Surgical Principles 848th Forward Surgical Team

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Surgical Principles848th Forward Surgical Team
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• You are the leaven which binds together the
• entire fabric of our national system of defense
• This does not mean that you are warmon-
• gers. On the contrary, the soldier, above all
• other people, prays for peace, for he must suf-
• fer and bear the deepest wounds and scars of
• war. But always in our ears ring the ominous
• words of Plato, that wisest of all philosophers
  Only the dead have seen the end of war
• General of the army, Douglas MacArther, U.S.
  Military Academy, West Point, NY, 12 May 1962

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Thought of a WWI Surgeon While on His Way to the
Front

• Soon, at the front, I would have a lot of work,
  but there would be no mentor near by. God help
  me when that day arrived. More accurately, God
  help my patients when that day arrived. If an
  assignment put me in harms way, and a bullet or
  shell found me, that would not be my fault. It
  would be the luck of the draw, the fate that can
  befall any soldier. No shame in that, but if I
  failed my patients if I fell apart when men
  needed a skilled, confident doctor if men died
  who might otherwise have lived, then it would be
  my fault. Then would be shame in that. My
  shame

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5 Echelons (levels, degrees, or tiers) of
Battlefield Medical Care

• Rational
• Aggressive resuscitation and evacuation of the
  wounded soldier
• Efficient flow of care, to maximize survival
• Treatment of injuries appropriately by priority,
  for optimal use of resources
• Staged treatment of severe or extensive injuries
• Do everything we can to save life or limb, and
  return the soldier to duty when ever possible

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Surgical Mortality for Various Wounds U.S.
Military

• War Head Thorax Abd.
• WWI 40 37 67
• WWII 14 10 23
• Korea 10 8 9
• Vietnam 10 7 9

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Characteristic Delay Before Definitive Operative
Management of Wounds in 20th Century Wars

• WWI 1-2 days
• WWII 8-12 days
• Korea 3-6 days
• Vietnam 1-4 days

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Wartime Surgery

• 1. In general, surgical techniques for critical
  injuries (civilian or military) are similar
• 2. Penetrating neck injuries high-velocity
  GSWs, high-energy frag. wounds
• Indirect damage most neck injuries are
  explored or debrided
• 3. Probably higher rate of thoracotomy than in
  civilian injuries
• 4. Operative approach and control of hemorrhage
  are same

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Wartime Surgery

• 5. Celiotomy, including approach to
  retroperitoneum and pelvis, are same
• 6. Orthopedic injuries
• More common of external fixators
• Wounds closed secondarily or skin-grafted later
• 7. Peripheral vascular injuries managed in
  similar fashion
• 8. Intensive care and organ support/ equipment
  same in level I Trauma Center and CSH

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Wartime Surgery Characteristics

• 1. Large numbers of patients can arrive
  simultaneously with casualty rates as high as 30
• Triage is critical optimal use of resources
  (conservation high-yield patients)
• Distribute casualties to multiple medical units
• 2. Mobility of forward medical units
• Rapidly deployable, highly mobile, small units
• Accompany the combat troops one FST to every
  maneuver brigade
• Provide life- and limb-saving surgery in a war
  zone
• 3. Austere conditions
• Lack of diagnostic equipment and supplies
• Limited choice of antibiotics, suture, etc.
• Possible lack of A/C, environmental control

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Wartime Surgery Characteristics

• 4. Casualty evacuation transfer to a
  higher-level care facility
• Factors military tactical situation, nature of
  wound, anticipation of new casualties,
  overextension of resources
• 5. Environment is hostile
• Rain, snow, mud, or tropical heat
• Desert warfare
• Cleanliness/sterility difficult to maintain
• 6.Moral of medical personnel
• Effects of fatigue, fear, large numbers of
  casualties, and harsh environment

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Wartime Surgery Characteristics

• 1. Prehospital time longer
• 2. Large number of patients dilutes surgeons
  attention
• Resuscitation may be delegated to nonsurgeon
  physician, nurses, and corpsmen trained in the
  principles of resuscitation
• 3. Types of wounds seen
• High energy/high velocity projectiles
• High energy fragmentation wounds
• Traumatic amputations
• Severe burns
• 4.Prehospital resuscitation
• Combat medic
• Soldiers dehydrated, fatigued, cold, and
  constricted
• RL, control of bleeding
• Future hypertonic saline hemoglobin solutions

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Wartime Surgery Characteristics

• 5. Abdominal injuries
• Mandatory colostomy for any colon injury
• No attempt to save the spleen
• Concept of damage control salvage surgery
• 6. Vascular surgery
• Arteriogram unavailable
• Proximity injuries are explored
• No synthetic grafts
• 7. Soft tissue injuries
• Extensive debridement (clothing, battlefield
  debris)
• Liberal use of fasciotomy
• 8. Lack of continuity of care
• Evacuation to rear fixed facilities
• Surgeon cannot follow postop care
• Wound management protocols essential
• Written communications

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FST

• Forward deployed/positioned far forward of fixed
  hospital in the danger zone
• Surgical provides early, basic, emergency
  life/limb-saving damage-control/salvage-surgery,
  including triage and preparation for evacuation
• Team small unit 20 soldiers
• Rapidly deployable and highly mobile
• Personal, tight, and cohesive

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WWI Through Desert Storm

• A consistent percentage of casualties died of
  wounds approximately 20
• 67 of these die within 10 minutes of wounding
• 33 die after surviving at least 10 minutes, most
  due to hemorrhage
• Therefore, we focus on this 33
• 10 of soldiers who died on battlefield due to
  hemorrhage in Vietnam had solitary extremity wound

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The Forward Surgical Team

• Mission To provide emergency life- and
  limb-saving surgery on critically injured
  soldiers, for stabilization for evacuation to
  rear echelon hospitals for definitive surgical
  treatment
• Function Emergency resuscitative surgery damage
  control surgery/salvage surgery no definitive
  surgery no lengthy or reconstructive operations

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Forward Surgical Team

• Types of casualties
• Major chest and/or abdominal wounds
• Ongoing Hemorrhage
• Severe shock
• Wound with airway compromise/resp. distress
• Massive soft tissue damage
• Severe extremity trauma

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Psychological Effects on the War Fighter

• Maintain medical presence with the soldier
• Want him/her to know that if he/she is injured
  there are competent, dedicated medical personnel
  who will take care of him/her
• It is a privilege to help take care of our
  soldiers, our gallant knights.

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Patient Care in Forward Setting

• 1. Volume of casualties
• 2. Multiple high velocity injuries with much
  associated soft tissue damage from cavitation
  effect
• Bullets, fragments from grenades/mines,
  glass/debris from blast, other missiles (MOUT)
• 3. Patients are often
• Dehydrated, hypothermic, and peripherally
  constricted
• 4. Austere conditions harsh environment

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Patient Care in Forward Setting

• 5. Lack of supportive/diagnostic equipment
• 6. Limited resources blood, IV fluid, gauze pads
• Limited monitoring equipment
• Limited holding capacity
• 7. TRIAGE!! Optimal use of personnel and
  resources
• 8. Mobility of forward medical units (up to 100
  miles/day, to maintain pace with combat troops)

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Patient Care in Forward Setting

• However dedicated personnel
• Importance of nonphysician medical personnel
• Efficiency of Medevac system
• Patients are generally young and in good physical
  condition
• Future
• Hypertonic saline
• Hemoglobin solutions
• Dry fibrin sealant
• Anticipate casualties better
• Logistics of supplies
• MRI

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Damage Control/Resuscitative Surgery

• Purpose to deal acutely with life-threatening
  injuries, to provide for temporary stabilization
  for future definitive surgery on a more stable
  patient
• General principle
• Control of hemorrhage, packing
• Prevention of contamination/enteric spillage
• Debridement of devitalized or freshly
  contaminated tissue
• Rapid end to operation, possibly with temporary
  closure
• Establish airway
• Large bore IV, warm IV fluids
• Volume resuscitation to systolic BP of 80-90
• Packing of multiple trauma patients
• Rapid evacuation

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Deadly Triad (hypothermia, acidosis,
coagulopathy)

• 1. Hemorrhagic shockgtdecreased cellular
  perfusion/oxygenationgtinadequate heat
  productiongthypothermiagtcoagulopathy
• 2. Hemorrhagic shockgtdecreased cellular
  perfusiongtlactic acidgtmetabolic acidosis
  gtinterferes with coagulation mechanism
• Resultant vicious cycle great definitive repair
  of the severely injured patient, followed by MSOF
  and high mortality

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Damage Control Principle

• Abdominal injuries
• Midline incision can be extended
• Four quadrant packing
• Aortic control at diaphragmatic hiatus, manual,
  clamp
• Look for main source of bleeding, manual pressure
• Bleeding from liver, spleen, kidney large
  abdominal packs for pressure
• Explore and evacuate hematomas
• Visceral rotation maneuvers
• Packing, ligation, clamping, balloon catheter
  tamponade, shunt for vascular injuries

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Damage Control Principle

• Rapid closure of any hollow viscus injuries
  ligate, staple, running suture
• Rapid abdominal closure continuous skin suture,
  towel clips, Bogota Bag if necessary for
  massive edema
• Rapid arterial repair vs. intravascular shunts
• Venous injuries ligated
• Warm the patient
• Control spillage of gut contents
• Resect nonviable bowel and close the ends leave
  in abdomen for later anastomosis
• Mandatory colostomy, not matured
• No spleen saving techniques

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Damage Control Principle

• Thoracic injuries
• 90 treatable with chest tube alone
• Indications for thoracotomy massive air leak,
  continuous hemorrhage, suspected large vessel
  injury, tamponade
• Extremity injuries
• Debride, pack, splint, ship
• Liberal use of fasciotomy
• Vascular shunt autologous tissue for repair

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Even with all our technology (smart bombs, cruise
missiles, robotic surveillance, stealth
aircraft), ground troops are still needed to take
objectives, and subdue the enemy

• Medical assets needed wherever the troops are!
• There are medical assets/personnel on all parts
  of the battlefield, in harms way (Medic!!!)
• Medical presence allows our warriors to do their
  job with some confidence, take more risks
• Importance of the AMEDD 70 reserves

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Paradox of Medical Personnel

• 1. We train for war, but hope for peace
• If our training is effective, some soldiers will
  survive severe injuries
• 2. We try to save soldiers lives for return to
  duty
• 3. We willingly go into harms way to do our job

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This War on Terrorism is Real

• Some soldiers (men women) will die others will
  be saved by heroic efforts of our medical
  personnel
• Radical Islamic fundamentalists want to kill all
  Americans, whenever they are found
• This is a fight for our families, your families,
  our way of life, our freedom and security, our
  childrens future
• There are things worth taking risks for, worth
  making sacrifices for, worth dying for

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Questions

• Col. Mike Oddi