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The Medical Implications of Nuclear War, Institute of Medicine. ~ 1986 by the National Academy of Sciences. National Academy Press, Washington, D.C. Burn and Blast Casuallies: Triage in Nuclear War JENNIFER LEANING, M.D. Harvard Community Health Plan, Boston, Massachusetts THE CONCEPT OF TRIAGE During the last century, events creating large numbers of casualties have, with infrequent but depressing repetition, absorbed the attention of the world community. In these years, nations have increased to sufficient population densities and have developed technologies of sufficient power to create the conditions for sudden catastrophe, whereby in a relatively brief time span an enormous number of people may be killed or injured. When discussing nuclear war, reference to precedent may admit sources of serious error, since in terms of scale of effects, this disaster would depart fundamentally from anything the world has yet experienced. Yet people still struggle to comprehend what nuclear war might mean, if only . As part of this attempt to make real the unimaginable' it is instructive to inquire into how massive numbers of to give better warning now casualties have been managed in the past. The perspective taken here is the organization of medical response. Wars and major civilian disasters provide the context and the time frame dates from the U.S. Civil War. The current theory of mass casualty management rests on the concept of triage, according to which casualties are sorted into categories by severity of injury and treatment plans assigned to each based on assessment of transport availability and resources. The word is said to derive from the French triage, meaning the process of sorting by quality, and its use in the wool and coffee trades during the eighteenth and nineteenth centuries carried the distinct connotation of separating higher from lower quality. ~ Although the process of prioritizing military casualties on the basis of 251 1
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252 HEALTH CONSEQUENCES OF NUCLEAR WAR wound severity has been traced to Baron Dominique Jean Larrey, surgeon in chief of Napoleon's Russian Campaign, 2 the term triage was first applied in this context during World War I.3 The British Expeditionary Force used triage to mean division into three: those who could withstand travel back from the front, those who required immediate surgery, and those whose injuries were so severe that they would be left to die.4 The U.S. military command currently prefers the term sorting, but in all other respects relies on the concept of triage in its protocols for mass casualty management.5 The principle of sorting casualties into categories carries both technical and ethical complexities. To sort is to assign value, according to a system that may or may not be explicit. In modern casualty medicine, this system must also respect the issue of time. Medical understanding and skill have advanced to the point at which salvage of the severely injured can be accomplished if intervention proceeds within 6 to ~ hours.6 In settings in which resources are ample and accessible, the act of triage devolves into a straightforward organizing technique. For the sake of clarity and eff~- ciency, the most severely injured get treated first, and the less severely injured get treated second. All casualties are assured of rapid assessment and appropriate disposition; all are assured of receiving the best care in adequate time. The triage technique requires experience and skill, and consequently, in well-designed mass casualty systems, it is the most sea- soned medical officer who takes on this task.7 Ethical issues intrude in settings of relative resource scarcity, which often pertain to mass casualty situations. The code of ethics for physicians, which has evolved over centuries, squarely assigns to the physician the responsibility of protecting the interests of the individual patient in all situations. The physician is enjoined to refrain from a calculus that in- corporates any consideration other than the patient's well-being.8 When resources are perceived as scarce, however, other social or institutional values weigh in and attempt to influence physician choice and behavior. In peacetime, as technology has offered technically feasible but expensive possibilities for individual salvage, society has begun to debate cost-benef~t ratios in health care, a discussion fraught with ethical complexity for physicians as practitioners and for society as a whole.9 In mass casualty situations, triage decisions provide ample opportunities for ethical analyses that lie outside the scope of this discussion. In the absence of an explicit ethical code for physicians in settings in which need has far outstripped the available capacity to respond, it has become accepted practice to assign top priority to those who, without intervention, would otherwise die.~° All other casualties, who would live despite initial delay in transport or treatment, are relegated to lower-priority categories. Those who would die regardless of treatment are assigned to the category of lowest priority. ~ ~
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BURN AND BLAST CASUALTIES: TRIAGE lN NUCLEAR WAR 253 The underlying principle at work is to provide the greatest good, defined as life, for the greatest number, defined as all casualties. i2 According to this principle, it is unsound medical practice to devote time and resources to someone whose chances of living in any case are minimal, at the cost of losing the lives of some who could very well be salvaged. The principle of maximizing the number of lives that can be saved, although axiomatic to those in emergency and trauma medicine, in actual situations translates into some exceedingly difficult ethical decisions. The process can succinctly be illustrated as follows: Typically, a hospital with only a limited supply of blood on hand and with little likelihood of more becoming available in the near future will use that blood so as to aid in the recovery of the largest number of injured. On this basis, the critically wounded man who would require all of the only 10 units of blood available in order to aid in his possible recovery would drop in priority to a position below that of the five casualties whose recovery would be assured by the receipt of 2 units each. Conversely, where only 2 units of blood are on hand to treat the shock of 10 casualties, the best utilization of this item would entail using it in the resuscitation of no more than one or two of these casualties rather than wasting it by giving each only 1/5 unit. ~3 The process of sorting according to this principle of extending life to the largest number of people, as much as it is at a variance with the ethical approach of the individual physician to his or her individual patient, has come to be accepted by both the profession and society in general when it is invoked in settings of plenty, to sort for the sake of efficiency, and in settings of scarcity, to sort so that the greatest number of casualties may survive. Triage during wartime conforms to a different principle. As a particular and relatively modern aspect of military medicine, the concept of triage reflects the interest of the military leadership in maximizing the fighting capacity of the force. ~4 Sorting of casualties appears to date from the era of standing armies, during which, from the perspective of military effi- ciency, casualties were seen, first, as encumbrances.~S During the wars of the seventeenth and eighteenth centuries, this interest of the military command extended to identifying those too injured to continue fighting and removing them from the path of the advancing or retreating armies. 16 Although over the centuries the record abounds with examples of the ways in which military administrators and individuals and groups within the physician and religious communities participated in preventive and re- habilitative care of the soldier, ~7 the injection of a more humane spirit in the systematic approach to casualties took the influence of several factors that were at work in the nineteenth century. During this period, significant sections of civilian elites witnessed the battlefield horrors at the Crimean and U.S. Civil wars. Their outcry and
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254 HEALTH CONSEQUENCES OF NUCLEAR WAR subsequent efforts contributed greatly to the transport and resource systems that supported military medicine in World War I. ~8 Second, developments in weapons technology began to inflict an increasingly high proportion of injures at a time when engagements were still decided by how many soldiers were on the field. The military began to place a premium on returning the maximum number of soldiers to active duty as soon as possible. For all conventional wars in the twentieth century and in current North Atlantic Treaty Organization (NATO) protocols for nuclear war, this same instruction has been given to military physicians. i9 The third factor in the shift from getting nd of the wounded to returning them to battle has been progress in medical skill and knowledge. Especially since the latter part of World War II, military physicians have had at their command a significant range of techniques and interventions that can markedly alter the morbidity and mortality of casualties from conventional war.20 It has been precisely during this time frame that the dilemma for military physicians has been the most intense: equipped with the skills to save the severely injured, in the setting of resource scarcity physicians are constrained by military guidelines not to carry out triage according to salvage of life but according to salvage of fighting capacity. As General Patton is said to have enjoined a group of medical officers in Casablanca in 1943: If you have two wounded soldiers, one with a gunshot wound of the lung, and the other with an array or leg blown off, you save the s.o.b. with the lung wound and let the g.d.s.o.b. with an amn~ltntP.`l arm or 1P.S, OO try hPl1 HP ;Q nix ~ r1 11Q" to us anymore.21 ~1~1~ ~1 :1 ~ _ ~my_ ~^w _ _ _ · 1 ·. _ _ 1 · ~ ~--AN ~^ A_ t ~_ ~~ ~^ ~4 4_ $ ~AAV ~ - ~ - ~1~ 111~; ull~IArlIIlas lor me mllllaIy pnyslclan In a mass casualty situation, in which he or she is asked to function as a triage officer, structured according to the military principle of maximizing the fighting force, are not directly addressed in the Geneva Conventions of 1949, which affirm even in time of war the physician's personal responsibility for the care of the individual patient and define the limits within which a military or political bureaucracy can intrude upon that obligation.22 The World Med- ical Association in 1956 prepared a statement on the code of ethics for physicians in wartime, referring obliquely to this triage dilemma, by re- jecting all forms of distinction among patients "except those justified by medical urgency...."23 The ethical questions involved in military triage become even more complex as weapons of mass destruction threaten to engulf the civilian noncombatant population as well as the military force. The military, with some support from civilians within the medical ethics community, 24 has a clear point of view. In mass casualty settings involving both civilians and soldiers, the role of the military medical officer is to concentrate first
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BURN AND BLAST CASUALTIES: TRIAGE IN NUCLEAR WAR 255 on the combatant military force. as The NATO field manual on emergency war surgery devotes several pages to careful explication of this principle, concluding: Even in the thermonuclear age, however, the basic principle of military medicine remains unchanged. It is, as it has always been, the salvage of the greatest possible number of lives for the support of the military mission.26 In this regard the Geneva Conventions are also silent, perhaps not anticipating the extent to which military war might extend to mass civilian catastrophe. EXPERIENCE WITH MASS CASUALTY MANAGEMENT Triage protocols have defined the organization of medical management of mass casualties by framing the problem in terms of where to do what to whom when. The actual details of how medical response is mobilized and how the outcome is achieved have always had to conform to two key variables defined by the existing situation: available modes of transpor- tation and relative reserves of resources. A brief account of military man- agement of mass casualty medicine during the last 150 years demonstrates the increasing capacity of the medical profession to manage the care of large numbers of injured people and Illuminates tne ways In wn~cn one variables of field conditions and resources have always imposed limits on medical response and shaped triage protocols - r ~· ~ ~· ~^1 ~.u ~u 4 ~ A The record also reveals the paradoxical effects of technology. As the weapons of war have been perfected to inflict a wider variety and pro- portionately greater number of battlefield casualties, the innovations in response (transport, facilities, understanding, skill) have not only more than kept pace but have in fact occurred in large part because of the challenge of war. The management of complex medical and surgical prob- lems has taken quantum leaps during and after each war of the twentieth century, and the tenets of civilian mass casualty medicine derive directly from this military experience. Since the last world conflict, the technology of war has taken another quantum leap, raising again the question of medical response. The medical community has evolved, as will be dis- cussed, a serviceable system for what has been encountered in the past. The issue is how it would fare in the setting of nuclear war. In tracing the development of mass casualty medicine, I outline here a history that may or may not prepare us to meet the possible near future. The U.S. Civil War In the early years of the U.S. Civil War, a principal problem in treating the wounded was geKing to them. Neither the North nor the South had
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256 HEALTH CONSEQUENCES OF NUCLEAR WAR developed transport systems for the retrieval of battle casualties, yet the new rifles and artillery used during this war exacted an unprecedented toll.27 Contributing to the increased destructive power of the infantry on both sides were the breech-loading magazine rifles and the Minie rifled bullet, accurate to 500 yards (which replaced muzzle-loading flintlock rifles with accuracy only up to 200 yards), and the widespread heavy use of artillery batteries comprised of 6-pounder bronze guns and 12-pounder bronze howitzers. Cavalry charges and bayonet warfare slipped into the past. 28 After the Second Battle of Bull Run (August 29-30, 1862), the fields were strewn with the dead and injured: 1,747 killed and 8,452 wounded on the Union side; 1,481 killed and 7,627 wounded on the Confederate side.29 Despite substantial improvement in transport services since the First Battle of Bull Run almost a year earlier, the casualties from this engagement lay on the field for days. At both these battles, outraged civilians organized cavalcades of volunteers from adjacent towns to go in with wagon trains, gather up the wounded who were still alive, and bring them to whatever hospitals were available. In response to public pressure, Dr. Jonathan Letterman was appointed Medical Director of the Army of the Potomac and by 1864 had organized an ambulance corps for the entire Union Army, providing each regiment with four horse-drawn wagon am- bulances and drivers. The South could not marshal! the resources to support such a system, which, even at its best, was routed or overwhelmed by the heaviest battles of the war.30 Delivery of care was also impeded by available resources. Organizing an effective medical response during the Civil War was complicated by the fact that the lines of battle moved rapidly and unpredictably. The establishment of a secure forward medical station was fraught with hazard. Yet it was found that carrying casualties by horse-drawn wagon or cart to field hospitals 5 to 10 miles distant from the front inflicted great hardship on all casualties and increased morbidity and mortality.3i In this setting, the heroic battlefield interventions attributed to Clara Barton and others make much medical sense.32 It has become a standard of mass casualty medicine that the more distant and inaccessible the site for definitive care, the more extensive must be the on-site treatment. It was apparent even to the medical providers at the time that although it was important to remove casualties from the battlefield in order to be able to care for them, and although it was prudent to remove them beyond the reach of the next day's front line, subsequent questions about where to do what had no clear answers. The field hospitals were poorly equipped, the physicians lacked knowledge, if not experience, and the rear hospitals, whether Union or Confederate, offered little more technological or material . . . - . ~
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.B URN AND BLAST CASUALTIES: TRIAGE IN NUCLEAR WAR 257 support than whatever the armies could drag with them.33 The role of the military physician in the Civil War, and in other wars waged with similar technologies and supported by similar levels of medical understanding, acquired at best a humanitarian function. There were so few technically effective interventions known to physicians that removing the wounded from cold damp fields and placing them in bed, giving them food and water, and administering whiskey and morphine constituted the essence of appropriate treatment. Whatever else physicians attempted (amputa- tions, applications of poultices and liniments, experimental explorations under ether or chloroform) were as likely to add to patient morbidity as to detract from it. Deep wounds of the thigh with fracture of the femur earned fatality rates of 50 percent if not treated, and 34-70 percent if treated.34 Abdominal wounds were usually fatal and were found in about one-tenth of those dying on the field.35 Those with upper limb and su- perf~cial scalp wounds were most likely to survive, perhaps chiefly because they could wale off the battlefield and seek help on their own.36 An authoritative summary of military casualties from the Civil War suggests that on both sides as many soldiers died from their wounds as were killed outr~ght,37 a ratio that is difficult to compare with modern statistics because of the delay that transport conditions introduced between the time of injury and the time of treatment. The Civil War data do show, however, that death from disease was more than double the overall mortality from bat- tlefield wounds.38 Inpatient mortality from local wound infection ranged from 40 to 60 percent; if bacteremia ensued, mortality was virtually as- sured.39 Of those who developed tetanus in the hospital, 89 percent died.40 Poor water, inadequate hygiene, overcrowding, and malnutrition, all of which are factors that defined the hospital environments at field and rear echelons, also proved major determinants of outcome among hospitalized casualties.4~ World War l During World War I, innovations in transport and treatment at a forward medical station created conditions for developing distinct stages in the management of battle casualties. The advent of motorized ambulances (drawn out of the Letterman tradition and used first by the British during the Boer War) permitted the rapid removal of casualties from the initial triage site, the Regimental Aid Post, to the casualty clearing station (CCS). Situated within a few miles of the front line, the CCS afforded medical personnel an enclosed, moderately well-equipped, rudimentary hospital which, by design, could be swiftly packed up and moved if the tactical situation required immediate retreat.42 As it turned out, however, this
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258 HEALTH CONSEQUENCES OF NUCLEAR WAR mobility was unnecessary because the front lines in World War I proved relentlessly stable. Innovations in artillery (quick-firing, nonrecoiling car- tridges with ranges up to 3,000 yards) inflicted enormous numbers of casualties43 (60,000 British were killed or wounded in the first day of the Battle of the Somme).44 These weapons were supplemented by the per- fected magazine rifle, which was accurate up to 2,000 yards, and the water-cooled, hand-held machine gun.45 The fixed forward lines on the European front allowed for detailed stratification of care by geographic location. The CCS was initially set up to handle 200 casualties per day. The work consisted primarily of sorting, bandaging, and returning to the field those who could still fight or sending the more seriously wounded by ambulance back to the rear. Facilities were available to hold casualties at the site for 1 to 3 days. As evidence began to accumulate about the morbidity of casualties handled in this way, however, and as physicians became more experienced in the treatment of traumatic injury, the techniques used at the CCS evolved into a more complex and almost comprehensive approach to care. The CCS became, in effect, a semipermanent triage and treatment center, with facilities that allowed postoperative cases to stay for 1 to 3 weeks.46 The relative stability of the front, the extensive supply lines that could thus be set up and maintained, and the motorized transport services allowed physicians at the CCS to develop increasingly aggressive techniques and test out increasingly explicit treatment guidelines. By the end of the war, wound care consisted of wide debridement and excision (the risk of gas gangrene from wounds incurred in the Belgian and French countryside had become well recognized) and local application of antiseptic wound packs. The patients were then sent back from the front for more definitive care (delayed primary closure) at the rear hospitals. Those arriving off the field with impending shock were wrapped in warm blankets, given oral fluids if they could still swallow and intravenous gum acacia solutions if necessary and if available, and rushed by ambulance back to the field hospital. Many died in transit, and others arrived at the field hospital profoundly hypovolemic as they faced immediate surgery. Casualties ar- riving at the CCS who were already in frank shock were given fluid resuscitation (the widespread use of blood and plasma awaited collection and storage methods not developed until the latter part of World War II), and thoracic and abdominal explorations might have been attempted. The issue of when, then, to transport the postoperative survivors remained unresolved. Burn cases were wrapped in gauze and sent back from the front; at the field hospital the dressings were changed and the patients were put to bed. The incidence of shock in burn patients was underesti- mated, although by the end of the war it became general practice to refrain
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BURN AND BLAST CASUALTIES: TRIAGE IN NUCLEAR WAR 259 from frequent dressing changes in order to reduce the risk of infection.47 Organized to manage casualties by these guidelines, the CCS at its peak could accommodate over 1,000 admissions per day. Data from the Battle of the Somme in July 1916 indicate that on the first day 14,400 men were admitted to 13 clearing stations; on the second day, 13,806 were admitted, and on the third day 8,793 were admitted.48 This influx stretched medical capacities to their limits, and the experience has been cited later by senior medical officers as reflecting the utmost in medical organization and dis- cipline.49 Despite the advances in surgical assessment and technique forged during this war, the initial delay in retrieving the wounded from the field and bringing them to the Regimental Aid Post often stretched for hours, oc- casionally days. Many of the most seriously injured died before they were reached by the stretcher-bearers, whose round trip from field to aid post and back averaged 1 hour. Each battalion had 32 stretcher-bearers, but in some of the heavier battles of this war, every battalion suffered hundreds of casualties.50 Worm War lI The improved motor vehicle technology that sustained the mobility of all armies in World War II made the Allied front fluctuate far more swiftly and dramatically than it had in World War I.si These fluid field conditions also made forward placement of complex medical response units much more problematic. The technological innovations in offensive military vehicles had not yet extended to the transport systems for removing the injured from the scene of battle, so that paradoxically the imbalance between fighting mobility and speed of medical retrieval paralleled the situation in the U.S. Civil War more than that in World War I. The major new weapons of World War II were the tank and the tactical airplane, overpowering well-equipped infantry and rendering distinctions between land and sea warfare obsolete.52 Forward clearing stations were far flung and forced by rapid shifts in battle lines to curtail capacities for intervention. Yet at the same time medical knowledge had advanced to the point at which it was becoming increasingly apparent how much could be done during the first 6 to 8 hours of resuscitation if the resources were at hand. The lifesaving potential of fluid replacement in the treatment of burns and the use of plasma and blood transfusions preoperatively in the stabilization of those with serious traumatic injury had become extensively appreciated techniques. Penicillin was first widely used in the treatment of battle wounds during the early part of 1943 at the start of the Italian campaign and heralded the enormous
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260 HEALTH CONSEQUENCES OF NUCLEAR WAR importance of antibiotics in determining medical outcome. The practice of exploring penetrating wounds of the thorax and abdomen had become routine, and much discussion surrounded the management of bowel in c~ Jurles.=J The combination of increased medical understanding about how to sal- vage the severely injured with the difficulties in securing a stable forward treatment base forced World War II physicians into finely developed assessments of when to time critical interventions. The morbidity attached to the postoperative transport of patients with bowel injuries and the high incidence of hypotension in seriously burned patients presented particu- larly acute dilemmas to a medical service that could not, owing to the tactical situation, count on being in one place for more than 12 hours. Senior medical officers began to devise tight and detailed triage protocols and undertook systematic evaluations of front line casualty experiences. Their memoranda provide a terse and intense record of how informed, observant, and pragmatic physicians attempted to construct from their daily practice a manual of military medicine that could promise the injured the best care possible in circumstances that were constantly shifting.54 The Vieinam War The helicopter revolutionized military medical care. s, Developed during the latter years of the Korean War and introduced gradually during the Vietnam War, the helicopter permitted the immediate extrication of the injured and the rapid transit over insecure territory to a field hospital where major stabilization and, often, definitive care could be delivered. Over the years of this war, the field hospital structure increasingly conformed to the geography of the battlefield. In Vietnam there were no front lines. Pockets of intense engagement riddled the countryside, and areas of rel- atively permanent safety were located within 30 to 40 miles (about 48 to 64 km) of these war zones. The concept of the field hospital supported by the full-service hospital in the rear secure zone telescoped into a flexible system of clearing stations, hospitals and the MUST (Medical Unit, Self- Contained, Transportable) unit. First deployed in 1966, the MUST unit evolved into the site for the delivery of much definitive care. Soldiers injured in the field were picked up by medical evacuation teams assigned to helicopters, carried by helicopter to the semipermanent MUST hospitals, and given whatever treatment they required. If their injuries were suffi- ciently severe as to eliminate the possibility of return to combat or if convalescence were to extend beyond 30 days, soldiers would be sent by C-141 transport plane to major offshore hospitals. This combination of secure bases in transport proximity to the war zones and rapid retrieval afforded by the helicopter transformed the concept of casualty sorting at
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BURN AND BLAST CASUALTIES: TRIAGE IN NUCLEAR WAR 261 the front into a process less fraught with hard decisions.56 The new weapons used in Vietnam (high-velocity, lightweight rounds from the M16 and AK47 rifles, claymore mines, fragmentation grenades, varieties of cluster bombs and booby traps, phosphorus and napalm chem- icals) inflicted particularly severe and dirty wounds.57 Casualties in the Vietnam War experienced an increased incidence of small fire injuries with a relatively higher proportion of trunk wounds.58 As the medical capacity to intervene improved during these years, the question of resource availability at the front might have been expected to move into increasingly sharp focus. During the Vietnam War, however, the medical resource systems and the casualty transport systems kept pace with each other and with the pace of medical technology. U.S. military hospitals never lacked blood, receiving shipments of more than 350,000 units during the peak year of 1968.59 Sophisticated radiology and operating suites relied on plumbing and generator systems installed on site at the MUST units; and the most complex cardiac, vascular, and neurosurgical procedures could be accomplished within a 30-minute helicopter ride from the combat zone.60 The hospitalized mortality rate for wounded casualties in Vietnam dur- ing the 5-year period from 1965 to 1970 was 2.6 percent, compared with 4.5 percent in World War II, 8.1 percent in World War I, and 14.1 percent in the U.S. Civil War.6~ This decline in mortality occurred despite the successful helicopter evacuation to hospitals of those so severely injured that, in earlier wars, they would have died on the field or in transit. This decline is due in part to the speed with which the injured were transported to the source of care. Since the U.S. Civil War, the delay from time of injury to time of first aid has been much reduced, compressed from several days in the early years of that war to within 1 day during World War I, to a few hours in World War II, and a matter of 15 to 45 minutes during the Vietnam War.62 This decline in mortality is also due to the resources available at the site of care. As an index of medical effectiveness, the U.S. Army employs the concept of "deaths as a percent of hits," or the ratio of deaths to deaths plus surviving wounded. For World War II, the ratio was 29.3 percent, and for the Vietnam War, the ratio was 19 percent.63 The average inpatient length of stay was reduced from 80 to 63 days, and, reflecting progress in vascular surgical practice, the amputation rate for those with significant arterial and venous injury was 13 percent during the Vietnam War, compared with 49 percent during World War II.64 Summary of Experience from Conventional War Although the course of military medicine in the last century has been characterized by significant discontinuities, as one generation of military
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274 HEALTH CONSEQUENCES OF NUCLEAR WAR approximately 1.6 miles (about 2.6 km) wide and 62 miles (about 100 km) around the zone of total destruction. This site, the area of several fronts in World Wars I and II, would constitute the triage location- adjacent to the devastation, it would be the first stop for all seeking help. In terms of infrastructure damage and social regrouping, it corresponds rough- ly to the 2-4-km zone around ground zero in Hiroshima. The terrain would have sustained blast waves of 1.S to 2 psi, which is sufficient to destroy much of the building stock and disrupt roads and bridges throughout. (The model of Daugherty et al. ins discusses the pos- sibility of scattered secondary fires in this zone.) During the first day, the winds would probably be in the range of 30- to SO-mile per hour (about 48 to 80 km per hour). These winds would be filled with hot and toxic fumes from the central fire zone. From the standpoint of setting up a medical triage system in this setting, the first issue to determine is that of timing. Can transport or medical resources be marshalled sufficiently to make it possible to intervene during the critical 6 to ~ hours during which all salvage of the seriously injured must take place? Timing will cease to exist as the critical variable when lack of transportation or resources, relative to numbers of casualties, precludes complex medical intervention. At that point the triage protocols for mass casualties would be reduced to a most austere mode, and medical management, if the term can still be used, would revert to that of another era. In the reference case used here, both factors (overwhelming numbers and resource scarcity) apply in full force even at the relatively constrained end of the spectrum of possible attack parameters. Here the example of New York City is discussed. In the first few hours, at a rate dependent at least in part on road and fire conditions, physicians would begin to congregate at whatever health facilities remained standing. Including those physicians in the 12-lS-km zone and those from the 15-18-km zone, in New York City there would be approximately 1 physician for every 72 people injured from the bomb- ing. In the U.S. Civil War, approximately 16,500 physicians enrolled on both sides were involved in treating 318,200 wounded, yielding a ratio of 1 physician for every 19 injured people.~09 Each physician would have to choose between two strategies: one of rapid triage and one that essentially abandons triage and treats each patient in order, a serial pattern described among Japanese physicians during the first several days after the bombings. In rapid triage, the physician would move quickly from one casualty to the next, assigning each to a treatment category, carrying out the role of labeling victims, but not treating them. In the reference case setting, in which the capacity to deliver advanced care would be problematic, a large number of casualties would be placed
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BURN AND BLAST CASUALTIES: TRIAGEIN NUCLEAR WAR 275 in the expectant category. A In serial treatment, the physician would move from one casualty to the next, spending whatever time may be necessary to stabilize or support the patient. This strategy might well result in the pnys~c~an railing to see or treat some of the most severely injured; yet these, even if seen, might present problems too complex for resolution in this context. . . . ~ .,. Every square mile (about 2.62 km2) of this triage area in New York City would contain 12,274 injured people. Statistically, there would be one casualty every 19-20 yards (about 17-18 m). The majority of the casualties would have sustained first- and second-degree burns of the upper body, covering less than 20 percent of their body surface area, fractures of the upper limbs and torso, contusions and lacerations of all kinds, and head and face injuries. They might well be mobile and would constitute the population that would flock to sites of care. Approximately 37 percent of those who would be injured in the 12-15-km zone, or 296,000 people, would be severely injured (see Table 3~. Some of these people would be trapped in collapsed buildings, pinned under heavy wreckage, and unable to move on their own. Their injuries would include blunt and penetrating chest and abdominal trauma, major long-bone and pelvic fractures with significant hemorrhage, and extensive second- and third-degree burns. Even under the best of circumstances, for people with these injuries to survive, they would have to be found, assessed, and treated within 6 to 8 hours. In the first 2 days, each physician might be able to encounter 72 cas- ualties, but, in these postattack conditions, advanced intervention would be very difficult to carry out or sustain. The situation would present two insuperable obstacles: no transport or access to the victims and scarce resources. The skills and experience of the teams that assembled would be relatively random. It is likely that no power or water would be available for the first several days. Equipment and supplies would be limited to what remained on site at standing health facilities. Extncating victims is a time-consuming and arduous task: it took several heavy construction cranes, 10 hydraulic rescue tools, and scores of fire department members and emergency medical technicians a total of 13 hours to remove 301 people (113 of them dead) from the wreckage of the Hyatt Hotel in Kansas City in 1981. ~ ~ ~ Transporting these severely injured from where they were found to a site of care might prove impossible. Treating these patients would require intravenous fluids, blood transfusions, intravenous anti- biotics, airway resuscitation and maintenance, debridement and excision of contaminated wounds, fracture stabilization, and operative intervention for those with penetrating injuries or ongoing internal bleeding. Unless circumstances permitted an intense and focused allocation of medical
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276 C~ C) C~ P~ . g ~_ cn ._ ._ C) CO - - Ct - ~: o ca .= ·E' C~ o ._ ~: z IJ m E~ ~ .B . _ O ~ S O Z O oo z ~ ~ .= D ~5 ~ m ·~ ~ ~ (,., c~ D o ·~? ~ C~ Ct O ~ O Z m m o A s - , _ 3 e~ zo m ~o S e O ~ ~i z v, m - e~ .3 m o . =~ 0 ~ ~ Z m _ _I _ 0 1 Z - ._ p v, ~ `; 0 0 0 0 0 0 0 ~ so ~ _ 0 0 Q Q _ ~ - oo QO O ~ O O O oo t- ~ Q Q O Q O - O O ~ X U) r~ ~ Oo o° 8 r~ o o ~ ~ ~ _ o o ~ 0 0 ~ 0 0 ~ 0 ~ 0 ~ ~ _ - Q Q O o o V~ O O ~ O O O oo l- C~ Q O Q g g g Q Q o O oo ~ U O ~ z 3 a u, . cd ca ct c, ca ct - ~D ;~ c~ D U, m o A g c~ ct ~ _ O - ~00 :> ~ 43 ;-, ca c~ 0 ~ ·> c~o O4 4) s ~ 0 cS'q ~ D c ~. ~ca ~4) _ . _ . _ Cd ~ai ~ ~ 4) ~ ~ ~ Ce ~ S ~ CO ~ ~ Ct - C~ ~_ D D D S D `, ~ `, ~ O o O o O `: ~ ~ ~c: D O O O ~ca fi .. ct ca u~ c~ a ~pt a~ :~s Ct Cd Ct ~s ~v,
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BURN AND BLAST CASUALTIES: TRIAGE IN NUCLEAR WAR 277 resources on systems of support and intervention, the mortality rate among these severely injured would approach 100 percent within 2 days. The majority of the injured (assumed here to be the thousands who fled the 10-12-km zone and those in the 12-15-km zone) would confront a much lower ongoing mortality rate, due primarily to hypovolemia from dehydration or hemorrhage, the effects of exposure and exhaustion, and the impact of infection. In the 1-Mt scenario for one city, radiation would not be a significant factor, but the medical care available to these survivors might well not match the resources marshalled by the Japanese in the early postattack period. The pattern of medical management this data base implies mirrors what took place during the U.S. Civil War, in which those listed as wounded were those who had survived the privation of days of lying in fields before being picked up or, for the bulk of them, those who had walked to sites of care. Whether or not these reference case casualties would survive their injuries would depend, as it did in the U.S. Civil War, on whatever food and water could be obtained, the subsequent risk of infection in an ef- fectively preantibiotic era, and the local incidence of disease. Mortality rates among those hospitalized in the U. S. Civil War were approximately 14 percent; it is unlikely that the prevailing rate for the moderately and mildly injured survivors of a nuclear war could be less. A most conser- vative estimate of early mortality among each group of 72 initial survivors thus approximates 100 percent for all severely injured and 14 percent for all others, resulting, among those not killed outright at the time of the bombing, in an overall death rate, 20 days later, of 46 percent, or 33 of every 72 injured. This figure results from what might grimly be termed best case analysis, in which the population casualty rates are the lowest of all instances prepared in the 100-Mt urban reference attack, in which systematic re~- version to an austere triage posture is assumed and in which the care of the moderately injured is estimated to be in accord with the hospital experience of the U.S. Civil War. A number of assumptions were made in evaluating the New York City 1-Mt nuclear attack example; these assumptions will certainly not hold in progressively more comprehensive reference cases. 1. All surviving physicians were assumed to possess some knowledge of acute care medicine, to behave professionally, and to maintain a triage discipline not previously demanded of any U.S. physician, civilian or member of the military. The inadequacy of this assumption is profound. The disaster of nuclear war, even as narrowly defined as it is in this reference case, would create an enormous stress on those attempting to function in the role of health care provider. The literature on coping
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278 HEALTH CONSEQUENCES OF NUCLEAR WAR behavior among disaster victims does not support facile assumptions in this regard. Pushed to his limits, Sasaki, a physician in Hiroshima, roamed among the injured aimlessly "wiping, daubing, winding, wiping, daubing, winding.''ll3 Behavior in the postattack world may well reach extremes of fragmentation, terror, and involution we have not yet seen. ~4 Nothing in the training of a physician confers protection against the psy- chological ravages of this environment. 2. Those with moderate and minor injuries were assumed to suffer the same mortality rates as hospitalized casualties in the U.S. Civil War, a cohort composed predominantly of patients with blast injuries, subject to high rates of infection and disease, yet of young and vigorous constitution and sustained by a system of medical supply and nursing care incomparably superior to that which the injured survivors of nuclear war would face. There is no basis, aside from common sense, for extrapolating a higher mortality rate: data from later wars increase the disparity in support system comparability; data from earlier wars or disasters yield less reliable in- formation on early and delayed mortality. As an underestimate, it con- tributes a cautious level of magnitude to the dimensions of mass casualty management in this circumstance. 3. By limiting the discussion to the 100-Mt airburst reference case, the factor of radioactive fallout was excluded. In the more extensive cases, involving surface as well as air explosions, radiation injury would con- tribute seriously to all subsequent mortality rates for those injured by burn and blast. Estimates of excess mortality in this setting of mixed trauma might serve to increase to 50 percent the proportion of those classified as severely injured (and thus expected to die) and might well double the 14 percent mortality rate among those with moderate and minor injuries. CONCLUSION The methodical approach to such dimensions is to recognize the limits of possible intervention. Modern triage protocols apply to conditions in which the mix of transport and resource availability allows physicians to make early headway against the high mortality of the severely injured. From World War I on, the knowledge that complex support delivered within a matter of hours could save lives once thought lost has driven the development and design of the response to mass casualties. If it is ac- knowledged at the outset that no galvanization of effort can contribute to the salvage of the severely injured, the problem becomes less complex. The choices then revolve around how much time and material should be expended on humanitarian support of those who are probably going to die and how much should be devoted to the care of those with moderate
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BURN AND BLAST CASUALTIES: TRIAGE IN NUCLEAR WAR 279 injuries who might live. Those with minor injures, in this setting, could not receive care. The reference case employed here, and all those developed by Daugherty et al.,~°5 refrain from a discussion of a massive nuclear war. Population losses in such a catastrophe lie outside our experience and defy the human and technological systems we have so far devised to attempt to mitigate disaster and alleviate suffering. On the global scale of nuclear war, as described in the scenario of Harwell and Grover,~is people would face a picture of such devastation and death that the concept of mass casualty management loses all meaning. Historically, such medical management has constituted a highly complex human enterprise. In the bleakness of a post-war world, virtually every survivor would be a casualty, and social organization could well prove unsustainable. Mass casualty medicine, crafted and practiced in war, is a product of He process that may eventually drive it, and everything we know, into oblivion. ACKNOWLEDGMENT The author would like to thank Robert Mascola for his contribution as research assistant in the preparation of this paper. NOTES The Shorter Oxford English Dictionary, Third Edition, Vol. 2. Pp. 2358, 2375. Oxford: Clarendon Press; Rund, D. A., and T. S. Rauseh. 1981. Triage. P. 3. St. Louis: C. V. Mosby. Richardson, R. G. 1974. Larrey: Surgeon to Napoleon's Guard. Pp. 1-6, 158-168. London: John Murray. 3Tuttle, A. D. 1927. Handbook for the Medical Soldier. Pp. 84-85. New York: William Wood and Co. 4Keegan, J. 1976. The Face of Battle. Pp. 267-269. New York: Viking Press. sU.S. Armed Forces. 1958. Emergency War Surgery, NATO Handbook, Pp. 163-173. Washington, D.C.: U.S. Department of Defense, U.S. Government Printing Office. 6Baker, S. P., B. O'Neill, W. Haddon, Jr., and W. B. Long. 1974. The injury severity score: A method for describing patients with multiple injuries and evaluating emergency care. J. Trauma 14:187-196;Ebskov, B. 1981. Initialhospitalcareof the multitraumatized patient. Ann. Chir. Gyn. 70:233-236; Melsom, M. A., M. D. Farrar, and R. C. Vowers. 1975. Battle casualties. Ann. R. Coll. Surg. 56:289-303; Ryan, J. M. 1984. The Falklands War Triage. Ann. R. Coll. Surg. 66:195-196. 7Cowley, R. A., ed. 1982. Mass Casualties: A Lessons Learned Approach. Pp. 141- 145. Washington, D.C.: U.S. Department of Transportation, U.S. Government Printing Office. ~Goldwyn, M., and V. W. Sidel. 1968. The Physician and War. Pp. 325-346 in E. F. Torrey, ea., Ethical Decisions in Medicine. Boston: Little, Brown.
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280 HEALTH CONSEQUENCES OF NUCLEAR WAR 9Zawacki, B. E. 1985. ICU physician's ethical role in distributing scarce resources. Crit. Care Med. 13:57-60. Morton, J. H., L. M. Cramer, and S. I. Schwartz. 1964. Emergency management of a major civilian disaster. Arch. Surg. 89: 105-113. ~Yates, D. W. 1979. Major disasters: Surgical triage. Br. J. Hosp. Med. 22(4):323- 328. Winslow, G. R. 1982. Triage and Justice. Pp. 1-23. Berkeley, Calif.: University of California Press. 3Ziperman, H. H. 1959. Sorting for Disaster Survival. J. Am. Med. Assoc. 171:202. ~4Straub, P. F. 1912. Medical Service in Campaign: A Handbook for Medical Officers in the Field. Pp. 5-6. Surgeon General's Office, War Department. Philadelphia: P. Blak- iston's Son & Co.; Tuttle, Handbook, p. 84; Spencer, J. H. 1963. Mass casualties in the civilian hospital. Bull. Am. Coll. Surg. 4g:342-361. ~5Keegan, Face of Battle, pp. 112-113, 197-203; Winslow, Triage and Justice, pp. 1 3. Richardson, Larrey, pp. 2-4. Garrison, F. H. 1922. Notes on the History of Military Medicine. Pp. 5, 41-46, 84- 95, 133-134. Washington, D.C.: Association of Military Surgeons. brooks, S. 1966. Civil War Medicine. Pp. 50-62. Springfield, Ill.: Charles C Thomas; Woodham-Smith, C. 1960. The Reason Why. Pp. 258-271. New York: E. P. Dutton. DUES. Army. 1959. Medical Service Theater of Operations, Field Manual FM8-10. P. 17. Washington, D.C.: Department of the Army. As cited in Goldwyn and Sidel, Ethical Decisions, p. 346. 20Fulton, J. F. 1953. Medicine, warfare, and history. J. Am. Med. Assoc. 153:482- 488. Churchill, E. D. 1972. Surgeon to Soldiers: Diary and Records of the Surgical Con- sultant, Allied Force Headquarters, World War II. P. 89. Philadelphia: J. B. Lippincott. 22Goldwyn and Sidel, Ethical Decisions, pp. 335-336. 23World Medical Association. 1956. Code of Ethics in Wartime. World Medical As- sociation: New York. As cited in Goldwyn and Sidel, Ethical Decisions, p. 346. 24O'Donnell, T. J. 1960. The morality of triage. Georgetown Med. Bull. 14:68-71. 2sU.S. Armed Forces, Emergency War Surgery, pp. 1-6. 26Ibid., p. 7. 27Brooks, Civil War Medicine, pp. 3-40; Cunningham, H. H. 1968. Field Medical Services at the Battles of Manassas. Pp. 1-22. Athens, Gal: University of Georgia Press. 28Fuller, J. F. C. 1961. The Conduct of War 1789-1961. Pp. 105-106. London: Me- thuen; Millis, W. 1956. Arms and Men. Pp. 114-116. New York: New American Library. 29Cunningham, Field Medical Services, p. 61,90. 30Maxwell, W. Q. 1956. Lincoln's Fifth Wheel: The Political History of the United States Sanitary Commission. Pp. 70-92. New York: Longmans, Green; Brooks, Civil War Medicine, pp. 36-37. brooks, Civil War Medicine, pp. 22-40; Cunningham, Field Medical Services, pp. 1-41. 32Adams, G. W. 1952. Doctors in Blue: The Medical History of the Union Army in the Civil War. Pp. 67-70. New York: Henry Schuman. 33Ibid., pp. 1 12- 129 34Diffenbough, W. G.1965. Military surgery in the Civil War. Military Med. 130:492- 493. 35Ibid., p. 493. 36Brooks, Civil War Medicine, pp. 1-10.
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BURN AND BLAST CASUALTIES: TRIAGE IN NUCLEAR WAR 281 37Commager, H. S., ed. 1950. The Blue and the Gray. New York: Bobbs-Merrill. 38Ibid., p. 769; Steiner, P. E. 1968. Disease in the Civil War. Pp. 3-45. Springfield, Ill.: Charles C Thomas. 39Diffenbough, Military Surgery, pp. 491-492. 40Ibid., p. 492. 4iAdams, Doctors in Blue, pp. 130-173; Brooks, Civil War Medicine, pp. 106-121. 42Wallace, C., and J. Fraser. 1918. Surgery at a Casualty Clearing Station. Pp. 1-6. London: A.&C. Black. 43Millis, Arms and Men, p. 185; Fuller, Conduct of War, pp. 134-45, 166-67, 171. 44Keegan, Face of Battle, p. 255. 45Fuller, Conduct of War, p. 135. 46Wallace and Fraser, Casualty Clearing Station, p. 2. 47Ibid., pp. 1-320 48Churchill, Surgeon to Soldiers, pp. 272-274. 49Ibid. 50Keegan, Face of BaKle, p. 268. Willis, Arms and Men, pp. 252-254. s2Ibid. 53Beebe, G. W., and M. E. DeBakey. 1952. Battle Casualties: Incidence, Mortality and Logistic Considerations. Pp. 74-147. Springfield, Ill.: Charles C Thomas. 54Churchill, Surgeon to Soldiers, pp. 12-25, 36-70, 456-466, 475; Simeone, F. A. 1984. Studies of trauma and shock in man: William S. Stone's role in the military effort. J. Trauma 24:281-287. 55Neel, S. 1973. Medical Support of the U.S. Army in Vietnam 1965-1970. P. 59. Washington, D.C.: Department of the Army; Whelan, T. J., Jr., W. E. Burkhalter, and A. Gomez. 1968. Management of war wounds. Adv. Surg. 3:338-349. 56Neel, Medical Support, pp. 59-79. 57Ibid., pp. 49, 53. 58Bellamy, R. F. 1984. The causes of death in conventional land warfare: Implications for combat casualty care research. Military Med. 148:55-62. 59Neel, Medical Support, p. 119. 60Neel, Medical Support, pp. 46-58; Whelan et al., Management of war wounds, Adv. Surg., pp. 229-257. 6~Neel, Medical Support, pp. 50-51. 62Keegan, Face of Battle, pp. 269-270. 63Neel, Medical Support, p. 52. 64Ibid. 6sDepartment of Defense. 1976. In Connection with the Conflict in Vietnam, fact sheet January 1976, Washington, D.C.: U.S. Government Printing Off~ce. As cited in G. Emer- son. 1976. Winners and Losers. Pp. 58-59. New York: Harcourt Brace Jovanovich. 66Rund and Rausch, Triage, pp. 3- 10. 67U.S. Armed Forces, Emergency War Surgery, pp. 172-173; Department of the Army. 1973. NATO Handbook on the Medical Aspects of NBC Defensive Operations, AMedP- 6. Pp. 6-1-6-11. Washington, D.C.: Department of the Army. 68Glasstone, S., and P. J. Dolan. 1977. The Effects of Nuclear Weapons. Pp. 80-86, 132-153. Washington, D.C.: U.S. Department of Defense, U. S. Government Printing Office; Cooper, J., R. L. Maynard, N. L. Cross, and J. F. Hill. 1983. Casualties from terrorist bombings. J. Trauma 23:955-967; Stapczynski, J. S. 1982. Blast injuries. Ann. Emerg. Med. 11:687-694. 69Glasstone and Dolan, Nuclear Weapons, pp. 548-559.
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282 HEALTH CONSEQUENCES OF NUCLEAR WAR 70Cooper, Terrorist Bombings, p. 959. 7iKennedy, T. L., and G. W. Johnston. 1975. Civilian bomb injuries. Br. Med. J. Vol. I, February 15, p 383. 72Glasstone and Dolan, Nuclear Weapons, pp. 553-557, 175- 189. 73Keegan, Face of Battle, p. 264. 74Cooper, G. J., B. P. Pearce, M. C. Stainer, and R. L. Maynard. 1982. The biome- chanical response of the thorax to nonpenetrating impact with particular reference to cardiac injuries. J. Trauma 22:994-1008. 75Coppel, D. L. 1976. Blast injuries of the lungs. Br. J. Surg. 63:735-737. 76Cooper, Terrorist Bombings, p. 961. 77Ibid; Glasstone and Dolan, Nuclear Weapons, p. 552. 78Blocker, V., and T. G. Blocker, Jr. 1949. The Texas City disaster: A survey of 3000 casualties. Am. J. Surg. 78:756-771. 79Cooper, Terrorist Bombings, pp. 960-961. 8°Blocker and Blocker, Texas City Disaster, pp. 756-771. Kennedy and Johnston, Civilian Bomb Injuries, p. 382; Stapczynski, Blast Injuries, p. 690. 82Cooper, Terrorist Bombings, pp. 955-967. 83Ibid., pp. 959-960; Kennedy and Johnston, Civilian Bomb Injuries, pp. 382-383. 84Cooper, Terrorist Bombings, pp. 959-961. 85Blocker and Blocker, Texas City Disaster, pp. 756-771. 86Coppel, Blast Injuries of the Lungs, pp. 735-736. 87Kennedy and Johnston, Civilian Bomb Injuries, p. 383. 88Rodgers, H. W., and J. D. A. Robb. 1973. Surgery of civil violence. Pp. 321-331 in Selwyn Taylor, ea., Recent Advances in Surgery, no. 8, Edinburgh: Churchill Living- stone. 89Glasstone and Dolan, Nuclear Weapons, p. 566. 90Constable, J. D. 1982. Burn injuries among survivors. Pp. 202-210 in E. Chivian et al., eds., Last Aid. San Francisco: W. H. Freeman. 9iCooper, Terrorist Bombings, pp. 961-962; Glasstone and Dolan, Nuclear Weapons, pp. 568-570; Committee for the Compilation of Materials. 1981. Hiroshima and Nagasaki. Pp. 118-121. New York: Basic Books. 92Glasstone and Dolan, Nuclear Weapons, pp. 563-565. 93Glasstone and Dolan, Nuclear Weapons, pp. 568-574; Constable, Burn Injuries among Survivors, pp. 202-210. 94Beecher, H. K. 1943. Resuscitation and sedation of patients with burns which include the airway. Ann. Surg. 117:825-833; Churchill, Surgeon to Soldiers, pp. 12-25. 95Dimick, A. R. 1981. Triage of Burn Patients. Pp. 17-20 in Thermal Injuries, Topics in Emergency Medicine. Gaithersburg, Md.: Aspen Systems Corp.; Glasstone and Dolan, Nuclear Weapons, pp. 558-559; Committee for the Compilation of Materials, Hiroshima and Nagasaki, pp. 120-121. 96Constable, Burn Injuries among Survivors, pp. 202-210. 97Artz, C. P., and D. R. Yarbrough III. 1972. Burns. Pp. 272-293 in D. C. Sabiston, Jr., ea., Textbook of Surgery. Philadelphia: W. B. Saunders. 98Daugherty, W., B. Levi, and F. von Hippel. 1986. Casualties Due to the Blast, Heat, and Radioactive Fallout from Various Hypothetical Nuclear Attacks on the U.S. This volume. 99Oughterson, A. W., and S. Warren. 1956. Medical Effects of the Atomic Bomb in Japan. Pp. 6-8, 90-93, 437-443. New York: McGraw-Hill. ~°°Committee for the Compilation of Materials, Hiroshima and Nagasaki, p. 523.
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BURN AND BLAST CASUALTIES: TRIAGE IN NUCLEAR WAR 283 0lCommittee for the Compilation of Materials, Hiroshima and Nagasaki, pp. 107-114. Committee for the Compilation of Materials, Hiroshima and Nagasaki, pp. 503-510. Rund and Rausch, Triage, pp. 84-96. 4Committee for the Compilation of Materials, Hiroshima and Nagasaki, pp. 107-114. 05Daugherty et al. This volume. 106Postol, T. A. 1986. Possible fatalities from superfires following nuclear attacks in or near urban areas. This volume. 107Abrams, H. L. 1984. Medical resources after nuclear war. J. Am. Med. Assoc. 252:653- 658. l08These assumptions overstate the number available by (a) ignoring the probability that the physicians might be more densely settled in the central areas of the cities, and (b) by not accounting for injuries among those physicians in the 12-15 km area. This latter effect is somewhat offset by assuming that all physicians among the injured who fled the 10-12 km zone would be considered in the category of casualty and not provider. i09Diffenbough, Military Surgery, pp. 490-491. ii°Sheedy, J. A. 1962. The role of forward medical support in handling masses of cas- ualties in active nuclear warfare. Military Med. 127:147-154; Warren, R., and J. H. Jackson. 1950. Suggestions for first-aid treatment of casualties from atomic bombing. N. Engl. J. Med. 243:696-698. Err, S. M., and W. A. Robinson. 1983. The Hyatt Regency skywalk collapse: An EMS-based disaster response. Ann. Emerg. Med. 12:601-605. ii2Lifton, R. J., et al. 1984. The second death: Psychological survival after nuclear war. Pp. 285-400 in J. Leaning and L. Keyes, eds., The Counterfeit Ark. Cambridge, Mass.: Ballinger. ii3Hersey, J. 1977. Hiroshima. Pp. 33-34. New York: Bantam Books. ii4Sorokin, P. A. 1942. Man and Society in Calamity. New York: E. P. Dutton; Lifton, Second Death, pp. 285-400; Kinston, W., and R. Rosser. 1974. Disaster: Effects on mental and physical state. J. Psychosomat. Res. 18:437-456. i~5Harwell, M. A., and H. D. Grover. 1985. Biological effects of nuclear war I: Impact on humans. Bioscience 35:570-583.
Representative terms from entire chapter: