Process of care for battle casualties at Walter Reed Army Medical Center: Part I. Orthopedic surgery service

Walter Reed Army Medical Center has been a primary hub in the United States for receiving Army battle casualties from Operation Enduring Freedom and Operation Iraqi Freedom. We detail the process of care that was developed to effect the timely effective management of these casualties.     

U.S. Army disease and nonbattle injury model, refined in Afghanistan and Iraq

Previous analysis of Operation Desert Shield/Operation Desert Storm data yielded a disease and nonbattle injury (DNBI) model using distinct 95th percentile daily admission rates during the three phases of a war-fighting operation to predict medical requirements. This study refines the model with data from Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF). Inpatient health care records of U.S. Army soldiers deployed to OEF and OIF who were admitted with DNBI diagnoses were analyzed. DNBI admission rates for OEF and OIF were compared with rates for Operation Desert Shield/Operation Desert Storm. DNBI admission rates for OEF and OIF were lower than those for Operation Desert Shield/Operation Desert Storm. Rates among the phases of OIF were distinctly different. DNBI admission rates have been reduced during recent deployments. The concepts of the original model based on Operation Desert Shield/Operation Desert Storm data were validated by experiences during OEF and OIF. Continuous surveillance of DNBI admission rates is recommended.     

透视美军自杀防控工作

过去10年间,尤其是阿富汗和伊拉克战争爆发以来,美军的自杀问题日益突出,其自杀率呈持续上升趋势,为此,美国国防部和各军种采取了一系列自杀防控措施,取得了一定效果.本文对美军自杀问题现状、采取的防控措施及面临的主要挑战进行了分析,并对中国军队做好相关工作提出了若干启示.     

Combat casualty care: the Alpha Surgical Company experience during Operation Iraqi Freedom

BACKGROUND: Operation Iraqi Freedom was the first large-scale combat operation involving the U.S. Marine Corps since the Persian Gulf War in 1991. Data from a combat surgical company are presented. METHODS: Records of all U.S. and Iraqi combat casualties admitted to the surgical company were reviewed. RESULTS: Fifty-three (57%) of 93 patients suffered penetrating injuries. Most wounds were produced by high-explosive munitions (mines, hand grenades, and rocket-propelled grenades), and the majority (51%) of wounds were to the extremities. The time to surgical care averaged 4.7 hours (range, 1.5-48 hours), and 98% of the patients seen at our facility survived. CONCLUSIONS: The time from injury to surgical care was considered long by civilian standards; however, this did not appear to affect outcomes substantially. A small percentage (5.2%) of injuries were to the torso. Hypothermia was commonly present. Because of the nature of their wounds, all patients required additional surgery after evacuation to rear area facilities. The outcomes of individual patients are not known, although it is known that only one Marine died after reaching medical care and, to date, no Marines have subsequently died of their wounds.     

Hydrogen fluoride inhalation injury because of a fire suppression system

Automatic fire suppression systems (FSSs) use hydrofluorocarbons (HFCs) to chemically extinguish fires. At high temperatures, HFC can release hydrogen fluoride (HF), a toxic and potentially lethal gas. We report the deaths of three U.S. military personnel at Bagram Air Base from acute respiratory failure after the FSS in their vehicle received a direct hit from a rocket-propelled grenade. Despite presenting with little to no additional signs of trauma, these individuals all died within 24 hours from HF-induced respiratory failure. When two patients later presented with similar symptoms after damage to their vehicle's FSS, they were aggressively treated with nebulized calcium and positive pressure ventilation. Both survived. The presence of HFC-containing FSSs in military vehicles may lead to future cases of HF inhalation injury, and further research must be done to help rapidly diagnose and effectively treat this injury.     

Process of care for battle casualties at the Walter Reed Army Medical Center: Part III. Physical medicine and rehabilitation service

The Physical Medicine and Rehabilitation Service provides a critical role in the assessment, management, and disposition of the newly injured combatant. This role has been well demonstrated during Operation Enduring Freedom and Operation Iraqi Freedom. Military physiatrists are uniquely suited to support military service members as they maximize their function and either return to duty or transition to civilian life.     

Process of care for battle casualties at Walter Reed Army Medical Center: Part II. Physical therapy service

Physical therapists, physical therapy assistants, and physical therapy technicians provide care to soldiers, sailors, Marines, and airmen returning from Operation Enduring Freedom and Operation Iraqi Freedom. We describe the inpatient and outpatient services provided, the problems and solutions encountered, and the lessons learned at the beginning of the war.     

美军联合战场创伤系统的发展及应用

联合战场创伤系统是美军为了提高伊拉克和阿富汗战场上的战伤救治效果而建立的一种创伤救治系统。2004年美军开始在伊拉克战场应用该系统,2005年开始在伊拉克和阿富汗战场全面应用。本文梳理了美军联合战场创伤系统的发展历史,探讨了该系统的任务、目标及组织构成,分析了其在伊拉克和阿富汗战场上的应用效果。     

A review of 41 upper extremity war injuries and the protective gear worn during Operation Enduring Freedom and Operation Iraqi Freedom

Forty-one patients with upper extremity war injuries sustained during combat operations Operation Enduring Freedom and Operation Iraqi Freedom were reviewed to report on protective gear availability and usage at the time of injury. Participants treated at the Madigan Army Medical Center occupational therapy clinic from August 2004 until February 2005 completed a questionnaire regarding injuries sustained during deployment. Overall, 6 injuries were to upper extremity regions that were covered with issued protective gear; 21 injuries were to areas not covered with issued protective gear (i.e., participant was not wearing issued gear), and 22 injuries were to regions that were not covered because no protective gear was issued for that body area. Although this study is limited, future research would provide valuable insights about the efficacy of current body armor and the need for additional or modified gear.     

The prevalence and impact of respiratory symptoms in asthmatics and nonasthmatics during deployment

OBJECTIVE: The purpose of this study was to compare the prevalence, severity, and impact of respiratory symptoms in asthmatics and nonasthmatics during Operation Enduring Freedom and Operation Iraqi Freedom. METHODS: A survey was given to 1,250 active duty soldiers and Department of Defense contractors returning from Operation Enduring Freedom/Operation Iraqi Freedom. Subjects were asked about demographics, smoking habits, respiratory symptoms, and impact on job performance before and during deployment. Patients with a history of asthma were asked method of diagnosis, current symptoms, and asthma therapy. RESULTS: A total of 1,193 subjects returned the completed questionnaire (95% response rate). Mean age of respondents was 38 +/- 11 years, 83% (n = 977) were male, and 31% (n = 375) were past or present smokers. Sixty-one subjects (5%) reported a previous diagnosis of asthma. Both asthmatics and nonasthmatics had increased respiratory symptoms of wheezing, cough, sputum production, chest pain/tightness, and allergy symptoms during deployment compared to predeployment (p < 0.05 for all). When compared to nonasthmatics, asthmatic subjects reported more wheezing, sputum production, and chest pain/tightness during deployment (p < 0.0001, 0.05, 0.05 respectively), had more difficulty with military duties (p < 0.05), and were more likely to seek medical attention and receive duty restrictions (p < 0.0001). Twenty-six percent (n = 16) of asthmatics reported poor baseline symptom control, and this group had significantly increased symptoms, functional limitations, and health care utilization when compared to asthmatics who were symptom-controlled at baseline. CONCLUSIONS: Respiratory symptoms were common among both asthmatics and nonasthmatics during deployment. Differences in symptoms and health care utilization in this group of asthmatics were primarily due to subjects with poor baseline control.     

Assessment of changes in mental health conditions among sailors and marines during postdeployment phase

Previous research regarding the mental health ramifications of military deployments focused on the U.S. Army population. As part of its deployment health surveillance mission, Navy and Marine Corps Public Health Center conducted a study of the Department of Navy population to identify reported mental health effects associated with Operation Iraqi Freedom, describe mental health care utilization by returning service members previously deployed in support of Operation Iraqi Freedom, and examine the relationships between self-identified risks and provider referral practices. Despite a considerable number of self-reported mental health concerns, referral for mental health consultations and health care utilization were rare. The psychological well-being of service members is essential to the military's optimum functionality and operational readiness; therefore, continued research in this area has significant bearing on future force health protection efforts. Additionally, this study highlights the need for further research on deployment-related mental health concerns.     

Test-retest reliability of the Traumatic Brain Injury Screening Instrument

The Traumatic Brain Injury Screening Instrument (TBISI) was implemented in Veterans Affairs medical facilities in an attempt to identify Operation Enduring Freedom and Operation Iraqi Freedom (OEF/OIF) veterans with possible mild TBI. Despite its widespread implementation, the reliability and validity of the screening tool has not yet been established. The current study reports preliminary findings on the test-retest reliability of the TBISI in 44 OEF/OIF veterans referred for neuropsychological evaluation following a positive TBI screen. Results suggest overall poor test-retest reliability of the TBI screening tool with regard to type of event, injuries sustained, and resulting sequelae. These findings underscore the importance of further investigation of its psychometric properties to promote accurate identification and referral of veterans with possible TBI.     

Illness in a redeployed soldier

Overseas deployments place military personnel at risk for tropical diseases not typically observed on the U.S. mainland. This case describes the first reported case of brucellosis returning from Operation Enduring Freedom and Operation Iraqi Freedom. A 31-year-old infantry soldier complained of a 6-week history of headaches, relapsing fever, and constitutional symptoms since returning from Iraq. This soldier was determined to have the only reported case of brucellosis, but was one of many soldiers at risk from eating unpasteurized cheese on the local economy. Although malaria and leishmaniasis continue to be the most common deployment-related illnesses, brucellosis must also be considered in the differential of any redeployed soldier with headache, fever, and body aches. Public health as well as command elements must reinforce their role in preventing exposure to this pathogen.     

Descriptive summary of patients seen at the surgical companies during Operation Iraqi Freedom-1

The Navy-Marine Corps Combat Trauma Registry is a data repository summarizing information from data sets describing injuries sustained and treatments administered to casualties from the point of injury to rehabilitation. Among the medical facilities contributing data to the Combat Trauma Registry during Operation Iraqi Freedom were the Marine Corps forward surgical companies. The surgical companies offer resuscitative surgery, medical treatment, and temporary holding facilities, in addition to preparing patients for evacuation. This article reviews the types of patients admitted and treatments provided at the surgical companies during the major combat period of Operation Iraqi Freedom. The surgical companies saw an average of 15 to 17 patients per day during this period. Less than 20% of the U.S. casualties seen were wounded in action. In contrast, >75% of the enemy prisoner of war presentations were for battle injuries. Less than 15% of the patients were held at the facilities for >24 hours.     

Ocular diseases and nonbattle injuries seen at a tertiary care medical center during the Global War on Terrorism

We retrospectively reviewed the records of 107 U.S. military personnel referred to the Walter Reed Army Medical Center ophthalmology service with eye diseases and nonbattle injuries diagnosed during Operation Enduring Freedom and Operation Iraqi Freedom. Ocular diseases and nonbattle injuries ranged from minor to vision-threatening, represented a broad variety of conditions, and required the expertise of a number of ophthalmic subspecialists. The most common diagnoses were uveitis (13.1%), retinal detachment (11.2%), infectious keratitis (4.7%), and choroidal neovascularization (4.7%). Eighty-four patients (78.5%) met Army retention standards and were returned to duty. Twenty patients (18.7%) were referred to a medical evaluation board, seven (6.5%) of whom failed to meet retention standards for eye and vision; the retention status of three patients (2.8%) remains to be determined.     

Infectious disease case: mixed malaria infection with Plasmodium falciparum and Plasmodium vivax in a deployed service member in Afghanistan

The objective of this case report is to present an interesting case of a mixed malaria infection of Plasmodium falciparum and Plasmodium vivax in a U.S. service member deployed in support of Operation Enduring Freedom in Afghanistan and the use of rapid malaria tests with microscopy for the diagnosis of malaria and the treatment of this infection.     

Visceral leishmaniasis in a soldier returning from Operation Enduring Freedom

This report presents a case of visceral leishmaniasis in a soldier returning from Operation Enduring Freedom. During the United States' last major military conflict, Operation Desert Storm, the diagnosis of multiple cases of visceral leishmaniasis led to policy changes, including a temporary ban on troop blood donation. This case demonstrates the applicability of recently developed Leishmania polymerase chain reaction and serological assays when conventional methods of diagnosis, such as tissue microscopy and culture, fail.     

Postdeployment health care for returning OEF/OIF military personnel and their social networks: a qualitative approach

Little is known regarding the health care needs of Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) deployed veterans seeking care outside of Veterans Affairs facilities. Responding to this gap, we conducted a mixed methods study of postdeployment health among veterans and members of their social networks in six community-based primary care clinics. A total of 347 patients completed a survey dealing with deployment to Iraq/Afghanistan (whether their own or that of a family member, friend, or coworker), and subsequent psychosocial and health problems. A subset of 52 participants responded to an open-ended question requesting additional information about experiences during and postdeployment. Content analysis of these responses revealed five overarching themes: connectedness, perceptions of conflict, consequences of deployment, health and treatment concerns, and respect and concern for service members/veterans. These data point to significant deployment-related disruptions in the well-being of service members and those in their broader social networks, with implications for defining service needs in community health settings.     

Deployment risk factors and postdeployment health profiles associated with traumatic brain injury in heavy drinking veterans

Along with post-traumatic stress disorder (PTSD), mild traumatic brain injury (mTBI) is considered one of the "signature wounds" of combat operations in Iraq (Operation Iraqi Freedom [OIF]) and Afghanistan (Operation Enduring Freedom [OEF]), but the role of mTBI in the clinical profiles of Veterans with other comorbid forms of post-deployment psychopathology is poorly understood. The current study explored the deployment risk and postdeployment health profiles of heavy drinking OIF and OEF Veterans as a function of mTBI. Sixty-nine heavy-drinking OIF/OEF Veterans were recruited through a Veterans' Affairs Medical Center and completed questionnaires and structured interviews assessing war-zone experiences, postdeployment drinking patterns, and PTSD symptoms. Veterans with positive mTBI screens and confirmed mTBI diagnoses endorsed higher rates of combat experiences, including direct and indirect killing, and met criteria for PTSD at a higher rate than Veterans without a history of mTBI. Both PTSD and combat experiences independently predicted screening positive for mTBI, whereas only combat experiences predicted receiving a confirmed mTBI diagnosis. mTBI was not associated with any dimension of alcohol use. These results support a growing body of literature linking mTBI with PTSD.