The authors have no relevant financial information or potential conflicts of interest to disclose.
Effect of Military Conflicts on the Formation of Emergency Medical Services Systems Worldwide
Article first published online: 14 MAY 2013
© 2013 by the Society for Academic Emergency Medicine
Academic Emergency Medicine
Volume 20, Issue 5, pages 507–513, May 2013
How to Cite
Academic Emergency Medicine 2013; 20:507–513 © 2013 by the Society for Academic Emergency Medicine
- Issue published online: 14 MAY 2013
- Article first published online: 14 MAY 2013
- Manuscript Accepted: 2 DEC 2012
- Manuscript Revised: 5 NOV 2012
- Manuscript Revised: 20 AUG 2012
- Manuscript Received: 28 MAY 2012
This article briefly reviews the evolution of medical support during wars and conflicts from ancient to modern times and discusses the effect warfare has had on the development of civilian health care and emergency medical services (EMS). Medical breakthroughs and discoveries made of necessity during military conflicts have developed into new paradigms of medical care, including novel programs of triage and health assessment, emergency battlefield treatment and stabilization, anesthesia, and other surgical and emergency procedures. The critical role of organizations that provide proper emergency care to help the sick and injured both on the battlefield and in the civilian world is also highlighted.
Efecto de los Conflictos Militares en la Formación de los Sistemas de Servicios de Emergencias Médicas en Todo el Mundo
Este artículo revisa brevemente la evolución del soporte médico durante las guerras y los conflictos desde los tiempos ancestrales hasta la modernidad, y discute el impacto que ha tenido la guerra el desarrollo de la atención sanitaria civil y de los sistemas de emergencias médicas. Los descubrimientos y los logros médicos hechos por necesidad durante los conflictos militares han evolucionado hacia nuevos paradigmas en la atención médica, que incluyen los programas novedosos de triaje y valoración médica, el tratamiento emergente en el campo de batalla y la estabilización, la anestesia y otros procedimientos de emergencias y quirúrgicos. También se destaca el papel crítico de las organizaciones que proporcionan la atención emergente adecuada para ayudar al enfermo y al herido tanto en el campo de batalla como en el mundo civil.
Physical injuries, much like sickness and disease, are a fundamental part of human history. The importance of providing primary medical treatment at the site of injury has been understood from the times of the ancient Greeks and Romans. Both societies expended great effort to ensure medical treatment and analgesia for their wounded soldiers in the field.
Physicians in Greece were laypeople. They were often graduates of formal medical schools such as the school on Kos Island where, in the fourth to third centuries BC, Hippocrates lived and practiced. Similar schools included that on the Island of Rhodes and those of Kroton and Kyrene. After taking the Hippocratic Oath, graduates of these schools took up their practices in specially designated facilities called infirmaries (Gr. Jatrejon). These buildings were specifically designed to care for the sick, reflecting modern society's hospitals and rehabilitation centers. Some Greek doctors became specialized in narrow fields, such as the extraction of teeth. Others practiced more generalized medicine or concentrated on surgery.
Many Greek physicians had public appointments and worked in an official capacity for the nation-state. Their responsibilities included deployment with the army and they were charged with the care of wounded soldiers. This tradition was introduced by Lycyrgus of the Spartan army. In his work, the Iliad, Homer described aid stations providing treatment for the injured in the Battle of Troy. Doctors in the service of the army were forbidden to carry arms.
Ancient Romans further developed the Greek methods of treating the sick and wounded. In the first century AD, Romans began the practice of erecting special buildings in places that were likely to see large-scale conflict to guarantee medical care for wounded legionnaires. These structures were rectangular buildings that resembled small towns. They fed onto a central square where there was a small temple dedicated to Aesculapius, the God of the Art of Healing. Around the main square there were rows of rooms for the sick and wounded as well as rooms for the physicians and their assistants. These facilities were supplied with clean drinking water in addition to legionary bath complexes (Lat. thermae legionis) providing hot and cold water. Latrines were flushed with water and the sewage was brought beyond the walls of the compounds. Ancient military hospitals were also integrated into the forts of each legion in the Roman Empire.
One such fort has been excavated by the International Interdisciplinary Archaeological expedition from the Adam Mickiewicz University in Poznań, in the region of a Roman legionary camp hospital of the Legion I Italica in Novae (at present the town of Svishtov in Bulgaria). These excavations confirmed the general architectural form and structure of the valetudinarium. The hospital of Novae was built between the first and second centuries AD during the reign of Emperor Trajan and functioned continuously until the first decades of the third century AD. It was surrounded by a high wall, behind which there were rooms for ambulatory care as well as operating and inpatient rooms. In the center of the valetudinarium there was a large square, which on one hand provided a tranquil environment for wounded legionnaires and on the other was most likely a place of religious reflection. The hospital at Novae had the capacity to care for approximately 300 sick or injured legionnaires.[3, 4]
The Romans were the first army in the world to use dedicated trained medical personnel to care for their wounded. The Roman legions had their own physicians (Lat. medici castrenses). Each doctor had a specific specialty and also had assistants at his disposal—a nurse and orderly. By the time of Markus Aurelius, the military medical service had adopted as its symbol a serpent entwined around a wood rod (Lat. Aesculapius caducifer), which has continued to be the emblem of medical services to the present day. The duties of Roman military doctors included the examination and selection of recruits, treatment of the sick, and care of the wounded. This included the stemming of hemorrhage, amputation of limbs, ligation of vessels, and the reduction and dressing and fractures or dislocations. Wounded soldiers were transported from the battlefield to these ancient medical centers. Despite these efforts, mortality rates for the wounded on the battlefield during this period reached 80%.[5-7]
In the Roman Empire, medical care and treatment were not limited to professionals trained to treat injured legionnaires. Medicine was taught and studied as part of the educational system of the age. Doctors had their own practices and facilities, and provided advice for the ill in their homes. Medical practices were also established at important public institutions, which resulted in distinct specialized doctors for sports, gladiators, and the fire brigades. Initially, civilian health care was limited to wealthy Romans who would call upon private physicians. However, by the second century AD a system of care and social welfare was created that provided free care for the underclasses.[5-7]
The fall of the Roman Empire resulted in the Dark Ages, and society lost its knowledge of the ancient sciences and culture, including medicine. Consequently, organized medical care for wounded soldiers was practically nonexistent until the Napoleonic Wars.[5-7]
Many historians credit Baron Dominique Jean Larrey (1766–1842) with the creation of modern traumatology and a military system of prehospital emergency medical services (EMS) based on triage and transport of casualties.[8, 9] By the age of 21 years, Larrey was already a trained surgeon and when he joined the French Navy. He was considered an exceptional surgeon, known for the amazing speed at which he was able to operate, and was also a renowned organizer. From 1805 until the Battle of Waterloo, he was the Chief Surgeon and Inspector General of the Office of the Health of the Army.[8, 9] He accompanied Napoleon through 25 campaigns, 60 battles, and over 400 skirmishes.[10, 11] Larrey believed that rapid medical care was paramount to saving the lives of soldiers who had been wounded on the battlefield. He also believed that shortened surgical times resulted in less shock to the body and mind. Furthermore, he advocated that damaged limbs and tissues should be immediately removed and that efforts to save them should not be undertaken as this would only increase psychological trauma and raise the risk of infection. In 1812, at the Battle of Borodino, Larrey performed over 200 amputations of limbs of wounded soldiers.[8, 9] In his detailed battlefield journals, Larrey documented cases of tetanus, the pathophysiology of hypothermic injuries, methodologies of effectively controlling hemorrhage, the drainages of empyemas and hemithoraces, the aspiration of pericardial effusions or hemopericardium, and the packing of sucking chest wounds.
In 1792, Larrey and Pierre Francois Percy (French military surgeon, baron, and professor at the military medical school in Paris) designed a new type of medical wagon, a so-called flying ambulance (Fr. Ambulace volante). This was a light, well-sprung, and maneuverable carriage that was drawn by one or two horses. It served to rapidly evacuate wounded soldiers from the battlefield to nearby field hospitals and replaced the human-powered carriages used prior to that time. These had been drawn by orderlies, who were themselves exposed to injury while en route to aid stations with the wounded.[8, 9, 12]
Such early ambulances were first utilized on a large scale during the first Italian Campaign in 1797. To evacuate the soldiers from the battlefield, Larrey and Percy introduced into the French Army a battalion of “ambulance soldiers” that comprised doctors, noncommissioned officers, and a troop of orderly stretcher-bearers. This battalion was then equipped with the new ambulances.[8, 9] Larrey firmly supported the practice of providing rapid medical care to soldiers wounded on the battlefield. During the Napoleonic Wars, in accordance with Larrey's recommendations, physicians would go to their patients who stayed in medical aid stations located in the vicinity of the battlefield to perform emergency surgeries for life-threatening injuries. Larrey believed that severely wounded soldiers could not be left without medical care, and field hospitals must therefore be organized as near to the battlefields as possible. For example, during the Battle of Waterloo, Larrey established his field hospital in the buildings of the farm of La Belle Alliance, a bare 400 meters from the front line and practically without any chance of evacuation or withdrawal. When the British general Wellington learned of the field hospitals location in the ruined buildings of the farm, he halted his bombardment, believing this to be the only way in which he could honor the devotion and loyalty of the French doctors who at the risk of their own lives were providing assistance for the wounded soldiers.[8, 13, 14] At Waterloo, Larrey was captured and sentenced to death. However, he was saved by the personal intervention of the Prussian General, Blucher.
Larrey contended that treatment of wounded soldiers should be prioritized according to the severity of their injuries and not influenced by rank or nationality (the French Army was a multinational force). Those soldiers who were less severely wounded should therefore wait until medical care had been provided to their more seriously injured brothers-in-arms. Furthermore, those with minor wounds did not need to be treated on the battlefield and could be sent to hospitals located far from the front lines as their lives were not in immediate danger.[14, 15] Thanks to the innovations by Larrey regarding early treatment and quick evacuation of casualties to field hospitals, outcomes improved considerably, and there was a marked decrease in mortality among the wounded soldiers of the Napoleonic Army. For example, during the Battle of Aspen (May 21–22, 1809), of 1,200 wounded guardsmen, only 45 died. In subsequent years, the system of casualty triage established by Larrey was modified to better serve the needs of the military health service. These principles of casualty triage were ultimately adopted and transformed to serve the civilian EMS.
Until the 18th century, the system of treatment of wounded soldiers directly upon or close to the battlefield prevailed. This stemmed from the fact that before this time period, individual single battles would typically decide the outcomes of entire wars and that the treatment of wounded in close vicinity to the battlefield did not in fact expose either patients or providers to severe danger given the relatively short range of weapons used by contemporary armies.[9, 16]
In subsequent decades, the application of new technologies created more devastating weapons, the scale of conflicts and armed forces increased, and new means of rapid transportation accelerated warfare. These developments all resulted in more rapid growth in the number and severity of war-related injuries. For example, during the Crimean War in 1853–1856, as many as 60% of total wounds proved fatal. The Battle of Solferino on June 24, 1859, alone resulted in 40,000 casualties among the French, Austrian, and Sardinian soldiers. This enormous loss of life as a result of military conflicts spurred further development of medical sciences and newer methods of providing initial treatment to the wounded. These losses also initiated the undertaking of charitable activity on behalf of casualties of war.
Henry Dunant was a Swiss citizen and an eyewitness to the Battle of Solferino. Upon returning to his homeland, he published a book titled A Memory of Solferino. This work was inspired by the sight of the wounded and dying soldiers, whom the few and poorly organized medical corps could not adequately manage. Dunant postulated that it was during peacetime that organizations should be created to care for the wounded soldiers. Upon the outbreak of hostilities, these organizations would already have trained and prepared medical staff who could provide care for casualties. He further advocated for the recognition and protection by international law of volunteers providing medical services to the military.
In 1863, while considering Dunant's ideas, the Geneva Society for Public Welfare summoned a commission comprising Gustave Moynier, Guillaume-Henri Dufour, Louis Appia, Theodore Maunoir, and Henry Dunant. The Commission set up the International Committee for the Relief of the Wounded, which would later become the International Committee of the Red Cross (ICRC). Following the five founding members of the ICRC, the Swiss Government in 1864 organized a diplomatic conference that included 16 participating nations. These adopted the “Convention for the Amelioration of the Condition of the Wounded and Sick in Armed Forces in the Field”—the first international humanitarian law document. In 1906 and in 1929, succeeding conventions expanded the scope of legal protections afforded to war casualties and furthermore took upon improving the fates of prisoners of war.[5, 17-19]
The Russian surgeon and anatomist Nikolai Ivanovich Pirogov is considered to be the founder of modern techniques in providing medical care in mass casualty situations and events. In the second half of the 19th century, he published “Beginnings of General Military Field Surgery” (1865–1866) and “Military Medicine and First Aid in the War Theatre in Bulgaria and Behind the Lines” (1879), which called attention to the importance of organized logistics in providing medical care for the wounded. In his work, he states that “… to achieve good results in military field hospitals, not only scientific surgery is needed, but good and properly organized administration. It is … the administration, and not … the medicine, that determines whether all injuries without exception are able to receive aid within an appropriate time frame.”
Pirogov called war a “traumatic epidemic” and believed that the severe nature of wounds inflicted on the battlefield required early, specialized treatment. His methods abandoned the practice of immediate amputation of injured limbs and replaced it by the surgical dressing of the wounds. In 1847, Pirogov was the first to use chloroform anesthesia during surgery on the battlefield. In 1854, he was the first to apply plaster for the immobilization of a gunshot fracture. He was also one of the forerunners in the use of antiseptics. He provided a description of shock and the principles of medical triage of casualties. Pirogov was an advocate of transporting the wounded to hospitals at the rear of the front, the so-called “dispersion of casualties.” In 1855, during the defense of Sevastopol, he arranged for women to care for the injured at the front, echoing the efforts made by Florence Nightingale.[16, 20, 21]
The next significant development of EMS and medical transport took place during the United States' Civil War, between 1861 and 1865. Initially during the conflict, the military medical care systems of the North and South did not provide for the removal of casualties from the battlefield or their transport to aid stations or hospitals. Surgeon General William A. Hammond recognized this deficiency in combat casualty care and stated that “An ambulance corps should be organized and set in instant operation ….” Hammond subsequently appointed Jonathan Letterman as the new medical director of the Union Army.
Letterman adopted some of the ideas first put forth by Larrey, such as the introduction of flying ambulances as an effective means to transport wounded soldiers of the Union Army. He established an effective ambulance corps trained in techniques for loading and unloading patients on stretchers into and out of ambulance wagons. He ordered that all ambulances must be staffed with dedicated attendants at all times and be prepared to move immediately and quickly when called upon. Letterman determined that light, two-wheeled ambulance carts should be used to retrieve the wounded from the battlefield to dressing stations or field hospitals. Meanwhile, larger, four-wheeled wagon ambulances were reserved to move patients to more definitive facilities, such as general hospitals and rear echelon military medical facilities.
After the Seven-Days Battle, Letterman transferred the Quartermaster Corps to the medical staff of the Union Army and introduced forward first-aid stations at the regiment level to administer medical care closer to the battlefield. Hammond's and Letterman's reorganization of the military medical care system significantly reduced mortality rates at the Battle of Antietam. This led the United States Congress to establish these protocols as the standard medical procedure for the entire Union Army. On March 11, 1864, President Lincoln signed into law legislation (“An Act to Establish a Uniform System of Ambulances in the Armies of the United States”) passed by Congress that established a standardized system of ambulance service throughout the military. The law also mandated the use of special uniforms for the ambulance corps and special signs for the ambulances themselves. Regulations issued during the war by both sides, and subsequently incorporated into the aforementioned law, also conventionalized specific insignia and signage for recognition of ambulances and hospitals.
The knowledge, skills, and experiences gained while providing medical assistance to the wounded during the American Civil War and subsequent military conflicts drastically affected the development of many branches of medicine. It also accelerated the improvement of organizational issues, such as medical triage and transport, and became a basis for the development of civilian models for providing initial medical care to casualties.
During the second half of the 19th century, in the United States and in Europe, the need for organizing medical assistance, not only for war casualties, but also for peacetime emergencies, was recognized. The advent of the Industrial Revolution saw an increase in the types and severity of injuries and created an urgent need for prehospital treatment of victims. It was in these settings that civilian EMS began to be formed. Their roles began with the transport of patients to hospitals by provisional ambulances that initially were drawn by horses. With the advancement of technologies during the Industrial Revolution, self-propelled mechanical ambulances began to appear.
A fundamental contributor to the evolution of civilian EMS in United States was the availability of medical personnel discharged from the military after the Civil War. In 1865, a prehospital EMS was created, based out of the Commercial Hospital in Cincinnati, Ohio (now, Cincinnati General Hospital)—the first civilian ambulance service in the United States.
In 1869, a former military surgeon, Edward B. Dalton, and the sanitary superintendent at the Metropolitan Board of Health, together with Bellevue Hospital, founded an ambulance service in New York. Its personnel included physicians. The service utilized specialized equipment for the treatment of patients both at the scene of the emergency and also en route to the hospital. This equipment included stretchers, handcuffs, and straightjackets; under the driver's seat was a box with brandy, two tourniquets, six bandages, sponges, splint material, and a small bottle of persulfate of iron.
As with many industries, important change often comes only through tragedy. In 1881, a fire at the Ring Theatre in Vienna was an important impetus for the creation of the first ambulance service in Europe. The rescue operation was poorly organized, and the responding firefighters could do little at the scene. That fire killed at least 384 people and injured hundreds more. Two years later, the “Vienna Voluntary Rescue Society” was founded on the initiative of Dr. Jaromir V. Mundy (a witness to the fire), Count J. N. Wilczek, and Eduard Lamezan-Salins. Numerous ambulance stations and services were established throughout Europe in the ensuing years. In June 1887, the St. John Ambulance Brigade (modeled on a military-style command and discipline structure) was established to provide first aid and ambulance services at public events in London.[25, 26]
The first ambulance station in Poland was organized in 1891 in Krakow. As with the Vienna Voluntary Rescue Society, this service was founded because of the many fires that occurred in this city in 1890, resulting in the loss of many lives. The proponents for the creation of the ambulance station were Arnold Bannet (later a well-known ophthalmologist), Alfred Obaliński (Professor at the Jagiellonian University), and Wincenty Eminowicz (then head of the fire brigade). Jaromir Mundy and Jan Wilczek, the organizers of rescue services in Vienna, provided many of the operating guidelines for this service. The City Council of Krakow appropriated rooms in the fire brigade building and agreed to finance the ambulance station. On June 6, 1891, the first ambulance appeared in the streets of Krakow—a coach drawn by two horses and equipped with two pairs of stretchers. The ambulance belonged to the Krakow Voluntary Rescue Society. The personnel were volunteers—senior students of the Department of Medicine at the Jagiellonian University. Ambulance stations were subsequently created in other Polish cities: Lvov in 1893, Warsaw in 1897, Łódź in 1899, Vilnius in 1902, Lublin in 1917, and in Poznań in 1928.
In 1916, using Pirogov's concept of prioritization, a Russian surgeon, Vladimir Oppel, refined a military system for triaging and managing casualties based on a unified doctrine of treatment and evacuation procedures. This doctrine consisted of transporting casualties to medical aid stations and field hospitals. His guidelines emphasized continuity of treatment at all stages of evacuation.[16, 28]
During World War I (WWI), the U.S. Army assigned nonphysicians to front-line trenches for the treatment of casualties. These men would treat soldiers directly at the site of injury if casualty levels were light. Otherwise, company litter-bearers would carry the injured to company aid stations and then to battalion aid posts. Treatment included hemorrhage control and the splinting of fractures. At the company aid station, medical personnel would further control hemorrhage, adjust bandages and splints, and administer antitetanus serum before moving the injured to the battalion aid post. From there, the wounded were evacuated to ambulance dressing stations, at the point nearest the front lines that ambulances could reach safely. At these stations, battlefield placement of dressings and splints could be revised if necessary, and the wounded were triaged for further transport.
Procedures that were developed and implemented in WWI were carried over to World War II (WWII). Oppel's system was used by the Soviet, American, Polish, and other armies. During WWII, while organizing medical assistance for wounded soldiers, authorities paid more attention to the importance of minimizing the time between injury and initiation of definitive medical care. It was observed that minimizing the time to treatment considerably decreased mortality among casualties. These experiences would be successfully used in subsequent military conflicts.
Between WWII and the Vietnam War, the time from injury to the initiation of medical care was further shortened. Medical aid stations were organized as close to the front line as possible to provide wounded soldiers quick access to definitive treatment. During the Korean War, the wounded were transported by helicopter and the U.S. Army located Mobile Army Surgical Hospitals (MASHs) on the battlefields. In April 1962, the U.S. Army initiated helicopter evacuation of combat wounded on the battleground with the 57th Medical Detachment (HelAmb). This strategy of providing early definitive care for casualties was further improved during the Vietnam War (1965–1973) by conveying the wounded by helicopter directly to the full service hospitals, e.g., omitting the MASH. This enabled a reduction of the waiting time for definitive treatment to 60 minutes (at that time considered the “Golden Hour”) in many instances. As a result of this and other innovations, mortality among wounded soldiers decreased to 1.7%.[34-36]
The experiences and knowledge gained by the U.S. military again served as the basis for changes in the civilian health service. From the second half of the 1960s, there was a rapid development in civilian EMS. The evolution of modern cardiopulmonary resuscitation and the recognition of motor vehicle crashes as one of the greatest public health problems in the United States have been well chronicled.
The first developments in prehospital medical care based on the chain of survival concept came from Belfast in Northern Ireland. Through a grant from the British Heart Foundation, a system of rapid cardiologic care for patients with acute myocardial infarction was established January 1, 1966. A mobile intensive care unit comprising an extremely well-equipped resuscitation ambulance staffed by a physician and a nurse was developed for this purpose.[19, 37] On August 5, 1967, conclusions from the Belfast Project were published in the journal Lancet and included data from 312 patients over a 15-month period. The encouraging results of this project evoked a considerable response worldwide. Within 2 years, similar programs for providing prehospital assistance were being implemented in other countries.
In 1968, St. Vincent's Hospital in New York City started the first mobile coronary care unit, and Eugene Nagel, MD, established the first mobile, advanced life support service in the United States that was not staffed by physicians in Miami, Florida.
Drawing on the combat casualty care model used in Vietnam, R Adams Cowley, MD, collaborated with the Maryland State Police under a grant from the National Highway Safety Administration, deploying a military model helicopter to assist in the rapid transport of patients to the Center for the Study of Trauma (now known as the R Adams Cowley Shock Trauma Center). This marked the beginning of modern emergency medical helicopter transport in the United States. The first civilian, hospital-based medical helicopter program in the United States, Flight For Life Colorado, began in 1972 with a single Alouette III helicopter based at St. Anthony Central Hospital in Denver.
Contemporary military experiences confirmed the benefits to injured patients brought about by initial medical care in combination with quick evacuation to centers providing definitive treatment. In the global war on terror in Iraq and Afghanistan, military combat medicine has further defined and validated tactical combat casualty care (TCCC). There are now validated treatment guidelines for the use of tourniquets (combat application tourniquet), hemostatic agents, needle chest decompression, and hypotensive resuscitation.
For many years, a civilian EMS system (based on the Anglo-American EMS system) has been progressively implemented in Poland. Since January 1, 2007, the EMS Act has been in effect. The units of the system include basic ambulances with paramedics, specialist ambulances with a physician, medical air rescue, EDs, and trauma centers. Currently, Polish Medical Air Rescue operates from 17 permanent bases, at which helicopter EMS (Eurocopter EC 135) are stationed. Each airborne helicopter team includes a pilot, paramedic, and a physician to provide rapid and specialized, prehospital care to patients with life-threatening conditions.
Armed conflicts and the evolution of military medicine have profoundly influenced the development of modern civilian EMS systems. The importance of providing rapid and safe transportation of casualties to the hospital came from Larrey's “flying” ambulances. In the American Civil War, Letterman designated emergency vehicles intended strictly for the transport of wounded soldiers that could not be appropriated for other activities. The protocols for field management of wounded soldiers developed by N. Pirogov and V. Oppel contributed to the concept of the chain of survival and formed the basis for civilian EMS organization. The treatment of wounded casualties at the site of injury derived from trench warfare in WWI and was carried forward by the combat medics of WWII. Air transport for the wounded was introduced in WWII and refined during the Korean and Vietnam Wars and now often involves transportation of wounded soldiers directly from the site of injury to fully capable trauma hospitals. The global war on terror has seen improved methods and equipment for treating victims of severe trauma through TCCC guidelines. Important tactics in both combat and civilian EMS systems remain providing lifesaving interventions at the site of illness or injury and reducing time to definitive medical care.
The editors thank Dr. Tom Obrzut of the Yale-New Haven Medical Center emergency medicine residency program, for an outstanding job of editorial translation.
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