legitimate lifesaving technical actions they need. Furthermore it was necessary to preserve operational capabilities of our own medical support (only one scope, only one transportable mechanical respirator and a limited supply of oxygen). Moreover, the work was performed under some constraints: long evacuation delays and little surgical possibilities on the forward operating base. Hence a new triage was needed at the VSM (too small for the magnitude of the inflow), as well as decisions for secondary evacuations. Because of the different practices in the two medical teams, the doctor of the triage was chosen right at the start, which simplified the chain of command and kept discussions to a minimum. Given the large amount of casualties and the limited material available, medical care had to be targeted (no drugs to ensure the patients’ comfort for example) and implemented according to the MARCHE RYAN protocol. As such the consequences of the wounds were treated to ensure the survival of as many casualties as possible, until they could be taken to a surgical unit (photo 6). The medical acts were mainly damage control (a dozen tourniquets were left in place), resuscitation (exsufflation, thoracostomy) and preparation. The medicalization of this type of massive inflow of casualties must be simple and kept to a strict minimum to meet operational demands: ‘‘the right act performed
at the right moment on the right person’’. Furthermore, total blood transfusions in the field were very difficult, given the context, cryo-removed plasma could be a good substitute given the evacuation times.
Field medical records (FMR)
The evolution of field medical records has been researched for many years, yet their limitations are obvious when dealing with a massive inflow of casualties. People need to write quickly, this is a major constraint in field medicine. Furthermore, the stressful environment makes it difficult to fill in all the items needed for any medical records. Yet the risk is to leave out a crucial piece of information2. Standard medical forms were used for the first wave of twelve casualties, however, given the fact that the forms were not properly filled in (the soldiers exchanged their forms or withdrew them altogether), that the inflow of casualties was massive and that there were not enough medical field records, we subsequently used sheets of paper on which we centralised the data in a note pad with the numbering described above (photo 7). These notes (on four sheets of paper) were given to the MEDEVAC doctor during his first round, then to the intensivist of the VSM. No verbal exchange could be recorded because there was not enough time and the helicopters made too much noise. The ideal medical record remains wishful thinking. A simplified version could be implemented (with boxes to
Photo 6: Example of medicalization: tourniquet, immobilisation, drip, wrapping (personal collection).
Photo 7: Data is recorded on a note pad, an example of a sheet of paper sent to the VSM (triage and orientation were carried out subsequently in intensive care) (personal collection).
International Review of the Armed Forces Medical Services
Revue Internationale des Services de Santé des Forces Armées