Lessons Learned in War Bradley S. Butler, MD, FACEP L CDR MC, USN - - PowerPoint PPT Presentation

Lessons Learned in War

Bradley S. Butler, MD, FACEP LCDR MC, USN

Dept Head and Trauma Team Leader NATO Role 3 MMU Kandahar, Afghanistan 2011-2012

DISCLAIMER

• US Navy Reservist
• This lecture (except where specifically noted) does

not represent the official policy or views of the US Navy or the US Department of Defense

OBJECTIVES

• Medical/Professional lessons learned and their civilian uses
• Understand the historical role of medicine in armed

conflict and how it has changed over time

• Understand the different injury patterns associated with

OEF/OIF

• Understand the causes of death in battle, and how it relates

to new training, equipment, resuscitation, and civilian uses

• Medical Advances
• Personal lessons learned
• What “happens” in war?
• Motivation Learned

ROLE OF MEDICINE IN ARMED CONFLICT

ROLE OF MEDICINE IN ARMED CONFLICT

• Changes in mortality (NEJM Dec2004)
• WWII: 70% survival rate
• Viet Nam: 76% survival rate
• OIF: 90% SURVIVAL RATE!
• Why the difference?

ROLE OF MEDICINE IN ARMED CONFLICT

• Advances in patient transport
• Advances in personnel/vehicular

protection (i.e. body armor/kevlar helmets/MRAP’s)

• Pre-hospital training (i.e. TCCC)
• Tourniquets/Hemostatic Agents
• Damage Control Resuscitation

ROLE OF MEDICINE IN ARMED CONFLICT

• Transportation times have shortened
• Viet Nam: ave time from battlefield to US=45 days
• OEF/OIF: ave time < 4 days
• HOW???
• Civil War (ambulance) Korea (helo) OEF: CCATT
• CCATT = Critical Care Air Transport Team
• History
• 1983 (concept)
• 1989-99 (development)
• 2001-2004 (confirmed in OEF/OIF)
• Composition: Critical Care Physician, CCRN, RT

CCATT

CCATT

ROLE OF MEDICINE IN ARMED CONFLICT

• Taking the care to the need
• ROLE I
• BAS/STP- Basic ATLS/resuscitation (airway/bleeding)
• ROLE II
• FST (Army)/FRSS (Navy/Marines)- Mobile surgical

team (damage control surgery)

• ROLE III
• Combat Hospital (i.e. Level I Trauma Center in theater)
• ROLE IV
• US Hospitals (Bethesda/San Antonio (burn)/San Diego)
• Germany (Landstuhl)

INJURY PATTERNS IN OEF/OIF

INJURY PATTERNS IN OEF/OIF

• Blasts predominate over penetrations
• Less GSW’s (body armor)
• Improvised Explosive Device (IED’s)

predominate

• VBIED or vehicle-born IED
• Suicide IED (suicide vests, even on kids)
• Emplaced IED’s (pressure plate, remote control,

wire)

• IED’s = Amputations/Head injuries

“PREVENTABLE” CAUSES OF DEATH IN COMBAT

“PREVENTABLE” CAUSES OF DEATH

“Preventable” Causes of Death

• Has led to many advances- focused on

the “preventable” causes of death

• Equipment
• Training (prehospital)
• Medical Advances

EQUIPMENT

“Up-armored” Humvee’s and MRAP’s

EQUIPMENT

Body Armor/Kevlar Helmets

EQUIPMENT- Civilian Applications

• Armored vehicles being utilized by

law enforcement as well as wealthy citizens (especially in foreign countries) for protection

• Body armor being upgraded on a

regular basis and utilized in both civilian law enforcement and military

TRAINING

TCCC (Tactical Combat Casualty Care)

• Civilian/Military Difference in “pre-hospital” care
• Civilian: Casualty IS the mission
• Military: Mission DESPITE the casualties
• Principles
• Prevent further casualties, accomplish mission,

maximize lives saved, minimize morbidity/mortality

• Based on treating “preventable” causes of death
• (Extremity) Hemorrhage
• Tension Pneumothorax
• Airway

TRAINING/TCCC

Three “phases”

• Care under fire
• Return fire, TQ (self aid), get to safety
• Tactical Field Care
• In a (relatively) safe environment
• TQ/Hemorrhage control (“c” before “A”)
• Airway management
• Decompression of tension pneumothorax
• Evacuation Care
• CASEVAC (evac by opportunity- no medical care)
• MEDIVAC (evac by medical-medics, RN, MD)
• Variable (i.e. IV, meds, blood products, advanced airway)

TRAINING/TCCC

Emphasis on “preventable” causes, not IV!

• Stopping Hemorrhage (7-9%)
• TQ and Hemostatic Agents
• Tension Pneumothorax (3-4%)
• Airway (1%)
• Emphasis on OPA/NPA (NOT advanced airway)
• Rarely cric and/or devices (KingLT, LMA, etc)
• “Future” emphasis
• Hypothermia (leads to coagulopathy, multisystem
• rgan failure, and other morbidity/mortality)
• Pain control

TRAINING/TCCC

IFAK (individual first aid kit)

TRAINING/TCCC- Civilian Applications

• TCCC- concepts, techniques, and

training being utilized in law enforcement currently

• IFAK- contents (part or all) being

adopted by law enforcement

Utilization of Working Dogs

Utilization of Working Dogs- Types

• PEDD- Patrol Explosive Detector Dog
• PNDD- Patrol Narcotic Detector Dog
• SSD- Specialized Search Dog
• MDD- Mine Detector Dog
• IDD- IED Detector Dog
• TEDD- Tactical Explosive Detector Dog
• CTD- Combat Tracker Dog
• AAA/AAT- Animal Assisted Therapy Dog
• CWD- Contract Working Dog
• MPC- Multi Purpose Canine
• HRD- Human Remains Detector

Utilization of Working Dogs- Types

Utilization of Working Dogs Medical Care

MEDICAL ADVANCES

HEMOSTATIC AGENTS

MECHANICAL

• Pressure
• Tourniquets
• New/Field testing
• C-Clamp (CROC)
• Abdominal tourniquet
• XSTAT
• Dressings (prior to OEF/OIF- AFB or “army

field bandage.” Consisted of layers of gauze in bandage with long ties)

MECHANICAL- Tourniquets

• HISTORY: documented use back in 1634

(Surgery, 1958) to now (at least one on every soldier)

MECHANICAL- Tourniquets

• No evidence of TQ, even when improperly used,

resulting in loss of limb or permanent disability (US Army Bulletin 1945 and J Trauma 2003)

• TCCC recommendations: use in uncontrolled

extremity hemorrhage in tactical environment

MECHANICAL- Tourniquets

• Significant anecdotal evidence in OEF/OIF of

lives saved

MECHANICAL- Tourniquets

Civilian Applications

• Law enforcement
• EMS
• Useful in penetrating extremity wounds

and/or amputations

• Barrier: cost (about $35 for CAT)

MECHANICAL- JUNCTIONAL

MEDICAL ADVANCES- Hemostatic Agents HISTORY

• Hippocrates: caustics to achieve hemostasis
• Bone wax (1886): combination of beeswax, salicylic

acid, and almond oil

• Gelfoam (1946): physical matrix from ground skin
• Surgicel (1960): oxidized cellulose
• Thrombin (1960’s)
• Chitin/Chitosan (2003)- chitin from crustaceans
• Human Recombinant Factor VII
• Mineral-based (2007): combat gauze
• Future: Thrombin based?

MEDICAL ADVANCES- Hemostatic Agents 7 Properties of “ideal” Agent (Pusateri 2006)

• Capable of stopping art/venous bleeding < 2 minutes

though a pool of blood

• No requirement of premixing or preparation
• Simplicity of application by victim, buddy, or medic
• Lightweight and durable
• Long shelf life in extreme environments
• Safe to use with no risk of tissue injury or

transmission of infection

• Inexpensive

HEMOSTATIC AGENTS

“SEALANTS” or Chitin-based

• Mechanism: mucoadhesive (“sticks” to

adjacent tissues) and seals injured vessels and (+) charge attracts (-) charged RBC’s

• Properties
• Biodegradable, non-toxic, complex carbohydrate

derived from chitin (naturally occurring substance found in crustacean shells- shellfish allergy)

• Bacteriostatic
• Freeze-dried and made into stiff dressing/bandage

HEMOSTATIC AGENTS- “Sealants”

• HemCon Bandage (HC)- 2002

HEMOSTATIC AGENTS- HemCon

• Effective in appropriate wounds, but not after

1 hour

• Must be “flat” wound (bandage is stiff and

must be cut to size)

• Easily removed with saline
• Not pliable for hard to reach wounds
• Expensive ($90 per dressing)
• Replaced by Combat Gauze (CG)

HEMOSTATIC AGENTS- Celox

• Celox (CX)- granular/powder form of chitin
• “Poured” into wound and covered with dressing
• Must be removed prior to definitive surgery
• Difficult to use in windy/low light conditions
• Found to be no more effective than pressure

dressing in femoral artery injury/pig model (Acad Emer Med 2011) and other studies with variable efficacy (one study found it was more effective than QC and HC Acad Emer Med 2008)

HEMOSTATIC AGENTS

MINERAL-BASED

• Mechanism: rapid absorption of water,

concentrating clotting factors/platelets and (-) charge activates/accelerates intrinsic clotting

• REQUIRES INTACT PATIENT CLOTTING!
• Properties
• Made from minerals (zeolite/smectite)
• Not biodegradable- removed prior to surgery
• Small particles “clog” blood vessels, leading to PE

(WS/QC, not with CG J Trauma 2010)

HEMOSTATIC AGENTS- Mineral Based

• QuickClot (QC)- first generation (2002)
• Zeolite granules
• More effective than gauze dressing (100% survival

vs 60% J Trauma 2004)

• Exothermic reaction (caused burns/ ? may have

contributed to hemostasis)

• Had to be removed prior to

surgery

• No longer made

HEMOSTATIC AGENTS- Mineral Based

• WoundStat (WS)- second generation
• Smectite granules (non-metallic “clay” of silicates,

aluminum, Na, Cl)

• More effective than HC in one study (100% vs 10%

survival J Trauma 2009) but no more effective than standard pressure dressing in another (Acad Emer Med 2011)

• NO thermal injuries
• Because of thromboembolic and tissue necrosis

side effects, it was withdrawn from market and never used in the field

HEMOSTATIC AGENTS- Mineral Based

• Combat Gauze (CG)- second generation

HEMOSTATIC AGENTS- Combat Gauze

• Made from kaolin “clay” (aluminum silicate)
• Impregnated in 4 yd long, 3 in wide roll
• Easy to remove
• Safe (no thermal reaction or thromboemboli)
• Effective (most effective agent in one femoral

artery pig model 80% survival J Trauma 2009)

• Tactical Combat Casualty Care Committee

recommended it as first line for hemorrhage not amenable to TQ in 2008

• Currently in all IFAK’s

HEMOSTATIC AGENTS

CLOTTING FACTORS

• The “Future”
• Independent of patient’s own clotting status

(decreased in acidosis, hypothermia, blood loss- i.e. TRAUMA!) 38% of trauma patients already coagulopathic on arrival (J Trauma2008)

• Biodegradable
• Safe (if recombinant vs concentrated “donor”)
• Expensive
• Being studied (requires FDA approval)

HEMOSTATIC AGENTS- Clotting Factors

• rFactorVII
• IV form
• Expensive
• No improvement in mortality
• Led to frequent thromboembolic complications
• No longer routinely used in trauma
• Fibrin based dressings
• The “future”
• Highly concentrated clotting factors
• EX’s: Dry Fibrin Sealant Dressing (DSFD), FAST,

Fibrin Patch (all being studied)

MEDICAL ADVANCES- Hemostatic Agents Civilian Applications

• Widely available to law enforcement,

EMS, and civilians (i.e. at REI/Amazon)

• Effective for brisk hemorrhage
• Latest versions safe (i.e. combat gauze)
• Only barrier: COST (~$35-50/dressing)

DAMAGE CONTROL RESUSCITATION

• Historical perspective- “Classic ATLS” teaches

aggressive resuscitation with crystalloids then transfusion of PRBC’s

• Probably “acceptable” for 90% of trauma pt’s
• Estimated that 7% of casualties will require

“massive transfusion” (J Trauma 2007)

• Damage Control

Resuscitation, or DCR, developed in last 15 years of war

DCR- Principles

• Minimize hemorrhage
• Hypotensive resuscitation
• Hemostatic resuscitation
• Damage Control Surgery

DCR- Minimize Hemorrhage

• Concept of “cABC”
• Use of pressure dressings, TQ’s, and

hemostatic agents

• Pelvic stabilization in obvious fracture or

instability or mechanism

• Minimize transport times (minimize “on

scene” procedures)

DCR- Hypotensive Resuscitation

• Basis
• (over)Resuscitation Injury
• “Da Nang Lung” (ARDS)- described in Viet Nam
• Abdominal/extremity compartment syndrome
• Dilution of coagulation factors
• Break up of existing clots
• What Fluid?
• LR- Standard (cell damage from neutrophil activation)
• NS- hyperchloremic acidosis/dilutional coagulopathy
• HTS- no benefit
• Colloids (i.e. albumin/HS/HSD/Dextran)- no benefit

DCR- Hypotensive Resuscitation

• Delayed Resuscitation
• No fluids until bleeding controlled
• Evidence (Cochrane Review 1994) 62% vs 70%

mortality in aggressive resuscitation

• Permissive Hypotension
• Only one human study- found no difference in
• utcome (hypotensive group vs regular)
• US Military recommendations:
• No head injury- bolus to “maintain pulse/mentation”
• Head injury- normotension

DCR- Hemostatic Resuscitation

• Resuscitate with blood/blood products
• Use fixed ratio (PRBC’s:Platelets:FFP)
• Consider cryoprecipitate
• TXA (Tranexamic Acid)
• Anti-fibrinolytic (inhibits fibrinolysis)
• CRASH-2 Trial (Lancet 2010)
• Mortality decreased from 16% to 14.5%
• Best if within 1 hr
• Cheap ($20)
• Safe

DCR-Damage Control Surgery

• Minimize time in OR
• Only life-saving/hemorrhage control
• Delay definitive surgery/treatments
• Minimize acidosis
• Minimize hypothermia

Damage Control Resuscitation Civilian Applications

• Concept of “cABC” is being integrated into

trauma protocols/TCCC/ATLS

• Hypotensive resuscitation gaining favor in

EMS

• Transfusions now used in fixed ratios (1:1:1)
• TXA
• Damage Control Surgery for “sickest of the

sick” trauma patients

PERSONAL LESSONS LEARNED

What “Happens” in War?

PATRIOTISM HAPPENS

(POLITICS DOESN’T)

What “Happens” in War?

PATRIOTISM HAPPENS

• A generation of

kids send letters to troops overseas

What “Happens” in War?

PATRIOTISM HAPPENS

• A generation of young

video game addicts aka “vidiots” joined the service

What “Happens” in War?

PATRIOTISM HAPPENS

What “Happens” in War?

TEAMWORK HAPPENS

What “Happens” in War?

AMERICAN INGENUITY HAPPENS

What “Happens” in War?

AMERICAN INGENUITY HAPPENS

What “Happens” in War?

AMERICAN INGENUITY HAPPENS

What “Happens” in War?

AMERICAN INGENUITY HAPPENS

What “Happens” in War?

FATE HAPPENS Part I aka “THE 7 P’s”

What “Happens” in War?

FATE HAPPENS Part II aka “SHIT HAPPENS”

What “Happens” in War?

MIRACLES HAPPEN

What “Happens” in War?

MIRACLES HAPPEN http://www.youtube.com/watch?v=j 7zdgmfQUMs&feature=player_emb edded

What “Happens” in War?

MIRACLES HAPPEN

What “Happens” in War?

MIRACLES HAPPEN

What “Happens” in War?

YOU APPRECIATE THE “FIVE F’s”

What “Happens” in War? WAR IS HELL

Death/Casualty Toll

• US (OIF): 4,500 KIA 32,000 WIA (1:7 Ratio)
• US (OEF): 2,300 KIA 20,000 WIA (1:8 Ratio)

Death/Casualty Toll

• Civilians OIF: estimates 115,000-150,000
• Civilians OEF: estimates over 12,000 since 2007

Mental Health Toll

• Suicide rate in US Army doubled from

2004-2009, surpassing civilian rate

COST

• Future costs of casualties
• $1.3 TRILLION death and disability

benefits owed as of 2009

• This EXCLUDES medical and

psychiatric care costs

MEMORIES

DIGNIFIED TRANSFER

MOTIVATION LEARNED

QUOTE/CHALLENGE

• “If you had one shot, one opportunity

to seize everything you ever wanted, one moment... would you capture it, or just let it slip?”

• “You only get one shot, do not miss your chance…

This opportunity comes once in a lifetime.”

(Eminem “Lose Yourself” 8 Mile Shady Records 2008)