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 Table of Contents  
MILITARY MEDICINE
Year : 2017  |  Volume : 19  |  Issue : 2  |  Page : 134-137

Tactical combat casualty and critical care-An evolving concept in casualty management in a Tertiary Care Hospital


1 Cl Spl Surgery and Vas Surg, Department of Surgery, INHS Asvini, Mumbai, Maharashtra, India
2 Cl Spl ENT, Military Hospital, Meerut, Uttar Pradesh, India
3 Cl Spl Surgery and Recon Surg, Department of Surgery, Command Hospital (Eastern Command), Kolkata, West Bengal, India

Date of Web Publication13-Feb-2018

Correspondence Address:
Dr. Vivek Kumar Singh
Department of Surgery, INHS Asvini, RC Church, Colaba, Mumbai - 400 005, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jmms.jmms_4_17

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  Abstract 


Introduction: The Indian Army has been in engaged in wars, counter terrorism operations and relief work during natural or manmade disasters for a long time. An observational study of 707 casualties admitted in a tertiary care hospital was conducted to analyse tactical combat casualty care in the Indian perspective and assess the survival outcomes. Method: The study included the type of casualties, their mode of evacuation, patient survival and outcome. Results: Total 707 casualties incurred 780 wounds. All of them were initially managed at peripheral Medical Inspection Room (MI Room) and then evacuated to the tertiary hospital via road/air. Total 535 casualties were transferred by air and 172 by road. Average time taken by air was 45 minutes and by road was 3 hours and 35 minutes. Road traffic accident was the greatest contributor and averaged 76.8%. Injury distribution in our study was head and neck 2.94%, chest 1.79%, abdomen 17.94%, and extremities 77.30%. 610 injuries were operated at tertiary hospital and remaining 170 were operated at peripheral hospitals. There were three hospital deaths while one patient died at peripheral hospital during resuscitation. Discussion: We reviewed the epidemiology of military trauma to identify survival patterns from which operationally appropriate treatment strategies may be developed. Due to absence of night flying, two casualties were forced to be evacuated by road. One casualty expired during evacuation due to gunshot wound of chest and exsanguination. Patients who required surgery were operated upon within five hours, thus achieving maximum survival benefit. The study highlights the constraints in tactical combat care because of unconventional nature of conflicts and hostile terrains. However, an appropriately triaged patient can be referred for more definitive management, or if possible can be air - evacuated to the tertiary care hospital directly for better survival outcomes.

Keywords: Casualty evacuation, golden hour, tactical combat casualty care


How to cite this article:
Singh VK, Singh N, Malik P. Tactical combat casualty and critical care-An evolving concept in casualty management in a Tertiary Care Hospital. J Mar Med Soc 2017;19:134-7

How to cite this URL:
Singh VK, Singh N, Malik P. Tactical combat casualty and critical care-An evolving concept in casualty management in a Tertiary Care Hospital. J Mar Med Soc [serial online] 2017 [cited 2019 Oct 19];19:134-7. Available from: http://www.marinemedicalsociety.in/text.asp?2017/19/2/134/225273




  Introduction Top


The Indian Army has been engaged for several years in conventional and nonconventional warfare, both abroad and at home. The casualty figure in Jammu & Kashmir from 1990 to 2001 stands at 9718 civilians and 3053 security forces casualties as per official report from Ministry of External Affairs, India.[1] Uncontrolled bleeding from extremity haemorrhage was the cause of death for >2500 fatalities in Vietnam War and is still the leading cause of preventable deaths on the battlefield today (Maughon, 1970; King et al., 2006; Starnes et al., 2006).[2]

The US military is in a state of conflict for the past 15 years that followed the attacks of September 11, 2001. This prolonged interval of continuous combat operations allowed the US military and its coalition partners to make major advances in trauma care and to achieve unprecedented casualty survival rates.[3] The standards of care have been redefined in prehospital hemorrhage control, transfusion medicine, and care during casualty transport.[4] The United States and its coalition partner nations have now developed a joint trauma system that works closely with the combat theatre medical leadership to establish and ensure standards for battle field, evacuation, and in-hospital trauma care.[4]

There have been very few Indian studies about casualty care and management. Therefore, a retrospective study was conducted at a tertiary care hospital, in the operational area. The aim of this study was to evaluate the efficacy of tactical combat casualty care in the Indian perspective at a tertiary hospital. The objectives were to assess patient survival and outcome after emergency and definitive treatment.


  Materials and Methods Top


The study population included all injured soldiers who required hospital admission or were transferred from lower echelons.

It included casualty demographics, injury characteristics, mechanisms and operational contexts, patient condition, and medical care rendered at the various treatment stations, including information regarding injuries sustained, care provided and outcome.

The study excluded causalties which were managed at various peripheral hospitals and sent to the tertiary hospital for recovery or phased reconstructive surgeries.

All casualties were attended by authorized medical attendant. The first aid and minor surgical procedures were performed at the first echelon. This involved control of haemorrhage securing the airway, establishing a lifeline, adequate fluid resuscitation, and immobilization of injured extremities. Thereafter, patients were transferred to either to forward surgical unit or directly to the tertiary hospital by road or air.

Patients were initially admitted to the Intensive Care Unit (ICU) where a trauma team was positioned. The team examined and triaged the cases. Later, patients were taken to the operation theatre for immediate surgical intervention, depending on the nature of the case. The rest of the patients were treated at the ICU. After, the definitive surgical and ICU care, patients were stepped down to casualty ward for recovery and follow-up. This drill was followed for every case. A total of 707 patients were managed and studied as per the records available in the trauma register at the hospital. The casualties were divided into subgroups based on the mode of injury, anatomical part involved, definitive surgical care provided and its impact on reducing morbidity and improving survival. The study also determined whether the chain of evacuation was maintained, the concept of golden hour were followed and whether the mode of evacuation, had a bearing on survival.


  Results Top


A total of 707 patients were received by the trauma team in a span of four years and included in the study.

Road Traffic Accident (RTA) was the greatest contributor of morbidity and mortality as mentioned in [Table 1] and [Table 2].
Table 1: Mode of injury

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Table 2: Anatomical part involved in injury

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A total of 535 casualties were transferred by air and 172 by road. The average time taken by air was 45 min and 3 h 35 min by road respectively.

All 707 patients were operated. 610 cases were operated at tertiary hospital and 170 at peripheral hospital. Life and limb saving procedures were done as mentioned in [Table 3]. The types of surgeries done at the hospitals has been outlined in [Table 4]. Maximum surgeries involved the extremities (Total 603). There were three fatalities at the tertiary hospital and one at the peripheral hospital. One casualty expired enroute while being transferred to the tertiary hospital due to exsanguination [Table 5].
Table 3: Surgeries at peripheral hospital and tertiary hospital

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Table 4: Anatomical distribution and type of surgery at tertiary hospital and peripheral hospital

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Table 5: Casualty management results

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The severity of cases determined the evacuation to the nearest echelon, either to Forward Surgical Centre (FSC) or directly to the tertiary hospital by road or air. The mean operating time for initial surgery from the time of injury was 4 h, 50 min and 1 h, 32 min, when casualties were evacuated by road and air respectively. It is important to stress here that in nonconventional warfare and hostile terrains, causalties usually do not follow the chain of evacuation when evacuated by air. There were >90% patients who were evacuated directly to the tertiary hospital.

Two patients were transferred by air to the quaternary hospital for further management by vascular surgeon. Three patients were lost during the course of treatment due to posttraumatic complications.


  Discussion Top


We reviewed the epidemiology of military trauma to identify survivable patterns with the aim to develop operationally appropriate treatment strategies. Our main source for data collection was trauma register at a tertiary hospital. Its data sets included comprehensive medical data on each patient, including detailed information.

The high rate of penetrating injuries (73.0% as primary injury mechanism and 75.9% as either primary or secondary) in this study is typical of military trauma in conflicts. In more recent reports from Afghanistan and Iraq, the rate of penetrating trauma was 61%–63%.[5],[6]

In Lebanon War II (2006), injury to the extremities was the most common with 241 (upper) and 306 (lower) injuries, accounting for 17.5% and 22.2% of all injuries, respectively. Despite their high prevalence, injuries to the extremities were actually slightly less frequent than in the first Lebanon war in 1982 and other recent conflicts.[7] Our study showed a high incidence of extremity injuries (77.05%).

Owens et al.[8] reported the highest rate of injuries per combatant in a study evaluating combat wounds in operation Iraqi Freedom And Operation Enduring Freedom, which describes 6,609 combat wounds in 1,566 combatants, averaging 4.2 wound per combatant. The methodology used in that study, however, differs from ours, precluding accurate comparison. While, we counted the number of anatomic regions involved, they counted the number of wounds, some of them within the same anatomic region.

During Operation Enduring Freedom and Operation Iraqi Freedom, rapid evacuation from the point of injury by rotary wing medical evacuation promptly delivered casualties within minutes to awaiting operating rooms at surgically capable facilities (Level II or Level III).[9]

In the Indian scenario, road evacuation accounted for 172 and air evacuation for 535 casualties. To reach the nearest echelon the average time taken by road was 3 h, 35 min and air evacuation directly to tertiary hospital took 45 min. The delay in evacuation by road took place due to difficult terrain, hostile weather, and constraints of counter-insurgency. Due to the absence of night flying, two casualties were forced to be evacuated by road.

Primary survey and treatment of casualties were done by a medical attendant, average time taken being 35 min. Casualties were evacuated to nearest medical center either by road or air. The first procedure was done at a Forward Operating Base with a smaller Level II facility followed by rapid evacuation to the larger, central Level III combat support/theater hospital. Further, surgery was undertaken as necessary at the Level III facility. Patients who required surgery were operated on within 5 h of injury, thus achieving maximum survival benefit.


  Conclusion Top


Indian Defence Forces have been continuously engaged with Counter Insurgency Operations. In the era of modern warfare, there have been substantial combat causalties during unconventional operations. The medical evacuation system is a continuum from the forward line of troops through the field operational areas. Casualty evacuation is the timely, efficient movement and en route care of sick or injured persons from the battlefield to a medical treatment facility.

We observed that the maximum survival benefit could be offered to the injured when they were evacuated to the hospital within 1–5 h. This interim period is the time when life-saving intervention-based tactical combat casualty care can be provided. The study highlights the constraints in tactical combat care because of unconventional nature of conflicts and hostile terrains. However, an appropriately triaged patient can be referred for more definitive management at the tertiary level, and can be airborne to the tertiary hospital directly for better survival outcomes.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
The Accession of Jammu and Kashmir to India-1947; 2002. Available from: http://www.mea.gov.in/in-focus-article.htm?18987/Fact+Sheet+on+Jammu+amp+Kashmir. [Last accessed on 2017 Nov 01].  Back to cited text no. 1
    
2.
Butler FK Jr., Holcomb JB, Giebner SD, McSwain NE, Bagian J. Tactical combat casualty care 2007: Evolving concepts and battlefield experience. Mil Med 2007;172:1-9.  Back to cited text no. 2
    
3.
Holcomb JB, Stansbury LG, Champion HR, Wade C, Bellamy RF. Understanding combat casualty care statistics. J Trauma 2006;60:397-401.  Back to cited text no. 3
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4.
Blackbourne LH, Baer DG, Eastridge BJ, Butler FK, Wenke JC, Hale RG, et al. Military medical revolution: Military trauma system. J Trauma Acute Care Surg 2012;73:S388-94.  Back to cited text no. 4
[PUBMED]    
5.
Peoples GE, Gerlinger T, Craig R, Burlingame B. Combat casualties in Afghanistan cared for by a single forward surgical team during the initial phases of operation enduring freedom. Mil Med 2005;170:462-8.  Back to cited text no. 5
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6.
Ivey KM, White CE, Wallum TE, Aden JK, Cannon JW, Chung KK, et al. Thoracic injuries in US combat casualties: A 10-year review of operation enduring freedom and Iraqi freedom. J Trauma Acute Care Surg 2012;73:S514-9.  Back to cited text no. 6
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7.
Schwartz D, Glassberg E, Nadler R, Hirschhorn G, Marom OC, Aharonson-Daniel L, et al. Injury patterns of soldiers in the second Lebanon war. J Trauma Acute Care Surg 2014;76:160-6.  Back to cited text no. 7
    
8.
Owens BD, Kragh JF Jr., Wenke JC, Macaitis J, Wade CE, Holcomb JB, et al. Combat wounds in operation Iraqi freedom and operation enduring freedom. J Trauma 2008;64:295-9.  Back to cited text no. 8
    
9.
Ingalls N, Zonies D, Bailey JA, Martin KD, Iddins BO, Carlton PK, et al. A review of the first 10 years of critical care aeromedical transport during operation Iraqi freedom and operation enduring freedom: The importance of evacuation timing. JAMA Surg 2014;149:807-13.  Back to cited text no. 9
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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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Abstract
Introduction
Materials and Me...
Results
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