Role 3 Transfer For Neurosurgical Evaluation & Care

Neurosurgical care in a combat theater is a limited resource and often requires air transport to get patients to the closest neurosurgeon or even Computed Tomography (CT) for diagnosis and treatment. Both over- and under-utilization should be avoided.

COALITION Casualties

- Coalition casualties may require transfer for formal evaluation with a CT scan and/or a neurosurgeon when they:
  - continue to have a GCS < 14 (mild TBI needs further evaluation in coalition casualties if the GCS does not return to GCS of 15).
  - are confused or have continued cognitive deficits.
- The MACE2 is validated for determining the presence of an mTBI and should be used as an initial screening tool for to evaluate mTBI. It should not be used to determine worsening intracranial injury.15-17
- All coalition casualties should be referred for neurosurgical evaluation if they have:
  - Penetrating brain injury
  - Open skull fracture
  - Moderate or severe brain injury
  - Head trauma AND unexplained neurologic deficit s

HOST NATION (HN) CASUALTIES

- Management of host nation casualties should be in accordance with medical rules of eligibility (MEDROE) established for the area of responsibility. TBI management and neurosurgical care of HN casualties are MEDROE dependent. Providers should care to the best of their capabilities for HN TBI patients and involve the theater Trauma Medical Director (TMD) and neurosurgery (NS) early in the management.
- When MEDROE permits, moderate brain injury in HN casualties should be referred to Role 3 facilities with neurosurgical capability for definitive care.
- All patients should ethically receive equal care; however, the realities of combat are that HN casualties with severe brain injury have a poor prognosis when follow-on care is not available after discharge from the military MTF. The decision to transfer HN casualties with severe brain injury to Role 3 is based on mission, tactical situation, and resource availability and is ideally preceded by direct communication and discussion with the TMD and neurosurgeon.
- Depending on the severity of TBI, considerations for transfer of HN casualties to HN facilities after Role 3 MTF care can be complicated, multifactorial, and dependent on current MEDROEs. HN patients may not receive optimal care after leaving the military MTF, which adds to the complexity of decision-making for the care of these patients. For patients with severe TBI and poor prognosis, palliative care at the in-theatre MTF may be most appropriate. These decisions should be made in the context of TBI severity and the available continuum of care for the patient in their nation of origin. Discussions with the theater neurosurgeon, TMD, and command elements can aid in this difficult decision.