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Polley CC, Adu-Gyamfi R, Mahama-Toure T, Okpoti Konney F, Oti-Boateng E, Nsohlebna Nsoh L, Ballard T. Sustainable Tactical Combat Casualty Care Implementation in Ghana: A Model for Future Development. Mil Med 2024; 189:e1221-e1225. [PMID: 37651582 DOI: 10.1093/milmed/usad333] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Revised: 07/10/2023] [Accepted: 08/10/2023] [Indexed: 09/02/2023] Open
Abstract
INTRODUCTION Department of Defense policy for Global Health Engagement (GHE) activities prioritizes interoperability and sustainability within security cooperation, yet these elements, along with monitoring and evaluation, are not well reported. MATERIALS AND METHODS In this case study reviewing 1 year after the implementation of a Tactical Combat Casualty Care (TCCC) program in Ghana, the Ghana Armed Forces (GAF) has conducted five independent TCCC Medical Provider Tier courses and four All Service Member Tier courses. They have certified 240 students, 21 instructors, and appointed 2 affiliate faculty members with the National Association of Emergency Medical Technicians (NAEMT). Ghana is one of the only four active NAEMT-certified TCCC training sites in Africa. The principles that allowed for this achievement could serve as a 'best practice' model for GHE. RESULTS Principally, the GAF took ownership of the program from the onset. The program also had an extensive preparatory phase 0 before initiating phase 1 on the ground training, which included establishing leadership and a medical modeling and simulation center pre-engagement. The triple partnership achieved between the U.S. DoD's African Peacekeeping Rapid Response Partnership, the GAF, and the NAEMT, a civilian certifying organization, allowed the sustainment of the TCCC program. African Peacekeeping Rapid Response Partnership also built on experience from other programs to develop a multifaceted model. Persisting challenges to the current program and future GHEs include continued funding and equipment, the associated issues with rapid expansion, and monitoring and evaluation, which all pose barriers to continued sustainment. CONCLUSION The year sustainment of the GAF TCCC training program provides hope as a model for future DoD GHEs to attain sustainable development and points to the possibility of long-term programs with meaningful outcomes.
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Affiliation(s)
- Catherine C Polley
- Uniformed Services University and Center for Global Health Engagement, Bethesda, MD 20814, USA
| | - Rossi Adu-Gyamfi
- Trauma and Surgical Emergency, 37 Military Hospital, Accra, Ghana
| | | | | | | | | | - Timothy Ballard
- Air Force Medical Readiness Agency, Defense Health Headquarters, Falls Church, VA 22042, USA
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Terrorist Attacks Against Performing Arts Venues: Global Trends and Characteristics Spanning 50 Years. Prehosp Disaster Med 2022; 37:593-599. [PMID: 35942627 PMCID: PMC9474675 DOI: 10.1017/s1049023x22001145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
INTRODUCTION In fostering community and culture through entertainment in shared spaces, performing arts venues have also become targets of terrorism. A greater understanding of these attacks is needed to assess the risk posed to different types of venues, to inform medical disaster preparedness, to anticipate injury patterns, and to reduce preventable deaths. METHODS A search of the Global Terrorism Database (GTD) was conducted from the year 1970 through 2019. Using pre-coded variables for target/victim type and target subtype, attacks involving "business" and "entertainment/cultural/stadium/casino" were identified. Attacks targeting performing arts venues were selected using the search terms "theater," "theatre," "auditorium," "center," "hall," "house," "concert," "music," "opera," "cinema," and "movie." Manual review by two authors was performed to confirm appropriateness for inclusion of entries involving venues where the primary focus of the audience was to view a performance. Descriptive statistics were performed using R (version 3.6.1). RESULTS A total of 312 terrorist attacks targeting performing arts venues were identified from January 1, 1970 through December 31, 2019. Two-hundred nine (67.0%) attacks involved cinemas or movie theaters, 80 (25.6%) involved unspecified theaters, and 23 (7.4%) specifically targeted live music performance venues. Two-hundred thirty-four (75.0%) attacks involved a bombing or explosion, 50 (16.0%) damaged a facility or infrastructure, and 17 (5.4%) included armed assault. Perpetrators used explosives in 234 (75.0%) attacks, incendiary weapons in 50 (16.0%) attacks, and firearms in 19 (6.1%) attacks. In total, attacks claimed the lives of 1,307 and wounded 4,201 persons. Though fewer in number, attacks against music venues were responsible for 29.4% of fatalities and 35.0% of those wounded, and more frequently involved the use of firearms. Among 95 attacks falling within the highest quartile for victims killed or wounded (>two killed and/or >ten wounded), 83 (87.4%) involved explosives, seven (7.4%) involved firearms, and three (3.2%) involved incendiary methods. CONCLUSION While uncommon, terrorist attacks against performing arts venues carry the risk for mass casualties, particularly when explosives and firearms are used.
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Applying the Haddon Matrix to Frontline Care Preparedness and Response in Asymmetric Warfare. Prehosp Disaster Med 2022; 37:577-583. [PMID: 35875999 PMCID: PMC9470527 DOI: 10.1017/s1049023x22001066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Introduction: Asymmetric warfare and the reaction to its threats have implications in the way far-forward medical assistance is provided in such settings. Investments in far-forward emergency resuscitation and stabilization can contribute to saving lives and increase the resilience of health systems. Thus, it is proposed to extend the use of the Haddon Matrix to determine a set of strategies to better understand and prioritize activities to prepare for and set-up frontline care in the form of Trauma Stabilization Points (TSPs). Methods: An expert consensus methodology was used to achieve the research aim. A small subject matter experts’ group was convened to create and validate the content of the Haddon Matrix. Results: The result of the expert group consultations presented an overview of TSP Preparedness and Operational Readiness activities within a Haddon Matrix framework. Main strategies to be adopted within the cycle from pre- to post-event had been identified and presented considering the identified opportunities in the context of the possibility of implementation. Of particular importance was the revision of a curriculum that fits the civilian medical system and facilitates its adaptation to the context and available resources. Conclusion: The new framework to enhance frontline care preparedness and response using the Haddon Matrix facilitated the identification of a set of strategies to support frontline health care workers in a more efficient manner. Since the existing approach and tools are insufficient for modern warfare, additional research is needed.
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Legare T, Schroll R, Hunt JP, Duchesne J, Marr A, Schoen J, Greiffenstein P, Stuke L, Smith A. Prehospital Tourniquets Placed on Limbs Without Major Vascular Injuries, has the Pendulum Swung Too far? Am Surg 2022; 88:2103-2107. [PMID: 35435022 DOI: 10.1177/00031348221088968] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Combat applications of tourniquets for extremity trauma have led to increased civilian prehospital tourniquet use. Studies have demonstrated that appropriate prehospital tourniquet application can decrease the incidence of arrival in shock without increasing limb complications. The aim of this study was to examine outcomes of prehospital tourniquet placement without definitive vascular injury. METHODS Retrospective review was performed of a prospectively maintained database by the American Association for the Surgery of Trauma from 29 trauma centers. Patients in this subset analysis did not have a significant vascular injury as determined by imaging or intra-operatively. Patients who received prehospital tourniquets (PHTQ) were compared to patients without prehospital tourniquets (No-PHTQ). Outcomes were amputation rates, nerve palsy, compartment syndrome, and in-hospital mortality. RESULTS A total of 622 patients had no major vascular injury. The incidence of patients without major vascular injury was higher in the PHTQ group (n = 585/962, 60.8 vs n = 37/88, 42.0%, P < .001). Cohorts were similar in age, gender, penetrating mechanism, injury severity scores (ISS), abbreviated injury score (AIS), and mortality (P > .05). Amputation rates were 8.3% (n = 49/585) in the PHTQ group compared to 0% (n = 0/37) in the No-PHTQ group. Amputation rates were higher in PHTQ than No-PHTQ with similar ISS and AIS (P = .96, P = .59). The incidence of nerve palsy and compartment syndrome was not different (P > .05). CONCLUSIONS This study showed a significant amount of prehospital tourniquets are being placed on patients without vascular injuries. Further studies are needed to elucidate the appropriateness of prehospital tourniquets, including targeted education of tourniquet placement.
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Affiliation(s)
- Timothy Legare
- Department of Surgery, 12258Louisiana State University Health Science Center, New Orleans, LA, USA
| | - Rebecca Schroll
- Department of Surgery, 12255Tulane University School of Medicine, New Orleans, LA, USA
| | - John P Hunt
- Department of Surgery, 12258Louisiana State University Health Science Center, New Orleans, LA, USA.,University Medical Center, New Orleans, LA, USA
| | - Juan Duchesne
- Department of Surgery, 12255Tulane University School of Medicine, New Orleans, LA, USA.,University Medical Center, New Orleans, LA, USA
| | - Alan Marr
- Department of Surgery, 12258Louisiana State University Health Science Center, New Orleans, LA, USA.,University Medical Center, New Orleans, LA, USA
| | - Jonathan Schoen
- Department of Surgery, 12258Louisiana State University Health Science Center, New Orleans, LA, USA.,University Medical Center, New Orleans, LA, USA
| | - Patrick Greiffenstein
- Department of Surgery, 12258Louisiana State University Health Science Center, New Orleans, LA, USA.,University Medical Center, New Orleans, LA, USA
| | - Lance Stuke
- Department of Surgery, 12258Louisiana State University Health Science Center, New Orleans, LA, USA.,University Medical Center, New Orleans, LA, USA
| | - Alison Smith
- Department of Surgery, 12258Louisiana State University Health Science Center, New Orleans, LA, USA.,University Medical Center, New Orleans, LA, USA
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Van Boxstael S, Borgers F, Sabbe M. Response to Dr. Corcostegui concerning use of tourniquet in France. J Trauma Acute Care Surg 2021; 91:e147-e148. [PMID: 34538820 DOI: 10.1097/ta.0000000000003413] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Corcostegui SP, Galant J, Boutillier du Retail C. Use of tourniquet in France: Advances in military and civilian settings. J Trauma Acute Care Surg 2021; 91:e146-e147. [PMID: 34538822 DOI: 10.1097/ta.0000000000003414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Sabate-Ferris A, Pfister G, Boddaert G, Daban JL, de Rudnicki S, Caubere A, Demoures T, Travers S, Rongieras F, Mathieu L. Prolonged tactical tourniquet application for extremity combat injuries during war against terrorism in the Sahelian strip. Eur J Trauma Emerg Surg 2021; 48:3847-3854. [PMID: 34775509 DOI: 10.1007/s00068-021-01828-4] [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: 08/31/2021] [Accepted: 11/01/2021] [Indexed: 10/19/2022]
Abstract
PURPOSE This study reports on complications following extended tourniquet application in patients with combat extremity injuries treated by the French Military Health Service in the Sahelian strip. METHODS A retrospective review was performed in a French forward medical treatment facility deployed in Gao, Mali, between 2015 and 2020. All patients treated for an extremity injury with the application of at least one tourniquet for a minimum of 3 h were included. Prehospital data were injury pattern, associated shock, tourniquet location, and duration. Subsequent complications and surgical procedures performed were analyzed. RESULTS Eleven patients with a mean age of 27.4 years (range 21-35 years) were included. They represented 39% of all patients in whom a tourniquet was applied. They had gunshot wounds (n = 7) or multiple blast injuries (n = 4) and totaled 14 extremity injuries requiring tourniquet application. The median ISS was 13 (interquartile range: 13). Tourniquets were mostly applied proximally on the limb for a mean duration of 268 min (range 180-360 min). Rhabdomyolysis was present in all cases. The damage control surgeries included debridement, external fixation, vascular repair, and primary amputation. Ten injuries were complicated by compartment syndrome requiring leg or thigh fasciotomy in the field or after repatriation. Two severely injured patients died of their wounds, but the others had a favorable outcome even though secondary amputation was sometimes required. CONCLUSIONS Extended and proximal tourniquet applications led to significant morbidity related to compartment syndrome and rhabdomyolysis. Hemorrhagic shock, mass casualty incident, and tactical constraints often precluded revising the temporary tourniquet applied under fire.
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Affiliation(s)
- Alexandre Sabate-Ferris
- Department of Orthopedic, Trauma and Reconstructive Surgery, Percy Military Hospital, Clamart, France
| | - Georges Pfister
- Department of Orthopedic, Trauma and Reconstructive Surgery, Percy Military Hospital, Clamart, France
| | - Guillaume Boddaert
- Department of Thoracic and Vascular Surgery, Percy Military Hospital, Clamart, France.,French Military Health Service Academy, Ecole du Val-de-Grâce, Paris, France
| | - Jean-Louis Daban
- Department of Anesthesiology and Intensive Care, Percy Military Hospital, Clamart, France
| | - Stéphane de Rudnicki
- Department of Anesthesiology and Intensive Care, Percy Military Hospital, Clamart, France
| | - Alexandre Caubere
- Department of Orthopedic and Trauma Surgery, Saint-Anne Military Hospital, Toulon, France
| | - Thomas Demoures
- Department of Orthopedic and Trauma Surgery, Bégin Military Hospital, Saint-Mandé, France
| | - Stéphane Travers
- French Military Health Service Academy, Ecole du Val-de-Grâce, Paris, France.,Medical Department, Fire Brigade of Paris, Paris, France
| | - Fréderic Rongieras
- French Military Health Service Academy, Ecole du Val-de-Grâce, Paris, France.,Department of Orthopedic and Trauma Surgery, Edouard Herriot Hospital, Lyon, France
| | - Laurent Mathieu
- Department of Orthopedic, Trauma and Reconstructive Surgery, Percy Military Hospital, Clamart, France. .,French Military Health Service Academy, Ecole du Val-de-Grâce, Paris, France.
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