Eastern Association for the Surgery of Trauma 28 th Annual Scientific Assembly Sunrise Session 11 Preparing for the Next War: Pivotal Military Civilian Relationships January 16, 215 Disney s Contemporary Resort Lake Buena Vista, Florida Page 1
Preparing for the Next War: Pivotal Military-Civilian Relationships Masterminding the Joint Trauma System Donald H Jenkins MD FACS Trauma Director Saint Marys Hospital Rochester MN 16 January 215 45 4 35 3 25 2 15 5 Percentage Of Total Combat Deaths Over Time Immed <5 3 2 hr 6 hr 1 d 1 wk > 1 wk Time from Wounding Bellamy Anes & Periop Care of Combat Cas KIA DOW Early, Adequate Surgery is the Answer to Died of Wounds Most important steps are stopping hemorrhage and avoiding infection and sepsis Wounds debrided of nonviable, contaminated tissue with good blood supply are best able to resist infection Page 2
Early OIF Surgical Sites PROXIMITY SURVIVABILITY COMBAT TRAUMA SYSTEM REALITY in Early OIF UNDER-triage Point of Injury Major trauma Reasons cited 1. Casevac 2. Closest medic 3. Poor casualty assessment 4. Unaware of capability/necessity Evac#1 MAJOR FSMC Evac #2 FST TRIAGE Level I Avoidable risk CSH CSH CSH Page 3
CONSEQUENCE We had fallen behind the construct of experience gained and lessons learned from civilian trauma systems Trauma System DEFINITION An arrangement of available resources that are coordinated for the effective delivery of emergency health care services in geographical regions consistent with planning and management standards. GOAL Get the right patient to the right hospital in the right amount of time DEL RIO MODEL OF TRAUMA CARE Page 4
COMBAT TRAUMA SYSTEM DESIRED ENDSTATE Point of Injury evac OTHER FSMC TRIAGE Level I MAJOR OVER-triage Participation in PI process by both EAC and Divisional medical units Crosslevel or redeploy, based on med req FST CSH CSH SOP developed and trained Trauma System = Increased Survival CONTINUOUS EN ROUTE CARE Current Route from Injury to Definitive Care BAS Level 1 CASEVAC 1 Hour Forward Surgical Teams Level 2 TACTICAL MEDEVAC 1-24 Hours CSH, EMEDS, EMF Level 3 STRATEGIC AE 24-72 Hours Definitive Care Level 4 SURGICAL CAPABILITY PUSHED FAR FORWARD Page 5
Combat Application Tourniquet 6515-1-521-7976 Windlass Omni Tape Band Windlass Strap Burns May-July 26 28 US Troops identified with burns transferred to Level III: 82% due to IED; 68% Soldiers 64% required surgery in theater 7% > % Total Body Surface Area 39%TBSA (avg 23-5 = 14%) Burn outcome: DOW = 5 (18%) (mortality 23-25 = 3.8%) Good Data = Good Decisions $25 million in Nomex uniforms distributed to all troops going outside the wire # US Military burn TX to Level III 18 16 14 12 8 6 4 2 Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun 25-26 Trend is from 3 US troops burned/month Jun 5 to 12 burned/month June 6 Decision to use Nomex uniforms 12 8 6 4 2 Jan Ma Se Jan Ma Se Jan Ma Se # Major Burns 25-7 Page 6
Mortality by Plasma : RBC Ratio Mortality 7 6 5 4 3 2 65% 34% 19% (Low) 1:8 (Medium) 1:2.5 (High) 1:1.4 The ratio of blood products transfused affects mortality in patients receiving massive transfusions at a combat support hospital. Borgman MA, et. al. Comparison of Statistics for Battle Casualties, 1941-25 World War II Vietnam War Iraq & Afghanistan %KIA 23.7% 21.3% 12.5% %DOW 3.4% 3.5% 4.1% %CFR 22.8% 16.5% 8.8% Combat Casualty Statistics OIF/OEF 12 OIF Cumulative Monthly Avg CFR%, DOW%, KIA% and ISS Jan 24 - Feb 28 CUM AVG ISS CUM KIA % 25% 2% 8 15% 6 4 % 2 5% % JAN 4 MAR_4 MAY_4 JUL 4 SEP_4 NOV 4 JAN 5 MAR_5 MAY 5 JUL 5 SEP_5 NOV_5 JAN_6 MAR_6 MAY_6 JUL_6 SEP_6 NOV_6 JAN_7 MAR_7 MAY_7 JUL_7 SEPT_7 NOV_7 JAN_8 Cum Avg ISS Month and Year Data Source: Defense Manpower Data Center Statistical Analysis Division, OSD, JTTR v3. Page 7
Combat Casualty Mortality (Cumulative % of All Wounded) IN-THEATER COMBAT MORTALITY 45 4 35 3 25 2 15 5 185 Mortality after Entering Echelon Hospital Chain Combat Zone Mortality Prior to First MTF 1865 188 1895 19 1925 194 1955 197 25 % Decrease in combat deaths 4.1 % 12.5 % Crimean War Russian-Japanese War WWI WWII Vietnam War American Civil War Korean War MAJ Mark D. Taylor Army surgeon killed 2 MAR 24 COL Brian D. Allgood Army surgeon killed 2 JAN 27 Page 8
John P. Pryor, KIA Mosul Iraq 25 December 28 The Future is in Research Will require close military/civilian collaboration Will require dedicated funding We must follow long term outcomes through the VA system What Are We Doing About It? Defense Health Board and its Trauma and Injury Subcommittee: report on lessons learned to SecDef National Trauma Institute: working with DoD researchers American Surgical Organizations Collaborative National Trauma Research Repository Development Large scale national injury and treatment studies Advocating for National Trauma Clinical Research Network Development and Funding Page 9
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