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Bryce-Alberti M, Bosché M, Benavente R, Chowdhury A, Steel LB, Winslow K, Bain PA, Le T, Hamzah R, Ilkhani S, Pratt M, Carroll M, Nunes Campos L, Anderson GA. Examining nonmilitary and nongovernmental humanitarian surgical capacity and response in armed conflicts: A scoping review of the recent literature. Surgery 2024:S0039-6060(24)00364-7. [PMID: 38955644 DOI: 10.1016/j.surg.2024.05.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2024] [Revised: 05/10/2024] [Accepted: 05/18/2024] [Indexed: 07/04/2024]
Abstract
BACKGROUND Armed conflicts pose a burden on health care services. We sought to assess the surgical capacity and responses of nonmilitary and nongovernmental humanitarian responders in armed conflicts through proxy indicators to identify strategies to address surgical needs. METHODS We searched 6 databases for articles/studies from January 1, 2013, to March 10, 2023. We included articles detailing the surgical capacity of nonmilitary, nongovernmental organizations operating in armed conflicts. We defined surgical capacity through indicators including the type and number of surgical procedures; number of operating rooms, surgical beds, surgeons, anesthesiologists, and surgical equipment; and type of anesthesia employed. RESULTS We screened 2,187 abstracts and 279 full texts and included 30 articles/studies. Our sample covered 23 countries and 17 surgical specialties. Most publications focused on surgical capacity assessment (63.3%, 19/30) and surgical and clinical outcomes (63.3%, 19/30). Most articles/studies reported surgical capacity indicators at the hospital (56.7%, 17/30) and multinational (26.7%, 8/30) levels. The number (86.7%, 26/30) and type (76.7%, 23/30) of surgical procedures performed were the most commonly reported. More than one half of the articles (53.3%, 16/30) described strategies to meet surgical needs in armed conflicts. Most strategies addressed information management (68.8%, 11/16), health workforce (62.5%, 10/16), and service delivery (62.5%, 10/16). CONCLUSION This review collated common approaches for strengthening health care services in armed conflicts. Several articles emphasized strategies for improving information management, service delivery, and workforce capacity. Hence, we call for standardization of response protocols and multilevel collaborations to maintain or even scale up surgical capacity in armed conflicts.
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Affiliation(s)
- Mayte Bryce-Alberti
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA; Department of Surgery, Rutgers New Jersey Medical School, Newark, NJ.
| | | | | | | | - Lili B Steel
- Division of Nutritional Sciences, Cornell University, Ithaca, NY
| | - Kiana Winslow
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA
| | - Paul A Bain
- Countway Library, Harvard Medical School, Boston, MA
| | - Thalia Le
- Drexel College of Medicine, Philadelphia, PA
| | - Radzi Hamzah
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA
| | - Saba Ilkhani
- Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Malerie Pratt
- Department of Surgery, Brigham and Women's Hospital, Boston, MA
| | - Madeleine Carroll
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA; Department of Surgery, Yale University School of Medicine, New Haven, CT
| | - Letícia Nunes Campos
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA; Faculty of Medical Sciences, Universidade de Pernambuco, Recife, PE, Brazil
| | - Geoffrey A Anderson
- Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Department of Surgery, Brigham and Women's Hospital, Boston, MA; US Air Force Reserves, 439th Aeromedical Staging Squadron, Westover Air Reserve Base, Chicopee, MA
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Aryankalayil J, Shields M, Baird M, Gunasingha RMKD, Pullen WM, Johnson M, Fitch J, Uber I, Worlton T. Evaluation of a Military Global Health Engagement Mission for Critical Wartime Surgical Specialty Readiness. Mil Med 2024:usae242. [PMID: 38758070 DOI: 10.1093/milmed/usae242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Revised: 03/29/2024] [Accepted: 04/23/2024] [Indexed: 05/18/2024] Open
Abstract
INTRODUCTION Surgical volume at Military Treatment Facilities (MTFs) has been gradually decreasing for roughly the past 2 decades. The Knowledge, Skills, and Abilities (KSA) Clinical Readiness Program linked surgical volume and readiness using a tool known as the KSA metric. However, the extent to which military medical missions contribute to the readiness of critical wartime specialties has not been evaluated using this metric. METHODS In this study, a retrospective analysis was conducted using the surgical case logs from the US Naval Ship (USNS) Comfort missions in 2018 and 2019. The comprehensive case log data were categorized by year, surgeon, procedure, and location. The analysis focused on providing detailed descriptive statistics, including percentages pertaining to the types of procedures performed during these missions. The 2018 mission was 11 weeks in duration, and supported activities in Ecuador, Peru, Colombia, and Honduras. The USNS Comfort mission in 2019 lasted 6 months (June-November 2019), and visited 12 countries in Central America, South America, and the Caribbean. RESULTS The 2019 mission case log, spanning 6 months, was evaluated using the KSA score in order to assess readiness and compare against 6 months of MTF KSA values within the same calendar year. In 2019, the orthopedic surgeon aboard the USNS Comfort had a total KSA score of 44,006, but the 6-month USNS Comfort mission only contributed 5,364 points (12% of the annual score). The general surgery practice aboard the USNS Comfort produced lower KSA scores compared to each surgeon's respective MTF practice (Table III). Analyzing the cases logged by general surgeons also highlights minimal surgical diversity during these missions, with more than 90% of cases being hernia repairs or laparoscopic cholecystectomies (Table I). In addition, 35% of total procedures performed in 2018 and 2019 were performed laparoscopically. CONCLUSIONS The analysis of operative data from the 2019 USNS Comfort mission, in comparison with the surgeons' work at their respective MTFs, reveals limited benefit in the ability of hospital-ship missions to bolster surgical readiness as measured by the KSA score. However, this is not a reflection on the value of Global Health Engagement (GHE) itself but a review of the way in which it is leveraged to support surgical readiness. Military surgeons participate in GHE as part of a larger strategy to strengthen relationships with partner nations, improve military medical force interoperability, and bolster partner nation medical capacity and capabilities. The KSA score offers an excellent tool to compare readiness metrics across significantly different GHE missions, and facilitates the opportunity for future prospective studies to improve case volume, diversity, and ultimately readiness.
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Affiliation(s)
- Joseph Aryankalayil
- General Surgery Department, Walter Reed National Military Medical Center, Bethesda, MD 20889, USA
- Department of Surgery, Uniformed Services University, Bethesda, MD 20889, USA
| | - Margaret Shields
- Department of Surgery, Uniformed Services University, Bethesda, MD 20889, USA
| | - Michael Baird
- Department of Surgery, Uniformed Services University, Bethesda, MD 20889, USA
- Orthopedic Surgery Department, Walter Reed National Military Medical Center, Bethesda, MD 20889, USA
| | | | - W Michael Pullen
- Orthopedic Surgery Department, Medical University of South Carolina, Charleston, SC 29425, USA
| | - Mark Johnson
- Fleet Surgical Team Four, Portsmouth, VA 23708, USA
| | - Jamie Fitch
- General Surgery Department, Naval Medical Center Camp Lejeune, Jacksonville, NC 28542, USA
| | - Ian Uber
- Eyes, Ear, Nose, and Throat Department, Naval Medicine Readiness and Training Command, Portsmouth, VA 28542, USA
| | - Tamara Worlton
- General Surgery Department, Walter Reed National Military Medical Center, Bethesda, MD 20889, USA
- Department of Surgery, Uniformed Services University, Bethesda, MD 20889, USA
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McWhirter KK, April MD, Fisher AD, Wright FL, Rizzo JA, Corley JB, Getz TM, Schauer SG. Blood consumption in the Role 2 setting: A Department of Defense Trauma Registry analysis. Transfusion 2024; 64 Suppl 2:S42-S49. [PMID: 38361432 DOI: 10.1111/trf.17741] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Revised: 01/19/2024] [Accepted: 01/19/2024] [Indexed: 02/17/2024]
Abstract
BACKGROUND The Role 2 setting represents the most far-forward military treatment facility with limited surgical and holding capabilities. There are limited data to guide recommendations on blood product utilization at the Role 2. We describe the consumption of blood products in this setting. STUDY DESIGN AND METHODS We analyzed data from 2007 to 2023 from the Department of Defense Trauma Registry (DODTR) that received care at a Role 2. We used descriptive and inferential statistics to characterize the volumes of blood products consumed in this setting. We also performed a secondary analysis of US military, Coalition, and US contractor personnel. RESULTS Within our initial cohort analysis of 15,581 encounters, 17% (2636) received at least one unit of PRBCs or whole blood, of which 11% received a submassive transfusion, 4% received a massive transfusion, and 1% received a supermassive transfusion. There were 6402 encounters that met inclusion for our secondary analysis. With this group, 5% received a submassive transfusion, 2% received a massive transfusion, and 1% received a supermassive transfusion. CONCLUSIONS We described volumes of blood products consumed at the Role 2 during recent conflicts. The maximum number of units consumed among survivors exceeds currently recommended available blood supply. Our findings suggest that rapid resupply and cold-stored chain demands may be higher than anticipated in future conflicts.
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Affiliation(s)
- Kelly K McWhirter
- 2nd Stryker Brigade Combat Team, 4th Infantry Division, Fort Carson, Colorado, USA
- Shenandoah University, Winchester, Virginia, USA
| | - Michael D April
- 14th Field Hospital, Fort Stewart, Georgia, USA
- Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
| | - Andrew D Fisher
- Department of Surgery, University of New Mexico School of Medicine, Albuquerque, New Mexico, USA
- Texas National Guard, Austin, Texas, USA
| | - Franklin L Wright
- Department of Surgery, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Julie A Rizzo
- Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
- Brooke Army Medical Center, JBSA Fort Sam Houston, Texas, USA
| | - Jason B Corley
- Medical Capability Development Integration Directorate, JBSA Fort Sam Houston, Texas, USA
| | - Todd M Getz
- Center for Combat and Battlefield (COMBAT) Research, Aurora, Colorado, USA
| | - Steven G Schauer
- Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
- Center for Combat and Battlefield (COMBAT) Research, Aurora, Colorado, USA
- Department of Anesthesiology, University of Colorado School of Medicine, Aurora, Colorado, USA
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
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Ghabi A, De Geofroy B, Gorin C, Candoni P, Blomme E, Ezanno AC. Surgical Experiences From a French Forward Surgical Team on Board of the Landing Helicopter Deck MISTRAL. Mil Med 2023; 188:e2891-e2895. [PMID: 36794819 DOI: 10.1093/milmed/usad031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2022] [Revised: 10/03/2022] [Accepted: 01/25/2023] [Indexed: 02/17/2023] Open
Abstract
INTRODUCTION Onboard surface ships like destroyers and frigates, there is ROLE 1, whereas on a three-landing helicopter deck (LHD) and aircraft carrier, there is ROLE 2, with a surgical team. At sea, evacuation takes more time than on any other theater of operation. It also costs more money, so we wanted to analyze how many patients have been maintained onboard, thanks to ROLE 2. Moreover, we wanted to analyze the surgical activities on the LHD MISTRAL ROLE 2. METHODS We performed a retrospective observational study. We retrospectively analyzed all surgery cases performed on the MISTRAL between January 1, 2011, and June 30, 2022. During this period, there were only 21 months with a surgical team ROLE 2 onboard. We included all consecutive patients who underwent minor or major surgery onboard. RESULTS A total of 57 procedures were performed during the period, involving 54 patients (52 males and 2 females) with an average age of 24.4 ± 1.9 years. The most frequent pathology was abscess (pilonidal sinus abscess, axillary abscess, or perineal abscess) (n = 32; 59.2%). Only two Medical Evacuations were conducted because of surgery; the other patients who underwent surgery were maintained onboard. CONCLUSIONS We have shown that using ROLE 2 aboard the LHD MISTRAL decreases the use of Medical Evacuation. It also helps to perform surgery under better conditions for our sailors. Doing everything to keep sailors onboard seems to be an important point.
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Affiliation(s)
- Ammar Ghabi
- Department of Orthopedic, Trauma and Reconstructive Surgery, Laveran Military Hospital, Marseille 13013, France
| | - Bernard De Geofroy
- Department of Orthopedic, Trauma and Reconstructive Surgery, Laveran Military Hospital, Marseille 13013, France
| | - Cécile Gorin
- Department of Psychiatry, St Anne Military Hospital, Toulon 83000, France
| | - Philippe Candoni
- Department of Orthopedic, Trauma and Reconstructive Surgery, Laveran Military Hospital, Marseille 13013, France
| | - Edouard Blomme
- Department of Orthopedic Surgery, Begin Military Hospital, Saint-Mandé 94160, France
| | - Anne Cecile Ezanno
- Department of Visceral and Endocrine Surgery, Begin Military Hospital, Saint-Mandé 94160, France
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Sauder M, Kornblith L, Gurney J, Elkbuli A. Trauma care during times of conflict: Strategic targeting of medical resources & operational logistics to save more lives. Injury 2023; 54:271-273. [PMID: 36379738 DOI: 10.1016/j.injury.2022.11.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2022] [Revised: 09/30/2022] [Accepted: 11/07/2022] [Indexed: 11/10/2022]
Affiliation(s)
- Matthew Sauder
- NSU NOVA Southeastern University School of Allopathic Medicine, Fort Lauderdale, FL, USA
| | - Lucy Kornblith
- Department of Surgery, Division of Trauma and Surgical Critical Care, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, CA, USA; University of San Francisco, San Francisco, CA, USA
| | - Jennifer Gurney
- US Army Institute of Surgical Research and the DoD Joint Trauma System, San Antonio, TX, USA
| | - Adel Elkbuli
- Department of Surgery, Division of Trauma and Surgical Critical Care, Orlando Regional Medical Center, Orlando, FL, USA, 86 W Underwood St., Orlando, FL 32806, USA; Department of Surgical Education, Orlando Regional Medical Center, Orlando, FL, USA.
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Ponomarenko OV, Pysanko VV, Mialkovskyi DS, Tkachuk DV. THE MANAGEMENT OF THE VICTIMS WITH GUNSHOT WOUNDS OF THE EXTREMITIES WITH EXTENSIVE DEFECTS OF THE SOFT TISSUES AT THE LEVEL OF QUALIFIED MEDICAL CARE. CASE-SERIES. WIADOMOSCI LEKARSKIE (WARSAW, POLAND : 1960) 2023; 76:1227-1232. [PMID: 37364077 DOI: 10.36740/wlek202305214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/28/2023]
Abstract
OBJECTIVE The aim: To highlight the original experience of diagnosis and treatment of patients with gunshot wounds of the extremities with extensive defects of the soft tissues. PATIENTS AND METHODS Materials and methods: The total number of treated patients with massive gunshot wounds from February 2022 to March 2023 was 60 males. Basic labo¬ratory tests, X-rays of the affected limbs were performed to all patients. USS of the vessels with color Doppler was performed to those casualties who had no peripheral pulses on the wounded extremity. All injured persons underwent wound debridement and fasciotomy on the day of admission, 8 more casualties underwent surgical interventions on the major vessels and nerves. RESULTS Results: Good treatment outcomes for patients with extensive soft tissue injury were achieved by early surgical intervention to remove non-viable tissue. Limb preservation was achieved in 98.3% of cases. CONCLUSION Conclusions: The study's conclusion emphasizes the importance of a multidisciplinary approach to treating patients with gunshot wounds to the limbs with extensive soft tissue injury. Early surgical interventions with the removal of non-viable tissues are necessary for good outcomes. Revascularization of the affected limb is essential in case of major vessel injury if there is no thread to the life.
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Affiliation(s)
- Olena V Ponomarenko
- ZAPORIZHZHIA STATE MEDICAL AND PHARMACEUTICAL UNIVERSITY, ZAPORIZHZHIA, UKRAINE
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Vladychuk V, Nikolakea M, Matiashova L, Tsagkaris C. Medical supplies for musculoskeletal infections are needed in Kharkiv and throughout Ukraine. BMJ 2022; 377:o1072. [PMID: 35504623 DOI: 10.1136/bmj.o1072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Affiliation(s)
| | - Melina Nikolakea
- Faculty of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Lolita Matiashova
- L T Malaya Therapy National Institute, National Academy of Medical Sciences of Ukraine, Kharkiv, Ukraine
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Adler M, Pellett S, Sharma SK, Lebeda FJ, Dembek ZF, Mahan MA. Preclinical Evidence for the Role of Botulinum Neurotoxin A (BoNT/A) in the Treatment of Peripheral Nerve Injury. Microorganisms 2022; 10:microorganisms10050886. [PMID: 35630331 PMCID: PMC9148055 DOI: 10.3390/microorganisms10050886] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Revised: 03/29/2022] [Accepted: 04/17/2022] [Indexed: 01/27/2023] Open
Abstract
Traumatic peripheral nerve injuries tend to be more common in younger, working age populations and can lead to long-lasting disability. Peripheral nerves have an impressive capacity to regenerate; however, successful recovery after injury depends on a number of factors including the mechanism and severity of the trauma, the distance from injury to the reinnervation target, connective tissue sheath integrity, and delay between injury and treatment. Even though modern surgical procedures have greatly improved the success rate, many peripheral nerve injuries still culminate in persistent neuropathic pain and incomplete functional recovery. Recent studies in animals suggest that botulinum neurotoxin A (BoNT/A) can accelerate nerve regeneration and improve functional recovery after injury to peripheral nerves. Possible mechanisms of BoNT/A action include activation or proliferation of support cells (Schwann cells, mast cells, and macrophages), increased angiogenesis, and improvement of blood flow to regenerating nerves.
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Affiliation(s)
- Michael Adler
- Neuroscience Department, Medical Toxicology Division, U.S. Army Medical Research Institute of Chemical Defense, 8350 Ricketts Point Rd., Aberdeen Proving Ground, MD 21010, USA
- Correspondence: ; Tel.: +1-410-436-1913
| | - Sabine Pellett
- Department of Bacteriology, University of Wisconsin-Madison, 1550 Linden Drive, Madison, WI 53706, USA;
| | - Shashi K. Sharma
- Division of Microbiology, Center for Food Safety and Applied Nutrition, Food and Drug Administration, College Park, MD 20740, USA;
| | - Frank J. Lebeda
- Biotechnology, Protein Bioinformatics, Zanvyl Krieger School of Arts & Sciences, Johns Hopkins University, Advanced Academic Programs, 9601 Medical Center Drive, Rockville, MD 20850, USA;
| | - Zygmunt F. Dembek
- Department of Military and Emergency Medicine, Uniformed Services University of Health Sciences, 3154 Jones Bridge Rd., Bethesda, MD 20814, USA;
| | - Mark A. Mahan
- Department of Neurosurgery, Clinical Neurosciences, University of Utah, 175 N Medical Drive East, Salt Lake City, UT 84132, USA;
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Brown S, Mool JL, Young WE, Hollensteiner KM, Cyr A, Yi F, Gausepohl AJ. A Case Report of External Cardiac Pads Used for Internal Cardiac Defibrillation During Resuscitative Thoracotomy. Mil Med 2021; 187:259-261. [PMID: 34676401 DOI: 10.1093/milmed/usab433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Revised: 07/14/2021] [Accepted: 10/14/2021] [Indexed: 11/12/2022] Open
Abstract
This is a case report regarding the use of non-conventional methods to perform internal cardiac defibrillation on a trauma patient in an austere environment. The patient was a polytrauma causality of an improvised explosive device who arrived to a far forward resuscitative surgical team during a recent armed conflict. After arrival, the patient lost pulses. An emergency resuscitative thoracotomy was performed, and the patient was noted to have ventricular fibrillation on direct cardiac visualization. In the absence of standard surgical defibrillation paddles, the team applied external defibrillator stickers directly to the patient's myocardium to deliver an electrical shock. The procedure successfully led to the return of spontaneous circulation. This report highlights a novel approach to resuscitation in resource-limited environments by a military surgical team.
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Affiliation(s)
- Samuel Brown
- Department of Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, TX 78234, USA
| | - Jason L Mool
- Interservice Physician Assistant Program, Ft Campbell, KY 42223, USA
| | - William E Young
- Department of Surgery/Trauma ICU, Brooke Army Medical Center, Fort Sam Houston, TX 78234, USA
| | | | - Ashley Cyr
- Memorial Hospital North Conway, North Conway, NH 03860, USA
| | - Fia Yi
- The Colorectal Institute, Fort Myers, FL 33912, USA
| | - Andrew J Gausepohl
- Family Emergency Center, Wilford Hall Ambulatory Surgical Center, Lackland Air Force Base, TX 78236, USA
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Bulleid V, Hooper T, Nordmann G. Reviewing the needs of forward deployed critical care: South Sudan and the future. BMJ Mil Health 2021; 167:372-374. [PMID: 34493611 DOI: 10.1136/bmjmilitary-2021-001906] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
The UK military medical treatment facility (MTF) that deployed to the United Nations Mission in South Sudan in 2017 was based on a facility that can provide damage control surgery and resuscitation for soldiers with ballistic trauma injuries. It had to be supplemented with additional medical equipment and drugs that could support a peacekeeping mission in Africa. The clinicians used this experience and opportunity to review the critical care capability of UK Army Medical Services forward MTFs and recommend changes to reflect the increasing contemporaneous need on recent deployments to support more casualties with medical, infectious diseases and other non-battle injuries and illnesses. A concurrent review of the facility's critical care transfer equipment was also undertaken and allowed it to be adapted for use as either transfer equipment or as a critical care surge capability, to increase the facility's critical care capacity.
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Affiliation(s)
| | - T Hooper
- Department of Anaesthetic, Southmead Hospital, Bristol, UK
| | - G Nordmann
- Academic Department of Military Anaesthesia, Royal Centre for Defence Medicine, Birmingham, B15 2WB, UK
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Venables KM. Surgery on the battlefield: Mobile surgical units in the Second World War and the memoirs they produced. JOURNAL OF MEDICAL BIOGRAPHY 2021:9677720211012190. [PMID: 34081544 PMCID: PMC10403958 DOI: 10.1177/09677720211012190] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
In the Second World War, there was a flowering of the battlefield surgery pioneered in the Spanish Civil War. There were small, mobile surgical units in all the theatres of the War, working close behind the fighting and deployed flexibly according to the nature of the conflict. With equipment transported by truck, jeep or mule, they operated in tents, bunkers and requisitioned buildings and carried out abdominal, thoracic, head and neck, and limb surgery. Their role was to save life and to ensure that wounded soldiers were stable for casualty evacuation back down the line to a base hospital. There is a handful of memoirs by British doctors who worked in these units and they make enthralling reading. Casualty evacuation by air replaced the use of mobile surgical units in later wars, throwing into doubt their future relevance in the management of battle wounds. But recent re-evaluations by military planners suggest that their mobility still gives them a place, so the wartime memoirs may have more value than simply as war stories.
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Naumann DN, Beaven A, Naumann LK, Taylor B, Barker T, Seery J, Bowley DM. Where Do Surgeons Belong on the Modern Battlefield? Mil Med 2021; 186:136-140. [PMID: 33253352 DOI: 10.1093/milmed/usaa521] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Revised: 11/06/2020] [Accepted: 11/14/2020] [Indexed: 11/13/2022] Open
Affiliation(s)
- David N Naumann
- Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, Queen Elizabeth Hospital Birmingham, Birmingham, West Midlands, B152TH, UK
| | - Alastair Beaven
- Regimental Headquarters, 202 Field Hospital, Birmingham, West Midlands, B146NY, UK
| | - Laura K Naumann
- Academic Department of Military Anaesthesia and Critical Care, Royal Centre for Defence Medicine, Queen Elizabeth Hospital Birmingham, Birmingham, West Midlands, B152TH, UK
| | - Ben Taylor
- Academic Department of Military Anaesthesia and Critical Care, Royal Centre for Defence Medicine, Queen Elizabeth Hospital Birmingham, Birmingham, West Midlands, B152TH, UK
| | - Tom Barker
- Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, Queen Elizabeth Hospital Birmingham, Birmingham, West Midlands, B152TH, UK
| | - Jason Seery
- US Army Central Command, Shaw Air Force Base, SC 29152, USA
| | - Douglas M Bowley
- Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, Queen Elizabeth Hospital Birmingham, Birmingham, West Midlands, B152TH, UK
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13
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Recker AJ, Danelson K, Coates KE. Forward Surgical Teams as a Model for Humanitarian Orthopedic Surgical Care: A Review of Current Literature. Mil Med 2021; 186:e505-e511. [PMID: 33210715 DOI: 10.1093/milmed/usaa451] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Revised: 08/31/2020] [Accepted: 10/14/2020] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION Orthopedic trauma is a significant portion of global burden of disease in low- and middle-income countries (LMICs). This has led the World Health Organization to advocate for increased surgical intervention in LMICs. The two largest barriers to orthopedic surgical care for LMICs are cost of procedure and geographic access to centers with appropriate surgical capabilities. There is no current consensus on how to structure surgical interventional teams. The overall objective of this study is to describe the composition of a forward surgical team (FST), including its abilities and limitations. It is hypothesized that an FST is an effective model for orthopedic surgical relief efforts in LMICs. METHODS A narrative literature review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-analysis standards published by the National Academies of Medicine. Studies were evaluated by structured review procedures to identify an FST's capacity for orthopedic surgery, as well as applicability for humanitarian care. Articles detailing FST logistics, types of orthopedic treatment provided, and instances of humanitarian care while deployed in austere environments were included for review. RESULTS The FST is a military surgical unit operating with a small crew of surgeons and supporting staff who use tents or trailers that can be positioned near points of conflict, often in remote or austere environments. FSTs were designed to treat traumatic injuries, including orthopedic trauma from RTIs. If used as a sponsored humanitarian aid mission, FSTs can provide surgical care at free or greatly reduced costs. Because FSTs carry limited supplies and personnel, they are highly mobile surgical units that can be transported via truck. CONCLUSION FSTs are effective models for humanitarian orthopedic surgery in LMICs. FSTs were designed to treat orthopedic trauma, the largest burden of orthopedic care in LMICs. Efficient use of limited equipment allows FSTs to be cost effective for funding sources and highly mobile to reduce the geographic barrier to care. Further research is needed to determine the cost to operate an FST and ethical consideration for military intervention for foreign humanitarian aid.
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Affiliation(s)
- Andrew J Recker
- Wake Forest School of Medicine, Bowman Gray Center for Medical Education, Winston-Salem, NC 27101, USA
| | - Kerry Danelson
- Department of Orthopedics, Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, NC 27157, USA
| | - Kevin E Coates
- Department of Orthopedics, Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, NC 27157, USA
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Luft A, Pasquier P, Soucanye de Landevoisin E, Morel-Stum N, Baillon A, Louis S, Menini W, Sagalle Y, Gintte J, Bouquet A, Avaro JP. The Damage Control Resuscitation and Surgical Team: The New French Paradigm for Management of Combat Casualties. Mil Med 2020; 187:e275-e281. [PMID: 33242064 DOI: 10.1093/milmed/usaa322] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Revised: 07/15/2020] [Accepted: 08/20/2020] [Indexed: 01/13/2023] Open
Abstract
INTRODUCTION The aim of this work was to introduce the new French forward resuscitation and surgical unit. It's also to discuss the choices and waivers granted to fit the tactical context of modern conflicts and the current epidemiology of combat casualties. MATERIALS AND METHODS A multidisciplinary task force of 11 people proceeded to the conception and the creation of a new military resuscitation and surgical unit. The preliminary work included a scoping review of the combat casualties' epidemiology in modern conflicts and an analysis of the recent French medical-surgical treatment facilities lessons learned. In April 2019, a technical-operational evaluation was conducted to confirm all the technical, ergonomic, and organizational choices made during the design phase. RESULTS The multidisciplinary task force resulted in the creation of the Damage Control Resuscitation and Surgical Team (DCRST). The DCRST focused on the resuscitation strategy, including transfusion of blood products, and the life-saving surgical procedures to be performed as close as possible to the point of injury. It was designed for the resuscitation of two patients: the life-saving surgery of two patients and the very short-term intensive care (<12 hours) of four patients at the same time. The DCRST provided sufficient autonomy to provide take care of four T1 and four T2 or T3 casualties per day for 48 hours. It was armed with 23 soldiers. The technical equipment represented 5,300 kg and 27 m3. All the technical medical equipment could be stored in two 20-foot containers. CONCLUSION The DCRST represents a new paradigm in medical support of French military operations. It offers the advantage of two combat casualties' surgical management at the same time, as close as possible to the combat zone. It responds to a 2-fold epidemiological and logistical challenge.
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Affiliation(s)
- Antoine Luft
- French Military Medical Service - Surgeon General Office, 75509 Paris Cedex 15, France.,French Military Medical Service - Percy Military Training Hospital, 92 140 Clamart, France
| | - Pierre Pasquier
- French Military Medical Service - Percy Military Training Hospital, 92 140 Clamart, France
| | | | - Nelly Morel-Stum
- French Military Medical Service- Military Medical Supply and Health Care Product General Office, 45400 Chanteau, France
| | - Arthur Baillon
- French Military Medical Service - Military Medical Supply and Health Care Product General Office, 45400 Chanteau, France
| | - Serge Louis
- French Military Medical Service - Military Medical Supply and Health Care Product General Office, 45400 Chanteau, France
| | - William Menini
- French Military Medical Service - Sainte Anne military training hospital, 83000 Toulon, France
| | - Yannick Sagalle
- French Military Medical Service - Percy Military Training Hospital, 92 140 Clamart, France
| | - Julie Gintte
- French Military Medical Service - 12th Military Medical Center, 33068 Bordeaux CEDEX, France
| | - Antoine Bouquet
- French Military Medical Service - Surgeon General Office, 60 boulevard du Général Valin CS 21623, 75509 Paris Cedex 15, France
| | - Jean-Philippe Avaro
- French Military Medical Service - Sainte Anne Military Training Hospital, 83000 Toulon, France
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Wild H, Stewart BT, LeBoa C, Stave CD, Wren SM. Epidemiology of Injuries Sustained by Civilians and Local Combatants in Contemporary Armed Conflict: An Appeal for a Shared Trauma Registry Among Humanitarian Actors. World J Surg 2020; 44:1863-1873. [PMID: 32100067 PMCID: PMC7223167 DOI: 10.1007/s00268-020-05428-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND Conflict-related injuries sustained by civilians and local combatants are poorly described, unlike injuries sustained by US, North Atlantic Treaty Organization, and coalition military personnel. An understanding of injury epidemiology in twenty-first century armed conflict is required to plan humanitarian trauma systems capable of responding to population needs. METHODS We conducted a systematic search of databases (e.g., PubMed, Embase, Web of Science, World Health Organization Catalog, Google Scholar) and grey literature repositories to identify records that described conflict-related injuries sustained by civilians and local combatants since 2001. RESULTS The search returned 3501 records. 49 reports representing conflicts in 18 countries were included in the analysis and described injuries of 58,578 patients. 79.3% of patients were male, and 34.7% were under age 18 years. Blast injury was the predominant mechanism (50.2%), and extremities were the most common anatomic region of injury (33.5%). The heterogeneity and lack of reporting of data elements prevented pooled analysis and limited the generalizability of the results. For example, data elements including measures of injury severity, resource utilization (ventilator support, transfusion, surgery), and outcomes other than mortality (disability, quality of life measures) were presented by fewer than 25% of reports. CONCLUSIONS Data describing the needs of civilians and local combatants injured during conflict are currently inadequate to inform the development of humanitarian trauma systems. To guide system-wide capacity building and quality improvement, we advocate for a humanitarian trauma registry with a minimum set of data elements.
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Affiliation(s)
- Hannah Wild
- Stanford University School of Medicine, 291 Campus Drive, Stanford, CA, 94305, USA.
| | - Barclay T Stewart
- Department of Surgery, University of Washington, Seattle, WA, USA
- Harborview Injury Research and Prevention Center, Seattle, WA, USA
| | | | - Christopher D Stave
- Lane Medical Library, Stanford University School of Medicine, Stanford, CA, USA
| | - Sherry M Wren
- Stanford University School of Medicine, 291 Campus Drive, Stanford, CA, 94305, USA
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Silina EV, Manturova NE, Vasin VI, Artyushkova EB, Khokhlov NV, Ivanov AV, Stupin VA. Efficacy of A Novel Smart Polymeric Nanodrug in the Treatment of Experimental Wounds in Rats. Polymers (Basel) 2020; 12:E1126. [PMID: 32423071 PMCID: PMC7285345 DOI: 10.3390/polym12051126] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Revised: 04/23/2020] [Accepted: 05/11/2020] [Indexed: 12/13/2022] Open
Abstract
High-quality and aesthetic wound healing, as well as effective medical support of this process, continue to be relevant. This study aims to evaluate the medical efficacy of a novel smart polymeric nanodrug (SPN) on the rate and mechanism of wound healing in experimental animals. The study was carried out in male Wistar rats (aged 8-9 months). In these animals, identical square wounds down to the fascia were made in non-sterile conditions on the back on both sides of the vertebra. SPN was used for the treatment of one wound, and the other wound was left without treatment (control group). Biocompatible citrate-stabilized cerium oxide nanoparticles integrated into a polysaccharide hydrogel matrix containing natural and synthetic polysaccharide polymers (pectin, alginate, chitosan, agar-agar, water-soluble cellulose derivatives) were used as the therapeutic agent. Changes in the wound sizes (area, volume) over time and wound temperature were assessed on Days 0, 1, 3, 5, 7, and 14. Histological examination of the wounds was performed on Days 3, 7, and 14. The study showed that the use of SPN accelerated wound healing in comparison with control wounds by inhibiting the inflammatory response, which was measured by a decreased number of white blood cells in SPN-treated wounds. It also accelerated the development of fibroblasts, with an early onset of new collagen synthesis, which eventually led to the formation of more tender postoperative scars. Thus, the study demonstrated that the use of SPN for the treatment of wounds was effective and promising.
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Affiliation(s)
- Ekaterina V. Silina
- Department of Human Pathology, I.M. Sechenov First Moscow State Medical University (Sechenov University), Trubetskaya Str, 8, 119991 Moscow, Russia
| | - Natalia E. Manturova
- Department of Plastic and Reconstructive Surgery, Cosmetology and Cell Technologies, N.I. Pirogov Russian National Research Medical University (RNRMU), Ostrovityanova St., 1, 117997 Moscow, Russia;
| | - Vitaliy I. Vasin
- Department of Hospital Surgery №1, N.I. Pirogov Russian National Research Medical University (RNRMU), Ostrovityanova St., 1, 117997 Moscow, Russia; (V.I.V.); (V.A.S.)
| | - Elena B. Artyushkova
- Research Institute of Experimental Medicine, Kursk State Medical University, Karl Marx St, 3, 305041 Kursk, Russia; (E.B.A.); (N.V.K.)
| | - Nikolay V. Khokhlov
- Research Institute of Experimental Medicine, Kursk State Medical University, Karl Marx St, 3, 305041 Kursk, Russia; (E.B.A.); (N.V.K.)
| | - Alexander V. Ivanov
- Department of Histology, Embryology, Cytology, Kursk State Medical University, Karl Marx St, 3, 305041 Kursk, Russia;
| | - Victor A. Stupin
- Department of Hospital Surgery №1, N.I. Pirogov Russian National Research Medical University (RNRMU), Ostrovityanova St., 1, 117997 Moscow, Russia; (V.I.V.); (V.A.S.)
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Description of trauma among French service members in the Department of Defense Trauma Registry: understanding the nature of trauma and the care provided. Mil Med Res 2019; 6:7. [PMID: 30813959 PMCID: PMC6391821 DOI: 10.1186/s40779-019-0197-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Accepted: 02/19/2019] [Indexed: 11/16/2022] Open
Abstract
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.
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