The Medical Implications of Nuclear War (1986) / Chapter Skim
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11 Burn and Blast Casualties: Triage in Nuclear War
11 Burn and Blast Casualties: Triage in Nuclear War
Pages 251-283
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From page 251... ...
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.
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From page 252... ...
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 seasoned medical officer who takes on this task.7 Ethical issues intrude in settings of relative resource scarcity, which often pertain to mass casualty situations.
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From page 253... ...
Civil wars. Their outcry and
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From page 254... ...
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.
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From page 255... ...
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 transportation and relative reserves of resources. A brief account of military management 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.
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From page 256... ...
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.
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From page 257... ...
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 superf~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 battlefield wounds.38 Inpatient mortality from local wound infection ranged from 40 to 60 percent; if bacteremia ensued, mortality was virtually assured.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.
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From page 258... ...
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)
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From page 259... ...
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.
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From page 260... ...
The morbidity attached to the postoperative transport of patients with bowel injuries and the high incidence of hypotension in seriously burned patients presented particularly 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.
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From page 261... ...
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.
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From page 262... ...
3. The principle of triage persists as the active sorting method in all mass casualty situations.
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From page 263... ...
Its inapplicability to the disaster of a nuclear war arises from a failure to recognize the limits of our past experience and a failure to imagine what the next war might be. Triage in Nuclear War According to NATO guidelines, the medical response is to be organized by echelon: the battle aid station and field hospital would be in the combat zone, the full service hospital in the communications zone, and the rehabilitative facilities at some distant undefined site.
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From page 264... ...
mainland. This data range permits an assessment of potential medical response from the perspective of mass casualty management.
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From page 265... ...
, but injury correlates are confined to animal models.69 The medical literature describes the injuries seen in settings ranging from conventional war to terrorist bombings but cannot retrospectively establish precisely the physical characteristics of the explosions.70 A few general conclusions emerge from this experience and apply to a taxonomy of injuries to be expected in the vicinity of all cities hit by the airburst of a 1-megaton (Mt) nuclear weapon.
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From page 266... ...
Lacerations, abrasions, and contusions form the majority of wounds encountered among survivors of blast injury and are caused primarily by the effects of penetrating missiles accelerated to high velocities by the blast wave. In the winds created by the blast of nuclear explosions, almost any object can be transformed into a penetrating missile; in conventional war and terrorist bombings, the examples range from shards of glass to table legs.82 Lacerations causing extensive soft tissue destruction or wounds penetrating deeply create ideal conditions for serious infections such as gas gangrene; damage to major vessels or organs can also prove life threatening.
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From page 267... ...
89 Flame burns, resulting from exposure to secondary fires or contact with ignited clothing, are identical to the burns seen in conventional war or peacetime disasters.90 From the standpoint of patient management, flash burns, although limited to exposed surfaces and tending, perhaps, to give rise to slightly less tissue swelling and fluid loss, can be seen as resembling first- and second-degree burns along the continuum routinely used in burn classif~cation.9~ First-degree burns, affecting only the epidermis, can cause transient dehydration and pain but require no emergency treatment. Second-degree burns (or partial-thickness burns)
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From page 268... ...
.93 Failure to recognize that people with these injuries will require early and significant intravenous fluid and electrolyte replacement, scrupulous treatment of infection, and possibly aggressive airway support has led in the past to significant mortality among initial survivors of major burn disasters. Only well into World War II and after the analysis of deaths from the Cocoanut Grove Fire in Boston in 1943 did the risks of shock and hypoxia or airway obstruction from pulmonary injury become fully appreciated.94 Other factors contributing to increased mortality from burns include extremes of age and combined traumatic and burn injury.
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From page 269... ...
Review of Hiroshima and Nagasaki Data To evaluate the role of medical triage at the site of a disaster, it is necessary to have some grasp of the number of injured people alive at the time the triage intervention is applied. The reference cases rely on the standard partition of killed and injured developed from the Hiroshima casualty data compiled previously.98 Based on surveys of hospitalized survivors who were alive after 20 days, this data base counts as dead both those who had died immediately in the bombing and those who had died from their injuries during the intervening 20 days.99 Given the chaos and destruction that reigned during those first few weeks, it is remarkable that the record is as precise as it is: the medical relief stations did not begin recording casualty data at Hiroshima until August 11, five days after the
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From page 270... ...
i02 As it was, the imbalance between need and resources remained marked. It is axiomatic in medical triage that in settings in which severe injuries occur, treatment delays will result in increased mortality.~03 The most comprehensive compilation of casualty data from Hiroshima and Nagasaki estimates that 90-100 percent of all deaths occurred within the first 2 weeks; another source estimates that the 2-week mortality rate was 61.2 percent of the total recorded deaths.~04 A Japanese source, relying on police records of people seeking help from the station about 15 km from the hypocenter, reports that 50 percent of those severely injured had died by day 6; another 25 percent died by day 12, and 90 percent of all deaths had occurred by day 40 after the bombing.
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From page 271... ...
This proportion is in accord with the hypothetical injury profile recently constructed from an analysis of the mix of burn and blast casualties found at Hiroshima and Nagasaki and among the survivors of the Texas City fertilizer explosion.~07 These people with severe injuries in the 12-15-km zone would be truly incapacitated and would have to rely on the help of others to get to sources of care.
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From page 272... ...
272 ._ v 4 to to 2 Cal ._ 4 ._ v 4Cal o o ._ Cal o x 8 a, 4 Cd Cal A .
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From page 273... ...
273 an C)
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From page 274... ...
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.
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From page 275... ...
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~.
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From page 277... ...
A most conservative 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.
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From page 278... ...
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 information on early and delayed mortality.
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From page 279... ...
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.
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From page 280... ...
1966. Civil War Medicine.
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From page 281... ...
130-173; Brooks, Civil War Medicine, pp.
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From page 282... ...
960-961. 8°Blocker and Blocker, Texas City Disaster, pp.
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From page 283... ...
1962. The role of forward medical support in handling masses of casualties in active nuclear warfare.
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