1. MILITARY TRIAGE AND EVACUATION: PARALLELS TO CIVILIAN SYSTEMS CDR JOHN P. WEI, USN MC MD 4 th Medical Battallion, 4 th MLG, BSRF-12

2. MILITARY MASS CASUALTIES Long protracted event Long protracted event Extensive locally or at battlefield Extensive locally or at battlefield Variable number of injured or dead Variable number of injured or dead Health facilities always ready to receive injured Health facilities always ready to receive injured Resources potentially unlimited Resources potentially unlimited Natural and geographic limitations Natural and geographic limitations Usually occurs on foreign soil Usually occurs on foreign soil

5. MILITARY CARE FOR BATTLEFIELD CASUALTIES Save lives Save lives Reduce permanent morbidity and deficits Reduce permanent morbidity and deficits Return fighting force to battlefront Return fighting force to battlefront Evacuate casualties for definitive care Evacuate casualties for definitive care

6. STANDARD TRIAGE Provide orderly care to those who need most urgently Provide orderly care to those who need most urgently Save most number of lives Save most number of lives Coded system: Coded system: Green: minor injuries Green: minor injuries Yellow: major injuries, acceptable for delayed care Yellow: major injuries, acceptable for delayed care Red: major injuries, require immediate treatment Red: major injuries, require immediate treatment Black: expectant Black: expectant

7. MILITARY CARE FOR BATTLEFIELD CASUALTIES Depend upon battlefield conditions Urban vs rural mountainous terrain Small arms fire vs. explosive devices Geography of battlefield Dedicated resources available on site Health care system primary mission is treatment of casualties

9. CARE OF BATTLEFIELD CASUALTIES Stratified to provide immediate access to basic care Stabilization in the battle field Progressive levels of evacuation to advanced care in rear Evacuation to homeland for definitive care & recovery

10. DIFFERENTIATED LEVELS OF CARE Echelon I: Buddy-aid, corpsman/medic, First-Aid Station Echelon II: FST / FRSS field support hospital with surgical capacity Echelon III: fixed base advanced care hospital Echelon IV: complex advanced stabilization and care Echelon V: definitive CONUS hospital

11. ECHELON I Buddy-aid: every soldier carries tourniquet, QuikClot pack Medic/Corpsman – first aid pack with I.V.'s RL, bandages, needles First Aid Station: if available, GMO / ER physician

12. CASUALTY EVACUATION Casualty evacuation via ground ambulance CASEVAC – Difficult terrain – Remote location Medical evacuation MEDEVAC – Air rescue by Blackhawk/Seahawk or Chinook helicopter

14. ECHELON II Forward surgical capability Mobile combat support hospital Basic surgical capacity to save lives

15. ECHELON III Fixed brick/mortar hospital with ICU capacity, advanced radiology, neurosurgical & orthopedic capability

16. AEROMEDICAL EVACUATION Critical care transport in air Transcontinental evacuation Transport of mass casualties Provision of sophisticated ICU care while en route

18. ECHELON IV Landstuhl Regional Medical Center, Germany Intermediate advanced surgical care for stabilization Intensive care unit provisions

20. ECHELON V Definitive care for battle injuries Recuperation in CONUS Walter Reed MC, Bethesda NMC, Brooke AMC

21. CIVILIAN MASS CASUALTIES Acute isolated event Acute isolated event Extensive destruction Extensive destruction Large number of ill, injured, or dead Large number of ill, injured, or dead Health facilities overwhelmed by ill or injured Health facilities overwhelmed by ill or injured Resources damaged or limited Resources damaged or limited Natural and Geologic Natural and Geologic Weather and Atmospheric Weather and Atmospheric Biologic and Infectious Biologic and Infectious Terrorist Acts Terrorist Acts Man-made Accidents Man-made Accidents Catastrophes Catastrophes

23. CIVILIAN HOSPITAL PREPAREDNESS Emergency practice drills Emergency practice drills Hospital planning Hospital planning Variability Variability In trained personnel In trained personnel Integration with local EMS Integration with local EMS Liason with municipalities Liason with municipalities

24. CIVILIAN TRAUMA SYSTEMS American College of Surgeons Committee on Trauma Training of personnel Physical capacity and capability Triage of patients by severity of injuries to designated centers: Level I, II, III

25. CIVILIAN TRAUMA SYSTEM Geographically dependent on resources No dedicated resources at all levels Not all hospital facilities are trauma capable No dedicated trauma/critical care personnel

26. CIVILIAN TRAUMA SYSTEM Emergency first responders: variable ambulance services dependent on municipality, private services, hospital BLS/EMT vs. advanced care with paramedics

27. CIVILIAN TRAUMA SYSTEM Air evacuation via helicopter limited to Level I centers with air services Limitations of time and distance Severity of injuries Access to Level I care

28. SUMMARY Current civilian trauma system takes origin from military experience Battlefield mass casualties demand different resources and capabilities Principles of triage and evacuation similar between military and civilian systems Military system dedicated to trauma care as primary mission