Over the past ten years, the military MCI has been confined in specific areas, particularly the three southern border provinces where terrorism produces continuing violence with a variety of incidents primarily shootings, and secondly, bombings both in rural and downtown areas. A previous study of military MCI regarding Thai military units in the southern trauma registry reported that mechanism of injury about 71%, blast injury and 29%, firearm or gunshot wound . This present study showed a higher ratio of blast injury (90.2%) while the second most common injury was gunshot wound (6.5%) implying that weapons of mass destruction (WMDs) will be one of the major concerns in our armed conflict casualties in the future even though the incident was in the capital city.
The previous study of southern conflict in Thailand demonstrated the anatomic distribution of injured body regions indicating head & neck was 21.8%, the torso (chest, abdomen, trunk and pelvis) was 24.5% and the most common injured body region was the extremities 51.6% . Compared with a previous study, this represented a lower distribution, i.e., head & neck (5.1%), abdomen (7.9%) and chest (10.1%). Perhaps this is due to effective protective body armour vests and helmets. However, the injury to the extremities still exhibits a high percentage, 48.5% (134 of 276 injured body regions) implying that protection in this areas is not effective enough.
In this study, prehospital treatment received cooperation from many government sectors and the Ministry of Defence to prepare field-operation military medical teams to transport injured soldiers to PMK Hospital where prehospital time was recorded by military health care officers. Although this MCI occurred April 10, 2010, many injured soldiers had to be transported at the same time, leading to unreliable accuracy of time recordings. Unreliable prehospital time data was found in 14 of 153 cases, so the prehospital time records of the remaining 139 cases were analyzed for accuracy. About 29% of injured soldiers presented to the hospital within the first hour of trauma care that may be inappropriate in prehospital transportation during this MCI because health care providers could not suddenly evacuate casualties during continuous firing and bombing in those dangerous areas and transportation was blocked by crowds.
The analysis finally showed that the factors influencing ISS with a statistically significant difference at the 0.05 level were age (p = 0.04), abdomen injury (adjusted OR = 29.9; 95% CI, 5.8-153.5; P < 0.01), head & neck injury (adjusted OR = 13.8; 95% CI, 2.4-80.4; P < 0.01) and chest injury (adjusted OR = 9.9; 95% CI, 2.1-47.3; P < 0.01).
This study emphasized report only MCI April 10, 2010. Soldiers with high ISS, more than 16 points, totalled 18 of 153 victims (11.8%). This low percentage of severe injury is the characteristics of this MCI; the protective equipments, that lower ISS, may be effectively used.
These data including mechanism of injury & distribution of injured body regions and factors influencing ISS were important keys in the implications for hospital organizations to manage limited health care resources. As a result, management in MCI could be handled within the resources of the emergency team based on emergency physicians cooperating with other specialists, as well as nursing staffs. Finally, it was found that three victims were predicted to die due to high TRISS but one victim unexpectedly survived despite having a high TRISS due to effective resuscitation and good cooperation from multidisciplinary health care services.
By nature, research on disaster medicine is largely descriptive as MCI is virtually impossible to study via prospective randomized controlled trials and the study could not be double blinded or concealed.
Regarding hospital preparedness in specific circumstances as military MCI, health care providers cannot normally access in the operation zone where WMDs were used and could not normally evacuate or transport casualties because of entrapment by the crowds resulting in delayed prehospital time from minutes to hours or even days.
Implementation and suggestion
Knowledge in mechanism of injury, distribution of injured body regions together with the proven factors influencing ISS used to predict mortality, are all important keys for proper medical management and preventive measures.
Implications concerning hospital organizational aspects include improving management with limited health care resources and enhancing hospital surge capacity for MCI. Implications concerning the Ministry of Defence aspects include improving effectiveness of protective equipment in future military MCI. Implications concerning the national aspects include establishing harmonized military-civilian collaboration in MCI response network.
This study is based on cases in a military hospital, and recommendations may require non- military studies in public health hospitals to compare results. MCIs are heterogeneous by nature and their unexpectedness favors an "all-hazard" approach including radiation & nuclear wastes, bioterrorism, chemical weapons or explosion. MCI preparedness must be prompt every time.