Page 52 - 2020 JSOM Winter

Optimal strategies to combat NCTH on the battlefield have of adverse events during rotary wing transport from the POI
included pre-hospital resuscitation with blood products and itself. For select casualties, the benefit of an experienced team
the ability to control NCTH in the earliest phases by expedient capable of responding to these decompensations is apparent.
surgical intervention or other means. 1,5–9 Improved data are required, however, to optimize selection of
the need for DCS following combat injury by this unique ca-
A Secretary of Defense directive issued in 2009 established a pability. The judicious utse of this resource is paramount to
“golden hour” as the time standard for the delivery of combat success, as it is clear that not every casualty will require the
casualties to an environment capable of DCS intervention. A DCS capabilities afforded.
subsequent review reported by Kotwal and colleagues retro-
spectively examined the effects of this time-sensitive interven- It is also important to note that the successes achieved in our
tion on subsequent combat casualty outcomes from military report were achieved only in the setting of effective TCCC care
action in Afghanistan. 10,11 The investigators examined out- prior to SRT intercept and a robust and mature MTF to receive
comes from 21,089 military casualties occurring from Septem- the casualties after SRT management. In an era of increasingly
ber 2001 to March 2014 and noted that after adjustment for burdened military medical resources, it would almost certainly
injury severity, casualties who received a transfusion or were prove counterproductive to convert a large number of surgical
transferred to DCS capability within an hour of injury were teams to the kind of in-flight capabilities described. Without
less likely to die of combat wounds. This group of investiga- appropriate investment of these capabilities in the receiving
tors estimated that the practice of delivering casualties to a MTFs, the in-flight capabilities become the proverbial “bridge
DCS-capable environment in this time frame resulted in 359 to nowhere.” In this regard, additional study and consider-
lives saved over the study period. 10,11 ation are required to determine the appropriate balance along
the chain of care.
The data from this important effort by Kotwal and colleagues
were, however, largely collected during a period of robust mil- Resuscitative thoracotomy remains a heroic effort of trauma
itary activity in a mature combat theater. Accordingly, the time care, reserved for those patients who are not responding to
period of examination was associated with the availability of resuscitation with blood products – regardless of the environ-
a relatively developed casualty evacuation system and a med- ment in which it is used. The addition of advanced invasive
ical “footprint” designed to optimally position DCS capabili- resuscitative interventions in the prehospital setting by well-
ties with the establishment of Role 2 and Role 3 MTFs. More trained teams is not novel and has been described in a variety
contemporary experience suggests that future military medical of both military and civilian environments. 18–25 In-flight use
care may be required in less mature environments, in which of damage control surgery, however, represents specific chal-
distances to an established Role 2 or Role 3 DCS capability lenges. The performance of DCS interventions on an aircraft
may prove more challenging. In addition, there is emerging require an experienced provider who is well trained to conduct
civilian evidence that the timeframes required to optimize out- procedures in a chaotic environment characterized by active
comes of those that require surgery after major trauma are movement, noise, and lighting challenges. They must be able
much shorter in interval than those prescribed by traditional to intervene with only a limited toolset relative to more robust
“golden hour” principles. 12 civilian environments. Despite these challenges, our described
results compare favorably to those of mature civilian trauma
Furthermore, the future construct of military resuscitation and environments. In the largest reported experience with resus-
DCS capabilities may be evolving. Traditional forward surgi- citative thoracotomy to date, DuBose et al. documented out-
4
cal elements depend largely on the establishment of a robust comes from 310 procedures conducted at American College
supply chain, and are relatively large in size. 13–15 Additionally, of Surgeons Level I trauma centers. They found that injuries
26
the traditional forward surgical teams of various military ser- resulting from penetrating mechanisms among civilian casual-
vices are less mobile, due to larger footprints and ancillary ties presenting with SOL resulted in survival in 13.9% (11/79),
requirements, within the very short timeframes potentially and only 1.7% (2/118) when SOL were not present on arrival.
required to effectively respond to distant emergent contingen- In our more limited combat environment experience, we ob-
cies. While more mobile resuscitative prehospital capabilities, served corresponding survival rates of 75% (3/4) and 33%
4
such as the UK MERT, were developed during recent conflicts, (1/3), respectively.
these unique platforms offer primarily nonsurgical resuscita-
tive capabilities and require the optimal placement of DCS We have previously described the SRT as designed specifically
capabilities relative to mission locations. These specific units for rapid and flexible response to emerging contingencies in
16
are also not designed to be used in a flexible manner to sup- various roles. This unit is capable of effectively bridging the
27
port contingency situations in various environments outside gap between TCCC and definitive surgical care in a variety of
their tightly defined roles. settings. A unique selection and training regimen is required
for the development of this capability. Our data demonstrates
Earlier intervention during transport from POI to an MTF the wide range of skills implemented effectively by an SRT
warrants consideration but requires an appreciation that ro- team must be capable of providing appropriate TCCC inter-
tary wing transport of combat casualties represents a unique ventions, the benefit of which has been demonstrated in sev-
environment requiring specialized training and capabilities. In eral large reports. 3,28-30 In addition, the multidisciplinary SRT
one review of 149 combat platform helicopter transports con- maintains currency in the effective utilization of a wide va-
ducted by Lehmann and colleagues, 30% of casualties trans- riety of resuscitative adjuncts, including the ability to secure
ported by this modality had in-flight clinical deterioration and an advanced airway, establish rapid venous access (by central
9% required urgent intervention after delivery to a receiving venous cannulation if necessary), transfusion, and resuscita-
facility. This work focused on interfacility transfers, with tive endovascular occlusion of the aorta. Finally, the SRT
9
17
comparatively less having been reported about the occurrence can transition rapidly to providing surgical intervention in
50 | JSOM Volume 20, Edition 4 / Winter 2020