Kyle N. Remick

Fresh whole blood use by forward surgical teams in Afghanistan is associated with improved survival compared to component therapy without platelets

In Afghanistan, a substantial portion of resuscitative combat surgery is performed by US Army forward surgical teams (FSTs). Red blood cells (RBCs) and fresh frozen plasma (FFP) are available at these facilities, but platelets are not. FST personnel frequently encounter high‐acuity patient scenarios without the ability to transfuse platelets. An analysis of the use of fresh whole blood (FWB) at FSTs therefore allows for an evaluation of outcomes associated with this practice.

Evaluation of role 2 (R2) medical resources in the Afghanistan combat theater: Initial review of the joint trauma system R2 registry.

BACKGROUND A Role 2 registry (R2R) was developed in 2008 by the US Joint Trauma System (JTS). The purpose of this project was to undertake a preliminary review of the R2R to understand combat trauma epidemiology and related interventions at these facilities to guide training and optimal use of forward surgical capability in the future. METHODS A retrospective review of available JTS R2R records; the registry is a convenience sample entered voluntarily by members of the R2 units. Patients were classified according to basic demographics, affiliation, region where treatment was provided, mechanism of injury, type of injury, time and method of transport from point of injury (POI) to R2 facility, interventions at R2, and survival. Analysis included trauma patients aged ≥18 years or older wounded in year 2008 to 2014, and treated in Afghanistan. RESULTS A total of 15,404 patients wounded and treated in R2 were included in the R2R from February 2008 to September 2014; 12,849 patients met inclusion criteria. The predominant patient affiliations included US Forces, 4,676 (36.4%); Afghan Forces, 4,549 (35.4%); and Afghan civilians, 2,178 (17.0%). Overall, battle injuries predominated (9,792 [76.2%]). Type of injury included penetrating, 7,665 (59.7%); blunt, 4,026 (31.3%); and other, 633 (4.9%). Primary mechanism of injury included explosion, 5,320 (41.4%); gunshot wounds, 3,082 (24.0%); and crash, 1,209 (9.4%). Of 12,849 patients who arrived at R2, 167 (1.3%) were dead; of 12,682 patients who were alive upon arrival, 342 (2.7%) died at R2. CONCLUSION This evaluation of the R2R describes the patient profiles of and common injuries treated in a sample of R2 facilities in Afghanistan. Ongoing and detailed analysis of R2R information may provide evidence-based guidance to military planners and medical leaders to best prepare teams and allocate R2 resources in future operations. Given the limitations of the data set, conclusions must be interpreted in context of other available data and analyses, not in isolation. LEVEL OF EVIDENCE Epidemiologic study, level IV.

Defining and predicting surgeon utilization at forward surgical teams in Afghanistan

BACKGROUND The forward surgical team (FST) is the US Armys smallest surgical element. These teams have supported current conflicts since 2001. The purpose of this study was to determine if surgeon utilization varied at two different FSTs and to determine factors that may predict the need for a surgeon. METHOD Data from two FSTs were reviewed. A t-test was used to compare the military injury severity scores (mISS) and the revised trauma scores (RTS). χ(2) analysis was used to compare types and mechanisms of injury and to compare life- or limb-saving surgeries (LLSS) and life-saving interventions among the FSTs. Logistic regression was used to determine if mISS, RTS, physiologic parameters, or laboratory values predicted the need for LLSS or life-saving intervention. RESULTS The 541st FST treated a larger volume of patients than the 772nd FST (n = 761 versus n = 311). The 772nd FST performed a significantly higher percentage of LLSS; however, absolute number of LLSS was 31 at both FSTs. The mISS among operative patients were similar, but RTS were significantly different (772nd FST = 7.28 versus 541st FST = 7.58, P = 0.008). The 772nd FST saw a higher percentage of motor vehicle collision and rocket-propelled grenade injuries and thoracic and neurologic injuries, and the 541st FST saw a higher percentage of blast and gunshot wound injuries and abdominal injuries. Lactate level was the most significant predictor of the need for LLSS. CONCLUSION Although percentage of surgical interventions varied between the two FSTs, the absolute number of needed surgical interventions was the same and was small. Lactate level predicted the need for surgical intervention in our population.

Consensus recommendations for essential vascular care in low- and middle-income countries

OBJECTIVE Many low- and middle-income countries (LMICs) are ill equipped to care for the large and growing burden of vascular conditions. We aimed to develop essential vascular care recommendations that would be feasible for implementation at nearly every setting worldwide, regardless of national income. METHODS The normative Delphi method was used to achieve consensus on essential vascular care resources among 27 experts in multiple areas of vascular care and public health as well as with experience in LMIC health care. Five anonymous, iterative rounds of survey with controlled feedback and a statistical response were used to reach consensus on essential vascular care resources. RESULTS The matrices provide recommendations for 92 vascular care resources at each of the four levels of care in most LMICs, comprising primary health centers and first-level, referral, and tertiary hospitals. The recommendations include essential and desirable resources and encompass the following categories: screening, counseling, and evaluation; diagnostics; medical care; surgical care; equipment and supplies; and medications. CONCLUSIONS The resources recommended have the potential to improve the ability of LMIC health care systems to respond to the large and growing burden of vascular conditions. Many of these resources can be provided with thoughtful planning and organization, without significant increases in cost. However, the resources must be incorporated into a framework that includes surveillance of vascular conditions, monitoring and evaluation of vascular capacity and care, a well functioning prehospital and interhospital transport system, and vascular training for existing and future health care providers.

Review of the Fifth Annual Joint Theater Trauma System Trauma Conference

Military conflict requires the military health system to respond to new wounding patterns, geography, climate, and uncommon health hazards. A continuously learning health system will use multiple avenues to advance improvements. Conferences in a theater of operations are one such vehicle. This report documents specific issues of concern to military providers as discussed at a trauma conference conducted in the Afghanistan Theater of Operations in 2014.

Catastrophic Non-Survivable Brain Injury Care–Role 2/3

A catastrophic brain injury is defined as any brain injury that is expected to result in permanent loss of all brain function above the brain stem level. These clinical recommendations will help stabilize the patient so that they may be safely evacuated from theater. In addition to cardiovascular and hemodynamic goals, special attention must be paid to their endocrine dysfunction and its treatment-specifically steroid, insulin and thyroxin (t4) replacement while evaluating for and treating diabetes insipidus. Determining the futility of care coupled with resource management must also be made at each echelon. Logistical coordination and communication is paramount to expedite these patients to higher levels of care so that there is an increased probability of reuniting them with their family.

Combat vascular injury: Influence of mechanism of injury on outcome

BACKGROUND Haemorrhage is the leading cause of death on the battlefield. Seventy percent of injuries are due to explosive mechanisms. Anecdotally, these patients have had poorer outcomes when compared to those with penetrating mechanisms of injury (MOI). We wished to test the hypothesis that outcomes following vascular reconstruction were worse in blast-injured than non blast-injured patients. METHODS Retrospective cohort study. British and American combat casualties with arterial injuries sustained in Iraq or Afghanistan (2003-2014) were identified from the UK Joint Theatre Trauma Registry (JTTR). Eligibility included explosive or penetrating MOI, with follow-up to UK hospital discharge, or death. Outcomes were mortality, amputation, graft thrombosis, haemorrhage, and infection. Statistical analysis was performed using Pearson Chi-Square test, t-tests, ANOVA or non-parametric equivalent, and survival analyses. RESULTS One hundred and fifteen patients were included, 80 injured by explosive and 35 by penetrating mechanisms. Evacuation time, ISS, number of arterial injuries, age and gender were comparable between groups. Seventy percent of arterial injuries resulted from an explosive MOI. The explosive injuries group received more blood products (p = 0.008) and suffered more regions injured (p < 0.0001). Early surgical interventions in both were ligation (n = 36, 31%), vein graft (n = 33, 29%) and shunting (n = 9, 8%). Mortality (n = 12, 10%) was similar between groups. Differences in limb salvage rates following explosive (n = 17, 53%) vs penetrating (n = 13, 76.47%) mechanisms approached statistical significance (p = 0.056). Nine (28%) vein grafted patients developed complications. No evidence of a difference in the incidence of vein graft thrombosis was found when comparing explosive with non-explosive cohorts (p = 0.154). CONCLUSIONS The recorded numbers of vein grafts following combat arterial trauma in are small in the JTTR. No statistically-significant differences in complications, including vein graft thrombosis, were found between cohorts injured by explosive and non-explosive mechanisms.

Military-Civilian Collaboration for National Preparedness During Peace and War

Military surgeons have gained combat experience over the past 15 years of conflict in Iraq and Afghanistan. Historically, these valuable lessons tend to fade from the military knowledge base in between conflicts. Thus, we strive to preserve these lessons within the military surgical culture and also to translate them to benefit civilian trauma care. Strong military-civilian partnerships may help to ensure retention of this combat surgical knowledge so that military surgeons are prepared for future conflicts and enable collaboration and translation of important lessons in support of national preparedness on the home front. The long running conflicts in Iraq, Afghanistan, and other areas have resulted in an unprecedented level of cooperation and shared vision between the military and civilian trauma and surgical communities and organizations. Most recently, a report from the National Academy of Sciences has called for a national integration of military and civilian trauma systems, a national trauma research plan, and other actions with the shared goal of “zero preventable deaths.” In this chapter, we will discuss these recent and ongoing military-civilian partnerships that contribute to national preparedness for future battlefield trauma care and enhancement of civilian trauma care and systems.

Combat casualty care: Partnering for preparedness.

T theme for this year’s supplement, ‘‘Partnering for Preparedness,’’serves notice to the nation regarding the urgency to maintain our investment in combat casualty care research, both to benefit our US military service members and to best prepare our nation on the home front. Department of Defense funding primarily seeks to optimize combat casualty care for US service members injured in conflict. In the face of military budget cuts, we must seek increased partnerships to stay ahead of the curve in combat casualty care research and to maintain our lessons learned to sustain readiness. Similarly, we are all compelled to improve care for injured American citizens. This shared goal is especially relevant and timely, given the increasing number of intentional mass casualty events on the home front. We don’t need another ‘‘history repeats itself ’’ lesson to prove to us the importance of military and civilian collaboration in trauma care. We already know that during war research is stimulated by large casualty volumes leading to advances in combat casualty care. Our society then indirectly benefits from these advances through the adaptation of combat casualty care lessons to the care of injured citizens. We also know that between wars we seek to sustain and improve our trauma knowledge by leveraging the expertise in research and training at our nation’s civilian trauma centers. Unfortunately, our national and military leadership has the tendency to quickly forget the importance of advances made through a dedicated and focused investment in operationally relevant, gap-driven trauma research. In addition, the skills of combat casualty care experienced physicians, nurses, medics, and ancillary staff rapidly fade because of attrition to civilian life and because of a lack of dedicated sustainment of trauma skills as these military medical personnel return to a military facility practices not involving routine trauma care. In an unsettling way, we are told that we have reached the conclusion of military conflicts in Iraq (2012) and in Afghanistan (2014), yet we remain involved with a significant number of US Military service members deployed in harm’s way in both locations. In addition to Afghanistan and Iraq, we are also engaged globally with small military teams working in dispersed and remote locations such as in Africa and Asia without the benefit of a robust Joint Trauma System, which has given us the lowest case fatality rate in military history. Equally concerning, we are experiencing an increase in the frequency and number of intentional mass casualty events from active shooter and intentional bombings on the home front. Almost daily, we see news reports of events involving multiple casualty scenarios right here on our home soil. We face an onslaught of intentional harm events with increasing complexity and are compelled to act with urgency to ensure that investment is commensurate to the importance of supporting ongoing military operations and civilian mass casualty preparedness. Increased funding for trauma research and partnership between military and civilian trauma communities are essential to meet this threat. Internationally, we must also partner for preparedness. Part of our success in providing a Joint Trauma System for two theaters of operation for over a decade has been the result of a mutually beneficial investment in preparedness in combat casualty care across multiple nations. Our ability to work together to provide trauma care has fostered international medical partnerships in trauma care that would not otherwise have been possible. The fruits of this international investment are FOREWORD

Combat surgeon readiness: Partnering during war and peace.

I n thewake of the National Academy ofMedicine report, ANational Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths After Injury, we recognize the need for continuous interactions between the military and civilian surgical communities.Military-civilian trauma training collaborations, in which military surgeons work and train in civilian centers, allow for the exchange of lessons learned to ensure surgeons are prepared to provide combat casualty care and to ensure surgeon readiness in support of national preparedness on the home front. The core mission of the Military Health System Strategic Partnership with the American College of Surgeons (MHSSPACS) is to support such bilateral exchanges. Experienced combat surgeons understand that when you go towar, you mature your personal surgical skills at an accelerated pace. Oftentimes, experience gained during a single combat deployment is enough to inform the care of civilian surgical patients over an entire career due to the sheer volume and variety of injuries seen in even a short period of war. Similarly during war, the US Military’s medical infrastructure by necessity becomes laser focused on providing an optimal trauma care system throughout the continuum from point of injury and initial life-saving care in the combat theater all the way back to restoration and rehabilitation of function. Despite best intentions, history has revealed little success at maintaining a combat-focused surgery culture in between wars. The Uniformed Services University (USU) as “America’s Medical School” and the surgical residency training programs within our Military Health System (MHS) form the core platforms for training our future combat surgeons and are dedicated not to repeat this pattern. One key way to overcome this is to leverage military-civilian partnerships to maintain the skills of our current military surgical cadre and to train the next generation of military and civilian surgeons capable of caring for service members deployed and our civilian populace on the home front.