Date post: | 24-Dec-2014 |
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Health & Medicine |
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Why?
●A short history of military medicine–Changing battlefields–EBM, Better data sets–Save before you can fix–Resource constraints●Drive to more efficient care●Reduce Longterm dependancy
Goal
To perform the correct intervention at the correct time in the continuum of Care to improve survival and reduce morbidity.
In other words, a medically correct intervention performed at the wrong time in the military continuum of care may lead to further casualties or worse outcomes
Factors influencing combat casualty care
●Enemy Fire●Medical Equipment Limitations●Widely Variable Evacuation Time●Tyranny of numbers
Principles of TCCC
• The three goals of Tactical Combat Casualty Care (TCCC) are:
–1. Save preventable deaths
–2. Prevent additional casualties
–3. Complete the mission
Development
PhysiologyOf trauma
Principles oftrauma care
Risk tolerance
Principles ofTCCC
Trauma registry
Carepathway
HowCONCEPT OF CARE Date : Version : 001
SELECT
MD 717 release policy
ENHANCE
REHAB PATHWAY
MONITOR
PREVENTPROTECT
ANALYSE
INCIDENT
REVIEW BOARD
REVISED Conditions of
Service
MAJOR PATHWAY
Minorpathway
RELEASE MANAGEMENT
RESIDUAL LIABILITY
Mitigateinnovate
Selection standards policyAppeal policyWaiver policyComplaints policy
Complex case policy
MD 715 Medical release policy
VANZ attributable policyNon VANZ attributable policyWelfare support policy
Revised conditions of service policy
Medical Review Board policy
Release process Instruction
Rehabilitation Policy
Acute incident management policiesPIP policy
Minor Health Intervention policy
Release Management policy
Physical conditioning policyMental conditioning policyPerformance aids policyHealth promotion policy
Health Risk assessment policy
Health Research policy
Health StandardsOSH policy
Health reporting policy
Forensics
Improvisation
Mid tour christmas Party
Parasitology
Ground Ambulance
MASH
WHO?
●Changing patient–The 90/10 rule●WW1 90% mil 10% Civ, ●OIF/OEF 90% Civ 10% Mil
●Historically 90% non battle casualties (disease predominantly)●Modern conflicts 90% battle casualties
Monthly Admissions by Facility
Bagram Kandahar Bastion Dwyer0
50
100
150
200
250
300
350 Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
04/10/2023 8Right Patient, Right Care, Right Place, Right Time
OEF Total Trauma AdmissionsBattle vs. Non-Battle Injury
Apr-10
May
-10Jun-10
Jul-10
Aug-10
Sep-10
Oct-10
Nov-10
Dec-10
Jan-11
Feb-11
Mar-
110
100200300400500600700800900
1000
385
572725 743 722
627 589477
348 348 302448
126
93
120 117 111
8783
110
126 130114
150
Battle vs. Non-Battle Injury – 1 Year
Series3 Non-Battle (25%)
04/10/2023 12Right Patient, Right Care, Right Place, Right Time
How - Cause of InjuryMar 2011
148
10
23
6
249
717
2 14
63
9 44 Bullet/GSW/Firearm
Burn
Fall
Hand Grenade
IED
Knife/Other Sharp Object
Machinery/Equipment
Mine/Landmine
Mortar/Rocket/Artillery Shell
MVC
RPG
Other
04/10/2023 36Right Patient, Right Care, Right Place, Right Time
*Includes both battle and non-battle injury
Trauma and The Lethal Triad
Acidosis Hypothermia
Coagulopathy
Death
Brohi, K, et al. J Trauma, 2003.
Combat Deaths
•KIA: 31% Penetrating head trauma•KIA: 25% Surgically uncorrectable torso trauma•KIA: 10% Potentially surgically correctable trauma•KIA: 9% Hemorrhage from extremity wounds•KIA: 7% Mutilating blast trauma•KIA: 5% Tension pneumothorax•KIA: 1% Airway problems•12% Mostly from infections and complications of shock
PREVENTABLE CAUSES OF COMBAT DEATH
•60% Hemorrhage from extremity wounds
•33% Tension pneumothorax
•6% Airway obstruction e.g., maxillofacial trauma
•* Data is extrapolated from Vietnam to present day Iraq and Afghanistan
Survival80% survive
70% survive at 1 hour
60% survive to 24 hours
50% survive to 72 hours
20% die immediately
10% die over the first hour – Hg/Airway\
Further 10% die by 6 hours – lethal triad
10% die over the next 48 hours – lethal triad and late complications
Summary
• There are three categories of casualties on the battlefield:
1. Operators who will live regardless
2. Operators who will die regardless
3. Operators who will die from preventable deaths unless there is intervention
• Target the intervention to the mechanism and time window
CMAST 43
Injury severity
OEF Shock on Admission (BD > 5)
OEF0
20
40
60
80
100
120
140Apr-10
May-10
Jun-10
Jul-10
Aug-10
Sep-10
Oct-10
Nov-10
Dec-10
Jan-11
Feb-11
Mar-11
13.3% of total OEF admissions
04/10/2023
18
Right Patient, Right Care, Right Place, Right Time
1-Year’s Data: Apr 10– Mar 11
OEF HypothermiaBreakdown
US Mil-itary
Coalition All Others
0
5
10
15
20
25
30
35
40
7
2
27
Admission Temperature < 96 F or < 35.5 C
Oct-10
Nov-10
Dec-10
Jan-11
Feb-11
Mar-11
1% of all US admissions
.3% of all Coalition admissions
04/10/2023 17Right Patient, Right Care, Right Place, Right Time
4.5% of all Others admissions
OEF TotalCasualties Requiring
Blood
Apr-10
May-10
Jun-10
Jul-1
0
Aug-10
Sep-10
Oct-10
Nov-10
Dec-10
Jan-11
Feb-11
Mar-1
10
20
40
60
80
100
120
140 (2050/7758= 26.4%)
US Mil 32% (N=663)
Coalition 11% (N=225)
Others 57% (N=1161)
Num
ber o
f Adm
issi
ons
04/10/2023 20Right Patient, Right Care, Right Place, Right Time
Massive Transfusion Component Therapy
PRBC FFP Platelets Cryo RBC Age0
5
10
15
20
25
30
18.2 18.7
3.2 3.1
21
Mar 2011 MT Patients (N= 49)
Mean # units trans-fused
Mean RBC Age
Platelets: 1 unit = 6 pk plts
04/10/2023 25Right Patient, Right Care, Right Place, Right Time
Total Units FWB: 0Doses of Factor VII: 1 (Level III Only)
OEF Level III Massive Transfusion
Survival
2nd Qtr 10 3nd Qtr 10 4th Qtr 10 1st Qtr 11 0
20
40
60
80
100
120
140
70%
75%
80%
85%
90%
95%
100%
# Massive Transfusions % Survival
# M
as
siv
e T
ran
sfu
sio
ns
% S
urv
iva
l
04/10/2023 23Right Patient, Right Care, Right Place, Right Time
OEF Massive Transfusion Survival Long Term US Military Only
2nd Qtr 10 3rd Qtr 10 4th Qtr 10 1st Qtr 11 0
10
20
30
40
50
60
70
70%
75%
80%
85%
90%
95%
100%
# Massive Transfusions % Survival
# M
as
siv
e T
ran
sfu
sio
ns
% S
urv
iva
l
04/10/2023 18Right Patient, Right Care, Right Place, Right Time
OEF Massive Transfusion Survival Long Term Coalition Only
2nd Qtr 10 3rd Qtr 10 4th Qtr 10 1st Qtr 11 0
10
20
30
40
50
60
70
70%
75%
80%
85%
90%
95%
100%
# Massive Transfusions % Survival
# M
as
siv
e T
ran
sfu
sio
ns
% S
urv
iva
l
04/10/2023 24Right Patient, Right Care, Right Place, Right Time
More Complicated Than Anticipated – Acute Coagulopathy of Trauma Shock
25% of trauma patients present coagulopathic
WHERE
Platform agnostic
When is crucial to outcome, where is not.
Putting it all together
Concept of Medical Support
FAST
FIX 6 – 24 hours 80%
STABILISE 1 Hour 3% surgical
RESUSCITATE 15 Minutes 100%
SAVE 5 Minutes 100%
Fd HospFSSD
FASTBuddy Aid
CLS
Point of injury
Forward casualty Circulation
Rear casualty Circulation
17% Return to duty 72 hours
SMART
Questions?