Evacuation Chain Research Articles

Military medical revolution

Abstract : The battlefield has seen tremendous revolutions in military medical affairs (RMMAs) as a result of the last decade of continuous combat operations. The advances in deployed and en route combat casualty care are categorized as individual RMMAs shown in Table 1. As with prehospital advances, the basis for many of the RMMAs in the deployed hospital care environment as well as en route care was translated from civilian trauma practice but is realistic and relevant to the battlefield context. As the conflict evolved, the substantive data from the battlefield led to many new paradigms of treatment and evacuation. The successful implementation of many of these battlefield practices was then effectively translated back into the civilian injury care environment as has been typical of medical advances developed subsequent to previous conflicts of antiquity. The RMMAs that occurred during the last 10 years of combat casualty care are in the realm of deployed hospital care and en route care and are discussed in detail in this article.

Blast-Induced Lower Extremity Fractures With Arterial Injury: Prevalence and Risk Factors for Amputation After Initial Limb-Preserving Treatment

The purpose of this study is to determine the rate of late (secondary) amputation and to identify risk factors for amputation in injuries that were initially treated with limb preservation on the battlefield. A retrospective review at our institution identified 24 consecutive patients with 26 blast-induced open fractures distal to the joint that had associated arterial injuries. All injuries were initially cared for on the battlefield and during the evacuation chain of care with limb preservation protocols. All definitive orthopaedic care was provided by a single fellowship-trained orthopaedic trauma surgeon at a tertiary care stateside facility. Injury factors were analyzed based on radiographic and chart review to determine associations with amputation. Twenty of 26 injured limbs received an amputation for a total amputation rate of 76.9% (95% confidence interval, 57.9-88.9%). Fourteen limbs received early amputation before limb salvage attempts. Six of the 12 limbs that received limb salvage underwent late amputation. The rate of amputation in severe blast-induced extremity fractures combined with an arterial injury initially treated with limb preservation on the battlefield and before transfer to the definitive military treatment facility is extremely high. Blast-injured lower limbs with a combined severe bony and soft tissue injury should be carefully assessed when arterial injury is present because they may require early amputation during initial surgical care on the battlefield.

Operational Anaesthesia for the Management of Traumatic Brain Injury

The primary brain insult that occurs at the time of head injury, is determined by the degree of neuronal damage or death and so cannot be influenced by further treatment....

Tourniquet Application in a Rural Queensland HEMS Environment

The role of tourniquets in hemorrhage control remains controversial and depends on the clinical and logistic situation in which they are applied. Recent military experience of tourniquet efficacy with a low apparent complication rate has been obtained in the presence of a rapid evacuation chain for definitive care. However, in remote environments with scarce healthcare resources and long transportation times, a strategy of meticulous wound packing and compression dressing is preferred. Air medical retrieval teams in Australia operate over vast geographic areas and therefore encounter both ends of this logistic spectrum. This is exemplified by a case of exsanguinating hemorrhage from a partial amputation sustained in rural Queensland 500 km from the nearest trauma centre. In these settings, an understanding of both strategies is required to guide patient management during air medical retrieval.

Pedicled Thoracoabdominal Flap Coverage about the Elbow in Traumatic War Injuries

Current military conflicts in Iraq and Afghanistan have produced a significant number of complex injury patterns. Multiple extremity trauma and wide zones of injury mandate a flexible approach to these problems. We report our experience with periarticular elbow injuries with large soft tissue defects. Acute vascular reconstruction and multiple wound debridements throughout the evacuation chain set the stage for successful rigid fixation. The judicious use of pedicled thoracoabdominal flaps remains a viable solution when microvascular techniques are less appropriate.

What is the Ideal Pre-Hospital Analgesic? – A Questionnaire Study

AimTo determine clinical opinion of effectiveness of current battlefield analgesia and the realistic options to improve future analgesia in hostile environments.MethodsStructured electronic questionnaire distributed to selected individuals in UK and...

Field Trauma Care in the 21st Century

The nature of trauma care on the modern battlefield is changing quickly. Leading figures in UK field trauma care spoke at a recent meeting of the Haywood Club. The challenge...

Audit of prescription of anti-malarial prophylaxis to patients admitted to Royal Centre for Defence Medicine (RCDM following evacuation from Afghanistan

For most of the year Military personnel deployed to Afghanistan are required to take anti-malarial chemoprophylaxis (AMC). This audit aims to quantify how many personnel taking AMC in theatre have it continued at RCDM. A database kept at RCDM was searched for details of all evacuated patients. Records of these patients were then searched to find out which had been admitted, how many had been taking AMC prior to admission and how many were prescribed it in hospital. During the study period 40 patients were evacuated to RCDM. 26 of these were admitted and had notes available and were therefore included in the study. 9 of these had been taking AMC prior to admission; of them, only 4 had been continued on AMC by the time they were admitted to RCDM. Insufficient numbers of patients taking AMC prior to admission have it continued as an inpatient. Awareness of this issue needs to be raised at all points of the medical evacuation chain.

Is There One Optimal Medical Treatment and Evacuation Chain for All Situations: “Scoop-and-Run” or “Stay-and-Play”

In 2006, the Ministry of Defense of the Netherlands initiated a targeted agenda program for the World Congress on Disaster and Emergency Medicine in Amsterdam in 2007 (15WCDEM). The issue to be discussed was if there is one "golden" treatment and evacuation system that is applicable for different military and civilian situations. And, if there is not such a system, which parameters are important to construct the most optimal system for each different situation. This issue is related to the applicability and evidence base of the standards of the North Atlantic Treaty Organization. A group of experts started a website discussion on the issue during December 2006. During the 15WCDEM, several other participants were active in the discussion. Using the different experiences and the outcome of the discussions, it was concluded that there is not one "golden" medical emergency system, there are no "golden" timelines, and no "golden" skills. A medical system should be flexible and be able to adjust on each specific, local situation. First responder and non-medical people with medical skills (first responders) are essential in the front line of the emergency medical systems. More research is needed on the medical techniques and skills that are most effective early in the treatment and evacuation systems. Lessons learned from the military system are relevant for the civilian emergency medical services and vice-versa. The World Association for Disaster and Emergency Medicine can be an important platform to share and exchange information between these two systems. The target of the platform should be to obtain a generic picture of the important elements in prehospital emergency medical care.

D-Day on Board a Tank Landing Ship: Meat, Cheese and Blood Transfusion

Tank Landing Ships were used as evacuation station hospitals during D-Day of World War Two. This historical vignette describes how difficulties were overcome in blood transfusion and trauma surgery aboard...

Military Intensive Care Part 3. Future Directions

Activated Protein C Activated Protein C has been shown to decrease mortality in sepsis [1]. It would seem to be most beneficial in a select group of patients (those with...

Prehospital Care of Orthopedic Injuries

Orthopedic injuries are predominant among combat casualties, and carry the potential for significant morbidity. An expert consensus process (Prehospital care of military orthopedic trauma: A consensus meeting, Israel Defense Forces Medical Corps, May 2003) was used to create guidelines for the treatment of these injuries by military prehospital providers. The consensus treatment guidelines developed by experienced orthopedic trauma personnel from leading trauma centers in Israel are presented in this paper. For victims with open fractures, the first priority is hemorrhage control. Splinting, irrigation, and wound care should be performed while waiting for transport, or, in any scenario, in the case of an isolated limb injury. The use of traction splints was advocated for both the rapid transport scenario (up to one hour from the time of injury to arrival at the hospital) and the delayed transport scenario. In the urban setting, traction splints may not be necessary. Any victim experiencing pelvic pain following a high-energy mechanism of injury should be presumed to have an unstable pelvic fracture, and a sheet should be tied around the pelvis. The panel agreed that field-reduction of dislocations should be avoided by the medical officer unless it is anticipated that the patient will need to go through a long evacuation chain and the medical officer is familiar with specific reduction techniques.

Moderatorsʼ Summary: Wound Management (Session II)

Moderatorsʼ Summary: Wound Management (Session II)

Moderatorsʼ Summary: Amputee Care

Moderatorsʼ Summary: Amputee Care

Assessing Airway Patency And Breathing In NBC Category 4R - The RG Method.

IntroductionConfirming airway patency and the presence of breathing has significant limitations when both the casualty and medical personnel are in NBC category 4R. In casualties with limited signs of breathing,...

Prediction of Upper Airway Closure in Inhalational Injury

Inhalational injury is an imprecise term used to refer to a wide range of airway and pulmonary problems in the context of thermal injury. It markedly increases the mortality and morbidity of a given degree of cutaneous thermal injury. The incidence of proximal airway edema on the modern battlefield is likely to increase with the advent of enhanced blast and thermobaric weapons systems. Current military medical doctrine suggests that soldiers who are at risk of airway closure from edema should have a surgical airway provided. This in turn is likely to lead to complications in the hands of inexperienced nonsurgeons far-forward and a choking of the medical evacuation chain more rearward. This article examines the pathophysiology of inhalational injury and ways in which prediction of airway closure might be effected to prevent unnecessary surgical airway operations.

Documentation and tagging of casualties in multiple casualty incidents.

The use of triage tags is widely advocated as a tool to improve the management of multiple casualty incident scenes. However, there are no published reports to suggest that triage tags have improved the management of incidents involving more than 24 persons, and a number of reports have detailed problems associated with triage tag use. Alternative systems of scene management such as geographical triage have been successfully used in very large incidents, and are recommended as an alternative to triage tags. Documentation cards attached to casualties may be of use in situations where casualties will pass through an extended evacuation chain, and clear labels for deceased casualties are of benefit as they discourage repeat assessments. Adoption of an evidence-based approach to multiple casualty incident scene management will require a paradigm shift in the thinking of ambulance services. A broad-based educational approach that encourages critical reappraisal of existing procedures is recommended.

The Evolution Of Casualty Evacuation In The British Army In The 20th Century (Part 3) – 1945 To Present

This is the third in a series of papers describing the evolution of the British casualty evacuation chain during the 20th century. This period was dominated by the threat of...

The Evolution of casualty evacuation in the British Army in the 20th Century (Part 2) –1918 to 1945

This is the second in a series of papers that examine the evolution of the military casualty evacuation chain during the 20th century. The Spanish Civil War demonstrated to the...

An Australian mass casualty incident triage system for the future based upon triage mistakes of the past: the Homebush Triage Standard.

The purpose of this study was to create a system of mass casualty incident triage that provides a common language platform for both ambulance and hospital personnel based upon standard daily operating procedures for both groups. An annotated literature review was conducted. The Homebush Triage Standard taxonomy consists of five categories: immediate, urgent, not urgent, dying and dead, which are given the phonetic alphabet designations of Alpha, Bravo, Charlie, Delta and Echo, respectively, to facilitate radio voice communications. Colours are assigned to each category: red (Homebush Red), yellow (Homebush Gold), green (Homebush Green), white and black comply with Standards Australia AS-2700 1996 Colour Standard for General Purposes, to ensure triage materials have consistent production standards. Numbers are reserved to either quantify or stratify individuals within a particular triage category. The Homebush Triage Standard methodology is based on START (Simple Triage Assessment and Rapid Transport) and SAVE (Secondary Assessment of Victim Endpoint) and documents triage priority using geographic triage with triage flags, instead of triage tags. The Homebush Triage Standard provides a basis for both seamless patient reassessment at all points along the casualty evacuation chain and the audit of the medical response to mass casualty incidents. It allows hospital and ambulance staff to keep working using familiar routines and removes fundamental barriers to good communication during a time of crisis.