1. Introduction

The history of the military medicine development formed in the interests of the national military institutions, which testifies to the diversity of the existing forms and approaches of military medical support in wars and armed conflicts, emergencies of peace and wartime. According to the historic lessons and the life path of outstanding scientists of military physicians and previous war experiences, we once again confirm the important truth - one cannot prepare for medical aid to the wounded in war. The fear of the use of chemical weapons during World War I enforced Russian Military Medical Academy professor V.A. Opelya to devote a significant part of his last book “Surgery of War” to the peculiarities of chemical gas threats. In the Second World War, no toxic chemical substances were used. After use of atomic bomb in Japan in 1945, the world for several decades (and, accordingly, all military medicine) lived in anticipation of a nuclear war, and in the second half of the 20th century, military field surgery in local wars with its aeromedical evacuation by helicopters became relevant.

An important feature in military medicine is the tendency of update and improvement by introducing all cutting edge technology that appears in medicine as a whole. In the past few centuries, it was asepsis and antiseptic, x-rays, advances in microbiology, then ultrasonography, immunology and genetics, but now endovideosurgery, telemedicine, information and reconstructive technologies in injury surgery. A distinctive feature of military doctors, especially military field surgeons, has always been the desire for the practical implementation of these achievements for the benefit of healing the wounded in war.

2. Materials and Methods

Over the past three decades, military medicine has gained considerable experience in the system of administering medical aid to the wounded in local wars and armed conflicts. At one time, combat operations medical evacuation support (MES) of the Soviet troops in Afghanistan (1979-1989) was considered only as "features of staged treatment of the wounded in hot climates and mountain- desert terrain." However, the medical experience of subsequent regional conflicts and local wars in the Middle East and counter-terrorism operations in the North Caucasus has shown the need for significant changes in the organization of medical care, especially with regard to organizational issues of surgical care for the wounded. Administering medical care to large contingents of the wounded implies scientifically based, proven in practice actions, in many respects similar to those which take place in the war. Experience has shown that medical tactics for any type of mass trauma must necessarily be based on the principles of military field surgery.

Conceptual features include the following:

A) A decisive factor and a key aspect in the organization of medical care in the conditions of modern local wars and armed conflicts is the possibility of early aviation medical evacuation of wounded directly from battle line to the stage of providing specialized medical care.

Active use of air transport to evacuate the heaviest contingent of wounded, thereby achieving an increase in the chances of their survival. From the experience of the Soviet troops during the Afghan war, medical evacuation from combat zones was carried out by all means of transportation. At the same time, during 1980-1988 the 68.8% evacuees were evacuated by air, 14.4% by armored military vehicles and 12% of them by road transport (39.5% of them by ambulance). In total, from 1980-1988 more than 25,000 wounded and injured were evacuated from the combat zones by helicopters. At the same time, there were no contraindications to the evacuation of the wounded from the battle zones by helicopters.

A clear example of helicopter aeromedical evacuation is the operation of Israeli forces in Lebanon in 2006. Helicopters of the Air Force UH-60 “Black Hawk” (“Yanshuf’) made about 120 evacuation sorties. About half of them were on enemy territory under the enemy fire. These flights evacuated about 360 casualties and wounded. Evacuation of the wounded from the battlefield by air transport on average lasted about 3.5 hours. On average 4-5 wounded soldiers were evacuated in one flight. It should be noted that during the air evacuation there were no fatal cases among the wounded. In other words, staged casualty medical care is not an end in itself and is not the same with the administration of all types of consistent medical aid, starting with First Aid (FA) and ending with specialized surgical care (SSC). In the modern wars context, a number of medical evacuation stages may fall out from evacuation chain, and the role of others is seriously changing.

According to the Vietnam War experience, when helicopter aeromedical evacuation was first used in the North Caucasus average time for specialized surgical care was significantly reduced by evacuating wounded soldiers from medical companies and squads, directly to the first-tier multi-profile military hospitals (MMH). During the early air delivery of the wounded in the first-tier MMH, SSC was performed in 2 hours after the injury. In traditional multi-stage medical treatment of the wounded with the consistent provision of the first medical care (PFM) and qualified surgical care (QSC) the deadline for the provision of SSC increased almost 10 times (up to 20 hours). The frequency of complications in this case increased by 2 times (from 32.9 to 68.2%), mortality by 1.8 times (from 5.1 to 9.8%).

Consequently, the main feature of the surgical care organization for the wounded in local wars and armed conflicts is the reduction of multistage medical care with the aim of reducing the time for SSC. This tendency in the organization of surgical care for the wounded was called the “concept of early specialized surgical care”. This concept was successfully implemented in the first armed conflict in the North Caucasus (1994-1996) in 30% of the wounded, in the second conflict (1999-2002) in 55% of the wounded.

The British army has a Medical Emergency Response Team (MERT) equipped with a heavy military-transport medical module called the "Chinook" to provide emergency medical assistance in critical situations. The team is capable of performing anesthesia, draining pleural cavities, tracheal intubation or cricothyrotomy, and transfusing blood and blood components. The use of helicopters not only speeds up evacuation but also improves the quality of the hospital phase. The MERT team includes highly skilled and experienced doctors who can provide rapid therapy, two paramedics, and a nurse. To ensure safe loading of the wounded, four trained soldiers were also added to the team [7].

B) The organization and content of measures of medical care to the wounded in local wars and armed conflicts have a number of fundamental features, due to the changing nature of the combat operations.

During the medical-evacuation measures in army medical services special attention was paid to the first-priority medical care.

First aid (FA), quickly and correctly rendered medical aid, remains the main means of saving the wounded from the life-threatening effects of combat trauma, primarily from bleeding, acute asphyxiation. According to the combat operations experience in Afghanistan, the Soviet troops in most cases, the FA was provided by sanitary instructors or assistants and gunners directly on the battlefield. In combat operations on average one sanitary instructor or paramedic (medical attendant) was allocated for 24 soldiers. In some particular cases, by the decision of the commanders, paramedics or doctors were involved in rendering the FA.

They were assigned to units or divisions, on the basis of one doctor for 250-350 soldiers, and one paramedic - for 210-250 people. Since the medical posts of the battalions and regiments were practically not deployed, the paramedics and doctors usually with a set of medical equipment were on the Armored Personnel Carriers (APC) and Infantry Combat Vehicles (ICV) and often provided only first aid. According to thesis research of Yu.V. Nemitin, based on experience of medical-evacuation activities during the specific missions and army operations of the 40^th Army in 1984-1986, for 94%) of the wounded FA was administered in the first 30 minutes from the moment of injury, which undoubtedly had a positive effect on the outcomes and the proportion of minor wounded.

The importance of FA provision to the wounded in the North Caucasus was demonstrated in a comparative analysis of the staged treatment outcomes. In case of timely FA provision mortality among the same severity of injured groups comparably fell three times (2.3 % vs. 6.1%).

It is logical that the impact of the other types of medical care provision (PFM, SSC) on the prevention of the lethal outcome of injury was significantly less. Profuse external bleeding or acute asphyxiation is fatal within a few minutes. During this time either the injured person or the person nearby can provide effective first aid. Intensive military medical training of military personnel significantly contributed to improving the quality of FA provision.

During the conflict in 1994-1996 mutual medical aid was 28.6% of FA provision and in 1999-2002 it was already 73.4%. According to the archives of the US combat operation in 2011, all the Rangers and doctors trained in providing medical assistance on the battlefield prevented the death of wounded US troops on the battlefield by 24%, the Rangers by 90%.

The role of pre-medical (paramedic) assistance to the wounded in local wars and armed conflicts is declining. During the Afghan war, first aid was provided to an average of 8.4% of the wounded. In some operations, this figure reached a maximum of 15-20%. Such a low percentage of first aid is explained by the fact that the majority of the wounded (73-100%) were evacuated by helicopters to the next stage of medical care. First aid was most often carried out at the assembly point of the wounded near the helicopter landing point and usually associated with FA procedures. It will be noted inadequate infusion therapy. Preparation of the wounded for evacuation remained one of the main tasks of the stage. This is due to the handover of a number of its activities to the list of FA, the constant military doctors’ appointments in battalion medical aid station (the shortage of military paramedics is also important). In addition, due to the close proximity location of the Regiment Medical Center (RMC) to the combat formations of troops, the wounded are delivered there immediately after the FA has been rendered.

3. Results and Discussions

According to the military-medical doctrine the organization of medical service of the US Armed Forces in tactical level, medical assistance in the theater of military operations (theater of operations) consists of 4 echelons (Echelon of care). The first echelon is the “battlefield-battalion”. The key unit of the medical service in this level is the Battalion Medical Unit (BMU). Brigade combat command (BCC) is the second echelon. The key unit of the medical service is the Advanced Surgical Team (AST). The third echelon is the rear of military operations theater. Accordingly, this is incomplete military district. However, at this stage there is a Field Support Hospital (FSH), which is closely related to the previous stages. And the extreme 4^th echelon is stationary hospitals outside the theater of military operation.

On the combat zone, the FA is provided in manner of self- care and mutual assistance. Pre-medical and first medical aid is carried out by the battalion medical service personnel. In addition, each platoon (about 40 personnel) has its own fulltime combat paramedic. Thus, the total number of combat paramedics in the battalion ranges from 15-20 people. They are considered the basis for the battalion medical care provision. The task of the BMU is to provide first-aid and first medical aid on the battlefield, collect the wounded, casualties and stabilize their condition until they can be evacuated to a higher stage. Functionally, the BMU can be divided within 24 hours into 2 parts, which provides the necessary tactical maneuverability of the battalion medical service. The Main Aid Station is headed by the chief of the BMU, includes 3 combat paramedics. The Forward Aid Station is headed by an assistant physician, also includes 3 combat paramedics. In recent years, the battalion medical service has been equipped with new samples of medical equipment and supplies. This is a fibrin bandage to stop bleeding, containing fibrinogen and thrombin, reducing over 50-85% of blood loss, chitosan bandage to stop bleeding, anesthetic patch that replaces morphine and does not have a sedative effect, field monitoring systems (remotely monitored battlefield sensor system) that allow you to remotely monitor vital parameters such as pulse rate, respiration rate, electrocardiograph machine (ECG), oxygen saturation; Personal Information Carrier sensor which stores personal service information including medical ones. The first medical aid in the experience of recent local wars and military conflicts (as the most effective and high quality method of pre-evacuation preparation) has become the main kind of prehospital care. A significant improvement in the quality of First Medical Care FMC was achieved by strengthening medical company with surgeons and anesthesiologists from a separate medical battalion, as well as by appointing doctors who had experienced an internship in surgery and anesthesiology. In the course of counterterrorist operations in the North Caucasus the proportion of FMC provided by surgeons and resuscitation anesthetists increased almost six times (from 4.8 to 30.8%), which significantly increased its effectiveness.

According to combat operations’ statistics in Afghanistan (1979-1989), the role of FMC to some extent reduced: on average to 18% of the wounded FMC were provided in first-aid posts. However, this does not include medical assistance provision in raids. On average 55-60% of the wounded (in the “Pandsher” military operations, the percentage of the wounded who received FMC was higher than 23%) was provided medical aid by the doctors of company and battalion groups and it was actually the first medical care. It was mandatory to carry out rescue operations and evacuation transport classification.

C) The experience of local wars and armed conflicts shows the need for significant development and upgrading of the existing medical equipment and supplies.

Nowadays a number of countries have involved in medical service and the military medical science development. However, it is vital to consider economic structure of the country. Capital investments in military health care are carried out only to the extent that they contribute to maintaining the armed forces combat capability and ensure to resupply the loss through returning the wounded and casualties to duty. The commercial approach to the military health issues impacts on medical service existence, reality and the future.

French experts Sh. Speer and P. Lombardi wrote back in 1925: “Every expenditure on sanitary leads to saving of human life. Conversely, any savings in sanitary facilities are reflect on the civil damage of victims and casualties.

In addition, it reduces chances of war-winning. Such an approach is certainly contradicting genuine humanism and concern for the life and health of the casualties and wounded.

Dynamic progress and integration with the scientific and technological development of the military-industrial complex of the country effectively influences the economic potential of the country and the timely response to political decisions.

During the military threats and emergency situations, it is impossible to rely solely on the delivery of foreign manufactured war equipment and weapons. For instance, the high level of the military industry of Israel. Apparently, today products of Israeli industry cover practically all major branches of military production and include electronic and electrical (radar and telecommunications equipment, precision optical equipment, light weapons, missiles, some of which are perfect in their class, personal equipment, and military medical equipment, etc.

4. Conclusions

In summary, the important factors determining the long-term military medicine development at the tactical level are the familiarization and use of the advanced foreign military paramedics experience in military operations, as well as planned and targeted military medical training of all personnel to provide self and mutual medical assistance in the battlefield to perfection, the wide use of helicopter aeromedical evacuation of the wounded directly from the combat zone to the stage of specialized medical care provision.