ARRANGEMENT AND STRATEGIES OF PREHOSPITAL CARE FOR VICTIMS IN CONDITIONS OF MODERN WARFARE: EXPERIENCE OF MILITARY FORCES OF NATO COUNTRIES IN IRAQ AND AFGHANISTAN Rovenskikh D.N., Usov S.A., Shmidt T.V.
EvroMedclinica Plus,
Army General Yakovlev Novosibirsk Military Institute of National Guard Forces of the Russian Federation, Novosibirsk, Russia
Positive changes in arrangement of prehospital medical care for military victims in the first decade of the 21st century can be characterized as groundbreaking [1]. During war conflicts in Iraq and Afghanistan, the lowest mortality among victims has been achieved over the whole period of U.S. military forces. The analysis of 56,763 cases of injuries in U.S. military men showed the decrease in mortality from 20 % to 8.6 % in Afghanistan, and to 10.1 % in Iraq. Moreover, the survival rate in patients with critical ISS (27-75) has increased from 2.2 % to 39.9 % (Afghanistan), and from 8.9 % to 32.9 % (Iraq) [2]. Among British military personnel, the values of New Injury Severity Score (NISS), relating to 50 % chance for survival gradually increased from 32 in 2003 to 60 in 2012 [3]. The achieved results can be mainly explained by improvement in quality of components of arrangement of medical care at the prehospital stage [2]. The presented foreign literature review is dedicated to analysis of these advancements. PubMed, Cochrane, and available Internet recourses were analyzed.
Features of modern combat injury and the idea of potentially preventable death
During Iraqi Freedom and Enduring Freedom military operations, and subsequent (still ongoing) long term combat activity against irregular military troops in the territory of Afghanistan, where the epicenter of the war is located now, the following features of the modern combat injury have been identified:
1. Constant and wide use of measures for armor protection (body armour, kevlar helmets) has caused the significant decrease in incidence of injuries to the body and the skull, with corresponding increase in injuries to unprotected parts of the body (extremities, face, neck etc.) [3, 4].
2. Tactics of insurgents − mainly, avoidance of direct firefight, and the wide use of self-made explosive devices (SMED) − has resulted in high incidence of mine-blast injury with traumatic detachment or crush injury to extremities [5, 6, 7]: up to 70-75 % of all combat injuries [3, 4, 5, 6]. Due to high power of SMED, the incidence of polytrauma has increased: extensive injuries (above the level of ankle or forearm), including bilateral ones, with pelvic fractures, perineal and genital urinary injuries, abdominal, thoracic and CNS injuries [4, 8, 9, 10].
During the analysis of autopsy results in 4,569 military men with combat injuries for the period from October, 2001, to June, 2011, BJ Eastbridge et al. found that mine-blast injury was the cause of death in 70.3 % of cases, gunshot injuries − in 22.1 %, others − in 4.2 %. The unpreventable causes of death (fatal injuries) were body dissection, severe cerebral injuries (evisceration, penetrating cranial injuries with injuries to basal nuclei or to big vascular structures and brain stem)), full dissection of cervical spine above C3, involvement of respiratory tracts in thoracic region, cardiac injuries with length > 1/2 inch, thoracic aorta and pulmonary artery injuries, liver laceration (sixth degree), catastrophic abdominal and pelvic injuries with amputation of the lower extremity, with opened pelvic fracture and with high losses of soft tissues (traumatic hemipelvectomy). Death after all other injuries was considered as potentially preventable. In the analyzed group, 87.3 % of victims died at the prehospital stage, with 75.5 % of cases estimated as unpreventable death, and with 24.3 % − as potentially preventable. The cases of potentially preventable death included bleeding (90.9 %) and respiratory system injuries (8 %). The sources of fatal bleeding were injuries to distal parts of extremities in 13.5 %, junctional injuries − in 19.2 %, and body damages − in 67.3 %. Body damages included thoracic injuries in 36 %, and abdominal and pelvic injuries in 64 % [6].
Therefore, massive bleeding, tension pneumothorax and airway obstruction were the main causes of potentially preventable death during military operations in Iraq and Afghanistan. Massive blood loss was the main cause (more than 80 % of cases of preventable death),whereas the proportion of tension pneumothorax and airway obstruction, and thoracic injury-related respiratory disorders was 10-15 % [5, 6, 11, 12, 3].
J Kelly et al. analyzed 232 cases of deaths in 2003-2006 and found that bleeding was the cause of death in 81 % of victims with non-fatal injuries. They distributed types of bleeding into "tourniquet" bleeding (arrested with application of the tourniquet from the individual first-aid kit) (TB), "non-tourniquet, but potentially responsive to compression bleeding" in injuries to regions of joints to the body (neck, perineal region, axillary cavity) (NTPRCB), and to compression-resistant bleeding (CRB). Bleeding in the mentioned locations were the cause of death in wounded persons with potentially non-life-threatening injuries in 20 %, 30 % and 50 %, correspondingly [7].
CRB is determined as bleeding in an injury to one or several regions: magistral vessels of the body, pulmonary injuries, injuries to parenchymal abdominal organs (liver, kidneys, spleen; degree 4 and higher), or pelvic fractures with pelvic ring rupture. Here, unstable hemodynamics is observed, and/or urgent bleeding arrest is required. In the group of 296 wounded persons with such injuries, the mortality was 85.5 %; most of them (75 %) died at the prehospital stage [14, 15].
Therefore, the most significant problem is aid for victims with CRB and NTPRCB, although most bleedings after combat injuries are assigned to TB, considering that limb injuries are more frequent [3, 16].
The features of modern combat injury, and the structure of causes of subsequent conditions in wounded military men determine the changes in the training system for military personnel, in improvement of provision, and in strategies and techniques for arrangement of prehospital medical care [17].
Training of military personnel in arrangement of medical aid for combat injury
The system of arrangement of medical care for wounded persons in NATO armies is divided into five levels; the first level is prehospital [18]. At this stage, the arrangement of primary care is realized as self-care or buddy care (performed by any serviceman who received basic training). Moreover, at the present time, the basic training for arrangement of care is performed for at least one soldier in each division who receives the lifesaver status. Besides the basic skills in care arrangement, military servicemen are trained to install the nasopharyngeal tube, to perform pleural cavity decompression with the puncture needle under supervision of the combat medic. Each troop has the combat medic who has skills in urgent medical care (emergency medical technician) of B level (basic),with special 16-week training (EMT-B). Prehospital medical care is also conducted by more qualified paramedics who work in military troops [12]. Names of their job positions can vary in dependence on branches of army (ground troops, marines, air force, special operation forces) [18]. The perfect example is the training system for 75th Ranger Regiment of the U.S. Army. In this division, all military servicemen receive basic training in medical care for wounded persons. The special accent is given to bleeding arrest. Moreover, annual retraining, and additional intensive two-week training for arrangement of care for wounded are carried out before each duty in Afghanistan. Arrangement of care for victims with combat injuries is included into scenario of tactical trainings of rangers. At the level of subdivision, one military man is trained as EMT-B, at the level of a troop − as medical ranger (16-week training program for military medical specialist, or 26-week program for medical specialist of special ops forces) [11].
Tactics of care arrangement for wounded in action
In the U.S. Army and in other NATO armies, the main direction for arrangement of care for combat injury is Tactical Combat Casualty Care (TCCC), which is published for all participants of military actions and for military medical specialists and paramedics. It is developed by the TCCC Committee, which works with Joint Trauma System (JTS) of Institute of Surgical Research of the U.S. Army. The committee includes volunteers (who have main job in U.S. Military Forces or in the U.S. Government), trauma surgeons, critical care medicine specialists, physicians and assistant physicians in critical care medicine, health care providers for wounded in action, specialists in military medical training for servicemen). Each member of the Committee participated in military operations. At least 30 % of them were or are combat medics (for ground forces), corpsmen (marines) or pararescue jumpers (PJs) (Air Force Special Ops Command). 42 members of the Committee with voting power present the army, air forces, war fleet, marines and United States Coast Guard. The expert estimation of results of activity of TCCC committee is made by the U.S. Main Surgeon, and by the head of Trauma Committee of American College of Surgeons [19].
TCCC is regularly republished along with accumulation of new data on results of care arrangement for wounded, data analysis, conclusions, results of practical use, and development of new measures for care arrangement [19, 20, 21]. Currently, TCCC is the standard of prehospital care for wounded in action [16].
During preparation of the manual, the patterns of combat injury are taken into attention, as well as the structure of causes of potentially preventable deaths, and understanding of the facts that arrangement of care for wounded in combat has its own specifics. This specifics include:
1. Threat of enemy fire for a victim or a person who renders care.
2. The need for primary focus on main causes: bleeding, pneumothorax, airway obstruction.
3. Time of evacuation to a medical facility can take much more time than for an accident in a city in peaceful time.
4. Combat medics and paramedics can be well trained, but they can have much less experience in arrangement of care as compared to their civilian colleagues.
5. A single incident (a blast, firefight) can involve a lot of victims.
6. Care is realized in extremely unfavorable conditions: mountain or desert areas, night time and others [11, 19].
Moreover, a wounded soldier presents not only medical, but also tactical problem, which impedes realization of a battle mission. It requires for adherence to strict consequence of the following interrelated actions:
1. To arrange care for a victim.
2. To prevent emergence of other victims by means of massive counterstrike.
3. And the main thing − to successfully compete the mission of a subdivision [11].
Considering the above-mentioned facts, 3 phases of care for a victim are presented:
1. Care under enemy fire.
2. Tactical field care.
3. Assistance during evacuation of a victim [11, 12].
This phasal nature provides the best arrangement of care without decreasing efficiency of military actions by small subdivisions [19].
In the first phase, the care includes dragging a victim to the nearest shelter, and Combat Application Tourniquet (CAT). All other problems are solved after elimination of thereat of fire for a victim and for a soldier who helps with direct counterstrike (the phases 2, 3) [11, 12, 20, 21]. The subsequence of examination of a victim, and subsequence of care actions for life-threatening combat injuries are determined by MARCH mnemonic hint (currently − MARCH PAWS) [23]:
· Massive hemorrhage control. It is commonly performed as self-care or buddy care by any military man. According to the data by E Savage, who analyzed the experience in care arrangement for Canadian wounded servicemen in Afghanistan, non-medical staff performed 26 % of cases of bleeding arrest (including 42 % of tourniquet application) [12].
· Airway management: from stable positioning to installment of the nasopharyngeal tune, and coniotomy.
· Respiratory management: occlusive dressing with outlet valve in opened pneumothorax, and puncture thoracocentesis with the catheter needle for tension pneumothorax.
· Circulation: search for other sources of external bleeding, hemostasis, intravenous or intraosseous approach, infusion-transfusion therapy, estimation of applied tourniquets and their replacement to compressing dressings if possible.
· Hypothermia, Head injury.
· Pain relief.
· Antibiotics.
· Wounds dressing.
· Splinting.
Certainly, the important factors of efficient care for combat injury are rapidness of evacuation from the accident site to medical facilities with recourses for qualified surgical care (at least, level 2 of care [18]). In 2009, the Secretary of Defense set a task of helicopter transportation for critically ill patients from the accident site to the nearest medical facility within 60 minutes (the golden hour). Gradually, the percentage of missions with helicopters for evacuation of victims within 60 minutes increased from 24.8 % (181 of 731) to 75.2 % (2,867 of 3,811) (p < 0.001). Moreover, among all wounded, the percentage of deceased persons at the prehospital stage, and mortality decreased: the first value − from 16 % (386 of 2,011) to 9.9 % (964 of 9,755) (p < 0.001); the second value − from 13.7 % to 7.6 % (1,344 of 17,660) (p < 0.001). The rate of deceased patients in hospitals remained the same (4.1-4.3 %).
The decrease in mortality after setting this task was associated with increasing amount of patients transferred by a helicopter within the first 60 minutes after wound (regression coefficient -0.141; p < 0.001). The number of saved lives was 359 cases higher than the predicted number.
The prehospital mortality in critical wounded persons was lower than in patients with hemotransfusion (6.8 % (40 of 589) against 51 % (249 of 488), p < 0.001), and in persons transferred by a helicopter within 60 minutes after wound (25.7 % (205 of 799) vs. 30.2 % (84 of 278), p < 0.01) [23].
Besides rapidness of evacuation, the quality of prehospital care can be improved. For evacuation of critically ill victims, British military servicemen use the military transport helicopter Chinook, with Medical Emergency Response Team (MERT). MERT is headed by a qualified physician with experience in intensive care. The team also includes two paramedics, and a nurse. They are accompanied by four armed soldiers for provision of additional safety during transportation. Actually, a helicopter presents the mobile and well-equipped intensive care unit with possibilities for narcosis, pleural cavity draining, tracheal intubation, coniotomy, transfusion of whole blood and/or its components through venous approach, as well as other manipulations, operations or procedures [17]. The comparison of results of activities of MERT helicopter teams and PEDRO teams headed by a paramedic (U.S. Air Forces) showed that the mortality in patients with ISS of 20-29 was lower than in MERT (4.8 % vs. 16.2 %, p = 0.021) [24].
CONCLUSION
The wide use of tourniquets for massive blood loss, blood transfusion, and faster transportation to hospital determined the decrease in total mortality in victims with combat injuries by 44.2 % [2]. Moreover, the mortality from bleedings after limb injuries was 7.8 % in Vietnam war [7], and it decreased to 2.6 % in the end of 2011 (military operations in Afghanistan) − by 67 % [19].
The list of main components of prehospital care for combat injury, which promoted such positive changes, was described by FK Butler [19] (some links to publications are presented):
· Phasal nature of prehospital care with optimal combination of quality for a victim, and strategies of actions for subdivisions [11, 12].
· Active use of TCCC-recommended tourniquets for primary control of external bleeding, and removal of tourniquets (if possible) at the stages 2-3 of care [17, 25, 26].
· The use of TCCC-recommended hemostatic dressings for NTPRCB [25, 27].
· The use of compression tourniquets for junctional injuries for arrest of NTPRCB [28, 29].
· Sitting position with forward lean for prevention of dislocation and aspiration asphyxia.
· If it is impossible, use of coniotomy with Cric-Key technique [30].
· Active use of puncture draining of pleural cavity with the catheter-needle ( 14-G or 10-G diameter, length − 3.25 inches) in case of suspected tension pneumothorax [20, 21, 31, 32].
· Application of sealing dressings with outlet valve for opened pneumothorax [21, 33].
· Installation of intravenous catheter only for cases with evident need for intravenous injections and infusions [34].
· The preference to "the lock" with crystalloid solution with constant infusion of fluid for maintenance of patency of the catheter [21].
· The use of intraosseous infusions if venous approach is impossible [21, 35].
· The early use of tranexamic acid at the prehospital stage (before initiation of infusion of other fluids) for victims with hemorrhagic shock or high risk of its development [36].
· Intensive transfusion therapy of whole blood or its components (packed red blood cells and plasma) with 1:1 ratio at the prehospital stage (if possible) [21, 37].
· If no − infusion of hydroxyethyl starch (in TCCC − Hextend, Hospira Inc., Lake Forest, Illinois, USA) with maintenance of moderate hypotension [34, 38].
· Safer, faster and more efficient correction of pain syndrome with use of three-variant approach to analgesia on the battlefield: paracetamol and maloxicam for slight injuries; preferred use of lozenges with phentanyl, and intravenous introduction of ketamine instead of intramuscular introduction of morphine for strong pain [21, 39].
· The use of ondansentronum for nausea caused by trauma or opioids [21].
· Prevention of hypothermia and secondary coagulopathy be means of use of advanced technologies for prevention of warm losses [40].
· Prehospital antibiotic prevention of wound infections, their complications and death with use of maxifloxacin or ertapenem [21].
· Training of arrangement of medical care in small subdivisions in various combat conditions.
· The use of data from TCCC casualty card and electronic TCCC medical after-action reports for objective documentation of details and total level of care arrangement.
For bleeding arrest, along with compressing dressings, and wound packing with hemostatic gauze for NTCRCB and RCB, it is recommended to use new techniques: injector of synthetic hemostatic sponges XStat™ (for narrow and deep wounds in junction sites), and hemostatic clamp iTClamp (individually or in combination with XStat™) [21, 41, 42].
Therefore, the achieved progress has been determined by combination of optimal (for reality of modern warfare) organization and strategies of prehospital care for combat victims, with constant improvement in ways for arrangement of care on the basis of advances in medical science and medical technologies. The mean principles of prehospital care for victims with combat injuries are successfully used in civilian medicine in development of programs for arrangement of medical care for victims of terroristic attacks and mass shooting (for example, Hartford consensus, Stop Bleed program [43, 44, 45]), and actions of special helicopter teams and ground teams in such extreme situations [17, 35].
Information on financing and conflict of interest
The study was conducted without sponsorship.
The authors declare the absence of any clear and potential conflicts of interests relating to publication of this article.