Advances in combat casualty care have improved combat survivability over the past two decades. However, these outcomes remain incompletely framed in the broader context of combat casualty outcomes ...over the past eighty years. We hypothesized that starting with World War II, combat survival worsened at the beginning of each new conflict but then improved over time. To evaluate long-term trends in combat casualty outcomes, monthly combat injuries and deaths during World War II, the Korean conflict, the Vietnam conflict, Operation Iraqi Freedom (OIF), and Operation Enduring Freedom (OEF) were collated. From these numbers, we calculated the monthly case fatality rate (CFR), the killed in action rate (%KIA), and the died of wounds rate (%DOW). We analyzed these metrics for significant trends during and between each conflict using linear and Loess regression. We then simulated alternate outcome scenarios by eliminating outcome variability. In this comprehensive analysis, CFR decreased over the study period in parallel with a decrease in %KIA. When examining individual conflicts, however, several unfavorable trends emerged including a spike in all fatality measures at the end of Vietnam and a rise in %DOW over the course of Korea and OIF. In comparing CFR at the beginning of each conflict to the best CFR from the prior conflict, high mortality outliers occurred in every conflict after a period of relative peace, and a clear "peacetime effect" occurred in both World War II and Vietnam. Eliminating these negative trends and the attendant preventable deaths would have reduced combat fatalities over the course of eighty years by 107,256 (39.7%). In summary, although combat mortality rates have generally improved since World War II, closer examination indicates several unfavorable trends both during and between conflicts. Identifying factors behind these trends will reveal further opportunities to improve combat casualty outcomes in the future. LEVEL OF EVIDENCE: III, Epidemiological.
Background
In
A
fghanistan, a substantial portion of resuscitative combat surgery is performed by
US A
rmy forward surgical teams (
FST
s). Red blood cells (
RBC
s) 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
FST
s 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
FST
s from
D
ecember 2005 to
D
ecember 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
T
ype
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
G
lasgow
C
oma
S
cale in those who received or did not receive
FWB
.
I
njury
S
everity
S
cores were higher in patients transfused
FWB
. In our adjusted analyses, patients who received
RBC
s and
FFP
with
FWB
had improved survival compared with those who received
RBC
s and
FFP
without
FWB
. Of 94
FWB
recipients, 46
FWB
recipients (49%) were given uncrossmatched
T
ype
O FWB
, while 48 recipients (51%) received type‐specific
FWB
. There was no significant difference in mortality between patients that received uncrossmatched
T
ype
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
RBC
s and
FFP
alone. Mortality was similar for patients transfused uncrossmatched
T
ype
O
compared with
ABO
type‐specific
FWB
in an austere setting.
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BFBNIB, FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SBCE, SBMB, UL, UM, UPUK
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.
Airway management is a cornerstone of medical support in the event of a chemical, biological, radiological, nuclear, or explosive event (CBRNE). Challenges are presented due to: the potential of ...having a large number of patients needing immediate treatment, lack of medical providers skilled in complex airway management tasks such as intubation, tactile and movement challenges caused by providers wearing protective gear and copious airway secretions in the event of a nerve agent exposure. These difficulties may increase the chance of emergency providers placing the endotracheal tube in an improper location during intubation. This study utilized telebronchoscopy to confirm proper endotracheal tube placement by anesthesia providers located at a transcontinental site. The results of this paper show that tele-video laryngoscopy and telebronchoscopy may be useful tools for emergency personnel providing airway management in the event of a CBRNE situation.
Incident Summary: “The patient arrived at the Forward Surgical Team (FST) site 30 minutes after being wounded in the right thigh. A tourniquet had completely arrested the bleeding from the injured ...superficial femoral artery. The surgeons at the FST decided to repair the artery onsite and the 3 hour surgery was reported to have gone well. The patient had received 4 units of packed red blood cells and a reverse saphenous interposition graft had been used to repair the injured superficial femoral artery. However, when the proximal and distal clamps were removed, the patient began to bleed profusely from all his wound sites. Plasma was not available. Fresh whole blood was called for but could not be quickly obtained. The patient was emergently evacuated from the forward surgical team to the combat support hospital but arrested in flight and could not be resuscitated. He was pronounced dead shortly after his 45 minute flight to the combat support hospital.”
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Available for:
FIS, FZAB, GEOZS, GIS, IJS, IMTLJ, KILJ, KISLJ, MFDPS, NUK, OBVAL, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UKNU, UL, UM, UPUK, VKSCE, ZAGLJ
Eighty percent of patients treated medically for gastroesophageal reflux disease relapse after treatment. Many of these patients require indefinite treatment with omeprazole to prevent recurrence. ...Nissen fundoplication has been shown to be effective, safe and cost effective in the management of gastroesophageal reflux disease. We suggest a treatment algorithm, which encourages early surgical intervention in cases of recurrent esophagitis after a previously successful two-month course of omeprazole.
We have offered laparoscopic Nissen fundoplication since 1993. Patients who received Nissen fundoplication since 1990 were asked to report return to baseline activity, medications, and lifestyle changes. Concurrent chart review of patients treated with omeprazole was conducted to analyze cost.
Patients receiving laparoscopic Nissen fundoplication were discharged significantly sooner and spent significantly less time convalescing when compared to those who underwent open Nissen fundoplication. Laparoscopic Nissen fundoplication became cost effective at 1.5 to 2 years when compared to omeprazole.
Based on cost analysis, patient satisfaction, acceptable complication rate, and efficient use of time and resources, we recommend laparoscopic Nissen fundoplication as the appropriate treatment in patients who develop recurrent esophagitis after a two-month treatment with omeprazole.
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