Edward C.T.H. Tan

Systematic review of the prevalence and characteristics of battle casualties from NATO coalition forces in Iraq and Afghanistan

BACKGROUNDnThe North Atlantic Treaty Organization (NATO) coalition forces remain heavily committed on combat operations overseas. Understanding the prevalence and characteristics of battlefield injury of coalition partners is vital to combat casualty care performance improvement. The aim of this systematic review was to evaluate the prevalence and characteristics of battle casualties from NATO coalition partners in Iraq and Afghanistan. The primary outcome was mechanism of injury and the secondary outcome anatomical distribution of wounds.nnnMETHODSnThis systematic review was performed based on all cohort studies concerning prevalence and characteristics of battlefield injury of coalition forces from Iraq and Afghanistan up to December 20th 2013. Studies were rated on the level of evidence provided according to criteria by the Centre for Evidence Based Medicine in Oxford. The methodological quality of observational comparative studies was assessed by the modified Newcastle-Ottawa Scale.nnnRESULTSnEight published articles, encompassing a total of n=19,750 battle casualties, were systematically analyzed to achieve a summated outcome. There was heterogeneity among the included studies and there were major differences in inclusion and exclusion criteria regarding the target population among the included trials, introducing bias. The overall distribution in mechanism of injury was 18% gunshot wounds, 72% explosions and other 10%. The overall anatomical distribution of wounds was head and neck 31%, truncal 27%, extremity 39% and other 3%.nnnCONCLUSIONSnThe mechanism of injury and anatomical distribution of wounds observed in the published articles by NATO coalition partners regarding Iraq and Afghanistan differ from previous campaigns. There was a significant increase in the use of explosive mechanisms and a significant increase in the head and neck region compared with previous wars.

Retention of first aid and basic life support skills in undergraduate medical students

Background Undergraduate medical students follow a compulsory first aid (FA) and basic life support (BLS) course. Retention of BLS seems poor and only little information is provided on the retention of FA skills. This study aims at evaluating 1- and 2-year retention of FA and BLS training in undergraduate medical students. Methods One hundred and twenty students were randomly selected from first year (n=349) medical students who successfully followed a compulsory FA and BLS course. From these 120 students, 94 (78%) and 69 (58%) participated in retention tests of FA and BLS skills after 1 and 2 years, respectively. The assessment consisted of two FA stations and one BLS station. Results After 1 year, only 2% passed both FA and BLS stations and 68% failed both FA and BLS stations. After 2 years, 5% passed and 50% failed both FA and BLS stations. Despite the high failure rate at the stations, 90% adequately checked vital signs and started cardiopulmonary resuscitation appropriately. Conclusions The long-term retention of FA and BLS skills after a compulsory course in the first year is poor. Adequate check of vital signs and commencing cardiopulmonary resuscitation retained longer.Background Undergraduate medical students follow a compulsory first aid (FA) and basic life support (BLS) course. Retention of BLS seems poor and only little information is provided on the retention of FA skills. This study aims at evaluating 1- and 2-year retention of FA and BLS training in undergraduate medical students. Methods One hundred and twenty students were randomly selected from first year (n=349) medical students who successfully followed a compulsory FA and BLS course. From these 120 students, 94 (78%) and 69 (58%) participated in retention tests of FA and BLS skills after 1 and 2 years, respectively. The assessment consisted of two FA stations and one BLS station. Results After 1 year, only 2% passed both FA and BLS stations and 68% failed both FA and BLS stations. After 2 years, 5% passed and 50% failed both FA and BLS stations. Despite the high failure rate at the stations, 90% adequately checked vital signs and started cardiopulmonary resuscitation appropriately. Conclusions The long-term retention of FA and BLS skills after a compulsory course in the first year is poor. Adequate check of vital signs and commencing cardiopulmonary resuscitation retained longer.

Review of 58 patients with necrotizing fasciitis in the Netherlands

BackgroundNecrotizing fasciitis is a rare, life threatening soft tissue infection, primarily involving the fascia and subcutaneous tissue. In a large cohort of patients presenting with Necrotizing fasciitis in the Netherlands we analysed all available data to determine the causative pathogens and describe clinical management and outcome.MethodsWe conducted a retrospective, multicentre cohort study of patients with a necrotizing fasciitis between January 2003 and December 2013 in an university medical hospital and three teaching hospitals in the Netherlands. We only included patients who stayed at the Intensive Care Unit for at least one day.ResultsFifty-eight patients were included. The mortality rate among those patients was 29.3xa0%. The central part of the body was affected in 28 patients (48.3xa0%) and in 21 patients (36.2xa0%) one of the extremities. Most common comorbidity was cardio vascular diseases in 39.7xa0%. Thirty-nine patients (67.2xa0%) were operated within 24xa0h after presentation. We found a type 1 necrotizing fasciitis in 35 patients (60.3xa0%) and a type 2 in 23 patients (39.7xa0%).ConclusionsOur study, which is the largest study in Europe, reaffirmed that Necrotizing fasciitis is a life threatening disease with a high mortality. Early diagnosis and adequate treatment are necessary to improve the clinical outcome. Clinical awareness off necrotizing fasciitis remains pivotal.

Prehospital use of hemostatic dressings in emergency medical services in the Netherlands: A prospective study of 66 cases

BACKGROUNDnUncontrolled haemorrhage is the leading cause of potentially preventable death in both civilian and military trauma patients. Animal studies and several case series have shown that hemostatic dressings reduce haemorrhage and might improve survival. One of these products is HemCon ChitoGauze(®). The objective of this study was to determine the effectiveness and safety of ChitoGauze in achieving hemostasis in massive traumatic bleeding in civilian emergency medical services.nnnMETHODSnFrom June 2012 to December 2014, all ambulances of two emergency medical services in the Netherlands were equipped with ChitoGauze. The dressing was used according to protocol; if conventional treatment (gauze dressing with manual pressure) failed to control external traumatic bleeding or if conventional treatment was unlikely to achieve hemostasis. The ambulance personnel filled in an evaluation form after each use.nnnRESULTSnA total of 66 patients were treated with ChitoGauze during the study period. Twenty-one patients were taking anticoagulants or suffered from a clotting disorder. The injuries were located in the extremities (n=29), the head and face (n=29), or the neck, thorax and groin (n=8). In 46/66 patients, the use of ChitoGauze resulted in cessation of haemorrhage. In 13/66 patients, Chitogauze application reduced haemorrhage. ChitoGauze failed to control haemorrhage in 7/66 patients, whereby user error was a contributing factor in 3 of these failures. No side effects have been observed during treatment or transport of the patients and no adverse effects have been reported in discharge letters.nnnCONCLUSIONnThis is the largest prospective study in civilian healthcare and the second largest case series with prehospital use of hemostatic dressings. It demonstrated that ChitoGauze is an effective and safe adjunct in the prehospital treatment of massive external traumatic haemorrhage.

Combat related vascular injuries: Dutch experiences from a role 2 MTF in Afghanistan

BACKGROUNDnIn a combat environment, major vascular trauma endures as the leading cause of death. The Dutch role 2 Medical Treatment Facility (MTF), provided supportive care during the mission in Uruzgan, Afghanistan. Aim of this study was to conduct detailed analysis of the admitted major haemorrhages (vascular injuries) and to compare our findings with NATO coalition partners.nnnMETHODSnRetrospective, descriptive study. Participants eligible for this study came from the role 2 MTF admission database, where they fitted the criteria Major haemorrhage (class 2 haemorrhage or more according to the ATLS(®) classification) between 2006 and 2010. Results were contrasted with studies from coalition partners.nnnRESULTSnThe query revealed 194 casualties sustaining 208 central (60% abdominal, 40% thoracic/neck), and 99 extremity major haemorrhages leading to 1.6 major haemorrhages per casualty. Survival was significantly better (p<0.05) in the peripheral vascular injuries cohort (96% versus 72%). Primary amputation was needed in 73/84 of lower, and in 8/15 of upper extremity major haemorrhages. Vascular repair or vascular Damage Control Surgery techniques (e.g. shunting) were used in 19/84 cases in the lower, and 7/15 in the upper extremity cohort, with a success rate of 69.2 percent. Amputation rates of coalition partners, using different inclusion and exclusion criteria, ranged from 5 to 60 percent.nnnCONCLUSIONSnOnly in a few cases genuine peripheral vascular surgery was needed (<1%). This limited number of reconstructions does not demonstrate the need for extensive skills in all areas of vascular surgery. Achieved success rate until discharge was almost 70%. Vascular damage control surgery seems effective as initial limb saving skill in a role 2 MTF. The difference in usage of definitions concerning vascular injuries in current literature warrants further assessment. For optimal analysis there is need for detailed (NATO wide) registration with uniform definitions for vascular injuries.nnnLEVEL OF EVIDENCEnLevel IV--Epidemiologic study.

Pediatric Surgical Care in a Dutch Military Hospital in Afghanistan

BackgroundFrom August 2006–August 2010, as part of the ISAF mission, the Armed Forces of the Netherlands deployed a role 2 enhanced Medical Treatment Facility (R2E-MTF) to Uruzgan province, Afghanistan. Although from the principle doctrine not considered a primary task, care was delivered to civilians, including many children. Humanitarian aid accounted for a substantial part of the workload, necessitating medical, infrastructural, and logistical adaptations. Particularly pediatric care demanded specific expertise and equipment. In our pre-deployment preparations this aspect had been undervalued. Because these experiences could be influential in future mission planning, we analyzed our data and compared them with international reports.Methods This is a retrospective, descriptive study. Using the hospital’s electronic database, all pediatric cases, defined as patients <17xa0years of age, who were admitted between August 2006 and August 2010 to the Dutch R2E-MTF at Multinational Base Tarin Kowt (MBTK), Urzugan, Afghanistan were analyzed.ResultsOf the 2736 admissions, 415 (15.2xa0%) were pediatric. The majority (80.9xa0%, 336/415) of these admissions were for surgical, often trauma-related, pathology and required 610 surgical procedures, being 26xa0% of all procedures. Mean length of stay was 3.1xa0days. The male to female ratio was 70:30. Girls were significantly younger of age than boys. In-hospital mortality was 5.3xa0%.ConclusionPediatric patients made up a considerable part of the workload at the Dutch R2E-MTF in Uruzgan, Afghanistan. This is in line with other reports from the recent conflicts in Iraq and Afghanistan, but used definitions in reported series are inconsistent, making comparisons difficult. Our findings stress the need for a comprehensive, prospective, and coalition-wide patient registry with uniformly applied criteria. Civilian disaster and military operational planners should incorporate reported patient statistics in manning documents, future courses, training manuals, logistic planning, and doctrines, because pediatric care is a reality that cannot be ignored.

Feedback activities of instructors during a trauma surgery course

BACKGROUNDnThe aim of this study was to examine the quality and quantity of feedback and instruction from faculty members during an acute trauma surgery team training using a newly designed observational feedback instrument.nnnMETHODSnDuring the training, 11 operating teams, each consisting of 1 instructor coaching 2 trainees, were videotaped and audiotaped. Forty-five minutes of identical operating scenarios were reviewed and analyzed. Using a new observational feedback instrument, feedback and instruction, containing different levels of specific information related to technical and nontechnical skills, were noted.nnnRESULTSnInstructors more often provided instruction (25.8 ± 10.6 times) than feedback (4.4 ± 3.5 times). Most feedback and instruction contained either nonspecific or less specific information and referred to technical skills. Instructors addressed communication skills more specifically.nnnCONCLUSIONSnCoaching by faculty members predominantly contained unspecific instructions regarding technical skills. The observational feedback instrument enabled scoring of the coaching activities.

The iTClamp in the management of prehospital haemorrhage.

INTRODUCTIONnBleeding remains a leading cause of death in trauma patients. The iTClamp is a temporary wound closure device designed to control external bleeding within seconds of injury. We describe our experience using this device on 10 patients in the prehospital environment.nnnMETHODSnWe have implemented the iTClamp for prehospital use through our physician-staffed helicopter emergency medical service (HEMS). Indications were massive bleeding that could not be controlled with an ordinary compressive bandage or a haemostatic bandage.nnnRESULTSnTen patients were treated with the iTClamp. Seven patients had a severe head injury due to various traumas, one patient had a neck injury from a disk cutter, one patient had an open chest wound and one patient had an open femur fracture. After applying the iTClamp, bleeding was controlled in 90% of these patients (n=9), with complete cessation reported in 60% (n=6), partial cessation with adequate control reported in 30% (n=3); in one patient, the bleeding could not be controlled with the iTClamp alone. It took an average of 10s to apply the iTClamp, and the average usage satisfaction score was 7.7.nnnCONCLUSIONnWe conclude that the iTClamp is a safe, fast and useful tool for stopping or controlling external blood loss in our series of prehospital patients. Further studies of the iTClamp are needed to determine which patients might benefit from this device.

Indications and results of emergency surgical airways performed by a physician-staffed helicopter emergency service.

BACKGROUNDnAirway management is essential in critically ill or injured patients. In a cant intubate, cant oxygenate scenario, an emergency surgical airway (ESA), similar to a cricothyroidotomy, is the final step in airway management. This procedure is infrequently performed in the prehospital or clinical setting. The incidence of ESA may differ between physician- and non-physician-staffed emergency medical services (EMS). We examined the indications and results of ESA procedures among our physician-staffed EMS compared with non-physician-staffed services.nnnMETHODSnData for all forms of airway management were obtained from our EMS providers and analyzed and compared with data from non-physician-staffed EMS found in the literature.nnnRESULTSnAmong 1871 patients requiring a secured airway, the incidence of a surgical airway was 1.6% (n=30). Fourteen patients received a primary ESA. In 16 patients, a secondary ESA was required after failed endotracheal intubation. The total prehospital ESA tracheal access success rate was 96.7%.nnnCONCLUSIONnThe incidence of ESA in our patient population was low compared with those reported in the literature from non-physician-staffed EMS. Advanced intubation skills might be a contributing factor, thus reducing the number of ESAs required.

Coaching during a trauma surgery team training: perceptions versus structured observations

BACKGROUNDnUsing the concept perception to quantify coaching skills during surgical training is questionable. This study compared the perceptions reported by the trainees and the faculty members following an emergency surgery team training with structured observations made on the basis of video registrations.nnnMETHODSnFor each faculty member, we scored 45xa0minutes of identical scenarios to enable the quantitative assessment of the use of positive feedback, corrective feedback, as well as instruction and in particular comments containing how and why explanations. We compared the values determined from the video scores with the perceptions reported by the trainees and faculty on questionnaires.nnnRESULTSnThe trainee and faculty ratings for the coaching differed, with trainees generally giving a higher rating. While both the trainees and the faculty gave high ratings for the non-technical skills, corrective and complimenting feedback, and explanations why, the structured video observations showed lower scores in these categories.nnnCONCLUSIONSnBoth the trainees and the faculty overrated the coaching. Trainee questionnaires and faculty self-reports neither reflected the actual coaching activities nor identified coaching skill deficits.