Combat related maxillofacial injuries the kandahar experience- tong
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Transcript of Combat related maxillofacial injuries the kandahar experience- tong
Combat Related Maxillofacial Injuries
Lt Col Darryl Tong RNZAMCOral and Maxillofacial Surgeon
Disclaimer and OPSEC
Role 3 MMU KAF
• Only designated Role 3 medical facility in Southern Afghanistan
• Role 3 NATO asset designation• Also Level III medical facility
• Highest level of care available within the combat zone
• ICU and ward beds• General, orthopaedic, neurosurgery,
maxillofacial • Blood bank, laboratory, x-ray and CT,
mortuary
Role 3 MMU KAF
• Nations represented include:• Canada (lead Nation)• Denmark• Netherlands• United States• United Kingdom• Australia• New Zealand
MMUCOMKAF HQ
Q
Primary care
Role 3 MMU KAF
• 2 Surgical teams each consisting of:• Anaesthetist• Nurse anaesthetist• General Surgeon• Orthopaedic Surgeon• Theatre staff
• 24 hour shifts with call-back option on off days as required
• Canadian – Danish rotation
Role 3 MMU KAF
• Neurosurgery and Maxillofacial surgery stand alone specialties
• R3 MMU is the referral centre for all neurosurgical and maxillofacial trauma for Southern Afghanistan
• 24 hour on call, 7 days a week• Neurosurgery: United Kingdom• Maxillofacial Surgery: UK, Canada, NZ
Role 3 MMU KAF
• 8 wards beds with surge capability of extra 4 beds = 12 total
• 5 ICU beds with ventilators with one extra bed often used for recovery
• 4 extra beds for ward or ICU capability• One isolation room for infectious
disease or detainees
Role 3 MMU KAF
• Extra 8 beds in primary care and surge capabilities in respective Role 1 facilities (UK, Dutch, Danish etc)
• 6 trauma bays with surge capability of 8 extra bays = total 14 trauma bays with overflow to Role 1 facilities
Role 3 MMU KAF
• 2 operating theatres • X-ray department• Laboratory and blood bank• Dental section ( 2 dentists + DAs)• Psych med section (psychiatrist and 2
MH RNs)• Prev med section• Pharmacy
Patients
• Coalition personnel• Civilian contractors• ANA and militia• ANP• Local population
• Significant paediatric patient flow• Minimal women’s health involvement
Surgeries by specialty
50 115273
648
893
Other 4%Neuro 7%Maxfax 16%General 39%Ortho 53%
Period: 01 Sep 2007 – 01 Mar 2009
N = 1675
Patient category
642 635
303
48 47
0
100
200
300
400
500
600
700
Period: 01 Sep 2007 – 01 Mar 2009
Trauma sequence
• 9- liner called through• Trauma teams notified• Specialist staff notified• Operating theatre on standby• Triaged• Primary survey: MARCHH• Secondary survey
Maxillofacial injuries in combat
• Incidence of HFN wounds from Iraq and Afghanistan currently ranges from 21-29% (US and UK data)
• Israeli data ranges from 26-54% (Lebanon, Gaza and West Bank)
• Dobson et al. 1988: 13 major conflicts from 1914-1986 Overall incidence HFN wounds 16%
including WW1, WW2, Vietnam and
Maxillofacial injuries in combat
• Second most common injuries sustained among combat personnel
• Fragment injuries >> GSW• Blunt trauma still occurs• Concomitant injuries: Cervical spine Traumatic head injury Ocular/Otologic
Maxillofacial injuries in combat
• Proportional increase in HFN injuries due to survivability from the use of CBA
• Exposed areas of extremities, face and neck are issues for CBA design
• Mobility and ability to fight versus protection
Surgical considerations
• Damage control surgery vs. definitive care
• Primary versus secondary reconstruction
• Choice of hardware• General condition of patient• Patient disposition• Antibiotics
Surgical considerations
• Life, limb, eyesight• Damage control surgery is typically
not necessary apart from airway or haemorrhage control
• UK favours early evacuation for definitive maxillofacial repair
• US study: definitive feasible in-country but following strict criteria
Surgical considerations
• Potential need for secondary surgery depends on: Patient condition Availability of tissue Surgeon skill set Demands on operating theatre Timings for STRATEVAC
Surgical considerations
• Local nationals tended to receive as much definitive surgery as possible Local expertise issues Rehab and post op care issues
• Often time delay in presentation General condition of patient Availability of medevac Tactical situation at the time
Multiple roles in trauma
• Maxillofacial trauma Soft tissue Hard tissue
• Teeth • Bones
• Ocular injuries• Advanced airway management
including surgical airway• Neck exploration
Multiple roles in trauma
• First assistant Orthopaedic surgery General surgery Neurosurgery
• Trauma team leader• Post operative care complications
Points to consider
• Combat body armour saves lives but not necessarily limbs or faces
• Head, face and neck wounds second most common injuries in combat personnel
• Surgeons with expertise in maxillofacial trauma are an integral part of the current military surgical team
Points to consider
• Maxillofacial surgeons are force multipliers• Essential that the lessons learnt in combat
trauma are passed on to other military surgeons
• Maxfax surgeons need to be familiar with other surgical specialties: Eyes / ENT Neurosurgery Orthopaedic surgery General surgery
Points to consider
• Adaptability essential (not civilian tertiary hospital-centric mentality)
• Basic maxillofacial trauma skills as part of a training module for other specialists
• Regular opportunities to share information
Acknowledgements
• AMMA/Joint Health Command• NZ Defence Force• University of Otago• Role 3 MMU KAF
““The Best Care AnywhereThe Best Care Anywhere””