|
 
 |
| CASE REPORT |
|
| Year : 2021 | Volume
: 9
| Issue : 2 | Page : 77-80 |
|
Lessons from a battle-front: When and where to “scoop and scoot”?
Shibu Sasidharan1, BL Lahareesh1, Harpreet Singh Dhillon2
1 Department of Anaesthesia and Critical Care, Level III IFH Hospital, MONUSCO, Goma, Democratic Republic of the Congo
2 Department of Psychiatry, Level III IFH Hospital, MONUSCO, Goma, Democratic Republic of the Congo
| Date of Submission | 23-Jan-2021 |
| Date of Decision | 11-Mar-2021 |
| Date of Acceptance | 25-Mar-2021 |
| Date of Web Publication | 11-Jun-2021 |
Correspondence Address:
Dr. Shibu Sasidharan
Department of Anaesthesia and Critical Care, Level III IFH Hospital, Goma
Democratic Republic of the Congo
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/mjhs.mjhs_6_21
There has been game-changing advances in battlefield medicine. Improved training and expertise has enabled emergency medical personnel to provide advanced levels of care at the scene of trauma. It is better to “scoop and run” than “stay and play”. Current data relates to the urban environment where transport times to trauma centres are short and where it appears better to simply rapidly transport the patient to hospital than attempt major interventions at the scene. There may be more need for advanced techniques in the rural environment or where transport times are prolonged and certainly a need for more studies into subsets of patients who may benefit from interventions in the field. This report examines how time and early response is crucial in saving lives and decreasing morbidity. This article also gives insight into the to-do list for paramedics and doctors before and during causality transfers.
Keywords: Battlefield Medicine, CASEVAC, MEDEVAC, Casualty Evacuation, Trauma
How to cite this article:
Sasidharan S, Lahareesh B L, Dhillon HS. Lessons from a battle-front: When and where to “scoop and scoot”?. MRIMS J Health Sci 2021;9:77-80 |
| Introduction | |  |
In a war zone, artillery and firearm injuries are common. The forward surgical units, like ours, situated at Goma in the DR Congo, that cater to such injuries are equipped with emergency medical and surgical capabilities, as per the level of care. Trauma centers are classified from Level 1 to 5.[1] Most often than not, the causalities that reach our emergency bay are cases that have been initially managed by the first responders (doctors or paramedics) and come to our hospital for further care. Taking two reference case, we like to highlight a few points to remember when managing and most importantly deciding when, how and where to evacuate the patient.
| Case 1 | | |
We recently had a case of bullet injury to the head that was evacuated to our hospital by air from a forward location. A 26-year-old soldier was shot on the head in a close range with a rifle. As the perpetrators fled, he was left in a “pool of blood.” Patient was unconscious, but was breathing normally. Help arrived in the form of paramedics, who informed the doctor, who was an hour away at a different location. Taking his advice on phone, tight compressive dressing was given, and oxygen was administered to the patient. The doctor meanwhile raised a causality evacuation call, to shift to our center which is a level 3 hospital. In the frenzy of the moment, his initial intimation to this hospital was “patient has suffered a bullet injury to the head by a gun shot and is critical.” The patient had got injured at 0400 h in the morning. He arrived at our center at 1200 h, 8 h after getting injured. The patient arrived in the emergency bay, with a Glasgow Coma Score (GCS) of 03/15, with no definite airway, no oxygen and only connected to a SpO2 probe which read 68%–72%. On arrival, his blood pressure was recorded as 132/60 mm Hg, heart rate– 99 bpm and electrocardiogram– sinus tachycardia. There were entry and exit wounds on both sides of his forehead on the temporal side (Rt – 1 cm and Lt – 1.5 cm). He was rushed to the intensive care unit, urgent blood panels sent including blood grouping, GCS reassessed, and definitive airway was taken and was mechanically ventilated. Before intubation, it was noted that his mouth was frothing with fresh blood and he had aspirated the same, which also came out through the endotracheal tube after intubation. Aspirate was suctioned using sterile techniques. A central line was inserted in the Rt subclavian, and X-ray images were taken of skull and chest. Since this center did not have advanced imagine facilities such as computed tomography scan or magnetic resonance imaging and super-specialties like neurosurgery, a decision was taken to immediately evacuate the patient to a Level 4 center which had all these facilities. The clearance for travel by air to a neighboring country (Uganda) in these times of COVID-19 needed a mandatory reverse transcription polymerase chain reaction (RT PCR) negative status. This report took 02 h to come. By then, his blood panels had come. Hb: 8.8 mg/dl, packed cell volume: 25.2%, white blood cell: 5900/cu.mm, total leukocyte count: N79E2B0M3 L16, platelets: 103 × 103, international normalized ratio 1.7, bleeding and clotting time: within normal limits.
Radiograph skull anteroposterior (AP) and lateral view showed a bony defect in bilateral temporal region (entry and exit wounds) with fracture line extending anteriorly and posteriorly from them. The anterior fracture line extended to the frontal bone and the posterior fracture line extends posteriorly within temporal bone before dividing to superior arm extending to parietal bone and inferior – extending to base of skull in region in petrous part of temporal bone. Pneumoencephalus was noted in the frontal region on the lateral view. There were few bone fragments noted within the calvarium – Likely scattered skull fragments. There was a fracture of the lateral aspect of greater wing of right sphenoid (likely site of entry wound) and fracture of mid third of greater wing of sphenoid (left-exit wound).
Chest AP view showed central line in situ inserted from the right subclavian region and tip in region of superior vein cava/Brachiocephalic junction. Scattered air space opacities are noted in both lung fields (right > left).
Just as the patient was being prepared to be shifted, the patient had sudden hypotension with bradycardia, which progressed to ventricular tachycardia (VT). Despite starting inotropes at the very onset of hypotension, the patient quickly deteriorated and in the next 03 min arrested with a VT. Despite all treatment given as per the advanced cardiovascular life support protocols, the patient could not be revived and was declared dead at 1530 h.
| Case 2 | | |
Two soldiers suffered injuries after a generator blast close to their duty station. This sent flying pieces of metal into the air which in great velocity injured the soldiers, including fracturing the skull of a patient. Both patients had extensive trauma to their limbs and abdomen. Since medical help was immediately available, both the patients were rushed to the medical bay, where compression dressing was applied to stop the bleeding, and they were given oxygen, started on iv fluids, given pain medications and antibiotics. The patient with a penetrating trauma to the head had GCS 15/15 and was conversing, though with pain.
They were shifted to our hospital for staging while procedures to shift the patient to a level 4 centre was already in motion. As the patients arrived, RT PCR samples were taken and as soon the reports came, they were shifted to the higher center. Both patients survived the incident and are presently in rehabilitation.
| Discussion | | |
Trauma center levels across the many countries of the world are identified in a designation process. The different levels (i.e., Level I, II, III, IV, or V) refer to the kinds of resources available in a trauma center and the number of patients admitted yearly. These are categories that define national standards for trauma care in hospitals. Categorization is unique to both adult and pediatric facilities.[2]
Trauma center designation is a process outlined and developed at a state or local level. The state or local municipality identifies unique criteria in which to categorize trauma centers. These categories may vary from state to state and are typically outlined through legislative or regulatory authority.
Emergency evacuation in a health care environment has focused on methods for evacuating a facility, resources for transferring patients, and sufficient capacity at sheltering facilities.[2] What has been overlooked is the interaction between health-care facility evacuation that would result in cases of significant logistic congestion. Every medical unit should have a deterministic optimization approach for identifying the staffing and vehicle transport requirements, as well as the scheduling of these requirements, within a prespecified evacuation time period while minimizing cost.[3]
Patient transfers can be placed in three broad categories. The first category includes the horizontal transfer of a patient from one flat surface to another. The second category involves upright transfers where a patient is moved from a horizontal position to an upright position or a sitting position in a wheelchair, chair or commode and the return of the patient to the horizontal position from an upright or sitting position. The third category of transfer relates to the movement of patients to change their position in a bed or chair, such as pulling the patient up in the bed or rolling the patient from side to side. Although many attempts have been made to devise improved systems for patient transfer, almost all of these transfers are continued to be manually performed.[4]
| Establishing Patient Movement Requirement | | |
It is pertinent to establish and document what treatment a patient needs and where the patient can get that from. It is important to identify patients that can and cannot be evacuated, establish evacuation options and requirements for special needs of patients (neonatal, critical care, psychiatric, dialysis, and nursing home) aanticipate medical personnel and equipment requirements to transport a wide range of civilian patient categories.[5]
| Appropriate Patient Preparation | | |
Patients moved from war zones are often high acuity critical care patients. Although there are no absolute contraindications to aeromedical evacuation, patient selection and preparation are key elements in safe patient movement. The major medical risks associated with air transport are hypoxia and gas expansion. Other factors that may affect patients include noise, temperature variations, vibration, low lighting, and the stresses of multiple patient transfers. During a disaster, the sending physician has to believe the level of care will be improved by transferring the patient from one medical facility to another and be willing to accept the risk associated with the transfer.[5] This being said, a disaster may mandate hospital evacuation because of loss of infrastructure. The transferring physician should consider that it may take considerable amount of time before the patient is back in a hospital comparable with the one the patient left.[6]
Few considerations before transfer by air
- Airway protected?
- Breathing adequately supported?
- Circulation acceptable?
- Disability?
- Brain injuries swell and seizure thresholds lower at altitude. Take precautions and premedicate to prevent seizures, if needed. Ensure the aeromedical evacuation crews have the tools they need to address seizures if they develop (i e., IV Ativan and IV access).
- Expansion, as in trapped air
- Ensure careful fixation and stabilization of all lines and tubes
- Equipment and supplies
- Psychiatric patients are likely to need attendants, they must not be disruptive, and they must be able to follow directions.[7]
| Conclusion | | |
In Case 1, it is likely that despite our best efforts, we would not been able to save the patient due to the nature of the injury. In Case 1, the patient should have gone directly to Level 4/5, and in Case 2, the patient took the benefit of Level 3 hospital while already being in line for transfer to Level 4/5. This saves precious time. However, since the patient deteriorated hemodynamically only after 11 h of insult, there is a remote possibility that some neuro-intervention could have possibility made a difference in outcome. Patient's airway was unprotected during the transfer during which oxygen was also not administered. This could have caused hypoxic brain damage, in a journey spanning 45 min. Our patient could have succumbed to his head trauma, aspiration pneumonitis, or hypovolemia. Timely and vigorous intervention on two cases mentioned in Case 2, saw favorable outcomes.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | |
| 2. | Duanmu J, Taaffe K, Chowdhury M. Minimizing patient transport times during mass population evacuations. Transp Res Rec J Transp Res Board 2010;2196:150-8. Available from: http://journals.sagepub.com/doi/100.3141/2196-16. [Last accessed on 2021 Jan 20].  |
| 3. | Tayfur E, Taaffe K. A model for allocating resources during hospital evacuations. Comput Ind Eng 2009;57:1313-23. |
| 4. | Sasidharan S, Singh V, Dhillon HS, Babitha M. Patient isolation pods for the evacuation of COVID-19 infected patients – Is this the answer? J Anaesthesiol Clin Pharmacol [serial online] 2020 [cited 2021 Apr 13];36, Suppl S1:152-5. |
| 5. | |
| 6. | Patterson CM, Woodcock T, Mollan IA, Nicol ED, McLoughlin DC. United Kingdom military aeromedical evacuation in the Post-9/11 Era. Aviat Sp Environ Med 2014;85:1005-12. |
| 7. | Hurd WW, Montminy RJ, De Lorenzo RA, Burd LT, Goldman BS, Loftus TJ. Physician roles in aeromedical evacuation: Current practices in USAF operations. Aviat Space Environ Med 2006;77:631-8. |
|
Search Pubmed for