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Medicine In Traveller - Trauma (2)

Assessment and Management of Trauma Victims

Triage (Fr., roughly, "to sort")
The effective use of limited resources in a battlefield or other disaster situation requires medical personnel to rapidly assess casualties and prioritise them.

General priorities

The Primary Survey
Identify and treat the immediately life-threatening problems. (=resuscitation or Immediate Action) OR Keep the patient alive until someone can provide definitive treatment.

The method to do this is best summarised by the first aid mnemonic

  1. Airway : ensure that it is patent. Assess the patient.
  2. Breathing : supply oxygen, treat pain
  3. Circulation : maintain a blood pressure sufficient to perfuse vital organs (brain, heart/lungs, kidneys)

Tasks for Resuscitation/Immediate Action

To Assess Injury Severity (overview):
Average, Medical/First Aid, Edu, uncertain
Difficult if in the field.
Medical scanner +5 to uncertainty roll.
Varying amounts of truth change the estimate up or down levels (ref's choice).
Severity of Injury
and Number of Injured Areas
Number of Characteristics at Zero Severity Number of Injured Areas
None Superficial 1
1 Minor 1
2 Major 2
3 Destroyed 3


Wound Locations

Roll on 2D Location Refinement of Location
2 Head Roll 1D:
1 - 3 Face
4 - 5 Skull
6 Neck
3 - 5 Chest -
6 - 8 Abdomen -
9 - 10 Arms Roll 1D:
1 - 3 Left; 4 - 6 Right;
Roll 1 on 1D for Hand
11 - 12 Legs Roll 1D:
1 - 3 Left; 4 - 6 Right;
Roll 1 on 1D for Foot


Wound Assessment
Wound Severity Needs Treatment Within If Not Treated
Superficial 2D hrs Check for catastrophe every 1 hr
Minor 1D * 10 min Check for catastrophe every 15 min
Major 2D min Check for catastrophe every 5 min
Destroyed 1D min Death


To Check for Catastrophe:
Difficult, Medical/First Aid, patient's End.
Failure - 1D more damage.
To Maintain Consciousness (patient task)
Difficult, End
Patients with Major level damage or greater will show signs of shock, i.e. altered level of consciousness (decreased or delirious), impaired breathing (A, B, or C causes?), decreased blood pressure and usually an increased pulse (hypotension and tachycardia).


Anatomy: In a human (or Vargr or Aslan, for that matter), the nose and mouth join in a common pathway at the back of the throat - the pharynx. Just above the 'Adam's apple' in a human is the entry to the windpipe (trachea) ; this is the larynx. The vocal cords are in the upper part of the larynx. A muscular flap, the epiglottis, sits above the laryngeal opening. It normally protects the lungs from being soiled with food on eating or vomitting. (This requires an intact reflex arc which may not be present in a severely ill person). The trachea continues into the chest, where it birfucates to supply each lung.

The most basic airway manoeuvres aim to keep the pathway from pharynx to trachea open.

Airway tubes can be placed

Alternately, surgical airways can be formed. Just below the laryngeal prominence ("Adam's apple") is a small gap in the cartilage in the midline. This is the cricothyroid membrane. Making an incision or puncture here and passing an airway tube is relatively easy. Tracheostomies - holes in the trachea - can be made at this level or lower. Bleeding and air tracking into the chest can ensue if you go too low, though. The utility of surgical airways becomes evident in the context of severe facial injury.

Airway Manoeuvre tasks
Difficulty, Med/First Aid, Dex (Difficulty from table as follows)

Airway Task Difficulty Levels

Manoeuvre Indication Base Difficulty Bonus to B/C Tasks*
Chin Lift (Jaw Thrust) unconscious Easy 0
Reduce Facial Fracture Major (or more severe) facial damage Difficult +1
Oropharyngeal or Nasopharyngeal Airway unconscious Average +1
Laryngeal Mask (LMA) unconscious, or Destroyed damage Average if unconscious or general anaesthetic. Difficult if local anaesthetic only. +2
Endotracheal tube (ETT) As per LMA Average if unconscious or general anaesthetic. Difficult if local anaesthetic only. +3
Cricothyroid puncture or tracheostomy Failure to pass LMA or ETT, or to reduce facial facture; major (or more severe) damage to face and/or neck Average if done in operating theatre or ICU, with at least local anaesthetic.  Increase difficulty 1 level for impromptu tools, field conditions. First Aid skill at half. +2

All airway manoeuvres have a risk of mishap : disrupting the cervical spine, base of skull (making existing injuries worse) or putting an endotracheal tube into the oesophagus (unrecognised, this is a lethal error) instead of the trachea readily spring to mind.

* On Spectacular Failure : 1D further damage. Tasks may be repeated. You must secure an airway, else all other effort will be wasted!


Breathing Tasks
Difficulty, Medical/First Aid, Dex
Breathing Task Difficulty Levels
Manoeuvre Indication Base Difficulty Bonus to C Tasks
Start Oxygen mandatory no task 0
Ventilate Major (or more severe) chest damage Easy +1
Insert Chest Drain* Major (or more severe) chest damage Average; requires apporopriate tools and local or general anaesthetic or unconsciousness +1
Insert Gastric Tube Major (or more severe) chest or abdominal damage Average; requires appropriate tools +1

The end of a chest drain is meant to sit between the chest wall and the lung, to drain air or fluid which may have collected there.

Gastric tubes can be passed either through the nose or mouth.

* Inserting drainage tubes can make things worse. Hearts have been perforated by personnel inserting chest drains. Stomachs have been perforated inserting gastric tubes. Never, never introduce a gastric or airway tube through the nose of someone who may have a base of skull fracture ; it may end up poking into the brain...

On Spectacular failure : 1D damage


Circulation Tasks
Difficulty, Medical/First Aid, Dex
Circulation Task Difficulty Levels
Manoeuvre Indication Difficulty
Direct Pressure Control External Bleeding Easy
Insert IV Cannula Permit Volume Resuscitation Average; Difficult if major or more sever damage.
Volume resuscitation
(wound difficulty), Med/First Aid, victim's End (co-operative), bonuses from previous steps
Wound Difficulty Levels
Wound Severity Difficulty Level
Superficial Easy (usually not required)
Minor Average
Major Difficult
Destroyed Formidable

Success restores consciousness if not anaesthetised/sedated or Destroyed level damage (nearly dead!). A safe blood pressure is maintained in the presence of a patent airway and adequate oxygenation.

On Failure : catastrophe check. On Spectacular failure : catastrophe check +1D damage. On Spectacular success : 'rolls back' half die (D3) of damage.

These tasks permit catastrophe checks and Spectacular Failure damage to be reversed or ignored. Success leads to a restoration of normal heart rhythm with stable blood pressure. Failure causes 1D damage. Ventilation and cardiac massage will need to be continued until definitive treatment can be performed.

Other Measures
Manoeuvre Indication Difficulty Level
Pericardium Tap Major or more severe Chest damage Difficult with proper tools; +1 Difficulty Level if done impromptu.
Cardiac Massage Destroyed damage Average for external stimulation; Difficult if done "open heart". Assumes proper tools; +1 Difficulty Level if done impromptu.
The  sac covering the heart. Fluid can accumulate in the sac and depress heart function, as the pericardium is relatively stiff. When this occurs, it is called cardiac tamponade.
Volume resuscitation
Adding blood, blood products (e.g., clotting factors), colloids (protein or starch solutions), crystalloids (salt solutions) into patient circulatory system.  Possible at TL 4+. Crystalloids or colloids can be used until blood is available. Blood and blood products should be used only when bleeding is controlled (except for very dire circumstances).
5. Stabilised or not?
Further catastrophe checks can be made every ten minutes or so or at important points (transfer onto or off a vehicle, or for dramatic effect...)
The Secondary Survey
Evaluate injury by region and treat accordingly.


Clinical examination can be supplemented by

To diagnose injury
Average, Medical, Edu, uncertain

This task can be co-operative (either with sophont physicians or expert systems). The practical upper limit is three medics. Higher technology level investigations reduce uncertainty:

Technology Level Modifiers
on Diagnostic Uncertainty
TL of Investigation DM on Uncertainty
4 - 5 +1
6 - 8 +3
9 - 11 +4
11+ +5


Uncertainty Results Modification
to Treatment Tasks
Result DM to Treatment Tasks
Total Truth +2
Some Truth 0
Some Untruth -1
Total Untruth -2
*To perform a successful embolisation
Difficult, Medical, Dex. Equipment is required to attempt this task.
Indication :- Major or more severe abdominal damage. Surgery is required if embolisation fails.
At lower tech levels, more surgery is performed. At higher tech levels, more sophisticated tests are performed.
Catastrophe checks should be made during the evaluation process.
Injury rating system

The abbreviated injury score (AIS) is a Real World system used to evaluate the management of trauma victims. It was initially devised to develop standards of care for road accident casualties, but the scope of its use has increased.
The body is divided into regions: head, neck and face, thorax, abdomen, pelvis and extremities, external (skin!).
Injuries are rated on the following scale
0: no injury
1: minor
2: moderate
3: serious, not life threatening
4: severe, survival probable
5: critical, survival uncertain
6: unsurvivable
This scale readily lends itself to Traveller application.
0 to 1: superficial
2 to 3: minor (one characteristic at zero)
4 to 5: serious (two characteristics at zero)
6: destroyed (all chars at zero)


Examples of Injuries and Their Treatment

Superficial injuries
e.g., Shallow lacerations or cuts, abrasions (scrapes), simple fractures or dislocations (closed, (non)reduced, not hand, femur, spine or depressed skull), corneal abrasions or foreign bodies.
Treatments may include suturing (TL 2+), bandaging and dressing (TL 1+), immobilisation in plaster cast or splinting (TL 1+), pain relief (TL 1+).
Suturing a wound, or reducing a fracture/dislocation requires either local anaesthesia (TL 5+) or reliable sedation up to and including general anaesthetic (TL 4+).
e.g., deep lacerations (skin traversed), multiple simple limb or facial or individual compound fractures (bone through skin) of same, simple pneumothoraces (collections of air in the chest outside the lungs), superficial foreign bodies (bullets/shrapnel), penetrating eye injuries.
Treatments may include exploration and suturing of wounds (local or general anaesthesia required, so TL 4+) or placement of a chest drain (TL 4+). Complicated fractures (eg. hand/wrist, femur, depressed skull) and eye injuries require surgery (general anaesthetic, TL 4+). All require analgesia.
e.g., Head injuries with symptomatic intracranial haemorrhage or compound fracture, pelvic ring fractures, multiple rib or sternum fractures (if three or more adjacent ribs are fractured, a so called flail segment is produced. Ventilating the lung becomes difficult.), blunt or penetrating cardiac or chest injury, blunt or penetrating abdominal trauma, multiple compound fractures, limb crush injuries or (near-)amputations.
Surgical intervention after resuscitation is mandatory, if only to control bleeding and remove dead tissue. Resuscitation and placement into low berth is an alternative if technology permits.
e.g., combinations of Major injuries, above, with the additional complication of cardiac arrest (actual or imminent).
Resuscitation is required within five minutes of cardiac standstill to permit brain salvage (in the absence of mitigating protective factors like severe hypothermia or some drugs).
Placement in a low berth and transport to a TL 13+ medical facility offers the best chance for long-term survival, in the absence of prompt heroic medical and surgical intervention.

The following task covers any area not previously specified.

To treat injuries
variable, Medical/First Aid, Edu/Dex.  + evaluation mods, as above.
Treatment Difficulty Levels
Wound Severity Treatment Difficulty
Superficial Easy; First Aid OK
Minor Average; First Aid OK
Major Difficult
Destroyed Formidable

This is a co-operative task ; the surgeon's first assistant provides half their skill. Optionally, up to two surgical teams (surgeon+first assistant) can operate at the same time on different parts of the patient. This permits wounds to be separated into different tasks.

Regions (1 team per region)

Surgery requiring general anaesthetic, or resuscitation for Destroyed injuries requires an endotracheal tube to control the airway and an anaesthetist.

+1 difficulty level for impromptu/inadequate tools (e.g., suturing without local anaesthetic) and/or setting (in the field vs. operating theatre).

**The usual outcome for this task is to enable healing. On a Spectacular Success, 1D damage points are 'rolled back'. On Spectacular Failure inflict additional 1D damage.

The anaesthetist can make a task roll as above to try and reverse Spectacular Failure. He or she cannot improve on Spectacular Success.

Aftercare and Outcomes

Survival depends primarily on two factors
The rapidity and appropriateness of resuscitation. The concept of 'the golden hour' is well established. People tend to survive if definitive treatment after resuscitation has started within the first hour after injury.
The severity of head injury sustained. There are three mortality peaks: immediate (massive injuries), hours later (decompensated shock, usually in the emergency room or operating theatre), and days to weeks later (from head injury complications or multi-organ failure, usually in the wards or ICU).
Injury Severity Supplies? Home Care? Ward Care? ICU Care? Operating Theatre/
Superficial Yes, 3D No No No Maybe, 500
Minor No Yes, Until Recovery 100 No Maybe, 500 * 1D
Major No Yes, Until Recovery 100 500 Yes, 1000 * 1D
Destroyed No Yes, Until Recovered 100 500 1000 * 1D/250K
Numbers and Dice Rolls represent cost in Credits per Day of hospitalization or occasion of service
Healing rates
Superficial 1 point, all affected chars, per day
Minor 1 point, all affected chars, per day
Major 1 point, one characteristic, per day
Destroyed 1 point, one characteristic, per week, until 50% of points recovered - then treat as Major
Slow drug speeds this up by a factor of ten. Its use is confined to ICU and Major or more severe damage.
A patient is transferred from ICU to Ward when one characteristic is recovered or patient is conscious.
A patient is transferred from Ward to Home when all chars 50% of original value
For Superficial and Minor injuries
Enhanced wound healing doubles the rate of recovery at TL 9+, triples it at TL 12+ (gentle growth quickening and tissue culture tech)

Progress and Complications

Severity of Injury Check for How often?
Superficial Infection 3 days after injury
Minor Infection 3 days after injury
Major Consciousness once per day
Catastrophe Every second day (every day if using slow drug)
Destroyed Consciousness twice per week
Catastrophe every day
To Avoid Infection
Average, (patient) End.  If in hospital, Average, Medical (attendant), End (patient).
Infection occurs only on Spectacular Failure. When infection occurs, healing stops until the infection is treated.
To diagnose causative organism
Difficult, Medical, End, uncertain
Laboratory investigations can reduce uncertainty:
Laboratory Investigation Modifiers
Uncertainty of Infection Diagnosis
TL of Investigation DM to Uncertainty
4 - 5 +1
6 - 8 +3
9 - 11 +4
11+ +5
with micro lab or medical computer (interchangeably)
To treat infection
(difficulty), Medical, patient's End, uncertain if organism unknown.
Difficulty Level is Easy for Superficial damage, Average otherwise.
Laboratory investigations reduce uncertainty.

Modifiers for Treatment of Infection

Treatment uses Modifier
Appropriate anti-infectives +3
Broad-spectrum vaccine, TL10+ +3
Broad-spectrum vaccine, TL13+ +4

Spectacular Success rolls back 2D of damage. Spectacular Failure causes 1D of damage. Failure: catastrophe check.

To Check for Consciousness
Difficult, End. Wake up if successful.
To Check for Catastrophe
Difficult, Medical (attendant), End (patient)
Spectacular Failure leads to the development of some problem. 1D damage is applied promptly.
All characteristics to zero: cardiac arrest, any cause
Two characteristics to zero: e.g., severe infection, bleeding, pulmonary embolism (blood clot to lungs), heart attack (myocardial infarction).
One characteristic to zero: minor infection or wound breakdown.

Miscellaneous Medical Tasks

To thaw from low berth
Difficult, Med, Edu.
Spectacular Failure leads to automatic Destroyed damage (cardiac arrest).
Formidable, Medical, Edu task (co-operative OK).
+1 difficulty level if fast drug used instead of low berthing.

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