Missed injuries in combat casualties: Lessons from Iraq and Afghanistan

A Quantitative and Qualitative Literature Analysis of the Orthopedic Surgeons' Experience: Reflecting on 20 Years in the Global War on Terror

INTRODUCTION

After over 20 years of war in the Middle East, orthopedic injuries have been among the most prevalent combat-related injuries, accounting for 14% of all surgical procedures at Role 2/3 (R2/R3) facilities according to the DoD Trauma Registry. To further delineate the role of the deployed orthopedic surgeon on the modern battlefield, a retrospective review was performed highlighting both quantitative and qualitative analysis factors associated with orthopedic surgical care during the war in the Middle East.

METHODS

A retrospective review was conducted of orthopedic surgeons in the Middle East from 2001 to 2021. A comprehensive literature search was conducted using the PubMed and Embase databases using a two-reviewer strategy. Articles were compiled and reviewed using Covidence. Inclusion criteria included journal articles focusing on orthopedic injuries sustained during the Global War on Terror (GWoT) in an adult U.S. Military population. In the event of a conflict, a third author would determine the relevance of the article. For the remaining articles, a full-text review was conducted to extract relevant predetermined quantitative data, and the Delphi consensus method was then utilized to highlight relevant qualitative themes.

RESULTS

The initial search yielded 1,226 potentially relevant articles. In all, 40 studies ultimately met the eligibility criteria. With the consultation of previously deployed orthopedic surgeons at the Walter Reed National Military Medical Center, a retrospective thematic analysis of the 40 studies revealed five themes encompassing the orthopedic surgeons experience throughout GWoT. These themes include unique mechanisms of orthopedic injury compared to previous war injuries due to novel weaponry, differences in interventions depending on R2 versus R3 locations, differences in injuries from those seen in civilian settings, the maintained emphasis on humanitarian aspect of an orthopedic surgeon's mission, and lastly relation of pre-deployment training to perceived deployed success of the orthopedic surgeons. From this extensive review, we found that explosive mechanisms of injury were greatly increased when compared to previous conflicts and were the etiology for the majority of orthopedic injuries sustained. With the increase of complex explosive injuries in the setting of improved body armor and overall survival, R2/3 facilities showed an increased demand for orthopedic intervention including debridement, amputations, and external fixation. Combat injuries sustained during the GWoT differ in the complications, management, and complexity when compared to civilian trauma. "Humanitarian" cases made up a significant number of operative cases for the deployed orthopedic surgeon. Lastly, heterogeneous training opportunities were available prior to deployment (fellowship, combat extremity surgical courses, and dedicated pre-deployment training), and the most commonly identified useful training was learning additional soft-tissue coverage techniques.

CONCLUSION

These major themes indicate an emphasis on pre-deployment training and the strategic positioning of orthopedic surgeons to reflect the changing landscape of musculoskeletal trauma care. Moving forward, these authors recommend analyzing the comfort and perceived capability of orthopedic surgeons in these unique military environments to best prepare for a changing operational format and the possibility of future peer-peer conflicts that will likely lead to a lack of medical evacuation and prolonged field care.

Analysis of Missed Skeletal Injuries Detected Using Whole-Body Bone Scan Applied to Trauma Patients: A Case-Control Study

(1) Background: Skeletal injuries may be missed in patients presenting multiple traumas during initial assessment. A whole-body bone scan (WBBS) may aid the detection of missed skeletal injuries, but the current level of research in this regard is insufficient. Thus, this study aimed to investigate whether a WBBS is useful for the detection of missed skeletal injuries in patients with multiple traumas. (2) Methods: This retrospective, single-region, trauma center study was conducted at a tertiary referral center from January 2015 to May 2019. The rate of missed skeletal injuries detected via WBBSs was evaluated, and factors that could influence the outcome were analyzed and divided into missed and not-missed groups. (3) Results: A total of 1658 patients with multiple traumas who underwent WBBSs were reviewed. In the missed group, the percentage of cases with an Injury Severity Score (ISS) ≥ 16 was higher than the not-missed group (74.66% vs. 45.50%). The rate of admission route through surgery and embolization was high in the missed group. Moreover, the proportion of patients that experienced shock in the missed group was higher than that in the not-missed group (19.86% vs. 3.51%). In univariate analysis, ISS ≥ 16, admission route through surgery and embolization, orthopedic surgery involvement, and shock were related to missed skeletal injuries. ISS ≥ 16 was determined to be statistically significant in multivariate analysis. Additionally, a nomogram was constructed based on multivariable analysis. (4) Conclusions: Missed skeletal injuries were significantly associated with several statistical factors, and a WBBS can be used as a screening method to detect missed skeletal injuries in patients with multiple blunt traumas.

Incidence and Epidemiology of Traumatic Tympanic Membrane Rupture: A National Trauma Data Bank Analysis

The incidence of traumatic tympanic membrane rupture (TTMR) has increased over recent decades. The association of certain external injury causes and bone fracture patterns with TTMR is anecdotal. It has been suggested that a diagnosis of TTMR may be missed during the acute trauma admission. The authors sought to evaluate the incidence of TTMR according to external injury cause and evaluate the association of skull fracture patterns with TTMR using a national trauma database. A cross-sectional analysis of trauma encounters was conducted using the National Trauma Data Bank (NTDB) from 2008 to 2015. Demographic and injury data were abstracted. Poisson regression was used to determine the incidence rate ratios of tympanic membrane rupture by external injury cause and logistic regression was used to estimate odds ratios (OR) of TTMR by skull fracture type. A total of 8214 patients were identified with TTMR during acute admission. The majority were on average 30 years old, 76% male, 71% White, had a mean Injury Severity Score of 14, and 42% were admitted to level I centers. The incidence rate ratio was only higher in lightning related injuries [5.262; 95% confidence interval (CI): 4.194-6.602] when using those caused by explosives as a reference. Basilar skull (OR: 12.95; 95% CI: 12.095-12.866) and cranial vault (OR: 2.938; 95% CI: 2.647-3.260) fractures were most associated with TTMR. The high incidence TTMR in association with certain external causes of injury and types of skull fractures should drive screening in the acute setting in order to increase detection and reduce morbidity from missed injuries.

Obstructive sleep apnea among survivors of combat-related traumatic injury: a retrospective cohort study

STUDY OBJECTIVES

Obstructive sleep apnea is prevalent among military members despite fewer traditional risk factors. We sought to determine the incidence and longitudinal predictors of obstructive sleep apnea in a large population of survivors of combat-related traumatic injury and a matched control group.

METHODS

Retrospective cohort study of military service members deployed to conflict zones from 2002-2016 with longitudinal follow-up in the Veterans Affairs and Military Health Systems. Two cohorts of service members were developed: (1) those who sustained combat injuries and (2) matched, uninjured participants.

RESULTS

17,570 service members were retrospectively analyzed for a median of 8.4 years. After adjustment, traumatic brain injury (hazard ratio [HR] 1.39, 95% confidence interval [CI] 1.20-1.60), posttraumatic stress disorder (HR 1.24, 95% CI 1.05-1.46), depression (HR 1.52, 95% CI 1.30-1.79), anxiety (HR 1.40, 95% CI 1.21-1.62), insomnia (HR 1.71, 95% CI 1.44-2.02), and obesity (HR 2.40, 95% CI 2.09-2.74) were associated with development of obstructive sleep apnea. While combat injury was associated with obstructive sleep apnea in the univariate analysis (HR 1.25, 95% CI 1.17-1.33), the direction of this association was reversed in the multivariable model (HR 0.74, 95% CI 0.65-0.84). In a nested analysis, this was determined to be due to the effect of mental health diagnoses.

CONCLUSIONS

The incidence of obstructive sleep apnea is higher among injured service members (29.1 per 1,000 person-years) compared to uninjured service members (23.9 per 1,000 person-years). This association appears to be driven by traumatic brain injury and the long-term mental health sequelae of injury.

CITATION

Haynes ZA, Stewart IJ, Poltavskiy EA, et al. Obstructive sleep apnea among survivors of combat-related traumatic injury: a retrospective cohort study. J Clin Sleep Med. 2022;18(1):171-179.

Situational Awareness: Forecasting Successful Military Medical Teams

INTRODUCTION

Military healthcare providers working in military interprofessional healthcare teams (MIHTs) require situational awareness (SA) to ensure safe and efficacious patient care. This study aimed to explore SA in MIHTs to understand how SA can be reinforced and maintained in MIHTs. The research team set out to answer two questions: "What aspects of individual and team SA are particularly important for MIHTs?" and "How can we enable military healthcare providers to be effective MIHTs members with robust SA?".

METHODS

This study used Grounded Theory methodology collecting perspectives from 30 study participants from various backgrounds, including 11 different healthcare professions from the U.S. Army, Air Force, and Navy. Each study participant had experiences participating in, leading one, or leading many MIHTs. Data were collected in three cycles and analyzed within each cycle until saturation was reached.

RESULTS

Five themes were robustly represented in the data set regarding SA: (1) contextually informed adaptability, (2) readiness, (3) trust, (4) communication, and (5) mission focus.

CONCLUSIONS

The urgency often faced by MIHTs brings SA and the principles that underpin SA into sharper focus. The SA themes identified in this research may provide insight into training effectiveness, team strengths and weaknesses, and team performance.

Risk factors of persistent insomnia among survivors of traumatic injury: a retrospective cohort study

STUDY OBJECTIVES

Insomnia is a diagnosis with broad health and economic implications that has been increasingly recognized in military service members. This trend was concurrent with an increase in traumatic wartime injuries. Accordingly, we sought to determine longitudinal predictors of persistent insomnia in combat veterans who sustained traumatic injuries.

METHODS

Retrospective cohort study of service members deployed to conflict zones from 2002-2016, with longitudinal follow-up in the Veterans Affairs and Military Health Systems. Two cohorts were derived: 1) service members who sustained traumatic injuries and 2) an age, sex, and service component matched cohort of uninjured service members who deployed to a combat zone. Insomnia was defined using International Classification of Diseases Ninth Revision or International Classification of Diseases Tenth Revision Clinical Modification codes.

RESULTS

The final population of 17,374 service members was followed from date of injury (or date of matched participant's injury) for a median of 8.4 (IQR 5.3-10.7) years. Service members with traumatic injury were at significantly greater risk of developing insomnia than uninjured service members (HR=1.43, 95% CI 1.30-1.58) after adjustment. Traumatic brain injury (TBI) was associated with insomnia when compared to patients without TBI in the multivariable model: mild/unclassified TBI (HR=2.07, 95% CI 1.82-2.35), moderate/severe/penetrating TBI (HR=2.43, 95% CI 2.06-2.86). Additionally, burn injury (HR=1.95, 95% CI 1.47-2.59) and amputation (HR=1.61, 95% CI 1.26-2.06) significantly increased the risk of a diagnosis.

CONCLUSIONS

Traumatic injuries significantly predicted a diagnosis of insomnia after controlling for mental health disorders. Our findings strongly suggest the need for long-term surveillance of sleep disorders in trauma survivors.