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
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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?
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