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Primary Surgery Vol.2 – Trauma |  |
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Primary Surgery Vol.2 – Trauma | |
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We assume that you are the senior triage officer. Your task is to direct other people, not to become involved in the care of particular patients yourself. As soon as you learn of the disaster, order the present shift to stay on duty, and summon the shift which is off duty. Send immediately for whatever supplies and help you think you will need.
You will need quantities of intravenous fluids, drip sets and dressings, and a supply of 1.5 mm 
40 mm intravenous needles that you can quickly boil up and use to set up drips. Have these ready.
Clear a ward, designate it as ‘the mass casualty area’, and choose a nearby room for minor operations under local anaesthesia. Warn all departments, such as the laboratory and the X–ray department, to prepare for action. Get the sterilizers ready, assemble and sterilize the general sets and minor suture sets.
Triage the patients and allocate them to particular doctors, or, if necessary, medical assistants or nurses. Ask a clerk to stick lables on each patient’s forehead indicating his category, and to make out a record sheet for each patient, like that in Fig. 51–8. This is reproduced again larger on an endpaper, so that you can photocopy it. If a patient’s name is not known, give his label and his form a number.
Staff who have been allocated patients can then start examining and treating them, concentrating entirely on their own patients. Their first task should be to attend to airways and set up drips. Go round looking for seriously ill patients who have been missed in the first triage. These are usually the silent ones; the fit ones will probably be shouting for attention. Visit each staff member in charge of patients to find out what he has discovered, and record your instructions.
Meanwhile, the next most surgically competent person goes to the theatre and waits for the first patient to be sent to him by the triage officer.
After treatment, return all patients to the mass casualty area, so that they are all together. Put a doctor directly responsible to you in charge of them.
should be kept separately somewhere else. Put someone with good public relations ability in charge of them to reassure them, and to answer their questions as best he can. Only in exceptional circumstances allow them near the patients. Ask them to donate blood.
Where necessary, secure each patient’s airway (52.1), control bleeding (55.1), seal any open chest wounds (65.7), and set up drips. Only an occasional patient will have severe facial injuries and need an emergency tracheostomy. For the others, an oropharyngeal airway will be enough. Some will need nasogastric suction and some catherization (68.1). Undress all casualties, and don’t forget to look at all their backs.
Decide which are the urgent operations and do these first; many fractures, for example, can wait a few days. When you operate, be radical, try to do everything necessary at one operation, because there may be no chance to do another. Do radical excisions, and, where necessary, guillotine amputations.
Your assistants can go down the rows of patients in the ward sewing up minor wounds and dressing them.
Don’t forget tetanus prophylaxis (54.12). It is tragic to work hard to save lives, only to lose them weeks later quite unnecessarily from tetanus. Some days later, if you are worried about tetanus, ask patients to open their mouths as you go round the wards. Those who have difficulty doing so may have it.
If INTRAVENOUS FLUIDS AND DRESSINGS are scarce, try to save as many patients as possible with a good chance of survival. Treat those whose lives might be saved with 3 litres before those who need 15 litres. Provided there are no contraindications, such as an abdominal injury or intestinal obstruction, you can give burns patients an oral salt and sodium bicarbonate solution, such as Moyer’s solution (NaCl 4 g, NaHCO
1.5 g in water to a litre) or (NaCl 5 g, NaHCO 4 g, in water to a litre). These solutions are adequate for adults with burns of up to 15%. They have been used to treat burns of up to 30% successfully.
If you run out of dressings, use any clean cloth you have.
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Primary Surgery Vol.2 – Trauma | |
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