Page 94 - JSOM Fall 2023

However, future conflicts with a peer and/or near-peer adver- teams, a hospital, etc.). Finally, the authors aimed to evaluate
sary are likely to create situations in which far-forward com- the feasibility of employing these devices and techniques in
bat units operating in austere environments will be denied austere environments and recommend design improvements
7
ground and air operational support. The subsequent lack of that may advance patient care.
air superiority may delay casualty evacuation for days or even
8
weeks, far exceeding the traditional “Golden Hour.” This may Methods
be associated with additional challenges, such as the need for
9
ground unit mobility to evade an adversary’s attack. This The literature search was executed using scientific search en-
evolving paradigm highlights the ever-growing importance gines (e.g., PubMed, Web of Science, Google Scholar, etc.). The
of prolonged casualty care (PCC), defined as the provision of literature review was divided into key topic areas: 1) commer-
care in austere environments when evacuation to a more tradi- cially available splints, 2) improvised splinting techniques, 3)
tional fixed-based hospital is unavailable. 8,10 orthotic interventions, and 4) biomaterial approaches to local
fracture stabilization. Abstracts and conference proceedings
Challenges to providing prolonged casualty care (PCC) in written in English were included, and there were no exclusions
far-forward or remote environments include limited space for based on publication year. The bibliographies of articles iden-
supplies among dismounted medical teams; fighting and ap- tified by the initial search were examined to find previously
proach loads for a Combat Medic are 24.7-kg (54.5-lb) and published literature. In an effort to gain access to articles de-
41.6-kg (91.7-lb) respectfully, which would limit their ability scribing the most modern techniques, forward searches were
to carry more items. Further challenges would be presented executed to locate papers referencing key literature identified
12
by lack of far-forward surgical support, risk to rescuers in dif- previously as using the aforementioned approaches.
ficult terrain, and the need for dedicated air support. 5,11 Nearly
25% of recent PCC scenarios were under enemy fire, thus ad- Fracture Management in the Austere Environment
ditionally complicating the provision of medical care. 13
Splinting, or the provisional immobilization of an injured ex-
Many characteristics of PCC are also seen in the civilian sec- tremity, is the current standard of care for orthopedic injuries
tor, in which managing lower extremity injuries sustained in sustained in the field in order to facilitate casualty transporta-
wilderness areas involves overcoming many of the same chal- tion by MEDEVAC or CASEVAC (Figure 1). The benefits of
lenges as battlefield injuries sustained in austere environments. fracture immobilization through splinting include pain man-
Up to three-quarters of injuries to individuals participating in agement, protection of injured soft tissues, and, depending on
mountaineering, rock climbing, canyoning, and caving involve the technique, application of traction or provisional reduction.
the lower extremities, with 41% of injuries resulting in frac- It also contributes to reduced blood loss, compression on ad-
tures. 14–17 While the most common mechanism of injury for jacent neurovascular structures, and risk of fat embolism and
civilians engaged in recreational wilderness activities is a fall pulmonary complications. 19–25 Splinting is appropriate for early
(as opposed to a blast injury), the environment and severity of post-injury care or when more definitive treatment options
those injuries make many aspects of wilderness patient care such as surgical management are not immediately available
similar to those faced by providers in far-forward military op- (e.g., PCC scenario) or appropriate (e.g., sub-sterile conditions).
erations. For example, challenges include the following: the
remote locale, limited communication between the point of Splints employed in the austere prehospital environment
injury and higher levels of care, limited or delayed rescue ca- should be lightweight and easily packaged but strong enough
pabilities (via air or ground resources), lack of point-of-care to immobilize a fractured limb, especially if it needs reduction.
medical resources, and physical risk to rescuers. Harsh or They must also be adaptable across a range of limb shapes
18
volatile weather conditions may compound these difficulties. and sizes. Excellent designs allow for wound access and can be
quickly applied with minimal personnel with limited medical
Several splinting designs have been developed as commercial training. 23,26 Designs that apply constant circumferential pres-
products or improvised in the field, yet it is unclear if these sure should be avoided for lower extremity injuries if the per-
27
could be used to enable mobility until more definitive treat- son develops an acute compartment syndrome. Splints can
ment is available. Likewise, there are orthotic designs that en- be made from fiberglass or plaster, pre-packaged (i.e., com-
able weight-bearing mobility, but these may not be available in mercially available), or can be improvised in the field using
PCC scenarios. Finally, several novel and biologically-focused principles outlined in this review and with available materials
technologies have been proposed that may stabilize the indi- (Table 1). In addition to satisfying these basic requirements,
vidual and allow them to bear weight on a fractured bone. the ideal device would allow early patient mobilization (cur-
Lessons learned from these treatment developments may fa- rent splints do not allow for weight bearing), which would
cilitate repurposing available technology or generating new thereby facilitate team/unit mobility during PCC scenarios.
technology for PCC scenarios. The development of solutions The following sections will explore prefabricated and impro-
that mitigate the effects of lower extremity injuries in PCC sce- vised splint designs.
narios will have a major impact on both military and civilian
personnel. The common characteristics described above led to the devel-
opment of several splint designs. Simple preformed wooden
The goal of this literature review was to define the challenges splints were used successfully during the U.S. Civil War, while
associated with managing extremity injuries in a PCC scenario. the Thomas traction splint, developed in the late 1800s, was
Then, the objectives were to identify technologies that could utilized in the prehospital setting from World War I through
be used temporarily to stabilize lower extremity fractures and modern conflicts (Figure 2). 23,28–31 The Thomas splint’s bi- polar
even enable early mobility until the patient can be evacuated design provides traction, stability, and as a consequence, hem-
to more resourced echelons of care (e.g., forward surgical orrhage control for complex femur injuries (Figure 3). 28–30 By

92 | JSOM Volume 23, Edition 3 / Fall 2023