The Evolution of Battlefield Surgery Post Damage Control Surgery

Transcription

1 The Evolution of Battlefield Surgery Post & Damage Control Surgery LTC DUANE DUKE MD FACS Division Chief of Pediatric Surgery USU Walter Reed Surgery 19OCT2016

2 Disclosure I have no personal or professional financial relationships or interests with any proprietary entity producing healthcare goods/or services

3 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.

4 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

5 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

6 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

7 Point of Injury Care - TCCC TCCC Trauma 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.

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

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10 MIST Report Hand-over M Mechanism I Injuries Sustained S Signs (Vitals) and Symptoms T Treatments rendered

11 Updated TCCC card to incorporate MIST report

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

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

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

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

16 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.

17 Role II Asset: Forward Surgical Team man team (FST) 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.

18 Hardened Role II Forward Surgical Team (FST) Operating Room

19 Pediatric Trauma Surgery Downrange at Fixed FST

20 Role II Forward Surgical Team

21 Laparoscopic Surgery at Fixed Role II Facility Downrange

22 Role III Combat Support Hospital (CSH) Aerial Photo and Schematic

23 Role IV - MEDCEN

24 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.

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

26 GHOST Team Team Golden Hour Offset Surgical Team = a subteam 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

27 GHOST Team Sets-Up for Damage Control Surgery

28 Cheeky Mural Painted on T-wall

29 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

30 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

31 Damage Control Surgery 30:30:30 target: 30 minutes to set-up, 30 minutes to do operation, 30 minutes to teardown and leave no trace Objectives: Control Hemorrhage, Mitigate Contamination, Prep patient for Transport Performed in Building of Opportunity Improvised evacuation platform

32 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.

33 Backpack Based Mobile OR

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35 Pressure Based Instrument Sterilizer aka Lobster Pot

36 Building of Opportunity

37 BUILDING OF OPPORTUNITY 30 minute Set-Up 30 minute Tear-Down

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39 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

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41 Casting/Splinting Class

42 Wound Closure Clinic

43 Damage Control Surgery

44 Improvised Ground Transport

45 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).

46 Humanitarian Care Recovering Burn Wound Patient

47 Right Fibula with Chronic Osteomyelitis in a 3 year old male

48 Open Debridement of Right Fibula in a 3 year old male

49 Questions?