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