Injured Casualties Research Articles

Identifying the factors affecting road accidents and providing multi-criteria hybrid decision-making methods for ranking hazardous points

Traffic accidents and their consequences are among the major issues that need to be seriously addressed in today’s world. In this study, the prioritization of hazardous points on the roads is discussed, using multi-criteria decision-making (MCDM) techniques considering different natural and environmental criteria affecting road accidents. The Neyshabour-Sabzevar and vice versa road axes in Khorasan province, Iran, are considered as a case study for the implementation of the proposed method. Initially, 20 criteria were identified in 4 different categories to prioritize the hazardous points using the literature review and the experts’ opinion. In this paper, the MDL (Modified Digital Logic) and AHP (Analytical Hierarchy Process) methods are used to determine the criteria’s weights. By combining these techniques, four hybrid methods MDL-TOPSIS (Technique for order preference by similarity to an ideal solution), MDL-VIKOR (Vlse Kriterijumska Optimizacija I Kompromisno Resenje), AHP-TOPSIS, and AHP-VIKOR are obtained to prioritize the mentioned points, each producing different results. Two models were used to obtain the final ranking. In the first model, the results of these four methods are integrated using the COPELAND method. In the second model, the entropy method (Emerging Network To Reduce Orwellian Potency Yield) is used to modify the weight of the criteria. The innovation of the paper is presenting a new hybrid MCDM method that is used to prioritize hazardous points. Results showed that using the entropy method for modifying the weight of the criteria causes the methods to produce the same results. Moreover, results show that the number of deadly injured casualty of an accident is the most important criterion. Additionally, Zafaranieh residential area gained the highest priority.

Highly realistic cadaveric trauma simulation of the multiply injured battlefield casualty: an international, multidisciplinary exercise in far-forward surgical management.

We designed an ultra-high-fidelity military cadaveric surgical simulation course to train military medical teams for specific battlefield injuries. Our aim was to deliver a highly realistic, immersive simulation training experience, teaching both technical and non-technical skills necessary for the management of war-injuries in the austere environment of a far forward surgical facility. We designed an educational cohort study around the course to measure its learning impact. 25 personnel participated in 15 non-continuous hours of simulation that included 12 patient scenarios. Participants were given previously piloted questionnaires pre- and post-simulation to assess their confidence with managing battlefield injuries by body area, their views on the realism of the simulation, and their perceptions of training benefit. All questions were assessed using a Likert scale of 1-10 (10=best). The response rate for complete questionnaires was 95%. Baseline confidence scores were; abdomen (5.5), pelvis (5.7), chest (6.2), airway (6.3), extremity (7.3). Confidence gains following training were; abdomen (+1.7), pelvis (+ 1.6), chest (+1.6), airway (+1.2), extremity (+0.8). The most realistic aspects of the simulation were; injury replication (9.1), the cadaver as a multiply injured casualty (9.1) and the multidisciplinary team (9.2). The mean ratings for technical and non-technical skill acquisition were 9.1 and 9.0 respectively. Cadaveric simulation was reported to be ideal for learning military medical skills (9.3), and participants strongly recommended that provision should be increased (9.7). We have demonstrated an ability to recreate highly realistic injuries in an ultra-high-fidelity simulation of a multiply injured military casualty. There was a measurable increase in confidence for both technical skills in all major body areas, and non-technical skills. Multinational and multidisciplinary working strongly enhanced learning.

An Inventory of the Combat Medics' Aid Bag.

Tactical Combat Casualty Care (TCCC) recommends life-saving interventions; however, these interventions can only be implemented if military prehospital providers carry the necessary equipment to the injured casualty. Combat medics primarily use aid bags to transport medical materiels forward on the battlefield. We seek to assess combat medic materiel preparedness to employ TCCC-recommended interventions by inventorying active duty, combat medic aid bags. We sought combat medics organic to combat arms units stationed at Joint Base Lewis McChord. Medics volunteered to complete a demographic worksheet and have the contents of their aid bag photographed and inventoried. We spoke with medic unit leadership prior to their participation and asked that the medics bring their aid bags in the way they would pack for a combat mission. We categorized medic aid bag contents in the following manner: (1) hemorrhage control; (2) airway management; (3) pneumothorax treatment, or (4) volume resuscitation. We compared the items found in the aid bags against the contemporary TCCC guidelines. In January 2019, we prospectively inventoried 44 combat medic aid bags. Most of the medics were male (86%), in the grade of E4 (64%), and had no deployment experience (64%). More medics carried a commercial aid bag (55%) than used the standard issue M9 medical bag (45%). Overall, the most frequently carried medical device was an NPA (93%). Overall, 91% of medics carried at least one limb tourniquet, 2% carried a junctional tourniquet, 31% carried a supraglottic airway (SGA), 64% carried a cricothyrotomy setup/kit, 75% carried a chest seal, and 75% carried intravenous (IV) fluid. The most commonly stocked limb tourniquet was the C-A-T (88%), the airway kit was the H&H cricothyrotomy kit (38%), the chest injury set were prepackaged needle decompression kits (81%), and normal saline was the most frequently carried fluid (47%). Most medics carried a heating blanket (54%). Most medics carried materiels that address the common causes of preventable death on the battlefield. However, most materiels stowed in aid bags were not TCCC-preferred items. Moreover, there was a small subset of medics who were not prepared to handle the major causes of death on the battlefield based on the current state of their aid bag.

Forward Surgical Team Procedural Burden and Non-operative Interventions by the U.S. Military Trauma System in Afghanistan, 2008-2014.

No published study has reported non-surgical interventions performed by forward surgical teams, and there are no current surgical benchmarks for forward surgical teams. The objective of the study was to describe operative procedures and non-operative interventions received by battlefield casualties and determine the operative procedural burden on the trauma system. This was a retrospective analysis of data from the Joint Trauma System Forward Surgical Team Database using battle and non-battle injured casualties treated in Afghanistan from 2008-2014. Overall procedure frequency, mortality outcome, and survivor morbidity outcome were calculated using operating room procedure codes grouped by the Healthcare Cost and Utilization Project classification. Cumulative attributable burden of procedures was calculated by frequency, mortality, and morbidity. Morbidity and mortality burden were used to rank procedures. The study population was comprised of 10,992 casualties, primarily male (97.8%), with a median age interquartile range of 25.0 (22.0-30.0). Affiliations were non-U.S. military (40.0%), U.S. military (35.1%), and others (25.0%). Injuries were penetrating (65.2%), blunt (32.8), and burns (2.0%). Casualties included 4.4% who died and 14.9% who lived but had notable morbidity findings. After ranking by contribution to trauma system morbidity and mortality burden, the top 10 of 32 procedure groups accounted for 74.4% of operative care, 77.9% of mortality, and 73.1% of unexpected morbidity findings. These procedure groups included laparotomy, vascular procedures, thoracotomy, debridement, lower and upper gastrointestinal procedures, amputation, and therapeutic procedures on muscles and upper and lower extremity bones. Most common non-operative interventions included X-ray, ultrasound, wound care, catheterization, and intubation. Forward surgical team training and performance improvement metrics should focus on optimizing commonly performed operative procedures and non-operative interventions. Operative procedures that were commonly performed, and those associated with higher rates of morbidity and mortality, can set surgical benchmarks and outline training and skillsets needed by forward surgical teams.

The US military experience with THAM

BackgroundAcidosis, a part of the lethal trauma triad, occurs frequently after major combat trauma. Tris-hydroxymethyl aminomethane (THAM) has been used to effectively treat acidosis in injured casualties. No research has been conducted assessing the safety of THAM in the military combat setting. We sought to describe the US military experience with THAM administration to battlefield injury subjects. MethodsWe conducted a retrospective descriptive cohort study reviewing the trauma data from the Department of Defense Trauma Registry. US military personnel with an injury severity score greater than 15, between September 2001 and December 2014, were analyzed. Our primary outcome was the 30-day all-cause mortality among cohort treated with THAM versus those who were not. Differences between the cohort were examined using a student t-test (continuous variables), Wilcoxon Rank Sum test (ordinal variables), and chi-squared test (nominal variables). Results4558 subjects met the inclusion criteria. 69 received THAM and 4489 did not. Casualties receiving THAM had higher mean ISS scores (33 vs. 27, p < 0.001), and required significantly higher amounts of packed red blood cells (RBCs, 37 vs. 10, p < 0.001). THAM cohort had longer ventilator and intensive care unit (ICU) days with an overall lower survival to hospital discharge. On univariable analysis, THAM was associated with lower odds of survival (OR 0.18, 95% CI 0.11–0.31) but on multivariable analysis, when controlling for confounders, THAM use was not associated with a worse odds of survival (OR 0.83, 95% CI 0.21–3.24). ConclusionsWithin our combat trauma population, we were unable to detect worse 30 day mortality associated with THAM administration. Prospective investigations are needed to validate its use in critically injured combat casualties.

40 Incidence of Hyperoxia in Combat Wounded in Iraq and Afghanistan: Opportunity for Oxygen Conservation

Oxygen supplementation is frequently used in critically injured trauma casualties in the deployed, combat setting. Unlike the civilian setting, resources are limited in the forward combat environment, which poses challenges for oxygen supply including transportation of often-times heavy and large tanks and managing oxygen resupply. Excessive use of oxygen may unnecessarily consume this limited resource and may be associated with worse clinical outcomes. We describe the incidence of supraphysiologic oxygenation (hyperoxia) within casualties in the Department of Defense Trauma Registry (DoDTR).

Incidence of Hyperoxia in Combat Wounded in Iraq and Afghanistan: A Potential Opportunity for Oxygen Conservation.

Oxygen supplementation is frequently used in critically injured trauma casualties in the combat setting. Oxygen supplies in the deployed setting are limited so excessive use of oxygen may unnecessarily consume this limited resource. We describe the incidence of supraphysiologic oxygenation (hyperoxia) within casualties in the Department of Defense Trauma Registry (DoDTR). This is a subanalysis of previously published data from the DoDTR - we isolated casualties with a documented arterial blood gas (ABG) and categorized hyperoxia as an arterial oxygen >100 mmHg and extreme hyperoxia > 300 mmHg (a subset of hyperoxia). We defined serious injuries as those with an Abbreviated Injury Score (AIS) of 3 or greater. We defined a probable moderate traumatic brain injury of those with an AIS of 3 or greater for the head region and at least one Glasgow Coma Scale at 8 or less. Our initial search yielded 28,222 casualties, of which 10,969 had at least one ABG available. Within the 10,969, the proportion of casualties experiencing hyperoxia in this population was 20.6% (2,269) with a subset of 4.1% (452) meeting criteria for extreme hyperoxia. Among those with hyperoxia, the median age was 25 years (IQR 21-30), most were male (96.8%), most frequently US forces (41.4%), injured in Afghanistan (68.3%), injured by explosive (61.1%), with moderate injury scores (median 17, IQR 10-26), and most (93.8%) survived to hospital discharge. A total of 17.8% (1,954) of the casualties underwent endotracheal intubation: 27.5% (538 of 1,954) prior to emergency department (ED) arrival and 72.5% (1,416 of 1,954) within the ED. Among those intubated in the prehospital setting, upon ED arrival 35.1% (189) were hyperoxic, and a subset of 5.6% (30) that were extremely hyperoxic. Among those intubated in the ED, 35.4% (502) were hyperoxic, 7.9% (112) were extremely hyperoxic. Within the 1,277 with a probable TBI, 44.2% (565) experienced hyperoxia and 9.5% (122) met criteria for extreme hyperoxia. In our dataset, more than 1 in 5 casualties overall had documented hyperoxia on ABG measurement, 1 in 3 intubated casualties, and almost 1 in 2 TBI casualties. With limited oxygen supplies in theater and logistical challenges with oxygen resupply, efforts to avoid unnecessary oxygen supplementation may have material impact on preserving this scarce resource and avoid potential detrimental clinical effects from supraphysiologic oxygen concentrations.

Use of Combat Casualty Care Data to Assess the US Military Trauma System During the Afghanistan and Iraq Conflicts, 2001-2017

Although the Afghanistan and Iraq conflicts have the lowest US case-fatality rates in history, no comprehensive assessment of combat casualty care statistics, major interventions, or risk factors has been reported to date after 16 years of conflict. To analyze trends in overall combat casualty statistics, to assess aggregate measures of injury and interventions, and to simulate how mortality rates would have changed had the interventions not occurred. Retrospective analysis of all available aggregate and weighted individual administrative data compiled from Department of Defense databases on all 56 763 US military casualties injured in battle in Afghanistan and Iraq from October 1, 2001, through December 31, 2017. Casualty outcomes were compared with period-specific ratios of the use of tourniquets, blood transfusions, and transport to a surgical facility within 60 minutes. Main outcomes were casualty status (alive, killed in action [KIA], or died of wounds [DOW]) and the case-fatality rate (CFR). Regression, simulation, and decomposition analyses were used to assess associations between covariates, interventions, and individual casualty status; estimate casualty transitions (KIA to DOW, KIA to alive, and DOW to alive); and estimate the contribution of interventions to changes in CFR. In aggregate data for 56 763 casualties, CFR decreased in Afghanistan (20.0% to 8.6%) and Iraq (20.4% to 10.1%) from early stages to later stages of the conflicts. Survival for critically injured casualties (Injury Severity Score, 25-75 [critical]) increased from 2.2% to 39.9% in Afghanistan and from 8.9% to 32.9% in Iraq. Simulations using data from 23 699 individual casualties showed that without interventions assessed, CFR would likely have been higher in Afghanistan (15.6% estimated vs 8.6% observed) and Iraq (16.3% estimated vs 10.1% observed), equating to 3672 additional deaths (95% CI, 3209-4244 deaths), of which 1623 (44.2%) were associated with the interventions studied: 474 deaths (12.9%) (95% CI, 439-510) associated with the use of tourniquets, 873 (23.8%) (95% CI, 840-910) with blood transfusion, and 275 (7.5%) (95% CI, 259-292) with prehospital transport times. Our analysis suggests that increased use of tourniquets, blood transfusions, and more rapid prehospital transport were associated with 44.2% of total mortality reduction. More critically injured casualties reached surgical care, with increased survival, implying improvements in prehospital and hospital care.

Neck Injuries: a Complex Problem in the Deployed Environment

Evaluation and treatment of injuries to the neck has received a lot of attention over the past 20 years. New evaluation protocols and treatment recommendations have been developed. The goal of this review is to examine these strategies and evaluate their suitability for treatment of patients in a deployed setting. Studies from several large trauma centers have changed common practice with regard to both penetrating and blunt neck injuries. The requirement to explore all zone II neck injuries has largely been replaced by a selective exploration based on physical examination and imaging. Also, blunt cerebrovascular injuries, once thought to be rare, have been demonstrated to be common and treatment dramatically reduces the morbidity and mortality. Injuries to the neck are a significant problem in the deployed environment. The blast injuries that are common in Iraq and Afghanistan produce multiple injured casualties. In addition to injuries to other body regions, injuries to the neck can involve both blunt and penetrating mechanisms as well as injuries to the spinal column. The extent and outcome of these complex injuries has not been fully evaluated and would remain an area worthy of study.

Operational Advantages of Enteral Resuscitation Following Burn Injury in Resource-Poor Environments: Palatability of Commercially Available Solutions.

In recent combat operations, 5% to 15% of casualties sustained thermal injuries, which require resource-intensive therapies. During prolonged field care or when caring for patients in a multidomain battlefield, delayed transport will complicate the challenges that already exist in the burn population. A lack of resources and/or vascular access in the future operating environment may benefit from alternative resuscitation strategies. The objectives of the current report are 1) to briefly review actual and potential advantages/caveats of resuscitation with enteral fluids and 2) to present new data on palatability of oral rehydration solutions. A review of the literature and published guidelines are reported. In addition, enlisted US military active duty Servicemembers (N = 40) were asked to taste/rank five different oral rehydration solutions on several parameters. There are several operational advantages of using enteral fluids including ease of administration, no specialized equipment needed, and the use of lightweight sachets that are easily reconstituted/ administered. Limited clinical data along with slightly more extensive preclinical studies have prompted published guidelines for austere conditions to indicate consideration of enteral resuscitation for burns. Gatorade® and Drip-Drop® were the overall preferred rehydration solutions based on palatability, with the latter potentially more appropriate for resuscitation. Taken together, enteral resuscitation may confer several advantages over intravenous fluids for burn resuscitation under resource-poor scenarios. Future research needs to identify what solutions and volumes are optimal for use in thermally injured casualties.

The first domestic devices for intraosseous infusion - is the great advance of military medicine in pre-hospital stage enhancement

Traumatic shock is considered to be the most common clinical form of a severe patient’s condition (63%). Timely and adequate blood volume resuscitation is one of the most important procedures in providing medical care to critically injured casualties and patients at the forward medical evacuation stage. The key to this problem, especially when the infusion therapy is needed at the pre-hospital stage, is the development of alternative (extravascular) techniques of plasma volume expander administration. The article presents the results of testing of the first domestic medical devices for intraosseous infusion in critically injured casualties and patients. At present, on commission of the Russian Ministry of Defense and with the scientific support of Kirov Military Medical Academy, domestic enterprises developed test samples of medical devices to provide intraosseous infusions: a «Disposable device for intraosseous infusion of solutions if there is no intravenous access, which was designed on the basis of a spring drive» - the index «VKI-P», developed by limited liability company «Novoplast-М» and a set for intraosseous infusion using an electric drive - the index « VKI-E», developed by limited liability company «Research engineering company «Spetsproekt». Assessment of performance of test samples of the medical devices for intraosseous infusions «VKI-P» and «VKI-E» was carried out using pathophysiologic model of traumatic shock in 14 experimental animals (pigs) by creating artificial blood loss of medium severity, 25% of circulating blood volume (in average 440 ml), followed by its resuscitation with intraosseous infusion of 0,9% solution of NaCl. As a result of the performed tests it was found that the device «VKI-P» and the set «VKI-E» provide for NaCl infusion in major vessels (with an intraosseous infusion), 750 ml of volume during 45-50 min, and can be used as an alternative access to provide infusion as a part of anti-shock therapy, which solves the problem of volume resuscitation when giving care to severely injured casualties and patients at the forward medical evacuation stages. These samples may be recommended for inclusion into the medical service list of complete supplies and the Medical Corps supply support, the Armed Forces of the Russian Federation.

Estimation of the number of seriously injured road users in France, 2006–2015

Background The European Commission requests its member states to provide the number of serious road injuries, according to MAIS 3 + =Maximum AIS 3+, where AIS = Abbreviated Injury Scale. This challenges in all countries the issue of under-reporting of road injuries in the official police data and the issue of using a medical trauma scale. Methods In France, as in most countries, police data provide the frequency of road casualties, but they suffer from large under-reporting and strong selection bias (on severity, mode of transport, etc). In the Rhone county (pop 1.6 M inhabitants). Other data are available: a road trauma registry has been set up in 1996. It covers fatalities, hospitalized, and those attending the Emergency departments only. All injuries are directly coded into the Abbreviated Injury Scale, by the registry physician. At the Rhone county level, both databases are linked. Annually, on the 2006–2012 period, the police reports 2800 casualties, the road trauma registry 7400 by the registry and 1700 are identified as common to both sources. A capture-recapture approach is then used, so that we can estimate the real number of road casualties (in the Rhone). More importantly the corrections factors between the police data and the estimated real subgroup of road causalities in the Rhone. In particular, to account for some conditions for applying capture-recapture, a multivariate model is used, including the variables that are associated with lower probability of reporting by the police: type of police, road network, severity measured by hospitalised (yes/no), MAIS3+, road user type (pedestrian, cyclist, car occupant…), whether the crash involved a crash opponent or not, etc. The police correction factors are finally applied to the national police data with the assumption that police recording practices are rather homogenous across France, by type of police force, and type of road casualties, This corresponds to indirect standardization, not on age and sex as usual but on the characteristics influencing police reporting. Results The national number of injured road casualties, respectively for all severity, and for MAIS3+, are estimated at 285,000 and 24,000 resp. in 2015. The 2015 frequency of sMAIS3+ roadusers consists of 6850 motorized two-wheel users, 6500 car occupants, 3550 cyclists, 3500 pedestrians and 800 others (van, bus, truck users). This confirms the heavy burden suffered by Motorized two-wheel users. Moreover, they only account for 2% of traveled kilometers whereas car occupants account for 70% of traveled kilometers. Also, these results show a different pattern than the number of fatalities, where it is the number of killed car occupants that is the highest. Conclusions The frequency of injured road users, all severities, has been confirmed by other sources, namely: the French national Travel Survey, and by the annual firemen data (they provide first aid on crash scene). Concerning the number of seriously injured road users, the ratio of the number of MAIS3+ casualties divided by the number of fatalities enables country to country comparison.

An analysis of casualties presenting to military emergency departments in Iraq and Afghanistan

BackgroundDuring the past 17 years of conflict the deployed US military health care system has found new and innovative ways to reduce combat mortality down to the lowest case fatality rate in US history. There is currently a data dearth of emergency department (ED) care delivered in this setting. We seek to describe ED interventions in this setting. MethodsWe used a series of ED procedure codes to identify subjects within the Department of Defense Trauma Registry from January 2007 to August 2016. ResultsDuring this time, 28,222 met inclusion criteria. The median age of causalities in this dataset was 25 years and most (96.9%) were male, US military (41.3%), and part of Operation Enduring Freedom (66.9%). The majority survived to hospital discharge (95.5%). Most subjects sustained injuries by explosives (55.3%) and gunshot wound (GSW). The majority of subjects had an injury severity score that was considered minor (74.1%), while the preponderance of critically injured casualties sustained injuries by explosive (0.7%). Based on AIS, the most frequently seriously injured body region was the extremities (23.9%). The bulk of administered blood products were packed red blood cells (PRBC, 26.4%). Endotracheal intubation was the most commonly performed critical procedure (11.9%). X-ray (79.9%) was the most frequently performed imaging study. ConclusionsUS military personnel comprised the largest proportion of combat casualties and most were injured by explosive. Within this dataset, ED providers most frequently performed endotracheal intubation, administered blood products, and obtained diagnostic imaging studies.

Prevalence of alcohol among nonfatally injured road accident casualties in two level III trauma centers in northern Ghana

ABSTRACTBackground: Alcohol use is pervasive among motorists on the road in Ghana; however, we do not know the extent to which this behavior is implicated in road accidents in this country.Objectives: The main objective of this research was to establish the prevalence of alcohol in the blood of nonfatally injured casualties in the emergency departments (EDs) in northern Ghana.Method: Participants were injured road traffic crash victims, namely, pedestrians, cyclists, motorcyclists, and drivers seeking treatment at an ED. The study sites were 2 level III trauma centers located in Wa and Bolgatanga. Participants were screened for alcohol followed by breath tests for positive participants using breathalyzers.Results: Two hundred and sixty-two accident victims visited EDs, 58% of whom were in Wa. Among the victims, 41% were hospitalized and 57% experienced slight injuries. The vast majority (76%) of the casualties were motorcyclists, 13% were pedestrians, 8% were cyclists, and 2% were drivers. Casualties who had detectable alcohol in their blood were predominantly vulnerable road users. In all, 34% of participants had detectable blood alcohol concentrations (BACs) and the mean BAC for all casualties who tested positive and could give definitive BACs was 0.2265 (226 mg/dl). The prevalence of alcohol use was 53% among cyclists, 34% among motorcyclists, 21% among pedestrians, and 17% among drivers. Male casualties were more likely to test positive for alcohol than females. In addition, the prevalence of alcohol was significantly higher among injured casualties in Bolgatanga compared to Wa.Conclusion: There was a high prevalence of alcohol use among nonfatally injured casualties in northern Ghana and injury severity increased with BAC. AUDIT screening in the hospital, alcohol consumption guideline, road safety education with an emphasis on minimizing or eliminating alcohol consumption, and enhanced enforcement of the BAC limit among motorists are recommended.

Single Unprotected Road User Crashes: Europe we have a Problem!

Unprotected Road Users (URU) are a subset of Vulnerable Road Users (VRU) who are not protected in their vehicles: pedestrians, cyclists and powered two-wheelers. EU statistics for 2014 show that their share in road traffic fatalities was 22% for pedestrians, 8% for cyclists and 18% for Powered Two-Wheelers, in total 47% of the fatalities. From explorative studies regarding injured road traffic casualties it is found that about two thirds of the transportation casualties are Unprotected Road Users, of which two thirds are single accidents, i.e. crashes where no other road user is involved. Most of these single crashes are not (yet) detected in the standard police reported accident statistics, but do represent costs to society that probably exceed crash costs of car related crashes. It can be expected that the shares of URU fatal and injury crashes will increase, particularly because of the ageing of the population, urbanization and despite ICT/ITS developments. Some of these crashes can be prevented by relatively simple measures, others need more investments e.g. infrastructure, legislation or enforcement. From a policy point of view it will be wise to address this issue, not only for road safety reasons, but also because the elderly are getting more numerous and a serious economic and political factor.

Agent-based simulation of emergency response to plan the allocation of resources for a hypothetical two-site major incident

During a major incident, the emergency services work together to ensure that those casualties who are critically injured are identified and transported to an appropriate hospital as fast as possible. If the incident is multi-site and resources are limited, the efficiency of this process is compromised as the finite resources must be shared among the multiple sites. In this paper, agent-based simulation is used to determine the allocation of resources for a two-site incident which minimizes the latest hospital arrival times for critically injured casualties. Further, how the optimal resource allocation depends on the distribution of casualties across the two sites is investigated. Such application supports the use of agent-based simulation as a tool to aid emergency response.

Pathogens present in acute mangled extremities from Afghanistan and subsequent pathogen recovery.

Given the changing epidemiology of infecting pathogens in combat casualties, we evaluated bacteria and fungi in acute traumatic wounds from Afghanistan. From January 2013 to February 2014, 14 mangled lower extremities from 10 explosive-device injured casualties were swabbed for culture at Role 3 facilities. Bacteria were recovered from all patients on the date of injury. Pathogens recovered during routine patient care were recorded. The median injury severity score was 29, median initial Role 3/4 blood product support was 32 units, and median evacuation time was 42 minutes to first surgical care. Gram-positive bacteria were found in some wounds but not methicillin-resistant Staphylococcus aureus or vancomycin-resistant Enterococcus. Most wounds were colonized with low-virulence, environmental gram-negative bacteria, and not recovered again during therapy, reflecting wound contamination. Only one wound had the same bacteria (E. cloacae) throughout care at the Role 3, 4, and 5 facilities. Three cultures from two patients had multidrug-resistant bacteria (E. cloacae, E. coli), all detected at Role 5 facilities. Molds were not detected at Role 3, whereas one patient had a mold at Role 4 and 5. Mangled lower extremity injuries have a high contamination rate with environmental organisms, which are not typically associated with infections during the course of the patient's care.

Evaluating cold, wind, and moisture protection of different coverings for prehospital maritime transportation-a thermal manikin and human study.

Prehospital maritime transportation in northern areas sets high demands on hypothermia prevention. To prevent body cooling and hypothermia of seriously-ill or injured casualties during transportation, casualty coverings must provide adequate thermal insulation and protection against cold, wind, moisture, and water splashes. The aim of this study was to determine the thermal protective properties of different types of casualty coverings and to evaluate which would be adequate for use under difficult maritime conditions (cold, high wind speed, and water splashes). In addition, the study evaluated the need for thermal protection of a casualty and verified the optimum system for maritime casualty transportation. The study consisted of two parts: (1) the definition and comparison of the thermal protective properties of different casualty coverings in a laboratory; and (2) the evaluation of the chosen optimum protective covering for maritime prehospital transportation. The thermal insulations of ten different casualty coverings were measured according to the European standard for sleeping bags (EN 13537) using a thermal manikin in a climate chamber (-5°C) with wind speeds of 0.3 m/s and 4.0 m/s, and during moisture simulations. The second phase consisted of measurements of skin and core temperatures, air temperature, and relative humidity inside the clothing of four male test subjects during authentic maritime prehospital transportation in a partially-covered motor boat. Wind (4 m/s) decreased the total thermal insulation of coverings by 11%-45%. The decrement of thermal insulation due to the added moisture inside the coverings was the lowest (approximately 22%-29%) when a waterproof reflective sheet inside blankets or bubble wrap was used, whereas vapor-tight rescue bags and bubble wrap provide the most protection against external water splashes. During authentic maritime transportation lasting 30 minutes, mean skin temperature decreased on average by 0.5°C when a windproof and water-resistant rescue bag was used over layered winter clothing. The selected optimum rescue bag consisted of insulating and water-resistant layers providing sufficient protection against cold, wind, and water splashes during prehospital transportation lasting 30 minutes in the uncovered portion of a motor boat. The minimum thermal insulation for safe maritime transportation (30 minutes) is 0.46 m²K/W at a temperature of -5°C and a wind speed of 10 m/s.

A review of the first 10 years of critical care aeromedical transport during operation iraqi freedom and operation enduring freedom: the importance of evacuation timing.

Advances in the care of the injured patient are perhaps the only benefit of military conflict. One of the unique aspects of the military medical care system that emerged during Operation Iraqi Freedom and Operation Enduring Freedom has been the opportunity to apply existing civilian trauma system standards to the provision of combat casualty care across an evolving theater of operations. To identify differences in mortality for soldiers undergoing early and rapid evacuation from the combat theater and to evaluate the capabilities of the Critical Care Air Transport Team (CCATT) and Joint Theater Trauma Registry databases to provide adequate data to support future initiatives for improvement of performance. Retrospective review of CCATT records and the Joint Theater Trauma Registry from September 11, 2001, to December 31, 2010, for the in-theater military medicine health system, including centers in Iraq, Afghanistan, and Germany. Of 2899 CCATT transport records, those for 975 individuals had all the required data elements. Rapid evacuation by the CCATT. Survival as a function of time from injury to arrival at the role IV facility at Landstuhl Regional Medical Center. The patient cohort demonstrated a mean Injury Severity Score of 23.7 and an overall 30-day mortality of 2.1%. Mortality en route was less than 0.02%. Statistically significant differences between survivors and decedents with respect to the Injury Severity Score (mean [SD], 23.4 [12.4] vs 37.7 [16.5]; P < .001), cumulative volume of blood transfused among the patients in each group who received a transfusion (P < .001), worst base deficit (mean [SD], -3.4 [5.0] vs -7.8 [6.9]; P = .02), and worst international normalized ratio (median [interquartile range], 1.2 [1.0-1.4] vs 1.4 [1.1-2.2]; P = .03) were observed. We found no statistically significant difference between survivors and decedents with respect to time from injury to arrival at definitive care. Rapid movement of critically injured casualties within hours of wounding appears to be effective, with a minimal mortality incurred during movement and overall 30-day mortality. We found no association between the duration of time from wounding to arrival at Landstuhl Regional Medical Center with respect to mortality.

Injured and disabled casualties of the Northern Ireland conflict: issues in immediate and long-term treatment, care and support

Even though injury due to armed conflict is more commonly caused than death, research into injury due to Northern Ireland’s four decades of otherwise exhaustively documented conflict is sparse. This article reports on a 2011 study based on interviews with 30 people seriously physically injured in the conflict and 20 of their carers and a self-administered questionnaire survey of a further 90 people injured in political violence in Northern Ireland. All injured respondents reported that emergency medical emergency treatment had been excellent. Those injured in the 1970s reported low expectations of their life expectancy and rehabilitation, a lack of psychological support and lack of help with chronic injury-related conditions. More recently injured people had psychological support and were more successfully rehabilitated but those injured earlier often saw it as ‘too late’ for psychological help. Influences on well-being seem to be: changing professional standards and awareness; policies acknowledging of the effects of conflict; anti-discrimination legislation; development of rehabilitation services; and the reform of disability benefits. Inter alia, health professionals’ attitudes towards victims and their treatment of injury appear to have a significant influence on outcomes for injured people.