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Military and civilian experience has contributed to the current state of the art in management of extremity vascular injuries. Thorough physical examination and judicious use of emergency center arteriography and formal arteriography provide means for prompt diagnosis and treatment which is critical is limb loss and disability are to be avoided. Prosthetic graft material has provided an alternative to vein grafting in many circumstances for arterial and venous injuries. Compartment syndrome should be anticipated when an ischemic extremity is revascularized and fasciotomy should be used liberally. Vascular repairs are the first priority in extremity wounds, but associated injuries to bones, joints, soft tissues, and nerves are often critical determinants of rehabilitation once blood supply has been re-established. The best results are obtained when a multidisciplinary approach is used combining expertise in orthopedic surgery, neurosurgery, and plastic surgery.

The nature of mankind is a concern for those in need. Disasters, both natural and manmade, have been with us since the beginning of recorded history but media coverage of them is a relatively new phenomenon. When these factors come together, there is great potential to both identify and serve the sick and injured. However, the mass media by its nature tends to enhance the humanistic aspect of rescue while minimizing the practical problems involved. We describe a recent scenario in Haiti that puts some of these complications into a practical perspective.

The medical support for the coordinated effort for Harris County Texas (Houston) to rescue evacuees from New Orleans following Hurricane Katrina was part of an integrated collaborative network. Both public health and operational health care was structured to custom meet the needs of the evacuees and to create an exit strategy for the clinic and shelter. Integrating local hospital and physician resources into the Joint Incident Command was essential. Outside assistance, including federal and national resources must be coordinated through the local incident command.

When a disaster occurs, it is for governments to provide the leadership, civil defense, security, evacuation, and public welfare. The medical aspects of a disaster account for less than 10% of resource and personnel expenditure. Hospitals and health care provider teams respond to unexpected occurrences such as explosions, earthquakes, floods, fires, war, or the outbreak of an infectious epidemic. In some geographic locations where natural disasters are common, such as earthquakes in Japan, such disaster practice drills are common. In other locations, disaster drills become pro forma and have no similarity to real or even projected and predicted disasters. The World Trade Center disaster on 11 September 2001 provides new information, and points out new threats, new information systems, new communication opportunities, and new detection methodologies. It is time for leaders of medicine to re-examine their approaches to disaster preparedness.

This report concentrates on the 15% of chest injuries requiring thoracotomy. Eighty-five percent of cases may be managed by a large-bore chest tube placed in the midaxillary line. The indications for thoracotomy following placement of a chest tube are immediate egress of 1,500 ml of blood, continued bleeding at a rate of more than 100 ml/h, and large air leaks that prevent re-expansion of the lung or that, on the ventilator, constitute a significant fraction of the tidal volume. Immediate thoracotomy is also indicated for the patient with a penetrating wound that may have reached the heart in association with acute loss of vital signs or shock that does not quickly respond to blood replacement. Emergency room thoracotomy may also allow salvage of blunt trauma patients with blood loss in the chest by allowing more effective control of blood loss, cardiac massage, and cross-clamping of the aorta. A persistent diagnostic suspicion of the hidden injuries such as aortic rupture, esophageal injury, airway rupture, blunt cardiac injuries, and diaphragmatic rupture must be maintained, so that these injuries are properly diagnosed and treated. Sepsis following trauma to the chest is generally related to retained hematoma and damaged tissue. It is probably wise to resect the pulmonary parenchyma damaged by a high velocity gunshot wound. Chest tubes for hemothorax should be placed so that the blood is totally evacuated; otherwise, the clotted blood usually restricts pulmonary ventilation and commonly leads to an empyema which requires surgery.