Page 124 - JSOM Spring 2023

3 Dr Foricher is affiliated with the French Military Medical Service,
4
French Military Blood Institute, France. Prof Hejl is affiliated with the
Percy Military Teaching Hospital, Department of Laboratory Med- Killed In Action (KIA)
5
icine, France. Prof Travers is affiliated with the Paris Fire Brigade,
Emergency Medical Service. Dr Foissaud is affiliated with the Percy
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Military Teaching Hospital, Department of Laboratory Medicine. How Golden Are 60 Minutes?
7 Prof Martinaud is affiliated with the French Military Medical Service,
French Military Blood Institute.
Stacey Webster, MD ; Ed Barnard, MD2;
1
Jason Smith, MD ; Max Marsden, MD ;
4
3
Human Factors in Critical Situations Alan Hepper, MD ; Chris Wright, MD 6
5
Learning Objectives
Anthony Vacher, MD, PhD
1. Describe the epidemiology of killed-in-action (KIA) combat
deaths in the UK military population.
Context 2. Discuss significant differences in time to death for different
Human factors play a crucial role in patient safety and the primary anatomic injuries in combat trauma.
performance of care, particularly in critical situations that 3. Describe the differences in pre-hospital and in-hospital
refer to a vast variety of situations having in common that mortality of UK casualties throughout the Afghanistan con-
they are life-threatening for the patient and place the health- flict (2004–2014).
care team under stress, high workload, temporal pressure, and
uncertainty. Introduction
Most combat deaths in Afghanistan occurred before patient
Objective arrival at a medical treatment facility. However, there are no
To provide a brief overview of the guidelines on human factors published data on how quickly these deaths occurred, the effect
in critical situations jointly developed by the French Society of primary injury on time to death, and whether improvements
of Anesthesia and Intensive Care Medicine and the Human in survival were made in the pre-hospital or in-hospital phase.
Factors in Healthcare Group. Through novel linkage of tactical and medical databases, we
aimed to report accurate time to death for a large cohort of pa-
tients who were killed in action (KIA) and to compare pre-hos-
Method pital and in-hospital mortality rates during this conflict.
A committee of 19 experts from the two above-mentioned
learned societies has been set up. The committee followed the Methods
GRADE (Grading of Recommendations, Assessment, Devel-
opment, and Evaluation) method to assess the quality of the The UK Joint Trauma Theatre Registry (JTTR) was used to
evidence on which the recommendations were based. identify all UK military personnel who died in Afghanistan
(2004–2014). These data were linked to nonmedical tactical
records to provide an accurate timeline of events in the combat
Results space. Time of death in-hospital is recorded in the JTTR; time
Based on a strong agreement between experts, 21 recommen- of death pre-hospital was defined as “loss of central pulse”
dations were produced. These recommendations concern four or “CPR [cardiopulmonary resuscitation] started” (without
main areas of human factors: Communication, Organization recovery).
of Work, Work Environment, and Education and Training.
The primary objective was to report KIA mortality at key
NATO medical paradigm intervals: 0, 10, 60, and 120 min-
Discussion utes. Secondary objectives included comparison of time to
These first French guidelines concerning human factors in crit- death for different primary injuries, evaluation of opportuni-
ical situations constitute a genuine idea box and toolbox avail- ties to improve pre-hospital survival, and a comparison of pre-
able to healthcare teams and their organization to prepare, and in-hospital mortality by year.
cope with, and learn from critical situations they encounter, as
well as in a hospital or an extreme and degraded pre-hospital Data were analyzed in Prism 8.0 for MacOS (GraphPad Soft-
military environment. ware, v8.3.0). Data are presented as n (%) and median (in-
terquartile range), as appropriate. Analysis of proportions
Dr Anthony Vacher is affiliated with the Institut de Recherche Bio- was undertaken with a Fisher’s exact test, a Baptista-Pike
médicale des Armées—Unité d’Ergonomie Cognitive des Situations method odds ratio (OR), reported as OR (95% confidence
Opérationnelles, Brétigny sur Orge, France. interval [CR]), and a Koopman asymptotic score relative
risk (RR) as RR (95% CI). Survival was analyzed with a Ge-
han-Breslow-Wilcoxon test. Statistical significance (p values)
is presented without correction for multiple comparison. Ano-
nymized data were supplied from the JTTR, and, in accordance
with institutional agreement, ethical review was not required.

122 | JSOM Volume 23, Edition 1 / Spring 2023