Organization of Physiotherapeutic Assistance to Victims during the Armed Conflict in the Chechen Republic (1999–2000)

The dissertation is devoted to the research of the organization of physiotherapeutic assistance to victims during the armed conflict in the Chechen Republic in 1999–2001. The work analyzes the system of rendering physiotherapeutic assistance to the wounded and sick at various stages of medical evacuation — from troop to hospital — and evaluates the volume, structure, and effectiveness of the physical treatment methods applied. The research is based on the analysis of medical documentation of personal records of the victims and covers both peacetime and wartime experience of the organization of physiotherapy in medical institutions.

Relevance of the Research Topic.

The necessity of studying and researching the experience of medical support of the unified group of forces (UGF) in armed conflicts is dictated by the realities of the present time.

A preliminary analysis and generalized results of medical support of the unified group of forces during the counter-terrorist operation in the North Caucasus in 1999–2001 indicate that the medical service successfully fulfilled its tasks during that period [Chizh I.M., et al., 2003].

At the onset of the armed conflict in the North Caucasus, there existed an organizationally formalized territorial system of medical care, the principal functional core of which were base medical institutions. They underwent successful testing in various peacetime situations and demonstrated high effectiveness in combat conditions during the armed conflicts in the Chechen Republic in 1994–1996 and 1999–2001, as vividly evidenced by the results of medical support of the grouping of forces [Benya F.M., Ulunov A.D., 2003].

Approximately 40,000 wounded and sick (40% wounded, burned, and traumatized and 60% sick) were admitted at the stages of medical evacuation, 90% of whom were hospitalized in medical institutions established both in the area of the armed conflict and beyond its limits. Treatment was completed and 89.5% of the wounded and 95% of the sick were discharged with recovery. Mortality amounted to 1.5% among the wounded and 0.3% among the sick. The remainder — 9% of the wounded and approximately 5% of the sick — were discharged from the Armed Forces of the Russian Federation due to disability or referred to medical institutions at their place of conscription without rendering an expert conclusion. More than 100,000 wounded and sick were evacuated by all types of sanitary transport (accounting for one-, two-, and triple transfers of the same victims to various stages of medical evacuation), with approximately 80% of them evacuated by air transport (Chizh I.M., Shelepov A.M., 2003).

A certain role in achieving such results was played by timely rendered physiotherapeutic assistance, which made it possible to significantly reduce the frequency of complications among the wounded, accelerate the terms of recovery, and decrease the proportion of military personnel discharged from the Armed Forces of the Russian Federation. The organization of physiotherapeutic assistance, as one of the types of specialized medical care, makes it possible to significantly improve the results of medical rehabilitation of victims during the armed conflict in the Chechen Republic (1994–1996), especially at the final stages (Nigmendzanov R.A., 2000).

In conditions of armed conflicts involving the use of modern types of conventional weapons, physical treatment methods will be required by up to 90% of the wounded and sick admitted to medical institutions at both initial and final stages of medical rehabilitation (Gurov A.N., 1993, Medical Rehabilitation, 1997, Ponomarenko G.N., 1998).

Despite the fact that the scientific problem of organization and rendering of physiotherapeutic assistance to the wounded and sick in armed conflicts has already been formulated (Nigmendzanov R.A., 2000), it is far from resolution. Analysis of isolated publications attests to the fact that today the tasks of organization and rendering of physiotherapeutic treatment at the troop stages of medical evacuation (medical platoon, medical evacuation company, mobile hospital) and physiotherapeutic assistance at the hospital stage are not fully substantiated and resolved. The development of unified and integral approaches to the organization of physiotherapeutic assistance to the wounded and sick in armed conflicts, its formation as a system of sequential and successive measures, is an actual scientific task of military public health and health care organization, rehabilitation medicine, and physiotherapy.

Analysis of the effectiveness, volume, structure, and content of physiotherapeutic assistance at various stages of medical evacuation, in various armed conflicts, possesses important theoretical significance for understanding the organizational aspects of medical support of the forces. It makes it possible to develop recommendations for creating a unified and integral system of organization of physiotherapeutic assistance to the wounded and sick in armed conflicts. The stated positions determined the relevance and choice of the dissertation research topic.

Objective of the Work:

- Investigation and evaluation of the volume, structure, and effectiveness of physiotherapeutic assistance to the wounded and sick in the armed conflict in the Chechen Republic in 1999–2001;

- Development and determination of the principal directions for the improvement of physiotherapeutic assistance to the wounded and sick in armed conflicts.

Tasks of the Research:

1. Conduct a comparative analysis of the organization of physiotherapeutic assistance to the wounded and sick in peacetime and wartime.

2. Analyze the magnitude and structure of sanitary losses and the medical-evacuation characteristics of the wounded and sick in the armed conflict in the Chechen Republic (1999–2001) admitted to treatment in physiotherapeutic subdivisions of medical institutions of the unified group of forces.

3. Investigate the volume and structure of rendering physiotherapeutic assistance to the wounded and sick at various stages of medical evacuation in the armed conflict in the Chechen Republic (1999–2001).

4. Evaluate the effectiveness of rendering physiotherapeutic assistance to the wounded and sick of different degrees of severity at various stages of medical evacuation in the armed conflict in the Chechen Republic (1999–2001).

5. Determine the principal directions for the improvement of physiotherapeutic assistance to the wounded and sick in armed conflicts.

6. Develop proposals for the improvement of the organizational and staffing structure and equipment of the troop stages of medical evacuation with forces and means for the creation of an integral system of physiotherapeutic assistance to victims of the armed conflict.

The solution of the set tasks was carried out in relation to the existing system of medical-evacuation measures and the structures of the medical service on which it is based.

The object of the research was the system of organization of medical-evacuation measures in the armed conflict and the organization of rendering physiotherapeutic assistance to the wounded and sick in the armed conflict in the Chechen Republic (1999–2001).

The subject of the research was the volume, structure, and effectiveness of rendering physiotherapeutic assistance to the wounded and sick in armed conflicts.

The following research methods were applied in the course of the work: comparative, logical and historical comparison, statistical and mathematical analysis.

For the execution of this research, the following were studied: domestic and foreign literary sources; archival materials of personal medical records of the wounded and sick (case histories, primary medical records); medical reports of medical institutions; scientific-research works and dissertation investigations; materials of scientific conferences; experience of medical support of the forces in armed conflicts of the second half of the twentieth century.

Scientific Novelty. The state and organization of rendering physiotherapeutic assistance to the wounded and sick in the armed conflict in the Chechen Republic (1999–2001) were studied. It was established that the volume of physiotherapeutic assistance to the wounded and sick in the armed conflict was insufficient and amounted to 69% and 63%, respectively, and the number of physiotherapeutic procedures was 11 and 8, respectively. The low coverage of the wounded and sick with physiotherapeutic assistance was due to insufficient equipment of medical institutions with physiotherapeutic apparatus, primarily portable, and the absence of forces and means for its rendering at the troop stages of medical evacuation (medical platoon, medical evacuation company, mobile hospital), where approximately 20% of lightly wounded complete treatment.

It was established that physiotherapeutic treatment was prescribed to the lightly wounded at earlier terms and in greater volume than to the heavily wounded, as a result of their more prolonged stay in military medical institutions of the unified group of forces (forces), where they completed treatment. The limited volume of physiotherapeutic assistance to the heavily wounded was due to: firstly, the insufficient quantity of portable physiotherapeutic apparatus, and as a consequence the impossibility of performing procedures in post-surgical departments, which substantially reduced the early prescription of therapeutic physical factors; secondly, the short duration of treatment of the heavily wounded in medical institutions of the UGF (forces), who did not complete the prescribed course of physiotherapeutic treatment due to the necessity of their further evacuation to medical institutions of the Center.

It was proven that the effectiveness of medical and surgical treatment was higher among those wounded and sick whose complex treatment included physiotherapeutic methods of treatment, and, according to our data, amounted to 72% among the wounded and 77.2% among the sick. The significant role in achieving high effectiveness of physiotherapeutic assistance depending on the terms of admission of the wounded and sick to military medical institutions was determined. Late prescription of physical treatment methods significantly reduced the effectiveness of physiotherapeutic assistance, and, conversely, its early prescription led to better remote results.

Theoretical and Practical Significance. The work presents a complete analysis of the system of rendering physiotherapeutic assistance to victims of armed conflicts. The identified causes and deficiencies in the organization of physiotherapeutic assistance to the wounded and sick made it possible to determine directions for their improvement, which should be taken into account when planning medical support of the forces (forces) in armed conflicts.

On the basis of evaluation of the volume and structure of physiotherapeutic assistance to the wounded and sick, the necessity of including in the composition of the troop stages of medical evacuation (medical platoon, medical evacuation company, and mobile hospital) a physiotherapy room with corresponding staffing and equipment, including in their staffing middle and junior medical personnel and a minimum list of physiotherapeutic apparatus, for the performance of the basic and most effective methods of physical treatment, was substantiated.

The obtained data may be used in the formation of the organizational and staffing structure of medical service units and institutions, for the training of chiefs of physiotherapeutic subdivisions within the system of postgraduate education, in the development of regulatory documents of the medical service. The conclusions of the work formed the basis of the methodological guide on the organization of physiotherapeutic assistance in medical institutions of the Armed Forces of the Russian Federation and of the project of the Order of the Ministry of Defense of the Russian Federation on equipment of military medical institutions with apparatus.

Personal Participation of the Author in Obtaining the Results. The author personally performed the entire volume of investigations, developed a case history coding card, carried out the formation of the database, conducted analysis of medical documents of personal records of the wounded and sick (case histories, primary medical records) and statistical processing of the obtained data. The results of statistical processing of the database constituted the basis of the conclusions and propositions submitted for defense.

Principal Propositions of the Dissertation Work to be Defended.

1. The principal factors determining the volume, structure, and effectiveness of physiotherapeutic assistance to the wounded and sick in the armed conflict in the Chechen Republic (1999–2001) were the terms of their admission to medical institutions after the received injury (illness), the localization of the injury (illness profile), and the degree of severity of their condition.

2. The structure of physiotherapeutic assistance to the wounded and sick in the armed conflict was determined by their medical-evacuation characteristics, the localization of the injury (illness profile), and the degree of severity of the condition of the victims.

3. The principal directions for the improvement of physiotherapeutic assistance to the wounded and sick in armed conflicts are the optimization of the organizational and staffing structure and norms of apparatus equipment of the troop stages of medical evacuation (medical platoon, medical evacuation company, and mobile hospital).

4. Proposals for the improvement of rendering physiotherapeutic assistance to the wounded and sick.

Realization and Implementation of the Obtained Research Results. The obtained results and practical recommendations are used in educational and scientific work of the departments of balneology and physiotherapy (with a course of medical rehabilitation), organization and tactics of the medical service of the S.M. Kirov Military Medical Academy. The materials of the research were realized in the development and substantiation of groups of specialized medical care used for reinforcement of stationary medical institutions in the area of the armed conflict (the "stationary" part of the hospital base).

Discussion and Publication of the Research Results.

The principal propositions of the dissertation work were reported and discussed at the international scientific congress "Zdravnitsa-2003" (Kislovodsk, 2003), the VI International Scientific Conference "Modern Technologies of Rehabilitation Medicine ASVOMED-2003" (Sochi, 2003), the I National Congress "Integrative Medicine. New Ideology of Health Care of Russia" (Saint Petersburg, 2003), the Jubilee Scientific and Practical Conference "Modern State and Prospects of Development of Medical Support of the Ground Forces" (Saint Petersburg, 2002).

The results of the conducted investigations were used at the S.M. Kirov Military Medical Academy in the execution of a number of scientific-research works (codes "Base," "Reformation," "Experience-3," "Experience-2.1.," "Rubric -2," "Physiotherapy").

Seven printed works were published on the dissertation topic.

Volume and Structure of the Dissertation Investigation.

The structure of the dissertation work is determined by the necessity of solving the set scientific tasks. The dissertation consists of an introduction, five chapters, a conclusion, conclusions, practical recommendations, appendices, and a list of used literature. It is presented on 150 sheets of typed text, contains 49 tables, 22 figures, and 10 appendices. The bibliography includes 145 sources, including 10 in foreign languages.