The Golden Hour: in Modern Combat Trauma: Different Battlefields, Same Problems
Matthew J. Martin, MD, FACS, Trauma Medical Director, Associate Residency Director, Madigan Army Medical Center, Tacoma, Washington, matthew.martin1@us.army.mil
Moderator: George Velmahos, MD, PhD, Professor of Surgery at Harvard Medical School and the Chief of the Division of Trauma, Emergency Surgery, and Surgical Critical Care at the Massachusetts General Hospital; CIMIT Program Leader, Trauma & Casualty Care
One of the few benefits of combat operations throughout history has been the significant advances realized in medical and surgical care of war casualties. In the current theater of operations in Iraq and Afghanistan, the United States has successfully projected a modern and robust system for the evacuation and acute care of wounded soldiers and civilians. This has been coupled with a research and administrative infrastructure capable of real-time data collection, analysis, and feedback to implement continuous quality-improvement measures at all levels of care. Matthew Martin will focus on two of the most pressing current issues in early combat casualty care: 1) The collection and transmission forward of prehospital medical data, and 2) New approaches to the early management of the bleeding patient.
The majority of combat-related fatalities occur prior to arrival at a level II or III facility (surgical capability), and are most commonly due to uncontrolled hemorrhage, head injury, or airway compromise. Although there has been significant improvement in controlling compressible extremity hemorrhage, the management of non-compressible (truncal) hemorrhage continues to represent an unsolved and often fatal problem. In addition, significant morbidity and late mortality among those who survive their initial injury may be attributed to problems in point-of-injury and pre-hospital care. A full exploration and analysis of these critical issues is hampered by the paucity of available data from the pre-hospital environment. Data collection in a chaotic and dangerous battlefield environment is hindered by a variety of situational factors and technical impediments.
Care in the "golden hour" is particularly critical in these most-severely injured patients. Robust and reliable data regarding the epidemiology, mechanisms, timing, physiologic response, and treatments for these injuries from the pre-hospital setting must be collected and analyzed in order to guide systematic approaches to improving outcomes. This will most likely require the development of new technology for more user-friendly and automated noninvasive patient monitoring and data collection equipment. Similarly, improving the early management of the patient with ongoing non-compressible hemorrhage will require new technology and novel approaches to metabolic and physiologic manipulation in an austere environment. Cooperation and coordination between experts from a wide variety of medical and non-medical disciplines to provide focused solutions is critically needed.
Continuity of Combat Casualty Care: The Case for Immediate Technological Improvement
David
King, MD, MAJ, MC, USAR,
Attending Trauma Surgeon, Attending Emergency General Surgeon, Attending
Intensive Care Surgeon and Clinical Instructor in Surgery, Massachusetts
General Hospital, Harvard Medical School, dking3@partners.org
Moderator: Marc de Moya, MD,
Surgeon, Division of Trauma, Emergency Surgery and Surgical Critical
Care; Associate Director of Advanced Trauma Operative Management; Attending
Surgeon, Surgical Intensive Care Unit; Medical Director, Trauma and
ER Surgical Nurse Practitioner Program - Massachusetts General Hospital;
Assistant Professor of Surgery, Harvard Medical School, mdemoya@partners.org
Surgical care of combat casualties remains extremely challenging. Often, complex non-standard operative interventions are carried out at far-forward low-echelon units in order to preserve life and limb. Paper medical records are commonly and routinely lost during multiple aero-medical transports within theater. Currently, there is no reliable effective mechanism in place to transmit critical patient care information as patients are evacuated through the lower levels of the military medical system. It is common for a patient to undergo multiple unnecessary operations, interventions, and imaging studies for lack of available historical clinical information. A new medical data collection system must be created which is reliable, reusable, and intrinsic to the patient, such that separation is exceedingly unlikely or impossible.
