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The Evolution of Battlefield Surgery Post-‘9-11’
& Damage Control Surgery
LTC DUANE DUKE MD FACS
Division Chief of Pediatric Surgery USU Walter Reed Surgery
19OCT2016
Disclosure I have no personal or professional financial
relationships or interests with any proprietary entity producing healthcare goods/or services
Military Disclosure
• The views expressed in this presentation do not represent the Army Medical Corps, the AMEDD Center or School, or the Department of Defense.
• With regards to Operational Security (OPSEC), specific locations, capabilities, dates and times will not be discussed.
Military Medicine Vocab
• TCCC – Tactical Combat Casualty Care
• Class VIII – expendable medical supplies (ex. gauze)
• Triage Categories: – Immediate
– Delayed
– Minimal
– Expectant
• CASEVAC – Casualty Evacuation
• MEDEVAC – Medical Evacuation
• AE – Aeromedical Evacuation
Additional Military Vocab
• CONUS vs. OCONUS
• DOWNRANGE
• CONVENTIONAL vs UNCONVENTIONAL
• ASYMMETRIC CONFLICT
• MATURE THEATRE
• SOF – Special Operations Forces
• METTTC (M – mission, E – enemy, T – terrain and weather, T-troops and support available, T- time available, C- civilian considerations) Dependent
Echelons/Roles/Levels of Care (Army)
• Role I – Battalion Aid Station
• Role II – Forward Surgical Team (FST)
• Role III – Combat Support Hospital (CSH)
• Role IV - MEDCEN– Medical Center
Point of Injury Care - TCCC
• TCCCTrauma Combat Casualty Care
• Point of Injury Care or Care Under Fire
• Self Aid and Buddy Aid
• Exceedingly difficult to perform.
• Win the fire-fight first.
• Focus is on stopping hemorrhage and patient evacuation.
• Limited ability to resuscitate.
‘MIST’ Report Hand-over
• M – Mechanism
• I – Injuries Sustained
• S – Signs (Vitals) and Symptoms
• T – Treatments rendered
Updated TCCC card to incorporate MIST report
http://combatmedicalsystems.com/wp-content/uploads/2015/08/TCCC-Card-with-logo.jpg
Role I – Battalion Aid Station
• Objective: Treat and Return to Duty (RTD) or stabilize and begin evacuation process.
• Staffing: MD (non-surgeon) or Physician Assistant and 1 or 2 medics.
• Limited Class VIII inventory.
• No surgical or patient holding capacity.
Role II Asset: Forward Surgical Team (FST)
• 20-30 man team
• 3 general surgeons, 1 orthopedic surgeon, 2 CRNAs, critical care nurses and technicians.
• Can be Fixed or Mobile, but requires significant resources for movement.
• Some Patient Holding Capacity.
Role III – Combat Support Hospital (CSH) Aerial Photo and Schematic
http://www.alu.army.mil/alog/issues/SepOct10/Story_Images/ms724_CSH.jpg
http://nursing411.org/Courses/MD0923_Intro_Operating_Room/MD0923/images/MD0923_img_2.jpg
Golden Hour Directive
• 2009 Secretary of Defense Directive
• All troops engaged in combat operations must be within 60 minutes of damage control surgery capability.
• Challenge comes when working in an immature theatre with a paucity of evacuation assets.
GHOST Team Team
• Golden Hour Offset Surgical Team = a sub-team drawn off FST man-power
• Prepositioned Damage Control Surgery Team w/i ‘Golden Hour’
• Developed for theatres/missions with prolonged evacuation times.
• Team has limited patient holding capacity, limited Class VIII resupply, limited blood product resupply
ERST Team
• Emergency Resuscitative Surgical Team • 8 man backpack based team • 2 sub components: 5-man damage control
surgical team and 3-man critical care evacuation team
• DCS = General Surgeon, Orthopedic Surgeon, CRNA, Emergency Medicine Physician, Surgical Technician
• CCET = Critical Care Physician, Critical Care Nurse, Emergency Medicine Nurse
Pre-Mission Train-Up
• Equipment Familiarity
• Rotary Wing Med-Evac Course for Evacuation Team
• ASSET, ATOM Course
• Emergency War Surgery Course
• 2 Day Army Tropical Medicine Course
• Field Exercise with Live Tissue Trauma models: caprine, bovine in austere settings
Damage Control Surgery
• 30:30:30 target: 30 minutes to set-up, 30 minutes to do operation, 30 minutes to tear-down and leave no trace
• Objectives: Control Hemorrhage, Mitigate Contamination, Prep patient for Transport
• Performed in ‘Building of Opportunity’
• Improvised evacuation platform
Damage Control Surgery
• Must have ability to Stop/Pause Procedure at any moment due to Security or Transport Constraints
• Must always prepare Bail-Out Maneuvers – ex. Control pedicles or divisible vessels with clamps, no time for complete ligation or complete organ resection
• No bovie, No suction, No power source
• 6U PRBC, 6U FFP, TXA – no platelets
• Limited crystalloid
• Walking Blood Bank feasible? – METTTC dependent.
Host Country Partnered Force Trauma/Medical Collaboration
• Capacity Building: Trauma Assessment Class, Ortho Splinting Class, Wound Closure Course
• Educational Exchange
• Train, Assist, Advise, and Accompany for Response to Trauma and Mass-Cals
• Mutual Benefit
Host Country Humanitarian Care
• Educational Exchange
• Capacity Building
• Enhances Readiness in low-kinetic environments
• Promotes Access to Community
• Limited by MEDROE (Medical Rules of Engagement).