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Épidémiologie des blessés de guerre français en Afghanistan : de la blessure à la réinsertion.
Abstract
Les treize années de présence française en Afghanistan ont été marquées par le caractère asymétrique du conflit et l'intensité de l'engagement opérationnel. Les explosions étaient le principal mécanisme lésionnel et les engins explosifs improvisés le principal agent vulnérant. Les membres et la région céphalique étaient les deux principales régions anatomiques lésées. La plupart des militaires blessés par engins explosifs, armes à feu et/ou dans des accidents de transport militaire étaient des traumatisés mineurs. L'amélioration de la prise en charge des blessés à l'avant a entraîné la survie de blessés plus graves présentant des traumatismes multiples et complexes à l'origine de séquelles sévères et nécessitant une longue prise en charge multidisciplinaire. La formation de tous les combattants au sauvetage au combat et l’initiation précoce des procédures de damage control ont permis de réduire les décès potentiellement évitables. Les états de stress posttraumatiques, les douleurs chroniques et les infections des plaies ont fréquemment compliqué les blessures physiques et retardé la réinsertion. Malgré une très forte mobilisation institutionnelle et associative autour du blessé de guerre, la réinsertion familiale, sociale et professionnelle était souvent longue et difficile. Le Service de santé des armées ne dispose actuellement pas de registre des traumatisés en opérations. Il est pourtant urgent qu’il s’en dote afin d’acquérir l’expertise médicale pertinente nécessaire à l’amélioration de ses pratiques et de valoriser ses savoir-faire.
... [10][11][12]15 To support the French Armed Forces currently engaged in the Sahel-Sahara strip, an area exceeding 5 million km 2 , the French Military Medical Service deployed an integrated survival chain, extending from life-saving interventions at the point of injury to rehabilitation in military training hospitals in France. 16 Due to the extensive size of the combat area, respecting a golden hour policy is virtually impossible, and meeting transfusion deadlines represent a complex challenge. 17,18 Indeed, while the median transport time from the point of injury to the medical treatment facility was 56 min during Operation Iraqi Freedom, Carfantan et al showed it to be 145 min for the most severe casualties in the Sahel-Sahara strip. ...
Background:
The French Armed Forces conduct asymmetric warfare in the Sahara-Sahel Strip. Casualties are treated with damage control resuscitation to the extent possible. Questions remain about the feasibility and sustainability of using blood for wider use in austere environments.
Methods:
We performed a retrospective analysis of all French military trauma patients transfused after injury in overseas military operations in Sahel-Saharan Strip, from the point of injury, until day 7, between January 11, 2013 to December 31, 2021.
Results:
Forty-five patients were transfused. Twenty-three (51%) of them required four red blood cells units (RBC) or more in the first 24H defining a severe hemorrhage. The median blood product consumption within the first 48 h, was 8 (IQR [3; 18]) units of blood products (BP) for all study population but up to 17 units (IQR [10; 27.5]) for the trauma patients with severe hemorrhage. Transfusion started at prehospital stage for 20 patients (45%) and included several blood products: French lyophilized plasma, RBCs, and whole blood. Patients with severe hemorrhage required a median of 2 [IQR 0; 34] further units of BP from day 3 to day 7 after injury. Eight patients died in theater, 4 with severe hemorrhage and these 4 used an average of 12 products at Role 1 and 2.
Conclusion:
The transfusion needs were predominant in the first 48 h after the injury but also continued throughout the first week for the most severe trauma patients. Importantly, our study involved a low-intensity conflict, with a small number of injured combatants.
... These injuries, which caused significant bleeding, were the cause of 50% of the deaths. In addition, the study also shows that 70.6% of deaths occurred before being taken care of by an operational medical unit, particularly because of hemorrhages causing heavy bleeding [1]. ...
La simulation est largement utilisée dans la formation continue des soignants. Les situations de crise et de stress, réelles ou simulées, affectent négativement les performances, peuvent entraver l'application des recommandations pour les soins aux blessés et peuvent être la source d'erreurs médicales. La thèse présentée ici s’est intéressée à la préparation opérationnelle des médecins et des infirmiers militaires ainsi qu’aux influences d’une aide cognitive (AC) digitale sur la performance technique et non-technique de ces professionnels de santé mais aussi sur la mémoire, en situation simulée de prise en charge des blessés de guerre à l’avant. Le 1er objectif de cette thèse était de faire état de l’accès à la formation continue et des possibilités de maintien des compétences dans le domaine de l’urgence des médecins et des infirmiers militaires susceptibles d’être projetés en opération extérieure (étude 1). Le 2ème objectif était d’étudier, dans un essai randomisé, l’effet sur la performance technique et non-technique des médecins et des infirmiers militaires, de l’utilisation de l’AC digitale MAX (Medical Assistant eXpert) pendant une situation complexe simulée par comparaison avec la mémoire seule, afin d’appliquer les étapes du protocole militaire de soins avec ou sans MAX (étude 2). Le 3ème objectif était de déterminer l’impact de l’utilisation de MAX sur la mémorisation à trois mois des messages pédagogiques donnés aux participants de la deuxième étude à la fin des deux scénarios simulés, utilisant ou non l’AC digitale (étude 3). Le 4ème objectif était de répertorier les raisons du succès de la simulation dans les formations en santé, civiles et militaires (études 4 et 5).
Résumé
La prise en charge du blessé de guerre sur le théâtre d’opérations a progressé et permis de sauver des vies supplémentaires. Les amputés en font partie. Face à ces nouveaux patients gravement atteints et polytraumatisés, l’hôpital d’Instruction des Armées Percy s’est adapté à leur prise en charge, de la blessure à la reconstruction.
Introduction:
Military anesthesiologists from the French Military Medical Service (FMMS) are part of the Forward Surgical Teams deployed in overseas military operations. The practice of anesthesia in combat zones requires specific skills that are not taught during the initial curriculum for French civilian anesthesiologist. The Pre-Deployment Advanced Course in Anesthesia and Resuscitation (DACAR) program was developed to prepare military anesthesiologist from the FMMS before their deployment in overseas military operations.
Methods:
Created in 2013 by the French Military Medical Academy, the DACAR program is divided into two modules and carried out once a year. The DACAR program trains all military anesthesiologist residents at the end of their curricula. Since 2019, a number of Certified Registered Nurse Anesthetists have completed the DACAR program. The DACAR program is organized around the main axes of experience feedback from previous deployments in combat zones as well as didactic learning and practical training using high-fidelity simulation.
Results:
Since 2013, a total of 99 trainees completed the DACAR program during six complete cycles of two modules. The DACAR program has gradually been enriched from 14 courses in 2013 to 28 in 2019. Participants' reported satisfaction rates have increased steadily since 2016, when 88% of courses were rated as "interesting" or "very interesting," and only 4% as "not very interesting." By 2019, those figures had improved to 96% and 2%, respectively.
Conclusion:
The DACAR program is a structured and adapted military medical course aimed at completing the curriculum of military anesthesiologists from the FMMS before deployment in overseas military operations. Regular audits and updates ensure that the DACAR training program maintains the highest standards of quality and rigor.
Résumé Introduction : Les causes d'avortement à répétition sont multiples. Actuellement, les étiologies thrombotiques sont les plus discutées. L'association antiphospholipides et avortements à répétition a été démontrée, mais l'origine thrombotique due à la résistance héréditaire du facteur V à la protéine C activée (APCR), est encore discutée. Objectif : Déterminer la prévalence de la thrombophilie chez les patientes ayant présentées des avortements à répétitions inexpliqués, et d’établir le profil clinique des patientes ayant ce genre d’anomalies biologiques. Matériel et méthodes : 21 patientes ayant présentées une maladie abortive inexpliquée ont été incluses dans l’étude. Un bilan de thrombophilie a été réalisé pour l’ensemble de ces patientes, incluant la recherche du lupus anticoagulant, le dosage des inhibiteurs physiologiques de la coagulation, et la recherche de la résistance à la protéine C activée. Résultats : La moyenne d’âge de la population d’étude était : 33+/-7 ans. La recherche du lupus anticoagulant était positive chez les 06 femmes soit 28.6% des cas. 04 femmes soit 19% ont présenté une résistance du facteur V à la protéine C activée. Deux déficits ont été trouvés : un déficit en protéine C et un autre en protéine S. Le nombre d’épisodes abortifs était plus élevé chez les patientes ayant un état de thrombophilie biologique (p=0.001). Tous les cas de résistance en protéine C activée étaient associées à des avortements à répétitions durant le deuxième trimestre (p=0.005). Conclusion : La thrombophilie joue un rôle important dans la survenue d’épisodes abortifs et sa recherche est systématique dans le cadre du diagnostic étiologique.
Introduction : La médicalisation de l'avant lors des conflits militaires implique la réalisation de gestes de sauvetage dans un environnement à haut risque et stressant. Les hémorragies de membre sont la première cause de mort évitable au combat. Nous avons cherché à explorer la relation entre certains traits de personnalité et la pose efficace d'un garrot tactique type SOFTT®. Matériel : Soixante-douze militaires français de l'armée de Terre, formés au préalable au Sauvetage au Combat de niveau 1, ont été inclus. La simulation reposait sur une hémorragie de jambe à prendre en charge sur un camarade. L'efficacité du garrot était définie par l'interruption de la pulsatilité du flux Doppler de l'artère poplitée. Des questionnaires spécifiques ont évalué la personnalité empathique des sujets, la qualité de leur relation à autrui (altruisme) ainsi qu'à euxmêmes (mindfulness et estime de soi). Résultats : La pose du garrot était efficace pour 37 participants (51,39%). 19 participants (26,39%) ont satisfait au critère composite d'efficience défini par une pose efficace et rapide (disparition du pouls poplité en moins de 60 secondes). Nous avons observé que les soldats avec des scores faibles d'altruisme actif posaient plus de garrots efficients que ceux ayant un score élevé d'altruisme actif (OR 0,15 IC95%[0,04-0,59]). Les participants avec des scores élevés d'estime de soi posaient également les garrots de façon efficiente plus fréquemment que ceux ayant des scores bas d'estime de soi (OR 3,95 IC95%[1,24-12,56]). Discussion : L'estime de soi apparait bénéfique en termes de compétence et de résilience en milieu militaire, ce qui est un atout dans les environnements stressants rencontrés en opération. Ces résultats ouvrent la voie à des recherches complémentaires pour explorer l'implication des processus psychologiques dans la réalisation des gestes de sauvetage potentiellement douloureux. Une prise en compte des facteurs psychologiques pourrait permettre d’améliorer l’efficacité de la réalisation de ces gestes, notamment la pose du garrot. L’enseignement du Sauvetage au Combat pourrait également prendre en compte ces composantes psychologiques afin d’améliorer l’impact de la formation
The aim of this study was to assess the faecal carriage of carbapenemase-producing enterobacteria (CPE) and extended-spectrum β-lactamase (ESBL)-producing enterobacteria among soldiers at admission in a French military hospital after aeromedical evacuation from overseas. During a period of 1 year, 83 rectal swabs collected in French soldiers at admission were screened for multidrug-resistant enterobacteria with a chromogenic medium. ESBL detection was performed with the double-disc synergy test in the absence or presence of cloxacillin. The genotypic characterisation of resistance mechanisms, sequence typing and phylotyping was performed by polymerase chain reaction (PCR) and sequencing with bacterial DNA extracted from isolates. No CPE was detected. Eleven ESBL Escherichia coli isolates belonging to four phylogenetic groups were detected, including ten CTX-M-15 and one CTX-M-14. The overall gut colonisation with ESBL-producing bacteria (13.25 %) was 6-fold higher than that reported in soldiers in the suburbs of Paris in 2009. ESBL faecal carriage was particularly high (34.48 %) in soldiers repatriated from Afghanistan (risk ratio = 18.62; p = 0.0001). This study highlights the importance of systematic additional contact precautions and CPE/ESBL screening in soldiers repatriated from overseas in French hospitals.
Over half of the veterans returning from the conflicts in Iraq and Afghanistan are burdened with chronic pain. Although these young veterans may have to live with pain for the rest of their lives, little is known about the struggles this new group of veterans faces, or their perceptions of support from family, friends, and others. The purpose of this study is to understand Operation Enduring Freedom/Operation Iraqi Freedom veterans' experiences with chronic pain and social support.
In-depth qualitative interviews were conducted with veterans who participated in an intervention for chronic pain. Grounded theory guided data analysis.
Veterans described a range of emotions associated with chronic pain, including hopelessness, anger, and fear that their pain would worsen. For some, talking about their pain was helpful, but others avoided talking about their pain, often because people did not understand or overreacted.
Although support from friends and family is often effective, veterans and others with chronic pain are uniquely positioned to offer support to others with pain. Clinically, an approach to pain management in which veteran peers are integrated into chronic pain treatment approaches, similar to the Veterans Affairs' mental health model of care, might offer additional benefits for veterans with chronic pain.
Since March 2003, military operations in Iraq “Operation Iraqi Freedom” (OIF) and in Afghanistan “Operation Enduring Freedom” (OEF), have made many wounded and killed in action (KIA). This article proposes to highlight the specific epidemiology of combat casualties, met in these both non-conventional and asymmetric conflicts. Personal protective equipments, Kevlar helmet and body armor, proved their efficiency in changing features of war injuries. Health Force Services organized trauma care system in different levels, with three main objectives: immediate basic medical care in battalion aid station, forward surgery and early aeromedical evacuation. The Joint Theater Trauma Registry (JTTR), a war injury registry, provides medical data, analyzed from the combat theater to the military hospital in United States. This analysis concluded that during modern conflicts, most injuries are caused by explosive devices; injuries are more severe and interestingly more specifically the head region and extremities than the trunk. Hemorrhage is the first cause of death, leading to the concept of avoidable death. Specific databases focused on mechanisms and severity of injuries, diagnostic and treatment difficulties, outcomes can guide research programs to improve war injuries prevention and treatment.
Blood vessel trauma leading to hemorrhage or ischemia represents a significant cause of morbidity and mortality following injury. The objective of this study is to characterize the epidemiology of vascular injury in the wars in Iraq and Afghanistan and delineate anatomic patterns of injury, and the management categories of repair and ligation. Methods: The Joint Theater Trauma Registry was queried (2002-2009) for vascular injury in US troops and specific (Group 1) and operative (Group 2) groups defined. Group numbers were divided by battle related injuries (non-return to duty) to establish injury rates. Results: Group 1 included 1,570 Troops injured in Iraq (OIF) (n=1,390) and Afghanistan (OEF) (n=180). Mechanism included explosive (73%), gunshot (27%) and other (<1%) with explosive more common in OIF than OEF (p<0.05). During this period, 13,076 battle related injuries occurred resulting in a specific rate of 12% (1,570/13,076) which was higher in OIF than OEF (12.5% vs. 9% respectively; p<0.05). Of Group 1, 60% (n=940) sustained injury to major or proximal vessels and 40% (n=630) to minor or distal vessels (unknown vessel location, n=27). Group 2 comprised 1,212 Troops revealing an operative rate of 9% (1,212/13,076) which included ligation (n=660; 54%) or repair (n=552; 46%). Peak rates in OIF and OEF occurred in November 2004 (15%) and August 2009 (11%) respectively and correlated with combat operational tempo. Conclusion: The rate of vascular injury in modern combat is 5 times previously reported and varies according to theater of war, mechanism of injury and operational tempo. Methods of reconstruction are now applied to nearly half of wartime vascular injuries and should be the focus of training and combat support surgery. Ligation of vascular injury remains an important management strategy especially for minor or distal vascular injuries.
: The battlefield has seen tremendous revolutions in military medical affairs (RMMAs) as a result of the last decade of continuous combat operations. The advances in deployed and en route combat casualty care are categorized as individual RMMAs shown in Table 1. As with prehospital advances, the basis for many of the RMMAs in the deployed hospital care environment as well as en route care was translated from civilian trauma practice but is realistic and relevant to the battlefield context. As the conflict evolved, the substantive data from the battlefield led to many new paradigms of treatment and evacuation. The successful implementation of many of these battlefield practices was then effectively translated back into the civilian injury care environment as has been typical of medical advances developed subsequent to previous conflicts of antiquity. The RMMAs that occurred during the last 10 years of combat casualty care are in the realm of deployed hospital care and en route care and are discussed in detail in this article.
Phantom limb pain (PLP) is a significant source of chronic pain in most persons with amputation at some time in their clinical course. Pharmacologic therapies for this condition are often only moderately effective and may produce unwanted adverse effects. There is growing empirical evidence of the therapeutic effectiveness of mind-body therapies for the relief of chronic pain; therefore, an exploration of their role in relieving amputation-related chronic pain is warranted. We undertook a focused literature review on mind-body interventions for patients with amputation who experience PLP. Because of study heterogeneity, only descriptive presentations of the studies are presented. Only studies of hypnosis, imagery, and biofeedback, including visual mirror feedback, were found; studies on meditation, yoga, and tai chi/qigong were missing from the literature. Few studies of specific mind-body therapies were dedicated to management of PLP, with the exception of mirror visual therapy. Overall, studies were largely exploratory and reflect considerable variability in the application of mind-body techniques, making definitive conclusions inadvisable. Nevertheless, the weight of existing findings indicates that a mind-body approach to PLP pain management is promising and that specific methods may offer either temporary or long-term relief, either alone or in combination with conventional therapies. The authors discuss the potential for usefulness of specific mind-body therapies and the relevance of their mechanisms of action to those of PLP, including targeting cortical reorganization, autonomic nervous system deregulation, stress management, coping ability, and quality-of-life. The authors recommend more and better quality research exploring the efficacy and mechanisms of action.
To evaluate battlefield survival in a novel command-directed casualty response system that comprehensively integrates Tactical Combat Casualty Care guidelines and a prehospital trauma registry.
Analysis of battle injury data collected during combat deployments.
Afghanistan and Iraq from October 1, 2001, through March 31, 2010.
Casualties from the 75th Ranger Regiment, US Army Special Operations Command.
Casualties were scrutinized for preventable adverse outcomes and opportunities to improve care. Comparisons were made with Department of Defense casualty data for the military as a whole.
A total of 419 battle injury casualties were incurred during 7 years of continuous combat in Iraq and 8.5 years in Afghanistan. Despite higher casualty severity indicated by return-to-duty rates, the regiment's rates of 10.7% killed in action and 1.7% who died of wounds were lower than the Department of Defense rates of 16.4% and 5.8%, respectively, for the larger US military population (P = .04 and P = .02, respectively). Of 32 fatalities incurred by the regiment, none died of wounds from infection, none were potentially survivable through additional prehospital medical intervention, and 1 was potentially survivable in the hospital setting. Substantial prehospital care was provided by nonmedical personnel.
A command-directed casualty response system that trains all personnel in Tactical Combat Casualty Care and receives continuous feedback from prehospital trauma registry data facilitated Tactical Combat Casualty Care performance improvements centered on clinical outcomes that resulted in unprecedented reduction of killed-in-action deaths, casualties who died of wounds, and preventable combat death. This data-driven approach is the model for improving prehospital trauma care and casualty outcomes on the battlefield and has considerable implications for civilian trauma systems.
There are no published studies directly addressing the issue of what is an acceptable timeline from point of wounding to surgical intervention within the military context. The proximal threshold has previously been determined by personal opinion, tactical, logistic and practical imperatives rather than by clinical demands. The aimof this paper is to review all relevantmilitary and civilian studies where timelines have been quoted and to reach a number of unambiguous consensus statements to state the perceived ideal upper limits from point of wounding to holistic and realistic surgical care in modern war.
An injured casualty should be transferred to an appropriate surgeon in an appropriate facility in as short a time from wounding as practical. It is clear that the best trauma surgery is performed in large, well resourced, well-supplied, airconditioned hospitals. Current advances aimed to stretch timelines from wounding to surgical intervention are exciting and hold potential but remain scientifically unproven and are currently without any firm evidence base. Further critical research is therefore necessary.
The effect of pre-hospital haemostatic resuscitation, provided by the enhanced Medical Emergency Response Team (MERTe) on patient outcome and effective timelines is currently unknown and unproven: it does have intuitive medical merit. There is also a very significant moral and morale component. MERTe serves two main functions; reduction in time from point of wounding to advanced / haemostatic resuscitation and provision of in-flight diagnostics. Continuation of in-flight resuscitation then allows physician-led decision making on critically unstable casualties. This allows either an expedited straight move from the HLS direct to the operating theatre or direct transfer to a regional neurosurgical centre. To prevent avoidable death, our unequivocal conclusion is that there must be an upper limit of 2 hours from wounding to surgical intervention (surgical haemorrhage control) for all casualties.
The aim of the present study was to provide a critical review of prevalence estimates of combat-related post-traumatic stress disorder (PTSD) among military personnel and veterans, and of the relevant factors that may account for the variability of estimates within and across cohorts, including methodological and conceptual factors accounting for differences in prevalence rates across nations, conflicts/wars, and studies. MEDLINE and PsycINFO databases were examined for literature on combat-related PTSD. The following terms were used independently and in combinations in this search: PTSD, combat, veterans, military, epidemiology, prevalence. The point prevalence of combat-related PTSD in US military veterans since the Vietnam War ranged from approximately 2% to 17%. Studies of recent conflicts suggest that combat-related PTSD afflicts between 4% and 17% of US Iraq War veterans, but only 3-6% of returning UK Iraq War veterans. Thus, the prevalence range is narrower and tends to have a lower ceiling among combat veterans of non-US Western nations. Variability in prevalence is likely due to differences in sampling strategies; measurement strategies; inclusion and measurement of the DSM-IV clinically significant impairment criterion; timing and latency of assessment and potential for recall bias; and combat experiences. Prevalence rates are also likely affected by issues related to PTSD course, chronicity, and comorbidity; symptom overlap with other psychiatric disorders; and sociopolitical and cultural factors that may vary over time and by nation. The disorder represents a significant and costly illness to veterans, their families, and society as a whole. Further carefully conceptualized research, however, is needed to advance our understanding of disorder prevalence, as well as associated information on course, phenomenology, protective factors, treatment, and economic costs.
There have been no large cohort reports detailing the wounding patterns and mechanisms in the current conflicts in Iraq and Afghanistan.
The Joint Theater Trauma Registry was queried for all US service members receiving treatment for wounds (International Classification of Diseases-9th Rev. codes 800-960) sustained in Operation Iraqi Freedom and Operation Enduring Freedom from October 2001 through January 2005. Returned-to-duty and nonbattle injuries were excluded from final analysis.
This query resulted in 3,102 casualties, of which 31% were classified as nonbattle injuries and 18% were returned-to-duty within 72 hours. A total of 1,566 combatants sustained 6,609 combat wounds. The locations of these wounds were as follows: head (8%), eyes (6%), ears (3%), face (10%), neck (3%), thorax (6%), abdomen (11%), and extremity (54%). The proportion of head and neck wounds is higher (p < 0.0001) than the proportion experienced in World War II, Korea, and Vietnam wars (16%-21%). The proportion of thoracic wounds is a decrease (p < 0.0001) from World War II and Vietnam (13%). The proportion of gunshot wounds was 18%, whereas the proportion sustained from explosions was 78%.
The wounding patterns currently seen in Iraq and Afghanistan resemble the patterns from previous conflicts, with some notable exceptions: a greater proportion of head and neck wounds, and a lower proportion of thoracic wounds. An explosive mechanism accounted for 78% of injuries, which is the highest proportion seen in any large-scale conflict.
Pour améliorer les chances de survie des blessés de guerre en respectant les délais cliniques de prise en charge, la formation des auxiliaires sanitaires au sauvetage au combat de deuxième niveau est nécessaire. La réalisation de certains gestes habituellement réalisés par un médecin ou un infirmier se justifie par le contexte d’emploi. Néanmoins si cette pratique est commune dans les armées de l’Organisation du traité de l’Atlantique Nord, il convient pour le Service de santé des armées de s’interroger sur cette pratique. Des voies de réflexion en matière d’intégration de ces auxiliaires de santé SC2 dans la doctrine française du soutien médical sont proposées.
Les ossifications hétérotopiques sont devenues des complications fréquentes des amputations traumatiques de guerre en raison de la multiplication des blessures par explosion dans les conflits les plus récents. Les facteurs de risque principaux de leur survenue sont le blast et l’amputation en zone blessée. Le traitement médical doit être privilégié. Leur physiopathologie n’est pas encore élucidée mais il semblerait qu’une cascade d’événements biochimiques inflammatoires mène à leur formation. Nous vous présentons le cas d’un militaire amputé tibial par explosion et présentant une ossification hétérotopique symptomatique du membre résiduel.
Abstract
Heterotopic ossification has become a frequent complication of combat amputations because of multiplication of war wounds caused by explosion in recent conflicts. Main risk factors are blast mechanism of injury and amputation within the initial zone of injury. Its treatment is first medical. Its physiopathology is not elucidated yet but a series of biochemical inflammatory events may lead to its formation. We present here the case of a soldier amputated by explosion and presenting a symptomatic residual limb heterotopic ossification.
Critical evaluation of all aspects of combat casualty care, including mortality, with a special focus on the incidence and causes of potentially preventable deaths among US combat fatalities, is central to identifying gaps in knowledge, training, equipment, and execution of battlefield trauma care. The impetus to produce this analysis was to develop a comprehensive perspective of battlefield death, concentrating on deaths that occurred in the pre-medical treatment facility (pre-MTF) environment.
The Armed Forces Medical Examiner Service Mortality Surveillance Division was used to identify Operation Iraqi Freedom and Operation Enduring Freedom combat casualties from October 2001 to June 2011 who died from injury in the deployed environment. The autopsy records, perimortem records, photographs on file, and Mortality Trauma Registry of the Armed Forces Medical Examiner Service were used to compile mechanism of injury, cause of injury, medical intervention performed, Abbreviated Injury Scale (AIS) score, and Injury Severity Score (ISS) on all lethal injuries. All data were used by the expert panel for the conduct of the potential for injury survivability assessment of this study.
For the study interval between October 2001 and June 2011, 4,596 battlefield fatalities were reviewed and analyzed. The stratification of mortality demonstrated that 87.3% of all injury mortality occurred in the pre-MTF environment. Of the pre-MTF deaths, 75.7% (n = 3,040) were classified as nonsurvivable, and 24.3% (n = 976) were deemed potentially survivable (PS). The injury/physiologic focus of PS acute mortality was largely associated with hemorrhage (90.9%). The site of lethal hemorrhage was truncal (67.3%), followed by junctional (19.2%) and peripheral-extremity (13.5%) hemorrhage.
Most battlefield casualties died of their injuries before ever reaching a surgeon. As most pre-MTF deaths are nonsurvivable, mitigation strategies to impact outcomes in this population need to be directed toward injury prevention. To significantly impact the outcome of combat casualties with PS injury, strategies must be developed to mitigate hemorrhage and optimize airway management or reduce the time interval between the battlefield point of injury and surgical intervention.Understanding battlefield mortality is a vital component of the military trauma system. Emphasis on this analysis should be placed on trauma system optimization, evidence-based improvements in Tactical Combat Casualty Care guidelines, data-driven research, and development to remediate gaps in care and relevant training and equipment enhancements that will increase the survivability of the fighting force.
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Hundreds of general surgeons from the army, navy, and air force have been deployed during the past 10 years to support combat forces, but little data exist on their preparedness to handle the challenging injuries that they are currently encountering. Our objective was to assess operative and operational experience in theater with the goal of improving combat readiness among surgeons.
A detailed survey was sent to 246 active duty surgeons from the army, navy, and air force who have been deployed at least once in the past 10 years, requesting information on cases performed, perceptions of efficacy of predeployment training, knowledge deficits, and postdeployment emotional challenges. Survey data were kept confidential and analyzed using standard statistical methods.
Of 246 individuals, 137 (56%) responded and 93 (68%) have been deployed two or more times. More than 18,500 operative procedures were reported, with abdominal and soft tissue cases predominating. Many surgeons identified knowledge or practice gaps in predeployment vascular (46%), neurosurgical (29.9%), and orthopedic (28.5%) training. The personal burden of deployment manifested itself with both family (approximately 10% deployment-related divorce rate) and personal (37 surgeons [27%] with two or more symptoms of posttraumatic stress syndrome) stressors.
These data support modifications of predeployment combat surgical training to include increased exposure to open vascular procedures and curriculum traditionally outside general surgery (neurosurgery and orthopedics). The acute care surgical model may be ideal for the military surgeon preparing for deployment. Further research should be directed toward identifying factors contributing to psychological stress among military medics.
The died of wounds (DOW) rate is cited as a measure of combat casualty care effectiveness without the context of injury severity or insight into lethality of the battlefield. The objective of this study was to characterize injury severity and other factors related to variations in the DOW rate.
The highest monthly DOW (HDOW) and lowest monthly DOW (LDOW) rates from 2004 to 2008 were identified from analysis and casualty report databases and used to direct a search of the Joint Theater Trauma Registry. Casualties from the HDOW and LDOW were combined into cohorts, and injury data were analyzed and compared.
The HDOW rates were 13.4%, 11.6%, and 12.8% (mean, 12.6%), and the LDOW rates were 1.3%, 2.0%, and 2.7% (mean, 2.0%) (p < 0.0001). The HDOW (n = 541) and LDOW (n = 349) groups sustained a total of 1,154 wounds. Injury Severity Score was greater in the HDOW than the LDOW group (mean [SD], 11.1 [0.53] vs. 9.4 [0.58]; p = 0.03) as was the percentage of patients with Injury Severity Score of more than 25 (HDOW, 12% vs. LDOW, 7.7%; p = 0.04). Excluding minor injuries (Abbreviated Injury Scale score of 1), there was a greater percentage of chest injuries in the HDOW compared with the LDOW group (16.5% vs. 11.2%, p = 0.03). Explosive mechanisms were more commonly the cause of injury in the HDOW group (58.7% vs. 49.7%; p = 0.007), which also had a higher percentage of Marine Corps personnel (p = 0.02).
This study provides novel data demonstrating that the died of wounds rate ranges significantly throughout the course of combat. Discernible differences in injury severity, wounding patterns, and even service affiliation exist within this variation. For accuracy, the died of wounds rate should be cited only in the context of associated injury patterns, injury severity, and mechanisms of injury. Without this context, DOW should not be used as a comparative medical metric.
Understanding the epidemiology of death after battlefield injury is vital to combat casualty care performance improvement. The current analysis was undertaken to develop a comprehensive perspective of deaths that occurred after casualties reached a medical treatment facility.
Battle injury died of wounds (DOW) deaths that occurred after casualties reached a medical treatment facility from October 2001 to June 2009 were evaluated by reviewing autopsy and other postmortem records at the Office of the Armed Forces Medical Examiners (OAFME). A panel of military trauma experts classified the injuries as nonsurvivable (NS) or potentially survivable (PS), in consultation with an OAFME forensic pathologist. Data including demographics, mechanism of injury, physiologic and laboratory variables, and cause of death were obtained from the Joint Theater Trauma Registry and the OAFME Mortality Trauma Registry.
DOW casualties (n = 558) accounted for 4.56% of the nonreturn to duty battle injuries over the study period. DOW casualties were classified as NS in 271 (48.6%) cases and PS in 287 (51.4%) cases. Traumatic brain injury was the predominant injury leading to death in 225 of 271 (83%) NS cases, whereas hemorrhage from major trauma was the predominant mechanism of death in 230 of 287 (80%) PS cases. In the hemorrhage mechanism PS cases, the major body region bleeding focus accounting for mortality were torso (48%), extremity (31%), and junctional (neck, axilla, and groin) (21%). Fifty-one percent of DOW casualties presented in extremis with cardiopulmonary resuscitation upon presentation.
Hemorrhage is a major mechanism of death in PS combat injuries, underscoring the necessity for initiatives to mitigate bleeding, particularly in the prehospital environment.
Infections are a common acute and chronic complication of combat-related injuries; however, no systematic attempt to assess infections associated with US combat-related injuries occurring in Iraq and Afghanistan has been conducted. The Joint Theater Trauma Registry (JTTR) has been established to collect injury specific medical data from casualties in Iraq and Afghanistan.
We reviewed the JTTR for the identification of infectious complications (IC) using International Classification of Diseases, 9th Revision (ICD-9) coding during two phases of the wars, before and after the end of the major ground operations in Iraq (19 March-May 31, 2003 and June 1, 2003-December 31, 2006). ICD-9 codes were combined into two categories; anatomic or clinical syndrome and pathogen. An IC was defined as the presence of ICD-9 codes that included both anatomic or clinical syndrome and a pathogen.
There were 425 patients evaluated in phase I and 684 in phase II with approximately one third having an IC. The most common anatomic or clinical syndrome codes were skin or wound followed by lung, and the most common pathogen code was gram-negative bacteria. The site of injury had varying rates of IC: spine or back (53%), head or neck (44%), torso (43%), and extremity (35%). Injury Severity Score and certain mechanisms of injury (explosive device, bomb, and landmine) were associated with an IC on multivariate analysis (p < 0.01).
Infections are common after combat-related injuries. Although the JTTR can provide general information regarding infections, improved data capture and more specific clinical information is necessary to improve overall combat-related injury infection care.
The present retrospective study was performed to determine the incidence and outcome of primary blast injury and to identify possible changes over the course of the conflicts between 2003 and 2006.
Combat physicians treating patients injured in overseas contingency operations observed an increase in the severity of explosion injuries occurring during this period.
This retrospective study included service members injured in explosions between March 2003 and October 2006. The Joint Theater Trauma Registry provided demographic information, injury severity score, and International Classification of Diseases 9 codes used to diagnose primary blast injury. Autopsy reports of the last 497 combat-related deaths of 2006 were also reviewed.
Of 9693 admissions, of which 6687 were injured in combat, 4765 (49%) were injured by explosions: 2588 in 2003-2004 and 1935 in 2005-2006. Dates of injury were unavailable for 242 casualties. Injury severity score (9 +/- 10 vs. 11 +/- 10, P < 0.0001) and incidence of primary blast injury (12% vs. 15%, P < 0.01) increased. The return-to-duty rate decreased (40% vs. 18%, P < 0.001), but mortality remained low (1.4% vs. 1.5%, P = NS). There was no significant difference in incidence of primary blast injury between personnel who were killed in action and those who died of wounds at a medical facility.
Injury severity and incidence of primary blast injury increased during the 4-year period, whereas return-to-duty rates decreased. Despite increasingly devastating injuries, the mortality rate due to explosion injuries remained low and unchanged.
A prospective, longitudinal analysis of injuries sustained by a large combat-deployed maneuver unit has not been previously performed.
A detailed description of the combat casualty care statistics, distribution of wounds, and mechanisms of injury incurred by a U.S. Army Brigade Combat Team during "The Surge" phase of Operation Iraqi Freedom was performed using a centralized casualty database and an electronic medical record system.
Among the 4,122 soldiers deployed, there were 500 combat wounds in 390 combat casualties. The combat casualty rate for the Brigade Combat Team was 75.7 per 1,000 soldier combat-years. The % killed in action (KIA) was 22.1%, and the %died of wounds was 3.2%. The distribution of these wounds was as follows: head/neck 36.2%, thorax 7.5%, abdomen 6.9%, and extremities 49.4%. The percentage of combat wounds showed a significant increase in the head/neck region (p < 0.0001) and a decrease in the extremities (p < 0.03) compared with data from World War II, Korea, and Vietnam. The percentage of thoracic wounds (p < 0.03) was significantly less than historical data from World War II and Vietnam. The %KIA was significantly greater in those soldiers injured by an explosion (26.3%) compared with those soldiers injured by a gunshot wound (4.6%; p = 0.003). Improvised explosive devices accounted for 77.7% of all combat wounds.
There was a significantly higher proportion of head/neck wounds compared with previous U.S. conflicts. The 22.1% KIA was comparable with previous U.S. conflicts despite improvements in individual/vehicular body armor and is largely attributable to the lethality of improvised explosive devices. The lethality of a gunshot wound in Operation Iraqi Freedom has decreased to 4.6% with the use of individual body armor.
Health-care providers are increasingly faced with the possibility of needing to care for people injured in explosions, but can often, however, feel undertrained for the unique aspects of the patient's presentation and management. Although most blast-related injuries (eg, fragmentation injuries from improvised explosive devices and standard military explosives) can be managed in a similar manner to typical penetrating or blunt traumatic injuries, injuries caused by the blast pressure wave itself cannot. The blast pressure wave exerts forces mainly at air-tissue interfaces within the body, and the pulmonary, gastrointestinal, and auditory systems are at greatest risk. Arterial air emboli arising from severe pulmonary injury can cause ischaemic complications-especially in the brain, heart, and intestinal tract. Attributable, in part, to the scene chaos that undoubtedly exists, poor triage and missed diagnosis of blast injuries are substantial concerns because injuries can be subtle or their presentation can be delayed. Management of these injuries can be a challenge, compounded by potentially conflicting treatment goals. This Seminar aims to provide a thorough overview of these unique primary blast injuries and their management.
Data from recent wars indicate that a wounded Marine had a 20% lower risk of dying than an Army soldier. Possible reasons for this difference are (1) Navy care is superior, (2) soldiers sustained more severe wounds, and (3) the services count casualties differently. Injury severity was measured in random samples of Marines and soldiers that were selected from the Wound Data and Munitions Effectiveness Team database. There was no difference in the lethality of injury and the prevalence of lifesaving first aid. Wounded Marines were more likely to wear protective vests, and this decreased Marine mortality in Vietnam. Hospitalized Marines had lower Injury Severity Scores and were less likely to be returned to duty without first being admitted to a medical treatment facility. Lower Marine combat mortality is primarily the result of the fact that a Marine with a minor soft tissue wound was more likely to be hospitalized than was a soldier with a similar injury.
Traumatic combat injuries differ from those encountered in the civilian setting in terms of epidemiology, mechanism of wounding, pathophysiologic trajectory after injury, and outcome. Except for a few notable exceptions, data sources for combat injuries have historically been inadequate. Although the pathophysiologic process of dying is the same (i.e., dominated by exsanguination and central nervous system injury) in both the civilian and military arenas, combat trauma has unique considerations with regard to acute resuscitation, including (1) the high energy and high lethality of wounding agents; (2) multiple causes of wounding; (3) preponderance of penetrating injury; (4) persistence of threat in tactical settings; (5) austere, resource-constrained environment; and (5) delayed access to definitive care. Recognition of these differences can help bring focus to resuscitation research for combat settings and can serve to foster greater civilian-military collaboration in both basic and transitional research.
As of November 9, 2004, a total of 10,153 service members had suffered war injuries. Dr. Atul Gawande writes about a military medical system that has made fundamental and effective changes in the strategies and systems of battle care.
Maintaining good hospital records during military conflicts can provide medical personnel and researchers with feedback to rapidly adjust treatment strategies and improve outcomes. But to convert the resulting raw data into meaningful conclusions requires clear terminology and well thought out equations, utilizing consistent numerators and denominators. Our objective was to arrive at terminology and equations that would produce the best insight into the effectiveness of care at different stages of treatment, either pre or post medical treatment facility care. We first clarified three essential terms: 1) the case fatality rate (CFR) as percentage of fatalities among all wounded; 2) killed in action (KIA) as percentage of immediate deaths among all seriously injured (not returning to duty); and 3) died of wounds (DOW) as percentage of deaths following admission to a medical treatment facility among all seriously injured (not returning to duty). These equations were then applied consistently across data from the WWII, Vietnam and the current Global War on Terrorism. Using this clear set of definitions we used the equations to ask two basic questions: What is the overall lethality of the battlefield? How effective is combat casualty care? To answer these questions with current data, the three services have collaboratively created a joint theater trauma registry (JTTR), cataloging all the serious injuries, procedures, and outcomes for the current war. These definitions and equations, consistently applied to the JTTR, will allow meaningful comparisons and help direct future research and appropriate application of personnel.
Bullet-proof vests and helmets protect from harm in combat and military engagements. The use of armor against shrapnel has been studied, yet little has been documented as to how they protect from high velocity gunshots. This study aims to describe the medical consequences of high velocity firearm injuries and to differentiate between patients injured while using protective wear and those injured unprotected.
National trauma registry data on injury characteristics, treatment and outcomes between October 1, 2000 and December 31, 2003 were retrieved and analyzed.
There were 669 terror-related firearm injuries recorded: 236 (37.8%) in soldiers (protected) and 433 (62.2%) in civilians (unprotected). Injury severity was notably higher in civilian patients (31% versus 16% with Injury Severity Score>or=16). Civilians had more ICU care (26% versus 20%, p=0.06), and double the inpatient mortality (8.6% [n=37] versus 3.4% [n=8] patients). Protected body regions such as abdomen, chest, and brain, were injured less frequently. Once a traumatic brain injury was sustained, no statistical differences were found in severity distribution, ICU stay, or inpatient death between protected and unprotected patients. But injury severity in patients with chest injuries was much higher in those who were unprotected (Injury Severity Score>or=25, 41% versus 23%, respectively, p=0.08). This increased severity could be attributed partly to more multiple injuries involving the chest. Abdominal injuries showed a similar pattern.
Body armor has a protective effect on victims of high velocity gunshot wounds; lower rates of head, brain, chest, and abdominal injuries are seen. In addition, armor reduces the severity of injuries to the chest and the abdomen.
Medical lessons learned from Vietnam and previous military conflicts led to the development of civilian trauma systems in the United States. Operation Iraqi Freedom represents the first protracted, large-scale, armed conflict since the advent of civilian trauma systems in which to evaluate a similar paradigm on the battlefield.
Collaborative efforts between the joint military forces of the United States initiated development of a theater trauma system in May 2004. Formal implementation of the system occurred in November 2004, the collaborative effort of the three Surgeons General of the U.S. military, the United States Army Institute of Surgical Research, and the American College of Surgeons Committee on Trauma. One trauma surgeon (Trauma System Director) and a team of six trauma nurse coordinators were deployed to theater to evaluate trauma system component issues. Demographic, mechanistic, physiologic, diagnostic, therapeutic, and outcome data were gathered for 4,700 injured patients using the Joint Theater Trauma Registry. Interview and survey methods were utilized to evaluate logistic aspects of the system.
System implementation identified more than 30 systemic issues requiring policy development, research, education, evaluation of medical resource allocation, and alterations in clinical care. Among the issues were transfer of casualties from point of injury to the most appropriate level of care, trauma clinical practice guidelines, standard forms, prophylactic antibiotic regimens, morbidity/mortality reporting, on-line medical evacuation regulation, improved data capture for the trauma registry, and implementation of a performance improvement program.
The implementation of a theater trauma system demonstrated numerous opportunities to improve the outcome of soldiers wounded on the battlefield.
Enhanced medical training of front line medical personnel, personal protective equipment, and the presence of far forward surgical assets have improved the survival of casualties in the current wars in Iraq and Afghanistan. As such, casualties are at higher risk of infectious complications of their injuries including sepsis, which was a noted killer of casualties in previous wars. During the current conflicts, military personnel who develop combat-related injuries are at substantial risk of developing infections with multidrug resistant bacteria. Herein, we describe the bacteriology of combat-related injuries in Operation Iraqi Freedom and Operation Enduring Freedom that develop infections with particular attention to injuries of the extremities, central nervous system, abdomen and thorax, head and neck, and burns. In addition, the likely sources of combat-related injuries with multidrug resistant bacteria infections are explored.
Although the use of damage control surgery for blunt and penetrating injury has been widely reported and defined, the use of damage control surgery on the battlefield (combat damage control surgery) has not been well detailed.
Damage control surgery is now well established as the standard of care for severely injured civilian patients requiring emergent laparotomy in the United States. The civilian damage control paradigm is based on a "damage control trilogy." This trilogy comprises an abbreviated operation, intensive care unit resuscitation, and a return to the operating room for the definitive operation. The goal of damage control surgery and the triology is avoidance of irreversible physiological insult termed the lethal triad. The lethal triad comprises the vicious cycle of hypothermia, acidosis, and coagulopathy. Although the damage control model involves the damage control trilogy, abbreviated operation, intensive care unit resuscitation, and definitive operation, all in the same surgical facility, the combat damage control paradigm must incorporate global evacuation through several military surgical facilities and involves up to ten stages to allow for battlefield evacuation, surgical operations, multiple resuscitations, and transcontinental transport.
Combat damage control surgery represents many unique challenges for those who care for the severely injured patients in a combat zone.
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