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Sun Nov 30 18:33:39 GMT 2008

From: KMATTOX at aol.com> The immediate medical response to disaster is always TWO things: It is LOCAL, and it is SURGICAL. Period, enough said.

--> I am not certain how much of a welcome to debate I should read in "Period, enough said", but here are a couple of thoughts. They are based upon my understanding of what is meant by "immediate" & "medical". I am certain that my experience is not even close to extensive when compared to some on this list. AND I am not a surgeon, nor am I an expert.

1. There are not always many surgeons available in the LOCAL area. Sometimes the local area is unable to physically sustain a surgical operating environment. I have found this to be especially true in a maritime setting, but also on land. Patients may well require to be moved and to survive the move and to have a secure airway for the move and to be made comfortable analgesia/sedation-wise for the move. While surgeons could be trained to provide all these functions, in my experience these are services often provided by paramedics/fire, nurses & pre-hospital physicians who are also trained in resuscitation.
2. Some systems around the world DO NOT rely on the provision of trauma centres, staffed by surgeons. Thankfully, in many places there is not that much "trauma" requiring surgery every day, so Emergency Departments take over this role and they are not staffed by surgeons.
3. My meagre experience shows that SOME patients who arrive at the main receiving hospital/s during the disaster response may still not require only a surgeon, unless that surgeon plans to perform all the imaging & labs and then the RSI and anaesthesia & post-op intensive care. And there will probably be a few collapsed patients at the incident site with airway burns, chemical burns, radiation contamination, blast lungs and even the occasional dust-induced asthma attack or stress-induced chest pain or other non-scalpel conditions...
4. The 10% rule continues to exist (only 10% of those arriving alive at the hospital are really critical)... which leads to the requirement for someone to deal with the 90% who will not be seeing the surgeon right now... First step, probably, is to find someone able to distinguish WHO is in the 10%, WITHOUT "using up" for this purpose the surgeon who should be operating...
5. The local surgeons rise to the occasion, as do the other 90-something percent of the health response... There's this problem with surgeons, I find - there are not that many of them about in some places...

I fully agree with the advice for outside help NOT to "show up" unless invited. They should instead make themselves ready and available and notify the management team at the scene, through the appropriate channels. They may well be required for some incidents, especially if they are able to bring portable operating theatres/equipment with them, perhaps for secondary procedures and even unrelated cases, for which the local surgeons may be too tired to respond after the first day or two...

Perhaps some ITU staff might also be required to deal with the patients who are left waiting and deteriorating while the operating theatres are occupied with cases from the disaster. These are cases which were there before the incident and were graually "converting" into the category of "need surgery now". Just their bad luck to have an incident jump in the way and use up the surgical slot... Although these cases thus become a part of the incident, they are often not included in the statistics - one cannot easily include them in the statistic of within-24-hours-of-incident...
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