Christensen PA.
J Spec Oper Med. Spring 2018;18(1):150-154.
Austere care of the wounded is challenging for all Western medical professionals-nurse, medic, or physician. There can be no doubt that working for the first time, either for a nongovernment organization or in the Special Forces, you will be taking care of wounded patients outside your training and experience. You must have the ability to adapt to and overcome lack of resources and equipment, and accept standards of treatment often very different and lower than that common in western hospitals. The International Committee of the Red Cross (ICRC) was asked to provide relief for the Pakistan Red Crescent in 1982 and set up the ICRC Hospital for Afghan War Wounded in Peshawar on the border to Afghanistan. This article relates how a western-trained young anesthetist on a ICRC surgical team experienced this, at the time, austere environment.
Drake SA, Wolf DA, Meininger JC, Cron SG, Reynold T, Wade CE, Holcomb JB
Trauma Surg Acute Care Open. 2017 May 31;2(1):e000106
This article describes a methodology to establish a trauma preventable death rate (PDR) in a densely populated county in the USA. Harris County has >4 million residents, encompasses a geographic area of 1777 square miles and includes the City of Houston, Texas. Although attempts have been made to address a national PDR, these studies had significant methodological flaws. There is no national consensus among varying groups of clinicians for defining preventability or documenting methods by which preventability is determined. Furthermore, although trauma centers routinely evaluate deaths within their hospital for preventability, few centers compare across regions, within the prehospital arena and even fewer have evaluated trauma deaths at non-trauma centers. Comprehensive population-based data on all trauma deaths within a defined region would provide a framework for effective prevention and intervention efforts at the regional and national levels. The authors adapted a military method recently used in Southwest Asia to determine the potential preventability of civilian trauma deaths occurring across a large and diverse population. The project design will allow a data-driven approach to improve services across the entire spectrum of trauma care, from prevention through rehabilitation.
Kotwal RS, Staudt AM, Trevino JD, Valdez-Delgado KK, Le TD, Gurney JM, Sauer SW, Shackelford SA, Stockinger ZT, Mann-Salinas EA.
Mil Med. 2018 Mar 1;183(suppl_1):134-145
Critically injured trauma patients benefit from timely transport and care. Accordingly, the provision of rapid transport and effective treatment capabilities in appropriately close proximity to the point of injury will optimize time and survival. Pre-transport tactical combat casualty care, rapid transport with en route casualty care, and advanced damage control resuscitation and surgery delivered early by small, mobile, forward-positioned Role 2 medical treatment facilities have potential to reduce morbidity and mortality from trauma. This retrospective review and descriptive analysis of trauma patients transported from Role 1 entities to Role 2 facilities in Afghanistan from 2008 to 2014 found casualties to be diverse in affiliation and delivered by various types and modes of transport. Air medical evacuation provided transport for most patients, while the shortest transport time was seen with air casualty evacuation. Although relatively little data were collected for air casualty evacuation, this rapid mode of transport remains an operationally important method of transport on the battlefield. For prehospital care provided before and during transport, continued leadership and training emphasis should be placed on the administration and documentation of tactical combat casualty care as delivered by both medical and non-medical first responders.
Lane I, Stockinger Z, Sauer S, Ervin M, Wirt M, Bree S, Gross K, Bailey J, Hodgetts BT, Mann-Salinas E
Mil Med. 2017 Mar;182(S1):32-40
This article forms part of a series that will explore the effect that Role 2 (R2) medical treatment facilities (MTFs) had on casualty care during the military campaign in Afghanistan and how we should interpret this to inform the capabilities in, and training for future R2 MTFs. Key aspects of doctrine which influence the effectiveness of R2 MTFs include timelines to care, patient movement capabilities, and MTF capabilities. The focus of this analysis was to review allied doctrine from the United States, United Kingdom, and the North Atlantic Treaty Organization to identify similarities and differences regarding employment of R2 related medical assets in the Afghan Theater, specifically for trauma care. Several discrepancies in medical doctrine persist among allied forces. Timelines to definitive care vary among nations. Allied nations should have clear taxonomy that clearly defines MTF capabilities within the combat casualty care system. The R2 surgical capability discrepancy between United States and North Atlantic Treaty Organization doctrine should be reconciled. Medical evacuation capabilities on the battlefield would be improved with a taxonomy that reflected the level of capability. Such changes may improve interoperability in a dynamic military landscape.
Staudt AM, Savell SC, Biever KA, Trevino JD, Valdez-Delgado KK, Suresh M, Gurney JM, Shackelford SA, Maddry JK, Mann-Salinas EA
Crit Care Nurse. 2018 Apr;38(2):e7-e15
BACKGROUND: En route care is the transfer of patients requiring combat casualty care within the US military evacuation system. No reports have been published about en route care of patients during transfer from a forward surgical facility (role 2) to a combat support hospital (role 3) for comprehensive care.
OBJECTIVE: To describe patients transferred from a role 2 to a role 3 US military treatment facility in Afghanistan.
METHODS: A retrospective review of data from the Joint Trauma System Role 2 Database was conducted. Patient characteristics were described by en route care medical attendants.
RESULTS: More than one-fourth of patients were intubated at transfer (26.9%), although at transfer fewer than 10% of patients had a base deficit of more than 5 (3.5%), a pH of less than 7.3 (5.2%), an international normalized ratio of more than 2 (0.8%), or temporary abdominal or chest closure (7.4%). The en route care medical attendant was most often a nurse (35.5%), followed by technicians (14.1%) and physicians (10.0%). Most patients (75.3%) were transported by medical evacuation (on rotary-wing aircraft).
CONCLUSION: This is the first comprehensive review of patients transported from a forward surgical facility to a more robust combat support hospital in Afghanistan. Understanding the epidemiology of these patients will inform provider training and the appropriate skill mix for the transfer of postsurgical patients within a combat setting.
Stevenson T, Carr DJ, Penn-Barwell JG, Ringrose TJ, Stapley SA
Injury. 2018 Mar 27 Epub ahead of print
INTRODUCTION: Gunshot wounding (GSW) is the second most common mechanism of injury in warfare after explosive injury. The aim of this study was to define the clinical burden of GSW placed on UK forces throughout the recent Iraq and Afghanistan conflicts.
METHODS: This study was a retrospective review of data from the UK Military Joint Theatre Trauma Registry (JTTR). A JTTR search identified records within the 12 year period of conflict between 19 Mar 2003 and 27 Oct 2014 of all UK military GSW casualties sustained during the complete timelines of both conflicts. Included cases had their clinical timelines and treatment further examined from time of injury up until discharge from hospital or death.
RESULTS: There were 723 casualties identified (177 fatalities, 546 survivors). Median age at the time of injury was 24 years (range 18-46 years), with 99.6% of casualties being male. Most common anatomical locations for injury were the extremities, with 52% of all casualties sustaining extremity GSW, followed by 16% GSW to the head, 15% to the thorax, and 7% to the abdomen. In survivors, the rate of extremity injury was higher at 69%, with head, thorax and abdomen injuries relatively lower at 5%, 11% and 6% respectively. All GSW casualties had a total of 2827 separate injuries catalogued. A total of 545 casualties (523 survivors, 22 fatalities) underwent 2357 recorded surgical procedures, which were carried out over 1455 surgical episodes between admission to a deployed medical facility and subsequent transfer to the Royal Centre for Defence Medicine (RCDM) in the UK. This gave a median of 3 (IQR 2-5) surgical procedures within a median of 2 (IQR 2-3) surgical episodes per casualty. Casualties had a combined length of stay (LoS) of 25 years within a medical facility, with a mean LoS in a deployed facility of 1.9 days and 14 days in RCDM.
CONCLUSION: These findings define the massive burden of injury associated with battlefield GSW and underscore the need for further research to both reduce wound incidence and severity of these complex injuries.
Zong ZW, Zhang LY, Qin H, Chen SX, Zhang L, Yang L, Li XX, Bao QW, Liu DC, He SH, Shen Y, Zhang R, Zhao YF, Zhong XZ; representing the PLA Professional Committee and Youth Committee on Disaster Medicine.
Collaborators: Bao JQ, Bao QW, Chen L, Chen SX, Du GF, Fan HJ, He Z, Huang J, Huang LS, Huo JT, Jing JJ, Kuai LP, Li N, Li XB, Li XD, Li XX, Li GD, Liu H, Liu TT, Niu YF, Qiao ZY, Qin H, Qiu ZW, Ren GH, Shan Y, Shen Y, Shu LX, Su JC, Su BX, Wang GD, Wang DW, Wang JX, Wang Q, Wang ZN, Wu W, Yang L, Yang JZ, Yang J, Yao Y, Yu B, Yue S, Zhang B, Zhang G, Zhang LY, Zhang L, Zhang R, Zhang YX, Zhang YF, Zhang Y, Zhao YF, Zhou SH, Zong ZW, Zuo HY.
Mil Med Res. 2018 Feb 13;5(1):6
The accurate assessment and diagnosis of combat injuries are the basis for triage and treatment of combat casualties. A consensus on the assessment and diagnosis of combat injuries was made and discussed at the second annual meeting of the Professional Committee on Disaster Medicine of the Chinese People's Liberation Army (PLA). In this consensus agreement, the massive hemorrhage, airway, respiration, circulation and hypothermia (MARCH) algorithm, which is a simple triage and rapid treatment and field triage score, was recommended to assess combat casualties during the first-aid stage, whereas the abbreviated scoring method for combat casualty and the MARCH algorithm were recommended to assess combat casualties in level II facilities. In level III facilities, combined measures, including a history inquiry, thorough physical examination, laboratory examination, X-ray, and ultrasound examination, were recommended for the diagnosis of combat casualties. In addition, corresponding methods were recommended for the recognition of casualties needing massive transfusions, assessment of firearm wounds, evaluation of mangled extremities, and assessment of injury severity in this consensus.