Beyond Stopping the Bleed: Opportunities for Plastic Surgeons in the Response to Mass Casualty Events.

Abstract

Sir: Increased survivability from otherwise lethal trauma has marked the modern wartime experience, because of improvements in protective body armor, field care, and medical evacuation.1 However, an increasing number of victims now emerge with complex injuries to the head, neck, and extremities, areas that are less shielded. As a result, the direct involvement of plastic surgeons in battlefield care has increased significantly, including 40 percent of military surgical cases during recent coalition combat operations in Afghanistan.1 In the civilian setting, mass-shooting events and explosive terrorist attacks have yielded similar survivable injuries, because of short urban transport times and the recent aggressive reintroduction of tourniquets into prehospital care.2 In this evolving context, the role of plastic surgeons in the acute management of complex and/or multiple extremity injury is of increasing significance, with consequences on amputation and prosthetic rehabilitation versus replantation or limb salvage and reconstruction.3 Over the past decade, mass-casualty events have engendered a reconceptualization of civilian trauma care. The Sandy Hook Elementary School shooting, which resulted in the death of 20 first graders and six educators, led to the creation of the Hartford Consensus,4 which established a framework for minimizing preventable deaths by emphasizing the role of first responders and disseminating training in extremity exsanguination control.4 It evolved to include representatives from the American College of Surgeons, the Federal Bureau of Investigation, the Major Cities Chiefs Association, the International Association of Fire Chiefs, and the Committee on Tactical Combat Casualty Care, to formulate bleeding control recommendations tailored to the general public. Those recommendations formed the basis for the Stop the Bleed campaign, which was adopted by the Department of Homeland Security and endorsed by the White House. The implementation of the Stop the Bleed campaign is championed by the American College of Surgeons and grass-roots efforts aiming to educate schoolteachers and community leaders.5 The necessity of such initiatives is obvious, as mass casualty events continue to target community institutions and gathering spaces. With proper training, nonmedical professionals can help bridge the continuum of prehospital trauma care. Educational initiatives are slowly propagating, but active engagement of surgical specialists has the potential to improve their effectiveness. Such outreach initiatives could also provide a vehicle for broader impact; for example, the incorporation of educational material on the preservation and transportation of amputated parts may warrant consideration. The challenges posed by current trends in civilian and military trauma call for more pronounced engagement of the plastic and reconstructive surgery community. Multidisciplinary collaboration with trauma and general surgeons, prehospital emergency providers, and community first responders would augment the impact of a well-targeted nationwide initiative. It would also provide valuable perspectives on management strategies for complex extremity injury. Advances in life and limb preservation will continue to be accompanied by a rising demand for reconstruction, rehabilitation, and/or eventual vascularized composite allotransplantation. Plastic surgeons have the opportunity to play a critical role in ensuring that the tremendous advances of the trauma system are sustained, and translate into optimal long-term function and meaningful recovery for surviving patients. DISCLOSURE The authors have no financial interest to declare in relation to the content of this article. No funding was received for this work. Elie P. Ramly, M.D.Allyson R. Alfonso, B.S., B.A.Rami S. Kantar, M.D.J. Rodrigo Diaz-Siso, M.D.Eduardo D. Rodriguez, M.D., D.D.S.Hansjörg Wyss Department of Plastic SurgeryNew York University Langone HealthNew York, N.Y.