Fundamentals of Frontline Surgery

Mansoor Khan, David Nott, Mansoor Khan, David Nott, Mansoor Ali Khan, Mansoor Ali Khan

• Publisher: CRC Press
• Year: 2021
• Print ISBN: 9780367437497
• eBook ISBN: 9781000341355
• Edition: 1
• Topic: Medicine
• Subtopic: Diseases & Allergies

Fundamentals of Frontline Surgery is an easy to read text, written by world class faculty, that provides clinicians with succinct and didactic information about what to do in high intensity, resource limited situations.With global conflicts and humanitarian emergencies on the rise, there has been a dramatic uptake in the number of volunteers for both military and humanitarian operations. This manual aids best practice and fast decision making in the field.

The Resource-Limited Environment

1

Mansoor Khan and David Nott

Introduction

There has been significant change in injury patterns of conflict over the last 100 years. In the initial Great War (World War I), there was a high burden of penetrating trauma from ballistic weaponry. Subsequently, the Second World War saw a rise in both blast and ballistic injury, the former occurring in maritime forces and the latter predominately in combat infantry units.

With the evolution of weaponry, defensive strategies also improved, especially in the advent of modern armour. There were significant number of torso injuries in the Korean and Vietnam conflicts, whereas, with the evolution of body armour, the injury pattern changed in the Iraq and Afghanistan conflicts to target junctional regions – neck, axillae, and groins.

The most recent conflicts in Iraq and Afghanistan have led to the widespread adoption of Improvised Explosive Devices (IEDs). These low-cost, easy-to-produce-and-distribute explosives have established themselves as ‘territory depriver’ and ‘fear’ weapons of choice by those who utilise them.

It is important to note that frontline surgery does not just refer to conflicts, but also surgical responses to humanitarian disasters. These, invariably by the time surgical facilities have been established, are not for the management of acute waves of injuries but rather for managing humanitarian and second waves of debridement and corrective surgeries. In these environments, particularly outside military evacuation chains, individuals with a high burden of injury invariably fail to survive in definitive care. The application point of wounding limb tourniquets has undisputedly led to substantial gains in casualty survival. Patients who survive require a spectrum of surgical care seldom in the skill set of a single surgeon. Humanitarian disaster relief, particularly from a surgical perspective, has a high burden of obstetric care.

What Makes Conflict or Disaster Surgery Different?

There are multiple, noticeable differences between conflict/military/humanitarian surgery when compared with normal civilian practice. Even within the conflict and disaster setting, there are different levels of care available compounded by hostilities, availability of resources, location of the conflict, manpower, and skill set availability. All of these factors greatly influence the capability of care available and, in some circumstances, rationalisation of healthcare with organisational and governmental matrices. The phrases ‘austere’ and ‘resource-limited’ are not interchangeable and, although sometimes interdependent, carry significantly different meanings.

Hostilities play a factor in terms of not only personal safety but also logistical supply lines. One of the greatest reasons for the survival of casualties is the evacuation chain and timeline. The vast majority of casualties during the conflicts in Iraq and Afghanistan reached definitive care in under one hour from time of injury. The greatest reason for this was air superiority; if the airspace isn’t controlled, then this would not be a viable option. Humanitarian disasters, such as volcanic eruptions and severe weather, would invariably prevent an air evacuation chain and, needless to say, would compound the problems experienced by ground evacuation. Therefore, without air evacuation and air replenishment, a relatively well-stocked facility has the potential to become resource-limited.

An austere medical facility is not necessarily resource-limited. For example, Camp Bastion, although present in an austere environment, had all of the facilities – including the manpower of a fully functioning Westernised hospital. On the other hand, there are also many locations in the world where a Forward Surgical Team or a Non-Governmental Organisation Hospital facility is located in an austere setting with limited resources.

The level of facility and care available also plays a significant role in casualty management. The principles of damage control are often applied to allow transfer of patients between ‘roles’ or ‘echelons’ of care.

Echelons and Roles of Medical Support

The term ‘role’ or ‘echelon’ is used to describe the different levels of medical support in deployed operations. Different nations and armed forces will have differing notations to describe these roles/echelons, but they universally have the same definitions (Figure 1.1):

• Role 1 – Combat Medical Support provides medical care for routine primary care ailments and point of injury care for injured personnel, dealing with the CABC paradigm (Catastrophic bleed, Airway, Breathing, and Circulation). This is usually a key component in all forward-deploying military units, allowing for control of most compressible haemorrhage sites.

• Role 2 – Forward surgical team provides a significantly higher level of care than Role 1 and is able to manage non-compressible torso haemorrhage (NCTH). It has the ability to provide damage control resuscitation and damage control surgery, allowing casualties to have immediate, life-threatening haemorrhage control before onward transfer. In certain circumstances, it may also offer a holding facility for casualties.

• Role 3 – Combat Support Hospital provides a significantly resourced facility in terms of specialities (determined by medical intelligence prior to deployment), diagnostics, and overall resources. In the last two decades, these have evolved into hardstanding facilities established for medium- to long-term missions.

• Role 4 – Repatriated Definitive Care Facility is usually located in the home country, or outside the conflict zone, of an allied nation. It provides the complete range of facilities and care that are unsuitable to deploy in conflict zones.

Figure 1.1 Roles of care.

There are no defined echelons or roles of care in a humanitarian environment; the two broad categories that can be applied are immediate stabilisation and onward surgical care – in effect similar to Role 2 and Role 3 or Role 4 in the military setting.

Evacuation Chain Between Roles or Echelons of Care

The injured has to transfer from one role to another to receive subsequent levels of care. They are usually managed in Role 1 by a Combat Medic and then transported either by vehicle or foot to the First Aid Post. From this point, they are transferred to a Role 2 facility by vehicle or an aeromedical asset. This usually occurs within the first hour of injury.

Once the patient has been stabilised and life-threatening injuries have been contained, he or she is transferred by aeromedical assets to Role 3; this can occur on the first 72 hours, depending on the operational environment. Subsequent transfer from Role 3 to Role 4 is taken as required but can be anywhere over 72 hours post-arrival.

For the patient to be transferred, a number of conditions need to be met:

• The patient must be physiologically stable for transfer;

• The patient’s airway must be patent without danger of compromise;

• All access and tubing must be secured;

• A thorough CABC assessment should be made to identify any life-threatening injuries and treated prior to transfer (i.e. thoracotomies); and

• Patient should have protective measures against hypothermia implemented.

Humanitarian or Conflict Response Categories

The following classifications are based on the authors’ experience and, to their knowledge, there are no similar references in literature. These classifications are borne of necessity, and arbitrarily, but they will help understand the different scenarios conflict and humanitarian surgeons may find themselves in. In general, the situations faced in humanitarian work can be broadly divided into five categories:

1. High public financing

2. Developed country

3. Lesser developed country

4. Non-state actors, guerrilla groups

5. Natural disaster, earthquake, and tsunami

The first category, involving high public financing, is exemplified by the Defence Medical Services response within Afghanistan. This was a highly funded multinational campaign which had arguably the best trauma hospital and prehospital facilities in the world.

An example of a developed country conflict would be that of the Libyan conflict in 2011. The environment is tagged as a warzone with unsafe infrastructure – difficult to enter and exit. The amenities are not reliable; there is depletion in manpower and an unreliable logistics chain.

The third category is still in a warzone but involves a lesser developed country, Yemen being a prime example. Much like Libya, entry and exit from the country is extremely difficult. There are comparable problems to that of Libya in 2011, but the general infrastructure and development of resources within the country are substantially less than those displayed by countries in Category 2.

Non-state actors and guerilla groups make up Category 4. Again, a warzone, but with several factions fighting for power. Invariably, there is an absence of a supply chain and logistical support, with depleted manpower and no facilities for transfer. This is without a doubt a resource-limited environment, usually in an extremely austere setting.

Category 5 can occur in a relatively well-developed country but, due to the nature of the event, can leave the region devastated. Initial entry may have to be via rotary-wing platforms, as runways and ports may be made inaccessible. Invariably, there will be a complete loss of infrastructure with no electricity supply or running water. The supply chains will take at least 7–10 days to establish. The major cause of morbidity after the first 24–48 hours is the lack of sanitation and potable water sup...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Dedication
• Contents
• Forewords
• Preface
• Editors
• Contributors
• 1 The Resource-Limited Environment
• 2 Patterns of Injury
• 3 Damage Control Resuscitation
• 4 No Blood … What to Do?
• 5 Point-of-Care Ultrasound
• 6 Thoracic Injury Management
• 7 Junctional and Extremity Vascular Trauma
• 8 Trauma Laparotomy and Damage Control Laparotomy
• 9 Damage Control for Severe Pelvic Haemorrhage in Trauma
• 10 Abdominal Injuries
• 11 Acute Care Emergency Surgery
• 12 Frontline Consideration for Paediatric Emergency and Trauma Surgery
• 13 RLE Orthopaedic Injury Management
• 14 Neurotrauma in the Field
• 15 Management of Ballistic Face and Neck Trauma in an Austere Setting
• 16 Management of Ophthalmic Injuries by the Forward Surgical Team
• 17 Resource-Limited Environment Plastic Surgery
• 18 Acute Acoustic Trauma and Blast-Related Hearing Loss
• 19 Obstetrics in Limited-Resource Settings
• Index