Showing papers on "Afghan Campaign 2001- published in 2011"

The impact of the conflicts of Iraq and Afghanistan: a UK perspective.

Abstract: Concerns about the mental health of military personnel deployed to Iraq and Afghanistan has led to a new generation of research. This review is an examination of the UK literature on the mental health consequences of deployment of armed forces personnel to Iraq and Afghanistan. As yet, deployment to Iraq or Afghanistan has not been associated with a general increase in mental health problems for the UK Armed Forces. However, research has highlighted certain problems that continue to need to be addressed. Whilst, the rate of post-traumatic stress disorder (PTSD) is low in the UK Armed Forces (1.6-6%), deployment to Iraq or Afghanistan is associated with an increased risk of PTSD for reserve personnel. In contrast to PTSD, the rate of alcohol misuse is high in the UK Armed Forces (between 16-20%), and has been associated with deployment to Iraq or Afghanistan for regular personnel. As the UK military engagement in Afghanistan continues and more personnel are deployed, the demand for help from military health services, the NHS and the service charities will increase.

Surgical experience at the Canadian-led Role 3 Multinational Medical Unit in Kandahar, Afghanistan

Abstract: Introduction The purpose of this study was to document the surgical experience of the Role 3 Multinational Medical Unit (R3MMU) at Kandahar Airfield Base while Canada was the lead nation for the facility. This study will help inform on future staffing, training, and deployment issues of field hospitals on military missions. Methods From February 2, 2006, to October 15, 2009, the Canadian Forces Health Services served as the lead nation for the R3MMU. We retrospectively reviewed the electronic and the actual operative database during this timeframe to assess surgical workload, types of surgical procedures performed, and the involved anatomic regions of the surgical procedures. Results During this timeframe, there were 6,735 operative procedures performed on 4,434 patients. The majority of our patients were Afghan nationals, with Afghan civilians representing 34.8%, Afghan National Security Forces 31.6%, and North Atlantic Treaty Organization forces 25.3%. The number of operative procedures by specialty were 3,329 in orthopedic surgery (49.4%), 2,053 general surgery (30.5%), 930 oral maxillofacial surgery (13.8%), and 272 neurosurgery (6%). The most frequently operated on body region was the soft tissue, followed by the extremities and then the abdomen. Thoracic operations were very infrequent. Conclusion Our operative data were slightly different from historical controls. Hopefully, this data will help with planning for future deployments of field hospitals on military missions.

Understanding substance use in military spouses.

Abstract: In their paper, ‘‘Screening, Brief Intervention, and Referral to Treatment [SBIRT] for Military Spouses Experiencing Alcohol and Substance Use Disorders: A Literature Review’’, Ahmadi and Green (2011) endeavor to better understand substance use among military spouses, and the utility of SBIRT as an effective means to address it. Their work highlights some important knowledge gaps, such as the dearth of information available about substance use among military spouses, in general, and specifically, the potential for substance-related problems stemming from the stress of military life (i.e., deployment) to develop in this population. They also present one potential, clinically based solution to a problem that to date remains relatively undefined. The idea that operations in Iraq and Afghanistan have taken an emotional toll on military spouses is both logical and supported by the literature. Certain stressors specific to deployment are known to negatively impact the spouses of service members, such as fear for the safety of loved ones, single parent responsibilities, and marital strain (Schumm, Bell, & Gade, 2000). Increased rates of child maltreatment within families during combat deployment versus periods of nondeployment have been reported (Gibbs, Martin, Kupper, & Johnson, 2007), and a dose-response relationship was observed for mental health diagnoses among military spouses as the deployment time of their partners increased (Mansfield et al., 2010). Indeed, younger military families may be at higher risk for distress due to inexperience, new marriages, young children, and lower income (Watson Wiens & Boss, 2006). To date, however, increases in substance abuse and dependence have not been well documented. Several factors may explain the lack of information concerning substance use and related issues among military family members. For example, data comparing military spouses to individuals with similar sociodemographic characteristics in the general population are not readily available. Essentially all existing research in military families focuses on the service member, highlighting the need for more research directed specifically at spouses and children. One of the few sources of information on substance use among military spouses is from an analysis of outpatient medical data for over 250,000 wives of U.S. Army active duty personnel. While prolonged deployment was associated with notable increases in diagnoses of depression, anxiety, sleep, and stress-related disorders when compared with wives of nondeploying soldiers, increases for diagnoses relating to alcohol and drug problems were less substantial (Mansfield et al., 2010). One issue is that reliance upon care-seeking or clinical assessment to study disordered substance use is likely to miss individuals who do not seek medical care for their problems. Even among military spouses who would seek care, access is often reduced or deferred to outside facilities due to the heavy influx of soldiers needing mental health and substance abuse treatment. Furthermore, substance misuse is often carefully hidden from detection, an effect potentially amplified in an occupational health setting such as the military. To fully comprehend the extent of substance use in this population will require field epidemiological methods designed to identify problems that those affected A. J. Mansfield (&) National Center for PTSD-Pacific Islands Division, Department of Veterans Affairs, 3375 Koapaka Street, Suite I-560, Honolulu, HI 96819, USA e-mail: alyssa.mansfield@va.gov

Strengthening Our Soldiers (SOS) and Their Families: Contemporary Psychological Advances Applied to Wartime Problems. Why Now? Why Us? What Next?

Abstract: Since October 2001, approximately 2 million U.S. troops have been deployed for Operations Enduring Freedom and Iraqi Freedom (OEF/OIF) in Afghanistan and Iraq. Serving in military campaigns such as OEF/OIF provides service members with income to support themselves and their families, job skills, opportunities for physical fitness, health care, educational opportunities (especially in regards to cutting edge technology), and a support network. However, early evidence suggests that the psychological toll of these deployments—many involving prolonged exposure to combat-related stress over multiple rotations—may be disproportionately high compared with the physical injuries of combat (Tanielian et al., 2007). Between 11% and 42% of returning service members report some type of mental health problem during post-deployment screenings (Hoge et al., 2004; Milliken, Auchterlonie, & Hoge, 2007). Concerns have been most recently centered on two combat-related injuries in particular: post-traumatic stress disorder (PTSD) and traumatic brain injury (TBI). In fact, many recent reports have referred to these as the signature wounds of the Afghanistan and Iraq conflicts and remarked that even more new cases will likely be identified over time (Milliken et al., 2007). The operational tempo associated with OEF/OIF in conjunction with extended and multiple deployments and shortened dwell time between deployments have placed unprecedented stress upon service members. Simultaneously, the survival rate of exceeds those of all previous wars (Lew et al., 2009). OEF/OIF war fighters have extreme physical demands placed on their bodies, including the need to move rapidly while carrying heavy loads over difficult terrain. They are engaged in and exposed to high stress conditions combined with sleeping on cots with little back support, standing on their feet for hours at a time, riding in convoys in crunched positions and wearing heavy body armor. All of these activities contribute to musculoskeletal problems, which are the number one cause of disability discharge from the military (USARIEM, 2006). The human stress response has a number of checks and balances to ensure that various components do not become hyperactive. Unfortunately, in the case of severe or chronic stress, these normal checks and balances can fail. When they do, humans become vulnerable to disease. This failure leads to a series of physiologic consequences, such as sleep disruptions; changes to brain structures, such as the hippocampus and prefrontal cortex; bone mineral loss; abdominal obesity; and increased risk of cardiovascular disease (McEwen, 2003). B. G. Melamed Former Director, Clinical Heath Psychology Postdoctoral Fellowship Program, Department of Psychology, Tripler Army Medical Center, Honolulu, HI 96859, USA e-mail: barbara@drmelamed.net

A piece of my mind. Sleepless.

Abstract: Sleepless I THOUGHT ABOUT OUR ENEMIES TONIGHT, AND WHY AND how we physicians care for them. It has been said that downed American pilots and other servicemen returning from German prison camps after World War II were sometimes found to have metal rods inside their fractured femurs. One such story was the subject of a 1945 article in Time magazine called “Amazing Thighbone.” A mix of curiosity and disgust followed over such apparent human experimentation, though the servicemen had actually received an advanced treatment for femur fractures ahead of its time: an intramedullary nail. The captivating thought in the anecdote, though, is that the enemy would render not just reluctant care, but outstanding care. Today is February 27, 2010. We at the 452nd Combat Support Hospital in Khost, Afghanistan, just sent a wounded insurgent, an “enemy combatant,” up range to the hospital at Bagram Airfield for neurosurgical care. He was injured in a firefight with US troops and sustained a severe head injury, chest injury, and fragmentation wounds of his arms and legs. We have been caring for this patient for the better part of two days, because ever since he was admitted, the high mountain passes out of Khost province were closed to air traffic due to bad weather. On the day he was wounded and brought to us shortly after midnight, he was critically ill. After we secured his airway, he went through CT scans, two chest tubes, a central line, warming blankets, IV drips, pain medication, sedation, and several hours of resuscitation with fluids and blood products. Around 5 AM I caught two or three hours of sleep on the couch in the operating room lounge, then got up to look in on him again. We diagnosed an arm “compartment syndrome” from where the intravenous contrast for the CT scan had infiltrated the tissues of his arm rather than flowing into the vein as intended, so I took him to the operating room to open and release the muscle compartment. We diagnosed a deep vein thrombosis in the thigh and put a state-of-the-art, retrievable clot filter into his inferior vena cava through a tiny puncture in his groin, the metal sentry silently standing guard over the patient’s pulmonary vessels. We painstakingly suctioned mucus and blood plugs from his airways when the right upper lobe of his lung, bruised and shredded from the fragmentation wounds, was not inflating properly. Unspoken in my mind, and probably in the minds of others with me, are the thoughts, Wouldn’t it be easier to let nature take its course and let this enemy combatant die of his severe injuries? He would certainly die if he was in a local hospital or insurgent aid station. Or could I just let him writhe in pain for a little longer? He wouldn’t hesitate to slit my throat if he could. Why am I busting my butt to save his? Why am I losing sleep over this guy? Maybe I could . . . ignore his declining oxygen saturation level. Maybe I could . . . not ignore him, but make him my last priority for the operating room, drag my feet in getting around to looking at his labs, put off that therapeutic bronchoscopy until tomorrow. All of these are small decision points, none of them wildly and explicitly corrupt, but all of them in aggregate may lead to a different outcome than in the conscientiously treated patient, perhaps even a fatal outcome. Then the self-justification would start: “Well, it was inevitable,” we would say. “We did what we could in the circumstances, but these things happen.” Everyone would shake their head, shrug their shoulders, disperse. It would be easy. And more convenient. But we don’t. We treat the heck out of him, losing a perfectly good night’s sleep keeping this man alive who was just trying to kill one of our fellow countrymen. Nobody was forcing us to work up each symptom, keep each other motivated, or intervene at what we thought were the right moments. Most of the nonmedical onlookers were uninterested, bored. This case had none of the “flair” of saving one of our own soldiers. The battalion commander over the team who had taken the enemy combatant down and brought him in asked one of the hospital personnel why we were “expending resources” to save an insurgent’s life. I’m not some exceptional bleeding-heart hero either; every surgeon I know would have done the same as me, I think. Why do we go to such trouble to treat our enemies? Automatic action? a trained response? fear of bad publicity, echoing Abu Ghraib? the Geneva Conventions looming over our heads? some Pollyanna notion that when we nurse him back to health, he’ll fall down sobbing and ask for forgiveness for his actions? a desire for “actionable intelligence” that he might give our interrogators once he’s off the ventilator and talking? Maybe some of these thoughts enter my mind, but the reason I went nearly sleepless that night is so that I can sleep all the other nights. It’s essentially the same reason I take extra care with each patient at home. A common phrase in my operating room is “I do it this way so I can sleep at night.” I can go to bed knowing I cut no corners, I gave each patient the best possible chance at a good outcome. There are still bad outcomes, and I agonize over those, replaying each decision in my head afterward. But I did the best I could by each one.

Introduction to the Canadian Forces supplement on war surgery.

Abstract: Improvements in trauma care have been inextricably linked to wars. Surgical techniques and trauma systems have been refined in successive conflicts. Ambroise Paré, perhaps the first modern trauma surgeon, pioneered the use of antiseptic ointments for the treatment of gunshot wounds and the use of ligature, instead of cauterization, to control arterial bleeding. Dominique-Jean Larrey, Napoleon’s surgeon, addressed trauma from a systematic and organizational standpoint by introducing the concept of the “flying ambulance,” the sole purpose of which was to provide rapid removal of wounded soldiers from the battlefield. From his own World War II experiences, Michael DeBakey noted that wars have always promoted advances in trauma care because of the concentrated exposure of military hospitals to large numbers of injured people. Furthermore, DeBakey felt that this wartime medical experience fostered a fundamental desire to improve outcomes by im prov ing practice. In July 2011, Canada ended its combat mission in Af ghan istan. During our 9 years in Afghanistan, we have accomplished much, but at a significant cost. A total of 157 Canadian Forces (CF) personnel have died in the war since 2002 — the largest number for any single Canadian military mission since the Korean War. Among the dead were 8 CF medical technicians, who always accompan ied our combat troops on patrol “outside the wire” and who were killed in action while providing medical support to them. On Remembrance Day, we reflect on the sacrifices made by CF members in this most recent and other previous conflicts. As first-hand witnesses to the sacrifices made by our brothersand sisters-in-arms, members of the Canadian Forces Health Services (CFHS) are also remind ed of our solemn responsibility to care for our wounded. Our sense of responsibility continues to be our fundamental motivation to improve practice in order to improve outcomes for those who serve. Compared with past conflicts, this current conflict has seen a dramatic reduction in the number of soldiers killed from combat wounds: the current case fatality rate is 8.8%, whereas the rate during World War II was 22.8%. Better body and vehicle armour, technology and tactics all likely contributed substantially to this improved survival rate. However, advances in prehospitaland hospital-based trauma care have also improved survival. In addition, comprehensive rehabilitative and mental health care have improved the quality of life of our wounded soldiers after they return to Canada. As this Remembrance Day passes, members of the CFHS have contributed their reflections on lessons learned during the war in Afghanistan to this supplement of the Can­adian­Journal­ of­Surgery. We hope that our wartime experiences and lessons will be the starting point for future health care innovation that helps us continue to sustain and shield our fighting forces when they deploy on future military missions.