Page 49 - 2020 JSOM Winter

Life and Limb In-Flight Surgical Intervention

Fifteen Years of Experience by
Joint Medical Augmentation Unit Surgical Resuscitation Teams

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Joseph J. DuBose, MD *; Daniel J. Stinner, MD, PhD ; Aric Baudek, CRNA ;
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Dan Martens, PAC ; Ben Donham, MD ; Matt Cuthrell, PAC ; Tony Stephens, SO-ATP ;
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Jerry Schofield ; Curt Conklin ; Simon Telian, MD 10
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ABSTRACT
Background: Expedient resuscitation and emergent damage Introduction
control interventions remain critical tools of modern combat
casualty care. Although fortunately rare, the requirement for Recent experiences in modern regions of conflict have demon-
life and limb salvaging surgical intervention prior to arrival strated a continued need to develop and effectively employ
at traditional deployed medical treatment facilities may be re- strategies to mitigate the risk of hemorrhagic death on the
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quired for the care of select casualties. The optimal employ- battlefield. These include early resuscitation with blood
ment of a surgical resuscitation team (SRT) may afford life products and the ability to control noncompressible torso
and limb salvage in these unique situations. Methods: Fifteen hemorrhage (NCTH) early after injury by expedient surgi-
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years of after-action reports (AARs) from a highly specialized cal intervention or other means. A Secretary of Defense
SRTs were reviewed. Patient demographics, specific details of mandate issued in 2009 established a desired “golden hour”
encounter, team role, advanced emergent life and limb inter- standard for the delivery of combat casualties to an environ-
10,11
ventions, and outcomes were analyzed. Results: Data from ment capable of damage control surgery (DCS). However,
317 casualties (312 human, five canines) over 15 years were contemporary experience suggests that medical support for
reviewed. Among human casualties, 20 had no signs of life military conflict may face significant challenges to meet this
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at intercept, with only one (5%) surviving to reach a Mili- mandate. Current evidence also suggests that the “golden
tary Treatment Facility (MTF). Among the 292 casualties with hour” is not an accurate timeframe upon which to base im-
signs of life at intercept, SRTs were employed in a variety of provement in survival after major traumatic injury. Much
roles, including MTF augmentation (48.6%), as a transport shorter time intervals are associated with more significant im-
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capability from other aeromedical platforms, critical care provements in outcome among those requiring surgery.
transport (CCT) between MTFs (27.7%), or as an in-flight
damage control capability directly to point of injury (POI) Existing forward surgical unit configurations, while a mainstay
(18.2%). In the context of these roles, the SRT performed in recent conflicts, may not be practically designed to support a
in-flight life and limb preserving surgery for nine patients. full range of rapid medical and surgical response contingencies
Procedures performed included resuscitative thoracotomy across the range of medical operations (ROMO) and across
(7/9; 77.8%), damage control laparotomy (1/9; 11.1%) and significant geographical distances. While more mobile resus-
extremity fasciotomy for acute lower extremity compartment citative prehospital capabilities were developed during recent
syndrome (1/11; 11%). Survival following in-flight resuscita- conflicts, such as the UK Medical Response Team (MERT),
tive thoracotomy was 33% (1/3) when signs of life (SOL) were these units possess inherent limitations and do not afford DCS
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absent at intercept and 75% (3/4) among patients who lost capabilities.
SOL during transport. Conclusion: In-flight surgery by a spe-
cifically trained and experienced SRT can salvage life and limb We describe the experience of a surgical resuscitation team
for casualties of major combat injury. Additional research is (SRT) specifically designed to respond rapidly in support of
required to determine optimal SRT utilization in present and emerging contingencies in the modern battlefield. This unit ef-
future conflicts. fectively bridges the gaps between Tactical Combat Casualty
Care (TCCC), further damage control, and definitive surgical
care in a variety of settings and platforms. More specifically,
Keywords: in-flight; surgical rescusitation team; casualty; the SRT is uniquely capable of expediently and effectively pro-
limb salvage; military treatment facility; trauma
viding delivery of both resuscitation and DCS in austere envi-
ronments on multiple platforms.
*Correspondence to R. Adams Cowley Shock Trauma Center, University of Maryland Medical Center, 22 South Greene Street, Baltimore, MD
21201; or jjd3c@yahoo.com
1 Col DuBose is a trauma and vascular surgeon at the University of Maryland Medical Center, Baltimore, Maryland and the Director of the Center
for the Sustainment of Trauma and Readiness Skills (C-STARS) Baltimore. Dr Stinner is an orthopedic surgeon at Vanderbilt University Med-
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ical Center, Nashville, Tennessee. Mr Baudek is a certified registered nurse anesthetist at the San Diego Naval Medical Center, San Diego, CA.
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4 Mr Marten is a physician assistant, LTC Donham is an emergency medicine physician, and Mr Cuthrell is a physician assistant at Womack
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Army Medical Center, Fort Bragg, NC. COL Telian is a general surgeon and assigned to the Joint Special Operations Command. Mr Stephens,
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9 Mr Schofield, and Mr Conklin are at the Joint Special Operations Command.
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