Utility of ultrasound in the combat theater: experiences of a gynecologist during Operation Iraqi Freedom/Operation Enduring Freedom

OBJECTIVE: The purpose of this study was to evaluate the utility of ultrasound in a combat theater. METHODS: A retrospective review of gynecology visits was evaluated at Camp Doha, Kuwait, from August 2003 through April 2004. Of the 1,737 visits, 237 required pelvic ultrasound. Demographic information, as well as the indications, diagnosis, and disposition of the patients, was compiled. RESULTS: The average age of the patient requiring ultrasound was 28 +/- 8 years. The primary presenting complaint was pelvic pain. Forty percent with pelvic pain had no identifiable cause. The most common final diagnosis was pregnancy. Of the 237 visits, the use of ultrasound resulted in 136 return-to-duty dispositions. Of the 31% who were administratively redeployed, the majority were secondary to pregnancy. CONCLUSION: Gynecologic ultrasound was found to be a very useful tool in the combat theater. Ultrasound resulted in improved diagnostic ability and enhanced reassurance to both provider and patient.     

美军伊拉克和阿富汗战争战伤救治新理念

“战术战伤救治”的概念最早由美海军特种作战部队于1996年首次提出,在伊拉克和阿富汗战争中成为美军战术环境中伤员救治的标准规范,也是美军伊拉克和阿富汗战争中战伤救治取得的一大进展.战术战伤救治的应用使美军达到了有史以来最低的伤亡率.该文梳理了美军战术战伤救治理念的发展,分析了战术战伤救治的阶段划分,探讨了美军战术战伤救治的组织实施,并提出了对我军的启示.     

Orthopedic injuries during Operation Enduring Freedom

Orthopedic injuries comprise a majority of combat injuries seen in recent U.S. military conflicts. Interventions in the forward deployed area have played an important role in improving mortality rates of soldiers as well as outcome at a medical center level. A retrospective review was conducted on orthopedic injuries from Operation Enduring Freedom evaluated at Walter Reed Army Medical Center (WRAMC). Patients were grouped into one of five injury categories (open fracture, amputation, arterial injuries, neurological injuries, and soft tissue injury) with evacuation time (days from time of injury to arrival at WRAMC) and procedures performed before arrival at WRAMC evaluated. The average evacuation time for all orthopedic casualties was 7.9 days. There was an average of 2.6 procedures performed per patient before arrival at WRAMC. There was no difference in evacuation time among the injury groups. Those with only soft tissue injuries underwent fewer procedures than the other injury groups; however, there was no difference among the injury groups in terms of procedures performed. The number of procedures performed did not affect the evacuation time. Fifty-six percent of casualties required operative intervention after arrival at WRAMC. With the unavoidable evacuation time that all casualties must endure regardless of severity of the injury, early operative intervention in forward deployed medical assets, such as the forward surgical team and combat support hospital, remains a necessity for rehabilitative and reconstructive efforts of the soldiers at the medical center level.     

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.     

Review of non-battle injuries in Air Force personnel deployed in support of Operation Enduring Freedom and Operation Iraqi Freedom

This study examines non-battle injuries among U.S. Air Force members deployed during Operations Iraqi and Enduring Freedom. A cohort of 275,843 Active Duty, Guard, and Reserve members were identified for the period September 11, 2001 through October 31, 2006. Data on injuries were obtained from electronic medical records and deployment time was obtained from manpower records. Poisson regression was used to estimate adjusted incidence rate ratios (IRRs). The most common non-battle injuries were sprains and strains (53%) followed by open wounds (27%). Guard and Reserve members tended to have a lower rate of orthopedic non-battle injuries than Active Duty members in crude analyses and after adjustment for age, previous deployment, sex, race/ethnicity, and occupation (IRR = 0.95; 95% CI = 0.89-1.02 and IRR = 0.85; 95% CI = 0.77-0.93). Results from this study are intended to facilitate further research of potential differences between Air Force components to reduce non-battle injuries in a deployed environment.     

Effects of transcendental meditation in veterans of Operation Enduring Freedom and Operation Iraqi Freedom with posttraumatic stress disorder: a pilot study

We conducted an uncontrolled pilot study to determine whether transcendental meditation (TM) might be helpful in treating veterans from Operation Enduring Freedom or Operation Iraqi Freedom with combat-related posttraumatic stress disorder (PTSD). Five veterans were trained in the technique and followed for 12 weeks. All subjects improved on the primary outcome measure, the Clinician Administered PTSD Scale (mean change score, 31.4; p = 0.02; df = 4). Significant improvements were also observed for 3 secondary outcome measures: Clinician's Global Inventory-Severity (mean change score, 1.60; p < 0.04; df = 4), Quality of Life Enjoyment and Satisfaction Questionnaire (mean change score, -13.00; p < 0.01; df = 4), and the PTSD Checklist-Military Version (mean change score, 24.00; p < 0.02; df = 4). TM may have helped to alleviate symptoms of PTSD and improve quality of life in this small group of veterans. Larger, placebo-controlled studies should be undertaken to further determine the efficacy of TM in this population.     

The 274th Forward Surgical Team experience during Operation Enduring Freedom

The 274th Forward Surgical Team (FST) was deployed in support of Operation Enduring Freedom from October 14, 2001 to May 8, 2002. During this period, the FST was asked to perform many nondoctrinal missions. The FST was tasked with functioning as a mini-combat support hospital during the earlier phases of Operation Enduring Freedom, performing in-flight surgical procedures and resuscitation of combat wounded, conducting split operations with surgical coverage of both Karshi and Khanabad, Uzbekistan, and Bagram, Afghanistan, and leading the multinational medical coalition assembled for Operation Anaconda and other combat operations staged from Bagram. Overall, the 274th FST took care of approximately 90% of U.S. combat casualties during this period and treated a total of 221 combat casualties. The FST treated 103 total surgical cases, including 73 with combat wounds. At the time, this experience with combat casualties and the surgical care of combat wounds was the largest since the Persian Gulf War. More importantly, this account describes the flow, frequency, and type of combat casualties seen in a low-intensity conflict like that being waged currently in Afghanistan. It is hoped that this depiction will aid in the preparation, equipping, and overall utilization of surgical assets in similar future conflicts.     

Air medical evacuations of soldiers due to oral-facial disease and injuries, Operations Enduring Freedom/Iraqi Freedom

This retrospective study was conducted to assess the nature and causes of serious oral-facial illnesses and injuries among U.S. Army personnel deployed to Iraq and Afghanistan in 2003 and 2004. Information for this study came from the U.S. Air Force Transportation Regulating and Command & Control Evacuation System database for medical evacuations (MEDEVACS) for 2003 to 2004. The study found 327 oral-facial MEDEVACS out of Iraq (cumulative incidence: 11/10,000 soldiers per year) and 47 out of Afghanistan (cumulative incidence: 21/10,000 soldiers per year), for a total of 374 MEDEVACS. Forty-two percent (n = 158) of all oral-facial MEDEVACS were due to diseases of the oral cavity, salivary glands, and jaw. Another 36% (n = 136) of oral-facial MEDEVACS were for battle injuries, primarily fractures of the mandible, caused by acts of war. Twenty-one percent (n = 80) of oral-facial MEDEVACS were due to nonbattle injuries, primarily fractures of the mandible, mainly caused by motor vehicle accidents and fighting.     

Drowning deaths of U.S. Service personnel associated with motor vehicle accidents occurring in Operation Iraqi Freedom and Operation Enduring Freedom, 2003-2005

OBJECTIVE: We examined common factors in vehicular drowning deaths that might lead to changes in equipment or training. METHODS: Drowning deaths among service members deployed to Operations Iraqi Freedom or Enduring Freedom, 2003 to 2005, were ascertained using the Armed Forces Medical Examiner Tracking System database. Cases were linked to Army and Navy safety and investigative files. RESULTS: Fifty-two cases of vehicular drowning deaths were identified. These occurred mostly at night, were almost always the result of a rollover, and were most frequently associated with a high-mobility medium-weight vehicle. Seat belts were rarely worn, but the majority of injuries should not have been severe enough to affect egress from the vehicle. These drowning deaths seldom occurred while engaged with the enemy and were rarely associated with bad road conditions or bad weather. CONCLUSIONS: Effective preventive strategies might focus on training and equipment to reduce rollover events and on the expeditious extrication of victims.     

Use of surgisis for abdominal wall reconstruction/closure in battlefield casualties during Operation Iraqi Freedom

A case series and discussion based on experiences gained during Operation Iraqi Freedom are presented. The Army previously published an article on the use of Gore-Tex mesh in the staged closure of open abdominal wounds. We thought that use of a biomaterial could shorten the overall course of abdominal closure and improve outcomes. This is mainly a "proof of concept" type of study. Although class I data are not presented, a useful concept is discussed. To our knowledge, no other report of the use of biomaterials for battle casualties has been published. Several issues that are faced by the military medical system are presented. The use of Surgisis (lyophilized porcine small intestinal submucosa; Cook Biotech, West Lafayette, Indiana) in the described setting is presented as one possible solution.     

Dental satisfaction survey at an expeditionary dental clinic in support of Operations Enduring Freedom and Iraqi Freedom

This study used a survey to gather information about soldiers' perceptions of the quality of dental treatment delivered at a deployed clinic. An ordinal scale of 1 through 5 scored access, dental facility and equipment, pain control, technical skill, and interpersonal skills of the provider. Four additional items identified whether the respondent was new to military or deployment dentistry, was in pain before arriving at the clinic, or had any concerns about being treated at a deployed dental clinic. Percentages for each type of response were recorded. Data were further analyzed by the Mann-Whitney U test to investigate the relationship between respondent variables and how they rated the attributes of quality. Deployed service members reported a high degree of satisfaction with the quality of care they received. Ninety-seven percent of respondents believed that the care they received was as good as the care they would have received at their regular stateside military dental facility.     

Preventive medicine in Task Force 1st Armored Division during Operation Iraqi Freedom

Task Force 1st Armored Division (TF1AD) deployed to Baghdad and South Central Iraq from April 2003 through July 2004. TF1AD preventive medicine had responsibility for ensuring divisional force health protection, including soldier health, disease and nonbattle injury mitigation, health promotion, and civil affairs operations. Heat injury, diarrheal disease, skin and respiratory disease, and eye and musculoskeletal injury rates were high. Command emphasis and preventive medicine action resulted in better living conditions and personal sanitation. To counter the threat, the TF1AD preventive medicine/ division surgeon team used a "spiraling out" approach that focused attention first on hand-washing, potable water, vector control, waste disposal, and food sanitation and later on noise, asbestos, environmental contamination, and radiation. In April 2004, TF1AD shifted focus to the Multinational Division Central-South region of Iraq and many similar problems occurred as in May 2003, although they were less severe, in part because of the lessons learned in Baghdad.     

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.     

Anesthesia services aboard USNS COMFORT (T-AH-20) during Operation Iraqi Freedom

USNS COMFORT (T-AH-20), the only U.S. hospital ship to be deployed in support of combat operations during Operation Iraqi Freedom, sailed from Baltimore, Maryland, on January 6, 2003, and returned on June 12, 2003. During the course of her deployment, 648 anesthetic procedures were performed. We describe the anesthesia services provided, lessons learned, and recommendations for future concepts of employment.     

Spectrum of care provided at an echelon II Medical Unit during Operation Iraqi Freedom

We describe the types of medical problems encountered at a U.S. Army echelon II medical facility during Operation Iraqi Freedom in the period after completion of major ground combat operations, a time of nation restructuring and intermittent, intense, armed conflict. A total of 4,831 patients were assessed between October 1, 2003 and June 30, 2004, 74% with disease and nonbattle injury presentations, 19% with dental complaints, and 7% wounded in action (WIA). Disease and nonbattle injury evaluations were predominantly musculoskeletal. Improvised explosive devices or mortars caused 78% of the WIA casualties. The most frequent dental evaluations were for restorations (47%). Thirty-eight individuals were admitted to holding beds, most commonly to receive intravenous antibiotic treatment for cellulitis (29%). Three hundred forty-one individuals were evacuated, including 150 WIA. Determining the types of casualties seen at forward echelons of medical care during different phases of conflict can aid medical planning and help predict the type of medical resources required.     

The U.S. Navy's forward resuscitative surgery system during Operation Iraqi Freedom

The forward resuscitative surgery system (FRSS) is the Navy's most forward-deployed echelon II medical unit. Between March and August 2003, six FRSS teams were deployed in support of Operation Iraqi Freedom (OIF). During the combat phase of OIF (March 21 to May 1, 2003), a total of 34 Marine Corps and 62 Iraqi patients underwent treatment at a FRSS. FRSS teams were assigned two distinct missions; "forward" FRSS teams operated with combat service support elements in direct support of regimental combat teams, and "jump" FRSS teams served as a forward element of a surgical company. This article presents the experiences of the FRSS teams in OIF, including a discussion of time to presentation from wounding, time to operation, time to evacuation, and lessons learned from the deployment of the FRSS.     

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.