3. JOINT HEALTH COMMAND
The Mission
• Australia’s military commitment to
Afghanistan as part of the NATO-led
International Security Assistance Force
(ISAF)
– as a peace-enforcement mission under
Chapter VII of the UN Charter
– at the invitation of the Government of the
Islamic Republic of Afghanistan (GIRoA)
– under the United Nations Security Council
resolution (UNSCR) 1833
4. JOINT HEALTH COMMAND
My Deployment
• Requirement to replace injured
Orthopaedic Surgeon in RAAF-led
Surgical Team within a Netherlands Army
Role 2E Hospital in Tarin Kowt, Uruzgan,
Afghanistan
• Joined team for final 3.5 weeks of their 10
week deployment
6. JOINT HEALTH COMMAND
Role 2E Hospital
• Netherlands Army Hospital
– Command & Control, Health Ops
– Emergency Room, Resuscitation, Ward,
Outpatients, Theatre Tech, ICU Medic,
Dental, Radiography, Physio, Laboratory,
Blood, Pharmacy, Medical Supply,
Sterilisation, Biomedical Techs, Mortuary
• Australian Surgical and ICU Team
• Singaporean Team
7. JOINT HEALTH COMMAND
Situation
• Australian Bushmaster armoured vehicle
carrying soldiers from MTF-1 sustained an
Improvised Explosive Device (IED) attack in
the Chora Valley area of Uruzgan province
• 5 of the 9 occupants were wounded in action
and transferred by AME to the ISAF Role 2E
Hospital in Tarin Kowt
• Above details from www.defence.gov.au and are
UNCLASSIFIED
• Specific further details of the incident are SECRET and
will not be discussed in this presentation
8. JOINT HEALTH COMMAND
Casualty Reception
• AME conducted as per
evacuation priority
• Transferred from the
airfield by ambulance
• Search of casualties at the
entrance
• Brought into the
Emergency Department /
Resuscitation Area
9. JOINT HEALTH COMMAND
Casualty Assessment
• Assessment by Resus Teams in
accordance with standard EMST principles
• 4 teams working simultaneously
• Primary Survey and resuscitation with
concurrent digital imaging, FAST and
pathology
• Surgeon involvement with surgical triage
and secondary survey
16. Case 1 Progress
Concern of possible lumbar fracture
Neurologically intact
Transferred to Role 3 Hospital by
helicopter for CT spine
CT revealed unexpected burst fracture of
T12 with small amount of retropulsion
18. Case 1 Management
Neurosurgeon opinion that fracture did not
require operative management
Sent to the US Forces Landstuhl Regional
Medical Center (LRMC) in Germany for
spinal brace then Return to Australia
(RTA)
19. Case 2 (Soldier F)
Primary survey stable
Complaining of mid-thoracic back pain
Neurologically intact
Tender lower C-spine and at T6 region
X-rays difficult to interpret
Abnormal C4/5 but no obvious fracture
Sent to Role 3 Hospital for CT scan
22. Case 2 Management
CT scan revealed compression fractures
at T5, T6 and T7
– The abnormality of the C-spine felt to be from
previous injury or congenital
Non-operative management
Analgesia
RTA
23. Case 3 (Soldier G)
Stable, C-collar, chin laceration
Complaining of lower back pain
Tender lower lumbar spine on palpation
Neurologically intact
Possible small L5 compression fracture on
plain X-ray
Sent to Role 3 Hospital for CT scan
26. Case 3 Management
CT scan showed compression fracture of
T12 with minimal loss of height
Neurosurgeon opinion stable fracture
No operation or bracing required
RTA
27. Injury Pattern
All 3 casualties were seated at the time of
ED strike in an armoured vehicle
All were wearing body armour system that
prevented flexion in thoracolumbar region
Axial compressive force of blast resulted in
compression /burst fractures of the
horacic spine
28. Main Clinical Issue
n 2 of 3 cases T12 fractures were not
clinically suspected on secondary survey
– CT scans done for other potential spinal
pathology
29. Other Casualties
1 casualty with tibial
plafond fracture
– Treated operatively
1 casualty with flank
pain but no midline
enderness
– X-ray showed possible
fracture of pedicle at
L3
30. Other Occupants
The 4 remaining occupants were reviewed
n subsequent days
– 1 occupant with thoracolumbar pain
• Normal X-ray
• CT scan did not reveal a fracture
– 2 occupants complained of neck pain
– 1 occupant with periscapular contusion
31. Literature Review
US Forces paper
Retrospective
bjective: analysis of spine fractures
sustained by NATO soldiers when vehicles
are attacked by IEDs
ethods: review of all soldiers admitted
with spine fractures following vehicle IED
rom 1 Jan – 15 May 2008 (OEF)
32. Literature Review
esults:
12 male patients with 16 thoracolumbar
ractures
– 6 flexion-distraction fractures (Chance
fractures) = 38%
– 7 compression fractures
– 3 burst fractures
3 patients had neurologic deficits
34. Literature Review
onclusion:
Reported incidence of flexion-distraction
ractures 1-2.5% in world literature
n this study the incidence was 38%
The blast pattern from IED explosion may
be responsible for the high rate of these
njuries in vehicle occupants
35. Discussion
Our case series did not have any flexion-
distraction injuries, only compression and
burst fractures
– postulated that the spine support provided by
the body armour prevented the flexion-
distraction injuries
– still allowed axial transmission of the blast to
cause compression and burst fractures
36. Discussion
No cases with neurological injury in our
series
– May be related to magnitude of blast or
protection from armoured vehicle
Physical examination unreliable
– Only 1 casualty had thoracic tenderness
– Need high index of suspicion based on blast
mechanism of injury
37. Discussion
None of the casualties were wearing seat
restraints at the time
– Was it protective to be unrestrained?
Majority of seated personnel complained
of lumbar pain
– Possibly related to edge of body armour
– Superficial trauma
38. Conclusion
Personnel involved in IED strikes while in
armoured vehicles must be closely
scrutinised for spinal injuries afterwards
39. Conclusion
Medical staff treating casualties following
an IED vehicle attack should have a low
ndex of suspicion for spinal fractures
– Physical exam alone may be unreliable
especially when other injuries are present
CT scans are recommended for all IED
casualties with back pain or tenderness
40. Future Research
Seat design to absorb blast
Types of restraints that reduce injury
Possible protection from flexion-distraction
njuries at thoracolumbar junction from
body armour?
