Highlights of the 2nd Greek Armed Forces Medical Corps Meeting
Highlights of the 2nd Greek Armed Forces Medical Corps Meeting
Combat critical care medicine is unique in a number of ways. As one can imagine, it is an entirely different way of practicing medicine in an intensive care unit (ICU). Staff and equipment resources are limited and the standard of care is subject to frequent change such that one must be flexible and adapt to and overcome many unexpected challenges.
Erik Osborn, MD, a Major in the US Army who was deployed to Iraq as an emergency department (ED) and intensive care physician, discussed the challenges of critical care in a combat zone, the epidemiology of injuries sustained in the War in Iraq, challenges faced by those responsible for transfer of casualties, and lessons learned. The comments presented reflect Dr. Erik Osborn's views and not necessarily those of the US Army. Dr. Osborn served in the 67th Combat Support Hospital (CSH) in Mosul, Iraq, which included 6 ED beds, 2 operating tables, 12 ICU beds, and 22 ward beds. Figures 1 and 2 are aerial views of the CSH in Mosul. The ED is shown in Figure 3.
(Enlarge Image)
The emergency department, operating room, and intensive care unit are in the center. Personnel lived at the trailers in the back.
(Enlarge Image)
A closer view of the essential components of the 67th Combat Support Hospital.
(Enlarge Image)
Empty trauma bed in the emergency department. The hallway on the left is to the operating room.
The mission of the 67th CHS was to treat life-, limb-, and eyesight-threatening injuries and to stabilize the patient, perform damage control surgery, and eventually transport the patient or return him/her to duty. The CSH was staffed by 9 physicians (general surgeon, orthopedic surgeon, anesthesiologist, internist, family practitioner, ED physician, obstetrician/gynecologist, oral surgeon, and psychiatrist) and nursing staff (approximately 3 times the number of physicians). Portable x-ray and ultrasound equipment was available. There was a laboratory for basic tests and a pharmacy staffed with a pharmacist. Additional support specialty staff included a respiratory therapist and a physical therapist.
In the battlefield, the time lag between injury and treatment may result in early death, loss of the golden hour of trauma care, and late death from sepsis and/or multiorgan failure (MOF). The injured were constantly moved and there was no continuity of care as multiple physicians were involved in various levels of care. Wounds most frequently resulted from blunt, penetrating, thermal, or blast injury, which are seen less frequently in the civilian setting. In addition, many wounded patients also suffered from noninjury somatic and psychological conditions or diseases, including dehydration and malnutrition.
Battlefield triage is different from civilian or large medical center triage; the triaging officer must quickly decide which patients are salvageable and who should receive the limited available resources (there was only 1 general surgeon and only 20 units of blood were available). There are 4 general triage categories: immediate, delayed, minimal, and expectant. In Dr. Osborn's experience, this classification was dynamic, as combat conditions affected the normal flow of patients. But in general...
A patient categorized as "immediate" requires medical attention right away. The patient has unstable vital signs and an injury that is severe and will benefit from immediate treatment. A patient categorized as "delayed" means that the patient has a mild injury, is hemodynamically stable, and can wait for treatment. Patients with "minimal" injuries can walk and actually help with the care of other patients, and they are expected to quickly return to duty. Patients categorized as "expectant" are those who will unfortunately die from severe, immediate, life-threatening wounds that cannot be effectively treated with the resources of the CSH.
No clear trimodal distribution (at scene, golden hour, late sepsis/MOF) of death was observed. Seventy percent of the injured died in the first 5 minutes, and 80% to 90% died in the first hour due to penetrating injury and exsanguination; thus, most of the wounded with fatal injuries died prior to transport or arrival to a care facility.
An unusual occurrence was young, otherwise healthy patients, without a history of taking antibiotics, presenting with resistant Acinetobacter baumanii infection (Figure 4). These patients came from multiple sites, so it is unlikely that an infected healthcare worker transmitted the bacteria. War wounds are not treated in the same fashion as at a civilian trauma center. Antibiotics, pulse irrigation, and antibiotic beads are not substitutes for surgical debridement in this setting, and, most important, war wounds must be left open.
(Enlarge Image)
Multiple infections with Acinetobacter baumanii were seen.
Besides caring for the sick, security and safety is a major concern with unpredictable enemy action. Injured patients had to be checked for weapons and biochemical contamination. In addition, lines of evacuation and supply had to be secured. Several small arms fire and mortar attacks occurred during surgical operations. The surgical team had to keep operating even though most of the rest of the hospital staff took cover in bunkers (Figure 5 and 6). In addition, a physician or respiratory therapist had to stay with mechanically ventilated patients, since there were few staff members experienced with ventilator management.
(Enlarge Image)
Operating with a helmet on is but one of the unique challenges faced by the surgical team.
(Enlarge Image)
Mortar and rocket attacks significantly affected patient care. The trailers providers lived in are on the right and the bunker outside in which they would take cover during mortar attacks is on the left.
Resource limitations dictated the most cost-effective use of equipment. Uni-Vent Impact 750 and Impact 754 portable mechanical ventilators (Figure 7) were used. Oxygen supply was a problem because storage of oxygen was not feasible. Consequently, a sizeable (weight 100 kg) portable oxygen generator was used.
(Enlarge Image)
Uni-Vent Impact 750 and Impact 754 portable ventilators used in the War in Iraq.
And, finally, a peculiarity seen in the field is worth mentioning. Several cases of eosinophilic pneumonia were seen after soldiers began smoking local Iraqi cigarettes.
Combat critical care medicine is unique in a number of ways. As one can imagine, it is an entirely different way of practicing medicine in an intensive care unit (ICU). Staff and equipment resources are limited and the standard of care is subject to frequent change such that one must be flexible and adapt to and overcome many unexpected challenges.
Erik Osborn, MD, a Major in the US Army who was deployed to Iraq as an emergency department (ED) and intensive care physician, discussed the challenges of critical care in a combat zone, the epidemiology of injuries sustained in the War in Iraq, challenges faced by those responsible for transfer of casualties, and lessons learned. The comments presented reflect Dr. Erik Osborn's views and not necessarily those of the US Army. Dr. Osborn served in the 67th Combat Support Hospital (CSH) in Mosul, Iraq, which included 6 ED beds, 2 operating tables, 12 ICU beds, and 22 ward beds. Figures 1 and 2 are aerial views of the CSH in Mosul. The ED is shown in Figure 3.
(Enlarge Image)
The emergency department, operating room, and intensive care unit are in the center. Personnel lived at the trailers in the back.
(Enlarge Image)
A closer view of the essential components of the 67th Combat Support Hospital.
(Enlarge Image)
Empty trauma bed in the emergency department. The hallway on the left is to the operating room.
The mission of the 67th CHS was to treat life-, limb-, and eyesight-threatening injuries and to stabilize the patient, perform damage control surgery, and eventually transport the patient or return him/her to duty. The CSH was staffed by 9 physicians (general surgeon, orthopedic surgeon, anesthesiologist, internist, family practitioner, ED physician, obstetrician/gynecologist, oral surgeon, and psychiatrist) and nursing staff (approximately 3 times the number of physicians). Portable x-ray and ultrasound equipment was available. There was a laboratory for basic tests and a pharmacy staffed with a pharmacist. Additional support specialty staff included a respiratory therapist and a physical therapist.
In the battlefield, the time lag between injury and treatment may result in early death, loss of the golden hour of trauma care, and late death from sepsis and/or multiorgan failure (MOF). The injured were constantly moved and there was no continuity of care as multiple physicians were involved in various levels of care. Wounds most frequently resulted from blunt, penetrating, thermal, or blast injury, which are seen less frequently in the civilian setting. In addition, many wounded patients also suffered from noninjury somatic and psychological conditions or diseases, including dehydration and malnutrition.
Battlefield triage is different from civilian or large medical center triage; the triaging officer must quickly decide which patients are salvageable and who should receive the limited available resources (there was only 1 general surgeon and only 20 units of blood were available). There are 4 general triage categories: immediate, delayed, minimal, and expectant. In Dr. Osborn's experience, this classification was dynamic, as combat conditions affected the normal flow of patients. But in general...
A patient categorized as "immediate" requires medical attention right away. The patient has unstable vital signs and an injury that is severe and will benefit from immediate treatment. A patient categorized as "delayed" means that the patient has a mild injury, is hemodynamically stable, and can wait for treatment. Patients with "minimal" injuries can walk and actually help with the care of other patients, and they are expected to quickly return to duty. Patients categorized as "expectant" are those who will unfortunately die from severe, immediate, life-threatening wounds that cannot be effectively treated with the resources of the CSH.
No clear trimodal distribution (at scene, golden hour, late sepsis/MOF) of death was observed. Seventy percent of the injured died in the first 5 minutes, and 80% to 90% died in the first hour due to penetrating injury and exsanguination; thus, most of the wounded with fatal injuries died prior to transport or arrival to a care facility.
An unusual occurrence was young, otherwise healthy patients, without a history of taking antibiotics, presenting with resistant Acinetobacter baumanii infection (Figure 4). These patients came from multiple sites, so it is unlikely that an infected healthcare worker transmitted the bacteria. War wounds are not treated in the same fashion as at a civilian trauma center. Antibiotics, pulse irrigation, and antibiotic beads are not substitutes for surgical debridement in this setting, and, most important, war wounds must be left open.
(Enlarge Image)
Multiple infections with Acinetobacter baumanii were seen.
Besides caring for the sick, security and safety is a major concern with unpredictable enemy action. Injured patients had to be checked for weapons and biochemical contamination. In addition, lines of evacuation and supply had to be secured. Several small arms fire and mortar attacks occurred during surgical operations. The surgical team had to keep operating even though most of the rest of the hospital staff took cover in bunkers (Figure 5 and 6). In addition, a physician or respiratory therapist had to stay with mechanically ventilated patients, since there were few staff members experienced with ventilator management.
(Enlarge Image)
Operating with a helmet on is but one of the unique challenges faced by the surgical team.
(Enlarge Image)
Mortar and rocket attacks significantly affected patient care. The trailers providers lived in are on the right and the bunker outside in which they would take cover during mortar attacks is on the left.
Resource limitations dictated the most cost-effective use of equipment. Uni-Vent Impact 750 and Impact 754 portable mechanical ventilators (Figure 7) were used. Oxygen supply was a problem because storage of oxygen was not feasible. Consequently, a sizeable (weight 100 kg) portable oxygen generator was used.
(Enlarge Image)
Uni-Vent Impact 750 and Impact 754 portable ventilators used in the War in Iraq.
And, finally, a peculiarity seen in the field is worth mentioning. Several cases of eosinophilic pneumonia were seen after soldiers began smoking local Iraqi cigarettes.
Source...