|Ahead of print publication
The management of trauma cases at a forward surgical center in a counter-insurgency Ops
Department of Anesthesiology and Critical Care, Armed Forces Medical College, Pune, Maharashtra, India
|Date of Submission||06-Apr-2020|
|Date of Decision||03-May-2020|
|Date of Acceptance||17-May-2020|
|Date of Web Publication||25-Aug-2020|
Department of Anesthesiology and Critical Care, Armed Forces Medical College, Wanowrie Road, Pune - 411 040, Maharashtra
Source of Support: None, Conflict of Interest: None
Introduction: Forward surgical centers (FSCs) provide combat medical support to troops in the field. They comprise a surgical team with radiology and laboratory services. Methodology: Two years data from a single FSC located in a counter-insurgency operational zone were recorded and analyzed on several parameters. The admission and discharge registers, operation theater records of surgery and anesthesia, and the fatal case records were used as data sources. Results: About 60% of the trauma cases were penetrating trauma. The most common region of the body that was injured was the extremities mainly upper limbs. The torso injuries were less than expected presumably due to the use of body armor. Majority of the cases were priority 2 cases requiring urgent surgery. Fifty percent of cases required general anesthetic and the remaining were done under neuraxial blockade or regional or local anesthesia. Eight percent of cases required blood transfusion at the FSC. As banked blood was not readily available, the FSC relied on fresh whole blood. Forty-nine percent of the operated cases were discharged from the FSC without needing transfer to the rear. In 85% of the cases, the surgical team was able to perform definitive surgery. Forty-seven percent of cases were transferred to the next level of surgical care. The overall survival of the trauma cases received at the FSC was 97.12% with a mortality of 2.88%. The leading cause of death was head and chest injuries. The results of this study are comparable to the results of the American experience in Iraq and Afghanistan. Conclusion: This study analyzes the data from a FSC to provide an analysis of the surgical case load in a counterinsurgency area. In spite of multiple limitations, the FSC provided definitive surgery to more than 85% of the trauma cases. The remaining 15% received emergency surgery and were later transferred to the next higher medical facility for superspecialty treatment. About half the number of patients were discharged from the FSC, implying that the true picture of combat trauma should be assessed at the level of FSC and not a referral/zonal hospital.
Keywords: Combat trauma, counter-insurgency operations, forward surgical center
| Introduction|| |
The forward surgical centers (FSCs) are traditionally considered to have the role of performing life and limb saving surgery in times of war, but their role in the counter-insurgency environment has not been adequately analyzed.
FSCs act as the first point of definitive or staging treatment for all cases of trauma. A large number of cases are discharged from the FSCs without ever needing to go to a hospital. Therefore, an analysis of the trauma workload at a FSC can provide a more realistic picture of trauma in forward combat zones.
| Methodology|| |
This is a retrospective data analysis study of all trauma cases managed at a FSC in a counter-insurgency operational area during a 2-year period.
The cases were followed up till they were discharged from FSC, referral hospital or died. The data were analyzed by parameters detailed in [Table 1].
Results of Data Analysis
The analysis of the data shows that approximately 1 in 3 cases of trauma reaching the FSC required some kind of operative intervention.
Age distribution analysis of the trauma cases shows that 76.4% cases were below the age of 35 years [Table 2]. The favorable results could be ascribed to the fact that these patients had good physiological reserves on account of their age.
[Figure 1] shows that the most common mode of injury seen at the FSC was penetrating trauma (59.61%); however, nonbattle trauma cases formed a significant part of cases at FSC (40.39%).
The most common region of the body involved was the extremities (59.62%), followed by multiple injuries (17.78%). This was followed by head and neck injuries (13.46%) [Figure 2].
The chest and abdomen injuries were less in numbers due to widespread use of bulletproof jackets. However, lack of protection on the flanks leads to some chest and abdominal trauma in spite of the jackets. Twelve of the 13 cases of chest injuries that reached the FSC alive survived to discharge.
Overall, a large number of cases of chest injuries died before reaching the hospital.
Prioritization of the cases is depicted in [Figure 3]. The majority of the cases (74%) were priority 2 cases that required early surgery. 14.4% of cases were in hypovolemic shock, due to excessive blood loss from the injury or delay in transport. Priority was assigned based on the standard triage classification of Indian Army.
The anesthesia technique chosen for the operated cases is shown in [Figure 4]. 38.94% of trauma cases required a general anesthetic. Surprisingly, a large number of cases were done under regional or local anesthesia (33.65%). This included some cases of Gun Shot Wound of chest where only tube thoracostomy was done along with wound debridement.
9.62% of cases had lost 2 l or more of blood before reaching the hospital. 8.17% of casualties required blood transfusion at FSC level and were managed with nonbanked fresh blood donations after screening for transfusion-transmitted diseases. In keeping with the Transfusion Requirements in Critical Care study, a lower transfusion trigger than the conventional 10 gm% was used.
Definitive surgery was done in 85.57% of cases received at the FSC. 37.02% of the operated cases required transfer to a referral center for superspecialty care or postoperative hospitalization. 48.55% of the operated cases were discharged from the FSC, without ever going to a referral hospital. 68.27% casualties arrived as single cases at FSC allowing us the time and resources to do definitive surgery in most cases.
The most common referrals were for orthopedics care. Postoperative ventilation was required in 4.80% of the cases. Of the cases transferred to referral hospital, 46.75% required evacuation to referral hospital by air. 3.85% of the cases required transfer on ventilator. This figure is of importance as such patients require larger helicopters for casualty evacuation.
Although the role of airborne transport in casualty evacuation is controversial in civilian situations, casevac by air is one of the most important factors to have reduced morbidity and mortality in the field due to trauma by reducing the time to reach a definitive center of surgical care.
[Figure 5] shows that overall 97.12% cases survived, of which 9.13% survived with significant disability. 2.88% cases died in the FSC or the referral hospital.
Although formal analysis was not carried out for the purpose of this paper, it seemed that approximately 9%–10% of the cases that were brought in dead might have been surgically salvageable. Delayed evacuation due to operational reasons, noncompressible hemorrhage from torso injuries, inability to evacuate the case due to enemy firing or nonavailability of air evacuation at night in the mountain terrain played a large role in the adverse outcome in these cases. The most common cause of death in the prehospital scenario was head injuries followed by chest injuries.
There were 57 instances of multiple casualties and 9 instances of mass casualty seen in 24 months of the study period.
| Discussion|| |
Caring for combat casualties presents health care providers with challenges unique to the military.
There are substantial differences between acute resuscitation of injured patients in the civilian and military arenas. These are the results of factors unique to combat, including the high energy and high lethality of wounding agents, multiple causes of wounding, preponderance of penetrating injury, persistence of threat in tactical settings, austere resource-constrained environment, and delayed access to definitive care.
Comparing our results with the forward surgical teams of US Army in Afghanistan and Iraq, we find that penetrating trauma accounts for 83% of the injuries in American experience, while in our study, it is only 59.61%. The most common site of injury in Operation Iraqi freedom and Operation Enduring Freedom is an extremity in 59% of the cases. This is same in our study results of 59.62%.
The in-hospital mortality of combat injuries has remained 2%–4% after World War 2 (WWII) and the overall mortality is 10%–20%. This is in spite of the fact that significant improvements have been made in trauma care since WWII. In this single-center experience, the in-hospital mortality was 2.88% and the overall mortality was 13.88%.
This number looks encouraging probably because some of the more seriously wounded die before reaching the hospital. An area that requires improvement is “time to hospital” and the “prehospital combat casualty care.” The average time to reach hospital in the American and Israeli experience is approximately 53 min. However, our subjective impression was that the evacuation time is much longer than in these studies although we were unable to quantify the time.
The leading cause of death is head injury followed by chest injuries in both American experience and our study.
There has been intense research in the field of tactical combat casualty care by the US army and Navy following their military operations in Afghanistan and Iraq. The lessons learned have been implemented in their ongoing operations and have helped them to improve survivability in the combat zone. These lessons are also being implemented by the armed forces medical services (AFMSF) in order to improve the survivability of our troops. We must also apply these evidence-based strategies and interventions for management of combat casualties during the prehospital phase and in-hospital surgical management.
Among the key lessons is the prevention of serious combat injuries especially torso and head injuries by use of proper protective body armor. The presently used bulletproof jackets and helmets have a scope for improvement because of which torso and head injuries are still the main cause of death in our setting as compared to the American experience where exsanguinations from limb injuries is the main cause of death.,
The leading cause of death in combat casualties is hemorrhagic shock, often due to prolonged evacuation time. The time required for the casualty to reach an FSC or hospital is determined by several factors like accessibility to the casualty due to ongoing enemy activity, mountain or desert terrain, weather, availability of transport by air or road. Casualty evacuation by air significantly reduces the time to reach the FSC and should be used wherever feasible.
Due to prolonged evacuation time to the FSC, good hemostasis in the prehospital setting can prove lifesaving. This includes the effective use of tourniquets, topical hemostatic agents like QUICKCLOT® and HEMCON® (chitosan based dressing), low volume resuscitation with 6% Hetastarch, permissive hypotension and prevention of hypothermia are other key factors in reducing blood loss in the prehospital and in hospital combat casualty care. In the FSC setting use of fresh whole blood for massive blood transfusion, preventing coagulopathy by using Fresh Frozen Plasma and platelets in the ratio of 1:1:1 with blood, damage control surgery and use of Tranexamic acid have helped in reducing mortality.,,,,,,
Truncal and junctional hemorrhages are not easily compressible or controllable in the prehospital scenario. In the recent past, some new devices have become commercially available and have been used to stop hemorrhage and improve survival. These include Resuscitative Endovascular Balloon Occlusion of the Aorta,, the Innovative Trauma Clamp, Junctional Tourniquets such as the Combat Ready Clamp (CRoC®), the SAM® Junctional Tourniquet, Abdominal Aortic Junctional Tourniquet®, and various types of pelvic binders.
Wide availability of these newer devices at the forward locations will go a long way in ensuring better prehospital combat casualty care. This will ensure that more combat casualties reach the FSC alive.
The transport of critically wounded casualties in a hostile environment especially at night is a challenging task. The air evacuation facilities of the Indian Airforce and Army have been doing an excellent job in evacuating casualties from operationally active zones.
| Conclusion|| |
This retrospective study highlights the pattern of injuries in counter-insurgency operations. It shows the significant role of FSCs in managing combat casualties in a forward area. It also suggests areas that require attention, namely casualty evacuation, prehospital combat casualty care, protective body armor, medical equipment and infrastructure, data collection and analysis, training, and research. This has important implications for future Military medical practice, planning, and logistics. Constant learning from our own past experience and also from experience of other army medical corps can further improve our management of combat casualties.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Hébert PC. Transfusion requirements in critical care (TRICC): A multicentre, randomized, controlled clinical study. Transfusion Requirements in Critical Care Investigators and the Canadian Critical care Trials Group. Br J Anaesth 1998;81 Suppl 1:25-33.
Lockey D. Aeromedical evacuation of the trauma patient. Trauma 1999;1:12-22.
Kellly JF, Ritenour AE. Injury severity and causes of death from operation Iraqi freedom and operation enduring freedom: 2003–2004 Versus 2006. J Trauma 2008;64:S21-7.
Champion HR, Bellamy RF. A profile of combat injury. J Trauma 2003;54:S13-9.
Beekley AC, Sebesta JA, Blackbourne LH, Herbert GS, Kauvar DS, Baer DG, et al
. Members of the 31st
Combat Support Hospital Research Group. Prehospital tourniquet use in operation Iraqi freedom: Effect on hemorrhage control and outcomes. J Trauma 2008;64:S28-37.
Rhee P, Brown C, Martin M, Salim A, Plurad D, Green D, et al
. Quik clot use in trauma for hemorrhage control: Case series of 103 documented uses. J Trauma 2008;64:1093-9.
Wedmore I, McManus JG, Pusateri AE, Holcomb JB. A special report on the chitosan-based hemostatic dressing: Experience in current combat operations. J Trauma 2006;60:655-8.
Repine TB, Perkins JG, Kauvar DS, Blackborne L. The use of fresh whole blood in massive transfusion. J Trauma 2006;60:S59-69.
Gonzalez EA, Moore FA, Holcomb JB, Miller CC, Kozar RA, Todd SR, et al
. Fresh frozen plasma should be given earlier to patients requiring massive transfusion. J Trauma 2007;62:112-9.
Fox CJ, Gillespie DL, Cox ED, Mehta SG, Kragh JF Jr., Salinas J, et al
. The effectiveness of a damage control resuscitation. Strategy for vascular injury in a combat support Hospital: Results of a case control study. J Trauma 2008;64:S99-107.
Shakur H, Roberts I, Bautista R, Caballero J, Coats T, Dewan Y, et al
.; The CRASH-2 Trial Collaborators. Effects of tranexamic acid on death, vascular occlusive events and blood transfusion in trauma patients with significant hemorrhage (CRASH-2): A randomized, placebo controlled trial. Lancet 2010;376:23-32.
Northern DM, Manley JD, Lyon R, Farber D, Mitchell BJ, Filak KJ, et al
. Recent advances in austere combat surgery: Use of aortic balloon occlusion as well as blood challenges by special operations medical forces in recent combat operations. J Trauma Acute Care Surg 2018;85 1 Suppl 2:S98-103.
Smith SA, Hilsden R, Beckett A, McAlister VC. The future of resuscitative endovascular balloon occlusion in combat operations. J R Army Med Corps 2017;163. pii: jramc-2017-000788.
Paquette R, Bierle R, Wampler D, Allen P, Cooley C, Ramos R, et al
. External soft-tissue hemostatic clamp compared to a compression tourniquet as primary hemorrhage control device in pilot flow model study. Prehosp Disaster Med 2019;34:175-81.
Meusnier JG, Dewar C, Mavrovi E, Caremil F, Wey PF, Martinez JY. Evaluation of two junctional tourniquets used on the battlefield: Combat ready clamp® versus SAM® junctional tourniquet. J Spec Oper Med 2016;16:41-6.
Lyon M, Shiver SA, Greenfield EM, Reynolds BZ, Lerner EB, Wedmore IS, et al
. Use of a novel abdominal aortic tourniquet to reduce or eliminate flow in the common femoral artery in human subjects. J Trauma Acute Care Surg 2012;73 2 Suppl 1:S103-5.
Van Oostendorp SE, Tan EC, Geeraedts LM. Prehospital control of life-threatening truncal and junctional haemorrhage is the ultimate challenge in optimizing trauma care; a review of treatment options and their applicability in the civilian trauma setting. Scand J Trauma Resusc Emerg Med 2016;24:110.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
[Table 1], [Table 2]