Page 84 - Journal of Special Operations Medicine - Fall 2015

Resuscitation During Critical Care Transportation in Afghanistan

Joshua M. Tobin, MD;
Giles R. Nordmann, BSc (Hons), MB, ChB, FRCA; Eric J. Kuncir, MD, MS, FACS

ABSTRACT

Objective: These data describe the critical care procedures rather than smaller, less-specialized hospitals. Throughout
3,4
performed on, and the resuscitation markers of, critically western Europe and Australia, intensivist-led aeromedical
wounded personnel in Afghanistan following point of injury transport teams have demonstrated better outcomes in blunt
(POI) transports and intratheater transports. Providing this trauma, as well as improved survival in head-injured patients. 5–9
information may help inform discussion on the design of criti-
cal care transportation platforms for future conflicts. Meth- In the military experience, intensivist-led teams such as the Brit-
ods: The Department of Defense Trauma Registry (DoDTR) ish Medical Emergency Response Team (MERT) have demon-
was queried for descriptive data on combat casualties with strated better-than-expected survival in traumatic brain injury
Injury Severity Score (ISS) greater than 15 who were trans- (TBI) and thoracic injury. Davis et al. wrote that this improve-
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ported in Operation Enduring Freedom (OEF) from 1 Janu- ment in outcome may be due to the ability to intubate and place
ary 2010 to 31 December 2010. Both POI transportation chest tubes. Comparisons of the available medical evacuation
events and interfacility transportation events were reviewed. platforms in Afghanistan found a “distinct survival advantage”
Base deficit (BD) was evaluated as a maker of resuscitation, with an advanced critical care model. Specifically, lower-than-
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and international normalized ratio (INR) was evaluated as predicted mortality was noted in more severely injured patients
a measure of coagulopathy. Results: There were 1198 trans- with an ISS of 20 to 29, as well as lower-than-predicted mortal-
portation events that occurred during the study period—634 ity for all groups with an ISS greater than 10. Olson et al. also
(53%) transports from the POI and 564 (47%) intratheater recently noted that the MERT model conferred a survival ad-
transports. Critical care interventions were performed dur- vantage among medical evacuation platforms in Afghanistan.
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ing 147 (12.3%) transportation events, including intubation, Additionally, critical events during transportation are not un-
cricothyrotomy, double-lumen endotracheal tube placement, common. In one review of combat trauma patients transported
needle or tube thoracostomy, central venous access placement, by helicopter, half were on a ventilator, nearly a third had a
and cardiopulmonary resuscitation. The mean BD on arrival clinical deterioration in flight, and 10% required urgent inter-
in the emergency department was –5.4 mEq/L for POI trans- vention on arrival at the next level of care. 13
ports and 0.68 mEq/L intratheater transports (p < .001). The
mean INR on arrival in the emergency department was 1.48 Future wars may involve significantly longer transporta-
for POI transports and 1.21 for intratheater transports (p < tion times, as conflict occurs outside of the immediate reach
.001). Conclusions: Critical care interventions were needed of more traditional medical support. The role of the Special
frequently during evacuation of severely injured personnel. Operations medical community, as providers for the distrib-
Furthermore, many troops arrived acidotic and coagulopathic uted troops who carry out these operations, will undoubtedly
following initial transport from POI. Together, these data sug- impact this discussion. Therefore, a careful evaluation of the
gest that a platform capable of damage control resuscitation critical care interventions performed for, and the resuscitation
and critical care interventions may be warranted on longer status of, the cohort of medical transports in Afghanistan is
transports of more critically injured patients. helpful in determining lessons learned for future conflicts.

Keywords: transportation, critical care; resuscitation, trauma;
damage control; emergency medical services; care, out-of- Methods
hospital This DoDTR query investigation contains the procedures per-
formed for, and initial Military Treatment Facility (MTF) emer-
gency department laboratory values of, patients transported
Introduction during OEF. This study was conducted under a protocol re-
viewed and approved by the Navy Medical Center San Diego
A recent analysis describing service members killed in Iraq or Institutional Review Board (CIP No. NMCSD.2013.0018),
Afghanistan found that nearly 1000 deaths were “potentially and a waiver of informed consent was granted to access the
survivable” and a Marine Expeditionary Force point paper in study patients’ deidentified health information based on mini-
2011 identified several patient safety incidents, making recom- mal risk. The Institute of Surgical Research (ISR) reviewed the
mendations for improved critical care transportation in Af- proposal and offered a Letter of Support. Data elements were
ghanistan during OEF. Survival of trauma patients improves collected as defined in the Data Request Form, and an age
1,2
not only when they are cared for in trauma centers but also parameter was requested separately at a later date following
when they are transported directly to those trauma centers, IRB approval.

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