Emergency War Surgery: The Survivalist's Medical Desk Reference

Appendix 1

Principles of Medical Ethics relevant to the role of health personnel, particularly physicians, in the protection of prisoners and detainees against torture* and other cruel, inhuman or degrading treatment or punishment

Adopted by United Nations General Assembly Resolution 37/194 of 18 December 1982

Principle 1

Health personnel, particularly physicians, charged with the medical care of prisoners and detainees have a duty to provide them with protection of their physical and mental health and treatment of disease of the same quality and standard as is afforded to those who are not imprisoned or detained.

Principle 2

It is a gross contravention of medical ethics, as well as an offence under applicable international instruments, for health personnel, particularly physicians, to engage, actively or passively, in acts which constitute participation in, complicity in, incitement to or attempts to commit torture or other cruel, inhuman or degrading treatment or punishment.

Principle 3

It is a contravention of medical ethics for health personnel, particularly physicians, to be involved in any professional relationship with prisoners or detainees the purpose of which is not solely to evaluate, protect or improve their physical and mental health.

Principle 4

It is a contravention of medical ethics for health personnel, particularly physicians:

(a) To apply their knowledge and skills in order to assist in the interrogation of prisoners and detainees in a manner that may adversely affect the physical or mental health or condition of such prisoners or detainees and which is not in accordance with the relevant international instruments;

(b) To certify, or to participate in the certification of, the fitness of prisoners or detainees for any form of treatment or punishment that may adversely affect their physical or mental health and which is not in accordance with the relevant international instruments, or to participate in any way in the infliction of any such treatment or punishment which is not in accordance with the relevant international instruments.

Principle 5

It is a contravention of medical ethics for health personnel, particularly physicians, to participate in any procedure for restraining a prisoner or detainee unless such a procedure is determined in accordance with purely medical criteria as being necessary for the protection of the physical or mental health or the safety of the prisoner or detainee himself, of his fellow prisoners or detainees, or of his guardians, and presents no hazard to his physical or mental health.

Principle 6

There may be no derogation from the foregoing principles on any ground whatsoever, including public emergency.

________

*1. For the purpose of this Declaration, torture means any act by which severe pain or suffering, whether physical or mental, is intentionally inflicted by or at the instigation of a public official on a person for such purposes as obtaining from him or a third person information or confession, punishing him for an act he has committed or is suspected of having committed, or intimidating him or other persons. It does not include pain or suffering arising only from, inherent in or incidental to, lawful sanctions to the extent consistent with the Standard Minimum Rules for the Treatment of Prisoners.

2. Torture constitutes an aggravated and deliberate form of cruel, inhuman or degrading treatment or punishment.

Article 7 of the Declaration states:

“Each State shall ensure that all acts of torture as defined in article 1 are offences under its criminal law. The same shall apply in regard to acts which constitute participation in, complicity in, incitement to or an attempt to commit torture.”

Appendix 2

Glasgow Coma Scale

GLASGOW COMA SCALE

Component

Response

Score

Motor Response

Obeys verbal command

6

(best extremity)

Localizes pain

5

 

Flexion-withdrawal

4

 

Flexion (decortication)

3

 

Extension (decerebration)

2

 

No response (flaccid)

1

 

Subtotal

(1–6)

Eye Opening

Spontaneously

4

 

To verbal command

3

 

To pain

2

 

None

1

 

Subtotal

(1–4)

Best Verbal Response

Oriented and converses

5

 

Disoriented and converses

4

 

Inappropriate words

3

 

Incomprehensible sounds

2

 

No verbal response

1

 

Subtotal

(1–5)

 

Total

(3–15)

Appendix 3

Theater Joint Trauma Record

General

Evidence-based medicine has become the goal of all specialties. Unfortunately, because of the realities of Combat Trauma, timely and accurate data collection and interpretation of results are difficult. Quality information on casualties for combatant commanders is essential because it facilitates optimal placement, utilization, and resupply of scarce medical resources, and rapid identification of new trends in wounding and treatment. Accurate, aggregated theater information is necessary to shorten quality improvement cycles in deployed treatment facilities.

Furthermore, these data placed on a website could provide rapid feedback to the sending physicians, allowing individual follow-up on their patients. These concepts are not new: they are routinely employed in the > 1,000 verified trauma centers in the US. Application of these principles to the battlefield, using a limited set of jointly approved data elements is described below. This data collection effort is not designed to be an extra step. The proposed form can be used as the trauma chart (both battle and nonbattle injury) and sent to the next evacuation Level with the casualty.

Situational Awareness

The revolution in warfighting which has digitized the battlefield to display friendly positions, intelligence, and engagements electronically has not been equally applied to the casualty side of the equation. This places demands on medical organizations to provide online and continuously updated status and location information on killed, wounded, ill, and psychologically impaired combatants and noncombatants; which includes both the casualty loss to the unit and the return to duty patient. This need will only escalate, as medical situational awareness plays an increasing role in the tactical risk assessment process. At a minimum, commanders should be able to assess Killed In Action (KIA, died before reaching medical care/force wounded) and Died Of Wounds (DOW, die after reaching medical care/force wounded) in order to measure risk associated with operations and the capability of the medical force to control mortality.

Where admitted is defined as any casualty that stays at a Level II facility or above. These definitions do not include the carded for record category in the denominator.

A breakdown of casualties by type of injury and the major body regions (ie, face, head and neck, chest, abdomen and pelvis, upper and lower extremities, and skin) will enable an analysis of injury patterns that can be utilized to design interventions resulting in a decrease in morbidity and mortality.

Other Uses

Data on types of wounds, their causes, and appropriate procedures have potential value in constructing predictive models for medical force development and placement, logistical delivery systems, and research on improved medical interventions. The history of improvements in medicine and surgery are grounded on the battlefield, and dissemination should not be limited to the isolated innovator with a personal spreadsheet for documentation. Individual providers at individual medical treatment facilities (MTFs) have long recorded clinical data and observations. This Joint Theater Trauma Record effort is an extension of their efforts.

Minimum Essential Data

In addition to recording the standard contents of the postprocedure note (ie, who did what, on whom, why, and a plan), the standard data components of a trauma registry are especially helpful (eg, demographics, circumstance and mechanism of injury, pre-hospital monitoring and care, hospital monitoring and care, outcome, participants, direct assessment against standards). Figure A-1 (see next four pages) is a sample form that can serve as both the trauma chart and the data entry source. These minimum essential elements have been agreed on by the US Army, Air Force and Navy. Data will be collated and placed on a website at the first Level IV facility in the evacuation chain.

Recommended Methods and Technology

The process to document emergency trauma care can be employed on either the immature or mature battlefield. This would entail utilizing paper or computer-assisted electronic technology, respectively. In the ideal environment, this would be a single step process. Reality is much different. It is important to recognize that documentation should occur at all Levels, while aggregation of data should occur at the first Level that can support such activity. At a minimum, paper documentation should be used for each casualty and the chart should accompany the patient to the rear as evacuation occurs. When electronic records are available, this process will be simplified.