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Stark PW, Borger van der Burg BLS, van Waes OJF, van Dongen TTCF, Wouter, Casper M, Hoencamp R. Telemedicine-Guided Two-Incision Lower Leg Fasciotomy Performed by Combat Medics During Tactical Combat Casualty Care: A Feasibility Study. Mil Med 2024; 189:e645-e651. [PMID: 37703048 PMCID: PMC10898936 DOI: 10.1093/milmed/usad364] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2023] [Revised: 08/25/2023] [Accepted: 09/03/2023] [Indexed: 09/14/2023] Open
Abstract
INTRODUCTION During tactical combat casualty care, life- and limb-saving procedures might also be performed by combat medics. This study assesses whether it is feasible to use a head-mounted display (HMD) to provide telemedicine (TM) support from a consulted senior surgeon for combat medics when performing a two-incision lower leg fasciotomy. MATERIALS AND METHODS Nine combat medics were randomized into groups to perform a two-incision lower leg fasciotomy. One group used the Vuzix M400 and the second group used the RealWear HMT-1Z1. A third, control, group received no guidance. In the Vuzix M400 group and RealWear HMT-1Z1 group, a senior surgeon examined the results after the two-incision lower leg fasciotomy was finished to assess the release of compartments, possible collateral damage, and performance of the combat medics. In the control group, these results were examined by a surgical resident with expertise in two-incision lower leg fasciotomies. The resident's operative performance questionnaire was used to score the performance of the combat medics. The telehealth usability questionnaire was used to evaluate the usability of the HMDs as perceived by the combat medics. RESULTS Combat medics using an HMD were considered competent in performing a two-incision lower leg fasciotomy (Vuzix: median 3 [range 0], RealWear: median 3 [range 1]). These combat medics had a significantly better score in their ability to adapt to anatomical variances compared to the control group (Vuzix: median 3 [range 0], RealWear: median 3 [range 0], control: median 1 [range 0]; P = .018). Combat medics using an HMD were faster than combat medics in the control group (Vuzix: mean 14:14 [SD 3:41], RealWear: mean 15:42 [SD 1:58], control: mean 17:45 [SD 2:02]; P = .340). The overall satisfaction with both HMDs was 5 out of 7 (Vuzix: median 5 [range 0], RealWear: median 5 [range 1]; P = .317). CONCLUSIONS This study shows that it is feasible to use an HMD to provide TM support performance from a consulted senior surgeon for combat medics when performing a two-incision lower leg fasciotomy. The results of this study suggest that TM support might be useful for combat medics during tactical combat casualty care when performing life- and limb-saving procedures.
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Affiliation(s)
- P W Stark
- Trauma Research Unit, Department of Surgery, Erasmus University Medical Center, Rotterdam, Zuid-Holland 3015 GD, The Netherlands
- Department of Surgery, Alrijne Hospital, Leiderdorp, Zuid-Holland 2353 GA, The Netherlands
| | | | - O J F van Waes
- Trauma Research Unit, Department of Surgery, Erasmus University Medical Center, Rotterdam, Zuid-Holland 3015 GD, The Netherlands
- Defense Healthcare Organization, Ministry of Defense, Den Haag, Zuid-Holland 2511 CB, The Netherlands
| | - T T C F van Dongen
- Department of Surgery, Alrijne Hospital, Leiderdorp, Zuid-Holland 2353 GA, The Netherlands
- Defense Healthcare Organization, Ministry of Defense, Den Haag, Zuid-Holland 2511 CB, The Netherlands
| | - Wouter
- Defense Healthcare Organization, Ministry of Defense, Den Haag, Zuid-Holland 2511 CB, The Netherlands
| | - Marnalg Casper
- Defense Healthcare Organization, Ministry of Defense, Den Haag, Zuid-Holland 2511 CB, The Netherlands
| | - R Hoencamp
- Trauma Research Unit, Department of Surgery, Erasmus University Medical Center, Rotterdam, Zuid-Holland 3015 GD, The Netherlands
- Department of Surgery, Alrijne Hospital, Leiderdorp, Zuid-Holland 2353 GA, The Netherlands
- Defense Healthcare Organization, Ministry of Defense, Den Haag, Zuid-Holland 2511 CB, The Netherlands
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Stark PW, Borger van der Burg BLS, van Dongen TTCF, Casper M, Wouter, Hoencamp R. Telemedicine Improves Performance of a Two-Incision Lower Leg Fasciotomy by Combat Medics: A Randomized Controlled Trial. Mil Med 2023:usad486. [PMID: 38141250 DOI: 10.1093/milmed/usad486] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Revised: 11/13/2023] [Accepted: 12/11/2023] [Indexed: 12/25/2023] Open
Abstract
INTRODUCTION The primary aim of this randomized controlled trial was to assess if a head-mounted display (HMD) providing telemedicine support improves performance of a two-incision lower leg fasciotomy by a NATO special operations combat medic (combat medic). MATERIALS AND METHODS Thirty-six combat medics were randomized into two groups: One group performed a two-incision lower leg fasciotomy with the assistance of an HMD, while the control group completed the procedure without guidance. A Mann-Whitney U test was used to determine the possible differences in release of compartments and performance scores, as assessed by a supervising medical specialist. A Fisher's exact test was used to compare the proportions of collateral damage between groups. An independent-samples t-test was used to interpret total procedure times. The usability and technical factors involving HMD utilization were also assessed. RESULTS Combat medics in the HMD group released the anterior compartment (P ≤ .001) and deep posterior compartment (P = .008) significantly better. There was significantly more iatrogenic muscle (P ≤ .001) and venous damage (P ≤ .001) in the control group. The overall performance of combat medics in the HMD group was significantly better than that of the control group (P < .001). Combat medics in the control group were significantly faster (P = .012). The combat medics were very satisfied with the HMD. The HMD showed no major technical errors. CONCLUSIONS This randomized controlled trial shows that a HMD providing telemedicine support leads to significantly better performance of a two-incision lower leg fasciotomy by a combat medic with less iatrogenic muscle and venous damage.
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Affiliation(s)
- Pieter W Stark
- Trauma Research Unit, Department of Surgery, Erasmus MC University Hospital, Rotterdam, South Holland 3015 GD, The Netherlands
- Department of Surgery, Alrijne Hospital, Leiderdorp, South Holland 2353 GA, The Netherlands
| | | | - Thijs T C F van Dongen
- Department of Surgery, Alrijne Hospital, Leiderdorp, South Holland 2353 GA, The Netherlands
- Ministry of Defense, Defense Healthcare Organization, Den Haag, South Holland 2511 CB, The Netherlands
| | - Marnalg Casper
- Ministry of Defense, Defense Healthcare Organization, Den Haag, South Holland 2511 CB, The Netherlands
| | - Wouter
- Ministry of Defense, Defense Healthcare Organization, Den Haag, South Holland 2511 CB, The Netherlands
| | - Rigo Hoencamp
- Trauma Research Unit, Department of Surgery, Erasmus MC University Hospital, Rotterdam, South Holland 3015 GD, The Netherlands
- Department of Surgery, Alrijne Hospital, Leiderdorp, South Holland 2353 GA, The Netherlands
- Ministry of Defense, Defense Healthcare Organization, Den Haag, South Holland 2511 CB, The Netherlands
- Department of Surgery, Leiden University MC, Leiden, South Holland 2333 ZA, The Netherlands
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Holm E, Cook J, Porter K, Nelson A, Weishar R, Mallory T, Cantor A, Croft C, Liwag J, Harrington CJ, DesRosiers TT. A Quantitative and Qualitative Literature Analysis of the Orthopedic Surgeons' Experience: Reflecting on 20 Years in the Global War on Terror. Mil Med 2023; 188:2924-2931. [PMID: 35862000 DOI: 10.1093/milmed/usac219] [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: 04/01/2022] [Revised: 06/18/2022] [Accepted: 07/01/2022] [Indexed: 11/12/2022] Open
Abstract
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.
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Affiliation(s)
- Erik Holm
- Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
| | - John Cook
- Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
| | - Kaitlin Porter
- Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
| | - Andrew Nelson
- Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
| | - Robert Weishar
- Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
| | - Taylor Mallory
- Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
| | - Addison Cantor
- Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
| | - Caitlynn Croft
- Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
| | - Jonah Liwag
- Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
| | - Colin J Harrington
- Department of Orthopedics, Walter Reed National Military Medical Center, Bethesda, MD 20814, USA
| | - Taylor T DesRosiers
- Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
- Combat Trauma Research Group U.S. Navy, USA
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Stern CA, Glaser JJ, Stockinger ZT, Gurney JM. An Analysis of Head and Neck Surgical Workload During Recent Combat Operations From 2002 to 2016. Mil Med 2023; 188:e1401-e1407. [PMID: 36574225 DOI: 10.1093/milmed/usac402] [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: 08/19/2022] [Revised: 10/28/2022] [Accepted: 12/12/2022] [Indexed: 02/17/2024] Open
Abstract
INTRODUCTION In battle-injured U.S. service members, head and neck (H&N) injuries have been documented in 29% who were treated for wounds in deployed locations and 21% who were evacuated to a Role 4 MTF. The purpose of this study is to examine the H&N surgical workload at deployed U.S. military facilities in Iraq and Afghanistan in order to inform training, needed proficiency, and MTF manning. MATERIALS AND METHODS A retrospective analysis of the DoD Trauma Registry was performed for all Role 2 and Role 3 MTFs, from January 2002 to May 2016; 385 ICD-9 CM procedure codes were identified as H&N surgical procedures and were stratified into eight categories. For the purposes of this analysis, H&N procedures included dental, ophthalmologic, airway, ear, face, mandible maxilla, neck, and oral injuries. Traumatic brain injuries and vascular injuries to the neck were excluded. RESULTS A total of 15,620 H&N surgical procedures were identified at Role 2 and Role 3 MTFs. The majority of H&N surgical procedures (14,703, 94.14%) were reported at Role 3 facilities. Facial bone procedures were the most common subgroup across both roles of care (1,181, 75.03%). Tracheostomy accounted for 16.67% of all H&N surgical procedures followed by linear repair of laceration of eyelid or eyebrow (8.23%) and neck exploration (7.41%). H&N caseload was variable. CONCLUSIONS H&N procedures accounted for 8.25% of all surgical procedures performed at Role 2 and Role 3 MTFs; the majority of procedures were eye (40.54%) and airway (18.50%). These data can be used as planning tools to help determine the medical footprint and also to help inform training and sustainment requirements for deployed military general surgeons especially if future contingency operations are more constrained in terms of resources and personnel.
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Affiliation(s)
- Caryn A Stern
- Joint Trauma System, DoD Center of Excellence for Trauma, 3611 Chambers Dr, Joint Base San Antonio, Fort Sam Houston, Texas 78234, USA
| | - Jacob J Glaser
- Naval Medical Research Unit, 3650 Chambers Pass, Joint Base San Antonio, Fort Sam Houston, Texas 78234, USA
| | - Zsolt T Stockinger
- Naval Hospital Jacksonville & Navy Medicine Reediness and Training Command, 2080 Child St, Jacksonville, Florida 32214, USA
| | - Jennifer M Gurney
- Joint Trauma System, DoD Center of Excellence for Trauma, 3611 Chambers Dr, Joint Base San Antonio, Fort Sam Houston, Texas 78234, USA
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Stern CA, Liendo JA, Graham BA, Johnson GM, Kotwal RS, Shackelford S, Gurney JM, Janak JC. Nonfatal Injuries From Falls Among U.S. Military Personnel Deployed for Combat Operations, 2001-2018. Mil Med 2023; 188:e2405-e2413. [PMID: 36576031 DOI: 10.1093/milmed/usac410] [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: 08/31/2022] [Revised: 11/04/2022] [Accepted: 12/12/2022] [Indexed: 12/29/2022] Open
Abstract
INTRODUCTION Falls are a leading mechanism of injury. Hospitalization and outpatient clinic visits due to fall injury are frequently reported among both deployed and non-deployed U.S. Military personnel. Falls have been previously identified as a leading injury second only to sports and exercise as a cause for non-battle air evacuations. MATERIALS AND METHODS This retrospective study analyzed the Department of Defense Trauma Registry fall injury data from September 11, 2001 to December 31, 2018. Deployed U.S. Military personnel with fall listed as one of their mechanisms of injury were included for analysis. RESULTS Of 31,791 injured U.S. Military personnel captured by the Department of Defense Trauma Registry within the study time frame, a total of 3,101 (9.8%) incurred injuries from falls. Those who had fall injuries were primarily 21 to 30 years old (55.4%), male (93.1%), Army (75.6%), and enlisted personnel (56.9%). The proportion of casualties sustaining injuries from falls generally increased through the years of the study. Most fall injuries were classified as non-battle injury (91.9%). Falls accounted for 24.2% of non-battle injury hospital admissions with a median hospital stay of 2 days. More non-battle-related falls were reported in Iraq-centric military operations (62.7%); whereas more battle-related falls were reported in Afghanistan-centric military operations (58.3%). CONCLUSIONS This study is the largest analysis of deployed U.S. Military personnel injured by falls to date. Highlighted are preventive strategies to mitigate fall injury, reduce workforce attrition, and preserve combat mission capability. LEVEL OF EVIDENCE Level III Epidemiologic.
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Affiliation(s)
- Caryn A Stern
- Joint Trauma System, DoD Center of Excellence for Trauma, 3611 Chambers Dr, Joint Base, San Antonio, Fort Sam Houston, Texas 78234, USA
| | - Jessica A Liendo
- Joint Trauma System, DoD Center of Excellence for Trauma, 3611 Chambers Dr, Joint Base, San Antonio, Fort Sam Houston, Texas 78234, USA
| | - Brock A Graham
- Joint Trauma System, DoD Center of Excellence for Trauma, 3611 Chambers Dr, Joint Base, San Antonio, Fort Sam Houston, Texas 78234, USA
| | - Grant M Johnson
- Joint Trauma System, DoD Center of Excellence for Trauma, 3611 Chambers Dr, Joint Base, San Antonio, Fort Sam Houston, Texas 78234, USA
| | - Russ S Kotwal
- Joint Trauma System, DoD Center of Excellence for Trauma, 3611 Chambers Dr, Joint Base, San Antonio, Fort Sam Houston, Texas 78234, USA
| | - Stacy Shackelford
- Joint Trauma System, DoD Center of Excellence for Trauma, 3611 Chambers Dr, Joint Base, San Antonio, Fort Sam Houston, Texas 78234, USA
| | - Jennifer M Gurney
- Joint Trauma System, DoD Center of Excellence for Trauma, 3611 Chambers Dr, Joint Base, San Antonio, Fort Sam Houston, Texas 78234, USA
| | - Jud C Janak
- Joint Trauma System, DoD Center of Excellence for Trauma, 3611 Chambers Dr, Joint Base, San Antonio, Fort Sam Houston, Texas 78234, USA
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Kuchyn I, Horoshko V. Chronic pain in patients with gunshot wounds. BMC Anesthesiol 2023; 23:47. [PMID: 36750768 PMCID: PMC9903440 DOI: 10.1186/s12871-023-02005-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2022] [Accepted: 02/02/2023] [Indexed: 02/09/2023] Open
Abstract
BACKGROUND In civilian life, from 11 to 40% of patients suffer from chronic pain after receiving injuries. There are almost no data on chronic pain in patients with gunshot wounds, isolated clinical cases have been published. The purpose of our study is to determine the factors that can potentially affect the results of treatment of such patients, namely the frequency of development of chronic pain, acute stress reactions, satisfaction with the results of treatment and the number of wound localizations. METHODS The treatment of 769 patients was analyzed. Pain intensity was diagnosed using a visual analog scale (VAS). To detect neuropathic pain, the Douleur Neuropathique 4 questions (DN4). The presence of an acute stress reaction (ASR) was diagnosed using The hospital anxiety and depression scale (HADS) and medical history, the diagnosis was established by a psychiatrist. Satisfaction with treatment results was studied using the Chaban quality of life scale (CQLS). Group comparisons were made using the Mann-Whitney test and the chi-square test, taking into account continuity correction. RESULTS Chronic pain was observed in 538 (70% 95% CI 66.7%-73.1%) patients with gunshot wounds: of them, 439 patients had wounds in 1, 2 anatomical parts of the body, here the frequency of pain chronicity is 69.7% (95% CI 66.0%-78.5%), and 99 patients had wounds in 3 or more anatomical parts of the body - 71.2% (95%CI 63.4%-78.5%). DN4 data suggest the presence of a neuropathic pain component in these patients. Also, all patients were diagnosed with ASR upon admission: the number of HADS points ranged from 9 to 25 points. CQLS data indicate that satisfaction with treatment outcomes was high (76 points) before hospital discharge, but subsequently decreased to a low level (64 points). CONCLUSIONS Patients with gunshot wounds have a high risk of chronic pain, averaging 45% higher than the general population in civilian trauma patients. A greater frequency of the neuropathic component of pain and acute stress reactions is the reason for such chronicity. A decrease in the level of satisfaction with the results of treatment, in the remote period of observation, compared to the level at the time of discharge from the hospital, is probably a consequence of the formation of chronic pain. TRIAL REGISTRATION ClinicalTrials.gov: Retrospectively registered on August 1, 2022, NCT05489029.
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Affiliation(s)
- Iurii Kuchyn
- grid.412081.eNational Medical University Named After O. O. Bogomolets, Kiev, Ukraine
| | - Vasyl’ Horoshko
- grid.412081.eNational Medical University Named After O. O. Bogomolets, Kiev, Ukraine
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Ravindra VM, Tadlock MD, Gurney JM, Kraus KL, Dengler BA, Gordon J, Cooke J, Porensky P, Belverud S, Milton JO, Cardoso M, Carroll CP, Tomlin J, Champagne R, Bell RS, Viers AG, Ikeda DS. Attitudes Toward Neurosurgery Education for the Nonneurosurgeon: A Survey Study and Critical Analysis of U.S. Military Training Techniques and Future Prospects. World Neurosurg 2022; 167:e1335-e1344. [PMID: 36103986 DOI: 10.1016/j.wneu.2022.09.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Accepted: 09/07/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND The U.S. military requires medical readiness to support forward-deployed combat operations. Because time and distance to neurosurgical capabilities vary within the deployed trauma system, nonneurosurgeons are required to perform emergent cranial procedures in select cases. It is unclear whether these surgeons have sufficient training in these procedures. METHODS This quality-improvement study involved a voluntary, anonymized specialty-specific survey of active-duty surgeons about their experience and attitudes toward U.S. military emergency neurosurgical training. RESULTS Survey responses were received from 104 general surgeons and 26 neurosurgeons. Among general surgeons, 81% have deployed and 53% received training in emergency neurosurgical procedures before deployment. Only 16% of general surgeons reported participating in craniotomy/craniectomy procedures in the last year. Nine general surgeons reported performing an emergency neurosurgical procedure while on deployment/humanitarian mission, and 87% of respondents expressed interest in further predeployment emergency neurosurgery training. Among neurosurgeons, 81% had participated in training nonneurosurgeons and 73% believe that more comprehensive training for nonneurosurgeons before deployment is needed. General surgeons proposed lower procedure minimums for competency for external ventricular drain placement and craniotomy/craniectomy than did neurosurgeons. Only 37% of general surgeons had used mixed/augmented reality in any capacity previously; for combat procedures, most (90%) would prefer using synchronous supervision via high-fidelity video teleconferencing over mixed reality. CONCLUSIONS These survey results show a gap in readiness for neurosurgical procedures for forward-deployed general surgeons. Capitalizing on capabilities such as mixed/augmented reality would be a force multiplier and a potential means of improving neurosurgical capabilities in the forward-deployed environments.
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Affiliation(s)
- Vijay M Ravindra
- Department of Neurosurgery, Bioskills Training Center, Naval Medical Readiness Training Command, San Diego, California, USA; Department of Neurosurgery, University of California San Diego, San Diego, California, USA; Department of Neurosurgery, University of Utah, Salt Lake City, Utah, USA
| | - Matthew D Tadlock
- Department of Surgery, Bioskills Training Center, Naval Medical Readiness Training Command, San Diego, California, USA; Bioskills Training Center, Naval Medical Readiness Training Command, San Diego, California, USA; 1st Medical Battalion, 1st Marine Logistics Group, Camp Pendleton, California, USA
| | - Jennifer M Gurney
- U.S. Army Institute of Surgical Research, Joint Base San Antonio, San Antonio, Texas, USA
| | - Kristin L Kraus
- Department of Neurosurgery, University of Utah, Salt Lake City, Utah, USA
| | - Bradley A Dengler
- Department of Neurosurgery, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
| | - Jennifer Gordon
- Department of Surgery, U.S. Naval Hospital Okinawa, Okinawa, Japan
| | - Jonathon Cooke
- Department of Neurosurgery, Bioskills Training Center, Naval Medical Readiness Training Command, San Diego, California, USA
| | - Paul Porensky
- Department of Neurosurgery, Bioskills Training Center, Naval Medical Readiness Training Command, San Diego, California, USA
| | - Shawn Belverud
- Department of Neurosurgery, Bioskills Training Center, Naval Medical Readiness Training Command, San Diego, California, USA
| | - Jason O Milton
- Department of Neurosurgery, Bioskills Training Center, Naval Medical Readiness Training Command, San Diego, California, USA
| | - Mario Cardoso
- Department of Brain and Spine Surgery, Naval Medical Center, Portsmouth, Virginia, USA
| | - Christopher P Carroll
- Department of Brain and Spine Surgery, Naval Medical Center, Portsmouth, Virginia, USA
| | - Jeffrey Tomlin
- Department of Brain and Spine Surgery, Naval Medical Center, Portsmouth, Virginia, USA
| | - Roland Champagne
- Bioskills Training Center, Naval Medical Readiness Training Command, San Diego, California, USA
| | - Randy S Bell
- Department of Neurosurgery, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
| | - Angela G Viers
- Department of Surgery, U.S. Naval Hospital Okinawa, Okinawa, Japan
| | - Daniel S Ikeda
- Department of Neurosurgery, Walter Reed National Military Medical Center, Bethesda, Maryland, USA.
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Barsky D, Ben Ya’acov A, Avraham LW, Nachman D, Eisenkraft A, Mintz Y, Shteyer E. A feasibility study using sodium alginate injection for penetrating abdominal trauma in a swine model. Sci Rep 2022; 12:17132. [PMID: 36224357 PMCID: PMC9556518 DOI: 10.1038/s41598-022-22186-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2022] [Accepted: 10/11/2022] [Indexed: 01/04/2023] Open
Abstract
Penetrating abdominal injury is a major cause of death in trauma. Sodium alginate hydrogel, a hemostatic agent, offers a platform for targeting both mechanical and biological injuries. The current study assessed the effect of Very Low Viscosity (high) G (VLVG) alginate following abdominal trauma in a swine model of penetrating abdominal injury. Seven anesthetized pigs were instrumented with invasive monitoring catheters and abdominal trauma was introduced by laparoscopic hepatectomy. Ten minutes after the induction of hypovolemic shock, three animals were intra-abdominally administered with VLVG alginate (study group) and four animals with saline (control group). During 8 h of continuous monitoring, various hemodynamic and biochemical variables were measured and liver biopsies for histological evaluation were taken. Hemodynamically, VLVG alginate-treated animals were more stable than controls, as reflected by their lower heart rate and higher blood pressure (p < 0.05 for both). They also had lower levels of liver enzymes and lactate, and less histopathological damage. We show that VLVG alginate might be a promising new agent for reducing penetrating intra-abdominal injury, with hemostatic and biocompatibility efficiency, and tissue preserving properties. Future effort of integrating it with a dispersal device may turn it into a valuable pre-hospital emergency tool to improve survival of trauma casualties.
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Affiliation(s)
- Daniel Barsky
- grid.9619.70000 0004 1937 0538Faculty of Medicine, Hebrew University of Jerusalem, Ein Kerem, P.O. Box 12271, Jerusalem, Israel
| | - Ami Ben Ya’acov
- grid.9619.70000 0004 1937 0538Juliet Keidan Pediatric Gastroenterology Institute, Shaare Zedek Medical Center and the Hebrew University of Jerusalem, Shmuel Bait St 12, Jerusalem, Israel
| | - Linn Wagnert Avraham
- grid.9619.70000 0004 1937 0538Institute for Research in Military Medicine, the Hebrew University Faculty of Medicine, Ein Kerem, P.O. Box 12271, Jerusalem, Israel
| | - Dean Nachman
- grid.9619.70000 0004 1937 0538Institute for Research in Military Medicine, the Hebrew University Faculty of Medicine, Ein Kerem, P.O. Box 12271, Jerusalem, Israel ,grid.17788.310000 0001 2221 2926Department of Internal Medicine, Hadassah Medical Center, Ein Kerem, P.O. Box 91120, Jerusalem, Israel
| | - Arik Eisenkraft
- grid.9619.70000 0004 1937 0538Institute for Research in Military Medicine, the Hebrew University Faculty of Medicine, Ein Kerem, P.O. Box 12271, Jerusalem, Israel ,Faculty of Medicine, Institute for Research in Military Medicine, POB 12272, 91120 Jerusalem, Israel
| | - Yoav Mintz
- grid.9619.70000 0004 1937 0538Faculty of Medicine, Hebrew University of Jerusalem, Ein Kerem, P.O. Box 12271, Jerusalem, Israel ,grid.17788.310000 0001 2221 2926Department of General Surgery, Hadassah Hebrew University Medical Center, Ein Kerem, P.O. Box 91120, Jerusalem, Israel
| | - Eyal Shteyer
- grid.9619.70000 0004 1937 0538Juliet Keidan Pediatric Gastroenterology Institute, Shaare Zedek Medical Center and the Hebrew University of Jerusalem, Shmuel Bait St 12, Jerusalem, Israel
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Characterization of Humanitarian Trauma Care by US Military Facilities During Combat Operations in Afghanistan and Iraq. Ann Surg 2022; 276:732-742. [PMID: 35837945 DOI: 10.1097/sla.0000000000005592] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To characterize humanitarian trauma care delivered by US military treatment facilities (MTFs) in Afghanistan and Iraq during combat operations. BACKGROUND International Humanitarian Law, which includes the Geneva Conventions, defines protections and standards of treatment to victims of armed conflicts. In 1949 these standards expanded to include injured civilians. In 2001, the Global War on Terror began in Afghanistan and expanded to Iraq in 2003. US MTFs provided care to all military forces, civilians, and enemy prisoners. A thorough understanding of the scope, epidemiology, resource requirements and outcomes of civilian trauma in combat zones has not been previously characterized. METHODS Retrospective cohort analysis of the Department of Defense Trauma Registry from 2005-2019. Inclusion criteria were civilians and non-NATO coalition personnel (NNCP) with traumatic injuries treated at MTFs in Afghanistan and Iraq. Patient demographics, mechanism of injury, resource requirements, procedures, and outcomes were categorized. RESULTS A total of 29,963 casualties were eligible from the Registry. There were 16,749 (55.9%) civilians and 13,214 (44.1%) NNCP. The majority of patients were age >13 years [26,853 (89.6%)] and male [28,000 (93.4%)]. Most injuries were battle-related: 12,740 (76.1%) civilians and 11,099 (84.0%) NNCP. Penetrating trauma was the most common cause of both battle and nonbattle injuries: 12,293 (73.4%) civilian and 10,029 (75.9%) NNCP. Median injury severity score (ISS) was 9 in each cohort with ISS scores ≥ 25 in 2,236 (13.4%) civilians and 1,398 (10.6%) NNCP. Blood products were transfused to 35% of each cohort: 5,850 civilians received a transfusion with 2,118 (12.6%) of them receiving ≥10 units; 4,590 NNCPs received a transfusion with 1,669 (12.6%) receiving ≥ 10 units. MTF mortality rates were civilians 1,263 (7.5%) and NNCP 776 (5.9%). Interventions, both operative and non-operative, were similar between both groups. CONCLUSIONS In accordance with International Humanitarian Law, as well as the US military's medical rules of eligibility, civilians injured in combat zones were provided the same level of care as non-NATO Coalition Personnel. Injured civilians and NNCP had similar mechanisms of injury, injury patterns, transfusion needs, and ISS. This analysis demonstrates resource equipoise in trauma care delivered to civilians and NNCP. Hospitals in combat zones must be prepared to manage large numbers of civilian casualties with significant human and material resources allocated to optimize survival. The provision of humanitarian trauma care is resource-intensive, and these data can be used to inform planning factors for current or future humanitarian care in combat zones.
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Burn Injuries from a military perspective. CURRENT TRAUMA REPORTS 2022. [DOI: 10.1007/s40719-022-00232-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Epidemiology, patterns of care and outcomes of traumatic brain injury in deployed military settings: implications for future military operations. J Trauma Acute Care Surg 2021; 93:220-228. [PMID: 34908023 DOI: 10.1097/ta.0000000000003497] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Traumatic brain injury (TBI) is prevalent and highly morbid among Service Members. A better understanding of TBI epidemiology, outcomes, and care patterns in deployed settings could inform potential approaches to improve TBI diagnosis and management. METHODS A retrospective cohort analysis of Service Members who sustained a TBI in deployed settings between 2001 and 2018 was conducted. Among individuals hospitalized with TBI, we compared the demographic characteristics, mechanism of injury, injury type, and severity between combat and non-combat injuries. We compared diagnostic tests and procedures, evacuation patterns, return to duty rates and days in care between individuals with concussion and those with severe TBI. RESULTS There were 46,309 Service Members with TBI and 9,412 who were hospitalized; of those hospitalized, 55% (4,343) had isolated concussion and 9% (796) had severe TBI, of whom 17% (132/796) had polytrauma. Overall mortality was 2% and ranged from 0.1% for isolated concussion to 18% for severe TBI. The vast majority of TBI were evacuated by rotary wing to Role 3 or higher, including those with isolated concussion. As compared to severe TBI, individuals with isolated concussion had fewer diagnostic or surgical procedures performed. Only 6% of Service Members with severe TBI were able to return to duty as compared to 54% of those with isolated concussion. TBI resulted in 123,677 lost duty days; individuals with isolated concussion spent a median of 2 days in care and those with severe TBI spent a median of 17 days in care and a median of 6 days in the intensive care unit. CONCLUSIONS While most TBI in the deployed setting is mild, TBI is frequently associated with hospitalization and polytrauma. Over-triage of mild TBI is common. Improved TBI capabilities applicable to forward settings will be critical to the success of future multi-domain operations with limitations in air superiority. LEVEL OF EVIDENCE Prognostic, Level III.
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Bozzay JD, Walker PF, Schechtman DW, Shaikh F, Stewart L, Carson ML, Tribble DR, Rodriguez CJ, Bradley MJ. Risk factors for abdominal surgical site infection after exploratory laparotomy among combat casualties. J Trauma Acute Care Surg 2021; 91:S247-S255. [PMID: 33605707 PMCID: PMC8324514 DOI: 10.1097/ta.0000000000003109] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Surgical site infections (SSIs) are well-recognized complications after exploratory laparotomy for abdominal trauma; however, little is known about SSI development after exploration for battlefield abdominal trauma. We examined SSI risk factors after exploratory laparotomy among combat casualties. METHODS Military personnel with combat injuries sustained in Iraq and Afghanistan (June 2009 to May 2014) who underwent laparotomy and were evacuated to participating US military hospitals were included. Log-binominal regression was used to identify SSI risk factors. RESULTS Of 4,304 combat casualties, 341 patients underwent a total of 1,053 laparotomies. Abdominal SSIs were diagnosed in 49 patients (14.4%): 8% with organ space SSI, 4% with deep incisional SSI, and 4% with superficial SSIs (4 patients had multiple SSIs). Patients with SSIs had more colorectal (p < 0.001), small bowel (p = 0.010), duodenum (p = 0.006), pancreas (p = 0.032), and abdominal vascular injuries (p = 0.040), as well as prolonged open abdomen (p = 0.004) and more infections diagnosed before the SSI (or final exploratory laparotomy) versus non-SSI patients (p < 0.001). Sustaining colorectal injuries (risk ratio [RR], 3.20; 95% confidence interval [CI], 1.58-6.45), duodenum injuries (RR, 6.71; 95% CI, 1.73-25.58), and being diagnosed with prior infections (RR, 10.34; 95% CI, 5.05-21.10) were independently associated with any SSI development. For either organ space or deep incisional SSIs, non-intra-abdominal infections, fecal diversion, and duodenum injuries were independently associated, while being injured via an improvised explosive device was associated with reduced likelihood compared with penetrating nonblast (e.g., gunshot wounds) injuries. Non-intra-abdominal infections and hypotension were independently associated with organ space SSIs development alone, while sustaining blast injuries were associated with reduced likelihood. CONCLUSION Despite severity of injuries and the battlefield environment, the combat casualty laparotomy SSI rate is relatively low at 14%, with similar risk factors and rates reported following severe civilian trauma. LEVEL OF EVIDENCE Epidemiological, level III.
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Affiliation(s)
- Joseph D Bozzay
- From the Department of Surgery, Uniformed Services University of the Health Sciences, Walter Reed National Military Medical Center (J.D.B., P.F.W., M.J.B.), Bethesda, Maryland; Brooke Army Medical Center (D.W.S.), JBSA Fort Sam Houston, Texas; Infectious Disease Clinical Research Program, Department of Preventive Medicine and Biostatistics (D.R.T.), Uniformed Services University of the Health Sciences, Bethesda, Maryland; Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc. (F.S., L.S., M.L.C.), Bethesda, Maryland; John Peter Smith Hospital (C.J.R.), Fort Worth, Texas, Bethesda, Maryland
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Haag A, Cone EB, Wun J, Herzog P, Lyon S, Nabi J, Marchese M, Friedlander DF, Trinh QD. Trends in Surgical Volume in the Military Health System-A Potential Threat to Mission Readiness. Mil Med 2021; 186:646-650. [PMID: 33326571 DOI: 10.1093/milmed/usaa543] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Revised: 11/15/2020] [Accepted: 11/26/2020] [Indexed: 12/13/2022] Open
Abstract
INTRODUCTION The Military Health System (MHS) is tasked with a dual mission both to provide medical services for covered patients and to ensure that its active duty medical personnel maintain readiness for deployment. Knowledge, skills, and attitudes (KSA) is a metric evaluating the transferrable skills incorporated into a given surgery or medical procedure that are most relevant for surgeons deployed to a theatre of war. Procedures carrying a high KSA value are those utilizing skills with high relevance for maintaining deployment readiness. Given ongoing concerns regarding surgical volumes at MTFs and the potential adverse impact on military surgeon mission readiness were high-value surgeries to be lost to the civilian sector, we evaluated trends in the setting of high-value surgeries for beneficiaries within the MHS. METHODS We retrospectively analyzed inpatient admissions data from MTFs and TRICARE claims data from civilian hospitals, 2005-2019, to identify TRICARE-covered patients covered under "purchased care" (referred to civilian facilities) or receiving "direct care" (undergoing treatment at MTFs) and undergoing seven high-value/high-KSA surgeries: colectomy, pancreatectomy, hepatectomy, open carotid endarterectomy, abdominal aortic aneurysm (AAA) repair, esophagectomy, and coronary artery bypass grafting (CABG). Overall and procedure-specific counts were captured, MTFs were categorized into quartiles by volume, and independence between trends was tested with a Cochran-Armitage test, hypothesizing that the proportion of cases referred for purchased care was increasing. RESULTS We captured 292,411 cases, including 7,653 pancreatectomies, 4,177 hepatectomies, 3,815 esophagectomies, 112,684 colectomies, 92,161 CABGs, 26,893 AAA repairs, and 45,028 carotid endarterectomies. The majority of cases included were referred for purchased care (90.3%), with the proportion of cases referred increasing over the study period (P < .01). By procedure, all cases except AAA repairs were increasingly referred for treatment over the study period (all P < .01, except esophagectomy P = .04). On examining volume, we found that even the highest-volume-quartile MTFs performed a median of less than one esophagectomy, hepatectomy, or pancreatectomy per month. The only included procedure performed once a month or more at the majority of MTFs was CABG. CONCLUSION On examining volume and referral trends for high-value surgeries within the MHS, we found low surgical volumes at the vast majority of included MTFs and an increasing proportion of cases referred to civilian hospitals over the last 15 years. Our findings illustrate missed opportunities for maintaining the mission readiness of military surgical personnel. Prioritizing the recapture of lost surgical volume may improve the surgical teams' mission readiness.
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Affiliation(s)
- Austin Haag
- Department of Preventive Medicine and Biometrics, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
| | - Eugene B Cone
- Brigham and Women's Hospital, Division of Urological Surgery, Harvard Medical School, Boston, MA 02114, USA.,Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02114, USA
| | - Jolene Wun
- Department of Preventive Medicine and Biometrics, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
| | - Peter Herzog
- Brigham and Women's Hospital, Division of Urological Surgery, Harvard Medical School, Boston, MA 02114, USA
| | - Samuel Lyon
- Brigham and Women's Hospital, Division of Urological Surgery, Harvard Medical School, Boston, MA 02114, USA
| | - Junaid Nabi
- Brigham and Women's Hospital, Division of Urological Surgery, Harvard Medical School, Boston, MA 02114, USA.,Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02114, USA
| | - Maya Marchese
- Brigham and Women's Hospital, Division of Urological Surgery, Harvard Medical School, Boston, MA 02114, USA
| | - David F Friedlander
- Brigham and Women's Hospital, Division of Urological Surgery, Harvard Medical School, Boston, MA 02114, USA.,Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02114, USA
| | - Quoc-Dien Trinh
- Brigham and Women's Hospital, Division of Urological Surgery, Harvard Medical School, Boston, MA 02114, USA.,Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02114, USA
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Breeze J, Gensheimer W, Berg C, Sarber KM. Head Face and Neck Surgical Workload From a Contemporary Military Role 3 Medical Treatment Facility. Mil Med 2021; 187:93-98. [PMID: 34056658 DOI: 10.1093/milmed/usab221] [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: 03/05/2021] [Revised: 05/08/2021] [Accepted: 05/18/2021] [Indexed: 11/14/2022] Open
Abstract
INTRODUCTION Previous analyses of head, face, and neck (HFN) surgery in the deployed military setting have focused on the treatment of injuries using trauma databases. Little has been written on the burden of disease and the requirement for follow-up care. The aim of this analysis was to provide the most comprehensive overview of surgical workload in a contemporary role 3 MTF to facilitate future planning. METHOD The operating room database and specialty surgical logbooks from a U.S.-led role 3 MTF in Afghanistan were analyzed over a 5-year period (2016-2020). These were then matched to the deployed surgical TC2 database to identify reasons for treatment and a return to theatre rate. Operative records were finally matched to the deployed Armed Forces Health Longitudinal Technology Application-Theater outpatient database to determine follow up frequency. RESULTS During this period, surgical treatment to the HFN represented 389/1989 (19.6%) of all operations performed. Surgery to the HFN was most commonly performed for battle injury (299/385, 77.6%) followed by disease (63/385, 16%). The incidence of battle injury-related HFN cases varied markedly across each year, with 117/299 (39.1%) being treated in the three summer months (June to August). The burden of disease, particularly to the facial region, remained constant throughout the period analyzed (mean of 1 case per month). CONCLUSIONS Medical planning of the surgical requirements to treat HFN pathology is primarily focused on battle injury of coalition service personnel. This analysis has demonstrated that the treatment of disease represented 16% of all HFN surgical activities. The presence of multiple HFN sub-specialty surgeons prevented the requirement for multiple aeromedical evacuations of coalition service personnel which may have affected mission effectiveness as well as incurring a large financial burden. The very low volume of surgical activity demonstrated during certain periods of this analysis may have implications for the maintenance of surgical competencies for subspecialty surgeons.
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Affiliation(s)
- John Breeze
- Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, Birmingham B15 2TH, UK
| | - William Gensheimer
- Warfighter Eye Center, Malcolm Grow Medical Clinics and Surgery Center, Joint Base Andrews, MD 20762, USA
| | - Craig Berg
- Department of Neurosurgery, 88th SGC/SGCO, Wright-Patterson Air Force Base, Dayton, OH 45433, USA
| | - Kathleen M Sarber
- Department of Otolaryngology, 96th Medical Group, Eglin AFB, FL 32542, USA
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Carleton MM, Sefton MV. Promoting endogenous repair of skeletal muscle using regenerative biomaterials. J Biomed Mater Res A 2021; 109:2720-2739. [PMID: 34041836 DOI: 10.1002/jbm.a.37239] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Revised: 05/14/2021] [Accepted: 05/18/2021] [Indexed: 02/06/2023]
Abstract
Skeletal muscles normally have a remarkable ability to repair themselves; however, large muscle injuries and several myopathies diminish this ability leading to permanent loss of function. No clinical therapy yet exists that reliably restores muscle integrity and function following severe injury. Consequently, numerous tissue engineering techniques, both acellular and with cells, are being investigated to enhance muscle regeneration. Biomaterials are an essential part of these techniques as they can present physical and biochemical signals that augment the repair process. Successful tissue engineering strategies require regenerative biomaterials that either actively promote endogenous muscle repair or create an environment supportive of regeneration. This review will discuss several acellular biomaterial strategies for skeletal muscle regeneration with a focus on those under investigation in vivo. This includes materials that release bioactive molecules, biomimetic materials and immunomodulatory materials.
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Affiliation(s)
- Miranda M Carleton
- Institute of Biomedical Engineering, University of Toronto, Toronto, Ontario, Canada
| | - Michael V Sefton
- Institute of Biomedical Engineering, University of Toronto, Toronto, Ontario, Canada.,Department of Chemical Engineering and Applied Chemistry, University of Toronto, Toronto, Ontario, Canada
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Richards CRN, Joel C, Dickens JF. Review of a Role 2 in Afghanistan: Understanding the Data on Medical and Surgical Volumes in a Deployed Setting. Mil Med 2021; 186:e599-e605. [PMID: 33206967 DOI: 10.1093/milmed/usaa472] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Revised: 08/04/2020] [Accepted: 10/26/2020] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION The U.S. forward military surgical assets have deployed throughout the Iraq and Afghanistan theaters of operations to maintain surgical support for injured service members in compliance with the "golden hour" as specified in the Gates Memorandum. The support of evacuation times of less than 60 minutes to a surgical capability has resulted in smaller surgical teams being deployed to an increased number of locations. Over the last 5 years, the combat trauma patient encounters have decreased. Although some Role 2 medical treatment facilities (MTFs) maintain a medical mission, most of them are set up to provide trauma care. The largest and busiest Role 2 MTF is located near Kabul and serves the NATO population. The aims of this review are to examine the epidemiological data of the largest Role 2 MTF in theater, to examine damage control surgical capability optimization in a facility with a largely medical mission, and to analyze what this may mean in the context of surgical skill atrophy. METHODS As part of a performance improvement project, a retrospective review of prospectively collected data at the Hamid Karzai NATO Role 2 MTF was conducted. Four years of clinical and epidemiological data were reviewed. Independent source verification of the records was conducted by validating records via comparison to the ancillary services' records. When available, data on other MTFs in Afghanistan were used for comparison. Descriptive statistics were used to analyze demographics, evacuations, surgeries, and admissions. RESULTS Over the studied period, 0.7% of patients were seen for battle injuries. The average number of patients seen was 636 per month with 184 per month in 2016 and a steady increase to 805 per month in 2019. The operative volume was a mean of 2.8 surgeries per month with a median of 2 surgeries per month (orthopedic and general surgery combined). Other Role 2 facilities were on average seeing even fewer operative patients, although there were some treating more operative patients. From available data, no other Role 2 MTFs were treating close to as many total patients (all types combined). The two Role 3 facilities evaluated saw significantly more operative patients at an average of 53 surgeries per month. CONCLUSION The ratio of operative cases per surgeon is substantially higher at these Role 3 facilities, when compared to Role 2 facilities, although still significantly lower than would be expected at an U.S. Level 1 trauma center. This is consistent with other larger epidemiological studies on forward MTF workload. The vast majority of patient care is related to treatment of disease and preventative medicine. Only 0.7% of the large volume of patient visits evaluated were for battle injuries. There is a scarcity of both surgical and trauma patients, with a more pronounced reduction at Role 2 compared to Role 3 facilities. This is especially evident here with a facility that has such a large patient population but low trauma or surgical patient volume. Sustaining trauma and surgical skills for both surgeons and trauma teams with a paucity of trauma patients is a significant concern.
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Affiliation(s)
- Carly R N Richards
- Department of Surgery, Martin Army Community Hospital, Fort Benning, GA 31905, USA
| | - Constance Joel
- Department of Surgery, Martin Army Community Hospital, Fort Gorden, GA 30905, USA
| | - Jon F Dickens
- Department of Orthopedic Surgery, Walter Reed National Military Medical Center, Bethesda, MD 20814, USA
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Nealeigh MD, Kucera WB, Artino AR, Bradley MJ, Meyer HS. The Isolated Surgeon: A Scoping Review. J Surg Res 2021; 264:562-571. [PMID: 33461780 DOI: 10.1016/j.jss.2020.12.032] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2020] [Revised: 12/10/2020] [Accepted: 12/16/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND Surgeons in resource-limited environments often provide care outside the expected scope of current general surgery training. Geographically isolated patients may be unwilling or unable to travel for specialty care. These same patients also present with life-threatening emergencies beyond the typical breadth of a general surgeon's practice, in hospitals with limited professional and material support. This review characterizes the unique role of isolated surgeons, so individual surgeons and health care organizations may focus professional development resources more efficiently, with the ultimate goal of improved patient care. METHODS We performed a scoping review of the isolated surgeon, reviewing 25 years of literature regarding isolated US civilian and military surgeons. We examined emerging themes regarding the definition of an isolated surgeon, the scope of surgical practice beyond current training norms, and training gaps identified by surgeons in an isolated role. RESULTS From 904 articles identified, we included 91 for final review. No prior definition exists for the isolated surgeon, although multiple definitions describe rural surgeons, patients, or hospitals; we propose an initial definition from consistent themes in the literature. Isolated surgeons across varied practice settings consistently performed relatively large volumes of cases of, and identified training gaps in, orthopedic, obstetric and gynecologic, urologic, and vascular surgery subspecialties. Life-threatening, "rare-but-real" cases in the above and neurosurgical disciplines are uncommon, but consistent across practice settings. CONCLUSIONS This review represents the largest examination of the isolated surgeon in the current literature. Clarifying the identity, practice components, and training gaps of the isolated surgeon represent the first step in formalizing support for this small but critical group of surgeons and their patients.
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Affiliation(s)
- Matthew D Nealeigh
- Department of Surgery, Walter Reed National Military Medical Center and the Uniformed Services University of the Health Sciences, Bethesda, Maryland.
| | - Walter B Kucera
- Department of Surgery, Walter Reed National Military Medical Center and the Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Anthony R Artino
- Department of Health, Human Function, & Rehabilitation Sciences, George Washington University School of Medicine & Health Sciences, Washington, District of Columbia
| | - Matthew J Bradley
- Department of Surgery, Walter Reed National Military Medical Center and the Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Holly S Meyer
- Center for Health Professions Education, Uniformed Services University of the Health Sciences, Bethesda, Maryland
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Cant MR, Naumann DN, König TC, Bowley DM. How do deployed general surgeons acquire relevant skill sets and competencies and mitigate skill fade? BMJ Mil Health 2020; 167:209-213. [PMID: 33328277 DOI: 10.1136/bmjmilitary-2020-001641] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Revised: 10/22/2020] [Accepted: 10/27/2020] [Indexed: 12/28/2022]
Abstract
There are recognised difficulties internationally with acquisition and retention of skills among deployed military general surgeons. These are compounded by reduced trauma workload in non-deployed roles or during low tempo or limited activity deployments, and the winding-down of combat operations in Iraq and Afghanistan. We summarise the relevant military-run courses, military-civilian collaborations and potential future strategies that have been used to address skill sets and competencies of deployed surgeons. We use examples from the American, British, Danish, French, German and Swedish Armed Forces. There is variation between nations in training, with a combination of didactic lectures, simulation training and trauma placements in civilian settings at home and overseas. Data regarding effectiveness of these techniques are sparse. It is likely that combat surgical skill-set acquisition and maintenance requires a combination of employment at a high-volume trauma centre during a surgeon's non-deployed role, together with military-specific courses and high-fidelity simulation to fill skill gaps. There are multiple newer modalities of training that require further evaluation if they are to prove effective in the future. We aimed to summarise the current methods used internationally to ensure acquisition and retention of vital skill sets for these surgeons.
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Affiliation(s)
| | - D N Naumann
- Academic Department of Military Surgery and Trauma, Birmingham, UK
| | - T C König
- Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, Queen Elizabeth Hospital, Birmingham, UK.,16 Medical Regiment, Royal Army Medical Corps, Merville Barracks, Colchester, Essex, UK
| | - D M Bowley
- Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, Queen Elizabeth Hospital, Birmingham, UK
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Improved outcomes utilizing a novel pectin-based pleural sealant following acute lung injury. J Trauma Acute Care Surg 2020; 89:915-919. [PMID: 33108138 DOI: 10.1097/ta.0000000000002754] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Persistent air leaks after thoracic trauma are associated with significant morbidity. To evaluate a novel pectin sealant in a swine model of traumatic air leaks, we compared a pectin biopolymer with standard surgical and fibrin-based interventions. METHODS A standardized lung injury was created in male Yorkshire swine. Interventions were randomized to stapled wedge resection (n = 5), topical fibrin glue (n = 5), fibrin patch (n = 5), and a pectin sealant (n = 6). Baseline, preintervention and postintervention tidal volumes (TV) were recorded. Early success was defined as the return to near-normal TV (>95% of baseline). Late success was defined as no detectable air leak in the chest tube after chest closure. RESULTS There were no differences in injury severity between groups (mean TV loss, 62 ± 17 mL, p = 0.2). Early success was appreciated in 100% (n = 6) of the pectin interventions which was significantly better than the fibrin sealant (20%, n = 1), fibrin patch (20%, n = 1), and stapled groups (80%, n = 4, p = 0.01). The percent of return to baseline TV after sealant intervention was significantly increased in the pectin (98%) and staple arms (97%) compared with the fibrin sealant (91%) and fibrin patch arms (90%) (p = 0.02; p = 0.03). Late success was also improved with the pectin sealant: no air leak was detected in 83% of the pectin group compared with 40% in the stapled group (p = 0.008)-90% of the fibrin-based interventions resulted in continuous air leaks (p = 0.001). CONCLUSION Pectin-based bioadhesives effectively seal traumatic air leaks upon application in a porcine model. Further testing is warranted as they may provide a superior parenchymal-sparing treatment option for traumatic air leaks.
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Outcomes of Exploratory Laparotomy and Abdominal Infections Among Combat Casualties. J Surg Res 2020; 257:285-293. [PMID: 32866669 DOI: 10.1016/j.jss.2020.07.075] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Revised: 07/09/2020] [Accepted: 07/11/2020] [Indexed: 01/01/2023]
Abstract
BACKGROUND Abdominal injuries historically account for 13% of battlefield surgical procedures. We examined the occurrence of exploratory laparotomies and subsequent abdominal surgical site infections (SSIs) among combat casualties. METHODS Military personnel injured during deployment (2009-2014) were included if they required a laparotomy for combat-related trauma and were evacuated to Landstuhl Regional Medical Center, Germany, before being transferred to participating US military hospitals. RESULTS Of 4304 combat casualties, 341 (7.9%) underwent laparotomy. Including re-explorations, 1053 laparotomies (median, 2; interquartile range, 1-3; range, 1-28) were performed with 58% occurring within the combat zone. Forty-nine (14.4%) patients had abdominal SSIs (four with multiple SSIs): 27 (7.9%) with deep space SSIs, 14 (4.1%) with a deep incisional SSI, and 12 (3.5%) a superficial incisional SSI. Patients with abdominal SSIs had larger volume of blood transfusions (median, 24 versus 14 units), more laparotomies (median, 4 versus 2), and more hollow viscus injuries (74% versus 45%) than patients without abdominal SSIs. Abdominal closure occurred after 10 d for 12% of the patients with SSI versus 2% of patients without SSI. Mesh adjuncts were used to achieve fascial closure in 20.4% and 2.1% of patients with and without SSI, respectively. Survival was 98% and 96% in patients with and without SSIs, respectively. CONCLUSIONS Less than 10% of combat casualties in the modern era required abdominal exploration and most were severely injured with hollow viscus injuries and required massive transfusions. Despite the extensive contamination from battlefield injuries, the SSI proportion is consistent with civilian rates and survival was high.
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Outcomes following penetrating neck injury during the Iraq and Afghanistan conflicts: A comparison of treatment at US and United Kingdom medical treatment facilities. J Trauma Acute Care Surg 2020; 88:696-703. [PMID: 32068717 PMCID: PMC7182242 DOI: 10.1097/ta.0000000000002625] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Supplemental digital content is available in the text. The United States and United Kingdom (UK) had differing approaches to the surgical skill mix within deployed medical treatment facilities (MTFs) in support of the military campaigns in Iraq and Afghanistan.
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Staudt AM, Suresh MR, Gurney JM, Trevino JD, Valdez-Delgado KK, VanFosson CA, Butler FK, Mann-Salinas EA, Kotwal RS. Forward Surgical Team Procedural Burden and Non-operative Interventions by the U.S. Military Trauma System in Afghanistan, 2008-2014. Mil Med 2020; 185:e759-e767. [PMID: 31863088 DOI: 10.1093/milmed/usz402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION No published study has reported non-surgical interventions performed by forward surgical teams, and there are no current surgical benchmarks for forward surgical teams. The objective of the study was to describe operative procedures and non-operative interventions received by battlefield casualties and determine the operative procedural burden on the trauma system. METHODS This was a retrospective analysis of data from the Joint Trauma System Forward Surgical Team Database using battle and non-battle injured casualties treated in Afghanistan from 2008-2014. Overall procedure frequency, mortality outcome, and survivor morbidity outcome were calculated using operating room procedure codes grouped by the Healthcare Cost and Utilization Project classification. Cumulative attributable burden of procedures was calculated by frequency, mortality, and morbidity. Morbidity and mortality burden were used to rank procedures. RESULTS The study population was comprised of 10,992 casualties, primarily male (97.8%), with a median age interquartile range of 25.0 (22.0-30.0). Affiliations were non-U.S. military (40.0%), U.S. military (35.1%), and others (25.0%). Injuries were penetrating (65.2%), blunt (32.8), and burns (2.0%). Casualties included 4.4% who died and 14.9% who lived but had notable morbidity findings. After ranking by contribution to trauma system morbidity and mortality burden, the top 10 of 32 procedure groups accounted for 74.4% of operative care, 77.9% of mortality, and 73.1% of unexpected morbidity findings. These procedure groups included laparotomy, vascular procedures, thoracotomy, debridement, lower and upper gastrointestinal procedures, amputation, and therapeutic procedures on muscles and upper and lower extremity bones. Most common non-operative interventions included X-ray, ultrasound, wound care, catheterization, and intubation. CONCLUSIONS Forward surgical team training and performance improvement metrics should focus on optimizing commonly performed operative procedures and non-operative interventions. Operative procedures that were commonly performed, and those associated with higher rates of morbidity and mortality, can set surgical benchmarks and outline training and skillsets needed by forward surgical teams.
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Affiliation(s)
- Amanda M Staudt
- Joint Base San Antonio-Fort Sam Houston, U.S. Army Institute of Surgical Research, 3698 Chambers Pass, TX 78234
| | - Mithun R Suresh
- Joint Base San Antonio-Fort Sam Houston, U.S. Army Institute of Surgical Research, 3698 Chambers Pass, TX 78234
| | - Jennifer M Gurney
- Joint Base San Antonio-Fort Sam Houston, U.S. Army Institute of Surgical Research, 3698 Chambers Pass, TX 78234.,Joint Trauma System, DoD Center of Excellence for Trauma, Joint Base San Antonio-Fort Sam Houston, 3698 Chambers Pass, TX 78234
| | - Jennifer D Trevino
- Joint Base San Antonio-Fort Sam Houston, U.S. Army Institute of Surgical Research, 3698 Chambers Pass, TX 78234
| | - Krystal K Valdez-Delgado
- Joint Base San Antonio-Fort Sam Houston, U.S. Army Institute of Surgical Research, 3698 Chambers Pass, TX 78234
| | - Christopher A VanFosson
- Joint Base San Antonio-Fort Sam Houston, U.S. Army Institute of Surgical Research, 3698 Chambers Pass, TX 78234
| | - Frank K Butler
- Joint Trauma System, DoD Center of Excellence for Trauma, Joint Base San Antonio-Fort Sam Houston, 3698 Chambers Pass, TX 78234
| | - Elizabeth A Mann-Salinas
- Joint Trauma System, DoD Center of Excellence for Trauma, Joint Base San Antonio-Fort Sam Houston, 3698 Chambers Pass, TX 78234
| | - Russ S Kotwal
- Joint Base San Antonio-Fort Sam Houston, U.S. Army Institute of Surgical Research, 3698 Chambers Pass, TX 78234.,Joint Trauma System, DoD Center of Excellence for Trauma, Joint Base San Antonio-Fort Sam Houston, 3698 Chambers Pass, TX 78234
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Abstract
BACKGROUND Thoracic surgery constitutes 2.5% of surgical procedures performed in theater, but the skills required are increasingly foreign to military surgeons. This study examines thoracic surgical workload in Iraq and Afghanistan to help define surgical training gaps. METHODS Retrospective analysis of Department of Defense Trauma Registry for all role 2 (R2) (forward surgical) and role 3 (R3) (theater) military facilities, from January 2002 to May 2016. The 95 thoracic surgical International Classification of Diseases-9th Rev.-Clinical Modification procedure codes were grouped into 10 categories based on anatomy or endoscopy. Select groups were further stratified by type of definitive procedure. Procedure groupings were determined and adjudicated by surgeon subject matter experts. Data analysis used Stata Version 15 (College Station, TX). RESULTS Of the total procedures, 5,301 were classified as thoracic surgical procedures and were included in the present study. The majority of thoracic surgical procedures (4,645 [87.6%]) were recorded as being performed at R3 medical treatment facilities (MTFs). The thoracic surgical procedures groups with the largest proportions were: bronchoscopy (39.1%), thoracotomy (16.9%), diaphragm (15.6%), and lung (11.4%). The most common lung procedure subgroup, aside from not otherwise specified, was segmentectomy (28.8%). The R3 MTFs recorded nearly five times the number of lung procedures compared with R2 MTFs; with R3 MTFs recording more than eight times the number of lobectomies compared with R2 MTFs. Thoracic workload was variable over the 15-year study period. CONCLUSION Thoracic surgical skills are necessary in the deployed environment to manage combat-related injuries. Given the current trends in training and specialization, development and sustainment of thoracic surgical skills is challenging in the deployed US trauma system and likely for other nations, and humanitarian surgical care as well. Current training and practice paradigms pose both training and sustainment challenges for surgeons who deploy to a combat zone. LEVEL OF EVIDENCE Therapeutic/Care Management IV.
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Kauvar DS, Propper BW, Arthurs ZM, Causey MW, Walters TJ. Impact of Staged Vascular Management on Limb Outcomes in Wartime Femoropopliteal Arterial Injury. Ann Vasc Surg 2020; 62:119-127. [DOI: 10.1016/j.avsg.2019.08.072] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Revised: 07/17/2019] [Accepted: 08/22/2019] [Indexed: 10/26/2022]
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Cardi M, Ibrahim K, Alizai SW, Mohammad H, Garatti M, Rainone A, Di Marzo F, La Torre G, Paschetto M, Carbonari L, Mingarelli V, Mingoli A, Sica GS, Sibio S. 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. World J Emerg Surg 2019; 14:51. [PMID: 31832085 PMCID: PMC6868865 DOI: 10.1186/s13017-019-0272-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Accepted: 10/17/2019] [Indexed: 11/10/2022] Open
Abstract
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.
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Affiliation(s)
- Maurizio Cardi
- Emergency NGO Medical Division, Lashkargah Hospital, Lashkargah, Afghanistan.,2Dipartimento di Chirurgia "P. Valdoni", Sapienza Università di Roma, Viale del Policlinico155, 00161 Rome, Italy
| | - Khushal Ibrahim
- Emergency NGO Medical Division, Lashkargah Hospital, Lashkargah, Afghanistan
| | - Shah Wali Alizai
- Emergency NGO Medical Division, Lashkargah Hospital, Lashkargah, Afghanistan
| | - Hamayoun Mohammad
- Emergency NGO Medical Division, Lashkargah Hospital, Lashkargah, Afghanistan
| | - Marco Garatti
- Emergency NGO Medical Division, Lashkargah Hospital, Lashkargah, Afghanistan.,Chirurgia Generale, Fondazione Poliambulanza, Istituto Ospedaliero, Via Bissolati 57, Brescia, Italy
| | - Antonio Rainone
- Emergency NGO Medical Division, Lashkargah Hospital, Lashkargah, Afghanistan
| | - Francesco Di Marzo
- 4Chirurgia Generale, Ospedale Versilia, Via Aurelia 335, 55041 Lido di Camaiore, LU Italy
| | - Giuseppe La Torre
- 5Dipartimento di Sanità Pubblica e Malattie Infettive, Sapienza Università di Roma, Viale del Policlinico155, 00161 Rome, Italy
| | - Michela Paschetto
- Emergency NGO Medical Division, Lashkargah Hospital, Lashkargah, Afghanistan
| | - Ludovica Carbonari
- 2Dipartimento di Chirurgia "P. Valdoni", Sapienza Università di Roma, Viale del Policlinico155, 00161 Rome, Italy
| | - Valentina Mingarelli
- 2Dipartimento di Chirurgia "P. Valdoni", Sapienza Università di Roma, Viale del Policlinico155, 00161 Rome, Italy
| | - Andrea Mingoli
- 2Dipartimento di Chirurgia "P. Valdoni", Sapienza Università di Roma, Viale del Policlinico155, 00161 Rome, Italy
| | - Giuseppe S Sica
- 6Dipartimento di Chirurgia, Università Tor Vergata, Viale Oxford 81, 00133 Rome, Italy
| | - Simone Sibio
- Emergency NGO Medical Division, Lashkargah Hospital, Lashkargah, Afghanistan
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Stern CA, Stockinger ZT, Todd WE, Gurney JM. An Analysis of Orthopedic Surgical Procedures Performed During U.S. Combat Operations from 2002 to 2016. Mil Med 2019; 184:813-819. [DOI: 10.1093/milmed/usz093] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Revised: 03/15/2019] [Accepted: 04/02/2019] [Indexed: 11/13/2022] Open
Abstract
Abstract
Introduction
Orthopedic surgery constitutes 27% of procedures performed for combat injuries. General surgeons may deploy far forward without orthopedic surgeon support. This study examines the type and volume of orthopedic procedures during 15 years of combat operations in Iraq and Afghanistan.
Materials and Methods
Retrospective analysis of the US Department of Defense Trauma Registry (DoDTR) was performed for all Role 2 and Role 3 facilities, from January 2002 to May 2016. The 342 ICD-9-CM orthopedic surgical procedure codes identified were stratified into fifteen categories, with upper and lower extremity subgroups. Data analysis used Stata Version 14 (College Station, TX).
Results
A total of 51,159 orthopedic procedures were identified. Most (43,611, 85.2%) were reported at Role 3 s. More procedures were reported on lower extremities (21,688, 57.9%). Orthopedic caseload was extremely variable throughout the 15-year study period.
Conclusions
Orthopedic surgical procedures are common on the battlefield. Current dispersed military operations can occur without orthopedic surgeon support; general surgeons therefore become responsible for initial management of all injuries. Debridement of open fracture, fasciotomy, amputation and external fixation account for 2/3 of combat orthopedic volume; these procedures are no longer a significant part of general surgery training, and uncommonly performed by general/trauma surgeons at US hospitals. Given their frequency in war, expertise in orthopedic procedures by military general surgeons is imperative.
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Affiliation(s)
- Caryn A Stern
- Joint Trauma System, DoD Center of Excellence for Trauma, 3611 Chambers Dr, Joint Base San Antonio, Fort Sam Houston, TX 78234
| | - Zsolt T Stockinger
- Naval Hospital Jacksonville & Navy Medicine Readiness and Training Command, 2080 Child St, Jacksonville, FL 32214
| | - William E Todd
- Naval Hospital Jacksonville & Navy Medicine Readiness and Training Command, 2080 Child St, Jacksonville, FL 32214
| | - Jennifer M Gurney
- Joint Trauma System, DoD Center of Excellence for Trauma, 3611 Chambers Dr, Joint Base San Antonio, Fort Sam Houston, TX 78234
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Hall A, Qureshi I, Shackelford S, Glaser J, Bulger EM, Scalea T, Gurney J. Objective model to facilitate designation of military-civilian partnership hospitals for sustainment of military trauma readiness. Trauma Surg Acute Care Open 2019; 4:e000274. [PMID: 31058239 PMCID: PMC6461135 DOI: 10.1136/tsaco-2018-000274] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2018] [Revised: 01/15/2019] [Accepted: 01/30/2019] [Indexed: 11/08/2022] Open
Abstract
Background A major dilemma of the military surgeon is the requirement for battlefield trauma expertise without regular exposure to a traumatically injured patient. To solve this problem, the military is partnering with civilian trauma centers to obtain the required trauma exposure. The main objective of this article is to quantify institutional differences and develop a predictive model for estimating the number of 24-hour trauma shifts a surgeon must be on call at civilian centers to experience urgent trauma cases. Methods Trauma databases from multiple institutions were queried to obtain all urgent trauma cases occurring during a 2-year period. A predictive model was used to estimate the number of urgent surgical cases in multiple specialties surgeons would experience over various numbers of 24-hour shifts and the number of 24-hour shifts required to experience a defined number of cases. Results Institution 1 had the lowest number of required 24-hour shifts to experience 10 urgent operative cases for general/trauma surgery (10 calls) and orthopedic surgery (6 calls) and the highest number of predicted cases over 12 days, 18.3 (95% CI 11 to 27), with 95% confidence. The expected trauma cases and 24-hour shifts at Institution 1 were statistically significant (p<0.0001). There were seasonal effects at all institutions except for Institution 3. Discussion There are significant variabilities in trauma center volume and therefore, the expected number of shifts and cases during a specific period of time is significantly different between trauma centers. This predictive model is objective and can therefore be used as an extrapolative tool to help and inform the military regarding placement of personnel in optimal centers for trauma currency rotations. Level of evidence Economic and value-based evaluations, level II.
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Affiliation(s)
- Andrew Hall
- Center for the Sustainment of Trauma and Readiness Skills - St. Louis, Saint Louis University Hospital, Saint Louis, Missouri, USA
| | - Iram Qureshi
- Naval Medical Research Unit San Antonio, San Antonio, Texas, USA
| | - Stacy Shackelford
- Joint Trauma System, Defense Center of Excellence, San Antonio, Texas, USA
| | - Jacob Glaser
- Naval Medical Research Unit San Antonio, San Antonio, Texas, USA
| | - Eileen M Bulger
- Department of Surgery, University of Washington, Seattle, Washington, USA
| | - Thomas Scalea
- R Adams Cowley Shock Trauma Center, Baltimore, Maryland, USA
| | - Jennifer Gurney
- Joint Trauma System, Defense Center of Excellence, San Antonio, Texas, USA
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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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Abdominal trauma surgery during recent US combat operations from 2002 to 2016. J Trauma Acute Care Surg 2018; 85:S122-S128. [DOI: 10.1097/ta.0000000000001804] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Vascular surgery during U.S. combat operations from 2002 to 2016: Analysis of vascular procedures performed to inform military training. J Trauma Acute Care Surg 2018; 85:S145-S153. [DOI: 10.1097/ta.0000000000001849] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Turner CA, Orman JA, Stockinger ZT, Hudak SJ. Genitourinary Surgical Workload at Deployed U.S. Facilities in Iraq and Afghanistan, 2002–2016. Mil Med 2018; 184:e179-e185. [DOI: 10.1093/milmed/usy152] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Accepted: 05/29/2018] [Indexed: 11/14/2022] Open
Affiliation(s)
- Caryn A Turner
- Joint Trauma System, 3698 Chambers Pass, Ft. Sam Houston, TX
| | - Jean A Orman
- Joint Trauma System, 3698 Chambers Pass, Ft. Sam Houston, TX
| | | | - Steven J Hudak
- San Antonio Military Medical Center, Urology Clinic, 3551 Roger Brooke Drive, Ft. Sam Houston, TX
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Analysis of Pediatric Trauma in Combat Zone to Inform High-Fidelity Simulation Predeployment Training. Pediatr Crit Care Med 2018; 19:e199-e206. [PMID: 29369076 DOI: 10.1097/pcc.0000000000001461] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES The military uses "just-in-time" training to refresh deploying medical personnel on skills necessary for medical and surgical care in the theater of operations. The burden of pediatric care at Role 2 facilities has yet to be characterized; pediatric predeployment training has been extremely limited and primarily informed by anecdotal experience. The goal of this analysis was to describe pediatric care at Role 2 facilities to enable data-driven development of high-fidelity simulation training and core knowledge concepts specific to the combat zone. SETTING AND PATIENTS A retrospective review of the Role 2 Database was conducted on all pediatric patients (< 18 yr) admitted to Role 2 in Afghanistan from 2008-2014. INTERVENTIONS Three cohorts were determined based on commercially available simulation models: Group 1: less than 1 year, Group 2: 1-8 years, Group 3: more than 8 years. The groups were sub-stratified by point of injury care, pre-hospital management, and Role 2 facility medical/surgical management. MEASUREMENTS AND MAIN RESULTS Appropriate descriptive statistics (chi square and Student t test) were utilized to define demographic and epidemiologic characteristics of this population. Of 15,404 patients in the Role 2 Database, 1,318 pediatric subjects (8.5%) were identified. The majority of patients were male (80.0%) with a mean age of 9.5 years (± SD, 4.5). Injury types included: penetrating (56%), blunt (33%), and burns (7%). Mean transport time from point of injury to Role 2 was 198 minutes (±24.5 min). Mean Glasgow Coma Scale and Revised Trauma Score were 14 (± 0.1) and 7.0 (± 1.4), respectively. Role 2 surgical procedures occurred for 424 patients (32%). Overall mortality was 4% (n = 58). CONCLUSIONS We have described the epidemiology of pediatric trauma admitted to Role 2 facilities, characterizing the spectrum of pediatric injuries that deploying providers should be equipped to manage. This analysis will function as a needs assessment to facilitate high-fidelity simulation training and the development of "pediatric trauma core knowledge concepts" for deploying providers.
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Performance Improvement in Combat Casualty Care. CURRENT TRAUMA REPORTS 2018. [DOI: 10.1007/s40719-018-0111-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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