Shooting through windscreens: ballistic injury assessment using a surrogate head model-two case reports.

A synthetic head model developed to reproduce military injuries was assessed in two different scenarios involving shooting through intermediate targets (a laminated vehicle windscreen in scenario 1 and a military helicopter windscreen in scenario 2) with 7.62 × 39-mm mild steel core (MSC) ammunition. The injury patterns resulting from the two scenarios were assessed by a military radiologist and a forensic pathologist with combat injury experience and found to be clinically realistic.

Extinction vortex dynamics of top predators isolated by urbanization.

Extinction risk is elevated in small, isolated populations due to demographic and genetic interactions. Therefore, it is critical to model these processes realistically in population viability analyses (PVA) to inform local management and contribute to a greater understanding of mechanisms within the extinction vortex. We conducted PVA's for two small mountain lion populations isolated by urbanization in southern California to predict population growth, extinction probability, and loss of genetic diversity with empirical data. Specifically, we (1) provide the first PVA for isolated mountain lions in the Santa Ana Mountains (SAM) that considers both demographic and genetic risk factors and (2) test the hypothesis that variation in abundance and mortality between the SAM and Santa Monica Mountains (SMM) result in differences in population growth, loss of heterozygosity, and extinction probability. Our models predicted 16-21% probability of local extinction in the SAM due purely to demographic processes over 50 yr with current low levels or no immigration. Our models also predicted that genetic diversity will further erode in the SAM such that concern regarding inbreeding depression is warranted unless gene flow is increased, and that if inbreeding depression occurs, rapid local extinction will be highly likely. Dynamics of the two populations were broadly similar, but they also exhibited differences driven by larger population size and higher mortality in the SAM. Density-independent scenarios predicted a rapidly increasing population in the SMM, whereas growth potential did not differ from a stable trend in the SAM. Demographic extinction probability and loss of heterozygosity were greater in the SMM for density-dependent scenarios without immigration. However, higher levels of immigration had stronger, positive influences on both demographic viability and retention of genetic diversity in the SMM driven by lower abundance and higher adult survival. Our results elucidate demographic and genetic threats to small populations within the extinction vortex, and how these vary relative to demographic structure. Importantly, simulating seemingly attainable increases in connectivity was sufficient to greatly reduce extinction probability. Our work highlights that conservation of large carnivores is achievable within urbanized landscapes, but requires land protection, connectivity, and strategies to promote coexistence with humans.

Assessment of polyurethane spheres as surrogates for military ballistic head injury.

SYNBONE® spheres were impacted with 7.62 × 39 mm mild steel core ammunition at a mean impact velocity of 654 m/s, SD 7 m/s, to simulate engagement distances of around 50-100 m. The wounds and fracture patterns were assessed by two forensic pathologists familiar with military cranial injury. The overall fracture pattern was assessed as being too comminuted when compared with actual injury. This suggests the SYNBONE® spheres have less utility for simulating military injury than other purposes described in the literature.

Forensic reconstruction of two military combat related shooting incidents using an anatomically correct synthetic skull with a surrogate skin/soft tissue layer.

Six synthetic head models wearing ballistic protective helmets were used to recreate two military combat-related shooting incidents (three per incident, designated 'Incident 1' and 'Incident 2'). Data on the events including engagement distances, weapon and ammunition types was collated by the Defence Science and Technology Laboratory. The models were shot with 7.62 × 39 mm ammunition downloaded to mean impact velocities of 581 m/s (SD 3.5 m/s) and 418 m/s (SD 8 m/s), respectively, to simulate the engagement distances. The damage to the models was assessed using CT imaging and dissection by a forensic pathologist experienced in reviewing military gunshot wounds. The helmets were examined by an MoD engineer experienced in ballistic incident analysis. Damage to the helmets was consistent with that seen in real incidents. Fracture patterns and CT imaging on two of the models for Incident 1 (a frontal impact) were congruent with the actual incident being modelled. The results for Incident 2 (a temporoparietal impact) produced realistic simulations of tangential gunshot injury but were less representative of the scenario being modelled. Other aspects of the wounds produced also exhibited differences. Further work is ongoing to develop the models for greater ballistic injury fidelity.

Spatial processes decouple management from objectives in a heterogeneous landscape: predator control as a case study.

Predator control is often implemented with the intent of disrupting top-down regulation in sensitive prey populations. However, ambiguity surrounding the efficacy of predator management, as well as the strength of top-down effects of predators in general, is often exacerbated by the spatially implicit analytical approaches used in assessing data with explicit spatial structure. Here, we highlight the importance of considering spatial context in the case of a predator control study in south-central Utah. We assessed the spatial match between aerial removal risk in coyotes (Canis latrans) and mule deer (Odocoileus hemionus) resource selection during parturition using a spatially explicit, multi-level Bayesian model. With our model, we were able to evaluate spatial congruence between management action (i.e., coyote removal) and objective (i.e., parturient deer site selection) at two distinct scales: the level of the management unit and the individual coyote removal. In the case of the former, our results indicated substantial spatial heterogeneity in expected congruence between removal risk and parturient deer site selection across large areas, and is a reflection of logistical constraints acting on the management strategy and differences in space use between the two species. At the level of the individual removal, we demonstrated that the potential management benefits of a removed coyote were highly variable across all individuals removed and in many cases, spatially distinct from parturient deer resource selection. Our methods and results provide a means of evaluating where we might anticipate an impact of predator control, while emphasizing the need to weight individual removals based on spatial proximity to management objectives in any assessment of large-scale predator control. Although we highlight the importance of spatial context in assessments of predator control strategy, we believe our methods are readily generalizable in any management or large-scale experimental framework where spatial context is likely an important driver of outcomes.

Navigating snowscapes: scale-dependent responses of mountain sheep to snowpack properties.

Winters are limiting for many terrestrial animals due to energy deficits brought on by resource scarcity and the increased metabolic costs of thermoregulation and traveling through snow. A better understanding of how animals respond to snow conditions is needed to predict the impacts of climate change on wildlife. We compared the performance of remotely sensed and modeled snow products as predictors of winter movements at multiple spatial and temporal scales using a data set of 20,544 locations from 30 GPS-collared Dall sheep (Ovis dalli dalli) in Lake Clark National Park and Preserve, Alaska, USA from 2005 to 2008. We used daily 500-m MODIS normalized difference snow index (NDSI), and multi-resolution snow depth and density outputs from a snowpack evolution model (SnowModel), as covariates in step selection functions. We predicted that modeled snow depth would perform best across all scales of selection due to more informative spatiotemporal variation and relevance to animal movement. Our results indicated that adding any of the evaluated snow metrics substantially improved model performance and helped characterize winter Dall sheep movements. As expected, SnowModel-simulated snow depth outperformed NDSI at fine-to-moderate scales of selection (step scales < 112 h). At the finest scale, Dall sheep selected for snow depths below mean chest height (<54 cm) when in low-density snows (100 kg/m3 ), which may have facilitated access to ground forage and reduced energy expenditure while traveling. However, sheep selected for higher snow densities (>300 kg/m3 ) at snow depths above chest height, which likely further reduced energy expenditure by limiting hoof penetration in deeper snows. At moderate-to-coarse scales (112-896 h step scales), however, NDSI was the best-performing snow covariate. Thus, the use of publicly available, remotely sensed, snow cover products can substantially improve models of animal movement, particularly in cases where movement distances exceed the MODIS 500-m grid threshold. However, remote sensing products may require substantial data thinning due to cloud cover, potentially limiting its power in cases where complex models are necessary. Snowpack evolution models such as SnowModel offer users increased flexibility at the expense of added complexity, but can provide critical insights into fine-scale responses to rapidly changing snow properties.

Ballistic impacts on an anatomically correct synthetic skull with a surrogate skin/soft tissue layer.

The aim of this work was to further develop a synthetic model of ballistic head injury by the addition of skin and soft tissue layers to an anatomically correct polyurethane skull filled with gelatine 10% by mass. Six head models were impacted with 7.62 x 39 mm full metal jacket mild steel core (FMJ MSC) bullets with a mean velocity of 652 m/s. The impact events were filmed with high-speed cameras. The models were imaged pre- and post-impact using computed tomography. The models were assessed post impact by two experienced Home Office pathologists and the images assessed by an experienced military radiologist. The findings were scored against real injuries. The entry wounds, exit wounds and fracture patterns were scored positively, but the synthetic skin and soft tissue layer was felt to be too extendable. Further work is ongoing to address this.

The effect of helmet materials and simulated bone and tissue layers on bullet behaviour in a gelatine model of overmatch penetrating head injury.

The aim of this work was to simulate an overmatch ballistic event against a head wearing a helmet. The experiments were designed to understand how layers of bone (or synthetic bone), synthetic skin and currently used helmet materials influence the behaviour of full metal jacket mild steel core (FMJ MSC) 7.62 × 39 mm bullets, impacting on targets with a mean velocity of 650 m/s. Bullet behaviour within 10% (by mass) gelatine blocks was assessed by measurements made of the temporary cavity within the blocks using high-speed video and of the permanent cavity by dissecting blocks post firing. While ANOVA did not find significant difference at the 0.05 level in the mean values of most of the measurements, there was a significant difference in neck length within the gelatine blocks. The addition of material layers did produce greater variability in the temporary cavity measurements under some of the conditions. One of the synthetic bone polymers with a synthetic skin layer produced similar results within the gelatine blocks to the horse scapulae (with residual tissue) and may be suitable for future ballistic experiments.

Interactions between demography, genetics, and landscape connectivity increase extinction probability for a small population of large carnivores in a major metropolitan area.

The extinction vortex is a theoretical model describing the process by which extinction risk is elevated in small, isolated populations owing to interactions between environmental, demographic, and genetic factors. However, empirical demonstrations of these interactions have been elusive. We modelled the dynamics of a small mountain lion population isolated by anthropogenic barriers in greater Los Angeles, California, to evaluate the influence of demographic, genetic, and landscape factors on extinction probability. The population exhibited strong survival and reproduction, and the model predicted stable median population growth and a 15% probability of extinction over 50 years in the absence of inbreeding depression. However, our model also predicted the population will lose 40-57% of its heterozygosity in 50 years. When we reduced demographic parameters proportional to reductions documented in another wild population of mountain lions that experienced inbreeding depression, extinction probability rose to 99.7%. Simulating greater landscape connectivity by increasing immigration to greater than or equal to one migrant per generation appears sufficient to largely maintain genetic diversity and reduce extinction probability. We provide empirical support for the central tenet of the extinction vortex as interactions between genetics and demography greatly increased extinction probability relative to the risk from demographic and environmental stochasticity alone. Our modelling approach realistically integrates demographic and genetic data to provide a comprehensive assessment of factors threatening small populations.

Defining the essential anatomical coverage provided by military body armour against high energy projectiles.

INTRODUCTION: Body armour is a type of equipment worn by military personnel that aims to prevent or reduce the damage caused by ballistic projectiles to structures within the thorax and abdomen. Such injuries remain the leading cause of potentially survivable deaths on the modern battlefield. Recent developments in computer modelling in conjunction with a programme to procure the next generation of UK military body armour has provided the impetus to re-evaluate the optimal anatomical coverage provided by military body armour against high energy projectiles. METHODS: A systematic review of the literature was undertaken to identify those anatomical structures within the thorax and abdomen that if damaged were highly likely to result in death or significant long-term morbidity. These structures were superimposed upon two designs of ceramic plate used within representative body armour systems using a computerised representation of human anatomy. RESULTS AND CONCLUSIONS: Those structures requiring essential medical coverage by a plate were demonstrated to be the heart, great vessels, liver and spleen. For the 50th centile male anthropometric model used in this study, the front and rear plates from the Enhanced Combat Body Armour system only provide limited coverage, but do fulfil their original requirement. The plates from the current Mark 4a OSPREY system cover all of the structures identified in this study as requiring coverage except for the abdominal sections of the aorta and inferior vena cava. Further work on sizing of plates is recommended due to its potential to optimise essential medical coverage.

Towards the next frontier for simulation-based training: full-hospital simulation across the entire patient pathway.

OBJECTIVE: To evaluate the efficacy of an entire hospital simulation in imparting skills to expert healthcare providers, encompassing both retention and transfer to clinical practice. BACKGROUND: Studies demonstrating the effectiveness of simulation do not concentrate upon expert multidisciplinary teams. Moreover, their focus is confined to a single clinical setting, thereby not considering the complex interactions across multiple hospital departments. METHODS: A total of 288 participants (Attending surgeons, anesthesiologists, physicians, and nurses) completed this largest simulation study to date, set in the UK Defence Medical Services' Hospital Simulator and the conflict zone in Afghanistan. The simulator termed "Hospital Exercise" (HOSPEX) is a fully immersive live-in simulation experience that covers the entire environment of a military hospital with all departments. Participants undertook a 3-day training program within HOSPEX before deployment to war zones. Primary outcome measures were assessed with IMPAcT (the Imperial Military Personnel Assessment Tool). IMPAcT measures crisis management, trauma care, hospital environment, operational readiness, and transfer of skills to civilian practice. Reliability, skills learning, and retention in the conflict zone were assessed statistically. RESULTS: Reliability in skills assessment was excellent (Cronbach α: nontechnical skills = 0.87-0.94; environment/patient skills = 0.83-0.95). Pre/post-HOSPEX comparisons revealed significant improvements in decision making (M = 4.98, SD = 1.20 to M = 5.39, SD = 0.91; P = 0.03), situational awareness (M = 5.44, SD = 1.04 to M = 5.74, SD = 0.92; P = 0.01), trauma care (M = 5.53, SD = 1.23 to M = 5.85, SD = 1.09; P = 0.05), and knowledge of hospital environment (M = 5.19, SD = 1.17 to M = 5.42, SD = 0.97; P = 0.04). No skills decayed over time when assessed several months later in the real conflict zone. All skills transferred to civilian clinical practice. CONCLUSIONS: This is the first study to describe the value of a full-hospital simulation across the entire patient pathway. Such macrosimulations may be the way forward for integrating the complex training needs of expert clinicians and testing organizational "fitness for purpose" of entire hospitals.

A protected area influences genotype-specific survival and the structure of a Canis hybrid zone.

It is widely recognized that protected areas can strongly influence ecological systems and that hybridization is an important conservation issue. However, previous studies have not explicitly considered the influence of protected areas on hybridization dynamics. Eastern wolves are a species of special concern and their distribution is largely restricted to a protected population in Algonquin Provincial Park (APP), Ontario, Canada, where they are the numerically dominant canid. We studied intrinsic and extrinsic factors influencing survival and cause-specific mortality of hybrid and parental canids in the three-species hybrid zone between eastern wolves, eastern coyotes, and gray wolves in and adjacent to APP. Mortality risk for eastern wolves in areas adjacent to APP was significantly higher than for other sympatric Canis types outside of APP, and for eastern wolves and other canids within APP. Outside of APP, the annual mortality rate of all canids by harvest (24%) was higher than for other causes of death (4-7%). Furthermore, eastern wolves (hazard ratio = 3.5) and nonresidents (transients and dispersing animals, hazard ratio = 2.7) were more likely to die from harvest relative to other Canis types and residents, respectively. Thus, eastern wolves dispersing from APP were especially vulnerable to harvest mortality. For residents, eastern wolf survival was more negatively influenced by increased road density than for other Canis types, further highlighting the sensitivity of eastern wolves to human disturbance. A cycle of dispersal from APP followed by high rates of mortality and hybridization appears to maintain eastern wolves at low density adjacent to APP, limiting the potential for expansion beyond the protected area. However, high survival and numerical dominance of eastern wolves within APP suggest that protected areas can allow rare hybridizing species to persist even if their demographic performance is compromised and barriers to hybridization are largely absent in the adjacent matrix.

Early management of pediatric vascular injuries through humanitarian surgical care during U.S. military operations.

BACKGROUND: The objective of this report is to describe our experience of pediatric vascular injuries in a U.S. military combat support hospital in Baghdad, Iraq. A retrospective study was designed using Joint Theater Trauma Registry (JTTR) records in order to evaluate the pediatric (age <18 years) population presenting with vascular trauma to a combat hospital in Baghdad, Iraq between April 2006 and August 2008. Demographic data comprised casualty, age, gender, and mechanism of injury. Physiologic data included presenting vital signs (rectal temperature, blood pressure, and heart rate), arterial pH, base deficit, hemoglobin (g/dL), and international normalized ratio. RESULTS: Twenty-five children, median age 14 years (range, 5-17 years), median weight 48 kg (range, 15-80 kg) sustained 18 (72%) blast and 7 (28%) gunshot wounds. The mean Injury Severity Score was 25 ± 16.2. The median operative time for the vascular repairs was 189 minutes (range, 41-505 minutes). Patients were tachycardic (mean ± standard deviation, 136 ± 29 bpm), hypotensive (109/63 ± 29/19 mm Hg), and acidemic (pH 7.26 ± 0.07; BD -5.57 ± 5.1 mEq/L) on arrival to the emergency department and were physiologically improved upon admission to the intensive care unit 3 hours later. Repair techniques were ligation (14; 39%), saphenous graft (11; 31%), lateral suture (7; 19%), end anastomosis (2; 5%), patch (1; 3%), and thrombectomy (1; 3%). Twenty-four hour mean transfusion requirements included crystalloid 102 mL/kg (range, 19-253), transfused blood 47 mL/kg (range, 0-119), fresh frozen plasma 14 mL/kg (range, 0-68), and apheresis platelets (1.2 ± 3.68 units). Over a follow-up of 22 ± 5.5 days, the amputation-free survival was 80%. CONCLUSIONS: This is the largest reported wartime series to demonstrate in children that damage control resuscitation despite high injury severity permits simultaneous limb salvage.

Repetitive, but Not Single, Mild Blast TBI Causes Persistent Neurological Impairments and Selective Cortical Neuronal Loss in Rats.

Exposure to repeated mild blast traumatic brain injury (mbTBI) is common in combat soldiers and the training of Special Forces. Evidence suggests that repeated exposure to a mild or subthreshold blast can cause serious and long-lasting impairments, but the mechanisms causing these symptoms are unclear. In this study, we characterise the effects of single and tightly coupled repeated mbTBI in Sprague-Dawley rats exposed to shockwaves generated using a shock tube. The primary outcomes are functional neurologic function (unconsciousness, neuroscore, weight loss, and RotaRod performance) and neuronal density in brain regions associated with sensorimotor function. Exposure to a single shockwave does not result in functional impairments or histologic injury, which is consistent with a mild or subthreshold injury. In contrast, exposure to three tightly coupled shockwaves results in unconsciousness, along with persistent neurologic impairments. Significant neuronal loss following repeated blast was observed in the motor cortex, somatosensory cortex, auditory cortex, and amygdala. Neuronal loss was not accompanied by changes in astrocyte reactivity. Our study identifies specific brain regions particularly sensitive to repeated mbTBI. The reasons for this sensitivity may include exposure to less attenuated shockwaves or proximity to tissue density transitions, and this merits further investigation. Our novel model will be useful in elucidating the mechanisms of sensitisation to injury, the temporal window of sensitivity and the evaluation of new treatments.

Impact of an acute pain service on pain outcomes with combat-injured soldiers at Camp Bastion, Afghanistan.

BACKGROUND: Few studies demonstrate the impact of early aggressive analgesia with acute pain service (APS) involvement at combat support hospitals (CSHs) using real-time data. Collaboration between the British and the United States (US) Army led to a 3-month deployment of a US Army APS to Camp Bastion, the main British military base in southern Afghanistan, from April to July 2009. METHODS: Pain outcomes data were collected at Camp Bastion from 71 soldiers sustaining major combat injuries followed by an APS. RESULTS: The sample was predominantly male (98.6%) and Caucasian (98.8%) with a mean age 25.4 years ± 5.4 (range 18-45). Regional nerve blocks were performed in 51 (71.8%) and epidurals placed in 11 (15.5%) of the cases. Repeated measures analysis of variance showed a statistically significant decreases in pain intensity (numeric rating scale from 0 for "none" to 10 for "as bad as you can imagine") over the three data collection points; first 3, 4-6, and 7-10 hours (F = 133.35; degrees of freedom [df; 1,68]; P < 0.001). Mean percent pain relief (0% "no relief" to 100% "complete relief") increased significantly over time (F = 193.12; df[1,69]; P < 0.001) with scores 31.29% ± 20.3 (initial 3 hours), 74.86% ± 27.5 (4-6 hours), and 83.14% ± 19.3 (7-24 hours). Overall, the perceived quality of pain control by soldiers was high. CONCLUSIONS: Findings from this quality of pain care study show that aggressive multimodal analgesia interventions by an APS in a CSH is associated with decreased pain intensity and increased pain relief.

A survey of military health professionals' perceptions of an acute pain service at Camp Bastion, Afghanistan.

OBJECTIVE: The primary goal of this investigation was to survey military health care professionals at a Camp Bastion, Afghanistan, regarding their perceptions of care delivered by an anesthesiologist-directed acute pain service (APS) at a British Combat Support Hospital (CSH)-Role 3. METHODS: The APS was directed by a U.S. Army anesthesiologist experienced in acute pain medicine who established an APS within a deployed British CSH. A brief 15-item survey was developed to assess impressions of outcomes, complexity of care, and satisfaction with the APS. Content validity was established through limited published surveys of APSs, expert review, and end user evaluation. RESULTS: The sample (N = 70, of which 61.4% were male) included 50% nurses, 15.8% surgeons, and 10% anesthesiologists who completed the survey at the end of the 3-month APS implementation period. Approximately 75% of the sample agreed or strongly agreed that injured soldiers managed by an APS obtained better pain relief than those who were not. With a 10-point scale, respondents rated how satisfied they were with the APS (mean 7.70 ± 1.7), how beneficial it was for patients (7.89 ± 2), and how important it would be to deploy an APS again to a level 3 facility (8.52 ± 1.7). Internal consistency reliability (Cronbach's alpha) for the 12-items measuring perceptions was acceptable, alpha = 0.82. CONCLUSIONS: Overall, the majority of military health care survey responders indicated support for an APS team as part of a CSH care, and confirmed its contributions to improving trauma care.

How Should Access to Military Health Care Facilities Be Controlled in Conflict?

This commentary on a case analysis examines the principles that govern decisions about which patients might be admitted to an international military hospital during humanitarian or combat operations. It explores the balance between duties under the Geneva Conventions and other international humanitarian laws, the requirement to be able to provide medical support to the military mission, and the obligation of clinicians to coordinate with other health care practitioners (local civilian, local military, and nongovernment organizations). Finally, this commentary considers the practical aspects of implementing these arrangements.

Thematic Analysis of Military Medical Ethics Publications From 2000 to 2020-A Bibliometric Approach.

INTRODUCTION: There has been external criticism of the compliance of military health personnel with internationally agreed principles in military medical ethics (MME). In response, a number of authors have called for clarity on the principles and topics within the domain of MME. This complements an increased acknowledgment of the need for education in MME for military health personnel. Our paper utilizes bibliometric techniques to identify key themes in MME to inform the development of a curriculum for this subject. MATERIALS AND METHODS: We designed a search strategy to find publications over the period January 1, 2000-December 31, 2020 in the domain of MME from the three databases, PubMed, Web of Science, and Scopus, using the search string (ethic* OR bioethics* OR moral*) AND military AND (medic* OR health*). We obtained a total of 1,115 publications after duplication removal. After exclusion based on topic, year, and study design, we analyzed a total of 633 publications using Scopus's embedded analysis tool and the software VOSViewer. We generated a co-occurrence word map from the abstracts of each of the publications. We deduced themes of MME based on the clusters shown in the word map, and we categorized each publication into one of these themes to analyze the change of themes over time. RESULTS: We observed a 10-fold increase in annual publications on MME between 2000 and 2020. The majority of papers were written by U.S. (72%) and UK (13%) authors, although a total of 15 countries were represented. After using VOSViewer to identify co-occurring keywords in titles and abstracts from these publications, nine themes were identified: biomedical research, care to detained populations, disaster/triage, mental health, patient-focused foundations, technology, dual loyalty, education/training, and frameworks. The relative proportion of each of these themes changed over the study period, with mental health being dominant by the end. CONCLUSIONS: This study has identified key themes that might inform the development of a curriculum for teaching MME. It is noticeable that the majority of themes cover MME from the perspective of professional practice on military operations; noting, the research and technology themes also pertain to the generation of knowledge for military operations. There were a limited number of publications covering practice in the non-deployed or garrison settings, and these were codified under the themes of "framework" and "dual loyalty". The results are skewed toward English-speaking countries and exclude non-academic publications. Further work will search for other open-source information and non-English publications. To our knowledge, this exploratory bibliometric analysis on MME in the academic literature is the first of its kind. This article has demonstrated the use of bibliometric techniques to evaluate the evolution of knowledge in MME, including the identification of key themes. These will be used to support further work to develop a curriculum for the teaching of MME to military medical audiences.

A descriptive analysis of patients admitted to the intensive care unit of the 10th Combat Support Hospital deployed in Ibn Sina, Baghdad, Iraq, from October 19, 2005, to October 19, 2006.

BACKGROUND: Although a review of the 1-month experience of a British intensive care unit (ICU) deployed in 2003 to Iraq outlining its care of 47 patients exists, a descriptive study outlining patient characteristics, workload, and outcomes of an ICU during a long-term deployment to Operation Iraqi Freedom is lacking in the medical literature. METHODS: Between October 19, 2005, and October 19, 2006, the 10th Combat Support Hospital (CSH) deployed in an ICU to Ibn Sina Hospital in Baghdad, Iraq. Staff prospectively collected patient admission data from November 1, 2005, to August 31, 2006, in handwritten logbooks. This information included nationality (United States/Iraqi/other), military versus civilian, mechanism of injury or nontrauma admission diagnosis, ICU length of stay (LOS), and outcome. These data were retrospectively reviewed for the purpose of reporting the experience of the 10th CSH ICU during its deployment. RESULTS: The 10th CSH ICU admitted 875 patients during the study period. This represented 27% of all hospital admissions (n = 3289). Categories of patients admitted to the ICU included United States military, US contractor, Iraqi military, Iraqi civilian, non-US contractor, coalition military personnel, and security internee. Three patients were unable to be classified due to missing information. The most common patient category of admission was Iraqi civilian (n = 472, 53.9%). Noncoalition (Iraqi civilian, Iraqi military, non-US contractors, and other noncoalition military) admissions made up 76.9% (n = 673) of all admissions. US military (n = 165) and US contractors (n = 31) made up 22.4% of all ICU admissions. Trauma-related admissions were the most common diagnoses (n = 730, 83.4%). Other admission diagnostic categories included medical (n = 125, 14.3%) and postoperative (n = 5, 0.6%) patients. A total of 15 patients (1.7%) were unable to be categorized based on diagnosis due to missing information. The most common medical diagnosis requiring ICU admission was related to cardiovascular disease (n = 51, 40.8%). Seven of the admissions to the ICU were pediatric patients (0.8%). US military personnel traumatically injured suffered significantly more explosion injuries and burns than their Iraqi military and other noncoalition military counterparts. The ICU LOS was significantly shorter in US military and US contractor patients compared to all other groups, likely a result of expeditious air evacuation to a higher level of care. This air evacuation of US personnel combined with the fact that Iraqi patients were transferred to local civilian hospitals prior to the completion of intensive care stay limited follow-up. Despite a lack of meaningful follow-up, the observed ICU all-cause mortality was 5.0% (n = 44). CONCLUSIONS: The primary mission of a US military ICU deployed in support of combat operations is the care of its injured troops. However, the 10th CSH deployed in an urban region of Iraq in a mature theater of operations and its ICU more commonly cared for non-US patients during combat medical operations. These patients included pediatric patients as well as admissions for nontrauma illnesses. This mission was accomplished by nurses and physicians faced with unique challenges and resulted in an acceptable ICU mortality rate.