64 results on '"Stockinger ZT"'
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2. An Analysis of Head and Neck Surgical Workload During Recent Combat Operations From 2002 to 2016.
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Stern CA, Glaser JJ, Stockinger ZT, and Gurney JM
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- Humans, Retrospective Studies, United States, Iraq War, 2003-2011, Craniocerebral Trauma surgery, Craniocerebral Trauma epidemiology, Military Personnel statistics & numerical data, Neck Injuries surgery, Neck Injuries epidemiology, Registries statistics & numerical data, Male, Adult, Workload statistics & numerical data, Workload standards, Afghan Campaign 2001-
- Abstract
Introduction: In battle-injured U.S. service members, head and neck (H&N) injuries have been documented in 29% who were treated for wounds in deployed locations and 21% who were evacuated to a Role 4 MTF. The purpose of this study is to examine the H&N surgical workload at deployed U.S. military facilities in Iraq and Afghanistan in order to inform training, needed proficiency, and MTF manning., Materials and Methods: A retrospective analysis of the DoD Trauma Registry was performed for all Role 2 and Role 3 MTFs, from January 2002 to May 2016; 385 ICD-9 CM procedure codes were identified as H&N surgical procedures and were stratified into eight categories. For the purposes of this analysis, H&N procedures included dental, ophthalmologic, airway, ear, face, mandible maxilla, neck, and oral injuries. Traumatic brain injuries and vascular injuries to the neck were excluded., Results: A total of 15,620 H&N surgical procedures were identified at Role 2 and Role 3 MTFs. The majority of H&N surgical procedures (14,703, 94.14%) were reported at Role 3 facilities. Facial bone procedures were the most common subgroup across both roles of care (1,181, 75.03%). Tracheostomy accounted for 16.67% of all H&N surgical procedures followed by linear repair of laceration of eyelid or eyebrow (8.23%) and neck exploration (7.41%). H&N caseload was variable., Conclusions: H&N procedures accounted for 8.25% of all surgical procedures performed at Role 2 and Role 3 MTFs; the majority of procedures were eye (40.54%) and airway (18.50%). These data can be used as planning tools to help determine the medical footprint and also to help inform training and sustainment requirements for deployed military general surgeons especially if future contingency operations are more constrained in terms of resources and personnel., (Published by Oxford University Press on behalf of the Association of Military Surgeons of the United States 2022. This work is written by (a) US Government employee(s) and is in the public domain in the US.)
- Published
- 2023
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3. Recommended medical and non-medical factors to assess military preventable deaths: subject matter experts provide valuable insights.
- Author
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Harrison WY, Wardian JL, Sosnov JA, Kotwal RS, Butler FK, Stockinger ZT, Shackelford SA, Gurney JM, Spott MA, Finelli LN, Mazuchowski EL, Smith DJ, and Janak JC
- Subjects
- Expert Testimony statistics & numerical data, Humans, Military Medicine methods, Qualitative Research, Risk Management trends, Expert Testimony methods, Military Medicine standards, Risk Management methods
- Abstract
Introduction: Historically, there has been variability in the methods for determining preventable death within the US Department of Defense. Differences in methodologies partially explain variable preventable death rates ranging from 3% to 51%. The lack of standard review process likely misses opportunities for improvement in combat casualty care. This project identified recommended medical and non-medical factors necessary to (1) establish a comprehensive preventable death review process and (2) identify opportunities for improvement throughout the entire continuum of care., Methods: This qualitative study used a modified rapid assessment process that includes the following steps: (1) identification and recruitment of US government subject matter experts (SMEs); (2) multiple cycles of data collection via key informant interviews and focus groups; (3) consolidation of information collected in these interviews; and (4) iterative analysis of data collected from interviews into common themes. Common themes identified from SME feedback were grouped into the following subject areas: (1) prehospital, (2) in-hospital and (3) forensic pathology., Results: Medical recommendations for military preventable death reviews included the development, training, documentation, collection, analysis and reporting of the implementation of the Tactical Combat Casualty Care Guidelines, Joint Trauma System Clinical Practice Guidelines and National Association of Medical Examiners autopsy standards. Non-medical recommendations included training, improved documentation, data collection and analysis of non-medical factors needed to understand how these factors impact optimal medical care., Conclusions: In the operational environment, medical care must be considered in the context of non-medical factors. For a comprehensive preventable death review process to be sustainable in the military health system, the process must be based on an appropriate conceptual framework implemented consistently across all military services., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. No commercial re-use. See rights and permissions. Published by BMJ.)
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- 2020
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4. Combat thoracic surgery in Iraq and Afghanistan: 2002-2016.
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Stern CA, Stockinger ZT, and Gurney JM
- Subjects
- Afghan Campaign 2001-, Clinical Competence, Humans, Iraq War, 2003-2011, Military Medicine education, Registries, Retrospective Studies, Thoracic Injuries epidemiology, Thoracic Surgery education, United States, Thoracic Injuries surgery, Thoracic Surgical Procedures statistics & numerical data, War-Related Injuries surgery
- Abstract
Background: Thoracic surgery constitutes 2.5% of surgical procedures performed in theater, but the skills required are increasingly foreign to military surgeons. This study examines thoracic surgical workload in Iraq and Afghanistan to help define surgical training gaps., Methods: Retrospective analysis of Department of Defense Trauma Registry for all role 2 (R2) (forward surgical) and role 3 (R3) (theater) military facilities, from January 2002 to May 2016. The 95 thoracic surgical International Classification of Diseases-9th Rev.-Clinical Modification procedure codes were grouped into 10 categories based on anatomy or endoscopy. Select groups were further stratified by type of definitive procedure. Procedure groupings were determined and adjudicated by surgeon subject matter experts. Data analysis used Stata Version 15 (College Station, TX)., Results: Of the total procedures, 5,301 were classified as thoracic surgical procedures and were included in the present study. The majority of thoracic surgical procedures (4,645 [87.6%]) were recorded as being performed at R3 medical treatment facilities (MTFs). The thoracic surgical procedures groups with the largest proportions were: bronchoscopy (39.1%), thoracotomy (16.9%), diaphragm (15.6%), and lung (11.4%). The most common lung procedure subgroup, aside from not otherwise specified, was segmentectomy (28.8%). The R3 MTFs recorded nearly five times the number of lung procedures compared with R2 MTFs; with R3 MTFs recording more than eight times the number of lobectomies compared with R2 MTFs. Thoracic workload was variable over the 15-year study period., Conclusion: Thoracic surgical skills are necessary in the deployed environment to manage combat-related injuries. Given the current trends in training and specialization, development and sustainment of thoracic surgical skills is challenging in the deployed US trauma system and likely for other nations, and humanitarian surgical care as well. Current training and practice paradigms pose both training and sustainment challenges for surgeons who deploy to a combat zone., Level of Evidence: Therapeutic/Care Management IV.
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- 2020
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5. Establishing an enduring Military Trauma Mortality Review: Misconceptions and lessons learned.
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Janak JC, Mazuchowski EL, Kotwal RS, Howard JT, Stockinger ZT, Gurney JM, and Shackelford SA
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- Cause of Death, Humans, Injury Severity Score, Trauma Severity Indices, United States, War-Related Injuries therapy, Wounds and Injuries mortality, Wounds and Injuries therapy, Military Medicine standards, Military Personnel, War-Related Injuries mortality
- Abstract
Under direction from the Defense Health Agency, subject matter experts (SMEs) from the Joint Trauma System, Armed Forces Medical Examiner System, and civilian sector established the Military Trauma Mortality Review process. To establish the most empirically robust process, these SMEs used both qualitative and quantitative methods published in a series of peer-reviewed articles over the last 3 years. Most recently, the Military Mortality Review process was implemented for the first time on all battle-injured service members attached to the United States Special Operations Command from 2001 to 2018. The current Military Mortality Review process builds on the strengths and limitations of important previous work from both the military and civilian sector. To prospectively improve the trauma care system and drive preventable death to the lowest level possible, we present the main misconceptions and lessons learned from our 3-year effort to establish a reliable and sustainable Military Trauma Mortality Review process. These lessons include the following: (1) requirement to use standardized and appropriate lexicon, definitions, and criteria; (2) requirement to use a combination of objective injury scoring systems, forensic information, and thorough SME case review to make injury survivability and death preventability determinations; (3) requirement to use nonmedical information to make reliable death preventability determinations and a comprehensive list of opportunities for improvement to reduce preventable deaths within the trauma care system; and (4) acknowledgment that the military health system still has gaps in current infrastructure that must be addressed to globally and continuously implement the process outlined in the Military Trauma Mortality Review process in the future. LEVEL OF EVIDENCE: Level III.
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- 2020
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6. Tactical Combat Casualty Care Training, Knowledge, and Utilization in the US Army.
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Gurney JM, Stern CA, Kotwal RS, Cunningham CW, Burelison DR, Gross KR, Montgomery HR, Whitt EH, Murray CK, Stockinger ZT, Butler FK, and Shackelford SA
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- Cross-Sectional Studies, Emergency Medical Services trends, Humans, Logistic Models, Military Medicine standards, Military Medicine statistics & numerical data, Teaching statistics & numerical data, United States, Emergency Medical Services methods, Military Medicine education, Military Personnel education, Teaching standards, Warfare
- Abstract
Introduction: Tactical Combat Casualty Care (TCCC) is the execution of prehospital trauma skills in the combat environment. TCCC was recognized by the 2018 Department of Defense Instruction on Medical Readiness Training as a critical wartime task. This study examines the training, understanding, and utilization of TCCC principles and guidelines among US Army medical providers and examines provider confidence of medics in performing TCCC skills., Materials and Methods: A cross-sectional survey, developed by members of the Committee on TCCC, was distributed to all US Army Physicians and Physician Assistants via anonymous electronic communication., Results: A total of 613 completed surveys were included in the analyses. Logistic regression analyses were conducted on: TCCC test score of 80% or higher, confidence with medic utilization of TCCC, and medic utilization of ketamine in accordance with TCCC., Conclusions: <60% of respondents expressed confidence in the ability of the medics to perform all TCCC skills. Supervising providers who that believed 80 to 100% of their medics had completed TCCC training had more confidence in their medic's TCCC abilities. With TCCC, a recognized lifesaver on the battlefield, continued training and utilization of TCCC concepts are paramount for deploying personnel., (© Association of Military Surgeons of the United States 2020. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)
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- 2020
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7. An Analysis of Orthopedic Surgical Procedures Performed During U.S. Combat Operations from 2002 to 2016.
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Stern CA, Stockinger ZT, Todd WE, and Gurney JM
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- Afghan Campaign 2001-, Amputation, Surgical methods, Amputation, Surgical statistics & numerical data, Debridement methods, Debridement statistics & numerical data, Fasciotomy methods, Fasciotomy statistics & numerical data, Fractures, Open epidemiology, Fractures, Open surgery, Humans, Iraq War, 2003-2011, Military Medicine methods, Military Medicine statistics & numerical data, Orthopedic Procedures methods, Registries statistics & numerical data, Retrospective Studies, United States epidemiology, Orthopedic Procedures statistics & numerical data, Warfare statistics & numerical data
- Abstract
Introduction: Orthopedic surgery constitutes 27% of procedures performed for combat injuries. General surgeons may deploy far forward without orthopedic surgeon support. This study examines the type and volume of orthopedic procedures during 15 years of combat operations in Iraq and Afghanistan., Materials and Methods: Retrospective analysis of the US Department of Defense Trauma Registry (DoDTR) was performed for all Role 2 and Role 3 facilities, from January 2002 to May 2016. The 342 ICD-9-CM orthopedic surgical procedure codes identified were stratified into fifteen categories, with upper and lower extremity subgroups. Data analysis used Stata Version 14 (College Station, TX)., Results: A total of 51,159 orthopedic procedures were identified. Most (43,611, 85.2%) were reported at Role 3 s. More procedures were reported on lower extremities (21,688, 57.9%). Orthopedic caseload was extremely variable throughout the 15-year study period., Conclusions: Orthopedic surgical procedures are common on the battlefield. Current dispersed military operations can occur without orthopedic surgeon support; general surgeons therefore become responsible for initial management of all injuries. Debridement of open fracture, fasciotomy, amputation and external fixation account for 2/3 of combat orthopedic volume; these procedures are no longer a significant part of general surgery training, and uncommonly performed by general/trauma surgeons at US hospitals. Given their frequency in war, expertise in orthopedic procedures by military general surgeons is imperative., (© Association of Military Surgeons of the United States 2019. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)
- Published
- 2019
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8. Nonfatal motor vehicle related injuries among deployed US Service members: Characteristics, trends, and risks for limb amputations.
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Schweizer MA, Janak JC, Graham B, Mazuchowski EL, Gurney JM, Shackelford SA, Stockinger ZT, and Monchal T
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- Accidents, Traffic prevention & control, Accidents, Traffic statistics & numerical data, Adult, Armed Conflicts statistics & numerical data, Cross-Sectional Studies, Explosions, Female, Humans, Injury Severity Score, Male, Military Personnel statistics & numerical data, Motor Vehicles, Outcome and Process Assessment, Health Care, Risk Assessment, Risk Factors, United States epidemiology, Amputation, Surgical methods, Amputation, Surgical statistics & numerical data, Blast Injuries diagnosis, Blast Injuries epidemiology, Blast Injuries etiology, Blast Injuries surgery
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Background: Motor vehicle-related (MVR) incidents are important causes of morbidity among deployed US service members (SMs). Nonbattle MVR injuries are usually similar to civilian MVR injuries, while battle MVR injuries are often unique due to the blast effects from precipitating explosive mechanisms. Our primary objective was to describe the characteristics and trends of nonfatal MVR injuries sustained by deployed US SMs. A second objective was to assess the association between mechanism of injury (i.e., explosive vs. nonexplosive) and limb amputation., Methods: We conducted a retrospective cross-sectional analysis using data from the Department of Defense Trauma Registry collected from October 2001 to December 2018. Descriptive statistics were reported stratified by mechanism of injury (explosive vs. nonexplosive). The association between mechanism of injury and limb amputation was assessed using logistic regression models., Results: There were 3,119 US casualties who sustained nonfatal MVR injuries, 2,380 (76.3%) SMs sustained nonexplosive MVR injuries while 739 (23.7%) sustained explosive MVR injuries. Of all MVR casualties, 2,085 (66.9%) were in Iraq or Syria and 1034 (33.1%) in Afghanistan. The annual prevalence of nonfatal MVR battle casualties was highest in Iraq and Syria from 2003 to 2009 and Afghanistan from 2009 to 2014, ranging overall 15 to 50 MVR casualties per 1,000 wounded in action. There were 92 limb amputations associated with MVR incidents. Compared with nonexplosive MVR mechanisms, explosive MVR mechanisms had higher association with limb amputation (adjusted odds ratio, 2.6; confidence interval, 1.7-3.9), even after adjusting for injury year and Injury Severity Score (AOR, 2.1; confidence interval: 1.4-3.4)., Conclusion: Motor vehicle-related incidents are an important cause of injury in US military operations. Compared with nonexplosive MVR incidents, explosive MVR incidents result in more severe injuries, and have a higher associated risk of limb amputation. Continued efforts to improve injury prevention through protective equipment and medical training specific to MVR injuries are needed., Level of Evidence: Prognostic and epidemiological study, Level III.
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- 2019
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9. Patterns of Anatomic Injury in Critically Injured Combat Casualties: A Network Analysis.
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Janak JC, Mazuchowski EL, Kotwal RS, Stockinger ZT, Howard JT, Butler FK, Sosnov JA, Gurney JM, and Shackelford SA
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- Adolescent, Adult, Cause of Death, Female, Humans, Injury Severity Score, Male, Military Personnel, Young Adult, Wounds and Injuries mortality
- Abstract
A mortality review of death caused by injury requires a determination of injury survivability prior to a determination of death preventability. If injuries are nonsurvivable, only non-medical primary prevention strategies have potential to prevent the death. Therefore, objective measures are needed to empirically inform injury survivability from complex anatomic patterns of injury. As a component of injury mortality reviews, network structures show promise to objectively elucidate survivability from complex anatomic patterns of injury resulting from explosive and firearm mechanisms. In this network analysis of 5,703 critically injured combat casualties, patterns of injury among fatalities from explosive mechanisms were associated with both a higher number and severity of anatomic injuries to regions such as the extremities, abdomen, and thorax. Patterns of injuries from a firearm were more isolated to individual body regions with fatal patterns involving more severe injuries to the head and thorax. Each injury generates a specific level of risk as part of an overall anatomic pattern to inform injury survivability not always captured by traditional trauma scoring systems. Network models have potential to further elucidate differences between potentially survivable and nonsurvivable anatomic patterns of injury as part of the mortality review process relevant to improving both the military and civilian trauma care systems.
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- 2019
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10. Correction to: Description of trauma among French service members in the Department of Defense Trauma Registry: understanding the nature of trauma and the care provided.
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Schweizer MA, Janak JC, Stockinger ZT, and Monchal T
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After publication of this article [1], it was brought to our attention that the Fig. 2 is incorrect. The correct Fig. 2 is as below.
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- 2019
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11. Use of Combat Casualty Care Data to Assess the US Military Trauma System During the Afghanistan and Iraq Conflicts, 2001-2017.
- Author
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Howard JT, Kotwal RS, Stern CA, Janak JC, Mazuchowski EL, Butler FK, Stockinger ZT, Holcomb BR, Bono RC, and Smith DJ
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- Afghan Campaign 2001-, Female, Humans, Incidence, Injury Severity Score, Iraq War, 2003-2011, Male, Retrospective Studies, Survival Rate trends, United States epidemiology, Wounds and Injuries diagnosis, Emergency Medical Services statistics & numerical data, Military Medicine statistics & numerical data, Military Personnel statistics & numerical data, Wounds and Injuries epidemiology
- Abstract
Importance: Although the Afghanistan and Iraq conflicts have the lowest US case-fatality rates in history, no comprehensive assessment of combat casualty care statistics, major interventions, or risk factors has been reported to date after 16 years of conflict., Objectives: To analyze trends in overall combat casualty statistics, to assess aggregate measures of injury and interventions, and to simulate how mortality rates would have changed had the interventions not occurred., Design, Setting, and Participants: Retrospective analysis of all available aggregate and weighted individual administrative data compiled from Department of Defense databases on all 56 763 US military casualties injured in battle in Afghanistan and Iraq from October 1, 2001, through December 31, 2017. Casualty outcomes were compared with period-specific ratios of the use of tourniquets, blood transfusions, and transport to a surgical facility within 60 minutes., Main Outcomes and Measures: Main outcomes were casualty status (alive, killed in action [KIA], or died of wounds [DOW]) and the case-fatality rate (CFR). Regression, simulation, and decomposition analyses were used to assess associations between covariates, interventions, and individual casualty status; estimate casualty transitions (KIA to DOW, KIA to alive, and DOW to alive); and estimate the contribution of interventions to changes in CFR., Results: In aggregate data for 56 763 casualties, CFR decreased in Afghanistan (20.0% to 8.6%) and Iraq (20.4% to 10.1%) from early stages to later stages of the conflicts. Survival for critically injured casualties (Injury Severity Score, 25-75 [critical]) increased from 2.2% to 39.9% in Afghanistan and from 8.9% to 32.9% in Iraq. Simulations using data from 23 699 individual casualties showed that without interventions assessed, CFR would likely have been higher in Afghanistan (15.6% estimated vs 8.6% observed) and Iraq (16.3% estimated vs 10.1% observed), equating to 3672 additional deaths (95% CI, 3209-4244 deaths), of which 1623 (44.2%) were associated with the interventions studied: 474 deaths (12.9%) (95% CI, 439-510) associated with the use of tourniquets, 873 (23.8%) (95% CI, 840-910) with blood transfusion, and 275 (7.5%) (95% CI, 259-292) with prehospital transport times., Conclusions and Relevance: Our analysis suggests that increased use of tourniquets, blood transfusions, and more rapid prehospital transport were associated with 44.2% of total mortality reduction. More critically injured casualties reached surgical care, with increased survival, implying improvements in prehospital and hospital care.
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- 2019
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12. Description of trauma among French service members in the Department of Defense Trauma Registry: understanding the nature of trauma and the care provided.
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Schweizer MA, Janak JC, Stockinger ZT, and Monchal T
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- Adult, Afghan Campaign 2001-, Female, France ethnology, Humans, Iraq War, 2003-2011, Male, Middle Aged, Registries statistics & numerical data, United States, United States Department of Defense organization & administration, United States Department of Defense statistics & numerical data, Military Personnel statistics & numerical data, Wounds and Injuries epidemiology
- Abstract
Background: Since 2001, the French Armed Forces have sustained many casualties during the Global War on Terror; however, even today, there is no French Military trauma registry. Some French service members (SMs) were treated in US Military Medical Treatment Facilities (MTFs) and were recorded in the US Department of Defense Trauma Registry (DoDTR). Our objective was to conduct a descriptive analysis of the injuries sustained by French SMs reported in the DoDTR and subsequent care provided to them to assist in understanding the importance of building a French Military trauma registry., Methods: Using DoDTR data collected from 2001 to 2017, a retrospective descriptive analysis was conducted. We identified 59 French SMs treated in US MTFs. The characteristics of the SMs' demographics, injuries, care provided to them, and discharge outcomes were summarized., Results: Among the 59 French SMs identified, 46 (78%) sustained battle injuries (BIs) and 13 (22%) sustained nonbattle injuries (NBIs). There were 47 (80%) SMs injured in Afghanistan (Opération Pamir), while 12 (20%) were injured in Opération Chammal in Iraq and Syria. Explosives accounted for 52.5% of injuries, while 25.4% were due to gunshot wounds; all were BIs. The majority of reported injuries were penetrating (59.3%), most of which were BIs (71.7%). The mean Injury Severity Score for BIs was 12 (SD = 8.9) compared to 6 (SD = 1.7) for NBIs. Around half of SMs (n = 30; 51%) were injured in Afghanistan between the years 2008-2010. Among a total of 246 injuries sustained by 59 patients, extremities were the body part most prone to BIs followed by the head and face. Four SMs died after admission (6.8%)., Conclusions: The DoDTR provides extensive data on trauma injuries that can be used to inform injury prevention and clinical care. The majority of injuries sustained by French SMs were BIs, caused by explosives, and predominantly occurring to the extremities; these findings are similar to those of other studies conducted in combat zones. There is a need to establish a French Military trauma registry to improve the combat casualty care provided to French SMs, and its creation may benefit from the DoDTR model.
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- 2019
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13. Genitourinary Surgical Workload at Deployed U.S. Facilities in Iraq and Afghanistan, 2002-2016.
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Turner CA, Orman JA, Stockinger ZT, and Hudak SJ
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- Adult, Afghan Campaign 2001-, Afghanistan, Female, Humans, Iraq, Iraq War, 2003-2011, Male, Military Facilities organization & administration, Military Facilities statistics & numerical data, Registries statistics & numerical data, United States epidemiology, United States Department of Defense organization & administration, United States Department of Defense statistics & numerical data, Urologic Diseases epidemiology, Urologic Diseases surgery, Urologic Surgical Procedures methods, Workload psychology, Workload statistics & numerical data, Urologic Surgical Procedures statistics & numerical data, Workload standards
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- 2019
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14. Re: Laparoscopy in a combat theater of operations.
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Stockinger ZT, Turner CA, and Gurney JM
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- Warfare, Laparoscopy, Military Medicine
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- 2018
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15. The Need for a Combat Casualty Care Research Program and Trauma Registry for Military Working Dogs.
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Orman JA, Parker JS, Stockinger ZT, and Nemelka KW
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- Animals, Dogs, Military Medicine methods, Military Medicine statistics & numerical data, United States, Wounds and Injuries epidemiology, Wounds and Injuries veterinary, Military Personnel statistics & numerical data, Registries, Wounds and Injuries therapy
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- 2018
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16. MRI in Management of Mild TBI/Concussion in the Deployed Setting.
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Marion DW, Grimes JB, Hinds Ii SR, Lewis J, Baugh L, and Stockinger ZT
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- Brain Concussion diagnosis, Brain Concussion diagnostic imaging, Continuity of Patient Care standards, Humans, Magnetic Resonance Imaging trends, Neuroimaging methods, Brain Concussion therapy, Magnetic Resonance Imaging methods
- Abstract
Magnetic resonance imaging (MRI) has specific limitations in theater and has unique requirements for its safe use with patients which require additional technician training and strict adherence to MRI-specific safety protocols. Neuroimaging is recommended for the evaluation of service members with clinical red flags new onset or persistent or worsening symptoms, and individuals whose recovery is not progressing as anticipated. This article is a brief discussion of when MRI is appropriate.
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- 2018
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17. Amputation: Evaluation and Treatment.
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Gordon W, Balsamo L, Talbot M, Osier C, Johnson A, Shero J, Potter B, and Stockinger ZT
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- Amputation, Surgical standards, Debridement methods, Guidelines as Topic, Humans, Limb Salvage methods, Research Design, Severity of Illness Index, Surgical Flaps surgery, Amputation, Surgical methods, Treatment Outcome
- Abstract
Combat extremity injury and amputation is a life threatening injury. Initial surgical care should focus on hemostasis followed by irrigation and debridement of contaminated and nonviable tissue. Preservation of limb length begins at the initial surgical procedure, to include retention of atypical soft tissue flaps for later reconstruction and treatment of proximal fractures. Serial irrigation and debridements are required throughout the MEDEVAC system as the evolving zone of injury becomes more mature, followed by the appropriate timing of closure outside the combat theater.
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- 2018
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18. Catastrophic Non-Survivable Brain Injury Care-Role 2/3.
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Neal CJ, Bell RS, Carmichael JJ, DuBose JJ, Grabo DJ, Oh JS, Remick KN, Bailey JA, and Stockinger ZT
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- Brain Injuries classification, Brain Injuries mortality, Hospitals, Military trends, Humans, Medical Futility psychology, Patient Transfer methods, Resuscitation Orders psychology, Treatment Outcome, Warfare, Brain Injuries therapy, Hospitals, Military classification
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A catastrophic brain injury is defined as any brain injury that is expected to result in permanent loss of all brain function above the brain stem level. These clinical recommendations will help stabilize the patient so that they may be safely evacuated from theater. In addition to cardiovascular and hemodynamic goals, special attention must be paid to their endocrine dysfunction and its treatment-specifically steroid, insulin and thyroxin (t4) replacement while evaluating for and treating diabetes insipidus. Determining the futility of care coupled with resource management must also be made at each echelon. Logistical coordination and communication is paramount to expedite these patients to higher levels of care so that there is an increased probability of reuniting them with their family.
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- 2018
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19. Burn Casualty Care in the Deployed Setting.
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Driscoll IR, Mann-Salinas EA, Boyer NL, Pamplin JC, Serio-Melvin ML, Salinas J, Borgman MA, Sheridan RL, Melvin JJ, Peterson WC, Graybill JC, Rizzo JA, King BT, Chung KK, Cancio LC, Renz EM, and Stockinger ZT
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- Anti-Bacterial Agents therapeutic use, Antibiotic Prophylaxis methods, Burns, Chemical drug therapy, Burns, Electric therapy, Guidelines as Topic, Humans, Military Medicine methods, Physical Examination methods, Burns therapy, Warfare
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Management of wartime burn casualties can be very challenging. Burns frequently occur in the setting of other blunt and penetrating injuries. This clinical practice guideline provides a manual for burn injury assessment, resuscitation, wound care, and specific scenarios including chemical and electrical injuries in the deployed or austere setting. The clinical practice guideline also reviews considerations for the definitive care of local national patients, including pediatric patients, who are unable to be evacuated from theater. Medical providers are encouraged to contact the US Army Institute of Surgical Research (USAISR) Burn Center when caring for a burn casualty in the deployed setting.
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- 2018
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20. Pelvic Fracture Care.
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Gordon WT, Fleming ME, Johnson AE, Gurney J, Shackelford S, and Stockinger ZT
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- Debridement methods, Disease Management, Fracture Fixation methods, Fracture Fixation trends, Fractures, Bone physiopathology, Humans, Pelvis physiopathology, Wounds and Injuries physiopathology, Wounds and Injuries surgery, Fractures, Bone therapy, Pelvis injuries
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While combat-related pelvis fractures are more commonly open, higher energy, and complex in pattern than those seen in the civilian setting, the principles of management are similar. The primary differences are related to the austere setting in which the initial management takes place, and the lack of resources typically available. Initial management consists of cessation of hemorrhage, along with the multi-disciplinary prioritized management of associated injuries, and skeletal stabilization. This is most commonly achieved with a compressive sheet or pelvic binder, with pelvic external fixation when resources allow, and debridement of open wounds as necessary. Definitive, internal fixation is delayed until the patient arrives at a higher echelon of care.
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- 2018
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21. Acute Extremity Compartment Syndrome and the Role of Fasciotomy in Extremity War Wounds.
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Gordon WT, Talbot M, Shero JC, Osier CJ, Johnson AE, Balsamo LH, and Stockinger ZT
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- Compartment Syndromes prevention & control, Extremities surgery, Fasciotomy trends, Humans, Limb Salvage methods, Limb Salvage trends, Retrospective Studies, Surgical Procedures, Operative methods, Treatment Outcome, Compartment Syndromes surgery, Extremities injuries, Fasciotomy methods, Warfare
- Abstract
Acute compartment syndrome (CS) is a frequent and potentially devastating complication of blunt and penetrating extremity injuries. Extremity war injuries are particularly susceptible to CS due to associated vascular injuries; high Injury Severity Score; extensive bone and soft tissue injury; and frequent transportation that may limit close monitoring of the injured extremity. Treatment consists of prompt fasciotomy of all compartments in the involved segment, over their full length. Delayed or incomplete fasciotomy is associated with worse outcomes, including muscle necrosis, infection, and amputation. Enhanced pre-deployment training of surgeons decreases the need for revision fasciotomy at higher echelons of care and should be continued in future conflicts. We recommend the liberal use of prophylactic fasciotomy prior to aeromedical evacuation and after limb reperfusion. For leg fasciotomy, we recommend a two-incision approach as it is more reproducible and allows easy vascular exposure when necessary.
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- 2018
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22. The Joint Trauma System and the Fog of War.
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Stockinger ZT
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- Afghan Campaign 2001-, Evidence-Based Practice history, History, 20th Century, History, 21st Century, History, Ancient, Humans, Iraq War, 2003-2011, Quality Improvement history, Quality Improvement statistics & numerical data, Registries statistics & numerical data, United States, Warfare statistics & numerical data, Evidence-Based Practice standards, Military Medicine history
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- 2018
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23. High Bilateral Amputations and Dismounted Complex Blast Injury (DCBI).
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Gordon W, Talbot M, Fleming M, Shero J, Potter B, and Stockinger ZT
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- Blast Injuries physiopathology, Blast Injuries surgery, Debridement methods, Humans, Military Medicine methods, Military Medicine trends, Military Personnel statistics & numerical data, Wound Healing, Amputation, Surgical classification, Amputation, Surgical methods, Blast Injuries complications, Walking physiology
- Abstract
High, combat-related bilateral lower extremity amputations rarely occur in isolation. Dismounted complex blast injury is a devastating and life-threatening constellation of multisystem injuries most commonly due to dismounted contact with improvised explosive devices. Rapid damage control resuscitation and surgery are essential to improve patient survival and minimize both early complications and late sequelae. A coordinated team approach is essential to provide simultaneous airway management, volume resuscitation (ideally with whole blood or ratio transfusion), and immediate control of life-threatening hemorrhage. Temporary aortic or iliac vessel clamping during concurrent exploratory or vascular control laparotomy is frequently required. Stabilization of unstable pelvic fractures is then performed, followed by debridement and irrigation of all wounds, which should be left open, and subsequent provisional stabilization of long bone fractures. The goal of the initial surgical resuscitative endeavor is rapid concurrent control of all sources of hemorrhage to avoid the lethal triad of acidosis, hypothermia and coagulopathy. To this end, multiple surgeons or surgical teams should be utilized whenever feasible. Patients then require ongoing resuscitation followed by early and frequent return to the operating suite throughout the evacuation chain. Utilizing this approach, a high survival rate with reasonable functional outcomes is achievable despite the extreme severity of the DCBI pattern.
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- 2018
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24. A 12-Year Analysis of Nonbattle Injury Among US Service Members Deployed to Iraq and Afghanistan.
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Le TD, Gurney JM, Nnamani NS, Gross KR, Chung KK, Stockinger ZT, Nessen SC, Pusateri AE, and Akers KS
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- Adult, Afghan Campaign 2001-, Female, Humans, Incidence, Iraq War, 2003-2011, Male, Retrospective Studies, United States epidemiology, Young Adult, Accidental Falls statistics & numerical data, Accidents, Traffic statistics & numerical data, Military Medicine statistics & numerical data, Military Personnel statistics & numerical data, Registries, Wounds, Nonpenetrating epidemiology
- Abstract
Importance: Nonbattle injury (NBI) among deployed US service members increases the burden on medical systems and results in high rates of attrition, affecting the available force. The possible causes and trends of NBI in the Iraq and Afghanistan wars have, to date, not been comprehensively described., Objectives: To describe NBI among service members deployed to Iraq and Afghanistan, quantify absolute numbers of NBIs and proportion of NBIs within the Department of Defense Trauma Registry, and document the characteristics of this injury category., Design, Setting, and Participants: In this retrospective cohort study, data from the Department of Defense Trauma Registry on 29 958 service members injured in Iraq and Afghanistan from January 1, 2003, through December 31, 2014, were obtained. Injury incidence, patterns, and severity were characterized by battle injury and NBI. Trends in NBI were modeled using time series analysis with autoregressive integrated moving average and the weighted moving average method. Statistical analysis was performed from January 1, 2003, to December 31, 2014., Main Outcomes and Measures: Primary outcomes were proportion of NBIs and the changes in NBI over time., Results: Among 29 958 casualties (battle injury and NBI) analyzed, 29 003 were in men and 955 were in women; the median age at injury was 24 years (interquartile range, 21-29 years). Nonbattle injury caused 34.1% of total casualties (n = 10 203) and 11.5% of all deaths (206 of 1788). Rates of NBI were higher among women than among men (63.2% [604 of 955] vs 33.1% [9599 of 29 003]; P < .001) and in Operation New Dawn (71.0% [298 of 420]) and Operation Iraqi Freedom (36.3% [6655 of 18 334]) compared with Operation Enduring Freedom (29.0% [3250 of 11 204]) (P < .001). A higher proportion of NBIs occurred in members of the Air Force (66.3% [539 of 810]) and Navy (48.3% [394 of 815]) than in members of the Army (34.7% [7680 of 22 154]) and Marine Corps (25.7% [1584 of 6169]) (P < .001). Leading mechanisms of NBI included falls (2178 [21.3%]), motor vehicle crashes (1921 [18.8%]), machinery or equipment accidents (1283 [12.6%]), blunt objects (1107 [10.8%]), gunshot wounds (728 [7.1%]), and sports (697 [6.8%]), causing predominantly blunt trauma (7080 [69.4%]). The trend in proportion of NBIs did not decrease over time, remaining at approximately 35% (by weighted moving average) after 2006 and approximately 39% by autoregressive integrated moving average. Assuming stable battlefield conditions, the autoregressive integrated moving average model estimated that the proportion of NBIs from 2015 to 2022 would be approximately 41.0% (95% CI, 37.8%-44.3%)., Conclusions and Relevance: In this study, approximately one-third of injuries during the Iraq and Afghanistan wars resulted from NBI, and the proportion of NBIs was steady for 12 years. Understanding the possible causes of NBI during military operations may be useful to target protective measures and safety interventions, thereby conserving fighting strength on the battlefield.
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- 2018
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25. Unexploded Ordnance Management.
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Oh JS, Seery JM, Grabo DJ, Ervin MD, Wertin TM, Hawks RP, Benov A, and Stockinger ZT
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- Blast Injuries prevention & control, Blast Injuries therapy, Hazardous Substances administration & dosage, Hazardous Substances adverse effects, Humans, Operating Rooms methods, Operating Rooms trends, United States, Explosive Agents adverse effects, Handling, Psychological
- Abstract
The purpose of this Clinical Practice Guide is to provide details on the procedures to safely remove unexploded ordnance from combat patients, both loose and impaled, to minimize the risks to providers and the medical treatment facility while ensuring the best outcome for the patient. Military ordnance, to include bullets, grenades, flares, and explosive ordnance, retained by a patient can be a risk to all individuals and equipment along the continuum of care. This is especially true from the point of injury to the first treatment facility. Management of patients with unexploded ordnance either on or in their body is a rare event during combat surgery. Loose munitions are usually noted and easily removed prior to the patient receiving medical treatment. However, impaled munitions provide a significant challenge. These are usually caused by large caliber, high-velocity projectiles. Patients who survive to arrive at a treatment facility must be triaged safely and simultaneously treated appropriately to ensure both the survival of the patient and the treatment team. Between WWII and the Somalia conflict, there have been 36 reported cases of unexploded ordnance from U.S. soldiers. Since 2005, there have been six known cases during the U.S. wars in Afghanistan and Iraq and one additional case in Pakistan. Optimal outcomes require a basic knowledge of explosives and triggering mechanisms, as well as adherence to basic principles of trauma resuscitation and surgery.
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- 2018
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26. A US military Role 2 forward surgical team database study of combat mortality in Afghanistan.
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Kotwal RS, Staudt AM, Mazuchowski EL, Gurney JM, Shackelford SA, Butler FK, Stockinger ZT, Holcomb JB, Nessen SC, and Mann-Salinas EA
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- Adult, Afghanistan epidemiology, Databases, Factual, Female, Humans, Injury Severity Score, Male, Military Medicine standards, Retrospective Studies, Surgeons supply & distribution, Time Factors, Transportation of Patients methods, United States epidemiology, Wounds and Injuries surgery, Wounds and Injuries therapy, Mass Casualty Incidents mortality, Military Medicine trends, Military Personnel statistics & numerical data, Surgeons organization & administration, Transportation of Patients statistics & numerical data, Wounds and Injuries mortality
- Abstract
Background: Timely and optimal care can reduce mortality among critically injured combat casualties. US military Role 2 surgical teams were deployed to forward positions in Afghanistan on behalf of the battlefield trauma system. They received prehospital casualties, provided early damage control resuscitation and surgery, and rapidly transferred casualties to Role 3 hospitals for definitive care. A database was developed to capture Role 2 data., Methods: A retrospective review and descriptive analysis were conducted of battle-injured casualties transported to US Role 2 surgical facilities in Afghanistan from February 2008 to September 2014. Casualties were analyzed by mortality status and location of death (pretransport, intratransport, or posttransport), military affiliation, transport time, injury type and mechanism, combat mortality index-prehospital (CMI-PH), and documented prehospital treatment., Results: Of 9,557 casualties (median age, 25.0 years; male, 97.4%), most (95.1%) survived to transfer from Role 2 facility care. Military affiliation included US coalition forces (37.4%), Afghanistan National Security Forces (23.8%), civilian/other forces (21.3%), Afghanistan National Police (13.5%), and non-US coalition forces (4.0%). Mortality differed by military affiliation (p < 0.001). Among fatalities, most were Afghanistan National Security Forces (30.5%) civilian/other forces (26.0%), or US coalition forces (25.2%). Of those categorized by CMI-PH, 40.0% of critical, 11.2% of severe, 0.8% of moderate, and less than 0.1% of mild casualties died. Most fatalities with CMI-PH were categorized as critical (66.3%) or severe (25.9%), whereas most who lived were mild (56.9%) or moderate (25.4%). Of all fatalities, 14.0% died prehospital (pretransport, 5.8%; intratransport, 8.2%), and 86.0% died at a Role 2 facility (posttransport). Of fatalities with documented transport times (median, 53.0 minutes), most (61.7%) were evacuated within 60 minutes., Conclusions: Role 2 surgical team care has been an important early component of the battlefield trauma system in Afghanistan. Combat casualty care must be documented, collected, and analyzed for outcomes and trends to improve performance., Level of Evidence: Therapeutic/Care Management, level IV.
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- 2018
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27. JTS CPG Development Process.
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Spott MA, Burelison DR, Kurkowski CR, and Stockinger ZT
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- Humans, Military Medicine standards, Registries standards, Guidelines as Topic standards, Military Medicine methods
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- 2018
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28. Hyperkalemia and Dialysis in the Deployed Setting.
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Stewart IJ, Bolanos JA, Little DJ, Chung KK, Sosnov JA, Miller N, Poirier MD, Saenz KK, McAlister VC, Moghadam S, Kao R, and Stockinger ZT
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- Acute Kidney Injury complications, Acute Kidney Injury therapy, Catheterization, Central Venous methods, Dialysis trends, Disease Management, Fluid Therapy methods, Guidelines as Topic, Humans, Hyperkalemia etiology, Military Medicine methods, Dialysis methods, Hyperkalemia therapy, Warfare
- Abstract
Acute kidney injury is a recognized complication of combat trauma. The complications associated with acute kidney injury, such as life-threatening hyperkalemia, are usually delayed in onset. In the recent conflicts, rapid evacuation of U.S. and coalition personnel generally resulted in these complications occurring at higher echelons of care where renal replacement therapies were available. In the future however, deployed providers may not have this luxury and should be prepared to temporize patients while they await transport. In this clinical practice guideline, recommendations are made for the management of patients with, or at risk for, acute kidney injury and hyperkalemia in the austere, deployed environment.
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- 2018
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29. Emergency Resuscitative Thoracotomy in the Combat or Operational Environment.
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Monchal T, Martin MJ, Antevil JL, Bennett DR, DeVries WC, Zakaluzny S, Ricca RL, Tien H, Mullenix PS, and Stockinger ZT
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- Humans, Injury Severity Score, Military Personnel, Resuscitation trends, Retrospective Studies, Survival Analysis, Thoracotomy trends, Warfare, Resuscitation methods, Thoracotomy methods
- Abstract
Resuscitative thoracotomy has been extensively described in the civilian trauma literature and has a high mortality rate, due largely to the nature of the injuries leading to arrest. The survival rates are generally highest (10-30%) for penetrating truncal injuries and patients who arrive with vital signs and proceed to arrest or who have impending arrest. They are significantly lower (less than 5%) for blunt trauma victims, particularly those who arrest in the field or during transport (1% or less). In addition, the likelihood of survival with intact neurologic function is significantly lower than the overall survival rates, particularly for blunt trauma victims and for prehospital arrest.
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- 2018
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30. Neurosurgical workload during US combat operations: 2002 to 2016.
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Turner CA, Stockinger ZT, Bell RS, and Gurney JM
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- Afghanistan, Hospitals, Military statistics & numerical data, Humans, Iraq, Military Medicine statistics & numerical data, Registries, Retrospective Studies, United States, United States Department of Defense, War-Related Injuries epidemiology, Military Personnel statistics & numerical data, Neurosurgical Procedures statistics & numerical data, War-Related Injuries surgery, Workload statistics & numerical data
- Abstract
Background: Approximately 4.5% of surgical procedures performed at Role 2 (R2) (forward surgical) and Role 3 (R3) (theater) medical treatment facilities can be classified as neurosurgical. These procedures are foreign to the routine daily practice of the military general surgeon. The purpose of this study was to examine the neurosurgical workload in Iraq and Afghanistan in order to inform the future predeployment neurosurgical training needs of nonneurosurgical providers., Methods: Retrospective analysis of the Department of Defense Trauma Registry for all R2 and R3 medical facilities, from January 2002 to May 2016. The 103 neurosurgical International Classification of Diseases, Ninth Revision, Clinical Modification procedure codes identified were grouped by anatomic location. Select groups were further subdivided. Data analysis used Stata version 14 (College Station, TX)., Results: A total of 7,509 neurosurgical procedures were identified. The majority (7,244 [96.5%]) occurred at R3 theater hospitals. Cranial procedures were the most common at both R2 (120, 45.3%) and R3 (4,483 [61.9%]), with craniotomy/craniectomy the most frequent procedure. Spine procedures were performed almost exclusively at R3, with 61.1% being fusions/stabilizations and 26.9% being spinal decompression alone. Neurosurgical caseload was variable over the 15-year study period, dropping to almost zero in 2016., Conclusions: Neurosurgical procedures were performed primarily at larger R3 theater hospitals where neurosurgeons were assigned if present in theater; however, more than 100 cranial procedures were performed at forward R2 where neurosurgeons were not deployed. Considering that neurosurgeons are not everywhere available within the war zone, deploying general surgeons should have familiarity with trauma neurosurgery., Level of Evidence: Epidemiologic study, level III; Care Management, level IV.
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- 2018
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31. Vascular surgery during U.S. combat operations from 2002 to 2016: Analysis of vascular procedures performed to inform military training.
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Turner CA, Stockinger ZT, and Gurney JM
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- Afghan Campaign 2001-, Amputation, Surgical statistics & numerical data, Fasciotomy statistics & numerical data, Humans, Iraq War, 2003-2011, Registries, Retrospective Studies, United States, Vascular Grafting statistics & numerical data, Vascular System Injuries epidemiology, Vascular Surgical Procedures statistics & numerical data, Vascular System Injuries surgery, War-Related Injuries surgery
- Abstract
Background: Vascular surgery constitutes approximately 6.5% of surgical procedures performed for combat injuries, yet general surgeons are increasingly unfamiliar with vascular surgery. This study examines the frequency and type of vascular surgical procedures performed during recent US Military operations from 2002 to 2016., Methods: A retrospective analysis of the Department of Defense Trauma Registry was performed for all Role (R)2 and R3 medical treatment facilities (MTFs), from January 2002 to May 2016. A total of 106 International Classification of Diseases-9th Rev.-Clinical Modification (ICD-9-CM) procedure codes were categorized as vascular and were included in the present analysis. Procedure codes were separated by anatomic location and procedure type. Ligation as part of an amputation was excluded. Grafts were further subdivided by type: synthetic, autologous, and unknown. Procedure grouping and categorization were determined by subject matter experts. Data analysis used Stata Version 14 (College Station, TX)., Results: A total of 25,816 vascular surgical procedures were identified at R2 and R3 MTFs. Role 3 MTFs reported more than four times the number of procedures compared to R2 MTFs. The most common anatomic locations documented were extremity (64.96%) and not otherwise specified (28.1%). The most common procedures overall were amputation (33.36%) and fasciotomy (18.83%). The most common graft type was autologous (68.87%), and the least common was synthetic (5.69%)., Conclusion: While amputation, fasciotomy, and ligation were the most common vascular procedures performed for combat trauma, the need for definitive repair including grafting is common at both R2 and R3 MTFs. Vascular surgery therefore remains a necessary skill set for the deployed US Military surgeon; military general surgeons need to train and sustain their vascular skills, including proficiency at amputation and fasciotomy., Level of Evidence: Epidemiologic study, level III.
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- 2018
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32. Abdominal trauma surgery during recent US combat operations from 2002 to 2016.
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Stockinger ZT, Turner CA, and Gurney JM
- Subjects
- Abdominal Injuries epidemiology, Afghan Campaign 2001-, Humans, Intestines injuries, Intestines surgery, Iraq War, 2003-2011, Laparoscopy statistics & numerical data, Registries, Retrospective Studies, United States, War-Related Injuries epidemiology, Abdominal Injuries surgery, War-Related Injuries surgery
- Abstract
Background: Abdominal surgery constitutes approximately 13% of surgical procedures performed for combat injuries. This study examines the frequencies and type of abdominal surgical procedures performed during recent US Military operations., Methods: A retrospective analysis of the Department of Defense Trauma Registry was performed for all Role 2 (R2) and Role 3 (R3) medical treatment facilities (MTFs), from January 2002 to May 2016. The 273 International Classification of Diseases, Ninth Revision, Clinical Modification procedure codes that were identified as abdominal surgical procedures were stratified into 24 groups based on anatomic and functional classifications and then grouped by whether they were laparoscopic. Procedure grouping and categorization were determined, and adjudicated if necessary, by subject matter experts. Data analysis used Stata version 14 (College Station, TX)., Results: A total of 26,548 abdominal surgical procedures were identified at R2 and R3 MTFs. The majority of abdominal surgical procedures were reported at R3 facilities. The largest procedure group at both R2 and R3 MTFs were procedures involving the bowel. There were 18 laparoscopic procedures reported (R2: 4 procedures, R3: 14 procedures). Laparotomy not otherwise specified was the second largest procedure group at both R2 (1,060 [24.55%]) and R3 (4,935 [22.2%]) MTFs. Abdominal caseload was variable over the 15-year study period., Conclusions: Surgical skills such as open laparotomy and procedures involving the bowel are crucial in war surgery. The abundance of laparotomy not otherwise specified may reflect inadequate documentation, or the plethora of second- and third-look operations and washouts performed for complex abdominal injuries. Traditional elective general surgical cases (gallbladder, hernia) were relatively infrequent. Laparoscopy was almost nonexistent. Open abdominal surgical skills therefore remain a necessity for the deployed US Military General Surgeons; this is at odds with the shifting paradigm from open to laparoscopic skills in stateside civilian and military hospitals., Level of Evidence: Epidemiologic study, level III.
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- 2018
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33. Unrealized potential of the US military battlefield trauma system: DOW rate is higher in Iraq and Afghanistan than in Vietnam, but CFR and KIA rate are lower.
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Nessen SC, Gurney J, Rasmussen TE, Cap AP, Mann-Salinas E, Le TD, Shackelford S, Remick KN, Akers KS, Eastridge BJ, Jenkins D, Stockinger ZT, Murray CK, Gross KR, Seery J, Mabry R, and Holcomb JB
- Subjects
- Adult, Emergency Medical Services organization & administration, Emergency Medical Services statistics & numerical data, Female, History, 20th Century, History, 21st Century, Humans, Male, United States, War-Related Injuries history, War-Related Injuries therapy, Young Adult, Afghan Campaign 2001-, Iraq War, 2003-2011, Military Medicine history, Military Medicine organization & administration, Military Medicine statistics & numerical data, Vietnam Conflict, War-Related Injuries mortality
- Abstract
Level of Evidence: Observational/retrospective/historic controls, level IV.
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- 2018
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34. The effect of prehospital transport time, injury severity, and blood transfusion on survival of US military casualties in Iraq.
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Kotwal RS, Scott LLF, Janak JC, Tarpey BW, Howard JT, Mazuchowski EL, Butler FK, Shackelford SA, Gurney JM, and Stockinger ZT
- Subjects
- Adult, Blood Transfusion statistics & numerical data, Emergency Medical Services statistics & numerical data, Female, Humans, Injury Severity Score, Male, Retrospective Studies, Time Factors, Transportation of Patients statistics & numerical data, United States, War-Related Injuries pathology, War-Related Injuries therapy, Young Adult, Blood Transfusion mortality, Iraq War, 2003-2011, War-Related Injuries mortality
- Abstract
Background: Reducing time from injury to care can optimize trauma patient outcomes. A previous study of prehospital transport of US military casualties during the Afghanistan conflict demonstrated the importance of time and treatment capability for combat casualty survival., Methods: A retrospective descriptive analysis was conducted to analyze battlefield data collected on US military combat casualties during the Iraq conflict from March 19, 2003, to August 31, 2010. All casualties were analyzed by mortality outcome (killed in action, died of wounds, case fatality rate) and compared with Afghanistan conflict. Detailed data for those who underwent prehospital transport were analyzed for effects of transport time, injury severity, and blood transfusion on survival., Results: For the total population, percent killed in action (16.6% vs. 11.1%), percent died of wounds (5.9% vs. 4.3%), and case fatality rate (10.0 vs. 8.6) were higher for Iraq versus Afghanistan (p < 0.001). Among 1,692 casualties (mean New Injury Severity Score, 22.5; mortality, 17.6%) with detailed data, the injury mechanism included 77.7% from explosions and 22.1% from gunshot wounds. For prehospital transport, 67.6% of casualties were transported within 60 minutes, and 32.4% of casualties were transported in greater than 60 minutes. Although 97.0% of deaths occurred in critical casualties (New Injury Severity Score, 25-75), 52.7% of critical casualties survived. Critical casualties were transported more rapidly (p < 0.01) and more frequently within 60 minutes (p < 0.01) than other casualties. Critical casualties had lower mortality when blood was received (p < 0.01). Among critical casualties, blood transfusion was associated with survival irrespective of transport time within or greater than 60 minutes (p < 0.01)., Conclusion: Although data were limited, early blood transfusion was associated with battlefield survival in Iraq as it was in Afghanistan., Level of Evidence: Performance improvement and epidemiological, level IV.
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- 2018
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35. Analysis of Pediatric Trauma in Combat Zone to Inform High-Fidelity Simulation Predeployment Training.
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Reeves PT, Auerbach MM, Le TD, Caldwell NW, Edwards MJ, Mann-Salinas EA, Gurney JM, Stockinger ZT, and Borgman MA
- Subjects
- Afghanistan, Child, Child, Preschool, Cohort Studies, Databases, Factual, Female, Hospitalization statistics & numerical data, Humans, Infant, Male, Military Personnel, Retrospective Studies, Simulation Training, United States, War-Related Injuries therapy, Hospitals, Military statistics & numerical data, War-Related Injuries epidemiology
- Abstract
Objectives: The military uses "just-in-time" training to refresh deploying medical personnel on skills necessary for medical and surgical care in the theater of operations. The burden of pediatric care at Role 2 facilities has yet to be characterized; pediatric predeployment training has been extremely limited and primarily informed by anecdotal experience. The goal of this analysis was to describe pediatric care at Role 2 facilities to enable data-driven development of high-fidelity simulation training and core knowledge concepts specific to the combat zone., Setting and Patients: A retrospective review of the Role 2 Database was conducted on all pediatric patients (< 18 yr) admitted to Role 2 in Afghanistan from 2008-2014., Interventions: Three cohorts were determined based on commercially available simulation models: Group 1: less than 1 year, Group 2: 1-8 years, Group 3: more than 8 years. The groups were sub-stratified by point of injury care, pre-hospital management, and Role 2 facility medical/surgical management., Measurements and Main Results: Appropriate descriptive statistics (chi square and Student t test) were utilized to define demographic and epidemiologic characteristics of this population. Of 15,404 patients in the Role 2 Database, 1,318 pediatric subjects (8.5%) were identified. The majority of patients were male (80.0%) with a mean age of 9.5 years (± SD, 4.5). Injury types included: penetrating (56%), blunt (33%), and burns (7%). Mean transport time from point of injury to Role 2 was 198 minutes (±24.5 min). Mean Glasgow Coma Scale and Revised Trauma Score were 14 (± 0.1) and 7.0 (± 1.4), respectively. Role 2 surgical procedures occurred for 424 patients (32%). Overall mortality was 4% (n = 58)., Conclusions: We have described the epidemiology of pediatric trauma admitted to Role 2 facilities, characterizing the spectrum of pediatric injuries that deploying providers should be equipped to manage. This analysis will function as a needs assessment to facilitate high-fidelity simulation training and the development of "pediatric trauma core knowledge concepts" for deploying providers.
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- 2018
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36. En Route Care Provided by US Navy Nurses in Iraq and Afghanistan.
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Blackman VS, Walrath BD, Reeves LK, Mora AG, Maddry JK, and Stockinger ZT
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- Adult, Afghan Campaign 2001-, Female, Humans, Iraq War, 2003-2011, Male, United States, Young Adult, Critical Care methods, Critical Care statistics & numerical data, Military Nursing methods, Military Nursing statistics & numerical data, Military Personnel statistics & numerical data, War-Related Injuries nursing
- Abstract
Background: US Navy nurses provide en route care for critically injured combat casualties without having a formal program for training, utilization, or evaluation. Little is known about missions supported by Navy nurses., Objectives: To characterize the number and types of patients transported and skill sets required by Navy nurses during 2 combat support deployments., Methods: All interfacility casualty transfers between 2 separate facilities in Iraq and Afghanistan were assessed. Number of patients treated, number transported, en route care provider type, transport priority level and duration, injury severity, indication for critical care transport, en route care interventions, and vital signs were evaluated., Results: Of 1550 casualties, 630 required medical evacuation to a higher level of care. Of those, 133 (21%) were transported by a Navy nurse, with 131 (98.5%) classified as "urgent," accounting for 46% of all urgent transports. The primary indication for en route care nursing was mechanical ventilation of intubated patients (97%). Mean (SD) patient transport time was 29.8 (7.9) minutes (range, 17-61 minutes). The most common en route care interventions were administration of intravenous sedation (80%), neuromuscular blockade (79%), and opioids (48%); transfusions (18%); and ventilation changes (11%). No intubations, cricothyroidotomies, chest tube placements, or needle decompressions were performed en route. No deaths occurred during transport., Conclusions: US Navy nurses successfully transported critically injured patients without observed adverse events. Establishing en route care as a program of record in the Navy will facilitate continuous process improvement to ensure that future casualties receive optimized en route care., (©2018 American Association of Critical-Care Nurses.)
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- 2018
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37. Comparison of Military and Civilian Methods for Determining Potentially Preventable Deaths: A Systematic Review.
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Janak JC, Sosnov JA, Bares JM, Stockinger ZT, Montgomery HR, Kotwal RS, Butler FK, Shackelford SA, Gurney JM, Spott MA, Finelli LN, Mazuchowski EL, and Smith DJ
- Subjects
- Humans, Military Medicine standards, Quality Improvement, Military Medicine methods, Quality Assurance, Health Care, Wounds and Injuries mortality
- Abstract
Importance: Military and civilian trauma experts initiated a collaborative effort to develop an integrated learning trauma system to reduce preventable morbidity and mortality. Because the Department of Defense does not currently have recommended guidelines and standard operating procedures to perform military preventable death reviews in a consistent manner, these performance improvement processes must be developed., Objectives: To compare military and civilian preventable death determination methods to understand the existing best practices for evaluating preventable death., Evidence Review: This systematic review followed the PRISMA reporting guidelines. English-language articles were searched from inception to February 15, 2017, using the following databases: MEDLINE (Ovid), Evidence-Based Medicine Reviews (Ovid), PubMed, CINAHL, and Google Scholar. Articles were initially screened for eligibility and excluded based on predetermined criteria. Articles reviewing only prehospital deaths, only inhospital deaths, or both were eligible for inclusion. Information on study characteristics was independently abstracted by 2 investigators. Reported are methodological factors affecting the reliability of preventable death studies and the preventable death rate, defined as the number of potentially preventable deaths divided by the total number of deaths within a specific patient population., Findings: Fifty studies (8 military and 42 civilian) met the inclusion criteria. In total, 1598 of 6500 military deaths reviewed and 3346 of 19 108 civilian deaths reviewed were classified as potentially preventable. Among military studies, the preventable death rate ranged from 3.1% to 51.4%. Among civilian studies, the preventable death rate ranged from 2.5% to 85.3%. The high level of methodological heterogeneity regarding factors, such as preventable death definitions, review process, and determination criteria, hinders a meaningful quantitative comparison of preventable death rates., Conclusions and Relevance: The reliability of military and civilian preventable death studies is hindered by inconsistent definitions, incompatible criteria, and the overall heterogeneity in study methods. The complexity, inconsistency, and unpredictability of combat require unique considerations to perform a methodologically sound combat-related preventable death review. As the Department of Defense begins the process of developing recommended guidelines and standard operating procedures for performing military preventable death reviews, consideration must be given to the factors known to increase the risk of bias and poor reliability.
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- 2018
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38. A Review of Casualties Transported to Role 2 Medical Treatment Facilities in Afghanistan.
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Kotwal RS, Staudt AM, Trevino JD, Valdez-Delgado KK, Le TD, Gurney JM, Sauer SW, Shackelford SA, Stockinger ZT, and Mann-Salinas EA
- Subjects
- Adult, Afghan Campaign 2001-, Afghanistan, Female, Humans, Male, Military Medicine methods, Military Medicine trends, Mortality, Patient Transfer methods, Retrospective Studies, Air Ambulances statistics & numerical data, Military Personnel statistics & numerical data, Patient Transfer statistics & numerical data
- Abstract
Critically injured trauma patients benefit from timely transport and care. Accordingly, the provision of rapid transport and effective treatment capabilities in appropriately close proximity to the point of injury will optimize time and survival. Pre-transport tactical combat casualty care, rapid transport with en route casualty care, and advanced damage control resuscitation and surgery delivered early by small, mobile, forward-positioned Role 2 medical treatment facilities have potential to reduce morbidity and mortality from trauma. This retrospective review and descriptive analysis of trauma patients transported from Role 1 entities to Role 2 facilities in Afghanistan from 2008 to 2014 found casualties to be diverse in affiliation and delivered by various types and modes of transport. Air medical evacuation provided transport for most patients, while the shortest transport time was seen with air casualty evacuation. Although relatively little data were collected for air casualty evacuation, this rapid mode of transport remains an operationally important method of transport on the battlefield. For prehospital care provided before and during transport, continued leadership and training emphasis should be placed on the administration and documentation of tactical combat casualty care as delivered by both medical and non-medical first responders.
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- 2018
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39. Reexamination of a Battlefield Trauma Golden Hour Policy.
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Howard JT, Kotwal RS, Santos-Lazada AR, Martin MJ, and Stockinger ZT
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- Adult, Blood Transfusion, Female, Humans, Injury Severity Score, Male, Retrospective Studies, Young Adult, Afghan Campaign 2001-, Emergency Medical Services, Military Medicine, Policy, Wounds and Injuries mortality
- Abstract
Background: Most combat casualties who die, do so in the prehospital setting. Efforts directed toward alleviating prehospital combat trauma death, known as killed in action (KIA) mortality, have the greatest opportunity for eliminating preventable death., Methods: Four thousand five hundred forty-two military casualties injured in Afghanistan from September 11, 2001, to March 31, 2014, were included in this retrospective analysis to evaluate proposed explanations for observed KIA reduction after a mandate by Secretary of Defense Robert M. Gates that transport of injured service members occur within 60 minutes. Using inverse probability weighting to account for selection bias, data were analyzed using multivariable logistic regression and simulation analysis to estimate the effects of (1) gradual improvement, (2) damage control resuscitation, (3) harm from inadequate resources, (4) change in wound pattern, and (5) transport time on KIA mortality., Results: The effect of gradual improvement measured as a time trend was not significant (adjusted odds ratio [AOR], 0.99; 95% confidence interval [CI], 0.94-1.03; p = 0.58). For casualties with military Injury Severity Score of 25 or higher, the odds of KIA mortality were 83% lower for casualties who needed and received prehospital blood transfusion (AOR, 0.17; 95% CI, 0.06-0.51; p = 0.002); 33% lower for casualties receiving initial treatment by forward surgical teams (AOR, 0.67; 95% CI, 0.58-0.78; p < 0.001); 70%, 74%, and 87% lower for casualties with dominant injuries to head (AOR, 0.30; 95% CI, 0.23-0.38; p < 0.001), abdomen (AOR, 0.26, 95% CI, 0.19-0.36; p < 0.001) and extremities (AOR, 0.13; 95% CI, 0.09-0.17; p < 0.001); 35% lower for casualties categorized with blunt injuries (AOR, 0.65; 95% CI, 0.46-0.92; p = 0.01); and 39% lower for casualties transported within one hour (AOR, 0.61; 95% CI, 0.51-0.74; p < 0.001). Results of simulations in which transport times had not changed after the mandate indicate that KIA mortality would have been 1.4% higher than observed, equating to 135 more KIA deaths (95% CI, 105-164)., Conclusion: Reduction in KIA mortality is associated with early treatment capabilities, blunt mechanism, select body locations of injury, and rapid transport., Level of Evidence: Therapy, level III.
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- 2018
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40. Follow-Up Evaluation of the U.S. Army Institute of Surgical Research Burn Flow Sheet for En Route Care Documentation of Burned Combat Casualties.
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Caldwell NW, Serio-Melvin ML, Chung KK, Salinas J, Shiels ME, Cancio LC, Stockinger ZT, and Mann-Salinas EA
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- Air Ambulances organization & administration, Body Surface Area, Burn Units organization & administration, Burn Units trends, Burns epidemiology, Checklist methods, Documentation methods, Fluid Therapy standards, Follow-Up Studies, Humans, Military Medicine methods, Resuscitation methods, Resuscitation standards, Retrospective Studies, Burns nursing, Checklist standards, Documentation standards
- Abstract
Introduction: In 2006, burn clinical practice guidelines were developed to provide recommendations for optimal care of U.S. military and local national burn casualties. As part of that effort, a paper-based Burn Flow Sheet (BFS) was included to document the burn resuscitation of combat casualties with ≥20% total body surface area burns. The purpose of this study was to evaluate the BFS in terms of ongoing utilization, resuscitation management, and outcomes of patients transported., Materials and Methods: A retrospective review was performed of hard-copy BFSs received from January 2007 to December 2013. En route injury and treatment data from these flowsheets were manually transcribed into the research database. Outcomes and complications of BFS subjects were extracted from the Burn Center Registry and added to the research database., Results: A total of 73 BFSs were collected from the study period. On average, BFSs were 61 ± 30% complete with a total of 14.7 ± 7 hours documented per patient in the first 24-hours postburn. Patients received nearly 7 L more fluid than estimated by traditional formulas. Sixteen patients (26%) received greater than 250 mL/kg of fluid, half of whom had concomitant traumatic injuries. Fifteen patients received a fasciotomy (21%), 4 received a laparotomy (5%), and 8 (11%) received both. No patients developed abdominal compartment syndrome associated with fluid resuscitation. Overall mortality was 21%., Conclusions: Although the majority of providers did initiate a BFS, it was not always used as intended; problems included missing data and miscalculations. Although there was a clear improvement with decline in the incidence of abdominal compartment syndrome, mortality did not change for severely burned patients. Simplification of the recommendations, additional built-in prompts, and automated tools such as computerized decision support software may help standardize practice and improve outcomes., (Reprint & Copyright © 2017 Association of Military Surgeons of the U.S.)
- Published
- 2017
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41. Association of Prehospital Blood Product Transfusion During Medical Evacuation of Combat Casualties in Afghanistan With Acute and 30-Day Survival.
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Shackelford SA, Del Junco DJ, Powell-Dunford N, Mazuchowski EL, Howard JT, Kotwal RS, Gurney J, Butler FK Jr, Gross K, and Stockinger ZT
- Subjects
- Adult, Air Ambulances, Female, Humans, Male, Proportional Hazards Models, Retrospective Studies, Survival Analysis, Time-to-Treatment, United States, Wounds and Injuries mortality, Young Adult, Afghan Campaign 2001-, Blood Transfusion, Emergency Medical Services, Military Medicine, Military Personnel, Wounds and Injuries therapy
- Abstract
Importance: Prehospital blood product transfusion in trauma care remains controversial due to poor-quality evidence and cost. Sequential expansion of blood transfusion capability after 2012 to deployed military medical evacuation (MEDEVAC) units enabled a concurrent cohort study to focus on the timing as well as the location of the initial transfusion., Objective: To examine the association of prehospital transfusion and time to initial transfusion with injury survival., Design, Setting, and Participants: Retrospective cohort study of US military combat casualties in Afghanistan between April 1, 2012, and August 7, 2015. Eligible patients were rescued alive by MEDEVAC from point of injury with either (1) a traumatic limb amputation at or above the knee or elbow or (2) shock defined as a systolic blood pressure of less than 90 mm Hg or a heart rate greater than 120 beats per minute., Exposures: Initiation of prehospital transfusion and time from MEDEVAC rescue to first transfusion, regardless of location (ie, prior to or during hospitalization). Transfusion recipients were compared with nonrecipients (unexposed) for whom transfusion was delayed or not given., Main Outcomes and Measures: Mortality at 24 hours and 30 days after MEDEVAC rescue were coprimary outcomes. To balance injury severity, nonrecipients of prehospital transfusion were frequency matched to recipients by mechanism of injury, prehospital shock, severity of limb amputation, head injury, and torso hemorrhage. Cox regression was stratified by matched groups and also adjusted for age, injury year, transport team, tourniquet use, and time to MEDEVAC rescue., Results: Of 502 patients (median age, 25 years [interquartile range, 22 to 29 years]; 98% male), 3 of 55 prehospital transfusion recipients (5%) and 85 of 447 nonrecipients (19%) died within 24 hours of MEDEVAC rescue (between-group difference, -14% [95% CI, -21% to -6%]; P = .01). By day 30, 6 recipients (11%) and 102 nonrecipients (23%) died (between-group difference, -12% [95% CI, -21% to -2%]; P = .04). For the 386 patients without missing covariate data among the 400 patients within the matched groups, the adjusted hazard ratio for mortality associated with prehospital transfusion was 0.26 (95% CI, 0.08 to 0.84, P = .02) over 24 hours (3 deaths among 54 recipients vs 67 deaths among 332 matched nonrecipients) and 0.39 (95% CI, 0.16 to 0.92, P = .03) over 30 days (6 vs 76 deaths, respectively). Time to initial transfusion, regardless of location (prehospital or during hospitalization), was associated with reduced 24-hour mortality only up to 15 minutes after MEDEVAC rescue (median, 36 minutes after injury; adjusted hazard ratio, 0.17 [95% CI, 0.04 to 0.73], P = .02; there were 2 deaths among 62 recipients vs 68 deaths among 324 delayed transfusion recipients or nonrecipients)., Conclusions and Relevance: Among medically evacuated US military combat causalities in Afghanistan, blood product transfusion prehospital or within minutes of injury was associated with greater 24-hour and 30-day survival than delayed transfusion or no transfusion. The findings support prehospital transfusion in this setting.
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- 2017
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42. Military use of tranexamic acid in combat trauma: Does it matter?
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Howard JT, Stockinger ZT, Cap AP, Bailey JA, and Gross KR
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- Adult, Female, Humans, Male, Retrospective Studies, Survival Rate, Treatment Outcome, Warfare, Young Adult, Antifibrinolytic Agents therapeutic use, Military Medicine, Tranexamic Acid therapeutic use, Wounds and Injuries mortality, Wounds and Injuries therapy
- Abstract
Background: Tranexamic acid (TXA) has been previously reported to have a mortality benefit in civilian and combat-related trauma, and was thus added to the Joint Theater Trauma System Damage Control Resuscitation Clinical Practice Guideline. As part of ongoing system-wide performance improvement, the use of TXA has been closely monitored. The goal was to evaluate the efficacy and safety of TXA use in military casualties and provide additional guidance for continued use., Methods: A total of 3,773 casualties were included in this retrospective, observational study of data gathered from a trauma registry. The total sample, along with three subsamples for massive transfusion patients (n = 784), propensity-matched sample (n = 1,030), and US/North Atlantic Treaty Organization (NATO) military (n = 1,262), was assessed for administration of TXA and time from injury to administration of TXA. Outcomes included mortality and occurrence of pulmonary embolism and deep vein thrombosis. Multivariable proportional hazards regression models with robust standard error estimates were used to estimate hazard ratios (HR) for assessment of outcomes while controlling for covariates., Results: Results of univariate and multivariate analyses of the total sample (HR, 0.97; 95% confidence interval [CI], 0.62-1.53; p = 0.86), massive transfusion sample (HR, 0.84; 95% CI, 0.46-1.56; p = 0.51), propensity-matched sample (HR, 0.68; 95% CI, 0.27-1.73; p = 0.34), and US/NATO military sample (HR, 0.76; 95% CI, 0.30-1.92; p = 0.48) indicate no statistically significant association between TXA use and mortality. Use of TXA was associated with increased risk of pulmonary embolism in the total sample (HR, 2.82; 95% CI, 2.08-3.81; p < 0.001), massive transfusion sample (HR, 3.64; 95% CI, 1.96-6.78; p = 0.003), US/NATO military sample (HR, 2.55; 95% CI, 1.73-3.69; p = 0.002), but not the propensity-matched sample (HR, 3.36; 95% CI, 0.80-14.10; p = 0.10). TXA was also associated with increased risk of deep vein thrombosis in the total sample (HR, 2.00; 95% CI, 1.21-3.30; p = 0.02) and US/NATO military sample (HR, 2.18; 95% CI, 1.20-3.96; p = 0.02)., Conclusion: In the largest study on TXA use in a combat trauma population, TXA was not significantly associated with mortality, due to lack of statistical power. However, our HR estimates for mortality among patients who received TXA are consistent with previous findings from the CRASH-2 trial. At the same time, continued scrutiny and surveillance of TXA use in military trauma, specifically for prevention of thromboembolic events, is warranted., Level of Evidence: Therapeutic, level IV.
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- 2017
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43. Combat surgical workload in Operation Iraqi Freedom and Operation Enduring Freedom: The definitive analysis.
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Turner CA, Stockinger ZT, and Gurney JM
- Subjects
- Adult, Afghan Campaign 2001-, Clinical Competence, Hospitals, Military, Humans, Iraq War, 2003-2011, Military Medicine, Registries, Retrospective Studies, United States, Workload, Wounds and Injuries surgery
- Abstract
Background: Relatively few publications exist on surgical workload in the deployed military setting. This study analyzes US military combat surgical workload in Iraq and Afghanistan to gain a more thorough understanding of surgical training gaps and personnel requirements., Methods: A retrospective analysis of the Department of Defense Trauma Registry was performed for all Role 2 (R2) and Role 3 (R3) military treatment facilities from January 2001 to May 2016. International Classification of Diseases, Ninth Revision, Clinical Modification procedure codes were grouped into 18 categories based on functional surgical skill sets. The 189,167 surgical procedures identified were stratified by role of care, month, and year. Percentiles were calculated for the number of procedures for each skill set. A literature search was performed for publications documenting combat surgical workload during the same period., Results: A total of 23,548 surgical procedures were performed at R2 facilities, while 165,619 surgical procedures were performed at R3 facilities. The most common surgical procedures performed overall were soft tissue (37.5%), orthopedic (13.84%), abdominal (13.01%), and vascular (6.53%). The least common surgical procedures performed overall were cardiac (0.23%), peripheral nervous system (0.53%), and spine (0.34%).Mean surgical workload at any point in time clearly underrepresented those units in highly kinetic areas, at times by an order of magnitude or more. The published literature always demonstrated workloads well in excess of the 50th percentile for the relevant time period., Conclusions: The published literature on combat surgical workload represents the high end of the spectrum of deployed surgical experience. These trends in surgical workload provide vital information that can be used to determine the manpower needs of future conflicts in ever-changing operational tempo environments. Our findings provide surgical types and surgical workload requirements that will be useful in surgical training and placement of medical assets in future conflicts., Level of Evidence: Epidemiologic study, level III; Care management, level III.
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- 2017
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44. Establishing a Joint Theater Trauma System During Phase Zero Operations.
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Walker JJ, Stockinger ZT, and Chinn CG
- Subjects
- Hospitals, Military organization & administration, Humans, Military Medicine trends, Pacific Ocean epidemiology, Time Factors, Warfare, Wounds and Injuries epidemiology, Cooperative Behavior, Hospitals, Military trends, Military Medicine methods
- Abstract
Objectives: Military personnel risk injury due to accidents, disasters, and military threats during Phase Zero "shaping" operations. Medical facilities must be poised to respond., Methods: The U.S. Pacific Command (PACOM) Area of Responsibility (AOR) covers more than 50% of the earth's surface; relevant Clinical Practice Guidelines must include the maritime setting and extended evacuation periods. Military hospitals in the region are not connected by a defined Trauma System. There is variable adherence to trauma training requirements before assignment in this AOR. Demand for trauma care at any 1 location is low and trauma teams have little opportunity to maintain competency for high-risk/low-volume interventions. There is no documentation of total demand for trauma care in the AOR. Trauma care in PACOM is often deferred to civilian facilities., Results: Core elements of a Joint Theater Trauma System (JTTS) as established during combat operations in U.S. Central Command are applicable during Phase Zero. A PACOM JTTS was established to address the region's readiness to respond to Phase Zero trauma as well as escalation of regional threats. Information technology coordination was a critical hurdle to overcome., Conclusion: PACOM lessons learned are applicable to other Geographic Combatant Commands developing a JTTS during Phase Zero operations., (Reprint & Copyright © 2017 Association of Military Surgeons of the U.S.)
- Published
- 2017
- Full Text
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45. Evaluation of role 2 (R2) medical resources in the Afghanistan combat theater: Initial review of the joint trauma system R2 registry.
- Author
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Mann-Salinas EA, Le TD, Shackelford SA, Bailey JA, Stockinger ZT, Spott MA, Wirt MD, Rickard R, Lane IB, Hodgetts T, Cardin S, Remick KN, and Gross KR
- Subjects
- Afghan Campaign 2001-, Humans, Retrospective Studies, United States, Military Medicine, Military Personnel statistics & numerical data, Registries, Traumatology statistics & numerical data, Wounds and Injuries epidemiology
- Abstract
Background: A Role 2 registry (R2R) was developed in 2008 by the US Joint Trauma System (JTS). The purpose of this project was to undertake a preliminary review of the R2R to understand combat trauma epidemiology and related interventions at these facilities to guide training and optimal use of forward surgical capability in the future., Methods: A retrospective review of available JTS R2R records; the registry is a convenience sample entered voluntarily by members of the R2 units. Patients were classified according to basic demographics, affiliation, region where treatment was provided, mechanism of injury, type of injury, time and method of transport from point of injury (POI) to R2 facility, interventions at R2, and survival. Analysis included trauma patients aged ≥18 years or older wounded in year 2008 to 2014, and treated in Afghanistan., Results: A total of 15,404 patients wounded and treated in R2 were included in the R2R from February 2008 to September 2014; 12,849 patients met inclusion criteria. The predominant patient affiliations included US Forces, 4,676 (36.4%); Afghan Forces, 4,549 (35.4%); and Afghan civilians, 2,178 (17.0%). Overall, battle injuries predominated (9,792 [76.2%]). Type of injury included penetrating, 7,665 (59.7%); blunt, 4,026 (31.3%); and other, 633 (4.9%). Primary mechanism of injury included explosion, 5,320 (41.4%); gunshot wounds, 3,082 (24.0%); and crash, 1,209 (9.4%). Of 12,849 patients who arrived at R2, 167 (1.3%) were dead; of 12,682 patients who were alive upon arrival, 342 (2.7%) died at R2., Conclusion: This evaluation of the R2R describes the patient profiles of and common injuries treated in a sample of R2 facilities in Afghanistan. Ongoing and detailed analysis of R2R information may provide evidence-based guidance to military planners and medical leaders to best prepare teams and allocate R2 resources in future operations. Given the limitations of the data set, conclusions must be interpreted in context of other available data and analyses, not in isolation., Level of Evidence: Epidemiologic study, level IV.
- Published
- 2016
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46. Assessment of Groin Application of Junctional Tourniquets in a Manikin Model.
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Kragh JF, Lunati MP, Kharod CU, Cunningham CW, Bailey JA, Stockinger ZT, Cap AP, Chen J, Aden JK, and Cancio LC
- Subjects
- Emergency Treatment methods, Humans, Military Medicine methods, Military Medicine standards, Simulation Training methods, United States, Emergency Treatment standards, Groin injuries, Hemorrhage therapy, Manikins, Military Medicine education, Simulation Training standards, Tourniquets
- Abstract
Unlabelled: Introduction To aid in preparation of military medic trainers for a possible new curriculum in teaching junctional tourniquet use, the investigators studied the time to control hemorrhage and blood volume lost in order to provide evidence for ease of use. Hypothesis Models of junctional tourniquet could perform differentially by blood loss, time to hemostasis, and user preference., Methods: In a laboratory experiment, 30 users controlled simulated hemorrhage from a manikin (Combat Ready Clamp [CRoC] Trainer) with three iterations each of three junctional tourniquets. There were 270 tests which included hemorrhage control (yes/no), time to hemostasis, and blood volume lost. Users also subjectively ranked tourniquet performance. Models included CRoC, Junctional Emergency Treatment Tool (JETT), and SAM Junctional Tourniquet (SJT). Time to hemostasis and total blood loss were log-transformed and analyzed using a mixed model analysis of variance (ANOVA) with the users represented as random effects and the tourniquet model used as the treatment effect. Preference scores were analyzed with ANOVA, and Tukey's honest significant difference test was used for all post-hoc pairwise comparisons., Results: All tourniquet uses were 100% effective for hemorrhage control. For blood loss, CRoC and SJT performed best with least blood loss and were significantly better than JETT; in pairwise comparison, CRoC-JETT (P .5, all models)., Conclusion: The CRoC and SJT performed best in having least blood loss, CRoC performed best in having least time to hemostasis, and users did not differ in preference of model. Models of junctional tourniquet performed differentially by blood loss and time to hemostasis. Kragh JF Jr , Lunati MP , Kharod CU , Cunningham CW , Bailey JA , Stockinger ZT , Cap AP , Chen J , Aden JK 3d , Cancio LC . Assessment of groin application of junctional tourniquets in a manikin model. Prehosp Disaster Med. 2016;31(4):358-363.
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- 2016
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47. The Military Injury Severity Score (mISS): A better predictor of combat mortality than Injury Severity Score (ISS).
- Author
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Le TD, Orman JA, Stockinger ZT, Spott MA, West SA, Mann-Salinas EA, Chung KK, and Gross KR
- Subjects
- Adult, Afghan Campaign 2001-, Female, Humans, Iraq War, 2003-2011, Male, Predictive Value of Tests, Registries, United States, Injury Severity Score, Military Personnel statistics & numerical data, Wounds and Injuries mortality
- Abstract
Background: The Military Injury Severity Score (mISS) was developed to better predict mortality in complex combat injuries but has yet to be validated., Methods: US combat trauma data from Afghanistan and Iraq from January 1, 2003, to December 31, 2014, from the US Department of Defense Trauma Registry (DoDTR) were analyzed. Military ISS, a variation of the ISS, was calculated and compared with standard ISS scores.Receiver operating characteristic curve, area under the curve, and Hosmer-Lemeshow statistics were used to discriminate and calibrate between mISS and ISS. Wilcoxon-Mann-Whitney, t test and χ tests were used, and sensitivity and specificity calculated. Logistic regression was used to calculate the likelihood of mortality associated with levels of mISS and ISS overall., Results: Thirty thousand three hundred sixty-four patients were analyzed. Most were male (96.8%). Median age was 24 years (interquartile range [IQR], 21-29 years). Battle injuries comprised 65.3%. Penetrating (39.5%) and blunt (54.2%) injury types and explosion (51%) and gunshot wound (15%) mechanisms predominated. Overall mortality was 6.0%.Median mISS and ISS were similar in survivors (5 [IQR, 2-10] vs. 5 [IQR, 2-10]) but different in nonsurvivors, 30 (IQR, 16-75) versus 24 (IQR, 9-23), respectively (p < 0.0001). Military ISS and ISS were discordant in 17.6% (n = 5,352), accounting for 56.2% (n = 1,016) of deaths. Among cases with discordant severity scores, the median difference between mISS and ISS was 9 (IQR, 7-16); range, 1 to 59. Military ISS and ISS shared 78% variability (R = 0.78).Area under the curve was higher in mISS than in ISS overall (0.82 vs. 0.79), for battle injury (0.79 vs. 0.76), non-battle injury (0.87 vs. 0.86), penetrating (0.81 vs. 0.77), blunt (0.77 vs. 0.75), explosion (0.81 vs. 0.78), and gunshot (0.79 vs. 0.73), all p < 0.0001. Higher mISS and ISS were associated with higher mortality. Compared with ISS, mISS had higher sensitivity (81.2 vs. 63.9) and slightly lower specificity (80.2 vs. 85.7)., Conclusion: Military ISS predicts combat mortality better than does ISS., Level of Evidence: Prognostic and epidemiologic study, level III.
- Published
- 2016
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48. A piece of my mind. Death and life in Afghanistan.
- Author
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Stockinger ZT
- Subjects
- Afghanistan, Attitude of Health Personnel, Humans, United States, Afghan Campaign 2001-, Military Medicine, Physician's Role, Traumatology
- Published
- 2009
- Full Text
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49. A piece of my mind. Death and life in Iraq.
- Author
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Stockinger ZT
- Subjects
- Attitude of Health Personnel, General Surgery, Humans, Iraq, Male, Military Personnel, Traumatology, United States, Wounds, Gunshot surgery, Attitude to Death, Military Medicine, Warfare
- Published
- 2005
- Full Text
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50. Cervical spine imaging in comatose patients.
- Author
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Stockinger ZT and McSwain NE Jr
- Subjects
- Humans, Magnetic Resonance Imaging, Tomography, X-Ray Computed, Brain Injuries diagnostic imaging, Cervical Vertebrae diagnostic imaging, Coma diagnostic imaging
- Published
- 2005
- Full Text
- View/download PDF
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