Update on War Zone Injuries Stan Breuer, OTD, OTR/L, CHT Colonel, United States Army

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1 Update on War Zone Injuries Stan Breuer, OTD, OTR/L, CHT Colonel, United States Army Disclaimer: The opinions or assertions contained herein are the private view of the author and are not to be construed as official or reflecting the views of the Department of Defense or United States Government. The author is an employee of the U.S. Government and this work was prepared as part of his official duties. Agenda: Objectives Casualty Statistics Common Injuries Battlefield Medical Care Medical Evacuation from the Battlefield Advances in Battlefield Medicine Conclusion Objectives: 1) Review common upper extremity injuries associated with combat 2) Describe the evacuation of combat wounded from the battlefield to the United States 3) Describe battlefield medicine contributing to a decrease in case fatality rate Casualty Statistics: Operation Iraqi Freedom (OIF) Deaths: 4,488 (1) Wounded In Action: 31,949 (2) Operation Enduring Freedom (OEF) Deaths: 2351 (1) Wounded In Action: 20,048 (3) Case Fatality Rate: decrease from 16% (2006) to 9% (2014) (4) Injury Severity Score: increased from 12 (2006) to 13.5 (2014) (4) Common Upper Extremity Injuries: Crush Injury Dislocation Fracture Shrapnel Gun Shot Wound Burn

2 Upper Extremity Injuries by Type: Type of UE Injury % of UE Injuries Orthopedic Injuries and Fractures 46.1% Vascular Injuries 6.4% Soft Tissue Injuries 78.6% Burns 1.6% Major Limb Amputations: Upper Extremity Lower Extremity Upper & Lower Extremity Source of Injury: Blast (relatively close proximity) Improvised Explosive Device Rocket Propelled Grenade Land Mine Gun Shot Thermal Other combat related Casualty Flow: Level I : Buddy Aid/Medic/Unit level Aid Station Level II: Area Support Medical Battalion/Company Forward Surgical Team Level III: Combat Support Hospital Level IV: Germany - Landstuhl Army Regional Medical Center Level V: US Military Hospital / VA Hospital / Civilian Hospital

3 Hierarchy of Care: ABCs (Levels I-III) Critical Care (I-III) Early Wound/Injury Management (Level III) -debridement -antibiotics -skeletal stabilization Evacuation (Level I-IV) Definitive Care and Rehabilitation (Level IV-V) Rehab is Minimal (Level I-III) Treatment of Combat Injuries: Complicating factors in Combat Casualty Care -Hostile environment -Extremely high energy injuries -Grossly contaminated wounds -Limitations of forward care -Multiple injury -Mass casualty -Evacuation chain -Information transfer Evacuation from the Battlefield: Increased size of Air Ambulance Units Flight medics certified and trained paramedics Standardize en route critical care En route critical care nurses Medical Company (Level II) Forward Surgical Team Patient collection and evacuation within 24 hours Evaluate casualty wounds to determine treatment and evacuation Resuscitative surgical capabilities by the forward surgical team Combat Support Hospital (Level III) Hospital facilities Resuscitative care Intensive care Initial wound surgeries Definitive and reconstructive surgery Postoperative treatment Surgical to stabilize for evaluation or return to duty hour evaluation

4 Landstuhl Germany (Level IV) Further stabilized and evacuated to US General and specialized medical and surgical care Rehab and reconditioning for those returning to Iraq and Afghanistan Average length of stay 4 days Stateside (Level V) Advanced wound coverage Skeletal reconstruction Nerve repair / graft / transfer Tendon reconstruction Lengthy rehabilitation and reconditioning Advances in Battlefield Medicine: Tactical Combat Casualty Care (TCCC) -Keep the injured alive until they reach a hospital TCCC Priority is Prevention then Treatment -First engage and repel the enemy -Second provide care with emphasis on controlling bleeding 2004: Combat Application Tourniquet Issued to all troops Complex Comorbid Problems: Brain Injury Spinal Cord Injury Limb Trauma/Amputation Facial Trauma Peripheral Nerve Injury Internal Organ Damage Pain Management Burns Infection Sensory Loss (Visions/Hearing) Conclusion: 3 Rules of the Combat Medic 1. Good men will die. 2. Doc can t save everyone. 3. Doc will be willing to die to break rules 1 and 2. (unknown) References: 1. Operation Iraqi Freedom and Operation Enduring Freedom Casualty Count, Accessed 1 Dec U.S. Military Casualties - Operation Iraqi Freedom (OIF) Wounded in Action, Accessed 1 Dec 2014 Accessed 1 Dec U.S. Military Casualties - Operation Enduring Freedom (OEF) Wounded in Action, Accessed 1 Dec 2014.

5 4. Case Fatality Rate versus Injury Severity Score1 NOV Jun 2014, Department of Defense Trauma Registry. 5. US Military Battle Casualties with Upper Extremity Injuries in OIF, OEF and OND admitted to a Role 3 MTF from 1 October 2001 to 1 December 2014, Department of Defense Trauma Registry. 6. Department of Defense Major Limb Amputations Operations Iraqi Freedom and Enduring Freedom, DoD-VA Extremity Trauma and Amputation Center of Excellence.