Application of ultrasound examination in tactical conditions illustrated with an example of the Field Hospital of the Polish Military Contingent in Afghanistan

Abstract

It is assumed that tactical medicine encompasses all therapeutic activities performed by a military medical service during military and humanitarian missions. Its scope is only apparently limited by the standards which, when referred to the NATO member countries, have been collected in the Joint Theater Trauma System – Clinical Practice Guidelines. The stage-structured character of medical assistance and treatment of the wounded, injured and sick patients assumes that the scope of therapeutic activities performed at each stage is limited only to essential actions. Consequently, more injured patients may be saved – those for whom life-saving activities are performed prior to their transfer to a higher level. The second level is represented by a field hospital. Its first structure is the trauma room in which a rescue team saves and qualifies the injured for further medical activities. Each injured patient undergoes an eFAST ultrasound examination which allows for a quick decision about a surgical treatment to be provided. Moreover, this technique is helpful in vascular cannulation. The authors present their own experiences with using an ultrasound examination during the work in the Field Hospital of the Polish Military Contingent in Afghanistan.

Tactical medicine, sometimes referred to as battlefield medicine, is probably the oldest medical discipline. It has accompanied people for ages since history has always been associated with war and bloodshed. Until recently, soldiers were in the center of military medicine interest – they were the ones who required immediate assistance in order to reduce the extensiveness of secondary injuries and to make them able to perform further military operations as soon as possible. For several dozen years, military medical service has also been helping the injured who are not connected with the army and who have become incidental victims of military operations – civilians, including women and children.

It has been observed that the chances of survival increase when medical activities are limited only to certain medical actions which are never so-called final management of sustained injuries. Such management:

• does not require much time to be devoted to a patient, which enables assistance to be given to a greater number of the injured;

• ensures maintaining vital signs;

• prolongs time needed for final management of sustained injuries.

In tactical conditions, primarily the extremities, sight and, in particular, life should be saved by controlling hemorrhages, decompressing chest in pneumothorax with hyper-tension and clearing the airways.

In brief, medical activities performed in a military operation zone are stage-structured. This means that the medical activities depend on the place in which aid is given. The Polish military doctrine assumes a four-stage system of providing aid:

• Stage I – zone of direct combat; in this place, medical assistance is based on self-help, peer help or aid provided by a combat medic or a medical evacuation team (medevac);

• Stage II – activities are conducted in the region neighboring the combat zone; this is the stage II field hospital in which life-saving procedures can be conducted due to the presence of surgeons, anesthesiologists and orthopedists;

• Stage III – represented by a military specialized hospital in the country at war but not in the direct vicinity to the region where combat takes place;

• Stage IV – a military specialized hospital in the homeland (Poland).

A field hospital (stage II) operates in accordance with the standards of the US Army presented in the Joint Theater Trauma System Clinical Practice Guidelines – JTTS CPG⁽¹⁾. According to these guidelines, a field hospital must provide:

• a trauma room in which (following triage) patients are placed in order to conduct life-saving activities and examinations, establish diagnoses and qualify for emergency/urgent procedures or procedures necessary due to their conditions, or in order to stabilize the general condition and prepare the patient for further evacuation;

• an operating room;

• an intensive care unit (which can hospitalize patients to maximum 72 hours from sustaining trauma, although the preferred hospitalization time should not be longer than 8 hours);

• a hospital unit.

In the trauma room, trauma teams take care of patients. A trauma team consists of:

• the team leader – a trauma surgeon;

• an anesthesiologist;

• a nurse anesthetist (“head”);

• two treatment nurses (“right and left hands”);

• a recorder.

Each injured (according to the JTTS CPG) must be examined. Each injured patient must undergo an eFAST examination (extended focused assessment with sonography for trauma). The condition for therapeutic (invasive) decisions is the detection of the following in a US scan:

• fluid/air in the pleural cavity;

• fluid in the pericardial sac;

• fluid in the peritoneal cavity.

A decision about a surgery cannot be made unless an ultra-sound examination is performed. This means that each patient admitted to the hospital as an emergency under-goes, among other tests, a US examination.

In the stage II hospital, sonography is also used for central venous cannulation (if the condition of the patient is severe – acute hypovolemia) and for cannulation of the peripheral arteries. Although the field hospital was equipped with several US systems, sometimes cannulation procedures were performed based on anatomic markers, since eFAST examination is the priority (which is understandable). The field hospital of the Polish Military Contingent in Afghanistan was equipped with the following US systems:

• SonoSite 180 Plus;

• SonoSite M-Turbo;

• Dramiński Opus D;

• Dramiński iScan.

The figures present standard US applications in the field conditions, except for the two first images (fig. 1 and 2) which present non-routine, exceptional US examinations performed while the patient's transport began in a medical evacuation vehicle (MEV). MEV is a wheeled armored vehicle (KTO Rosomak). According to the authors, such an approach to a US examination, which is of an “off-label” nature, is redundant and a “waste of time.” This is because it does not contribute to therapeutic decisions and, therefore, was not included in the JTTS CPG⁽¹⁾. The subsequent (figures 3–8) present activities conducted in the trauma room.

Fig. 1.

Medic performing an eFAST examination in the medical evacuation vehicle (MEV). Author: T. Wiśniewski

Fig. 2.

Medic performing an eFAST examination in the medical evacuation vehicle (MEV). Author: T. Wiśniewski

Fig. 3.

Trauma team during life-saving activities. Author: W. Machała

Fig. 8.

IScan during guide wire position verification in the RIJV. Author: T. Wiśniewski

Fig. 4.

Trauma leader and anesthesiologist during life-saving activities conducted in the trauma room. Author: W. Machała

Fig. 5.

Trauma team during life-saving activities. The team leader is performing an eFAST examination. Author: W. Machała

Fig. 6.

Trauma room while aid is being provided to the injured. Author: W. Machała

Fig. 7.

Trauma room – trauma team during life-saving activities in a patient with a gunshot wound to the chest. Author: W. Machała

Figures 9 and 10 are shots of the combat camera (mounted on the head of the first author) and show the plethora of activities associated with the injured in the trauma room: simultaneous performance of needle thoracentesis (fig. 9) and rescue thoracotomy (fig. 10). In the patient who underwent an emergency thoracotomy, due to a gunshot wound to the chest at the left side without an exit wound (fig. 10), a FAST (focused assessment with sonography for trauma) examination was conducted to facilitate decision-making concerning rescue laparotomy. Further diagnostic examinations (C-arm X-ray conducted in the operating room) revealed that the bullet was embedded in the IV cervical vertebral body.

Fig. 9.

Trauma room – preparation for eFAST examination in an injured patient who underwent needle thoracentesis. Author: W. Machała

Fig. 10.

Trauma room – preparation for a FAST examination in an injured patient during rescue thoracotomy. Author: W. Machała

Figure 11 illustrates an eFAST examination conducted in a patient on the same day after a surgery in order to monitor the dynamics of the sustained injury.

Fig. 11.

EFAST in an injured patient in t he ICU. Author: T. Wiśniewski

The usage of sonography in the tactical settings fulfils all the criteria of point-of care ultrasonography⁽²⁾, i.e.:

• the examination is used for specifically defined purposes and is associated with an improvement of therapeutic outcomes;

• the examination is goal-oriented and focuses on a given aim;

• the results are easy to interpret;

• the examination is easy to learn;

• the examination is conducted rapidly;

• it is a bedside examination.

Conclusions

1. The eFAST examination is a basic diagnostic test conducted in each injured patient in tactical settings.

2. A US examination belongs to the standard medical procedures conducted by the military medical service.

Conflict of interests

None.