Level I (i.e., point of injury)
Combat medic
General physician
Physician assistant
Level II (i.e., forward surgical team)
Combat medic
Nurse
Surgeon
Anesthesiology provider
Level III (i.e., combat support hospital)
Combat medic
Nurse
Physician assistant
Surgeon (including specialists)
Emergency physician
Anesthesiology provider
General physician
Radiologist
Members of modern war zone trauma teams can include varying numbers of surgeons and surgical specialists, emergency physicians, combat medics, anesthesiologists, nurses, and additional ancillary providers (Table 31.1) [4–8]. The multidisciplinary physician nature of modern robust military trauma teams provides optimal care to combat casualties and addresses the frequently devastating penetrating, blast, and orthopedic injuries seen on the battlefield. Radiologists may aid in the triage of imaging studies for trauma patients and report immediate results to trauma team leaders. Many additional providers assist in patient care at the higher echelons including blood bank, pharmacy, laboratory services, and operating room personnel. In multi-casualty and mass-casualty incidents, the trauma team members vary based on number of casualties and the priority and nature of their injuries.
War zone casualties can include soldiers, adult civilians, children, and enemy combatants and often arrive with little warning, in critical condition, and in multi-casualty or mass-casualty numbers. Team preparedness to ensure effective communication, identified leadership, role clarity, situational awareness, and action anticipation is imperative. The ability of the individual and the trauma teams to function in a predictable manner to dynamic situations is key to care in the combat setting. Team training prior to combat deployment, ongoing training in the war zone, and consistent debriefing are vital to optimizing battlefield care.
Pre-deployment simulation-based training has positively affected trauma team performance in areas such as modern battlefield injury care, individual performance awareness, and team performance during mass-casualty incidents [3, 9, 10]. Importantly, pre-deployment training can identify critical areas of needed improvement in trauma team performance such as communication lapses, inappropriate trauma triaging, delays to lifesaving procedures, and failure to recognize hazards such as unexploded ordnance [11]. In the war zone, ongoing team exercises and simulation-based training can be an effective tool to maintain and improve trauma team performance and may be particularly valuable to orient new members to the deployed trauma team. Team exercises can target critical events, can complement debriefing tools, and can include all aspects of patient care from initial triage through evacuation to higher levels of care.
Care of the trauma patient can be stressful for care team members in any setting. The consistent high acuity and devastating nature of battlefield casualties within unfamiliar surroundings combined with a setting typically removed from a medical provider’s usual personal and professional support can add additional emotional burden. Medical providers in combat settings are at risk of developing syndromes such as post-traumatic stress disorder and should be offered interventions such as critical incident debriefing [12]. Regular debriefing of trauma care as well as critical incident debriefing of particularly stressful events may optimize team and individual performance, enhance individual coping, nurture team communication, and prevent stress reactions or identify individuals in need of more mental health resources.
Biological Warfare
Agents of biological warfare are unconventional weapons considered to be a modern threat in military and civilian settings. Although these agents are relatively inefficient as weapons on the modern battlefield, the relative ease in which they can be obtained, produced, and delivered makes them attractive to terrorist organizations, antagonistic foreign governments, and related entities. Several unique factors make biological warfare situations problematic for the trauma team. The presence of these toxic agents may remain unnoticed for days or weeks due to delayed onset of illness after exposure or when initially being overlooked as the effects of a natural endemic [13–15]. Multi-casualty or mass-casualty events of both victims of these toxic agents and the “worried well” may overwhelm healthcare facilities [13–15]. Patients may require critical decontamination to mitigate further effects of such poisoning to include preventing the spread of these agents to healthcare providers as secondary casualties [13–15]. Care of the trauma patient in the setting of biological warfare can be optimized by an understanding of some aspects of these rarely encountered agents as well as unique considerations of their impact to the trauma team dynamics.
Biological warfare agents are generally infectious and often living particles [13, 14]. Most of these entities can be categorized as bacterial, viral, or toxin in nature and are generally most efficiently weaponized as an aerosol (Table 31.2). There are a great number of bacterial organisms which include anthrax, cholera, and plague, while viral agents include smallpox and viral hemorrhagic fevers, and weaponized toxins include ricin and Clostridium botulinum spores. A myriad of physiological derangements may manifest after exposure to these agents and may complicate the spectrum of care of the trauma patient (Table 31.3).
Biological agent | Delivery mode | Physiological effect |
---|---|---|
Bacterial | ||
Anthrax (Bacillus anthracis spores) | Aerosol release | Pulmonary, gastrointestinal, cutaneous |
Food and water contamination | ||
Brucellosis (Brucella bacteria) | Aerosol release | Bone and joint, pulmonary, genitourinary |
Plague (Yersinia pestis bacteria) | Aerosol release | Pulmonary, hematologic |
Cholera (Vibrio cholerae bacteria) | Aerosol release | Gastrointestinal |
Food and water contamination | ||
Viral | ||
Smallpox (variola major or minor virus) | Aerosol release | Skin, pulmonary, hematologic, neurologic |
Viral hemorrhagic fevers (i.e., Ebola) | Aerosol release | Skin, hematologic, neurologic |
Toxin | ||
Clostridium botulinum toxin | Aerosol release | Neurologic, gastrointestinal |
Food and water contamination | ||
Ricin | Aerosol release | Pulmonary, gastrointestinal |
Food and water contamination | ||
Trichothecene mycotoxin | Aerosol release | Hematologic, neurologic, pulmonary, gastrointestinal |
Food and water contamination |
Table 31.3
Suggested precautions and personal protective equipment (PPE) against selected agents of biological warfare [13]
Precautions and PPE | Biological agent
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