Operation Enduring Freedom: the 48th Combat Support Hospital in Afghanistan

OBJECTIVE: To examine the experience of the 48th Combat Support Hospital (CSH) while deployed to Afghanistan, with an emphasis on trauma care. MATERIALS AND METHODS: Before redeployment, a retrospective review was performed on the medical records of all patients treated at the 48th CSH from December 6, 2002 through June 7, 2003. RESULTS: During the 6-month period, 10,679 patients were evaluated and/or treated. There were 477 hospital admissions (adults, 387; children, 90; trauma, 204) and 634 operating room procedures. The most common mechanisms of injury were land mines/unexploded ordinance (74 = 36%) and gunshot wounds (41 = 20%). Extremities were the most common site. A total of 358 cases was performed on 168 trauma patients (mean, 2 cases per patient; range, 1-12). There were 63 complications in 40 trauma patients and 11 patients died. CONCLUSIONS: The 48th CSH supported military and humanitarian operations with an ongoing process of re-evaluation, adaptation, and medical education that resulted in low morbidity and mortality rates.     

Operation Enduring Freedom: trends in combat casualty care by forward surgical teams deployed to Afghanistan

This study examined the clinical experience of a U.S. Army Forward Surgical Team (FST) deployed to Afghanistan in 2005 and compared the findings with those of 3 previously deployed FSTs. Medical records of all patients evaluated by the FST were abstracted for analysis. Demographically, the cohort (n = 614) was predominantly male (94%), with a median age of 24, and distributed according to the following: disease (8.6%), nonbattle injury (42%), and battle injury (49%). Combat casualties were mostly Afghan National Army or Police (56%) and U.S. military (21%). Predominant wounding instruments were small arms (34%), improvised explosive devices (33%), and rocket-propelled grenades (15%). Anatomical sites of battle injury were extremities (38%), external soft tissue (35%), and head/neck/torso (28%). Operative procedures for combat injury (n = 227) were primarily orthopedic (45%) or thoracic/abdominal (36%). Combat casualty statistics provide insight to trauma epidemiology, patterns, and trends vital for surgical management. Workload statistics guides the structuring, training, and employment of FSTs.     

Combat casualties in Afghanistan cared for by a single Forward Surgical Team during the initial phases of Operation Enduring Freedom

BACKGROUND: The 274th Forward Surgical Team (FST) was the first FST deployed to Bagram, Afghanistan, to provide surgical care for combat casualties during the initial phases of Operation Enduring Freedom. This is an analysis of the distribution, cause, and severity of wounds for combat casualties and the surgical procedures they required. METHODS: A prospective database was maintained for combat casualties cared for by the 274th FST. The database included demographic data, vital status, mechanism of injury, distribution and severity of wounds, and surgical care provided. RESULTS: The FST cared for 224 combat casualties, including 153 U.S. soldiers, 19 coalition soldiers, 32 Afghan militia forces soldiers, and 20 detainees. Fragments were the most common mechanism of injury (49%), and the extremity was the most common location of injury (58%), whereas gunshot wounds were the most common cause of death (57%). There were few significant head, chest, or abdominal wounds (13%). The FST treated 103 surgical cases (73 with combat wounds), including neurosurgical, thoracic, general, orthopedic, and vascular cases, with a total of 180 procedures. CONCLUSIONS: The distribution, cause, and severity of wounds were similar to those in the Persian Gulf War, despite the obvious differences between these conflicts. The use of modern technologies, such as compact, portable, ultrasound and digital X-ray systems, expanded the capabilities of the FST. Even low-intensity conflicts can produce significant numbers of combat casualties, and the FST must be manned, trained, equipped, and supplied to treat a wide variety of combat wounds.     

美军伊拉克和阿富汗战争战伤救治新理念

“战术战伤救治”的概念最早由美海军特种作战部队于1996年首次提出,在伊拉克和阿富汗战争中成为美军战术环境中伤员救治的标准规范,也是美军伊拉克和阿富汗战争中战伤救治取得的一大进展.战术战伤救治的应用使美军达到了有史以来最低的伤亡率.该文梳理了美军战术战伤救治理念的发展,分析了战术战伤救治的阶段划分,探讨了美军战术战伤救治的组织实施,并提出了对我军的启示.     

Review of non-battle injuries in Air Force personnel deployed in support of Operation Enduring Freedom and Operation Iraqi Freedom

This study examines non-battle injuries among U.S. Air Force members deployed during Operations Iraqi and Enduring Freedom. A cohort of 275,843 Active Duty, Guard, and Reserve members were identified for the period September 11, 2001 through October 31, 2006. Data on injuries were obtained from electronic medical records and deployment time was obtained from manpower records. Poisson regression was used to estimate adjusted incidence rate ratios (IRRs). The most common non-battle injuries were sprains and strains (53%) followed by open wounds (27%). Guard and Reserve members tended to have a lower rate of orthopedic non-battle injuries than Active Duty members in crude analyses and after adjustment for age, previous deployment, sex, race/ethnicity, and occupation (IRR = 0.95; 95% CI = 0.89-1.02 and IRR = 0.85; 95% CI = 0.77-0.93). Results from this study are intended to facilitate further research of potential differences between Air Force components to reduce non-battle injuries in a deployed environment.     

Utility of ultrasound in the combat theater: experiences of a gynecologist during Operation Iraqi Freedom/Operation Enduring Freedom

OBJECTIVE: The purpose of this study was to evaluate the utility of ultrasound in a combat theater. METHODS: A retrospective review of gynecology visits was evaluated at Camp Doha, Kuwait, from August 2003 through April 2004. Of the 1,737 visits, 237 required pelvic ultrasound. Demographic information, as well as the indications, diagnosis, and disposition of the patients, was compiled. RESULTS: The average age of the patient requiring ultrasound was 28 +/- 8 years. The primary presenting complaint was pelvic pain. Forty percent with pelvic pain had no identifiable cause. The most common final diagnosis was pregnancy. Of the 237 visits, the use of ultrasound resulted in 136 return-to-duty dispositions. Of the 31% who were administratively redeployed, the majority were secondary to pregnancy. CONCLUSION: Gynecologic ultrasound was found to be a very useful tool in the combat theater. Ultrasound resulted in improved diagnostic ability and enhanced reassurance to both provider and patient.     

A review of 41 upper extremity war injuries and the protective gear worn during Operation Enduring Freedom and Operation Iraqi Freedom

Forty-one patients with upper extremity war injuries sustained during combat operations Operation Enduring Freedom and Operation Iraqi Freedom were reviewed to report on protective gear availability and usage at the time of injury. Participants treated at the Madigan Army Medical Center occupational therapy clinic from August 2004 until February 2005 completed a questionnaire regarding injuries sustained during deployment. Overall, 6 injuries were to upper extremity regions that were covered with issued protective gear; 21 injuries were to areas not covered with issued protective gear (i.e., participant was not wearing issued gear), and 22 injuries were to regions that were not covered because no protective gear was issued for that body area. Although this study is limited, future research would provide valuable insights about the efficacy of current body armor and the need for additional or modified gear.     

The most frequently requested precombat refresher training by the Special Forces medics during Operation Enduring Freedom

The tactical environment and the mission given the Special Operations Forces in Afghanistan during the initial phases of Operation Enduring Freedom placed the Special Operations Forces medics (18Ds) in a position of significant medical responsibility. The 18Ds became the primary care providers for the indigenous anti-Taliban fighters as well as U.S. military personnel; the care of the latter was further complicated by long evacuation times. Because of these issues and several events that occurred in the combat zone, the 18Ds requested their supporting forward surgical team (FST) (274th FST) to provide specific refresher training before combat deployment into Afghanistan. The areas of greatest interest and concern were orthopedics, field transfusions, and field-expedient anesthesia. It is hoped that the training prepared and given to the 18Ds by the personnel of the 274th FST and presented in this article not only was useful to them but also will be of benefit to 18Ds who find themselves in similar situations in the future.     

Effects of transcendental meditation in veterans of Operation Enduring Freedom and Operation Iraqi Freedom with posttraumatic stress disorder: a pilot study

We conducted an uncontrolled pilot study to determine whether transcendental meditation (TM) might be helpful in treating veterans from Operation Enduring Freedom or Operation Iraqi Freedom with combat-related posttraumatic stress disorder (PTSD). Five veterans were trained in the technique and followed for 12 weeks. All subjects improved on the primary outcome measure, the Clinician Administered PTSD Scale (mean change score, 31.4; p = 0.02; df = 4). Significant improvements were also observed for 3 secondary outcome measures: Clinician's Global Inventory-Severity (mean change score, 1.60; p < 0.04; df = 4), Quality of Life Enjoyment and Satisfaction Questionnaire (mean change score, -13.00; p < 0.01; df = 4), and the PTSD Checklist-Military Version (mean change score, 24.00; p < 0.02; df = 4). TM may have helped to alleviate symptoms of PTSD and improve quality of life in this small group of veterans. Larger, placebo-controlled studies should be undertaken to further determine the efficacy of TM in this population.     

The quantitative analysis of depleted uranium isotopes in British,Canadian, and U.S. Gulf War veterans

The purpose of this work was to determine the concentration and ratio of uranium isotopes in allied forces Gulf War veterans. The 27 patients had their 24-hour urine samples analyzed for 234U, 235U, 236U, and 238U by mass spectrometry. The urine samples were evaporated and separated into isotopic dilution and concentration fraction by the chromatographic technique. The isotopic composition was measured by a thermal ionization mass spectrometer using a secondary electron multiplier detector and ion-counting system. The uranium blank control and SRM960 U isotopic standard were analyzed by the same procedure. Statistical analysis was done by an unpaired t test. The results confirm the presence of depleted uranium (DU) in 14 of 27 samples, with the 238U:235U ratio > 207.15. This is significantly different from natural uranium (p < 0.008) as well as from the DU shrapnel analysis, with 22.22% average value of DU fraction, and warrants further investigation.     

Y-chromosomal STR analysis in the Pashtun population of Southern Afghanistan

Afghanistan is a landlocked country in the heart of Asia and since the dawn of humankind Afghanistan has faced centuries of turmoil, strife, conflict, warfare, distress, social unrest, difficult climate, harsh terrain and due to its unique geostrategic position in Eurasia which has historically attracted commerce and conflict. It is an important stop along the Silk Road, connecting the far eastern civilizations to the western world. A 5000-year history of constant invasion. Afghanistan has been repeatedly invaded and conquered by rulers and super powers, neighboring interference in this conflict-tattered land for centuries yet rarely leading to the conquest of this rugged and challenging terrain nation. Afghans are not only shepherds, farmers and nomads but also intense fighters and fierce warriors. Currently very limited genetic studies have been performed in Afghan populations. 17 Y chromosomal short tandem repeats (Y-STRs) were analyzed in 125 unrelated Pashtun (in hindi: Pathan) males residing in the Kandahar region of Southern Afghanistan. A total of 92 unique haplotypes were observed. The predominant haplotype reached a frequency of 9.6%. The haplotype diversity was 0.987 and the discrimination capacity 73.6%. Analysis of molecular variance (AMOVA) reveals a considerable regional stratification within the country as well as between different Pashtun (Pathan) groups from Afghanistan, Pakistan and India.     

Drowning deaths of U.S. Service personnel associated with motor vehicle accidents occurring in Operation Iraqi Freedom and Operation Enduring Freedom, 2003-2005

OBJECTIVE: We examined common factors in vehicular drowning deaths that might lead to changes in equipment or training. METHODS: Drowning deaths among service members deployed to Operations Iraqi Freedom or Enduring Freedom, 2003 to 2005, were ascertained using the Armed Forces Medical Examiner Tracking System database. Cases were linked to Army and Navy safety and investigative files. RESULTS: Fifty-two cases of vehicular drowning deaths were identified. These occurred mostly at night, were almost always the result of a rollover, and were most frequently associated with a high-mobility medium-weight vehicle. Seat belts were rarely worn, but the majority of injuries should not have been severe enough to affect egress from the vehicle. These drowning deaths seldom occurred while engaged with the enemy and were rarely associated with bad road conditions or bad weather. CONCLUSIONS: Effective preventive strategies might focus on training and equipment to reduce rollover events and on the expeditious extrication of victims.     

The major causes of death in the Army and comparisons with the civilian population

Statistics of 881 British Army male non-operational deaths between 1980 and 1984 were analysed and comparisons made with civilian mortality for certain categories of deaths. Disease accounted for 32% and injury for 68% of the deaths. Road traffic accidents (RTAs) comprised 40% and ischaemic heart disease (IHD) 13% of the total. The overall Standardised Mortality Ratio (SMR) was 92. By comparison with the UK civil population serving members of the Regular Army suffered considerably less from disease deaths (SMR 58) with the exception of IHD (SMR 92), but more from injury deaths (SMR 135). RTA deaths had an SMR of 200. The review suggests that attention should be directed towards incidents causing RTAs and drowning. Action taken in peace may have relevance to survival on operations.     

A method for the rapid radiochemical analysis of uranium and thorium isotopes in impure carbonates.

A simple method combining solvent extraction and electrodeposition procedures is described for the determination of the isotopic composition and content of uranium and thorium in travertine samples. The actinide elements are extracted with diethyl ether from a calcium nitrate solution. The isolation of the elements and the alpha source preparation are performed in two steps after the sample digestion. The acid leaching of samples is performed using both partial and total dissolution methods. High recoveries of both uranium and thorium and good alpha-spectra are obtained with both partial and total dissolution methods.     

铀矿工人尿铀含量测定与染色体畸变率分析

目的:了解铀矿工人所处的核辐射环境对体内尿铀剂量的影响,并估算吸入铀所致的内照射剂量,计算外周血淋巴细胞染色体畸变率,分析尿铀含量与外周血淋巴细胞染色体畸变率的相关性,为提高铀矿工人的健康监护水平提供客观依据。方法:以某地铀矿执行采挖工作的一线工人为观察组,不执行采挖工作的人员为对照组,采用N-235萃取法测定24h尿铀量,依此计算吸入铀所致的有效剂量当量值;用微量全血培养法,双人双盲各计数200个分裂相外周血淋巴细胞,计算出染色体畸变率。结果:留取24h尿共查3次尿铀取平均值,观察组(0.861±0.552)μg/L,与对照组(0.688±0.435)μg/L相比无显著性差异;外周血淋巴细胞染色体畸变率均处于正常范围内,两组相比无显著性差异(P>0.05)。结论:在目前矿区职业防护条件下,某铀矿工人吸入铀所致的内照射剂量在安全范围内,铀矿工人所处环境对尿铀含量及染色体畸变率均无明显影响。     

Medical problems of detainees after the conclusion of major ground combat during Operation Iraqi Freedom

After the conclusion of major ground combat operations during Operation Iraqi Freedom, the focus of the mission changed, although intense armed conflict continued. Included in this mission was management of security detainees, including provision of their medical care. We retrospectively reviewed the admission records identified at a short-term holding facility over 2 months and diagnoses of detainees admitted to a combat support hospital over 4 months as a health care service utilization statistics review. Six thousand six hundred thirty-one detainee encounters occurred at the short-term facility with approximately 45% of detainees reporting medical problems during each daily evaluation. Most frequent complaints were neurological (11%), gastrointestinal (10%), and respiratory (8%). Two hundred nineteen detainees' admission diagnoses were retrospectively reviewed from the combat support hospital, 98 (45%) due to gunshot or fragmentary injuries and 121 (55%) to other medical problems. Medical problems included cardiac (29%), gastrointestinal (17%), neurological (14%), musculoskeletal (11%), and pulmonary (6%) disease. Medical problems not traditionally dealt with in a combat theater, including management of transplant recipients, patients with cardiac valve replacement, and cancer patient, were also seen.     

A quantitative assessment of changes in the dermal fibroblast population of pig skin after single doses of X-rays

Investigations were carried out into the time- and dose-related changes in the density of fibroblasts in the dermis of irradiated pig skin. The time course of these changes in the density of fibroblast nuclei in the reticular dermis was studied from 6 to 104 weeks after irradiation with a single dose of 15.4 Gy of X-rays. The largest decrease in the number of fibroblasts occurred between 12 weeks and 26 weeks after irradiation; after this time there was only a slight fall in the fibroblast number until 104 weeks when the observations ceased. At 26 weeks and later times after irradiation the reduction in the density of fibroblast nuclei in the reticular dermis was dose-dependent for single doses in the range 8.0-20.7 Gy. The dose-response curve had an initial shoulder, after which the fall in the fibroblast nuclear density was linearly related to dose. Data obtained at other times, between 26 weeks and 104 weeks after irradiation, could be fitted by the same dose-response curve. The fall in the counts of fibroblast nuclei was compared with earlier studies in pig skin. The loss of fibroblasts occurred after an initial reduction in blood flow in the pig skin but was concomitant with the general reduction in dermal thickness.