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Vincent Y, Baltazard C, Pfister G, Pons F, Poichotte A, Goudard Y, Hornez E, Malgras B, Boddaert G, Balandraud P, Avaro JP, de Lesquen H. Effectiveness of a specific trauma training on war-related truncal injury management: A pre-post study. Injury 2024; 55:111676. [PMID: 38897902 DOI: 10.1016/j.injury.2024.111676] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2024] [Revised: 05/16/2024] [Accepted: 06/10/2024] [Indexed: 06/21/2024]
Abstract
BACKGROUND Non-Compressible Torso Hemorrhage (NCTH) is the leading cause of preventable death in combat casualty care. To enhance the French military surgeons' preparedness, the French Military Health Service designed the Advanced Course for Deployment Surgery (ACDS) in 2008. This study evaluates behavioral changes in war surgery practice since its implementation. METHODS Data were extracted from the OPEX® registry, which recorded all surgical activity during deployment from 2003 to 2021. All patients treated in French Role 2 or 3 Medical Treatment Facilities (MTFs) deployed in Afghanistan, Mali, or Chad requiring emergency surgery for NCTH were included. The mechanism of injury, severity, and surgical procedures were noted. Surgical care produced before (Control group) and after the implementation of the ACDS course (ACDS group) were compared. RESULTS We included 189 trauma patients; 99 in the ACDS group and 90 in the Control group. Most injuries were combat-related (88 % of the ACDS and 82 % of the Control group). The ACDS group had more polytrauma (42% vs. 27 %; p= 0.034) and more e-FAST detailed patients (35% vs. 21 %; p= 0.044). Basics in surgical trauma care were similar between both groups, with a tendency in the ACDS group toward less digestive diversion (n= 6 [6 %] vs. n= 12 [13 %]; p= 0.128), more temporary closure with abdominal packing (n= 17 [17 %] vs. n= 10 [11 %]; p= 0.327), and less re-operation for bleeding (n= 0 [0 %] vs. n= 5 [6 %]; p= 0.046). CONCLUSION The French model of war trauma course succeeded in keeping specialized surgeons aware of the basics of damage control surgery. The main improvements were better use of preoperative imaging and better management of seriously injured patients.
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Affiliation(s)
- Yohann Vincent
- Department of Thoracic and Vascular Surgery, Sainte Anne Military Teaching Hospital, Toulon, France.
| | | | - Georges Pfister
- Department of Orthopaedic, Trauma and Reconstructive Surgery, HIA Percy, Clamart, France
| | - François Pons
- French Military Health Service Academy, Ecole du Val-de-Grâce, Paris, France
| | - Antoine Poichotte
- French Military Health Service Academy, Ecole du Val-de-Grâce, Paris, France
| | - Yvain Goudard
- Department of Visceral Surgery, Laveran Military Teaching Hospital, French Military Health Service, Marseille, France
| | - Emmanuel Hornez
- Digestive surgery, Percy Military teaching hospital, 1 rue Raoul Batany, 92140, Clamart, France; École du Val-de-Grâce, French Military Medical Service Academy, Paris, France
| | - Brice Malgras
- Department of Digestive Surgery, Begin Military Teaching Hospital, Saint Mandé, France; French Military Health Service Academy, Ecole du Val de Grace, Paris, France
| | | | - Paul Balandraud
- Department of Visceral Surgery, Sainte Anne Military Teaching Hospital, Toulon, France
| | - Jean-Philippe Avaro
- Department of Thoracic and Vascular Surgery, Sainte Anne Military Teaching Hospital, Toulon, France
| | - Henri de Lesquen
- Department of Thoracic and Vascular Surgery, Sainte Anne Military Teaching Hospital, Toulon, France
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Cant MR, Naumann DN, Swain C, Mountain AJ, Baden J, Bowley DM. Acquisition and retention of military surgical competencies: a survey of surgeons' experiences in the UK Defence Medical Services. BMJ Mil Health 2024; 170:117-122. [PMID: 35649691 DOI: 10.1136/bmjmilitary-2022-002112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Accepted: 05/15/2022] [Indexed: 11/03/2022]
Abstract
INTRODUCTION The acquisition and retention of militarily relevant surgical knowledge and skills are vital to enable expert management of combat casualties on operations. Opportunities for skill sustainment have reduced due to the cessation of combat operations in Iraq and Afghanistan and lack of military-relevant trauma in UK civilian practice. METHODS A voluntary, anonymous online survey study was sent to all UK Defence Medical Services (DMS) surgical consultants and higher surgical trainees in Trauma and Orthopaedics, Plastic and Reconstructive, and General and Vascular surgical specialties (three largest surgical specialties in the DMS in terms of numbers). The online questionnaire tool included 20 questions using multiple choice and free text to assess respondents' subjective feelings of preparedness for deployment as surgeons for trauma patients. RESULTS There were 71 of 108 (66%) responses. Sixty-four (90%) respondents were regular armed forces, and 46 (65%) worked in a Major Trauma Centre (MTC). Thirty-three (47%) had never deployed on operations in a surgical role. Nineteen (27%) felt they had sufficient exposure to penetrating trauma. When asked 'How well do you feel your training and clinical practice prepares you for a surgical deployment?' on a scale of 1-10, trainees scored significantly lower than consultants (6 (IQR 4-7) vs 8 (IQR 7-9), respectively; p<0.001). There was no significant difference in scores between regular and reservists, or between those working at an MTC versus non-MTC. Respondents suggested high-volume trauma training and overseas trauma centre fellowships, simulation, cadaveric and live-tissue training would help their preparedness. CONCLUSIONS There was a feeling among a sample of UK DMS consultants and trainees that better preparedness is required for them to deploy confidently as a surgeon for combat casualties. The responses suggest that UK DMS surgical training requires urgent attention if current surgeons are to be ready for their role on deployed operations.
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Affiliation(s)
| | - D N Naumann
- Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, Birmingham, UK
| | - C Swain
- Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, Birmingham, UK
| | - A J Mountain
- Department of Military Trauma and Orthopaedics, Royal Centre for Defence Medicine, Birmingham, UK
| | - J Baden
- Department of Military Plastic and Reconstructive Surgery, Royal Centre for Defence Medicine, Birmingham, UK
| | - D M Bowley
- Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, Birmingham, UK
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Stansfield T, Tai N. Skill decay in surgeons deployed on military operations: a systematic review. BMJ Mil Health 2024; 170:155-162. [PMID: 35589135 DOI: 10.1136/bmjmilitary-2021-001919] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Accepted: 04/15/2022] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Decay of surgical skills due to paucity of opportunity to operate is a potential threat to patients being cared for by the Defence Medical Services while on operational deployment. Our aim was to review the literature regarding skill decay in the trained surgeon in order to understand how it may affect clinical performance and patient outcomes. We also wished to survey the likely causes of such decay and possible means of mitigation. METHODS A systematic review of the literature was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Study bias assessment was also undertaken. Content summaries for the papers included study design and methodology, participant level of experience, measures and magnitude of effect, duration of no practice, and study limitations. RESULTS Five papers met the selection criteria. There were insufficient quantitative data on the impact of surgical skill decay on patient outcome, surgeon performance or mitigation strategies, and a meaningful quantitative synthesis could not be undertaken. CONCLUSIONS This systematic review of the literature found very little specific evidence confirming or refuting surgical skill decay in trained surgeons, with measurement of decay hampered by the lack of an accepted methodology. Studying this in the deployed setting may offer a firmer evidence base from which to generate policy. Potential mitigation strategies are discussed. PROSPERO registration number ID260846.
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Affiliation(s)
- Tim Stansfield
- Vascular Surgery, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - N Tai
- Centre For Trauma Sciences, The Royal London Hospital, London, UK
- Research and Clinical Innovation, Royal Centre for Defence Medicine, Birmingham, UK
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Haverkamp FJC, van Leest TAJ, Muhrbeck M, Hoencamp R, Wladis A, Tan ECTH. Self-perceived preparedness and training needs of healthcare personnel on humanitarian mission: a pre- and post-deployment survey. World J Emerg Surg 2022; 17:14. [PMID: 35248111 PMCID: PMC8898429 DOI: 10.1186/s13017-022-00417-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2022] [Accepted: 02/17/2022] [Indexed: 11/21/2022] Open
Abstract
Background Humanitarian healthcare workers are indispensable for treating weapon-wounded patients in armed conflict, and the international humanitarian community should ensure adequate preparedness for this task. This study aims to assess deployed humanitarian healthcare workers’ self-perceived preparedness, training requirements and mental support needs. Methods Medical professionals deployed with the International Committee of the Red Cross (ICRC) between October 2018 and June 2020 were invited to participate in this longitudinal questionnaire. Two separate questionnaires were conducted pre- and post-deployment to assess respondents’ self-perceived preparedness, preparation efforts, deployment experiences and deployment influence on personal and professional development. Results Response rates for the pre- and post-deployment questionnaires were 52.5% (114/217) and 26.7% (58/217), respectively. Eighty-five respondents (85/114; 74.6%) reported feeling sufficiently prepared to treat adult trauma patients, reflected by predeployment ratings of 3 or higher on a scale from 1 (low) to 5 (high). Significantly lower ratings were found among nurses compared to physicians. Work experience in a high-volume trauma centre before deployment was associated with a greater feeling of preparedness (mean rank 46.98 vs. 36.89; p = 0.045). Topics most frequently requested to be included in future training were neurosurgery, maxillofacial surgery, reconstructive surgery, ultrasound, tropical diseases, triage, burns and newborn noncommunicable disease management. Moreover, 51.7% (30/58) of the respondents regarded the availability of a mental health professional during deployment as helpful to deal with stress. Conclusion Overall, deployed ICRC medical personnel felt sufficiently prepared for their missions, although nurses reported lower preparedness levels than physicians. Recommendations were made concerning topics to be covered in future training and additional preparation strategies to gain relevant clinical experience. Future preparatory efforts should focus on all medical professions, and their training needs should be continuously monitored to ensure the alignment of preparation strategies with preparation needs. Supplementary Information The online version contains supplementary material available at 10.1186/s13017-022-00417-z.
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Affiliation(s)
- Tim Stansfield
- Vascular Surgery, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - N Tai
- Centre for Trauma Sciences, The Royal London Hospital, London, UK.,Research and Clinical Innovation, Royal Centre for Defence Medicine, Birmingham, UK
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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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Johnston AM. Deskilling and return to practice on low-tempo contingency operations. J ROY ARMY MED CORPS 2019; 165:310-311. [PMID: 31053613 DOI: 10.1136/jramc-2019-001162] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/04/2019] [Indexed: 11/04/2022]
Affiliation(s)
- Andrew McDonald Johnston
- Department of Anaesthesia and Intensive Care Medicine, Royal Centre for Defence Medicine, Birmingham, UK
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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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Mercer SJ. Using full immersive simulation to prepare trauma teams to work in a major trauma centre. TRAUMA-ENGLAND 2017. [DOI: 10.1177/1460408616680384] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
A reconfiguration of trauma services in the UK has led to the development of trauma networks with major trauma centres. This article describes the use of fully immersive simulation to train whole trauma teams in both a traditional simulation centre setting and ‘in situ’ in the clinical environment. Carefully designed scenarios that are driven by experienced faculty allow modern trauma management concepts, such as damage control resuscitation and massive transfusion to be explored within a hospital’s own organisational structure. Human factors specific to the trauma team can also be explored as part of a video-assisted debrief.
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Affiliation(s)
- Simon J Mercer
- Anaesthetic Department, Aintree University Hospital NHS Foundation Trust, Liverpool, UK
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Shastri-Hurst N, Naumann DN, Bowley DM, Whitbread T. Military surgery in the new curriculum: whither general surgery training in uniform? J ROY ARMY MED CORPS 2014; 161:100-5. [DOI: 10.1136/jramc-2013-000211] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2013] [Accepted: 12/22/2013] [Indexed: 11/04/2022]
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Ramasamy A, Hinsley DE, Edwards DS, Stewart MPM, Midwinter M, Parker PJ. Skill sets and competencies for the modern military surgeon: lessons from UK military operations in Southern Afghanistan. Injury 2010; 41:453-9. [PMID: 20022003 DOI: 10.1016/j.injury.2009.11.012] [Citation(s) in RCA: 71] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2009] [Revised: 10/11/2009] [Accepted: 11/23/2009] [Indexed: 02/02/2023]
Abstract
INTRODUCTION British military forces remain heavily committed on combat operations overseas. UK military operations in Afghanistan (Operation HERRICK) are currently supported by a surgical facility at Camp Bastion, in Helmand Province, in the south of the country. There have been no large published series of surgical workload on Operation HERRICK. The aim of this study is to evaluate this information in order to determine the appropriate skill set for the modern military surgical team. METHOD A retrospective analysis of operating theatre records between 1st May 2006 and 1st May 2008 was performed. Data was collated on a monthly basis and included patient demographics, operation type and time of operation. RESULTS During the study period 1668 cases required 2210 procedures. Thirty-two per cent were coalition forces (ISAF), 27% were Afghan security forces (ANSF) and 39% were civilians. Paediatric casualties accounted for 14.7% of all cases. Ninety-three per cent of cases were secondary to battle injury and of these 51.3% were emergencies. The breakdown of procedures, by specialty, was 66% (1463) orthopaedic, 21% (465) general surgery, 6% (139) head and neck, 5% (104) burns surgery and a further 4% (50) non-battle, non-emergency procedures. There was an almost twofold increase in surgical workload in the second year (1103 cases) compared to the first year of the deployment (565 cases, p<0.05). DISCUSSION Surgical workload over the study period has clearly increased markedly since the initial deployment of ISAF forces to Helmand Province. A 6-week deployment to Helmand Province currently provides an equivalent exposure to penetrating trauma as 3 years trauma experience in the UK NHS. The spectrum of injuries seen and the requisite skill set that the military surgeon must possess is outside that usually employed within the NHS. A number of different strategies; including the deployment of trainee specialist registrars to combat hospitals, more focused pre-deployment military surgery training courses, and wet-laboratory work are proposed to prepare for future generations of surgeons operating in conflict environments.
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Affiliation(s)
- Arul Ramasamy
- Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, West Wing, Birmingham Research Park, Vincent Drive, Birmingham B5 1SQ, United Kingdom.
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