SPAŠAVANJE NA OPASNOM PODRUČJU PRILIKOM NEPOSREDNE UGROŽENOSTI

SPAŠAVANJE NA OPASNOM PODRUČJU PRILIKOM NEPOSREDNE UGROŽENOSTI

Dimitar Anakiev, dr.med
Médecins du Monde Belgique,
Azilni dom sa podružnicama, Ljubljana,
Cesta v Gorice 15, 1000 Ljubljana

UVOD
Akcija spašavanja doktrinarno otpočne pitanjem „Da li smo bezbedni?“ i nastavlja se odgovorom „Bezbedni smo“. Vreme u kojem živimo, nažalost, često ponudi odgovor „Nismo bezbedni“. HMP je u državama EU u zadnjih 21 godinu zbrinjavala 88.984 povređenih u terorističnim napadima, što na godišnjoj ravni znači 4.237 povređenih. U istom periodu je kao posledica terorističkog napada život  izgubilo 507 ljudi (podaci: Wikipedija). U pitanju je dakle pravi rat koji se događa unutar EU i u kojem mora učestvovati takođe HMP.
Verovatno smo iz istih razloga u Sloveniji nedavno izveli Vežbu masivne nesreće na stadionu Stožice, u toku koje je HMP zdravstveno zbrinula 700 hipotetično ugroženih, među kojima je bilo 250 povređenih. U slovenačkim medijima smo nedavno mogli opaziti niz informacija koje govore o kupovini pancirnih košulja za spasioce HMP zato da bi mogli delovati na područjima na kojima se ne osećaju bezbedni. Opasnost takođe u HMP Slovenije sve više postaje važan činioc radnog prostora na kojega moraju računati kako urgentni doktori tako i spasioci. Znači ima smisla baviti se strategijom i taktikom spašavanja na opasnom području i takođe razmišljati o spašavanju prilikom neposredne ugroženosti.
Altruistični karakter lekarskog posla i priroda posla HMP pretpostavlja dobrovoljnu saradnju spasioca i lekara u akcijama spasavanja gde bezbednost nije potpuna, odnosno gde postoji rizik letalnog ishoda i povrede sudelujućih, čak i u slučajevima gde rizik prevazilazi benefit akcije spašavanja. Sa tim pitanjem se bavi takođe Toni Houp (Tony Hope) u svojoj studiji „Slučaj zarobljenog rudara“. Autor tvrdi, da je za spasioce u akciji spašavanja prihvatljiv rizik 1:10.000 na kojega većina lekara i zdravstvenih radnika pristaje bez razmišljanja. U manjim akcijama spasavanja, gde je broj učesnika ograničen, rizik 1:10.000 je još prihvatljiviji, odnosno takoreći se odmah pretpostavi. Tu moramo razlikovati spašavanja vojnih lekara i spasioca, koja se odvijaju po posebnim taktičkim protokolima i po načelu dvostrukog rukovođenja (vojnog i stručnog). To što nas u našem slučaju zanima je spasavanje kojim se stručno rukovodi i koje se događa u opasnim situacijama (koje mogu biti ratovi ili druge masovne nesreće).
Kao dugogodišnji vojni lekar nekadašnje JNA više puta sam učestvovao u spašavanju koje se događa u opasnim okolnostima, takođe i u takvim akcijama spašavanja koje nisu bile deo taktične vojne operacije. Predstaviću dva slučaja iz rata koji je nastao raspadom Jugoslavije. Obe akcije spašavanja su se dogodila februara 1992 u Glini, u Hrvatskoj, približno dva  meseca pre nego što je Hrvatska postala nezavisna država.

PRETSTAVLJANJE SLUČAJEVA

Slučaj „A“: Rano ujutru, oko 5 sati, dok je napolju bilo još tamno, primim, kao dežurni lekar garnizona Glina, poziv iz Komande garnizona. Saopšte mi, da je pinzgauer JNA prilikom razvoženja doručka vojnicima u blizini linije razgraničenja sa hrvatskim vojnim formacijama ZNG, naišao na protivtenkovsku minu, koja je eksplodirala i povredila vozača i suvozača. Saopšte mi takođe tačne koordinate kraja nesreće, detelje o povređenima nemaju. Narede mi da se uputim na kraj nesreće, koji
je od ambulante udaljen približno 5 km... Sledi dogovor sa dežurnim vozačem ambulante kojom prilikom odlučim da ćemo se uputiti na kraj nesreće vozilom S-4. U tadašnjoj vojnoj terminologiji je izraz S-2 označavao vozilo za dva ranjenika, opremljeno sa dvema posteljama (pinzgauer), dok je izraz S-4 označavao vozilo opremljeno sa četiri postelje (kamion TAM-110). Kada bi odluku donosio na osnovu broja povređenih – dva – morao bi izabrati pinzgauera, međutim, ja sam izabrao dosta veće vozilo, jer sam se plašio da je u zadnjem delu intendantskog vozila bio još neki vojnik, koga su u komandi prevideli (kuvari nisu bili poznati po disciplini, pa su često podele doručka iskorišćavali za privatne posete).     Odluka o izboru vozila se je kasnije pokazala ključnom za uspešan tok naše akcije spašavanja. Četvoročlanu ekipu so sastavljali lekar, dva tehničara i vozač. Naoružani smo bili sa automatskim oružjem (kalašnikov), koje naravno nismo nosili, već su stajali u posebnim nosačima u kabini. Na mesto nesreće došli smo uspešno i brzo.Teško oštećeni intendantski pinzgauer je bio na sred puta delimično prevrnut na bok. S-4 smo parkirali pored njega  i radili na svetlu farova. Vozač, po činu zastavnik, je bio nesvestan i u stanju šoka, levu nogu je imao amputiranu ispod kolena. Namestili smo Esmarh i postavili infuziju. Suvozač je bio običan vojnik, Rom po nacionalnosti, svestan (jeca) ali takođe u šoku i prorešetan sa više stotina gelera rasejanim po celom telu, licu i u očnim jamama. Rane na licu smo samo prekrili navlaženom sterilnom gazom, postavili smo infuziju i analgeziju, a onda smo se obrnuli i po istom putu se vratili u Glinu. Sve zajedno spašavanje i transport do Gline trajali su 35 minuta. Napolju se je danilo. Ranjenike smo pretovarili u helikopter MI-22 i odmah uzleteli prema Beogradu, koji je bio udaljen 300 km. Tek u vazduhu postao sam svestan opasnosti. Helikopter veličine manjeg autobusa, bio je laka meta, i mogao je da ga pogodi praktično svaki vojnik pomoću toplotno vođenog projektila „strela“, koga su imale u naoružanju sve čete. Nakon približno 40 minuta smo doletili na VMA (Vojno-medicinska akademija) gde smo oba ranjenika živa predala u dalji tretman. Nakon povratka u Glinu posetio me je inženjerijski major. Njegova jedinica je na istom putu kojim smo mi toga jutra evakuirali ranjenike, tokom dana iskopala još 7 (sedam) protivtenkovskih mina. To je značilo da smo vozili - u oba smera – preko 7 protivtenkovskih mina. Jednom, pa još jednom. Kada bi upotrebili prilično uže vozilo S-2 sigurno bi naišli na minu. Ovako je širina našeg vozila bila odlučujuća da smo uspeli obići mine, odnosno, ostale su između naših točkova.

Slučaj „B“: Februara 1992, približno sedam dana posle događaja „A“, oko 21:00 časova, bio sam poslat na spašavanje pogođenog HMP vozila TO (teritorijalne odbrane) u dolinu reke Gline. U pogođenom vozilu trebalo je da se nalazi ranjeni medicinski tehničar, dok se je drugi tehničar nepovređen izvukao i prijavio dogođaj. Na mestu nesreće dolina ima oblik latiničnog slova „V“, što je značilo da je od lokacije pogođenog vozila HMP do položaja na drugoj strani reke - odakle se pucalo - bilo približno 300-400 metara vazdušne linije. Vozili smo se u pinzgaueru nadole prema reci, dok su prema nama leteli razni svetleći projektili. Vozili smo bez svetla i bez gasa, tako da smo se jedva pomerali. Bili smo u potpunom tami. Svetlost letećih metaka u tamnoj noći nas je potpuno očarala – leteli su prema nama iz svih mogućih pozicija i sve je izgledalo kao jedna magična predstava. Nije bilo jasno, da li su užarena zrna, koja smo očarano gledali, ispaljena zaradi nas ili na neku drugu metu, jer nalazili smo se u neposrednoj blizi prve borbene linije. Veliki broj tih zrna završio je u našoj neposrednoj blizini i mogli smo čuti njihov zvuk. Svaka minuta izgledala nam je kao večnost. Vreme se je zaustavilo jer smo se jedva pomerali zato da bi ostali eventuelno neopaženi. Na pola brda smo konačno u tami opazili pogođeno sanitetsko vozilo. Vozač je bio mrtav, medicinski tehničar pored njega bio je pogođen u predelu hipogastrijuma, u stanju šoka ali svestan. Sve što smo u tom trenutku napravili bilo je da smo ranjenog tehničara prebacili iz pogođenog vozila u naše vozilo. A onda smo sa punim gasom, još uvek bez svetla, pošli putem napred prema vrhu. Od buke našeg motora nismo više znali da li pucaju na nas – liniji fronta smo obrnuli leđa i brzo bežali. Kroz nekoliko minuta smo se zaustavili na bezbednoj lokaciji i zbrinuli ranjenika, zatim smo ga vozili dalje.    

RASPRAVA

Na opasnom području, kakvo je ratno područje i krajevi masivnih nesreća, mnoga pravila postanu relativna dok se veoma poveća značaj trenutne procene i lične odgovornosti lekara/vođe tima kako za početak tako i sprovođenje akcije spašavanja. U navedenim primerima videli smo da pravilo „uvek se vraćaj putem kojim si došao na kraj nesreće“ nije uvek dobar izbor. U našem slučaju „B“ bilo je vraćanje istim putem nemoguće, dok je u slučaju „A“ još više povećalo rizik. Izbor vozila i sredstava nije uvek podrazumevajući. Noć predstavlja rizik, ali istovremeno nudi zaštitu. Ambivalentnost pravila je česta. U oba navedena primera smo videli da preliminarne akcije nije bilo moguće izvesti, odnosno bila bi besmislena (razlika između ofanzivnih, taktički vođenih akcija sa inicijativom, gde se može planirati i izvoditi protokol, i pasivnim, odbrambenim događanjem, gde je kontrola događaja otežana). Spašavanje je u oba navedena primera teklo na osnovu lične procene lekara o preuzimanju rizika za spašavanje. Ona je na početku bila više intuitivno-emocionalna nego racionalna, iako je lekaru situacija na terenu, zbog čestih obilazaka jedinica, bila delimično poznata. Svakako postoje takođe racionalni razlozi. Američka vojno-medicinska literatura navodi samo dva razloga za (eventualno) spašavanje prilikom neposredne ugroženosti:


1.Apsolutno esencijalno preduzimanje mera (kao što je na primer Esmarh)
2.Unesrećeni mora biti hitno premešten/umaknut sa mesta nesreće (zbog takve ili onakve ugroženosti)

Dva takva slučaja su napred opisana. Samo spašavanje bilo je izvršeno protokolarno korektno, ali na način koji su diktirale okolnosti. Naša želja da bi okolnosti kontrolisali nije uvek ostvariva. Spašavanje pri neposrednoj ugroženosti se ne može isključiti iz lekarske profesije i zato ga je potrebno razmatrati kao stručni problem (umesto da bi ga „doktrinarno“ izbegavali). Svest o opasnosti je često nepotpuna, sa druge strane je opasnost sve više deo našeg života.

LITERATURA: 1. Campbell, John E. in Alson Roy L. 2015. ITLS for Emergency Care Providers - eighth edition. Boston: Pearson Education, xii-xii, 2-5. 2. Campbell, John E., Heiskell E. Lawrence, Smith Jim in Wipfler John E. 2012. Tactical Medicine Essentials. Sudbury: Jones and Bartlett Learning, 4-15. 3. Campbell, John E., Pfeifer William in Kagel Andrew. 2014. ITLS Military Second Edition. Boston: Pearson Education, 2-3. 4. Hope, Tony. 2014. Medicinska etika. Zelo kratek uvod. Ljubljana: Založba Krtina, 48.

Prvi put publikovano na slovenačkom jeziku u časopisu URGENTNA MEDICINA – IZABRANA POGLAVLJA br.23/2016 str.206-208

RESCUE IN THE DANGER ZONE UNDER IMMEDIATE THREAT

Dimitar Anakiev, dr.med
Médecins du Monde Belgique,
Azilni dom sa podružnicama, Ljubljana,
Cesta v Gorice 15, 1000 Ljubljana, Slovenia


INTRODUCTION

       A rescue mission principally starts with a question, „Are we safe?“ and proceeds with an answer, „Yes, we are“. Unfortunately, the times we are living in very often offer another answer, „No, we are not“. EMS in the EU states has, in the last 21 years, treated as many as 88.984 injured in terrorist attacks which annually means 4.237 cases of injury. In the same period, as a consequence of terrorist attacks, 507 people lost their lives (data: Wikipedia). What we are witnessing is a real war happening within the EU in which Emergency Medical Service must be involved as well.
      This is probably the reason why we have recently carried out, in Slovenia, a mass casualty incident drill on Stožice stadium during which the Emergency Medical Service medically treated 700 hypothetically vulnerable including 250 injured. In Slovenian media we could recently notice a set of information about purchase of bullet-proof vests for EMS rescuers so that they could act on the locations they do not feel safe at. Thus danger in the EMS of Slovenia increasingly becomes an important factor of work space that emergency doctors as well as rescuers must take into consideration. This means it makes sense to deal with rescue strategy and tactics in the danger zone as well as to think about rescue on occasions of immediate endangerment.
      Altruistic character of medical vocation as well as the very nature of emergency medicine assume voluntary cooperation between the rescuer and the doctor in the rescue actions in which safety is not complete, that is, where there is a risk of lethal outcome and injury of the participants even in the cases where the risk overcomes potential benefits from the rescue action. This issue is also dealt by Tony Hope in his study of the case of a trapped miner. He claims that, for rescuers in the rescue mission, the acceptable risk is 1:10000 as the one that majority of doctors and medical workers accept without thinking. In smaller rescue missions with a limited number of participants, the risk of 1:10000 is even more acceptable, that is, it is assumed right away. There we should distinguish rescue by military doctors and that by rescuers since they are done according to separate tactic protocols and on the principle of double management (military and professional). What interests us, though, in our case is the rescue professionally managed in dangerous situations (which might be wars or other mass incidents).
        As a military doctor, for many years, of former Yugoslav People Army (YPA) I participated many times in the rescues taking place under dangerous circumstances as well as in such rescue actions that were not part of a tactical military operation. I will present two cases from the war that broke out with the collapse of Yugoslavia. Both the rescue actions had taken place in February 1992 in Glina, Croatia, approximately two months before Croatia became an independent state.

PRESENTATION OF THE CASES

      Case “A”: Early in the morning, about 5 am, while it was still dark outside, as a doctor on duty of Glina Garrison, I received a call from the Garrison Command. They told me that a YPA Pinzgauer, while distributing breakfast to the soldiers close to the dividing line with Croatian military (ZNG) (Croatian National Guard) formations, hit upon an anti-tank mine that exploded and hurt both the driver and the person sitting next to him. They also gave me the exact coordinates of the incident location but no details about the injured. They ordered me to go to the site which was about 5 km away from the ambulance.... Then I had a talk with the ambulance driver on duty and decided to take vehicle S-4 to get to the incident site. In the former military terminology abbreviation S-2 meant a vehicle for two injured, equipped with two beds (Pinzgauer) while expression S-4 referred to a vehicle with four beds (truck TAM-110). If I had made a decision on the basis of the number of injured – two – I would have to choose Pinzgauer; however, I picked up quite a larger vehicle for fear I might find, in the back part of the quartermaster’s vehicle, some other soldiers overlooked by the Command (cooks were not praised for their discipline since very often they used breakfast distribution for private visits).
      The decision about vehicle choice later turned out to be crucial for a successful course of our rescue mission. A four-member team included a doctor, two technicians and a driver. We were armed with automatic weapons (Kalashnikov) that we, naturally, did not carry on us but that were placed in special carriers in the cabin. The site of incident we reached successfully and fast. A heavily damaged quartermaster’s pinzgauer was in the middle of the road, partly tipped over onto its side. S-4 we parked next to it and worked under the headlights. The driver, sergeant major by rank, was unconscious and in the state of shock; he had his left leg amputated beneath the knee. We applied Esmarch bondage and set up infusion. The person next to the driver was a common soldier, Roma by nationality, conscious (sobbing) but also in shock and riddled with many hundred shell pieces scattered all over his body, face and eye holes. The face injuries we covered with wet sterile gauze, set up infusion and analgesia and then we turned round and took the same road to get back to Glina.            The rescue and transport to Glina, altogether, took us 35 minutes. Outside it was dawning. The injured soldiers were turned over to the chopper MI-22 which immediately took off towards Belgrade which was 300 km away. It was in the air that I became aware of the danger. The chopper of the size of a smaller bus was an easy target and could be hit by practically every soldier with a thermal projectile Strela that all the troops had in arms. After approximately 40 minutes we landed at the Military Medical Academy where we handed over both wounded - alive - for further treatment. After returning to Glina, I was visited by engineering major. He told me that his unit dug out, on the same road that we used this morning to evacuate the wounded, on that very day, 7 more anti-tank mines. Which means that we drove – both ways – over 7 anti-tank mines. Once, and once again. If we had used a much narrower vehicle such as S-2, we would have surely hit a mine. Yet the width of our vehicle was decisive in helping us avoid the mines which remained between our wheels.

      Case “B”: In February, 1992, approximately seven days after the event “A”, about 9 pm, I was sent on a rescue mission to the hit EMS vehicle of the TD (Territorial Defense) in the valley of the River Glina. In the struck vehicle there would have been an injured medical technician while the other technician got away with no harm and reported on the event. At the incident site the valley has a form of Latin “V” which means that from the location of the struck UMC vehicle to the position on the other side of the river – where the shots came from – the distance was approximately 300 to 400 meters as the crow flies. We were driving in a Pinzgauer downwards, towards the river while to us were flying various glowing projectiles. We drove with no light nor gas so that we hardly moved. We were in utter darkness. The light from the glowing missiles in the dark night absolutely enchanted us – they were flying to us from all possible positions so that all seemed like a magic performance. It was not clear whether these fiery bullets that we watched as if charmed were fired at us or some other target since we were in immediate vicinity of the first fighting line. A great number of the bullets ended close to us and we could hear their sounds. Every minute seemed like eternity. Time stopped for us to hardly move at all so as to possibly remain unnoticed. Half way up the hill we spotted, in the darkness, a hit ambulance. The driver was dead; the medical technician next to him was hit in the region of hypogastrium, in the state of shock but conscious. All we did at that very moment was to move the injured technician from the damaged ambulance to our vehicle. Then, at full gas rate, still without lights, we drove ahead towards the peak. The noise of our engine was such that we could not even know whether they were still shooting at us or not – at the front line we turned back and ran away as fast as we could. In a few minutes we stopped at a safe location and treated the injured before driving him further on.

DISCUSSION

     In dangerous zones such as the war ones or those of mass catastrophes, many rules become relative while considerably increasing is the importance of immediate assessment and personal responsibility of the team doctor/leader both for initiating and carrying out a rescue mission. In the cases described above we have seen how the rule of “always coming back along the same route you used to get to the end point of the incident” is not always a good choice. In our case “B” the return by the same road was impossible while in the case “A” the risk of taking it even increased. The choice of vehicles and means is not always “presumed”. The night itself is a risk while offering, at the same time, protection. Ambivalence of the rules is frequent. In both the given examples we have seen that preliminary actions were not possible to perform, that is, they would be meaningless (as the difference between offensive, tactically-guided actions with initiative in which the protocol can be planned and applied and, on the other hand, passive defense event with control of the situation is difficult). The rescue operations in both the cases proceeded on the basis of the doctor’s personal assessment about taking a rescue risk. It was, at the start, more intuitive-emotional than rational though the doctor was, due to his frequent tours of the troops, partly familiar with the situation on the site. Surely there were rational reasons as well. American military-medical literature states only two reasons for (possible) rescue under immediate threat, i.e.:

-Absolute essential undertaking actions (such as, for instance, Esmarch), and,
-The injured must be urgently transported/moved away from incident site (due to this or that threatening danger). 

    Two such cases are described above. As for the rescue itself, it was done correctly in terms of the protocol but in the way dictated by the circumstances. Our desire to control the circumstances is not always feasible. Rescue under immediate threat cannot be excluded from medical profession and that is why it has to be considered as a professional problem (instead of being “principally” avoided). Awareness of the danger is often incomplete; on the other hand, danger is more and more part of our life.

REFERENCES:

1. Campbell, John E. in Alson Roy L. 2015. ITLS for Emergency Care Providers - eighth edition. Boston: Pearson Education, xii-xii, 2-5.
2. Campbell, John E., Heiskell E. Lawrence, Smith Jim in Wipfler John E. 2012. Tactical Medicine Essentials. Sudbury: Jones and Bartlett Learning, 4-15.
3. Campbell, John E., Pfeifer William in Kagel Andrew. 2014. ITLS Military Second Edition. Boston: Pearson Education, 2-3.
4. Hope, Tony. 2014. Medicinska etika. Zelo kratek uvod. Ljubljana: Založba Krtina, 48

ABSTRACT

Our desire to control fully the circumstances in rescuing endangered is not always feasible. Rescuing human lives under a immediate threat cannot be excluded from the medical profession and we need to address it as a professional problem (rather than "doctrinaire" avoiding). Awareness of danger is often incomplete but the risk is increasingly part of our lives. Two examples from the recent past.



First published in Slovenian in the journal of Emergency Medicine – Selected Chapters, No. 23/2006, p. 206-208

A RARE CASE OF PENIS INJURY

 A  R A R E  C A S E  O F  P E N I S  I N J U R Y

Grigor ANAKIEV, Vojislav NIKOLIĆ, Dragoslav SPASIĆ, Miloš MAKSIMOVIĆ, Zoran STANKOVIĆ

       Patient S. B. from the village of Jelašnica near Niš, a worker by occupation (history of disease No. 192/73). Admitted to the Hospital Department on May 3, 1973, at 9 pm, as an emergency in the state of shock due to bleeding from the genital organs.
       A clinical examination of the injured ascertained that it is the matter of penis amputation, that is, complete cutting off of both cavernous bodies and urethras at the root of the penis. The scrotum was open; the left testis was ejected from the scrotal sac and slightly cut by a sharp blade; it lied bare on the belly skin. The right testis, likewise bare, was located at its place within the scrotum. The penis was hanging on a narrow strip of the scrotum skin. The injury was a cut, of smooth and flat surface, at the level of the abdomen skin. The injured was distinctly pale, his pupils slightly dilated, his consciousness preserved, and greatly irritable. P=100min. The erectile stage of shock was followed by hypovolemia caused by bleeding from the injury. Further on, the state of shock was deepened; arterial tension dropped and the pulse increased. The injured was transferred to the Department for Intensive Care and Reanimation.
       Way of injury: On that very day, the injured came, around 8 pm, to a date with his former girlfriend who felt left and deceived. Yearning for revenge, she came to the date with an already made plan and engaged in a love game. When she felt her partner totally surrendered to love ecstasy she coldbloodedly plunged a knife into his genitals. On hearing a painful scream of the injured his friend, waiting for him close-by, came running to help him. At 9 pm the injured was brought to our Department.
         Two hours after having received the injured, and applied reanimation methods to stabilize his state, we decided on a surgical intervention. We were in two minds about whether to complete amputation of the penis or perform its reimplantation. We opted for the latter. After the chemostasis, we pushed a Tiemann catheter 22 Ch through the urethra of the amputated part of the penis and then pushed it through the remaining part of the urethra to the bladder. Through the catheter we performed urethrorrhaphy. By means of two sutures on the penis septum we drew the amputated part of the penis. The tunica albuginea was also drawn and pinned down by separate sutures circularly while in the second layer we sewed fascia and skin. Finally we did a cystostomy for urine derivation. From the onset we prescribed high doses of antibiotics and enzymes (Fig.1).
         The most immediate postoperative course was uneventful. On the second and even more on the third postoperative day, the penis skin became cold and cyanotic with the emergence of phlyctena and single initial necrotic foci. The state did not essentially alter even on the fourth day but on the fifth postoperative day the penis skin became somewhat warmer while the phlyctena began to get dry. The improvement continued on the sixth day as well; the skin became warm; the colors pale pink, almost normal and the phlyctena got dry. The necrotic foci began to heal. On the ninth day the stitches were removed. The transurethral catheter was removed on the twelfth day while the Pezzer's catheter was removed on the eighteenth postoperative day.
          On June 5, 1973, the patient was discharged from the hospital; he was in a good psychophysical condition. The act of urination was normalized, erection present. At control examinations the patient complained of long painful erections. He had no urination disturbances. Coitus he performed as prolonged; for a while with no orgasm and later on with no disturbances whatsoever.

Conclusion

· The described penis injury represents a heavy damage to the organism, accompanied with physical as well as psychic consequences. The injured cannot urinate in a standing position, only while squatting. Apart from being deprived of sexual enjoyment, the knowledge that he is demasculinized throws him into frequent depressions and finally leads to a feeling of inferiority. Neither should the consequences regarding the preservation of family nor the change of the environment attitudes be left out since all this can induce an antisocial posture and behavior of the injured.
· The revenge by penis amputation is a rare event; but, if it happens, our opinion is that reimplantation should be attempted if the injured gets to the surgical institution in optimal time. If the reimplantation succeeds, all the above listed consequences of the injury are avoided.
· The described case is presented here as rare and instructive both regarding the causes of the injury and the way of inducing it, as well as for the favorable result of the undertaken treatment.

LITERATURE:

Adanja S. (1953) Ratna hirurgija, Medicinska knjiga, Beograd
Rhoacls, R. (1977) Textbook of Surgcry. Lippincott, Philadelphia

AUTHOR: Dr. Grigor Anakiev, urologist, Surgery Department of the Military Hospital Niš, Bul. Braće Taskovića 3, 18000 Niš, Serbia, Yugoslavia

First time published in ACTA MEDICA MEDIANE, Niš 1973