Prehospital Interventions Performed in Afghanistan Between November 2009 and March 2014

A Pilot Study on the Role of Experience and Patient Gender on MARCH Treatment Sequence

INTRODUCTION

The brevity of training for soldiers and combat medics to learn how to provide treatment on the battlefield may restrict optimal performance for treating chest and airway injuries, particularly when treating female soldiers. The present study tested treatment performance on patient simulators by battlefield medic trainees to determine whether there is a need for more extensive training on chest and airway procedures on female soldiers.

MATERIALS AND METHODS

Battlefield medic trainees treated male and female patient simulators in counterbalanced order. The assessment considered the effects of patient gender and order on procedures performed, particularly critical chest and airway interventions such as needle chest decompression (NCD), and considered the appropriate order of treatment tasks. Four coders rated video footage of three simulated procedures, i.e., tourniquet, chest seal (front and back application), and NCD, using a binary coding system to determine completeness and order correctness according to the Massive hemorrhage, Airway, Respiration, Circulation, and Head injury/Hypothermia (MARCH) mnemonic.

RESULTS

Results from analysis of variance showed that when presented with a female patient first, trainees performed significantly fewer total procedures on both the female and male simulators. More experienced trainees completed significantly more procedures compared to trainees with minimal experience. Results from the binary logistic regression showed that trainees with more experience and trainees presented with the male patient simulator first performed significantly more procedures in the correct order. Finally, an examination of the NCD procedure found that trainees presented with the female patient simulator first had more errors and that trainees with less experience were less likely to perform the procedure adequately.

CONCLUSIONS

The findings suggest that treating a female patient first may lead to undertreatment of both patients. Furthermore, the observed differences in treating sensitive areas of the body (e.g., near female breasts) suggest providing greater opportunities for trainees to practice often missed or incorrectly performed procedures. Treating a female patient remains a novel experience for many trainees, such that trainees are less likely to fully treat a female patient and are less likely to treat female soldiers for the most life-threatening injuries. In fact, the initial presentation of the female patient simulator appeared to affect experienced trainees, suggesting that removing the experience of novelty and stress requires more extensive exposure and alternative training. The study's small sample size with a wide range of trainee experience may limit the findings, which may fail to capture some study effects. Finally, the study did not request trainees' experience treating female soldiers, so future studies should examine the extent to which experience is predictive of performance. There is a need for more interactive approaches in patient simulations to provide opportunities for practice, especially those that require the treatment of sensitive areas.

Level 1 Trauma Centers and OEF/OIF Emergency Departments: Comparison of Trauma Patient Populations

INTRODUCTION

Brooke Army Medical Center (BAMC), the largest military hospital and the only level 1 trauma center in the DoD, cares for active duty, retired uniformed services personnel, and beneficiaries. In addition, BAMC works in collaboration with the Southwest Texas Regional Advisory Council (STRAC) and University Hospital (UH), San Antonio's other level 1 trauma center, to provide trauma care to residents of the city and 22 counties in southwest Texas from San Antonio to Mexico (26,000 square mile area). Civilian-military partnerships are shown to benefit the training of military medical personnel; however, to date, there are no published reports specific to military personnel experiences within emergency care. The purpose of the current study was to describe and compare the emergency department trauma patient populations of two level 1 trauma centers in one metropolitan city (BAMC and UH) as well as determine if DoD level 1 trauma cases were representative of patients treated in OEF/OIF emergency department settings.

MATERIALS AND METHODS

We obtained a nonhuman subjects research determination for de-identified data from the US Air Force 59th Medical Wing and the University of Texas Health Science Center at San Antonio Institutional Review Boards. Data on emergency department patients treated between the years 2015 and 2017 were obtained from the two level 1 trauma centers (BAMC and UH, located in San Antonio, Texas); data included injury descriptors, ICU and hospital days, and department procedures.

RESULTS

Two-proportion Z-tests indicated that trauma patients were similar across trauma centers on injury type, injury severity, and discharge status; yet trauma patients differed significantly in terms of mechanism of injury and regions of injury. BAMC received significantly greater proportions of patients injured from falls, firearms and with facial and head injuries than UH, which received significantly greater proportion of patients with thorax and abdominal injuries. In addition, a significantly greater proportion of patients spent more than 2 days in the ICU and greater than two total hospital days at BAMC than in UH. In comparison to military emergency departments in combat zones, BAMC had significantly lower rates of blood product administration and endotracheal intubations.

CONCLUSIONS

The trauma patients treated at a military level 1 trauma center were similar to those treated in the civilian level 1 trauma center in the same city, indicating the effectiveness of the only DoD Level 1 trauma center to provide experience comparable to that provided in civilian trauma centers. However, further research is needed to determine if the exposure rates to specific procedures are adequate to meet predeployment readiness requirements.

Prehospital Life-Saving Interventions Performed on Pediatric Patients in a Combat Zone: A Multicenter Prospective Study

OBJECTIVES

We aimed to describe and evaluate prehospital life-saving interventions performed in a pediatric population in the Afghanistan theater of operations.

DESIGN

Our study was a post hoc, subanalysis of a larger multicenter, prospective, observational study.

SETTING

We evaluated casualties enrolled upon admission to one of the nine military medical facilities in Afghanistan between January 2009 and March 2014.

PATIENTS

Adult and pediatric (<17 yr old) patients.

MEASUREMENTS

We conducted initial descriptive analyses followed by comparative tests. For comparative analysis, we stratified the study population (adult vs pediatric), and subsequently, we compared injury descriptions and the interventions performed. Following tests for normality, we used the t test or Wilcoxon rank-sum test (nonparametric) for continuous variables and chi-square or Fisher exact for categorical variables. We reported percentages and 95% CIs.

MAIN RESULTS

We enrolled 2,106 patients, of which 5.6% (n = 118) were pediatric. Eighty-two percent of the pediatric patients were male, and 435 had blast related injuries. A total of 295 prehospital life-saving interventions were performed on 118 pediatric patients, for an average of 2.5 life-saving interventions per patient. Vascular access (IV 96%, intraosseous 91%) and hypothermia prevention-related interventions (69%) were the most common. Incorrectly performed life-saving interventions in pediatric patients were rare (98% of life-saving interventions performed correctly) and n equals to 24 life-saving interventions over the 6-year period were missed. The most common incorrectly performed and missed life-saving interventions were related to vascular access. When compared with adult life-saving interventions received in the prehospital environment, pediatric patients were more likely to receive intraosseous access (p < 0.0001), whereas adult patients were more likely to have a tourniquet placed (p = 0.0019), receive wound packing with a hemostatic agent (p = 0.0091), and receive chest interventions (p = 0.0003).

CONCLUSIONS

In our study, the most common intervention was vascular access followed by hypothermia prevention and hemorrhage control. The occurrence of missed or incorrectly performed life-saving interventions were rare.

An analysis of the incidence of hypothermia in casualties presenting to emergency departments in Iraq and Afghanistan

INTRODUCTION

Hypothermia on the battlefield has been shown to be associated with severe injury and higher mortality. The incidence of battlefield casualties presenting with hypothermia are described.

METHODS

The Department of Defense Trauma Registry (DoDTR) was queried from January 2007 to August 2016. We identified casualties with a documented temperature of <32°Celsius (C) (severe), 32-33.9 °C (moderate), 34-36 °C (mild). We defined serious injuries as those resulting in an AIS of ≥3 by body region.

RESULTS

There were 25,484 records with at least one documented temperature and 2501 (9.8%) casualties with hypothermia within our range. Nineteen (0.75%) casualties presented with severe hypothermia, 225 (9%) with moderate, and 2257 (90%) with mild. The mean injury severity score (ISS) for non-hypothermic, mild, moderate, and severe hypothermic casualties was 8 [4-14], 14 [6-24], 21 [13-29], and 21 [9-25], (p <0.001), respectively. Survival for casualties with severe hypothermia was 57.8%, moderate 80.9%, mild hypothermia 90.9%, and non-hypothermic group 97.6%, p<0.001. When adjusting for composite injury score, patient category, mechanism of injury, and location, this finding remained significant (OR 0.27, 0.21-0.34, p<0.001). Massive transfusion was more common in hypothermia casualties n = 566 (19%) versus non-hypothermic recipients n = 1734 (6.9%), p <0.001.

CONCLUSIONS

Though the number of casualties that presented hypothermic was small, their injuries were more severe, and were more likely to receive massive blood transfusions. This cohort also had a higher mortality rate, a finding which held when adjusting for confounders. There appears to be an opportunity to improve hypothermia prevention for combat.