Prolonged casualty care: Extrapolating civilian data to the military context

Mould‐Millman, Nee‐Kofi; Baidwan, Navneet Kaur; Beaty, Brenda; Suresh, Krithika; Dixon, Julia; Patel, Chandni; Vries, Shaheem de; Lategan, Hendrick J; Steyn, Elmin; Verster, Janette; Schauer, Steven G; Becker, Tyson E.; Cunningham, Cord W.; Keenan, Sean; Moore, Ernest E.; Wallis, Lynne; Ginde, Adit A.; Bebarta, Vikhyat S.

doi:10.1097/ta.0000000000003675

Cited by 7 publications

(19 citation statements)

References 32 publications

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“…Data collectors discussed the case with the pathologist if discrepancies between autopsy notes and clinical course were noted. The full methodology used in the EpiC pilot study has been described previously 11,24 …”

Section: Methodsmentioning

confidence: 99%

“…There is a dearth of evidence to guide clinical management and predict outcomes in such prolonged care situations, both in civilian and military contexts 11 . An improved understanding of the delivery and timing of interventions can elucidate knowledge gaps and inform advances to ameliorate traumatic death and disability 12 .…”

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confidence: 99%

“…In collaboration with civilian partners in the United States and South Africa, the US Department of Defense (DOD) has funded a multicenter, prospective observational, large-scale epidemiologic study in South Africa, called “Epidemiology and Outcomes of Prolonged Trauma Care: A Prospective Multi-Center Observational Study in the Western Cape of South Africa” (EpiC) 14 . Upon its conclusion in late 2024, the EpiC study will uniquely assess the effects of early resuscitation on postinjury mortality and morbidity in patients experiencing prolonged care 11,15,16 . The Western Cape trauma system is particularly military relevant because critically injured patients undergo sequential transportation to successive echelons of trauma care, similar to the military deployed setting 12,17–20 .…”

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confidence: 99%

“…There is a dearth of evidence to guide clinical management and predict outcomes in such prolonged care situations, both in civilian and military contexts. 11 An improved understanding of the delivery and timing of interventions can elucidate knowledge gaps and inform advances to ameliorate traumatic death and disability. 12 United States military trauma experts have also called for a more robust base of scientific evidence to inform improvements of clinical guidelines relevant for prolonged care settings.…”

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confidence: 99%

“…13 The Western Cape of South Africa is an ideal and exceptional setting to gather evidence relevant to prolonged care, partly because it has one of the largest populations of severe patients facing prolonged care and documentation that is readily accessible. 11 In collaboration with civilian partners in the United States and South Africa, the US Department of Defense (DOD) has funded a multicenter, prospective observational, large-scale epidemiologic study in South Africa, called "Epidemiology and Outcomes of Prolonged Trauma Care: A Prospective Multi-Center Observational Study in the Western Cape of South Africa" (EpiC). 14 Upon its conclusion in late 2024, the EpiC study will uniquely assess the effects of early resuscitation on postinjury mortality and morbidity in patients experiencing prolonged care.…”

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confidence: 99%

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Feasibility of conducting a military-relevant multicenter cohort study to assess outcomes of early trauma resuscitative interventions in a prolonged care civilian setting

Mould‐Millman

Dixon

Lategan

et al. 2023

J Trauma Acute Care Surg

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BACKGROUND The Epidemiology and Outcomes of Prolonged Trauma Care (EpiC) study is a 4-year, prospective, observational, large-scale epidemiologic study in South Africa. It will provide novel evidence on how early resuscitation impacts postinjury mortality and morbidity in patients experiencing prolonged care. A pilot study was performed to inform the main EpiC study. We assess outcomes and experiences from the pilot to evaluate overall feasibility of conducting the main EpiC study. METHODS The pilot was a prospective, multicenter, cohort study at four ambulance bases, four hospitals, and two mortuaries from March 25 to August 27, 2021. Trauma patients 18 years or older were included. Data were manually collected via chart review and abstraction from clinical records at all research sites and inputted into Research Electronic Data Capture. Feasibility metrics calculated were as follows: screening efficiency, adequate enrollment, availability of key exposure and outcome data, and availability of injury event date/time. RESULTS A total of 2,303 patients were screened. Of the 981 included, 70% were male, and the median age was 31.4 years. Six percent had one or more trauma relevant comorbidity. Fifty-five percent arrived by ambulance. Forty percent had penetrating injuries. Fifty-three percent were critically injured. Thirty-three percent had one or more critical interventions performed. Mortality was 5%. Four of the eight feasibility metrics exceed the predetermined threshold: screening ratio, monthly enrollment, percentage with significant organ failure, and missing injury date/time for emergency medical services patients. Two feasibility metrics were borderline: key exposure and primary outcome. Two feasibility metrics fell below the feasibility threshold, which necessitate changes to the main EpiC study: percentage with infections and missing injury date/time for walk-in patients. CONCLUSION The EpiC pilot study suggests that the main EpiC study is overall feasible. Improved data collection for infections and methods for missing data will be developed for the main study. LEVEL OF EVIDENCE Prognostic and Epidemiological; Level V.

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Section: Methodsmentioning

confidence: 99%

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confidence: 99%

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confidence: 99%

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confidence: 99%

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confidence: 99%

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Feasibility of conducting a military-relevant multicenter cohort study to assess outcomes of early trauma resuscitative interventions in a prolonged care civilian setting

Mould‐Millman

Dixon

Lategan

et al. 2023

J Trauma Acute Care Surg

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Patterns of on‐scene and healthcare system trauma deaths in the Western Cape of South Africa

Finn,

Dixon,

Moreira

et al. 2023

World j. surg.

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BackgroundInjuries account for 8% or 4.4 million deaths annually worldwide, with 90% of injury deaths occurring in low‐ and middle‐income countries. Inter‐personal violence and road traffic injuries account for most injury deaths in South Africa, with rates among the highest globally. Understanding the location, timing, and factors of trauma deaths can identify opportunities to strengthen care.MethodsThis is a retrospective cross‐sectional secondary analysis of trauma deaths from 2021 to 2022 in the Western Cape of South Africa. Healthcare system trauma deaths were identified from a multicenter study paired with a dataset for on‐scene (i.e., prior to ambulance or hospital) trauma deaths in the same jurisdictions. We describe locations, timing, injury factors, and cause of death. We assess associations between those factors.ResultsThere were 2418 deaths, predominantly young men, with most (2274, 94.0%) occurring on‐scene. The most frequent mechanism of injury for all deaths was firearms (32.6%), followed by road traffic collisions (17.8%). On‐scene deaths (33.2%) were significantly more likely to be injured by firearms compared to healthcare system deaths (23.6%) (p‐value <0.01). Most healthcare system deaths within 4–24 h of injury occurred in a hospital emergency center. Among healthcare system decedents, half died in the emergency unit.ConclusionsWe identified a large burden of deaths from interpersonal violence and road traffic collisions, mostly on‐scene. In addition to primary prevention, shortening delays to care can improve mortality outcomes especially for deaths occurring within 4–24 h in emergency centers.

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Addressing Differences in Knowledge and Experience in Trauma Care Capabilities Among an International Team of Military Medical Care Providers in a Deployed Setting

Holvelinsky,

Travers,

Stierwalt

et al. 2024

Military Medicine

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Military medical personnel are crucial in providing life-saving care at the point of injury (POI) in challenging environments such as combat zones and disaster areas. This article examines the specialized training US Military medical personnel undergo before deployment and the increasing trend of deploying as part of multinational forces in operations like those in Afghanistan with NATO and non-NATO countries. Integrating medical teams from diverse backgrounds poses significant challenges in maintaining a cohesive and efficient team due to varying trauma management training standards and medical practices among the allied forces. Tactical Combat Casualty Care (TCCC) training and the development of clinical practice guidelines (CPG) by the US Joint Trauma Service have been key strategies by the US Military to standardize care. However, the variation in trauma management training among NATO allies and the differences in medical subspecialties and approaches can lead to inefficiencies and reduced effectiveness in a multinational trauma center setting. For instance, the approach to trauma care can significantly differ between the US and European countries, impacting the interoperability and teamwork in multinational medical teams. To address these challenges, the article highlights the importance of standardized medical training programs that include cultural awareness to enhance the effectiveness of multidisciplinary, multinational medical teams. It also underscores the necessity for standardized international trauma training in the face of increasing global conflicts and the potential for large-scale combat operations. The article discusses the “Trauma Tuesday” program implemented in Kabul, Afghanistan, as an example of how intensive training and simulation exercises can improve team dynamics, knowledge, and skills in trauma management among a diverse team from various nations. The need for ongoing education and developing a standard for managing trauma patients in international teams is emphasized to ensure effective communication and coordination. The article suggests that multinational trauma training can significantly improve team cohesion and critical life-saving skills, essential for future battlefields where access to definitive care may be delayed. Further research is recommended to explore the best methods for achieving effective multinational medical team integration and training standardization.

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Prolonged casualty care: Extrapolating civilian data to the military context

Cited by 7 publications

References 32 publications

Feasibility of conducting a military-relevant multicenter cohort study to assess outcomes of early trauma resuscitative interventions in a prolonged care civilian setting

Feasibility of conducting a military-relevant multicenter cohort study to assess outcomes of early trauma resuscitative interventions in a prolonged care civilian setting

Patterns of on‐scene and healthcare system trauma deaths in the Western Cape of South Africa

Addressing Differences in Knowledge and Experience in Trauma Care Capabilities Among an International Team of Military Medical Care Providers in a Deployed Setting

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