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.

Simultaneous surgeries in a split forward surgical team: a case study.

INTRODUCTION: The 541st Forward Surgical Team performed split-based operations, with one site in the city of Pol-e-Khumri. One evening, the 10-person team received two pediatric patients simultaneously and conducted simultaneous surgeries. CASE PRESENTATION: The 3-year-old female sustained severe injuries to bilateral lower extremities and a puncture wound to her right forearm. The 13-year-old sustained fragmentary wounds to her left hand, left foot, right medial calf, and evisceration to her left lower quadrant. The patients presented in extremis after being taken to a civilian hospital initially, spending approximately 1.5 hours receiving no resuscitative therapy. The 3-year-old underwent amputations of bilateral lower extremities and a fasciotomy of the right forearm. The 13-year-old survived an exploratory laparotomy and irrigation and debridement of intra-abdominal wounds. CONCLUSION: The successful completion of simultaneous surgeries, by a split forward surgical team at a remote location, for two critically ill patients is possible. It should not become the standard of care. Prior planning made this occurrence feasible and safer, but such situations put the patients at risk for complications.

Emergency canine surgery in a deployed forward surgical team: a case report.

INTRODUCTION: Forward surgical teams (FSTs) perform a variety of non-doctrinal functions. During their deployment to Afghanistan, the 541st FST (Airborne) performed emergency surgery on a German shepherd military working dog (MWD). METHODS: Retrospective examination of a case of veterinary surgery in a deployed FST. RESULTS: A 5 1/2-year-old German shepherd MWD presented with extreme lethargy, tachycardia, excessive drooling, and a firm, distended abdomen. These conditions resulted from gastric dilatation with volvulus. Since evacuation to a veterinarian was untenable, emergency laparotomy was performed in the FST. The gastric dilatation with volvulus was treated by detorsion and gastropexy, and the canine patient fully recovered. CONCLUSION: Canine surgery can be safely performed in an FST. Based on the number of MWDs deployed throughout the theater, FSTs may be called upon to care for them in the absence of available veterinary care.

Laparoscopic sleeve gastrectomy: outcomes at a military training center.

Laparoscopic sleeve gastrectomy (LSG) has gained support as a single-staged and stand-alone bariatric procedure. Reports of excess weight loss of 35 to 83 per cent, reduction in comorbidities, and decreased operative morbidity have garnered support for LSG. This study represents an initial outcome analysis of LSG performed solely at a military treatment center. This study is a retrospective analysis of all patients receiving LSG at Dwight D. Eisenhower Army Medical Center from September 2007 to December 2009. The patients were planned for a stand-alone procedure. One hundred and fifteen patients received LSG over this time period with a mean body mass index of 45.5 +/- 6.2 (range 35.1-58.3). The average age was 47.4 +/- 12.5 years. Diabetes mellitus was seen in 47 per cent and 68 per cent of patients had hypertension. The mean and median length of operation was 124 +/- 48 and 115.5 minutes. The mean percentage of excess weight loss was 16.6 +/- 6.40 per cent at 1 month, 31.5 +/- 7.6 per cent at 3 months, 41.2 +/- 13.9 per cent at 6 months, and 53.7 +/- 12.5 per cent at 1 year from surgery. One or more of patient's preoperative diabetic or hypertensive medications were improved postoperatively in 18.7 per cent and 16.3 per cent, respectively. Incidence of major complications occurred in 4.35 per cent of patients in this study to include four leaks (3.4%), one death (0.87%), and 10 readmissions. Midterm analysis of outcomes related to LSG as a single-stage bariatric procedure is promising as long-term outcome data is collected; the efficacy of this procedure as a sole bariatric procedure will continue to be borne out.

Scholarly Output by Army General Surgery Residents.

INTRODUCTION: To characterize and compare the scholarly activity of applicants to Army First Year Graduate Medical Education (FYGME) general surgery positions over the course of a residency. METHODS: All applicants for the 2011-2012 Army FYGME positions in general surgery were included. Applications were used to obtain demographics and peer-reviewed publications. Publications were verified using PubMed and Google Scholar. Applicants were tracked for acceptance to a FYGME position, graduation from a general surgery program, and future publications. Comparisons were made between selectees and non-selectees. RESULTS: There were 46 applicants for 22 positions. Seven of the selectees (32%) had prior publications versus three non-selectees (12%; p < 0.109). Eighteen of the selectees went on to complete a general surgery residency by 2017. Of those who completed a general surgery residency, 16 (89%) have at least one publication with the mean number of publications of 4.0 versus 10 (43%), and of those not selected had at least one publication and the mean number of publications was 0.7 (p < 0.05). CONCLUSIONS: The majority of applications for general surgery residencies have no prior research publications. However, after 6 years, graduates of a general surgery residency have significantly published out those not selected for training.

Cerebral air embolism following removal of central venous catheter.

Cerebral air embolism occurs very seldom as a complication of central venous catheterization. We report a 57-year-old female with cerebral air embolism secondary to removal of a central venous catheter (CVC). The patient was treated with supportive measures and recovered well with minimal long-term injury. The prevention of air embolism related to central venous catheterization is discussed.

Achieving Mastery of General Surgery Operative Skill in the Army Healthcare System.

INTRODUCTION: Operative case volumes for military surgeons are reported to be significantly lower than civilian counterparts. Among the concern that this raises is an inability of military surgeons to achieve mastery of their craft. MATERIAL AND METHODS: Annual surgical case reports were obtained from seven Army military treatment facilities (MTF) for 2012-2016. Operative case volume and cumulative operative time were calculated for active duty general surgeons and for individual MTFs. Subgroup analyses were also performed based upon rank. Results were extrapolated to calculate the amount of time it would take to reach a cumulative of 10,000 hours of operative time (the a priori definition for achieving mastery). RESULTS: One hundred and two active duty general surgeons operated at the seven MTFs during the study period and met the inclusion criteria. The average surgeon performed 108 ± 68 cases/year. The average surgeon operated 122 ± 82 hours/year. At this rate, it would take over 80 years to reach mastery of surgery. When stratified based upon rank, Majors averaged 113 ± 75 hours/year, Lieutenant Colonels averaged 170 ± 100 hours/year, and Colonels averaged 136 ± 101 hours/year (p < 0.05). When stratified based upon individual MTF, surgeons at the busiest facility averaged 187 ± 103 hours/year and those at the least busy facility averaged 85 ± 56 hours/year (p < 0.05). CONCLUSIONS: Obtaining mastery of general surgery is a nearly impossible proposition given the current care models at Army MTFs. Alternative staffing and patient care models should be developed if Army surgeons are to be masters at their craft.

Blunt Abdominal Trauma, Splenectomy, and Post-Splenectomy Vaccination.

Unlike penetrating abdominal injuries where the decision to operate is relatively straight forward, those combat casualties that sustain blunt abdominal trauma offer more of a diagnostic and clinical challenge. For unstable patients with a positive focused abdominal sonography in trauma or diagnostic peritoneal lavage, exploratory laparotomy should be undertaken immediately. All grade IV-V splenic injuries should undergo splenectomy, patients undergoing attempted splenic salvage should be monitored in the Role 3 facility and embolization of such splenic injuries may be considered if available. Patients who fail non-operative management of the spleen require splenectomy at the Role 3 prior to aeromedical evacuation. Overwhelming post-splenectomy infection is a serious disease that can progress from a mild flu-like illness to fulminant sepsis in a short period of time. Although relatively rare, it has a high mortality rate with delayed or inadequate treatment. All splenectomized patients and those deemed to be functionally asplenic should be vaccinated within 14 days from splenectomy and prior to aeromedical evacuation.

Prevention of Deep Venous Thromboembolism.

The nature of many combat wounds puts patients at a high risk of developing deep venous thrombosis (DVT) and pulmonary embolism (PE), which fall under the broader disease category of venous thromboembolism (VTE). In addition to the hypercoagulable state induced by trauma, massive injuries to the extremities, prolonged immobility, and long fixed wing transport times to higher echelons of care are unique risk factors for venous thromboembolism in the combat-injured patient. These risk factors mandate aggressive prophylaxis for DVT and PE that can effectively be achieved by the use of lower extremity sequential compression devices and low dose unfractionated heparin or low molecular weight heparin. In addition, inferior vena cava filters are often used for PE prophylaxis when chemical DVT prophylaxis fails or is contraindicated. The following Department of Defense (DoD) Joint Trauma System (JTS) Clinical Practice Guideline (CPG) discusses the current recommendations for the prevention of DVT and PE including the use of inferior vena cava filters (IVCFs).

Unexploded Ordnance Management.

The purpose of this Clinical Practice Guide is to provide details on the procedures to safely remove unexploded ordnance from combat patients, both loose and impaled, to minimize the risks to providers and the medical treatment facility while ensuring the best outcome for the patient. Military ordnance, to include bullets, grenades, flares, and explosive ordnance, retained by a patient can be a risk to all individuals and equipment along the continuum of care. This is especially true from the point of injury to the first treatment facility. Management of patients with unexploded ordnance either on or in their body is a rare event during combat surgery. Loose munitions are usually noted and easily removed prior to the patient receiving medical treatment. However, impaled munitions provide a significant challenge. These are usually caused by large caliber, high-velocity projectiles. Patients who survive to arrive at a treatment facility must be triaged safely and simultaneously treated appropriately to ensure both the survival of the patient and the treatment team. Between WWII and the Somalia conflict, there have been 36 reported cases of unexploded ordnance from U.S. soldiers. Since 2005, there have been six known cases during the U.S. wars in Afghanistan and Iraq and one additional case in Pakistan. Optimal outcomes require a basic knowledge of explosives and triggering mechanisms, as well as adherence to basic principles of trauma resuscitation and surgery.

Factors associated with trauma patients' length of stay at Role 2 facilities in Afghanistan, October 2009 to September 2014.

BACKGROUND: Understanding patients' length of stay at far-forward Role 2 surgical units may help to determine support needs, stabilization requirements, predeployment training, and necessity of increased care capability before or during transport to a higher level of care. The objectives of this study were to (1) evaluate the amount of time patients spent at Role 2 and (2) determine the factors associated with trauma patients' length of stay at Role 2. METHODS: We conducted a secondary data analysis of the Joint Trauma System Role 2 Database. Logistic regression was used to determine factors associated with extended length of stay at Role 2. RESULTS: There were 7,912 study patients, and the overall median (interquartile range) amount of time patients spent at Role 2 was 2.5 (1.2-5.5) hours. The adjusted odds ratio (aOR) of extended stay for civilian/other forces and non-US military patients were 1.2 (95% confidence interval [CI], 1.0-1.4) and 1.4 (95% CI, 1.2-1.7) times higher as compared with US military patients, respectively. The aOR of extended stay were higher for patients who received blood transfusions (aOR, 1.4; 95% CI, 1.2-1.6), surgical procedures (aOR, 1.6; 95% CI, 1.4-1.8), or did not use a tourniquet (aOR, 1.2; 95% CI, 1.0-1.5). As compared with those injured by an explosion, the adjusted odds of extended stay were 1.2 (95% CI, 1.0-1.4) times higher for patients injured by another mechanism. The odds of extended stay were lower (aOR, 0.3; 95% CI, 0.2-0.5) for patients who died and higher (aOR, 1.4; 95% CI, 1.2-1.6) for transferred patients as compared with patients who returned to duty. CONCLUSION: In this study, interventions, patient affiliation, discharge status, and injury mechanism were associated with length of stay at Role 2. Our study results will help inform training and current Role 2 logistic and personnel support needs. LEVEL OF EVIDENCE: Prognostic, level III.

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.

Management of Suspected Tension Pneumothorax in Tactical Combat Casualty Care: TCCC Guidelines Change 17-02.

This change to the Tactical Combat Casualty Care (TCCC) Guidelines that updates the recommendations for management of suspected tension pneumothorax for combat casualties in the prehospital setting does the following things: (1) Continues the aggressive approach to suspecting and treating tension pneumothorax based on mechanism of injury and respiratory distress that TCCC has advocated for in the past, as opposed to waiting until shock develops as a result of the tension pneumothorax before treating. The new wording does, however, emphasize that shock and cardiac arrest may ensue if the tension pneumothorax is not treated promptly. (2) Adds additional emphasis to the importance of the current TCCC recommendation to perform needle decompression (NDC) on both sides of the chest on a combat casualty with torso trauma who suffers a traumatic cardiac arrest before reaching a medical treatment facility. (3) Adds a 10-gauge, 3.25-in needle/ catheter unit as an alternative to the previously recommended 14-gauge, 3.25-in needle/catheter unit as recommended devices for needle decompression. (4) Designates the location at which NDC should be performed as either the lateral site (fifth intercostal space [ICS] at the anterior axillary line [AAL]) or the anterior site (second ICS at the midclavicular line [MCL]). For the reasons enumerated in the body of the change report, participants on the 14 December 2017 TCCC Working Group teleconference favored including both potential sites for NDC without specifying a preferred site. (5) Adds two key elements to the description of the NDC procedure: insert the needle/ catheter unit at a perpendicular angle to the chest wall all the way to the hub, then hold the needle/catheter unit in place for 5 to 10 seconds before removing the needle in order to allow for full decompression of the pleural space to occur. (6) Defines what constitutes a successful NDC, using specific metrics such as: an observed hiss of air escaping from the chest during the NDC procedure; a decrease in respiratory distress; an increase in hemoglobin oxygen saturation; and/or an improvement in signs of shock that may be present. (7) Recommends that only two needle decompressions be attempted before continuing on to the "Circulation" portion of the TCCC Guidelines. After two NDCs have been performed, the combat medical provider should proceed to the fourth element in the "MARCH" algorithm and evaluate/treat the casualty for shock as outlined in the Circulation section of the TCCC Guidelines. Eastridge's landmark 2012 report documented that noncompressible hemorrhage caused many more combat fatalities than tension pneumothorax.1 Since the manifestations of hemorrhagic shock and shock from tension pneumothorax may be similar, the TCCC Guidelines now recommend proceeding to treatment for hemorrhagic shock (when present) after two NDCs have been performed. (8) Adds a paragraph to the end of the Circulation section of the TCCC Guidelines that calls for consideration of untreated tension pneumothorax as a potential cause for shock that has not responded to fluid resuscitation. This is an important aspect of treating shock in combat casualties that was not presently addressed in the TCCC Guidelines. (9) Adds finger thoracostomy (simple thoracostomy) and chest tubes as additional treatment options to treat suspected tension pneumothorax when further treatment is deemed necessary after two unsuccessful NDC attempts-if the combat medical provider has the skills, experience, and authorizations to perform these advanced interventions and the casualty is in shock. These two more invasive procedures are recommended only when the casualty is in refractory shock, not as the initial treatment.

Expeditionary Resuscitation Surgical Team: The US Army's Initiative to Provide Damage Control Resuscitation and Surgery to Forces in Austere Settings.

Improvements in surgical care on the battlefield have contributed to reduced morbidity and mortality in wounded Servicemembers. 1 Point-of-injury care and early surgical intervention, along with improved personal protective equipment, have produced the lowest casualty statistics in modern warfare, resulting in improved force strength, morale, and social acceptance of conflict. It is undeniable that point-of-care injury, followed by early resuscitation and damage control surgery, saves lives on the battlefield. The US Army's Expeditionary Resuscitation Surgical Team (ERST) is a highly mobile, interprofessional medical team that can perform damage control resuscitation and surgery in austere locations. Its configuration and capabilities vary; however, in general, a typical surgical element can perform one major surgery and one minor surgery without resupply. The critical care element can provide prolonged holding in garrison, but this diminishes in the austere setting with complex and acutely injured patients.

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.

Recent Advances in Forward Surgical Team Training at the U.S. Army Trauma Training Department.

U.S. Army Forward Surgical Teams (FSTs) are elite, multidisciplinary units that are highly mobile, and rapidly deployable. The mission of the FST is to provide resuscitative and damage control surgery for stabilization of life-threatening injuries in austere environments. The Army Trauma Training Center began in 2001 at the University of Miami Ryder Trauma Center under the direction of COL T. E. Knuth, MC USA (Ret.), as a multimodality combination of lectures, laboratory exercises, and clinical experiences that provided the only predeployment mass casualty and clinical trauma training center for all FSTs. Each of the subsequent five directors has restructured the training based on dynamic feedback from trainees, current military needs, and on the rapid advances in combat casualty care. We have highlighted these evolutionary changes at the Army Trauma Training Center in previous reviews. Under the current director, LTC J. M. Seery, MC USA, there are new team-building exercises, mobile learning modules and simulators, and other alternative methods in the mass casualty exercise. This report summarizes the latest updates to the state of the art training since the last review.