Maintaining Surgical Readiness While Deployed to Low-Volume Military Treatment Facilities: A Pilot Program for Clinical and Operational Sustainment Training in the Deployed Environment

The SHADER model: forward surgical teams managing high-intensity, low-frequency military surgery incidents

INTRODUCTION

The UK Defence Medical Services (UK DMS) surgical teams have been deployed in small, low resource, remote mobile Role 2 (R2) facilities globally to provide Damage Control Resuscitation and Surgery for combat casualties. It is vital that commanders understand the expected workload for specific operations for planning and training and sustainment of high-quality surgical capability. The current study examined the surgical workload from a complete forward UK DMS R2 facility deployment to better inform future operations of this nature.

METHODS

A retrospective observational study was undertaken using a prospectively collected Operative Department Logbook to determine the number and type of procedures undertaken during a complete deployment between September 2019 and March 2024 (including 18 deployments of 3 months each). Patient and operative details were collected, including the indication (trauma or non-trauma), and compared between Trauma & Orthopaedic (T&O) and General & Vascular (G&V) surgeons.

RESULTS

There were 35 patients who had surgery. The median age was 25 (IQR 22-31), and 33/35 (94%) were male. There were 20/35 (57%) procedures following trauma, and the remainder were for non-trauma emergencies. 11/35 (31%) patients were injured by gunshot or blast mechanism. No mass casualty situations within the Area of Operations, nor outbreaks of infectious diseases within the deployed forces occurred during the time period. More procedures were undertaken by G&V specialists than T&O for (20 vs 16, respectively, with one combined procedure). However, the operations were less likely to be for a trauma indication as a proportion of their workload (6/20 (29%) vs 15/16 (93%), respectively; p<0.001).

CONCLUSIONS

This remote, forward R2 deployment was characterised by low volume of surgical workload, but a requirement for high readiness and competency in major trauma surgery. This represents a challenge for training and currency that must be addressed for optimal surgical care in ongoing and future operations.

Effect of Fusion and Arthroplasty for Cervical Degenerative Disc Disease in Active Duty Service Members Performed at an Overseas Military Treatment Facility: A 2-Year Retrospective Analysis

INTRODUCTION

Among U.S. military active duty service members, cervicalgia, cervical radiculopathy, and myelopathy are common causes of disability, effecting job performance and readiness, often leading to medical separation from the military. Among surgical therapies, anterior cervical discectomy and fusion (ACDF) and cervical disc arthroplasty (CDA) are options in select cases; however, elective surgeries performed while serving overseas (OCONUS) have not been studied.

MATERIALS AND METHODS

A retrospective analysis of a prospectively collected surgical database from an OCONUS military treatment facility over a 2-year period (2019-2021) was queried. Patient and procedural data were collected to include ACDF or CDA surgery, military rank, age, tobacco use, pre- and post-operative visual analogue scales for pain, and presence of radiographic fusion after surgery for ACDF patients or heterotopic ossification for CDA patients. Chi-square and Student t-test analyses were performed to identify variables associated with return to full duty.

RESULTS

A total of 47 patients (25 ACDF and 22 CDA) underwent surgery with an average follow-up of 192.1 days (range 7-819 days). Forty-one (87.2%) patients were able to return to duty without restrictions; 10.6% of patients remained on partial or limited duty at latest follow-up and one patient was medically separated from the surgical cohort. There was one complication and one patient required tour curtailment from overseas duty for ongoing symptoms.

CONCLUSIONS

Both ACDF and CDA are effective and safe surgical procedures for active duty patients with cervicalgia, cervical radiculopathy, and cervical myelopathy. They can be performed OCONUS with minimal interruption to the patient, their family, and the military unit, while helping to maintain surgical readiness for the surgeon and the military treatment facility.

Craniotomies at an overseas military treatment facility: Maintaining readiness for the unit and the surgeon

INTRODUCTION

Craniotomy and craniectomy are common neurosurgical procedures with wide applications in both civilian and military practice. Skill maintenance for these procedures is required for military providers in the event they are called to support forward deployed service members suffering from combat and non-combat injuries. The presents investigation details the performance of such procedures at a small, overseas military treatment facility (MTF).

MATERIALS AND METHODS

A retrospective review of craniotomy procedures performed at an overseas military treatment facility (MTF) over a 2-year period (2019-2021) was performed. Patient and procedural data were collected for all elective and emergent craniotomies including surgical indications, outcomes, complications, military rank, and impact on duty status and tour curtailment.

RESULTS

A total of 11 patients underwent a craniotomy or craniectomy procedure with an average follow-up of 496.8 days (range 103-797). Seven of the 11 patients were able to undergo surgery, recovery, and convalesce without transfer to a larger hospital network or MTF. Of the 6 patients that were active duty (AD), one returned to full duty while three separated and two remain in partial duty status at latest follow-up. There were four complications in four patients with one death.

CONCLUSIONS

In this series, we demonstrate that cranial neurosurgical procedures can be performed safely and effectively while at an overseas MTF. There are potential benefits to the AD service members, their unit, and family as well as to the hospital treatment team and surgeon as this represents a clinical capability requisite to maintain trauma readiness for future conflicts.

Characterization of Humanitarian Trauma Care by US Military Facilities During Combat Operations in Afghanistan and Iraq

OBJECTIVE

To characterize humanitarian trauma care delivered by US military treatment facilities (MTFs) in Afghanistan and Iraq during combat operations.

BACKGROUND

International Humanitarian Law, which includes the Geneva Conventions, defines protections and standards of treatment to victims of armed conflicts. In 1949 these standards expanded to include injured civilians. In 2001, the Global War on Terror began in Afghanistan and expanded to Iraq in 2003. US MTFs provided care to all military forces, civilians, and enemy prisoners. A thorough understanding of the scope, epidemiology, resource requirements and outcomes of civilian trauma in combat zones has not been previously characterized.

METHODS

Retrospective cohort analysis of the Department of Defense Trauma Registry from 2005-2019. Inclusion criteria were civilians and non-NATO coalition personnel (NNCP) with traumatic injuries treated at MTFs in Afghanistan and Iraq. Patient demographics, mechanism of injury, resource requirements, procedures, and outcomes were categorized.

RESULTS

A total of 29,963 casualties were eligible from the Registry. There were 16,749 (55.9%) civilians and 13,214 (44.1%) NNCP. The majority of patients were age >13 years [26,853 (89.6%)] and male [28,000 (93.4%)]. Most injuries were battle-related: 12,740 (76.1%) civilians and 11,099 (84.0%) NNCP. Penetrating trauma was the most common cause of both battle and nonbattle injuries: 12,293 (73.4%) civilian and 10,029 (75.9%) NNCP. Median injury severity score (ISS) was 9 in each cohort with ISS scores ≥ 25 in 2,236 (13.4%) civilians and 1,398 (10.6%) NNCP. Blood products were transfused to 35% of each cohort: 5,850 civilians received a transfusion with 2,118 (12.6%) of them receiving ≥10 units; 4,590 NNCPs received a transfusion with 1,669 (12.6%) receiving ≥ 10 units. MTF mortality rates were civilians 1,263 (7.5%) and NNCP 776 (5.9%). Interventions, both operative and non-operative, were similar between both groups.

CONCLUSIONS

In accordance with International Humanitarian Law, as well as the US military's medical rules of eligibility, civilians injured in combat zones were provided the same level of care as non-NATO Coalition Personnel. Injured civilians and NNCP had similar mechanisms of injury, injury patterns, transfusion needs, and ISS. This analysis demonstrates resource equipoise in trauma care delivered to civilians and NNCP. Hospitals in combat zones must be prepared to manage large numbers of civilian casualties with significant human and material resources allocated to optimize survival. The provision of humanitarian trauma care is resource-intensive, and these data can be used to inform planning factors for current or future humanitarian care in combat zones.

Aligning Air Force Ground Surgical Team (GST) Training With the Deployment Experience

INTRODUCTION

The Air Force Ground Surgical Team (GST) Phase 1 course is a two-week pre-deployment training for the Air Force's conventional austere surgical care platform. Since the creation of the GST platform and associated training pipeline in 2017, course adjustments and improvements have relied on expert opinion and anecdote. To gain a more robust understanding of GST deployment clinical and operational activities, we conducted a survey of all surgeons who completed GST Phase 1 training from its inception in April 2017 to September 2020.

MATERIALS AND METHODS

87 surgeons took the course from April 2017 to September 2020. 60 of those surgeons were still on active duty and were candidates to complete the survey sent from the Air Force Survey Office. 31 individuals responded and their identification was kept blinded. An IRB exemption was issued before study initiation.

RESULTS

Of the 31 respondents, 9 took the GST Phase 1 course but never deployed, and were excluded. The remaining 22 surgeons deployed at some point from 2017 to 2020. Four surgeons reported providing no surgical care during their deployment. 68% of the surgeons deployed to an actual standalone GST platform, while the rest were retained at larger military treatment facilities (MTFs) or Role III facilities. The median number of surgeries performed was 2 for surgeons at standalone GSTs and 7 for those at larger MTFs/Role IIIs. A holding time of greater than 12 hours was reported for 15% of operative patients and 58% of nonoperative patients at standalone GSTs. 28% (n = 5) of surgeons reported taking care of patients in the Golden Hour of surgery, and 23% of teams reported a patient death. Two surgeons cared for a military working dog, and four surgeons cared for pediatric patients. 50% of surgeons had more than one patient present simultaneously for care. 50% of surgeons' resupply were in the greater than 30 days or never received category.

CONCLUSIONS

The GST Phase 1 course has a unique role in preparing students to provide austere surgical care. This includes both preparing to function in the operational military environment as well as applying sound in-garrison trauma surgical care techniques to the austere, resource variable environment. The results of this survey suggest that a broadening of content-specific deployment-related topics, the formalization of documentation education, incorporating formal evidence-based nontechnical skills training, and identifying optimal GST context-specific behaviors will strengthen the effectiveness of the course in preparing students for deployment.