Robert M. Rush

Forward surgical team (FST) workload in a special operations environment: the 250th FST in operation ENDURING FREEDOM

PURPOSE Forward Surgical Teams (FST) deploy to support conventional combat units of at least regimental size. This report examines the injuries and treatments of an FST in an environment of unconventional tactics, limited personal protection, and extended areas of responsibility during Operation ENDURING FREEDOM. METHODS A prospective evaluation of the personal protective measures, mechanisms of injury, types of injuries, and times to treatment in Operation ENDURING FREEDOM. Additionally, per-surgeon caseloads, operative interventions, and outcomes are examined. The first phase of this deployment involved co-locating with an Air Force Expeditionary Medical Squadron at Seeb Air Base, Oman (SABO). The second phase involved stand-alone operations at Kandahar International Airport (KIA). Participants include U.S. Special Forces, conventional U.S forces, coalition country special forces, and anti-Taliban Afghan soldiers. RESULTS During the deployment, the FST performed 68 surgical procedures on 50 patients (19 SAB, 31 KIA). There were 35 orthopedic cases (2 to 28 per surgeon), 30 general surgery cases (2 to 10 per surgeon), and 3 head/neck cases. Mechanism of injury included non-battle injury (13), bomb blast (13), gunshot wounds (8), mine (8), and grenades (5). Primary injuries were to the extremities in 27, torso in 9, and head/neck in 11. Three patients had appendicitis. Five patients were wearing body armor, whereas 4 wore helmets. The mean Relative Trauma Score was 7.4. Thirty-one patients were treated at KIA with a mean time to operative treatment of 2.7 +/- 2.7 hours, whereas 19 were treated in SABO with a mean time to operative treatment of 12.4 +/- 15.1 hours. Nine patients received transfusions. Three nonoperative patients died of wounds. CONCLUSION Despite the lack of personal protective gear, most patients had extremity wounds as their primary injuries. In this special operations environment, time to operative treatment was significantly longer than expected.

Application of the Mangled Extremity Severity Score in a Combat Setting

OBJECTIVE The aim of this study was to examine the Mangled Extremity Severity Score (MESS) in a combat setting. METHODS Data on extremity injuries were collected from a forward surgical team. MESS and Revised Trauma Score values were retrospectively calculated for each patient. Students t test was used to compare amputated and salvaged limbs. RESULTS A total of 60 extremities was identified in 49 patients. There were 10 major vascular repairs (20%). MESS values differed significantly for the eight amputations performed (mean MESS, 7.87 +/- 1.91) and 50 salvaged extremities (mean MESS, 2.44 +/-_ 0.438; p = 0.001). CONCLUSIONS A MESS of >7 correlated with amputation, thus validating the MESS in a combat setting. A young average patient age and high-energy injury mechanism on the battlefield leave ischemic time and shock as the most important factors in dictating whether a MESS is >7 or <7.

Efficacy of Three Topical Hemostatic Agents Applied by Medics in a Lethal Groin Injury Model

BACKGROUND Advanced topical hemostatic agents are increasingly utilized to control traumatic hemorrhage. We sought to determine the efficacy of three chitosan based hemostatic agents in a lethal groin injury model when applied by combat medic first responders. METHODS After creation of a standardized femoral artery injury in a goat model, medics attempted hemorrhage control with standard gauze dressing followed by randomization to one of three hemostatic agents in this two tiered study. In the first tier, medics were randomized to either a chitosan based one-sided wafer (OS) or a dual-sided, flexible, roll (DS). In the second tier, medics were randomized to the flexible DS dressing or a chitosan powder (CP). Efficacy of gauze, each chitosan agent, proper application, and participant surveys were obtained and included for analysis using univariate techniques. RESULTS From January 2007 to June 2007, 55 (45%) DS, 36 (29%) OS, and 32 (26%) CP agents were used to treat 123 actively bleeding arterial injuries in 62 animals. Standard gauze failed to stop hemorrhage in 122 (99%) groins. Although all three chitosan agents were marginally effective at 2 min, the recommended time for application, hemostasis improved after 4 min. The DS dressing was the most effective, controlling hemorrhage 76% at 4 min. Of the failures, 3 (23%) DS and 9 (53%) OS were due to improper application. End-user survey results demonstrated that medics preferred the DS dressing 77% and 60% over the OS and CP, respectively. CONCLUSIONS Chitosan based bandages are significantly more effective at hemorrhage control compared to standard gauze field dressings. The dual-sided chitosan dressing demonstrated better hemorrhage control than the one-sided dressing and the chitosan powder, and was less likely to fail despite application errors.

Incidence of low vitamin A levels and ocular symptoms after Roux-en-Y gastric bypass

BACKGROUND Previous reports have demonstrated a significant incidence of fat-soluble vitamin deficiency after bariatric surgery. The purpose of the present study was to determine the incidence of vitamin A deficiency after Roux-en-Y gastric bypass and to correlate the laboratory findings with ocular symptoms potentially related to vitamin A deficiency. METHODS All patients who had undergone Roux-en-Y gastric bypass were invited to participate in a nutritional screening. The patients completed a detailed survey concerning ocular symptoms and had their vitamin A level evaluated. RESULTS A low vitamin A level was identified in 7 (11%) of 64 RYBG patients. Ocular xerosis was present in 18 patients (27%), with night vision changes reported in 45 (68%). Visual disturbances were present in 7 patients (11%) found to have low vitamin A levels, with hypovitaminosis A present in 22% of patients with xerosis (P <.05). CONCLUSION Low vitamin A levels and frequent ocular complaints that might be associated with decreased vitamin A are common findings in the post-RYBG patient population. Additional study is needed to assess the role of routine vitamin A screening and replacement in the postbariatric surgery patient.

Factors influencing humanitarian care and the treatment of local patients within the deployed military medical system: casualty referral limitations

BACKGROUND Humanitarian medical care is an essential task of the deployed military health care system. The purpose of this study was to analyze referral acceptance in treating injured local national patients during Operation Enduring Freedom. METHODS A prospective observation study of local nationals who were referred for humanitarian trauma care in Afghanistan from March through August 2009. RESULTS Sixty-six patients were referred for evacuation for suspected non-coalition-caused injuries. The bed status at the receiving hospital was defined as green (able to accept patients), amber (nearing capacity), and red (at capacity). The only factor associated with acceptance was the accepting hospital bed status (odds ratio = 1.57%, 95% confidence interval, 1.11-2.22; P = .009). Factors not significant were age, the province of origin, the type of referring facility, a prior operation before the request, patient status/affiliation, or the mechanism of injury. CONCLUSIONS Humanitarian medical care is directly related to the capacity for high-acuity care because bed availability is the predominate reason for acceptance or rejection.

Management of complex extremity injuries: tourniquets, compartment syndrome detection, fasciotomy, and amputation care.

Historically, complex extremity injuries, otherwise known as mangled extremities, have been difficult management problems. This is especially true in multiply-injured patients where many priorities exist and where amputation is considered a failure of limb salvage. Over the past decade, advances in the total management of complex extremity injuries, from the placement of life-saving and limb-saving tourniquets in the prehospital setting to the advancement of prosthetics and rehabilitation months to years later, have resulted in superb functional results regardless of whether limb salvage or amputation is undertaken.

Perceived effects of deployments on surgeon and physician skills in the US Army Medical Department

BACKGROUND The military health care system is unique in that almost every physician deploys for ≥6 months to a combat or far-forward setting. The aim of this study was to determine the perceived changes in clinical skills in this deployed population. METHODS A survey was sent out to all specialty consultants to the Army Surgeon General to query active duty staff physicians in their specialty areas who have deployment experience in August 2007. Questions concerning specialty, length of deployment, perceived changes in skills, skill use while deployed, and time to get back to baseline clinically after deployment were asked. RESULTS Surveys were sent to approximately 1,500 physicians, of which 673 were usable, for a 45% response rate. More than 70% of respondents were deployed for >6 months. Fifty-nine percent reported that they were used in their specialties <40% of the time deployed. Surgeons rated surgical skills before and after deployment as 6.0 ± 1.0 and 4.0 ± 1.5, respectively (on a 7-point, Likert-type scale ranging from 1 = worst to 7 = best; P = .001). Most felt that the time needed to get back to predeployment skill levels was 1 to 6 months. CONCLUSIONS There was significant perceived degradation in both the surgical and clinical skills of those deploying for >6 months, and the degradation was correlated with the length of time deployed. Most surgical specialists felt that it took them 3 to 6 months to return to their clinical and surgical performance baseline upon returning from a deployment and that 6 months was the most amount of time they could be deployed without a significant decrement in skills.

Resectional gastric bypass outcomes in active duty soldiers: a retrospective review

BACKGROUND As in civilian life, some active duty service members have developed severe obesity that is refractory to diet alteration and exercise. In addition to controlling obesity, surgical weight control measures in an active duty population must consider the effect of the postbariatric state on a service members ability to continue to be deployable to a war zone or other austere military assignment. We report our experience with such patients undergoing open resectional gastric bypass. METHODS We retrospectively reviewed the perioperative and long-term outcomes of 33 active duty service members who had undergone open gastric bypass by the same surgical team at a single institution during a 30-month period. Data were collected by chart review and questionnaires. Descriptive and inferential analyses were performed using Statistical Package for Social Sciences, version 14.0. RESULTS The questionnaires were returned by 27 patients (13 women and 14 men). The mean age at surgery was 34.2 years (range 24-51). The mean follow-up was 218 weeks (range 162-369). The mean preoperative body mass index was 40.6 kg/m(2) (range 34.0-49.4). The mean postoperative BMI was 25.6 kg/m(2) (range 19-34.7). Using the Bariatric Analysis and Reporting Outcome System outcome criteria for these 27 patients, the results were fair for 4 patients (15%), good for 9 (33%), very good for 12 (44%), and excellent for 2 (7%). No patients had treatment failure according to the Bariatric Analysis and Reporting Outcome System criteria. Also, 5 patients who had previously been nonpromotable because of their weight were reclassified as promotable after the results of the bariatric intervention. Of the 27 patients, all but 3 maintained or achieved deployable status after surgical recovery. CONCLUSION As in civilian populations, bariatric surgery improves the quality of life of active duty service members who have failed nonoperative means of obesity control. Most service members who undergo bariatric intervention are able to successfully deploy to war zones without adverse effects on their military performance and retain or improve their competitiveness for career promotion.

The Use of a Temporary Intraluminal Shunt to Restore Lower Limb Perfusion Over a 4,000 Mile Air Evacuation in a Special Operations Military Setting: A Case Report

Copyright in this article, its metadata, and any supplementary data is held by its author or authors. It is published under the Creative Commons Attribution By licence. For further information go to: http://creativecommons.org/licenses/by/3.0/. The Use of a Temporary Intraluminal Shunt to Restore Lower Limb Perfusion Over a 4,000 Mile Air Evacuation in a Special Operations Military Setting: A Case Report

What Patients Really Want: Optimizing the Military Preoperative Evaluation Clinic

The idea of the preoperative anesthesia clinic as a means of examining and treating the patient so that he will arrive in the operating theater as strong and healthy as possible is well established in practice and literature.However, problems in clinic design and execution often result in high patient waiting times, decreased patient and staff satisfaction, decreased patient capacity, and high clinic costs. Although the details of clinic design, outcomes, and satisfaction have been extensively evaluated at civilian hospitals, we have not found corresponding literature addressing these issues specifically within military preoperative evaluation clinics. We find that changing to an appointment-based (versus walk-in) system and eliminating data collection step redundancies will likely result in lower wait times, higher satisfaction, lower per patient costs, and a more streamlined and resource-efficient structure.