Command Decision Priorities At Compound With Treatment Facility

Safe removal of UXO requires significant coordination with local security, the base command element, and EOD personnel. Specific duties include:

Base Security and Command Team

The area where the patient is located should be secured or cordoned off. The time to identify this area is during the initial establishment of a treatment facility, long before a potential patient may arrive in need of care. Non-treating personnel should remain in protected location at a safe distance beyond the blast radius of the ordnance. All non-essential personnel, including medical providers, should move to that stand off point. The local commander should be informed that a patient with UXO is under medical care at the MTF or is due to arrive if prior notification is given.

Explosive Ordnance Disposal Team

It is imperative that EOD staff participate in mass casualty exercises involving UXO scenarios in order to develop robust procedures and guidelines. Furthermore, EOD can advise and assist in construction of a UXO barricade where the UXO can be removed and a second secured area to place the UXO once it has been removed following surgery. This is best done after the primary MTF has been established. The EOD unit contact information should be clearly posted in the surgical facilities administrative area and the phone number validated periodically. The EOD technician or other subject matter expert must provide input on the type of ordnance present, whether the explosive portion is still present, and the likelihood of detonation. All of this information must be factored into a risk benefit analysis. As the common impaled ordnance types have a number of variants, the EOD specialist can provide advice on specific concerns to prevent arming and detonating the device. In some instances, EOD technicians have assisted in removal of the ordnance during surgery.

Patient Triage

During patient triage, the triaging officer must always inspect soldiers for loose UXO and impaled UXO. This must occur at all levels of care within the evacuation chain. If possible, the initial triage of the patients once at an MTF should be done outside the main treatment facility. Ideally, this is done nearby, but at a safe standoff distance. To assist with this, standard metal detector wands can be used with little risk of causing loose or impaled UXO to arm or detonate. During mass casualty situations, a patient with an impaled UXO could potentially endanger the staff, other patients, ground and rotary transport vehicles and drivers, and the main MTF. If there is a low probability of survival, they must be triaged to a delayed or expectant category, particularly when there are multiple casualties requiring surgical care. Comfort care, when appropriate, can be provided with the patient moved to a safe distance from the fixed or tented surgical facility.

Ancillary Surgical Site

Safe removal of the UXO should be accomplished in an ancillary surgical site when time and casualty flow permit. This is done to avoid bringing the ordnance into the main Operating Rooms (ORs). This ancillary site should be established outside the main surgical facility where the removal of the ordnance can be expeditiously and safely performed. This site should also be well lit and have all the necessary anesthetic and surgical equipment readily available. The floor should be level and large enough to place a field operating table, a litter stand, or a litter on a wheeled litter system since it can be moved with minimal amount of personnel and can immediately be converted to a stable platform for performing surgery. Ensure that the set-up can accommodate the use of portable X-ray since it may be required to help identify the ordnance. Ideally, the site would provide a blast wall next to the table or litter that other medical staff can stand behind and be available for assistance or consultation. This location should be clearly established during the initial establishment of the treatment facility since it is difficult to identify and create a site in the midst of a patient with UXO impaled in their body. Avoid conducting this type of surgery in a confined space such as a contained bunker since the overpressure from a blast will only exacerbate the trauma from an explosion. Once the UXO has been removed, the patient can be moved to the main surgical facility to complete the operation.

X-Ray and Ultrasound

Plain radiographs are generally considered safe with respect to potential inadvertent triggering of the UXO.2 The patient should not be reoriented to obtain the films as any movement can inadvertently complete the arming or triggering mechanism and cause an explosion. The effects of ultrasound or CT scan on UXO are not documented in the literature.4 Therefore; it is prudent to avoid these imaging modalities until studies confirm that they are safe.

Surgical Instruments and Adjuncts

Use of electrocautery, mechanical blood warmers, monitors, blood pressure gauges, infusers, or pumps should be minimized in order to reduce the risk of static electrical discharge.5,6 Likewise, mechanical saws and drills that utilize electricity and pneumatics should be avoided in favor of non-powered manual saws due to concerns of discharge and vibrations.6 In addition, surgical instruments, equipment, and supplies used for UXO surgery must be identified early on as part of the initial establishment or transfer of authority of a treatment facility. If available, these items should be placed in a container that can be rapidly moved to the ancillary surgical site. A list of items not in the container should be affixed to the top of the container so it can be collected Enroute to the ancillary surgical site. Do not use combustible agents in vicinity of patient (e.g., oxygen, alcohol-based solution, combustible volatile anesthetics).

Operating Personnel

Personnel deemed not absolutely essential to achieve safe removal of the ordnance should be removed from the vicinity of the UXO.7 Furthermore, all necessary equipment should be laid out in advance of the operation, eliminating the need for an OR technician whenever possible. A surgical assistant should only be used if it is absolutely necessary and the safe removal of the ordnance could not otherwise be accomplished. The UXO triage and operating team will vary from unit to unit and based on the specifics of the “impaled” ordnance. Each unit will need to identify who their primary UXO staff will be upon establishment of the treatment facility. This group of providers will need to periodically practice performing this task due to the complexities and stress involved.

Personnel typically volunteer to participate in these operations despite the significant danger. Final selection of the surgeon(s) to conduct the operation should be left up to the lead surgeon. It is imperative that the unit commander and the lead surgeon make every effort to limit the need for additional staff. This is done in order to minimize the risk to the surgical team, particularly in cases of mass casualties. Personnel participating in the surgery should gown and glove over ballistic protective equipment including safety glasses, helmet, and body armor with ballistic plates. An alternative approach is to perform UXO surgery while wearing an EOD bomb disposal helmet and suit (See Appendix B). This can be practiced in garrison and while deployed in collaboration with the local EOD unit. These suits have built in communications, heat-reducing technology, and are significantly better at protecting the entire body. All but the gloves can be worn providing protection to over 95% of the wearer’s body.

Anesthetic Considerations

In most cases, general anesthetic will be used for these operations since it provides a more controlled environment.7 For stable patients where the ordnance is impaled in an extremity, a nerve block is an acceptable alternative.2 Use of supplemental oxygen during the operation to remove the ordnance should be limited in order to eliminate this additional combustible source. Ensure that the “D” size oxygen tank is behind the barrier, where the non-participating staff is located, to prevent it from exploding if the ordnance detonates. Consider having the anesthesia provider remote to the patient but able to view monitoring devices.