Caring for the Wounded in the Future Supplément Sur Les Forces

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Vol. 58 (3 Suppl 3) June/juin 2015 canjsurg.ca

The Canadian Armed Forces Supplement on Military Medicine: Caring for the Wounded in the Future

Supplément sur les Forces armées canadiennes et la médecine militaire : l’avenir des soins aux blessés

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Vol. 53 (3 Suppl 3) June/juin 2015 canjsurg.ca

FOREWORD • AVANT-PROPOS S88 Technical innovations that may facilitate real- time telementoring of damage control surgery S80 Foreword in austere environments: a proof of concept Col H. Tien comparative evaluation of the importance of surgical experience, telepresence, gravity and S81 Avant-propos mentoring in the conduct of damage control Col H. Tien laparotomies Maj A.W. Kirkpatrick, A. LaPorta, S. Brien, T. Leslie, Col E. Glassberg, J. McKee, C.G. Ball, H.E. Wright Beatty, J. Keillor, INTRODUCTION • INTRODUCTION D.J. Roberts, Col H. Tien

S82 Introduction BGen J.-R. Bernier REVIEW • REVUE

S83 Introduction S91 Advances in damage control resuscitation and BGén J.-R. Bernier surgery: implications on the organization of future military field forces Col H. Tien, Maj A. Beckett, LCol N. Garraway, COMMENTARY • COMMENTAIRE LCol M. Talbot, Capt D. Pannell, T. Alabbasi

S84 In memoriam — Erin Savage, MD, CCFP(EM), Lieutenant Colonel, Royal RESEARCH • RECHERCHE Canadian Medical Service LCol C. Forestier S98 Medical mentorship in Afghanistan: How are military mentors perceived by Afghan health S85 The need for a robust 24/7 subspecialty care providers? “clearing house” response for telementored Maj A. Beckett, R. Fowler, N.K.J. Adhikari, trauma care L. Hawryluck, T. Razek, Col H. Tien Maj A.W. Kirkpatrick, D. Hamilton, Maj A. Beckett, A. LaPorta, S. Brien, S104 Cervical spine injury in dismounted Col E. Glassberg, C.G. Ball, D.J. Roberts, improvised explosive device trauma Col H. Tien J. Taddeo, Maj M. Devine, LCol V.C. McAlister

S78 J can chir, Vol. 58 (No 3 Suppl 3) juin 2015 ©2015 8872147 Canada Inc. S108 Blunt splenic injury and severe brain injury: S141 Factors affecting mortality of pediatric a decision analysis and implications for care trauma patients encountered in Kandahar, T. Alabbasi, A.B. Nathens, Col H. Tien Afghanistan Capt D. Pannell, J. Poynter, P.W. Wales, S118 Needle thoracostomy for tension Col H. Tien, A.B. Nathens, D. Shellington pneumothorax: the Israeli Defense Forces experience S146 The Canadian Armed Forces medical response LTC J. Chen, Capt R. Nadler, Maj D. Schwartz, to Typhoon Haiyan LCol E. Savage, Maj M.D. Christian, Col H. Tien, LTC A.P. Cap, Col E.Glassberg Maj S. Smith, Capt D. Pannell S125 Current use of live tissue training in trauma: a descriptive systematic review L.T. da Luz, B. Nascimento, Col H. Tien, DISCUSSIONS IN SURGERY M.J. Kim, A.B. Nathens, S. Vlachos, DISCUSSIONS EN CHIRURGIE Col E. Glassberg S153 Fresh whole blood transfusion capability for S135 Acute nontraumatic general surgical conditions Special Operations Forces on a combat deployment Maj A. Beckett, J. Callum, L.T. da Luz, Capt D. Pannell, A.B. Nathens, Col J. Ricard, J. Schmid, C. Funk, Col E. Glassberg, LCol E. Savage, Col H. Tien Col H. Tien

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Foreword

he Canadian Armed Forces protects Canada, defends national partners. The Canadian Institute for Military and North America and contributes to international peace Veteran Health Research is a unique consortium of more T and security in partnership with our allies. These part than 35 Canadian universities dedicated to researching the nerships are a key part of our national defence strategy, and health needs of military personnel, veterans and their fam are also important to how we provide medical care and how ilies. In addition, Canada has several formal and informal we innovate to improve care for our wounded. In the future, research relationships with our allies through the North different partner nations will contribute modules of medical Atlantic Treaty Organization and through the Technical and surgical capability that will be fastened together to form a Cooperation Program. We are also now developing solid network of care for our deployed soldiers. Likewise, net research partnerships with the Trauma Branch of the Israel works of national and international partners will come Defence Forces. Defence is now a multilateral and multi together to answer pressing questions to advance trauma national effort. Looking forward, the CFHS will continue medicine, and the care we deliver to our deployed soldiers. to partner with Canadian academic institutions and inter The Canadian Forces Health Services (CFHS) innovates national collaborators to foster future health care innova to improve care for our wounded. With our partners, the tion that helps us sustain and shield our fighting forces CFHS innovates in how we deliver prehospital trauma care when they deploy on military missions. on the battlefield; we innovate in how we resuscitate and provide surgical care at the field hospital level; and we inno Col Homer Tien, OMM, CD, MD, MSc vate in how we transport and care for our wounded back in Canadian Forces Health Services Canada. We also innovate in how we educate and prepare National Practice Leader — Trauma our health care teams for deployment to provide the highest level of trauma care possible. Competing interests: None declared. Much of the research presented in this supplement has been conducted in cooperation with our national and inter DOI: 10.1503/cjs.006615

Avant-propos

es Forces armées canadiennes protègent le Canada, Une grande partie de la recherche présentée dans le défendent l’Amérique du Nord et contribuent à la présent supplément a été effectuée en collaboration avec L paix et à la sécurité internationales en partenariat nos partenaires nationaux et internationaux. L’Institut cana avec ses alliés. Ces partenariats sont un élément détermi dien de recherche sur la santé des militaires et des vétérans nant de notre stratégie de défense nationale, mais ils est un consortium unique composé de plus de 35 universités jouent aussi un rôle important dans la façon dont nous canadiennes qui se consacrent à la recherche sur les besoins offrons les soins médicaux et innovons afin d’améliorer de santé du personnel militaire, des anciens combattants et les soins aux blessés. À l’avenir, des nations partenaires de leurs familles. De plus, le Canada entretient des relations contribueront des modules de ressources médicales et formelles et informelles en matière de recherche avec ses chirurgicales interreliés formant un réseau de soins solide alliés à l’Organisation du traité de l’Atlantique nord et avec pour nos militaires sur le terrain. De même, des réseaux la direction générale de traumatologie des Forces de de partenaires nationaux et internationaux se mobilise défense israéliennes. La défense est maintenant un effort ront afin de répondre à des questions pressantes pour multilatéral et multinational. À l’avenir, le Groupe des Ser améliorer la traumatologie médicale et les soins aux sol vices de santé des Forces canadiennes continuera de colla dats en mission. borer avec les établissements universitaires canadiens et des Le Groupe des Services de santé des Forces cana collaborateurs internationaux pour favoriser des innova diennes fait preuve d’innovation pour améliorer les soins tions en soins de santé qui aident à soutenir et à protéger offerts à ses blessés. En collaboration avec ses partenaires, nos forces combattantes lorsqu’elles sont déployées dans le le Groupe innove dans sa façon d’offrir les soins de trau cadre de missions militaires. matologie préhospitaliers sur le champ de bataille, les soins chirurgicaux et de réanimation dans les hôpitaux de Col Homer Tien, OMM, CD, MD, MSc campagne, ainsi que le rapatriement et les soins offerts aux Groupe des Services de santé des Forces canadiennes blessés au Canada. Nous innovons également dans la Chef national de l’exercice de la profession — Traumatologie manière dont nous formons nos équipes de soins et les préparons en vue du déploiement afin d’offrir les meilleurs Intérêts concurrents : Aucun déclaré. soins de traumatologie possible. DOI: 10.1503/cjs.006715

Introduction

commend the Canadian Journal of Surgery (CJS) for pub- and humanitarian operations in many troubled areas of the lishing its second military medicine supplement in recent world. Such research is pursued extensively within the Sur- I years. Military-specific research and knowledge translation geon General Health Research Program in partnership with are critical to Armed Forces, which must operate in a unique Defence Research and Development Canada, other govern- context of extreme environments; exceptional physiological ment departments and military allies, but collaborative part- and psychological stresses; and extraordinary operational, nerships with civilian academic and clinical partners are occupational and environmental hazards. most essential to achieving synergistic benefits to both mili- This context often complicates or precludes the applica- tary and civilian populations. The enthusiastic dedication tion of civilian research findings to military populations, such with which civilian academia supports the Armed Forces in that a need for the application of science to military health this regard is reflected by the large number of civil–military issues has long been recognized. In fact, the first scientist in health research collaborations as well as by the broad what is now Canada, Michel Sarrazin, was Surgeon-Major to 33-university network of the Canadian Institute for Military the colonial regular troops of New France, and the original and Veteran Health Research. The fruits of such collabora- predecessor organization to the Canadian Institutes of tion informe the practice, for example, of Mobile Surgical Health Research was established in 1938 by the National Resuscitation Team members currently supporting our Spe- Research Council of Canada president, Lieutenant-General cial Forces in Iraq, as they did the practices of Sunnybrook Andrew McNaughton, to study the medical problems of Trauma Centre clinicians in their response to Toronto’s warfare. Many prominent Canadian physicians and surgeons mass shooting casualties in July 2012. researched military medical issues extensively, including On behalf of the Armed Forces, the Royal Canadian Brigadier Jonathan Meakins, founding president of the Royal Medical Service and the military and civilian populations College of Physicians and Surgeons of Canada; Surgeon they protect, I thank the many CJS readers who have so Captain Charles Best, who led Royal Canadian Navy medical faithfully collaborated with their military medical colleagues research in World War II; Major Sir Frederick Banting, who in the conduct of mutually beneficial research. led Royal Canadian Air Force (RCAF) medical research and was killed on a military medical research mission; Group BGen Jean-Robert Bernier, OMM, CD, QHP, BA, MD, Captain G. Edward Hall, who followed Major Banting as MPH, DEH head of RCAF medical research and was Western Univer Surgeon General sity’s longest-serving president; and many others. Head, Royal Canadian Medical Service Applied military health research remains a responsibility Commander, Canadian Forces Health Services Group and requirement of Royal Canadian Medical Service offi- Competing interests: None declared. cers. Its fundamental clinical and operational importance continues to be highlighted by the health impact of military DOI: 10.1503/cjs.015614

Introduction

e félicite le Journal canadien de chirurgie pour la les plans opérationnel et clinique est bien évidente dans publication de son second supplément sur la méde- les répercussions sur la santé découlant des opérations J cine militaire au cours des dernières années. La humanitaires et militaires dans plusieurs zones de conflit recherche et le transfert des connaissances dans le domaine dans le monde. Le personnel du Programme de recherche militaire jouent un rôle essentiel pour les Forces armées en santé du médecin général participe activement à ce qui œuvrent dans un contexte unique de milieux extrêmes, genre de recherches en partenariat avec Recherche et de stress physiologique et psychologique exceptionnel et développement pour la défense Canada et d’autres de dangers environnementaux, professionnels et opéra- ministères et alliés militaires. Ce sont toutefois les parte- tionnels extraordinaires. nariats de collaboration avec les secteurs cliniques et uni- Ce contexte complique ou empêche souvent l’appli versitaires au niveau civil qui sont les plus essentiels à la cation des résultats des recherches du secteur civil aux réalisation d’avantages synergiques pour les populations populations militaires. L’application des résultats scienti- militaires et civiles. Le soutien enthousiaste du milieu fiques aux problèmes de santé militaires est donc un universitaire civil à cet égard se reflète dans le nombre besoin reconnu depuis longtemps. Je pense à Michel élevé de collaborations militaires–civiles aux projets de Sarrazin, premier scientifique du Canada actuel, qui fut recherche sur la santé ainsi que dans le vaste réseau de chirurgien-major des troupes régulières coloniales de la 33 universités de l’Institut canadien de recherche sur la Nouvelle-France. Ou encore au lieutenant-général santé des militaires et des vétérans. Le fruit de ces colla Andrew McNaughton, président du Conseil national de borations éclaire la pratique, notamment celle des mem- recherches du Canada, qui créa en 1938 l’organisme pré- bres de l’Équipe mobile chirurgicale et de réanimation décesseur original des Instituts de recherche en santé du appuyant actuellement nos forces spéciales en Iraq, tout Canada afin d’étudier les problèmes médicaux issus de la autant que celle des cliniciens du Centre de traumatolo- guerre. Plusieurs éminents médecins et chirurgiens cana- gie Sunnybrook lors de la fusillade qui avait fait de nom- diens ont fait des recherches exhaustives sur les problèmes breux blessés à Toronto en juillet 2012. médicaux du personnel militaire, notamment le brigadier Au nom des Forces armées, du Service de santé royal Jonathan Meakins, président-fondateur du Collège royal canadien et des populations militaires et civiles qu’ils des médecins et chirurgiens du Canada, le médecin- protègent, je remercie les nombreux lecteurs du Journal capitaine Charles Best, qui a dirigé des recherches médi- canadien de chirurgie qui ont collaboré fidèlement avec cales pour la Marine royale canadienne durant la Seconde leurs collègues médecins militaires à des recherches Guerre mondiale, le major sir Frederick Banting, qui a mutuellement avantageuses. mené des recherches médicales pour l’Aviation royale canadienne (ARC) et qui a perdu la vie lors d’une mission Bgén Jean-Robert Bernier, OMM, CD, QHP, BA, MD, militaire de recherche médicale, le colonel d’aviation MPH, DEH G. Edward Hall, qui a succédé au major Banting à titre de Médecin général chef de recherche médicale de l’ARC et qui a servi le plus Chef, Service de santé royal canadien longtemps comme président de l’Université Western, et Commandant, Groupe des Services de santé des Forces canadiennes j’en passe. La recherche appliquée en santé militaire demeure une Intérêts concurrents: Aucun déclaré. responsabilité et une exigence des officiers du Service de santé royal canadien. Son importance fondamentale sur DOI: 10.1503/cjs.006815

In memoriam — Erin Savage, MD, CCFP(EM) Lieutenant Colonel, Royal Canadian Medical Service

LCol Colleen Forestier, MD Summary This supplement is dedicated to the memory of Lieutenant Colonel Erin Savage. Accepted for publication Erin passed away peacefully on Nov. 7, 2014, surrounded by loving family and Jan. 5, 2015 friends in Ottawa, Ont., after a lengthy battle with breast cancer. Correspondence to: C. Forestier 257 Currell Ave. Ottawa ON K1Z 7J5 his supplement is dedicated to [email protected] the memory of Lieutenant T Colonel Erin Savage. Erin passed away peacefully on Nov. 7, Affiliations: From Canadian Forces Health Services, Ottawa, Ont. 2014, surrounded by loving family and friends in Ottawa, Ont., after a Competing interests: None declared. lengthy battle with breast cancer. DOI: 10.1503/cjs.000915 Erin joined the Canadian Armed Forces (CAF) in 1998, during her second year of medical school at Dalhou- sie University, Halifax, NS. After completing her family medicine resi- dency in 2002, Erin was posted to the 2nd Battalion, The Royal Canadian Regiment, in Gagetown, NB, where she quickly earned a reputation as a fantastic clinician, passionate patient LCol Erin Savage. advocate and tough, “hard as nails” military officer. During her 17 years of service with the CAF, she rose to become one of the most respected physicians in the Forces. While serving her country, Erin deployed to both Haiti in 2004 and Afghanistan in 2007 in support of The Royal Canadian Regiment, where she earned a Chief of Defense Staff Commen- dation for her outstanding work as the senior combat medical physician and leader for Battle Group’s medical company. After returning from Afghanistan, Erin continued to work incredibly hard as an instructor and advocate for the CAF medical technicians. She ensured that they were sent to the battlefield with the skills and equipment they needed to save the lives of the soldiers they were there to support. Erin’s work in this area included published research that has garnered international attention and that will improve battlefield trauma care. Erin’s dedication to improving battlefield care will have a lasting impact on the CAF, and has influenced a large number of CAF medical technicians and physicians. Her impact, however, is perhaps best measured in the tributes from her colleagues in the combat infantry unit with which she served overseas: “The Royal Canadian Regiment has lost a great friend and true member of our regimental family … She will be remembered with affection and respect as LCol Erin Savage with WO Tim Ralph (retired). one of our own.”

The need for a robust 24/7 subspecialty “clearing house” response for telementored trauma care

Maj Andrew W. Kirkpatrick, MD Summary Douglas Hamilton, MD Traumatic injury is increasing in importance in all settings and environments Maj Andrew Beckett, MD worldwide. Many preventable deaths are from conditions that are common and Anthony LaPorta, MD treatable. However, as potentially lethal injuries often induce progressive and frequently irreversible physiologic decline, the timing of interventions is crit Susan Brien MD, MEd ical. Invasive treatments may need to be offered by prehospital care providers Col Elon Glassberg, MD, MHA who lack extensive training and practice. Telementoring allows experienced experts to guide less experienced providers remotely using information technol- Chad G. Ball, MD, MSc ogy (IT). Early experience has shown that these techniques are practical and Derek J. Roberts, MD, MSc considered valuable. Their translation to regular practice, however, will require Col Homer Tien, MD the immediate availability of appropriately trained remote experts willing to serve as mentors. Acute care trauma specialists are acclimatized to responding to out-of-hospital consultations and assuming overall responsibility for critical The research group is jointly supported physiology and transport and may serve as the backbone of such a national/ by the Canadian Forces Medical Services. international call response initiative.

Accepted for publication Oct. 14, 2014 raumatic injury remains a scourge that is only increasing in importance Correspondence to: A.W. Kirkpatrick in all settings and environments worldwide — military and civilian 1403 29 Street NW T alike. It is the leading cause of preventable years of life lost in the west- Calgary AB T2N 2T9 ern world and is increasing dramatically in incidence in the developing world [email protected] as mechanization progresses.1 Not surprisingly, traumatic death haunts all bat- tlefields, conflict zones and humanitarian crises as well as extreme sporting DOI: 10.1503/cjs.013914 events and expeditions. In all these settings, many deaths are from conditions that are both predictably common and potentially treatable if basic therapies and interventions are available. Such therapies range from simple direct pressure for hemorrhage control to airway management to percutaneous interventions for pneumothoraces to full intracavitary surgery. A critical distinction between traumatic injury and other medical conditions is that the former is extremely time-critical. The same initial interventions, such as drainage of a hemothorax, intubation or external hemorrhage control, that may completely manage a situation early may be futile if applied in a delayed fashion to a physiologically exhausted, dying patient. Trauma care also has to have a practical side, such that in mass casualty or austere situations psychologically burdensome decisions regarding futility or excessively resource-consumptive situations can be shared between first responders and remote specialists. To provide advanced care, however, the key ingredients to facilitate such interventions are appropriate equipment and supplies as well as appropriately trained caregivers. Realistically, it is often far easier logistically to have equipment available than it is to have providers to use it properly, especially if the equipment is as basic as a needle or pack of gauze. Practically, equipment that is increasingly likely to be present in any austere environment is communication technology with Internet access.2 Linked to informatic connectivity is the potential for telemedical support. Telementoring is a practice in which experienced experts guide less experienced providers remotely using information technology (IT) techniques.2

Early experience has shown that these techniques are made would involve whether such a network is permanent or practical and considered valuable by involved providers. convened on an ad hoc basis in response to a perceived mis- Translation to regular practice, however, will require the sion or anticipated event. Another is whether the network immediate availability of appropriately trained remote would simply focus on providing trauma care or whether it experts willing to serve as mentors.3 would address all anticipated emergency medical concerns, While being a content expert in a pertinent discipline is such as during disaster response. Yet another decision is necessary to telementor remote providers to address a par- whether all remote care would be provided, including care ticular clinical problem, this expertise in and of itself is not for acute and chronic conditions and for all age groups and wholly sufficient to designate someone a telementoring spe- both sexes. Major logistical questions include the eligibility cialist. The ability to telementor effectively requires com- criteria for telemedical support, both in terms of the remote munication skills flexible enough to enable the remote on- on-site providers and the intended patient population. site provider to perform to the best of their ability. Thus, it Wootton and colleagues5–7 recently reviewed the poten- becomes critical that the mentor understand whether they tial mechanisms for sharing expertise among experts are dealing with a trained physician, naive bystander, adult involved in separate long-standing telemedicine networks or child, or even whether the on-site provider is using their delivering humanitarian services using predominantly native tongue.4 Understanding “how it is out there” is cru- asynchronous (store-and-forward) methods. The conclu- cial. Otherwise the results will be the right advice for the sions of their review and tabletop exercises was that a com- wrong situation. It is also critical that a functional working bined database of all willing and able relevant specialists relationship be established, even if the setting is a just-in- could be stored in a combined clearing house–style data- time one in which the telementor and on-site provider have base and accessed through a secure Internet browser with never met. Formal studies on the technical or educational email as the suggested point of initial contact.5 requirements for telementoring are limited, but our anec- Such a network might comprise Canadian Forces (CF) dotal experience is that adaptability, congeniality, flexibility physicians and physicians currently providing call services and mutual respect are crucial. Much scientific study is within their regular schedules in Canadian hospitals. For a required to understand the details of with whom, how and World Health Organization–sponsored mission, perhaps the with what equipment the best mentoring of critical inter- remote expert mentors might include every known specialty ventions can occur. We also perceive that the discipline of from an international cadre supported by the United telementoring will need to become a recognized subspe- Nations. Recognizing the need for an immediate response cialty — one in which many other traditional specialties will for trauma and critical illness–type problems, the smartphone need to train after learning the core clinical knowledge — in would be the suggested initial point of access for those on call order to effectively reach out and provide such specialty being contacted by a central clearing house centre sometimes care over a regional, national or international network.4 a continent away. Initial experiences have shown that smart- Although telementoring may not ever be a subspecialty in phones are incredibly powerful and might enable global tele- itself, there may be multiple reasons why the fundamentals medical outreach on an unprecedented scale.8 of how to receive telementoring might become part of the Traditionally, Canadians have welcomed a presence in basic curriculum of medical and paramedical personnel international security missions, and this presence has often deploying to remote or austere locations. been heavily weighted to emphasize medical support in Clinical, telemedical support networks need to be created multinational military collaborations. Providing the back- and supported. In the big picture of global health, these net- bone for a temporary or better permanent telementoring works should be both synchronous and asynchronous, poten- network infrastructure might conceivably be a deliverable tially populated with “apps” and other popular tools for social that would fit well with Canada’s geopolitical resources media as vehicles for global consultation or just-in-time and philosophies and a task that might further justify the learning. For trauma care, however, functionally immediate existence of subspecialist physicians with the CF. At pres- 24/7 response times with a virtual but engaged expert will be ent we are aware of no such network in existence that func- required, as any other response defeats the purpose of min tions in real time, and there are multiple legislative, medi- imizing unnecessary trauma deaths. Acute care trauma spe- colegal and professional credentialing concerns to be cialists are, by training and practice, acclimatized to respond- addressed, although these are all theoretical rather than ing to out-of-hospital consultations and assuming overall absolute, as the technical solution exists. responsibility for critical physiology and transport; these Telementoring of many complex procedures has been specialists might be the backbone of such a national/ proven feasible and enables remote patients to receive tre- international call response, but they would need to be sup- mendous care in locations where such interventions would plemented by other disciplines. Trade-offs will be required be unthinkable. Such a response, however, relies on the between the practicality of call schedules and providing a full right expert picking up the (smart)phone or logging in range of subspecialty expertise requiring more involved per- when called and having the right answer based on the right sonnel. One of the myriad of administrative decisions to be experience and expertise.

S86 J can chir, Vol. 58 (No 3 Suppl 3) juin 2015 COMMENTARY

Affiliations: From the Regional Trauma Services, Calgary, Alta. 2. Pian L, Gillman LM, McBeth PB, et al. Potential use of remote tele- (Kirkpatrick, Ball, Roberts); Department of Surgery, University of Calgary, sonography as a transformational technology in underresourced and/ Calgary, Alta. (Kirkpatrick, Ball, Roberts); Canadian Forces Health Services or remote settings. Emerg Med Int 2013;28:986160. (Kirkpatrick, Tien); Department of Medicine, University of Calgary, Cal- 3. Dyer D, Cusden J, Turner C, et al. The clinical and technical evalua- gary, Alta. (Hamilton); the 1 Canadian Field Hospital, Petawawa, Ont. tion of a remote telementored telesonography system during the (Beckett, Tien); Trauma Program, McGill University Health Centre, Mon- tréal, Que. (Beckett); Rocky Vista School of Osteopathic Medicine, Parker, acute resuscitation and transfer of the injured patient. J Trauma Colo. (LaPorta); Royal College of Physicians and Surgeons of Canada, 2008;65:1209-16. Ottawa, Ont. (Brien); The Trauma & Combat Medicine Branch, Surgeon . 4 Kirkpatrick AW. 2010 Trauma Association of Canada presidential General’s HQ, Israel Defense Forces, Ramat Gan, Israel (Glassberg); address: why the Trauma Association of Canada should care about Trauma Services and the Department of Surgery, Sunnybrook Medical space medicine. J Trauma 2010;69:1313-22. Centre, Toronto, Ont. (Tien). 5. Wootton R, Bonnardot L, Geissbuhler A, et al. Feasibility of a clear- Competing interests: A.W. Kirkpatrick declares travel compensation ing house for improved cooperation between telemedicine networks from Innovative Trauma Care, LifeCell and Kinetic Concepts, all unre- delivering humanitarian services: acceptability to network coordina- lated to the content of this article. A. LaPorta declares travel assistance tors. Glob Health Action 2012;5:18713. through US federal grants during research for this product for the military. . 6 Wootton R, Geissbuhler A, Jethwani K, et al. Comparative per formance of seven long-running telemedicine networks delivering Contributors: All authors contributed substantially to the conception, humanitarian services. J Telemed Telecare 2012;18:305-11. writing and revision of this commentary and approved the final version for publication. . 7 Wootton R, McGoey ST. Who shall coordinate the coordinators? Facilitating the work of telemedicine networks which provide humanitarian services. J Telemed Telecare 2012;18:63-5. References 8. Kirkpatrick AW, Blaivas M, Sargsyan AE, et al. Enabling the mission 1. Murray CJ, Lopez AD. Global mortality, disability, and the contri- through trans-Atlantic remote mentored musculoskeletal ultrasound: bution of risk factors: Global Burden of Disease Study. Lancet case report of a portable hand-carried tele-ultrasound system for 1997;349:1436-42. medical relief missions. Telemed J Health 2013;7:530-4.

Can J Surg, Vol. 58 (Issue 3 Suppl 3) June 2015 S87 COMMENTARY • COMMENTAIRE

Technical innovations that may facilitate real-time telementoring of damage control surgery in austere environments: a proof of concept comparative evaluation of the importance of surgical experience, telepresence, gravity and mentoring in the conduct of damage control laparotomies

Maj Andrew W. Kirkpatrick, MD Summary Anthony LaPorta, MD Bleeding to death is the most preventable cause of posttraumatic death world- Susan Brien, MD, Med wide. Despite the fact that many of these deaths are anatomically salvageable with Tim Leslie, MSc relatively basic surgical interventions, they remain lethal in actuality in prehospital environments when no facilities and skills exist to contemplate undertaking Col Elon Glassberg, MD, MHA basic damage control surgery (DCS). With better attention to prehospital control Jessica McKee, MSc of extremity hemorrhage, intracavitary bleeding (especially intraperitoneal) remains beyond the scope of prehospital providers. However, recent revolutions Chad G. Ball, MD, MSc in the informatics and techniques of telementoring (TMT), DCS and highly Heather E. Wright Beatty, PhD realistic accelerated training of motivated first responders suggests that basic life- Jocelyn Keillor, PhD saving DCS may have applicability to save bleeding patients in austere environments previously considered unsalvageable. Especially with informatic advances, Derek J. Roberts, MD, MSc any provider with Internet connectivity can potentially be supported by highly Col Homer Tien, MD proficient specialists with content expertise in the index problem. This unprecedented TMT support may allow highly motivated but inexperienced personnel to provide advanced surgical interventions in extreme environments in many aus- Accepted for publication Nov. 18, 2014 tere locations both on and above the planet. Correspondence to: A.W. Kirkpatrick Departments of Surgery and Critical Care Medicine orldwide, traumatic injury is an ever-increasing cause of potentially University of Calgary preventable loss of life. Operative hemorrhage control is the most crit Calgary AB T2N 2T9 ical early intervention that could impact trauma mortality, as bleeding [email protected] W to death has been identified as the leading cause of potentially preventable injury- related mortality. The greatest challenge in changing these outcomes, however, is DOI: 10.1503/cjs.014214 that the majority of this lethal hemorrhage is intracavitary (chest and either intraperitoneal or retroperitoneal). Such bleeding requires advanced operative therapy to save lives, which implies both the need for surgical and life support equipment compatible with austere environments and for first responders capable of providing truncal hemorrhage control. This dilemma challenges all those providing care in civilian, military, humanitarian and operational settings without prejudice. A review of combat experiences revealed that traumatic hemorrhage may result in more than 50% of all battlefield deaths, with 90% being from truncal hemorrhage.1 In the civilian setting, up to 80% of all early trauma deaths result from uncontrolled hemorrhage, with as many as 99% of these hemorrhagic deaths being truncal.2 This corroborates reviews of Special Forces deaths in which truncal hemorrhage predominated as the most common etiology.3 Even in the extra- terrestrial environment, injury is ranked at the highest level of concern by the National Aeronautics and Space Administration (NASA), comparing the likelihood of occurrence with the impact on mission and health.

Damage control surgery for truncal We have found it very feasible to guide novice caregivers to hemorrhage control in austere and extreme perform just-in-time ultrasound examinations using hand- environments held smartphones in the hands of the remote mentor.7 We perceive that almost any potential care provider with Inter- In 1983, a council of trauma surgeons, space physicians and net access anywhere on the planet could be guided through biomedical engineers identified the performance of a lapa- advanced diagnostics and/or medical procedures. 8 rotomy as the minimum desirable surgical capability to save lives before transfer to Earth for the planned Space Station Surgery in weightlessness and space as an Freedom.4 Technically, a laparotomy would facilitate the example of the ultimate extreme environment utilization of damage control surgery (DCS), which could be as simple as placing “packs” around bleeding solid Although surgical diseases have been suspected and have organs and leaving the abdomen “open.” These most basic influenced decision-making, to date no human operations elements of damage control would result in transforming have ever been performed in space. However, complex sur- incompressible truncal hemmorhage into a now compress- gical procedures have been performed on animals in space.9 ible scenario. While presumably quite stressful to nonsur- A wide array of operations and invasive interventions have geons, incising the anterior abdominal wall to access the also been performed during the weightless conditions pro- peritoneal cavity is technically simple and is a procedure vided by parabolic flight, including minor procedures on that might be appropriate for telementoring. Nonphys living humans. The cumulative conclusions of these various icians have anecdotally performed this procedure success- investigations has emphasized that complex surgical pro fully,5 although there are no data on their performance ced ures should be technically feasible in weightless environ- compared with that of trained operators and/or on their ments if cardinal principles are respected.10 These studies, degree of stress. A future adjunct may also be the introduc- however, have all been conducted with experienced sur- tion of expanding foams, which might lessen the size of geons; to our knowledge, no experience mentoring nonsur- abdominal opening required in such a prehospital setting.6 geons in complex tasks in weightlessness has been completed to date. The nearest analogue is the successful Remote telementoring for advanced medical remote guidance that the group from Henry Ford Hospital interventions in Detroit, Mich., provided to a simulated Mars environment in the Canadian Arctic.11 This group was able to pro- Informatics advances have rapidly changed our society. The vide clinical control from a terrestrial base using telemen- planet is increasingly networked, and satellite-based infor- toring techniques to enable the remote diagnosis and matics are potentially accessible anywhere on or above the removal of an anatomical appendectomy model using lapa- Earth’s surface. Much of the greatest growth in connectiv- roscopic stapling technology by a nonsurgeon.11 ity has been in developing countries, where mobile phone services are increasingly available at rates out of proportion “Hyperrealistic training” and the Human Worn to the relative development of other basic infrastructure. Partial Task Surgical Simulator (Cut Suit) Philo sophically, the United Nations has considered the availability of Internet connectivity as a basic human right. In addition to remotely guiding less experienced respond- Such technical and practical advances have made remote ers to perform complex tasks, these responders can also telementoring for invasive procedures a viable alternative to be trained beforehand using highly realistic scenarios on-site mentoring in many situations. It has become rela- that involve advanced realism and detailed/functional tively commonplace to use informatics either to supervise anatomic/physiologically real training models. Besides and/or actively guide less experienced operators remotely to improving skills, such approaches also enable learners to perform a variety of surgical procedures regardless of better manage stress and increase confidence in situations whether the mentor is in the same institution, in another that have been termed “hyperrealistic.”12,13 The Human institution or even on another continent. Worn Partial Task Surgical Simulator (Cut Suit) is a real- With the paucity of experienced medical personnel in istic surgical training tool that allows for the simulated space, NASA has led efforts to marry information technol- performance of actual surgical procedures.12 In addition to ogy advances with “just-in-time” mentoring techniques to perfused extremities, the Cut Suit also has perfused inter- guide advanced ultrasound diagnoses on the International nal organs that may be accessed through the abdominal Space Station performed by mentored nonphysicians. wall and can be incised to bleed and repaired or excised to Recent innovations by our own research group have control hemorrhage. The Cut Suit is regularly being involved efforts to follow up on these techniques and upgraded and in the near future will be equipped with greatly simplify the infrastructure and technical require- specific in-line flow sensors that will permit an accurate ments for telementoring technical procedures, such as calculation of simulated blood loss during different pro point-of-care ultrasonography, to facilitate terrestrial care. cedures and situations and with different surgeons.

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Real-time telementoring of damage control (Kirkpatrick, Tien); Rocky Vista School of Osteopathic Medicine, Parker, Colo. (LaPorta); Royal College of Physicians and Surgeons of surgery in austere environments Canada, Ottawa, Ont. (Brien); NRC Aerospace Flight Research Labo- ratory, Ottawa, Ont. (Leslie, Wright-Beatty, Keillor); The Trauma & With this rationale and technology in place, our Canadian Combat Medicine Branch, Surgeon General’s HQ, Israel Defense Forces, Ramat Gan, Israel (Glassberg); Innovative Trauma Care, Forces–supported Tele-Mentored Damage Control Sur- Edmonton, Alta. (McKee); Trauma Services and the Department of gery in Austere Environments research group will be Surgery, Sunnybrook Medical Centre, Toronto, Ont. (Tien). undertaking a progressively more complex series of studies Competing interests: J. McKee is affiliated with Innovative Trauma to evaluate the feasibility of mentoring first responders to Care, who makes the iTClamp; but this product is not mentioned in any undertake hemostatic laparotomies with intraperitoneal way in the manuscript. A.W. Kirkpatrick was the principal investigator of a randomized controlled trial on open abdomen management funded packing in increasingly complex environments. The pro- by Acelity, and he declares consulting with Acelity after completion of gressively more complex phases of the study will build the trial. upon each other and will consist of controlled compari- Contributors: All authors contributed substantially to the conception, sons aiming to discern objective performance differences writing and revision of this commentary and approved the final version in the conduct of damage control laparotomies related to for publication. • surgical experience (trained surgeons v. nonphysician medics), References • telementoring (telementored nonphysicians v. unsup- 1. Bellamy RF. The causes of death in conventional land warfare: ported nonphysicians), and Implications for combat casualty care research. Milt Med 1984; • gravity (damage control laparotomy in weightlessness 149:55-62. [0g] v. terrestrial [1g] gravity). 2. Martinowitz U, Holcomb JB, Pusateri AE, et al. Intravenous rFVIIa There will also be 2 additional related and complemen- administered for hemorrhage control in hypothermic coagulopathic tary arms evaluating the performance benefits of remote swine with grade V liver injuries. J Trauma 2001;50:721-9. 3. Holcomb JB, McMullin NR, Pearse L, et al. Causes of death in U.S. telementoring in relation to performing damage control Special Operations Forces in the global war on terrorism: 2001– laparotomies in the austere environment of a far-forward 2004. Ann Surg 2007;245:986-91. operating base and on board a maritime vessel as well as 4. Houtchens B. System for the management of trauma and emergency the benefits of telementoring to assist in the performance surgery in space: final report. NASA Grant NASW-3744, Houston, of extremity hemorrhage control, emergency chest drain- Texas, NASA Johnson Space Center 1983. age, medication preparation and advanced surgical airway 5. Tisherman SA, Vandevelde K, Safar P, et al. Future directions for resuscitation research. V. Ultra-advanced life support. Resuscitation management. The primary outcome of all interventions 1997;34:281-93. will vary as appropriate to provide the most meaningful 6. Rago A, Duggan MJ, Marini J, et al. Self-expanding foam improves clinical parameter for assessment but will include the vol- survival following a lethal, exsanguinating iliac artery injury. J Trauma ume of reservoir simulated bloodshed before hemorrhage Acute Surg 2014;77:73-77. control is obtained. Nested throughout all these studies 7. Pian L, Gillman LM, McBeth PB, et al. Potential use of remote tele- will be comparative evaluations of the relative ratios of sali- sonography as a transformational technology in underresourced and/ or remote settings. Emerg Med Int 2013;28:986-160. vary stress hormones (e.g., cortisol), which indicate the rel- 8. McBeth P, Crawford I, Tiruta C, et al. Help is in your pocket: the ative degree of physiologic and psychological distress that potential accuracy of smartphone- and laptop-based remotely guided an operator is experiencing during any particular task. The resuscitative telesonography. Telemed J E Health 2013;19:924-930. hypothesis will be that the virtual presence of the remote 9. Campbell MR, Williams DR, Buckey JC, et al. Animal surgery during mentor will reduce the stress felt by the responder while spaceflight on the Neurolab shuttle mission.Aviat Space Environ Med 2005;76:589-93. completing their tasks. 10. Kirkpatrick AW, Campbell MR, Novinkov OL, et al. Blunt trauma Through this series of increasingly more complex studies and operative care in microgravity: a review of microgravity physiol- that build upon the prior iteration, the investigators hope to ogy and surgical investigations with implications for critical care and demonstrate that technical adequacy and safety can be pro- operative treatment in space. J Am Coll Surg 1997;184:441-53. vided with modern informatics to allow first responders to 11. Otto C, Comtois JM, Sargsyan A, et al. The Martian chronicles: safely perform damage control laparotomies in a variety of remotely guided diagnosis and treatment in the Arctic Circle. Surg Endosc 2010;24:2170-7. austere settings when no other clinical alternatives exist. 12. Mueller GR, Moloff AL, Wedmore IS, et al. High intensity scenario Acknowledgments: The research group is supported by the Canadian training of military medical students to increase learning capacity and Forces Health Services. management of stress response. J Spec Oper Med 2012;12:71-76. Affiliations: From Regional Trauma Services, Calgary, Alta. (Kirkpatrick, 13. Hoang TN, Kang J, Laporta AJ, et al. Filling in the gaps of prede- Ball, Roberts); Department of Surgery, University of Calgary, Calgary, ployment fleet surgical team training using a team-centered approach. Alta. (Kirkpatrick, Ball, Roberts); Canadian Forces Health Services J Spec Oper Med 2013;13:22-33.

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Advances in damage control resuscitation and surgery: implications on the organization of future military field forces

Col Homer Tien, MD Medical support to deployed field forces is increasingly becoming a shared responsibility Maj Andrew Beckett, MD among allied nations. National military medical planners face several key challenges, including fiscal restraints, raised expectations of standards of care in the field and a short- LCol Naisan Garraway, MD age of appropriately trained specialists. Even so, medical services are now in high LCol Max Talbot, MD demand, and the availability of medical support may become the limiting factor that determines how and where combat units can deploy. The influence of medical factors on Capt Dylan Pannell, MD, PhD operational decisions is therefore leading to an increasing requirement for multinational Thamer Alabbasi, MB medical solutions. Nations must agree on the common standards that govern the care of the wounded. These standards will always need to take into account increased public Accepted for publication expectations regarding the quality of care. The purpose of this article is to both review Feb. 23, 2015 North Atlantic Treaty Organization (NATO) policies that govern multinational medical missions and to discuss how recent scientific advances in prehospital battlefield care, Correspondence to: damage control resuscitation and damage control surgery may inform how countries H. Tien within NATO choose to organize and deploy their field forces in the future. Sunnybrook Health Sciences Centre H186 — 2075 Bayview Ave. Toronto ON M4N 3M5 De plus en plus, la responsabilité du soutien médical offert aux forces militaires [email protected] déployées sur le terrain devient partagée entre les nations alliées. Les planificateurs médicaux militaires nationaux font face à plusieurs défis importants, tels que restrictions budgétaires, attentes élevées au chapitre des normes de soin sur le terrain et pénurie de DOI: 10.1503/cjs.001815 spécialistes dûment formés. Malgré cela, les services médicaux sont présentement en grande demande et leur disponibilité pourrait devenir le facteur limitatif susceptible de déterminer de quelle façon et en quels lieux les unités de combat peuvent se déployer. L’impact des facteurs médicaux sur les décisions opérationnelles requiert donc de plus en plus des solutions médicales multinationales. Les nations doivent s’entendre sur des normes communes qui régissent les soins à prodiguer aux blessés. Ces normes devront toujours tenir compte des attentes accrues du public en regard de la qualité des soins. Le but de cet article est de revoir les politiques de l’Organisation du Traité de l’Atlantique Nord (OTAN) qui régissent les missions médicales multinationales et de discuter de la façon dont les progrès scientifiques récents des soins pré-hospitaliers sur les champs de bataille et les techniques de réanimation et de chirurgie de sauvetage peuvent éclairer la façon dont les pays de l’OTAN décideront d’organiser et de déployer leurs forces sur le terrain à l’avenir.

he mandate of the Canadian Armed Forces (CAF) is to protect Canada, defend North America in cooperation with the United States and contribute to international peace and security in partnership with allies T 1 from other countries. In principle, medical support to any CAF mission remains a national responsibility. The Canadian Forces Health Services (CFHS) is responsible for providing full-spectrum, high-quality health services to Canada’s military forces wherever they serve.2 In practice, however, medical support to expeditionary forces is increasingly becoming a shared responsibility among allied nations. National military medical planners face several key challenges, including fiscal restraints, raised expectations of standards of care in the field and a shortage of appropriately trained specialists.3 Even so, medical services are now in high demand, and the availability of medical support may become the limiting factor that determines how and where combat units can deploy. The influence of medical factors on operational decisions is therefore leading to an increasing

©2015 8872147 Canada Inc. Can J Surg, Vol. 58 (Issue 3 Suppl 3) June 2015 S91 REVUE requirement for multinational medical solutions. Collec- MTFs is mission-dependent; the decision to deploy a tively pooling medical resources has enabled Canada and its Role 2 MTF may depend on the risk assessment, on allies to generate military medical capabilities needed to geography and its effect on evacuation, or on the size of support recent missions in Afghanistan and around the the deployed force. It is in light of these factors that world. However, conducting multinational medical mis- NATO countries sometimes feel the need to increase the sions can be challenging.4 Nations must agree on the com- clinical capability of their Role 2 MTFs. Role 2 MTFs mon standards that govern the care of the wounded. These are now classified as Role 2 Basic and Role 2 Enhanced. A standards will always need to take into account increased Role 2 Enhanced facility will have more “enhanced” sur- public expectations regarding the quality of care. gical modules in order to provide commanders with a Since its inception in 1949, the North Atlantic Treaty more robust capability if required. Organization (NATO) has been a cornerstone of Canadian defence and security policy.5 The CAF have contributed to Role 3 every NATO operation since its founding5 and will likely Major specialist facilities are available at the Role 3 level of continue to do so as part of the CAF mandate to contribute care, including advanced diagnostic imaging, intensive care to international peace and security. The purpose of this units, holding and nursing capabilities. Final sorting of paper is to both review NATO policies that govern multi casualties for transfer to Role 4 or return to duties will national medical missions and to discuss how recent scien- occur at Role 3 facilities. tific advances in prehospital battlefield care, damage control resuscitation and damage control surgery (DCS) may Role 4 inform how countries within NATO choose to organize and Role 4 facilities provide the full spectrum of definitive deploy their Field Forces in the future. medical care that cannot be deployed to theatre or that is too time-consuming to be conducted in-theatre. This The NATO concept of medical support would normally include definitive care, specialist surgical and medical procedures, reconstructive surgery and Continuum of care rehabilitation. This care is highly specialized and comprehensive and is normally provided in the home country. NATO laid out its medical doctrine in its Allied Joint Publication 4–10(A), “Allied Joint Medical Doctrine.”6 In Timelines for care under NATO doctrine this publication, NATO defined medical treatment facil ities (MTFs) as the facilities where injured military mem- In its Allied Joint Medical Doctrine,6 NATO also laid out bers are treated throughout the entire continuum of care. its expectations regarding time-related constraints of med- These MTFs are designated a Role number to describe ical care, which begin at the time of wounding. The time their functional capability to deliver a specific level of constraints have been termed the NATO “1-2-4 rule:” care. In NATO doctrine, it is implicit that higher-level • golden hour — MEDEVAC and advanced trauma care Roles incorporate the functions of lower-level Roles. For assets must reach the casualty within 1 hour of wounding, example, a Role 2 MTF will routinely incorporate a pri- • DCS — casualties who require urgent surgery should mary care role, which is defined as a Role 1 function. The be under treatment in a facility staffed and equipped for broad capabilities that may be expected at each level are this within 2 hours of wounding (usually done at a Role described below.6 2 MTF), and • primary surgery — casualties should receive primary Role 1 surgery directed at first repair of local damage from Role 1 includes the provision of primary care, emergency wounding not more than 4 hours after injury (usually treatment, resuscitation and stabilization, and preparation performed in a Role 3 facility). for transfer. Generally, Role 1 medical support is a national However, following extensive national engagement, the responsibility and it must be readily and easily available to all June 2011 meeting of the NATO Committee of the Chiefs force personnel. Role 1 care is provided at the site or very of the Military Medical Services endorsed a NATO Life & close to the site of injury. Limb Saving Timeline to replace the “1-2-4” timeline. The new timeline is a “10-1-2” rule, which is described in the Role 2 Allied Command Operations (ACO) Directive 83–1 on A Role 2 MTF is a facility capable of receiving and triag- Medical Support to Operations:7 ing casualties and able to perform resuscitation and treat- • 10 minutes — enhanced first aid (immediate life saving ment of shock at a higher level than Role 1 facilities. Role measures applied by personnel trained in Tactical Com- 2 will routinely include DCS capabilities and may include bat Casualty Care (TCCC); bleeding and airway control a limited, short-term holding facility for casualties until for severely injured casualties to be achieved within evacuation can be arranged. The deployment of Role 2 10 minutes of wounding),

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• 1 hour — damage control resuscitation (DCR; resusci- Casualty management strategies tative measures initiated by emergency medical personnel within 1 hour of wounding), and Tactical Combat Casualty Care • 2 hours — DCS (depending on the specific and individ- While on expeditionary deployments, combat medical ual requirement, the aim is to be able to provide DCS technicians provide enhanced first aid within 10 minutes of within 1 hour but no later than 2 hours of wounding). injury using the paradigm of TCCC,9 which is a prehospital trauma approach designed to treat potentially prevent- Modular approach to multinational care able causes of death on the battlefield. However, TCCC acknowledges that application of these treatments may The need to have a facility capable of providing DCR within place the provider in jeopardy if performed at the wrong 1 hour of wounding and DCS within 1–2 hours of wounding time and may affect the mission. As such, TCCC has has increased the demands for advanced medical and surgical 3 goals: treat the casualty, prevent additional casualties and support to NATO missions. To mitigate potential medical complete the mission.10 To achieve these 3 goals, TCCC shortfalls, NATO has taken a multinational approach and a classifies the tactical situation with respect to health care modular approach to providing military health care along the provision into 3 phases — care under fire, tactical field care entire continuum of care, while on expeditionary operations.8 and tactical evacuation — and permits only certain inter- The purpose of the modular approach is to allow coalitions ventions to be performed during specific phases based on to pool and share national medical capabilities and create the danger to the provider and casualty. multinational treatment facilities. To ensure that this modu- During the care under fire phase, providers or casualties lar approach is workable, standardization of modular com are permitted only to apply tourniquets to exsanguinating ponents is required. extremity hemorrhages. Once into the tactical field care Seven core modules and 14 enhancing modules have phase, providers can treat acute airway obstruction with been identified. The enhancing modules can be selected either a nasopharyngeal airway or a cricothyrotomy. They from the so-called “NATO medical toolbox.” “Enhancing” can treat tension pneumothoraces with needle decompres- refers to an incremental increase in the level of care. Not all sion and treat open pneumothoraces with dressings. They modules are needed for each mission; the need for any are able to treat exsanguinating hemorrhage with tourni- particular module will depend on a risk assessment, host quets, wound packing, tranexamic acid administration, fluid nation support, climatic and epidemiological circumstances, administration and hypothermia-preventive measures. Pro- planned duration, and geographic and environmental viders can initiate treatment for penetrating eye injuries, factors. A third group of modular components, the com splint fractures and administer antibiotics and pain medica- plementary contributions, also exists. A list of common tion. Choices for the tactical evacuation phase include land modules is listed in Table 1. ambulance and rotary winged aircraft. There are data from the civilian literature to suggest that having rotary wing evacuation capability compared with only a land-based Table 1. Core, enhanced and complementary modules capability provides a survival benefit for trauma patients.11,12 Complementary Furthermore, there is literature from recent conflicts in Core modules Enhanced modules modules Iraq and Afghanistan suggesting that having physicians and Emergency department Primary surgery Oxygen production care (DCR) enhanced resuscitation capabilities on helicopters improves the chances for survival in critically injured soldiers.13–15 Initial surgery (DCS) Imaging Hyperbaric medicine Diagnostic capabilities CT scan Frozen blood products Damage control resuscitation (laboratory) Although DCR is not formally defined within NATO Patient holding (ward) Ward Animal care Postoperative care (high ICU Physiotherapy doctrine, the concept is now accepted throughout most dependency) NATO countries. Damage control resuscitation may be Command and control Laboratory Preventative medicine defined as a systematic approach to resuscitating critically Med supply Pharmacy Telemedicine injured trauma patients along the entire continuum of Dental Mortuary care; the target patients for DCR are the ones most at risk Mental health CBRN of traumatic coagulopathy and death.16 The providers who Internal medicine Subspecialist surgery start a DCR protocol are aiming to address the “lethal Isolation MRI triad” immediately upon initiating treatment of the Hospital management injured patient. Sterilization Primary care The “lethal triad” consists of hypothermia, coagulo pathy and acidosis; these 3 factors are known to be predict CBRN = chemical, biological, radiological and nuclear warfare; CT = computed tomography; DCR = damage control resuscitation; DCS = damage control surgery; ICU = ive of mortality in adult trauma victims.16 Hypothermia intensive care unit; MRI = magnetic resonance imaging. and acidosis have been shown to result in coagulopathy

Can J Surg, Vol. 58 (Issue 3 Suppl 3) June 2015 S93 REVUE and worsening shock, which further perpetuates the cycle.17 and because of the new NATO 10-1-2 timeline, there is an Damage control resuscitation attempts to address these increasing push to provide advanced DCR interventions in metabolic derangements early after injury in an effort to halt the prehospital, Role 1 and tactical evacuation settings. or ameliorate their consequences. The basic tenets of this This concept is now commonly referred to as remote approach include permissive hypotension, hemostatic resus- DCR.34 Limiting crystalloid infusion is easy to do in the citation and hemorrhage control using a DCS approach.16,18 prehospital setting. However, initiating a hemostatic resus- Efforts to prevent hypothermia and rewarm the patients are citation strategy in the prehospital setting may be chal- initiated early and maintained throughout. Damage control lenging. Even so, advocates of remote DCR point out that resuscitation may not be required for most injured patients; there is evidence to suggest that prehospital administration its greatest utility may be with the 25% of trauma patients of plasma may be beneficial.35 The logistical challenges who present with early coagulopathy and who may have a involved with deploying thawed plasma to the battlefield, mortality as high as 50%.19,20 however, have caused proponents of remote DCR to look Hypotensive resuscitation is a key tenet in DCR. In the for alternative solutions. prehospital setting, fluid administration is restricted by Freeze-dried plasma is a possible solution to the logisti- titrating its administration to a palpable radial pulse and cal challenges of providing plasma to forward deployed maintenance of the motor and verbal Glasgow Coma Scale areas. The French army has been using freeze-dried and score (in the absence of traumatic brain injury). This secured plasma (FDSP) since 1994. Plasma separated from approach is supported by 2 randomized controlled trials fresh blood is lyophilized to produce FSDP. It is compat that showed that using a restrictive prehospital fluid resus- ible with any blood type and easily rehydrated with citation strategy was associated with decreased mortality in 200 mL of water for injections in less than 3 minutes. After trauma patients presenting with shock.21,22 more than 2 years of storage at ambient temperature, the Upon arrival to an MTF, a hemostatic resuscitative fibrinogen and clotting factor levels of FDSP are equiva- approach may be adopted. This term suggests that blood lent to those of fresh frozen plasma.36–38 There is now and blood products, instead of crystalloid, may be used as increasing international interest in using freeze-dried primary resuscitation fluids to aggressively treat coagulo plasma for remote DCR,39,40 despite regulatory challenges. pathy and to prevent the development of a worsening Fibrinogen concentrate is another possible solution. dilutional coagulopathy. Borgman and colleagues23 retro Fibrinogen is the first coagulation factor to decrease dur- spectively studied all patients who received massive trans- ing trauma-induced coagulopathy, suggesting that pharma- fusions at U.S. Combat Support Hospitals and found that cological replacement might reverse coagulopathy. Cryo- patients who received a high ratio of plasma:packed red precipitate is currently used to provide fibrinogen blood cell (PRBC) transfusions had a much lower mortal- replacement for trauma patients in European trauma cen- ity (19% v. 65%). Despite methodological issues with this tres. There is increasing interest in substituting fibrinogen study, hemostatic resuscitation using 1:1:1 ratios of concentrate for cryoprecipitate in bleeding trauma plasma:platelets:PRBCs has been widely adopted, and ret- patients.41,42 Fibrinogen concentrate is supplied in a pow- rospective studies have shown tremendous potential for der that is stable and can be reconstituted easily and such an approach.24–29 A single centre pilot randomized administered in the field. The CAF is conducting a pilot controlled trial failed to show a survival benefit of this randomized controlled trial looking at fibrinogen concen- hemostatic resuscitation strategy.30 However, a larger mul- trate in trauma patients. ticentred randomized controlled trial has just been com- One last solution to the logistical challenges of doing pleted, and the results are still pending.31 remote DCR is implementing a fresh whole blood transfu- The administration of tranexamic acid (TXA) is another sion program. There are many potential benefits to this cornerstone in hemostatic resuscitation, as it also treats strategy.43 Fresh whole blood is warm, requires little logis- coagulopathy by targeting one of the underlying mech tical chain to administer in the field and contains all clot- anisms in the development of trauma associated coagulo ting factors. These advantages and challenges of imple- pathy: fibrinolysis. The landmark CRASH-2 trial random- menting a fresh whole blood transfusion protocol are ized 20 127 patients to receive TXA versus placebo. The reviewed in the article by Beckett and colleagues.43 study demonstrated a reduction in both all-cause mortality and death due to bleeding, without a significant increase in Damage control surgery vascular occlusive events.32 Tranexamic acid has also been NATO clearly defines DCS; it consists of emergency sur- shown to be effective in reducing mortality in the military gical procedures and treatment by a surgical team to setting.33 Subgroup analyses have suggested that TXA is stabilize casualties in order to save life, limb or function.6 most effective when administered within 3 hours of injury. Damage control surgery techniques are applied when the As discussed previously, DCR begins early after injury, magnitude of tissue and organ damage are such that defin- and occurs along the entire continuum of care. Because of itive surgery is likely to exceed the casualty’s physiologic potentially long evacuation times during military missions, limits. Examples of emergency DCS procedures include

S94 J can chir, Vol. 58 (No 3 Suppl 3) juin 2015 REVIEW cricothyrotomy for definitive airway control, laparotomy sues, minimize fat embolism and assist in transportation. or thoracotomy for control of exsanguinating hemor- Vascular damage control involves a truncated approach of rhage, laparotomy to control enteric spillage and tempor early and rapid revascularization, most often with an inter- ary restoration of blood flow to a limb using vascular postion shunt.56,57 Early external fixation offers the added shunts. Definitive surgery is then delayed until various advantage of providing skeletal stability to protect tem physiologic and other relevant parameters have been porary vascular shunts or definitive repairs.58,59 Extremity restored to as near normal as possible. In NATO doctrine, damage control also involves débridement of grossly con- primary surgery describes the surgery directed at repair of taminated tissues and the liberal use of fasciotomies. In a the local damage caused by wounding, rather than cor- retrospective study, Guerrero and colleagues60 found that recting the generalized effects;6 this can be equated with the incidence of limb loss was higher in patients with com- definitive surgery. The implication of distinguishing partment syndrome, confirming that early and aggressive between DCS and primary surgery (definitive surgery) is fasciotomies will significantly impact limb salvage rates. that continuity and quality of care during MEDEVAC Another study of 336 combat casualties who underwent between Role 2 and 3 MTFs is required to optimize fasciotomy found that early compartment release (before outcomes. air evacuation) was associated with better outcomes, nota- Originally, Rotondo and colleagues44 described 3 sepa- bly less necrotic muscle and a lower rate of amputation.61 rate and distinct aspects to DCS. The first phase of a DCS Following the initial damage control procedures, definitive operation involves obtaining surgical control of both hem- vascular and bony reconstruction and soft tissue coverage orrhage and contamination. During this initial operation, are performed sequentially at higher echelons of care. definitive repair of organs (e.g., bowel anastomosis) is deferred until the patient’s physiologic status is more favour- Implications on the capabilities of NATO medical able. The laparotomy is abruptly terminated and temporary modules abdominal closure is commenced. The second phase is continued DCR: rewarming, correction of coagulopathy and As future field medical forces modularize their medical maximization of hemodynamic parameters. The third phase capabilities in accordance with new NATO doctrine, par- can be instituted once normal physiology has been restored. ticipating countries will need to consider what capabilities Blackbourne45 defined “normal physiology” as temperature they might incorporate for each module. Particularly, above 36°C, base deficit greater than –5 meq/L, lactate nor- recent developments in DCR and DCS may impact how malization, urine output greater than 50 mL/h, correction the core modules of emergency department care and DCS of coagulopathy, and FiO2 less than 50%. Definitive sur (initial surgery) should be constituted. gical management of underlying injuries can then occur.45 For the emergency department care module (DCR), Recently, minimally invasive techniques have been there is the option of incorporating a remote DCR increasingly used to obtain definitive hemorrhage control capabil ity. One challenge with this would be the logistical in specific circumstances. Pelvic bleeding after blunt trauma challenge associated with conducting hemostatic resuscita- has traditionally been difficult to control surgically. tion in an austere environment where thawed blood pro Although recent reports have documented success with pre- ducts may not be available. Options available to NATO peritoneal packing of pelvic bleeding,46,47 angiographic countries include freeze-dried plasma, fibrinogen concen- embolization of pelvic bleeding has become a mainstay for trate, or a fresh whole blood transfusion capability. If a definitive control of massive pelvic bleeding48–50 after blunt country does not have a dedicated search and rescue trauma. This technique of angiographic embolization of capability, it may also consider investing in a dedicated pelvic bleeding currently requires fluoroscopy. However, combat search and rescue capability. If this capability is newer techniques are now being developed where intra- desired, each country has to consider what level of pro- aortic balloon occlusion is being used to obtain temporary vider will provide in-transit resuscitation for this combat hemorrhage control of intra-abdominal and pelvic bleeding search and rescue capability: medical technician, physician without the need of fluoroscopy.51–54 A recent analysis has assistant or physician providers. even suggested that this technique of resuscitative endovas- Hemorrhage control is the indispensable aspect of DCS. cular balloon occlusion of the aorta (REBOA) could have Considerations should include innovative methods for hem- potentially prevented a substantial number of UK combat orrhage control within the DCS module. Angiographic deaths if it had been available.55 Because REBOA does not embolization of pelvic bleeders is such a modality and require fluoroscopy, it has the potential of being deployed requires fluoroscopy. A decision to include this capability far forward as part of a remote DCR capability. within the DCS module would also need to take into con- Damage control surgical techniques are now also being sideration the considerable logistical challenges associated applied to extremity injuries. Orthopedic DCS consists of with transporting, maintaining and running a fluoroscopic early temporary stabilization of fractures (rapid splinting or capability. This decision may be helped by deciding whether external fixation) to minimize blood loss, protect soft tis- or not damage control orthopedic surgery capabilities will

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care in the Canadian Forces: lessons learned from the Afghan war. be included in the module. If damage control orthopedic Can J Surg 2011;54:S118-23. surgery is included, it still is possible that fluoroscopy is not 10. Butler F. Tactical combat casualty care: combining good medicine required; damage control orthopedics may just include plas- with good tactics. J Trauma 2003;54(Suppl):S2-3. ter splinting of fractures or application of temporary exter- 11. Galvagno SM. Jr1, Haut ER, Zafar SN, et al. Association between nal fixators without fluoroscopy. However, the deployment helicopter vs ground emergency medical services and survival for adults with major trauma. JAMA 2012;307:1602-10. of fluoroscopic capability with the DCS module may be use- 12. Baxt WG, Moody P. The impact of a rotorcraft aeromedical emer- ful both for hemorrhage control and for damage control gency care service on trauma mortality. JAMA 1983;249:3047-51. orthopedic surgery and so should remain a consideration. 13. Morrison JJ, DuBose JJ, O’Reilly DJ, et al. En-route care capability In addition, REBOA is a new, innovative procedure that from point of injury impacts mortality after severe wartime injury. NATO countries may wish to deploy with their DCS Ann Surg 2013;257:330-4. 14. Apodaca A. Olson CM Jr, Bailey J, et al. Performance improvement modules. However, countries may also consider deploying evaluation of forward aeromedical evacuation platforms in Operation a REBOA capability with its emergency department care Enduring Freedom. J Trauma Acute Care Surg 2013;75(Suppl module instead. If adopted, REBOA could be deployed as 2):S157-63. part of a remote DCR capability at a Role 1 facility or dur- 15. Mabry RL, Apodaca A, Penrod J, et al. Impact of critical care-trained ing tactical evacuation on a rotary wing platform. flight paramedics on casualty survival during helicopter evacuation in the current war in Afghanistan. J Trauma Acute Care Surg 2012;73(Suppl 1):S32-7. Conclusion 16. Jansen JO, Thomas R, Loudon MA, et al. Damage control resuscitation for patients with major trauma. BMJ 2009;338:b1778 New developments in DCR and DCS may have an impact 17. Hess JR, Brohi K, Dutton RP, et al. The coagulopathy of trauma: a on how NATO countries develop their core and enhanced review of mechanisms. J Trauma 2008;65:748-54. 18. Holcomb JB, Jenkins D, Rhee P, et al. Damage control resuscitation: modules for medical treatment facilities. Canada will con- directly addressing the early coagulopathy of trauma. J Trauma 2007; tinue to collaborate with NATO and other allied nations to 62:307-10. further develop the knowledge and concepts to enable and 19. Brohi K, Singh J, Heron M, et al. Acute traumatic coagulopathy. enhance the provision of high-quality combat casualty care. J Trauma 2003;54:1127-30. 20. Niles SE, McLaughlin DF, Perkins JG, et al. Increased mortality Affiliations: From Sunnybrook Health Sciences Centre, Toronto, Ont. associated with the early coagulopathy of trauma in combat casualties. (Tien, Pannell, Alabbasi); McGill University, Montréal, Que. (Beckett, J Trauma 2008;64:1459-63. Talbot); 1 Canadian Field Hospital, Petawawa, Ont. (Tien, Beckett, Garraway, Talbot, Pannell). 21. Bickell WH, Wall M, Pepe P, et al. Immediate versus delayed fluid resuscitation for hypotensive patients with penetrating torso injury. Competing interests: None declared. N Engl J Med 1994;331:1105-9. Contributors: H. Tien, A. Beckett, M. Talbot, D. Pannell and T. Alabbasi 22. Morrison CA, Carrick MM, Norman MA, et al. Hypotensive resuscita- designed the study. T. Alabbasi acquired and analyzed the data, which tion strategy reduces transfusion requirements and severe postoperative N. Garraway also analyzed. H. Tien, A. Beckett, D. Pannell and T. Alabbasi coagulopathy in trauma patients with hemorrhagic shock: preliminary wrote the article, which all authors reviewed and approved for publication. results of a randomized controlled trial. J Trauma 2011;70:652-63. 23. Borgman MA, Spinella PC, Perkins JG, et al. The ratio of blood References products transfused affects mortality in patients receiving massive transfusions at a combat support hospital. J Trauma 2007;63:805-13. 1. Government of Canada. National Defence and the Canadian Armed 24. Zink KA, Sambasivan CN, Holcomb JB, et al. A high ratio of plasma Forces. “About the Canadian Armed Forces.” Available: www.forces and platelets to packed red blood cells in the first 6 hours of massive .gc.ca/en/about/canadian-armed-forces.page (accessed 2014 Oct. 28). transfusion improves outcomes in a large multicenter study. Am J . 2 Government of Canada. National Defence and the Canadian Armed Surg 2009;197:565-70. Forces. “Caring for Our Own.” Available: www.forces.gc.ca/en/about 25. Cotton BA, Gunter OL, Isbell J, et al. Damage control hematology: -reports-pubs-health/caring-for-our-own.page (accessed 2014 Oct. 28). the impact of a trauma exsanguination protocol on survival and blood . 3 Robb DJ. NATO smart defence. 2013 Available: http://amops.org product utilization. J Trauma 2008;64:1177-82. /wp-content/uploads/2013/05/AMOPSRobbNATO.pdf (accessed 26. Hess JR, Holcomb JB, Hoyt DB. Damage control resuscitation: the 2014 Oct. 28). need for specific blood products to treat the coagulopathy of trauma. 4. Brisebois R, Hennecke P, Kao R, et al.; Canadian Forces Health Ser- Transfusion 2006;46:685-6. vices Research Consortium. The Role 3 multinational medical unit at 27. Holcomb JB, Jenkins D, Rhee P, et al. Damage control resuscitation: Kandahar Airfield 2005-2010.Can J Surg 2011;54:S124-9. directly addressing the early coagulopathy of trauma. J Trauma 2007; . 5 Government of Canada. National Defence and the Canadian Armed 62:307-10. Forces. “The Canada-U.S. Defence Relationship.” Available: www 28. Cotton BA, Reddy N, Hatch QM, et al. Damage control resuscita- .forces.gc.ca/en/news/article.page?doc=the-canada-u-s-defence tion is associated with a reduction in resuscitation volumes and -relationship/hob7hd8s (accessed 2015 May 1). improvement in survival in 390 damage control laparotomy patients. 6. North Atlantic Treaty Organization. Allied Joint Publication 4-10(A) Ann Surg 2011;254:598-605. Allied Joint Medical Doctrine; 2011. 29. Duchesne JC, Heaney J, Guidry C, et al. Diluting the benefits of . 7 North Atlantic Treaty Organization. Allied Command Operations hemostatic resuscitation: a multi-institutional analysis. J Trauma (ACO) Directive 83–1 on Medical Support to Operations; 2009. Acute Care Surg 2013;75:76-82. . 8 Allied Command Transformation. Conceptual basis for a modular 30. Nascimento B, Callum J, Tien H, et al. Effect of a fixed-ratio (1:1:1) approach to medical support capability. Enclosure to IMSM-0289- transfusion protocol versus laboratory-results-guided transfusion in 2012; 2012 Jul. 18. patients with severe trauma: a randomized feasibility trial. CMAJ . 9 Savage E, Forestier C, Withers N, et al. Tactical combat casualty 2013;185:E583-9.

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31. Baraniuk S, Tilley BC, del Junco DJ, et al.; PROPPR Study Group. 47. Beckett A, Tien H. What’s new in operative trauma surgery in the Pragmatic Randomized Optimal Platelet and Plasma Ratios last 10 years. Curr Opin Crit Care 2013;19:599-604. (PROPPR) trial: design, rationale and implementation. Injury 2014; 48. Schwartz DA, Medina M, Cotton BA, et al. Are we delivering two 45:1287-95. standards of care for pelvic trauma? Availability of angioembolization 32. CRASH-2 trial collaborators, Shakur H, Roberts I, et al. Effects of after hours and on weekends increases time to therapeutic interven- tranexamic acid on death, vascular occlusive events, and blood trans- tion. J Trauma Acute Care Surg 2014;76:134-9. fusion in trauma patients with significant haemorrhage (CRASH-2): 49. Metsemakers WJ, Vanderschot P, Jennes E, et al. Transcatheter a randomised, placebo-controlled trial. Lancet 2010;376:23-32. embolotherapy after external surgical stabilization is a valuable treat- 33. Morrison JJ, Dubose JJ, Rasmussen TE, et al. Military application of ment algorithm for patients with persistent haemorrhage from unsta- tranexemic acid in trauma emergency resuscitation (MATTERs) ble pelvic fractures: outcomes of a single centre experience. Injury study. Arch Surg 2012;147:113-9. 2013;44:964-8. 34. Gerhardt RT, Strandenes G, Cap AP, et al. PC; THOR Network 50. Velmahos GC, Chahwan S, Hanks SE, et al. Angiographic emboliza- and RemTORN Study Groups. Remote damage control resuscitation of bilateral internal iliac arteries to control life-threatening hem- tion and the Solstrand Conference: defining the need, the language, orrhage after blunt trauma to the pelvis. Am Surg 2000;66:858-62. and a way forward. Transfusion 2013;53(Suppl 1):9S-16S. 51. Scott DJ, Eliason JL, Villamaria C, et al. A novel fluoroscopy-free, 35. Kim BD, Zielinski MD, Jenkins DH, et al. The effects of prehospital resuscitative endovascular aortic balloon occlusion system in a plasma on patients with injury: a prehospital plasma resuscitation. J model of hemorrhagic shock. J Trauma Acute Care Surg 2013; Trauma Acute Care Surg 2012;73(Suppl 1):S49-53. 75:122-8. 36. Daban JL, Clapson P, Ausset S, et al. Freeze dried plasma: a French 52. Morrison JJ, Lendrum RA, Jansen JO. Resuscitative endovascular army specialty. Crit Care 2010;14:412. balloon occlusion of the aorta (REBOA): A bridge to definitive 37. Sailliol A, Martinaud C, Cap AP, et al. The evolving role of lyophil haemorrhage control for trauma patients in Scotland? Surgeon 2014; ized plasma in remote damage control resuscitation in the French 12:119-20. Armed Forces Health Service. Transfusion 2013;53(Suppl 1):65S-71S. 53. Brenner ML, Moore LJ, DuBose JJ, et al. A clinical series of resusci- 38. Martinaud C, Ausset S, Deshayes AV, et al. Use of freeze-dried tative endovascular balloon occlusion of the aorta for hemorrhage plasma in French intensive care unit in Afghanistan. J Trauma 2011; control and resuscitation. J Trauma Acute Care Surg 2013;75:506-11. 71:1761-4. 54. Morrison JJ, Percival TJ, Markov NP, et al. Aortic balloon occlusion 39. Glassberg E, Nadler R, Gendler S, et al. Freeze-dried plasma at the is effective in controlling pelvic hemorrhage. J Surg Res 2012; point of injury: from concept to doctrine. Shock 2013;40:444-50. 177:341-7. 40. Glassberg E, Nadler R, Rasmussen TE, et al. Point-of-injury use of 55. Morrison JJ, Ross JD, Rasmussen TE, et al. Resuscitative endovascu- reconstituted freeze dried plasma as a resuscitative fluid: a special lar balloon occlusion of the aorta: a gap analysis of severely injured report for prehospital trauma care. J Trauma Acute Care Surg 2013; UK combat casualties. Shock 2014;41:388-93. 75(Suppl 2):S111-4. 56. Taller J, Kamdar JP, Greene JA, et al. Temporary vascular shunts as 41. Meyer MA, Ostrowski SR, Windeløv NA, et al. Fibrinogen concen- initial treatment of proximal extremity vascular injuries during com- trates for bleeding trauma patients: What is the evidence? bat operations: the new standard of care at Echelon II facilities? J I2011;101:185-90. Trauma 2008;65:595-603. 42. Aubron C, Reade MC, Fraser JF, et al. Efficacy and safety of fibrinogen 57. Fox CJ, Gillespie DL, Cox ED, et al. Damage control resuscitation concentrate in trauma patients — a systematic review. J Crit Care for vascular surgery in a combat support hospital. J Trauma 2008; 2014;29:471.e11-7. 65:1-9. 43. Beckett A, Callum J, da Luz LT, et al. Fresh whole blood transfusion 58. Mathieu L. Bazile F, Barthélémy R, et al. Damage control orthopae- capability for Special Operations Forces. Can J Surg 2015;58(3 Suppl dics in the context of battlefield injuries: the use of temporary external 3):S153-6. fixation on combat trauma soldiers. Orthop Traumatol Surg Res 44. Rotondo MF, Schwab CW, McGonigal MD, et al. “Damage control”: 2011;97:852-9. an approach for improved survival in exsanguinating penetrating 59. Andersen RC, Ursua VA, Valosen JM, et al. Damage control ortho- abdominal injury. J Trauma 1993;35:375-82. paedics: an in-theater perspective. J Surg Orthop Adv 2010;19:13-7. 45. Blackbourne LH. Combat damage control surgery. Crit Care Med 60. Guerrero A, Gibson K, Kralovich KA, et al. Limb loss following 2008; 36(Suppl.): S304-S310. lower extremity arterial trauma: What can be done proactively? 46. Burlew CC, Moore EE, Smith WR, et al. Preperitoneal pelvic packing/ Injury 2002;33:765-9. external fixation with secondary angioembolization: optimal care for 61. Ritenour AE, Dorlac WC, Fang R, et al. Complications after fasciot- life-threatening hemorrhage from unstable pelvic fractures. J Am Coll omy revision and delayed compartment release in combat patients. J Surg 2011;212:628-35. Trauma 2008;64:S153-61.

Can J Surg, Vol. 58 (Issue 3 Suppl 3) June 2015 S97 RESEARCH • RECHERCHE

Medical mentorship in Afghanistan: How are military mentors perceived by Afghan health care providers?

Maj Andrew Beckett, MD Background: Previous work has been published on the experiences of high-resource Robert Fowler, MD setting physicians mentoring in low-resource environments. However, not much is known about what mentees think about their First World mentors. We had the Neill K.J. Adhikari, MD opportunity to explore this question in an Afghan Army Hospital, and we believe this Laura Hawryluck, MD is the first time this has been studied. Tarek Razek, MD Methods: We conducted a pilot cross-sectional survey of Afghan health care provid- Col Homer Tien, MD, MSc ers evaluating their Canadian mentors. We created a culturally appropriate 19-question survey with 5-point Likert scores that was then translated into the local Afghan language. The survey questions were based on domains of Royal College of Accepted for publication Physicians and Surgeons of Canada’s CanMEDS criteria. Oct. 16, 2014 Results: The survey response rate was 90% (36 of 40). The respondents included Correspondence to: 13 physicians, 21 nurses and 2 other health care professionals. Overall, most of the A. Beckett Afghan health care workers felt that working with mentors from high-resource set- 1 Canadian Field Hospital tings was a positive experience (median 4.0, interquartile range [IQR] 4–4), according Petawawa ON K8H 2X3 to CanMEDS domains. However, respondents indicated that the mentors were reli- [email protected] ant on medical technology for diagnosis (median 5.0, IQR 4–5) and failed to consider the limited resources available in Afghanistan. DOI: 10.1503/cjs.012214 Conclusion: The overall impression of Afghan health care providers was that mentors are appropriate and helpful. CanMEDS can be used as a framework to evaluate mentors in low-resource conflict environments.

Contexte : Des travaux ont déjà été publiés sur l’expérience des médecins de milieux favorisés en ressources qui font du mentorat dans des milieux défavorisés en ressources. Toutefois, on en sait relativement peu sur ce que pensent les pupilles de leurs mentors des pays industrialisés. Nous avons eu l’occasion d’explorer cette question dans un hôpital militaire afghan et nous croyons qu’il s’agit de la première fois que ce sujet est étudié. Méthodes : Nous avons réalisé un sondage pilote transversal auprès des professionnels de la santé afghans pour qu’ils évaluent leurs mentors canadiens. Nous avons créé un sondage culturellement approprié comportant 19 questions assorties d’échelles de Likert à 5 points, qui a ensuite été traduit en langue afghane locale. Les questions du sondage s’inspiraient des domaines des critères CanMEDS du Collège royal des médecins et chirurgiens du Canada. Résultats : Le taux de réponse au sondage a été de 90 % (36 sur 40). Les répondants étaient : 13 médecins, 21 infirmières et 2 autres professionnels de la santé. Dans l’ensemble, la plupart des professionnels de la santé afghans ont estimé que de tra- vailler avec des mentors provenant d’un milieu favorisé en ressources a été une expéri- ence positive (médiane 4,0; intervalle interquartile [IIQ] 4–4), selon les domaines CanMEDS. Les répondants ont toutefois indiqué que les mentors se fiaient à la tech- nologie médicale pour le diagnostic (médiane 5,0; IIQ 4–5) et négligeaient de tenir compte des ressources limitées accessibles en Afghanistan. Conclusion : L’impression globale des professionnels de la santé afghans a été que les mentors sont qualifiés et utiles. Les critères CanMEDS peuvent être utilisés comme cadre pour évaluer les mentors dans des zones de conflit où les ressources sont limitées.

revious work has been conducted on the experiences western Afghanistan. It was a 50-bed permanent hospital of high-resource setting medical and surgical men- and was expanding to 100 beds at the time the study was tors’ impressions of teaching in resource-poor conducted from Nov. 15 to Dec. 24, 2011. The hospital P 1,2 environments. Mentors’ perceptions, attitudes and actions included medical and surgical wards, 2 operating rooms, an in modelling professionalism and improving the quality of emergency department with outpatient clinics and dental patient care are important to the success of such structured services, and basic laboratory and radiology facilities. The mentorship programs,3,4 despite the difficulty in applying hospital mostly served Afghan National Army (ANA) sol- metrics to the concept of mentorship.5 However, mentoring diers, other members of the Afghan security forces and successfully in the immediate aftermath of a conflict situa- their dependents. tion poses additional challenges that have infrequently been described.16,7 Such mentorship could be an important com- Canadian Forces Health Services mentors ponent of rebuilding and stabilizing health care infrastructure in several countries, including Afghanistan.8 Members of the Canadian Forces Health Services (CFHS) In addition, there is a paucity of literature on how the mentorship team were trained before deployment using a recipients of such endeavours perceive such interactions modified CanMEDS model to give a Canadian values-based and their objectives. The importance of understanding model of health care professionalism and expertise to perceptions of Afghan trainees is not only to conduct more Afghan trainees. Training included cultural sensitivity train- effective training but also to avoid incidents where cultural ing, “train the trainer” instruction and a guide to Can- and personal differences may lead to resentment and even MEDS mentorship. The 3-day training program was violence against mentors.9,10 developed by Canadian Forces physicians and educational From 2011 to 2012, personnel from 1 Canadian Field content experts in consultation with global health educators. Hospital, Petawawa, Ont., were tasked with mentoring Canadian mentors had the largest representation on a health care providers in Mazar-e-Sharif and Kabul, Afghan United States–led NATO mentoring team. istan. This mentorship program for practising surgeons and physicians was the first mission of its kind for the Canadian Study survey military and presented a unique opportunity to explore mentees’ perceptions of optimal medical and surgical mentorship We developed a 19-question self-administered survey in a conflict environment.11 The program was designed to (Appendix 1) in consultation with native Afghan speakers include mentoring of the 7 roles that make up the Royal Col- and had it translated into the local official Afghan language lege of Physicians and Surgeons of Canada’s (RCPSC) Can- of Dari (Afghan Language Services, Toronto, Ont.). We MEDs framework: medical expert, communicator, collab carefully reviewed each question to ensure its validity and orator, manager, health advocate, scholar and professional. effectiveness when translated into Dari. The survey ques- The framework is based on empirical research, educational tions were back-translated using official local interpreters. design techniques and RCPSC consensus decisions.12 The back-translated questions matched the original English The primary objectives of the present study were to deter- questions. Pilot testing was not conducted. In addition, we mine how practising Afghan surgical and medical mentees adopted a prior survey technique without full steps of survey perceive mentors from Canada as members of a North Atlan- development methodology undertaken.13 This was done tic Treaty Organization (NATO) training mission in Afghan because of a limited time frame and because it was unknown istan, using a pilot self-administered, cross-sectional survey. A how many Afghan mentees would be present when the secondary objective was to improve predeployment training mentorship team arrived. This survey tool was not previ- for future Canadian mentorship teams in Afghanistan. ously validated, as no similar survey tool existed at the time The physician mentoring team consisted of a general and of deployment of the mentorship team. an orthopedic surgeon, an anesthesiologist, an internist and Question stems were based on domains of the RCPSC’s a family doctor. All specialists had served in combat and CanMEDS physician development program.12 Response low-resource areas before, and all were employed in aca- frames used a 5-point Likert scale (1 = very inappropriate/ demic centres before the study. Other members of the team strongly disagree, 2 = inappropriate/ disagree, 3 = included nurses, a pharmacist, a dentist and a laboratory and appropriate/neutral, 4 = good/agree, and 5 = very good/ diagnostic imaging technician. strongly agree). Designers of the study agreed to final question stems based on consensus. Methods Study participants Research setting We administered the survey among 40 Afghan army phys Afghan National Army Region Military Hospital North icians, nurses and other Afghan health care mentees work- (RMH-N) is located in the city of Mazar-e-Sharif in north- ing at RMH-N. Areas of the hospital covered in this survey

Can J Surg, Vol. 58 (Issue 3 Suppl 3) June 2015 S99 RECHERCHE were general surgery, orthopedic surgery, anesthesia, medians and interquartile ranges (IQR). No sample size cal- internal medicine, radiology, laboratory, emergency medi- culation was performed, as the number of potential respond cine and intensive care. Participation was voluntary, and all ents was not known before commencement of the study. responses were anonymous and confidential. Translators explained the purpose of the study and distributed it to Results potential participants. The participants were able to ask one of us (A.B.) questions of clarification before complet- Our survey response rate was 36 of 40 (90%); we received ing the survey. Completed surveys and the related database completed surveys from 13 physicians, 21 nurses and 2 other were stored in a secure, locked facility. The database was health care professionals. All respondents were men. stored on a password-protected computer. Respondents generally reported the experience of working with NATO medical advisors as positive (Tables 1–3). For Study approval the CanMEDS roles of medical expert and scholar, most respondents agreed that the training and advice offered by The research ethics board at the Canadian Defence NATO medical advisors was appropriate in the 6 items Research Development Centre in Toronto, Ont., the composing the medical expert role (mean rating 4.41). NATO Medical Training Advisory Group in Mazar-e- However, respondents indicated that NATO advisors Sharif and the ANA Commanding Officer of RMH-N relied too heavily on advanced medical technology for diag- approved the study. nosis (median 5.0, IQR 4–5), failing to consider the limited resources available in an Afghanistan clinical setting. For the Statistical analysis professional and communicator roles (Table 2), NATO advisors were perceived to be good partners in training and All quantitative analyses were performed using Microsoft in cross-cultural communication (mean score 4.46). For the Excel 2007. Descriptive data are presented using means, roles of collaborator, manager and health advocate, the

Table 1. Royal College of Physicians and Surgeons of Canada medical expert and scholar domains of Canadian military mentors assessed by Afghan health care trainees using a 5-point Likert score survey

Question Likert question stem 5-point Likert scale Mean (range) Median (IQR) 1 NATO physician mentors provide adequate training in clinical knowledge for 4.47 (1–5) 5.0 (4–5) Afghan physician trainees. 2 NATO physician mentors provide adequate training in clinical skills 4.41 (1–5) 4.0 (4–5) (procedures/operations) to Afghan physician trainees. 3 NATO physician mentors give appropriate feedback for you to improve your 4.73 (2–5) 4.5 (4–5) skills. 4 NATO physician mentors give sufficient supervision. 4.44 (2–5) 4.5 (4–5) 5 The quality of training provided by NATO physician members is adequate. 4.52 (2–5) 4.0 (4–5) 6 NATO physician mentors are reliant on diagnostic imaging and laboratory 4.50 (3–5) 5.0 (4–5) equipment.

IQR = interquartile range; NATO = North Atlantic Treaty Organization. Overall mean: 4.51 (n = 36).

Table 2. Royal College of Physicans and Surgeons of Canada professional and communicator domains of Canadian military mentors assessed by Afghan health care mentees using a 5-point Likert score survey

Question Likert question stem 5-point Likert scale Mean (range) Median (IQR) 1 NATO physician mentors set a good example for Afghan 4.47 (2–5) 5.0 (4–5) physician trainees. 2 NATO physician mentors are culturally sensitive to the needs of 4.47 (3–5) 5.0 (4–5) Afghan physician trainees. 3 The concern NATO physician mentors have for Afghan patients 4.47 (3–5) 4.0 (4–5) is appropriate. 4 NATO physician mentors are patient enough with Afghan 4.64 (2–5) 5.0 (4–5) physician trainees. 5 NATO physician mentors are approachable with regards to 4.44 (2–5) 5.0 (4–5) clinical matters and training issues. 6 NATO physician mentors are available for training of Afghan 4.52 (2–5) 5.0 (4–5) trainees.

IQR = interquartile range; NATO = North Atlantic Treaty Organization. Overall mean: 4.52 (n = 36).

S100 J can chir, Vol. 58 (No 3 Suppl 3) juin 2015 RESEARCH scores were slightly lower (mean score 4.04; Table 3). Most mentors.5 This is particularly important when repercus- respondents perceived their experience as having met their sions in the setting of conflict may include the threat of expectations (median 4.0, IQR 4–4). The overall score for physical or financial harm to participants or their fam their experience with NATO advisors was somewhat lower ilies and where there is no prior experience with (mean 3.97) than the scores in individual areas. research. However, research in these areas is still para- mount to improve care.7 Discussion Other surveys and needs assessments have been done in Afghanistan, demonstrating a willingness among health We found that ANA health care workers reported that care providers and consumers to participate. One survey the experience of NATO mentoring was beneficial was administered among Afghan consumers of health overall; however, respondents perceived that NATO care facilities and involved a novel visual analogue scale, advisors were heavily reliant on advanced medical tech- as many consumers were illiterate.14 Another one was a nology and had some difficulty adapting to realities of needs assessment on maternal health care needs.15 the limited resources available to Afghan military phys A survey of civilian surgical and trauma care services in icians. These findings were considered when training Afghanistan16 revealed a system that has many deficits to subsequent mentorship teams; training included greater providing adequate care to surgical and trauma patients. emphasis on the use of clinical examinations and avoid- The study reported that of the 17 surveyed Afghan ance of overusing diagnostic laboratory and radio- Health Care facilities only 5 (29.4%) had 24-hour sur graphic modalities. gical coverage, only 11 (64.7%) had certified surgeons, The RCPSC CanMEDS roles were easily under- and only 5 (29.4%) had certified anesthetists. Life-saving stood by Afghan respondents, revealing the cross- procedures are rarely available in peripheral hospitals cultural versatility of the program and their utility in a outside Kabul. Only 59% of facilities had functioning limited-resource setting. In all 7 domains of CanMEDs, anesthesia equipment, and one-third did not have a blood NATO mentors were evaluated as appropriate, compe- bank. Only 12 (70.6%) facilities had the capability to tent and helpful. position a chest tube, and only 8 (47%) had the capability This study is important because, to our knowledge, it to perform cricothyroidotomy and remove a foreign body reports the first survey of the perceptions of health care from the throat.16 workers from a low-resource setting in combat regard- Little previous work has focused on surgical and med- ing a health care mentorship program from high- ical training in Afghanistan. A recent, small study on the resource setting physicians. However, conducting sur- feasibility of laparoscopic cholecystectomy highlighted veys in regions that have been destabilized by conflict the difficulty and potential hazards of introducing sur and civil strife is difficult.7 Issues of trust, especially with gical techniques and training to Afghanistan; the study respect to confidentiality and anonymity of respondents, reported a high number of bile duct injuries and other are important. These issues are compounded by the dif- complications.17 In another small study, mentorship by ficulties of evaluating the process of mentorship, where NATO countries in an ANA intensive care unit was there can be role confusion between supervisors and shown to improve in-hospital mortality.6 The CFHS, as

Table 3. Royal College of Physicans and Surgeons of Canada collaborator, manager and advocate domains of Canadian military mentors assessed by Afghani health care trainees using a 5-point Likert score survey

Question Likert question stem 5-point Likert scale Mean (range) Median (IQR) 1 NATO physicians stay will stay long enough in Mazar e Sharif to allow for 4.50 (3–5) 5.0 (4–5) proper training of Afghan physician trainees. 2 NATO physician mentors have already prepared Afghan Army Physicians 4.52 (2–5) 4.5 (4–5) in Mazar e Sharif to establish a self sustaining Afghan Military Hospital. 3 NATO physician mentors provide clinical guidance that is appropriate to 4.38 (3–5) 4.0 (4–5) the local situation in Mazar e Sharif. 4 My opinion toward NATO physician mentors has changed since working 3.9 (1–5) 4.0 (4–4) with them. 5 Working with NATO physician mentors is what I expected. 4.05 (3–5) 4.0 (4–4) 6 The attitude of NATO physician mentors toward Afghan physician trainees 4.11 (2–5) 4.0 (4–4) is appropriate. 7 My overall experience with NATO physician mentors was good. 3.97 (2–5) 4.0 (4–4)

IQR = interquartile range; NATO = North Atlantic Treaty Organization. Overall mean: 4.2 (n = 36).

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References part of NATO, has had previous experience in training Afghan military health care providers in Kandahar prov- 1. Hubner ME, Ditzler TF. Humanitarian military medical mission in a ince. It was noted that providing an appropriate curricu- postconflict environment: lessons from Cambodia. Public Health lum to Afghan trainees in 2007 necessitated an increased 2004;118:421-5. emphasis on the basic principles of medical education, 2. Fricchione GL, Borba CP, Alem A, et al. Capacity building in global including anatomy and physiology.18 mental health: professional training. Harv Rev Psychiatry 2012;20:47-57. 3. Paice E, Heard S, Moss F. How important are role models in making Limitations good doctors? BMJ 2002;325:707-10. 4. Walker WOKP, Hume R. Mentoring for the New Millenium. Med Conducting this type of survey in a region of conflict has Educ Online 2002;7. the potential for multiple biases, including respondents 5. Taherian K, Shekarchian M. Mentoring for doctors. Do its benefits not wanting to criticize NATO advisors for unfounded outweigh its disadvantages? Med Teach 2008;30:e95-9. fears of repercussions. Many of the participants had 6. Lin AH, Glover DE, Myers JS Jr. An overview of Afghan National never seen or completed a survey previously. In addition, Army critical care capabilities. Mil Med 2011;176:1003-6. as we did not pilot the study question stems, it is possible 7. Ford N, Mills EJ, Zachariah R, et al. Ethics of conducting research that there were problems with the way these questions in conflict settings.Confl Health2009;3:7. were framed and that respondents were not reading the 8. Kerry VB, Auld S, Farmer P. An international service corps for survey correctly. Finally, we had an incomplete response health–an unconventional prescription for diplomacy. N Engl J Med 2010;363:1199-201. rate, and all respondents were men. As this was a unique environment, the generalizability of our results to other 9. Bergen P. Shootings by Afghan forces take growing toll on NATO troops. CNN 2012 Aug. 13. Available: www.cnn.com/2012/08/13 environments is uncertain. /opinion/bergen-green-on-blue/ (accessed 2015 Apr. 20). 10. Roggio B, Lundquist L. Green-on-blue attacks in Afghanistan: the Conclusion data. The Long War Journal 2012. Available: www.longwarjournal.org /archives/2012/08/green-on-blue_attack.php (accessed 2015 Apr. 20). To our knowledge, this is the first report of using the 11. Tien H. The Canadian Forces trauma care system. Can J Surg RCPSC CanMEDs framework to evaluate the perform 2011;54:S112-117. ance of medical and surgical advisors in a region of con- 12. Frank J, Jabbour, M. Report of the CanMEDS Phase IV Working flict. Our work demonstrates that surveys can be admin Groups. Ottawa: The Royal College of Physicians and Surgeons of istered and completed in a conflict environment, as we Canada; 2005. obtained a high response rate of 90%. The overall 13. Burns KE, Duffett M, Kho ME, et al. A guide for the design and impression of ANA health care providers was that NATO conduct of self-administered surveys of clinicians. CMAJ 2008;179: advisors are appropriate and helpful. This collaboration 245-252. shows that NATO mentors using CanMEDS mentoring 14. Hansen PM, Peters DH, Viswanathan K, et al. Client perceptions of techniques in this setting is effective. the quality of primary care services in Afghanistan. Int J Qual Health Care 2008;20:384-91. Acknowledgments: The authors are grateful to all those who helped with the distribution and collection of the surveys. 15. Khorrami H, Karzai F, Macri CJ, et al. Maternal healthcare needs assessment survey at Rabia Balkhi Hospital in Kabul, Afghanistan. Int Affiliations: From the 1 Canadian Field Hospital, Petawawa, Ont. J Gynaecol Obstet 2008;101:259-63. (Beckett, Tien); Trauma Program, McGill University Health Centre, Montréal, Que. (Beckett, Hawryluck, Razek); Critical Care Medicine, 16. Contini S, Taqdeer A, Cherian M, et al. Emergency and essential University of Toronto, Toronto, Ont. (Fowler, Adhikari); and Sunny- surgical services in Afghanistan: still a missing challenge. World J brook Health Sciences Centre, Toronto, Ont. (Fowler, Adhikari, Tien). Surg 2010;34:473-9. Competing interests: None declared. 17. Manning RGAA. Should laparoscopic cholecystectomy be practiced in the developing world: the experience of the first training program Contributors: A. Beckett, N. Adhikari and H. Tien designed the study. in Afghanistan. Ann Surg 2009;249:794-8. A. Beckett acquired the data, which all authors analyzed. A. Beckett, L. Hawryluck and H. Tien wrote the article, which all authors reviewed 18. Saguil A, McCormack MT. Preparing for Afghanistan’s medical and approved for publication. future. CMAJ 2008;178:990.

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Appendix 1: survey questionnaire for Afghan physician trainees on how First World surgical mentors are perceived by surgical trainees in Afghanistan, a low-income country

Indicate your judgment for each of the scales below by circling the number that you feel best characterizes your judgment Strongly disagree Disagree Neutral Good/agree Strongly agree A NATO physician mentors provide adequate training in clinical 1 2 3 4 5 knowledge for Afghan physician trainees B NATO physician mentors provide adequate training in clinical skills 1 2 3 4 5 (procedures/operations) to Afghan physician trainees C NATO physician mentors are culturally sensitive to the needs of 1 2 3 4 5 Afghan physician trainees D NATO physician mentors set a good example for Afghan physician 1 2 3 4 5 trainees E NATO physician mentors give appropriate feedback for you to improve 1 2 3 4 5 your skills F NATO physician mentors give sufficient suggestions 1 2 3 4 5 G NATO physician mentors provide clinical guidance that is appropriate to 1 2 3 4 5 the local situation in Mazar-e-Sharif H NATO physician mentors are reliant on dignostic imaging and 1 2 3 4 5 laboratory equipment I NATO physician mentors are available for training of Afghan trainees 1 2 3 4 5 J NATO physician mentors are approachable with regards to clinical 1 2 3 4 5 matters and training issues K The quality of training provided by NATO physician members is 1 2 3 4 5 adequate L The concern NATO physician mentors have for Afghan patients is 1 2 3 4 5 appropriate M NATO physicians stay long enough in Mazar-e-Sharif to allow for 1 2 3 4 5 proper training of Afghan physician trainees N NATO physician mentors have already prepared Afghan Army 1 2 3 4 5 physicians in Mazar-e-Sharif to establish a self-sustaining Afghan Military Hospital O NATO physician mentors are patient enough with Afghan physician 1 2 3 4 5 trainees P The attitude of NATO physician mentors toward Afghan physician 1 2 3 4 5 trainees is appropriate R My opinion toward NATO physician mentors has changed since 1 2 3 4 5 working with them S Working with NATO physician mentors is what I expected 1 2 3 4 5 T My overall experience with NATO physician mentors was good 1 2 3 4 5

This survey was translated in Afghan languages (Pashto and Dari). NATO = North Atlantic Treaty Organization.

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Cervical spine injury in dismounted improvised explosive device trauma

Joseph Taddeo, MD Background: The injury pattern from improvised explosive device (IED) trauma is differ Maj Melissa Devine, MN ent if the target is in a vehicle (mounted) or on foot (dismounted). Combat and civilian first response protocols require the placement of a cervical collar on all victims of a blast injury. LCol Vivian C. McAlister, MB Methods: We searched the Joint Theatre Trauma Registry (JTTR) and the Role 3 Accepted for publication: Hospital, Kandahar Airfield (KAF) database from Mar. 1, 2008, to May 31, 2011. We Jul. 23, 2014 collected data on cervical fracture; head injury; traumatic amputation; initial blood pressure, pulse, injury severity score (ISS), Glasgow Coma Scale (GCS) score and base Correspondence to: excess; and patient demographic information. V. McAlister Results: The concordance rate between JTTR and KAF databases was 98%. Of the C4-211 University Hospital 15 693 admissions in JTTR, 326 patients with dismounted IED injuries were located. London ON N5X2S1 The rate of cervical collar prehospital placement was 7.6%. Cervical fractures were found [email protected] in 19 (5.8%) dismounted IED victims, but only 4 (1.2%) were considered radiographic ally unstable. None of these 19 patients had prehospital placement of a collar. Patients DOI: 10.1503/cjs.013114 with cervical spine fractures were more severely injured than those without (ISS 18.2 v. 13.4; GCS 10.1 v. 12.5). Patients with head injuries had significantly higher risk of cervi cal spine injury than those with no head injury recorded (13.6% v. 3.9%). No differences in frequency of cervical spine injury were found between patients who had associated trau matic amputations and those who did not (5.4% v. 6.0%). Conclusion: Dismounted IED is a mechanism of injury associated with a low risk for cervical spine trauma. A selective protocol for cervical collar placement on victims of dismounted IED blasts is possible and may be more amenable to combat situations.

Contexte : Le type de blessures infligées par un engin explosif improvisé (EEI) est dif férent selon que la cible se trouve à l’intérieur d’un véhicule ou qu’elle circule à pied. Les protocoles de première intervention en zone de combat et auprès des populations civiles prévoient la pose d’un collet cervical chez toutes les victimes d’une blessure causée par une explosion. Méthodes : Nous avons interrogé le JTTR (Joint Theatre Trauma Registry – Registre des traumatismes liés au théâtre des opérations conjointes) et la base de données de l’hôpital de Rôle 3 de la base aérienne de Kandahar (BAK) entre le 1er mars 2008 et le 31 mai 2011. Nous avons recueilli des données sur les fractures cervicales, les trauma tismes crâniens, les amputations post-traumatiques, la tension artérielle initiale, le pouls, l’indice de gravité des traumatismes (IGT), le score à l’échelle de Glasgow (SG) et l’excès de base (gazométrie), de même que les caractéristiques démographiques des patients. Résultats : Le taux de concordance entre les bases de données du JTTR et de la BAK était de 98 %. Parmi les 15 693 admissions au JTTR, on a recensé 326 patients victimes de blessures causées par un EEI qui circulaient à pied. Le taux de pose de collet cervical préhospitalisation était de 7,6 %. Des fractures cervicales ont été observées chez 19 (5,8 %) des victimes d’EEI qui circulaient à pied, mais seulement 4 (1,2 %) étaient considérées radiographiquement instables. Aucun de ces 19 patients n’avait reçu de collet cervical avant l’hospitalisation. Les patients atteints d’une frac ture cervicale étaient plus gravement blessés que les autres (IGT 18,2 c. 13,4; SG 10,1 c. 12,5). Les patients victimes d’un traumatisme crânien étaient exposés à un risque significativement plus élevé de traumatisme cervical comparativement aux patients qui n’avaient pas de traumatisme crânien (13,6 % c. 3,9 %). On n’a observé aucune dif férence dans la fréquence des traumatismes cervicaux selon que les patients avaient ou non subi une amputation post-traumatique associée (5,4 % c. 6,0 %). Conclusion : Les blessures causées par un EEI chez une personne qui circule à pied sont associées à un risque faible de traumatisme cervical. Il serait possible d’adopter un protocole sélectif de pose de collet cervical chez les victimes d’EEI qui circulent à pied, ce qui pourrait être mieux adapté aux situations de combat.

n recent conflicts, blast injuries from improvised explo whose entries were performed by different personnel. We sive devices (IEDs) are the most common form of serious searched the database for injuries recorded between trauma.1 A recent review of combat-related IED injuries Mar. 1, 2008, and May 31, 2011; the start date was selected I 2 reported an associated spine fracture rate of 8%. The Joint as this is when a distinction between mounted and dis Theatre Trauma System (JTTS) publishes clinical practice mounted victims was first recorded in the JTTR. All ser guidelines (CPGs) concerning common injuries encoun vices and nationalities were included except local nationals tered in a combat zone. The cervical spine (C-spine) CPG under the age of 16 years, pregnant women and detainees. addresses the indication for placement of a cervical collar, The incidence of C-spine fractures was the primary out requiring its use on all patients injured by any explosive come variable and was determined by searching for ICD-9 mechanism.3 The CPG’s other indications for prehospital codes 805.01–805.07 and codes 805.11–805.17. We also placement of a cervical collar are similar to those of civilian extracted data on the presence of head injury (ICD-9 protocols, including trauma with loss of consciousness, falls codes 800–802, 873.63, 873.73 and 959.01), initial blood from a height, motor vehicle accidents and vehicle roll- pressure and pulse, injury severity score (ISS), Glasgow overs.4,5 However, there are substantial obstacles to the Coma Scale (GCS) score, base excess values, nationality, placement of a cervical collar or use of other forms of spine service and treating hospital. All cervical fractures were immobilization in the combat setting.6 Indeed, in our diagnosed or confirmed using CT. Fractures were deter experience over multiple deployments to Afghanistan mined to be unstable if 1 of the following signs was pres between 2008 and 2012, very few casualties arrived at the ent: bilateral interfacetal dislocation, teardrop fracture North Atlantic Treaty Organization Role 3 Multinational (flexion or extension), wedge fracture with posterior liga Medical Unit (R3-MMU) in Kandahar Air Field (KAF) mentous rupture, odontoid fracture (type II), Hangman’s from the point of injury with complete cervical spine pre fracture or burst fracture (e.g., Jefferson fracture). Spinal cautions. In the civilian arena, controversy exists regarding cord injury was diagnosed clinically. Magnetic resonance the universal use of cervical collar immobilization in con imaging was not available. scious patients. No evidence exists to support or reject the The study was approved by the Commanding Officer of use of a collar.7 There is concern that cervical collar place the R3-MMU, KAF, and by the Research Ethics Board of ment can, in some circumstances, cause harm.8 Western University. During this period of deployment, the JTTS CPGs also required all patients with IED blast injuries to undergo Statistical analysis computed tomography (CT) of the head, face, neck, chest, abdomen and pelvis to clear the spine of fractures and the Data are presented as means ± standard deviations, and we body of occult fragment injury.3,9 This provided us with an analyzed the data using Microsoft Excel. The Student t test opportunity to undertake a performance improvement was used to determine significant differences in population project regarding the care of dismounted victims of IED parameters, and the χ2 test was used to determine associa blasts to clarify the proper priority for spinal precautions. tion in categorical variables between 2 populations. We Blast injuries from IEDs can be divided into 3 types: used a χ2 distribution table with 1 degree of freedom and a mounted, dismounted and crowd attacks, in which the tar probability level of 0.05 to reject or accept association. gets of the attack are a vehicle (mounted), a person on foot (dismounted) or a crowd of people, respectively. Different Results patterns of injury are expected in each of these situations. Mounted IED attacks produce injuries similar to high- A total of 326 victims of dismounted IED blasts were iden energy motor vehicle accidents. Crowd attacks, such as the tified among 15 693 admissions in the JTTR during our Boston Marathon bombing, result in a wide spectrum of study period. Of these, 19 (5.8%) patients were found to injuries. A dismounted IED attacks an individual on foot have C-spine fractures. Only 4 (1.2%) patients were con by targeting them with a trigger device or by radio- sidered radiographically to be unstable. Coalition military controlled detonation under observation. We wished to force personnel accounted for 18 of the 19 patients with investigate dismounted IED injuries because of their cervical fractures, while 1 was a local national. The average prevalence in recent conflicts. ISS for all patients with dismounted IED injuries was 13.7, and the average GCS score was 12.3. The patients with a Methods C-spine fracture had a significantly higher mean ISS than those without a C-spine fracture (18.2 ± 11.4 v. 13.4 ± We queried the Joint Theatre Trauma Registry (JTTR) 11.8, p = 0.039). The patients with a C-spine fracture had a and the KAF patient tracking database for patients by fil significantly lower mean GCS score than those without a tering for blast injuries incurred as dismounted victims of C-spine fracture (10.1 ± 5.7 v. 12.5 ± 4.5, p = 0.041). The IEDs. Data from a subset of patients over 18 months were mean arterial pressure (92 mm Hg) and base deficit compared for concordance between the 2 databases, (–1.75 meq/L) did not differ between the groups.

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The number of patients with traumatic amputations of we verified that only a minority of patients (8%) had a the limbs totalled 96 (29%). C-spine fractures were found collar placed by first responders. Even among known only in those who lost lower limbs. There were 5 C-spine high-risk patients, dismounted IED victims with head fractures in 92 patients with lower-extremity traumatic injuries, only 9% had a collar placed at the point of amputations (5.4%). Four patients had isolated traumatic injury. Combat-related spine injuries can have serious amputations of the upper limbs and 8 had a combination of consequences.11 However, none of the patients with both, but no patients in either of these groups had C-spine C-spine fractures in this report had a collar placed. Fac fractures. tors related to the circumstances of combat rather than Of the 326 patients in this study, 66 were reported to the clinical factors are likely responsible for the low rate have injuries to the head and neck, yet only 9 (13.6%) of of compliance with the CPG.6 the patients with blunt or penetrating injuries to the head The incidence of C-spine fracture is very low in patients and neck were found to have a C-spine fracture. Of the with dismounted IED injuries, even when the blast is 19 patients with C-spine fractures recorded in this study, 10 severe enough to traumatically amputate an extremity. (52.6%) did not report or have clinical signs of a head or There was no history or clinical evidence of a C-spine neck injury. When reviewing prehospital placement of a injury in almost half of the patients with a C-spine frac protective cervical collar, we found that only 6 of the 66 ture, whose diagnoses were made on screening imaging. (9.1%) patients with head and neck injuries had them On the other hand, concomitant head injury increased the applied. Four of these patients had open skull or facial frac risk of C-spine fracture 4-fold, confirming an observation tures, but 1 had only a broken nose and 1 had only a broken that was known in civilian practice. A minority of C-spine tooth. Of the patients in whom C-spine fractures were ulti fractures were radiographically unstable. These findings mately diagnosed, none received cervical collars in the pre are very similar to those reported in a series of civilian hospital setting. The total number of patients who had col trauma patients12 where the universal application of cer lars placed before arriving to the trauma bay was 25 (7.6%). vical collars in conscious patients has been questioned.7,8 The radiographic diagnoses of C-spine fractures for 18 These data suggest that a selective protocol for applica of the 19 patients were provided. Four (22.2%) of these tion of a cervical collar to victims of dismounted IED were considered unstable based on radiographic criteria, blasts would be possible. The Canadian C-spine rule was including pedicle fracture (n = 2); multiple, 3-column frac developed as a structured approach to rapidly clear the ture (n = 1); and body fracture with tearing of ligament (n = C-spine by the selection of civilian trauma patients for CT 1). Stable fractures included transverse process (n = 5), imaging.13 The C-spine rule has been shown to be superior laminar fracture (n = 3), spinous process (n = 2), anterior to other selection protocols and has become the standard chip (n = 1), end-plate (n = 1), facet (n = 1) and lateral in emergency departments.14 It has since been applied to peripheral fracture (n = 1). None of the patients with a the prehospital setting.15 The C-spine rule combines fac radiographically unstable C-spine fracture had either a spi tors related to the patient, the mechanism of injury and nal cord injury or progression to a spinal cord injury. clinical factors to determine those at risk for a C-spine Our comparison of data entry between the JTTR and fracture. According to the rule, in traumas from a low-risk the KAF databases showed a concordance rate of 98%. mechanism of injury, patients younger than 65 years who are alert, ambulatory or sitting up and who have no pain or Discussion tenderness of the neck, or who voluntarily rotate their heads do not require imaging. Modern conflicts involve more unconventional warfare than in the past with changing profiles of injury.1,10 Insur Conclusion gents resist efforts to stabilize a country through the use of terror and ambush operations. Buried home-made Our data suggest that a dismounted IED is a mechanism explosives meet their objectives by restricting movement of injury with a low risk for neurologic injury. Targets of a and demoralizing the population. Both military and civil dismounted IED who are alert, who have sat up or walked ian populations are at risk of these attacks. The victims of since the injury and who spontaneously move their necks dismounted IEDs in this series received wounds so devas may not require cervical collar placement. This will have tating many would have been fatal were it not for the important implications for combat first responders who immediate attention of combat field medics and rapid often have to carry their own supplies; the space used by evacuation from the point of injury. One-third of the vic extra cervical collars can be usefully redeployed. On the tims had traumatic amputations. The blasts that these other hand, our data confirm the universal use of screen patients receive impart enough energy to raise concern ing CT in patients with dismounted IED trauma because for injury to the C-spine. This is the reason behind the clinical examination did not predict the presence of CPG to apply a cervical collar to all victims of an explo C-spine fractures and because of its use to diagnose occult sive injury. Despite the recommendations of the CPG, fragment injury.

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Affiliations: From the Maine Veterans’ Affairs Medical Center, Augusta, 6. Savage E, Forestier C, Withers N, et al. Tactical Combat Casualty Maine (Taddeo); Canadian Armed Forces Health Services, Ottawa, Ont. Care in the Canadian Forces: lessons learned from the Afghan war. (Devine, McAlister); and Department of Surgery, Western University, Can J Surg 2011;54(Suppl):S118-23. London, Ont. (McAlister). 7. Kwan I, Bunn F, Roberts I; WHO Pre-Hospital Trauma Care Steer Competing interests: None declared. ing Committee. Spinal immobilisation for trauma patients. Cochrane Database Syst Rev 2001;2:CD002803. Contributors: J. Taddeo and V. McAlister designed the study. J. Taddeo 8. Benger J, Blackham J. Why do we put cervical collars on conscious and M. Devine acquired and analyzed the data, which V. McAlister also trauma patients? Scand J Trauma Resusc Emerg Med 2009;17:44. analyzed. M. Devine and V. McAlister wrote the article, which all authors reviewed and approved for publication. 9. Blunt abdominal trauma. Joint Theater Trauma System clinical prac tice guideline. Available: http://usaisr.amedd.army.mil/cpgs/Blunt _Abdominal_Trauma_27_Sep_12.pdf (accessed 2015 Apr. 21). References 10. Brisebois R, Hennecke P, Kao R, et al. The Role 3 Multinational 1. Beckett A, Pelletier P, Mamczak C, et al. Multidisciplinary trauma Medical Unit at Kandahar Airfield 2005–2010. Can J Surg 2011; team care in Kandahar, Afghanistan: current injury patterns and care 54(Suppl):S124-9. practices. Injury 2012;43:2072-7. 11. Bevevino AJ, Lehman RA Jr, Tintle SM, et al. Incidence and morbid 2. Comstock S, Pannell D, Talbot M, et al. Spinal injuries after impro ity of concomitant spine fractures in combat-related amputees. Spine J vised explosive device incidents: implications for Tactical Combat 2014;14:646-50. Casualty Care. J Trauma 2011;71(Suppl 1):S413-7. 12. Stein DM, Kufera JA, Ho SM, et al. Occupant and crash characteris 3. Cervical spine evaluation and non-surgical management. Joint The tics for case occupants with cervical spine injuries sustained in motor ater Trauma System clinical practice guideline. Available: http vehicle collisions. J Trauma 2011;70:299-309. ://usaisr.amedd.army.mil/cpgs/Cervical_Spine_Evaluation_19_Mar_12 13. Stiell IG, Wells GA, Vandemheen KL, et al. The Canadian Cervical .pdf (accessed 2015 Apr. 21). Spine Radiography Rule for alert and stable trauma patients. JAMA 4. American College of Surgeons Committee on Trauma. Advanced 2001;286:1841-8. Trauma Life Support. 9th edition. Chicago: American College of Sur 14. Stiell IG, Clement CM, McKnight RD, et al. The Canadian C-Spine geons; 2013. Rule versus the NEXUS low-risk criteria in patients with trauma. 5. McSwain NE, Salomone JP, Pons PT, eds. Prehospital Trauma Life Sup- N Engl J Med 2003;349:2510-8. port. 6th edition. Chicago: National Association of Emergency Medical 15. Vaillancourt C, Stiell IG, Beaudoin T, et al. The out-of-hospital vali Technicians and Committee on Trauma of the American College of dation of the Canadian C-Spine Rule by paramedics. Ann Emerg Med Surgeons; 2007. 2009;54:663-671.

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Blunt splenic injury and severe brain injury: a decision analysis and implications for care

Thamer Alabbasi, MB Background: The initial nonoperative management (NOM) of blunt splenic injuries in Avery B. Nathens, MD, PhD hemodynamically stable patients is common. In soldiers who experience blunt splenic injuries with concomitant severe brain injury while on deployment, however, NOM may Col Homer Tien, MD, MSc put the injured soldier at risk for secondary brain injury from prolonged hypotension.

Accepted for publication Methods: We conducted a decision analysis using a Markov process to evaluate 2 strat- Nov. 11, 2014 egies for managing hemodynamically stable patients with blunt splenic injuries and severe brain injury — immediate splenectomy and NOM — in the setting of a field hos- Correspondence to: pital with surgical capability but no angiography capabilities. We considered the base H. Tien case of a 40-year-old man with a life expectancy of 78 years who experienced blunt Department of Surgery trauma resulting in a severe traumatic brain injury and an isolated splenic injury with an Sunnybrook Health Sciences Centre estimated failure rate of NOM of 19.6%. The primary outcome measured was life H186 - 2075 Bayview Ave. expectancy. We assumed that failure of NOM would occur in the setting of a prolonged Toronto ON M4N 3M5 casualty evacuation, where surgical capability was not present. [email protected] Results: Immediate splenectomy was the slightly more effective strategy, resulting in a very modest increase in overall survival compared with NOM. Immediate splenec- DOI: 10.1503/cjs.015814 tomy yielded a survival benefit of only 0.4 years over NOM. Conclusion: In terms of overall survival, we would not recommend splenectomy unless the estimated failure rate of NOM exceeded 20%, which corresponds to an American Association for the Surgery of Trauma grade III splenic injury. For military patients for whom angiography may not be available at the field hospital and who require prolonged evacuation, immediate splenectomy should be considered for grade III–V injuries in the presence of severe brain injury.

Contexte : La gestion non chirurgicale (GNC) initiale des traumatismes spléniques fermés chez les patients hémodynamiquement stables est fréquente. Toutefois, dans les cas de traumatismes spléniques fermés accompagnés de graves lésions cérébrales con- comitantes durant leur déploiement, la GNC peut exposer les soldats blessés à un risque de lésion cérébrale secondaire par suite d’une hypotension prolongée. Méthodes : Nous avons appliqué un modèle de Markov à l’analyse décisionnelle pour évaluer 2 stratégies de prise en charge des patients hémodynamiquement stables porteurs de traumatismes spléniques fermés et de graves lésions cérébrales, soit la splénectomie immédiate et la GNC, dans le contexte d’un hôpital de campagne doté d’installations chirurgicales mais non d’installations angiographiques. Nous avons étudié le scénario de référence d’un homme de 40 ans ayant une espérance de vie de 78 ans, victime d’un traumatisme fermé entraînant une lésion cérébrale grave et un traumatisme splénique isolé, avec un taux estimé d’échec de la GNC de 19,6 %. Le principal paramètre mesuré était l’espérance de vie. Nous avons présumé que l’échec de la GNC surviendrait dans le contexte d’une évacuation prolongée des blessés en l’absence d’installations chirurgicales. Résultats : La splénectomie immédiate s’est révélée être une stratégie légèrement plus efficace, entraînant une augmentation très modeste de la survie globale comparativement à la GNC. La splénectomie immédiate a produit un avantage de 0,4 an seulement au plan de la survie par rapport à la GNC. Conclusion : Au plan de la survie globale, nous ne recommanderions pas la splénecto- mie, à moins que le taux d’échec estimé de la GNC n’excède 20 %, ce qui correspond à un traumatisme splénique de grade III selon l’American Association for the Surgery of Trauma. Pour le personnel militaire blessé chez qui il est impossible de procéder à une angiographie dans un hôpital de campagne, et qui requiert une évacuation prolongée, il faut envisager une splénectomie immédiate pour les traumatisme de grade III V en présence de graves lésions cérébrales.

he spleen is the intra-abdominal organ most fre- immediate splenectomy for blunt grades IV and V splenic quently injured from blunt trauma.1 For most of the injuries, independent of the presence of severe brain injury.25 twentieth century, splenectomy was the treatment of To our knowledge, there are no clinical trials or cohort T 2 choice for splenic injuries. However, nonoperative man- studies that explicitly study the optimal management strategy agement (NOM) of blunt splenic injuries in hemodynam for splenic injuries in patients with severe brain injury. In the ically stable patients became attractive after reports detailed absence of such data, decisional analytic techniques are useful the significance and seriousness of asplenic sepsis.3,4 because they can explicitly model trade-offs between the risks Another impetus for this shift was the frequency of opera- and benefits of each treatment option. tive complications associated with splenectomy.5 Since then, numerous investigators have reported their successful Methods experiences with NOM in children and adults.6–11 Initially, patients were selected for NOM only if they had Reference case definition isolated low-grade splenic injuries and were neurologically intact. More recent reports have broadened the selection This study considered the base case of a 40-year-old man criteria to allow for concomitant trauma brain injury (TBI) with a life expectancy of 78 years26 who experienced blunt and higher grades of splenic injury.12–16 Watson and trauma resulting in a severe TBI (GCS score < 9 unrelated colleagues13 analyzed all blunt splenic injuries (n = 22 887) to alcohol or drug effects) and an isolated splenic injury entered into the US National Trauma Data Bank from 1997 (American Association for the Surgery of Trauma [AAST] to 2003. They reported that the frequency of attempted grade III with estimated failure rate of NOM of 19.6%). NOM for severe splenic injuries increased from 20.9% in We assumed that this patient did not require surgical 1997 to 43.4% in 2003. Furthermore, 30% of these patients intervention for his brain injury, arrived directly from the with severe splenic injuries also had accompanying severe scene of injury, required no blood transfusions, and was TBI (Glasgow Coma Scale [GCS] score < 9). hemodynamically stable from the time of injury to the time However, there are several reasons to suspect that NOM of assessment. The primary outcome measured was life may result in worse outcomes in patients with severe TBI. expectancy. We chose a societal perspective to capture all- First, NOM is associated with complications that may be important clinical outcomes in these trauma patients. detrimental to brain injury. One such complication is hypotension.12 When NOM fails, hypotension can ensue Decision model from the resulting hemorrhage. One episode of hypotension doubles the mortality for patients with severe TBI compared We created a multistate Markov analytic model (TreeAge with stable patients. 17–19 Another complication of NOM is Pro 2005) to evaluate overall survival with the adoption of increased exposure to allogenic blood products;12 increasing 2 strategies: immediate splenectomy or NOM with obser blood transfusion requirements is another indication that vation in an intensive care setting (Fig. 1). Indications for NOM has failed. However, blood transfusions are also delayed splenectomy for the NOM arm would include associated with increased mortality in trauma patients, both hypotension or a transfusion requirement of 2 or more from long-term causes, such as transfusion-related infections units of packed red blood cells (PRBCs). To maintain a (HIV, hepatitis B and C), and from short-term causes, such sharp focus on our initial question, we did not consider the as sepsis, major transfusion reactions and multiple organ possibility of performing splenic repair in either arm. failure.20–23 Angioembolization was considered an adjunct to NOM Soldiers who experience blunt splenic injuries while on that reduced the probability of failure of NOM for each deployment are particularly challenging to manage. First, grade of splenic injury and was not considered separately. field hospitals may not have angiographic capabilities. Also, Time was represented using a 1-year cycle in which injured military patients often require evacuation from a patients could move among health states according to varying field hospital within the theatre of operations to a larger probabilities of mortality until a lifetime horizon was reached. treatment facility outside the theatre of operations. For Assignment into 1 of multiple chronic health states occurred example, during Canada’s involvement in Southern Afghan only after considering the probabilities of 1 of several acute istan, injured Canadian soldiers were evacuated from the complications developing. Therefore, these probabilities were Canadian Role 3 facility at Kandahar Airfield Base to the considered immediately after selecting either strategy during U.S. Role 4 Facility in Landstuhl, Germany, making the first cycle (Fig. 1). Transitions among resulting chronic surgical care inaccessible to the patient for at least 7 hours.24 health states then occur in subsequent cycles. In this situation, NOM of splenic injuries may put the injured soldier at risk for prolonged hypotension. American First cycle — acute hospitalization military guidelines recommend immediate splenectomy if an ultrasound confirms hemoperitoneum and if the patient has In this model, we considered the probability of receiving a severe brain injury. The same guidelines recommend PRBC transfusions with each strategy. Acute transfusion-

Can J Surg, Vol. 58 (Issue 3 Suppl 3) June 2015 S109 RECHERCHE related mortality can be secondary to major hemolytic We also considered the possibility of acutely contracting a transfusion reactions, sepsis and immune-related chronic infectious disease from PRBC transfusions. We complications (e.g., transfusion-related acute lung injury).23 assumed that the patient could contract only HIV, hepatitis We considered the probability of in-hospital death per unit B or hepatitis C from transfusion and that 1 of these of PRBCs received from all causes during the first cycle. infections would preclude the other 2.

fatal complication dead

fatal transfusion stable (Tx) reaction dead

TBI mortality alive (stable) dead

nonfatal alive complication

immediate Tx disease splenectomy alive (HV, hep B, C)

neurological morbidity

fatal complication dead

fatal transfusion unstable (Tx) reaction dead

TBI mortality alive (unstable) dead

nonfatal alive complication

Tx disease alive (HV, hep B, C)

neurological morbidity

failure splenectomy

fatal complication dead

fatal transfusion nonoperative stable (Tx) reaction management dead

TBI mortality alive (stable) dead

alive Tx disease (HV, hep B, C)

success alive neurological morbidity

fatal complication dead

fatal transfusion unstable (Tx) reaction dead

TBI mortality alive (unstable) dead

alive Tx disease (HV, hep B, C)

alive neurological morbidity

Fig. 1. Decision model for management of blunt splenic injury. HV = hepatitis virus; TBI = traumatic brain injury.

S110 J can chir, Vol. 58 (No 3 Suppl 3) juin 2015 RESEARCH

We also considered the probability of death after severe health states for each factor is represented by simplified brain injury. In this model, we assumed that differences in Markov health state diagrams (Fig. 2A–C). We assumed that acute brain injury mortality between the 2 groups were HIV would begin progressing to AIDS only after the tenth solely due to the probability of secondary brain injury from year of infection27 but that cirrhosis could complicate either hemodynamic instability. hepatitis B or hepatitis C within the first year of infection.28 We assumed that hepatitis B and C would progress only to Chronic health states cirrhosis and then death. We also assumed that all changes in neurologic status would occur within the first 2 years of Each chronic health state in the Markov model was the injury29 and that no neurologic changes would occur sub product of 3 factors that were determined during the first sequently. We did assume, however, that “chronic care” cycle: surgical complication, neurologic outcome and patients could progress onwards to death,30 but that transfusion-related disease state. The transition among “disabled” or “well” patients would not die from their neurologic disabilities (Fig. 2A). The outcomes of splen A ectomy, including its potential complications, apply to all Transition states for neurological morbidity patients undergoing the procedure (either early or late) at Well Well the same rate. Acutely (first cycle), patients may die from surgical complications, or experience short-term compli cations from which they recover uneventfully (e.g., ventral Head injury Disabled Disabled hernia, wound infections, postoperative bleeding). We considered recurrent small bowel obstruction and asplenic sepsis as long-term complications. We considered mortality Chronic Chronic associated with asplenic sepsis only after the first cycle and assumed that this risk was constant over time.

Death Data sources, probabilities In-hospital, year 0 1–2 years 3–38 years We reviewed the English-language literature to determine Time probabilities for each of the branches in the tree. We searched Medline using the terms “spleen” and “blunt

B Transition states for transfusion diseases trauma.” Publications were evaluated for best evidence and where possible, data were restricted from 2000 onwards given the evolution of trauma care. If possible, case series were excluded in favour of cohort studies when estimating HIV AIDS Death probabilities. Otherwise, data from multiple case-series were weighted by their respective number of patients to estimate the transition probability used for modelling. Where HepB Cirr Death possible, we obtained probabilities for outcomes associated with severe brain injury from the Brain Trauma Foundation’s Guidelines for the Management of Severe Traumatic Brain Injury.30 Likewise, where possible, prob HepC Cirr Death abilities for short-term complications associated with transfusion were obtained from the Canadian Blood Services guidelines on transfusion medicine31 (Table 1). C Transition states for surgical complications Nonoperative management

Failure rates for NOM have ranged from 6% to 52% in Long term Short term complication Death reviewed studies.12,13,39–49 Most studies were retrospective, single-institution studies of relatively small numbers of patients and likely reflected the criteria and practices of individual Well surgeons. We found 1 well-designed, multi-institutional retrospective cohort study in our literature review that described rates of failure for NOM based on the initial grade Fig. 2. Transition states for (A) neurological morbidity, (B) trans- of splenic injury and reported the probability of hypotension fusion diseases and (C) surgical complications. Cirr = cirrhosis. and transfusion stratified by grade of splenic injury in patients

Can J Surg, Vol. 58 (Issue 3 Suppl 3) June 2015 S111 RECHERCHE for whom NOM failed.12 We chose the reported failure rate of Unfortunately, few of the reviewed studies stratified their NOM for AAST grade III splenic injury as our base case failure rates by grade of splenic injury or reported the probability for NOM failure (19.6%). We did not assume incidence of hypotension before angioembolization. As angioembolization was available to make the results useful to hypotension is likely to have the biggest effect on mortality all trauma centres. However, we considered the effect of associated with brain injury, we did not explicitly include angioembolization on the probability of failure of NOM by angioembolization in our NOM strategy arm. Because the performing a sensitivity analysis of the effect of the probability probability of failure varied so widely in different studies and failure of NOM on overall survival (Table 1). will vary with angioembolization, we conducted our sensi Recently, numerous centres have reported on the role of tivity analysis using a range from 0% to 100%. We also hope angioembolization as an adjunct to reduce the failure rate of to report a threshold value for the probability of failure, NOM.50–54 Although most studies agree that a protocol- where immediate splenectomy becomes the dominant driven approach appears to be associated with the lowest strategy over NOM. Then, each centre could look at their rates of failure of NOM, no clear consensus exists on the own failure rates with angioembolization to decide whether optimal strategy for its use. The spectrum of approaches has or not NOM should be applied to all patients with severe ranged in the literature from routine admission angiography TBI and blunt splenic injury (Table 1). for all patients with blunt splenic injury,50 to the application of strictly defined selection criteria for angioembolization Head injury mortality based on independent risk factors for failure.53 All of these studies reported an extremely low failure rate for NOM, For our base case scenario, we choose a probability of which is much lower than our base case of 20%. death from severe TBI of 27%. This was based on a

Table 1. Probabilities for important variables

Reference Variable Base case (range) studies Failure of NOM 0.25 (0–1.0) 12 Severe traumatic brain injury (TBI) mortality 0.27 (0.11–0.41) 32–34 Multiplier (effect of hypotension on TBI mortality) 2.4 (1.0–2.4) 32 Probability of hypotension for NOM 12 Probability failure = 0.05 0.15 Probability failure = 0.13 0.4 Probability failure = 0.2 0.45 Probability failure = 0.75 0.7 Probability of hypotension for immediate splenectomy 0.05 (0–0.15) 35,36 Mean units RBCs transfused (failed NOM) 4.1 (0–11) 12 Mean units of RBCs transfused (successful NOM) 1.2 (0–4.2) 12 Mean units of RBCs transfused (immediate splenectomy) 0.68 (0–1.88) 35,36 Probability of contracting HIV (per unit RBC) 0.0000003 23 Probability of contracting hepatitis B (per unit RBC) 0.000012 23 Probability of contracting hepatitis C (per unit RBC) 0.0000002 23 Probability of dying from asplenic sepsis (per yr) 0.0002 (0–0.00034) 35,36 Probability of fatal surgical complication 0.03 (0–0.08) 5 Postoperative complication (yr 1 of cycle) 0.10 37 Persistent postoperative complication (yr 2–38) 0.005 37 Progression of hepatitis B to cirrhosis (per yr) 0.017 28 Progression of hepatitis C to cirrhosis (per yr) 0.013 28 Progression of cirrhosis to death (per yr) 0.04 38 Progression of HIV to AIDS (per yr, yr 1–10) 0 27 Progression of HIV to AIDS (per yr, yr 11–38) 0.054 27 TBI disability upon hospital discharge requiring chronic care 0.25 29 TBI disability upon discharge allowing community living 0.2 29 No measurable TBI disability upon discharge 0.55 29 TBI disability (chronic care) if hypotension occurs 0.65 32–34 No measurable TBI disability if hypotension occurs 0.15 32–34 No change in neurologic state in year 1 after discharge 0.76 29 No change in neurologic state in years 3–38 1 29

NOM = nonoperative management; RBC = red blood cells; TBI = traumatic brain injury.

S112 J can chir, Vol. 58 (No 3 Suppl 3) juin 2015 RESEARCH well-designed prospective study of 717 patients, which reported for splenectomy are for those cases that proceed controlled for other injury factors.32 Because moderate immediately to splenectomy because of instability or cases brain injuries have a reported mortality of 7%–10%,55 we where NOM failed.12,39 These cases reflect a sicker cohort choose 11% as the estimate for the lower range of severe than patients eligible for NOM (Table 1). TBI mortality. A mortality multiplier of more than 2-fold As a result, we chose to estimate probabilities using (2.4)32 was used to describe the effect of hypotension on studies describing complications from open splenectomies brain injury mortality; as such, the uppermost range for performed for idiopathic thrombocytopenic purpura TBI mortality was defined as 41% to allow us to use the (ITP).35,36 In ITP, the spleen is of normal size, unlike many multiplier (Table 1). other hematological disorders. Although the spleen is not injured in patients with ITP, low platelet counts also make Effect of hypotension on TBI mortality the likelihood of intraoperative bleeding a possibility, as with trauma cases. For our base case scenario, we guessed Many studies described the effect of uncorrected pre- that the range for hypotension for immediate splenectomy hospital hypotension on brain injury mortality. In our study, was between 0 and 0.15 (Table 1). we assumed that patients were stable during the prehospital and initial trauma room phases of their care. As a result, they Sensitivity analyses were eligible for NOM. Hypotension resulted only from ongoing splenic bleeding during their admission, either We assessed the effect of uncertainty in key variables by from NOM or during immediate splenectomy. We used a performing sensitivity analyses over plausible ranges. We multiplier of 2.4 for the effect of hypotension on TBI selected pairs of variables that were influential and mortality in our base case scenario. Our choice was based on correlated for multiway sensitivity analyses. a well-designed prospective study that controlled for other injury factors and found that in-hospital hypotension was Results associated with a 65% mortality in severe TBI patients compared with 27% for those without hypotension.56 Table 2 presents the results of our 2 strategies for managing However, this reported increase in brain injury mortality blunt splenic injuries in stable patients with severe brain may be the result of unmeasured confounders, as to our injury: immediate splenectomy or initial NOM. Immediate knowledge no randomized controlled trial has been splenectomy was the slightly more effective strategy, performed to measure the effect of hypotension on brain resulting in a very modest increase in overall survival injury mortality. Therefore, a multiplier of 2.4 also likely compared with NOM. Immediate splenectomy yielded a represents the uppermost range of the mortality multiplier; survival benefit of only 0.4 years over NOM for the 38-year we used a multiplier of 1 as the estimate of the likely time horizon. In fact, the survival curves for both strategies lowermost range (Table 1). show that they were almost identical (Fig. 3).

Hypotension Sensitivity analyses

The NOM of blunt splenic injuries carries a risk of We assessed the sensitivity of the model to the probability of hypotension. In fact, hypotension is an indication that NOM failure. When we varied the failure rate for NOM, NOM has failed and that splenectomy is required.43,44 The we found that immediate splenectomy was equivalent to probability that hypotension occurs as a consequence of NOM at a threshold failure rate of 0.2 (Fig. 3). As the NOM varies with the grade of the splenic injury:12 the probability of NOM failure increased beyond 0.2, worse the splenic injury, the more likely hypotension will immediate splenectomy became superior to NOM. In our occur from ongoing bleeding. As a result, for our base base case scenario, the probability of failure of NOM was case (probability failure = 0.25), the probability of 0.25; therefore, the strategies were almost identical, with hypotension was 0.45.12 However, for our sensitivity immediate splenectomy being slightly superior to NOM. analysis on the probability of NOM, we varied the We also performed 2-way sensitivity analyses on pairs probability of hypotension with the probability of failure, of correlated and important variables. We assessed the as described by Peitzman and colleagues12 in a multicentre sensitivity of the model to the probability that patients trial of NOM of splenic injuries (Table 1). undergoing immediate splenectomy became hypotensive One difficulty in estimating probabilities for the base case scenario arose when considering the strategy of immediate Table 2. Survival of the 2 strategies splenectomy. There are currently no data on hypotension rates in patients treated by immediate splenectomy. Because Strategy Life expectancy NOM is the standard of care for the initial treatment of Splenectomy 25.8 yr stable patients with splenic injury, the only complications Nonoperative management 25.4 yr

Can J Surg, Vol. 58 (Issue 3 Suppl 3) June 2015 S113 RECHERCHE and to the effect of hypotension on TBI mortality performed that show a survival advantage of NOM in these (mortality multiplier; Fig. 4A–B). As expected, our model patients;7,8 in these studies, mortality from asplenic sepsis was sensitive to these 2 variables. The survival benefit of and from operative complications increase the relative immediate splenectomy (compared with NOM) is because survival benefit of NOM over immediate splenectomy. hypotension is avoided, which has beneficial effects on However, the base case scenarios for these studies did not brain injury mortality. If patients who undergo immediate involve patients with brain injuries. Furthermore, mortality splenectomy also become hypotensive, this benefit is lost; from asplenic sepsis and from transfusion diseases was not also, if hypotension does not increase brain injury mortality, the benefit of immediate splenectomy is lost. We also assessed the sensitivity of the model to the probability of fatal operative complications from A 28 Observe splenectomy and to the probability of asplenic sepsis 27 Immediate splenectomy (Fig. 4C). As expected, our model was sensitive to these 26 25 Threshold Values: 2 variables as well. The survival benefit of immediate 24 Pfailure = 0.2 23 EV = 25.8 splenectomy is progressively lost as the rate of fatal surgical 22 complications increases. Also, if an increasing number of 21 20

splenectomized patients die from asplenic sepsis, the Expected value 19 survival benefit of immediate splenectomy is lost. 18 17 0 2 4 6810 Discussion P-failure

Traumatic brain injury is the leading cause of death and 37 disability in young adults. The pathophysiology of TBI B is such that not all neurologic damage occurs immediately, 2.0 Observe 38 1.9 but rather evolves over time. This secondary brain injury Immediate splenectomy results from ongoing ischemia and contributes to the 1.8 1.7 overall mortality of TBI. Avoiding hypotension and 1.6 maintaining cerebral perfusion is the basis of the modern 1.5 medical management of TBI.38 P-TBI 1.4 1.3 Splenic injuries often accompany TBI, especially from 1.2 blunt trauma. There is substantial literature that supports 1.1 NOM for isolated, blunt splenic injuries in hemodynamic 1.0 0 0.10 0.20 0.30 0.40 0.50 ally stable patients. Two decision analyses have been P-immediate splenectomy

Survival curve 100 Observation C 90 0.10 Observe Immediate splenectomy 0.09 80 Immediate splenectomy 0.08 70 0.07 0.06 60 0.05 0.04 50 0.03

40 P-fatal complicatio n 0.02

% Surviving 0.01 30 0.00 0.0000 0.0003 0.0006 0.0009 20 P-asplenic sepsis 10 0 Fig. 4. (A) One-way sensitivity analysis on probability of nonopera- 0 510 15 20 25 30 35 tive management failure. (B) Two-way sensitivity analysis on hypotension from immediate splenectomy and on the mortality effect of Years hypotension on traumatic brain injury (TBI). (C) Two-way sensitivity analysis on probability of asplenic sepsis mortality and probability of Fig. 3. Survival curves for NOM versus immediate splenectomy. fatal surgical complication. EV = expected value; P = probability.

S114 J can chir, Vol. 58 (No 3 Suppl 3) juin 2015 RESEARCH modelled as a Markov process, but as immediate events, patients with hypotension are more severely injured than which would bias the results toward an apparent benefit of patients without hypotension and are therefore at increased NOM over immediate splenectomy. risk of dying. Despite this potential bias, however, all brain For the present study, we conducted a decision analysis injury management is based on this assumption. Both the using a Markov process to evaluate splenectomy and NOM Committee on Trauma of the American College of for managing hemodynamically stable patients with blunt Surgeons17 and the Brain Trauma Foundation30 teach splenic injuries and severe brain injury. Over a time trauma clinicians that hypotension doubles the mortality of horizon of 38 years, we found a survival benefit of patients with severe brain injuries. Furthermore, a immediate splenectomy over NOM for patients with a randomized controlled trial will likely never be performed probability of NOM failure greater than 0.2. This would to test this assumption. Therefore, our assumption that correspond to grade IV and V splenic injuries. The hypotension doubles the mortality of patients with severe 2 strategies were equivalent for patients with grade III brain injuries has face validity, and our decision analysis splenic injuries (probability of failure = 0.2); reasons to provides the mechanism to evaluate the appropriate perform immediate splenectomy on patients with grade III strategy, given this widely held assumption. splenic injuries would include other predictors of failure of Another limitation includes our assumptions surrounding NOM, such as age older than 55 years40,41 and arterial asplenic sepsis. Much of the literature on asplenic sepsis is contrast extravasation on computed tomography.57 For from splenectomies performed for hematologic diseases. military patients who may face prolonged transport from a Also, much of the literature on asplenic sepsis predates the field hospital to a Role 4 facility outside of the theatre of utilization of multiple vaccinations or the use of prophylactic operations, the risk of bleeding to death while in flight antibiotics postsplenectomy. However, many of these likely pushes the decision-making around grade III splenic methods for reducing asplenic sepsis are used in clinical injuries to favour immediate splenectomy, if there were a practice today. Therefore, our assumptions may result in an concomitant severe brain injury. overestimate of the asplenic sepsis rate. Trauma splenectomy Angioembolization can reduce the failure rate of patients tend to have lower asplenic sepsis rates than those nonoperative management of splenic injuries. In recent splenectomies resulting from hematologic diseases.58 The reports, the probability of failure rates of NOM were addition of multiple vaccinations and/or prophylactic reduced to below 10% for grade V injuries with the inclusion antibiotics in today’s practice might also reduce the asplenic of angioembolization in the protocol for NOM.53 In this type sepsis rate compared with previously published reports. of situation, irrespective of the grade of the splenic injury, Therefore, overestimating the asplenic sepsis rate in our base immediate splenectomy would never result in a better case scenario would make our findings even more robust. survival benefit than NOM, as the 2 strategies are equivalent Another limitation is the simplicity of our simple base only. Therefore, at institutions where the failure rate of case. Our base case scenario involved a patient with an NOM is below 20% irrespective of the grade of the splenic isolated blunt splenic injury with concomitant severe brain injury, all stable patients with blunt splenic injury and severe injury that did not require operative intervention. This is a TBI should undergo a trial of NOM. very limited scenario in that most splenic injuries are Immediate splenectomy, however, would not be associated with other visceral injuries. However, this appropriate at institutions that demonstrate high operative limitation also makes our findings more robust. Concomitant mortality from trauma splenectomies. Likewise, if patients visceral injuries may require operative intervention; undergoing immediate splenectomy were frequently noted therefore, the strategy of immediate splenectomy has the to be hypotensive intraoperatively because of inadequate advantage of identifying other visceral injuries, such as bowel resuscitation by anesthesia or because of poor selection, injuries before delayed complications (sepsis) can occur. immediate splenectomy would no longer be the appropriate Likewise, including severe brain injuries with extra-axial initial strategy. And if surgeons were not aggressive in hemorrhage also tends to make immediate splenectomy a reducing the mortality of asplenic sepsis (i.e., appropriate preferred strategy for similar reasons. Epidural and subdural vaccinations and/or prophylactic antibiotic use), the survival hematomas often require emergency drainage, which advantage of performing immediate splenectomies in severe precludes appropriate evaluation of the abdomen for other TBI patients with high grade splenic injuries would decrease. injuries. Immediate splenectomy has the advantage of identifying all visceral injuries before complications occur. Limitations Other limitations include our extrapolating known utilities to define brain injury utilities and our simplifi The major limitations of our study include the assumption cation of the natural history of transfusion-related diseases that 1 episode of hypotension doubles the mortality in (e.g., HIV to AIDS to death). Our assumptions simplify patients with severe brain injuries. This assumption is complex medical diseases, and may not reflect the natural derived from multiple retrospective studies of patients with history of the disease in many cases. However, our model severe brain injuries and suffers from a major potential bias: was insensitive to all utilities and the transfusion-related

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15. Archer LP, Rogers FB, Shackford SR. Selective nonoperative man- disease assumptions. Therefore, our simplifications likely agement of liver and spleen injuries in neurologically impaired adult did not appreciably affect our results. patients. Arch Surg 1996;131:309-15. 16. Keller MS, Sartorelli KH, Vane DW. Associated head injury should Conclusion not prevent nonoperative management of spleen or liver injury in children. J Trauma 1996;41:471-5. 17. Committee on Trauma, American College of Surgeons. Advanced Historically immediate splenectomy has been the preferred Trauma Life Support Course for Physicians, 7th edition. Chicago, 1997. strategy for patients with severe TBI, considering the 18. Chesnut RM, Marshall LF, Klauber MR, et al. The role of secondary deleterious effects of hypotension on head injury–related brain injury in determining outcome from severe head injury. J mortality. In terms of overall survival, we would not Trauma 1993;34:216-22. recommend splenectomy unless the estimated failure rate 19. Vassar MJ, Rischer RP, O’Brien PE, et al. A multi-center trial for resuscitation of injured patients with 7.5% sodium chloride: the of NOM exceeded 20%, which corresponds to an AAST effect of added dextran 70. Arch Surg 1993;128:1003-11. grade III splenic injury. For military patients requiring a 20. Pietropaoli JA, Rogers FB, Shackford SR, et al. The deleterious prolonged evacuation, immediate splenectomy should be effects of intraoperative hypotension on outcome in patients with considered, even for grade III injuries, in the presence of severe head injuries. J Trauma 1992;33:403-7. severe brain injury. 21. Moore FA, Moore EE, Sauaia A. Blood transfusion: an independent risk factor for postinjury multiple organ failure. Arch Surg 1997;132: 620-4. Affiliations: From the Department of Surgery, Sunnybrook Health Sci- 22. Robinson WP III, Ahn J, Stiffler A, et al. Blood tranfusion is an ences Centre, Toronto, Ont., (Alabbasi, Nathens, Tien); and Canadian independent predictor of increased mortality in non-operatively man- Forces Health Services, Ottawa, Ont. (Tien). aged blunt hepatic and splenic injuries. J Trauma 2005;58:437-44. Competing interests: None declared. 23. Callum JL, Pinkerton PH. Bloody easy 2. Blood transfusions, blood alternatives and transfusion reactions, 2nd edition. Toronto, Sunnybrook and Contributors: H. Tien designed the study and acquired the data, which Women’s College Health Sciences Centre, 2005. all authors analyzed. H. Tien wrote the article, which all authors 24. Brisebois R, Hennecke P, Kao R, et al. The Role 3 Multinational reviewed and approved for publication. Medical Unit at Kandahar Airfield 2005-2010. Can J Surg 2011;54:S124-9. References 25. The Institute for Surgical Research. Joint Theatre Trauma System Clinical Practice Guidelines. “Blunt Abdominal Trauma”. 25 June 1. Esposito TJ, Gamelli RL. Injury to the spleen. In Mattox KL, 2012. Available: www.usaisr.amedd.army.mil/cpgs/Blunt_Abdominal Feliciano DL, Moore EE (Eds): Trauma, 4th Edition. New _Trauma_27_Sep_12.pdf (accessed 2014 Oct. 21). York:McGraw-Hill, 2000. 26. Statistics Canada. Life expectancy at birth, by sex, by province. Avail- 2. Pachter HL, Guth AA, Hofstetter SR, et al. Changing patterns in the able: www.statcan.gc.ca/tables-tableaux/sum-som/l01/cst01 management of splenic trauma: the impact of non-operative manage- /health26-eng.htm (accessed 2006 Dec. 4). ment. Ann Surg 1998;227:708-17. 27. Mindel A, Tenant-Flowers M. ABCs of AIDS: Natural history and 3. O’Neal BJ, McDonald JC. The risk of sepsis in the asplenic adult. management of early HIV infection. BMJ 2001;322:1290-3. Ann Surg 1981;194:775-8. 28. Imperial JC. Natural history of chronic hepatitis B and C. J Gastroen- 4. King H, Schumacker HB Jr. Splenic studies: I. Susceptibility to infection terol Hepatol 1999;14(Suppl):S1-5. after splenectomy performed in infancy. Ann Surg 1952;136:239-42. 29. Doig E, Fleming J, Tooth L. Patterns of community integration 5. Ellison EC, Fabri PJ. Complications of splenectomy. Surg Clin North 2-5 years post-discharge from brain injury rehabilitation. Brain Inj Am 1983;63:1313-30. 2001;15:747-62. 6. Koury HI, Peschiera JL, Welling RE. Non-operative management of 30. The Brain Trauma Foundation. Resuscitation of blood pressure and blunt splenic trauma: a 10-year experience. Injury 1991;22:349-52. oxygenation. In: Guidelines for the Management of Severe Traumatic 7. Feliciano PD, Mullins RJ, Trunkey DD, et al. A decision analysis of Brain Injury. Available: www.braintrauma.org/pdf/protected traumatic splenic injuries. J Trauma 1992;33:340-7. /Guidelines_Management_2007w_bookmarks.pdfs_prehospital.pdf 8. Velanovich V. Blunt splenic injuries in adults: a decision analysis (accessed 2006 Dec. 4). comparing options for treatment. Eur J Surg 1995;161:463-70. 31. Naimark D, Krahn MD, Naglie G, et al. Primer on Medical Decision 9. Coburn MC, Pfeifer J, DeLuca FG. Nonoperative management of Analysis: Part 5 – Working with a Markov Process. Med Decis Making splenic and hepatic trauma in the multiply injured pediatric and adoles- 1997;17:152-9. cent patient. Arch Surg 1995;130:332-8. 32. Chesnut RM, Marshall SB, Piek J, et al. Early and late systemic hypoten- 10. Brasel KJ, DeLisle CM, Olson CJ, et al. Splenic injury: trends in sion as a frequent and fundamental source of cerebral ischemia following evolution and management. J Trauma 1998;44:283-6. severe brain injury in the Traumatic Coma Data Bank. Acta Neurochir 11. Hunt JP, Lentz CW, Cairns BA, et al. Management and outcome of Suppl (Wien) 1993;59:121-5. splenic injury: the results of a five-year statewide population based 33. Valadka AB. Injury to the Cranium. In Mattox KL, Feliciano DL, study. Am Surg 1996;62:911-7. Moore EE (Eds): Trauma, 4th Edition. New York, McGraw-Hill, 2000. 12. Peitzman AB, Heil B, Rivera L, et al. Blunt splenic injury in adults: 34. American College of Surgeons Committee on Trauma. Advanced Multi-institutional study of the Eastern Association for the Surgery of Trauma Life Support for Doctors. Chicago, IL, 7th edition: 1997. Trauma. J Trauma 2000;49:177-87. 35. Cordera F, Long KH, Nagorney DM, et al. Open versus laparoscopic 13. Watson GA, Rosengart MR, Zenati MS, et al. Nonoperative manage- splenectomy for idiopathic thrombocytopenic purpura: clinical and ment of severe blunt splenic injury: Are we getting better? J Trauma economic analysis. Surgery 2003;134:45-52. 2006;61:1113-8. 36. Brunt LM, Langer JC, Quasebarth MA, et al. Comparitive analysis 14. Shapiro MB, Nance ML, Schiller HJ, et al. Nonoperative manage- of laparoscopic versus open splenectomy. Am J Surg 1996;172:596-9. ment of solid abdominal organ injuries from blunt trauma: impact of 37. Duron JJ, Silva NJ, du Montcel ST, et al. Adhesive postoperative neurologic impairment. Am Surg 2001;67:793-6. small bowel obstruction: incidence and risk factors of recurrence

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after surgical treatment: a multicenter prospective study. Ann Surg 48. Velmahos GC, Toutouzas KG, Radin R, et al. Nonoperative treatment 2006;244:750-7. of blunt injury to solid abdominal organs: a prospective study. Arch Surg 38. Sangiovanni A, Prati GM, Fasani P, et al. The natural history of 2003;138:844-51. compensated cirrhosis due to hepatitis C virus: a 17-year cohort 49. Bee TK, Croce MA, Miller PR, et al. Failure of splenic nonoperative study of 214 patients. Hepatology 2006;43:1303-10. management: Is the glass half empty or half full? J Trauma 39. McIntyre LK, Schiff M, Jurkovich GJ. Failure of nonoperative manage- 2001;50:230-6. ment of splenic injuries: causes and consequences. Arch Surg 50. Haan J, Scott J, Boyd-Kranis RL, et al. Admission angiography for 2005;140:563-8. blunt splenic injury: advantages and pitfalls. J Trauma 2001;51:1161-5. 40. Godley CD, Warren RL, Sheridan RL, et al. Nonoperative manage- 51. Liu PP, Lee WC, Cheng YF, et al. Use of splenic angioembolization ment of blunt splenic injury in adults: age over 55 years as a powerful as an adjunct to nonsurgical management of blung splenic injury. J indicator for failure. J Am Coll Surg 1996;183:133-9. Trauma 2004;56:768-72. 41. Harbrecht BG, Peitzman AB, Rivera L, et al. Contribution of age and 52. Haan J, Obeid NI, Kramer M, et al. Protocol-driven non-operative gender to outcome of blunt splenic injury in adults: multicenter study management in patients with blunt splenic trauma and minimal associ- of the eastern association for the surgery of trauma. J Trauma ated injury decreases length of stay. J Trauma 2003;55:317-21. 2001;51:887-95. 53. Bhullar IS, Frykberg ER, Siragusa D, et al. Selective angiographic 42. Myers JG, Dent DL, Stewart RM, et al. Blunt splenic injuries: dedi- embolization of blunt splenic traumatic injuries in adults decreases fail- cated trauma surgeons can achieve a high rate of nonoperative success ure rate of nonoperative management. J Trauma Acute Care Surg in patients of all ages. J Trauma 2000;48:801-5. 2012;72:1127-34. 43. Konstantakos AK, Barnoski AL, Plaisier BR, et al. Optimizing the 54. Hagiwara A, Fukushima H, Murata A, et al. Blunt splenic injury: useful- management of blunt splenic injury in adults and children. Surgery ness of trans catheter arterial embolization in patients with a transient 1999;126:805-12. response to fluid resuscitation.Radiology 2005;235:57-64. 44. Meguid AA, Bair HA, Howells GA, et al. Prospective evaluation of 55. Thurman D, Guerrero J. Trends in hospitalization associated with criteria for the nonoperative management of blunt splenic trauma. traumatic brain injury. JAMA 1999;282:954-7. Am Surg 2003;69:238-42. 56. Tsugawa K, Koyanagi N, Hashizume M, et al. New insight for man- 45. Peitzman AB, Harbrecht BG, Rivera L, et al.; Eastern Association for agement of blunt splenic trauma: significant differences between young the Surgery of Trauma Multiinstitutional Trials Workgroup. Failure and elderly. Hepatogastroenterology 2002;49:1144-9. of observation of blunt splenic injury in adults: variability in practice 57. Yao DC, Jeffrey RB Jr, Mirvis SE, et al. Using contrast-enhanced helical and adverse consequences. J Am Coll Surg 2005;201:179-87. CT to visualize arterial extravasation after blunt abdominal trauma: inci- 46. Nix JA, Costanza M, Daley BJ, et al. Outcome of the current manage- dence and organ distribution. Am J Roentgenol 2002;178:17-20. ment of splenic injuries. J Trauma 2001;50:835-42. 58. Holdsworth RJ, Irving AD, Cuschieri A. Postsplenectomy sepsis and 47. Velmahos GC, Chan LS, Kamel JA, et al. Nonoperative management its mortality rate: actual versus perceived risk. Br J Surg 1991; of splenic injuries: have we gone too far? Arch Surg 2000;135:674-79. 78:1031-8.

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Needle thoracostomy for tension pneumothorax: the Israeli Defense Forces experience

LTC Jacob Chen, MD, PhD Background: Point of injury needle thoracostomy (NT) for tension pneumothorax is Capt Roy Nadler, MD potentially lifesaving. Recent data raised concerns regarding the efficacy of conventional NT devices. Owing to these considerations, the Israeli Defense Forces Medical Maj Dagan Schwartz, MD Corps (IDF-MC) recently introduced a longer, wider, more durable catheter for the Col Homer Tien, MD performance of rapid chest decompression. The present series represents the IDF- MC experience with chest decompression by NT. LTC Andrew P. Cap, MD, PhD Col Elon Glassberg, MD, MHA Methods: We reviewed the IDF trauma registry from January 1997 to October 2012 to identify all cases in which NT was attempted. Accepted for publication: Results: During the study period a total of 111 patients underwent chest decompres- Nov. 12, 2014 sion by NT. Most casualties (54%) were wounded as a result of gunshot wounds (GSW); motor vehicle accidents (MVAs) were the second leading cause (16%). Most Correspondence to: (79%) NTs were performed at the point of injury, while the rest were performed dur- E. Glassberg ing evacuation by ambulance or helicopter (13% and 4%, respectively). Decreased Trauma & Combat Medicine Branch breath sounds on the affected side were one of the most frequent clinical indications Surgeon General’s Headquarters, for NT, recorded in 28% of cases. Decreased breath sounds were more common in Medical Corps surviving than in nonsurviving patients. (37% v. 19%, p < 0.001). A chest tube was Israel Defense Forces installed on the field in 35 patients (32%), all after NT. Ramat Gan, Israel [email protected] Conclusion: Standard NT has a high failure rate on the battlefield. Alternative meas ures for chest decompression, such as the Vygon catheter, appear to be a feasible alternative to conventional NT. DOI: 10.1503/cjs.012914

Contexte : La thoracotomie à l’aiguille (TA) pour le pneumothorax sous tension sur les lieux mêmes du traumatisme peut sauver des vies. Des données récentes ont mis en doute l’efficacité des dispositifs de TA classiques. C’est pourquoi le corps médical de l’armée israélienne (CMAI) a récemment proposé un cathéter plus long, plus large et plus résistant pour décomprimer rapidement le pneumothorax. Le présent article résume l’expérience du CMAI en matière de décompression des pneumothorax au moyen de la TA. Méthodes : Nous avons passé en revue le registre des traumatismes de l’armée israé- lienne entre janvier 1997 et octobre 2012 pour relever tous les cas où une TA a été tentée. Résultats : Durant la période de l’étude 111 patients en tout ont subi une décom- pression à l’aide d’une TA. La plupart des cas (54 %) résultaient de blessures par balles; les accidents de la route venaient au second rang (16 %). La plupart (79 %) des TA ont été effectuées sur les lieux, tandis que les autres ont été effectuées durant l’évacuation par ambulance ou par hélicoptère (13 % et 4 %, respectivement). L’atténuation des bruits respiratoires du côté affecté était l’une des indications cliniques les plus fréquentes de la TA, enregistrée dans 28 % des cas. L’atténuation des bruits respiratoires était plus fréquente chez les patients qui ont survécu (37 % c. 19 %, p < 0,001). Un drain thoracique a été installé sur le terrain chez 35 patients (32 %), à chaque fois après une TA. Conclusion : La TA standard s’accompagne d’un taux d’échec élevé sur le champ de bataille. Une autre mesure de décompression, comme le cathéter Vygon, semble être une solution de rechange envisageable à la TA classique.

ension pneumothorax (TPTX) is a life-threatening side of the injury with a 14-gauge, 3.25 inch (8.25 cm) condition and the third most frequent cause of pre- needle/catheter.” 17,18 ventable deaths on the battlefield.1 Autopsy studies The catheter’s diameter is another concern. Martin and T 19 from the Vietnam War suggested that TPTX led to colleagues used a porcine model to show that the decom- 3%–5% of all potentially preventable deaths.2 The clinical pression of the chest by a 14-gauge needle should not be definition of TPTX is a PTX that results in hemodynamic expected to result in relief of tension physiology, as a sub- compromise, as the increased intrathoracic pressure inter- stantial air leak necessary to cause TPX physiology cannot feres with the venous return to the right atrium. Viewed on be effectively drained with a 14-gauge tube. chest imaging, lateral shift of the mediastinum concurrent The preferred NT insertion site itself is subject to with respiratory distress (or difficult ventilation) and/or debate, with evidence suggesting that the fourth and fifth hypotension is considered the hallmark of TPTX,3,4 even ICS (at the anterior axillary line, similar to the recom- though obtaining a chest radiograph for suspected tension mended TT insertion site) may be superior to the classic TPTX is considered an unjustified delay. The Advanced site (the midclavicular line).12,14 Others raised concerns Trauma Life Support (ATLS) guideline proposed by the regarding the function of the NT inserted in this site, and American College of Surgeons recommends that the diag- both insertion site options are currently considered valid.4 nosis be made based only on clinical grounds. Tension PTX Despite these and other concerns, the current recom- is caused by the progressive buildup of air within the pleural mended needle used for decompression is a 14-gauge space, and positive pressure ventilation may accelerate this angiocatheter.5 process, which may result in traumatic arrest. The ATLS Owing to these considerations, along with concerns recommends that needle thoracostomy should be performed regarding catheter kinking20 and blockage, in 2006 the at the second intercostal space (ICS) in the midclavicular Israeli Defense Forces Medical Corps (IDF-MC) intro- line using a catheter more than 5 cm long.5 duced a thicker, longer catheter for the performance of While the urgent evacuation of a patient with PTX is a rapid chest decompression. component of all emergency medical algorithms,5 contro- We report our experience with NT and preliminary versy remains regarding the optimal timing and means of data on our use of a 10-French Vygon TT unit (thoracic treatment prior to evacuation. Some consider needle trocar and drain; Vygon), instead of the traditional decompression (also called needle thoracostomy [NT]) as a 14-gauge angiocatheter, as the preferred means for rapid temporary means for pressure release and bridging therapy chest decompression. until the insertion of a tube thoracostomy (TT). Others suggest that NT can sometimes be definitive therapy, and Methods that not every NT should be followed by a TT insertion. Finally, some suggest TT, rather than NT, as the primary The IDF clinical practice guidelines for thoracic therapy.4,6,7 The reported success rates and the level of injury. training required for these procedures vary.8 Prehospital NT can be life-saving, but technical aspects The IDF-MC clinical practice guidelines (CPGs) concern- of the procedure have given rise to a discussion of whether ing thoracic injury advocate a high index of suspicion for it should be considered only a temporary measure. Investi- TPTX in patients with thoracic injuries. Casualties sustain- gators have reported chest wall thickness to be a key factor ing a penetrating injury to the thorax presenting with accounting for failures to successfully evacuate the chest, severe dyspnea, decreased oxygen saturation or hemody- and therefore recommend the use of longer needles. namic compromise should undergo chest decompression. Stevens and colleagues9 retrospectively examined thoracic Initial decompression is performed by NT; a TT is computed tomography (CT) studies and determined the installed if initial NT fails to improve the patient’s hemody- chest wall thickness at the midclavicular line to be namic status or oxygen saturation. A TT should also be 41–45 mm compared to the 14-gauge angiocatheter length installed following NT when casualty evacuation time to of 4.5 cm. They concluded that the standard angiocatheter the next echelon of care is expected to exceed 45 minutes was likely to be unsuccessful in 50% of trauma patients on (Fig. 1). While the TCCC guidelines instruct the sealing of the basis of body habitus alone. Similar findings were reported raising the same concerns.10-12 In other reports, techniques such as cadaver dissection13,14 and ultrasonography15,16 were used to detect the penetration of catheters. On the basis of these findings, a recommendation for change was issued, and many prehospital organizations have adopted the use of longer catheters. Tactical Combat Casualty Care (TCCC) Fig. 1. Vygon tube thoracostomy unit (thoracic trocar and guidelines recommend “decompress[ing] the chest on the 10-French drain) for pleural drainage in neonates.

Can J Surg, Vol. 58 (Issue 3 Suppl 3) June 2015 S119 RECHERCHE chest wounds using a vented chest seal,21 the IDF CPGs on duced the pediatric Vygon TT unit to be used for NT in the management of thoracic injuries instruct thoracic adults (Fig. 2). The device consists of a10-French drain decompression as the mainstay of therapy for any casualty made of transparent polyvinyl chloride with X.R.O. line, with a thoracic injury prior to sealing the wound. 1 lateral eye and markings at every centimetre. The tube is 8 cm long with a proximal female Luer-lock connector. Needle decompression in the IDF The procedure is performed preferably under aseptic conditions using a suitable skin disinfectant. Using a From 1997 to 2007, a 14-gauge angiocatheter inserted No. 11 blade, a small incision is made through the skin, into the second ICS in the midclavicular line was the subcutaneous tissue and muscle. The tube and the drain method of choice for NT. In 2007, the IDF-MC intro- are inserted bluntly and perpendicularly through the

Signicant chest injury? No Yes Yes

Signs of tension pneumothorax?*

1. Profound hemodynamic shock (no radial pulse or systolic blood pressure < 80 mmHg), not explainable by any source of bleeding. 2. Casualty with chest injuries suffering loss of vital signs over the Yes course of resuscitation.† (absent pulse and unmeasurable blood pressure)

Tactical and clinical judgment considerations:

1. Level of medical safeguarding/escort

2. Mode of transportation

3. Estimated evacuation time Yes 4. Positive pressure ventilation

5. Type of chest wound (sucking wound)

6. Hypoxic signs or oxygen saturation 90% despite supplemental oxygen

Consider chest decompression

Continue assessment and treatment No

Continue treatment and evacuation with best medical escort (ALS Chest decompression‡ is preferred)

Provide oxygen and analgesic drugs as required

†Bilateral chest decompression is indicated *Signs of tension PTX are loss of breath sounds on the injured side, provided the tracheal tube is correctly placed, plus signs of life- threatening hemodynamic and respiratory compromise ‡Needle thoracostomy (NT) as a temporary bridge before TT insertion

Fig. 2. Algorithm for the treatment of chest injuries on the battlefield according to Israeli Defense Forces Medical Corps clinical practice guidelines. ALS = advanced life support; TT = tube thoracostomy.

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anterior chest wall at the second ICS in the midclavicular specified. Eighty (72%) patients received medical care in line, penetrating the pleural cavity to relieve the TPTX. an austere environment or under threat, while 31 (28%) The trocar is removed and the tube is firmly attached to patients received care in a safe setting. the chest by means of adhesive tape. Most (54%) casualties were wounded as a result of gunshot wounds (GSW); motor vehicle accidents (MVA) were Study population the second leading cause (16%), and blast injuries caused by improvised explosive devices (IED) were the third most The IDF trauma registry is a prehospital military frequent cause (13%; Table 1). trauma registry containing data on trauma casualties The clinical indications for NT are shown in (civilian or military) cared for by military medical teams. Figure 3. Decreased breath sounds on the affected side Data are collected in the form of casualty cards. Cas were one of the most frequent clinical indications for ualty cards are followed by a more comprehensive after NT, occurring in 28% of all cases. Decreased breath action medical debriefing. Hospital data are collected sound was more common in surviving than in nonsurviv- directly from treating hospitals’ medical charts. All ing patients. (37% v. 19%, p < 0.001). Nonresponsive- available information is being integrated to the ITR at ness and absent peripheral pulses had similar overall fre- the Combat and Trauma Medicine Branch at the Sur- quency to decreased breath sounds; however, these geon General’s headquarters. features were more common in nonsurviving than sur- We searched through the registry for records from Jan- viving patients (47% v. 6%, p < 0.001). Shortness of uary 1997 to October 2012 to identify all patients in whom breath was present in 15% of patients, while low oxygen NT was attempted. We collected data on patient demo- saturation was observed in 17%. graphic characteristics, type of injury, vital signs, life- Engorged neck veins and limited chest expansion were saving procedures, number of NT attempts, success of NT observed in only a minority (7%) of patients, and tracheal (subjective improvement after NT was recorded, yes v. deviation was not reported. no), TT insertion, identity of caregiver, survival, iatrogenic The care providers reported a subjective improvement injuries and complications. Predefined signs and symptoms in patient respiratory function following NT in 83% of the of PTX were extracted from charts and assigned as NT surviving patients and in 86% of the nonsurviving patients. clinical indications. Unfortunately no further specification was available. The mean ISS was 31 ± 24.6, which indicates a cohort Statistical analysis of severely injured patients undergoing NT. Seventy-four (67%) patients were classified as urgent for evacuation by Data were entered into a Microsoft Excel spreadsheet and the medical provider at the point of injury, and only 10 analyzed using JMP statistical software. We obtained (9%) patients were classified as nonurgent (Fig. 4). descriptive statistics for all variables. Continuous variables The overall mortality was 51%. Twenty-three (21%) are presented as means ± standard deviations with 95% casualties were defined as killed in action (KIA), and 7 (6%) confidence intervals (CI). Categorical variables are pre- were pronounced dead on arrival at the trauma centre. sented as numbers and percentages where appropriate. None of the KIA patients had a return of spontaneous cir- We compared categorical variables using the Fisher exact culation in the field. Twenty-one (19%) patients died from test, and continuous variables were compared using the their wounds after hospital admission.22 Wilcoxon rank-sum test. Chest decompression was often performed rapidly in a complex resuscitation environment with patients under Results going multiple concurrent interventional procedures. Other life-saving procedures performed on this study population During the study period, 4621 patients were recorded in were endotracheal intubation (48%), cricothyroidectomy the IDF-MC database. A total of 111 (2.5%) of these patients underwent NT as part of their treatment, making Table 1. Mechanisms of injury up the study group. Seventeen (15%) patients underwent Mechanism % of injuries bilateral decompression, and 26 (23%) required multiple Penetrating 78 NT attempts on a single hemithorax. Thirty-five (32%) Gunshot wounds 54 patients had a chest tube placed in the field, all following Blast injuries (improvised explosive device) 13 NT attempts. Fragmentation 8 The patients’ mean age was 21 (range 20–25.5) years. Stab wounds 3 Most (101 of 111, 91%) patients were men. Blunt 19 Eighty-seven (78%) patients sustained penetrating Motor vehicle accident 16 injur ies, 21 (19%) were victims of blunt trauma, and in the Fall from height 3 remaining 3 (3%) patients the mechanism of injury was not Not specified 3

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(9%) and tourniquet application (6%). Twenty-six (23%) Discussion patients did not receive additional advanced live-saving procedures. Classic hallmarks of TPTX include a variety of signs and Prehospital NT was performed by military physicians in symptoms, the majority of which are nonsensitive and nonspe- 44% of patients, by military paramedics in 9% and by civilian cific.5 An analysis designed to assess the clinical presentation emergency medical services (EMS) paramedics in conjunc- guiding the decision to perform chest decompression in our tion with military medical teams (to soldiers and civilians study population revealed decreased breath sound, absent injured in areas with civilian EMS availability) in 12%. radial pulses and a low GCS to be the most common presenta- Unfortunately, the care providers’ identities were not tions. Unsurprisingly, decreased breath sounds as a clinical recorded in 39 (35%) cases. Subjective patient improvement presentation of TPTX was more common in patients who was reported by military physicians in 41 (84%) casualties, by survived their injuries than in patients who did not, whereas military paramedics in 9 (90%) and by civilian EMS para- depressed GCS (nonresponsiveness) and absent radial pulses medics in 11 (85%). Despite the impressive clinical improve- (both clinical indicators for decreased blood perfusion) were ment, mortality remained surprisingly high in the military more common in patients who died following their injuries. physicians’ and military paramedics’ groups: 55% and 90%, This finding is probably indicative of the more deranged respectively. The lowest mortality (23%) was found in the physiology associated with a PTX that resulted in hemody- civilian EMS paramedics’ group (p = 0.007). namic compromise. Tracheal deviation was not detected in The catheter used for NT was a 14-gauge angiocatheter in any of the casualties in this series, whereas dilated neck veins 88 (79%) patients and a Vygon TT unit in 6 (5%) casualties, were reported in only 7% of casualties. These 2 symptoms, all of whom were treated after 2007. For 16 (15%) patients which were once considered hallmarks of TPTX, are no lon- the documentation did not mention which type of device was ger considered necessary for diagnosis as they appear infre- chosen, and in 1 (1%) patient both devices were used owing quently in patients with TPTX and accordingly were not used to suspected failure of the 14-gauge angiocatheter. to instruct chest decompression in our series. Decreased level Most (79%) cases of NT were performed at the point of of consciousness and hypotension as well as decreased oxygen injury, and the rest were performed during transportation saturation, the second and third most prevalent indicators for on ambulance or helicopter (13% and 4% of the patients, chest decompression in this series, are considered inconsistent respectively). In 4 (4%) patients the location of chest or even rare signs of TPTX23 and are thus less useful for its decompression was not specified. diagnosis. However, as our series included a subset of patients No iatrogenic injuries or complications due to prehos- who required prehospital decompression of TPTX, these pital NT were reported. findings, suggestive of a significant disturbed physiology, were

Clinical indications for NT treatment

28% 27%

17%

15%

DBS TD ENV LOSSOB DCE U&APP

Fig. 3. Percentage of cases in which each clinical indication was used by flight surgeons to determine ned- dle decompression (NT) or tube thoracostomy treatment. Specific indications include decreased breath sounds (DBS) on 1 side, tracheal deviation (TD), engorged neck veins (ENV), low oxygen saturation (LOS), shortness of breath (SOB), decreased chest expansion (DCE) and unconsciousness and absent peripheral pulse (U&APP).

S122 J can chir, Vol. 58 (No 3 Suppl 3) juin 2015 RESEARCH more frequent than other symptoms indicating chest decom- eventually died from their injuries. This clinical success rate pression. This finding is consistent with the IDF-MC CPGs seems exceptionally high considering evidence suggesting for thoracic injuries that instruct NT or CD in casualties with that NT may fail to decompress TPTX in up to 50% of thoracic injuries who present with hemodynamic compromise patients.9-12, 27 Furthermore, because a similar rate of clinical or decreased oxygen saturation. improvement was reported in patients surviving their injur Current CPGs use a wide variety of indications for NT, ies as in patients who did not survive, it seems that these which inevitably results in chest decompression performed on high success rates are the result of inaccurate subjective patients who do not necessarily have TPTX. While the pre- assessment. In the present study, 32% of patients under sented data support the possibility to narrow the spectrum of going NT eventually had a CD installed in the prehospital signs and symptoms used to diagnose TPTX, the IDF CPGs setting, implying a true failure rate more consistent with were not altered owing to the assumption that overdiagnosis that reported in the available literature. and treatment of TPTX is preferable to underdiagnosis. While literature review revealed that major complica- A mean ISS of 31 in the present series suggests a cohort tions (hemorrhage and cardiac injuries) occur, no major of severely injured patients. This is unsurprising considering complications as a result of NT were reported in our the relatively high rate of GSW-related injuries, specifically series.28,29 However, as the majority of trauma victims in the when considering that in a military population the majority IDF do not undergo postmortem examination, this may be of GSWs are the result of high-velocity weapons. Postmor- the result of undiagnosed complications and could also have tem examinations in Israel are rarely performed, mainly been a result of the retrospective limitation of this report. because of religious considerations; it is therefore difficult to Some authors now advocate that longer catheters should determine cause of death. However, considering the high be used for NT, particularly in a military context,30-32 but mean ISS and the fact that in 77% of patients NT was not occlusion by blood or tissue and slippage out of the chest wall the only life-saving intervention performed, it is reasonable remain important concerns.33 Jones and Hollingsworth34 to assume that injuries other than TPTX contributed sub- described 3 cases suggesting angiocatheter failure attributed stantially to the high mortality. to kinking and proposed the use of a blunt-ended rigid device Despite a substantial failure rate,7,24-26 NT can relieve designed to treat TPTX. The catheter chosen by the IDF- intrapleural pressure and rapidly change a tension to a sim- MC to serve as the NT is a 10-French TT. The use of small- ple PTX, allowing time to prepare for TT. calibre chest tubes in the treatment of adult PTX was first In Israel, NT is the only procedure that EMS paramed- described by Sargent and Turner.35 They used a 9-French ics are allowed to perform in the civilian environment to (rather than the usual 32-French) catheter in combination treat a suspected TPTX. However, military paramedics are with a Heimlich valve, which was simple to insert. Several trained and authorized to insert a CD, according to phys subsequent series reported the use of a 9-French catheter for ician instruction, following an unsuccessful NT. the treatment of PTX, most frequently postlung biopsy. In the present series, medical providers reported a clinical These series report high success rates of 87%-95%.36-38 improvement in the patient respiratory status following NT The present series represents a transition in the device in 83% of surviving patients and in 86% of the patients who used to alleviate TPTX in the IDF, and while it is a preliminary report that was not designed to assess outcomes, Evacuation priority of NT patients initial experience suggest the feasibility of this method.

Dead on scene Nonurgent Limitations 3% 9% This study has several limitations. It was a small study with no formal sample size calculation. Data were collected retrospect ively, resulting in incomplete data collection. Several end Not speci ed 21% points were subjective, potentially resulting in reporting biases. Barton and colleagues24 reported that medical personnel may have documented the release of air or improved compliance to justify the use of NT; however, these are difficult to verify and may be influenced by wishful thinking. Finally, the study was performed in only a military environment in Israel. This population may not be representative of other trauma systems.

Urgent 67% Conclusion

We have described our experience with standard NT and Fig. 4. Evacuation priority of needle decompression (NT) patients. our preliminary results using Vygon TT in patients with

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ting for presumed pneumothorax: an ultrasound study. J UltraSound suspected TPTX. Standard NT has many limitations, while Med 2010;29:1285-9. NT using a Vygon catheter offers a potentially safe and rea- 16. McLean AR, Richards ME, Crandall CS, et al. Ultrasound determi- sonable alternative. It does not require advanced surgical skill nation of chest wall thickness: implications for needle thoracostomy. or training and can be inserted efficiently and safely by Am J Emerg Med 2011;29:1173-7. ATLS providers. This device should become an accepted 17. Unites States Army Institute of Surgical Research. Tactical Combat Casualty Care Guidelines. 2012. part of the military emergency care tool kit. Further pro 18. Dickey N, Jenkins D. Needle decompression of tension pneumothorax and spective studies should be performed to substantiate the effi- cardiopulmonary resuscitation: Tactical Combat Casualty Care Guidelines cacy and theoretical advantages of the Vygon TT unit over a recommendation. Defense Health Board memorandum 2011. 14-gauge angiocatheter. 19. Martin M, Satterly S, Inaba K, et al. Does needle thoracostomy provide adequate and effective decompression of tension pneumothorax? Affiliations: From the IDF Medical Corps, Israel (Chen, Nadler, J Trauma Acute Care Surg 2012;73:1412-7. Schwartz, Glassberg); Department of Surgery, Rabin Medical Center, 20. Beckett A, Savage E, Pannell D, et al. Needle decompression for tension Beilinson Campus, Petach Tikva, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel (Chen); Department of Emergency Medicine, pneumothorax in Tactical Combat Casualty Care: Do catheters placed Ben Gurion University of the Negev, Beer Sheva, Israel (Schwartz); US in the midaxillary line kink more often than those in the midclavicular Army Institute of Surgical Research, Fort Sam, Houston, Texas (Chen, line? J Trauma 2011;71(Suppl 1):S408-12. Cap); Canadian Armed Forces (Tien); and Sunnybrook Health Sciences 21. Butler FK, Dubose JJ, Otten EJ, et al. Management of open pneumo- Centre, University of Toronto, Toronto, Ont. (Tien). thorax in Tactical Combat Casualty Care: TCCC guidelines change 13-02. J Spec Oper Med 2013;13:81-6. Competing interests: None declared. 22. Glassberg E, Lipsky AM, Abramovich A, et al. Apples and oranges: Contributors: J. Chen designed the study. J. Chen and R. Nadler acquired looking forward to the next generation of combat casualty care statis- the data, which all authors analyzed. J. Chen, A. Cap and E. Glassberg tics. J Trauma Acute Care Surg 2013;74:683-6. wrote the article, which all authors reviewed and approved for publication. 23. Leigh-Smith S, Harris T. Tension pneumothorax — time for a re- think? Emerg Med J 2005;22:8-16. References 24. Barton ED, Epperson M, Hoyt DB, et al. Prehospital needle aspiration and tube thoracostomy in trauma victims: a six-year experience 1. Eastridge BJ, Mabry RL, Seguin P, et al. Death on the battlefield (2001- with aeromedical crews. Emerg Med J 1995;13:155-63. 2011): implications for the future of combat casualty care. J Trauma 25. Davis DP, Pettit K, Rom CD, et al. The safety and efficacy of pre- Acute Care Surg 2012;73(Suppl 5):S431-7. hospital needle and tube thoracostomy by aeromedical personnel. 2. McPherson JJ, Feigin DS, Bellamy RF. Prevalence of tension pneumo- Prehosp Emerg Care 2005;9:191-7. thorax in fatally wounded combat casualties. J Trauma 2006;60:573-8. 26. Eckstein M, Suyehara D. Needle thoracostomy in the prehospital 3. Kaufmann CR. Initial assessment and management. 6th ed: McGraw-Hill setting. Prehosp Emerg Care 1998;2:132-5. Medical; 2008. 27. Zengerink I, Brink PR, Laupland KB, et al. Needle thoracostomy in 4. Ball CG, Wyrzykowski AD, Kirkpatrick AW, et al. Thoracic needle the treatment of a tension pneumothorax in trauma patients: What size decompression for tension pneumothorax: clinical correlation with needle? J Trauma 2008;64:111-4. catheter length. Can J Surg 2010;53:184-8. 28. Butler KL, Best IM, Weaver WL, et al. Pulmonary artery injury and 5. American College of Surgeons. Advanced trauma life support for doctors. cardiac tamponade after needle decompression of a suspected tension 8th ed: American College of Surgeons; 2008. pneumothorax. J Trauma 2003;54:610-1. 6. Dominguez KM, Ekeh AP, Tchorz KM, et al. Is routine tube thoracos- 29. Rawlins R, Brown KM, Carr CS, et al. Life threatening haemorrhage tomy necessary after prehospital needle decompression for tension after anterior needle aspiration of pneumothoraces. A role for lateral pneumothorax? Am J Surg 2013;205:329-32. needle aspiration in emergency decompression of spontaneous pneumo 7. Cullinane DC, Morris JA Jr, Bass JG, et al. Needle thoracostomy thorax. Emerg Med J 2003;20:383-4. may not be indicated in the trauma patient. Injury 2001;32:749-52. 30. Britten S, Palmer SH. Chest wall thickness may limit adequate drainage 8. Cantwell K, Burgess S, Patrick I, et al. Improvement in the prehospi- of tension pneumothorax by needle thoracocentesis. J Accid Emerg Med tal recognition of tension pneumothorax: the effect of a change to 1996;13:426-7. paramedic guidelines and education. Injury 2014:45;71-6 31. Britten S, Palmer SH, Snow TM. Needle thoracocentesis in tension 9. Stevens RL, Rochester AA, Busko J, et al. Needle thoracostomy for ten- pneumothorax: insufficient cannula length and potential failure. sion pneumothorax: failure predicted by chest computed tomography. Injury 1996;27:321-2. Prehosp Emerg Care 2009;13:14-7. 32. Givens ML, Ayotte K, Manifold C. Needle thoracostomy: implications 10. Akoglu H, Akoglu EU, Evman S, et al. Determination of the appropriate of computed tomography chest wall thickness. Acad Emerg Med catheter length and place for needle thoracostomy by using computed 2004;11:211-3. tomography scans of pneumothorax patients. Injury 2013;44:1177-82. 33. Wayne MA, McSwain NE Jr. Clinical evaluation of a new device for 11. Yamagiwa T, Morita S, Yamamoto R, et al. Determination of the the treatment of tension pneumothorax. Ann Surg 1980;191:760-2. appropriate catheter length for needle thoracostomy by using computed tomography scans of trauma patients in Japan. Injury 2012;43: 34. Jones R, Hollingsworth J. Tension pneumothoraces not responding to 42-5. needle thoracocentesis. Emerg Med J 2002;19:176-7. 12. Inaba K, Ives C, McClure K, et al. Radiologic evaluation of alterna- 35. Sargent EN, Turner AF. Emergency treatment of pneumothorax. A tive sites for needle decompression of tension pneumothorax. Arch simple catheter technique for use in the radiology department. Am J Surg 2012;147:813-8. Roentgenol Radium Ther Nucl Med 1970;109:531-5. 13. Harcke HT, Pearse LA, Levy AD, et al. Chest wall thickness in military 36. Perlmutt LM, Braun SD, Newman GE, et al. Transthoracic needle personnel: implications for needle thoracentesis in tension pneumo aspiration: use of a small chest tube to treat pneumothorax. AJR Am thorax. Mil Med 2007;172:1260-3. J Roentgenol 1987;148:849-51. 14. Inaba K, Branco BC, Eckstein M, et al. Optimal positioning for emer- 37. Casola G, vanSonnenberg E, Keightley A, et al. Pneumothorax: gent needle thoracostomy: a cadaver-based study. J Trauma 2011;71: radiologic treatment with small catheters. Radiology 1988;166:89-91. 1099-103. 38. Conces DJ Jr, Tarver RD, Gray WC, et al. Treatment of pneumo- 15. Blaivas M. Inadequate needle thoracostomy rate in the prehospital set- thoraces utilizing small caliber chest tubes. Chest 1988;94:55-7.

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Current use of live tissue training in trauma: a descriptive systematic review

Luis Teodoro da Luz, MD Background: Growing public concern for animal welfare, advances in computerized Bartolomeu Nascimento, MD, MSc simulation and economic barriers have drawn a critical eye to the use of live tissue training (LTT) in trauma skills acquisition. As a consequence, other simulation methods Col Homer Tien, MD, MSc have replaced LTT, for example, in the Advanced Trauma Life Support (ATLS) Michael J. Kim, MD, MA course. Owing to the lack of clear conclusions in the literature, we conducted a systematic review to determine the value of LTT alone and in comparison to other simulation Avery B. Nathens, MD, PhD methods in trauma. Savvas Vlachos, MD Methods: We performed a systematic review of the literature considering observational Col Elon Glassberg, MD, MHA studies and randomized controlled trials (RCTs) that examined LTT in trauma exclusively or compared with other simulation methods. Independently and in duplicate, we adjudi- Accepted for publication cated studies for inclusion and data abstraction. We assessed the quality and risk of bias. Nov. 18, 2014 Results: Twelve studies met our inclusion criteria: 2 RCTs and 10 prospective cohort studies. Eight and 4 studies were performed in the military and in the civilian settings, Correspondence to: respectively. Anesthetized swine were used in 8 studies and goats in 1. The cohort studies L.T. da Luz involved LTT alone. Different adjunctive training modalities were included: mannequins 2075 Bayview Ave. Rm C1.60 in 6 studies, cadavers in 2, computer simulation in 1, video presentations in 2 and wound Toronto ON M4N 3M5 moulage scenarios in 1. The overall methodological quality was moderate as per the [email protected] Newcastle–Ottawa score (mean 6.0 ± 0, possible range 1–9). The 2 RCTs did not demonstrate adequate random sequence generation and allocation concealment. DOI: 10.1503/cjs.014114 Conclusion: There is limited evidence that other types of simulation are better than LTT. Data on training effects of LTT versus other simulations on outcomes are lacking.

Contexte : Les préoccupations croissantes du public envers le bien-être des animaux, le perfectionnement des dispositifs de simulation informatisés et les contraintes budgétaires ont remis en question la formation sur tissus vivant (FTV) pour l’acquisition des compé- tences en traumatologie. Par conséquent, d’autres méthodes de simulation ont remplacé la FTV, par exemple, le cours ATLS (Advanced Trauma Life Support — Cours avancé de réanimation des polytraumatisés). Étant donné l’absence de conclusions claires dans la littérature, nous avons procédé à une revue systématique afin de comparer la valeur de la FTV seule à celle d’autres méthodes de simulation en traumatologie. Méthodes : Nous avons procédé à une revue systématique de la littérature, plus parti culièrement des études d’observation et des essais randomisés et contrôlés (ERC) portant exclusivement sur la FTV en traumatologie ou en comparaison avec d’autres méthodes de simulation. De manière indépendante et dupliquée, nous avons sélectionné les études à inclure et nous en avons extrait les données. Nous avons évalué la qualité et le risque de biais. Résultats : Douze études répondaient aux critères d’inclusion : 2 ERC et 10 études de cohorte prospectives. Huit et 4 études ont été effectuées dans des contextes militaires et civils, respectivement. Des porcs anesthésiés ont été utilisés pour 8 études et des chèvres pour une étude. Les études de cohorte ne concernaient que la FTV. Les différentes modalités de formation complémentaires incluaient : mannequins dans 6 études, cadavres dans 2 études, simulation par ordinateur dans 1 étude, présentations vidéo dans 2 études et scénarios de moulage de plaies dans 1 étude. La qualité méthodologique globale s’est révélée modérée selon le score Newcastle–Ottawa (moyenne 6,0 ± 0, éventail de valeurs possibles 1–9). Les 2 ERC ne disposaient pas de séquences aléatoires adéquates et l’attribution des traitement n’y était pas effectuée à l’insu. Conclusion : Les preuves dont on dispose pour déterminer si d’autres types de simulation sont préférables à la FTV sont limitées. On manque de données comparatives concernant les effets de la FTV sur l’issue des interventions par rapport à d’autres types de simulations.

n both the military and civilian settings, medical care excluded studies that addressed only other types of simu- providers are trained in trauma care using a combina- lation (not LTT), that involved LTT not performed in I tion of approaches. For example, background know trauma, that used animals for experiments rather than ledge and theory are often provided through didactic lec- training, and that were case reports or case series. Two of tures, while practical and resuscitation skills are often us (L.T.D and S.V.) independently reviewed the abstracts based on a simulation-based platform, including computer of all studies. Agreement between reviewers was assessed simulation, task trainers and mannequins (human patient using Cohen’s κ.5 In case of disagreement, consensus was simulation [HPS]). Finally, live tissue training (LTT) is a reached by discussion with a third author (B.N.J.). Full- form of simulation used more consistently for teaching and text versions of the selected studies were retrieved, and practising more complex surgical procedures.1 we contacted the corresponding authors for further infor- Live tissue training in medical education has been mation if necessary. facing increasing scrutiny owing to the increased focus on animal welfare and by the rapid improvements in medical Data abstraction and analysis simulation technology.2 In the United States, the Depart- ment of Defence has closed a number of animal labora Data were extracted from original studies. We abstracted data tories, including those that used dogs for ballistic wound on study objective, setting and design; participant selection; management training and monkeys in chemical weapons types of LTT and other methods of simulation; intervention; casualty management exercises.3 In the civilian setting, the types of evaluation pre- and posttraining; and outcomes. Two American College of Surgeons’ Advanced Trauma Life of us (L.T.D. and S.V.) independently assessed the risk of bias Support (ATLS) course has largely moved away from for cohort studies based on the Newcastle–Ottawa scale6 and LTT to simulation-based training.1 for RCTs based on the Cochrane Collaboration tool.7 Our Currently, simulation and LTT are still both used in principal objective was to determine whether LTT is better trauma care skills acquisition. However, it remains unclear than any other method of simulation for trauma care skills whether simulation can completely replace LTT or whether acquisition. Owing to clinical and methodological hetero there still remains a role for LTT in trauma education. To geneity among studies, we anticipated reporting results quali- better explore this question, we conducted a systematic tatively instead of conducting a meta-analysis. review to determine the value of LTT alone and in comparison to other simulation training methods in trauma care. Results

Methods Our initial search strategy identified 385 potentially relevant studies. After evaluating 51 full-text manuscripts, we We conducted our systematic review in accordance with determined that 12 studies satisfied our inclusion criteria Preferred Reporting Items for Systematic Reviews and (Fig. 1). There was excellent agreement between the Meta-analyses (PRISMA) guidelines.4 reviewers for study inclusion (κ = 0.84).

Information sources and search technique Study characteristics

With the assistance of an experienced librarian, we searched Of the 12 studies included in our review (Table 1), 10 pub- MEDLINE (1947 to March 2014), EMBASE (1946 to lications8–11,13–17,19 were prospective observational cohort March 2014) and the Cochrane Central Register of Con- studies and 212,18 were RCTs. Eight studies8,11,13,15–19 were trolled Trials (up to March 2014) using the keywords “live performed in the military setting and 4 studies9,10,12,14 in tissue training AND trauma,” “simulation AND trauma,” the civilian setting. Anesthetized swine were used in or “simulation AND surgical training.” Citations of rele- 8 studies9–14,16,18 and goats15 in 1 study; the remaining vant full-text reports were manually searched for additional 3 studies8,17,19 did not report the type of live tissue used for studies. We did not impose language restrictions. Details of training. the search strategy are in Appendix 1. Training consisted of LTT with no direct comparison to other simulations in 10 studies.8–11,13–17,19 In those Eligibility criteria and study selection studies, only pre- and posttraining evaluations were performed, and LTT was conducted concurrently with other Studies were eligible for inclusion in the systematic simulation methods. The remaining 2 studies12,18 com- review if they were observational studies or randomized pared LTT to other training modalities. Different adjunc- controlled trials (RCTs) and if they addressed trauma tive training modalities were included: 6 studies12,15–19 used skills acquisition with LTT exclusively or if they HPS, 218,19 used cadavers, 112 used computer simulation, addressed trauma skills acquisition with LTT compared 28,10 used video presentations and 119 used wound moulage with any other method of training in trauma. We with human volunteers.

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Participant characteristics Interventions

The 12 studies included 2655 trainees. The sample size Cohort studies across studies varied markedly (range 15–1317, median All prospective cohort studies8–11,13–17,19 used LTT alone or 100, interquartile range [IQR] 47–184). In both civilian LTT in combination with some other form of simulation, and military settings the trainees included nonmedical but they made no comparisons between methods and, personnel, noncommissioned officers, medical techni- consequently, had no control groups. Training modalities cians, dentists, nurses, nurse anesthetists and physician in this group varied considerably. In 1 study,11 anesthe- assistants. Among the participants in the medical field tized swine were subjected to penetrating trauma to the were trainees, such as third-year medical students, and abdomen and legs. The ATLS principles were applied junior and more experienced physicians from several spe- initially, and subsequently the swine were transferred to a cialties (e.g., general surgery, trauma surgery, anesthesiol- field hospital and surgical procedures were performed. In ogy, emergency medicine, family medicine and gynecol- another study8 involving the Combat Trauma Life Sup- ogy). Ten studies8–13,16–19 reported the level of participating port (CTLS) course, there was no mention about the type trainees. The 2 randomized trials were conducted with of LTT used and the procedures performed during train- third-year medical students12 and with air force volunteers ing. In 4 studies9,10,13,14 more advanced surgical training with no practical trauma experience.18 was conducted, with repair of penetrating injures to the chest and abdomen; surgical repair of the heart, solid Methodological quality organs, hollow viscera and vessels; and management of injures to the extremities. These studies include the cur- The qualitative synthesis of the cohort studies was per- rent Definitive Surgical Trauma Care (DSTC) course9 formed using the Newcastle–Ottawa score6 (Table 2). The and the Advanced Trauma Operative Management score defines participant groups in cohort studies as com- (ATOM) course.10 Finally, King and colleagues13 studied parable in either the design or analysis when the effect of advanced training in penetrating neck injuries (repair of the exposure is adjusted for confounders. The overall carotid and jugular lesions), transmediastinal gunshot methodological quality was moderate (n = 10 studies), wounds (GSW) and thoracoabdominal penetrating with a mean score of 6.0 ± 0 (possible range 1–9). wounds performed in anesthetized swine. There was a wide variation in the experience of the train- Six studies12,15–19 included mannequins as adjuncts to ees, and the cohorts were representative of the overall popula- LTT. In the 2 studies conducted by Sohn and col- tion in the field of trauma training. Only 1 study11 had partici- leagues15,16 in the military setting, HPS was used for initial pants with similar level of experience. The 10 prospective assessment for endotracheal intubation, surgical airway, cohort studies were not controlled with other training modal- venous and interosseus accesses, tube thoracostomy, ities for trauma skills acquisition. All cohort studies involved tourniquet, triage and resuscitation scenarios. In the LTT pretraining questionnaires (used as control) and posttraining portion, several other more complex procedures were per- questionnaires. All studies had adequate follow-up to allow formed, including amputation, management of eviscer outcomes to occur, and no loss to follow-up was reported. ation and mesenteric bleeding, physiologic monitoring, We used the Cochrane Collaboration tool7 to assess risk moulage casualties and surgical simulation combined with of 5 bias domains in the 2 RCTs (Table 3). Sample size a real time field-training event. Finally, 1 study17 also used was not calculated in these studies. They did not demon- HPS and LTT in a cohort of trainees, but delegated some strate adequate random sequence generation and allocation procedures more appropriate to be performed on the live concealment. Outcome assessors were blinded in both tissue section of the training (e.g., management of eviscera- RCTs. Because the study durations were generally short, tion, local hemostasis, dissection for venous access). neither study had losses to follow-up. These 2 RCTs did not report missing data. No selective reporting or baseline Randomized controlled trials imbalance of participants was detected in either study. The 2 randomized controlled trials evaluated training across 3 different procedures. In the study by Bowyer and Presimulation phase colleagues,12 students were randomized to either LTT or a haptic simulator for teaching diagnostic peritoneal lavage Studies included various forms of adjunctive education (DPL). Both groups of 20 medical students were then approaches. A large variety of didactic lectures were asked to perform DPL in the HPS and were scored on this administered in 11 studies.8,10–19 Case study presenta- performance as the outcome measure. Hall18 administered tions,14–16 microteachings,8 video presentations,8,10 educa- didactic lectures and a basic suturing course and random- tional CD-ROMs,9,10 triage scenarios13,15,16 and discussions ized participants to perform cricothyroidotomy and tube on case simulations14–16,19 were administered mostly in the thoracostomy using HPS and LTT; participants per- presimulation phase. formed both procedures in human cadavers in sequence.

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Outcome measurements Outcomes

Not all studies evaluated their results objectively, and Cohort studies different measurements were performed across studies. Studies that used pre- and posttest questionnaires showed Nine studies8–13,15–17 used multiple-choice question- significant improvement posttraining. In general, posttest naires and Likert scales before and after the training questionnaires demonstrated improvement in knowledge, process, where knowledge, self-confidence, self-efficacy self-perceived confidence and self-awareness.8–12,14–17,19 and expertise were assessed. Details on surgical tech- Participants also felt that the principles taught during train- nique were evaluated in 4 studies.10,12,18,19 Sohn and col- ing were appropriate and necessary to subsequently be leagues,15 in a prospective cohort, conducted a com applied in real life on a patient.13,15,16 In 1 study8 involving the prehensive evaluation of the degree of learning on CTLS course, posttest scores increased from 65% to 76.6% technical skills, understanding of clinical aspects, iden- (p < 0.001) after LTT. In the DSTC course, where training tification of priorities and repair of the induced lesions in thoracic and abdominal lesions were evaluated, Jacobs and in a real time field-training event. Four studies13,15–17 colleagues9 reported that posttest score improvement was included a meeting for debriefing of performance at the greater in less experienced general surgery trainees than in end of the training process. Finally, in 2 studies,13,15 an fellows and staff surgeons. In another study involving the objective written metric questionnaire was completed ATOM course (which uses anesthetized swine for the train- during the training by staff members, and feedback was ing of general surgeons, trauma fellows and general surgery given to participants. residents), the same group10 demonstrated that the

385 potentially relevant citations Medline (n=125) Embase (n=249) Cochrane (n=11) Identi cation

26 duplicates removed

359 records left for screening Screening

308 citations excluded 359 citations screened by title and abstracts (did not meet the inclusion criteria)

39 excluded:

Eligibility 51 full-text articles 1 simulation not using LTT assessed for eligibility 9 nontrauma LTT 18 nontraining experiences using live tissue

12 studies included in qualitative synthesis Included

Fig. 1. Flow diagram of the screening process. LTT = live tissue training.

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knowledge of expert surgeons and trauma fellows improved more recent study19 where surgical skills were assessed in considerably (p = 0.016 and p = 0.005, respectively). Gaarder LTT and mechanical HPS, participants found that clinical and colleagues11 assessed teams of surgeons being trained in shadowing was less valuable than both methods of surgical peripheral lesions and damage control laparotomy in anes- skills acquisition. thetized swine. They reported an improvement of 43% and 60% of the overall score and of the score of younger general Randomized controlled trials surgeons, respectively. King and colleagues13 evaluated the The 2 RCTs involved a small number of participants (n = 64); surgical aspects of trauma management and concluded that had different types of interventions (DPL, tube thoracos- the trainees were able to avoid 20% of preventable deaths. tomy, cricothyroidotomy) and simulation controls; and However, they concluded that additional experience to quan- assessed knowledge, efficacy, competence, awareness and tify the training impact of the type of exercise as well as the technical skills in the 3 training modalities. Bowyer and col- validity of the used metrics were still required. leagues12 conducted a study with medical students, randomiz- In a study by Sohn and colleagues15 in which HPS and ing DPL in a haptic simulator and in anesthetized swine. Sub- LTT were used concurrently during training exercises, sequently, both groups performed DPL in an HPS model. LTT scored higher than HPS (1.48 v. 2.55, p < 0.01). Some There was a significant improvement from baseline know limitations of the study, such as quality of data, may have ledge in both groups, yet more improvement in the graphical affected inferences. Rubiano and colleagues17 reported that interface simulation group in terms of site selection (p < all participants trained using HPS and LTT demonstrated 0.001) and technique (p = 0.002) than those who trained on complete knowledge in the final evaluation. Finally, in a swine. In a study conducted with air force volunteers with no

Table 1. Characteristics of the studies included in the systematic review

Comparator Study Design Setting Participants N Interventions Evaluations group Kluger Prospective Military Students of CTLS course 77 1 – Videos, wound moulage Pre- and No control et al.8 cohort Military physicians, dissimilar 2 – LTT (details not reported) posttraining experience, different training levels Jacobs Prospective Civilian Students of DSTC course 15 1 – Interactive CD-ROM Pre- and No control et al.9 cohort PGY-4, PGY-5, fellows and junior 2 – Anesthetized swine posttraining attendings Jacobs Prospective Civilian Students of ATOM course 50 1 – Anesthetized swine Pre- and No control et al.10 cohort Traumatologists, general surgeons, posttraining trauma fellows, PGY-4 and 5 general surgery residents Gaarder Prospective Military 67% (n = 95) general surgeons 144 1 – Anesthetized swine Pre- and No control et al.11 cohort > 4y of experience inflicted by a GSW to the posttraining 33% (n = 49) < 4y of experience abdomen and to the thigh Bowyer Randomized Civilian Third-year medical students 40 1 – Graphical user interface Pre- and Computer et al.12 controlled No expertise in DPL simulator posttraining simulator trial 2 – Anesthetized swine 3 – HPS King Prospective Military General and orthopedic surgeons, 304 1 – Anesthetized swine Pre- and No control et al.13 cohort nurses, OR technicians, ED posttraining technicians Tugnoli Prospective Civilian Residents and general surgeons 126 1 – Anesthetized swine Posttraining No control et al.14 cohort Level of training not reported Sohn Prospective Military Soldiers deploying to combat 1317 1 – HPS Pre- and No control et al.15 cohort operations 2 – Anesthetized goats posttraining Level of training not reported Sohn Prospective Military Non-surgical graduating residents 60 1 – HPS Pre- and No control et al.16 cohort (internists, gynecologists and 2 – Anesthetized swine posttraining obstetricians) Rubiano Prospective Military Combat nurses, MEDTAC course 374 1 – HPS Pre- and No control et al.17 cohort in Colombia 2 – LTT posttraining Level of training not reported (both not described in details) Hall18 Randomized Military Air force volunteers with no prior 24 1 – HPS Posttraining HPS controlled medical training 2 – Anesthetized swine trial McLaughlin Prospective Military Physicians (general practitioners 124 1 – HPS Posttraining No control et al.19 cohort and surgeons), nurses, physicians 2 – LTT (no details reported) assistants and medical technicians 3 – Cadaveric models Level of training not reported

ATOM = Acute Trauma Operative Management; CTLS = Combat Trauma Life Support; DPL = diagnostic peritoneal lavage; DSTC = Definitive Surgical Trauma Care; ED = emergency department; GSW = gunshot wound; HPS = human patient simulation; LTT = live tissue training; MEDTAC = combat tactical medicine course; OR = operating room; PGY = postgraduate year.

Can J Surg, Vol. 58 (Issue 3 Suppl 3) June 2015 S129 RECHERCHE prior medical training, Hall18 conducted training in cricothy- (evaluation of an entire field exercise) to specific (evaluation of roidotomy and tube thoracostomy, randomizing LTT (anes- the performance on a specific surgical procedure). Our overall thetized swine) and HPS. In sequence, the 2 groups per- conclusion is that simulation, independent of its modalities, formed both procedures in human cadavers. There was no improves knowledge, efficacy, competency, surgical skills and statistical difference in average completion time for the pro awareness. We did not identify a body of evidence robust cedures in both groups (p = 0.74 and p = 0.32, respectively). enough to conclude whether LTT is better than other simu- Confidence was higher overall in the LTT group, but no sta- lation methods. Small sample size, different levels of training tistical difference was found (p = 0.42). The success rates of participants, different forms of interventions and simulators, cricothyroidotomy and chest tube placement were higher in absence of controls in the majority of studies and different the animal group, but with no statistical significance (p = 0.67 outcomes assessed are factors impeding a more reliable analy- and p = 0.99, respectively). There was no difference in out- sis and conclusion. Studies did not include reliability or valid- comes or confidence for both procedures in both groups. ity data, and a large number of them used different types of participant surveys to evaluate self-reported operative confi- Discussion dence or course efficacy. An additional limitation is the potential for assessor bias, as most prospective cohort studies Our systematic review yielded 12 studies addressing LTT involved 1 or more evaluators assessing performance, and alone or concurrently with other forms of simulation in these studies did not provide their curricular information. trauma, 2 of which were RCTs. The 10 prospective cohort Both RCTs had small sample sizes. There were only studies conducted pre- and posttraining evaluations but did 64 participants in total across both RCTs, which influenced not directly compare LTT with other methods of trauma the detection of differences among forms of training. There skills acquisition. The objectives varied, ranging from general were multiple and confounding comparisons. The power to

Table 2. Newcastle-Ottawa score6 for the cohort studies included in the systematic review

Selection of Outcome Representativeness nonexposed Ascertainment not Comparability Assessment Adequate Loss to Total Study of participants cohort of exposure present of controls of outcome follow-up follow-up score Kluger Somewhat No control Prospective Yes* No control Prospective Yes* None 6/9 et al.8 representative* group cohort* cohort* reported* Jacobs Somewhat No control Prospective Yes* No control Prospective Yes* None 6/9 et al.9 representative* group cohort* cohort* reported* Jacobs Somewhat No control Prospective Yes* No control Prospective Yes* None 6/9 et al.10 representative* group cohort* cohort* reported* Gaarder Truly representative* No control Prospective Yes* No control Prospective Yes* None 6/9 et al.11 group cohort* cohort* reported* King Somewhat No control Prospective Yes* No control Prospective Yes* None 6/9 et al.13 representative* group cohort* cohort* reported* Tugnoli Somewhat No control Prospective Yes* No control Prospective Yes* None 6/9 et al.14 representative* group cohort* cohort* reported* Sohn Somewhat No control Prospective Yes* No control Prospective Yes* None 6/9 et al.15 representative* group cohort* cohort* reported* Sohn Somewhat No control Prospective Yes* No control Prospective Yes* None 6/9 et al.16 representative* group cohort* cohort* reported* Rubiano Somewhat No control Prospective Yes* No control Prospective Yes* None 6/9 et al.17 representative* group cohort* cohort* reported* McLaughlin Somewhat No control Prospective Yes* No control Prospective Yes* None 6/9 et al.19 representative* group cohort* cohort* reported*

Refer to Wells et al.6 for a description of Newcastle–Ottawa Quality Assessment Scale for cohort studies. In general, more stars denote higher quality. Representativeness is awarded a star if the cohort is truly or somewhat representative of the population of interest. For selection of the nonexposed cohort, a star is awarded if it is drawn from the same population as the exposed cohort. The relevant exposure in this review is the surgical procedure performed in the live tissue; we considered a nonexposed cohort to be one that performed the procedure in another simulation method. Exposure is satisfactorily ascertained if data are collected from a secure record. A star is awarded if the outcome is not present at the start of the study. A maximum of 2 stars can be given for comparability of controls for controlling of confounders in either the design (matching) or analysis (statistical adjustment) phase. We also gave 1 star when selection criteria appeared to create comparable groups via restriction. Assessment of outcome is awarded a star if the outcomes were assessed by independent blind assessment or record linkage. The duration of follow-up was considered adequate if it was long enough for the outcomes to occur. Completeness of follow-up was considered adequate if all participants were accounted for or if the number lost to follow-up was sufficiently low to be unlikely to introduce bias.

Table 3. Risk of bias assessment for randomized controlled trials based on the Cochrane Collaboration tool7 Random Blinding of sequence Allocation participants and Incomplete Selective Study generation concealment researches outcome data reporting Baseline imbalance Sample size Bowyer et al.12 High risk High risk Low risk Low risk Low risk Low risk Not calculated Hall18 High risk High risk Low risk Low risk Low risk Low risk Not calculated

S130 J can chir, Vol. 58 (No 3 Suppl 3) juin 2015 RESEARCH detect any differences was further diluted by different com- A wide range of trauma training modalities exist,21 but each parisons, both within and between studies. The comparisons (including high-fidelity simulators) has limitations. Cherry may have also been confounded by factors such as mentor- and Ali21 commented on the realism and authenticity prob- ing, which could have swamped any effect of simulation. The lems of using simulators and concluded that these challenges component tasks varied considerably between studies. Com- needed to be overcome. Human cadavers and HPS currently parators were not standardized. In all studies, superiority of do not provide the ideal solution. Most patient simulators do simulation and LTT was found when any type of simulation not bleed. Those that do bleed do not respond in the same was applied compared with no simulation, but there was no biological way that bleeding patients do in clinical practice. standardization for comparison of LTT with another simula- Therefore, complex surgical skills are usually taught on live tion method. The surgical simulations may not have been tissue models, because dissection and bleeding is not properly intensive or long enough to show an effect on training. simulated in any other models. Likewise, research in bleeding While some simulator interventions were very brief, a prac- and hemorrhage control is never conducted using manne- tice effect with longer simulator exposure was not generally quins. Mannequins cannot simulate bleeding accurately. An evident. However, most simulator interventions showed sig- example of the importance of using live tissue is testing new nificant improvements pre- and postintervention. Outcome hemostatic dressings,22–32 which would be impossible to per- assessors in the RCTs were blinded to group, but the partici- form in mannequins or with virtual simulation. pants could not be blinded. Although human cadavers are advantageous because of their anatomic similarity, dead tissue does not respond to Limitations surgical procedures and other interventions in the same way that living patients do in everyday trauma practice. Different To our knowledge, our study is the first to summarize the lit- anatomy is a disadvantage in live animals. Clearly, dogs and erature concerning the use of LTT in trauma alone or com- goats do not have anatomy identical to humans, which is pared with other forms of simulation, but robust conclusions demonstrated in the study by McCarthy and colleagues.33 In are limited by the overall low methodological quality of the that study, necks with attempted cricothyroidotomies were included studies. We used a comprehensive search strategy inspected and mapped, and the authors found that 30.2% of to exhaustively identify any relevant studies in the published cricothyroidotomies in the canine models were misplaced. literature. We found only 2 small experimental studies and Cricothyroidotomy placement in human cadavers was cor- the quality of the observational analytic cohorts is limited. rect in 96.4%. Included studies were heterogeneous with respect to partici- We agree that supervised hands-on experience in the man- pants, interventions, controls, measurements and outcomes, agement of trauma patients would be the best solution; how- limiting clinical interpretation and generalizability. Major ever, this does not take into account the ongoing lack of limitations of this review are related to the limitations of the supervision in many hospitals nor does it account for the included studies. Better-designed and larger cohort studies reduced exposure to operative trauma being experienced by and RCTs are lacking. many trainees worldwide. On the other hand, there are a number of simulators available for generic training which, Unanswered questions and future research although improving in their ability to provide useful training, do not yet have the full capability of encompassing all aspects The current body of literature does not answer the persist of live tissue training.34 For this reason, the American College ent question of which method provides the most effective of Surgeons “supports the use and humane care and treat- training and improvement in self-confidence for physicians ment of laboratory animals in research, education, teaching, worldwide. In a study20 in the military setting, we assessed and product safety testing in accordance with applicable local, the association of experience using different training state, and federal animal welfare laws.” The American Col- modalities, including LTT, with self-reported confidence lege of Surgeons comments that “wherever feasible, alterna- in procedure performance. Advanced life support providers tives to the use of live animals should be developed and were sent a questionnaire regarding their experience with employed” but “believes that now and in the foreseeable and self-confidence levels in performing endotracheal intu- future it is not possible to completely replace the use of ani- bation, cricothyroidotomy, needle chest decompression, mals and that the study of whole living organisms, tissues, and tube thoracostomy and intraosseous infusion. Self- cells is an indispensable element of biomedical research, edu- confidence levels in procedure performance were positively cation, and teaching.”35 associated with experience gained from mannequins and Understandably, the primary argument against the use from supervised and unsupervised application in patients. of LTT encompasses highly emotive ethical and moral We were not able to demonstrate a clear benefit of an ani- objections to the harming of live animals. These cannot be, mal model in increasing self-confidence. A plateau was gen- nor should they be, ignored. However, to suggest that erally identified, indicating decreased benefit from the use there is evidence to say that the use of currently available of a particular training modality for a particular procedure. simulators is equivalent or superior to LTT for all trauma

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3. Reprieve from wound tests is ended for pigs and goats. New York procedures and skills is erroneous. The development of Times Jan. 24, 1984. Available: www.nytimes.com/1984/01/24/us more realistic simulators to address these issues needs to /reprieve-from-wound-tests-is-ended-for-pigs-and-goats.html (accessed progress in order that LTT can be discontinued. 2015 May 1). While simulators other than LTT have been developed 4. Moher D, Liberati A, Tetzlaff J, et al. Preferred reporting items for and have already replaced some use of live animals in systematic reviews and meta-analyses: the PRISMA statement. Int J Surg 2010;8:336-41. many areas of trauma training, there is still a need for 5. Cohen J. Weighted kappa: nominal scale agreement with provision development of clinically relevant simulation models. Fur- for scaled disagreement or partial credit. Psychol Bull 1968;70:213-20. thermore, such models will need to be validated by studies 6. Wells GA, Shea B, O’Connell D, et al. The Newcastle-Ottawa Scale that use assessment tools that reliably address skills acqui- (NOS) for assessing the quality of nonrandomised studies in meta- sition, the transfer of skills to the operating room and real analyses. Ottawa Hospital Research Institute. Available: www.ohri.ca /programs/clinical_epidemiology/oxford.asp (accessed 2015 May 1). trauma environments, and the retention of such skills over 7. Higgins JP, Altman DG, Gotzsche PC, et al. The Cochrane Collab- time. While there may be compelling reasons to reduce oration’s tool for assessing risk of bias in randomised trials. BMJ reliance on patients, cadavers and animals for trauma 2011;343:d5928. training, none of the methods of simulated training has 8. Kluger Y, Rivkind A, Donchin Y, et al. A novel approach to military yet been shown to be better than these forms of training. combat trauma education. J Trauma 1991;31(4):564-569. 9. Jacobs LM, Lorenzo C, Brautigam RT. Definitive surgical trauma Adequately powered, well-designed and unconfounded care live porcine session: a technique for training in trauma surgery. RCTs (preferably multicentre with similar protocols) are Conn Med 2001;65:265-8. needed, and outcome assessors need to be blinded. Out- 10. Jacobs LM, Burns KJ, Kaban JM, et al. Development and evaluation comes need to be tested in actual operative circumstances of the advanced trauma operative management course. J Trauma (or on validated systems). In particular, model simulation 2003;55:471-9. 11. Gaarder C, Naess PA, Buanes T, et al. Advanced surgical trauma needs to be further tested against computer simulation. care training with a live porcine model. Injury 2005;36:718-24. Studies of cost comparisons are also needed. The RCTs 12. Bowyer MW, Liu AV, Bonar JP. Validation of SimPL — a simulator included in our analysis dealt exclusively with technical for diagnostic peritoneal lavage training. Stud Health Technol Inform skills, although other skills, such as cognitive and com 2005;111:64-7. munication skills, are clearly integral parts of the trauma 13. King DR, Patel MB, Feinstein AJ, et al. Simulation training for a mass casualty incident: two-year experience at the army trauma train- training process. ing center. J Trauma 2006;61:943-8. 14. Tugnoli G, Ribaldi S, Casali M, et al. Initial evaluation of the Conclusion “trauma surgery course”. World J Emerg Surg 2006;1:5. 15. Sohn VY, Miller JP, Koeller CA, et al. From the combat medic to Our systematic review demonstrated limited observational the forward surgical team: the Madigan model for improving trauma readiness of brigade combat teams fighting the global war on terror. and experimental evidence on the use of LTT in trauma. J Surg Res 2007;138:25-31. This review will enable clinicians to better appreciate the 16. Sohn VY, Runser LA, Puntel RA, et al. Training physicians for combat deficiencies identified in the literature, and enable investiga- casualty care on the modern battlefield.J Surg Educ 2007;64:199-203. tors to design more appropriate trials in the future. The 17. Rubiano AM, Sanchez AI, Guyette F, et al. Trauma care training for existing literature helps clinicians to appreciate the potential national police nurses in Colombia. Prehosp Emerg Care 2010;14:124-30. 18. Hall AB. Randomized objective comparison of live tissue training impact of the use of LTT in trauma. However, adequately versus simulators for emergency procedures. Am Surg 2011;77:561-5. powered and methodologically sound RCTs will be 19. McLaughlin T, Hennecke P, Garraway NR, et al. A predeployment required to prove positive effects on outcomes. trauma team training course creates confidence in teamwork and clin ical skills: a post-Afghanistan deployment validation study of Canadian Affiliations: From the Department of Surgery and Critical Care Medi- forces healthcare personnel. J Trauma 2011;71(Suppl 1):S487-93. cine, Sunnybrook Health Sciences Centre, University of Toronto, 20. Sergeev I, Lipsky AM, Ganor O, et al. Training modalities and self- Toronto, Ont. (da Luz, Nascimento, Tien, Kim, Nathens, Vlachos); confidence building in performance of life saving procedures. Mil and Trauma & Combat Medicine Branch, Surgeon General Headquar- Med 2012;177:901-6. ters, Israel Defense Forces, Ramat Gan, Israel (Glassberg). 21. Cherry RA, Ali J. Current concepts in simulation-based trauma education. J Trauma 2008;65:1186-93. Competing interests: None declared. 22. Pusateri AE, Modrow HE, Harris RA. Advanced hemostatic dressing Contributors: L. da Luz, A. Nathens and H. Tien designed the study. development program: animal model selection criteria and results of L. da Luz, B. Nascimento, S. Vlachos and M. Kim acquired the data, a study of nine hemostatic dressings in a model of severe large venous which L. da Luz and E. Glassberg analyzed. L. da Luz, S. Vlachos and hemorrhage and hepatic injury in swine. J Trauma 2003;55:518-26. M. Kim wrote the article, which all authors reviewed and approved for 23. Alam HB, Chen Z, Jaskille A. Application of a zeolite hemostatic publication. agent achieves 100% survival in a lethal model of complex groin injury in swine. J Trauma 2004;56:974-83. References 24. Alam HB, Uy GB, Miller D, et al. Comparative analysis of hemo- 1. Matt Ritter E, Bowyer MW. Simulation for trauma and combat static agents in a swine model of lethal groin injury. J Trauma casualty care. Minim Invasive Ther Allied Technol 2005;14:224-34. 2003;54:1077-82. 2. Gala SG, Goodman JR, Murphy MP, et al. Use of animals by 25. Sondeen JL, Pusateri AE, Coppes VG, et al. Comparison of 10 differ- NATO countries in military medical training exercises: an interna- ent hemostatic dressings in an aortic injury. J Trauma 2003;54:280-5. tional survey. Mil Med 2012;177:907-10. 26. Ward KR, Tiba MH, Holbert WH, et al. Comparison of a new

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hemostatic agent to current combat hemostatic agents in a swine model hemostatic dressings in a large animal model of lethal groin injury. of lethal extremity arterial hemorrhage. J Trauma 2007;63:276-83. J Trauma 2006;61:1312-20. 27. Acheson EM, Kheirabadi BS, Deguzman R, et al. Comparison of 32. Kheirabadi BS, Acheson EM, Deguzman R, et al. The potential util- hemorrhage control agents applied to lethal extremity arterial hem- ity of fibrin sealant dressing in repair of vascular injury in swine. orrhages in swine. J Trauma 2005;59:865-74. J Trauma 2007;62:94-103. 28. Sohn VY, Eckert MJ, Martin MJ, et al. Efficacy of three topical 33. McCarthy MC, Ranzinger MR, Nolan DJ, et al. Accuracy of crico- hemostatic agents applied by medics in a lethal groin injury model. thyroidotomy performed in canine and human cadaver models during J Surg Res 2009;154:258-61. 29. Satterly S, Nelson D, Zwintscher N. Hemostasis in a noncompress- surgical skills training. J Am Coll Surg 2002;195:627-9. ible hemorrhage model: an end-user evaluation of hemostatic agents 34. Moore WA, Noonan AC. Using live tissue laboratories to promote in a proximal arterial injury. J Surg Educ 2013;70:206-11. clinical reasoning in doctor of physical therapy students. Adv Physiol 30. Kheirabadi BS, Acheson EM, Deguzman R, et al. Hemostatic effi- Educ 2010;34:54-8. cacy of two advanced dressings in an aortic hemorrhage model in 35. Statement on the use of animals in research, education, and teaching. swine. J Trauma 2005;59:25-34. American College of Surgeons, Oct. 1, 2002. Available: www.facs.org 31. Ahuja N, Ostomel TA, Rhee P, et al. Testing of modified zeolite /fellows_info/statements/st-10.html (accessed 2015 May 1).

Appendix 1: details of the search strategy for the systematic review Database: Embase Classic+Embase <1947 to 2014 Week 10> Search strategy: 1. exp injury/ (1651979) 2. exp traumatology/ (8546) 3. ((trauma or wound or injur*) adj5 (surgery or surgical or operat* or treat* or manage*)).mp. (170769) 4. 1 or 2 or 3 (1684927) 5. live tissue.mp. (293) 6. tissue training.mp. (17) 7. (human adj5 patient adj5 simulation).mp. (3748) 8. HPS.mp. (3409) 9. (simulation adj3 train*).mp. (2944) 10. exp computer simulation/ (81884) 11. patient simulation.mp. (591) 12. 5 or 6 or 7 or 8 or 9 or 10 or 11 (91737) 13. exp medical education/ or exp paramedical education/ (325721) 14. resident/ (10894) 15. ((resident* or fellow* or graduate or postgraduat* or post graduat* or surgery or 16. surgeon or surgical) adj5 (train* or intern* or learn* or teach* or mentor*)).mp. 17. (74077) 18. 13 or 14 or 15 (371806) 19. 4 and 12 and 16 (249) Database: EBM Reviews – Cochrane Central Register of Controlled Trials Search Strategy: 1. ((trauma or wound or injur*) adj5 (surgery or surgical or operat* or treat* or manage*)).mp. (8966) 2. live tissue.mp. (3) 3. tissue training.mp. (3) 4. (human adj5 patient adj5 simulation).mp. (10) 5. HPS.mp. (75) 6. (simulation adj3 train*).mp. (182) 7. computer simulation.mp. (1052) 8. patient simulation.mp. (258) 9. (resident* or fellow* or graduate or surgeon or postgraduat* or post graduat* or train* or intern* or learn* or education or mentor*).mp. (77945) 10. 10 1 and (2 or 3 or 4 or 5 or 6 or 7 or 8) and 9 (11)

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Appendix 1 (continued from previous page)

Database: Ovid MEDLINE(R) and Ovid OLDMEDLINE(R) <1946 to March Week 1 2014> Search strategy: 1. exp “Wounds and Injuries”/ (696127) 2. exp Traumatology/ (2119) 3. ((trauma or wound or injur*) adj5 (surgery or surgical or operat* or treat* or manage*)).mp. (121574) 4. 1 or 2 or 3 (762472) 5. live tissue.mp. (185) 6. tissue training.mp. (12) 7. (human adj5 patient adj5 simulation).mp. (99) 8. HPS.mp. (2296) 9. (simulation adj3 train*).mp. (1238) 10. exp Computer Simulation/ (146757) 11. patient simulation/ (3044) 12. 5 or 6 or 7 or 8 or 9 or 10 or 11 (152436) 13. exp education, professional/ (235463) 14. ((resident* or fellow* or graduate or postgraduat* or post graduat* or surgery or surgeon or surgical) adj5 (train* or intern* or learn* or teach* or mentor*)).mp. (33602) 15. 13 or 14 (252560) 16. 4 and 12 and 15 (125)

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Acute nontraumatic general surgical conditions on a combat deployment

Capt Dylan Pannell, MD, PhD Background: Literature is lacking on acute surgical problems that may be encoun- Avery B. Nathens, MD, PhD tered on military deployment; even less has been written on whether or not any of these surgical problems could have been avoided with more focused predeployment Col Jacques Ricard, MD screening. We sought to determine the burden of illness attributable to acute non- LCol Erin Savage, MD traumatic general surgical problems while on deployment and to identify areas where more rigorous predeployment screening could be implemented to decrease surgical Col Homer Tien, MD, MSc resource use for nontraumatic problems.

Accepted for publication Methods: We studied all Canadian Armed Forces (CAF) members deployed to Feb. 25, 2015 Afghanistan between Feb. 7, 2006, and June 30, 2011, who required treatment for a nontraumatic general surgical condition. Correspondence to: Results: During the study period 28 990 CAF personnel deployed to Afghanistan; D. Pannell 373 (1.28%) were repatriated because of disease and 100 (0.34%) developed an acute Sunnybrook Health Sciences Centre H171 — 2075 Bayview Ave. general surgical condition. Among those who developed an acute surgical illness, Toronto ON M4N 3M5 42 were combat personnel (42%) and 58 were support personnel (58%). Urologic [email protected] diagnoses (n = 34) were the most frequent acute surgical conditions, followed by acute appendicitis (n = 18) and hernias (n = 12). We identified 5 areas where intensified predeployment screening could have potentially decreased the incidence of in- DOI: 10.1503/cjs.013414 theatre acute surgical illness. Conclusion: Our findings suggest that there is a significant acute care surgery element encountered on combat deployment, and surgeons tasked with caring for this population should be prepared to treat these patients.

Contexte : Il y a un manque de données sur les problèmes chirurgicaux aigus qui peuvent survenir lors de déploiements militaires, et encore moins sur la question de savoir si on aurait pu éviter ces problèmes en faisant un dépistage plus ciblé avant le déploiement. Nous avons tenté de déterminer le fardeau de la maladie attribuable à des problèmes non traumatiques aigus de chirurgie générale pendant le déploiement, puis d’identifier les domaines où un dépistage préalable plus rigoureux pourrait être mis en œuvre pour réduire l’utilisation des ressources chirurgicales pour les pro blèmes non traumatiques. Méthodes : Notre étude a porté sur tous les membres des Forces armées canadiennes (FAC) déployés en Afghanistan entre le 7 février 2006 et le 30 juin 2011 et qui ont eu besoin de traitement pour un état chirurgical général non traumatique. Résultats : Pendant la période de l’étude, 28 990 membres des FAC ont été déployés en Afghanistan; 373 (1,28 %) ont été rapatriés en raison de maladie et 100 (0,34 %) ont développé un état chirurgical général aigu. Parmi ces derniers, 42 faisaient partie du personnel de combat (42 %) et 58 faisaient partie du personnel de soutien (58 %). Les diagnostics urologiques (n = 34) constituaient les états chirurgicaux aigus les plus fréquents, suivis de l’appendicite aiguë (n = 18) et des hernies (n = 12). Nous avons identifié 5 domaines où un dépistage intensifié, préalable au déploiement, aurait possiblement réduit l’incidence des états chirurgicaux aigus en théâtre d’opérations. Conclusion : Il ressort de nos conclusions que les missions de combat comportent un important élément de soins chirurgicaux aigus et que les chirurgiens chargés de soigner cette population devraient être préparés à traiter ces patients.

he Afghan war represented the largest combat Director of Health Service Operations database deployment of Canadian Armed Forces (CAF) per- T sonnel in a generation, with the involvement of The DHSO database was established for prospective almost 29 000 Canadian soldiers, sailors, airmen and air- evaluation of all CAF members who required medical women. In order to support this operation, considerable evacuation or repatriation commencing in November medical resources were deployed as well. Specifically, a 2006. All entries before November 2006 were captured Canadian-led Military Field Hospital was established at retrospectively. Final diagnoses were coded using ICD- Kandahar Airfield Field on Feb. 7, 2006. This facility was 9-CM codes after the patient was evaluated and treated known as the Role 3 Multinational Medical Unit and after his/her disposition was determined. This data- (R3-MMU). As a part of this field hospital, a substantial base tracked all cases of reported injury or illness in the surgical presence was necessary, including general sur- Afghan theatre of operations. The database included per- geons, anesthetists, operating room nursing staff and sonnel requiring medical evacuation from the battlefield operating room technicians. The R3-MMU provided to a higher echelon of care (usually the R3-MMU); per- frontline trauma care for Canadian and allied military personnel presenting to the R3-MMU who required hospi- sonnel. The success of this facility, and others like it, has talization but were not transported there via the normal been reported previously.1–3 military medical evacuation chain (e.g., soldiers who were In addition to providing care for injured military already stationed at Kandahar Airfield base or who were members, this medical facility also provided specialist transported there via means other than a formal medical care for nontraumatic general surgical emergencies. Such evacuation); and personnel requiring outpatient care, but emergencies included (but were not limited to) appendi- who subsequently required treatment not available at a citis, testicular torsion, diverticulitis, bowel obstructions military medical unit in Afghanistan or who required pro- and incarcerated hernias. In an attempt to mitigate the longed recovery and, as such, were repatriated back to need to expend resources on illness-related issues during either Landstuhl Regional Medical Center in Germany the mission, all CAF personnel underwent medical or back to Canada. screening immediately before deployment. The goal of this screening was to identify any medical conditions that Canadian Forces Health Information System could potentially result in illness or medical emergency. Previous investigators have reported the relative inci- The Canadian Forces Health Information System dence of surgical gastrointestinal illness requiring medical (CFHIS) is the electronic patient record system for the repatriation.4 Even so, there is a relative paucity of litera- CAF. It is the main repository of medical information ture on the specific acute (nontraumatic) surgical prob- for the Canadian Forces Health Services. The CFHIS lems that may be encountered on military deployment; was accessed to obtain information on predeployment even less has been written on whether or not any of these screening or previous occurrences of illness in patients surgical problems could have been avoided with more with acute general surgical conditions diagnosed in focused predeployment screening. theatre as well as medical sequelae of these conditions In this study, we sought to determine the burden of postdeployment. illness attributable to acute nontraumatic general sur gical problems while on deployment. Further, we also Acute nontraumatic general surgical conditions attempted to identify areas where more rigorous predeployment screening could be implemented to decrease At the R3-MMU, Canada deployed a maxillofacial sur- surgical resource use for nontraumatic problems. These geon, a general surgeon, an orthopedic surgeon and an data may help to plan future deployments both in terms anaesthesiologist along with a general internist. Upper of the nontrauma surgical capabilities of forward and lower endoscopy was the responsibility of the gen- deployed field hospitals as well as focusing predeploy- eral surgeon. The maxillofacial surgeon was responsible ment screening to better avoid the presentation of sur for problems related to the parotid, thyroid and salivary gical disease in theatre. glands and to other related nontraumatic conditions. We defined general surgical conditions as those involv- Methods ing the torso and/or skin and would include surgical problems that would have normally fallen under the care of We studied all Canadian Armed Forces (CAF) members thoracic surgery, gastroenterology, obstetrics and gynecol- deployed to Afghanistan between Feb. 7, 2006, and June ogy and urology. 30, 2011, who required treatment for a nontraumatic gen- Table 1 includes a list of ICD-9-CM diagnoses that eral surgical condition. All such incidents were captured were defined a priori as acute general surgical conditions through the Director of Health Service Operations and conditions that were excluded as general surgical con- (DHSO) database. ditions for the purposes of this study.

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Statistical analysis There was a wide spectrum of acute surgical conditions among patients requiring repatriation. Urologic diagnoses The DHSO database was queried for patients meeting (n = 34) were most frequent, including renal colic (n = 24), our inclusion criteria. All diagnoses attributed to trau- testicular tumours (n = 4), testicular torsion (n = 4) and acute matic injury were excluded. Once cases meeting our cri epididymitis/orchitis (n = 2). Acute appendicitis was the next teria were identified, we reviewed the electronic health most common (n = 18). Seventeen of these 18 patients records of each patient in CFHIS to identify previous underwent open appendectomy with return to full duties in occurrences of the same illness either before the incident theatre with no need for evacuation to higher echelon care. event or during predeployment screening. This study was One patient was managed nonoperatively. Hernias (n = 12) approved by the Surgeon General of the CAF and the were the third most common diagnosis: 11 inguinal and 1 institutional research ethics board of Sunnybrook Health incarcerated umbilical hernia. There were a total 6 cases of Sciences Centre, Toronto, Ont. acute cholecystitis, 7 cases of ischiorectal abscesses and 5 cases of inflammatory bowel disease (Table 2). Results Potentially preventable acute surgical diagnoses Demographics and acute surgical diagnoses Given the resources required to treat acute surgical issues Over the course of the 62-month study period 28 990 CAF in theatre, we next sought to identify potentially prevent- personnel deployed to Afghanistan as part of the combat able emergency surgical issues. We identified 5 areas operation. A total of 373 (1.28%) were repatriated because where intensified predeployment screening could have of disease and 100 (0.34%) developed an acute general potentially decreased the incidence of in-theatre acute surgical condition while in the Afghan Theatre of Opera- surgical illness. Specifically, we examined cases of hernias, tions (Table 2). The majority of these patients were men testicular masses, acute cholecystitis, renal colic and (94%) and the mean age was 29 (range 19–47) years. inflammatory bowel disease. Among those who developed an acute surgical illness, With regard to hernias, we retrospectively reviewed the 42 were combat personnel (42%) and 58 were support per- electronic medical records of all 12 patients with hernias sonnel (58%). With regards to the rank of these personnel, who required repatriation or acute surgical intervention. 73 were junior noncommissioned members, 20 were senior (Table 3). None of the 11 patients with groin hernias had noncommissioned members, 5 were junior officers and them documented in their predeployment physical exam 2 were senior officers. and only 7 of the patients (64%) had a documented groin

Table 1. ICD-9-CM general surgical diagnoses

ICD-9-CM diagnostic codes General surgical conditions Non–general surgical conditions 001–139 Infections and parasites 140–149, 190–94 Neoplasms of the head and neck 150–165, 170–89, Neoplasms of the chest and 195–99, 209–239 abdomen 200–208 Neoplasms of the lymphatic system and the blood 240–519 Aneurysms (441,442) Disease of the endocrine, blood, nervous, Arterial embolism (444) respiratory and circulatory systems. Mental Empyema (510, 513) disorders Pneumothorax (512) 520–579 Disease of the digestive system Oral cavity and neck (520–529) Functional disorder (564) Liver disorders (570–573) 580–629 Renal calculi (592–94) Disease of the genitourinary system Hydrocele (603) Epididymitis/orchitis (604) Testicular torsion (608) Breast problems (610–616) Female genital tract, pelvic organs (614–629) 630–679 Ectopic (630–33) Pregnancy Miscarriage (634–39) Antepartum hemorrhage (640–41) Peripartum complications (660–79) 680–686 Infections of the skin 690–709 Other skin disorders 710–779 Musculoskeletal, congenital, perinatal 780–799 Nonspecific symptoms

Can J Surg, Vol. 58 (Issue 3 Suppl 3) June 2015 S137 RECHERCHE exam. In the 1 patient with an umbilical hernia, the defect Afghanistan after undergoing laparoscopic cholecystec- was identified and documented before deployment; how- tomy in Canada or at Landstuhl Regional Medical Center. ever, at the time there was no evidence of incarceration One patient was managed nonoperatively with a return to and the patient was asymptomatic. duty and interval cholecystectomy postdeployment. There We reviewed the cases of the 4 patients with testicular were no clinically important sequelae associated with any masses who required repatriation for further investigation of these patients. and treatment (Table 4). We were able to review the pre- None of the patients with renal colic had a documented deployment physical examinations for 3 of these patients. history of previous episodes of renal colic. Of the 5 patients All 3 had testicular exams documented as normal, although with inflammatory bowel disease, only 1 had a previous in 1 patient a self-examination was performed. The time diagnosis of inflammatory bowel disease made in Canada. between the last full periodic health assessment and the diagnosis was 2 years in 1 patient, 10 months in the second Discussion and 14 months in the third, who performed a self-exam. No testicular masses were identified in any of these indi- We have described the acute care surgical issues encoun- viduals on these predeployment examinations. tered during a combat mission. Over the course of the There were a total of 6 patients with acute cholecystitis 5-year combat mission in Afghanistan, the CAF deployed encountered during deployment (Table 5). All of them nearly 29 000 personnel in support of this operation. required repatriation for cholecystectomy, as laparoscopic These personnel were all relatively healthy to begin with instruments were not available in theatre. All 6 patients by virtue of their employment as soldiers, sailors, airmen, had calculous cholecystitis. A review of their electronic and airwomen in the CAF. The relative absence or low patient records showed that none of them had reported incidence of some acute surgical diagnoses is reflective of any previous episodes of biliary colic or cholelithiasis. this fact. For example there were only 3 patients with Three of the 6 patients were able to return to duty in adhesive small bowel obstruction, 1 with intestinal ischemia and 1 with diverticular disease. As the popula- Table 2. Patient demographic and clinical tion we studied were predominantly young men, the characteristics and acute surgical diagnoses observed acute care surgical issues encountered were

Characteristic No. of patients* likely a reflection of this demographic. There was no significant difference in incidence of acute surgical illness General surgical diagnosis 100 Age, mean (range), yr 30 (19–47) between personnel deployed in either combat or support Male sex 95 roles, suggesting that acute care surgical issues affect per- Female sex 5 sonnel irrespective of their physical employment. Role Combat personnel 42 Table 3. Outcomes of hernia screening and identification Support personnel 48 Rank Outcome No. (%) of patients Junior NCM (Pte–MCpl) 73 Repatriations owing to umbilical hernias 1 (—) Senior NCM (Sgt–CWO) 20 Predeployment identification of umbilical hernia 1 (100) Junior officer (2Lt–Capt) 5 Repatriations owing to inguinal hernia 11 (—) Senior officer (Maj–Col) 2 Predeployment examination of groin 7 (64) Diagnosis Predeployment identification of inguinal hernia 0 Hernias 12 Testicular tumour 4 Table 4. Outcomes of testicular mass screening and Cholecystitis 6 identification Appendicitis 18 Outcome No. (%) of patients Ischiorectal abscess 7 Bowel obstruction 3 Repatriations owing to testicular masses 4 (—) Intestinal ischemia 1 Predeployment testicular exam* 3 (100) IBD 5 Identification of testicular masses 0 Renal colic 24 *There were no data available for 1 patient. Cololrectal cancer 1 Diverticulitis 1 Testicular torsion 4 Table 5. Outcomes of cholecystitis Epidymitis 2 Outcome No. (%) of patients Other 12 Repatriations owing to calculous cholecystitis 6 (—) IBD = inflammatory bowel disease; NCM = noncommissioned members. Predeployment biliary colic 0 *Unless otherwise indicated. Predeployment identification of cholelithiasis 0

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The most common acute surgical illness requiring in- the time from the last health assessment and diagnosis of a theatre surgical consultation was renal colic, and the most testicular mass in the 3 patients for whom data were obtain- common acute surgical illness that required an operation able was 2 years, 10 months and 14 months. Given the ten- was acute appendicitis. Almost all patients with appendi dency of many testicular tumours to grow rapidly, this citis underwent open appendectomy, and the patients screening interval may simply not have been adequate to recovered uneventfully with return to full duties. There diagnose these tumours. No studies of appropriate screening were 7 patients with ischiorectal abscesses documented in for testicular masses have been conducted; therefore, the theatre. All patients were men and underwent incision and Canadian Task Force on the Periodic Health Examination drainage with eventual return to full duties. None of these does not recommend including or excluding testicular cases were recurrences, and their development on deploy- examination as part of the routine physical examination.5,6 ment may have been coincidence. The identification of testicular masses described in this One of our study objectives was to identify potentially study reflect the fact that this cohort includes a large num- preventable causes of acute surgical illness encountered ber of young men and that testicular cancer is the most on deployment. We postulated that hernias, testicular common cancer in male patients aged 15–34 years.7,8 Given tumours, acute cholecystitis, renal colic and inflammatory the high ratio of young men deployed on combat opera- bowel disease could be potentially preventable given the tions, increased vigilance may be warranted. rigorous predeployment screening in this population. In the 6 patients with acute cholecystitis, individual In the 12 patients with hernias, 11 were inguinal hernias chart review showed that none of the individuals had previ- and 1 was an incarcerated umbilical hernia. On review of ously documented cases of biliary colic or cholelithiasis. the predeployment medical examination for these Based on the data presented here, no recommendations 11 patients with inguinal hernias, only 7 had a groin exam- regarding intensified predeployment screening for choleli- ination for hernias documented and none had a hernia thiasis can be made. This emphasizes the difficulty in diagnosed before it became symptomatic on deployment. screening for individuals who will go on to develop biliary These findings suggest that screening for groin hernias disease and suggests that medical mission planners and sur- should be emphasized in all predeployment medical exam geons on future deployments should be aware that such inations and that the physicians and physician assistants cases may present. If this were to occur, open cholecystec- conducting these examinations should be appropriately tomy remains an option if laparoscopic equipment is not trained in assessing patients for groin hernias with the available and if air evacuation cannot be arranged. Based patient both supine and standing and with Valsalva on the number of cases of acute cholecystitis and acute manoeuvres. From the data presented here, it appears that appendicitis combined, one could make a strong argument undiagnosed inguinal hernias become symptomatic on in favour of the deployment of a basic laparoscopic capabil- combat deployments given the rigorous physical activity ity at Role 3 hospitals. The cost of this capability would be involved in these operations and therefore should be offset by the decreased need for AIREVAC to Role 4 facil- screened more intensively. ities, such as Landstuhl Regional Medical Center. As mentioned previously, there was 1 patient with an None of the patients with renal colic previously had umbilical hernia that became incarcerated and necessitated documented attacks in Canada. The development of renal repair in theatre. This hernia had been identified on a pre- colic on deployment may be linked to the heat, the phys deployment ultrasound and was documented, although the ical exertion required of soldiers and dehydration. Only 1 patient was not symptomatic. However, the general trend of the 5 patients had previous inflammatory bowel disease from our data on groin hernias is that they tend to become documented back in Canada, but the disease activity was symptomatic on combat operations and therefore caution previously quiescent. should be taken when deploying personnel with these conditions. As we do not know how many soldiers deployed Conclusion with umbilical hernias and remained symptom-free, we are unable to suggest whether the predeployment identifica- A wide variety of acute surgical illnesses arise while on tion of an umbilical hernia should preclude a CAF member combat operations. Some are within the scope of modern from deployment. We do, however, suggest that thought general surgical training in North America. Others may be given to hernia size, previous symptoms and possible fall within another area of subspecialty expertise (e.g., renal predeployment evaluation by a general surgeon. colic, testicular torsion). Our findings reinforce the belief Next we examined the 4 patients who received new diag- that deploying military surgeons require an extend ed scope noses of testicular tumours during deployment. Two of of practice. these patients had benign testicular tumours and 2 had tes- The nontraumatic acute care surgical issues of a ticular cancers. Predeployment screening data were available deployed military population are substantially different for 3 of the 4 patients, and all 3 had documented testicular from those found at a normal general hospital in North exams, though 1 was a self exam. As mentioned previously, America. The patient population is primarily young men,

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Affiliations: From the Royal Canadian Medical Service, Department of who are otherwise very healthy. The number of such diag- National Defence, Ottawa, Ont. (Pannell, Ricard, Savage, Tien); Div noses are small and may be further minimized with careful ision of General Surgery, Sunnybrook Health Sciences Centre, predeployment screening. Some of these conditions, such Toronto, Ont. (Nathens, Tien); and the Department of Surgery, Divi- sion of General Surgery, University of Toronto, Toronto, Ont. (Pan- as acute appendicitis, are not preventable with screening nell, Nathens, Tien). and can be treated safely and effectively in theatre. Others, Competing interests: None declared. such as acute cholecystitis, require repatriation back to Canada for optimal therapy. Contributors: All authors designed the study. D. Pannell, J. Ricard, and E. Savage acquired the data, which all authors analyzed. D. Pannell, Our findings suggest that intensified predeployment J. Ricard and E. Savage wrote the article, which all authors reviewed screening for groin hernias may detect occult cases. This and approved for publication. may be important, as some may become symptomatic dur- References: ing the increased physical activity involved with combat operations. Military health organizations must balance the 1. Blackbourne LH. Baer, DG. Eastridge BJ. Military medical revolu- tion: deployed hospital and en route care. J Trauma Acute Care Surg burden of repatriating patients from theatre with the likeli- 2012;73:S378-87. hood of chronic diseases flaring up while on deployment. 2. Pannell D, Brisebois R, Talbot M, et al. Causes of death in Canadian For example, patients with inflammatory bowel disease Forces members deployed to Afghanistan and implication on tactical may flare while in theatre and require repatriation back combat casualty care provision. J Trauma 2011;71:S401-7. home. In most cases, however, increased predeployment 3. Brisebois RJ, Tien HC. Surgical experience at the Canadian-led Role 3 Multinational Medical Unit in Kandahar, Afghanistan. J Trauma screening will likely not reduce the need for surgical care 2011;71:S397-400. and repatriation while on deployment. 4. Cohen SP, Brown C, Kurihara C, et al. Diagnoses and factors associ- Surgeons have been an essential part of forward- ated with medical evacuation and return to duty for service members deployed medical care throughout the history of modern participating in Operation Iraqi Freedom or Operation Enduring warfare. Their early involvement in the treatment of the Freedom: a prospective cohort study. Lancet 2010;375:301-9. 5. The Canadian guide to clinical preventive health care. Chapter 74: traumatically injured is well documented in the literature. Screening for testicular cancer 1994. ed Elford, RW. Available: http However, based on the data presented in this paper it is ://canadiantaskforce.ca/guidelines/red-brick-1994-guidelines/ (acces apparent that there is also a significant acute care surgery sed 2015 May 11). element that is encountered on combat deployment, and 6. Canadian Task Force on the Periodic Health Examination. The periodic surgeons tasked with caring for this population should be health examination: 2. 1984 update. Can Med Assoc J 1984;130:1278-85. 7. McGlynn KA, Devesa SS, Sigurdson AJ, et al. Trends in the incidence of prepared to treat these cases. testicular germ cell tumors in the United States. Cancer 2003;97:63-70. Acknowledgments: This work was supported in part by the Canada 8. Garner MJ, Turner MC, Ghadirian P, et al. Epidemiology of testicu- Research Chair Program (A. Nathens). lar cancer: an overview. Int J Cancer 2005;116:331-9.

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Factors affecting mortality of pediatric trauma patients encountered in Kandahar, Afghanistan

Capt Dylan Pannell, MD, PhD Background: The North Atlantic Treaty Organization (NATO) Role 3 Multina- Jeffery Poynter, MD, MSc tional Medical Unit (R3-MMU) is a tertiary care trauma facility that receives casualties, both coalition and civilian, and provides humanitarian medical assistance when Paul W. Wales, MD, PhD able to the Kandahar province in southern Afghanistan. We examined the cohort of Col Homer Tien, MD, MSc pediatric patients evaluated at the facility during a 16-month period to determine the characteristics and care requirements of this unique patient population. Avery B. Nathens, MD, PhD David Shellington, MD, MC Methods: A database of Afghan patients younger than 18 years of age admitted to the NATO R3-MMU between January 2010 and April 2011 was developed from the Joint Theatre Trauma Registry. This patient cohort was analyzed to determine demographics, Accepted for publication injury mechanism, injury severity, resource utilization and factors associated with mortality. Feb. 25, 2014 Results: A total of 263 children were admitted to the NATO R3-MMU during the Correspondence to: study period, representing 12% of all trauma admissions during this time period. The D. Pannell median age was 9 years (range 3 mo–17 yr) with a predominance of male patients Division of General Surgery (82%). Battle-related trauma was responsible for 62% of admissions, with explosive Department of Surgery blast injury constituting the predominant mechanism (42%). The average injury sever- University of Toronto ity score was 12.3 ± 9.3. Overall mortality was 8%. Factors associated with increased risk 500 University Ave. of death included admission acidosis, coagulopathy, hypothermia and female sex. Toronto ON M5G 1V7 [email protected] Conclusion: Children represent a significant proportion of traumatic injuries encountered in a modern war zone; many of them are critically injured. Organizations DOI: 10.1503/cjs.017414 that provide health care in such environments should be prepared to care for this patient population where their mandates and facilities allow for it.

Contexte : L’Unité médicale multinationale de Rôle 3 (UMM R3) de l’Organisation du Traité de l’Atlantique Nord est un établissement de soins traumatologiques ter- tiaires qui reçoit les blessés des troupes de la coalition et de la population civile et offre une aide médicale humanitaire lorsqu’elle le peut à la population de la province de Kandahar, dans le Sud de l’Afghanistan. Nous avons étudié la cohorte de patients pédi- atriques évalués à cet établissement durant une période de 16 mois afin de déterminer les caractéristiques et les besoins médicaux de cette population unique de patients. Méthodes : Une base de données sur les patients afghans de moins de 18 ans admis à l’UMM R3 entre janvier 2010 et avril 2011 a été établie à partir d’un registre des traumatismes liés au théâtre des opérations conjointes (Joint Theatre Trauma Registry). Cette cohorte de patients a été analysée de manière à dégager les caractéristiques démographiques, le mécanisme des traumatismes, la gravité des blessures, l’utilisation des ressources et les facteurs associés à la mortalité. Résultats : En tout, 263 enfants ont été admis à l’UMM R3 pendant la période de l’étude, ce qui représente 12 % de toutes les admissions en traumatologie pendant cette période. L’âge médian était de 9 ans (entre 3 mois et 17 ans) et les patients étaient majoritairement de sexe masculin (82 %). Les traumatismes liés aux combats ont représenté 62 % des admissions, les blessures consécutives à une explosion en étant le mécanisme principal (42 %). Le score moyen de gravité des blessures était de 12,3 ± 9,3. La mortalité globale a été de 8 %. Les facteurs associés à un risque accru de décès incluaient l’acidose au moment de l’admission, la coagulopathie, l’hypothermie et le fait d’être de sexe féminin. Conclusion : Les enfants représentent une proportion significative des traumatismes ren- contrés en zone de guerre, et beaucoup d’entre eux sont grièvement blessés. Les orga nismes qui fournissent des soins de santé dans de tels environnements devraient être prêts à soigner cette population de patients là où leur mandat et leurs installations le permettent.

etween August 2007 and July 2011 the Canadian Methods Armed Forces (CAF) engaged in combat operations B in Kandahar, Afghanistan. As the lead nation in this Data collection province, the CAF contribution included deploying an infantry battle group as well as taking command of the Kandahar Using Joint Theatre Trauma Registry (JTTR) data, we Airfield Role 3 Multinational Medical Unit (R3-MMU). conducted a retrospective cohort study on all patients This rudimentary yet robust field hospital provided ter- younger than 18 years who were admitted to the tiary care to all deployed North Atlantic Treaty Organiza- R3-MMU between Jan. 1, 2010, and Apr. 30, 2011. To be tion (NATO) soldiers in the Kandahar area as well as some included in the JTTR, these patients had to be brought to Afghan National Security Forces (ANSF) whose injuries the R3-MMU either direct from the field via NATO exceeded the local military hospital’s ability to care for these 9-line MEDEVAC (urgent radio communication from patients. Afghan local nationals (civilians) were mainly cared the battlefield requesting medical evacuation) or transfer for in Mirwais Hospital in Kandahar City unless they from another facility, including NATO Forward Oper required subspecialist consultation. Once stabilized, efforts ating Bases, NATO Combat Support Hospitals, Afghan were made to repatriate patients from the R3-MMU to local military facilities or civilian hospitals. Pediatric patients facilities to ensure resources were available to treat any who were assessed or admitted to the R3-MMU for exam- incoming injured NATO soldiers, which was the primary ination by a subspecialist, including a pediatrician or oph- mission. The CAF Medical Rules of Eligibility (MROE) thalmologist, for nontraumatic illness were excluded from were followed to determine which patients were eligible for the analysis, as they are not captured in the JTTR.4 care at each site. There were incidents where critically injured children were simply brought to a CAF Forward Data analysis Operating Base by a parent searching for medical care. In these cases the child would often be transported to the We used the data obtained from the JTTR to create a data- R3-MMU. During this period, more than 4000 patients base of all pediatric trauma admissions during the study were treated, most of whom were ANSF or civilians.1–3 period. All data were stripped of identifiers before transfer On Oct. 15, 2009, Command of the R3-MMU was from the JTTR to the investigators. Specifically, gathered transferred to the U.S. Navy Medical Corps (USNMC). data included patient demographic characteristics, mech Canadian involvement continued as the CAF remained the anism of injury, injury scoring, transfer details (transfer second largest contributor of medical personnel at the from another facility or from point of injury), physiologic R3-MMU. During this time a larger, purpose-built medical data on presentation (initial trauma room vital signs, facility was constructed that was hardened against artillery Glasgow Coma Scale [GCS] score), initial trauma bay lab and rocket attack in order that patient care could continue oratory values, R3 trauma bay interventions, disposition, while under bombardment. This facility also had multiple length of stay (LOS; intensive care unit [ICU] v. ward), trauma resuscitation areas, up to 4 operating theatres and a ventilator days, discharge GCS score and discharge disposi- well-equipped ICU and ward capability. The USNMC also tion. We performed statistical analyses using SAS software tripled staffing to make this facility immensely robust. This version 9.2 (SAS Institute). This study was approved by the hospital became fully operational in May 2010. Joint Combat Casualty Research Team as a performance With these changes to capacity and resources the MROE improvement project and by the CAF Surgeon General. also changed. Specifically, a neurosurgeon, ophthalmologist, general pediatrician and pediatric critical care physician Results were all deployed to the R3-MMU by the USNMC. As such, the R3-MMU saw an increase in the number of pedi- During the 16-month study period a total of 2239 trauma atric patients who met MROE by virtue of their age, system patients were admitted to the R3-MMU. Of these patients, affected (i.e., ocular, neurotrauma) or severity of injuries. As 263 (11.7%) were younger than 18 years. Patient demo- a result, the relative number of pediatric trauma patients graphic characteristics are presented in Table 1. The seen at this facility became quite substantial. median age of this population was 9 years, with ages ranging In this study we describe the pediatric trauma patient from 3 months to 17 years. There was a strong sex bias, as population encountered at the R3-MMU. Specifically, we 82% of patients were boys. The majority of injuries (62%) have characterized this population with respect to demo- were categorized as battle injuries, which were sustained graphics, mechanisms and severity of injury, resource utili- either by exposure to improvised explosive devices (IEDs), zation and outcome. We also attempted to determine fac- discarded or unexploded munitions or gunshot wounds, tors associated with increased mortality in pediatric trauma possibly as a result of being caught in firefights between patients injured in war zones. It is hoped that these data Afghan or NATO allied forces and Taliban insurgents. will aid in future missions where Armed Forces health care In accordance with the above finding, blast injuries were personnel are called upon to treat pediatric civilian trauma. found to be the most common mechanism of injury, with

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42% of admissions being blast-related. (Table 2). Gunshot hospital admissions. With regards to discharge disposition, wounds accounted for 17% of injuries. Non–battle injuries, in-hospital mortality was approximately 8%, and 47% of including motor vehicle collision (MVCs; 16%) and falls patients were discharged home with a family member (8%), were also seen relatively frequently. As a result of (Table 3). However, 38% of pediatric patients were dis- these mechanisms, most patients (53%) experienced pene- charged to the Mirwais Hospital, the nearest local facility, as trating injuries, whereas purely blunt injuries were encoun- many patients required ongoing treatment. Unfortunately, it tered in 27% of patients. Burns and mixed pattern injuries was not possible to capture long-term outcome data on this each accounted for 10% of patients. It should be noted that population. As the R3-MMU had subspecialty capabilities in blast-related trauma can inflict all of these injury categories, neurosurgery, opthalmology and oral and maxillofacial sur- either separately or as part of a mixed pattern. The mean gery, patients were referred to the facility from other parts ISS for our pediatric patient population was 12.3, with a sig- of Afghanistan. At the end of subspecialist treatment these nificant proportion (35%) of patients having an ISS of 15 or patients were repatriated back to the original facility. These greater (Table 2). These data suggest that a large portion of patients accounted for approximately 8% of pediatric patients the pediatric patient population seen at the R3-MMU was at the R3-MMU. severely injured. In support of this finding, 36% of patients Finally, we performed a univariate logistic regression to had a GCS of 8 or less, suggesting either severe head injury attempt to identify patient factors independently associated or physiologic instability severe enough to impair cerebral with mortality in the pediatric population cared for at the perfusion. The patient cohort analyzed in this study was also R3-MMU the results of which are summarized in Table 4. noted to have a mean base deficit of –4.8 suggesting relative Interestingly, female sex, injury severity score (ISS), tempera- under-resuscitation en route to definitive care. This is ture on presentation, international normalized ratio, base perhaps explained by the fact that many of these patients deficit, GCS and battle-related injury were all associated with presented to NATO Forces for care through irregular in-hospital mortality (p < 0.05). Conversely, blast injury, means, such as simply being carried by a family member to initial cardiorespiratory vitals, partial pressure of carbon a Forward Operating Base or nearby patrol. dioxide, hematocrit and number of systems affected were not Once admitted to the R3-MMU, pediatric patients had a significantly associated with in-hospital death in our analysis. mean LOS of 5.3 days, although this was highly variable, These data suggest that factors other than physiologic status with LOS extending up to 43 days (Table 3). The mean may have played a role in a patient’s death. LOS in the ICU was 2.1 days, and the mean number of ventilator days 1.3. Again, both of these factors were vari- Table 2: Mechanism, classification and severity able, with ICU LOS and ventilator days reaching up to 23 of injuries and 22 days, respectively. These data reflect the fact that Injuries No. (%) Mean severely injured pediatric trauma patients require a substan- Mechanism tial amount of medical and critical resources during their Blast 111 (42) — GSW 45 (17) — MVC 42 (16) — Table 1. Demographic characteristics of patients Fall 22 (8) — younger than 18 years treated at the Role 3 Burn 11 (4) — Multinational Medical Unit, n = 263 Other 32 (12) — Characteristic No. (%)* Classification Sex Penetrating 140 (53) — Male 215 (82) Blunt 71 (27) — Female 48 (18) Burns 25 (10) — Injury Mixed 27 (10) — Battle injury 162 (62) Patient Non–battle injury 101 (38) characteristics Age, yr ISS 12.3 0–2 20 (8) 1–14 171 (65) 3–5 55 (21) > 15 92 (35) 6–8 53 (20) GCS score 10.7 9–11 59 (22) 3–8 96 (36) 12–14 51 (19) 9–12 14 (5) 15–17 25 (10) 13–15 153 (58) Mean 9 Base deficit — –4.8 Median 9 INR — 1.3 Range 3 mo to 17 yr GCS = Glasgow Coma Scale; GSW = gunshot wound; INR = international normalized ratio; ISS = injury severity score; MVC = *Unless otherwise indicated. motor vehicle collision.

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Discussion another level of complexity to trauma care and prevention in combat environments. The data presented in this paper further confirm the fact In our study population, more than one-third of pediat- that pediatric casualties are commonly encountered in a ric casualties were severely injured, with an ISS greater modern field hospital during combat operations.5–9 Many than 15. A similar proportion had injuries resulting in a pediatric patients were eligible for care at the R3-MMU by GCS score of 8 or lower, suggesting severe head injury or meeting the criteria of a battle injury or exceeding the capa- hemodynamic compromise. Admittedly, there is selection bilities of the Afghan local national facilities. Of this popu- bias in this population, as critically injured children were lation, more than one-quarter were children younger than more likely to be eligible for treatment at the R3-MMU. 6 years. Resuscitating these patients can require special However, treating critically injured pediatric trauma training and expertise, and the presence of a pediatric patients can be a daunting experience for all members of intensivist and nurses with pediatric training at the the health care team, especially given that many normally R3-MMU was invaluable in these circumstances. Many practise in adult centres. The presence of a pediatric sub- NATO military forces, including the CAF, do not employ specialist was certainly valuable in the treatment of these pediatricians or pediatric subspecialists, as their primary severely injured children, and although not all NATO mission is to care for the deployed NATO Forces them- countries employ physicians with this training, having selves as opposed to the civilian population. Therefore, access to this expertise via telemedicine capability may be deployed health care workers must be comfortable practis- worthy of consideration in future missions. The inclusion ing outside their normal comfort zone. One option for con- of pediatric staff by the USNMC was the result of feed- sideration in future missions where pediatric intensive care back from earlier missions.5,11 physicians are not available is to use telemedicine capabili- Pediatric trauma patients often required considerable ties for assistance in caring for these pediatric casualties. resources for their care, including critical care interven- Explosive blast injuries were by far the most prevalent tions such as mechanical ventilation and ward care. mechanism of injury in the pediatric population that we Members of the patient’s family would also be allowed to studied. This finding can be attributed to the ubiquitous use stay with them and had to be fed and sheltered at the of IEDs by Taliban insurgents, as well as the prevalence of R3-MMU. As a result, care of this population also pre- unexploded munitions in the country. Gunshot wounds in sented logistical challenges. Pediatric equipment often children were also encountered, though with much less fre- had to be specifically stocked or improvised, and family quency than wounds from explosions. Consistent with these needs had to be met. Despite these challenges, nearly findings, most pediatric patients had penetrating injuries. half of the patients were discharged directly home. The However, non–battle injuries from MVCs, falls and burns arrangement of follow-up care was also possible in many were also encountered. In Afghanistan, automotive safety cases. A large proportion (38%) were transferred to the devices are often not available or not used, road conditions are often poor, and many vehicles are overcrowded. As a Table 4. Association between patient factors and mortality result, single-family MVCs would often lead to multiple pediatric casualties. Falls were also a common occurrence, Group, mean ± SD often owing to the tradition of sleeping on the roofs of Factor Survivors Nonsurvivors p value houses during the summer months.10 Finally, a spike in burn Female sex 0.16 ± 0.37 0.45 ± 0.51 0.02 injuries was encountered during the winter months from the ISS 11.40 ± 8.00 23.20 ± 15.40 0.003 use of indoor kerosene heaters. The Kandahar City fire Temperature 36.80 ± 1.00 35.80 ± 1.00 0.01 chief initiated a burn prevention program that was successful INR 1.30 ± 0.40 2.30 ± 1.60 0.047 until he was targeted by a Taliban attack. This illustrates Base deficit –4.40 ± 4.60 –11.00 ± 5.00 < 0.001 GCS 11.00 ± 5.00 7.00 ± 5.00 0.001 Battle injury 0.63 ± 0.48 0.40 ± 0.50 0.04 Table 3: Hospital stay and discharge status Explosive injury 0.43 ± 0.50 0.30 ± 0.47 0.25 Characteristic No. [range] or no. (%) Heart rate, bpm 116.00 ± 28.00 123.00 ± 46.00 0.50 LOS, d 5.3 [0– 43] Systolic blood 116.00 ± 20.00 105.00 ± 35.00 0.20 pressure, mm Hg ICU LOS, d 2.1 [0–23] Respiratory rate, 27.00 ± 10.00 22.00 ± 8.00 0.20 Ventilator, d 1.3 [0–22] bpm Discharge status SpO2 99.00 ± 3.00 92.00 ± 24.00 0.25 Home 123 (47) Hematocrit 32.00 ± 6.00 33.00 ± 10.00 0.80 Local (Afghan) hospital 99 (38) pCO2 46.00 ± 34.00 52.00 ± 16.00 0.20 Other NATO hospital 21 (8) No. systems injured 3.90 ± 2.70 3.60 ± 2.80 0.60 Death 20 (8) bpm = beats or breaths/min; GCS = Glasgow Coma Scale; ISS = injury severity score; ICU = intensive care unit; LOS = length of stay; NATO = North INR = international normalized ratio; pCO2 = pressure of carbon dioxide; SD = standard Atlantic Treaty Organization. deviation; SpO2 = peripheral capillary oxygen saturation.

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local hospital, where resources were more limited and Conclusion nighttime care was carried out by the patient’s family. The long-term outcome data on these patients, inclu We have described the pediatric patient burden seen at a ding 30-day mortality, were not consistently available for modern military field hospital during combat operations. analysis. The children seen at the R3-MMU had often experienced The results of the univariate logistic regression provide severe injuries and required subspecialist care. This popula- some evidence that mortality was a result of multiple fac- tion constituted a large portion of the patient load and tors. Pediatric patients who died in hospital often displayed required substantial specialized care and resources. Modern evidence of the “lethal triad”; they were often found to be military health care elements must balance providing care cold, coagulopathic and acidemic. In our analysis they were for vulnerable civilian patient populations with the risk of also found to be more severely injured (higher ISS) and creating dependence on foreign health care resources. have a lower GCS score. These data support the evidence of the high acuity of pediatric patients seen at the Acknowledgments: This work was supported in part by the Canada R3-MMU and potentially offer further support for pediat- Research Chair Program (A. Nathens). ric critical care resources and expertise in these missions. Affiliations: From Canadian Forces Health Services, Ottawa, Ont. Interestingly, we found female sex to be independently (Pannell, Tien); Department of Surgery, Division of General Surgery, associated with mortality. This finding is consistent with University of Toronto, Toronto, Ont. (Pannell, Wales, Tien, Nathens); Division of General Surgery, Hospital for Sick Children, Toronto, Ont. those of other reports on pediatric trauma seen in combat (Poynter, Wales); Division of General Surgery, Sunnybrook Health Sci- support hospitals in Iraq and Afghanistan. There is no ences Centre, Toronto, Ont. (Tien, Nathens); Rady Children’s Hospi- clear explanation for this discrepancy, though some have tal, University of California, San Diego, San Diego, Calif. (Shellington). surmised that it may be attributable to cultural differences Competing interests: None declared. in the relative value placed on male versus female offspring Contributors: D. Pannell, J. Poynter and D. Shellington designed the when seeking medical attention. Another interesting find- study and acquired and analyzed the data, which P. Wales, H. Tien and ing was that battle injury, but not blast injury per se, was A. Nathens also analyzed. D. Pannell and J. Poynter wrote the article, which all authors reviewed and approved for publication. also associated with mortality. We can only speculate as to the reasons for this, but it may be owing to a factor such as References increased medical evacuation times because of tactical con- 1. Brisebois RJ, Tien HC. Surgical experience at the Canadian-led Role 3 siderations. Taken together as a whole, the data presented multinational medical unit in Kandahar, Afghanistan. J Trauma here illustrate the substantial challenges encountered and 2011;71:S397-400. 2. Brisebois R, Hennecke MP, Kao CNR, et al. The Role 3 multina- resources necessary for providing pediatric patient care in a tional medical unit at Kandahar Airfield 2005–2010. Can J Surg modern combat support hospital. 2011;54(Suppl):S124. 3. Tien H. The Canadian Forces trauma care system. Can J Surg Limitations 2011;54(Suppl):S112-7. 4. Eastridge BJ, Jenkins D, Flaherty S, et al. Trauma system development in a theater of war: experiences from Operation Iraqi Freedom and This study was conducted using data from the JTTR Operation Enduring Freedom. J Trauma 2006;61:1366-72. and, therefore, we were able to report only on pediatric 5. McGuigan R, Spinella PC, Beekley A, et al. Pediatric trauma: experi- patients admitted for traumatic injuries. There was also a ence of a combat support hospital in Iraq. J Pediatr Surg 2007; nontrauma pediatric patient population with severe 42:207-10. illness who received care at the hospital who were not 6. Burnett MW, Spinella PC, Azarow KS, et al. Pediatric care as part of the US Army medical mission in the global war on terrorism in captured in our data set. Therefore, the pediatric popu Afghanistan and Iraq, December 2001 to December 2004. Pediatrics lation described here is likely an underrepresentation 2008;121:261-5. of the overall patient caseload. Further, the role of the 7. Spinella PC, Borgman MA, Azarow KS. Pediatric trauma in an aus- R3-MMU was to provide short-term specialty care tere combat environment. Crit Care Med 2008;36:S293-6. before returning pediatric patients to the Afghan 8. Creamer KM, Edwards MJ, Shields CH, et al. Pediatric wartime admissions to US military combat support hospitals in Afghanistan national health care system. As a result, long-term out- and Iraq: learning from the first 2,000 admissions.J Trauma 2009; come measures of mortality and hospital readmission 67:762-8. were not consistently available. Finally, as not all pedi 9. Arul GS, Reynolds J, DiRusso S, et al. Paediatric admissions to the atric trauma patients were eligible for care at the British military hospital at Camp Bastion, Afghanistan. Ann R Coll Surg R3-MMU, there is an admitted selection bias in that Engl 2012;94:52. 10. Kaplan RD. Hunting the Taliban in Las Vegas. Atl Mon 2006;298:81. more severely injured patients and patients with head 11. Fuenfer MM, Spinella PC, Naclerio AL, et al. The US military war- injuries were more likely to be transferred and therefore time pediatric trauma mission: how surgeons and pediatricians are entered into the JTTR. adapting the system to address the need. Mil Med 2009;174:887-91.

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The Canadian Armed Forces medical response to Typhoon Haiyan

LCol Erin Savage, MD Background: In the setting of international disaster response, an important challenge Maj Michael D. Christian, MD, MSc is determining when it is appropriate to withdraw deployed assets as the acute disaster response transitions to recovery and rebuilding. We describe our experience with real- Maj Stephanie Smith, BScN, time data collection during our medical response to Typhoon Haiyan as a means to MADEM guide military aid mission parameters. Capt Dylan Pannell, MD, PhD Methods: The operational medical headquarters prospectively developed a database for use in this mission. Mobile medical teams (MMTs) were deployed to provide pri- Accepted for publication mary care, and the nurse designated to each MMT was responsible for entering and Feb. 23, 2015 transmitting data daily to the medical headquarters. Data collected included the MMT location, basic patient demographics, the primary reason for the encounter and any Correspondence to: treatment provided. These encounters were then classified as disaster, acute or chronic. D. Pannell Results: Between Nov. 16 and Dec. 16, 2013, medical care was provided to 6596 local Sunnybrook Health Sciences Centre nationals; 238 (3.6%) had disaster-related illness or injury, 4321 (65.5%) had acute post- H171 – 2075 Bayview Ave. disaster medical conditions and 2037 (30.9%) sought medical care for chronic conditions. Toronto ON M4N 3M5 Of the 257 patients with traumatic injuries, 28 (11%) had disaster-related injuries and [email protected] 214 (83%) had acute injuries that occurred postdisaster. Conclusion: The data collected during the mission to the Philippines was compiled with DOI: 10.1503/cjs.013514 performance metrics from the other Disaster Assistance Response Team components to help advise the Canadian government regarding mission duration. We recommended that data collection continue on all future missions and be modified to provide further information to larger disaster coordination teams, such as the United Nations Office for the Coordination of Humanitarian Affairs.

Contexte : Dans le domaine de l’intervention internationale en cas de catastrophe, il est souvent difficile de déterminer le moment approprié pour retirer les ressources déployées alors que l’on passe de la première intervention d’urgence à la période de rétablissement et de reconstruction. Nous décrirons ici notre expérience de collecte de données en temps réel durant notre intervention médicale après le typhon Haiyan, dans le but d’orienter les paramètres de mission de l’aide militaire. Méthodes : Le quartier général des opérations médicales avait préparé d’avance la base de données qui a été utilisée lors de cette mission. Des équipes médicales mobiles ont été déployées pour fournir des soins de base, et une infirmière ou un infirmier désigné dans chaque équipe était chargé d’entrer et de transmettre les données quotidiennement au quartier général des opérations médicales. Les données recueillies comprenaient la position de l’équipe médicale mobile, des données démographiques de base sur les patients, la raison première de la rencontre et les traitements fournis. Ces rencontres étaient ensuite classées comme catastrophiques, aiguës ou chroniques. Résultats : Du 16 novembre au 16 décembre 2013, des soins médicaux ont été prodigués à 6596 Philippins; 238 personnes (3,6 %) avaient des maladies ou des blessures liées au typhon, 4321 personnes (65,5 %) avaient des problèmes médicaux aigus d’après catastrophe et 2037 personnes (30,9 %) avaient besoin de soins pour des affections chroniques. Des 257 patients ayant subi des lésions traumatiques, 28 (11 %) avaient des blessures liées à la catastrophe et 214 (83 %) avaient des blessures aiguës reçues après la catastrophe. Conclusion : Les données recueillies durant la mission aux Philippines ont été compilées avec les indicateurs de rendement des autres composantes de l’équipe d’intervention en cas de catastrophe pour conseiller le gouvernement canadien au sujet de la durée des missions. Nous recommandons que la collecte de données se poursuive durant toutes les missions futures et soit modifiée afin de fournir plus de renseignements aux plus grandes équipes de coordination des interventions en cas de catastrophe, comme le Bureau de la coordination des affaires humanitaires de l’Organisation des Nations Unies.

nternational disaster response is a complex and chal- In this paper, we describe the health care needs of the lenging endeavour for both governmental and nongov- 6596 members of the local population treated by the med I ernmental organizations to undertake. However, an ical section of the DART during their 1-month deployment often greater challenge is determining when it is appropri- to the Philippines after Typhoon Haiyan. By prospectively ate to withdraw deployed assets as the acute disaster collecting data on the population treated, the CAF was able response transitions to recovery and rebuilding. This paper to acquire accurate data in a timely manner to document describes the feasibility of real-time data collection and the nature of medical issues encountered and aid in the analysis as a means to guide military aid mission param determination of optimal mission duration. This approach eters and facilitate collaborations with other civilian aid demonstrates the feasibility of real-time data collection as a agencies to achieve rapid and targeted medical assistance. means to guide military aid mission parameters and may be On Nov. 8, 2013, Typhoon Haiyan (also known as used in collaboration with other civilian aid agencies to “Yolanda”), one of the strongest typhoons on record, achieve rapid and increasingly targeted medical assistance struck the central region of the Philippines. In addition to in future relief operations. devastating infrastructure, property, power and communi- cations, this Category 5 supertyphoon resulted in substan- Methods tial losses of life and injury. As of Jan. 29, 2014, more than 6000 individuals were reported dead, 29 000 injured, and Operational structure approximately 1800 still missing.1 As part of the response to this overwhelming humanitar- In planning the optimal approach to provide medical aid to ian disaster, the Government of Canada rapidly made the Panay Island, the following factors were taken into decision to deploy the Canadian Armed Forces (CAF) Disas- account: 1) the availability of health care in urban centres ter Assistance Response Team (DART). This humanitarian remained similar to pre-typhoon levels; 2) there was a large mission was called Operation RENAISSANCE. The DART geographic area requiring assistance; and 3) the socioeco- is a multidisciplinary military unit comprising headquarters, nomic status of the people most in need, combined with logistics, engineering, security and medical sections that can damage to infrastructure, resulted in their inability to respond to natural disasters anywhere in the world in order travel to the urban centres for care. Therefore a decision to conduct emergency relief operations within 48 hours of was made to reconfigure the usual static format and deploy being notified. Its responsibilities are to stabilize the primary smaller, more agile teams, known as mobile medical teams effect of the disaster by providing medical care, clean water, (MMTs), which were able to provide primary care in an infrastructure repair, security and prevention of secondary outreach format. Though the overall composition of the disaster effects, such as disease spread. The goal is to gain MMTs varied, each MMT included a family physician, a time for other organizations to prepare and deliver long- nurse and 2 medical technicians at a minimum. Origin term recovery programs. Working with governmental and ating from the centrally located headquarters in Roxas nongovernmental organizations, the DART serves 3 critical City, there was a maximum of 4 MMTs operating at needs: production of safe drinking water, engineering aid and 1 time. The MMTs would use either land or air transport primary medical care.2 After an advance team comprising to travel to affected areas and provide care for a predeter- members from the CAF and Canadian government officials mined timeframe, which was communicated in advance to met with local officials in the Philippines, it was determined the local population. All team members were stationed in that the DART would be deployed to the city of Iloilo to Roxas City and departed to different locations based on provide relief to Panay Island. guidance from the local health authority. The medical component of the DART comprises med ical officers (physicians), physician assistants, nursing officers Data collection and medical technicians. Combined with a pharmacist, preventative medicine, laboratory and radiology technicians, As extensive data had not been collected on prior DART this team of approximately 50 personnel provides a substan- deployments, the operational medical headquarters tial and flexible primary care medical capability. The med prospectively developed a database for use in this mission ical team is responsible for meeting the medical needs of the using Microsoft Excel, version 14.3.8. Instructions on data disaster-affected population as well as the DART itself. By field definitions were provided to the DART medical providing primary care to the local population, one of the team on location in the Philippines. Data on patient mission objectives of the DART medical component is to encounters during a given MMT visit were collected from lessen the impact on local hospitals and medical facilities, patient records. The nurse designated to each MMT was thereby allowing these local resources to focus on the more responsible for entering and transmitting data daily to the seriously ill or injured individuals. The DART was able to medical headquarters. We attempted to mitigate data het- begin providing patient care to this population on Nov. 16, erogeneity by having the senior nursing officer review all 2013, 8 days after Typhoon Haiyan struck.3 data before final entry into the mission database. Any

Can J Surg, Vol. 58 (Issue 3 Suppl 3) June 2015 S147 RECHERCHE questions regarding patient classification were clarified children between the ages of 1 and 5 years presented with with the medical officer or medical technician directly respiratory illnesses. Gastrointestinal and dermatological involved in that patient’s care at the time the data was illnesses were other important contributors in the pediatric entered into the database. burden of illness. All infectious diagnoses were entered according to the We next determined which diagnoses occurred most system affected. The “health check” category was included, frequently in each of the disaster, acute and chronic cat as locals presented to the MMT simply for a check-up, often egories (Table 3). Of the 6596 patients who were encoun- never having encountered a health care professional before tered during the mission, 238 patients (3.6%) suffered and not having a specific presenting complaint. If the patient disaster-related illness or injury while 4321 patients presented with more than 1 symptom, the most acute diag- (65.5%) had acute post-disaster medical conditions and nosis was entered into the database as the final diagnosis. All 2037 patients (30.9%) sought medical care from the data entered into the database were stripped of individual DART for chronic conditions. patient identifiers and kept on secured hard drives. Traumatic injury accounted for 3.9% of all patient Data collected included the MMT location, basic encounters. Of the 257 patients treated for traumatic injur patient demographic characteristics and the primary reason ies, 28 (11%) had injuries classified as related directly to for the encounter based on the patients’ chief complaint, the disaster and 214 (83%) were considered to be acute along with any treatment provided. These encounters were injuries that occurred postdisaster. This finding may be then classified into 3 separate categories: attributable to the population having to live in the phys 1. disaster (i.e., injury or illness that occurred as a direct ically unsafe posttyphoon destruction and sustaining sec- result of the typhoon, such as cough or diarrhea in ondary injuries. Of interest, 8% of all disaster-related ill- patients displaced by the typhoon and living in unsani- nesses were psychiatric in nature, with patients experiencing tary conditions), symptoms of anxiety or insomnia after the devastation of 2. acute (injury or illness that was not directly attributable the typhoon. This group constituted 43% of all psychiatric to the typhoon and whose onset was within 4 weeks of complaints encountered during the mission. As mentioned, the patient encounter), or a substantial proportion of the patient population sought 3. chronic (injury or illness not directly related to the disas- medical attention from the MMTs for chronic health ter that had been a concern for longer than 4 weeks). Table 1. Demographic characteristics of local Statistical analysis population seen by the CAF DART medical team, n = 6596 All patients assessed by the DART MMTs were included Characteristic No. (%) of patients in the data analysis. Members of the CAF or other Canad Age, yr ian government agencies who received care from the < 1 333 (5.0) DART were excluded. Descriptive statistical analyses were 1–10 2386 (36.2) used by the mission command as a metric to determine 11–20 409 (6.2) ongoing population health care needs. 21–70 2774 (42.0) > 70 694 (10.5) Male sex 2356 (35.7) Results Female sex 4240 (64.3) Locations by province (no. of Between Nov. 16 and Dec. 16, 2013, medical care was villages) provided to 6596 local nationals. Demographic data for Dao (6) 505 (7.6) the treated population are presented in Table 1. The Ivisan (2) 209 (3.2) patients’ age ranged from 2 weeks to 98 years. A substan- Jamindan (4) 427 (6.5) tial proportion of patients were children. Specifically, Lemery (4) 431 (6.5) more than 40% of patients seen were younger than Libacao (7) 720 (10.9) 10 years of age, and 28% of all patients seen were younger Mambusao (9) 916 (13.9) than 5 years (Fig. 1). Approximately 64% of patients were Ma-Ayon (1) 47 (0.7) Panay (5) 365 (5.5) female and 36% were male. The DART MMTs treated Panitan (3) 315 (4.8) between 65 and 345 patients per day. During the mission, Pilar (2) 194 (2.9) MMTs visited 69 villages in 16 separate municipalities Pontevedra (4) 246 (3.7) 2 over an estimated area of 2700 km (Fig. 2). Sapi-An (1) 115 (1.7) Table 2 demonstrates the incidence of primary diagno- Sara (9) 880 (13.3) ses in each age group. It is notable that respiratory illness Sicogon Island (1) 101 (1.5) showed a strong predominance in the pediatric population; Sigma (7) 767 (11.6) 70.9% of infants younger than 1 year of age and 61.8% of Tibiao (4) 358 (5.4)

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Percentage 10

0 5 0 5 0 5 0 5 0 5 5 0 <1–5 6–10 1–2 1–35 1–55 1–75 11–1 16–2 2 26–3 3 36–40 41–4 46–50 5 56–6 61–6 66–7 7 76–80 81–8 86–90 91–9 96–10

Age in years Fig. 1. Age distribution of local population patient encounters.

Fig. 2. Sites of mobile medical team visits.

Can J Surg, Vol. 58 (Issue 3 Suppl 3) June 2015 S149 RECHERCHE problems. For example, 50% of musculoskeletal and more these areas were particularly affected by the typhoon. At day than 60% of cardiovascular diagnoses were determined to 31 posttyphoon the MMTs started to encounter a slight be of a chronic nature. predominance of chronic conditions compared with acute The number of disaster-related patient encounters was medical issues that recurred at days 34 and 38 posttyphoon. relatively stable throughout the deployment at 2%–3% of all patient encounters per day, with increases seen at day 16 Discussion (26.5%) and day 23 (11.1%) postdisaster (Fig. 3). These increases corresponded with targeted visits to villages in Sara The medical component of the DART was able to com- after information was obtained during the operation that mence providing care in the Philippines within 8 days of

Table 2. Diagnoses by system affected in each age group*

Group; no. (%) of patients

< 1 yr 1–10 yr 11–20 yr 21–70 yr > 70 yr Total System (n = 333) (n = 2386) (n = 409) (n = 2774) (n = 694) (n = 6596) Musculoskeletal† 0 14 (0.6) 12 (2.9) 581 (20.9) 249 (35.9) 856 (13.0) Trauma 1 (0.3) 84 (3.5) 41 (10.0) 127 (4.6) 4 (0.6) 257 (3.9) Gastrointestinal 23 (6.9) 270 (11.3) 32 (7.8) 312 (11.2) 62 (8.9) 699 (10.6) Genitourinary 0 17 (0.7) 6 (1.5) 73 (2.6) 11 (1.6) 107 (1.6) Respiratory 236 (70.9) 1428 (59.8) 149 (36.4) 653 (23.5) 150 (21.6) 2616 (39.7) Dermatological 50 (15.0) 234 (9.8) 49 (12.0) 177 (6.4) 19 (2.7) 529 (8.0) Cardiovascular 1 (0.3) 2 (0.1) 13 (3.2) 164 (5.9) 65 (9.4) 245 (3.7) Ear, nose, throat 4 (1.2) 134 (5.6) 40 (9.8) 197 (7.1) 74 (10.7) 449 (6.8) Dental 0 19 (0.8) 6 (1.5) 16 (0.6) 0 41 (0.6) Psychiatric 0 4 (0.2) 3 (0.7) 33 (1.2) 4 (0.6) 44 (0.7) Reproductive 0 0 3 (0.7) 41 (1.5) 0 44 (0.7) Neurological 0 28 (1.2) 24 (5.9) 257 (9.3) 25 (3.6) 334 (5.1) Other 11 (3.3) 107 (4.5) 21 (5.1) 49 (1.8) 10 (1.4) 198 (3.0) Health check 7 (2.1) 45 (1.9) 10 (2.4) 94 (3.4) 21 (3.0) 177 (2.7)

*Combines all patient encounters (disaster, acute, chronic). All infectious diseases were included in the system that they affect (i.e., cough included under the respiratory system). †Includes all nonacute trauma musculoskeletal issues, such as mechanical back pain or joint pain.

Table 3. Illness and Injury classification by category as attributable to the typhoon

Group; no. (%)

Disaster-related* Acute postdisaster† Chronic‡ System (n = 238) (n = 4321) (n = 2037) Musculoskeletal 40 (16.8) 344 (8.0) 422 (20.7) Trauma 28 (11.8) 214 (5.0) 33 (1.6) Gastrointestinal 29 (12.2) 437 (10.1) 234 (11.5) Genitourinary 2 (0.8) 66 (1.5) 39 (1.9) Respiratory 70 (29.4) 2042 (47.2) 502 (24.6) Dermatological 24 (10.1) 388 (9.0) 117 (5.7) Cardiovascular 4 (1.7) 86 (2.0) 154 (7.6) Ear, nose, throat 6 (2.5) 251 (5.8) 192 (9.4) Dental 0 30 (0.7) 11 (0.5) Psychiatric 19 (8.0) 20 (0.5) 11 (0.5) Reproductive 0 27 (0.6) 17 (0.8) Neurological 8 (3.4) 215 (5.0) 140 (6.9) Other 5 (2.1) 129 (3.0) 63 (3.1) Health check 3 (1.3) 72 (1.7) 102 (5.0)

*Injury or illness that occurred as a direct result of the typhoon. †Injuries or illnesses that were not directly attributable to the typhoon and had an onset within 4 wk of the patient encounter. ‡Injury or illness not directly related to the disaster that had been a concern for longer than 4 wk.

S150 J can chir, Vol. 58 (No 3 Suppl 3) juin 2015 RESEARCH the destruction caused by Typhoon Haiyan. The standard significant primary health care burden follows the onset of practice in previous DART missions was to establish a sin- humanitarian disaster crises.4,5 The MMTs saw only gle static site for the delivery of medical aid to the affected 11.8% disaster-related trauma, which may have been spe- population with occasional mobile teams. This mission was cific to Panay Island. Though psychiatric diagnoses were a the first time that the DART medical component delivered moderate contributor to the disaster-related illness burden, all medical care to the local population in a mobile format. they may have been underrepresented. It is possible that This was advantageous as it permitted care to be delivered patients who presented with vague somatic complaints may to many isolated villages across a sizeable geographic area; have had an underlying psychiatric illness related to the however, it limited the volume of patients that could be disaster. Though all of the patients seen could be managed seen in 1 day and also the ability of clinicians to follow up at the primary care level by the medical officers present, with patients and monitor clinical response to treatment. the literature surrounding the need for specific mental Though patients in the extremes of age were encoun- health providers is mixed. Certain studies of previous disas- tered, almost 50% were younger than 20 years and 40% ters have found that most acute mental health symptoms were younger than 10 years. The finding of such a high prev- are self-limited,5–8 while other studies state that there is a alence of the children within the patient population suggests justifiable need to include them.7 that disaster response elements should be appropriately The use of prospective, detailed data collection was also prepared to care for a high pediatric patient burden. This a novel approach as prior DART missions exclusively reinforces the current level of pediatric training the DART reported the numbers of patients seen per day. The pur- medical team receives prior to deployment. pose of data collection was to provide daily information Disaster-related illness and injuries represented approx- regarding the percentage of disaster, acute nondisaster and imately 4% of all patient encounters, with an increase in chronic cases seen by the MMTs to the operational head- more severely affected areas, such as the village of Sara, to quarters. This information was compiled with performance 26.5%. Overall, respiratory, gastrointestinal, dermato metrics from the other DART components to help advise logical and MSK diagnoses were the most common classi- the Canadian government regarding mission duration. fications of illness and injury among the entire patient However, throughout the mission it was also identified that population. The majority of patient presentations were for the data collection could be prospectively transmitted by health issues that could be managed by the primary care the MMTs to the United Nations Office for the Coordina- providers in the DART MMT. This finding is consistent tion of Humanitarian Affairs (UN OCHA) cluster meet- with those of other studies that have demonstrated that a ings. Data collection could also confirm when the MMTs

Disaster Acute Classication of patient encounters Chronic

Percentage of daily encounters 10

0 81113151719212325272931333537 Day postdisaster

Fig. 3. Classification of daily patient encounters by disaster, acute and chronic categories. Disaster refers to an injury or illness that occurred as a direct result of the typhoon. Acute refers to injuries or illnesses that were not directly attributable to the typhoon and had an onset within 4 weeks of the patient encounter. Chronic refers to an injury or illness not directly related to the disaster that had been a concern for longer than 4 weeks.

Can J Surg, Vol. 58 (Issue 3 Suppl 3) June 2015 S151 RECHERCHE had reached an area that was substantially affected by the vide further information to larger disaster coordination disaster and indicate when disaster-related illnesses and teams, such as the UN OCHA. injuries no longer represented a considerable burden of ill- Affiliations: From the Royal Canadian Medical Service, Deartment of ness in that particular area. The data were also analyzed ret- National Defence, Ottawa, Ont. (Savage, Christian, Smith, Pannell); rospectively to drive changes to the composition of future Mount Sinai Hospital and University Health Network, Department of Medicine and Dalla Lana School of Public Health, University of medical teams, their training and equipment. Toronto, Toronto, Ont. (Christian); 1 Canadian Field Hospital, Pet- awawa, Ont. (Christian, Smith); and Department of Surgery, Division Limitations of General Surgery, University of Toronto, Toronto, Ont. (Pannell). Competing interests: None declared. Though it is recognized that data collected during disas- Contributors: E. Savage and D. Pannell designed the study. E. Savage, ters can drive the disaster response,4 data collection during S. Smith and D. Pannell acquired the data, which all authors analyzed. a relief mission is technically challenging.9 As this was the E. Savage, S. Smith and D. Pannell wrote the article, which all authors reviewed and approved for publication. first attempt at prospective data collection for the DART, there were clinical parameters that were not included that References would have been beneficial; for example, the monitoring of infectious diseases so that outbreaks could be identified 1. National Disaster Risk Reduction and Management Council Update. early. Future missions using this approach would benefit SitRep No. 104 Effect of Typhoon “YOLANDA” (HAIYAN). 29 Jan from being able to capture data on infectious disease diag- 2014. Available: http://reliefweb.int/report/philippines/ndrrmc-update -sitrep-no-104-effects-typhoon-yolanda-haiyan (accessed 20 Feb 2014). noses that could be transmitted to UN OCHA and World 2. The Disaster Assistance Response Team. Available: www.forces.gc.ca Health Organization cluster meetings. /en/operations-aborad-recurring/dart/page? (accessed 20 Feb 2014). 3. Operation RENAISSANCE. 13-1 Timeline. Available: www.forces Conclusion .gc.ca/en/operations-abroad/op-renaissance-timeline.page (accessed 20 Feb 2014). 4. Noji EK. Medical and Public Health Consequences of Natural and Within 8 days of the destructive effects of Typhoon Biological Disasters. Nat Hazards Rev 2001;2:143-56. Haiyan on the Philippines, the CAF DART’s medical 5. Shoaf, KI, Rottman SJ. Public health impact of disasters. Australian J component was able to deliver primary health care to the Emerg Med. 2000. Spring: 58-63. local population of Panay Island. This was accomplished 6. Shultz JM, Russell J, Espinel Z. Epidemiology of tropical cyclones: using mobile multidisciplinary health care teams, which the dynamics of disaster, disease, and development. Epidemiol Rev 2005;27:21-35. allowed care to be provided to more than 60 villages and 7. Burkle FM. Acute-phase mental health consequences of disasters: more than 6000 local patients. implications for triage and emergency medical services. Ann Emerg For the first time, the DART prospectively collected epi- Med 1996;28:119-28. demiological and clinical data from patient encounters, 8. Bravo M, Rubio-Stipec M, Canino GJ, et al. The psychological which helped the Canadian government to determine opti- sequelae of disaster stress prospectively and retrospectively evaluated. Am J Community Psychol 1990;18:661-80. mal mission duration. It is recommended that data collec- 9. Noji EK. Analysis of medical needs during disasters caused by tropical tion continue on all future missions and be modified to pro- cyclones: anticipated injury patterns. J Trop Med Hyg 1993;96:370-6.

S152 J can chir, Vol. 58 (No 3 Suppl 3) juin 2015 DISCUSSIONS IN SURGERY • DISCUSSIONS EN CHIRURGIE

Fresh whole blood transfusion capability for Special Operations Forces

Maj Andrew Beckett, MD Summary Jeannie Callum, MD Fresh whole blood (FWB) transfusion is an option for providing volume and oxygen carrying capacity to bleeding Special Operations soldiers who are injured in Luis Teodoro da Luz, MD an austere environment and who are far from a regular blood bank. Retrospective Joanne Schmid, BSN data from recent conflicts in Iraq and Afghanistan show an association between Christopher Funk, MD the use of FWB and survival. We reviewed the literature to document the issues surrounding FWB transfusion to Special Operations soldiers in the austere Col Elon Glassberg, MD environment and surveyed the literature regarding best practice guidelines for and Col Homer Tien, MD patient outcomes after FWB transfusions. Most literature regarding FWB transfusion is retrospective or historical. There is limited prospective evidence currently Accepted for publication to change transfusion practice in tertiary care facilities, but FWB remains an Nov. 11, 2014 option in the austere setting.

Correspondence to: A. Beckett University of Toronto, Sunnybrook embers of the Canadian Armed Forces (CAF), particularly members Trauma of is Special Operations Forces, may deploy on combat missions to 2075 Bayview Ave. austere locations, far from tertiary-level medical and surgical sup- Toronto ON M4N3M5 M [email protected] port. Hemorrhage from combat injuries remains the leading cause of preventable death on the battlefield, and transfusing blood products remains a cornerstone in its treatment. However, providing blood component therapy to small DOI: 10.1503/cjs.012614 groups of Special Operations soldiers in the far-forward, austere environment is a tremendous logistical challenge. Fresh whole blood (FWB) transfusions may provide a solution to this problem.

History

The CAF has a long history of providing FWB transfusions in combat settings. Robertson, serving in the Canadian Army Medical Corps during the Great War, transfused FWB to injured soldiers at the Second Battle of Ypres in 1915.1 In 1937, during the Spanish Civil War, Norman Bethune organized one of the first mobile battlefield transfusion services, collecting and transfusing FWB.2 In recent years, the Canadian Forces Health Services (CFHS), in conjunc- tion with Canadian Blood Services, organized a Walking Blood Bank to provide an FWB transfusion capability at its Role 3 Multinational Medical Unit (R3-MMU), located at Kandahar Airfield in Afghanistan.3 Select volunteers were screened as per Canadian Blood Services donor standards before deployment. Upon activation of the Walking Blood Bank protocol at the R3-MMU, these same screened donors were rescreened before collection and transfusion of their blood. In 2010, 162 units of FWB were transfused at the R3-MMU at Kandahar Airfield by the CAF.4

Fresh whole blood and Special Operations Forces

Blood products from a regulated and approved source are always preferable. However, in austere environments, logistical constraints may lead to

circumstances where Special Operations Forces may have blood products, including bacterial contamination, no access to approved component blood. There are now transfusion-associated overload, transfusion-related acute also case reports in the literature about the successful use lung injury, acute transfusion reaction with hemolysis of FWB in the Special Forces environment.5 Other North (from ABO mismatch or otherwise).9 The risk for ana- Atlantic Treaty Org an ization (NATO) countries, such as phylaxis from transfusion is 1 in 18 017 and the risk for Norway, have developed an aggressive research and train- acute hemolytic reaction is 1 in 50 917 per units trans- ing program pertaining to FWB in Special Operations fused using component therapy in Canada.9 The risks for settings and have created a program called Blood Far For- acute transfusion reactions from FWB would likely be ward (BFF) to look at aspects of this practice.6,7 In particu- higher, but still much lower than the risk of death from lar, the Norwegian group has created a training program hemorrhage in this population. and protocol for collection and administration of FWB by Late risk to recipients of FWB transfusions include Special Operations Forces medics.7 exposure to transfusion-transmitted infections and possible seroconversion. From the recent conflicts, 761 FWB trans- Benefits of FWB in Special Operations fusions were reviewed in recipients who were available for environments follow-up. Only 1 case of recipient seroconversion to hepatitis C virus was found. Results of prescreening serol- There are advantages to transfusing FWB. Special Opera- ogy in 500 patients revealed 4 cases of hepatitis C, no cases tions Forces usually need to walk to wherever they are of HIV and 2 cases of chronic hepatitis B infection.10 Fatal going. Maintaining an FWB capability requires minimal graft versus host disease has also occurred post-FWB extra equipment to carry. Also, there are biological advan- transfusion in patients injured in combat.11 tages to FWB transfusions: FWB has been reported to have increased clotting factor activity and is already warm, Supporting evidence thereby making fluid warmers unnecessary.6,7 Finally, FWB is a source of fresh platelets; platelets are otherwise A recent, small randomized trial compared “modified” difficult, if not impossible, to transport and use in the far whole blood transfusions (cold) with standard component forward environment.6 therapy. After excluding enrolled patients with severe brain injury, the authors of this trial suggested that modi- Risks of FWB in Special Operations environments fied whole blood transfusions were associated with a decrease in transfusion requirements, with no difference Risk to donors in mortality.12 Furthermore, several retrospective studies Immediate risks to Special Operations FWB donors may have shown an association with improved survival using include hypotension during collection, and decreased FWB in forward damage control surgical facilities and exercise tolerance after donation. Work done by the Nor- larger combat hospital environments.13,14 wegian group has shown that donation of 1 unit of blood has no effect on their Special Operations operators in Alternatives to FWB in Special Forces environments terms of shooting and heavy physical exertion;8 however, they did note that this experiment took place under non- Recent technological advances have allowed Special Oper- combat conditions, where intense physical stressors, hun- ations Forces to bring packed red blood cells far forward ger and dehydration may become factors. They did not for a prolonged period of time, without the need for a consider the impact if the donor is wounded after dona- deployed blood refrigerator.15 Fresh whole blood should tion. As well, most patients who require damage control be given only if component therapy is not available. resuscitation (DCR) will require large amounts of products, and so the temptation of soldiers to donate more Decision to give FWB in Special Operations Forces than 1 unit of FWB may be intense. Late risks of FWB donation by Special Operations sol- The injured Special Operations soldier should first be diers are mostly administrative and ethical. If prescreen- cared for as per tactical combat casualty care principles, ing precludes a Special Operations soldier from FWB which include control of compressible hemorrhage, secur- donation before a mission, there may be administrative ing an airway, treatment of tension pneumothoraces, repercussions for that soldier. This may lead to many administration of tranexamic acid, avoidance of hypother- issues with confidentiality and/or stigmatization. In addi- mia and utilization of permissive hypotension.16 tion, this may cause issues with obtaining health care The risks and benefits of administering FWB must then insurance in the future. be weighed. The risk of death from hemorrhage should outweigh the above risks of FWB transfusion. It should be Risks to recipients kept in mind that many combat casualties will need multi- Early risks to FWB include all the risks of receiving ple units of blood during the course of their resuscitation.

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Casualties should be triaged to avoid wasting FWB on negative, low titre donors). Only 1 unit (500 mL) per Spe- nonsalvageable casualties in the context of the limited cial Forces donor should be collected, as further donation resources of the Special Forces environment. The decision may compromise operational capability.17 An intravenous to initiate FWB transfusion by the Special Operations blood tubing set should always be used during FWB trans- medic must be taken in context of transport times to a sur- fusion.4 Patients should be resuscitated with FWB to a pal- gical facility. pable radial pulse or evidence of end organ perfusion, such as urinary output or increased consciousness.16 Best practice guidelines The amount of FWB given and the donors should be recorded, if the situation permits. Strandenes and colleagues17 from the Norwegian group The FWB recipients who survive to forward surgical have recently published their set of protocols and guide facilities should be monitored continuously for transfusion lines. The U.S. Special Forces have also put in place and reactions. Blood products at more advanced facilities published guidelines on their FWB programs in tactical should be component type resuscitation wherever possible; settings.18 The following sections on training and donor however, banked FWB may be the only product avail- screening describe their general principles. able.17 In this setting, a rapid crossmatch (Eldoncard, Craig Medical) and rapid serology for transfusion-transmitted Training infections must be done to limit the exposure of the cas Special Forces medics must undergo specific training ualty to untested blood. Recipients of FWB who have sur- under physician supervision and be certified to be able to vived their injuries should be followed with serology at conduct FWB collections and transfusions.7 They must baseline, at 6 and 12 weeks and at 6 months and referred to demonstrate that they know when to initiate FWB an infectious disease specialist should they seroconvert. transfusion, understand the risks and benefits of FWB This was the practice of the CAF for casualties who transfusion and manage acute transfusion reactions. They received FWB during the period 2006–11. If a recipient must also demonstrate in a clinical training setting that seroconverts after FWB, an aggressive search must be they have technical skills to safely perform the collection made for the donors and offer them serology testing. and transfusion of FWB.18 It is unclear whether testing donors who have given FWB during their deployment offers any further benefit to Donor screening recipients, as no data exist. However, it may relieve some Donation of blood should be voluntary. Predeployment anxiety on the part of the recipient, so may be worthwhile. screening should take place using standard regulatory Medical confidentiality needs to be preserved for both the screening and interview forms, ABO and RhD blood donor and recipient in this situation. grouping and serology for syphilis, hepatitis B and C, human T–Cell lymphoma virus, Trypanosoma cruzi, and Conclusion nucleic amplification for hepatitis B and C, HIV and West Nile virus. Potential type O donors with “low” There may be a role for establishing an FWB transfusion anti-A, anti B titres (the definition of low titres varies capability for Special Operations soldiers who deploy on from country to country), should be identified as prefer- high-risk missions to austere locations. The evidence for ential donors.7 FWB outcomes is weak, consisting mostly of historical During long deployments, previously approved donors accounts, case reports, retrospective data and 1 small ran- should be rescreened at 3-month intervals. In the situa- domized trial. However, FWB may be lifesaving for the tion where an FWB transfusion will be conducted by a unstable bleeding Special Operations soldier when regular Special Operations medic, FWB collection by the medic blood component therapy is not available. Fresh whole blood should be done in a standard fashion into commercially should be considered only when there is reasonable hope of available citrated bags specifically designed for the pur- obtaining quick hemorrhage control. Donor autonomy and pose of far forward or buddy blood transfusion. Ideally, safety should also be respected throughout this practice. the medic should also conduct screening and perform a crossmatch and rapid serology testing on the donor blood Affiliations: From the 1 Canadian Field Hospital, Petawawa, Ont. before transfusion. However, time and logistical concerns (Beckett, Schmid, Tien); Trauma Program, McGill University Health Centre, Montréal, Que. (Beckett); Sunnybrook Heath Sciences Centre, may prevent these processes. Furthermore, if the transfu- Toronto, Ont. (Callum, da Luz, Tien); The Trauma & Combat Medi- sion is life-saving and no other option is available, the cine Branch, Surgeon General’s HQ, Israel Defense Forces, Ramat question arises as to whether the blood should be trans- Gan, Israel (Glassberg). fused anyway, even if the donor is tested and tests positive Competing interests: None declared. on any criteria. Contributors: All authors contributed substantially to the conception, The ABO and RhD compatible donors should be used writing and revision of this commentary and approved the final version first.17 The next best choice should be universal donors (O for publication.

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