Combat related maxillofacial injuries the kandahar experience- tong

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Combat related maxillofacial injuries the kandahar experience- tong

  1. 1. Combat Related Maxillofacial Injuries Lt Col Darryl Tong RNZAMC Oral and Maxillofacial Surgeon
  2. 2. Disclaimer and OPSEC
  3. 3. 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
  4. 4. Role 3 MMU KAF • Nations represented include: • Canada (lead Nation) • Denmark • Netherlands • United States • United Kingdom • Australia • New Zealand
  5. 5. MMU COMKAF HQ Primary care
  6. 6. 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
  7. 7. 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
  8. 8. 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
  9. 9. 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
  10. 10. 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
  11. 11. Patients • Coalition personnel • Civilian contractors • ANA and militia • ANP • Local population • Significant paediatric patient flow • Minimal women’s health involvement
  12. 12. Surgeries by specialty 50 115 273 648 893 Other 4% Neuro 7% Maxfax 16% General 39% Ortho 53% Period: 01 Sep 2007 – 01 Mar 2009 N = 1675
  13. 13. Patient category 642 635 303 48 47 0 100 200 300 400 500 600 700 Period: 01 Sep 2007 – 01 Mar 2009
  14. 14. Trauma sequence • 9- liner called through • Trauma teams notified • Specialist staff notified • Operating theatre on standby • Triaged • Primary survey: MARCHH • Secondary survey
  15. 15. 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
  16. 16. 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
  17. 17. 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
  18. 18. Surgical considerations • Damage control surgery vs. definitive care • Primary versus secondary reconstruction • Choice of hardware • General condition of patient • Patient disposition • Antibiotics
  19. 19. 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
  20. 20. Surgical considerations • Potential need for secondary surgery depends on:  Patient condition  Availability of tissue  Surgeon skill set  Demands on operating theatre  Timings for STRATEVAC
  21. 21. 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
  22. 22. Multiple roles in trauma • Maxillofacial trauma  Soft tissue  Hard tissue • Teeth • Bones • Ocular injuries • Advanced airway management including surgical airway • Neck exploration
  23. 23. Multiple roles in trauma • First assistant  Orthopaedic surgery  General surgery  Neurosurgery • Trauma team leader • Post operative care complications
  24. 24. 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
  25. 25. 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
  26. 26. 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
  27. 27. Acknowledgements • AMMA/Joint Health Command • NZ Defence Force • University of Otago • Role 3 MMU KAF ““The Best Care AnywhereThe Best Care Anywhere””

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