Combat Operations In Afghanistan Research Articles

Characterization of Humanitarian Trauma Care by US Military Facilities During Combat Operations in Afghanistan and Iraq.

To characterize humanitarian trauma care delivered by US military treatment facilities (MTFs) in Afghanistan and Iraq during combat operations. 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. Retrospective cohort analysis of the Department of Defense Trauma Registry from 2005 to 2019. Inclusion criteria were civilians and Non-North Atlantic Treaty Organization (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. 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 above 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≥25 in 2236 (13.4%) civilians and 1398 (10.6%) NNCP. Blood products were transfused to 35% of each cohort: 5850 civilians received a transfusion with 2118 (12.6%) of them receiving ≥10 units; 4590 NNCPs received a transfusion with 1669 (12.6%) receiving ≥10 units. MTF mortality rates were civilians 1263 (7.5%) and NNCP 776 (5.9%). Interventions, both operative and nonoperative, were similar between both groups. 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 NNCP. 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.

Incidence of post-traumatic seizures in children during combat operations in Afghanistan and Iraq

ObjectivesChildren represent a significant portion of the patient population treated at combat support hospitals. There is significant data regarding post injury seizures in adults but with children it is lacking. We seek to describe the incidence of post-traumatic seizures within this population. MethodsThis is a secondary analysis of previously described data from the Department of Defense Trauma Registry (DODTR). Within our dataset, we searched for documentation of seizures after admission. ResultsOf the 3439 encounters in our dataset, we identified 37 casualties that had a documented seizure after admission. Most were in the 1–4 year age group (37.8%), male (59.4%), injured by explosive (40.5%), with serious injuries to the head/neck (75.6%). The median ISS was higher in the seizure group (22 versus 10, p<0.001). Most survived to hospital discharge with no statistically significant increased mortality noted in the seizure group (seizure 90.2% versus 91.8%, p = 1.000). In the prehospital setting, the seizure group was more frequently intubated (16.2% versus 6.0%, p = 0.023), received ketamine (20.0% versus 3.2%, p<0.001), and administered an anti-seizure medication (5.4% versus 0.1%, p = 0.001). In the hospital setting, the seizure group was more frequently intubated (56.7% versus 17.7%, p<0.001), had intracranial pressure monitoring (24.3% versus 2.6%, p<0.001), craniectomy (10.8% versus 2.5%, p = 0.014), and craniotomy (21.6% versus 4.7%, p<0.001). ConclusionsWithin our dataset, we found an incidence of 1% of pediatric casualties experiencing a post-traumatic seizure. While this number appears infrequent, there is likely significant under detection of subclinical seizures.

Combat-Related Invasive Fungal Wound Infections.

During Operation Enduring Freedom in Afghanistan, an outbreak of combat-related invasive fungal wound infections (IFIs) emerged among casualties with dismounted blast trauma and became a priority issue for the Military Health System. In 2011, the Trauma Infectious Disease Outcomes Study (TIDOS) team led the Department of Defense IFI outbreak investigation to describe characteristics of IFIs among combat casualties and provide recommendations related to management of the disease. To support the outbreak investigation, existing IFI definitions and classifications utilized for immunocompromised patients were modified for use in epidemiologic research in a trauma population. Following the conclusion of the outbreak investigation, multiple retrospective analyses using a population of 77 IFI patients (injured during June 2009 to August 2011) were conducted to evaluate IFI epidemiology, wound microbiology, and diagnostics to support refinement of Joint Trauma System (JTS) clinical practice guidelines. Following cessation of combat operations in Afghanistan, the TIDOS database was comprehensively reviewed to identify patients with laboratory evidence of a fungal infection and refine the IFI classification scheme to incorporate timing of laboratory fungal evidence and include categories that denote a high or low level of suspicion for IFI. The refined IFI classification scheme was utilized in a large-scale epidemiologic assessment of casualties injured over a 5.5-year period. Among 720 combat casualties admitted to participating hospitals (2009-2014) who had histopathology and/or wound cultures collected, 94 (13%) met criteria for an IFI and 61 (8%) were classified as high suspicion of IFI. Risk factors for development of combat-related IFIs include sustaining a dismounted blast injury, experiencing a traumatic transfemoral amputation, and requiring resuscitation with large-volume (>20 units) blood transfusions. Moreover, TIDOS analyses demonstrated the adverse impact of IFIs on wound healing, particularly with order Mucorales. A polymerase chain reaction (PCR)-based assay to identify filamentous fungi and support earlier IFI diagnosis was also assessed using archived formalin-fixed, paraffin-embedded tissue specimens. Although the PCR-based assay had high specificity (99%), there was low sensitivity (63%); however, sensitivity improved to 83% in tissues collected from sites with angioinvasion. Data obtained from the initial IFI outbreak investigation (37 IFI patients) and subsequent TIDOS analyses (77 IFI patients) supported development and refinement of a JTS clinical practice guideline for the management of IFIs in war wounds. Furthermore, a local clinical practice guideline to screen for early tissue-based evidence of IFIs among blast casualties at the Landstuhl Regional Medical Center was critically evaluated through a TIDOS investigation, providing additional clinical practice support. Through a collaboration with the Uniformed Services University Surgical Critical Care Initiative, findings from TIDOS analyses were used to support development of a clinical decision support tool to facilitate early risk stratification. Combat-related IFIs are a highly morbid complication following severe blast trauma and remain a threat for future modern warfare. Our findings have supported JTS clinical recommendations, refined IFI classification, and confirmed the utility of PCR-based assays as a complement to histopathology and/or culture to promote early diagnosis. Analyses underway or planned will add to the knowledge base of IFI epidemiology, diagnostics, prevention, and management.

A Descriptive Analysis of Supermassive Transfusion Recipients Among US and Coalition Forces During Combat Operations in Afghanistan and Iraq.

Hemorrhage is the leading cause of potentially preventable death on the battlefield. Resuscitation with blood products is essential to restore circulating volume, repay the oxygen debt, and prevent coagulopathy. Massive transfusion (MT) occurs frequently after major trauma; a subset of casualties requires a supermassive transfusion (SMT), and thus, mobilization of additional resources remains unclear. This is a secondary analysis of a previously described dataset from the Department of Defense Trauma Registry. In this analysis, we isolated U.S. and Coalition casualties that received at least 1 unit of packed red blood cells (PRBCs) or whole blood (WB). Given a lack of consensus on the definition of SMT recipients, we included those patients receiving the top quartile of PRBC and WB administered within the first 24 hours following arrival to a military treatment facility. We identified 25,897 adult casualties from January 1, 2007 to March 17, 2020. Within this dataset, 2,608 (9.0%) met inclusion for this analysis. The median number of total products administered within the first 24 hours was 8 units of PRBC or WB. The upper quartile was 18 units (n = 666). Compared to all other blood product recipients, patients in the SMT cohort had a higher median injury severity score (27 vs 18, P < 0.001), were most frequently injured by explosives (84.9% vs 68.6%, P < 0.001), had a higher mean emergency department (ED) pulse (128 vs 111, P < 0.001), a lower mean systolic blood pressure (122 vs 132 mm Hg, P < 0.001), and a higher mean international normalized ratio (1.68 vs 1.38, P < 0.001). SMT patients experienced lower survival to hospital discharge (85.8% vs 93.3%, P < 0.001). Compared to all other PRBC and WB recipients, SMT patients experienced more injury by explosives, severe injury patterns, ED vital sign derangements, and mortality. These findings may help identify those casualties who may require earlier aggressive resuscitation. However, more data is needed to define this population early in their clinical course for early identification to facilitate rapid resource mobilization. Identifying casualties who are likely to die within 24 hours compared to those who are likely to survive, may assist in determining a threshold for a SMT.

473. Using Serosurveillance for SARS-CoV-2 to Conserve PCR Tests in a Resource Constrained Combat Environment

BackgroundIn March 2020, COVID-19 threatened combat operations in Afghanistan. At that time, the NATO Resolute Support mission involved nearly 17,000 troops from 38 partner nations, plus civilians who support the mission, scattered throughout Afghanistan. While Afghanistan did not initially report many confirmed cases, large numbers of cases were reported from neighboring countries with known migration across the borders (sometimes thousands/day). Military medical leaders advised commanders regarding the potential health risks to the force, balancing with risks to the mission. Quarantine and isolation protocols were established. Public health interventions of social distancing, cloth mask wear, enhanced environmental cleaning, active case finding, and emphasis on hand hygiene and cough etiquette were enforced. However, many base locations were unable to alleviate close living quarters. Testing was identified as a means to assess risk to the population. Testing capabilities were limited, particularly PCR. When this testing strategy was established, the utilization and interpretation of antibody tests was quite controversial. With rapid antibody kits, the time to detection of both IgM and IgG are similar; detection of either cannot identify the time since exposure.MethodsA novel surveillance plan was established whereby subpopulations at highest risk for exposure to the virus were screened with antibody tests from 17 Apr-1 Jun, 2020. High risk populations included: those leaving quarantine, base defense guards, isolation unit guards, medical personnel, dining facility workers, and those who interact with local populations. Individuals with detectable antibody (either IgM or IgG) were further evaluated with PCR tests.ResultsIn the first six weeks of this testing strategy, 1957 antibody tests were utilized. A total of 37 specimens were identified antibody positives with seroprevalence of 2% (Figure 1). Thirteen were identified to have positive IgG, 22 with IgM, and 2 with both. PCR was performed on those with detectable antibody, 13 (35%) had positive PCR.Figure 1:Seroprevalence of SARS-CoV-2 in Asymptomatic Populations at a Deployed Military BaseConclusionSerosurveillance of populations at high risk for exposure to the virus is a logical way to conserve testing resources in a constrained combat environment.DisclosuresAlex M. Case, n/a, United States Air Force (Employee)

Defining the Super Massive Transfusion in Pediatric Casualties during Combat Operations in Afghanistan and Iraq

Introduction: Hemorrhage is the leading cause of potentially preventable death on the battlefield. We previously published data defining the pediatric massive transfusion at 40mL/kg of total blood products. However, there is a subset of casualties that require large volumes of blood products - super massive transfusions - which remains unclear. We seek to determine what defines a super massive transfusion within the pediatric population as understanding this unique group would help mobilize resources early in their clinical course. Methods: This is a secondary analysis of a previously described dataset from the Department of Defense Trauma Registry. In this analysis, we sought all casualties within our dataset that met inclusion for MT. To describe the super MT, we sought the top quartile of total products administered within the first 24 hours on a volume per weight basis. Results: Within our original dataset of 3439 pediatric casualties, we identified 543 that met inclusion for massive transfusion, with the 75th percentile at 120.6 mL/kg - we rounded this to 120mL/kg for simplicity which left 137 for analysis. Most of the casualties were in the 5-9 and 10-14 age groups (24% and 39%, respectively) and were most frequently injured by explosive (71%). Those in the super MT group had lower survival (75% versus 84%, p=0.015), longer ventilator courses (median 3 days versus 2 days, p=0.029) despite similar median injury severity scores (17 versus 17, p=0.100). However, they more frequently had serious injuries to the extremities (62% versus 35%, p&amp;lt;0.001). Super MT casualties more frequently had age-adjusted hypotension (45% versus 26%, p&amp;lt;0.001) but no difference in age-adjusted tachycardia (88% versus 86%, p=0.514). Super MT casualties had worse international normalized ratios (2.06 versus 1.65, p=0.006), and worse base deficits (-11.3 versus -8.5, p&amp;lt;0.001). Conclusions: In our analysis, we found that 120 mL/kg of total blood products administered within the first 24 hours was the threshold for the top 25th percentile of pediatric blood product consumers. More data is needed to define this unique population that requires mobilization of extensive resources. Disclosures No relevant conflicts of interest to declare.

Defining the Super Massive Transfusion in US and Coalition Forces during Combat Operations in Afghanistan and Iraq

Introduction: Hemorrhage is the leading cause of potentially preventable death on the battlefield. After hemorrhage control, the resuscitation with blood products is essential to restore circulating volume and prevent coagulopathy. While massive transfusion (MT) occurs frequently after major trauma, it remains unclear who the subset of casualties is that define a super massive transfusion which would require mobilization of additional resources. We seek to determine what defines a super MT as this would help allocate resources. Methods: This is a secondary analysis of a previously described dataset from the Department of Defense Trauma Registry. In this analysis, we isolated US and Coalition casualties that received at least 1 unit of packed red cells or whole blood. To describe the super MT, we sought the top quartile of total products administered within the first 24 hours. Results: Out of the 28222 casualties within our dataset, we identified 2204 US military and 498 Coalition that met inclusion for this analysis. The median number of total products administered within the first 24 hours was 16 with 39 total product units at the 75th percentile, which included 691 casualties. Of those in the super MT group, their median injury severity score was higher (29 versus 18, p&amp;lt;0.001), they were most frequently injured by explosive (84% versus 69%, p&amp;lt;0.001), they had a higher mean emergency department pulse (116 versus 103, p&amp;lt;0.001), lower mean systolic 109 versus 122, p&amp;lt;0.001), and higher mean international normalized ratio (1.53 versus 1.28, p&amp;lt;0.001). They more frequently had serious injuries to the thorax (29% versus 22%, p&amp;lt;0.001), abdomen (32% versus 17%, p&amp;lt;0.001), and extremities (85% versus 64%, p&amp;lt;0.001). Super MT was associated with worse survival (86% versus 92%, p&amp;lt;0.001). Conclusions: In our dataset, we identified the top 25th percentile of total product administration within the first 24 hours at 39 total product units. More data is needed to define this population early in their clinical course to better mobile resources early when needed. Disclosures No relevant conflicts of interest to declare.

Combat Stress Management and Resilience: Adapting Department of Defense Combat Lessons Learned to Civilian Healthcare during the COVID-19 Pandemic.

Combat Stress Management and Resilience: Adapting Department of Defense Combat Lessons Learned to Civilian Healthcare during the COVID-19 Pandemic.

Досвід бойового застосування передових авіаційних навідників під час бойових дій в Афганістані

В статті автором, на підставі власного досвіду, детально проаналізовано порядок роботи передових авіаційних навідників по управлінню підрозділами армійської авіації при виконанні ними основних бойових завдань під час бойових дій в Афганістані, а саме, під час безпосередньої авіаційної підтримки сухопутних військ на полі бою, доставки в райони бойових дій боєприпасів і продовольства та евакуації звідти поранених і вбитих, десантування тактичних повітряних десантів та їх евакуації після виконання бойових завдань, супроводу автомобільних колон.

Defining the medical coverage of ballistic protection to the pelvis and thigh

IntroductionPelvis, lower limb and associated genital injury caused by explosive devices was responsible for mortality and considerable long-term morbidity for the UK Armed Forces during combat operations in Afghanistan, resulting...

A fit and function analysis of the UK OSPREY body armour system for female users

IntroductionOSPREY personal armour has been issued to UK forces since 2005. From 2015, the VIRTUS personal armour and load carriage system have been progressively replacing OSPREY. In 2016, the ban...

Prehospital airway procedures performed in trauma patients by ground forces in Afghanistan.

Airway management is of critical importance in combat trauma patients. Airway compromise is the second leading cause of potentially survivable death on the battlefield and accounts for approximately 1 in 10 preventable deaths. Reports from the Iraq and Afghanistan wars indicate 4% to 7% incidence of airway interventions on casualties transported to combat hospitals. The goal of this study was to describe airway management in the prehospital combat setting and document airway devices used on the battlefield. This study is a retrospective review of casualties that required a prehospital lifesaving airway intervention during combat operations in Afghanistan. We obtained data from the Prehospital Trauma Registry that was linked to the Department of Defense Trauma Registry for outcome data for the time period between January 2013 and September 2014. Seven hundred five total trauma patients were included, 16.9% required a prehospital airway management procedure. There were 132 total airway procedures performed, including 83 (63.4%) endotracheal intubations and 26 (19.8%) nasopharyngeal airway placements. Combat medics were involved in 48 (36.4%) of airway cases and medical officers in 73 (55.3%). Most (94.2%) patients underwent airway procedures due to battle injuries caused by explosion or gunshot wounds. Casualties requiring airway management were more severely injured and less likely to survive as indicated by Injury Severity Score, responsiveness level, Glascow Coma Scale, and outcome. Percentages of airway interventions more than tripled from previous reports from the wars in Afghanistan and Iraq. These changes are significant, and further study is needed to determine the causes. Casualties requiring airway interventions sustained more severe injuries and experienced lower survival than patients who did not undergo an airway procedure, findings suggested in previous reports. Prognostic and epidemiological study, level III.

Junctional Tourniquet Use During Combat Operations in Afghanistan: The Prehospital Trauma Registry Experience.

Hemorrhage is the leading cause of potentially preventable death on the battlefield. Although the resurgence of limb tourniquets revolutionized hemorrhage control in combat casualties in the recent conflicts, the mortality rate for patients with junctional hemorrhage is still high. Junctional tourniquets (JTQs) offer a mechanism to address the high mortality rate. The success of these devices in the combat setting is unclear given a dearth of existing data. From the Prehospital Trauma Registry (PHTR) and the Department of Defense Trauma Registry, we extracted cases of JTQ use in Afghanistan. We identified 13 uses of a JTQ. We excluded one case in which an improvised pelvic binder was used. Of the remaining 12 cases of JTQ use, seven had documented success of hemorrhage control, three failed to control hemorrhage, and two were missing documentation regarding success or failure. We report 12 cases of prehospital use of JTQ in Afghanistan. The findings from this case series suggest these devices may have some utility in achieving hemorrhage control strictly at junctional sites (e.g., inguinal creases). However, they also highlight device limitations. This analysis demonstrates the need for continued improvements in technologies for junctional hemorrhage control, prehospital documentation, data fidelity and collection, as well as training and sustainment of the training for utilization of prehospital hemorrhage control techniques.

Kinetic responses to global terrorism: Lessons from Africa

ABSTRACTThis essay recalls the immediate and longer-term responses of the US and its allies to the events of 9/11. It contends that the die for contemporary developments in transnational terrorism was cast in the immediate aftermath of 9/11 – in particular the launching of sustained ‘anti-terrorist’ military combat operations in Afghanistan and Iraq, and more covert ‘kinetic’ operations elsewhere in the Middle East and Africa. The essay seeks specifically to expose the counter-productivity of using military operations as the primary antidote to transnational terrorism. Focusing on the African ‘laboratory’ and the spread of transnational terrorism and Islamic militancy, particularly in West and East Africa, the essay concludes that radical Islamists have mastered the ‘battle of the narrative’ and that the Western penchant for dispensing a kinetic brand of medication is feeding rather than fighting the virus of global terrorism.

Extremity injuries sustained by the UK military in the Iraq and Afghanistan conflicts: 2003–2014

IntroductionExtremity injuries predominate in warfare, however their nature, and overall burden to the individual and the health service is yet to be characterised for the UK military in the recent conflicts of Iraq and Afghanistan. MethodsWe reviewed the all extremity injuries in survivors from the Joint Theatre Trauma Registry (JTTR) between 2003 and 2014. All cases recorded in the JTTR between the invasion of Iraq on the 19th March 2003 and cessation of combat operations in Afghanistan on the 27th October 2014, were examined. Casualties who were killed in action or died from their wounds were excluded. All extremity injury codes were included, capturing patients with soft tissue injuries but no fracture or amputation. ResultsOf 2348 UK combatants surviving injury in Iraq and Afghanistan, 1813 (77%) had extremity injuries; of these 205 (11%) had at least one amputation at the wrist/ankle or more proximal. Trans-tibial was the most common level of limb loss. Eighty five casualties lost 2 limbs, 83 of these (98%) lost both lower limbs and 17 lost 3 limbs. Aside from amputations, there were 1530 fractures, 501 (33%) involving the upper limb and 1029 (67%) in the lower limb and pelvis. The tibia was the most frequently fractured bone. Of the lower limb fractures, 597 (58%) were open compared with 344 (69%) in the upper limb.Total Length of Stay (LOS) following extremity injury was 24,486days or 69 years and 1 month; there were a total 2817 surgical episodes performed on extremities. Median length of stay Length of Stay (LOS) for major amputations (i.e. those at the wrist/ankle or more proximal) was 51days (IQR 30–65) with a median of 7 surgical procedures on their limbs (IQR 5–9). In casualties with fractures but no amputation, median LOS was 13days (IQR 6–25) with a median of 2 surgical procedures (IQR 1–4). ConclusionUtilising a dedicated injury database, this study illustrates for the first time in the United Kingdom military population, that the extremities are involved in the vast majority of combat injuries and the large surgical workload required for their treatment.

Flanders and Helmand: chaplaincy, faith and religious change in the British Army, 1914–2014

The year 2014 marked the centenary of the outbreak of the First World War and the end of eight years of major British combat operations in Afghanistan. Against the background of profound religious changes in British society over the course of the intervening century, this article examines the continuities and discontinuities between British army chaplaincy on the Western Front from 1914 to 1918 and in southern Afghanistan from 2006 to 2014, and explores the religious beliefs and practices of British soldiers caught up in the deadly and protracted struggles on the Western Front and in Helmand Province. While acknowledging major differences in the operational contexts involved and seismic shifts in British religious life over the course of the twentieth century, besides important divergences this article identifies striking degrees of continuity between the ministry of army chaplains and the religious attitude and behaviour of soldiers themselves.

METHOD OF ESTIMATION OF PHYSIOLOGICAL ADAPTATION AND THE RATE OF AGING IN PATIENTS WITH A HISTORY OF EMOTIONAL STRESS IN COMBAT SITUATION

Aim - to develop an automated program for the evaluation of physiological adaptation of the cardiovascular system for combat veterans. Materials and methods. The study included 60 male patients, average age 53.13 ± 2.9 years, who participated in combat operations in Afghanistan (1979 - 1989) and Chechnya (1994 - 2002). The study of adaptive homeostasis of the cardiovascular system is made on cellular, microvascular, cardiovascular and organ levels. Results. The veterans of combat operations are characterized by disturbances in the psychological, physiological and social adaptation, which leads to premature aging. The cardiovascular system is highly reactive and plays a major role in the adaptive changes of the functional state of the organism. Based on the model of canonical correlation with step-by-step inclusion and exclusion of predictors, parameters of the cardiovascular system, a computer system for assessment of the degree of adaptation was developed. Conclusion. The developed automated system can be used in treatment, prophylactic and rehabilitation institutions, as well as in research and education centers for the diagnosis and monitoring of the effectiveness of therapeutic and rehabilitation measures.

Hardiness, avoidance coping, and alcohol consumption in war veterans: A moderated-mediation study.

Military personnel often engage in excessive alcohol use after returning from deployments. Thus far, research has paid scant attention to personality factors that may increase or diminish the risk for increased alcohol consumption in this population. The present study explores how psychological hardiness, avoidance coping, and stress exposure may interact to influence alcohol consumption patterns in soldiers following deployment. U.S. Army National Guard soldiers (N=357) were surveyed shortly after returning from combat operations in Afghanistan. Conditional process analysis was used to test for mediation and moderation effects. Mediation effects were further tested in a replication sample of Norwegian Army soldiers (N=230) deployed to Kosovo. Findings show that hardiness is a significant (negative) predictor of increased alcohol use and that this relation is mediated by avoidance coping. Further, this effect was moderated by combat stress exposure in the U.S. sample, such that the mediation is stronger for those with greater exposure (moderated-mediation). Avoidance coping also mediated the effects of hardiness on alcohol consumption in the Norwegian sample. These findings suggest that avoidance coping and hardiness may be fruitful areas for interventions aimed at reducing risky drinking in high-stress groups like the military.

The surgical management of facial trauma in British soldiers during combat operations in Afghanistan

IntroductionThe recent Afghanistan conflict caused a higher proportion of casualties with facial injuries due to both the increasing effectiveness of combat body armour and the insurgent use of the improvised explosive device (IED). The aim of this study was to describe all injuries to the face sustained by UK service personnel from blast or gunshot wounds during the highest intensity period of combat operations in Afghanistan. MethodsHospital records and Joint Theatre Trauma Registry data were collected for all UK service personnel killed or wounded by blast and gunshot wounds in Afghanistan between 01 April 2006 and 01 March 2013. Results566 casualties were identified, 504 from blast and 52 from gunshot injuries. 75% of blast injury casualties survived and the IED was the most common mechanism of injury with the mid-face the most commonly affected facial region. In blast injuries a facial fracture was a significant marker for increased total injury severity score. A facial gunshot wound was fatal in 53% of cases. The majority of survivors required a single surgical procedure for the facial injury but further reconstruction was required in 156 of the 375 of survivors aero medically evacuated to the UK. ConclusionsThe presence and pattern of facial fractures was significantly different in survivors and fatalities, which may reflect the power of the blast that these cohorts were exposed to. The Anatomical Injury Scoring of the Injury Severity Scale was inadequate for determining the extent of soft tissue facial injuries and did not predict morbidity of the injury.

The Role of Military Plastic Surgeons in the Management of Modern Combat Trauma: An Analysis of 645 Cases.

Plastic surgery has historically been linked to war. Between 2008 and the end of combat operations in Afghanistan in 2014, British military plastic surgeons formed part of the multinational military surgical team at the Role 3 Medical Treatment Facility, Camp Bastion, Helmand Province. The present study aimed to analyze the activity of these surgeons objectively and to determine the utility of their deployment. Data were gathered prospectively from four periods (2009 to 2012). This coincided with different surgeons, types of combat activity, wounding patterns, and mission emphases for the hospital. Various metrics were employed. Plastic surgeons were involved in 40 percent of surgical cases (645 of 1654). This was consistent, despite changes in the predominant wounding mechanism and casualty population. One-third of cases involved the plastic surgeon as the lead or sole surgeon and two-thirds involved working with surgeons from other disciplines. Caseload by anatomical region was as follows: hand and upper limb, 64 percent; head and neck, 46 percent; lower limb, 40 percent; and trunk, 25 percent. A median of 1.75 body areas were operated on per patient. Involvement did not differ between patients wearing combat body armor when injured and those who were not. Plastic surgeons played a significant role in the management of modern military trauma. This reflects the types of injuries sustained and the expertise of military plastic surgeons complementing the skill set of the other surgical team members. The level of activity was independent of wounding patterns, suggesting that the specialty may be useful, irrespective of the nature of the conflict.