Lessons Learned in War Bradley S. Butler, MD, FACEP L CDR MC, USN - PowerPoint PPT Presentation

Lessons Learned in War Bradley S. Butler, MD, FACEP L CDR MC, USN Dept Head and Trauma Team Leader NATO Role 3 MMU Kandahar, Afghanistan 2011-2012

DISCLAIMER • US Navy Reservist • This lecture (except where specifically noted) does not represent the official policy or views of the US Navy or the US Department of Defense

OBJECTIVES • Medical/Professional lessons learned and their civilian uses • Understand the historical role of medicine in armed conflict and how it has changed over time • Understand the different injury patterns associated with OEF/OIF • Understand the causes of death in battle, and how it relates to new training, equipment, resuscitation, and civilian uses • Medical Advances • Personal lessons learned • What “happens” in war? • Motivation Learned

ROLE OF MEDICINE IN ARMED CONFLICT

ROLE OF MEDICINE IN ARMED CONFLICT • Changes in mortality ( NEJM Dec2004) • WWII: 70% survival rate • Viet Nam: 76% survival rate • OIF: 90% SURVIVAL RATE! • Why the difference?

ROLE OF MEDICINE IN ARMED CONFLICT • Advances in patient transport • Advances in personnel/vehicular protection (i.e. body armor/kevlar helmets/MRAP’s) • Pre-hospital training (i.e. TCCC) • Tourniquets/Hemostatic Agents • Damage Control Resuscitation

ROLE OF MEDICINE IN ARMED CONFLICT • Transportation times have shortened • Viet Nam: ave time from battlefield to US=45 days • OEF/OIF: ave time < 4 days • HOW??? • Civil War (ambulance) Korea (helo) OEF: CCATT • CCATT = Critical Care Air Transport Team • History • 1983 (concept) • 1989-99 (development) • 2001-2004 (confirmed in OEF/OIF) • Composition: Critical Care Physician, CCRN, RT

CCATT

CCATT

ROLE OF MEDICINE IN ARMED CONFLICT • Taking the care to the need • ROLE I • BAS/STP- Basic ATLS/resuscitation (airway/bleeding) • ROLE II • FST (Army)/FRSS (Navy/Marines)- Mobile surgical team (damage control surgery) • ROLE III • Combat Hospital (i.e. Level I Trauma Center in theater ) • ROLE IV • US Hospitals (Bethesda/San Antonio (burn)/San Diego) • Germany (Landstuhl)

INJURY PATTERNS IN OEF/OIF

INJURY PATTERNS IN OEF/OIF • Blasts predominate over penetrations • Less GSW’s (body armor) • Improvised Explosive Device (IED’s) predominate • VBIED or vehicle-born IED • Suicide IED (suicide vests, even on kids) • Emplaced IED’s (pressure plate, remote control, wire) • IED’s = Amputations/Head injuries

“PREVENTABLE” CAUSES OF DEATH IN COMBAT

“PREVENTABLE” CAUSES OF DEATH

“Preventable” Causes of Death • Has led to many advances- focused on the “preventable” causes of death • Equipment • Training (prehospital) • Medical Advances

EQUIPMENT “Up-armored” Humvee’s and MRAP’s

EQUIPMENT Body Armor/Kevlar Helmets

EQUIPMENT- Civilian Applications • Armored vehicles being utilized by law enforcement as well as wealthy citizens (especially in foreign countries) for protection • Body armor being upgraded on a regular basis and utilized in both civilian law enforcement and military

TRAINING TCCC (Tactical Combat Casualty Care) • Civilian/Military Difference in “pre-hospital” care • Civilian: Casualty IS the mission • Military: Mission DESPITE the casualties • Principles • Prevent further casualties, accomplish mission, maximize lives saved, minimize morbidity/mortality • Based on treating “preventable” causes of death • (Extremity) Hemorrhage • Tension Pneumothorax • Airway

TRAINING/TCCC Three “phases” • Care under fire • Return fire, TQ (self aid), get to safety • Tactical Field Care • In a (relatively) safe environment • TQ/Hemorrhage control (“c” before “A”) • Airway management • Decompression of tension pneumothorax • Evacuation Care • CASEVAC (evac by opportunity- no medical care) • MEDIVAC (evac by medical-medics, RN, MD) • Variable (i.e. IV, meds, blood products, advanced airway)

TRAINING/TCCC Emphasis on “preventable” causes, not IV! • Stopping Hemorrhage (7-9%) • TQ and Hemostatic Agents • Tension Pneumothorax (3-4%) • Airway (1%) • Emphasis on OPA/NPA (NOT advanced airway) • Rarely cric and/or devices (KingLT, LMA, etc) • “Future” emphasis • Hypothermia (leads to coagulopathy, multisystem organ failure, and other morbidity/mortality) • Pain control

TRAINING/TCCC IFAK (individual first aid kit)

TRAINING/TCCC- Civilian Applications • TCCC- concepts, techniques, and training being utilized in law enforcement currently • IFAK- contents (part or all) being adopted by law enforcement

Utilization of Working Dogs

Utilization of Working Dogs- Types • PEDD- Patrol Explosive Detector Dog • PNDD- Patrol Narcotic Detector Dog • SSD- Specialized Search Dog • MDD- Mine Detector Dog • IDD- IED Detector Dog • TEDD- Tactical Explosive Detector Dog • CTD- Combat Tracker Dog • AAA/AAT- Animal Assisted Therapy Dog • CWD- Contract Working Dog • MPC- Multi Purpose Canine • HRD- Human Remains Detector

Utilization of Working Dogs- Types

Utilization of Working Dogs Medical Care

MEDICAL ADVANCES

HEMOSTATIC AGENTS MECHANICAL • Pressure • Tourniquets • New/Field testing • C-Clamp (CROC) • Abdominal tourniquet • XSTAT • Dressings (prior to OEF/OIF- AFB or “army field bandage.” Consisted of layers of gauze in bandage with long ties)

MECHANICAL- Tourniquets • HISTORY: documented use back in 1634 ( Surgery, 1958 ) to now (at least one on every soldier)

MECHANICAL- Tourniquets • No evidence of TQ, even when improperly used, resulting in loss of limb or permanent disability (US Army Bulletin 1945 and J Trauma 2003) • TCCC recommendations: use in uncontrolled extremity hemorrhage in tactical environment

MECHANICAL- Tourniquets • Significant anecdotal evidence in OEF/OIF of lives saved

MECHANICAL- Tourniquets Civilian Applications • Law enforcement • EMS • Useful in penetrating extremity wounds and/or amputations • Barrier: cost (about $35 for CAT)

MECHANICAL- JUNCTIONAL

MEDICAL ADVANCES- Hemostatic Agents HISTORY • Hippocrates: caustics to achieve hemostasis • Bone wax (1886): combination of beeswax, salicylic acid, and almond oil • Gelfoam (1946): physical matrix from ground skin • Surgicel (1960): oxidized cellulose • Thrombin (1960’s) • Chitin/Chitosan (2003)- chitin from crustaceans • Human Recombinant Factor VII • Mineral-based (2007): combat gauze • Future: Thrombin based?

MEDICAL ADVANCES- Hemostatic Agents 7 Properties of “ideal” Agent (Pusateri 2006) • Capable of stopping art/venous bleeding < 2 minutes though a pool of blood • No requirement of premixing or preparation • Simplicity of application by victim, buddy, or medic • Lightweight and durable • Long shelf life in extreme environments • Safe to use with no risk of tissue injury or transmission of infection • Inexpensive

HEMOSTATIC AGENTS “SEALANTS” or Chitin-based • Mechanism: mucoadhesive (“sticks” to adjacent tissues) and seals injured vessels and (+) charge attracts (-) charged RBC’s • Properties • Biodegradable, non-toxic, complex carbohydrate derived from chitin (naturally occurring substance found in crustacean shells- shellfish allergy) • Bacteriostatic • Freeze-dried and made into stiff dressing/bandage

HEMOSTATIC AGENTS- “Sealants” • HemCon Bandage (HC)- 2002

HEMOSTATIC AGENTS- HemCon • Effective in appropriate wounds, but not after 1 hour • Must be “flat” wound (bandage is stiff and must be cut to size) • Easily removed with saline • Not pliable for hard to reach wounds • Expensive ($90 per dressing) • Replaced by Combat Gauze (CG)

HEMOSTATIC AGENTS- Celox • Celox (CX)- granular/powder form of chitin • “Poured” into wound and covered with dressing • Must be removed prior to definitive surgery • Difficult to use in windy/low light conditions • Found to be no more effective than pressure dressing in femoral artery injury/pig model ( Acad Emer Med 2011 ) and other studies with variable efficacy (one study found it was more effective than QC and HC Acad Emer Med 2008)

HEMOSTATIC AGENTS MINERAL-BASED • Mechanism: rapid absorption of water, concentrating clotting factors/platelets and (-) charge activates/accelerates intrinsic clotting • REQUIRES INTACT PATIENT CLOTTING! • Properties • Made from minerals (zeolite/smectite) • Not biodegradable- removed prior to surgery • Small particles “clog” blood vessels, leading to PE (WS/QC, not with CG J Trauma 2010 )

HEMOSTATIC AGENTS- Mineral Bas ed • QuickClot (QC)- first generation (2002) • Zeolite granules • More effective than gauze dressing (100% survival vs 60% J Trauma 2004) • Exothermic reaction (caused burns/ ? may have contributed to hemostasis) • Had to be removed prior to surgery • No longer made