Health Behaviors Among Service Members Injured on Deployment: A Study From the Wounded Warrior Recovery Project.

INTRODUCTION: Service members (SMs) who are injured on deployment are at risk for myriad long-term health problems that may be ancillary to their physical injury, including high rates of depression and posttraumatic stress disorder, and poor health behaviors (e.g., problem drinking, cigarette and tobacco use, poor sleep quality, and sedentary lifestyle). As the specific health behaviors injured SMs engage in have been largely ignored, the primary aim of this study was to compare health behavior patterns among those with and without mental health problems in a large, representative sample of SMs injured on combat deployment. MATERIALS AND METHODS: Participants (N = 3,303) completed behavioral health assessments between September 2018 and April 2019 as part of the Wounded Warrior Recovery Project. Multivariate linear regressions and binary logistic regressions were used to evaluate differences between mental health screening status and health behavior outcomes, adjusting for injury severity, age, and years since injury. RESULTS: Overall, about half of participants screened positive for posttraumatic stress disorder and/or depression (49%). Participants reported high rates of alcohol use and problems, cigarette and tobacco use, inadequate sleep and poor sleep quality, and low levels of physical activity. With the exception of number of drinking days and likelihood of current tobacco use, participants who screened positive for a mental health disorder evidenced significantly worse health behavior outcomes. CONCLUSIONS: The results provide a preliminary glance into the mental health and health behaviors of SMs roughly a decade after injury, and underscore the importance of examining the interplay between mental, physical, and behavioral health outcomes among wounded warriors to promote health and wellness.

Combat amputees' health-related quality of life and psychological outcomes: A brief report from the wounded warrior recovery project.

BACKGROUND: This study extends what is known about long-term health-related quality of life (HrQoL) and other psychosocial outcomes (i.e., depression, posttraumatic stress disorder [PTSD]) among US military combat amputees serving in Operation Enduring Freedom, Operation Iraqi Freedom, and Operation New Dawn. METHODS: A total of 63 combat amputees were identified from the Wounded Warrior Recovery Project, a study assessing long-term self-reported HrQoL and psychological outcomes among those wounded during military service. Another 477 service members from the Wounded Warrior Recovery Project were identified as a comparison group (i.e., nonamputees with moderate to severe extremity injuries). RESULTS: After adjusting for age, time since injury, overall injury severity, and traumatic brain injury, amputees had poorer functional HrQoL than those in the nonamputee comparison group overall and in the specific area related to performance of usual activities, and, to some degree, chronic and acute symptoms, and mobility/self-care. On the other hand, depression and PTSD symptoms were not different for the two groups. CONCLUSION: Results suggest that when assessed over 5 years postinjury, on average, amputees have unique physical and functional limitations, yet do not report greater depression or PTSD symptoms than others seriously injured in combat. It may be that state-of-the-art integrated amputee care that includes support networks and emphasis on adjustment and psychological health may increase successful coping and adjustment, at least to a level that is on par with other types of serious combat injury. LEVEL OF EVIDENCE: Epidemiologic/prognostic study, level III.

Venous thromboembolism after traumatic amputation: an analysis of 366 combat casualties.

BACKGROUND: We sought to determine the incidence, risk factors, and time course for deep vein thrombosis and pulmonary embolism (DVT/PE) after combat-related major limb amputations. METHODS: Patients with amputation in Iraq or Afghanistan from 2009 through 2011 were eligible. Details of postinjury care, date of diagnosis of DVT/PE, and injury specific data were collected. Military databases and chart reviews were used. RESULTS: In 366 patients, 103 (28%) had DVT/PE; PE was diagnosed in 59 (16%) and DVT in 59 (16%). Most DVT (69%) and PE (66%) occurred within 10 days. Increasing ventilator days (odds ratio [OR], 1.97; 95% CI, 1.16 to 3.37) and units of blood transfused (OR, 1.72; 95% CI, 1.11 to 2.68) were associated with DVT. Increasing units of fresh-frozen plasma were associated with PE (OR, 1.31; 95% CI, 1.10 to 1.55). CONCLUSIONS: The incidence of DVT/PE is high after combat-related amputation. Most DVT/PE occur early and prophylaxis is indicated.

Effectiveness of the combat pelvic protection system in the prevention of genital and urinary tract injuries: An observational study.

BACKGROUND: Historically, the incidence of genital and urinary tract (GU) injuries in major conflicts has been approximately 5%. To mitigate the risk of blast injury to the external genitalia, the United States and United Kingdom issued protective overgarments and undergarments to troops deployed in support of Operation Enduring Freedom. These two systems combined constitute the pelvic protection system (PPS). Our hypothesis was that PPS use is associated with a reduction of GU injuries in subjects exposed to dismounted improvised explosive device blast injuries. METHODS: We identified two groups for comparison: those who were confirmed to have worn the PPS at time of injury (n = 58) and a historical control group who were confirmed as not wearing the PPS (non-PPS) (n = 61). Patients with any level of lower extremity amputation from dismounted improvised explosive device blast mechanism were included. The primary outcome measure was presence of a GU injury on admission. A univariate analysis assessing the strength of association with odds ratios and 95% confidence intervals was performed between the PPS and non-PPS groups. RESULTS: Mean Injury Severity Score (ISS) was higher in the PPS versus the non-PPS group (26.1 vs. 19.3, p = 0.0012). Overall, 31% of the patients in the PPS group sustained at least one GU injury versus 62.3% in the non-PPS group. The odds ratio of sustaining a GU injury in the PPS group as compared with the PPS group is 0.28 (31% vs. 62.3%; 95 % confidence interval, 0.62-0.12; p < 0.001). The most frequent injures were open scrotal/testes wounds, followed by open penis, and open bladder/urethra injuries. CONCLUSION: The use of the PPS is associated with a decreased odds ratio of GU injury. Despite a 31% absolute reduction, future work should focus on improved efficiency. LEVEL OF EVIDENCE: Prognostic/epidemiologic study, level IV; therapeutic study, level V.

Airway Management in Severe Combat Maxillofacial Trauma.

OBJECTIVES: Airway stabilization is critical in combat maxillofacial injury as normal anatomical landmarks can be obscured. The study objective was to characterize the epidemiology of airway management in maxillofacial trauma. STUDY DESIGN: Retrospective database analysis. SETTING: Military treatment facilities in Iraq and Afghanistan and stateside tertiary care centers. SUBJECTS: In total, 1345 military personnel with combat-related maxillofacial injuries sustained March 2004 to August 2010 were identified from the Expeditionary Medical Encounter Database using International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) codes. METHODS: Descriptive statistics, including basic demographics, injury severity, associated injuries, and airway interventions, were collected. A logistic regression was performed to determine factors associated with the need for tracheostomy. RESULTS: A total of 239 severe maxillofacial injuries were identified. The most common mechanism of injury was improvised explosive devices (66%), followed by gunshot wounds (8%), mortars (5%), and landmines (4%). Of the subjects, 51.4% required intubation on their initial presentation. Of tracheostomies, 30.4% were performed on initial presentation. Of those who underwent bronchoscopy, 65.2% had airway inhalation injury. There was a significant relationship between the presence of head and neck burn and association with airway inhalation injury (P < .0001). There was also a significant relationship between the severity of facial injury and the need for intubation (P = .002), as well as the presence of maxillofacial fracture and the need for tracheostomy (P = .0001). CONCLUSIONS: There is a high incidence of airway injury in combat maxillofacial trauma, which may be underestimated. Airway management in this population requires a high degree of suspicion and low threshold for airway stabilization.

Combat injury coding: a review and reconfiguration.

BACKGROUND: The current civilian Abbreviated Injury Scale (AIS), designed for automobile crash injuries, yields important information about civilian injuries. It has been recognized for some time, however, that both the AIS and AIS-based scores such as the Injury Severity Score (ISS) are inadequate for describing penetrating injuries, especially those sustained in combat. Existing injury coding systems do not adequately describe (they actually exclude) combat injuries such as the devastating multi-mechanistic injuries resulting from attacks with improvised explosive devices (IEDs). METHODS: After quantifying the inapplicability of current coding systems, the Military Combat Injury Scale (MCIS), which includes injury descriptors that accurately characterize combat anatomic injury, and the Military Functional Incapacity Scale (MFIS), which indicates immediate tactical functional impairment, were developed by a large tri-service military and civilian group of combat trauma subject-matter experts. Assignment of MCIS severity levels was based on urgency, level of care needed, and risk of death from each individual injury. The MFIS was developed based on the casualty's ability to shoot, move, and communicate, and comprises four levels ranging from "Able to continue mission" to "Lost to military." Separate functional impairments were identified for injuries aboard ship. Preliminary evaluation of MCIS discrimination, calibration, and casualty disposition was performed on 992 combat-injured patients using two modeling processes. RESULTS: Based on combat casualty data, the MCIS is a new, simpler, comprehensive severity scale with 269 codes (vs. 1999 in AIS) that specifically characterize and distinguish the many unique injuries encountered in combat. The MCIS integrates with the MFIS, which associates immediate combat functional impairment with minor and moderate-severity injuries. Predictive validation on combat datasets shows improved performance over AIS-based tools in addition to improved face, construct, and content validity and coding inter-rater reliability. Thus, the MCIS has greater relevance, accuracy, and precision for many military-specific applications. CONCLUSION: Over a period of several years, the Military Combat Injury Scale and Military Functional Incapacity Scale were developed, tested and validated by teams of civilian and tri-service military expertise. MCIS shows significant promise in documenting the nature, severity and complexity of modern combat injury.

A comparison of health outcomes for combat amputee and limb salvage patients injured in Iraq and Afghanistan wars.

BACKGROUND: Treatment of military combatants who sustain leg-threatening injuries remains one of the leading challenges for military providers. The present study provides systematic health outcome data to inform decisions on the definitive surgical treatment, namely amputation versus limb salvage, for the most serious leg injuries. METHODS: This was a retrospective analysis of health records for patients who sustained serious lower-extremity injuries in the Iraq and Afghanistan conflicts, 2001 to 2008. Patients had (1) amputation during the first 90 days after injury (early amputees, n = 587), (2) amputation more than 90 days after injury (late amputees, n = 84), or (3) leg-threatening injuries without amputation (limb salvage [LS], n = 117). Injury data and health outcomes were followed up to 24 months. RESULTS: After adjusting for group differences, early amputees and LS patients had similar rates for most physical complications. Early amputees had significantly reduced rates of psychological diagnoses (posttraumatic stress disorder, substance abuse) and received more outpatient care, particularly psychological, compared with LS patients. Late amputees had significantly higher rates of many mental and physical health diagnoses, including prolonged infections and pain issues, compared with early amputees or LS patients. CONCLUSION: Early amputation was associated with reduced rates of adverse health outcomes relative to late amputation or LS in the short term. Most evident was that late amputees had the poorest physical and psychological outcomes. These findings can inform health care providers of the differing clinical consequences of early amputation and LS. These results indicate the need for separate health care pathways for early and late amputees and LS patients.

Deployment-related injury and posttraumatic stress disorder in US military personnel.

BACKGROUND: The current military conflicts in Iraq and Afghanistan have resulted in the most US casualties since the Vietnam War. Previous research on the association between deployment-related injury and posttraumatic stress disorder (PTSD) has yielded mixed results. OBJECTIVES: To examine the effect of battle injury (BI) relative to non-battle injury (NBI) on the manifestation of PTSD symptoms in military personnel and to assess the demographic, injury-specific, and pre-injury factors associated with PTSD following a BI. PATIENTS AND METHODS: A total of 3403 personnel with deployment-related injury (1777 BI and 1626 NBI) were identified from the Expeditionary Medical Encounter Database. Records were electronically matched to Post-Deployment Health Assessment (PDHA) data completed 1-6 months post-injury. The PTSD screening outcome was identified using a four-item screening tool on the PDHA. RESULTS: Compared to those with NBI, personnel with BI had more severe injuries, reported higher levels of combat exposure, and had higher rates of positive PTSD screen. After adjusting for covariates, personnel with BI were twice as likely to screen positive for PTSD compared to those with NBI (odds ratio [OR], 2.10; 95% confidence interval [CI], 1.60-2.75). In multivariable analysis among battle-injured personnel only, moderate and serious-severe injury (OR, 1.49; 95% CI, 1.12-2.00 and OR, 1.64; 95% CI, 1.01-2.68, respectively), previous mental health diagnosis within 1 year of deployment (OR, 2.69; 95% CI, 1.50-4.81), and previous BI (OR, 1.96; 95% CI, 1.22-3.16) predicted a positive PTSD screen. CONCLUSIONS: Military personnel with BI have increased odds of positive PTSD screen following combat deployment compared to those with NBI. Post-deployment health questionnaires may benefit from questions that specifically address whether service members experienced an injury during combat.

Postdeployment symptom changes and traumatic brain injury and/or posttraumatic stress disorder in men.

In Operation Iraqi Freedom and Operation Enduring Freedom, blast-related injuries associated with combat are frequent and can result in traumatic brain injury (TBI) symptoms that may be difficult to distinguish from psychological problems. Using data from the Post-Deployment Health Assessment and Reassessment, we identified 12,046 male U.S. Navy sailors and Marines with reported combat exposure from 2008 to 2009. Symptoms potentially associated with blast-related TBI and posttraumatic stress disorder (PTSD) that were reported immediately after deployment were compared with symptoms present several months later. Our study supports others that have found that subjects with blast-related injuries may experience the development or worsening of symptoms during the months following deployment. Additionally, our study found that those who screened positive for PTSD and TBI formed a unique group, with the presence of TBI exacerbating development of PTSD symptoms at reassessment. Providers should recognize the late development of symptoms, consider the possibility of comorbidity, and be prepared to treat multiple symptoms rather than a specific diagnostic category.

Cigarette smoking, body mass index, and physical fitness changes among male navy personnel.

INTRODUCTION: Cigarette smoking has been reported to be higher among deployed military men than among similarly aged civilian or nondeployed men, but the short-term effect of smoking on physical fitness among these young healthy men is unclear. This study examined self-reported smoking status and change in objectively measured fitness over 1-4 years while controlling for body mass index (BMI). METHODS: This study included a large sample of male U.S. navy personnel who deployed to Iraq or Kuwait between 2005 and 2008. A mixed modeling procedure was used to determine factors contributing to longitudinal changes in both BMI and fitness (measured by run/walk times, curl-ups, and push-ups). RESULTS: Of the total sample (n = 18,537), the 20% current smokers were more likely than nonsmokers to be enlisted, younger, and have lower BMI measurements at baseline. In addition, smokers had slower 1.5-mile run/walk times and could do fewer curl-ups and push-ups compared with nonsmokers. The run/walk time model indicated that over 4 years, smokers (compared with nonsmokers) experienced a significantly greater rate of decrease in cardiorespiratory fitness, even after controlling for changes in BMI. CONCLUSIONS: These results call for continued attention to the problem of nicotine use among young healthy men.

The use of temporary vascular shunts in military extremity wounds: a preliminary outcome analysis with 2-year follow-up.

BACKGROUND: The use of temporary vascular shunts (TVS)s in the management of wartime extremity vascular injuries has received an increasing amount of attention. However, the overall impact of this adjunct remains incompletely defined. The objective of this study is to characterize outcomes of those patients who suffered wartime extremity vascular injuries managed with TVSs. METHODS: This is a retrospective review of the Navy and Marine Corps Combat Trauma Registry examining peripheral vascular injuries treated during the military conflicts in the Middle East. Patient demographics, injury severity score, mechanism of injury, and vessels injured were recorded. Operative reports were reviewed for use of TVSs, type of definitive repair, the need for amputation, and survival. RESULTS: Eighty patients were included. Forty-six (57%) had TVSs placed and 34 (43%) underwent repair at initial presentation. The mean injury severity score for the TVS group and the non-TVS groups were 15.0 +/- 5.05 and 12.9 +/- 10.18, respectively, (p = 0.229). There were a total of 13 amputations, 6 (13%) in the TVS group and 7 (21%) in the non-TVS group (p = 0.38). There was no difference in amputation rates between either group. There were no recorded mortalities in either group. Median patient follow-up was 24.5 months (range, 3-48 months). CONCLUSIONS: This study demonstrates the importance and utility of TVSs in the management of wartime extremity vascular injury. When used to restore perfusion to an injured extremity, there seems to be no adverse effects or overall increase in limb loss rates and therefore a useful adjunct in the surgery for limb salvage.

Management of colorectal injuries during operation iraqi freedom: patterns of stoma usage.

BACKGROUND: Management of penetrating colorectal injuries in the civilian trauma population has evolved away from diversionary stoma into primary repair or resection and primary anastomosis. With this in mind, we evaluated how injuries to the colon and rectum were managed in the ongoing war in Iraq. METHODS: The records of Operation Iraqi Freedom patients evacuated to National Naval Medical Center (NNMC) from March 2004 until November 2005 were retrospectively reviewed. Patients with colorectal injuries were identified and characterized by the following: (1) injury type; (2) mechanism; (3) associated injuries; (4) Injury Severity Score; (5) levels of medical care involved in patient treatment; (6) time interval(s) between levels of care; (7) management; and (8) outcomes. RESULTS: Twenty-three patients were identified as having either colon or rectal injury. The average ISS was 24.4 (range, 9-54; median 24). On average, patients were evaluated and treated at 2.5 levels of surgically capable medical care (range, 2-3; median 2) between time of injury and arrival at NNMC, with a median of 6 days from initial injury until presentation at NNMC (range, 3-11). Management of colorectal injuries included 7 primary repairs (30.4%), 3 resections with anastomoses (13.0%), and 13 colostomies (56.6%). There was one death (4.3%) and three anastomotic leaks (30%). Total complication rate was 48%. CONCLUSIONS: Based upon injury severity, the complex nature of triage and medical evacuation, and the multiple levels of care involved for injured military personnel, temporary stoma usage should play a greater role in military casualties than in the civilian environment for penetrating colorectal injuries.

Descriptive summary of patients seen at the surgical companies during Operation Iraqi Freedom-1.

The Navy-Marine Corps Combat Trauma Registry is a data repository summarizing information from data sets describing injuries sustained and treatments administered to casualties from the point of injury to rehabilitation. Among the medical facilities contributing data to the Combat Trauma Registry during Operation Iraqi Freedom were the Marine Corps forward surgical companies. The surgical companies offer resuscitative surgery, medical treatment, and temporary holding facilities, in addition to preparing patients for evacuation. This article reviews the types of patients admitted and treatments provided at the surgical companies during the major combat period of Operation Iraqi Freedom. The surgical companies saw an average of 15 to 17 patients per day during this period. Less than 20% of the U.S. casualties seen were wounded in action. In contrast, >75% of the enemy prisoner of war presentations were for battle injuries. Less than 15% of the patients were held at the facilities for >24 hours.