Paul Parker

Percutaneous fluoroscopic screw fixation of acetabular fractures

Over a 2-year period eight patients underwent percutaneous fluoroscopic fixation of their acetabular fractures. Average patient age was 43 and mean ISS was 27. Mean blood loss was less than 100 ml. There were five transverse fractures, one affecting both columns, one anterior column-posterior hemitransverse and one T-type fracture. There were two ipsilateral femoral and two ipsilateral tibial fractures. Mean follow-up was 15 months. Three broad patient groups were identified. One patient died, one was lost to follow-up, four had full range of motion of the affected hip, one had good range with Brooker II heterotopic ossification and one was wheelchair-bound with Brooker IV heterotopic ossification. The technique, which requires only cannulated screws and fluoroscopy, is described.

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.

Damage Control Surgery and Casualty evacuation:Techniques for Surgeons, Lessons for Military Medical Planners

Damage Control Surgery (DCS) is a three-phase team-based approach to maximal injury penetrating abdominal trauma. In Phase I, the hypothermic, coagulopathic, acidotic, hypotensive casualty undergoes a proactively planned one-hour time limited laparotomy by an appropriately trained surgical trauma team. In phase II – physiological stabilization takes place in the Intensive Care Unit. In phase III – definitive repair occurs. DCS is extremely resource intensive but will save lives on the battlefield. A military DCS patient will perioperatively require fourteen units of blood and seven units of fresh frozen plasma - half the blood stock of a light-scaled FST. Two DCS patients will in one day, exhaust this FSTs oxygen supply. We know that hypothermic patients with an iliac vascular injury (initial core temp <34°C) suffer four-fold increases in their mortality, yet we cannot heat our tents above 20°C during a mild British winter. Our primary casualty retrieval is excessively slow. A simple casevac request has to go to too much ‘middlemanagement’ before a flight decision is made. In Vietnam, wounded soldiers arrived in hospital within twenty-five minutes of injury. In Iraq in 2005, that figure is over one hundred and ten minutes. We use support or anti-tank helicopters that are re-roled on an adhoc basis for the critical care and transport of our sickest patients. We still do not have a dedicated all-weather military helicopter evacuation fleet despite significant evidence that intensive care unit level military evacuation is safe and eminently achievable in both in the primary and secondary care setting. Should we not be asking why?

Improvised explosive device related pelvi-perineal trauma: anatomic injuries and surgical management

BACKGROUND Pelviperineal injuries, primarily due to blast mechanisms, are becoming the signature injury pattern on operations in Afghanistan. This study set out to define these injuries and to refine our team-based surgical resuscitation strategies to provide a resuscitation-debridement-diversion didactic on our Military Operational Surgical Training predeployment course to optimize our field care of these injuries. METHODS A retrospective study of the UK Joint Theatre Trauma Registry was performed looking at consecutive data from January 2003 to December 2010, identifying patients with perineal injuries. Data abstracted included patient demographics, mechanism of injury, Injury Severity Score (ISS), management, and outcomes. RESULTS Of 2204 UK military trauma patients, 118 (5.4%) had a recorded perineal injury and 56 (47%) died . Pelvic fractures were identified in 63 (53%) of 118 patients of which only 17 (27%) of 63 survived. Mortality rates were significantly different between the combined perineal and pelvic fracture group compared with the pelvic fractures or perineal injuries alone (107 [41%] of 261 and 11 [18%] of 56, respectively, p < 0.001). The median (interquartile range) ISS for all patients was 38 (29–57). The ISS for those with pelvic fractures were significantly higher than those with perineal injuries alone, 50 (38–71) versus 30 (15–35) (p < 0.001). CONCLUSION Improvised explosive device–related perineal injuries with pelvic fractures had the highest rate of mortality compared with perineal injuries alone. Early aggressive resuscitation (activation of the massive hemorrhage protocol) is essential to survival in this cohort. Our recommendations are uncompromising initial debridement, immediate fecal diversion, and early enteral feeding. LEVEL OF EVIDENCE Epidemiologic study, level III.

Triage of war wounded: the experience of the International Committee of the Red Cross

The hospitals of the International Committee of the Red Cross are often faced with situations in which the number of war wounded requiring surgical attention overwhelms the available facilities. Hospital organization, equipment and changes of attitude necessary for health professionals are considered with respect to triage. Practical aspects of assessment and categorization of the wounded are considered in the light of a large experience; relocation and reassessment of those who do not warrant immediate surgery benefit patients and hospital staff alike. The importance of adherence to an emergency plan and respect for the decisions of the person in charge of the triage are emphasized. The difficult and stressful nature of triage of war wounded should always be taken into account.

The evaluation of an abdominal aortic tourniquet for the control of pelvic and lower limb hemorrhage.

Despite improved body armor, hemorrhage remains the leading cause of preventable death on the battlefield. Trauma to the junctional areas such as pelvis, groin, and axilla can be life threatening and difficult to manage. The Abdominal Aortic Tourniquet (AAT) is a prehospital device capable of preventing pelvic and proximal lower limb hemorrhage by means of external aortic compression. The aim of the study was to evaluate the efficacy of the AAT. Serving soldiers under 25 years old were recruited. Basic demographic data, height, weight, blood pressure, and abdominal girth were recorded. Doppler ultrasound was used to identify blood flow in the common femoral artery (CFA). The AAT was applied while the CFA flow was continuously monitored. The balloon was inflated until flow in the CFA ceased or the maximum pressure of the device was reached. A total of 16 soldiers were recruited. All participants tolerated the device. No complications were reported. Blood flow in the CFA was eliminated in 15 out of 16 participants. The one unsuccessful subject was above average height, weight, body mass index, and abdominal girth. This study shows the AAT to be effective in the control of blood flow in the pelvis and proximal lower limb and potentially lifesaving.

CASUALTY EVACUATION TIMELINES : AN EVIDENCE-BASED REVIEW

There is no tri-modal death distribution demonstrable in modern military conflict. Recent UK, Palestinian and Israeli data suggests that nine out of every ten injured soldiers that die do so within minutes of wounding from insurvivable, unsalvagable trauma.Having the surgeon on the battlefield with the soldier has been shown tomake no difference to these survival rates. Early definitive airway control using rapid sequence induction and intubation is of benefit to the head and airway injured. Once this airway is secured, these early survivors may be transported for up to 2 hours receiving intensive care level treatment: Hypotensive resuscitation with blood transfusion, administration of adjunctive clotting factors, hypothermia mitigation, administration of antibiotics, analgesics, novel haemostatics, splintage, FAST scanning can all be performed in flight. The second peak of death comes from truncal bleeding and CNS injury. Those with truncal (or junctional) bleeding require significant surgical, logistic and haemostatic support. Those with CNS injury require CT scanning and specialized neurosurgical care. These subgroups do best in large well-resourced hospital units which have the infrastructure, blood, climate control, knowledge and staffing levels to deal with them. Stopping elsewhere en-route to these larger centres is of uncertain benefit. Our resources must be optimised to save the many that could be saved, rather than dispersed for the few who will not. Wounded soldiers need to be undergoing surgery in the operating theatres of these large centres within three hours of wounding.

Forward trauma surgery in Afghanistan: lessons learnt on the modern asymmetric battlefield.

The deployment of 16 Air Assault Brigade to Helmand Province, Afghanistan in April-October 2006 was supported by a two -surgeon Field Surgical Team (FST) embedded within a 25 bed medical facility. We report the summative operative experience of the FST in order to analyse workload, case-mix and outline future training requirements. Within this period, 138 patients underwent 255 theatre episodes and 322 surgical procedures. 106 of the 138 patients requiring surgery were battle-injured. Surgical procedures undertaken involved wound excision (95), major amputation (9), laparotomy (9), application of externalfixation/ skeletal traction (6), thoracotomy (4), plaster application (6), dural repair (2), and one tracheostomy with 13 other procedures. Procedures undertaken at subsequent surgery included delayed primary closure (65), split skin graft (7), wound excision (5), tendon repair (3) and 32 others. Complications included two patients with delayed reactionary haemorrhage / post-surgical bleeding requiring re-operation. There was one in-hospital death. Thirty-two patients underwent surgery to treat disease or non-battle injury (DNBI), including 9 patients with major burns who required 26 procedures for burn excision and primary skin grafting. Many of the operations required the deployed team to operate outside of their normal NHS comfort zone. The experiences and lessons learnt and re-learnt by this surgical team should be part of our institutional memory.

Taking transfusion forward.

In 2014, the nation commemorated the start of World War I. Conflict has always been a potent stimulus to medical innovation and transfusion medicine is no exception. The Spanish Civil War, both World Wars and more recent conflicts have led to significant advances in the practical application of

Novel haemostatic dressings.

Email: paul.parker@stees.nhs.uk Introduction The problem of haemorrhage is well recognised by the deploying military medical community. In 1970 Maughon, after examining the combat deaths of 2600 American servicemen in Vietnam, articulated the simple requirement that more be done on the battlefield to prevent death from haemorrhage: “The striking feature was to see healthy young Americans with a single injury of the distal extremity arrive at the magnificently equipped field hospital, usually within hours, but dead on arrival!”[1] This was reinforced by Rocko in 1982, who wrote of the need to prevent “public exsanguination” in civilian trauma [2]. Leaving aside unsurvivable CNS trauma, the commonest cause of preventable death in combat remains haemorrhage [3]. In Vietnam 23.9% of casualties that survived to reach a hospital died of haemorrhagic shock [4]. Thirty eight percent of those who succumbed to haemorrhage in the pre-hospital setting bled to death from wounds where control could have been achieved simply by direct pressure [5]. In recent conflicts, extremity trauma has accounted for 54% of wounds by anatomical region [6] and deaths from extremity trauma remain as prevalent in recent conflicts as in Vietnam [7]. Analysis of autopsy data from American casualties sustained in Iraq and Afghanistan has shown that over 80% of casualties with potentially survivable wounds died from haemorrhage. Of these, approximately 20% died from wounds in the neck, axilla and groin [8]. As death from haemorrhage can occur within minutes of injury, prompt effective treatment of any haemorrhage is paramount [9]. In the Defence Medical Services (DMS) this has seen a re-design of the protocols issued to pre-hospital care providers, with specific indications as to when to employ techniques from an armamentarium of treatments that includes; pressure, elevation, elasticated field dressings, tourniquets and novel haemostatic dressings [10] (Figure 1). The efficacy and rationale behind the use of tourniquets has been discussed in this journal previously [11] and will not be repeated. However, significant numbers of wounds remain that have accessible bleeding points but are not suitable for tourniquet application. These wounds have been described as “nontourniquetable but compressible” [8]. In the tactical situation, application of sustained effective pressure is difficult. There is a poorly defined subgroup of traumatic wounds that due to location [7], complexity [9] or coagulopathy [12] require adjuncts to direct pressure in order to arrest bleeding. It is in dealing with these injuries, particularly in the pre-hospital and transport environment that novel haemostatic dressings have the greatest role to play. It may be where we can have the greatest effect on mortality and morbidity by reducing blood loss and the need for haemostatic resuscitation. Whilst often controversial, it is always appropriate to regularly examine the scientific basis upon which novel products, techniques and developments are introduced and delivered to the battlefield. The American model has seen a variety of products developed via different research and funding streams and despite frequent joint force operations, there has been a confusing adoption of several different dressings within the individual American uniformed services. This has not occurred within the DMS. The UKs initial choice of dressing was simply based on pragmatism [13]. It was also, for that reason, to be subject to annual review [11]. DMS clinicians and Medics are happy with the training they receive in utilising all the products currently fielded within the DMS [14], but it is unclear whether the dressings are effective? Forty four unexpected survivors among British service personnel wounded since 2003 have been reported[15]; it is unknown whether novel haemostatics have played a significant part, or any role at all, in these successes. It may represent a defect in the application injury coding scores unused to severe military blast and ballistic trauma. In written evidence to the Select Committee on Defence, the introduction of several enhanced haemostatic products and devices (HemCon, QuikClot, CAT tourniquet and the new FFD (in addition to the team medic)) were credited with saving “over three lives by 2006” [16]. This review examines the scientific evidence that led to the adoption of these novel haemostatic dressings and the clinical evidence as to their effectiveness now available. It will concentrate on those products currently available or recently used within the military environment. Novel Haemostatic Dressings