Combat readiness for the modern military surgeon: data from a decade of combat operations.

OBJECTIVE: Hundreds of general surgeons from the army, navy, and air force have been deployed during the past 10 years to support combat forces, but little data exist on their preparedness to handle the challenging injuries that they are currently encountering. Our objective was to assess operative and operational experience in theater with the goal of improving combat readiness among surgeons. METHODS: A detailed survey was sent to 246 active duty surgeons from the army, navy, and air force who have been deployed at least once in the past 10 years, requesting information on cases performed, perceptions of efficacy of predeployment training, knowledge deficits, and postdeployment emotional challenges. Survey data were kept confidential and analyzed using standard statistical methods. RESULTS: Of 246 individuals, 137 (56%) responded and 93 (68%) have been deployed two or more times. More than 18,500 operative procedures were reported, with abdominal and soft tissue cases predominating. Many surgeons identified knowledge or practice gaps in predeployment vascular (46%), neurosurgical (29.9%), and orthopedic (28.5%) training. The personal burden of deployment manifested itself with both family (approximately 10% deployment-related divorce rate) and personal (37 surgeons [27%] with two or more symptoms of posttraumatic stress syndrome) stressors. CONCLUSION: These data support modifications of predeployment combat surgical training to include increased exposure to open vascular procedures and curriculum traditionally outside general surgery (neurosurgery and orthopedics). The acute care surgical model may be ideal for the military surgeon preparing for deployment. Further research should be directed toward identifying factors contributing to psychological stress among military medics.

Guidelines for the prevention of infection after combat-related injuries.

Management of combat-related trauma is derived from skills and data collected in past conflicts and civilian trauma, and from information and experience obtained during ongoing conflicts. The best methods to prevent infections associated with injuries observed in military combat are not fully established. Current methods to prevent infections in these types of injuries are derived primarily from controlled trials of elective surgery and civilian trauma as well as retrospective studies of civilian and military trauma interventions. The following guidelines integrate available evidence and expert opinion, from within and outside of the US military medical community, to provide guidance to US military health care providers (deployed and in permanent medical treatment facilities) in the diagnosis, treatment, and prevention of infections in those individuals wounded in combat. These guidelines may be applicable to noncombat traumatic injuries under certain circumstances. Early wound cleansing and surgical debridement, antibiotics, bony stabilization, and maintenance of infection control measures are the essential components to diminish or prevent these infections. Future research should be directed at ideal treatment strategies for prevention of combat-related injury infections, including investigation of unique infection control techniques, more rapid diagnostic strategies for infection, and better defining the role of antimicrobial agents, including the appropriate spectrum of activity and duration.

Prevention and management of infections associated with combat-related thoracic and abdominal cavity injuries.

During wartime, abdominal and thoracic trauma constitutes approximately 20% of combat-related injuries. Rates of infection vary based upon organ of injury with the highest rates noted for trauma to the colon. This review focuses on the management and prevention of infections related to injuries of the thoracic and abdominal cavity. The evidence upon which these recommendations are based included military and civilian data from prior published guidelines, clinical trials, where available, reviews, and case reports. Areas of focus include antimicrobial therapy, irrigation and debridement, timing of surgical care, and wound closure. Overall, there are limited data available from the modern battlefield regarding the prevention or treatment of these infections and further efforts are needed to answer best treatment strategies.

Analgesic administration prior to surgical evaluation for acute appendicitis.

BACKGROUND: The attitudes of surgeons and nonsurgeons regarding the administration of pain medicine prior to arriving at a surgical diagnosis are changing. It is common practice to administer narcotic analgesics prior to a general surgeon's evaluation. Several studies have advocated the safety of this practice in the emergency department. Many of these studies are flawed by inclusion of many patients who did not have a surgical illness. Our study examined the practice of narcotic administration in patients determined to have appendicitis who underwent operation. METHODS: We retrospectively reviewed 75 consecutive appendectomies. Emergency department records and in-patient charts were reviewed to assess differences in 2 groups of patients: those who received narcotic pain medicine and those who did not. Specific outcome parameters were reviewed such as time in hospital, time to the operating room, and complication rate. We also created a scoring system for the physical examination to attempt to quantify a difference between the groups. FINDINGS: Overall, 75 patient charts were reviewed. Nine patients were excluded. There was no statistically significant difference in the 2 groups in regard to time in hospital, time to operation, complication rate, perforation rate, or negative appendectomy rate. The physical examination scoring system did show a difference between those who got pain medicine and those who did not, but failed to show a difference between examiners after pain medicine was given. CONCLUSIONS: There does not appear to be a difference in hospital stay, time to the operating room, complication rate, negative appendectomy rate, or perforation rate in patients who received pain medicine prior to a surgeon's evaluation and those who did not in this retrospective review.