Page 106 - JSOM Spring 2021

Lessons Learned on the Battlefield Applied in a Civilian Setting

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Pierre-Yves Cordier, OF-4 *; Clément Benoît, OF-1 ;
Frédérik Bélot-De Saint Leger, OF-3 ; Ghislain Pauleau, OF-4 ; Yvain Goudard, OF-4 5
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ABSTRACT
We report the case of a civilian 27-year-old man treated in a mil- Paris fire department chief physician to write a few weeks
itary hospital in France who sustained multiple stab wounds, later that “lessons learned by physicians in the theaters of war
including one in the left groin, with massive external bleeding. saved lives in Paris on January 7, 2015.” Experience from
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When first responders arrived, the patient was in hemorrhagic the Iraq and Afghanistan conflicts led to the development of
shock. A tourniquet and two intraosseous catheters were placed damage-control resuscitation strategies, based on an early,
to start resuscitative care. On the patient’s arrival at the hospi- high ratio of plasma transfusion, to treat the trauma-induced
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tal, bleeding was not controlled, so a junctional tourniquet was coagulopathy. French lyophilized plasma, developed by the
put in place and massive transfusion was started. Surgical ex- French Military Blood Institute, was proved to be a logistically
ploration revealed a laceration of the superficial femoral artery superior alternative to fresh-frozen plasma for severe trauma
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and a disruption of the femoral vein. Vascular damage control patients. Whole blood transfusion, used in military environ-
was achieved by a general surgeon and consisted of primary ments because of logistical constraints, also demonstrated its
repair of the superficial femoral artery injury and venous liga- superiority in stored component therapy and is now consid-
tion. The patient was discharged from the intensive care unit ered for civilian use in massively bleeding patients. 5,6
after 2 days and from the hospital after 8 days. This case illus-
trates some of the persistent challenges shared between military We report the case of a young male victim of stab wounds
and civilian trauma care. The external control of junctional treated in a military hospital in France. This case illustrates
hemorrhage is not easily achievable in the field, and junctional some of the persistent challenges in casualty care, such as ex-
tourniquets have been therefore incorporated in the Tactical ternal control of junctional hemorrhage and vascular repair
Combat Casualty Care guidelines. French lyophilized plasma by nonspecialized surgeons. Lessons learned on the battlefield
was used for massive transfusion because it has been proven were applied to the benefit of the patient. Patient informed
to be a logistically superior alternative to fresh-frozen plasma. consent was obtained prior to this publication.
Management of vascular wounds by nonspecialized surgeons
is a complex situation that requires vascular damage-control Case Presentation
skills; French military surgeons therefore follow a comprehen-
sive structured surgical training course that prepares them to A civilian 27-year-old man sustained multiple stab wounds in
manage complex penetrating trauma in austere environments. a street in Marseille, France, including one in the left groin,
Finally, in this case, lessons learned on the battlefield were ap- with massive external bleeding. When first responders arrived,
plied to the benefit of the patient. the patient was anxious and confused. He was tachycardic,
and his radial pulse was not palpable. An Israeli bandage was
Keywords: penetrating trauma; casualty care; junctional applied on the groin wound, and a tourniquet was placed high
tourniquet; damage control on the left thigh to control the bleeding. Two intraosseous
catheters were placed in the right tibia and right humerus. The
patient received crystalloid solutions (1000mL total), titration
of epinephrine (by 0.1mg bolus), and continuous infusion of
Introduction
norepinephrine until a palpable radial pulse was obtained.
Lessons learned from combat casualty care have challenged Early administration of tranexamic acid (1g) was started just
the paradigms for trauma care in a civilian setting, promoting before leaving the scene.
the importance of early hemostasis, widespread use of tourni-
quets, and damage-control surgery. Military triage concepts When the patient arrived in the emergency department, his
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were applied during terrorist attacks in Paris, which led the heart rate was 140 beats per minute (bpm), and his blood
*Correspondence to py.cordier@icloud.com
1 Lt-Col Cordier is affiliated with the French Military Health Service, Intensive Care Unit, Laveran Military Teaching Hospital, Marseille, France,
and with LBA, UMRT 24, Aix Marseille Université-IFSTTAR, Marseille. Lt Benoît is affiliated with the French Military Health Service, Intensive
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Care Unit, Laveran Military Teaching Hospital. Cdt Bélot-De Saint Leger is affiliated with the French Military Health Service, Intensive Care
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Unit, Laveran Military Teaching Hospital and with LBA, UMRT 24, Aix Marseille Université-IFSTTAR. Lt-Col Pauleau is affiliated with the
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French Military Health Service, Visceral and Digestive Surgery Unit, Laveran Military Teaching Hospital. Lt-Col Goudard is affiliated with LBA,
UMRT 24, Aix Marseille Université-IFSTTAR, and with the French Military Health Service, Visceral and Digestive Surgery Unit, Laveran Military
Teaching Hospital.
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