Tarif Bader

Role I trauma experience of the Israeli Defense Forces on the Syrian border.

I has been in a state of conflict with the bordering country of Syria since 1948. Beginning in February 2011, Syria has been in a state of civil war that has taken the lives of civilians and resulted in more than a million refugees. In February 2013, casualties from the fighting in Syria arrived at the Israeli border seeking medical assistance. Despite the challenging scenario, members of the Israeli Defense Forces (IDF) provided care to this group of injured civilians. Since that time, such medical care was available to men, women, and children who arrive at the Syrian border. In contrast to endeavors in which the IDF-Medical Corps (MC) has deployed to sites of calamities around the globe, this operation began as one of expediency to provide humanitarian care on its own domestic border. As in other locations throughout the country, the IDF-MC has structured units at the Syrian border in echelons beginning with the Role I Battalion Aid Station. The Battalion Aid Station is composed of two medical teams, each consisting of an advanced life support (ALS) provider (physician or a paramedic, EMT-P) and three combat medics. These teams are mobilized by armored ambulances and provide care to anyone in need including measures of combat casualty care and a select number of advanced techniques such as the administration of reconstituted dried plasma as a resuscitative fluid. In the past months, with higher numbers of casualties at the border, additional Role 1 teams have been deployed in this region. Casualties arriving at the Role I team location are treated according to Israeli standards, adhering to clinical practice guidelines (CPGs) of the IDF-MC. Treating these casualties without knowledge of the happenings within Syria and without control of their time of presentation is especially challenging. After triage and stabilization, casualties requiring greater levels of care are evacuated to higher echelons in the form of a dedicated Role 2+ facility to provide lifesaving interventions (LSIs) and mid-sized Israeli tertiary civilian medical centers, which serve as the Role III echelons, providing advanced care. Demographic, injury, and treatment information on casualties is captured within these levels of care, and analysis of these data provides process improvement and maintenance of practice standards (i.e., CPGs). As part of the IDF-MC ongoing process of data collection, analysis, and learning, the objective of this report was to describe the unique Role 1 IDF experience including the types of patients, patterns of injury, and management strategies. Additional objectives were to characterize lessons learned and to identify strategies that may be useful in supporting combat casualty care around the world.

Body Mass Index and Kidney Disease-Related Mortality in Midlife: A Nationwide Cohort of 2.3 Million Adolescents: BMI and Death from Kidney Disease

This study aimed to evaluate the association of body mass index (BMI) in adolescence with mortality attributed to kidney disease.

Overuse Injuries in the IDF’s Combat Training Units: Rates, Types, and Mechanisms of Injury

Introduction Overuse injuries are responsible for most lost training days and attrition from combat training in the Israeli Defense Forces (IDF) as in armies around the world. The purpose of this study is to understand the rates, types, and mechanism of occurrence of overuse injuries in the IDF in order to provide the IDFs commanders a detailed updated situation report in order to enable commanders decision-making, prevention policy, and further research of this highly significant military public health issue. Methods A cross-sectional study including 20,000 soldiers recruited to combat units during the year of 2013 was performed. Most of the data were collected from the IDFs computerized medical consultation records package. Descriptive statistics (percent, mean, standard deviation, and median) were used in order to express results. The study was approved by the IDFs institutional review board. Results The overall injury rate was 24.5%. The total number of injuries was 6,393 with an average of 1.32 ± 0.22 injuries per injured soldier. The injury rate was 18.4% in the infantry units and 36.1% in non-infantry units. Of all injuries, 87% occurred in the lower back and lower limb regions. The most frequent injury sites were the calf and ankle (34%), the knee region (22%), and the lower back (19%). Of all injuries, 74% occurred during running (45%) or long-distance walking (29%). The average lost training days due to injuries was 9 d per soldier and 6.5 d per injury. The total number of stress fractures was 494-2.5% of all soldiers (four fractures per 100 person years). The calf and ankle region was the most frequent site of stress fractures and accounted for 84% of all stress fractures, the vast majority of them (95%) were fractures of the distal tibia. The average number of lost training days due to stress fractures was 16 ± 6.1 per fracture. Conclusions As in other armies around the world, overuse injuries in the IDF are a major public health problem and poses a significant challenge to the IDFs commanders and the medical corps policy leaders. Further studies should be performed in order to identify the risk factors for these injuries especially in the lower back and the lower limb regions as part of the effort to try and reduce the rates of these injuries as much as possible. This study emphasizes the need for a continuous surveillance and monitoring system for overuse injuries as a significant and integral component of any intervention plan in the domain of overuse injuries.

Overuse Injuries Among Female Combat Warriors in the Israeli Defense Forces: A Cross-sectional Study

Introduction Integration of females in combat units poses a unique challenge for army commanders around the world. The purpose of this study is to provide a detailed up-to-date situation report regarding overuse injuries among combat female warriors in the IDF (Israeli Defense Forces) in order to enable evidence-based decision-making, prevention policy, and further research of this highly significant military public health issue. Methods A cross-sectional descriptive study was conducted including 2,519 females recruited to combat duties during the year of 2013. The main data source was the IDFs computerized medical consultation records package (CPR). Descriptive statistics was performed and some results were compared with males using data from other reports and studies of the IDF. Results The overall injury rate was 28.3%. Of all injuries, 86% were in the ankle and calf (41%), the lower back (23%), and the knee (22%) regions. The average lost training days was 11 d for females as compared with 8 d for males. The overall rates of stress fractures and the rates of femur and femoral neck stress fractures were significantly higher among females as compared with males (11.2% vs. 2.5%, p = 0.0032, and 7.8% vs. 1.6% p = 0.00001, respectively). Conclusions The overuse injury rates among females in the IDF are high and may be considered a significant military public health problem. In order to reduce the numbers of overuse injuries, which is expected to significantly increase after the IDFs policy change regarding to combat duties open for females, we recommend planning and implementation of policies and intervention programs and further research regarding to overuse injuries among female combat warriors with special focus on the calf and ankle, lower back, and knee regions and femoral stress fractures.

Challenges in Implementing International Standards for the Field Hospital Emergency Department in a Disaster Zone: The Israeli Experience

BACKGROUND Medical response to world disasters has too often been poorly coordinated and nonprofessional. To improve this, several agencies, led by the World Health Organization (WHO), have developed guidelines to provide accreditation for Foreign Medical Teams (FMTs). There are three levels, with the highest known as FMT Type-3 providing outpatient as well as inpatient surgical emergency care in addition to inpatient referral care. In November 2016, the WHO certified the Israel Defense Forces Field Hospital as the first FMT Type-3. OBJECTIVES The objectives of this article are to describe the challenges in implementing these international standards for the field hospital emergency department in a disaster zone. DISCUSSION There are general standards for all levels of FMTs, as well as specific requirements for the FMT-3. These include a mechanism of appropriate triage, two operating suites, 40 regular beds, four to six intensive care unit beds, radiology facilities, and various staff specialties. Despite the sophistication of the field hospital, there are many challenges. Logistical challenges include constructing the hospital in a disaster zone and equipment issues. There are staff challenges such as becoming oriented to a new and difficult environment. Patient challenges include cultural differences, language barriers, and issues of follow-up. There are often ethical challenges unique to the disaster zone. CONCLUSION By presenting the experience and challenges of the first FMT Type-3, we hope that more countries can join this initiative and improve disaster care throughout the world.

Comparison of Two Intraosseous Devices: The NIO Versus the EZ-IO by Novice Users-A Randomized Cross Over Trial

Abstract Background: During resuscitation in the field, intraosseous (IO) access may be achieved using a variety of available devices, often attempted by inexperienced users. Aim: We sought to examine the success rate and ease-of-use ratings of an IO device, the NIO® (New Intraosseous Persys Medical, Houston, TX, USA) in comparison to the Arrow® EZ-IO® (Teleflex Medical Research Triangle Park, NC, USA) by novice users. Methods: We performed a randomized crossover trial. The study model was a porcine hind leg which was cut distally in order to expose the marrow. The Study population was composed of pre-graduate medical students without prior experience in IO use, all designated future field physicians. The students underwent instruction and practiced the use of both devices. After practice completion, each student attempted a single IO insertion with both devices sequentially in randomized fashion. Success was defined as a flow of fluid through the bone marrow after a single IO attempt. Investigators which determined the success rate were blinded to the used device. Results: 50 users (33 males, 17 females) participated in the trial, mean age of 21.7 years (±1). NIO users were successful in 92% (46/50) attempts while EZ-IO user success rate was 88% (44/50). NIO success rates were comparable to those of EZ-IO (p = NS). Results were similar when examining only the initial device used. Median score of ease of use was 4 (5 point Likert scale) in both devices (p = NS). 54% (27/50) of the participants preferred using the EZ-IO over the NIO (p = NS). Conclusion: Novice users were equally successful in establishing IO access with the NIO® in comparison to the EZ-IO® in a porcine model.

Procedural sedation and analgesia in the emergency room of a field hospital after the Nepal earthquake

Procedural sedation and analgesia (PSA) should be a priority in the emergency care of injured children. This humanistic approach is particularly important in paediatric victims of disaster, because these patients are prone to psychological distress secondary to the traumatic event. Following the Nepal earthquake, an Israeli field hospital (IFH) was deployed in Kathmandu. We report our experience with PSA in the emergency room (ER) of the IFH. 22 children underwent surgery in the operating room and 10 underwent PSA in the ER by paediatric emergency physicians: 6 had wound debridement, 2 had fracture reduction and 2 had laceration repair. All the procedures were successfully completed in the ER and no patient required intubation or admission to the intensive care unit due to an adverse event. The present study is the first report of the practice of paediatric PSA by non-anaesthesiologists in a field hospital.