Army General Surgery's Crisis of Conscience

Edwards, Mary J.; White, Christopher E.; Remick, Kyle N.; Edwards, Kurt; Gross, Kirby R.

doi:10.1016/j.jamcollsurg.2018.03.001

Cited by 50 publications

(49 citation statements)

References 18 publications

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“…The potential use of TXA in for military TBI is of particular interest given the fact that the military is currently moving towards smaller, more remote surgical teams in order to support lower profile military operations (16). Limited data is currently published about the effects of TXA in combatrelated TBI.…”

Section: Discussionmentioning

confidence: 99%

Outcomes following administration of tranexamic acid in combat-related intracranial hemorrhage: a cohort study

Walker

Bozzay

Johnston

et al. 2020

Preprint

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BACKGROUND: Tranexamic acid (TXA) may be a useful adjunct for military patients with severe traumatic brain injury (TBI). These patients are often treated in austere settings without immediate access to neurosurgical intervention. The purpose of this study was to evaluate any association between TXA use and progression of intracranial hemorrhage (ICH), neurologic outcomes, and venous thromboembolism (VTE) in TBI.METHODS: This was a retrospective cohort study of combat casualties from October 2010 to December 2015 who were transferred to a military treatment facility (MTF) in the United States. Data collected included: demographics, types of injuries, initial and interval head computerized tomography (CT) scans, Glasgow Coma Scores (GCS), and six-month Glasgow Outcome Scores (GOS). Results were stratified based on TXA administration, progression of ICH, and VTE.RESULTS: Of the 687 active duty service members reviewed, 71 patients had ICH (10.3%). Most casualties were injured in a blast (80.3%), with 36 patients (50.7%) sustaining a penetrating TBI. Mean ISS was 28.2 ± 12.3. Nine patients (12.7%) received a massive transfusion within 24 hours of injury, and TXA was administered to 14 (19.7%) casualties. Patients that received TXA had lower initial reported GCS (9.2 ± 4.4 vs. 12.5 ± 3.4, p=0.003), similar discharge GCS (13.3 ±4.0 vs. 13.8±3.2, p=0.58), and a larger improvement between initial and discharge GCS (3.7±3.9 vs. 1.3±3.1, p=0.02). However, there was no difference in mortality (7.1% vs. 7.0%, p=1.00), progression of ICH (45.5% vs. 14.7%, p=0.09), frequency of cranial decompression (50.0% vs. 42.1%, p=0.76), or mean GOS (3.5±0.9 vs. 3.8±1.0, p=0.13). Patients administered TXA had a higher rate of VTE (35.7% vs. 7.0%, p=0.01). On multivariate analysis, however, TXA was not independently associated with VTE.CONCLUSIONS: Patients that received TXA were associated with an improvement in GCS but not in progression of ICH or GOS. TXA was not independently associated with VTE, although this may be related to a paucity of patients receiving TXA. Decisions about TXA administration in combat casualties with ICH should be considered in the context of the availability of neurosurgical intervention as well as severity of extracranial injuries and need for massive transfusion.

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Section: Discussionmentioning

confidence: 99%

Outcomes following administration of tranexamic acid in combat-related intracranial hemorrhage: a cohort study

Walker

Bozzay

Johnston

et al. 2020

Preprint

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“…While operative experience is not the sole factor in determining the most appropriate TS-MCP, case volume cannot be underestimated as foundational to preparing a team or provider for surgical care of the combat casualty. Many military treatment facilities report low operative and trauma volumes, resulting in military providers that lack exposure to the critical skills needed to care for severely injured combat casualties 6–8. In addition, a model that accurately predicts trauma case volume at an institution would be valuable in establishing TS-MCP courses.…”

Section: Discussionmentioning

confidence: 99%

Validation of a predictive model for operative trauma experience to facilitate selection of trauma sustainment military–civilian partnerships

Hall

Qureshi²,

Glaser³

et al. 2019

Trauma Surg Acute Care Open

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BackgroundTrauma readiness is a Department of Defense requirement for military healthcare providers. Surgeons must maintain readiness to optimize surgical care on the battlefield and minimize preventable death. The objective of this study was to validate a predictive model for trauma operative exposure by applying the model prospectively.MethodsThe predictive model for operative trauma exposure was prospectively applied to predict the number of emergent operative cases that would be experienced over predetermined time periods at four separate trauma sustainment military–civilian partnerships (TS-MCP). Notional courses were designed to be 2 or 4 weeks long and consisting of 5 and 12 overnight call periods, respectively. A total of 51 separate 2-week courses and 49 4-week courses were evaluated using the model. The outcome measure was the number of urgent (occurring within a day of arrival) operative trauma cases.ResultsTrauma/general surgery case volumes during call periods of notional courses were within the predicted range at least 98% of the time. Orthopedic volumes were more variable with a range of 82%–98% meeting expectation depending on the course length and institution.ConclusionThe previously defined model accurately predicted the number of urgent trauma/general surgery cases course participants would likely experience when applied prospectively to TS-MCP; however, the model was less accurate in predicting acute orthopedic trauma exposure. While it remains unknown how many cases need to be performed meet a trauma sustainment requirement, having a model with a predictive capability for case volume will facilitate metric development. This model may be useful when planning for future TS-MCP.Level of evidenceEconomic and Value Based Evaluations Level II

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“…Urgent surgical operation in traumatically injured patients was selected as the intervention of interest most closely representing the role of forward-deployed surgeons 1 6–9. The most common scenario for deployed forward surgical teams includes a general and an orthopedic surgeon with a small team consisting of four to eight additional personnel in an austere far-forward, resource-constrained environment with little or no patient holding capacity.…”

Section: Methodsmentioning

confidence: 99%

“…During interwar periods when there are low combat casualty volumes, this unique skill set has to be acquired and sustained. A well-described dilemma of the military surgeon is this requirement for battlefield trauma expertise without regular exposure to a traumatically injured patient 1. This challenge was recognized at the national level in the National Defense Authorization Act for Fiscal Year 2017 (NDAA 2017), which defined a requirement for increased training of military surgeons in civilian trauma centers.…”

Section: Introductionmentioning

confidence: 99%

Objective model to facilitate designation of military–civilian partnership hospitals for sustainment of military trauma readiness

Hall

Qureshi²,

Shackelford

et al. 2019

Trauma Surg Acute Care Open

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BackgroundA major dilemma of the military surgeon is the requirement for battlefield trauma expertise without regular exposure to a traumatically injured patient. To solve this problem, the military is partnering with civilian trauma centers to obtain the required trauma exposure. The main objective of this article is to quantify institutional differences and develop a predictive model for estimating the number of 24-hour trauma shifts a surgeon must be on call at civilian centers to experience urgent trauma cases.MethodsTrauma databases from multiple institutions were queried to obtain all urgent trauma cases occurring during a 2-year period. A predictive model was used to estimate the number of urgent surgical cases in multiple specialties surgeons would experience over various numbers of 24-hour shifts and the number of 24-hour shifts required to experience a defined number of cases.ResultsInstitution 1 had the lowest number of required 24-hour shifts to experience 10 urgent operative cases for general/trauma surgery (10 calls) and orthopedic surgery (6 calls) and the highest number of predicted cases over 12 days, 18.3 (95% CI 11 to 27), with 95% confidence. The expected trauma cases and 24-hour shifts at Institution 1 were statistically significant (p<0.0001). There were seasonal effects at all institutions except for Institution 3.DiscussionThere are significant variabilities in trauma center volume and therefore, the expected number of shifts and cases during a specific period of time is significantly different between trauma centers. This predictive model is objective and can therefore be used as an extrapolative tool to help and inform the military regarding placement of personnel in optimal centers for trauma currency rotations.Level of evidenceEconomic and value-based evaluations, level II.

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Army General Surgery's Crisis of Conscience

Cited by 50 publications

References 18 publications

Outcomes following administration of tranexamic acid in combat-related intracranial hemorrhage: a cohort study

Outcomes following administration of tranexamic acid in combat-related intracranial hemorrhage: a cohort study

Validation of a predictive model for operative trauma experience to facilitate selection of trauma sustainment military–civilian partnerships

Objective model to facilitate designation of military–civilian partnership hospitals for sustainment of military trauma readiness

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