Improvement of the Organization of Medical Care for Victims of Accidents at Chemical Industry Facilities in the Republic of Tatarstan

The dissertation is devoted to the improvement of the organization of medical care for persons affected by accidents at chemical industry facilities of the Republic of Tatarstan. The research analyzes the current state of the disaster medicine system, identifies risk zones of emergency situations taking into account the location of potentially hazardous objects using accidentally dangerous chemical substances, and assesses the resource potential of preventive and treatment institutions of the region. Special attention is given to substantiating the possibility of engaging sanatorium-preventive institutions for the provision of assistance, treatment, and rehabilitation of victims in conditions of chemical accidents, as well as to the development of organizational-methodological foundations for improving the system of treatment and evacuation measures. The work is of a practical orientation and is aimed at increasing the effectiveness of emergency medical response to technogenic accidents with a chemical factor of injury.

Relevance of the Problem. According to data from the international register, up to 6 million toxic substances are currently used in industry, agriculture, and for household purposes worldwide. Approximately 60,000 of them are produced on an industrial scale, including more than 500 belonging to the group of accidentally dangerous chemical substances (ADCS) (Lazarev N.V., 1977; Krylov V.V., 1978; Marshall V., 1980, 1989; Goncharov S.F., Prostickishin G.P., Vorontsov I.V. et al., 1997). The production, transportation, use, and storage of ADCS are strictly regulated by special instructions and rules of control and industrial safety in their application. However, taking into account the human and technical factor, during large-scale industrial accidents, fires, natural disasters, and possible manifestations of acts of terrorism, destructions of production buildings, equipment, and technological lines, warehouses, vessels, pipelines, etc., may occur. As a result, large quantities of ADCS may enter the surrounding environment and spread across the territory not only of production areas but also beyond their borders. In adjacent settlements or city districts, focal points of chemical contamination with mass poisoning of the population may arise (Litvinov N.N., Ostapenko Yu.N., Kazachkov V.I. et al., 1997; Ivashina L.I., Osin O.M., Prostickishin G.P., 2002; Chasis Н., Zapp J.A., Bannon J.N. et al, 1987; Porier S., Wenig J., 1999; Ostheiner K.H., Lech A., 2002; Noji E.K., 2002).

The high level of industrial development of modern Tatarstan, while addressing economic tasks, may simultaneously give rise to negative phenomena associated with the safety of human health and the surrounding environment (Badyugin I.S., 1992; Karatay Sh.S., 1996; Ishalin E.R., Gasilov B.S., Chepegin I.V., Zinatullina G.N., 2004).

The territory of the Republic of Tatarstan possesses a powerful economic potential, a developed industry, in which the oil-extraction and oil-chemical sectors, mechanical engineering, energy, transport, and communications hold leading positions, along with a sufficiently stable agriculture and social infrastructure.

Analysis of actual material shows that within the studied territory of the Republic of Tatarstan, the major part of industrial production is located in the cities of Kazan, Almetyevsk, Bugulma, Zelenodolsk, Leninogorsk, Nizhnekamsk, Naberezhnye Chelny, and Chistopol. On the studied territory, approximately 91 potentially hazardous objects of the economy are located. These are, first and foremost, production-technical complexes and enterprises that use ADCS in their technologies and maintain large stocks of explosive, flammable, and other hazardous substances. Among such hazardous enterprises, a special place is occupied by objects using chlorine and ammonia in production (Bodrikov O.V., Banypikova Z.E., Glebov V.Yu., 1999).

Improvement of the organization of medical care for victims of accidents and catastrophes at economic facilities using accidentally dangerous chemical substances in their technological processes, despite the established system of disaster medicine both in our country and abroad, has not lost its relevance (Varenin S.A., Podelyakin N.A., 1992; Prostickishin G.P., Musiychuk Yu.I., 1993; Karatay Sh.S., 1996; Goncharov S.F., Prostickishin G.P., Vorontsov I.V. et al., 1997; Zhilyaev E.G., Lezin E.L., Yanushovsky A.K., 1997; Zhukov V.A., Skvortsov A.F., Zaitseva L.A., 2003; Sofronov G.A., Rumak B.S., 2003; Aspin B.R., 2003; Brismar В. 1993; Debaker М., 1993).

Analysis of works devoted to this circle of questions over the past 20 years testifies to the fact that the category of victims in emergency situations from the effects of ADCS in 100% of cases requires provision of emergency medical care at the pre-hospital stage (Nagnibeda A.N., Farshatov M.N., Kirilyuk I.G., 1991; Khalif R.A., Retunsky E.K., Gribanova T.N. et al., 1997; Vladimirov V.A., Isaev B.S., 2000; Ivashina L.I., Osin O.M., 2002; Dines G.B., 1990; Gemma W., 1985; Hauber P., 1981).

A significant proportion of the affected — up to 35% (Nagnibeda A.N., Farshatov M.N., Kirilyuk I.G., 1991; Gunn S.W.A., 1994) — die before the hospital stage. According to the same authors, victims with severe and moderate degrees of injury (with disability lasting no less than 3 weeks and requiring hospitalization) may constitute a group of 40 percent or more; also taking into account the exposure time of ADCS, the 'lightly affected' may constitute a share of 25%, of which 80% require inpatient treatment for 3–7 days, and 20% require ambulatory polyclinic treatment and observation. However, analysis of several large-scale accidents revealed that in the structure of injuries, poisonings of mild degree predominated (up to 60%), the number of victims with moderate and severe degrees requiring hospitalization constituted 35%, and lethal injuries were observed in 5% of cases (Varenin S.A., Podelyakin N.A., 1992).

According to the studies of Goncharov S.F., Prostickishin G.P., Vorontsov I.V. et al. (1997), in explosions and fires with emission of ADCS into the atmosphere, poisoning is expected in 60% of victims, mechanical injuries in 25%, burns in 15%, and 5% of the affected may have combined forms of injury, which in turn predetermines the specifics of the organization of medical care for victims (Gerasimova L.I., 1996; Zhizhin V.N., Kizhaev V.E., Petrov G.M., Goncharov S.F., 2000; Hendler M.J., Poles L., Neuman С., 2002; Norris D.A., 1989). When an emergency situation arises, affected by ADCS (under the system of disaster medicine adopted at the territorial level), the stream of victims requiring qualified and specialized medical care (practically 100%) is identified during medical triage at the hospital stage (Khatta Z.I., 1990; Novikov N.V., Petrenko E.B., 1990; Goldfarb Yu.S., Prostickishin G.P., 2002; Marschall V.C., 1987).

In connection with the deficit of specialized toxicological (toxicotherapy) beds planned for use in emergency situations (the deficit coefficient of toxicological beds by risk zones of the Republic of Tatarstan ranges from 1.8 to 12.4), the shortage of toxicologist physicians, the overload of therapeutic hospitals with severely ill patients (85–95%), and the adopted system of providing assistance at the hospital period (dispersion and distribution), the so-called phenomenon of 'swamping' of preventive and treatment facilities will be observed — the majority of victims will receive qualified and specialized assistance on a residual basis (Nasyrov I.R., 2001). With an optimal time for providing medical care of 2 hours for all victims, they may receive it only through 24–48 hours. From this, high mortality (35%), development of severe complications, increased length of hospital stay, exclusion from professional labor activity for a long term, and additional financial expenditures on treatment and rehabilitation are possible (Ivashkin V.T., Kirilov V.M., Aleksandrov T.R., 1989; Luzhnikov E.A., Safronov G.A., 1990; Belyaev V.R., 1991; Goncharov S.F., Lobanov G.P., Sakno I.I., 1994; Ivanov V.B., Nesterenko A.F., 1994). This problem especially concerns cities located in the 'Zakamye' zone — where the main guarantors of preserving life and health are city hospitals, whose capabilities clearly do not coincide with the needs for providing medical care to victims (Karatay Sh.S., 1996; Akhmerov F.R., Nurieva E.G., 2003).

What is the way out of the created situation? In our opinion, this question may be resolved to a certain extent by using sanatorium-preventive institutions and health centers for the provision of medical care, treatment, and rehabilitation of victims in chemical accidents and catastrophes, on the condition of advance planning of the system and organizational-functional restructuring of their work in emergency situations (ES).

In the Republic of Tatarstan, there are 44 such institutions located in immediate proximity to risk zones, with a bed capacity of 6,125 beds, equipped with departments and offices of traditional and non-traditional medicine, a modern laboratory-diagnostic base, and staffed with qualified physicians and middle medical personnel.

Goal of the Research: To substantiate the necessity and develop proposals for improving the organization of medical care for victims of accidentally dangerous chemical substances (ADCS) in emergency situations at chemical industry facilities of the Republic of Tatarstan.

Tasks of the Research:

1. To study the risk zones of emergency situations of the Republic of Tatarstan — potentially hazardous objects with a chemical factor of injury and the specific features of the organization of medical care in emergency situations.

2. To assess the needs and capabilities of preventive and treatment health care institutions located in risk zones, sanatorium-preventive institutions, for providing medical care to victims of ADCS in emergency situations.

3. To substantiate the necessity of using sanatorium-preventive institutions for providing medical care to victims in emergency situations of a chemical nature.

4. To develop proposals for improving the organizational-functional model of providing medical care to victims of chemical accidents and catastrophes in the conditions of the Republic of Tatarstan.

5. To assess the medical-social effectiveness of the improved model of providing medical care to victims of ADCS in the conditions of the Republic of Tatarstan.

Scientific Novelty.

For the first time with respect to the conditions of the Republic of Tatarstan: risk zones of emergency situations resulting from accidents at potentially hazardous objects with ADCS have been studied; the needs and capabilities of preventive and treatment health care institutions for providing medical care to victims of ADCS have been assessed; the possibility of using sanatorium-preventive institutions for providing medical care to victims in emergency situations of a chemical nature has been substantiated; proposals for improving the organizational-functional model of providing medical care to victims of ADCS using sanatorium-preventive institutions have been developed.

Scientific-Practical Value and Implementation of the Results of the Research in Practice.

The results of the present research made it possible: to comprehensively study and assess risk zones of emergency situations resulting from accidents at potentially hazardous objects with ADCS; for the first time on a scientific basis to assess the capabilities of preventive and treatment health care institutions for providing medical care in accidents at potentially hazardous objects with a chemical factor of injury; for the first time to comprehensively assess and substantiate the capabilities of using sanatorium-preventive institutions in the general system of providing medical care to victims of ADCS; to develop specific proposals for improving the system of organization of medical care in emergency situations with a chemical factor of injury.

The results and materials of the research were used: in the development of methodological recommendations 'Organization of Medical Care of the Population of the Republic of Tatarstan in Emergency Situations with a Chemical Factor of Injury' (Kazan, 2006, 47 pp.); on the basis of the results of the research, corrections (changes and additions) were introduced into the 'Plan of Medical Support of the Population of the Republic of Tatarstan Affected as a Result of Emergency Situations of a Technogenic and Natural Character' of the Ministry of Health of the Republic of Tatarstan (Kazan, 2006); in the development of the teaching-methodical manual 'Improvement of the Organization of Medical Care for Victims at Facilities of the Chemical Industry of the Republic of Tatarstan' (Kazan, 2005, 67 pp.); in writing the teaching manual for physicians 'Action of Toxic Substances Affecting the Respiratory Organs. Fundamentals of Providing Medical Care at Various Stages of Evacuation When Affected by ADCS Affecting the Respiratory Organs' (Kazan, 2005, 50 pp.).

The listed teaching-methodical manuals are included in the list of literature recommended for students of medical higher educational institutions, listeners of qualification improvement cycles, and are used in the educational process at the Department of Disaster Medicine and Emergency Medical Care of the Kazan State Medical Academy, at the Department of Military and Extreme Medicine of the Kazan State Medical University.

Testing of the Work. The dissertation work was tested at a meeting of the Department of Disaster Medicine and Emergency Medical Care of the State Educational Institution of Additional Professional Education 'Kazan State Medical Academy' of the Federal Agency for Health and Social Development (March 24, 2006).

The results of the research were reported at 5 conferences: at the II regional scientific-practical conference of the Volga Federal District 'Pediatrics and Pediatric Surgery in the Volga Federal District' (Kazan, 2005); the All-Ukrainian scientific-practical conference 'Scientific Research and Their Practical Application. Current State and Paths of Development' (Odessa, 2005); the conference 'Actual Problems of Improving the Health Care System', dedicated to the 10th anniversary of the Faculty of Management and Higher Nursing Education (Kazan, 2005); the XI All-Russian scientific-practical conference 'Young Scientists in Medicine' (Kazan, 2006); the All-Russian scientific-practical conference 'Actual Problems and Prospects of Development of Medical and Preventive Work in the Russian Federation' (Kazan, 2006).

Publications. Based on the materials of the research, 9 printed works were published, including 1 methodological recommendation approved by the Ministry of Health of the Republic of Tatarstan, and 2 teaching-methodical manuals.

Basic Propositions to be Defended.

The results of the conducted research made it possible to substantiate a number of propositions that are presented for defense:

1. The necessity and capabilities of using preventive and treatment health care institutions located in risk zones for providing medical care to victims of ADCS in emergency situations of a chemical nature.

2. The possibility and expediency of using sanatorium-preventive institutions for providing medical care to victims in emergency situations of a chemical nature.

3. Proposals for improving the organizational-functional model of providing medical care to victims in accidents and catastrophes in the conditions of the Republic of Tatarstan.

Structure and Volume of the Dissertation Work. The dissertation is presented on 152 pages of computer text. It consists of an introduction, a literature review, four chapters of original research, discussion of the obtained results, conclusions, practical recommendations, a list of abbreviations, a list of references (237 sources, including 78 foreign ones), and 1 appendix. The work is illustrated with 20 tables and 6 figures.