Peter F. Mahoney

Trauma governance in the UK defence medical services

Introduction Clinical governance is concerned with the application and enforcement of good clinical practice [1-4] and the management of military trauma patients is no exception. To this end, a framework of governance has been implemented to facilitate best practice, and to ensure that Service personnel who are seriously injured on deployed operations receive exemplary care. This paper describes the processes in place to capture data, interpret the data, and audit the process of trauma management in the UK Defence Medical Services.

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.

Targeted resuscitation improves coagulation and outcome.

BACKGROUND: Acute trauma coagulopathy in seriously injured casualties may be initiated by tissue hypoperfusion. A targeted (or novel hybrid [NH]) resuscitation strategy was developed to overcome poor tissue oxygen delivery associated with prolonged hypotension. METHODS: Under the Animals (Scientific Procedures) Act 1986, terminally anesthetized large white pigs were divided into four groups (n = 6). Groups 1 and 2 received blast injury and 3 and 4 no blast (sham). All were given a controlled hemorrhage (35% blood volume) and an uncompressed grade IV liver injury. Five minutes later, all were resuscitated with 0.9% saline to a systolic arterial pressure (SAP) of 80 mm Hg. After 60 minutes, the NH groups (1 and 3) were resuscitated to a SAP (110 mm Hg), whereas hypotensive groups (2 and 4) continued with SAP 80 mm Hg for up to 8 hours from onset of resuscitation. RESULTS: Mean survival time was shorter in group 2 (258 minutes) compared with groups 1, 3, and 4 (452 minutes, 448 minutes, and 369 minutes). By the end of the study, hypotension was associated with a significantly greater prothrombin time (1.73 ± 0.10 and 1.87 ± 0.15 times presurgery, groups 2 and 4) compared with NH (1.44 ± 0.09 and 1.36 ± 0.06, groups 1 and 3, p = 0.001). Blast versus sham had no significant effect on prothrombin time (p = 0.56). Peak levels of interleukin 6 were significantly lower in NH groups. Arterial base excess was significantly lower with hypotension (−18.4 mmol/L ± 2.7 mmol/L and −12.1 mmol/L ± 3.2 mmol/L) versus NH (−3.7 mmol/L ± 2.8 mmol/L and −1.8 mmol/L ± 1.8 mmol/L, p = 0.0001). Hematocrit was not significantly different between groups (p = 0.16). CONCLUSION: Targeted resuscitation (NH) attenuates the development of acute trauma coagulopathy and systemic inflammation with improved tissue perfusion and reduced metabolic acidosis in a model of complex injury. This emphasizes the challenge of choosing a resuscitation strategy for trauma patients where the needs of tissue perfusion must be balanced against the risk of rebleeding during resuscitation.

Died of wounds: a mortality review

Objectives Combat casualty care is a complex system involving multiple clinicians, medical interventions and casualty transfers. Improving the performance of this system requires examination of potential weaknesses. This study reviewed the cause and timing of death of casualties deemed to have died from their injuries after arriving at a medical treatment facility during the recent conflicts in Iraq and Afghanistan, in order to identify potential areas for improving outcomes. Methods This was a retrospective review of all casualties who reached medical treatment facilities alive, but subsequently died from injuries sustained during combat operations in Afghanistan and Iraq. It included all deaths from start to completion of combat operations. The UK military joint theatre trauma registry was used to identify cases, and further data were collected from clinical notes, postmortem records and coroners reports. Results There were 71 combat-related fatalities who survived to a medical treatment facility; 17 (24%) in Iraq and 54 (76%) in Afghanistan. Thirty eight (54%) died within the first 24 h. Thirty-three (47%) casualties died from isolated head injuries, a further 13 (18%) had unsurvivable head injuries but not in isolation. Haemorrhage following severe lower limb trauma, often in conjunction with abdominal and pelvic injuries, was the cause of a further 15 (21%) deaths. Conclusions Severe head injury was the most common cause of death. Irrespective of available medical treatment, none of this group had salvageable injuries. Future emphasis should be placed in preventative strategies to protect the head against battlefield trauma.

Combat “Category A” Calls: Evaluating The Prehospital Timelines in a Military Trauma System

Aim To establish the pre-hospital timelines for seriously injured UK military casualties on OP HERRICK. Population All consecutive MERT and MERT-E mobilizations from Camp Bastion, Helmand Province, between 04 May 06 and 18 Jun 07. Methods Interrogation of MS Access database compiled from paper patient report forms for each casualty transported. Results 528 patients were transported. 84.6% (456) were battle casualties. There were 192 GSW and 233 casualties with blast/fragmentation injuries. 189 of 528 (35.7%) were UK Service personnel. Median time from injury to handover at the emergency department for UK military T1 casualty subset was 99 minutes. Conclusion The public perception of excessive timelines for pre-hospital care in Afghanistan has been distorted. The ground truth is a pre-hospital time less than one quarter of the cited 7 hours for the seriously injured subset of UK Service personnel.

What is the Ideal Pre-Hospital Analgesic? – A Questionnaire Study

Aim To determine clinical opinion of effectiveness of current battlefield analgesia and the realistic options to improve future analgesia in hostile environments. Methods Structured electronic questionnaire distributed to selected individuals in UK and on operations. Population 122 UK Defence Medical Services and US Medical Corps doctors, nurses and combat medical technicians involved in the early management of severe trauma on deployment. Results 54 (44%) agreed and 63 (52%) disagreed that intramuscular morphine had the ideal analgesic properties for the military pre-hospital environment. Over half of those with operational experience reported multiple instances of intramuscular morphine providing inadequate analgesia. 86 (70%) desired a more potent analgesic than morphine in the first hour following injury. 101 (83%) identified simplicity and reliability of use by a soldier as of high importance. 99 (81%) identified rapid onset of action of high importance. With regard to an acceptable route of drug self-administration, 88 (72%) supported a nasal spray; 78 (64%) supported a sustained release buccal tablet (adhesive to the gum); 61 (50%) supported a disposable inhaler of volatile gas (although 91%had no experience of the currently available drug in this formulation); and 55 (45%) supported a skin patch. Conclusion Intramuscular morphine does not meet the needs of the majority of clinical stakeholders. Alternative routes of self-administration are acceptable, but support for available commercial solutions is clouded by incomplete awareness. Anaesthetists and emergency physicians desire a multimodal approach to battlefield analgesia within the evacuation chain.

Lessons Learnt from Explosive Attacks

Explosive Injury Mechanisms a brief overview. The damage created by a conventional explosion depends on a number of factors, including the type of explosive, the amount of explosive, and the environment within which the detonation takes place. Whenever and wherever an explosion occurs in air, the principles are the same. An understanding of the principles enables a prediction of likely injury [1][2]. As a substance explodes it rapidly expands from a solid (or liquid) state to a gas, increasing in volume by up to 100,000 times. The speed of expansion depends on the type of explosive. This expansion pushes out whatever is surrounding the explosive, such as casing (which may or may not be designed to fragment) or other items, for example nails or ball bearings. The explosion also compresses the surrounding air to form a shock-wave. This is a wave of very high pressure which expands away from the explosive at a speed greater than the speed of sound in air. The high pressure lasts for a very short period of time (milliseconds) and in an open air explosion, is relatively short-lived. As a result the peak overpressure decreases rapidly. For single shock waves in air, after the initial rise in pressure, the pressure drops to sub-atmospheric levels for a short time due to the elasticity of air (Figure 1). Under water, the shock wave is propagated for a much greater distance and the distance from the detonation at which injury may occur consequently increases.

Defining the essential anatomical coverage provided by military body armour against high energy projectiles

Introduction Body armour is a type of equipment worn by military personnel that aims to prevent or reduce the damage caused by ballistic projectiles to structures within the thorax and abdomen. Such injuries remain the leading cause of potentially survivable deaths on the modern battlefield. Recent developments in computer modelling in conjunction with a programme to procure the next generation of UK military body armour has provided the impetus to re-evaluate the optimal anatomical coverage provided by military body armour against high energy projectiles. Methods A systematic review of the literature was undertaken to identify those anatomical structures within the thorax and abdomen that if damaged were highly likely to result in death or significant long-term morbidity. These structures were superimposed upon two designs of ceramic plate used within representative body armour systems using a computerised representation of human anatomy. Results and conclusions Those structures requiring essential medical coverage by a plate were demonstrated to be the heart, great vessels, liver and spleen. For the 50th centile male anthropometric model used in this study, the front and rear plates from the Enhanced Combat Body Armour system only provide limited coverage, but do fulfil their original requirement. The plates from the current Mark 4a OSPREY system cover all of the structures identified in this study as requiring coverage except for the abdominal sections of the aorta and inferior vena cava. Further work on sizing of plates is recommended due to its potential to optimise essential medical coverage.

Evaluation Of Clinician Attitudes To The Implementation Of Novel Haemostatic Techniques

Innovation in industry, stimulated by the perceived requirement of the military customer, has generated a series of recent developments in the domain of external haemorrhage control. In response to tasking from Surgeon General, the Academic Department of Military Emergency Medicine (ADMEM) has guided the operational analysis and staged implementation of three changes to improve haemostasis following injury in combat. Two of these changes involve replacement of existing equipment (a new field dressing and a new arterial tourniquet); the third change is the adoption of a haemostatic agent, QuikClotTM. To enable the implementation, ADMEM developed a predeployment training programme to provide the necessary knowledge, skill and judgement to use the new products safely and effectively. This paper evaluates the confidence of clinicians to treat life-threatening external haemorrhage before and after training in the novel techniques.

Fluid Resuscitation: A Defence Medical Services Delphi Study into Current Practice

A Delphi study was carried out to investigate recent changes in the fluid resuscitation of patients. A thirty member panel was selected primarily from the UK Defence Medical Services but also included contributors from other NATO members and civilian practice. The study was carried out in two rounds and achieved consensus on a range of statements relating to fluid resuscitation. Key recommendations are grouped by category. Statements reaching consensus included the use of adult intraosseous access, limited hypotensive resuscitation and goal directed therapy in trauma patients. Consensus was not achieved with respect to the selection of non-oxygen carrying synthetic colloids. The study provides a broad review of current practice and adds to previous consensus publications on fluid resuscitation.