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

Effectiveness of a specific trauma training on war-related truncal injury management: A pre-post study

BACKGROUND

Non-Compressible Torso Hemorrhage (NCTH) is the leading cause of preventable death in combat casualty care. To enhance the French military surgeons' preparedness, the French Military Health Service designed the Advanced Course for Deployment Surgery (ACDS) in 2008. This study evaluates behavioral changes in war surgery practice since its implementation.

METHODS

Data were extracted from the OPEX® registry, which recorded all surgical activity during deployment from 2003 to 2021. All patients treated in French Role 2 or 3 Medical Treatment Facilities (MTFs) deployed in Afghanistan, Mali, or Chad requiring emergency surgery for NCTH were included. The mechanism of injury, severity, and surgical procedures were noted. Surgical care produced before (Control group) and after the implementation of the ACDS course (ACDS group) were compared.

RESULTS

We included 189 trauma patients; 99 in the ACDS group and 90 in the Control group. Most injuries were combat-related (88 % of the ACDS and 82 % of the Control group). The ACDS group had more polytrauma (42% vs. 27 %; p= 0.034) and more e-FAST detailed patients (35% vs. 21 %; p= 0.044). Basics in surgical trauma care were similar between both groups, with a tendency in the ACDS group toward less digestive diversion (n= 6 [6 %] vs. n= 12 [13 %]; p= 0.128), more temporary closure with abdominal packing (n= 17 [17 %] vs. n= 10 [11 %]; p= 0.327), and less re-operation for bleeding (n= 0 [0 %] vs. n= 5 [6 %]; p= 0.046).

CONCLUSION

The French model of war trauma course succeeded in keeping specialized surgeons aware of the basics of damage control surgery. The main improvements were better use of preoperative imaging and better management of seriously injured patients.

French mobile neurosurgical unit: a retrospective analysis of 22 years of mission

INTRODUCTION

The French mobile neurosurgical unit (MNSU) is used to provide specific support to remote military medicosurgical units deployed in foreign theatres. If a neurosurgical casualty is present, the Role 2 team may request the MNSU to be deployed directly from France. The deployed neurosurgeon can then perform surgery in Role 2 or decide to evacuate the casualty and perform surgery in Role 4 in France. We provide an epidemiological analysis of MNSU missions between 2001 and 2023 and investigate the value of the MNSU for the French Armed Forces.

METHODS

We conducted a retrospective case series that included patients managed by the MNSU from 1 January 2001 to 31 January 2023. We collected epidemiological data (eg, age, military or civilian status, delay between transmission and takeoff, origin of the injury and mission location), clinical records (aetiologies of the injury and disease), data on surgical intervention (operator nature and type of surgery) and data on postoperative outcomes recorded at the time of discharge from hospital.

RESULTS

51 patients were managed by the MNSU. 36 (70.5%) and 3 (5.8%) patients underwent surgery on Role 2 and Role 4, respectively. 39 (76.9%) interventions were due to traumatic injury, 4 (7.8%) due to hydrocephalus, 4 (7.8%) due to vascular causes, 3 (5.9%) due to tumour and 1 (2%) due to spine degeneration. In 30 (76.9%) of these cases, the first operator was a neurosurgeon from the MNSU, whereas in the remaining 9 (23.1%) cases, procedures were initially performed by a non-neurosurgeon.

CONCLUSION

The MNSU contribution to D1 casualties' strategic evacuation (STRATEVAC) is important. The MNSU provides additional support for STRATEVAC during the reorganisation of French Armed Forces engaged in several fronts. With the return of high-intensity wars, the French MNSU must develop and adjust for the management of massive influxes of casualties.

Nine years of surgical activity in the deployed French military role 2 medical treatment facility in Mali

INTRODUCTION

In January 2013, France launched a military operation in Mali, which ended in August 2022. This study aimed to analyse the global activity performed by a surgical team within the role 2 medical treatment facility (MTF) deployed in Gao during this period, in order to adapt medical battlefield support and combat casualty care teaching.

METHODS

A retrospective study was conducted using the French surgical database OpEX (French Military Health Service) from January 2013 to August 2022. All patients operated on were included.

RESULTS

During this period, 1298 patients with a median age of 29 (range: 23-38) years were included. Among them, 229 (17.6%) underwent a combat-related trauma surgery (CRTS), 234 (18.0%) underwent a non-CRTS, 167 (12.9%) underwent a non-trauma-related surgery and 668 (51.5%) underwent a scheduled surgery in the context of medical supply to the population.Among the CRTS group, 195 (85.2%) patients underwent an orthopaedic procedure, 73 (31.8%) required a general surgery. Finally, 15 (6.6%) wounded required a specialised surgery.

CONCLUSIONS

In line with the activity described in the role 2 MTF deployed in other contemporary asymmetric conflicts, this activity is moderate, especially if only combat-related injuries are considered; medical support to the population occupied most of the surgical activity. For CRTS, most of the traumas are limb traumas. Other traumas are composed of various lesions, which are often life-threatening. This fact imposes the presence of an orthopaedic surgeon with the appropriate equipment, as well as a general surgeon with a wide range of skills, in asymmetric conflicts.

Early Evaluation of a New French Surgery Course in the Best Practice of Dealing With Major Incidents and Mass Casualty Events

OBJECTIVE

The main objective of this study is to evaluate the impact of a nationwide 5-month course aimed to prepare surgeons for Major Incidents through the acquisition of key knowledge and competencies. Learners' satisfaction was also measured as a secondary objective.

DESIGN

This course was evaluated thanks to various teaching efficacy metrics, mainly based on Kirkpatrick's hierarchy in medical education. Gain in knowledge of participants was evaluated by multiple-choice tests. Self-reported confidence was measured with 2 detailed pre and post training questionnaires.

SETTING

Creation in 2020 of a nationwide, optional and comprehensive Surgical Training in War and Disaster Situation as part of the French surgery residency program. In 2021, data was gathered regarding the impact of the course on participants' knowledge and competencies.

PARTICIPANTS

The study included 26 students in the 2021 cohort (13 residents and 13 practitioners).

RESULTS

Mean scores were significantly higher in the post-test compared to the pre-test, showing significant increase in participants' knowledge during the course: 73,3% vs. 47,3% respectively (p ≤ 0.001). Average learners' confidence scores to perform technical procedures showed at least a +1-point increase on the Likert scale for 65% of items tested (p ≤ 0.001). 89% of items showed at least a +1-point increase on the Likert scale when it came to average learners' confidence score on dealing with complicated situations (p ≤ 0.001). Our post-training satisfaction survey showed that 92% of all participants have noticed the impact of the course on their daily practice.

CONCLUSION

Our study shows that the third level of Kirkpatrick's hierarchy in medical education was reached. This course therefore appears to be meeting the objectives set by the Ministry of Health. Being only 2 years old, it is on the road to gathering momentum and further development.

Animal model-based simulation training for three emergent and urgent operations of penetrating thoracic injuries

PURPOSE

To develop animal models of penetrating thoracic injuries and to observe the effects of the animal model-based training on improving the trainees' performance for emergent and urgent thoracic surgeries.

METHODS

With a homemade machine, animal models of lung injuries and penetrating heart injuries were produced in porcine and used for training of chest tube drainage, urgent sternotomy, and emergent thoracotomy. Coefficient of variation of abbreviated injury scale and blood loss was calculated to judge the reproducibility of animal models. Five operation teams from basic-level hospitals (group A) and five operation teams from level III hospitals (group B) were included to be trained and tested. Testing standards for the operations were established after thorough literature review, and expert questionnaires were employed to evaluate the scientificity and feasibility of the testing standards. Tests were carried out after the training. Pre- and post-training performances were compared. Post-training survey using 7-point Likert scale was taken to evaluate the feelings of the trainees to these training approaches.

RESULTS

Animal models of the three kinds of penetrating chest injuries were successfully established and the coefficient of variation of abbreviated injury scale and blood loss were all less than 25%. After literature review, testing standards were established, and expert questionnaire results showed that the scientific score was 7.30 ± 1.49, and the feasibility score was 7.50 ± 0.89. Post-training performance was significantly higher in both group A and group B than pre-training performance. Post-training survey showed that all the trainees felt confident in applying the operations and were generally agreed that the training procedure were very helpful in improving operation skills for thoracic penetrating injury.

CONCLUSIONS

Animal model-based simulation training established in the current study could improve the trainees' performance for emergent and urgent thoracic surgeries, especially of the surgical teams from basic-level hospitals.

Military Orthopedic Surgeons Are Not Just Traumatologists

INTRODUCTION

Each French military orthopedic surgeon is both an orthopedic surgeon and a trauma surgeon. Their mission is to support the armed forces in France and on deployment. The aim of this study was to describe the type of orthopedic surgery performed for the armed forces in France. Our hypothesis was that scheduled surgery was more common than trauma surgery.

METHODS

We conducted a retrospective descriptive analysis of the surgical activity for military patients in the orthopedic surgery departments of the four French military platform hospitals. All surgical procedures performed during 2020 were collected. We divided the procedures into the following categories: heavy and light trauma, posttraumatic reconstruction surgery, sports surgery, degenerative surgery, and specialized surgery. Our primary endpoint was the number of procedures performed per category.

RESULTS

A total of 827 individuals underwent surgery, 91 of whom (11%) were medical returnees from deployment. The surgeries performed for the remaining 736 soldiers present in metropolitan France (89%) consisted of 181 (24.6%) trauma procedures (of which 86.7% were light trauma) and 555 (75.4%) scheduled surgery procedures (of which 60.8% were sports surgery). Among the medical returnees, there were 71 traumatology procedures (78%, of which 87.3% were light traumatology) and 20 procedures corresponding to surgery usually carried out on a scheduled basis (22%, of which 95% were sports surgery).

CONCLUSION

Military orthopedic surgeons are not just traumatologists; their activity for the armed forces is varied and mainly consists of so-called programmed interventions.

Aeromedical Evacuations Within the French Armed Forces: Analysis of 2,129 Patients

INTRODUCTION

The doctrine of medical support during French military operations is based on a triptych: forward medical stabilization, forward damage control surgery, and early strategic aeromedical evacuation (Strategic-AE). The aim of this study was to describe the last piece, the evacuation process of the French Strategic-AE.

METHODS

We conducted a retrospective cohort analysis using patient records from 2015 to 2017. All French service members requiring an air evacuation from a foreign country to a homeland medical facility were included. Data collected included age, medical diagnosis, priority categorization, boarding location, distance from Paris, type of plane and flight, medical team composition, timeline, and dispatch at arrival.

RESULTS

We analyzed 2,129 patients evacuated from 71 countries, most from Africa (1,256), the Middle East (382), and South America (175). Most patients (1,958) were not severely injured, although some considered priority (103) or urgent (68). Diagnoses included disease (48.6%), nonbattle injuries (43%), battle stress (5.3%), and battle injuries (3%). 246 Strategic-AE used medical teams in flight, 136 of them in a dedicated Falcon aircraft. The main etiologies for those evacuations were battle injuries (24%), cardiovascular (15.4%), infections (8%), and neurologic (7.3%). The median time of management for urgent patients was about 16 hours but longer for priority patients (26 hours). Once in France, 1,146 patients were admitted to a surgery department and 96 to an intensive care unit.

CONCLUSION

This is the first study to analyze the French Strategic-AE system, which is doctrinally unique when compared to its North Atlantic Treaty Organization allies. North Atlantic Treaty Organization allies favor care in the theatre in place of the French early Strategic-AE. However, in the event of a high intensity conflict, a combination of these two doctrines could be useful.

French civilian surgical expertise still inadequately prepared for mass casualties 3 years after major terror attacks in Paris (2015) and Nice (2016)

BACKGROUND

Three years after the terror attacks in Paris and Nice, this study aims to determine the level of interest, the technical skills and level of surgical activity in exsanguinating trauma care for a nonselected population of practicing French surgeons.

METHODS

A questionnaire was sent between July and December 2017 to French students and practicing surgeons, using the French Surgical Colleges' mailing lists. Items analyzed included education, training, interest and clinical activity in trauma care and damage-control surgery (DCS).

RESULTS

622 questionnaires were analyzed and was composed of 318 (51%) certificated surgeons, of whom 56% worked in university teaching hospitals and 47% in Level I trauma centers (TC1); 44% were digestive surgeons and 7% were military surgeons. The mean score of 'interest in trauma care' was 8/10. Factors associated with a higher score were being a resident doctor (p = 0.01), a digestive surgeon (p = 0.0013), in the military (p = 1,71 × 10) and working in TC1 (p = 0.034). The mean "DCS techniques knowledge" score was 6.2/10 and factors significantly associated with a higher score were being a digestive surgeon (respectively, p = 0.0007 and p = 0.001) and in the military (respectively p = 1.74 × 10 and p = 3.94 × 10). Reported clinical activity in trauma and DCS were low. Additional continuing surgical education courses in trauma were completed by 23% of surgeons.

CONCLUSION

French surgeons surveyed showed considerable interest in trauma care and treatment. Despite this, and regardless of surgical speciality, their theoretical and practical knowledge of necessary DCS skills remain inadequate.

LEVEL OF EVIDENCE

Level III, Study Type Survey.

Injury patterns and causes of death in 953 patients with penetrating abdominal war wounds in a civilian independent non-governmental organization hospital in Lashkargah, Afghanistan

Background

Management of penetrating abdominal war injuries centers upon triage, echeloned care, and damage control. A civilian hospital based in a war zone can rarely rely upon these principles because it normally has limited resources and lacks rapid medical evacuation. We designed this study to describe organ injury patterns and factors related to mortality in patients with penetrating abdominal war injuries in a civilian hospital in an active war zone in Afghanistan, examine how these findings differ from those in a typical military setting, and evaluate how they might improve patients’ care.

Methods

We reviewed the records of all patients admitted at the Lashkargah “Emergency” hospital with penetrating abdominal injuries treated from January 2006 to December 2016. Demographic and clinical data were recorded; univariate and multivariate analyses were used to identify variables significantly associated with death.

Results

We treated 953 patients for penetrating abdominal injury. The population was mainly civilian (12.1% women and 21% under 14). Mean age was 23 years, and patients with blast injuries were younger than in the other groups. The mechanism of injury was bullet injury in 589 patients, shell injury in 246, stab wound in 97, and mine injury in 21. The most frequent abdominal lesion was small bowel injury (46.3%). Small and large bowel injuries were the most frequent in the blast groups, stomach injury in stab wounds. Overall mortality was 12.8%. Variables significantly associated with death were age > 34 years, mine and bullet injury, length of stay, time since injury > 5 h, injury severity score > 17, and associated injuries.

Conclusions

Epidemiology and patterns of injury in a civilian hospital differ from those reported in a typical military setting. Our population is mainly civilian with a significant number of women and patients under 14 years. BI are more frequent than blast injuries, and gastrointestinal injuries are more common than injuries to solid organs. In this austere setting, surgeons need to acquire a wide range of skills from multiple surgical specialties. These findings might guide trauma and general surgeons treating penetrating abdominal war wounds to achieve better care and outcome.

Medical evacuations of members of the French armed forces for infectious diseases in foreign operations

OBJECTIVES

Medical evacuations from foreign settings are a major health and strategic problem for the armed forces. This work aimed to study the characteristics of French military evacuations due to infectious diseases.

PATIENTS AND METHODS

We performed a retrospective study based on the registers of the French operational military staff for health to assess the characteristics of the strategic medical evacuation of French armed forces members on missions abroad between January 1, 2011 and December 31, 2016.

RESULTS

Out of 4633 included cases, 301 medical evacuations (6.5%) were carried out due to infectious situations. More than half of patients were repatriated to surgical wards (162 patients, 54%), 108 patients (36%) to medical wards, 21 patients (7%) to intensive care units, six patients (2%) to an armed forces medical center, and four files (1%) were incomplete. Among infectious emergencies, malaria led to 30 evacuations (10%) including 11 to intensive care units and one death before evacuation. Infectious diseases requiring medical evacuation were most often mild and community-acquired. Most soldiers were evacuated without medical assistance.

CONCLUSIONS

Infectious diseases during missions and medical repatriations carried out for infectious reasons are important epidemiological indicators to monitor. They make it possible to adapt preventive measures, training, and diagnostic and therapeutic tools which can be made available to front-line military physicians.

Description of trauma among French service members in the Department of Defense Trauma Registry: understanding the nature of trauma and the care provided

BACKGROUND

Since 2001, the French Armed Forces have sustained many casualties during the Global War on Terror; however, even today, there is no French Military trauma registry. Some French service members (SMs) were treated in US Military Medical Treatment Facilities (MTFs) and were recorded in the US Department of Defense Trauma Registry (DoDTR). Our objective was to conduct a descriptive analysis of the injuries sustained by French SMs reported in the DoDTR and subsequent care provided to them to assist in understanding the importance of building a French Military trauma registry.

METHODS

Using DoDTR data collected from 2001 to 2017, a retrospective descriptive analysis was conducted. We identified 59 French SMs treated in US MTFs. The characteristics of the SMs' demographics, injuries, care provided to them, and discharge outcomes were summarized.

RESULTS

Among the 59 French SMs identified, 46 (78%) sustained battle injuries (BIs) and 13 (22%) sustained nonbattle injuries (NBIs). There were 47 (80%) SMs injured in Afghanistan (Opération Pamir), while 12 (20%) were injured in Opération Chammal in Iraq and Syria. Explosives accounted for 52.5% of injuries, while 25.4% were due to gunshot wounds; all were BIs. The majority of reported injuries were penetrating (59.3%), most of which were BIs (71.7%). The mean Injury Severity Score for BIs was 12 (SD = 8.9) compared to 6 (SD = 1.7) for NBIs. Around half of SMs (n = 30; 51%) were injured in Afghanistan between the years 2008-2010. Among a total of 246 injuries sustained by 59 patients, extremities were the body part most prone to BIs followed by the head and face. Four SMs died after admission (6.8%).

CONCLUSIONS

The DoDTR provides extensive data on trauma injuries that can be used to inform injury prevention and clinical care. The majority of injuries sustained by French SMs were BIs, caused by explosives, and predominantly occurring to the extremities; these findings are similar to those of other studies conducted in combat zones. There is a need to establish a French Military trauma registry to improve the combat casualty care provided to French SMs, and its creation may benefit from the DoDTR model.

Acute neurosurgical management of traumatic brain injury and spinal cord injury in French armed forces during deployment

This article aims to describe the French concept regarding combat casualty neurosurgical care from the theater of operations to a homeland hospital. French military neurosurgeons are not routinely deployed to all combat zones. As a consequence, general surgeons initially treat neurosurgical wounds. The principle of this medical support is based on damage control. It is aimed at controlling intracranial hypertension spikes when neuromonitoring is lacking in resource-limited settings. Neurosurgical damage control permits a medevac that is as safe as can be expected from a conflict zone to a homeland medical treatment facility. French military neurosurgeons can occasionally be deployed within an airborne team to treat a military casualty or to complete a neurosurgical procedure performed by a general surgeon in theaters of operation. All surgeons regardless of their specialty must know neurosurgical damage control. General surgeons must undergo the required training in order for them to perform this neurosurgical technique.

Four years of orthopaedic activities in Chinese Role 2 Hospital of eastern Mali peacekeeping area

INTRODUCTION

The Chinese Role 2 Hospital (CHN-Role 2H) Medical Treatment Facility (MTF) was founded in July 2013 as part of the Chinese commitment to Multidimensional Integrated Stabilization Mission in Mali (MINUSMA). It provides medical care for approximately 5200 personnel of the whole Sector East of MINUSMA including UN military personnel, UN police and UN civilian staff. The aim of this study was to determine the orthopaedic surgical activity over a 4-year period to facilitate the training of future Chinese military surgical teams.

MATERIALS AND METHODS

Surgical records of all patients operated on at the CHN-Role 2H between 28 March 2014 to 28 March 2018 were identified, and all orthopaedic activity were analysed.

RESULTS

During this period, 1190 patients underwent 2024 surgical procedures. Orthopaedic procedures represented 961/2024 (47.5%) of all the procedures. Battle injury (BI) represented 43% of patients. Improvised explosive devices (IEDs) were responsible for 15.8 % casualties. Fractures (49%) and soft tissue injures (43%) were the most common injuries, with 61% of the fractures being open. Damage control surgery including debridement (23.52%) and external fixation (17.90%) were the most frequently performed interventions.

CONCLUSION

Orthopaedic surgery is the most frequently performed surgery in the CHN-Role 2H in Mali. The complexity and severity of injuries demonstrate the urgent need for tailored training and extended skill sets for deploying military orthopaedic surgeons.

Chinese expert consensus on echelons treatment of thoracic injury in modern warfare

The emergency treatment of thoracic injuries varies of general conditions and modern warfare. However, there are no unified battlefield treatment guidelines for thoracic injuries in the Chinese People's Liberation Army (PLA). An expert consensus has been reached based on the epidemiology of thoracic injuries and the concept of battlefield treatment combined with the existing levels of military medical care in modern warfare. Since there are no differences in the specialized treatment for thoracic injuries between general conditions and modern warfare, first aid, emergency treatment, and early treatment of thoracic injuries are introduced separately in three levels in this consensus. At Level I facilities, tension pneumothorax and open pneumothorax are recommended for initial assessment during the first aid stage. Re-evaluation and further treatment for hemothorax, flail chest, and pericardial tamponade are recommended at Level II facilities. At Level III facilities, simple surgical operations such as emergency thoracotomy and debridement surgery for open pneumothorax are recommended. The grading standard for evidence evaluation and recommendation was used to reach this expert consensus.

Developing a hospital-based combat injury registry at the Chinese Peacekeeping Level 2 Military Hospital in GAO, Mali

BACKGROUND

Having served more than 4000 personnel including the peacekeeping troops, UN police and civilian staff, the Chinese Peacekeeping Level 2 Military Hospital has accumulated 1235 inpatient medical records in 4 years. Assessment of the records stored in the CHN L2 identified that the data collected by different teams were incoherent and highlighted the need for implementation of a hospital-based combat injury registry and the establishment of a combat injury surveillance system.

METHODS

A one-page, 21-item registry form was designed to collect general information about the injuries, including such data as demographics, injury event, severity, diagnosis and treatment, and outcome. All relevant personnel was required to undergo a 2-day training in order to master the use of the registry form. The new registry form was used to collect the data on all of the cases recorded in the CHN L2 between 26 April 2014 and 31 March 2017.

RESULTS

Analysis of the collected data identified improvised explosive device as the most common (44.95%) mechanism of combat injury in Sector East of MINUSMA. Anefis, the centre of the UN logistic transit, was identified as the location where most of the combat injuries (42.20%) occurred. Based on these results, certain suggestions that addressed this threat were given to the Operation department in Sector East of MINUSMA.

CONCLUSION

A hospital-based combat injury registry was successfully developed and implemented in the Chinese Peacekeeping Level 2 Hospital. It can provide data to support the policy changes to minimise the impact of combat injuries on peacekeeping troops. The designed registry form provides more accurate estimates of the magnitude of the morbidity due to different causes in the battlefield and lays a foundation for an injury surveillance system.

The 7th French Airborne Forward Surgical Team experience of surgical support to the population of a low-income country: a prospective study on 341 patients with short-term follow-up

BACKGROUND

The 7th Airborne Forward Surgical Team (FST) has deployed to Chad in 2015 and 2016, in support of French military forces. Humanitarian surgical care is known to represent a significant part of the surgical activity in such missions, but to date limited data have been published on the subject.

METHODS

All surgical patients from a civilian host population treated by the FST during these missions have been prospectively included. Indications, operative outcomes and postoperative outcomes were evaluated.

RESULTS

During this period, the FST operated on 358 patients. Humanitarian surgical care represented 95% of the activity. Most patients (92.7%) were operated for elective surgery. Emergencies and infectious diseases represented, respectively, 7.3% and 9.1% of cases. The mean length of stay (LOS) was three days (2-4), and the median follow-up was 30 days (22-34). Mortality rate was 0.6% and morbidity was 5.6%. Parietal surgery had no significant complication and had shorter LOS (p<0.001). Emergent surgeries were more complicated (p<0.01) and required more reoperations (p<0.05). Surgical infectious cases had longer LOS (p<0.01).

CONCLUSIONS

Humanitarian surgical care can be provided without compromising the primary mission of the medical forces. Close surveillance and follow-up allowed favourable outcomes with low morbidity and mortality rates. Humanitarian care is responsible for a considerable portion of the workload in such deployed surgical teams. Accounting for humanitarian care is essential in the planning and training for such future medical operations.

Preparing Japanese surgeons for potential mass casualty situations will require innovative and systematic programs

INTRODUCTION

The ongoing state of global geo-political instability means that it is prudent to prepare civilian surgeons to manage major military-type trauma. Japan has enjoyed a prolonged period of peace and consequently it is unlikely that surgeons will have been exposed to a sufficient volume of cases. This study reviews the state of trauma training and preparedness in Japan and reviews the trauma workload of a major Japanese emergency medical center and compared with a major South African trauma center with the intention of quantifying and comparing the time needed to gain adequate exposure to major trauma at the two centers.

MATERIALS AND METHODS

The literature describing the surgical burden from a number of recent military missions was reviewed and the core surgical skills to manage military-type injuries were identified. We then went on to review all patients admitted to both Kurashiki Central Hospital (KCH) and Pietermaritzburg Metropolitan Trauma Service (PMTS) following trauma between the period September 2015 and August 2016. The burden of trauma at each center was quantified and the number of core surgical competencies or procedures performed at each center was then reviewed. These were then compared with the number of the core procedures which were performed on the reported military missions.

RESULTS

Three reports on military surgical missions were reviewed. These came from the Dutch, French and British military surgical services. The average number of each core procedures performed on each reported military surgery mission are tabulated in the text. The most common procedures were wound debridement and orthopedic fixation, followed by trauma laparotomy, neck exploration and thoracotomy. During the 12 month study period, 309 trauma patients were admitted to KCH. Of which 206 (67%) were male, and the mean age was 57 years. There were 10 penetrating injuries and 299 blunt injuries. Of the penetrating injuries there were no gunshot wounds. The mechanisms of injury for blunt trauma were as follows: Road traffic accidents (RTAs); 141 (47%), fall; 136 (46%) and other injuries; 22 (7%). In the same period, 2887 trauma patients were admitted by the PMTS. There were 1244 cases (43%) of penetrating trauma and 1644 cases (57%) of blunt trauma in PMTS. The mechanisms of injury for penetrating trauma were as follows: stab wounds (SWs); 955 (77%), gunshot wounds (GSWs); 252 (20%), and other injuries; 37 (3%) and for blunt trauma were as follows: assault; 739 (45%), RTAs; 669 (41%), fall; 166 (10%), and other injuries; 70 (4%). The exposure to all the key competencies required to manage trauma is overwhelmingly greater in South Africa than in Japan. The length of time needed to obtain an equivalent trauma exposure to that achieved in South Africa, working in Japan is prohibitively long.

CONCLUSION

Trauma training in Japan is hamstrung by a lack of clinical material as well as by systematic factors. Training a trauma surgeon is difficult. Developing a trauma system in the country may help address some of these deficits. South Africa in contrast has a huge burden of trauma and sufficient infrastructure to ensure that surgeons working there have adequate exposure to major trauma. Developing an academic exchange program between Japan and South Africa may allow for the transfer of trauma experience and skills between the two countries.

Military neurosurgery in operation: experience in the French role-3 medical treatment facility of Kabul

BACKGROUND

In 2009, during the war in Afghanistan, the increasing number of head injuries led to the deployment of a military neurosurgeon at the Kabul International Airport (KaIA) medical treatment facility, in March 2010. The main goal of this study was to depict the neurosurgical activity in this centre and to analyse its different aspects.

METHOD

A retrospective study of all the neurosurgical patients treated in KaIA from March 2010 to June 2013.

RESULTS

Three hundred and seventy-three interventions performed by the neurosurgeon deployed were reported for 373 surgeries, in 335 patients, representing 10.6 % of the overall surgical activity of the centre. Among the 69 interventions performed on soldiers, 57 surgeries were undertaken in emergency (82.6 %), while 12 were elective procedures (17.4 %). On the other hand, 289 surgeries were performed in civilian Afghans, with 126 emergency procedures in (43.6 %), against 163 elective interventions (56.4 %). Among the 44.5 % (n = 149) of the traumatic casualties, cerebral lesions represented 28.7 % (n = 96) and spinal lesions 12.4 % (n = 42). Ninety patients had multiple injuries. Additionally, patients without trauma accounted for 55.5 % (n = 186) of the overall population. Thus, 49 % (n = 164) were operated on for non-traumatic lesion of the spine. These were mostly civilian Afghans treated under medical aid to the population (90.2 %, n = 148/164).

CONCLUSIONS

The military neurosurgeon had two roles in KaIA: both to support the armed forces and to manage medical aid to the civilian population. This study gives food for thought on the neurosurgical needs in modern warfare, and on the skills required for the military neurosurgeon.

Surgical challenges in a new theater of modern warfare: The French role 2 in Gao, Mali

INTRODUCTION

On January 11th 2013, France launched Operation Serval in Mali following Resolution 2085 of the Security Council of the United Nations. Between January and March 2013, more than 4000 French soldiers were deployed to support the Malian National Army and the African Armed Forces.

METHODS

All of the patients who had surgery during Operation Serval were entered into a computerised database. Patients' demographic data (age, sex, status) and types of performed surgical procedures (specialties, injury mechanisms) were recorded.

RESULTS

268 patients were operated on in Gao's Role 2 with a total of 296 surgeries. Among those operated on, 40% were Malian civilians, 24% were French soldiers, and 36% were soldiers of the International Coalition Forces. The majority of the surgeries were orthopaedic, and visceral surgeries were common as well, representing 43% of the total surgeries. Specialised surgical procedures including neurosurgery, thoracic, and vascular surgery were also performed. Forty percent of the surgeries were scheduled. War-related traumatic surgeries represented 22% of the surgical procedures, with non-war related surgeries and non-trauma emergency surgeries making up the rest.

CONCLUSION

this analysis confirms the specific characteristic of asymmetric warfare that it results in a relatively reduced number of war-related casualties. Forward surgical teams have to deal with a wide range of injuries requiring several surgical specialties. Surgeries dedicated to medical aid provided to the population also represented an important part of the surgical activity. Because of the diversity and the technicality of the surgical procedures in Role 2, surgeons had to be trained in war surgery covering all of the surgical specialties, while they maintained their specific skills. In France in 2007, the French Military Health Service Academy (École du Val-de-Grâce, Paris, France) offered an advanced course in surgery for deployment in combat zones, with a special focus on damage control surgeries and the management of mass casualties incidents.

Level I academic trauma center integration as a model for sustaining combat surgical skills: The right surgeon in the right place for the right time

INTRODUCTION

As North Atlantic Treaty Organization (NATO) countries begin troop withdrawal from Afghanistan, military medicine needs programs for combat surgeons to retain the required knowledge and surgical skills. Each military branch runs programs at various Level I academic trauma centers to deliver predeployment training and provide a robust trauma experience for deploying surgeons. Outside of these successful programs, there is no system-wide mechanism for nondeploying military surgeons to care for a high volume of critically ill trauma patients on a regular basis in an educational environment that promotes continued professional development. We hypothesize that fully integrated military-civilian relationship regional Level I trauma centers provide a surgical experience more closely mirroring that seen in a Role III hospital than local Level II and Level III trauma center or medical treatment facilities.

METHODS

We characterized the Level I trauma center practice using the number of trauma resuscitations, operative trauma/acute care surgery procedures, number of work shifts, operative density (defined as the ratio of operative procedures/days worked), and frequency of educational conferences. The same parameters were collected from two NATO Role III hospitals in Afghanistan during the peak of Operation Enduring Freedom. Data for two civilian Level II trauma centers, two civilian Level III trauma centers, and a Continental United States Military Treatment Facility without trauma designation were collected.

RESULTS

The number of trauma resuscitations, number of 24-hour shifts, operative density, and educational conferences are shown in the table for the Level I trauma center compared with the different institutions. Civilian center trauma resuscitations and operative density were highest at the Level I trauma center and were only slightly lower than what was seen in Afghanistan. Level II and III trauma centers had lower numbers for both. The Level I trauma center provided the most frequent educational opportunities.

CONCLUSION

In a Level I academic trauma center integrated program, military and civilian surgeons have the same clinical and educational responsibilities: rounding and operating, managing critical care patients, covering trauma/acute care surgery call, and mentoring surgery residents in an integrated residency program. The Level I trauma center experience most closely mimics the combat surgeon experience seen at NATO Role III hospitals in Afghanistan compared with other civilian trauma centers. At high-volume Level I trauma centers, military surgeons will have a comprehensive trauma practice, including dedicated educational opportunities. We recommend integrated programs with Level I academic trauma centers as the primary mechanism for sustaining military combat surgical skills in the future.

French surgical experience in the role 3 medical treatment facility of KaIA (Kabul International Airport, Afghanistan): the place of the orthopedic surgery

INTRODUCTION

In 2009, the French took command of the Medical Hospital (MH) or Role 3 Hospital at KaIA (Kabul International Airport) within the framework of its role in the military mission Operation Pamir in Afghanistan. The goal of this study was to analyze the volume of orthopedic surgical activity for the last four years, to identify its specificities and to improve training of military orthopedic surgeons.

HYPOTHESIS

Orthopedic surgery is the most important activity in the field and surgeons must adapt to situations and injuries that are different from those encountered in France.

PATIENTS AND METHODS

All patients operated on between July 2009 and June 2013 were prospectively included in an electronic database. The analysis included the number of surgical acts and patients, the types of injuries and the surgical procedures.

RESULTS

Forty-three percent (n=1875) of 4318 procedures involved orthopedic surgery. Half of these were emergencies. French military personnel represented 17% of the patients, local civilians 47% and children 17%. Half of the procedures involved the soft tissues, 20% were for bone fixation and 10% for surgery of the hand. The rate of amputation was 6%. The diversity of the surgical acts was high ranging from emergency surgery to surgical reconstruction.

DISCUSSION

The activity of this Role 3 facility is comparable to that of other Role 3 facilities in Afghanistan, with an important percentage of acts involving medical assistance to the local population and scheduled surgeries as well as primary and/or secondary management of the wounded. The diversity of surgical acts confirms the challenge of training military orthopedic surgeons within the context of the hyperspecialization of the civilian sector. Specific training has been organized in France by the École du Val de Grâce. Specific continuing education is also necessary.

LEVEL OF EVIDENCE

IV (retrospective review).