Emergency Medical Services (EMS) providers face many ethical issues while providing prehospital care to children and adults. Although provider judgment plays a large role in the resolution of conflicts at the scene, it is important to establish protocols and policies, when possible, to address these high-risk and complex situations. This article describes some of the common situations with ethical underpinnings encountered by EMS personnel and managers including denying or delaying transport of patients with non-emergency conditions, use of lights and sirens for patient transport, determination of medical futility in the field, termination of resuscitation, restriction of EMS provider duty hours to prevent fatigue, substance abuse by EMS providers, disaster triage and difficulty in switching from individual care to mass-casualty care, and the challenges of child maltreatment recognition and reporting. A series of ethical questions are proposed, followed by a review of the literature and, when possible, recommendations for management.

Pediatric subjects comprised over 1 in 13 casualties treated in the joint theaters with the majority injured by explosives. Vascular access and hypothermia prevention interventions were the most frequently performed procedures.

Airway management is at the forefront for combat medics dealing with battlefield trauma. For military service members, compromised airways are the second leading cause of potentially survivable death on the battlefield, accounting for one in ten preventable combat deaths. Effective suction is a critical component of airway clearance. However, currently available devices are too heavy and bulky to be carried by combat medics and are insufficiently powered. The industry has not responded to the need, with companies continuing to produce models using 1970s technology. A literature review was completed with the assistance of a librarian. The databases searched included: Biomedical Research Database (BRD), Computer Retrieval of Information of Scientific Projects (CRISP), Federal Research in Progress (FEDRIP), Defense Technical Information Center (DTIC), Pub Med/Medline, and OVID. Additionally, a Google Scholar search was performed to identify nonstandard sources. After screening, a total of 40 articles were used. There were no randomized controlled trials or other high-quality evidence that addressed the issues; there was limited peer-reviewed literature on the use, effectiveness, adverse effects, and safety of suction for use in combat casualty care. A review of the available literature revealed no standards, either proposed, validated, or accepted, for the safety or avoidance of adverse effects for portable suction device use in combat casualty care. Similarly, there are no accepted standards to guide the safe use and anticipated adverse effects of suction for use in prehospital combat or emergency care. Nevertheless, there are meaningful data that can be extracted from the few studies available combined with non-clinical studies, narrative reviews and case reports, and expert opinions.

During battlefield and mass casualty incidents, triage has been traditionally performed by many different personnel, including medics, nurses, dentists, and physicians. The objective of this study was to determine which military medical providers are most knowledgeable in mass casualty triage. The design was a prospective, written, timed, case-based examination of triage knowledge. Participants were volunteers from the active duty medical (physician), dental, nursing, and enlisted corps of the three military services. Subjects completed a 16-minute written examination consisting of seven cases in each of three simulated mass casualty scenarios: combat; nuclear, biological, and chemical; and humanitarian. Tests were taken anonymously, although demographic data on medical specialty, training, and experience were collected. Participants were instructed to classify the cases using the NATO categories of immediate, delayed, minimal, or expectant. Scores were tabulated according to two grading scales: an absolute scale of number correct, and a weighted scale amplifying gross misclassifications. Median scores between groups were tested pairwise using the Kruskal-Wallis one-way analysis of variance with p < or = 0.05. Statistically significant differences were noted between the highest and lowest scoring groups in each scenario. Our conclusion is that among the subject groups tested, physicians were best at mass casualty triage. Dentists, nurses, and medics scored progressively less well on our examination.