A US military Role 2 forward surgical team database study of combat mortality in Afghanistan.

BACKGROUND: Timely and optimal care can reduce mortality among critically injured combat casualties. US military Role 2 surgical teams were deployed to forward positions in Afghanistan on behalf of the battlefield trauma system. They received prehospital casualties, provided early damage control resuscitation and surgery, and rapidly transferred casualties to Role 3 hospitals for definitive care. A database was developed to capture Role 2 data. METHODS: A retrospective review and descriptive analysis were conducted of battle-injured casualties transported to US Role 2 surgical facilities in Afghanistan from February 2008 to September 2014. Casualties were analyzed by mortality status and location of death (pretransport, intratransport, or posttransport), military affiliation, transport time, injury type and mechanism, combat mortality index-prehospital (CMI-PH), and documented prehospital treatment. RESULTS: Of 9,557 casualties (median age, 25.0 years; male, 97.4%), most (95.1%) survived to transfer from Role 2 facility care. Military affiliation included US coalition forces (37.4%), Afghanistan National Security Forces (23.8%), civilian/other forces (21.3%), Afghanistan National Police (13.5%), and non-US coalition forces (4.0%). Mortality differed by military affiliation (p < 0.001). Among fatalities, most were Afghanistan National Security Forces (30.5%) civilian/other forces (26.0%), or US coalition forces (25.2%). Of those categorized by CMI-PH, 40.0% of critical, 11.2% of severe, 0.8% of moderate, and less than 0.1% of mild casualties died. Most fatalities with CMI-PH were categorized as critical (66.3%) or severe (25.9%), whereas most who lived were mild (56.9%) or moderate (25.4%). Of all fatalities, 14.0% died prehospital (pretransport, 5.8%; intratransport, 8.2%), and 86.0% died at a Role 2 facility (posttransport). Of fatalities with documented transport times (median, 53.0 minutes), most (61.7%) were evacuated within 60 minutes. CONCLUSIONS: Role 2 surgical team care has been an important early component of the battlefield trauma system in Afghanistan. Combat casualty care must be documented, collected, and analyzed for outcomes and trends to improve performance. LEVEL OF EVIDENCE: Therapeutic/Care Management, level IV.

A 12-Year Analysis of Nonbattle Injury Among US Service Members Deployed to Iraq and Afghanistan.

Importance: Nonbattle injury (NBI) among deployed US service members increases the burden on medical systems and results in high rates of attrition, affecting the available force. The possible causes and trends of NBI in the Iraq and Afghanistan wars have, to date, not been comprehensively described. Objectives: To describe NBI among service members deployed to Iraq and Afghanistan, quantify absolute numbers of NBIs and proportion of NBIs within the Department of Defense Trauma Registry, and document the characteristics of this injury category. Design, Setting, and Participants: In this retrospective cohort study, data from the Department of Defense Trauma Registry on 29 958 service members injured in Iraq and Afghanistan from January 1, 2003, through December 31, 2014, were obtained. Injury incidence, patterns, and severity were characterized by battle injury and NBI. Trends in NBI were modeled using time series analysis with autoregressive integrated moving average and the weighted moving average method. Statistical analysis was performed from January 1, 2003, to December 31, 2014. Main Outcomes and Measures: Primary outcomes were proportion of NBIs and the changes in NBI over time. Results: Among 29 958 casualties (battle injury and NBI) analyzed, 29 003 were in men and 955 were in women; the median age at injury was 24 years (interquartile range, 21-29 years). Nonbattle injury caused 34.1% of total casualties (n = 10 203) and 11.5% of all deaths (206 of 1788). Rates of NBI were higher among women than among men (63.2% [604 of 955] vs 33.1% [9599 of 29 003]; P < .001) and in Operation New Dawn (71.0% [298 of 420]) and Operation Iraqi Freedom (36.3% [6655 of 18 334]) compared with Operation Enduring Freedom (29.0% [3250 of 11 204]) (P < .001). A higher proportion of NBIs occurred in members of the Air Force (66.3% [539 of 810]) and Navy (48.3% [394 of 815]) than in members of the Army (34.7% [7680 of 22 154]) and Marine Corps (25.7% [1584 of 6169]) (P < .001). Leading mechanisms of NBI included falls (2178 [21.3%]), motor vehicle crashes (1921 [18.8%]), machinery or equipment accidents (1283 [12.6%]), blunt objects (1107 [10.8%]), gunshot wounds (728 [7.1%]), and sports (697 [6.8%]), causing predominantly blunt trauma (7080 [69.4%]). The trend in proportion of NBIs did not decrease over time, remaining at approximately 35% (by weighted moving average) after 2006 and approximately 39% by autoregressive integrated moving average. Assuming stable battlefield conditions, the autoregressive integrated moving average model estimated that the proportion of NBIs from 2015 to 2022 would be approximately 41.0% (95% CI, 37.8%-44.3%). Conclusions and Relevance: In this study, approximately one-third of injuries during the Iraq and Afghanistan wars resulted from NBI, and the proportion of NBIs was steady for 12 years. Understanding the possible causes of NBI during military operations may be useful to target protective measures and safety interventions, thereby conserving fighting strength on the battlefield.

Unrealized potential of the US military battlefield trauma system: DOW rate is higher in Iraq and Afghanistan than in Vietnam, but CFR and KIA rate are lower.

LEVEL OF EVIDENCE: Observational/retrospective/historic controls, level IV.

Volumetric control of whole blood collection in austere environments.

INTRODUCTION: Fresh whole blood transfusions are a powerful tool in prehospital care; however, the lack of equipment such as a scale in field situations frequently leads to collections being under- or overfilled, leading to complications for both patient and physician. This study describes two methods for simple, rapid control of collection bag volume: (1) a length of material to constrict the bag, and (2) folding/clamping the bag. METHOD: Whole blood collection bags were allowed to fill with saline via gravity. Paracord, zip-tie, beaded cable tie, or tourniquet was placed around the bag at circumferences of 6 to 8.75 inches. A hemostat was used to clamp folds of 1 to 1.5 inches. Several units were drawn during training exercises of the 75th Ranger Regiment with volume controlled by three methods: vision/touch estimation, constriction by paracord, and clamping with hemostat. RESULTS: Method validation in the Terumo 450-mL bag indicated that paracord, zip-tie, and beaded cable tie lengths of 6.5 inches or clamping 1.25 inches with a hemostat provided accurate filling. The volume variance was significantly lower when using the beaded cable tie. Saline filling time was approximately 2 minutes. With the Fenwal 450-mL bag, the beaded cable tie gave best results; even if incorrectly placed by one/two beads, the volume was still within limits. In training exercises, the use of the cord/clamp greatly reduced the variability; more bags were within limits. CONCLUSIONS: Both constricting and clamping allow for speed and consistency in blood collection. The use of common cord is appealing, but knot tying induces inevitable variability; a zip/cable tie is easier. Clamping was quicker but susceptible to high variance and bag rupturing. With proper methodological training, appropriate volumes can be obtained in any environment with minimal tools. LEVEL OF EVIDENCE: Therapeutic/care management study, level IV.

Surgeon preparedness for mass casualty events: Adapting essential military surgical lessons for the home front.

Military surgeons have gained familiarity and experience with mass casualty events (MCEs) as a matter of routine over the course of the last two conflicts in Afghanistan and Iraq. Over the same period of time, civilian surgeons have increasingly faced complex MCEs on the home front. Our objective is to summarize and adapt these combat surgery lessons to enhance civilian surgeon preparedness for complex MCEs on the home front. The authors describe the unique lessons learned from combat surgery over the course of the wars in Afghanistan and Iraq and adapt these lessons to enhance civilian surgical readiness for a MCE on the home front. Military Damage Control Surgery (mDCS) combines the established concept of clinical DCS (cDCS) with key combat situational awareness factors that enable surgeons to optimally care for multiple, complex patients, from multiple simultaneous events, with limited resources. These additional considerations involve the surgeon's role of care within the deployed trauma system and the battlefield effects. The proposed new concept of mass casualty DCS (mcDCS) similarly combines cDCS decisions with key factors of situational awareness for civilian surgeons faced with complex MCEs to optimize outcomes. The additional considerations for a civilian MCE include the surgeon's role of care within the regional trauma system and the incident effects. Adapting institutionalized lessons from combat surgery to civilian surgical colleagues will enhance national preparedness for complex MCEs on the home front.

Fresh whole blood use by forward surgical teams in Afghanistan is associated with improved survival compared to component therapy without platelets.

BACKGROUND: In Afghanistan, a substantial portion of resuscitative combat surgery is performed by US Army forward surgical teams (FSTs). Red blood cells (RBCs) and fresh frozen plasma (FFP) are available at these facilities, but platelets are not. FST personnel frequently encounter high-acuity patient scenarios without the ability to transfuse platelets. An analysis of the use of fresh whole blood (FWB) at FSTs therefore allows for an evaluation of outcomes associated with this practice. STUDY DESIGN AND METHODS: A retrospective analysis was performed in prospectively collected data from all transfused patients at six FSTs from December 2005 to December 2010. Univariate analysis was performed, followed by two separate propensity score analyses. In-hospital mortality was predicted with the use of a conditional logistic regression model that incorporated these propensity scores. Subset analysis included evaluation of patients who received uncrossmatched Type O FWB compared with those who received type-specific FWB. RESULTS: A total of 488 patients received a blood transfusion. There were no significant differences in age, sex, or Glasgow Coma Scale in those who received or did not receive FWB. Injury Severity Scores were higher in patients transfused FWB. In our adjusted analyses, patients who received RBCs and FFP with FWB had improved survival compared with those who received RBCs and FFP without FWB. Of 94 FWB recipients, 46 FWB recipients (49%) were given uncrossmatched Type O FWB, while 48 recipients (51%) received type-specific FWB. There was no significant difference in mortality between patients that received uncrossmatched Type O and type-specific FWB. CONCLUSIONS: The use of FWB in austere combat environments appears to be safe and is independently associated with improved survival to discharge when compared with resuscitation with RBCs and FFP alone. Mortality was similar for patients transfused uncrossmatched Type O compared with ABO type-specific FWB in an austere setting.

Defining and predicting surgeon utilization at forward surgical teams in Afghanistan.

BACKGROUND: The forward surgical team (FST) is the US Army's smallest surgical element. These teams have supported current conflicts since 2001. The purpose of this study was to determine if surgeon utilization varied at two different FSTs and to determine factors that may predict the need for a surgeon. METHOD: Data from two FSTs were reviewed. A t-test was used to compare the military injury severity scores (mISS) and the revised trauma scores (RTS). χ(2) analysis was used to compare types and mechanisms of injury and to compare life- or limb-saving surgeries (LLSS) and life-saving interventions among the FSTs. Logistic regression was used to determine if mISS, RTS, physiologic parameters, or laboratory values predicted the need for LLSS or life-saving intervention. RESULTS: The 541st FST treated a larger volume of patients than the 772nd FST (n = 761 versus n = 311). The 772nd FST performed a significantly higher percentage of LLSS; however, absolute number of LLSS was 31 at both FSTs. The mISS among operative patients were similar, but RTS were significantly different (772nd FST = 7.28 versus 541st FST = 7.58, P = 0.008). The 772nd FST saw a higher percentage of motor vehicle collision and rocket-propelled grenade injuries and thoracic and neurologic injuries, and the 541st FST saw a higher percentage of blast and gunshot wound injuries and abdominal injuries. Lactate level was the most significant predictor of the need for LLSS. CONCLUSION: Although percentage of surgical interventions varied between the two FSTs, the absolute number of needed surgical interventions was the same and was small. Lactate level predicted the need for surgical intervention in our population.

US Army two-surgeon teams operating in remote Afghanistan--an evaluation of split-based Forward Surgical Team operations.

BACKGROUND: United States Army Forward Surgical Teams (FSTs) consist of twenty personnel and are the Army's smallest surgical units. Currently, they provide the majority of resuscitative surgical care for combat casualties in Afghanistan where the mission of the FST has been further extended to include "split-based operations." The effectiveness of these 10-person teams is unknown and outcome data has not been previously reported in the literature. This article evaluates the effectiveness of one split FST during a 14-month period in remote Afghanistan. METHODS: The primary endpoint was died of wounds (DOW) outcomes among United States Forces, Coalition Afghani Forces, and local national citizens. Mortality was evaluated separately for patients who received a blood transfusion. Secondary endpoints of the study included number of blood products transfused, Injury Severity Score (ISS), and mechanism of injury. RESULTS: Seven hundred sixty-one patients were treated and 327 patients underwent an immediate surgery. The average ISS was 12.05, and the DOW percentage was 2.36%. There were 61 patients with an ISS of greater than 24 (mortality = 23.0%), and 47 patients with an ISS of 16 to 24 (mortality = 2.13%). Nine of 121 patients transfused (7.4%) died. A total of 27 patients required massive blood transfusion and on average received 12.6 units of fresh frozen plasma and 18.2 units of packed red blood cell (ratio 1:1.49). Seven of 27 patients who received massive blood transfusion (25.9%) died. CONCLUSIONS: Small two-surgeon surgical teams can achieve acceptable DOW rates when compared with other larger surgical units currently operating in the Global War on Terror.

US Army split forward surgical team management of mass casualty events in Afghanistan: surgeon performed triage results in excellent outcomes.

OBJECTIVE: U.S. Army "split"forward surgical teams (FST) currently provide most of the resuscitative surgical care for combat patients in Afghanistan. These small units typically comprised 10 personnel and two surgeons each, who frequently encounter mass casualty (MASCAL) situations in geographically isolated regions. This article evaluates the effectiveness of one split FST managing 43 MASCAL situations in two separate locations for more than a 14-month period in Afghanistan. DESIGN: An Institutional Review Board-approved review of all admission data of the 541st FST was conducted. Comparison was made between patients treated in MASCAL situations to those of patients treated in non-MASCAL events. SETTING: Split-based US Army forward surgical elements in a combat environment in Afghanistan. PATIENTS: Two hundred eighty-two patients were treated during MASCAL events and 479 in non-MASCAL situations. MAIN OUTCOME MEASURES: The primary endpoint was survival outcomes among trauma patients when 5 or more patients arrived simultaneously or if3 or more patients required immediate surgery. RESULTS: Four patients (1.70 percent) died in the MASCAL group compared with 12 (3.30 percent) in the non-MASCAL group. The mortality of patients receiving surgery at the FST was 2.73 percent and the mortality was 0.93 percent in those transferred without surgery. In the MASCAL group, 41 patients (14.5 percent) were critically injured and the critical mortality rate was 6.25 percent. In MASCAL events, 39 percent of patients required surgery compared with 44.9 percent in the non-MASCAL group. The average Injury Severity Score (ISS) of the most severely injured patient was 21.19 and ISS rapidly decreased to scores consistent with mild injury suggesting over triage at the scene. CONCLUSIONS: Despite very limited resources, the split FST can achieve, with appropriate triage, acceptable mortality outcomes in MASCAL situations. Over triage at the wounding scene is common and surgical intervention is frequently required.