G The Role of Intensive Care in the Management of Ballistic Trauma in War

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The Role of Intensive Care in the Management of Ballistic Trauma in War

Matthew J. Roberts

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Critical care is an area that has changed beyond recognition since the 1991 Gulf war, in terms of equipment, staffing and clinical practice. The latest field intensive care modules are a compromise between sophistication and practicality.

Practicality requires items to be robust where possible, to have flexibil- ity in power supply and not to put great demands on the medical supply organization.

Versions of these up to date field intensive care facilities have been deployed on a small scale on recent peace support operations but casualty numbers were usually low and the experience did not inform as to the extent of intensive care utilization that could be expected in warfare.

This lesson had to be learned at the outset of the 2003 conflict in Iraq.

The casualty mix on operations other than warfighting tends to be dom- inated by road accidents, medical admissions, burns and the occasional mine strike. Large numbers of ballistic injuries are not seen so forecasts as to the requirement for intensive care for this conflict had to be based on estima- tion and assumption.

It was assumed that the number of casualties reaching the field hospital with penetrating limb injuries would by far out way those with abdominal or thoracic trauma, as a result of the lethality of high velocity wounds to the trunk, the self selection of survivable injuries and the wearing of body armor.

This proved to be correct.

It was assumed that limb injuries would be resuscitated pre and per- operatively, would have relatively short operating times and be transferred to the general wards.

In the event this assumption, partly based on the templates long used on medical exercises, proved to be less accurate.

Prior to the outset of hostilities the intensivists at 202 Field Hospital anticipated being relatively underemployed and so decided on an “out reach” policy whereby a consultant would attend each major resuscita-

tion in the A + E department and also “trawl” the operating theatres for patients who might benefit from a period of intensive or high dependency care.

However as the casualties began to arrive it soon became apparent that there would be no difficulty in filling the beds. The main concern was evac- uation from the hospital.

During the war fighting phase (17 March–30 April), the largest patient group by far requiring intensive care at 202 Field Hospital were those with ballistic trauma; bullets and fragments accounted for 55% of ICU admis- sions, more than twice the second group, burns with 27%.

Another assumption—that the unit would be primarily a high depen- dency ward—also had to be discarded as 45.5% of ICU patients required tracheal intubation and ventilation.

Many patients were admitted from theatre having undergone extensive debridement for multiple fragment injuries, perhaps prolonged attempts at limb salvage, successful or otherwise. They had received multiple unit blood transfusions and continued to bleed either because of a coagulopathy or the nature of their surgery. They were acidotic and frequently, despite the environmental conditions, hypothermic.

It is easy to imagine why in the major conflicts of the last hundred years early amputation might have been viewed as the better course of action than a prolonged, physiologically disturbing and potentially futile salvage procedure where postoperative facilities were limited.

The role of the intensive care unit in the field hospital consists primarily of either continued resuscitation (leading to early extubation and transfer to the general ward) or preparation for repatriation by a critical care trans- fer team.

This template does not take into account the management of enemy prisoners and civilians where transfer out of country is not a possibility;

over 80% of patients on the 202 Field Hospital intensive care unit were Iraqi.

The resulting length of stay on intensive care for Iraqi patients was between 2 and 3 times as long as for coalition troops with an obvious impact on bed occupancy.

It is clear that the intensivist cannot entirely avoid having to manage the later complications of severe injury by counting on early transfer out.

Equipment and drug scales need to take this requirement into account.

The presence of well staffed and equipped intensive care units during this conflict no doubt influenced the morbidity and mortality of casualties with ballistic trauma, but it had another more visible effect:

The ability to act as an extension to A + E, the operating theatres and the recovery ward, admitting patients from these departments for further resuscitation and monitoring, helped to maintain flow through the field hospital and allow the surgical teams to move rapidly on to the next cases.

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The very low number of patients who needed admission to the unit from the general wards was testament to the effectiveness of the policy of proac- tive intensive care.

Only 4.6% of 202 Field Hospital patients passed through the intensive care unit.

The ability to concentrate these, the sickest patients in the hospital, in one area with a high level of technology and a wealth of medical and nursing critical care experience, improved their chance of survival and no doubt allowed for better care of other patients on the general wards.

598 M.J. Roberts