Adam J. Brooks

Military General Surgical Training Opportunities on Operations in Afghanistan

INTRODUCTION In the UK, general surgical specialist trainees have limited exposure to general surgical trauma. Previous work has shown that trainees are involved in only two blunt and one penetrating trauma laparotomies per annum. During their training, nearly half of trainees will not be involved in the surgical management of liver injury, 20% will not undertake a trauma splenectomy and only a quarter will see a trauma thoracotomy. Military general surgical trainees require training in, and exposure to, the surgical management of trauma and specifically military wounding patterns that is not available in the UK. The objective of this study was to determine whether operative workload in the sole British surgical unit in Helmand Province, Afghanistan (Operation HERRICK) would provide a training opportunity for military general surgical trainees. PATIENTS AND METHODS A retrospective theatre log-book review of all surgical cases performed at the Role 2 (Enhanced) treatment facility at Camp Bastion, Helmand Province on Operation HERRICK between October 2006 and October 2007, inclusive. Operative cases were analysed for general surgical trauma, laparotomy, thoracotomy, vascular trauma and specific organ injury management where available. RESULTS A total of 968 operative cases were performed during the study period. General surgical procedures included 51 laparotomies, 17 thoracotomies and 11 vascular repairs. There were a further 70 debridements of general surgical wounds. Specific organ management included five cases of liver packing for trauma, five trauma splenectomies and four nephrectomies. CONCLUSIONS A training opportunity currently exists on Operation HERRICK for military general surgical specialist trainees. If the tempo of the last 12 months is maintained, a 2-month deployment would essentially provide trainees with the equivalent trauma surgery experience to the whole of their surgical training in the UK NHS. Trainees would gain experience in military trauma as well as specific organ injury management.

Preparing the surgeon for war: present practices of US, UK, and Canadian militaries and future directions for the US military.

T Armed Forces of the United States and their North Atlantic Treaty Organization (NATO) partners continue to be engaged around the world in regions of conflict. Consequently, combat casualty care is a central focus of the military medical community. Accordingly, present deployment requirements demand the sustaining of a significant number of ready and capable trauma surgical providers to optimize outcome for injured combat casualties. Preparing a surgeon for war requires the development and maintenance of skill sets unique to the combat environment. Although modern graduate medical education (GME) surgical training provides civilian trauma case experience with a wide range of experience, it does not adequately prepare graduates of these programs for the injury patterns specific to the battlefield environment. Even among more senior surgical providers, the civilian practice does not adequately prepare the surgeon for combat experiences. Vascular trauma, as a particular example, constitutes a significant portion of the injuries observed in the setting of warfare; yet, the acquisition of the open surgical skills necessary to effectively manage these injuries continues to be considerably challenged both by recent changes in surgical training case volume and the increased use of endovascular techniques. Each branch of the US Armed Services, as well as Canadian and UK NATO partners, has established predeployment training efforts designed to prepare surgeons for dealing effectively with combat-injured. In the United States, these programs began with programs initiated at Ben Taub General Hospital in 1999 and have continued to evolve. Present efforts are highly varied, however, in their constructs and conduct between US branches and NATO partners. There is also evidence to suggest that these programs are not effectively used by deploying surgeons, at least among US military providers. A recent survey of 137 active-duty US military surgeons from all three services revealed that only 44% had attended any form of combat-related trauma predeployment course. The authors have examined the present trauma surgical readiness practices of the US Military Medical Corps, both active and reserve components as well as those of our Canadian and UK NATO partners. Members of each of those medical services have described the present requirements for their surgical community. Capabilities and challenges of each unique community are examined. In final consideration of these efforts, we provide potential options for further optimization of surgical readiness efforts for both present and future conflicts.

Blunt abdominal injuries

The management of blunt abdominal injury (BAI) has undergone quite significant changes over recent years. The emphasis is now on the recognition and limitation of the underlying metabolic insult associated with severe abdominal injury. The concepts of damage control and non-operative management while seeming diametrically opposed have both found favour in selected patient groups. The interventional radiologist has opened a new dimension in the control of inaccessible bleeding and is able to contribute to non-operative approaches. The complimentary use of the methods of investigation available for BAI will also improve the accuracy and specificity of diagnosis allowing more appropriate management. Embracing these new concepts of management by all institutions dealing with trauma victims will hopefully reduce the morbidity and mortality of BAI.

Selective non-operative management of penetrating liver injuries at a UK tertiary referral centre

INTRODUCTION Selective non-operative management (SNOM) of penetrating abdominal injuries has increasingly been applied in North America in the last decade. However, there is less acceptance of SNOM among UK surgeons and there are limited data on UK practice. We aimed to review our management of penetrating liver injuries and, specifically, the application of SNOM. METHODS A retrospective review was performed of patients presenting with penetrating liver injuries between June 2005 and November 2013. RESULTS Thirty-one patients sustained liver injuries due to penetrating trauma. The vast majority (97%) were due to stab wounds. The median injury severity score was 14 and a quarter of patients had concomitant thoracic injuries. Twelve patients (39%) underwent immediate surgery owing to haemodynamic instability, evisceration, retained weapon or diffuse peritonism. Nineteen patients were stable to undergo computed tomography (CT), ten of whom were selected subsequently for SNOM. SNOM was successful in eight cases. Both patients who failed SNOM had arterial phase contrast extravasation evident on their initial CT. Angioembolisation was not employed in either case. All major complications and the only death occurred in the operatively managed group. No significant complications of SNOM were identified and there were no transfusions in the non-operated group. Those undergoing operative management had longer lengths of stay than those undergoing SNOM (median stay 6.5 vs 3.0 days, p<0.05). CONCLUSIONS SNOM is a safe strategy for patients with penetrating liver injuries in a UK setting. Patient selection is critical and CT is a vital triage tool. Arterial phase contrast extravasation may predict failure of SNOM and adjunctive angioembolisation should be considered for this group.

The Use of Improvised Bullet Markers with 3D CT Reconstruction in the Evaluation of Penetrating Trauma

Radio-opaque markers placed over entry and exit wounds, have been used to help evaluate penetrating injuries and provide a permanent record of wound location on plain radiographs. To date there are no published reports of the application of improvised bullet markers in the evaluation of penetrating injuries using computed tomography (CT). We report a series of 4 cases where bullet markers were used in combination with three-dimensional (3D) computerised tomography (CT) to ascertain the path of the bullets and to assess damage to vital structures. We believe that the use of bullet markers in penetrating trauma casualties undergoing CT is valuable in the surgical decision making process and allows planning of surgical approaches.

Direct determination of trace elements in austenitic stainless steel samples by ETV-ICPOES

Electrothermal vaporization (ETV) coupled to inductively coupled plasma optical emission spectrometry (ICPOES) was applied to the direct analysis of austenitic stainless steel powders using external calibration with increasing amounts of urban particulate matter (NIST 1648a) certified reference material. The method was first validated through the analysis of a reference material of free cutting steel, BCS 152/3, which was also analysed, following digestion in aqua regia, by ICPOES with external calibration using matrix-matched standard solutions. A four-step heating program, where the 30 s vaporization step was not ramped and followed a cooling step after pyrolysis, was used along with hemi-spherical graphite boats and trifluoromethane (CHF3, freon R-23) reaction gas, which resulted in sharp analyte signal peaks. Internal standardization with an argon emission line (415.859 nm) was applied throughout to compensate for sample loading effects on the plasma, improve the signal-to-background ratio and extend the linear dynamic range. Quantification limits ranged from 0.02 (Cd) to 200 (Si) μg g−1 in the solid using 5 mg aliquots, and are one or two orders of magnitude lower than those obtained by ICPOES with nebulization for several elements. The proposed method allowed determination of Al, Cd, Ce, Co, Cu, Mn, Pb, S, Si, Ti, V and Zn at levels in the 10 μg g−1 to 0.4% (m m−1) range, in agreement with results obtained by ICPOES following digestion. The method is suitable for alloy quality control, as it drastically reduces analysis time and cost by eliminating the acid digestion step altogether, which is quite attractive for industrial applications.

Recent advances in trauma management

Twenty-three thousand doctors in the UK have undertaken The Advanced Trauma Life Support Course for doctors over the past 12 years. The course was never designed to provide anything more than a framework within which inexperienced doctors could safely manage multiple injured patients until expert help arrived. Its critics will say that the course is didactic and its treatment protocols are not always up to date. Since its inception in 1976 in Nebraska it has undergone constant revision and the seventh edition of the course will appear in 2002. With each revision, evidence for new methods of management for the trauma victims are reviewed; some of these are discussed in this paper.

Damage control: The modern paradigm

It is more than 20 years since the term ‘Damage control’ was introduced to describe an emerging surgical strategy of abbreviated laparotomy for exsanguinating trauma patients. This strategy of temporisation and prioritisation of physiological recovery over completeness of anatomical repair was associated with improved survival in a subset of patients with combined major vascular and multiple visceral injuries. The ensuing years saw the rapid adoption of these principles as standard of care for massively injured and physiologically exhausted patients. Resuscitation of severely injured patients has changed significantly in the last decade with the emergence of a new resuscitation paradigm termed ‘damage control resuscitation’. Originating in combat support hospitals, damage control resuscitation emphasises the primacy of haemorrhage control while directly targeting the ‘lethal triad’ of coagulopathy, acidosis, and hypothermia. Integral to damage control resuscitation is the appropriate application of damage control surgery and together they constitute the modern damage control paradigm. This review aims to discuss the modern application of damage control resuscitation and damage control surgery and to review the evidence supporting its constituent components, as well as considering deficiencies in current knowledge and areas for future research.

Damage Control Surgery: Concepts

Damage Control Surgery (DCS) is an operative strategy that sacrifices the completeness of the immediate surgical repair in order to address the physiological consequences of the combined trauma of the injury and surgery. In the past this has been very much focussed on abdominal trauma and the idea of performing an “abbreviated laparotomy.” However the concepts outlined here are applicable to injury beyond the abdomen.1-3

Spectral and raw quasi in-situ energy dispersive X-ray data captured via a TEM analysis of an ODS austenitic stainless steel sample under 1 MeV Kr2+ high temperature irradiation

The data presented in this article is related to the research experiment, titled: ‘Quasi in-situ energy dispersive X-ray spectroscopy observation of matrix and solute interactions on Y-Ti-O oxide particles in an austenitic stainless steel under 1 MeV Kr2+ high temperature irradiation’ (Brooks et al., 2017) [1]. Quasi in-situ analysis during 1 MeV Kr2+ 520 °C irradiation allowed the same microstructural area to be observed using a transmission electron microscope (TEM), on an oxide dispersion strengthened (ODS) austenitic stainless steel sample. The data presented contains two sets of energy dispersive X-ray spectroscopy (EDX) data collected before and after irradiation to 1.5 displacements-per-atom (~1.25×10−3 dpa/s with 7.5×1014 ions cm−2). The vendor software used to process and output the data is the Bruker Esprit v1.9 suite. The data includes the spectral (counts vs. keV energy) of the quasi in-situ scanned region (512×512 pixels at 56k magnification), along with the EDX scanning parameters. The.raw files from the Bruker Esprit v1.9 output are additionally included along with the.rpl data information files. Furthermore included are the two quasi in-situ HAADF images for visual comparison of the regions before and after irradiation. This in-situ experiment is deemed ‘quasi’ due to the thin foil irradiation taking place at an external TEM facility. We present this data for critical and/or extended analysis from the scientific community, with applications applying to: experimental data correlation, confirmation of results, and as computer based modeling inputs.