陆军预备役战斗医务人员初级创伤护理经验是一种新途径吗_

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**陆军预备役战斗人员的初级创伤护理经验：**

**需要一种新的方法吗？**

**罗恩·本少校-亚伯拉罕*+**

***吉迪恩·帕雷特船长***

***约拉姆·克鲁格少校****

**战斗医务人员在任何战斗单位中都扮演着重要的角色。近年来，在和平和低强度军事冲突时期以及战争以外的行动中，预备役战斗医务人员面临着治疗战场重大伤亡的挑战。虽然这项工作需要重要的手册**

技能上，医生会执行基本的治疗操作

**不一定是为了拯救生命。对预备役战斗医务人员的抽样调查显示，大多数（70%）在常规和预备役服务期间为创伤受害者提供医疗护理。许多人（32.5%）涉及多起事件**

伤亡者这些事件包括严重受伤的妇女-

**其中，39.2%的医疗人员参与了空中疏散，44.4%的医疗人员患有死亡事件。并不是所有的医生都遭受过重大创伤，但对于那些遭受过重大创伤的人来说，每个医生的病人数量并不多。因此，需要教育医生在认知方面，更重要的是，在手工技能方面，是显而易见的。并对这些方法提出了建议。**

**介绍**

他对创伤受害者的急救质量

蝙蝠区对患者的预后至关重要。在很多情况下，在战斗场景中，高级创伤生命支持（ATLS）定义的“黄金时刻”在医生到达现场之前就已经过去了。它肯定会在将受害者疏散到一个最终的护理设施完成之前就已经通过了。由于能够被分配到前线战斗单位的医生数量很少，因此向伤员提供初步援助的责任主要是由战斗医务人员承担的。这些医务人员是现场伤员创伤链护理的重要组成部分。2

以色列国防军主要以预备役部队为基础。在完成3年的义务服役后，我们将签约到各陆军预备役部队，在那里我们必须服役到45到49岁。对于大多数人来说，这段时期远远超过20年。与每天处理创伤护理的护理人员不同，绝大多数医疗人员不参与医疗队以外的任何医疗系统。因此，我们唯一被要求展示我们在向创伤受害者提供初级保健方面的技能是在每年的预备役服役期间，在和平时期，每年可短短1个月。我们的研究是为了评估创伤护理中的储备医生的经验。其结果将有利于更好地分配有限的资源，以继续训练后备战斗医务人员的计划。

*以色列国防军，医疗队。

+Sackler医学院，特拉维夫大学，特拉维夫，以色列。

该手稿于1997年12月接受审查，并于1998年6月接受出版。

美国军事外科医生协会，1999年。

***约书亚·谢默尔准将****

**迈克尔·斯坦中校***

**人口和方法**

共有150名被分配到预备役战斗单位的预备役医务人员被要求匿名地、不受限制地完成一份预先设计的调查问卷。医务人员是从一组在以色列国防军医疗队军事医学院进行年度军事训练的医务人员中连续和随机地挑选出来的。调查问卷涉及医务人员在完成基本培训后的主观看法和实际的创伤护理经验。本研究只考虑了多重创伤病例的经验，包括严重的钝性和穿透伤，需要紧急疏散到一级或二级创伤中心。

**结果**

150名医务人员中有135人（90%）同意回答问卷，并完整地完成了问卷。表一总结了预备役战斗医务人员在完成基本训练后治疗多伤患者的经验数据。这种经历不包括在义务服务期间进行的治疗。seen，29.7%reported可以说，自从他们完成了基本的义务兵役训练（战斗医生课程）后，他们没有接触到创伤受害者，平均是11.7±7.4年前。在these，32.5%of中，所有医务人员都参与了多次伤亡事件期间的护理，24.4%在单独时有机会向创伤受害者提供现场创伤护理。

Furthermore，55.5%were提供了一个机会，作为一个团队的一部分工作，其中包括一名军事医生。在创伤事件中对受害者的护理，包括空中疏散，涉及39.2%的预备役战斗医务人员，以及在以死亡结束的创伤事件中的44.4%participated。在survey，58.5%of医生之前的一年里，没有遇到任何创伤患者（表一）。

表二列出了医务人员作为向创伤受害者提供的初步护理的一部分所使用的各种手工技能的数据。这些措施包括协助医生进行紧急救生程序，如插管、开胸管、中心静脉导管插入和骨内装置插入，以及其他手动skills，i.e.、骨折固定或烧伤伤口治疗。医务人员在军事医学院的基础训练期间被教授这些程序，因此，他们应在需要时执行这些程序。

关于紧急气道管理程序，40%的医生将口腔气道装置植入真正的创伤受害者。35.5%和38%的医生分别使用袋和口罩进行人工通气和协助插管。涉及快速安装的技术

军事医学，第164卷，1999年1月，48年

初级创伤护理49

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**表i**

医生在治疗患者方面的经验

他们基本的多重伤害![](/media/202412//1733470704.7052023.png)![](/media/202412//1733470704.7139063.png)![](/media/202412//1733470704.7220721.png)

项目合计

完成基础培训后的数年数11.7±7.4

完成基本training95（70.3%后治疗的受害者）参加了多个伤亡事件involving44（32.59%）

四名以上受害者

仅接受过治疗的创伤受害者就有33人（24.4%）

作为一个团队的一部分来治疗创伤受害者75(55.59%)

包括一位医生

参加了创伤事件，最后以一个53 (39.2%)

空运后送

参与了创伤事件，并最终结束了60(44.4%)

性质

**tableⅱ**

在调查前一年中接受预备役战斗医务人员治疗的创伤受害者人数（N =135）

创伤患者数量

合计

0

79 (58.5%)

1-5

43 (31.8%)

6-10

2 (1.4%)

11-20

6(4.4%)

≥20

5 (3.7%)

**表ⅲ**

由医务人员的辅助救生和其他程序

杜里![](/media/202412//1733470704.7327027.png)![](/media/202412//1733470704.741408.png))自

程序

合计

气道管理

54 (40%)

袋和口罩通风

48 (35.5%)

插管

52 (38%)

胸腔造口术

43 (31%)

中心静脉导管插入

29 (21%)

插入骨内装置

11(8%)

托马斯夹板

20 (14%)

开放性骨折固定

62(45%)

烧伤治疗

29(21.4%)

21%和8%的医生分别经历了严重injured，i.e.、中心静脉导管和骨内装置插入（对儿童受害者）。其他涉及伤员急性护理的活动分别有45名和21.9%的开放性和闭合性骨折固定和烧伤伤口治疗。

**讨论**

基本上，有三种类型的医疗提供者来照顾创伤

现场的受害者；在许多西方的妇女组织中，这些人是医生、护理人员和妇女医生。以色列军队有幸拥有相对大量的医生，在职业职位和现役预备役中服役。然而，即使是这个相对较大的数字也不能给我-

特别照顾全面战争中预期的大量伤亡。许多创伤受害者由于军事弹药的毁灭性影响，在受伤后不久就会死亡。事实上，超过90%的人在第一个小时内死亡，这与在城市创伤中观察到的结果相反。

毫无疑问，迅速和迅速地将严重伤者疏散到能够进行复苏手术的医疗设施，将对伤亡人员的生存有最大的影响。目前在以色列国防军医疗队中考虑的远距离手术团队的概念是这一理解的结果。

在战斗场景中，护理人员也可以对创伤受害者非常有益。事实上，在院前/术前设施中，经验丰富的护理人员（具有广泛的平民紧急医疗经验）和后备医务医生挽救生命的能力几乎没有差别。人们承认，普通护理人员的表现优于普通医生。由于在以色列的医疗环境中，护理人员相对稀少，我们需要严重依赖那些经验有限的常规医务人员。因此，今天的重点应该是使可抢救的受害者能够到达具有令人满意的生命体征的最终护理站，以确保他们的生存。这些包括足够的气道和呼吸，控制出血部位的出血，液体复苏以替代循环的容量损失。

从理论上讲，战斗医生可以用塑料口腔气道装置解决轻微的气道问题，进行短期口对口通气，并通过四肢周围的止血带和直接压迫其他地方获得体内平衡。虽然不能挽救生命，但仍然重要，但medic，i.e.、伤口护理、基本骨折稳定和疼痛控制（肌肉注射吗啡）。虽然不被认为对生存至关重要，但这些技能可能对战区的医疗角色至关重要。量化是不同的，但这种程序显然对某些伤害的发病率有影响，更重要的是，为创伤受害者提供一种幸福和舒适的感觉。这极大地提高了受害者和部队未受伤士兵的士气，并间接促进了部队更好的更好表现。

事实上，70%的医生参与了严重创伤患者的治疗，尽管这已经多年。然而，几乎30%的医务人员在完成基础培训后没有参与初级创伤护理。此外，对其他人来说，这种经验是有限的。这些发现对于整个陆军的不同部队（步兵、装甲和后方梯队）的医务人员都是一致的。由于几乎没有一名预备役战斗医务人员以平民的身份从事创伤护理，因此也可以假定他们在初级创伤护理方面的平民经验不存在。

本文提供的数据表明，在和平时期或低强度的冲突期间，大量的医务人员将遇到严重受伤的创伤受害者，无论是单独的还是作为医疗团队的一部分。因此，重要的是要提高他们在危及生命的情况和手工滑雪板中的知识和实践经验，这些都不是必须挽救生命，但在战区是创伤护理所必需的。

军事医学，第164卷，1999年1月

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战场上受伤士兵的创伤护理与医院不同。军事环境的额外压力，偶尔需要将伤员从燃烧或敌对的环境中解救出来，以及有限的医疗用品，为伤员的护理创造了欠佳的条件。这些额外的事实使战场上对伤员的治疗复杂化，并要求使用具有丰富经验的医务人员来成功地挽救生命的治疗。

近年来，为提高以色列国防军医疗队的医生提供的初级创伤护理的质量，人们作出了巨大的努力。因为最佳护理的严重受伤的病人被证明是依赖于紧急医疗服务的质量，4.5强调了提高知识和经验的人可能被要求治疗创伤患者，尽管这不是他们的日常职业。在20世纪90年代初，宣布所有军医都强制学习ATLS课程。后来，战斗创伤生命支持课程被创建。6.该课程的目的是为了弥合ATLS课程的平民性质和战场上医生的特殊需要之间的差距。最近（1996-1997年），对医生的初级创伤护理培训方案也进行了彻底修订。为期14周的年轻新兵的基本培训计划包括与军事医学有关的各种主题。这些内容包括预防医学和初级医学的要点。然而，新修订的课程有一个扩大的部分，专门为创伤护理。它也与医生所采取的ATLS课程的原则相一致。因此，当医护人员作为一个团队与他人合作时，也会遵循同样的原则。人们应该记住，这些年轻的新兵绝对没有医学背景，所以他们在基本医学课程的框架内获得的知识是他们的医学知识的全部范围。后来，从义务服务中出院后，绝大多数人根本不做医。

医生在现场的主要作用是在受伤后的第一阶段帮助创伤受害者。另外两个角色是执行伤口护理和比未受过训练的士兵更有效地控制疼痛。虽然这通常不会影响最终结果，但患者及其同志的心理状态有很大的改善。此外，医务人员是受害者的倡导者，并负责促进紧急疏散。当医生单独行动时，或在医生到来之前，他们的技能主要允许他们支持气道（基本支持），在出血的四肢上应用止血带，提供疼痛控制，并插入周围静脉导管。在医生到达后，他们可能会协助进行更先进的，ATLS型的程序。

我们已经证明，即使在和平时期，我们的一些医生也在现场接触到这些类型的程序

（表一）。插管由不少于40%的医生辅助插管，31%的医生辅助开胸插管。我们假设，在一场战争中，这些数字会大大增加。因此，我们应该向医务人员提供更多的手工技能培训，无论是通过视听方法，还是花费他们每年的部分储备时间在急诊科或院前紧急医疗系统救护车，这些程序每天都在那里进行。医务人员应每月到急诊室就诊，或陪同护理人员治疗和疏散平民伤亡人员，以保持其能力和专门知识。这可以通过建立一个有组织的持续医学教育和补充培训框架来实现。

一年一度的短期复习课程，内容类似于ATLS课程的技能站，但特别是为医务人员设计的，这是非常可取的。这些课程应伴随着基本理论知识的考试和手工技能的评估。主要的想法是尽量减少physicians.7.k的知识下降

**评论**

综上所述，负责义务服务和保留服务的医生的认知和手工技能最初是有限的。此外，这种知识会随着时间的推移而下降。然而，大多数医务人员即使在和平时期，也会遇到重大创伤受害者。需要采取有组织的方法，对预备役战斗医务人员进行持续教育。这应该在类似于那些针对医生的项目的基础上进行。当做出这样的努力时，医生在护理伤者方面的表现有望得到改善。

**参考文献**

1.高级创伤生命支持教练手册。芝加哥，美国外科医生学会，1993年

2.战场医学中的医疗责任链。Milit Med 1985;150:471-5.

3.《创伤受害者的三重死亡分散了注意力：黎巴嫩战争的军事经验》。Milit Med 1997;162:24-6.

4.美国急诊医师学院：创伤护理系统的质量改进指南。安·艾默格医学杂志1992：21：736-9。

5.德里斯科尔P，文森特CA：组织一个有效的创伤团队。受伤1992；23：107-10。

6.KlugerY, RtvkindA, Donchin Y,NotzerN.一种研究军事战斗创伤教育的新方法。J创伤1991；31：564-9。

7.加斯DA。L：医生和护士在心肺复苏培训后保留知识和技能。ManMedAssocJ1983；128：550-1。

8.在高级创伤生命支持（ATLS）课程后，高级创伤生命支持（ATLS）的认知和创伤管理技能。J创伤1996；40：860-6。

**军事医学，第164卷，1999年1月**

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**Primary Trauma Care Experience of Army Reserve Combat Medics**:

**Is a New Approach Needed?**

**Major Ron Ben-Abraham*+**

***Captain Gideon Paret****

***Major Yoram Kluger****

**Combat medics play a significant role in any fighting unit.In recent years,during times of peace and low-intensity military conflicts,as well as in operations other than war,reserve combat medics have been challenged to treat major casualties in the field.Although this work requires important manual**

skills,the medics perform basic treatment maneuvers that are

**not necessarily for saving of lives.A sample survey of reserve combat medics revealed that most (70%)were engaged in med- ical care for trauma victims during their regular and reserve service.Many (32.5%)were involved in incidents with multiple**

casualties.These incidents included seriously injured vic-

**tims,with 39.2%of the medics being involved with air evacu- ation and 44.4%with fatalities.Not all medics are exposed to major trauma,but for those who are,the numbers of patients per medic is not large.Therefore,the need to educate the medics in cognitive,and more importantly,in manual skills,is obvious.Suggestions for the means to do so are provided.**

**Introduction**

he quality of first aid applied to trauma victims in the com-

bat zone is crucial to patient outcome.In many cases,dur- ing a war in combat scenarios,the "golden hour,"as defined by Advanced Trauma Life Support (ATLS),'passes well before phy- sicians arrive at the scene.It certainly passes before evacuation of the victim to a definitive care facility is completed.Because the number of physicians capable of being assigned to front-line combat units is small,the responsibility for providing initial aid to the wounded lies primarily with the combat medics.These medics are an important part of trauma chain care for the wounded in the field.2

The Israel Defense Force is based largely on reserve units. After completion of our 3-year compulsory service,we are as- signed to various army reserve units,where we are required to serve until the age of 45 to 49.For most ofus,this period is well in excess of 20 years.Unlike paramedics,who deal with trauma care on a daily basis,the vast majority of medics do not partic- ipate in any medical system outside of the medical corps.As such,the only time we are asked to demonstrate our skills in providing primary care to trauma victims is during the annual reserve military service,which can be as short as 1 month per year during peacetime.Our study was conducted to assess reserve medic experience in trauma care.The outcome will fa- cilitate better allocation of limited resources for continuous training programs for reserve combat medics.

*Israel Defense Force,Medical Corps.

+Sackler School of Medicine,Tel Aviv University,Tel Aviv,Israel.

This manuscript was received for review in December 1997 and was accepted for publication in June 1998.

Reprint &Copyright O by Association of Military Surgeons of U.S.,1999.

***Brigadier General Joshua Shemer****

**Lieutenant Colonel Michael Stein***

**Population and Methods**

A total of 150 reserve medics assigned to reserve combat units were requested to complete a predesigned questionnaire anon- ymously and without restriction.Medics were chosen consecu- tively and randomly from a group of medics performing their annual military training in the Israel Defense Force Medical Corps School of Military Medicine.The questionnaire pertained to the subjective views of the medics and their actual trauma care experience after completion of their basic training.Only experience with cases of multiple trauma,including major blunt and penetrating injuries requiring urgent evacuation to level I or II trauma centers,was considered for the study.

**Results**

A total of 135 of 150 medics(90%)agreed to respond to the questionnaire and completed it in its entirety.Table I summa- rizes data concerning the experiences of the reserve combat medics in the treatment of patients with multiple injuries since completion of their basic training.This experience did not in- clude treatment performed during their compulsory service.As can be seen,29.7%reported that they were not exposed to trauma victims since the completion of their basic training in compulsory military service (the combat medic's course),which was 11.7±7.4 years earlier,on average.Of these,32.5%of all medics participated in the provision of care during a multiple casualty event,and 24.4%had the opportunity to provide trauma care in the field to trauma victims when they were alone.

Furthermore,55.5%were afforded the opportunity to work as part of a team that included a military physician during the period mentioned.Care to victims during trauma events that included air evacuation involved 39.2%of the reserve combat medics,and 44.4%participated in trauma events that ended with fatalities.During the year before the survey,58.5%of medics did not encounter any trauma patients (Table I).

Table II lists data on various manual skills used by medics as part of the initial care provided to trauma victims.These include assistance to physiclans in performing emergency lifesaving procedures such as intubation,tube thoracostomy,central ve- nous catheter insertion,and intraosseous device insertion,as well as other manual skills,i.e.,fracture fixation or burn wound treatment.Medics are taught these procedures during their basic training at the School of Military Medicine and,as such, they are expected to perform them when required.

With regard to emergency airway management procedures, 40%of medics had inserted an oral airway device into a real trauma victim.Manual ventilation using a bag and mask and assistance in intubation were experienced by 35.5 and 38%of medics,respectively.Techniques involving rapid installation of

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Primary Trauma Care **49**

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**TABLE I**

MEDIC EXPERIENCE IN THE TREATMENT OF PATIENTS WITH

MULTIPLE INJURIE![](/media/202412//1733470718.14788.png)![](/media/202412//1733470718.1633682.png)![](/media/202412//1733470718.172056.png)N OF THEIR BASIC

Item Total

Years since completion of basic training 11.7±7.4

Treated victims since completion of basic training95(70.3%) Participated in multiple casualty events involving44(32.59%)

more than four victims

Treated trauma victims alone 33 (24.4%)

Treated trauma victims as part of a team that 75(55.59%)

included a physician

Participated in trauma events that ended with an 53 (39.2%)

air evacuation

Participated in trauma events that ended in 60(44.4%)

atalities

**TABLEⅡ**

NUMBER OF TRAUMA VICTIMS TREATED BY RESERVE COMBAT MEDICS DURING THE YEAR BEFORE THE SURVEY (N =135)

No.of Trauma Victims

Total

0

79 (58.5%)

1-5

43 (31.8%)

6-10

2 (1.4%)

11-20

6(4.4%)

≥20

5 (3.7%)

**TABLE Ⅲ**

LIFESAVING AND OTHER PROCEDURES AS ASSISTED BY MEDICS

DURI![](/media/202412//1733470718.1849477.png)![](/media/202412//1733470718.2084093.png))SINCE

Procedure

Total

Airway management

54 (40%)

Bag and mask ventilation

48 (35.5%)

Intubation

52 (38%)

Tube thoracostomy

43 (31%)

Central venous catheter insertion

29 (21%)

Intraosseous device insertion

11(8%)

Thomas splint

20 (14%)

Open fracture fixation

62(45%)

Burn injury treatment

29(21.4%)

means for fluid resuscitation to the severely injured,i.e.,central venous catheter and intraosseous device insertion (to pediatric victims),were experienced by 21 and 8%of medics,respectively. Other activities involving acute care of the injured,which in- cluded open and closed fracture fixation and burn wound treat- ment,had been experienced by 45 and 21.9%of the reserve combat medics,respectively.

**Discussion**

Basically,three types of medical providers care for trauma

victims in the field;in many western miltary organizations, these are the medic,the paramedic,and the miltary physician. The Israeli Army is blessed with a relatively large number of physicians serving in career positions as well as in active reserve duty.However,even this relatively large number cannot imme-

diately care for the masses of casualties expected during full- scale war.Many of the trauma victims die soon after being injured because of the devastating effects of military munitions.9 In fact,more than 90%die within the first hour,in contrast to the results observed in urban trauma.

Undoubtedly,prompt and speedy evacuation of the severely injured to a medical facility capable of resuscitative surgery will have the greatest effect on casualty survival.The concept of far-forward surgery teams,currently contemplated in the Israel Defense Force,Medical Corps,is a result of this understanding.

Paramedics also can be extremely beneficial to the trauma victim in the combat scenario.There are,in fact,few differences between the capabilities of the experienced paramedic (with extensive civilian emergency medical experience)and those of the reserve miltary physician for saving life in the prehospital/ presurgical facility setup.It is acknowledged that the perfor- mance of the average paramedic is better than that of the aver- age physician.Because paramedics are relatively scarce in the Israeli medical environment,we need to rely heavily on the regular medics with their limited experience.The emphasis to- day,therefore,should be on enabling salvageable victims to arrive at the definitive care station with satisfactory vital signs that will ensure their survival.These include adequate airway and breathing,hemorrhage control of accessible bleeding sites,and fluid resuscitation to replace volume loss from the circulation.

The combat medic can,theoretically,resolve minor airway problems with a plastic oral airway device,perform short-term mouth-to-mouth ventilation,and obtain homeostasis with tour- niquets around extremities and direct pressure elsewhere.Al- though not lifesaving,but nevertheless important,are several other procedures performed by the medic,i.e.,wound care, basic fracture stabilization,and pain control (with intramuscu- lar morphine).Although not considered critical for survival, these skills are probably paramount to the role of the medic in the combat zone.It is dificult to quantify,but such procedures obviously have an effect on the morbidity of some injuries,and more importantly,provide the trauma victim with a feeling of well-being and comfort.This contributes immensely to the mo- rale of the victims and the unit's uninjured soldiers and indi- rectly promotes better performance of the unit.

Indeed,70%of the medics participated in the treatment of serious trauma patients,although this was over a period of many years.However,almost 30%of the medics did not partic- ipate in primary trauma care after completion of basic training. Moreover,for others,the experience was found to be limited. These findings were consistent for medics throughout the vari- ous units of the army (infantry,armored,and rear-echelon fa- cilities).Because practically none of the reserve combat medics are engaged in trauma care as civilians,it may also be assumed that their civilian experience concerning primary trauma care is nonexistent.

The data presented in this paper suggest that during peace- time or low-intensity conflicts,a significant number of medics will encounter severely injured trauma victims,either alone or as part of a medical team.Therefore,it is important to improve their knowledge and practical experience in both life-threaten- ing conditions and manual skils that are not necessarlly life- saving but are required for trauma care in the combat zone.

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Trauma care of the injured soldier in the field differs from that in the hospital.The additional stress of the military environment, the occasional need to extricate the wounded from a burning or hostile environment,and the limited medical supplies create suboptimal conditions for the care of the injured.These addi- tional facts complicate the treatment of the injured on the bat- tlefield and mandate the use of medics with extenstve experience for the success of lfesaving treatment.

In recent years,there has been a tremendous effort to improve the quality of primary trauma care provided by physicians in the Israel Defense Force Medical Corps.Because optimal care of the seriously injured patient proved to be dependent on the quality of the emergency medical services,4.5 emphasis was placed on improving the knowledge and experience of those who may be called upon to treat trauma patients,despite the fact that this is not their daily occupation.In the early 1990s,the ATLS course was declared mandatory for all military physicians.Later,the Combat Trauma Life Support Course was created.6 The purpose of the course was to bridge the gaps between the civilian nature of the ATLS course and the special needs of the physician in the battlefield.Recently(1996-1997),the primary trauma care training program for medics was also thoroughly revised.The 14-week basic training program for young recruits to become medics encompasses various topics related to military medicine. These include preventive medicine and essentials of primary medicine.However,the newly revised course has an expanded section dedicated to trauma care.It has also been aligned with the principles of the ATLS course taken by the physicians.Thus, when medics are working with others as a team,the same principles are followed.One should remember that these young recruits have absolutely no medical background,so the knowl- edge they obtain within the framework of their basic medic course is the full extent of their medical knowledge.Later,after being discharged from compulsory service,the vast majority will not deal with medicine at all.

The main role of the medic in the field is to aid the trauma victim during the very first period after injury.Two other roles are to perform wound care and to control pain more efficiently than the untrained soldier.Although this usually does not affect the final outcome,the psychological state of the patients and their comrades improves immensely.Also,the medic is the vic- tim's advocate and is responsible for promoting urgent evacua- tion.When medics act alone,or before the arrival of the physi- cian,their skills allow them mainly to support the airway (basic support),apply tourniquets on bleeding limbs,provide pain control,and insert peripheral intravenous lines.After the arrival of the physician,they may assist in more advanced,ATLS-type procedures.

We have shown that even during peacetime,some of our medics were exposed to these types of procedures in the field

(Table I).Intubation was assisted by no less than 40%of the medics,and tube thoracostomy by 31%.We assume that during a war these numbers greatly increase.For this reason,we should provide the medics with more training in manual skills, whether by means ofaudiovisual methods or by spending part of their annual reserve time in emergency departments or with prehospital emergency medical system ambulances,where these procedures are performed daily.Medics should attend the emergency room on a monthly basis or accompany paramedics in treatment and evacuation of civilian casualties to maintain their capabilities and expertise.This can be achieved by the establishment of an organized framework for continuous medi- cal education and supplementary training for reserve medics.

An annual short refresher course with contents similar to the skill stations of the ATLS course,but especially designed for medics,is highly desirable.These courses should be accompa- nied by examination of basic theoretical knowledge and evalu- ation of manual skills.The main idea is to try and minimize the decline of knowledge similar to that reported to occur among physicians.7.k

**Comments**

In conclusion,the cognitive and manual skills of medics dur- ing compulsory and reserve service is initially limited.Moreover, this knowledge declines over time.However,the majority of medics will encounter major trauma victims even during peace- time,when they serve their annual reserve service.An organized approach to continuous education of reserve combat medics is needed.This should be carried out on the basis of pro- grams similar to those for physicians.When such an effort is made,improved medic performance in the care of the injured is expected.

**References**

1.Advanced Trauma Life Support Instructor Manual.Chicago,American College of Surgeons,1993

2.Dolev E,Lewellyn CH:The chain of medical responsibilty in battlefield medicine. Milit Med 1985;150:471-5.

3.Gofrtt NO,Leibovicl D,Shapira CS:The trimodal death distrlbutlon of trauma victims:military experience from the Lebanon War.Milit Med 1997;162:24-6.

4.Amerlcan College of Emergency Physicians:Trauma care systems quallty im- provement guidelines.Ann Emerg Med 1992:21:736-9.

5.Driscoll PA,Vincent CA:Organizing an effective trauma team.Injury 1992;23: 107-10.

6.KlugerY,RtvkindA,Donchin Y,NotzerN.Shushan A.Danon Y:A novel approach to military combat trauma educatlon.J Trauma 1991;31:564-9.

7.Gass DA.Curry L:Physicians and nurses'retention of knowledge and sklls after training in cardiopulmonary resuscltation.Can Med Assoc J 1983;128:550-1.

8.AliJ,Cohen RA,Adam T,Gana J,Pierre E,Ali H,Bedaysie V,Winn J:Attrltlon of cognitive and trauma management skills after the Advanced Trauma Life Support (ATLS)course.J Trauma 1996;40:860-6.

**Military Medicine,Vol.164,January 1999**