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COMMENTARY
Ahead of print publication  

Commentary on: “Management of trauma cases at a forward surgical center in counter insurgency ops


 Prof. and HOD, Department of Anaesthesiology and Critical Care, Armed Forces Medical College, Pune, Maharashtra, India

Date of Submission27-May-2020
Date of Acceptance02-Jul-2020
Date of Web Publication21-Sep-2020

Correspondence Address:
Brig Rangraj Setlur,
Department of Anaesthesiology and Critical Care, Armed Forces Medical College, Pune - 411 040, Maharashtra
India
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jmms.jmms_66_20



How to cite this URL:
Setlur BR. Commentary on: “Management of trauma cases at a forward surgical center in counter insurgency ops. J Mar Med Soc [Epub ahead of print] [cited 2020 Nov 24]. Available from: https://www.marinemedicalsociety.in/preprintarticle.asp?id=295639



Military trauma care is frequently carried out in hostile and suboptimal conditions. It is, therefore, a continuous compromise between what is ideal and what is practical. It differs from standard trauma care in certain key features. The patient and the paramedic may both be under fire while treatment is in progress. To save a life, it may be more important in the initial period to return fire and establish a safety parameter than to provide medical care. In the prehospital period, there are only a limited number of interventions, which have been shown to reduce mortality – Application of a tourniquet, and decompression of a tension pneumothorax are key interventions.[1] In the Indian Army, difficult terrain, and the logistics of evacuation in inhospitable conditions can result in casualties being held in staging posts with very basic medical facilities for much longer periods than that would be considered advisable in ideal circumstances. These considerations make articles such as the one by Jahan N in this issue titled “Management of trauma cases at a forward surgical centre in counter-insurgency ops,” especially valuable, as they describe the scenario in less than ideal situations, providing both lessons as well as opportunities. The author provides a profile of the cases seen and makes the case that a forward surgical centre by nature of its proximity to the battleground is ideally suited to provide not only staging care but also definitive surgical interventions in a number of cases. This makes these units extremely important in counter-insurgency situations. The author also stresses the lifesaving importance of air evacuations in these situations.

The value of these lessons is not limited to military trauma. They have also been widely extrapolated to civilian trauma, and have resulted in significant improvements in the care of trauma patients in general. There have, for instance, been major changes in the policy of prehospital fluid resuscitation, which have been directly derived from the experience of evacuating wounded soldiers from the field. These changes have happened so imperceptibly that it is only when one looks back for 10–20 years that one realizes how much the landscape has altered. This applies, especially to prehospital fluid management in trauma patients.[2] Over the years, the philosophy has changed from emphasizing “organ perfusion” to an approach where “clot stabilisation” has been given priority practically to the exclusion of everything else. This has also reemphasized the importance of effective hemostasis and tranexamic acid.[3],[4] A number of these changes have become part of the current dogma and been in recent trauma guidelines. It is possible that more changes will be on the way. Do the current recommendations apply in ALL situations? Military trauma on the borders of this country has unique challenges due to the extremely difficult terrain and hostile weather. What if one is 6 h away from the nearest medical facility? What if one has to carry fluids on a long patrol, and colloids give a better expansion for an equal weight than crystalloids? What is the role of Forward Surgical Centres, and how should we conceptualize their role for future? Articles such as the one under reference written by an author who has treated casualties on the ground, and who has a detailed understanding of the practical challenges involved are especially valuable and provide a starting point for discussing future changes. What does future look like? Assessing compensatory reserve as a means of assessing shock and fluid requirements,[5] improved targeting of antifibrinolytics using dynamic indicators of coagulation[6] and the replacement of fresh-frozen plasma by fibrinogen concentrates[7] are at least some of the changes one can anticipate. These recent advances, when considered in the context of articles such as this one, should help us in planning future facilities and training required for Forward Surgical Centres in the Armed Forces Medical Services.



 
  References Top

1.
Butler Jr FK, Holcomb JB, Shackelford S, Barbabella S, Bailey JA, Baker JB, et al. Advanced Resuscitative Care in Tactical Combat Casualty Care: TCCC Guidelines Change 18-01:14 October 2018. J Spec Oper Med 2018;18:37-55  Back to cited text no. 1
    
2.
Hussmann B, Lefering R, Waydhas C, Touma A, Kauther MD, Ruchholtz S, et al. Does increased prehospital replacement volume lead to a poor clinical course and an increased mortality? A matched-pair analysis of 1896 patients of the Trauma Registry of the German Society for Trauma Surgery who were managed by an emergency doctor at the accident site. Injury 2013;44:611-7. Available from: http://dx.doi.org/10.1016/j.injury.2012.02.004.  Back to cited text no. 2
    
3.
Roberts I, Shakur H, Coats T, Hunt B, Balogun E, Barnetson L, et al. The CRASH-2 trial: A randomised controlled trial and economic evaluation of the effects of tranexamic acid on death, vascular occlusive events and transfusion requirement in bleeding trauma patients. Health Technol Assess 2013;17:1-79.  Back to cited text no. 3
    
4.
Morrison JJ, Dubose JJ, Rasmussen TE, Midwinter MJ. Military application of tranexamic acid in trauma emergency resuscitation (MATTERs) study. Arch Surg 2012;147:113-9.  Back to cited text no. 4
    
5.
Van Sickle C, Schafer K, Mulligan J, Grudic GZ, Moulton SL, Convertino VA. A sensitive shock index for real-time patient assessment during simulated hemorrhage. Aviat Space Environ Med 2013;84:907-12.  Back to cited text no. 5
    
6.
Walsh M, Shreve J, Thomas S, Moore E, Moore H, Hake D, et al. Fibrinolysis in Trauma: “Myth,” “Reality,” or “Something in Between”. Semin Thromb Hemost 2017;43:200-12.  Back to cited text no. 6
    
7.
Innerhofer P, Fries D, Mittermayr M, Innerhofer N, von Langen D, Hell T, et al. Reversal of trauma-induced coagulopathy using first-line coagulation factor concentrates or fresh frozen plasma (RETIC): A single-centre, parallel-group, open-label, randomised trial. Lancet Haematol 2017;4:e258-71.  Back to cited text no. 7
    




 

 
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