Wartime Injuries Research Articles

Use of a Shock Tube Platform in the Replication of Blast Lung Injury

War and asymmetrical conflicts are becoming increasingly prevalent in the modern world. Due to improvements in conflict medicine, survivable injuries are now more severe than they once were. Therefore, it is now more important than ever that there exist scientific and engineering methods for replicating wartime injuries in the context of the laboratory. We have developed one such method: a shock tube platform for testing ex vivo samples of the porcine respiratory system. Using this platform, we can, to some extent, simulate the pathophysiological consequences of blast lung. This is a condition commonly present in victims of explosive blasts, both those due to typical armaments and Improvised Explosive Devices (IEDs). Presented here are the results of experiments conducted using porcine bronchiole tissue as ex vivo organ cultures. Data presented show epithelial damage, consistent with known trauma-induced cell injury that can lead to acute respiratory distress syndrome (ARDS).

Bodies in Blue: Disability in the Civil War North by Sarah Handley-Cousins

Reviewed by: Bodies in Blue: Disability in the Civil War North by Sarah Handley-Cousins Peter C. Luebke (bio) Bodies in Blue: Disability in the Civil War North. By Sarah Handley-Cousins. (Athens: University of Georgia Press, 2019. Pp. 186. Cloth, $39.95.) When one thinks about Civil War casualties, one inevitably thinks about the piles of limbs outside of battlefield hospitals. The amputee with the empty sleeve draws attention as the epitome of the horror of war. But the amputee also presents an unambiguous figure, one whose broken body [End Page 292] self-evidently displays dedication to the cause. What about the thousands of soldiers who experienced other wounds? With Bodies in Blue: Disability in the Civil War North, Sarah Handley-Cousins takes an expansive view of wartime injuries and disabilities, charting a variety of harms. Soldiers, veterans, and the government struggled to define disability. They also grappled with who was worthy of government assistance and how much of it they should receive. In Bodies in Blue, “disability” serves as a concept that overlaps with masculinity. American masculinity in the nineteenth century meant “the ability to command one’s body and use it in labor to maintain independence” (3). Injury and illness threatened the ability of soldiers to control their bodies, which in turn undermined their ability to maintain independence through labor. Thus, during the war and after, the idea of disability remained imbricated with ideas of masculinity and who properly counted as a man. Handley-Cousins traces these struggles in six chapters. The first two chapters consider who possessed the authority to determine disability. The first chapter charts how the War Department, facing a manpower crisis, conceived of “disability as a continuum of degrees” and created the Invalid Corps, renamed the Veteran Reserve Corps in 1864 (18). The Veteran Reserve Corps, besides keeping bodies in uniform, aimed to give injured soldiers productive work, thereby keeping them off the pension rolls. The next chapter uses court-martial records to show how the men contested that officers had the “power to legitimize disability” (44). Unsurprisingly, officers and surgeons prevailed, with decisions often hinging on the perceived moral character of the enlisted soldier. How Union authorities sought to understand injury and illness through the creation of the Army Medical Museum provides the topic for the third chapter. Here, Handley-Cousins looks less at disability and more at how Union doctors appropriated bodies to serve their ends. Doctors claimed soldiers’ bodies in order to expand medical knowledge of war wounds, with specimens on display at the Army Medical Museum. Handley-Cousins maintains that the museum demonstrated how “Union doctors turned the bodies of soldiers into government property” (69). The fourth and fifth chapters look at disability after the war. The fourth chapter considers Joshua Lawrence Chamberlain, who suffered a grievous wound during the siege of Petersburg. The injuries to his hip, bladder, and penis afflicted him until they ultimately took his life in 1914. Unlike the missing limbs of amputees, Chamberlain’s wound remained private, which in turn made it difficult for him to receive a disability pension. The example of Chamberlain challenges notions that disability had to be visible. The fifth chapter appraises how the Pension Bureau judged soldiers against [End Page 293] an idea of masculinity and penalized those who failed to fit that ideal. As in the war, government authorities’ views of what disability looked like trumped those of the soldiers themselves. Finally, Handley-Cousins examines, in her sixth chapter, the invisible disability of wartime-related psychological trauma. Using case studies of several soldiers, Handley-Cousins demonstrates that suffering extended beyond the veterans themselves to their families. She also shows how psychiatric care often centered on restoring productivity to disabled veterans, which in turn rehabilitated their manhood and could facilitate their release. Indeed, “war trauma was not simple or static” (123). The chapters open interpretive space, but they also raise important questions about the scope of the book itself. Handley-Cousins focuses her discussion on white male soldiers, although brief references to African American soldiers and other people of color hover around the margins. Observations such as “Blackness itself was a kind of disability in ante-bellum America” and...

PROSTHESTIC ARM FOR AMPUTEES USING VOICE AND GESTURE RECOGNITION

Individuals with motor nerve impairments such as war-time injuries, accidents or amputation due to diseases rely on others to assist them in their daily activities. In the present world, there is an increased number of amputees due to many reasons. The main aim of this project is to develop two modules namely prosthetic arm with voice recognition module and hand gesture module which designed to facilitate the amputees. Prosthetic arm is controlled through voice commands received via microphone which acts as a transducer to convert the sound into electrical signals. These signals are recognized by voice recognition module, which is a speaker dependent module. This module provides an output which would be the input to Arduino microcontroller which controls the prosthetic arm. Hand gesture module is equipped with flex sensors that are made up of bend sensitive resistance elements which is fixed in the gloves. For each gesture, flex sensors produce a proportional change in resistance. This change in the resistance results in the variation of the electric signals which is given as input to the Arduino microcontroller. When an amputee cannot use voice recognition module, an alternative method used to control prosthetic arm is hand gesture module. In recent years, researchers have been focusing on hand gesture detections and voice-controlled applications which is extended in the area of artificial or prosthetic hand that can mimic the behavior of a natural human hand. The present study develops an evolution in the designing of prosthetic arm to control it independently.

“I Shall Get So Decayed with Laziness”: The Ideology of the Broke Down Veteran in Miss Ravenel’s Conversion

“I Shall Get So Decayed with Laziness”: The Ideology of the Broke Down Veteran in Miss Ravenel’s Conversion Ashley E. Bowen (bio) The American Civil War unmade the soldier’s body both literally and figuratively.1 New weaponry tore through flesh, camp diseases ravaged nearly everyone at some point, and poor nutrition slowed or prevented the body’s recovery. Although many soldiers underwent amputations during the war, 60,000 by most estimates, a much greater number returned from the Civil War with bodies that looked normal, or were at least whole and minimally scarred, but nevertheless broken. For them, bodies broken by war meant far more than scars. When they complained of feeling “broken down,” veterans referred to an expansive category of bodily experiences that encompassed both physical complaints (e.g. heart palpitations, diarrhea, tremors, weakness, fatigue, and more) and their emotional responses to the ways those complaints limited their lives. As historian William Etter observes, “all those who fought in the Civil War experienced, whether directly or as witnesses, the destruction of any conventional understanding of physical normality.”2 For veterans who were able to return to their prewar careers, some found that, as they aged, their bodies deteriorated much more rapidly than those who had not served.3 For [End Page 679] veterans who could not reenter the workforce, the inability to provide for a family and the threat of poverty weighed heavily. Private Joseph Work, for example, a volunteer with Co. I, 12th New Jersey Volunteer Infantry, received a pension for his heart condition nearly twenty years after it appeared. Just before the Battle of Gettysburg, Work’s heart had given out. He experienced pain in his chest, exhaustion, and serious heart palpitations.4 Although his physician claimed in 1870 that he “never has anything now that reminds him of his former trouble,” Work’s own assertions about his health indicate that he suffered a great deal for decades.5 In 1880, Work applied for and received a pension on the grounds of his cardiac condition. His application, coupled with supporting affidavits from coworkers and neighbors, explained that Work never managed a full day’s labor after the war. A neighbor told the Pension Office in 1881 that Work spent “a great deal on medicine” and used “some kind of inhaling apparatus which helps him a bit.” According to Work’s application, supported by the testimony of others, even the slightest exertion left him prostrate and in pain. For the next thirty-five years, Joseph Work received payment for his wartime injuries, but the chest pain and difficulty breathing never fully left him.6 American popular culture struggled to reconcile the myth of the citizen-soldier, made physically stronger and more emotionally resilient from his service, with the reality of actual veterans who came home ill, disabled, or dependent on their spouses or other family members. War-broken bodies challenged deep cultural assumptions about masculinity, family structure, and the value of work. The presence of crippled and ill men in public life, coupled with advances in medicine and an expanding bureaucratic state, created a moment when the meaning of the infirm white male body was in flux. But the social framing of ill or disabled bodies has never been neutral.7 This is especially [End Page 680] true of ill and disabled soldiers because the broken veteran’s body is both an object of pity and a symbol of national sacrifice. At the Civil War’s close, this dual role became particularly charged as families, communities, and the nation unavoidably confronted numerous broken soldiers returning home. Americans negotiated the meaning of the sick white soldier in medicine, government, their own families, and in popular culture. Specific negotiations differed contextually, but all were concerned with containing or neutralizing the problems created by men who could no longer work—the activity from which all other social positions in the family, community, and culture grew. Soldiers regularly applied for pensions on the grounds that injuries or illnesses sustained in the war rendered them unable to earn a living or support their family. Anxieties about the dependent veteran animated many of these negotiations while, at the same time, the veteran...

Morphological Foundations of Restoration of Motor Innervation in Injuries of Peripheral Nerves

The problem of restoration of motor innervation is considered to be challenging due to a significant proportion of the peripheral nerve damage in the general structure of peacetime and wartime injuries, as well as a high risk of permanent function loss of the affected limb. Injuries of the peripheral nerves result in a complex of pathophysiological processes from both – the side of damaged nerve stems and the side of denervated target tissues. Moreover, the morphological picture of tissue changes is both degenerative and regenerative simultaneously. The process of secondary degeneration of the distal segments of crossed axons is similar to aseptic inflammation and is a prerequisite for the subsequent regeneration of nerve fibers. The process of reinnervation of the distal segment of the crossed nerve stem has a certain similarity with the development of peripheral nerves in the embryonic period, but the branches of regenerating axons move in the distal direction along the preserved neuriluminal tubes. A prolonged absence of motor innervation causes pronounced dystrophic changes in muscle fibers and intercellular spaces filling with the fibrous connective tissue; this, in turns, may result in a lack of functional limb restoration even if the terminal branches of the damaged nerve are adequately reinnervated. The restoration of contractile activity of reinnervated muscles is morphologically determined by the functional hypertrophy of the preserved muscle fibers, since the complete restoration of the innervation of all muscle fibers is practically not achievable due to the peculiarities of the peripheral nerve suture technique and the patterns of nerve fiber regeneration. Thus, an understanding of the patterns and morphological manifestations of degenerative-regenerative processes in tissues with injuries of peripheral nerves will allow substantiating the need for reconstructive plastic interventions on nerve stems from morphological points of view, based on the possibilities of achieving significant functional results.

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.

Clinical implementation of the Humacyte human acellular vessel: Implications for military and civilian trauma care.

The incidence of wartime vascular injury has increased and is a leading cause of mortality and morbidity. While ligation remains an option, current resuscitation and damage control techniques have resulted in vascular repair being pursued in more than half of wartime injuries. Options for vascular reconstruction are currently limited to autologous vein or synthetic conduits, choices which have not changed in decades, both of which have problems. Autologous vein is preferable but requires time to harvest and may not be available. Synthetic grafts are poorly resistant to infection and associated with thrombotic complications. Recognizing this capability gap, the US Combat Casualty Care Research Program has partnered with academia and industry to support the development and clinical introduction of a bioengineered human acellular vessel. This human acellular vessel has the potential to be an off-the-shelf conduit that is resistant to infection and incorporates well into native tissues. This report reviews the rationale of this military-civilian partnership in medical innovation and provides an update on the clinical use and ongoing study of this new vascular technology. LEVEL OF EVIDENCE: Therapeutic, level III.

Witness to the Thousand-Yard Stare: Civilian Imagination of Service Members’ Mental Injuries in Wartime

The thousand-yard stare is a commonplace rhetorical convention in visual representations of US wars. This essay analyzes the stare in Tom Lea’s, David Douglas Duncan’s, and Luis Sinco’s war images, and asks: How does circulation of such images encourage civilian spectators to imagine their military representatives’ wartime experiences? Does this imagination support or constrain civic action on behalf of veterans? Unlike prior analyses, which critique the stare for constraining protest, this essay argues that the stare can encourage civilian action by productively mediating civilians’ distance from war’s violence. The stare indexes traumatic violence not presented in the image yet calls on spectators to imagine that violence in spite of its absence. Although Duncan’s framing of the stare offers a masculine, stoic, and sacrificial vision constraining its critical potential, Lea’s and Sinco’s framings offer multimodal depth, rendering originary violence, traumatic dissociation, and mental injury as public problems in need of redress.

End-to-side neurorrhaphy: expectations and reality

An increasing number of injuries with damage of peripheral nerves, including a substantial number of injuries with extensive defects of large nerve trunks, requires improvement in approach to surgical treatment of patients. High-energy impact injuries in peacetime and wartime often lead to persistent violations of musculoskeletal apparatus, a significant part of which is due to injuries of peripheral nerves. During peacetime, various types of peripheral nerve injuries occur in 2-6% of trauma patients. In today’s armed conflicts, various types of peripheral nerve injuries occur in nearly 80% of neurosurgical patients and are mostly of combined injury. Improvements in surgical methods of recovery of lost innervation due to an injury are directly associated with the development of fundamental understanding of the nature of occurring degenerative and regenerative processes in damaged nerve fiber. Nerve suture is only the creation of appropriate conditions that contribute to regeneration of nerve fibers and recovery of lost functions. When extensive defects of nerve trunks exist, connection of distal part damaged nerve with side surface of the intact nerve is the alternative to traditional replacement of extensive defects with nerve grafts. Positive outcomes of such interventions that were seen during tests on laboratory animals led to trials of this method on patients and resulted in a number of positive outcomes as well. Despite the fact that the question of morphological substantiation of reinnervation processes of the distal portion of a damaged nerve is the cause of heated disputes among scientists, some surgeons make attempts to define a set of specific conditions needed to justify the use of end-to-side neurorrhaphy.

Defense and Veterans Brain Injury Center: The First 25 Years

Defense and Veterans Brain Injury Center: The First 25 Years

Blockchain-Based Mobile Edge Computing Framework for Secure Therapy Applications

Mobile edge computing (MEC) is being introduced and leveraged in many domains, but few studies have addressed MEC for secure in-home therapy management. To this end, this paper presents an in-home therapy management framework, which leverages the IoT nodes and the blockchain-based decentralized MEC paradigm to support low-latency, secure, anonymous, and always-available spatiotemporal multimedia therapeutic data communication within an on-demand data-sharing scenario. To the best of our knowledge, this non-invasive, MEC-based IoT therapy platform is first done by our group. This platform can provide a full-body joint range of motion data for physically challenged individuals in a decentralized manner. With MEC, the framework can provide therapy diagnostic and analytical data on demand to a large portion of humanity who are either born with disabilities or became disabled due to accidents, war-time injuries, or old age. For security, the framework uses blockchain–Tor-based distributed transactions to preserve the therapeutic data privacy, ownership, generation, storage, and sharing. Our initial test results from a complete implementation of the framework show that it can support a sufficiently large number of users without considerable increase in mean processing time.

Early Clinical Predictors of 5-Year Outcome After Concussive Blast Traumatic Brain Injury

The long-term clinical effects of wartime traumatic brain injuries (TBIs), most of which are mild, remain incompletely described. Current medical disability cost estimates from world conflicts continually surpass projections. Additional information regarding long-term functional trajectory is needed to reduce this extensive public health burden. To examine 5-year clinical outcomes leveraging existing clinical data collected at 1 year after injury in the same patients and to identify early risk factors for long-term disability. This prospective, longitudinal study enrolled active-duty US military after concussive blast injury (n = 50) in the acute to subacute stage and combat-deployed control individuals (n = 44) in Afghanistan or after medical evacuation to Germany from November 1, 2008, through July 1, 2013. One- and 5-year clinical evaluations were completed in the United States. All concussive blast injuries met the Department of Defense definition of mild, uncomplicated TBI. In-person clinical evaluations included standardized evaluations for neurobehavior, neuropsychological performance, and mental health burden that were essentially identical to the evaluations completed at 1-year follow-up. Data were analyzed from October 1 through November 30, 2016. Changes in the in-person standardized evaluations for neurobehavior, neuropsychological performance, and mental health burden from the 1- to 5-year follow-up. Predictive modeling was used to identify early risk factors for long-term disability. Among the 94 participants (87 men [93%] and 7 women [7%]; mean [SD] age, 34 [8] years), global disability, satisfaction with life, neurobehavioral symptom severity, psychiatric symptom severity, and sleep impairment were significantly worse in patients with concussive blast TBI compared with combat-deployed controls, whereas performance on cognitive measures was no different between groups at the 5-year evaluation. Logistic regression on the dichotomized Extended Glasgow Outcome Scale (GOS-E) at 5 years as a measure of overall disability identified brain injury diagnosis, preinjury intelligence, motor strength, verbal fluency, and neurobehavioral symptom severity at 1 year as risk factors for a poor outcome at 5 years, with an area under the curve of 0.92 indicating excellent prediction strength. Thirty-six of 50 patients with concussive blast TBI (72%) had a decline in the GOS-E from the 1- to 5-year evaluations, in contrast with only 5 of 44 combat-deployed controls (11%). Worsening of symptoms in concussive blast TBI was also observed on measures of posttraumatic stress disorder and depression. Service members with concussive blast TBI experienced evolution, not resolution, of symptoms from the 1- to 5-year outcomes. Considerable decline was observed in military service members with concussive blast TBI when comparing 1- and 5-year clinical outcomes. These results advocate for new treatment strategies to combat the long-term and extremely costly effect of these wartime injuries.

A multi-institutional study of hemostatic gauze and tourniquets in rural civilian trauma.

Life-threatening hemorrhage is a leading cause of preventable mortality in trauma patients. Since publication of the Hartford Consensus statement, there has been intense interest in civilian use of commercial hemostatic gauze and tourniquets. Although the military has studied their use on soldiers with wartime injuries, there are limited data on patient outcomes following civilian prehospital use and no data on the use in rural trauma. We performed a multi-institutional retrospective analysis of clinical outcomes following prehospital use of QuikClot combat gauze (QC) and combat application tourniquets (CATs) from 2009 to 2014. The primary outcome measured was effectiveness. Secondary outcomes included morbidity, mortality, patients' demographics, injury characteristics, and hospital outcomes. Between 2009 and 2014, 95 patients were managed by prehospital personnel with QC and/or CAT. Forty received QC, 61 received CAT, and 6 received both products. The median age was 40 years (6-91 years), 29% were female, and the median injury severity score was 7 (1-25). QuikClot combat gauze was 89% effective. Minimal morbidity was associated with QC use. Combat application tourniquet was 98% effective. Median tourniquet time was 21 minutes (6-142 minutes), the median injury severity score was 9 (1-50), and mortality was 9.8%. Morbidities observed with tourniquet use included amputation, fasciotomy, rhabdomyolysis, and acute kidney injury. Risk of amputation was associated with higher injury severity (p = 0.04) but not with elderly age, obesity, or the presence of medical comorbidities. No amputations resulted solely from the use of tourniquets. QuikClot combat gauze and CAT are safe and effective adjuncts for hemorrhage control in the rural civilian trauma across a wide range of injury patterns. In a rural civilian population including women, children, and elderly patients with medical comorbidities, these devices are associated with minimal morbidity beyond that of the original injury. Therapeutic study, level V.

Outcome Trends after US Military Concussive Traumatic Brain Injury.

Care for US military personnel with combat-related concussive traumatic brain injury (TBI) has substantially changed in recent years, yet trends in clinical outcomes remain largely unknown. Our prospective longitudinal studies of US military personnel with concussive TBI from 2008-2013 at Landstuhl Regional Medical Center in Germany and twp sites in Afghanistan provided an opportunity to assess for changes in outcomes over time and analyze correlates of overall disability. We enrolled 321 active-duty US military personnel who sustained concussive TBI in theater and 254 military controls. We prospectively assessed clinical outcomes 6-12 months later in 199 with concussive TBI and 148 controls. Global disability, neurobehavioral impairment, depression severity, and post-traumatic stress disorder (PTSD) severity were worse in concussive TBI groups in comparison with controls in all cohorts. Global disability primarily reflected a combination of work-related and nonwork-related disability. There was a modest but statistically significant trend toward less PTSD in later cohorts. Specifically, there was a decrease of 5.9 points of 136 possible on the Clinician Administered PTSD Scale (-4.3%) per year (95% confidence interval, 2.8-9.0 points, p = 0.0037 linear regression, p = 0.03 including covariates in generalized linear model). No other significant trends in outcomes were found. Global disability was more common in those with TBI, those evacuated from theater, and those with more severe depression and PTSD. Disability was not significantly related to neuropsychological performance, age, education, self-reported sleep deprivation, injury mechanism, or date of enrollment. Thus, across multiple cohorts of US military personnel with combat-related concussion, 6-12 month outcomes have improved only modestly and are often poor. Future focus on early depression and PTSD after concussive TBI appears warranted. Adverse outcomes are incompletely explained, however, and additional studies with prospective collection of data on acute injury severity and polytrauma, as well as reduced attrition before follow-up will be required to fully address the root causes of persistent disability after wartime injury.

Initial Characterization of the Pig Skin Bacteriome and its Effect on in vitro Models of Wound Healing

Improved combat casualty care has increased survivability of traumatic wartime injuries, resulting in an emphasison longer‐term outcome such as wound healing. Recent advances in understanding the roles and composition of the humanskin microbiome have revealed a delicate interplay between resident microbes and combat wound healing. While pigs are the gold standard model for wound healing due to structural and healing similarities to human skin, the porcineskin microbiome has not been adequately elucidated. Moreover, no model organism has been established to examine the effects of novel pharmaceuticals on the skin microbiome in vivo. In the current study, we performed 16S rRNA gene sequencing on different anatomical locations from porcine skin, and utilized in vitro techniques to examine the paracrine effects of proteins released from these bacteria on human keratinocytes (NHEK) and fibroblasts (HDF). We found that the pig skin bacterial diversity varies in quantity and composition between subjects and anatomical locations. Moreover, t‐tests revealed significant effects on HDF and NHEK migration that was dependent on anatomical location. ELISA showed that, when cultured with NHEKs, bacterial releasate from certain anatomical locations reduced the amount of Vascular Endothelial Growth Factor present in the media and also induced NHEK apoptosis as determined via caspase‐3immunostaining. The results described herein further expand the knowledge of the cutaneous bacteriome of the healthy pig and suggest that naturally occurring bacterial flora may affect wound healing. This is particularly intriguing considering the amount of resources utilized for combat casualty wound care (i.e. healing, scarring, antibiotic resistance). Ultimately, if similarities between human and pig skin extend to the level of microbial diversity, the pig might be considered an ideal model for further investigations into the naturally occurring flora of the skin and its impact on wound healing process.

“Nowhere’s Safe”: Ruinous Reconstruction in Muriel Spark’s The Girls of Slender Means

This essay reads Muriel Spark’s The Girls of Slender Means as critiquing the mythology of Britain’s Second World War, especially the romanticization of the postwar welfare state. Refusing to find meaning in the ruins of war, Girls repudiates the reparative logic of reconstruction, and its transformation of wartime injury into an occasion for redemption. The essay also situates Spark in a longer trajectory of wartime writing, revealing her innovative social form. Employing a comparative postwar approach, it uses the work of Virginia Woolf to expose Spark’s destruction of modernist narrative architecture, showing its brand of individual sympathy to be inaccessible in the postwar period. The essay then turns to Hilary Mantel’s An Experiment in Love, a direct rewriting of Girls, which re-enchants welfare’s social potential in the face of its Thatcherite demolition.

Prehospital interventions in severely injured pediatric patients: Rethinking the ABCs.

The current conflict in Afghanistan has resulted in a high volume of significantly injured pediatric patients. The austere environment has demanded emphasis on prehospital interventions (PHIs) to sustain casualties during transport. The Department of Defense Trauma Registry was queried for all pediatric patients (≤18 years) treated at Camp Bastion from 2004 to 2012. PHIs were grouped by Advanced Trauma Life Support categories into (1) airway (A)--intubation or surgical airway; 2) breathing (B)--chest tube or needle thoracostomy; and 3) circulation (C)--tourniquet or hemostatic dressing. Outcomes were assessed based on injury severity, hemodynamics, blood products and fluids, as well as mortality rates. There were 766 injured children identified with 20% requiring one or more PHIs, most commonly circulation (C, 51%) followed by airway (A, 40%) and breathing (B, 8.7%). The majority of C interventions were tourniquets (85%) and hemostatic dressings (15%). Only 38% of patients with extremity vascular injury or amputation received a C intervention, with a significant reduction in blood products and intravenous fluids associated with receiving a C PHI (both p < 0.05). A interventions consisted of endotracheal intubation for depressed mental status (Glasgow Coma Scale [GCS] score < 8). Among patients with traumatic brain injury, A interventions were associated with higher unadjusted mortality (56% vs. 20%, p < 0.01) and remained independently associated with increased mortality after multivariate adjustment (odds ratio, 5.9; p = 0.001). B interventions were uncommon and performed in only 2% of patients with no recorded adverse outcomes. There is a high incidence of PHIs among pediatric patients with severe wartime injuries. The most common and effective were C PHI for hemorrhage control, which should remain a primary focus of equipment and training. A interventions were most commonly performed in the setting of severe traumatic brain injury but were associated with worse outcomes. B interventions seem safe and effective and may be underused. Care management/therapeutic study, level IV.

Current concepts in repair of extremity venous injury.

Extremity venous injury management remains controversial. The purpose of this communication is to offer perspective as well as experiential and technical insight into extremity venous injury repair. Available literature is reviewed and discussed. Historical context is provided. Indication, the decision process for repair, including technical conduct, is delineated. In particular, the authors' experiences in both civilian and wartime injury are used for perspective. Extremity venous injury repair was championed within data from the Vietnam Vascular Registry. However, patterns of extremity venous injury differ between combat and civilian settings. Since Vietnam, civilian descriptive series opine the benefits and potential complications associated with both venous injury repair and ligation. These surround extremity edema, chronic venous insufficiency, thromboembolism, and limb loss. Whereas no clear superiority in either approach has been identified to date, there appears to be no increased risk of pulmonary embolism or chronic venous changes with repair. Newer data from the wars in Iraq and Afghanistan and meta-analysis have reinforced this and also have suggested limb salvage benefit for extremity venous repair in combined arterial and venous injuries in modern settings. The patient's physiologic state and associated injury drive five triage categories suggesting vein injury management. Vein repair thrombosis occurs in a significant proportion, yet many recanalize and possibly have a positive impact on limb venous return. Further, early decompression favors reduced blood loss, acute edema, and inflammation, supporting collateral development. Large soft tissue injury minimizing collateral capacity increases the importance of repair. Constructs of repair are varied with modest differences in patency. Venous shunting is feasible, but specific roles remain nebulous. An aggressive posture toward extremity venous injury repair seems justified today because of the likely role in reducing venous hypertensive sequelae as well as a potential role in limb salvage. Appropriate triage selection for extremity vein repair is essential.

War-related extremity injuries in children: 89 cases managed in a combat support hospital in Afghanistan

BackgroundMeeting paediatric needs is among the priorities of western healthcare providers working in Afghanistan. HypothesisInsufficient information is available on paediatric wartime injuries to the extremities. Our objective here was to describe these injuries and their management on the field. Materials and methodsWe retrospectively reviewed consecutive cases of injuries to the extremities in children (<16 years of age) due to weapons and managed at the Kabul International Airport (KaIA) Combat Support Hospital between June 2009 and April 2013. We identified 89 patients with a mean age of 10.2±3.5 years and a total of 137 elemental lesions. ResultsExplosive devices accounted for most injuries (78.6%) and carried a significantly higher risk of multiple lesions. There were 54 bone lesions (traumatic amputations and fractures) and 83 soft-tissue lesions. The amputation rate was 18%. Presence of bone lesions was associated with a higher risk of injury to blood vessels and nerves. Of the 89 patients, four (4.5%) died and eight (9%) were transferred elsewhere. Of the 77 remaining patients, at last follow-up (median, one month; range, 0.1–16 months), 73 (95%) had achieved a full recovery (healed wound and/or fracture) or were recovering with no expectation that further surgery would be needed. DiscussionDespite the absence of paediatric surgeons, the combat support hospital provided appropriate care at the limb salvage and reconstruction phases. The highly specialised treatments needed to manage sequelae were very rarely provided. These treatments probably deserve to be developed in combat support hospitals. Level of evidenceIV, retrospective study.

Recording jaw injuries in wartime

Recording jaw injuries in wartime