Force Theater Hospital Research Articles

Penetrating femoropopliteal injury during modern warfare: Experience of the Balad Vascular Registry

Wounding patterns, methods of repair, and outcomes from femoropopliteal injury have been documented in recent civilian literature. In Operation Iraqi Freedom, as in past conflicts, these injuries continue to be a therapeutic challenge. Therefore, the objective of the current study is to document the pattern of femoropopliteal injuries, methods of repair, and early outcomes during the current military campaign in Iraq. From September 1, 2004, to April 30, 2007, all vascular injuries arriving at the Air Force Theater Hospital (the central echelon III medical facility in Iraq; equivalent to a civilian level I trauma center), Balad Air Base, Iraq were prospectively entered into a registry. From this, injuries involving the lower extremities were reviewed. During the 32-month study period, 9289 battle-related casualties were assessed. Of these, 488 (5.3%) were diagnosed with 513 vascular injuries, and 142 casualties sustained 145 injuries in the femoropopliteal domain. Femoral level injury was present in 100, and popliteal level injury occurred in 45. Injuries consisted of 59 isolated arterial, 11 isolated venous, and 75 combined. Fifty-eight casualties were evacuated from forward locations. Temporary arterial shunts were placed in 43, of which 40 (93%) were patent on arrival at our facility. Our group used shunts for early reperfusion before orthopedic fixation, during mass casualty care, or autogenous vein harvest in 11 cases. Arterial repair was accomplished with autogenous vein in 118 (88%), primary means in nine (7%), or ligation in seven (5%). Venous injury was repaired in 62 (72%). Associated fracture was present in 55 (38%), and nerve injury was noted in 19 (13%). Early limb loss due to femoropopliteal penetrating injury occurred in 10 (6.9%). Early mortality was 3.5% (n = 5). Femoropopliteal vascular injury remains a significant reality in modern warfare. Femoral injuries appear more prevalent than those in the popliteal region. Early results of in-theater repair are comparable with contemporary civilian reports and are improved from the Vietnam era. Rapid evacuation and damage control maneuvers such as temporary shunting and early fasciotomy assist timely definitive repair and appear effective.

Combat Casualty Care in an Air Force Theater Hospital: Perspectives of Recently Deployed Cardiothoracic Surgeons

Current military operations have generated a large number of casualties and have led to the establishment of the first Air Force Theater Hospital since Vietnam. Located at Balad Airbase, Iraq, this hospital is a busy trauma center. Thoracic injuries are relatively infrequent but highly lethal. The cardiothoracic surgeon is uniquely trained to provide sophisticated surgical management to some of the most severely injured patients. The operative experiences of four recently deployed cardiothoracic surgeons are described. Mortality from combat injury in this conflict is lower than in prior wars. Body armor may prevent some fatal injuries. Several features of military medical care process are helping to improve our outcomes-specifically, the development of a trauma care system modeled on successful civilian centers, the expanded use of damage control concepts, and utilization of early transportation out of the theater of operations using Critical Care Air Transport Teams (CCATT).

Ventilator Associated Pneumonia in a Military Deployed Setting: The Impact of an Aggressive Infection Control Program

Since the onset of military operations in Iraq and Afghanistan, there has been a marked increased in multidrug resistant bacterial infections among combat casualties. We describe the rates of ventilator-associated pneumonia (VAP) before and after the implementation of aggressive infection control measures at the Air Force Theater Hospital in Iraq. All patients admitted to the intensive care unit (ICU) were followed prospectively for the development of VAP. Baseline VAP rate was determined in May 2006, and preventive measures were implemented by June 2006. Interventions included hand hygiene, contact barrier precautions, patient and staff cohorting, chlorhexidine oral care, and reducing the duration and spectrum of surgical antimicrobial prophylaxis. Additionally, each ICU tent was closed periodically for cleaning and disinfection. Daily inspections provided ongoing staff education and enforcement of procedures. Monthly VAP rates were calculated and compared for trend. There were 475 ICU admissions from May 2006 through August 2006 for a mean admission rate of 119 per month. The rate of VAP per 1,000 ventilator days was 60.6 in May, 31.6 in June, 21.3 in July, and 11.1 in August (p = 0.029). Targeted surveillance in November and December revealed VAP rates of 11.6 and 9.7, respectively. Notably, the most common bacteria, Acinetobacter, had improved antimicrobial susceptibilities after the interventions. Implementation of aggressive infection control procedures in a combat military hospital was associated with a significant decrease in the rate of VAP. Despite the numerous challenges in theater, infection control can have measurable and sustainable impact in a combat theater hospital.

Repair of Facial Fractures in the Iraq War Combat Theater

Manuel A. Lopez, MD; Jonathan L. Arnholt, MD Objective: To determine the safety of definitive in-theater facial fracture repair on American military personnel wounded during Operation Iraqi Freedom. Methods: A retrospective review of all patients with head and neck trauma treated at the 322nd Expeditionary Medical Group/Air Force Theater Hospital, Balad Air Base, Iraq, from May 7, 2005, through September 18, 2005, was performed. This study focused on the outcomes of wounded American military personnel whose facial fractures were definitively repaired in theater. The criteria used to determine candidacy for definitive in-theater facial fracture repair on American military personnel were (1) the fracture site was exposed through either a soft tissue wound or because of an adjacent surgical approach, (2) treatment would not delay evacuation from theater, and (3) treatment would allow the military member to remain in theater. Results: From May 2005 to September 2005, 207 patients were taken to the operating room and required 388 procedures. A total of 175 patients (85%) were operated on for traumatic injuries, and 52 of these patients required open reduction and internal fixation (ORIF) of a facial fracture. Of the 52 patients who underwent an ORIF, 17 were American military personnel. Of the 17 American patients who were definitively treated for their facial fractures in theater, 16 were contacted and/or followed up on the global military medical database. None of these patients developed an Acinetobacter baumannii infection or had a complication caused by the definitive in-theater ORIF. The range of follow-up was 2 months to 11 months, with a mean of 8.3 months. Conclusions: Definitive repair of facial fractures with ORIF on American military personnel in theater is advised when the aforementioned criteria are observed. An otolaryngologist is a crucial member of the head and neck trauma team.

Safety of Definitive In-Theater Repair of Facial Fractures

To determine the safety of definitive in-theater facial fracture repair on American military personnel wounded during Operation Iraqi Freedom. A retrospective review of all patients with head and neck trauma treated at the 322nd Expeditionary Medical Group/Air Force Theater Hospital, Balad Air Base, Iraq, from May 7, 2005, through September 18, 2005, was performed. This study focused on the outcomes of wounded American military personnel whose facial fractures were definitively repaired in theater. The criteria used to determine candidacy for definitive in-theater facial fracture repair on American military personnel were (1) the fracture site was exposed through either a soft tissue wound or because of an adjacent surgical approach, (2) treatment would not delay evacuation from theater, and (3) treatment would allow the military member to remain in theater. From May 2005 to September 2005, 207 patients were taken to the operating room and required 388 procedures. A total of 175 patients (85%) were operated on for traumatic injuries, and 52 of these patients required open reduction and internal fixation (ORIF) of a facial fracture. Of the 52 patients who underwent an ORIF, 17 were American military personnel. Of the 17 American patients who were definitively treated for their facial fractures in theater, 16 were contacted and/or followed up on the global military medical database. None of these patients developed an Acinetobacter baumannii infection or had a complication caused by the definitive in-theater ORIF. The range of follow-up was 2 months to 11 months, with a mean of 8.3 months. Definitive repair of facial fractures with ORIF on American military personnel in theater is advised when the aforementioned criteria are observed. An otolaryngologist is a crucial member of the head and neck trauma team.

Civilian and Detainee Orthopaedic Surgical Care at an Air Force Theater Hospital

This study is a retrospective analysis of the orthopaedic care rendered to Iraqi citizens, both military and civilian, and detainees in Balad, Iraq, at an Air Force theater hospital. Defining the scope of care for this patient group and emphasizing the differences in care provided for the endemic population in contrast to the rapidly air-evacuated Coalition injured combatant are the primary focus of the study. Approximately 50% of more than 1600 trauma/combat-related injury admissions to Air Force Theater Hospital in Balad, Iraq, from the period of September 2, 2005 through January 18, 2006, were Iraqi citizens and detainees. The care rendered to this population differed from the care given to a rapidly air-evacuated patient in that definitive care of all combat wounds, including fracture care and soft tissue management, was the responsibility of the deployed surgeons. Open reduction and internal fixation, definitive debridement, Wound VAC placement (Vacuum-Assisted Closure Device; KCI International, San Antonio, Tex), and final soft tissue management were performed at Air Force Theater Hospital. All patients were treated according to their injuries, including detainees, who received the same level of care as any other injured patient. This article will depict examples of the civilian and detainee orthopaedic care available and performed in a war zone and how that care differed from that rendered to a rapidly evacuated American combatant. Injured Coalition combatants received high-level damage control orthopaedic care and initial debridements, with external fixation as the single most common means of long-bone fracture stabilization. Civilians and detainees seen at Balad received the same high-level care and much, if not all, of their definitive care while at Air Force Theater Hospital. The care rendered to Iraqi citizens and detainees at an Air Force theater hospital is described, with multiple case examples that reflect a high level of definitive care offered in a war zone.

Experience at the 332nd Air Force Theater Hospital: Evacuation Hub for Iraq

Experience at the 332nd Air Force Theater Hospital: Evacuation Hub for Iraq

The complete management of extremity vascular injury in a local population: A wartime report from the 332nd Expeditionary Medical Group/Air Force Theater Hospital, Balad Air Base, Iraq

Although the management of vascular injury in coalition forces during Operation Iraqi Freedom has been described, there are no reports on the in-theater treatment of wartime vascular injury in the local population. This study reports the complete management of extremity vascular injury in a local wartime population and illustrates the unique aspects of this cohort and management strategy. From September 1, 2004, to August 31, 2006, all vascular injuries treated at the Air Force Theater Hospital (AFTH) in Balad, Iraq, were registered. Those in noncoalition troops were identified and retrospectively reviewed. During the study period, 192 major vascular injuries were treated in the local population in the following distribution: extremity 70% (n=134), neck and great vessel 17% (n=33), and thoracoabdominal 13% (n=25). For the extremity cohort, the age range was 4 to 68 years and included 12 pediatric injuries. Autologous vein was the conduit of choice for these vascular reconstructions. A strict wound management strategy providing repeat operative washout and application of the closed negative pressure adjunct was used. Delayed primary closure or secondary coverage with a split-thickness skin graft was required in 57% of extremity wounds. All patients in this cohort remained at the theater hospital through definitive wound healing, with an average length of stay of 15 days (median 11 days). Patients required an average of 3.3 operations (median 3) from the initial injury to definitive wound closure. Major complications in extremity vascular patients, including mortality, were present in 15.7% (n=21). Surgical wound infection occurred in 3.7% (n=5), and acute anastomotic disruption in 3% (n=4). Graft thrombosis occurred in 4.5% (n=6), and early amputation and mortality rates during the study period were 3.0% (n=4) and 1.5% (n=2), respectively. To our knowledge, this study represents the first large report of wartime extremity vascular injury management in a local population. These injuries present unique challenges related to complex wounds that require their complete management to occur in-theater. Vascular reconstruction using vein, combined with a strict wound management strategy, results in successful limb salvage with remarkably low infection, amputation and mortality rates.

Lessons from Afghanistan and Iraq: The Costly Benefits from the Battlefield for Emergency Medicine

Whatever the geopolitical implications of the Iraq and Afghanistan wars may be, and despite their horrific costs in lives, limbs and dollars, the conflicts hold 2 undeniable and positive truths for emergency physicians: Emergency medicine has benefited from the American war effort, and the victims of those war-torn regions have benefited from emergency medicine. The lethality of war wounds in both Iraq and Afghanistan stands starkly lower than any other conflict in US history, and that is due at least in part to improved emergency medical care. At the same time, a new generation of emergency physicians and trauma surgeons has gained valuable experience with severe trauma, learned lessons that will improve civilian care, and gathered casualty data that will assess the value of new medical treatments and devices. “It has made me a better physician, no question,” said Dr. Brad Younggren, an emergency physician who worked as a Squadron Surgeon with Stryker team in Iraq from September 2004 to September 2005. “You see such a large volume of penetrating trauma. When you’re a resident, the vast majority of trauma is blunt trauma. We see gunshot wounds, penetrating shrapnel, and the sheer volume improves your skills in that regard.” Emergency medicine and war have had a symbiotic relationship for more than half a century. During World War II advances in front line trauma care— such as blood transfusions, resuscitation and rapid transport of injured soldiers to field hospitals—were lessons brought back to nascent US emergency departments. Despite these advances, according to the Department of Defense, 30% of the wounded died—more than any conflict since the Civil War. Such was the price of one of the first truly mechanized wars. Immediately after World War II in 1946, Congress passed the Hill-Burton Act. It provided federal funding for hospitals with a number of restrictions, one of which was that any facility built with the federal money must include an emergency department. In part because of the advent of helicopter evacuations, the lethality of war wounds in Korea and Vietnam fell to about 25%. This innovation was partially translated into civilian medicine, with the creation of modern emergency medical THE RISE OF EMERGENCY MEDICINE Since the Vietnam War, emergency medicine has become a full-fledged academic discipline, with significant advances in care for patients with severe trauma. It is perhaps no coincidence, then, that the lethality of war wounds in Iraq and Afghanistan has fallen to 10%. “The presence of emergency physicians and other physicians in the field has dramatically changed survival rates,” said Dr. Linda Lawrence, a colonel in the United States Air Force and the Chief of Medical Staff at Travis Air Force Base in California. “In all military services, significant revamping of the operational medical mission has resulted in the presence of life-saving treatment being readily available for all troops even at the front of the battlefield. Add the advanced treatment options available and sophisticated critical care air transport, and the outcomes are remarkable. Many valuable lessons can be learned from military emergency medical care that can hopefully be adapted for use in the civilian community.” Emergency physicians in Iraq and Afghanistan have had ample learning opportunities. As a squadron surgeon, Younggren supported between 400 and 800 troops, spending much of his time at aid stations and combat support hospitals in northern Iraq. Though his days varied, they almost always included sick calls for US troops and Iraqis. Often he would join soldiers in his squadron to support their missions. “We took fire, there were the IEDs, all that kind of stuff,” said Younggren, a Major. “Providing care under fire is definitely a whole other way to practice medicine. But with that being said, a majority of time the casualties were being brought to us.” There frequently were mass casualty events. Younggren recalled an event during early April 2005, in Tall Afar, a violent city of 250,000 about 40 miles from the Syrian border. A large bomb exploded near a bus carrying Iraqi soldiers who were returning from a week’s leave. The insurgency’s bomb killed at least 3 and wounded nearly 4 dozen soldiers. Such events—requiring rapid decisions in large triage areas with 40 to 50 injured soldiers—are simply not seen in civilian care, he said. Who should MEDEVAC first from the aid station to a combat support hospital? Which of the bloodied patients could wait? Decisions must be made in minutes, often without the benefit of consulting a colleague.

Children Treated at an Expeditionary Military Hospital in Iraq

To describe the treatment of children at an expeditionary military hospital in wartime Iraq. Descriptive, retrospective study. The 332nd Air Force Theater Hospital in Balad, Iraq, January 1, 2004, to May 31, 2005. All 85 children (of 1626 total patients) evaluated and treated at the hospital during the study period. Indicated surgical procedures performed on children. Age, sex, diagnosis, injury, operations, and complications for children during the study period. The 85 children (age range, 1 day to 17 years; mean, 8 years) represented 5.2% of all patients. Thirty-four (61%) of the 56 children for whom sex was recorded were male. Injury was the diagnosis for 48 children (56%). Of these, the cause was fragmentation wound in 25 children (52%), penetrating trauma in 11 (23%), burn in 9 (19%), and blunt trauma in 3 (6%). The site of injury was the lower extremity in 18 children (38%), head in 11 (23%), upper extremity in 8 (17%), abdomen in 8 (17%), and chest in 3 (6%). Nontraumatic conditions had congenital, infectious, gastrointestinal, and neoplastic causes. During the study, 134 operations were performed on 63 children. There were 5 deaths. Expeditionary military hospitals will encounter both injured and noninjured children seeking medical care. To optimize the care of these children, it will be necessary to provide the proper personnel, training, and equipment.

Echelons of Care and the Management of Wartime Vascular Injury: A Report From the 332nd EMDG/Air Force Theater Hospital, Balad Air Base, Iraq

The objective of this report is to provide a contemporary in-theater account on the systematic management of wartime vascular injury. Included are strategies at each echelon of care that affect the treatment of these injuries. In addition, the aim of this report is to present a modern wartime vascular registry describing rates and distribution of injury in what is now a mature military conflict. A 15-month review (September 1, 2004 through December 1, 2005) from the central level III echelon facility in Iraq (332nd EMDG/Air Force Theater Hospital) presented by the in-theater Consultants for Vascular Surgery. During this period 13 460 casualties were treated at or evacuated through our location, 3096 (23%) with battle-related injuries. Vascular injuries comprised 6.6% (N = 209) of battle-related trauma in the following distribution: extremity 79% (n = 166), neck 13% (n = 27), thoracoabdominal 8% (n = 16). Three levels (formerly echelons) of care are active in theater each with strategies that affect vascular injury management: Level 1: use of commercial tourniquets; level 2: use of temporary vascular shunts as damage control adjuncts; and level 3: definitive repair of arterial and venous injuries in theater using autologous vein. Evacuation patterns and the position of the Air Force Theater Hospital have allowed the formation of a contemporary wartime vascular registry. The rate of vascular injury appears increased compared to that of Vietnam with extremity injuries most prevalent. Effective strategies are in place at each of 3 levels of care that affect the management of vascular injury.

Experience of First Deployed Otolaryngology Team in Operation Iraqi Freedom: The Changing Face of Combat Injuries

In September, 2004, an Air Force otolaryngology team was deployed to Iraq as a member of the multispecialty head and neck team, which had historically consisted of neurosurgery, ophthalmology, and oral surgery. We examined our operative and outpatient experience to determine if otolaryngology would be a critical component of this new head and neck team. Between September 7, 2004, and January 22, 2005, we collected data on all otolaryngology operative procedures and outpatient visits at the Air Force Theater Hospital at Balad Air Base, Iraq. One hundred fifty-nine patients underwent 257 operative procedures with the 3 most common procedures being complex facial laceration repair, tracheostomy, and neck exploration for penetrating neck trauma. In the otolaryngology clinic, we examined and treated 529 patients from throughout the Middle East. The otolaryngology team proved to be a critical component of the Air Force multispecialty head and neck team. C-4.