wounded nests and the triage. The benefits of taking care of the casualties must be carefully assessed with regards to the location of the casualties and the safety of the first-aid workers and the medical staff. Hence any medical interventions on the battlefield must be carried out within a certain framework 6, 7 taking into account several precise criteria: - Tactical criteria: objectives, tolerable and expected attrition rate; - Technical criteria: available medical material and staff; - Logistic criteria: place of action, modalities and evacuation timeframe. Choosing a location for the wounded nest is crucial, even if it delays the complete medical care of the first casualties (for about an hour in our case), for once its position is decided, it is difficult if not impossible to change it. The following criteria are connected to choosing a suitable location: - Flat, unobstructed, accessible by vehicle; - Easily made secure: near a rock for lateral protection; - Close to the combat zones (300 m) in order to limit the number of avoidable deaths. Chadian soldiers had no training in level 1 combat rescue and had no medical kit. - Possible MH landing zone nearby (200 m) for evacuation. The flow of vehicles bringing in casualties from the battleground to the nest of wounded was continuous and varied according to the successive waves of assault. Moving the casualties turned out to be most difficult. As the casualties started to arrive, we decided to set up a reception zone. We first settled the wounded in lines, but ended up adopting a spiral shaped configuration. Thus, the working space was limited, which made monitoring the casualties and
further reassessment easier throughout the day. Similarly, the close proximity between the casualties made it easy for slightly injured soldiers to talk to more critically injured soldiers (figure 3). The traumatic casualties (the victims of vehicle accidents) were deliberately isolated from those injured by penetrating agents, for more clarity, and were numbered last. A sustained and time consuming effort was the dominant factor in organising the priorities and the management of the evacuations. This is the difficult reality of triage, a continuous, evolving and dynamic process8.
The triage happened mainly during the day which made its management far easier. Conversely, the identification of patients and of the nature of their wounds was difficult for those soldiers who had poor skills in the French language. Hence, following Aigle’s experience1, casualties were given a number. They were difficult to identify as their names were similar and they all looked the same to Western eyes. This number (photo 5) was written on their skin or on their combat uniforms, according to their order of arrival (except for the eight traumatic wounded). To make things easier, in the beginning, the medical team had to agree on two locations of numbering, preferably on the forehead, shoulders thorax or thighs. Because of this the doctor’s administrative follow up work, the medical supervision, the evacuation planning and the distribution of the casualties into the MHs, notably in the medical helicopter, were made a lot easier.
The saturating inflow of casualties included nineteen dead soldiers; most of them died before they arrived at the wounded nest. The death rate reached 26% (19/74). The number of reported KIA was higher than in any
Figure 3: Organisation of a wounded nest with an area assigned to fatalities, accident victims and soldiers injured by wounding agents. All of them are numbered and set up in order of arrival.
International Review of the Armed Forces Medical Services
Revue Internationale des Services de Santé des Forces Armées