Resolving the casualty evacuation conflict

One of the most contentious issues surrounding the prehospital management of the injured is the decision to stabilize on site or to rapidly evacuate the patient. Although there are vociferous proponents for both views, there appears to be little thought given to the rationalization of these decisions, and the subject has only merited lip-service in previous texts. Treatment choices and decisions in the prehospital environment are notoriously difficult to make. The doctor, unlike ambulance paramedics, does not necessarily work to didactic protocols and, if suitably trained, is at liberty to commence advanced resuscitation procedures at the roadside. However, these may be time consuming and, to be of greatest benefit to the patient, a fine balance between resuscitation and evacuation must be drawn. This paper aims to discuss some of the key issues which need to be considered in the prehospital scenario, such as treatment triage, evacuation priorities, mode of transportation and hospital destination. The end result must be to eliminate the medical 'bottleneck' and to afford early and appropriate definitive care to those in most need.