“Einsatzchirurgie”—experiences of German military surgeons in Afghanistan

Injury mechanisms and injury severity scores as determinants of urban terrorism-related thoracoabdominal injuries

Objective: Improving the care of injuries resulting from terrorist attacks requires understanding injury mechanisms in armed conflicts. The aim of this study was to identify injury characteristics in military personnel with thoracoabdominal combat injuries resulting from terrorist attacks in urban settings.

Material and Methods: A retrospective study of military personnel with thoracoabdominal injuries who were referred to a tertiary center after treating and stabilizing at a primary healthcare organization due to terror-related injuries in various urban regions of Turkey between June 2015 and December 2016 was performed.

Results: A total of 70 patients were included in this study, of whom 87.1% were injured by explosives and 12.9% (n= 9) had gunshot wounds (GSWs). Mean injury severity score (ISS) was 21, blood transfusion amount was 3.7 units, and mortality rate was 8.5%. Patients injured by explosives had most commonly abdominal and extremity injuries (31.1%), whereas isolated abdominal injuries (55.6%) were observed among patients with GSWs. There were no significant differences between the mechanisms of injuries and the ISS, blood transfusion, and mortality (p= 0.635, p= 0.634, and p= 0.770, respectively). A significant correlation was observed between the ISS and transfusion amounts (r= 0.548, p< 0.001). Mortality was significantly higher in those with a high ISS and those undergoing massive blood transfusions (p= 0.004 and p< 0.001, respectively).

Conclusion: Explosive injuries, concomitant vascular injuries, high ISS, and the need for massive transfusions increased the mortality rate in urban combat injuries. To quickly identify high-risk patients and improve the care of injuries, it is essential to use predictive models or scoring systems.

Laparotomy Due to War-Related Penetrating Abdominal Trauma in Civilians: Experience From Syria 2011-2017

OBJECTIVES

Penetrating abdominal trauma is one of the injuries that could affect civilians in wartime. This retrospective study investigates the commonly injured abdominal organs, and the impact of multiple injured organs on mortality.

METHODS

We reviewed the operating room (OR) logs of patients who presented to the surgical emergency department (SED) at Al-Mouwasat University Hospital with war-related abdominal penetrating trauma requiring exploratory laparotomy between April 1, 2011 and December 31, 2017.

RESULTS

Of 7826 patients with traumatic injuries, 898 patients (11.5%) required exploratory laparotomy. Of all patients who had an exploratory laparotomy (n = 898), 58 patients (6.5%) died in the perioperative period. Regarding complete laparotomies (n = 873 patients), small intestines, large intestines, and liver were the most commonly affected organs (36.4%, 33%, 22.9%, respectively). A total of 92 patients (10.2%) had negative laparotomy in which all the abdominal organs were not injured. The perioperative mortality rate (POMR) increased when more organs/organ systems were injured per patient reaching a peak at 3 organs/organ systems injuries with a POMR of 8.3%. POMR was highest in patients with musculoskeletal injuries (18.2%), followed by vascular injuries (11.8%), and liver injuries (7%).

CONCLUSIONS

The management of civilians' abdominal injuries remains a challenge for general and trauma surgeons, especially the civilian trauma team. The number and type of injured organs and their correlation with mortality should be considered during surgical management of penetrating abdominal injuries.

Spine surgery in the International Security Assistance Force Role 3 combat support hospital in Mazar-e-Sharif, northern Afghanistan, 2007-2014

OBJECTIVESince 2007, a continuous neurosurgery emergency service has been available in the International Security Assistance Force (ISAF) field hospital in Mazar-e-Sharif (MeS), Afghanistan. The object of this study was to assess the number and range of surgical procedures performed on the spine in the period from 2007 to 2014.METHODSThis is a retrospective analysis of the annual neurosurgical caseload statistics from July 2007 to October 2014 (92 months). The distribution of surgical urgency (emergency, delayed urgency, or elective), patient origin (ISAF, Afghan National Army, or civilian population), and underlying causes of diseases and injuries (penetrating injury, blunt injury/fracture, or degenerative disease) was analyzed. The range and pattern of diagnoses in the neurosurgical outpatient department from 2012 and 2013 were also evaluated.RESULTSA total of 341 patients underwent neurosurgical operations in the period from July 2007 to October 2014. One hundred eighty-eight (55.1%) of the 341 procedures were performed on the spine, and the majority of these surgeries were performed for degenerative diseases (127/188; 67.6%). The proportion of spinal fractures and penetrating injuries (61/188; 32.4%) increased over the study period. These spinal trauma diagnoses accounted for 80% of the cases in which patients had to undergo operations within 12 hours of presentation (n = 70 cases). Spinal surgeries were performed as an emergency in 19.8% of cases, whereas 17.3% of surgeries had delayed urgency and 62.9% were elective procedures. Of the 1026 outpatient consultations documented, 82% were related to spinal issues.CONCLUSIONSCompared to the published numbers of cases from neurosurgery units in the rest of the ISAF area, the field hospital in MeS had a considerably lower number of operations. In addition, MeS had the highest rates of both elective neurosurgical operations and Afghan civilian patients. In comparison with the field hospital in MeS, none of the other ISAF field hospitals showed such a strong concentration of degenerative spinal conditions in their surgical spectrum. Nevertheless, the changing pattern of spine-related diagnoses and surgical therapies in the current conflict represents a challenge for future training and material planning in comparable missions.

Concept and evaluation of the German War Surgery Course - Einsatzchirurgie-Kurs der Bundeswehr

INTRODUCTION

Military surgeons must be prepared to care for severe and complex life-threatening injuries rarely seen in the civilian setting. Typical civilian training and practice do not provide adequate exposure to the broad set of surgical skills required. The German Bundeswehr Medical Service has developed and refined the War Surgery Course (WSC) to meet this training gap. This article describes the recent experience with this readiness curriculum.

METHODS

Run annually since 1998, WSC consists nowadays of 5 days with 20 theoretical modules. Four sessions with standardised practical skills training use a live tissue porcine model, and the recently added cadaver-based Advanced Surgical Skills for Exposure in Trauma course. Sixteen military surgeons who participated in the WSC in January 2016 completed a survey of their self-rated readiness for 114 predefined emergency skills before and after completion, and provided an overall evaluation of the course.

RESULTS

Self-assessed readiness improved significantly over baseline for all areas covered in both the practical skills and theoretical knowledge portions of the WSC curriculum. Additionally, all participants rated the course as important and universally recommended it to other military surgeons preparing for missions.

CONCLUSIONS

The WSC course format was well received and perceived by learners as a valuable readiness platform. Ongoing evaluation of this course will enable data-driven evolution to ensure a maximum learning benefit for participants. With the increasing multinational nature of modern military missions, surgeons' training should follow international standards. Continuing evolution of military surgical training courses should further encourage the sharing and adoption of best educational practices.

[Near-infrared spectroscopy for the detection of traumatic intracranial hemorrhage: Feasibility study in a German army field hospital in Afghanistan]

Traumatic brain injury (TBI) is one of the most common causes of death in ordinary accidents, natural disasters, or warfare. The gold standard for diagnosis of TBI is the CT scan; a delay of diagnostics or medical care is the strongest independent predictor of mortality of TBI patients--particularly in the case of a surgically treatable intracranial hematoma. The proper classification of these patients is of major importance in situations where a CT is not accessible. A portable screening device that uses near-infrared spectroscopy (NIRS) technology allows a preliminary estimate of an intracranial hematoma. This study assessing practicability shows that the use of the device in a military medical rescue center (Kunduz, Afghanistan) is easy to learn and can be repeatedly used even under emergency room conditions. The technique can be applied in penetrating and blunt TBIs in the absence of an immediately available CT scan in rural areas, preclinically, under mass casualty conditions (e.g., in disaster situations) as well as in humanitarian crises or war zones. Nevertheless, further studies to assess the validity of this device are necessary.

[Spine surgery in a combat support hospital]

BACKGROUND AND AIM

From July 2007 to October 2014, neurosurgical services have been continuously available in a multinational Role 3 combat support hospital in Mazar-e-Sharif (MeS), Afghanistan. In this paper, we analyze a 7-year operative and outpatient spinal surgery caseload experience.

MATERIALS AND METHODS

The overall annual and monthly caseloads were determined. Additionally, the surgical cases were differentiated relating to the strength of the indication, the location of the surgical site, and the origin of the patients. The outpatient caseload and spectrum of the years 2012 and 2013 were also analyzed.

RESULTS

A total of 341 surgeries were performed and 188 of them were spinal surgeries (55.1 %). The vast majority of surgeries were performed for degenerative diseases (127/188; 67.6 %). The proportion of fractures and penetrating injuries (61/188; 32.4%) increased over the observation period. Eighty percent of the immediate and urgent surgeries (within 12 h; n = 70) were performed for these indications. 19.8 % of the surgeries were done as an emergency, whereas 17.3 % had delayed urgency, and 62.9 % were elective procedures. Of the 1026 outpatient consultations documented, 82 % of them were related to spinal diseases.

CONCLUSIONS

The overall caseload in addition to the distribution of location, strength of indication, and patient origin for MeS are significantly lower than that reported by other International Security Assistance Force (ISAF) nations in eastern and southern Afghanistan. In addition, the rate of elective surgeries and those carried out in civilian Afghan patients is highest in MeS. In comparison with MeS, none of the other ISAF military hospitals shows such a strong concentration of degenerative spinal conditions in their surgical spectrum. Nevertheless, the changing pattern of spine-related diagnoses and surgical therapies in the current conflict represents a challenge for future educational and material planning in comparable missions.

[Evaluation of interest in research among surgically active medical officers in the German Armed Forces]

BACKGROUND

Research in military medicine and in particular combat surgery is a broad field that has gained international importance during the last decade. In the context of increased NATO missions, this also holds true for the Bundeswehr (German Armed Forces); however, medical officers in surgery must balance research between their clinical work load, missions, civilian and family obligation.

MATERIAL AND METHODS

To evaluate engagement with and interest in research, a questionnaire was distributed among the doctors of the surgical departments of the Bundeswehr hospitals by the newly founded working group Chirurgische Forschung der Bundeswehr (surgical research of the Bundeswehr). Returned data were recorded from October 2013 to January 2014 and descriptive statistics were performed.

RESULTS

Answers were received from 87 out of 193 military surgeons (45 %). Of these 81 % announced a general interest in research with a predominance on clinical research in preference to experimental settings. At the time of the evaluation 32 % of the participants were actively involved in research and 53 % regarded it as difficult to invest time in research activities parallel to clinical work. Potential keys to increase the interest and engagement in research were seen in the implementation of research coordinators and also in a higher amount of free time, for example by research rotation.

CONCLUSION

Research can be regarded as having a firm place in the daily work of medical officers in the surgical departments of the Bundeswehr; however, the engagement is limited by time and structural factors. At the departmental level and in the command structures of the military medical service, more efforts are recommended in the future in order to enhance the engagement with surgical research. This evaluation should be repeated in the coming years as a measuring instrument and data should be compared in an international context.

Medical aspects of terrorist bombings - a focus on DCS and DCR

Although terrorist bombings have tormented the world for a long time, currently they have reached unprecedented levels and become a continuous threat without borders, race or age. Almost all of them are caused by improvised explosive devices. The unpredictability of the terrorist bombings, leading to simultaneous generation of a large number of casualties and severe "multidimensional" blast trauma require a constant vigilance and preparedness of every hospital worldwide. Approximately 1-2.6% of all trauma patients and 7% of the combat casualties require a massive blood transfusion. Coagulopathy is presented in 65% of them with mortality exceeding 50%. Damage control resuscitation is a novel approach, developed in the military practice for treatment of this subgroup of trauma patients. The comparison with the conventional approach revealed mortality reduction with 40-74%, lower frequency of abdominal compartment syndrome (8% vs. 16%), sepsis (9% vs. 20%), multiorgan failure (16% vs. 37%) and a significant reduction of resuscitation volumes, both crystalloids and blood products. DCS and DCR are promising new approaches, contributing for the mortality reduction among the most severely wounded patients. Despite the lack of consensus about the optimal ratio of the blood products and the possible influence of the survival bias, we think that DCR carries survival benefit and recommend it in trauma patients with exsanguinating bleeding.

A modern combat trauma

INTRODUCTION

The world remains plagued by wars and terrorist attacks, and improvised explosive devices (IED) are the main weapons of our current enemies, causing almost two-thirds of all combat injuries. We wished to analyse the pattern of blast trauma on the modern battlefield and to compare it with combat gunshot injuries.

MATERIALS AND METHODS

Analysis of a consecutive series of combat trauma patients presenting to two Bulgarian combat surgical teams in Afghanistan over 11 months. Demographics, injury patterns and Injury Severity Scores (ISS) were compared between blast and gunshot-injured casualties using Fisher's Exact Test.

RESULTS

The blast victims had significantly higher median ISS (20.54 vs 9.23) and higher proportion of ISS>16 (60% vs 33.92%, p=0.008) than gunshot cases. They also had more frequent involvement of three or more body regions (47.22% vs 3.58%, p<0.0001). A significantly higher frequency of head (27.27% vs 3.57%), facial (20% vs 0%) and extremities injuries (85.45% vs 42.86%) and burns (12.72% vs 0%) was noted among the victims of explosion (p<0.0001). Based on clinical examination and diagnostic imaging, primary blast injury was identified in 24/55 (43.6%), secondary blast injury in 37 blast cases (67.3%), tertiary in 15 (27.3%) and quaternary blast injury (all burns) in seven (12.72%).

CONCLUSIONS

Our results corroborate the 'multidimensional' injury pattern of blast trauma. The complexity of the blast trauma demands a good knowledge and a special training of the military surgeons and hospital personnel before deployment.

Lessons learned from the experience of visceral military surgeons in the French role 3 Medical Treatment Facility of Kabul (Afghanistan): an extended skill mix required

OBJECTIVE

To evaluate the activity of visceral surgeons assigned to the Medical Treatment Facility (MTF) (role 3) in Kabul International Airport (KAIA) and identify the skills and qualifications required by these specialists.

PATIENTS AND METHODS

Between July 2009 and December 2010, all the patients operated by the visceral surgeons were eligible for inclusion in this study. They were International Security and Assistance Force (ISAF), Afghan National Security Forces (ANSF) soldiers, non-afghan civilians personnel and local nationals (LNs). They sustained war-related injuries, non-war related trauma emergencies, non-trauma related emergencies or had elective surgical care. The mechanisms and types of injuries, the affected organs and the surgical procedures were collected.

RESULTS

Over the period of study, the visceral surgeons treated 261 over 971 patients (26.9%) achieving a total of 438 surgical procedures. Thirty one percent of these procedures were war-related, 26% non-war related, 24.2% non-trauma related emergencies and 18.1% elective surgery. Non-trauma related emergencies and elective surgery required the same skills as in civilian practice. War-related injuries and non-war related trauma emergencies were more challenging. Combined injuries represented 56% of the cases requiring damage control resuscitation procedures and/or treatment of severe burns. Life-threatening thoracic or vascular injuries (30%) required life-saving emergency surgical procedures.

CONCLUSION

A visceral surgeon in a role 3 MTF should master a wide range of skills and expertise to be able to deal with many complex situations, in particular life-threatening situations such as thoracic and vascular wounds. A comprehensive surgical training programme for surgeons in abroad deployment (Advance Course for Deployment Surgery - CACHIRMEX) has been designed and settled up in 2007 to provide these necessary skills. The feedback obtained from each previous deployment demonstrates that the advanced course for deployment surgery provides visceral surgeons the necessary skills required to deliver surgical healthcare in a role 3 MTF. However, a regular assessment of this programme is mandatory to ensure that this training stays appropriate and contributes to better outcomes and a decreased mortality rate.

Changes in surgical workload at the JF Med Gp Role 3 Hospital, Camp Bastion, Afghanistan, November 2008-November 2010

INTRODUCTION

The operative workload at the surgical facility in Camp Bastion, Afghanistan, has previously been reported for the two-year period 1 May 2006 to 1 May 2008. There have since been considerable changes not only in the casualty rates, but also in the injury patterns encountered. Severe wounds from improvised explosive devices (IEDs) have become the signature injury of the insurgency. We present recent data for the surgical activity at the Joint Forces Medical Group Role 3 Hospital, Camp Bastion, for the two-year period 1 November 2008 to 1 November 2010.

PATIENTS AND METHODS

A retrospective analysis of the operating theatre logbooks was undertaken for the period 1 November, 2008 to 1 November, 2010.

RESULTS

During the study period a total of 4276 cases required 5737 surgical procedures. Compared with the previously reported series from May 2006 to 2008, this represents a 2.6-fold increase in the surgical workload of the hospital. There has been a 5.7-fold increase in the number of amputations (483 during this study period, 8.4% all operative procedures), and for the lower limbs these have become increasingly proximal (48% all amputations were above-knee lower limb amputations). During the study period there were also significant increases in the frequency of perineal injuries as well as the numbers of cases involving 5 or more surgeons.

DISCUSSION

The surgical workload at the Role 3 Hospital, Camp Bastion, Afghanistan is increasing. This is a result not only of increasing casualty numbers but also of increasingly severe injury patterns. With the growing use of powerful IEDs, traumatic lower limb amputations in particular are becoming more common, and are increasingly associated with significant pelvic and perineal injury. These complex injury patterns necessitate a multi-surgeon approach, and it is important these trends are noted for future planning of medical support to military operations in Afghanistan.