Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Download medical advances as a result of war
Document related concepts
Transcript
MEDICAL ADVANCES AS A RESULT OF WAR James Cole, DO, FACS Assistant Director of Trauma Services Advocate Medical Group Advocate Good Samaritan Hospital Downers Grove, IL Medical Advances as a Result of War Prior to Current Wars Blood Program Variolation & Immunization Gangrene Treatment Necrotizing War Wound Treatment Cautery Food Preservation General Anesthesia Ligatures Helicopter Evacuation Antisepsis Tourniquet Vascular Surgery Credentialing Ambulance Shock Treatment Paramedics Surgery = extremity amputation of major extremity war wounds Cautery of bleeding stumps Application of red-hot heated irons Pouring on of boiling oil French military surgeon 1510 - 1590 Author of “Treatment Method for Wounds and Fractures of the Human Head” (Henri II) Authority on battlefield wounds and amputations Egg yolk, rose oil, and turpentine rather than boiling oil to treat GSWs Reintroduced ligatures THE REVOLUTIONARY WAR 50,000 Deaths Small Pox spread epidemically among soldiers General Washington ordered troop variolation Troops became ill for weeks Many deaths prevented 160/1,000 3/1,000 Beginning of mass immunization Most extremities were amputated To prevent future infection Pain Control Officers: Rum and Brandy Enlisted: Stick to bite upon Amputation Procedure 1718 Louis Petit Patient held down by two Surgeon’s Mates Tourniquet applied four fingers above wound Surgeon’s knife swiftly cut through muscle to bone Hand saw used to cut bone Bleeding stump dressed 35% survival rate Baron Dominique Larrey Napoleon's Surgeon The “Flying Ambulances” Rapid evacuation of casualties First aid supplies Advancements in field amputation Early amputation Creation of flaps Avoidance of putrefying agents Food often spoiled during campaigns Food-borne illness recognized Smoking / drying insufficient French Army prize for food preservation Appert developed “canning” in 1810 Nicholas Appert THE CIVIL WAR 1861 - 1865 625,000 deaths Inhalational sulfuric ether invented in 1846 Chloroform 1847 Chloroform officially issued to military doctors Union and Confederate “Painless surgery” on the civil war battlefield 8,900 documented uses 37 deaths due to Chloroform overdose Surgeon General J.K. Barnes, M.D. Collapse after a blow to abdomen (without a wound) may be due to “wound shock” from internal bleeding. “The collapse of bleeding resembles syncope.” “Rest in bed, opium, and warm formentations constitute treatment.” Louis Pasteur in 1861 identification of bacterial cause of putrefaction Erysipelas and “hospital gangrene” common Mortality if untreated ~ 50% Topical Bromine Used to kill bacteria ↓ Mortality to 2.6% Dr. John Letterman Each regiment assigned 3 ambulance teams 2 Privates 1 Driver Ambulance supplies 1 quart flask of brandy 2 tourniquets 6 bandages 6 small sponges Splint material Pieces of old blankets Jonathan Letterman, MD Union Surgeon Confederates similar order Ordered only experienced surgeons perform amputations 3 top Surgeons per Division Documented experience and competence “Medical and Surgical History of the War of the Rebellion” 6 volume publication of civil war injury, disease, and treatment Lt. Col. Joseph Woodward, MD Principle author Performed Lincoln autopsy THE SPANISH-AMERICAN WAR ~2,500 deaths Spanish-American War – first war fought across the ocean Malaria, yellow fever, dengue fever, and amoebic dysentery Maj Walter Reed established the relationship of mosquitoes and Yellow Fever Mosquito control began Sir Joseph Lister Discovery of antisepsis in 1867 Use of aerosolized carbolic acid in surgery Antiseptic surgery and topical antiseptics used widely in Spanish-Am War Antiseptics in first aid kits issued to all soldiers Significant ↓ in wound deaths WORLD WAR I 116,000 Deaths Horrific trench warfare Better weapons more casualties Better understanding of “shock” Recognition of temporary effect of crystalloid Tissue third spacing Development of “Gum Salt” 6% acacia plus salt solution Improved blood pressure with “Gum Salt” High incidence of fever and other reactions Motorized ambulance Whole blood transfusion Widely used during WWI Recognized effectiveness of raising BP and ↑ O2 delivery Small volumes administered ≤ 600 ml Fresh, warm blood given within 2 hours of donation Found to be very effective Elevation of feet Recognition of hypoxia – cyanotic appearance No method for oxygen administration Use of vasopressors (epinephrine) condemned Mr. George Grey Turner British War Surgeon First surgical attempt to retrieve an intracardiac bullet Bullet seen in heart on x-ray Heart exposed through left chest Bullet palpated lodged in septum. Not removed. Drain placed Pericardium sutured Casualty survived The birth of cardiac surgery Expectant management High mortality for persistent hemorrhage Lord Moynihan of Leeds British War Surgeon Introduced thoracotomy for persistent bleeding Improved survival rates Endotracheal tubes not in general use Catastrophic outcomes Recognized need for extensive tissue debridement Inter-Allied Surgical Conference of 1917 Extensive debridement Closure by secondary intention “4 C’s of Muscle Viability” Contraction, color, Consistency, capillaries Sir Henry Simpson Newland Australian Surgeon WWI WORLD WAR II 407,000 Deaths MG Norman Kirk Management of Extremity War Wounds Open circular amputation Close by secondary intention Colonic Injuries Diverting colostomy Mortality ↓ to 24% Significant inter-war setbacks Lessons learned in WWI largely forgotten Normal saline in limited availability “A spoonful of salt was added to distilled water, placed in a Salversan flask attached to an old rubber tube and needle.” Tube sterile, but pyrogens caused fevers > 105˚ Need for large volume fluid infusion forgotten Benefits of blood initially forgotten Plasma infusion the initial fluid of choice Shipment of blood to remote areas impractical Col Douglas Kendrick Surgical Consultant North African Theater Reinstituted use of whole blood for blood loss Developed the Army Blood Program Theater wide distribution of whole blood Forefather of regional blood banks “Battle Fatigue” “Shell Shock” Recognized mental effects of the exposure to war Unprecedented studies Aggressive push for outpatient care The beginnings of “Post Traumatic Stress Disorder” care The Korean War 36,000 deaths Brought surgical casualty management to the front CPT H. Richard Hornberger, Surgeon “Meatball Surgery” Patch the casualties up Save lives Ship them to US for definitive care Unprecedented salvage Absence of military bearing Nurses in combat hospitals 3 – 4 Bell H-13 Sioux helicopters per MASH Rapid CASEVAC – 10 miles Features Stretcher pod on skids “Goldfish bowl” Plexiglas canopy Heat piping into litter areas IV mounts on outside Amputation no longer always necessary Direct vascular repair Arterial replacement Col Michael Debakey Significant reduction in casualty amputation rate The Vietnam War 58,000 Deaths Life-saving emergency care pushed to the front lines Surgical airways Chest needle decompression Aggressive shock resuscitation Beginnings of civilian pre-hospital EMS OPERATION RESTORE HOPE -- 1993 Blackhawk helicopter crash Maj John Holcomb Surgeon – operated 30 consecutive hours 18 deaths in field 2 “potentially preventable” Exsanguination hemorrhage Research on hemostatic bandage technology Dry Fibrin Sealant (DFS) Fibrinogen, thrombin, Ca Activated by water Brittle, expensive QuikClot Zeolite powder Drying agent Exothermic reaction Hemcon Chitosan Local vasoconstrictor THE PAST DECADE OF WARS In Iraq and Afghanistan “Only do that which is necessary to save the life of the casualty…” Surgery Control hemorrhage Control soilage Prevent the “Lethal Triad” Resuscitate in “ICU” Take-back when stable Significant ↑ in survival DOW rate 0.8% Massive brain trauma “Compartment syndrome” of the head Analogy: Fasciotomy Use in malignant intracranial hypertension Increased survival ABC reporter Bob Woodward Combat Application Tourniquet – 2 Prevention of extremity hemorrhage Unstable stable Negligible incidence of limb loss from tourniquet Characteristics 2 inches Windlass Cessation of pulse NovoSeven Hemophilia War experience Israel War experience Iraq Critics ↑ thrombotic complications Advocates ↑ survival in multiple trauma “Flying ICUs” Large military aircraft Critical Care staff Pulmonologists, CCRNs, RTs, corpsmen/medics Critical care equipment Blood Critical care medications Evacuation war zone Landstuhl U.S. Limited availability FFP, platelets, cryoprecipitate pRBCs and saline Cold, old, no clotting factors / platelets Fresh, warm, whole blood FFP, cryo, platelets Extensively used in Iraq Thousands of units given Countless lives saved Transfusion reactions rare Extensive blast injuries New reconstructive methods IED to hand complete loss of metacarpals and hand tendons Reconstruction with ribs and serratus flap Versajet high pressure saline debridement Less tissue loss Fewer debridements Better graft take Wound Vac therapy Decreases healing time Earlier transport between institutions Multiple wounds to multiple body parts Multiple surgeries and anesthetics Creative use of local and regional anesthesia Research on treatment of phantom limb pain 1:30 combat vets amputee Defense Advanced Research Projects Agency Electrocortography brain mapping grids Use of brain signals to trigger prosthetics “House legs” for mobility in the home Military Medicine “Binding the Wounds of War” Dedicated to the Memory of John Pryor, MD Major, Medical Corps, US Army Reserve Trauma Surgeon, University of Pennsylvania Killed in Action December 25, 2008 Mosul, Iraq
