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The United Nations Military and Civil Defense Assets (UN MCDA) document provides guidelines for the use of international military and civil defense personnel, equipment, supplies and services in support of the United Nations in pursuit of humanitarian objectives in complex emergencies or in other large-scale emergencies. MCDA represents unique technological logistic capabilities that can be mobilized on short notice in a self-contained, self sufficient and highly mobile fashion, to support lifesaving relief efforts. Their military assets and capability is used for disaster relief and humanitarian assistance, nationally as well as internationally. Access to MCDA resources can protect and restore critical lifelines and services lost during sudden onset natural disasters or manmade disasters. UN Member States have recognized that these disasters can pose as lethal a threat as that of war, to any society’s stability.
Soldiers fight better and feel more secure if they know they will receive medical care when injured. Military nurses, nurses in uniform are nurses who also serve in the military and hold military rank, and can serve in a variety of roles. In the case of the Army, Air Force, Navy and Coast Guard the corps share the common mission of nursing. Military nurses are best known for their caring compassionate expertise in treating sick and wounded military soldiers, sailors, marines, and aviators. They work sometimes in tents, forward surgical teams, hospital ships, as flight nurses, and in fixed facilities or hospitals.
The Uniformed Services University of the Health Sciences (USU, formerly USUHS) is a health science university in Bethesda, Maryland run by the U.S. federal government, that prepare graduates for service to the U.S. at home and abroad in the medical corps. The university’s two mottos are "Learning to care for those in harm's way" and "Providing good medicine in bad places". Project HOPE organized U.S. health professionals who were volunteering in the disaster relief efforts in the Tsunami Emergency in South East Asia (the first left on the U.S. naval ship Mercy in January, 2005). The U.S. Army also helping out in Haiti after the January 2010 earthquake.
Examples of nursing corps include:
Militaries use the term killed in action (KIA) as a casualty classification to describe the deaths of their own forces, who has received hostile attack. Someone who is killed outright or who dies as a result of wounds or other injuries before reaching a medical treatment facility. Someone who died of wounds (DOW) survived to reach a medical treatment facility after being wounded in hostile action.
According to the New York Times on May 25, 2011, the Department of Defense has identified 4,444 American service members who have died since the start of the Iraq war and 1,571 who have died as a part of the Afghan war and related operations. There are many aviation accidents and incidents in the War in Afghanistan, both helicopters and fixed-wing aircraft.
In the Somali capital Mogadishu, more and more children are becoming victims (wounded or killed) of the fighting between pro-government forces and the Islamist militia al Shabab. According to the World Health Organization (WHO) the number of weapon-related casualties at the city’s three main hospitals reached a new peak in May 2011, of the nearly 1,600 casualties, 46 percent were under age five. The main types of injury are burns (many are third degree) and shrapnel, blast injuries and bullets. Children suffer from disfiguring scars and infection over much of their bodies, and need special care or reconstructive surgery.
War and civil strife are regarded as hazards or extreme events that produce disasters and often cause displacement of the population. War and civil strife include armed aggression, insurgency, weapons of mass destruction/terrorism, such as bombings, and bioterrorism, riots, and other actions leading to displaced persons and refugees. Competition for scarce resources, religious or ethnic intolerance, ideological differences, and civil unrest due to authoritarian role for many decades may be casual factors. This involves situations in which civilian populations suffer casualties, losses of property, basic services and means of livelihood. Complex emergencies is usually associated with problems of displaced people during times of civil conflict or population trapped and isolated from a government or private support structures as well as access to international relief. Today, 44 million people are displaced within or outside their own country.
To survive injury in combat, every second counts, and medical planners in the military now refer to the time immediately after the injury as the "platinum 10 minutes". To reduce the number of fatalities, emergency medicine can now be provided deep inside enemy territory (NHS choices, 2009). All soldiers on operation have basic first aid training, and there are army team medics with advanced first aid training. They carry additional medical equipment including products to stem excessive bleeding. If the injury is serious, a Medical Emergency Response Team (MERT) with highly specialist medical personnel is sent urgently. In Afghanistan, the British MERT is equipped to deliver live-saving care onboard the Chinook helicopter on the way to the field hospital.
Improvement to hardware, such as body armor and helmets has also made a difference. Iraq, Kuwait, Oman, Kosovo, Afghanistan are a few places where soldiers and medical personnel have been deployed. Research in combat fatalities shows that most deaths occur within the first hour. The standard ABC has been adapted to CABC, with the first C standing for catastrophic hemorrhage. The soldier himself can apply the HemCon bandage as the wound occurs. Army doctors have intraosseous needles, which are special syringes that deliver drugs or vital fluids into the bone when access to a vein is difficult or impossible due to severe injury (NHS choices, 2009).
U.S. military conflicts include World War I, World War II, Korean War, Vietnam War, Desert Shield/Desert Storm, Somalia, War on Terrorism, Iraqi Freedom, Kosovo, Afghanistan, and Libya. January 2011, protests, demonstrations and riots are erupting across North Africa and the Middle East in places like Tunisia, Egypt, Yemen, Syria, and Libya. The United States, NATO, and several European countries are involved in the military interventions in Libya, to help the civilians. Violence against civilians, including rape, is pervasive in several of these countries. Deployed medical professionals in Afghanistan learn to conduct sexual assault forensic exams in a two-day training course.
Landmines have strongly increased as a cause of injury. The majority of war injuries are penetrating trauma. The frequency of multiple injuries has increased, and burn injuries are common. Multiple injuries including penetrating brain injuries, gunshot wounds to the chest and abdomen, lung blast injuries, multiple injuries to limbs, which require amputation, causing life-threatening blood loss at the scene (see Chapters 6 and 7).
A landmine is usually a weight-triggered explosive device, which is intended to damage a target by means of a blast and/or fragment impact (Wikipedia - Land mine, 2011). Land mines are specifically manufactured as anti-personnel or anti-vehicle weapons and should be distinguished from improvised explosive devices (IEDs). They can remain dangerous many years after a conflict has ended. Land mines were designed to create defensive tactical barriers (to slow the enemy down), and to act as passive area-denial weapons (to help deny certain terrain to the enemy) in the demilitarized zones, such as Cyprus, Afghanistan, and Korea.
Anti-personnel mines are often designed to injure rather than kill to increase the evacuation and medical burden on the opposing force. Under the Ottawa Treaty 1997, signatory countries undertake not to manufacture, stockpile or use anti-personnel mines. As of 2011, it has been signed by 158 countries, and as an alternative to an outright ban, 10 countries follow regulations in a 1996 amendment. Placing minefields without marking and recording them for later removal is considered a war crime (Wikipedia - Land mine, 2011).
A single mine left on a civilian road to be detonated, may be used as one of the aims of terrorism or guerilla warfare to spread fear and panic. Often, single mines are backed by a secondary device that is designed to kill or maim those tasked with clearing the mine. Manual clearing remains the most effective technique of clearing mine fields; the use of rats and dogs are desirable due to their strong sense of smell, and they can be trained to detect the explosive agent itself (Wikipedia - Land mine, 2011).
Health care for people in conflicts settings needs to be updated (Spiegel, Checchi, Colombo, & Paik, 2010). Most contemporary wars are of protracted duration, intrastate, fought by irregular armed groups (fuelled by economy opportunities and ethnic rivalry). Violence against civilians, including rape, is pervasive. Increasing urbanization, ageing populations, and displaced people in urban areas, where providing health care is often complex. Much excess morbidity and mortality results from the exacerbation of non-infectious disease such as hypertension, diabetes and cancer after conflicts and natural disasters. Spiegel and his colleagues say new strategies are needed to deliver health services to dispersed, intermittently accessible populations in low-income settings, with a continuing high burden of infectious diseases and neonatal disorders; chronic diseases should be addressed more systematically in all conflict settings; creative approaches to ensure adequate health coverage and access for conflict-affected people living in urban areas should be developed; and surveillance, measurement and monitoring need to be addressed.
A weapon of mass destruction (WMD) is a weapon that can kill and harm a large number of humans (and other life forms) and cause great damage to man-made or natural structures, or the biosphere in general. The most widely used definition of weapons of mass destruction is that of nuclear, biological or chemical weapons (NBC), and chemical, biological, radiological, and nuclear weapons (CBRN) is also used. Within U.S. civil defense organizations, the category is now chemical, biological, radiological, nuclear, and explosive (CBRNE). Chemical (toxic or poisonous chemicals, or their precursors) and "dirty bomb" radiological weapons have limited destructive potential, whereas nuclear and biological (a disease organism) weapons have unique ability to kill large numbers of people with very small amounts of material (Wikipedia - Weapon of mass destruction, 2011).
Common hazard symbols (from Wikipedia - Weapon of mass destruction, 2011).
| Toxic symbol | |
| Radioactive symbol | |
| Biohazard symbol | |
Terrorists may use different tactics such as bombings (the 2004, train bombings in Madrid, Spain); suicide bombers (the 2005, suicide attacks upon Londoners using the public transportation system); and blast injuries. Terrorist bombings contribute to victims with crush injuries. In the case of blast injuries, a crush injury is classified as quaternary injury (see Chapter 7). The use of weapons of mass destruction include chemical agents (the 1995, sarin nerve gas attack in Tokyo, Japan); biological agents (the 2001, anthrax attack in the Washington DC area); and radiological agents (the 1945, atomic bomb in Hiroshima and Nagasaki, Japan).
Patients exposed to a biological agent may not have symptoms for hours, days, or weeks after the attack and may present in geographically dispersed areas. If terrorists are using the unknown agents or are not limited to the use of a single agent, clusters of patients may present with similar symptoms, but different diseases. The effects of chemical terrorism are usually immediate and obvious. A range of testing services is available. Radiation emergencies include dirty bombs, and nuclear blasts and the mass casualties may include explosion/blasts, burns, and severe injuries (see Chapters 7, 9, 10, 11, and 12).
The atomic bomb in Japan 1945 caused 245,000 deaths in Hiroshima (30% of the population), 30% were injured, and 220,000 deaths in Nagasaki (16% of the population), 20% were injured (Lennquist, 2002). The destruction of the twin towers of the World Trade Center in New York City on September 11, 2001, killed 2,595, and the physiological consequences continue to this day, with particle and dust injuries being a problem for the immediate victims, residents, medical and rescue personnel, as well as depression or posttraumatic stress disorders.
Florence Nightingale formed the first nucleus of a recognized Nursing Service for the Army in the Crimean War, 1854. Nursing schools responded in two war crises, World War I (Army School of Nursing developed), and World war II (accelerated program mandated; experience in military, federal, civilian hospitals, or public health agencies). The World War II left nursing in an even greater state of chaos than World War I because demands of nursing service were rapidly increased (newer treatment, social changes, lack of nursing students and nurses with leadership preparation).
International organizations: International Council of Nurses (ICN), founded in 1899 in Boston; International Red Cross, founded by Henri Dunant, a Swiss in 1863, and; World Health Organization (WHO), organized in 1946 as an agency of the United Nations. The American Red Cross (ARC) is a nationwide network dedicated to saving lives and helping prevent, prepare for and respond to emergencies. The Red Cross is the largest supplier of blood and blood products nationally and assists victim of international disasters and conflicts at locations worldwide. In addition to domestic disaster relief, the American Red Cross offer community services to help the needy; communication services and comfort of military members and their family members; blood collection; educational programs and preparedness, health and safety; and international relief and development programs.
Doctors Without Borders/Médecines Sans Frontières (MSF) is an international medical humanitarian organization, created in 1971 by a small group of French doctors and journalists. They are working in nearly 70 countries to assist people whose survival is threatened by violence, neglect, or catastrophe, primary due to armed conflict, epidemics, malnutrition, exclusion from health care, or natural disasters.
Registered nurses have long been frontline responders during major disasters, and all need a basic level of clinical competence (during initial assessment and management of emergency events) common to all health professionals.
CDC and the American Red Cross encourage everyone to prepare for an emergency or disaster. If you see something you say something. Terrorists use a variety of methods to create fear and inflict harm, but bombs are used most frequently. According to the U.S. Federal Bureau of Investigation (FBI), bombings accounted for nearly 70 percent of all terrorist attacks in the United States and its territories between 1980 and 2001 (U.S. Department of Justice, Federal Bureau of Investigation, 2001). Secure the scene and have a bomb squad sweep the area prior to treating the casualties. Prohibit the responders from entering the scene if sniper fire exists. Direct the wounded to pre-identified centers. Take pictures of the scene. Rapidly remove victims from the scene. Number the human remains sequently and place in body bags, then transport to the medical examiner’s office. Provide rapid cadaver identification, so that victim may be identified, released to their families, and buried. Establish a command information center, for the relatives, in search of their loved ones (Stein, & Hirshberg, 1999; Hiss, & Kahana, 2000; & Cox, 2008). During a mass casualty incident, advanced triage systems are activated, and first responders need to be protected. Record keeping has to be exceptional because it is the major means of leaving an audit trail. Primary and secondary surveys are critical in the evaluation of stable victims. Hemodynamically stable victims with fragment should be hospitalized for observation (it is not possible to explore all wounds at this time).
If in extremis victims (with respiratory failure and profound shock) make it to the hospital, the results of any immediate treatment are usually unfavorable. Isolated reports of survival for in extremis victims do exist, so resuscitation may be considered if resources are available. Many nurses find themselves unprepared for events when immediate survivors in extremis not are being treated and then dying.
Knowledge centers are established for disaster medicine, including international healthcare, radiation medicine at disasters, microbiological preparedness, disaster toxicology, and disaster psychiatry. Risk analyses, outcomes measurement, research and development are needed within the field of disaster, emergency and defense medicine. The analysis of every stage of treatment from the point of wounding to rehabilitation, to see were improvements can be made. The most important data from major accidents and disasters is the patient outcome. Patient outcome is the ultimate indicator on how an incidence was managed.
Efforts to measure outcomes and assure the quality of health care were first undertaken by Florence Nightingale and Ernest Amory Codman (a Boston surgeon, regarded in health care as "the father of outcomes measurement" (Edmunds, 1997). In 1863, Nightingale first called for a systematic inquiry in the nature of care processes as means of improving patient outcomes. In 1916, Codman published his studies of the end results of care for his patients one year after he had performed surgery. The rapid assessment of injuries among WTC attack survivors show that improving record keeping and reporting systems will assist in post disaster surveillance of disaster-related health effects and are an important part of effective disaster planning, preparedness, and response (Centers for Disease Control and prevention, 2002).