POSSIBILITIES OF INTER-TERRITORIAL MEDICAL ASSISTANCE IN EMERGENCY RECOVERY Bogdanov S.B., Porkhanov V.A., Baryshev A.G., Mukhanov M.L., Blazhenko A.N., Enikeev M.A., Khuzhina M.V., Bogdanova Yu.A., Shevchenko A.V.
Scientific Research Institution – S.V. Ochapovsky Regional Clinical Hospital No. 1,
Kuban State Medical University, Krasnodar, Russia,
Pirogov Kerch Hospital No. 1, Kerch, Russia
Over the whole history, the humanity has been exposed to emergencies, disasters, terroristic attacks and war conflicts [1, 2]. They cause significant harm for population health. For example, 16 serious terroristic attacks occurred in Moscow from 1996 to 2011. 530 persons died, 2,220 persons were injured (183 persons per year on average). After the terroristic attack at the underground stations Lyubyanka and Park Kultury on 29 March, 2010, 41 persons died, 88 − were injured, after the terroristic attack at the airport Domodedovo on 24 January, 2011, 38 persons died and 116 were injured. According to conclusion from British agency Maplecoft, Russia took 10-11 places among countries with highest threat of terroristic attacks in 2010-2011. From 2003 to 2010, more than 50 terroristic attacks occurred in Russia, more than 500 persons died. On 3 April, 2017, as result of a blast at running lines between the underground stations Sennaya Ploshchad and Technologichesky Institute, 115 persons and one terrorist died, 102 persons were injured [3, 4, 5].
According to the literature data, the medical consequences of terroristic attacks depend on various factors, including conditions of a blast. So, the ratio of fatalities and sanitary losses is 1:10 in the opened space and 1:5 in closed space [6]. For terroristic attacks with explosive substances, the following range of wounds is noted: head and neck injuries in 28 % of cases, chest injuries in 17 %, abdominal and pelvic injuries in 14 %, injuries to extremities in 41 %. In most cases, concomitant and multiple injuries are identified [7].
For mine-explosive wounds, a site of primary and secondary necrosis occurs which is was firstly described by N.I. Pirogov during the Crimean War. Owing to this reason, primary sutures are not applied usually, and primary skin plasty is limited [8-11].
Most victims of terroristic attacks need for inhospital treatment. High proportion of them receives urgent medical care.
An analysis of consequences of big emergency situations in Russia showed some significant difficulties in organization of procedures for provision of medical care. The scheme for surgical care for massive admission of patients is especially inefficient [12, 13].
When big emergency situations (ES) occur, each specialist must know his/her maneuver. Each physician must learn constantly and improve own skills. The integral system of medical care organization is arranged with trainings, which help to act in alternating situation professionally and without delay. Trainings help not to be lost during admission of high amount of patients who need for urgent care and to save maximally possible amount of injured [14, 15].
Objective − to analyze the possibility of providing inter-territorial medical care in the elimination of the consequences of a terrorist act.
MATERIALS AND METHODS
On 17 October, 2018, at 11:45 p.m., a blast occurred in a building of the polytechnic college in Kerch city. The student from Kerch shot at students. The emergency aid teams started medical care at the site of the incident and transportation to Kerch Hospital No. 1 named after N.I. Pirogov. The first victim was admitted at 12:10 p.m. First aid measures, primary surgical preparation of wounds, surgical treatment and intensive care were carried out in the hospital. Totally, 51 patients addressed to the hospital within 2 hours (41 adolescents and 10 lecturers). 34 persons were admitted. 3 patients died in the hospital in the first hour after admission as result of fatal injuries.
At 12:50, an emergency signal came from Kerch to medical facilities of Krasnodar region and Moscow. 7 emergency aid teams arrived from the nearest populated locality of Krasnodar region (Temryuk). By efforts of adult and pediatric sanitary aviation, 5 reanimobiles of class C were sent from Krasnodar. From the roof of Scientific Research Institution – S.V. Ochapovsky Regional Clinical Hospital No. 1, two helicopters were sent to Kerch (one sanitary aviation helicopter, the second − presented by administration of Krasnodar region for rapid delivery of physicians to the accident site). The ambulance cars from Temryuk arrived to the accident site at 14:00, but evacuation of victims to the medical facility had been completed already. The ambulance cars met 8 doctors who arrived by helicopter from Krasnodar and delivered them to the hospital. At 16:00, the first team of doctors arrived to Kerch Hospital No. 1 named after N.I. Pirogov (the reanimobiles from Krasnodar arrived at 16:30).
In Moscow, the complex medical team headed by V.I. Skvortsova, the health ministry of RF, was formed. From 16:00, Kuban medics initiated realization of high tech medical care (recurrent triage, surgical preparation of wounds, 2 surgeries for patients with abdominal injuries, osteosynthesis, intensive care, organizational activities). By the moment of 5 p.m., some critically patients were ready for transportation to Krasnodar. However, it was decided to wait for a medical team from Moscow and to transport the patients to Moscow.
On 18.10.2018, at 8 p.m., the specialists from Moscow arrived to the hospital. A concilium was held. All patients were examined. Intensive care and surgical management were carried out. Each 3 hours, doctors' round was carried out, as well as councils of physicians from Kerch, Moscow, Federal Medical and Biological Agency and Krasnodar. It was decided to evacuate all critically ill patients to the main clinics in Moscow.
Condition of the patients changed each hour. Traumatic disease developed. In the morning, on 18 October, 2018, condition of 2 patients was determined as critical. Therefore, the transfer to Moscow was cancelled, and they were transported to Scientific Research Institution – S.V. Ochapovsky Regional Clinical Hospital No. 1 within an hour at low altitude (by helicopter, without overloads).
From 7 p.m., 12 patients were transported by 5 helicopters from Kerch to the Simferopol airport, and then by special flight − to Moscow. 14 patients were transported to the hospitals of Krasnodar region, including 2 patient transferred by helicopter (with one flight with stabilization of an extremely severe patient). 15 patients in mild or middle severity condition were transported by cars to Simferopol. In the clinics of Moscow, Krasnodar and Simferopol, intensive general and local treatment was continued which lasted for several months.
Totally, 73 patients addressed for medical care (including mild injuries) to various facilities of Kerch. 19 patients died: 15 − on the site, 4 − within the first 3 hours after trauma.
The tables 1-4 shows an analysis of treatment arrangement for 51 patients in Kerch Hospital No. 1 named after N.I. Pirogov. One should note prevalence of opened fractures and detachments of extremity segments in combination with mine-blast and gun-shot injuries to soft tissues, whereas injuries to the head, chest, abdomen and pelvis (the table 1), had predominantly superficial pattern and required for only primary surgical preparation of wounds in most cases. So, among 5 patients with abdominal wounds, only one patient had the penetrating pattern of an injury, which required for laparotomy.
Table 1
Structure of injuries location according to anatomic fields
|
Injury location |
Amount, abs. |
Amount, % |
|
Head injuries |
7 |
10.40 |
|
Chest injuries |
3 |
4.50 |
|
Abdominal injuries |
5 |
7.50 |
|
Pelvic injuries |
1 |
1.50 |
|
Injuries to extremities with detached segments |
6 |
9.00 |
|
Injuries to extremities with bone fractures |
21 |
31.30 |
|
Injuries to extremities with soft tissue injuries |
24 |
35.80 |
The most severe patients had opened fractures and detachments of extremity segments in combination with mine-blast and gun-shot injuries to soft tissues (the table 2). Hence, most surgical interventions were primary surgical treatment of wounds and osteosynthesis with external fixing devices (the table 3).
Table 2
Structure of patients according to injury severity
|
Structure of patients according to injury severity |
Amount, abs. |
Amount, % |
|
Mild injuries |
17 |
33.30 |
|
Average severity injuries |
23 |
45.10 |
|
Severe injuries |
11 |
21.60 |
|
Total |
51 |
100.00 |
Table 3
Structure of surgical interventions
|
Structure of surgical interventions |
Amount, abs. |
|
Primary surgical preparation of wounds |
28 |
|
Primary surgical preparation of wounds and external fixation of extremity fractures |
23 |
|
Amputation of extremity segments |
5 |
|
Laparotomy |
1 |
|
Total |
57 |
26 patients were evacuated to medical facilities of Krasnodar and Moscow. 25 patients received the treatment in medical facilities of Crimea republic (the table 4).
Table 4
Distribution of patients according to place of treatment as result of triage
|
Form and place of final treatment |
Amount, abs. |
Amount, % |
|
Outpatient treatment according to place of residence (Crimea Republic) |
17 |
33.30 |
|
Inpatient treatment according to place of residence (Crimea Republic) |
8 |
15.70 |
|
Evacuation to medical facilities of Krasnodar |
14 |
27.50 |
|
Evacuation to medical facilities of Moscow |
12 |
23.50 |
|
Total |
51 |
100.00 |
RESULTS
On the site of care realization, Kuban medics performed secondary medical triage, patient round, clarification of lists of patients, communication with patients' relatives and identification of unknown persons. For treatment of 11 critically ill patients, 5 intensive care teams were formed, 2 operations for abdominal organs and 5 operations for mine-blast injuries were carried out (Fig. 1, 2), as well as medical evacuation by helicopter (to Simferopol and Krasnodar) was done and C class reanimobiles were provided.
Figure 1
The patient with a mine blast wound of the lower extremities 6 hours after injury
Figure 2
Removal of the damaging factor 7 hours after injury. 17.10.18, Kerch
From the moment of arrival of medical teams from Krasnodar and Moscow, nobody died. The first medical evacuation of all patients to the stage of high tech medical care was realized within the first 24 hours after the accident. It allowed maximally fast medical care. Significant complex work was done for salvation of patients' lives by the leading specialists of Kerch, Krasnodar, Moscow and Saint Petersburg.
In Krasnodar, treatment was performed for two extremely severe patients (the age of 16 and 57) who had been evacuated by helicopter. Over the period of treatment, multiple councils with participation of the leading specialists from Moscow, Saint Petersburg, Krasnodar and Health Ministry of RF were performed.
A patient, age of 16. The main diagnosis: "Closed TBI (17.10.2018), mild brain contusion with contusion focus of type 1 in the right frontal lobe, with an injury to duodenum, part of jejunum; an injury to soft tissues of the right hip".
Operations and manipulations: 17.10.2018 − laparotomy, abdominal cavity revision, primary surgical treatment of wounds. 18.10.2018 − laparotomy, suturing of ruptures of lower part of duodenum, removal of a foreign body, disconnection of duodenum, application of gastroenteroanastomosis for a small intestine loop with Roux-en-Y bypass, cholecystostomy, abdominal cavity draining. 19.10.2018 − delayed surgical treatment of surgical wounds, application of VAC-dressing. Aponeurosis not sutured. 22.10.2018 − change of VAC-dressing. 24.20.2018 − relaparotomy, abdominal cavity revision, recurrent surgical treatment of laparotomy wound, resection of a part of gteater omentum. Recurrent surgical treatment of the wound of the right hip with VAC-draining. 27.10.2018 − suturing of the right hip wound. 8.11.2018 − restoration of retroperitoneal space drain along the fistulous tract under X-ray control.
Complications of the main disease: generalized serous peritonitis. Retroperitoneal phlegmona to the right. Focal pancreatic necrosis. Sepsis.
Background diseases: adolescent angioneurosis of hypertonic type. Constitutional exogenous obesity of degree 3 (weight of 140 kg).
Concurrent diseases: adolescent angioneurosis of hypertonic type. Constitutional exogenous obesity of degree 3. Toxic metabolic cardiopathy. Deep venous thrombosis of lower extremities. Occlusive thrombosis of sural and muscular veins of the left lower extremity without data of flotation. Occlusive thrombosis of the great subcutaneous veins in both lower extremities.
The patient was discharged on 03.12.2018. His condition was satisfactory.
A patient, age of 57. Clinical diagnosis: "Combined injury to the head, spine, chest, abdomen and extremities (17.10.2018). Closed TBI in acute period. Brain contusion of middle severity. Traumatic subarachnoid bleeding. Contusion foci in parietal and occipital lobes in both semispheres of cerebellum. Scratches of the head. Closed chest injury. Bilateral spontaneous pneumothorax. Condition after pleural cavity draining (25.10.2018). Closed abdominal injury. Spleen laceration. Hydroperitoneum. Opened multi-fragmentary fracture of middle and lower one-third of the left leg, opened fracture of upper one-third of the left hip, extensive ruptured wound of lower one-third of the left leg and of lower one-third of the left hip with soft tissue defect, multiple lacerated wounds of the left leg. An injury to anterior and posterior tibial arteries to the left. Condition after ligation of anterior tibial artery and application of vascular autovenous anastomosis of posterior tibial artery to the left (18.10.2018). Thermal burns of both lower extremities of degree 2-3 A, 10 %. Acute period of spinal cord injury: cervical spine contusion of middle severity without traumatic injuries to the cervical spine SCIWORA). Tetraparesis".
Operations and manipulations: 18.10.2018 − ligation of anterior tibial artery and application of vascular autovenous anastomosis of posterior tibial artery to the left. 25.10.2018 – pleural cavity draining. 01.11.2018 – amputation of left lower extremity at level of upper one-third of the leg. 02.11.2018 – surgical treatment of wounds of left lower extremity, necrectomy. 04.11.2018 − surgical treatment of wounds, necrectomy. 05.11.2018 − recurrent surgical treatment of wounds of left lower extremity. 06.11.2018 − surgical treatment of stump of left leg. 09, 12.11.2018 − surgical treatment of stump of left leg with vacuum draining. 16.11.2018 – surgical treatment of surgical treatment of stump of left leg with suturing and vacuum draining. 20.11.2018 − surgical treatment of stump of left leg with suturing.
Complications of the main disease: purulent necrotic wounds of left leg stump. Autovenous anastomosis thrombosis. Anemia of middle severity. Thrombocytopenia. Bilateral posttraumatic chronic sensoneural bradyacuasia.
Concurrent diseases: alveolar rhabdomyosarcoma. Lumbar dystopia of right kidney. Incomplete movement of right kidney. Chronic pyelonephritis, latent course.
Short history of disease from presented documents. Injury on the job (a college lecturer). On 17.10.2018, at 11:50 a.m., a blast occurred in the Kerch polytechnic college. The patient was transported by ambulance car to Kerch Hospital No. 1. There she was examined, and intensive postsyndrome therapy was carried out. Primary surgical treatment of wounds of lower extremities was carried out, as well as ligation of anterior tibial artery to the left. External fixing apparatus was applied onto the left leg and foot.
The patient was discharged in satisfactory condition on 10.12.2018.
The presented clinical case shows the treatment of one of 12 patients of middle severity.
The patient, age of 20 (Fig. 3-8). Main diagnosis: "Mine-blast trauma. A penetrating gun-shot fragment wound of the right leg. A penetrating gun-shot wound of the left leg, 2A opened multi-fragmentary fracture of both bones of left talus bone with displaced fragments. Foreign body in the left leg".
Figure 3
The wound in the area of the right ankle joint and foot
Figure 4
The wound of the right lower leg, view in the operating room, removal of foreign bodies
Figure 5
Management of wounds under vacuum dressings
Figure 6
View of granulation wounds before free skin autoplasty
Figure 7
Repaired skin on the right foot
Figure 8
Result of reconstructive surgery of the left leg and ankle joint
Short anamnesis of disease. By the statement of the patient and data of medical documents, the injury was received as result of a blast in the dining hall of the college in Kerch on 17.10.2018 about 11:50 a.m. The patient was in the dining hall with her classmates, when the blast occurred. She fell onto the ground from blast wave. She was in consciousness. Bystanders helped her to leave the building. Her relatives delivered her to the Kerch City Hospital No. 1. She received clinical and radiological examination. The diagnosis was opened fracture of the left leg. Medical care was performed: analgetics, infusion and transfusion therapy, primary surgical treatment of both legs, immobilization of the left lower extremity. After condition stabilization and approval from Health Ministry of RF, the patient was transferred to City Clinical Hospital No. 1 to receive further surgical treatment. After admission, she was examined according to the concomitant injury algorithm.
Surgical treatment: 19.10.2018: 1) surgical treatment of a lacerated wound of the right leg, removal of a foreign body in the right foot, VAC-dressing; 2) surgical treatment of the left leg, removal of a foreign body in the left leg, opened reposition of distal epiphyseal cartilage of the left tibial bone, mounting of external fixing apparatus for leg/foot to the left, VAC-dressing. 22, 25.10.2018 – change of vacuum dressing. 29.10.2018 − surgical treatment of the wound, autodermoplasty with split perforated skin graft, VAC-dressing. 12.11.2018 − surgical treatment of the wound, autodermoplasty with split non-perforated skin flap.
The patient was discharged for outpatient treatment up to complete healing of wounds and for preparation of the second stage of surgical treatment − reconstructive plasty surgery for the ankle joint.
The second admission on 12.12.2018. The main diagnosis: "Consequences of mine-blast injury. Condition after penetrating gun-shot fragment wound of the lower one-third of the right leg, lower one-third of the left leg. Condition after autodermoplasty from 29.10.2018, 12.11.2018. Non-united fracture of distal part of both legs of the left leg, left talus bone in condition of external fixation from 19.10.2018".
Surgical treatment: 18.12.2018: 1) removal of a metal construct from the left tibial bone. 2) Arthrodesis of the left ankle joint with DeOst 9 × 240 mm.
The patient was discharged on 26.12.2018 for outpatient treatment.
DISCUSSION
In our country, patients are admitted to a hospital, which is at the nearest distance from an accident site. Therefore, each surgeon should have multi-sided training and knowledge of diagnostics algorithm at admission of a patient in satisfactory condition and with multiple injuries and contusion of internal organs. Traditionally, military field surgery is strong in Russia. The word injury should be understood in wider sense, not only as traumatology. The strategy of treatment has changed in modern clinics. All leading surgeons must know it since damage control concept showed high efficiency in various fields of surgery.
Unfortunately, senior divisions are closed in medical institutes. In case of emergency situation, all patients are delivered to municipal medical facilities. 3 years ago, the exam for traumatology and military field surgery has been introduced only for general medicine department, but it is insufficient for achievement of maximal knowledge for realization of medical care during emergency response.
The favorable factors of medical care arrangement after terroristic attack in Kerch on 17.10.2018 were: 1) terroristic attack in working time; 2) absence of traffic jam in Kerch; 3) arrangement of first aid by employees of the nearest emergency station, by students and employees of a medical college, which is also not far from; 4) Kerch bridge introduced into operation; 5) warm season of the year; 6) flight weather. Cellular transmission was not jammed, but air space was closed. Helicopters from Krasnodar landed on the military airdrome.
The self-made blast device was under the table. Therefore, the blast wave with self-made impact factors injured mainly lower extremities that promoted a decrease in mortality.
During medical care at the accident site, the possible scenarios of development of this emergency situation were analyzed. The limit of the hospital for critical care was used at 80-90 %. For possible recurrent blast (that is often in terroristic attacks), for critical care realization, the hospital had additional 7 ALV devices in the surgery room, 5 − in reanimobiles and 5 − in helicopters (1 from Krasnodar, 4 from Federal Medical Biological Agency).
In realization of first medical aid in Pirogov Kerch Hospital No. 1 at admission within the first 2 hours after trauma, patients with mine-blast injuries received application of rare primary sutures. Sutures were removed within the first 1-2 days in all patients. Wounds were managed mainly with vacuum therapy, with application of sutures after removal of secondary necrosis, with formation of zone of molecular contusion.
During planning of evacuation to Moscow, it was decided not to transfer two critically ill patients due to extremely severe condition. Time of supposed evacuation to the hospital in Moscow was 5-6 hours, with multiple repositioning of the extremely severe patient. It was more appropriate to use the helicopter, and only one time. At very low altitude (without overload for ALV patients), the helicopter delivered patients to the Krasnodar clinic within 45 minutes. The clinic has a helicopter landing site on the roof. Several minutes later, patients were transferred to the intensive care unit in specially equipped elevators.
In the All-Russian people's front, some issues were discussed, including intensifying training of civilian medics for medical care arrangement in case of emergency situation, regular trainings in medical facilities with various scenarios and opening of military departments in medical universities.
CONCLUSION
Realization of constant trainings for emergency response in medical facilities increases the organization and quality of medical care in real conditions.
For intensifying medical care on sites of emergency it is necessary to interact with neighboring territories, from which specialists may arrive faster.
Recently, owing to reorientation of many medical facilities to admission of patients with COVID-19, it is necessary to develop routing of admission of patients in case of emergency situation.