# Care of casualties in Iraq and Afghanistan



## Fraser.g (10 Dec 2004)

I think a few of you may find this article and the following photo essay from the New England Journal of Medicine interesting.

A friend of mine sent them to me this morning.

GF


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## Fraser.g (11 Dec 2004)

From the New England Journal of Medicine 
Caring for hte wounded in Iraq.
http://content.nejm.org/cgi/content/full/351/24/2476

Note the patern of shrapnel wounds on the pers who was wearing his body armour when he was hit on page 2477.

GF


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## Adam (21 Aug 2005)

Those pictures are are pretty scary.  lets hope we never see pictures like that from afganistan.


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## Fraser.g (21 Aug 2005)

Adam said:
			
		

> Those pictures are are pretty scary.   lets hope we never see pictures like that from afganistan.



Hope yes, Be prepared for Absolutely not.

We have troops in an active theater of operations. To hope and not prepare is a foolhardy venture at the best of times.

GF


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## Armymedic (21 Aug 2005)

Adam said:
			
		

> Those pictures are are pretty scary.   lets hope we never see pictures like that from afganistan.



Read the news, US forces are dealing with those same injuries weekly in Afghanistan, vs daily in Iraq...but they are happening.

Better to be prepared than caught unaware.


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## medicineman (22 Aug 2005)

Certainly a wake up call for those people that haven't come in contact with that stuff - almost had a flashback or two.

MM


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## Old Ranger (25 Aug 2005)

Interesting Pictures, gives an Idea of what you all deal with.

Side Question;
Do you vary what you carry in your bags overseas?
Working amongst Civi population eg. paediatric resus equip?
What do you find is Best Carried?
Do you have vehicles close to keep extra kit in?

Not sure if this has already been answered. 
Sorry if it has.


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## Armymedic (25 Aug 2005)

Its covered in other threads but I'll give short answers for here...



> Do you vary what you carry in your bags overseas?


 yes, medics carry different stuff from what a doctor or nurse carry. Overseas we tend to carry more trauma (badages, dressings, IV fluids) then medications and bandaids because we tend to out of a base camp where the clinics are.



> Working amongst Civi population eg. paediatric resus equip?


 Not usually, but I did carry child and infant size airway tubes as I daily traveled along the busy roads where kids walk to school. 



> What do you find is Best Carried?


 vague question but it is personal preference and answered on other threads here.



> Do you have vehicles close to keep extra kit in?


 Depends on the task/mission. Roto 3 medics had patrols that departed Camp Julien in a LAV and had the veh in close radio contact. They would carry a small thigh pack and a couple other immediate things on them as they patrolled with the big bag in the vehicle.

I had my jump bag with me all the time, but supplemented fd dressings, bandages, and IV fluids in each of the 6 G wagons my team had.


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## Old Ranger (25 Aug 2005)

Thanks, I'll check the other threads again.

Ben


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## Dale Turner (26 Aug 2005)

WOW! A picture says a thousand words!  I think that pics like that should be shown to everyone on work up training. 

Thanks.


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## kj_gully (25 Feb 2006)

1st off, thanks for the many well thought out replies to my posts so far. This question is about live tissue training. Are medics getting any live tissue lab time pre-deployment? Aside from our SF medics, I mean. Speakers at a military medicine conference I recently attended spoke extremely highly of the value of both Cadaver training, and Live tissue training. It would seem that there are some "bigwhigs" at least senior medic pers on this site, and hope you would consider sending some key pers on training during predeployment. this course is representative of some of the training out there, and came to me highly reccommended from a fellow Canadian (operational overseas...)  http://www.oems.org/ I hope to attend training there at some point in my career.


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## Armymedic (26 Feb 2006)

All PAs and MOs going overseas do a predeployment stint at the trauma training center in Vancouver for 4 weeks. There they do rounds, in addition to retesting on all ATLS and ACLS skills.


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## JANES (26 Feb 2006)

What do you want to know about the course Gulley?


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## kj_gully (26 Feb 2006)

All I really want to know, is if the medic trade sends anybody, the medics in the "real" army.If not, why not, and is it as helpful as I have heard.


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## JANES (26 Feb 2006)

Conventional Canadian Army medics are not sent on the course.  The course is extremely worth it.  Stress inoculating WRT dealing with real traumatic injuries en mass scale, pentrating and blast type.  Gets you used to dealing with the real thing instead of seeing it for the first time, when is happens to your buddy beside.


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## herseyjh (2 Mar 2006)

Is the use of on scene ID prophylactic antibiotics for open trauma been explored by the CF?  Is this something that we are doing right now?  Just wondering.


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## Guy. E (2 Mar 2006)

Perhaps a graphic image warning somewhere?

When I hunt, I see that kind of stuff on the animals that I and other people kill. its just different/ unpleasant to see to see it on a person...


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## Armymedic (2 Mar 2006)

herseyjh said:
			
		

> Is the use of on scene ID prophylactic antibiotics for open trauma been explored by the CF?  Is this something that we are doing right now?  Just wondering.



No, and not exploring it as of right now either, as far as I know.


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## JANES (2 Mar 2006)

TCCC working group discussed it.  They ran into problems with choosing the right type.  I appologize, I am not up to date on the specific drugs.  The US changes the type frequently.  The broad spectrum one they were using at the time the WG discussed had a confliction issue with Mefloquin.  There is no doubt that there are effective braod spectrum ones out there that dont conflict with other drugs, and have a low allergy frequency.  The US is probably using them right now.  I think the current problem is that there just isn't the staff or time to research, recommend and impliment this.  This is just the CF's priority due to poverty.  It's unfortunate.  Everyone in the US Army gets a pill pack in theatre.  When you get shot or blowed up, and you're still conscious, you pop your pill pack full of pain relief anti-inflamitories and a dose of anti-biotics that will do you for 24hrs (prophylactically as was mentioned).  Maybe one day, after we sort out the tourniquet and HSD issue we can move onto this, and try mitigate that 12%ish that DOW.


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## herseyjh (2 Mar 2006)

Sorting out which antibiotics to carry would pose an interesting problem.  I guess as long as evac times stay short this shouldn't be a major factor in patient outcomes.  Also, in our defence, the US military took time to adopt this stance.  I was just reviewing one study where the idea of antibiotics was scoffed at as research from EMS showed that their was no real benefit, and it wasn't until Mogadishu and prolonged evac times did intrest spark up again.


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## medicineman (3 Mar 2006)

Last I read, the US were using gabifloxacin in their pill packs for their ABx.

MM


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## Fraser.g (3 Mar 2006)

Here is a link that have been modified in the last year. They have changed from Vioxx to Celebrex as well as Cipro to Gati.

file:///C:/WINDOWS/Temporary%20Internet%20Files/Content.IE5/PNN3XKIL/257,2,Combat Pill Pack


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## kj_gully (3 Mar 2006)

Hey, hi again from your airforce cousin. SAR Techs have a liberal protocol for prophy antibiotics, basically if the wound has the potential to become infected, we give cefazolin, and if they're allergic, they get clindamyacin. It stems from the mindset that we sometimes have delays in evac, but from some ( and as you all know, probably against the advice of many more) ER docs encourage us to give it to any dirty wound, once everything else is done, that it will improve pt outcome.


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## JANES (3 Mar 2006)

Thats all great, the medics should carry IV/IM antibiotics.  But the US Army is giving soldiers oral antibiotics, along with antinflamitories and analgesics.  They swallow them all by themself without having to have a medic administer.


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## kj_gully (4 Mar 2006)

Is it a daily regimen? or as req'd? I am sure that there must be a lively debate about prophy antibiotics with the so called superbug in theater.


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## medicineman (4 Mar 2006)

They scarf them down if they get wounded - they aren`t a daily regimen.

MM


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## JANES (4 Mar 2006)

The idea is that it will last them until they can get to a hospital, hopefully within 24 hours, or at least a medic with IV or an IM shot.  Liberal use in theater is encouraged, and discouraged domestically.  The idea is to stop that superbug in it's tracks.  The one that is causing so many problems with the casulaties coming back from Afghanistan and Iraq.


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## herseyjh (4 Mar 2006)

A friend of mine said that that the medics are carrying antibiotics now, so I guess it just hasn't hit the troop level yet.  

KJ are you antibiotic protocols based on the timeline you expect it will take to get the patient back to the hospital, or is it standard for all of your trauma patients?


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## Armymedic (4 Mar 2006)

herseyjh said:
			
		

> A friend of mine said that that the medics are carrying antibiotics now, so I guess it just hasn't hit the troop level yet.
> 
> KJ are you antibiotic protocols based on the timeline you expect it will take to get the patient back to the hospital, or is it standard for all of your trauma patients?



If he is refering to Cdn Med Techs, your friend is wrong. Or the medics he saw are doing something they should not be as there are no oral or IV antibiotics on our formulary.


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## herseyjh (4 Mar 2006)

I will have to ask him again as it was my understanding, from him, that this was the case.  He said that the medics (PRT only) were carrying injectable cefazolin.

Of intrest I was reviewing prophylaxis antibiotic therapy in an anaesthesia reference and I came across the following table:

*Contaminated wound:*
- fresh trauma would, entry hollow viscus with spillage, especially colon.  Operative site contaminated by infecting bile or urine, acute inflammation present
- Infection rate 15-20%

*Dirty wound: *
- Old traumatic wound with devitalized tissue, presence of foreign body, fecal contamination or existing infection
- Infection rate: 25-40%

I think for the most part we can assume that the wounds are going to be 'dirty.'  The ideal timeline from a surgical standpoint was to administer antibiotics 0-2 hours before surgery and extend coverage for at least 24 hours.  So from a field perspective, and I am assuming this, as I haven't tracked down a reference specific to 'military' medicine yet, but if we manage to get wounded evaced within 2 hours front line antibiotic coverage should be to much of a problem.  That is a big 'if' though but I think until medics and troops start carrying antibiotics we will have to bank on this if.

Oh, JANES, I meant to ask you do you know which specific super-bug is causing problems?  I am curious as I was assuming that maybe military medical facilities might be a bit light on the superbugs as they don't have the classic bug breeding grounds that hospitals have, namely ICUs.


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## medicineman (4 Mar 2006)

The bacteria is called acinetobacter baumanii - it`s fairly common in the soil and water in Iraq.

http://www.cbc.ca/calgary/story/ca-superbug20060223.html

'Superbug' slowing soldiers' recovery  
Last updated Feb 23 2006 12:41 PM MST
CBC News 
The recovery of three Canadian soldiers injured in Afghanistan has been beset by the same drug-resistant bacteria that is plaguing troops in Iraq, according to medical doctors in Edmonton.

Doctors won't say to what extent the infection has interfered with the recovery of Master-Cpl. Paul Franklin, Pte. William Edward Salikin, and Cpl. Jeffrey Bailey but confirmed all three have been treated for the bug.

The Edmonton-based soldiers were injured in January when a suicide bomber attacked the vehicle they were travelling in. Canadian diplomat Glyn Berry was killed in the incident and Bailey almost lost his life. Franklin had both legs amputated.

FROM JAN 19, 2006: Soldiers could be home next week 
Among the military, the virus is referred to as the Iraqi superbug. In the medical community, it's known acinetobacter. Its been linked to some deaths in American military hospitals.

Doctors say it's unclear whether the contamination is occurring in the battlefield or in military hospitals. In any case, they say the infection is proving difficult to treat and is contagious.

Dr. Gina Dorlac says a mix of drug were used on the injured Canadian soldiers.

"Most of your drugs that you have don't work on this particular organism, so it can be difficult to treat and keep people in the hospital longer and possibly cause death that would not otherwise have happened."

Dr. Steven Shafran said it's possible the Canadian soldiers contracted the infection at a U.S. military hospital in Landstuhl, Germany where they were initially taken.

Shafran says doctors started to take note of acinetobacter five years ago.

"One of the things that has been observed with acinetobacter baumannii over the past five years is that it is increasingly becoming resistant to antibiotics," he said.

Acinetobacter has become the most common infection among American troops wounded in Iraq. The bacteria is found in the soil and water there.

Dorlac said the bacteria has the potential to cause some serious problems.

"You take sick people and put them altogether and give them antibiotics and the bugs they have are going to get nastier." 

Stuff is likely resistant due to prohylactic use in wounds combined with the fact alot of antibiotics can be bought over the counter in the Middle East.  And why does every reporter out there think a virus and a bacteria are one and the same?

MM


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## Armymedic (4 Mar 2006)

herseyjh said:
			
		

> I will have to ask him again as it was my understanding, from him, that this was the case.  He said that the medics (PRT only) were carrying injectable cefazolin.



And I would mention that if they are doing that then there is a 50/50 chance of them not doing something they are not allowed to...

The other half being the MO they work for specifically trained them to do it.

Either way, it is not part of our training and something that would cause a shitstorm in Ottawa if it got out. 

Also if I remember correctly cefazolin as supplied to the CF is an IM or IV injectable which needs reconstitution. Then this enters into the casualty evacuation care phase, and seeing how evac times currently in Afghanistan are still less then 2 hrs from POI to Role 3....then is it really necessary?

Don't get me wrong, I am all for pushing this down to med techs as a strict protocol. But seeing how we med techs still are not "allowed" by CFMG to practice TCCC concepts, I will not hold my breath that we will be able to be legally allowed to give in the fd immediate POI antibiotics any time soon.


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## kj_gully (5 Mar 2006)

hersheyj, we have the antibiotic protocol because it is possible we may be with a casualty in excess of 24 hours before we can evac. Having said that, we are not limited by time to give it, just ask if there is an allegy, then give it as an IM injection. If they are allergic to cefazolin, we give them clindamiacin, if they aren't allergic to that. BTW we carry quite a bit of epi too, so if they are allergic and don't know it, we can still potentially save the day. It boggles me that med a's have the identical qual as us @ the 5a level (pcp1), probably have at least as good clinical judgement as us, but are so restricted in their scope of practice. This was fine when they are in garrison, but operationally, they should be doing at least what we are, no?


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## herseyjh (5 Mar 2006)

I would agree with you on that point as if you look at how the situation stands now as long as evac is prompt then the lack of coverage is manageable.  I think, at the least, medics should have the option in case this is not so.  That could  be an easy battle to win.  Now having everyone carry PO antibiotics just in case would be a bit more tricky; someone could argue that non-medical people, aka infantry types, don't have the background to make the call (I disagree with that statement, just pointing out the possible argument).

I think the problem might also be CFMS.  They are sometimes slow to respond to change, that coupled with the fact that antibiotic treatment options traditionally have been under the direction of a physician, give you the easy knock out.  One can argue that they are not emergency drugs, or traditional EMS drugs, so they can be deferred to the hospital setting.  That might be right from a civi EMS standpoint but not from a field perspective we know that might not work.

As for why the restriction in the scope of practice I guess it could be that there are a lot more Med-As out there than say SAR Techs so as a whole skills are a lot harder to maintain.  You also see that on civi side when you compare certain ALS EMS systems.  The larger the scale the smaller the scope of practice.


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## kj_gully (5 Mar 2006)

I know I'm preaching to the choir, but how about working up and getting the commensurate training b4 deploying, and not retaining the skill in Canada? There isn't any requirement to maintain the advanced skillset here, if that is a logistical mountain your people don't want to move.


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## herseyjh (6 Mar 2006)

That is a good point as that is what happens now.  For example when I went overseas when I was in the infantry we received IV training and training on how to administer morphine and narcan if required.  So, on the converse, if the CF did adopt this concept then training the medics who are being deployed would be a logical step.


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## JANES (7 Mar 2006)

It is my understanding that every Canadian soldier in Afghanistan has been given a C-A-T, two Israeli dressing and a pack of Quick Clot.  Thank goodness.  So to all the Quick Clot haters out ther, you know who you are, (I seem to remember the Quick Clot rep getting shoed out of here some time ago), take note.  Looks like we're slowly getting our act together.  What's next Combat SAR Techs ?


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## Armymedic (7 Mar 2006)

Hey, I don't hate Quickclot, I just think that it should only be used by trained people and not just issue out to everyone for thier use, like what the US Army did before pulling it, and what we are going to do. 

It works great, when used properly.

As for the kit, you mentioned....thats the plan. Thats why we are teaching the training in Petawawa as part of TMST.


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