Arul Ramasamy

Injuries from roadside improvised explosive devices.

BACKGROUND After the invasion of Iraq in April 2003, coalition forces have remained in the country in a bid to maintain stability and support the local security forces. The improvised explosive device (IED) has been widely used by the insurgents and is the leading cause of death and injury among Coalition troops in the region. METHOD From January 2006, data were prospectively collected on 100 consecutive casualties who were either injured or killed in hostile action. Mechanism of injury, new Injury Severity Score (NISS), The International Classification of Disease-9th edition diagnosis, anatomic pattern of wounding, and operative management were recorded in a trauma registry. The weapon incident reports were analyzed to ascertain the type of IED employed. RESULTS Of the 100 casualties injured in hostile action, 53 casualties were injured by IEDs in 23 incidents (mean 2.3 casualties per incident). Twenty-one of 23 (91.3%) of the IEDs employed were explosive formed projectile (EFP) type. Twelve casualties (22.6%) were either killed or died of wounds. Median NISS score of survivors was 3 (range, 1-50). All fatalities sustained unsurvivable injuries with a NISS score of 75. Primary blast injuries were seen in only 2 (3.8%) and thermal injuries in 8 casualties (15.1%). Twenty (48.7%) of survivors underwent surgery by British surgeons in the field hospital. At 18 months follow, all but one of the United Kingdom Service personnel had returned to military employment. CONCLUSIONS The injury profile seen with EFP-IEDs does not follow the traditional pattern of injuries seen with conventional high explosives. Primary blast injuries were uncommon despite all casualties being in close proximity to the explosion. When the EFP-IED is detonated, the EFP produced results in catastrophic injuries to casualties caught in its path, but causes relatively minor injuries to personnel sited adjacent to its trajectory. Improvements in vehicle protection may prevent the EFP from entering the passenger compartments and thereby reduce fatalities.

Improvised Explosive Devices: Pathophysiology, Injury Profiles and Current Medical Management

The Improvised Explosive Device (IED), in all its forms, has become the most significant threat to troops operating in Afghanistan and Iraq. These devices range fromrudimentary homemade explosives to sophisticated weapon systems containing high-grade explosives. Within this broad definition they may be classified as Roadside explosives and blast mines, Explosive Formed Pojectile (EFP) devices and Suicide bombings. Each of these groups cause injury through a number of different mechanisms and can result in vastly different injury profiles. The “Global War on Terror” has meant that incidents which were previously exclusively seen in conflict areas, can occur anywhere, and clinicians who are involved in emergency trauma caremay be required tomanage casualties fromsimilar terrorist attacks. An understanding of the types of devices and their pathophysiological effects is necessary to allow proper planning of mass casualty events and to allow appropriate management of the complex poly-trauma casualties they invariably cause. The aim of this review article is to firstly describe the physics and injury profile from these different devices and secondly to present the current clinical evidence that underpins their medical management.

A review of casualties during the Iraqi insurgency 2006–A British field hospital experience

BACKGROUND Following the invasion of Iraq in April 2003, British and coalition forces have been conducting counter-insurgency operations in the country. As this conflict has evolved from asymmetric warfare, the mechanism and spectrum of injury sustained through hostile action (HA) was investigated. METHOD Data was collected on all casualties of HA who presented to the British Military Field Hospital Shaibah (BMFHS) between January and October 2006. The mechanism of injury, anatomical distribution, ICD-9 diagnosis and initial discharge information was recorded for each patient in a trauma database. RESULTS There were 104 HA casualties during the study period. 18 were killed in action (KIA, 21%). Of the remaining 86 surviving casualties, a further three died of their wounds (DOW, 3.5%). The mean number of diagnoses per survivor was 2.70, and the mean number of anatomical regions injured was 2.38. Wounds to the extremities accounted for 67.8% of all injuries, a percentage consistent with battlefield injuries sustained since World War II. Open wounds and fractures were the most common diagnosis (73.8%) amongst survivors of HA. Improvised explosive devices (IEDs) accounted for the most common cause of injury amongst casualties (54%). CONCLUSIONS Injuries in conflict produce a pattern of injury that is not seen in routine UK surgical practice. In an era of increasing surgical sub-specialisation, the deployed surgeon needs to acquire and maintain a wide range of skills from a variety of surgical specialties. IEDs have become the modus operandi for terrorists. In the current global security situation, these tactics can be equally employed against civilian targets. Therefore, knowledge and training in the management of these injuries is relevant to both military and civilian surgeons.

Predicting the need for early amputation in ballistic mangled extremity injuries.

BACKGROUND Despite modern advances, amputation is still a commonly performed operation in war. It is often difficult to decide whether to amputate after high-energy trauma to the lower extremity. To help guide this assessment, scoring systems have been developed with amputation threshold values. These studies were all conducted on a civilian population, encompassing a wide range of ages and methods of injury. The evidence for their sensitivity and specificity is inconclusive. The aim of this study was to assess the validity of the mangled extremity severity score (MESS), the only verified score, in a population of UK military patients with ballistic mangled extremity injuries. METHODS We identified from the prospectively kept Joint Theater Trauma Registry all patients who had sustained ballistic lower limb open fractures during the recent conflicts in Iraq and Afghanistan (May 2003-April 2008). Demographics were assessed using both the trauma audit and the hospital notes. Patients were retrospectively evaluated with the MESS system for lower extremity trauma. Those that required an amputation were compared with those that had successful limb salvage. RESULTS Seventy-seven military patients with 86 limbs who had ballistic mangled extremity injuries were identified, 22 of whom required amputation. The MESS did not help to decide whether or not an amputation was appropriate and in particular, the age was not relevant. A skeletal score of 4, while being associated with a higher amputation rate, was not predictive of its need. Most amputations were performed when an ischemic limb was present, and the general condition of the casualty precluded the lengthy reconstruction required for salvage. CONCLUSIONS The management of ballistic extremity injuries in military patients should be considered separate to that of civilians with high-energy trauma extremity injuries. The authors have identified important factors in the management, in particular the need for early amputation, of the military mangled extremity.

Learning the lessons from conflict: pre-hospital cervical spine stabilisation following ballistic neck trauma

BACKGROUND Current ATLS protocols dictate that spinal precautions should be in place when a casualty has sustained trauma from a significant mechanism of injury likely to damage the cervical spine. In hostile environments, the application of these precautions can place pre-hospital medical teams at considerable personal risk. It may also prevent or delay the identification of airway problems. In todays global threat from terrorism, this hostile environment is no longer restricted to conflict zones. The aim of this study was to ascertain the incidence of cervical spine injury following penetrating ballistic neck trauma in order to evaluate the need for pre-hospital cervical immobilisation in these casualties. METHODS We retrospectively reviewed the medical records of British military casualties of combat, from Iraq and Afghanistan presenting with a penetrating neck injury during the last 5.5 years. For each patient, the mechanism of injury, neurological state on admission, medical and surgical intervention was recorded. RESULTS During the study period, 90 casualties sustained a penetrating neck injury. The mechanism of injury was by explosion in 66 (73%) and from gunshot wounds in 24 (27%). Cervical spine injuries (either cervical spine fracture or cervical spinal cord injury) were present in 20 of the 90 (22%) casualties, but only 6 of these (7%) actually survived to reach hospital. Four of this six subsequently died from injuries within 72 h. Only 1 (1.8%) of the 56 survivors to reach a surgical facility sustained an unstable cervical spine injury that required surgical stabilisation. This patient later died as result of a co-existing head injury. CONCLUSIONS Penetrating ballistic trauma to the neck is associated with a high mortality rate. Our data suggests that it is very unlikely that penetrating ballistic trauma to the neck will result in an unstable cervical spine in survivors. In a hazardous environment (e.g. shooting incidents or terrorist bombings), the risk/benefit ratio of mandatory spinal immobilisation is unfavourable and may place medical teams at prolonged risk. In addition cervical collars may hide potential life-threatening conditions.

Blast mines: physics, injury mechanisms and vehicle protection

Since World War II, more vehicles have been lost to land mines than all other threats combined. Anti-vehicular (AV) mines are capable of disabling a heavy vehicle, or completely destroying a lighter vehicle. The most common form of AV mine is the blast mine, which uses a large amount of explosive to directly damage the target. In a conventional military setting, landmines are used as a defensive force-multiplier and to restrict the movements of the opposing force. They are relatively cheap to purchase and easy to acquire, hence landmines are also potent weapons in the insurgents’ armamentarium. The stand-off nature of its design has allowed insurgents to cause significant injuries to security forces in current conflicts with little personal risk. As a result, AV mines and improvised explosive devices (IEDs) have become the most common cause of death and injury to Coalition and local security forces operating in Iraq and Afghanistan. Detonation of an AV mine causes an explosive, exothermic reaction which results in the formation of a shockwave followed by a rapid expansion of gases. The shockwave is mainly reflected by the soil/air interface and fractures the soil cap over the mine. The detonation products then vent through the voids in the soil, resulting in a hollow inverse cone which consists of the detonation gases surrounded by the soil ejecta. It is the combination of the detonation products and soil ejecta that interact with the target vehicle and cause injury to the vehicle occupants. A number of different strategies are required to mitigate the blast effects of an explosion. Primary blast effects can be reduced by increasing the standoff distance between the seat of the explosion and the crew compartment. Enhancement of armour on the base of the vehicle, as well as improvements in personal protection can prevent penetration of fragments. Mitigating tertiary effects can be achieved by altering the vehicle geometry and structure, increasing vehicle mass, as well as developing new strategies to reduce the transfer of the impulse through the vehicle to the occupants. Protection from thermal injury can be provided by incorporating fire resistant materials into the vehicle and in personal clothing. The challenge for the vehicle designer is the incorporation of these protective measures within an operationally effective platform.

Skill sets and competencies for the modern military surgeon: lessons from UK military operations in Southern Afghanistan

INTRODUCTION British military forces remain heavily committed on combat operations overseas. UK military operations in Afghanistan (Operation HERRICK) are currently supported by a surgical facility at Camp Bastion, in Helmand Province, in the south of the country. There have been no large published series of surgical workload on Operation HERRICK. The aim of this study is to evaluate this information in order to determine the appropriate skill set for the modern military surgical team. METHOD A retrospective analysis of operating theatre records between 1st May 2006 and 1st May 2008 was performed. Data was collated on a monthly basis and included patient demographics, operation type and time of operation. RESULTS During the study period 1668 cases required 2210 procedures. Thirty-two per cent were coalition forces (ISAF), 27% were Afghan security forces (ANSF) and 39% were civilians. Paediatric casualties accounted for 14.7% of all cases. Ninety-three per cent of cases were secondary to battle injury and of these 51.3% were emergencies. The breakdown of procedures, by specialty, was 66% (1463) orthopaedic, 21% (465) general surgery, 6% (139) head and neck, 5% (104) burns surgery and a further 4% (50) non-battle, non-emergency procedures. There was an almost twofold increase in surgical workload in the second year (1103 cases) compared to the first year of the deployment (565 cases, p<0.05). DISCUSSION Surgical workload over the study period has clearly increased markedly since the initial deployment of ISAF forces to Helmand Province. A 6-week deployment to Helmand Province currently provides an equivalent exposure to penetrating trauma as 3 years trauma experience in the UK NHS. The spectrum of injuries seen and the requisite skill set that the military surgeon must possess is outside that usually employed within the NHS. A number of different strategies; including the deployment of trainee specialist registrars to combat hospitals, more focused pre-deployment military surgery training courses, and wet-laboratory work are proposed to prepare for future generations of surgeons operating in conflict environments.

Penetrating Missile Injuries During the Iraqi Insurgency

INTRODUCTION Since the invasion of Iraq in 2003, the conflict has evolved from asymmetric warfare to a counter-insurgency operation. This study investigates the pattern of wounding and types of injuries seen in casualties of hostile action presenting to a British military field hospital during the present conflict. PATIENTS AND METHODS Data were prospectively collected on 100 consecutive patients either injured or killed from hostile action from January 2006 who presented to the sole coalition field hospital in southern Iraq. RESULTS Eighty-two casualties presented with penetrating missile injuries from hostile action. Three subsequently died of wounds (3.7%). Forty-six (56.1%) casualties had their initial surgery performed by British military surgeons. Twenty casualties (24.4%) sustained gunshot wounds, 62 (75.6%) suffered injuries from fragmentation weapons. These 82 casualties were injured in 55 incidents (mean, 1.49 casualties; range 1-6 casualties) and sustained a total 236 wounds (mean, 2.88 wounds) affecting a mean 2.4 body regions per patient. Improvised explosive devices were responsible for a mean 2.31 casualties (range, 1-4 casualties) per incident. CONCLUSIONS The current insurgency in Iraq illustrates the likely evolution of modern, low-intensity, urban conflict. Improvised explosive devices employed against both military and civilian targets have become a major cause of injury. With the current global threat from terrorist bombings, both military and civilian surgeons should be aware of the spectrum and emergent management of the injuries caused by these weapons.

Modern military surgery

The types of explosive devices used in warfare and the pattern of war wounds have changed in recent years. There has, for instance, been a considerable increase in high amputation of the lower limb and unsalvageable leg injuries combined with pelvic trauma. The conflicts in Iraq and Afghanistan prompted the Department of Military Surgery and Trauma in the United Kingdom to establish working groups to promote the development of best practice and act as a focus for research. In this review, we present lessons learnt in the initial care of military personnel sustaining major orthopaedic trauma in the Middle East.

Complications of extremity vascular injuries in conflict

INTRODUCTION The extremities remain the most common sites of wounding in conflict, are associated with a significant incidence of vascular trauma, and have a high complication rate (infection, secondary amputation, and graft thrombosis). AIM The purpose of this study was to study the complication rate after extremity vascular injury. In particular, the aim was to analyze whether this was influenced by the presence or absence of a bony injury. METHODS A prospectively maintained trauma registry was retrospectively reviewed for all UK military casualties with extremity injuries (Abbreviated Injury Score >1) December 8, 2003 to May 12, 2008. Demographics and the details of their vascular injuries, management, and outcome were documented using the trauma audit and medical notes. RESULTS Thirty-four patients (34%)--37 limbs (30%)--had sustained a total of 38 vascular injuries. Twenty-eight limbs (22.6%) had an associated fracture, 9 (7.3%) did not. Twenty-nine limbs (23.4%) required immediate revascularization to preserve their limb: 16 limbs (13%) underwent an initial Damage Control procedure, and 13 limbs (10.5%) underwent Definitive Surgery. Overall, there were 25 limbs (20.2%) with complications. Twenty-two were in the 28 limbs with open fractures, 3 were in the 9 limbs without a fracture (p < 0.05). There was no significant difference in the complication rate with respect to upper versus lower limb and damage control versus definitive surgery. CONCLUSION We have demonstrated that prognosis is worse after military vascular trauma if there is an associated fracture, probably due to higher energy transfer and greater tissue damage.