TRAINING FOR ARMED CONFLICTS General hospital “Dr. Josip Benčević” Hrečkovski Boris Department of surgery General hospital “Dr. Josip Benčević” Slavonski Brod Croatia

Historical evidence make it all clear, and besides that, in a knowledge which is based on experience, have excellent evidence power. More than anywhere else, this is thrue in war practice. Clausewitz

The more things change, the more they seem to remain the same The more things change, the more they seem to remain the same. - remarkable changes in surgical diagnostic and therapeuthics in the last two decades - wound ballistics, injuries are the same - DOW in Word War II 3.5%, Vietnam 3.4% - penetrating wounds of the head and chest are as lethal today as they where in biblical times Dave Ed. Lounsbury, MD Colonel, Medical Corps Emergency War Surgery, 2004.

Aim of combat medicine is to achieve the return of the greatest number of injured to combat and the preservation of life, limb, eyesight. “Victory is the best medicine”

How to achieve improvement in combat medicine How to achieve improvement in combat medicine? - body armours in combat operations - move surgeons towards front line, FSU - training medical personality for armed conflicts - BLS education for all professional soldiers, BTLS for special forces units - new concept - tactical combat casualty care TCCC - damage control surgery - combat trauma life support course

Differences in civilian and military prehospital environments 1 Differences in civilian and military prehospital environments 1. Scene safety 2. Number of causalties 3. Time on scene 4. Type of causalties 5. Transport time 6. Limitation of medical resources

Prehospital care in the tactial environment (TCCC) 1. Care under fire 2. Tactical field care 3. Combat Casualty Evacuation Care (CASEVAC)

Tactical Combat Casualty Care has been approved by the American College of Surgeons and National Association of EMTs and is included in the Pre-hospital Trauma Life Support manual 5th edition. Three goals of TCCC 1. Treat the casualty – save preventable death 2. Prevent additional casualties 3. Complete the mission

Factors influencing tactical combat casualty care - Enemy Fire - Medical Equipment Limitations - Widely Variable Evacuation Time - Tactical Considerations - Casualty Transportation

Tactical Combat Casualty Care This approach recognizes a particularly important principle – Performing the correct intervention at the correct time in the continuum of combat care. A medically correct intervention performed at the wrong time in combat may lead to further casualties.

Care under fire Hot Zone SECURITY Care under fire Hot Zone SECURITY!! Limited to what is carried by medic and soldiers Care based on MARCH acronym M – Massive Bleeding A – Airway R – Respirations C – Circulation H - Head The best treatment for a patient under fire …… is to gain Fire Superiority!!

Care under fire - move from hot zone, hemorrhage control - suppressing the enemys fire-return fire - decision maker is tactical commander - medical focus is on hemorrhage control - best method - tourniqets

Combat Tourniquet

Medical personnel’s firepower may be essential in obtaining tactical fire superiority. Attention to suppression of hostile fire may minimize the risk of injury to personnel and minimize additional injury to previously injured soldiers. Personnel may need to assist in returning fire instead of stopping to care for casualties Wounded soldiers who are unable to fight should lay flat and motionless if no cover is available or move as quickly as possible to any nearby cover

PREVENTABLE Mortality – armed conflicts

Mortality curve penetrating trauma Instantaneous Death 100% Breathing complications 80% 70% 60% 50% PPE and good tactics Shock Hemorrhage Airway obstruction Infections Ø      About 20% of the injuries have an Instantaneous Death Rate (IDR) no matter what care they receive. These would include casualties with major system trauma (heart or CNS). The IDR has changed very little during the last 200 years. The use of modern Personal Protective Equipment (PPE) has reduced the rate from 25% to 20%. There are documented cases of casualties with non-survivable injuries surviving for up to six minutes. Therefore, after six minutes, about 80% will be alive.   Ø      By the end of the first hour, another 10% will die from exsanguinating hemorrhage (carotid or femoral arteries) or from obstruction of the airway (choking, facial tissue and/or swelling occluding the airway). If a casualty can make it through the first hour, highly probable they will make it to the third hour. Therefore, after sixty minutes, about 70% will be alive. Ø      By six hours, another 10% will succumb from breathing complications (even those with large sucking chest wounds can survive up to six hours). By this time, there will be some showing the first signs of shock caused by subtler bleeding. Although at this stage, they are unlikely to die from shock alone. Lose about half for every subsequent six-hour delay in evacuation/care. Therefore, after six hours, about 60% will be alive. Ø      Between six and twenty-four hours, deaths occur from shock early on, but after this condition, they remain relatively stable. Therefore, after six hours, curve is relatively unchanged, about 60% will still be alive. Ø      By seventy-two hours, deaths occur mostly from infections. Therefore, after seventy-two hours, about 50% will still be alive. MITIGATING FACTORS v     0-6 minutes – Not much. Prevent injuries; PPE and good tactics. v     6-60 minutes – Basic Care. Self aid / Buddy aid / EMT-B. Stop exsanguinating hemorrhage by direct pressure or tourniquet, open occluded airway. v     1-6 hours – ALS level skills. Decompress chest, chest tubes, oxygen, IV access / resuscitation, airway management. v     6 hours or more – Surgery interventions required to show any marked improvements in survival rates. ALS level skills Self aid Buddy aid EMT-B Surgery interventions And Antibiotics 6min 1hr 6hr 24hr 72hr

Tactical field care Warm zone - move to warm zone, out of direct line of enemy fire, threat still exist. - ABC procedures starts - tension pneumothorax was the second leading cause of preventable combat mortality in Vietnam War - causalties with uncontrolled hemorrhage (internal or external) require a hypotensive resuscitation protocol - analgesia, antibiotics - hypothermia (first sign of lethal triad) 80% of nonsurviving patients have had body temperature <34° - prevention of hypothermia is much easier than threatment of hypothermia

Combat Causalty Evacuation Care - care of the causalty during evacuation via ground, air, wather - additional equipment and personell assist in causalty care, opportunity to increase medical support - continuing evaluation, monitoring, preventing hypothermia, establishing IVs, splinting, endotracheal intubation, drainage of thorax - 1/3 of helicopter evacuation missions might be aborted because of weather, inability to locate scene, etc.

Tactical Combat Causalty Care - provide medical support at right place, at right time without interrupting or interfering with tactical procedures - two competing thruths exist a) proper prior planning prevents poor performance b) best planes always fall appart when bullets start flying - formulate appropriate medical plan = understand proposed tactical plan - medical providers must understand principles of TCCC

Tactical Combat Causalty Care - tactical environment is difficult, sometimes exotic place to give medical care - ATLS if often non feasible or applicable to the tactical medical environment - BLS is able to prevent further injury. When resources are constrained move from BLS to ALS procedures - military decision making process: key questions what medical support is required, where and when is needed, what type of causality is anticipated - good medicine can sometimes be bad tactics and bad tactics can lead to mission failure

TCCC - armed tactical medical personell are able to protect themself, defend patient, move independently within combat zone, build trust and confidence of the team - 70 hours per year tactical physician should be training with tactical team - tactical team will establish a safe perimeter where medical personell can work - medical personell preffered qualifications - BLS, ALS, BTLS, IPLS - ability to perform medical duties under adverse conditions - skills to be learned must be trained in a tough, realistic environment

Damage control – capacity of a ship to absorb damage and maintain mission integrity. USA Navy

Lesson from War in Croatia 1991-1995 - good integrated health system of civilian and military medical care - 20-30% mobilised medical personell is not suitable for work in tactical enviroment - motivation - tehnical skills and knowledge - equipment Difference in work with professional and reserve soldiers units.

Conclusion - mission success is the ultimate objective in military - civilian surgeon v.s. army surgeon - develop new courses (combat trauma life support) - bring medicine to non medical personell (Tactical Combat Casualty Care) - disaster medicine - victory - DOW in Homeland war 1991-1995 - soldiers 1,8% - civilians - 3,6 %

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