Combat Support Hospital Research Articles

Operation "NeuroTeam": rendering the absolute best care for the most deserving patients under the most difficult conditions

The tenets of neurosurgery worldwide, whether in the civilian or military sector, espouse vigilance, the ability to adapt, extreme ownership, and, of course, an innate drive for developing a unique set of technical skills. At a time in history when the complexity of battlefield neurotrauma climaxed coupled with a chronic shortage of military neurosurgeons, modernized solutions were mandated in order to deliver world-class neurological care to our servicemen and servicewomen. Complex blast injuries, as caused by an increased incidence of improvised explosive devices, yielded widespread systemic inflammatory responses with multiorgan damage. In response to these challenges, the "NeuroTeam," originally a unit of two neurosurgeons as deployed during Operation Desert Storm, was redesigned to instead pair a neurosurgeon with a neurointensivist and launched itself during two specialized missions in Operations Iraqi Freedom and Enduring Freedom. Representing a hybridized version of present-day neurocritical care teams, the purpose of this unit was to optimize neurosurgical care by focusing on interdisciplinary collaboration in an Echelon III combat support hospital. The NeuroTeam provided unique workflow capabilities never seen collectively on the battlefield: downrange neurosurgical capability by a board-certified neurological surgeon within 60 minutes from the point of injury paired with a neurocritical care-trained intensivist. This also set the stage for intraoperative telemedicine infrastructure for neurosurgery and optimized the ability to evaluate, triage, and stabilize patients prior to medical evacuation. This novel military partnership ultimately allowed the neurosurgeon to focus on the tenets of the craft and thereby the dynamic needs of the patient first and foremost. Since the success of these missions, the NeuroTeam has evolved into a detachable unit, the "Head and Neck Team," comprising neurosurgeons, otolaryngologists, and ophthalmologists, supported by a postinjury hospital unit, which includes an embedded neurocritical care physician. The creation and evolution of the NeuroTeam, necessitated by a shortage of military neurosurgeons and the dangerous shift in military wartime tactics, best exemplifies multidisciplinary collaboration and military medicine agility. As neurocritical care continues to evolve into a highly complex, distinct specialty, the lessons learned by the NeuroTeam ultimately serve as a reminder for civilian and military physicians alike. Despite the conditions and despite one's professional ego, patients with highly complex morbid neurological disease deserve expert, multidisciplinary management for survival.

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.

An Analysis of Intracranial Hemorrhage in Wartime Pediatric Casualties

Children make up a significant cohort of patients treated at combat support hospitals. Where traumatic head injury, including intracranial hemorrhage (ICH), is well studied in military adults, such research is lacking regarding pediatric patients. We seek to describe the incidence and outcomes of ICH within this population. This is a secondary analysis of a previously published dataset from the Department of Defense Trauma Registry for all pediatric casualties in Iraq and Afghanistan from January 2007 to January 2016. Within our dataset, we searched for casualties with an ICH. Of the 3439 pediatric encounters in our dataset, we identified 495 (14%) casualties that had at least 1 type of ICH. Most were between 5 and 12 years of age, male (74%), and injured by an explosive (42%). Of the casualties with ICHs, 82 had epidural (16.6%), 237 had subdural (47.9%), 153 had subarachnoid (30.9%), 157 had parenchymal bleeds (31.7%), and 239 had ICHs not otherwise specified (48.3%). In the hospital setting, the epidural group was more frequently treated with skull decompression (41%) and craniotomy with skull elevation (28%). The subdural group was more frequently treated with a craniectomy (17%) and the parenchymal group had more frequent intracranial pressure monitoring (18%). In our dataset, 22 received ketamine prehospital (4.4%) and most were discharged alive from the hospital (79%). Within our dataset, we identified 495 cases of ICH in pediatric patients. Most survived to hospital discharge despite less than half undergoing a decompression procedure.

Combat-related ocular trauma and visual outcomes during counter-terrorism urban warfare operations in Turkey.

The study was to report the clinical features and post-operative outcomes in military personnel admitted to the Ocular Trauma Center of Gülhane Training and Research Hospital after sustaining combat injuries in urban warfare. This is a retrospective, non-comparative, interventional case series analyzing Turkish military personnel transferred to our tertiary ocular trauma center from the warfare zone and combat support hospitals. Ocular injuries were subdivided into zones and ocular trauma classification. There were 103 combat ocular injuries in 74 military personnel. The average age was 27.31±4.64 years (range; 21-48 years), and all were men (100%). The average follow-up was 529.34±213.98 days (288-1464 days). There were 84 open-globe and 19 closed-globe injuries. Thirty-six (34.9%) had final vision of 20/40 or better. Pars plana vitrectomy was the most common surgery (79.6%). Five eyes underwent evisceration, and seven eyes developed phthisis bulbi. The globe survival rate was 88.3%. Zone III injuries (32.2%) were the most common cause of unfavorable visual outcomes, and most injuries were caused by improvised explosive devices (IEDs) (59.2%). These devices also had the worst impact on globe survival and visual improvement. These eyes had a higher likelihood ratio of requiring globe removal surgery or developing phthisis bulbi [odds ratio: 21.5 (95% CI: 1.23-373)]. Two eyes that underwent keratoprosthesis-assisted pars plana vitrectomy followed by penetrating keratoplasty (PKP) during the same session developed PKP failure while failure was not seen in any of the cases that underwent PKP in a later session. Ocular injuries related to IEDs had the most significant impact on both visual and anatomic prognoses, and globe survival was less likely in eyes with zone III trauma, in which intraocular foreign bodies penetrated the choroid. There is a higher pos-sibility of PKP failure if this procedure is performed during the same session as other ocular surgery.

Reduction in Medical Evacuations from Iraq and Syria Following Introduction of an Asynchronous Telehealth System.

While deployed, military medical personnel manage routine medical issues that fall under the category of Disease Non-Battle Injury (DNBI). The 86th Combat Support Hospital (CSH) partnered with Combined Joint Task Force-Operation Inherent Resolve (CJTF-OIR) Surgeon Cell, and Special Operations Joint Task Force-Operation Inherent Resolve (SOJTF-OIR) Surgeon Cell, to introduce the Health Experts onLine Portal (HELP) telemedicine system to medical personnel in Iraq and Syria. HELP is an asynchronous (store and forward) online system that provides secure provider-to-provider teleconsultation services for routine patient care and medical evacuation (MEDEVAC) coordination. The goal was to reduce the need for MEDEVAC by providing expert consultation to medical providers in farther-forward deployed units. In June 2017, the 86th CSH launched HELP telemedicine services for Kuwait. Following the successful implementation of the telemedicine system in Kuwait, the 86th CSH leadership partnered with CJTF-OIR and SOJTF-OIR medical leadership in launching the system within Iraq and Syria as well as making the system available to all deployed locations in Central Command (CENTCOM). This was a prospective cohort study designed to determine if having convenient and secure access to remote subspecialty consultation would be associated with a reduction in routine MEDEVACs from far forward in the battle space. In August 2017, new-user training was completed and the program launched in Iraq and Syria. This study analyzes the baseline MEDEVAC rate in 3 months before the implementation of HELP telemedicine compared to 3 months following the implementation. Iraq and Syria cases in the HELP telemedicine system accounted for 17.2% (76) of total CENTCOM telemedicine case volume over the 7-month study period. Comparing the 3-month period before and after implementation of HELP, use of asynchronous telemedicine in Iraq and Syria was associated with a reduction in total MEDEVACs from 157 to 68 (56.7% reduction, p<0.001). DNBI represented the majority of the change, (65.0% reduction, p<0.001). MEDEVAC for battle-related injuries decreased slightly from 13 to 6 per 3-month period (p=0.03). This is the first prospective study to demonstrate an association between the initiation of asynchronous telemedicine capabilities in a combat zone and decreased MEDEVACs. Annualized numbers would predict a reduction of 328 MEDEVACs/year for each 10,000 personnel by utilizing asynchronous telemedicine. This represents a significant potential cost savings of $1.2 million/year through avoidance of routine medical movement of personnel and supports unit readiness by retaining service members in areas of combat operations.

Tranexamic acid in pediatric combat trauma requiring massive transfusions and mortality.

Tranexamic acid (TXA) has been demonstrated to decrease mortality in adult trauma, particularly in those with massive transfusions needs sustained in combat injury. Limited data are available for the efficacy of TXA in pediatric trauma patients outside of a single combat support hospital in Afghanistan. The Department of Defense Trauma Registry was queried for trauma patients younger than 18 years from Iraq and Afghanistan requiring 40 mL/kg or greater of blood product within 24 hours of injury. Burns and fatal head traumas were excluded. Primary outcome was in-hospital mortality. Secondary outcomes were hospital, ventilator, and intensive care unit-free days, as well as total blood product volume. Among those pediatric patients receiving massive transfusions, those who received TXA were less likely to die in hospital (8.5% vs. 18.3%). Patients who received TXA and those who did not have similar hospital-free days (19 vs. 20), ventilator-free days (27 vs. 27), and intensive care unit-free days (25 vs. 24). Those who received TXA had higher 24-hour blood product administration (100 mL/kg vs. 75 mL/kg). None of our results rose to the level of statistical significance. The TXA administration significantly reduced odds of death on logistic regression (odds ratio, 0.35; 95% confidence interval, 0.123-0.995; p = 0.0488). Use of TXA in pediatric patients with combat trauma requiring massive transfusions trended toward a significant improvement in in-hospital mortality (p = 0.055). This mortality benefit is similar to that seen in adult studies and a less well characterized cohort in another pediatric study suggesting TXA administration confers mortality benefit in massively transfused pediatric combat trauma victims. Evidence (retrospective cohort), Level IV.

Orthopaedic care provided by the 14th combat support hospital in support of humanitarian and disaster relief after hurricane Maria in Puerto Rico.

On September 20, 2017 Hurricane Maria, a category 4 hurricane, made landfall on the eastern coast of Puerto Rico. This was preceded by Hurricane Irma, a category 5 hurricane, which passed just off the coast 13 d prior. The destruction from both Hurricane Irma and Maria precipitated a coordinated federal response which included the Federal Emergency Management Agency (FEMA) and the United States military. The United States Army dispatched the 14th Combat Support Hospital (CSH) to Humacao, a city on the eastern side of the island where Maria made landfall. The mission of the 14th CSH was to provide medical humanitarian aid and conduct disaster relief operations in support of the government of Puerto Rico and FEMA. During the 14th CSH deployment to Puerto Rico, 1157 patients were evaluated and treated. Fifty-seven operative cases were performed to include 23 orthopaedic cases. The mean age of the orthopaedic patients treated was 45.7 years (range 13-76 years). The most common operation was irrigation and debridement of open contaminated and/or infected wounds. Patients presented a mean 10.8 d from their initial injury (range 1-40 d). Fractures and infections were the most common diagnoses with the greatest delay in treatment from the initial date of injury. The deployment of the 14th CSH to Puerto Rico was unique in its use of air transport, language and local customs encountered, as well as deployment to a location outside the continental United States. These factors coupled with the need for rapid deployment of the 14th CSH provided valuable experience which will undoubtedly enable future success in similar endeavors.

Application of the Joint Trauma System Clinical Practice Guideline for Pain, Anxiety, and Delirium in a Combat Support Hospital in Iraq.

The 2017 Joint Trauma System Clinical Practice Guideline for Pain, Anxiety, and Delirium (JTS CPG) provides an evidence-based framework for managing pain, anxiety, and delirium in combat settings. In this study, we evaluate the use of multimodal analgesia and assess pain outcomes, as indicated by the JTS CPG, at the combat support hospital (CSH). In this quality improvement project, data were collected for all patients, presenting to the CSH in Baghdad, Iraq, who received consultation from the acute pain service from October 10, 2017 to February 27, 2018. Univariate analyses described patient demographic and clinical characteristics. Defense and Veterans Pain Rating Scale (DVPRS) scores, physical therapy completion, and sleep duration were recorded for each patient daily. Correlations assessed relationships between variables, including clinical characteristics and DVPRS scores. 34 patients were included in this study. About 65% of the patients included in this study were Iraqi military, while the other 35% were U.S. or Coalition Forces. Over half received more than one class of analgesic medication. The majority of patients received regional anesthesia, with 17 different techniques utilized. The DVPRS had acceptable internal consistency (Cronbach alpha=0.87, 95% CI 0.80, 0.95). There was a significant difference in median DVPRS pain intensity scores between those who met physical therapy goals and those who did not. Sleep duration was negatively correlated with both the DVPRS pain intensity and sleep scores. This report indicates that acute pain service teams integrated in a CSH can feasibly implement JTS CPGs using a team-based approach. Given the military's emphasis on managing complex pain and disability among survivors beginning in the combat environment, it is imperative that innovations and best practices, like the JTS CPG, be assessed in the combat setting.

Primary Blast Lung Injury: The UK Military Experience.

Primary blast lung injury occurs when an explosive shock wave passes through the thorax and transits through tissues of varying densities. It requires close proximity to an explosion and presents quick with respiratory distress in survivors. The Joint Theatre Trauma Registry and the Defence Statistics (Health) Database were interrogated for casualties injured as a result of an explosion during the conflict in Afghanistan. The case notes and imaging of casualties meeting the criteria for diagnosis were reviewed. Demographic and clinical data on casualties with primary blast lung injury were analyzed. 848 blast-exposed casualties survived to discharge from intensive care, and 238 blast-exposed casualties were killed in action. Following exclusions, 111 case notes and all postmortem reports were reviewed in detail. About, 25 casualties had isolated primary blast lung injury (2.9% of casualties surviving to discharge from intensive care) and 31 nonsurvivors (13% of nonsurvivors) had the disease documented at postmortem. Severe cases of primary blast lung injury required an estimated average of 4.5days of conventional mechanical ventilation. 8.1% of blast exposed casualties suffered primary blast lung injury. It was a less severe disease than other nontraumatic forms of acute lung injury and did not cause deaths once a casualty had reached a combat support hospital. It was well managed with a relatively brief period of conventional mechanical ventilation.

Diagnosis and treatment of traumatic vascular injury of limbs in military and emergency medicine: A systematic review.

Background:Traumatic vascular injury is caused by explosions and projectiles (bullets and shrapnel); it may affect the arteries and veins of the limbs, and is common in wartime, triggering bleeding, and ischemia. The increasing use of high-energy weapons in modern warfare is associated with severe vascular injuries.Methods:To summarize the current evidence of diagnosis and treatment for traumatic vascular injury of limbs, for saving limbs and lives, and put forward some new insights, we comprehensively consulted literatures and analyzed progress in injury diagnosis and wound treatment, summarized the advanced treatments now available, especially in wartime, and explored the principal factors in play in an effort to optimize clinical outcomes.Results:Extremity vascular trauma poses several difficult dilemmas in diagnosis and treatment. The increasing use of high-energy weapons in modern warfare is associated with severe vascular injuries. Any delay in treatment may lead to loss of limbs or death. The development of diagnose and treat vascular injury of extremities are the clinical significance to the tip of military medicine, such as the use of fast, cheap, low invasive diagnostic methods, repairing severe vascular injury as soon as possible, using related technologies actively (fasciotomy, etc).Conclusion:We point out the frontier of the diagnosis and treatment of traumatic vascular injury, also with a new model of wartime injury treatment in American (forward surgical teams and combat support hospitals), French military surgeons regarding management of war-related vascular wounds and Chinese military (“3 districts and 7 grades” model). Many issues remain to be resolved by further experience and investigation.

Enucleations and Eviscerations for Combat Ocular Trauma Performed During Operations Iraqi and Enduring Freedom: 2001 to 2011.

To describe the demographics and clinical outcomes of patients who underwent posttraumatic enucleation or evisceration during Operations Iraqi Freedom (OIF) and Enduring Freedom (OEF) from 2001 to 2011. The Walter Reed Ocular Trauma Database is a retrospective case series of US Servicemembers and Department of Defense civilians who had combat ocular injuries in OIF and OEF. Data regarding posttraumatic enucleations and eviscerations performed during OIF and OEF were extracted. The main outcomes analyzed were the number of enucleations and eviscerations performed, location of the surgery, laterality, and graft type. The secondary outcome measures included: mechanism of injury and Ocular Trauma Score classification. One hundred nine enucleations and eviscerations were performed on the 890 eyes (12.24%). Sixty-three (57.80%) primary enucleations, 36 (33.03%) secondary enucleations, 5 (4.59%) postretinal detachment repair enucleations, and 5 (4.59%) primary eviscerations were completed. The surgeries were completed at a combat support hospital (57; 52.3%), or Walter Reed Army Medical Center (49; 45.0%). All surgeries were unilateral except in 2 patients. The most common graft type used was silicone (n = 56; 51.38%). Improvised explosive devices caused 76 (69.72%) eye injuries. Ocular Trauma Score were recorded as 56 (51.38%) between 0 and 44, 44 (40.37%) between 45 and 65, and unknown in 9 (8.26%). Posttraumatic enucleation or evisceration due to devastating ocular trauma is required in about 15% of ophthalmic patients in modern combat trauma. The psychosocial impact on veterans who have required an enucleation or evisceration from combat trauma has been poorly studied and requires further review.

Lateral Canthotomy and Cantholysis in Operations Iraqi Freedom and Enduring Freedom: 2001–2011

To describe outcomes and associated ocular injuries of lateral canthotomy and cantholysis (LCC) as performed in combat ocular trauma. Data from the Walter Reed Ocular Trauma Database of patients requiring LCC during Operations Iraqi Freedom and Enduring Freedom was reviewed as a retrospective cohort. Primary outcome measures included final visual acuity (VA) and Ocular Trauma Score. Secondary outcome measures were associated injuries and timing of surgery. Thirty-six LCCs were recorded on a total of 890 eyes (4.04 %) in the Walter Reed Ocular Trauma Database. Eighteen out of 36 eyes (50.00%) had a final VA of the affected eye of 20/200 or worse vision. From the initial available VA measured either at the time of injury or at Walter Reed Army Medical Center, 13 eyes (40.63%) had no change in VA, 15 eyes (46.88%) had improvement, and 4 (12.5%) had a decrease in VA (n = 32, data unavailable for 4 eyes). Ocular Trauma score 0-65 was noted in 14 (38.9%) and 66-100 (61.1%). Retinal detachment (6, 16.67%), optic nerve injuries (7, 19.44%), orbital fractures (20, 55.56%), and retrobulbar hematoma (25, 69.44%) were commonly associated injuries. Of the 36 LCC, 18 (50.00%) were performed as the first surgery performed at the combat support hospital, 13 (36.11%) as the second, 4 (11.11%) as the third, and 1 (2.78%) as the fourth. The largest subgroup of patients had an improvement in VA associated with performance of LCC; however, half of patients remained with a final VA of equal to or worse than 20/200 due to severe ocular trauma.

Non-battle Emergency Department Utilization of the First Modular Army Field Hospital Prototype in Support of Operation INHERENT RESOLVE.

The 2010-2011 withdrawal from Iraq included the closure of all fixed-facility military medical resources. Operation INHERENT RESOLVE, the United States-led counter-terrorism mission in Iraq and Syria, subsequently commenced in 2014. With increasing combat operations, the 28th Combat Support Hospital deployed to Iraq to support that mission as a limited footprint unit prototyped after the new modular Army Field Hospital. We describe the non-battle utilization of the emergency medical treatment section. We prospectively collected data for this project as part of a performance improvement initiative to track healthcare utilization to guide emergency medical treatment section staffing. The project took place at a combat support hospital near Baghdad, Iraq from July 2016 through January 2017. During this time, the emergency department (ED) averaged 3.5 visits per day totaling 675 non-battle encounters. Most (84.6%) were U.S. military personnel with a median age of 32 (IQR 26-38). The most common procedure performed was point-of-care ultrasound (n = 33). Most patients (96.9%) underwent discharge from the ED. Of the 21 subjects admitted, 6 were for surgical intervention and the remaining for medical or observational indications. The most common chief complaints were musculoskeletal (31.1%, n = 210), respiratory (15.3%, n = 103), and dermatologic (12.0%, n = 81). Non-battle injuries and illnesses were the predominant reason for ED utilization. Most subjects were discharged back to duty with relatively low-resource utilization. Few visits required procedural interventions.

Spine surgery in the International Security Assistance Force Role 3 combat support hospital in Mazar-e-Sharif, northern Afghanistan, 2007-2014.

OBJECTIVESince 2007, a continuous neurosurgery emergency service has been available in the International Security Assistance Force (ISAF) field hospital in Mazar-e-Sharif (MeS), Afghanistan. The object of this study was to assess the number and range of surgical procedures performed on the spine in the period from 2007 to 2014.METHODSThis is a retrospective analysis of the annual neurosurgical caseload statistics from July 2007 to October 2014 (92 months). The distribution of surgical urgency (emergency, delayed urgency, or elective), patient origin (ISAF, Afghan National Army, or civilian population), and underlying causes of diseases and injuries (penetrating injury, blunt injury/fracture, or degenerative disease) was analyzed. The range and pattern of diagnoses in the neurosurgical outpatient department from 2012 and 2013 were also evaluated.RESULTSA total of 341 patients underwent neurosurgical operations in the period from July 2007 to October 2014. One hundred eighty-eight (55.1%) of the 341 procedures were performed on the spine, and the majority of these surgeries were performed for degenerative diseases (127/188; 67.6%). The proportion of spinal fractures and penetrating injuries (61/188; 32.4%) increased over the study period. These spinal trauma diagnoses accounted for 80% of the cases in which patients had to undergo operations within 12 hours of presentation (n = 70 cases). Spinal surgeries were performed as an emergency in 19.8% of cases, whereas 17.3% of surgeries had delayed urgency and 62.9% were elective procedures. Of the 1026 outpatient consultations documented, 82% were related to spinal issues.CONCLUSIONSCompared to the published numbers of cases from neurosurgery units in the rest of the ISAF area, the field hospital in MeS had a considerably lower number of operations. In addition, MeS had the highest rates of both elective neurosurgical operations and Afghan civilian patients. In comparison with the field hospital in MeS, none of the other ISAF field hospitals showed such a strong concentration of degenerative spinal conditions in their surgical spectrum. Nevertheless, the changing pattern of spine-related diagnoses and surgical therapies in the current conflict represents a challenge for future training and material planning in comparable missions.

Making biologics on demand

As a U.S. Army doctor stationed in Afghanistan in 2003, Geoffrey Ling had a hard time accessing medicines his patients needed. “The combat support hospital was nothing more than a tent city,” he says. “When you’re in a situation like that, you have limited supplies.” In particular, biopharmaceuticals, like insulin, were hard to obtain and store. “I wanted to have a machine that could make any drug at any time in any quantity for providers in situations like I was in, austere situations where they have to take care of patients,” Ling says. “Instead of carrying around boxes and boxes of drugs that they may never use, they would just carry some basic reagents and make what they needed.” When he joined the U.S. Defense Advanced Research Projects Agency (DARPA) as a program manager, he found himself in a position to do something about it. In 2010, DARPA leadership let

Application of damage control orthopedics to combat-related hand injuries

The purpose of this report was to analyze sequential management of patients with combat-related hand injuries in the Kabul International Airport Combat Support Hospital and to identify principles of hand damage control orthopedics (DCO). A retrospective study was conducted using the French Opex data system that included all the patients who received sequential treatment for combat-related hand injuries from 2009 to 2013. Demographics, mechanism, injury pattern, reasons for DCO application and surgical procedures performed during initial and definitive treatment were described. Forty-one patients were included: 14 French soldiers and 27 Afghan patients. Explosive devices were the most common injury mechanism. There were multiple reasons for DCO application in 20 cases. Debridement, skeletal fixation by pinning or splinting, and delayed primary closure were the main emergent procedures. Primary and secondary treatment data did not differ between French and Afghan patients. Although Afghan patients were fully treated on site, the time to secondary procedures was three time higher in this group because of intense operational activity during the period study. The functional outcome was only evaluated in French soldiers who were treated definitely in France. Hand DCO may be required in various situations encountered in both military and civilian settings: polytrauma; delayed transfer to hand specialist; complex high-energy injuries due to firearms or explosive devices. The basic elements of this specific surgical tactic are meticulous debridement, detailed wound assessment and temporary skin coverage.

Attitudes and Beliefs of Deployed United States Military Medical Personnel about Providing Healthcare for Iraqi Patients

This study surveyed 1,129 U.S. military medical personnel deployed to a combat support hospital in Iraq regarding their attitudes and beliefs about providing healthcare to Iraqi National Guard, civilian, and security detainee patients. A significant percentage of military medical personnel reported they were comfortable treating Iraqi patients. However, a notable proportion indicated discomfort in this role, especially when interacting with security detainees. Nearly half of the medical personnel did not feel adequately prepared or trained for this role. U.S. military medical personnel may benefit from enhanced predeployment cultural education and training tailored to care for the local civilian patient population.

Lessons Learned from the Humanitarian Hurricane Medical Relief Response of the US Army 14th Combat Support Hospital for the People of Humacao, Puerto Rico

Heidenreich, Bethany M. DO; Sessions, Daniel J. MD; Hale, Diane F. MD; Jordan, Christopher MD; Ahnfeldt, Eric P. DO, FACS Author Information

Damage Control Resuscitation.

Damage control resuscitation (DCR) is a strategy for resuscitating patients from hemorrhagic shock to rapidly restore homeostasis. Efforts are focused on blood product transfusion with whole blood or component therapy closely approximating whole blood, limited use of crystalloid to avoid dilutional coagulopathy, hypotensive resuscitation until bleeding control is achieved, empiric use of tranexamic acid, prevention of acidosis and hypothermia, and rapid definitive surgical control of bleeding. Patients receiving uncrossmatched Type O blood in the emergency department and later receiving cumulative transfusions of 10 or more red blood cell units in the initial 24-hour post-injury (massive transfusion) are widely recognized as being at increased risk of morbidity and mortality due to exsanguination. Ideally, these patients should be rapidly identified, however anticipating transfusion needs is challenging. Useful indicators of massive transfusion reviewed in this guideline include: systolic blood pressure <110 mmHg, heart rate > 105 bpm, hematocrit <32%, pH < 7.25, injury pattern (above-the-knee traumatic amputation especially if pelvic injury is present, multi-amputation, clinically obvious penetrating injury to chest or abdomen), >2 regions positive on Focused Assessment with Sonography for Trauma (FAST) scan, lactate concentration on admission >2.5, admission international normalized ratio ≥1.2-1.4, near infrared spectroscopy-derived StO2 < 75% (in practice, rarely available), BD > 6 meq/L. Unique aspects of out-of-hospital DCR (point of injury, en-route, and remote DCR) and in-hospital (Medical Treatment Facilities: Role 2b/Forward surgical teams - role 3/ combat support hospitals) are reviewed in this guideline, along with pediatric considerations.

Genitourinary Injuries Among Female U.S. Service Members During Operation Iraqi Freedom and Operation Enduring Freedom: Findings from the Trauma Outcomes and Urogenital Health (TOUGH) Project.

Until recently, female U.S. service members (SMs) have not been permitted to serve in direct combat roles. However, during Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF), a large number of female SMs have been wounded while serving in combat support roles. This included an unprecedented number of women with genitourinary (GU) injuries. No previous studies have reported either the incidence or clinical picture of these injuries. The objective of this study is to describe the epidemiology of GU injuries among female U.S. SMs during OIF/OEF and understand the potential for increased female GU injuries in future conflicts and the long-term sequelae from these injury patterns. The Department of Defense Trauma Registry was reviewed to identify all U.S. SMs diagnosed with GU injury from 2001 to 2013. The Department of Defense Trauma Registry includes data for wounded SMs treated at any U.S. combat support hospital, the in-theater equivalent of a civilian trauma center. Female SMs with ICD-9-CM diagnosis codes and/or Abbreviated Injury Scale codes for GU injury were included. Data on all females with GU injury were reviewed, including battle injury (BI) and non-BI. Basic demographic and injury characteristics were reported. Among the 1,463 U.S. SMs diagnosed with GU injury while deployed to OIF/OEF, 20 (1.4%) were female (median age: 25 yr; interquartile range 21-27 yr). Of these, nine were BI (45%) and 11 were non-BI (55%). The distribution of injury location was as follows: renal injuries (n = 12), vulvar injuries (n = 3), vaginal injuries (n = 3), perineal injury (n = 1), and bladder injury (n = 1). Median Injury Severity Score was in the severe range of 21 (interquartile range 6-32), and four women (20%) died of their wounds. Important associated injuries included colorectal (n = 5) and lower extremity amputation(s) (n = 2). The most common mechanism of injury among the nine women with GU BI was improvised explosive device blast (n = 6), followed by other explosions (n = 2) and gunshot wound (n = 1). Mechanisms of GU non-BI varied, including gunshot wound (n = 2), fall (n = 2), fire/flame (n = 1), knife wound (n = 1), unintentional machine injury (n = 1), motor vehicle accident (n = 1), sports injury (n = 1), fight (n = 1), and pedestrian injury (n = 1). Female GU injuries comprise a small portion of all GU injuries sustained during OIF/OEF with the most predominant being renal injury. Now that the ground combat exclusion policy has been lifted, these data can be used as a model for the expected injury patterns in future female combatants. Long-term applications for these data include research and development for personal protective equipment and development of a multidisciplinary approach to long-term comprehensive care following GU trauma.