential complication of NSAIDS like GIT ulceration, decreased platelet aggregation, impairment of renal function etc, should not be hindrance in their short term use in trauma patients.
Presently ketorolac tromethamine (15,30 mg/ml vials), diclofenac sodium (25 mg/ml in 3 ml ampoules and 30 ml vials), tramadol (50, 100 mg/ml) and nefopam hydochloride (20 mg/ml) are cheaply available in injectable forms and can be safely given for short duration in trauma patients. Ketorolac and tramadol can also be given IV .
Ketamine is known for its strong analgesic effect. This property can be utilised in the battle field. Analgesia occurs at considerably low blood levels than loss of consciousness . The doses of ketamine for sedation and analgesia are :-
Notcutt used ketamine in doses of 1.5mg/kg in easing the pain during transport of patient with spinal metastasis . Preservation of muscle tone, laryngeal reflexes and respiratory activity apart from cardiovascular stability in hypovolamic patients, makes it an ideal analgesic in the battle field even in the hands of paramedical personnel (in analgesic doses only). It is available in 50 mg and 100 mg/ml in multidose vials and is thus convenient for packing and administration. A dose of 2-4 mg/kg IM is recommended and can be repeated on demand. Ketamine can be specially useful prior to air evacuation of casualty by helicopter or aircraft. Intramuscular ketamine may have a place as short term analgesic. Unpleasant emergence delirium may occur in a few cases in analgesic doses also . Its incidence and intensity can be reduced by subsequent benzodiazepines. Role of ketamine in war casualties needs to be explored after further trials.
Anaesthesiologist plays an important role in supervising resuscitation, anaesthesia, post operative care and respiratory support to mass casualties. He should be able to adapt to difficult situations and modify techniques accordingly keeping in mind the limited manpower, resources and drugs. Following points should be kept in mind prior to handling war casualties:-
Wide range of techniques are available for anaesthesia in the field. One should be able to use all methods from open drop ether to the latest feasible techniques, trying various combination as per the prevailing situation. Basic requirements are safety, simplicity and speed. Some of the points worth mentioning are;
With the rapid pace of modernisation in the field of anaesthesia, there is also a scope of modernisation in field anaesthesia. This depends on the financial constraints and overall permissible weight:-
Successful management of mass casualties in modern battle field depends on medical planning, coordination, training and rehearsals, keeping in mind the variables associated with such operation. The anticipation of casualties based on the variables can be made. Proper selection of manpower and equipment and packing is important specially in the airborne operations compared to the conventional warfare. Light weight equipments, shelters and modern drugs are desirable for efficient management of casualties in the battlefield.