Basic therms, parametrs, characterics whith are nessesery during preparation to lesson.

Therm	Definition
1. Military-medical doctrine.	It is set of scientifically reasonable principles defining system and methods of medical ensuring operations of armies in specific historical conditions, containing means and methods of the armed fight, level of medical science and practice, a condition of forces and means, and also features of battle fields.
2. Medical situation.	It is set of factors and the conditions characterizing forces and means of a health service, the contents and volume of future work, a sanitary and epidemic condition of provided armies and the area of their operations, and also other factors and conditions which can affect preparation and a course of medical providing armies.
3. Medical sorting.	This distribution of victims and patients to groups, proceeding from needs for priority and uniform actions (medical, preventive, evacuation) in a concrete situation. Even two victims who have arrived at the same time, require carrying out medical sorting. When carrying out medical sorting hyper diagnostics is allowed. Sorting basis: uniform ideas of diagnostics, medical actions and forecasts of results of treatment. Sorting purpose: to provide timely rendering medical care to the maximum number of victims in optimum volume. The condition of injured children and pregnant women without visible damages is always estimated as heavy, evacuation and assistance is carried out at first the stage.
4. Stages of medical evacuation.	Medical aid stations and the medical institutions developed on ways of evacuation with a task of reception, medical sorting of victims and patients, rendering to them medical care, treatment and their preparation for further evacuation; in medicine of catastrophes – expansion of only two stages is provided, as a rule; the first – groups of the first medical care, the second – hospital base in military medicine.

4.2. Theoretical questions for lesson: 1. Organizational structure of health service of Ukrainian Armed forces; 2. Structure of stages of medical evacuation. 3. Equipment of stages of medical evacuation. 4. Problems of stomatology of extreme situations. 5. Types of medical care. 6. Forces of a health service of Armed forces of Ukraine according to types of medical care. 7. Means of a health service of Armed forces of Ukraine according to types of medical care.

4.3. Practical skills for lesson: 1. To get skills of the organization of rendering medical care maxillofacial wounded at stages of medical evacuation. 2. To get skills of medical sorting of the maxillofacial wounded. 3. To acquire skills of providing medical care maxillofacial wounded at stages of medical evacuation. 4. To carry out a kuration of the maxillofacial wounded.

5. TABLE OF CONTENTS OF THEME:

Principles of military doctrine (time of Second World war)

1. All gunshot wounds are initially bacterial infected.

2. The only reliable method of the prevention of development of an infection is early surgical treatment of wounds which should as soon as possible.

3. Early surgical treatment of wounds is demanded by the greatest part of wounded.

4. The prognosis of treatment and consequence of wound is the best if early surgical treatment of a wound is carried out.

5. The volume of medical care, choice of medical actions and order of evacuation depends not only on especially surgical indications, but, mainly, on a military and medical situation.

Medical situation is the number of wounded who get on this stage, their condition, number of surgeons, existence transport, medical equipment and so forth means.

In the Great Patriotic War profile of medical care by the maxillofacial wounded was approached to a front line. Even at the advanced stages - medical care in the conditions of a regiment appeared taking into account features of this group of wounded (a thirst satisfying, imposing of gauze and standard bandages and so forth).

There is actual a problem of treatment of victims with burns of face and with combined injures.

At the combined radiation injures there are peculiar features of a current both radiation illness, and wound process.

Development of anesthesiology and resuscitation opened new opportunities in fight against traumatic shock and expanded borders of surgical treatment of wounded in maxillofacial area.

At explosion of a ball bomb from different places of the spherical case 300 balls take off (diameter of 5,56 mm, weight of 0,7 g), the bomb has big striking force and causes emergence of multiple wounds. Wounds are very life-threatening and are difficult for treatment.

Bullets of caliber of 5,56 mm at hit they overturn and move to tissues in the cross direction, causing in depth and in the field of an exhaust outlet big destruction of tissues. There are also artillery shells, each of which is filled with small arrows (length of 3-4 cm, thickness of 0,1-0,2 cm) in quantity to 10 thousand.

The above and other new types of weapon are characterized by their damaging shells is less on diameter and easier on weight in comparison with last, but they possess enormous initial speed (from 700 to 1500 m/s). Emergence of wound channels often also has a talk with the freakish directions, and considerable damages of tissues and organs.

In this regard the principles of the organization of help to wounded in modern conditions of war have to change.

Use of the nuclear missile weapon is accompanied by emergence in very short periods of mass sanitary losses in a wartime and in front areas in quantities which are exceeded considerably by that took place in the period of the Great Patriotic War.

The structure and nature of fighting damages will change also in these conditions: on the first place there will be burns, traumas and the combined damages (mainly radiation), the specific weight of seriously wounded (shock, a crush-syndrome, radiation injuries) will increase. Gunshot wounds thus lose the dominating value.

At mass receipt of victims there is a need for evacuation maneuver which has the purpose dispersal of victims between several stages and which is carried out on the basis of careful sorting. Overloads of the next to the front (the defeat center) stages at which there is the first medical assistance, quite often are involved by reduction of indications to intervention (reduction of volume of medical care). In these cases it is necessary to be limited only to actions which provide elimination of direct threat of life or heavy complications (the help according to vital indications).

Important element of the organization of surgical work of each stage of medical evacuation is the "conveyor" principle (O.O.Vishnevsky) according to which all process of medical aid e to each victim is subdivided into some parts, is carried out in the different ways by different doctors (removal of a bandage, surgical treatment, imposing of tires and bandages and so forth).

The conveyor principle promotes increase of capacity operational and dressing.

Modern provisions of the military-medical:

the volume of medical care, order of evacuation and choice of medical actions depend not only on especially medical indications, but also, mainly, on fighting and medical circumstances;

creation of system of medical and evacuation actions is carried out with the maximum reduction of quantity of stages of medical evacuation;

objective assessment of weight of wound and condition of the wounded introduction of criteria of the forecast of treatment;

preservation of uniform approach to treatment of wounds;

priority value of emergency medical service actions, treatment of shock and to blood loss completion at all stages of medical evacuation;

specialization of the surgical help;

accurate organization and sequence in rendering the surgical help at the combined, multiple and combined injures;

increase in a role of the reanimatological and anesteziological help at treatment of wounded at stages of medical evacuation.

The stomatologic help in a wartime will be organized by the Head Military-medical department of the Ministry of Defence of Ukraine through the Chief stomatologist of Armed forces. At military-medical management of each front there is a regular chief stomatologist of the front, he is a deputy chief surgeon of the front. The military-medical service of Ukraine is valid also means which allow qualitatively and to render in due time medical care by the wounded in maxillofacial area in the battlefield and at stages of medical evacuation.

The help to wounded in maxillofacial area which appears in the battlefield in the center of mass sanitary losses, is called as the first medical care. It appears in the form of most and mutual aid or shooters-hospital attendants and sanitary instructors, and also staff of divisions who carry out rescue efforts. It should be noted that the self-help among wounded in maxillofacial area appears very seldom because of complexity of definition of localization, the amount of damage and insolvency of imposing of a bandage on face of victim. For most and mutual aid all military personnel is provided with individual prophylactics and rendering medical care. Them treat:

package the dressing individual;

first-aid antigas kit;

individual first-aid kit;

tablets for water disinfecting (Pantotsid, Akvasept).

Shooters-hospital attendants and sanitary instructor for search and carrying out of wounded, rendering the first medical care have special equipment:

Sanitary bag;

bag the medical military;

violent and special medical strap.

The pre-medical (medical assistant's) help appears the paramedic of a battalion in close proximity to a wound place, on the medical aid station of a battalion (MASB). It supplements the first medical care. However, possibilities of the paramedic on assistance, including elements of the stomatological help, much wider. Organic equipment of a medical aid station of a battalion, and also medical equipment of staff is applied to rendering the medical assistant's help. To complete organic equipment of MASB belong:

medical assistant's field;

sterile dressing means;

tires;

medical military bag;

bags of hospital attendants;

the first-aid kit military, and also, medical and medical means, devices (the device of artificial ventilation of lungs a portable, oxygen inhaler of KI-4, the mental tire with head bandages to them, we send for wounded to the head, a cape medical on 10 people, etc.). It is necessary to emphasize that the medical aid station of a battalion in defense when it works at a place, carries out functions of a stage of medical evacuation.

In a medical company of crew (MCC) there is the first medical and qualified aid. In structure MCC except doctors of an all-surgical and therapeutic profile is the atomatology. Main task of stomatologist of MCC is rendering the stomatological aid to regiment staff. During operations the stomatologist works as a part of an operative-dressing platoon in operational tent or as a part of sorting and evacuation office in dressing tent for lightly wounded, renders together with doctors of an all-surgical profile the first medical and qualified medical care, including the stomatologic. On MCC there can be patients and wounded for treatment with term of recovery of 3-5 days.

Specialized medical care to persons with damages and wounds of maxillofacial area render in maxillofacial offices of specialized hospitals for wounded in the head, neck and a backbone, in hospitals for treatment lightly wounded, and also in stomatologic offices of other hospitals of base of the front in which wounded with damages of maxillofacial area are on treatment concerning the main, more essential wound.

The significant part is assigned to stomatologic group of the front. The stomatologic group of the front is created for:

rendering the specialized help to maxillofacial wounded and patients who are on treatment in front hospitals;

rendering the stomatologic and dentoprosthetic aid to staff of parts, connections and establishments;

rendering the advisory help to dentists of medical divisions, parts and medical institutions.

The stomatologic group is headed by the doctor-stomatologist. Group structure: management; main divisions; providing divisions.

The main divisions, in turn, have also three divisions: stomatologic office - basic (3 stomatologist); dentoprosthetic office with dentoprosthetic laboratory (3 orthopedists, 5 dental technicians); ten mobile stomatologic offices (in each 2 stomatologist and the dental technician).

Mobile stomatologic offices go to medical institutions of the advanced hospital base for assistance to maxillofacial wounded, oral cavity sanitation by the serviceman, the patient and the wounded. These offices can go to connections, parts where there are no regular stomatologists for planned work on sanitation and oral cavity prosthetics.

All listed forces and means of a health service which carry out rendering the stomatologic help to maxillofacial wounded, at their rational and clever use, allow qualitatively and to carry out objectives in due time.

Medical sorting is a distribution of wounded and patients on groups and signs of requirement for uniform medical and evacuation and preventive actions according to medical indications, volume of medical care and the accepted order of evacuation.

Medical sorting of wounded is carried out by doctors of the sorting and evacuation office (SEO) of a medical company of crew. Main objective of medical sorting in SEO is selection from the general flow of wounded and patients who need medical care in MCCr, and, first of all, in the urgent medical and qualified medical care and sanitary processing, and also, wounded and patients to whom the qualified medical care can be delayed and which in these conditions are subject to further evacuation to the back without their direction in other functional divisions MCC.

If on MPP many wounded arrive, in sorting and evacuation office two crews one of which heads the doctor, and the second – the most skilled paramedic (nurse) can be created.

Wounded in maxillofacial area share on such groups:

І. Proceeding from need for sanitary processing and need for isolation: need partial sanitary processing; are subject to isolation; don't need sanitary processing and isolation.

II. Proceeding from need for medical care, place and sequence of its rendering:

1. Need rendering medical care in the dressing.

2. Don't need medical care or need medical care which can be rendered in a reception and classifying section. For wounded and patients who are subject to the direction in dressing, the turn – first of all, in the second turn is appointed.

III. Wounded and patients who don't need the medical help on MPP, and also what received it, are distributed on the following groups:

evacuations are subject;

are subject to return to the divisions.

In the course of medical sorting which is carried out on the sorting platform, all wounded and patients divide into groups:

In the first group enlist wounded who needs urgent actions of the first medical assistance (wounded with bleeding, asphyxia, shock, etc.). Them send directly to the dressing.

To the second group carry wounded then medical care can be rendered in a reception and classifying section (for example, injured with the closed fracture of the top jaw) at a satisfactory general condition of wounded who needs to give drink by means of a poilnik from the rubber tube put on his nose). After performance of the simple actions stated above this group of wounded is subject to the direction in SMB or SMG.

To the third group carry those wounded who without assistance on MPP go on the following stage of medical evacuation (for example the victim with the closed change of a malar arch and nose bones in the absence of bleeding).

To the fourth group carry lightly wounded which are subject to return to parts after rendering medical care to them (for example, the victim with wound of soft tissues of a face without the expressed hematoma).

To the fifth group carry those wounded and patients who are in an agony, or have traumas incompatible with life (for example, wounds of face and neck with a rupture of an internal carotid and noncompensated blood loss).

To clothes of the wounded or the patient who ate medical sorting, attach sorting brand in which specify, to what functional division it is necessary to send it. The sorting brand is the main reference point for hospital attendants-porters and the medical personnel.

6. MATHERIALS FOR SELF - CHECKING:

А. Questions for self-checking: 1. Types of medical aid. 2. Means of medical service. 3. Principles of medical sorting. 4. Organization of medical aid for maxillofacial wounded at stages of medical evacuation.

B. Tasks for self-checking: 1. The wound of the left cheek at wounded polluted by radioactive materials. There is bandage from a dressing package on a wound the, is carried out pain relief and antibacterial therapy. At what stage of medical evacuation it is necessary to replace a bandage? (Answer: at each stage of evacuation)

2. The general condition of wounded is moderate severity, consciousness is kept, skin pale with a cyanosis shade, lips cyanotic. Breath is complicated, 29 in a minute. There is a suspicion on existence of dislocational asphyxia. At what stage of medical evacuation wounded its tongue will be stitched by a silk ligature? (Answer: at a medical aid station of a battalion).

3. Two wounded come in hospital with wounds of the face, one – from a zone of radiation pollution are delivered. Who from them needs to carry out wound PST first of all? (Answer: wounded with the combined meсhano-radiation defeat).

C. Matherials for test control. Test tasks with one right answer (α = II):

1. What frequency of gunshot wounds of face and jaws by Great Patriotic War experience: A. around 1%; B. around 4%; C. around 50%; D. around 60%; E. around 90%. (Correct answer: В).

2. What is the mean of military-medical doctrine? A. Stages treatment of the military personnel and dispensary supervision; B. evacuation of wounded in rear country hospital; C. evacuation wounded out of limits of the center of defeat; D. system of stages treatment with evacuation to destination; E. rendering the specialized aid to victims in the war zone and return them in a system. (Correct answer: D).

3. Types of medical care in a wartime: A. mutual aid, first medical aid, specialized aid; B. first medical aid, pre-medical aid, first medical aid, qualified medical aid; C. pre-medical help, first medical aid, qualified medical aid, rehabilitation; D. first medical aid, medical aid, surgical aid, specialized aid; E. first medical aid, pre-medical care, first medical aid, qualified medical aid, specialized medical aid. (Correct answer: Е).

D. Educational tasks of 3 th levels (atypical tasks): 1. The wound of the left cheek at wounded polluted by radioactive materials. There is bandage from a dressing package on a wound the, is carried out pain relief and antibacterial therapy. At what stage of medical evacuation it is necessary to replace a bandage? (Answer: at each stage of evacuation).

2. The general condition of wounded is moderate severity, consciousness is kept, skin pale with a cyanosis shade, lips cyanotic. Breath is complicated, 29 in a minute. There is a suspicion on existence of dislocational asphyxia. At what stage of medical evacuation wounded its tongue will be stitched by a silk ligature? (Answer: at a medical aid station of a battalion).

3. Two wounded come in hospital with wounds of the face, one – from a zone of radiation pollution are delivered. Who from them needs to carry out wound PST first of all? (Answer: wounded with the combined meсhano-radiation defeat).

 

Theme 3. GENERAL CHARACTERISTIC, CLINICAL COARCE, DIAGNOSTIC OF GUNSHOT WOUNDS AND DAMAGES OF SOFT TISSUES, BONES OF FACE IN PEACE TIME: CLASSIFICATION, CLINICAL FEATERS, DIAGNOSTIC, MEDICAL AID, METHODS OF SURGICAL TREATMENT OF WOUNDS OF SOFT TISSUES OF FACE. INFLUENCE OF MALFUNCTION OF FACE ESTETIC AT PSYHIC OF WOUNDED. SELF WORK – PRACTICAL SKILLS OF FORMING OF SOFT BANDAGES.

1. ACTUALITY OF THEME: Damages of maxillofacial area at pease time and its treatment is very interesting and difficult branch of surgical stomatology. The insufficient awareness of the doctor in questions of surgical processing of such wounds leads to negative consequences in the form of a disfiguration of appearance of the patient, violation of such functions as speech, breath, chewing and so forth. For this reason the stomatologist has to know well features of surgical processing of such damages.

2. S PECIFIC GOALS: 1.1. To analyze clinical manifestations of traumatic damages of maxillofacial area at peace time. 1.2. To explain etiological and pathogenetical factors of emergence of traumatic damages of maxillofacial area at peace time. 1.3. To offer the plan of inspection of victims with a trauma maxillofacial area. 1.4. To classify traumatic damages of maxillofacial area. 1.5. To treat the principles of diagnostics and treatment of traumatic damages of maxillofacial area at peace time. 1.6. To draw the graphological scheme of lesson. 1.7. To analyze results of laboratory and instrumental investigations. 1.8. To make the scheme of treatment of patient with trauma of maxillofacial area.

3. BASIC KNOWLEDGE, ABILITIES, SKILLS, WHICH are NECESSARY FOR STUDY THEMES (intradisciplinary integration).