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.

Tactical Combat Casualty Care Update: 2015 Naval Aeromedical Conference 14 January 2015

http://1.bp.blogspot.com/-Dc_bQjUYPkg/VdElcTWq3vI/AAAAAAAAAhU/AiEVbyCbmYc/s1600/Combat%2BTrauma.jpg

‘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

Tactical Combat Casualty Care Update: 2015 Naval Aeromedical Conference 14 January 2015

Tactical Combat Casualty Care Update: 2015 Naval Aeromedical Conference 14 January 2015

Tactical Combat Casualty Care Update: 2015 Naval Aeromedical Conference 14 January 2015

Tactical Combat Casualty Care Update: 2015 Naval Aeromedical Conference 14 January 2015

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.

‘Hardened’ Role II Forward Surgical Team (FST) Operating Room

Pediatric Trauma Surgery Downrange at Fixed FST

Role II Forward Surgical Team

Laparoscopic Surgery at ‘Fixed’ Role II Facility Downrange

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

Role IV - MEDCEN

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.

Tactical Combat Casualty Care Update: 2015 Naval Aeromedical Conference 14 January 2015

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

GHOST Team Sets-Up for Damage Control Surgery

‘Cheeky’ Mural Painted on T-wall

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.

Backpack Based Mobile OR

Pressure Based Instrument Sterilizer aka ‘Lobster Pot’

‘Building of Opportunity’

30 minute Set-Up 30 minute Tear-Down

‘BUILDING OF OPPORTUNITY’

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

Casting/Splinting Class

Wound Closure Clinic

Damage Control Surgery

Improvised Ground Transport

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).

Humanitarian Care – Recovering Burn Wound Patient

Right Fibula with Chronic Osteomyelitis in a 3 year old male

Open Debridement of Right Fibula in a 3 year old male

Questions?