An Analysis of Ketamine Doses Administrated to Nonintubated Casualties Prehospital

ABSTRACT Introduction Previous studies demonstrate that a significant proportion of casualties do not receive pain medication prehospital after traumatic injuries. To address possible reasons, the U.S. Military has sought to develop novel delivery methods to aid in administration of pain medications prehospital. We sought to describe the dose and route of ketamine administered prehospital to help inform materiel solutions. Materials and Methods This is a secondary analysis of a previously described dataset focused on prehospital data within the Department of Defense Trauma Registry from 2007 to 2020. We isolated encounters in which ketamine was administered along with the amount dosed and the route of administration in nonintubated patients. Results Within our dataset, 862 casualties met inclusion for this analysis. The median age was 28 and nearly all (98%) were male. Most were battle injuries (88%) caused by explosives (54%). The median injury severity score was 10 with the extremities accounting to the most frequent seriously injured body region (38%). The mean dose via intravenous route was 50.4 mg (n = 743, 95% CI 46.5-54.3), intramuscular was 66.7 mg (n = 234, 95% CI 60.3-73.1), intranasal was 56.5 mg (n = 10, 39.1-73.8), and intraosseous was 83.3 mg (n = 34, 66.3-100.4). Most had a medic or CLS in their chain of care (87%) with air evacuation as the primary mechanism of evacuation (86%). Conclusions The average doses administered were generally larger than the doses recommended by Tactical Combat Casualty Care guidelines. Currently, guidelines may underdose analgesia. Our data will help inform materiel solutions based on end-user requirements.

Reviewing the needs of forward deployed critical care: South Sudan and the future

The UK military medical treatment facility (MTF) that deployed to the United Nations Mission in South Sudan in 2017 was based on a facility that can provide damage control surgery and resuscitation for soldiers with ballistic trauma injuries. It had to be supplemented with additional medical equipment and drugs that could support a peacekeeping mission in Africa. The clinicians used this experience and opportunity to review the critical care capability of UK Army Medical Services forward MTFs and recommend changes to reflect the increasing contemporaneous need on recent deployments to support more casualties with medical, infectious diseases and other non-battle injuries and illnesses. A concurrent review of the facility’s critical care transfer equipment was also undertaken and allowed it to be adapted for use as either transfer equipment or as a critical care surge capability, to increase the facility’s critical care capacity.

MEDIEVAL MUSLIM BURIAL OF MAN WITH BATTLE INJURIES NEAR DERBENT 'S WALLS

На территории Дербентского поселения I-VI веков н.э. в средневековье возник мусульманский некрополь, на котором в 1977, 1989, 2012, 2013, 2015-2019 гг. было раскопан 71 захоронение. В статье рассматривается погребение № 24, открытое на раскопе XXV (2016 г.). Оно, как и другие мусульманские захоронения этого могильника, было совершено в простой длинной узкой яме (араб. shiqq / shaqq ‘траншея’) по мусульманским погребальным нормам: погребенный лежал вытянуто на спине, головой на запад, череп повернут вправо лицевыми костями на юг по направлению киблы, инвентарь отсутствовал. В могиле был погребен мужчина, 45-55 лет, среднего роста и телосложения. На черепе зафиксированы следы трех единовременных травм от ударов саблей, одно из которых квалифицируется как смертельное. Датировка этого погребения, как и других захоронений могильника, опирается на находки надмогильной стелы с эпитафией и датой (915 г. хиджры / апрель 1509 – апрель 1510 г.) и фрагмента надмогильной стелы. В эпитафиях обеих стел упоминается титул шахид, которым были посмертно наделены умершие. Указанная на стеле дата дает возможность соотнести эти погребения шахидов с военно-политическими событиями этого времени на Восточном Кавказе, когда в 915 г.х. войска шаха Исмаила I, предприняли завоевание Ширвана под флагом борьбы шиитов с суннитами, заняли Шемаху, Баку, Шабиран, а затем предприняли успешную осаду Дербента. Очевидно, что и открытое погребение № 24, в котором был захоронен мужчина со следами боевых травм, относится именно к этому времени.

Review of a Role 2 in Afghanistan: Understanding the Data on Medical and Surgical Volumes in a Deployed Setting

Introduction The U.S. forward military surgical assets have deployed throughout the Iraq and Afghanistan theaters of operations to maintain surgical support for injured service members in compliance with the “golden hour” as specified in the Gates Memorandum. The support of evacuation times of less than 60 minutes to a surgical capability has resulted in smaller surgical teams being deployed to an increased number of locations. Over the last 5 years, the combat trauma patient encounters have decreased. Although some Role 2 medical treatment facilities (MTFs) maintain a medical mission, most of them are set up to provide trauma care. The largest and busiest Role 2 MTF is located near Kabul and serves the NATO population. The aims of this review are to examine the epidemiological data of the largest Role 2 MTF in theater, to examine damage control surgical capability optimization in a facility with a largely medical mission, and to analyze what this may mean in the context of surgical skill atrophy. Methods As part of a performance improvement project, a retrospective review of prospectively collected data at the Hamid Karzai NATO Role 2 MTF was conducted. Four years of clinical and epidemiological data were reviewed. Independent source verification of the records was conducted by validating records via comparison to the ancillary services’ records. When available, data on other MTFs in Afghanistan were used for comparison. Descriptive statistics were used to analyze demographics, evacuations, surgeries, and admissions. Results Over the studied period, 0.7% of patients were seen for battle injuries. The average number of patients seen was 636 per month with 184 per month in 2016 and a steady increase to 805 per month in 2019. The operative volume was a mean of 2.8 surgeries per month with a median of 2 surgeries per month (orthopedic and general surgery combined). Other Role 2 facilities were on average seeing even fewer operative patients, although there were some treating more operative patients. From available data, no other Role 2 MTFs were treating close to as many total patients (all types combined). The two Role 3 facilities evaluated saw significantly more operative patients at an average of 53 surgeries per month. Conclusion The ratio of operative cases per surgeon is substantially higher at these Role 3 facilities, when compared to Role 2 facilities, although still significantly lower than would be expected at an U.S. Level 1 trauma center. This is consistent with other larger epidemiological studies on forward MTF workload. The vast majority of patient care is related to treatment of disease and preventative medicine. Only 0.7% of the large volume of patient visits evaluated were for battle injuries. There is a scarcity of both surgical and trauma patients, with a more pronounced reduction at Role 2 compared to Role 3 facilities. This is especially evident here with a facility that has such a large patient population but low trauma or surgical patient volume. Sustaining trauma and surgical skills for both surgeons and trauma teams with a paucity of trauma patients is a significant concern.

Admiral Nelson’s illnesses and injuries

Horatio Nelson is one of the greatest English heroes. His key exploits at the battles of the Nile and Trafalgar, which led to Britain’s maritime supremacy, are well known and celebrated in the 5.5m statue at the summit of Nelson’s column in Trafalgar Square, London. The statue also showcases his most famous injuries, the injury to his right eye and arm amputation. However, as well as these he had a number of other battle injuries and afflictions including recurrent malaria, yellow fever, scurvy, tuberculosis and dysentery, which, although he bore with stoicism, may have affected his professional performance at different times in his career. The exact cause of his death was probably a combination of blood loss, lung injury and spinal shock.

Aeromedical Evacuations Within the French Armed Forces: Analysis of 2,129 Patients

Introduction The doctrine of medical support during French military operations is based on a triptych: forward medical stabilization, forward damage control surgery, and early strategic aeromedical evacuation (Strategic-AE). The aim of this study was to describe the last piece, the evacuation process of the French Strategic-AE. Methods We conducted a retrospective cohort analysis using patient records from 2015 to 2017. All French service members requiring an air evacuation from a foreign country to a homeland medical facility were included. Data collected included age, medical diagnosis, priority categorization, boarding location, distance from Paris, type of plane and flight, medical team composition, timeline, and dispatch at arrival. Results We analyzed 2,129 patients evacuated from 71 countries, most from Africa (1,256), the Middle East (382), and South America (175). Most patients (1,958) were not severely injured, although some considered priority (103) or urgent (68). Diagnoses included disease (48.6%), nonbattle injuries (43%), battle stress (5.3%), and battle injuries (3%). 246 Strategic-AE used medical teams in flight, 136 of them in a dedicated Falcon aircraft. The main etiologies for those evacuations were battle injuries (24%), cardiovascular (15.4%), infections (8%), and neurologic (7.3%). The median time of management for urgent patients was about 16 hours but longer for priority patients (26 hours). Once in France, 1,146 patients were admitted to a surgery department and 96 to an intensive care unit. Conclusion This is the first study to analyze the French Strategic-AE system, which is doctrinally unique when compared to its North Atlantic Treaty Organization allies. North Atlantic Treaty Organization allies favor care in the theatre in place of the French early Strategic-AE. However, in the event of a high intensity conflict, a combination of these two doctrines could be useful.

OP TRENTON 3: An analysis of primary care presentations to a deployed role 1 in support of a United Nation peacekeeping operation

ObjectivesHealth data of operational relevance from South Sudan are lacking, outdated and non-representative. This study sets out to record and analyse primary healthcare (PHC) presentations to a deployed UK Level 1 Primary Healthcare Centre (L1 PHC) facility in Bentiu, South Sudan, to inform on disease prevalence for UK Military Personnel in a sub-Saharan Operational environment.MethodsA prospective single-centre cohort study was completed for all PHC presentations to a UK L1 PHC facility while deployed on the United Nations Mission to South Sudan from June 2017 to November 2017.Results861 episodes of clinical care were recorded at Bentiu Camp during the 6-month period. 82% were from disease; 18% non-battle injuries and no battle injuries were seen. As per EPINATO2 categorisation, the top three presentations were acute gastrointestinal disease, dermatological disease and routine clinical care. Differences were noted for June–August and September–November, as a proportion of total cases seen. It was noted that gastrointestinal illnesses were three times more likely in the first half of the operation and bites and sting almost twice as likely.ConclusionsGastrointestinal disease results in a significant burden on humanitarian operations where an extended Relief-in-Place is a key area of risk. The EPINATO2 reporting tool provides insufficient detail for planning purposes and an improved method of data collection is required. Targeting the diagnosis and management of infectious diseases during predeployment training should prepare L1 PHC for the most common cases encountered. Delivery of targeted Force Health Protection training for all personnel with early deployment of L1 PHC forward could improve support to commanders during the highest risk periods.

Clinical activity at the UK military level 2 hospital in Bentiu, South Sudan during Op TRENTON from June to September 2017

IntroductionDiseases and non-battle injuries (DNBIs) are common on UK military deployments, but the collection and analysis of clinically useful data on these remain a challenge. Standard medical returns do not provide adequate clinical information, and clinician-led approaches have been laudable, but not integrated nor standardised nor used long-term. Op TRENTON is a novel UK military humanitarian operation in support of the United Nations Mission in South Sudan, which included the deployment of UK military level 1 and level 2 medical treatment facilities at Bentiu to provide healthcare for UK and United Nations (UN) personnel.MethodsA service evaluation of patient consultations and admissions at the UK military level 2 hospital was performed using two data sets collected by the emergency department (ED) and medicine (MED) teams.ResultsOver a three-month (13-week) period, 286 cases were seen, of which 51% were UK troops, 29% were UN civilians and 20% were UN troops. The ED team saw 175 cases (61%) and provided definitive care for 113 (40%), whereas the MED team saw and provided definitive care for 128 cases (45%). Overall, there were 75% with diseases and 25% with non-battle injuries. The most common diagnoses seen by the ED team were musculoskeletal injuries (17%), unidentified non-malarial undifferentiated febrile illness (UNMUFI) (17%), malaria (13%), chemical pneumonitis (13%) and wounds (8%). The most common diagnoses seen by the MED team were acute gastroenteritis (AGE) (56%), UNMUFI (12%) and malaria (9%). AGE was due to viruses (31%), diarrhoeagenic Escherichia coli (32%), other bacteria (6%) and protozoa (12%).ConclusionData collection on DNBIs during the initial phase of this deployment was clinically useful and integrated between different departments. However, a standardised, long-term solution that is embedded into deployed healthcare is required. The clinical activity recorded here should be used for planning, training, service development and targeted research.

Repatriation for diseases or non-battle injuries (DNBI): long-term impact on quality of life

IntroductionThroughout history, diseases and non-battle injuries (DNBI) have threatened deployed forces more than battlefield injuries. During the Dutch involvement in Afghanistan, the amount of DNBI that needed medical evacuation out of theatre (60%) exceeded the number of battle injuries (40%). The aim of this study is to explore the long-term quality of life (QoL) of Dutch service members that acquired a DNBI, warranting repatriation during their deployment to Afghanistan between 2003 and 2014.MethodsObservational cross-sectional cohort study in a selected group of Dutch service members who deployed to Afghanistan 2003–2014 and were repatriated due to DNBI. Using the 36-item Short Form, EuroQol-6D, Symptom Checklist 90 and Post Deployment Reintegration Scale questionnaires, their outcomes were compared with a control group of deployed service members who did not sustain injuries or illnesses.ResultsGroups were comparable in age, rank, number of deployments and social status. There were significant differences found in terms of physical functioning, pain and health perspective. No differences were seen in emotional or psychological outcomes.ConclusionThe amount of military service members who contract a DNBI is significant and imposes a burden on the capacity of the medical support, readiness of deployed units and sustainability of ongoing operations. However, regarding QoL, being forced to leave their units and to be repatriated to their home country due to a DNBI seems to have no significant impact on reported psychological symptoms of distress and reintegration experiences. Future research should focus on more in-depth registration of illnesses and not combat related diseases and injuries and even longer-term outcomes.

Utilization profile of the Canadian-led coalition Role 2 Medical Treatment Facility in Iraq: the growing requirement for multinational interoperability

Background: The Canadian Armed Forces deployed a Role 2 Medical Treatment Facility (R2MTF) to Iraq in November 2016 as part of Operation IMPACT. We compared the multinational interoperability required of this R2MTF with that of similar facilities previously deployed by Canada or other nations. Methods: We reviewed data (Nov. 4, 2016, to Oct. 3, 2017) from the electronic Disease and Injury Surveillance Report and the Daily Medical Situation Report. Clinical activity was stratified by Global Burden of Diseases category, ICD-10 code, mechanism of injury, services used, encounter type, nationality and blood product usage. We reviewed the literature to identify utilization profiles for other MTFs over the last 20 years. Results: In total, 1487 patients were assessed. Of these, 5.0% had battle injuries requiring damage-control resuscitation and/or damage-control surgery, with 55 casualties requiring medical evacuation after stabilization. Trauma and disease non-battle injuries accounted for 44% and 51% of patient encounters, respectively. Other than dental conditions, musculoskeletal disorders accounted for most presentations. Fifty-seven units of fresh frozen plasma and 64 units of packed red blood cells were used, and the walking blood bank was activated 7 times. Mass casualty activations involved coordination of health care and logistical resources from more than 12 countries. In addition to host nation military and civilian casualties, patients from 15 different countries were treated with similar frequency. Conclusion: The experience of the Canadian R2MTF in Iraq demonstrates the importance of multinational interoperability in providing cohesive medical care in coalition surgical facilities. Multinational interoperability derives from a unique relationship between higher medical command collaboration, international training and adherence to common standards for equipment and clinical practice.