Ukrainian medic Henri talks with the Prolonged Field Care Collective about conditions in Ukraine: most common injury patterns, weather and exposure, access difficulties, Russian drone attacks on medics, trench foot, dressing complex wounds, penetrating pelvic trauma, prevalence of pneumo-hemothorax over tension pneumothorax, body armor selection factors, and more.
Sunday, December 31, 2023
Saturday, December 30, 2023
Blood Loss and the Lethal Triad
Symptoms of blood loss:
500 mL - well tolerated, may produce slight tachycardia, equivalent to a typical blood donation volume.
1000 mL - tachycardia over 100
1500 mL - changes in mental status, weak radial pulse, persistant tachycardia, tachypnea
2000 mL - confusion, lethargy, weak radial, tachycardia over 120, tachypnea over 35, might be fatal if not managed properly
2500 mL - unconsciousness, no palpable radial pulse, tachycardia over 140, tachypnea over 35, fatal without intervention
In patients with blood loss, the "Lethal triad"- is a self-reinforcing cycle of acidosis, hypothermia, and coagulopathy.
Acidosis: Reduced circulating blood volume leads to shunting of blood from the periphery to vital organs in the core. Peripheral tissues resort to anaerobic metabolism, which creates lactic acid as a byproduct. This can be worsened by administration of large volumes of non-oxygen-carrying, acidic fluids, such as normal saline (pH 5.5).
Hypothermia: Develops easily and rapidly in trauma patents, even in warm conditions. Anaerobic metabolism, immobility, and other physiological responses to blood loss reduce heat production. Evidence shows that even small drops in body temperature (to 36C / 96.8F) can significantly increase mortality in trauma and burn patients. At core temperatures below 30C / 86F, patients stop shivering and cannot warm up without application of external heat, even if they are well-insulated. It is far easier to prevent hypothermia than to correct it.
Coagulopathy: Clot formation depends on a complex series of pH- and temperature-dependent chemical reactions. Loss of clotting factors due to bleeding, acidosis, and hypothermia all produce coagulopathy, which in turn further exacerbates blood loss, acidosis, and hypothermia.
Preventing the Lethal Triad cycle is crucial; once established, it is difficult to interrupt. Field treatment of patients with significant blood loss should include oxygen, insulation from the ground, covering with blankets/space blankets/ready-heat systems, and placement in a heated environment if possible.
Friday, December 29, 2023
Antibiotics in trauma
Evidence from historical US conflicts makes it clear that early administration of antibiotics in the field improves outcomes for battlefield casualties. Safety profiles are good for field antibiotics used in US combat medicine, and adverse reactions are rare. Currently, moxifloxacin (4th generation flouroquinolone) is the US military oral antibiotic of choice. Ertapenem (a carbapenem) is the parenteral antibiotic of choice. Together, these drugs cover a wide spectrum of potential infectious microbes.
The US Combat Wound Medication Pack contains 400mg moxifloxacin, along with 15mg meloxicam and 500mg acetominophen. The Ukrainian medication pack contains a similar assemblage of pills.
Wednesday, December 27, 2023
Tuesday, December 26, 2023
Giving Blood in the Field: current TCCC recommendations
Due to occasional severe transfusion reactions, whole blood fell out of favor after WWII. Separating blood into components, such as plasma, red blood cells (RBCs), and platelets allowed for a longer shelf life, easier transport and storage logistics, and reduced risk of disease and transfusion reactions. Separate blood components are needed for many medical interventions. An exception, however, is trauma with massive blood transfusion needed. Recent evidence suggests that, for trauma patients in hypovolemic shock, whole blood produces better outcomes.
TCCC recommendations have evolved through combat experience gained in Iraq and Afghanistan during the recent "Global War on Terror" (GWOT). Before the US invasion of Iraq, most forward resuscitation efforts for blood loss centered on providing non-blood products such as Hextend and PLASMA-LYTE. In 2003, TCCC recommended that blood be carried on casevac units if possible. In 2006, this recommendation was updated to specify low-titer type O blood. As ongoing studies demonstrated increased coagulopathy and reduced survival with non-blood product use, in 2014 TCCC moved blood products to the forefront of care for hemorrhagic shock. 2020 TCCC guidelines list whole blood as the "fluid of choice", with crystalloids, Hextend, and PLASMA-LYTE recommended only if blood products are unavailable.
Whole blood for trauma has a number of advantages. It contains clotting factors that are missing from individually packaged blood components, and has a reduced amount of artificial anti-clotting agents (which can lead to coagulopathy). Whole blood is faster and simpler to administer than individual blood products. This can be important during times of high demand on patient caregivers, reducing workload and opportunities for errors. In general, the sooner blood is given, the better the outcomes. A retrospective study of 502 US military combat casualties in Afghanistan between 2012 and 2015 showed that time to initial blood product transfusion was associated with a reduced 24-hour and 30-day mortality.
Non-blood products such as crystalloids, Hextend, and PLASMA-LYTE come with several negative side-effects. They may contribute to the "Lethal triad"- a self-reinforcing cycle of acidosis, hypothermia, and coagulopathy which is hard to interrupt once it sets in. Expanding blood volume without adding RBCs does not increase oxygen-carrying capacity, leading to ongoing lactic acid production via anaerobic metabolism in oxygen-deprived tissues. Normal saline is acidic (pH 5.5) and infusing large volumes can cause acidosis. Lactated ringers is less acidic (pH 6.5), but is slightly hypotonic and some experts believe it may worsen swelling in TBI patients. Even isotonic crystalloids may seep into damaged tissues, rather than stay in the vascular compartment, due to osmotic differences. High-volume unwarmed fluids contribute to hypothermia, which develops easily and rapidly in trauma patients, due to reduced heat generation during anaerobic metabolism, reduced circulating blood volume, immobility, and physiologic responses to blood loss. Clot formation depends on a complex series of pH- and temperature-dependent chemical reactions. Acidosis and hypothermia both produce coagulopathy, which in turn further exacerbates acidosis and hypothermia. Once established, the lethal triad cycle is difficult to interrupt.
The current TCCC-preferred fluid for blood loss replacement in trauma victims is "LTOWB": cold-stored, low-titer O-negative whole blood. The "ABO" blood groups refer to the presence of A-type and B-type antigens on the surface of red blood cells. Most antibodies are only produced after an exposure to an antigen ("sensitization"). For instance, someone with a severe allergy to bees only experiences an allergic reaction after their second bee sting- the first sting merely introduces foreign material that the body that incites antibody production. But, in the case of antibodies that act against A-type and B-type antigens, this is not true. Each person is born with innate A and/or B antibodies, with no foreign blood exposure required. If a patient with type-A blood is given a transfusion of type-B blood, each of the patient's anti-B antibodies will adhere to several type-B antigens in the donor blood. This causes the donor RBCs to clump together ("agglutination"). These clumps block small blood vessels throughout the body. As the cells of clumps break down ("hemolysis"), they release hemoglobin, which can clog the kidneys and result in kidney failure.
Image shows agglutination in a rapid blood-type test.
Those with blood type A innately have A antigens and anti-B antibodies. Those with blood type B have B antigens, and anti-A antibodies. Those with type O blood have no antigens, and both anti-A and anti-B antibodies. Therefore, type-O blood will not produce reactions in people with type A or B blood.
A second transfusion consideration is presence or absence of Rh factor. 85% of Americans are Rh-positive; they have Rh antigens, and therefore will not produce anti-Rh antibodies. Only Rh-negative individuals can produce anti-Rh antibodies, and they only do so after sensitization. Sensitization can occur via pregnancy with an Rh-positive fetus, or via an Rh-mismatched transfusion. In the case of pregnancy, Rh+ cells rarely cross the placenta; exposure may occur during childbirth, and may become an issue if a second pregnancy with an Rh+ fetus occurs. Similarly, a first transfusion with Rh-mismatched blood is not a problem, however a second transfusion or Rh+ pregnancy might cause a reaction.
Low-titer O blood refers to low levels of anti-A and anti-B antibodies in the type-O donor's blood. Titers below <256 are very unlikely to cause transfusion reactions in blood recipients. For massive transfusion purposes, low A/B antibody titers are more important than presence or absence of Rhesus factors (i.e. whether the blood is "O-positive" or O-negative". Because rhesus-negative patients don't develop sensitivity to Rh-positive products until several weeks after exposure, Rh+ blood can be given to Rh- acute trauma patients without significant risk of a transfusion reaction. So, while ABO-mismatched transfusion reactions can be severe, Rh-mismatch is less concerning in acute trauma situations. For acute trauma, low-titer O blood is best. For general medical transfusion applications, O-negative blood is most useful. Generally, people with type-O-negative blood are 'universal donors', and those with type AB-positive are 'universal recipients'.
TCCC Blood Products Order of Preference:
1) "LTOWB" Cold stored low-titer O negative whole blood. This product has had disease testing performed (HIV, HBV, HCV, West Nile, syphilis, HTLV, Chagas), anti-A/B antibody titer <256, and leukocyte reduction. Shelf life is 21-35 days.
2) "FWB" Pre-screened low-titer O fresh whole blood. 16ga IV should be used to collect from the donor; placement of an 18ga in the recipient is sufficient, safe, and encouraged. Shelf life 6-8 hours.
3) Plasma, RBCs, and platelets in 1:1:1 ratio
4) Plasma and RBCs in a 1:1 ratio. Shelf life 1 yr for plasma, 42 days for RBCs.
5) Plasma or RBCs alone. Some countries (including France, Germany, and South Africa) use freeze-dried plasma (FDP) for austere ops; FDP contains fibrinogen and other hemostatic factors.
Care should be used to prevent hypothermia; warm chilled blood before administration and use a filter to remove small clots. Citrate preservative used in blood collection bags binds with the patient's calcium, therefore 1g calcium should be given after administration of the first unit of blood (either 30mL 10% calcium gluconate or 10 mL 10% calcium chloride daily). Give blood until mental status improves, radial becomes palpable, or BP rises above 100.
Monitor for reactions:
1) Anaphylaxis: wheezing, stridor, shortness of breath, hypotension, hives. Give 0.3mg epi + 25mg benadryl and monitor airway. Optionally give 10-40mg methylprednisolone slow IVP.
2) Acute hemolytic reactions: rupture of RBCs and leakage of contents, generally due to blood mismatch. Symptoms include fever, flank pain, and red/brown urine. All 3 are rarely observed together in field, Pain may alternately occur in an arm, chest, or back, DIC may occur. Nausea may preceed other symptoms. Give 25mg benadryl via slow IV push.
Treatment measures for both anaphylactic and hemolytic reactions: immediately stop the transfusion, give normal saline, stabilize the patient, and try another blood product.
The Use of Low Titer Group O Whole Blood in Emergency Medicine
Mouse Fever- "Trench Nephritis"
During December of 2023, reports of Russian soldiers falling ill with fever, back and abdominal pain, red eyes, and kidney problems began to emerge from the trenches of Eastern Ukraine. Ukraine's Military Intelligence Directorate (GUR), has blamed the reports on "mouse fever", or Hemorrhagic Fever with Renal Syndrome (HFRS).
Although HFRS is poorly researched, it is likely this hemorrhagic viral disease accompanied many wars of the past. HFRS (aka Korean Hemorrhagic Fever, Epidemic Hemorrhagic Fever, or Nephropathia Epidemica), is a rodent-borne group of hantaviruses, of the family Bunyaviridae. Strains, which differ in their symptoms and epidemiology, include Hantaan, Dobrava (found in the Balkans), Saaremaa, Seoul (found worldwide), and Puumala (in Scandinavia, Russia, and W Europe). Poor wartime living conditions for soldiers and displaced populations contribute to both increases in rodent populations, and increased exposure to virus shed in the rodents' urine and feces. In Ukraine this year, warm fall weather and unharvested crops in fallow fields have led to a large winter rodent population. Life in the trenches increases soldiers' exposure to rodents. HFRS is spread by striped and yellow-necked field mice, norway rats, and bank voles, amongst others.
Unlike New World hantaviruses, which cause pulmonary disease with mortality rates of 40-50%, Old World hantaviruses tend to create generalized hemorrhagic symptoms and kidney problems. They are more likely to spread as epidemics and have lower case fatality rates (CFR 2-20%). Reports of wartime HFRS-like diseases have cropped up in many wars throughout history, often referred to as "trench nephritis", or mis-diagnosed as other conditions.
The first known written mention of HFRS was likely made in a Chinese medical book in AD 960. Mentions of "trench nephritis" during the US Civil War may be attributable to a kidney-targeting hantavirus, such as the Seoul strain. "Mouse Fever" appeared in a 1913 Vladivostok hospital record. "Field nephritis" affected both Allied and German troops in Flanders in WWI. During WWII, 10,000 Japanese soldiers fell victim to a HFRS-like illness in Manchuria, as did several hundred Russian soldiers in the Far East. More than 1,000 Finnish and German soldiers contracted what was probably the Puumala strain in Finland. 3,200 cases of HFRS were diagnosed amongst UN soldiers during the Korean War; these experienced a mortality rate of 15-20%. Numerous soldiers fell ill with HFRS symptoms during the Balkans war. Currently, an estimated 100,000 cases of HFRS occur each year worldwide. In Ukraine, one study found that 1.6% of healthy individuals have antibodies to hantaviruses.
HFRS is contracted by inhaling dried rodent urine, droppings, or saliva, or by touching mucous membranes after touching surfaces contaminated with rodent excrement. After a 1-2 week incubation, patients experience a sudden onset of flu-like symptoms. These can include severe headache, abdominal pain, nausea, vomiting, back pain, fever, chills, back pain, flushed face, red eyes, and blurred vision. In severe cases, the disease may progress to kidney failure, fluid overload, vascular leakage, hypotension, and possibly death. Hantaan and Dobrova strains are more like to cause severe illness; other strains tend to be more moderate. Ribavirin, if given very early, may help. Otherwise, supportive care focuses on maintaining fluid and electrolyte balance. Dialysis may be required. CFR ranges from 5-20% for Hantaan to <1% for Puumala virus. Complete recovery can take weeks or months. A vaccine for the Hantaan strain exists in Korea, but is little-used.
CDC HFRS page https://www.cdc.gov/hantavirus/hfrs/index.html
Article: Hemorrhagic Fever with Renal Syndrome
Hantaviruses: History and Overview
Monday, December 25, 2023
Christmas in Ukraine
Our Christmas Tree
Most people in Ukraine have shifted to celebrating Christmas Day on 25 December, instead of the Russian Orthodox tradition of 7 January. Thus, Christmas fell on our day off. We visited an old church, which was used as a sports hall during Soviet times, and has since been restored by donors.
We had a fairly simple Christmas repast. However, for many Ukrainians, old traditions have become more popular, such as caroling, serving 12 traditional dishes, and setting out a "dedukh" (rye sheath that symbolizes ancestral spirits).
Sunday, December 24, 2023
TCCC and Prolonged Field Care: more relevant than ever in Ukraine
For US medics in Afghanistan and Iraq, air superiority more often than not allowed for relatively quick evacuation of injured soldiers in need of advanced surgical care. In contrast, medics in Ukraine commonly are forced to provide prolonged care to patients at or near the frontlines. 4-12 hours, or more, may pass before conditions are safe enough for ground evacuation of patients. Air evacuation is generally impossible due to high risks from Russian air defense platforms, and to a lesser extent, Russian aircraft. Additionally, due to heavy use of artillery, patients often come in clusters. Attrition amongst experienced frontline medics has the potential to burden inexperienced replacement medics with multiple severely injured patients at once, who are in need of prolonged patient management under very austere circumstances.
Similar conditions might well prevail during a hypothetical ground war involving the US and either China, or a similarly strong alliance of powers. Under such conditions, ability to provide advanced prolonged care techniques in the field would be an important tool to improve patient outcomes.
US military working groups have made great progress on developing evidence-based prolonged field care guidelines, mostly based on experience in Iraq and Afghanistan over the past two decades. These guidelines are also applicable to traumatic injuries in many non-combat austere medical situations, such as maritime and wilderness environments. Tactical Casualty Combat Care - Prolonged Casualty Care Guidelines are published by the US Military Joint Trauma System here. In-depth podcasts on various prolonged field care topics can be found here, on the Prolonged Field Care Collective website, or on Spotify, and Youtube.
Saturday, December 23, 2023
ISW Report; THE HIGH PRICE OF LOSING UKRAINE: PART 2 — THE MILITARY THREAT AND BEYOND
"The ground truths of this war have not changed: Russia still explicitly intends to erase Ukraine as a concept, people, and state; Ukraine’s will to fight remains strong; Russia has made no operationally significant advances this year; and Ukraine’s will combined with the West’s collective capability (which dwarfs Russia’s) can defeat Russia on the battlefield.[1] US interests still include preventing future Russian attacks on Ukraine and helping Ukraine liberate its people and territory. Supporting Ukraine is still the best path for the United States to avoid higher costs, larger escalation risks, and a greater Russian threat. What’s changing is Americans’ perceptions of their interests, not the interests themselves. That American perceptions are changing is not an accident. It is, in fact, precisely the effect the Kremlin has been seeking to achieve. The Kremlin’s principal effort is destroying America’s will by altering Americans’ understanding of their interests, and this effort appears to be working. If Russia wins in Ukraine because of the collapse of Western aid, it will be because Russia has managed to shape Americans’ understanding of reality such that the United States willingly chooses to act against its interests and values without realizing that it is doing so. Russia will have manipulated America into abandoning its own interests in a fight it could and should have won. That’s a dangerous lesson for China, Iran, and other US adversaries to learn. America’s security now and in the future, in Asia and the Middle East as well as in Europe, depends on remaining solidly connected with our strategic interests and values and demonstrating that we will not fall prey to efforts to manipulate our perceptions of those interests."
-THE HIGH PRICE OF LOSING UKRAINE: PART 2 — THE MILITARY THREAT AND BEYOND
Dec 22, 2023 - ISW Press
Thursday, December 21, 2023
Ukraine War: Crush Injury Treatment
Heavy use of artillery has long been a defining trait of the Soviet and modern Russian militaries. During the Ukraine war, Russia has fired fast amounts of ordinance at Ukraine- peaking at 20,000 - 60,000 shells/day (Ukraine, in turn, holds the line using around 7,000 shells/day, depending on supply constraints). Traditional artillery such as mortars and rockets are now supplemented by loitering drone platforms, grenades attached to FPV hobby drones, purpose-built ballistic missiles, re-purposed anti-aircraft missiles, and GPS-guided bombs dropped by aircraft operating in the relative safety of Russian airspace. In addition to saturation bombing of frontline areas, civilian infrastructure in cities throughout Ukraine is frequently targeted. Since the start of the invasion, Russia has fired 7,400 missiles and 3,700 Shahed-type drones at Ukrainian territory.
All of this translates to a high rate of bombing-related trauma patients- not just for military medics, but also for municipal and national guard responders in civilian areas. It is estimated that in Ukraine, civilian deaths have passed 9,700, military deaths top 70,000, and injuries outnumber deaths by a factor of between 2:1 and 5:1. The war has caused an estimated 25,000-50,000 amputations within Ukraine.
Crush syndrome is an important phenomenon for medical responders to consider during conflict, It is often accompanied by a constellation of related injuries, including compartment syndrome and rhabdomyolysis.
Experience from earthquake and conflict response shows that up to 40% of multistory building collapse survivors experience crush syndrome. Crush syndrome, with ensuring rhabdomyolysis, is the 2nd most frequent cause of earthquake deaths (the 1st is direct trauma). Bombing can cause similar patterns of blunt trauma due to structural collapse and airborne debris.
Crush syndrome consists of direct damage to local tissue, and resulting systemic effects. Systemic effects include hypotension, hyperkalemia, hypocalcemia, dysrhythmias, and organ dysfunction. The initiating mechanism of crush syndrome is direct damage to the cell membranes surrounding muscle cells. Rhabdomyolysis, or muscle cell breakdown occurs (from the Greek rhabdos=rod + myo=muscle + lysis=breakdown).There is an influx of fluids and calcium into the damaged cells, and a release of cell contents such as potassium, phosphate, and creatine into the bloodstream. Systemic effects follow. Massive third spacing of fluids causes hypovolemia; 12 liters or more of fluids may migrate into crushed areas during the first 48 hours. Histamine and leukotriene release causes vasodilation and bronchoconstriction. General vasodilatory effects cause capillary bed leakage, which worsens edema, third spacing, and hypotension. Ongoing enzymatic damage occurs in muscles, accompanied by tissue hypoperfusion and hypoxia. Lactic acid from anaerobic respiration in damaged muscle tissue causes acidosis and dysrhythmias. Myoglobin and uric acid builds up in the kidneys faster than it is excreted, causing acute kidney failure. Potassium released from cells causes hyperkalemia and associated dysrhythmias. Thromboplastic release can lead to DIC.
Aggressive and comprehensive treatment of crush injuries is key, and should begin on-scene prior to patient extrication. Initiate early pain control using fentanyl or ketamine for preservation of blood pressure (IN route is an option). Avoid kidney-processed medications such as NSAIDs. Prevent hypothermia and consider TXA for bleeding. Begin fluid resuscitation without delay; a delay in fluids may increase incidence of renal failure by 50%, and a 12-hour delay in fluid administration has been associated with almost 100% rates of renal failure in crush injury patients. Renal failure carries a 20-40% mortality rate in crush injury victims. Administer 1.5L of NS over the first hour. Potassium-containing fluids such as lactated ringers and sterofundin ISO may exacerbate hyperkalemia and should be avoided. As a side note, in patients with noncompressible bleeding, fluids may worsen bleeding. Therefore, in some cases it may be necessary to balance the risk of uncontrolled hemorrhage with the risk of cardiotoxic levels of potassium. If extrication must be performed prior to IO/IV placement, consider short-term tourniquet placement. For prolonged field care, urine output of 100-200mL/hour is the target. if IV/IO access and fluids are not available, this may be achieved via oral or rectal hydration via ORS, pedialyte, or a water-sugar-salt-baking soda solution (1L water, 8tsp sugar, 0.5 tsp salt, 0.5tsp baking soda).
Patients should be transported gently and carefully monitored via EKG. In hyperkalemic patients 10 units regular insulin+50mL D50 glucose (onset 20 min,action duration 4-6 hrs), and high-dose albuterol (12mL of 2.5mg/3mL solution via nebulizor, onset 30min, action duration 2 hrs) help to push potassium out of circulation and back into cells. Correct hypocalcemia with 10 mL (10%) Calcium gluconate or calcium chloride administered over 2-3 minutes (action duration 30-60min). Recent studies have not found administration of bicarbonate or mannitol to have kidney-protective effects. Bicarb is not recommended in TCCC protocols for potassium reduction, due to its slow and unsustained effects on potassium levels. TCCC's prolonged care protocol recommends monitoring of potassium levels and use of sodium polystyrene sulfonate to permanently remove excess potassium from the body via the GI tract (other agents only temporarily force it back into cells).
All crush injury patients should be observed, even if they appear well. Significant toxin accumulation generally occurs after 4-6 hours of entrapment/tissue compression, but can occur in as little as 60 minutes. Unexpected mechanisms, such as prolonged immobilization due to unconsciousness, may result in crush or compartment syndrome within compressed tissue areas. Severe blunt trauma to an extremity, or reperfusion of a limb that has been tourniqueted for more than 2 hours may also result in crush-syndrome-like symptoms.
Signs of renal failure may be delayed. Most cases of acute renal failure will recover with dialysis, though recovery may take up to 60 days.
Compartment syndrome- swelling and pressure inside a muscle compartment, which impedes circulation within the compartment, may develop. Muscles are covered in dense membranes called fascia, which do not stretch under building pressure. Signs of compartment syndrome include extreme localized pain, pallor, pulselessness, paresthesia, and paralysis of the affected area. Presentation may be clandestine, due to local nerve damage or altered mental status. Muscle compartment pressures as low as 40mmHg can cause compartment syndrome, through pressures may reach 240mmHg after significant trauma. Fasciotomy may be required to relieve pressure.
2004 study: Brown C, Rhee P, Chan L, et al. Preventing renal failure in patients with rhabdomyolysis: Do bicarbonate and mannitol make a difference? J Trauma. 2004;56(6):1191—1196
2013 literature review: Scharman EJ, Troutman WG. Prevention of kidney injury following rhabdomyolysis: A systematic review. Ann Pharmacotherapy. 2013;47(1):90—105.
Wednesday, December 20, 2023
Monday, December 18, 2023
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Sunday, December 17, 2023
Ukraine has seen 20,000-50,000 War-related Amputations
On 2 August 2023, a Wall Street Journal investigation found that Ukrainian amputations in the war came to between 20,000 and 50,000- including both military and civilians. WSJ's estimate is based on data from the world's largest prosthetics manufacturer, Ottobock. In comparison, during World War I, 41,000 British and 67,000 Germans needed amputations. For background, the US (population 330mil) experiences 185,000 amputations per year. If Ukraine (population 44 million) had a similar pre-war all-causes amputation rate, this would amount to approximately 25,000 amputations/yr. So wartime amputations would represent a 50-100% annual surge over normal amputation events (i.e. those caused by trauma, medical conditions, etc). While WWI featured a larger scale of combatant forces and casualties, modern-day antibiotics, surgical techniques, and frontline medical interventions allow a greater portion of those who experience loss of limb to survive their injury.
After WWII, the USSR took pains to hide war amputees from social spaces and official media images. In modern Ukraine, various governmental, civil society and international groups are beginning the long process of addressing the war's legacy of amputees. Ukrainian public spaces are generally not engineered to be handicap-friendly. Major conversations about legislating equal access measures for the disabled do not seem to have emerged yet; these may be forthcoming as war wounded become increasingly visible in the public eye.
There are currently over 80 prosthetics fitters in Ukraine, many of these having opened since the 2022 Russian invasion. In much of Europe and the US, a prosthetic leg can cost between $3,000-$24.000, and a bionic arm may cost $20,000-80,000 USD. The maximum Ukrainian government coverage for a prosthesis is about $50,000, and compensation amounts for military service members are three times higher than for civilians. A Ukrainian information center for amputees, Protez Hub, finds that 'current government funding for prosthetics is sufficient in the predominant number of cases, however providers said that additional funding was required in civilian cases'. Protez's polls also found that the approximate ratio of upper limb to lower limb amputations is 35% to 65%. Prosthetics require a lifetime of maintenance and parts replacement/prosthetic updates. Protez find that the Ukrainian prosthetics industry is well-developed, and there is healthy competition. The industry continues to develop further, and is coping with the current higher-than-normal number of amputees.
Some Ukrainians injured early in the war have received advanced prosthetics, and have won medals in competitions such as the international Invictus Games and US Warrior Games.
Anastasia Shestopal, athlete, Tiktok and Instagram influencer, lost her leg in the
Kramatorsk railway station bombing in April 2022. Photo by Ukrainian Vogue Visible social project
Porter, Tom (2 August 2023), "Amputations in Ukraine are as widespread as in the Trenches of World War I due to Russia's heavy use of mines and artillery: report" Business Insider.
1 Aug 2023, Wall Street Journal: In Ukraine, Amputations already evoke scale of WW1
Nov 2023: Vogue: Visible: Amputees in Vogue Shoot
Saturday, December 16, 2023
Ketamine in War, including use in TBI patients
Fast-acting, easy to deliver, and respiratory-drive-sparing, ketamine is becoming an increasingly popular solution for pain control and/or sedation in emergency and combat medicine.
Traditional anesthetic and analgesic medications pose several challenges during wartime conditions. Opiates and benzodiazepines come with side effects, such as hypotension and respiratory depression, which can increase patient-management workload.
In 1958, the search for a safer anesthesia agent yielded PCP. However, severe psychological recovery effects quickly ruled out high-dose PCP as an anesthetic (non-schizophrenic patients tended to experience 1-2 days of artificially-induced withdrawal psychosis, while in schizophrenics existing symptoms were profoundly exacerbated).
200 derivatives of PCP underwent further testing. One of these, ketamine, was found to have a short duration of action and produce less stimulant effects than PCP. Ketamine could be delivered by multiple routes (IV, IM, IN) and spared patients' breathing and airway protection reflexes. Ketamine was first synthesized in 1962, and after testing on animals and volunteer prisoners, was approved for use in humans in 1970.
For many decades, concerns over misuse and hallucinogenic side effects discouraged use of ketamine in mainstream medical practice. However, the drug was used with some success in a number of conflicts during the 70's and 80's. Ketamine's first wartime use was by a composite team of UK, French, and US doctors during the 1970 Jordan-PLO civil war. This team used ketamine to sedate children during treatment of burns. IM administration simplified delivery, and having a sedation option with minimal airway impact freed up caregivers in a resource-poor setting.
Another early use of ketamine was during the Falklands conflict. Fifty burn patients were given ketamine during wound treatment on the Hospital ship Uganda. The patients came in in a wave of 150 casualties, after the bombing of two landing ships.
By the late 90's and early 2000's, research had disproved many misconceptions surrounding
ketamine. Emerging as one of the safest and most versatile battlefield medicines, the drug
saw renewed interest from the US military and from EMS systems. Various US special
operations teams added ketamine to their protocols during the Afghanistan and Iraq wars. In
2012, the US Defense Health Board added ketamine to TCCC protocols as a primary pain
control option (50mg IN or IM, of a 20mg slow IV/IO push). Various military studies from
this period suggest that ketamine administration had either a neutral or protective action against development of PTSD in injured soldiers.
Use of ketamine for pain control is an off-label use; however it seems to be a highly effective alternative to opiates. Ketamine antagonizes NMDA receptors. It interferes with the brain's chemical ability to receive incoming pain stimuli, and at the same time reduces the emotional reaction to pain. Pain control is achieved at a fraction of an anesthesia dose.
Several other factors make ketamine an ideal pain control+ sedation option in EMS,
wilderness medicine, and combat situations. Rather than dropping respiratory drive and
blood pressure, like opiates and benzodiapines ketamine produces hyper-adrenergic effects.
It stimulates the release of dopamine, norepinephrine, and serotonin, and blocks re-uptake of catecholamines. This leads to a slight increase in blood pressure and heartrate. Additional
benefits include a long shelf life, a wide storage temperature tolerance, low cost, good safety profile, ability to administer via IN, IM, IV or IO route, fast action onset, and a variety of dose-dependent effects. Recent studies have dismissed concerns about use of ketamine in TBI patients, showing that the drug does not have a negative impact on cranial perfusion pressure. Ketamine is recommended by the Wilderness Medical Society for use in remote environments, and is on the WHO essential medications list. In resource-poor countries, ketamine is sometimes used as a sole anesthesia agent during surgeries.
Ketamine is general very safe, but some considerations must be taken for patient safety.
Emergence reactions are not uncommon and may include hallucinations, disorientation,
nausea, and anxiety. Keeping the patient in a quiet room with low lighting can help avoid
emergence reactions. Use with caution in combination with other drugs, including sedative
agents, or in patients who have taken street drugs. Ketamine may worsen schizophrenia
symptoms, and may cause hypotension in severely catecholamine-depleted patients.
Although a major benefit of ketamine is its tendency to leave patient respiratory and airway
protective drives intact, patient level of consciousness and breathing should be
carefully monitored, especially with higher doses. This has recently been demonstrated in
the news stories about the death of actor Matthew Perry, and the manslaughter trial of two Aurora, CO paramedics, whose patient died after being given ketamine.
"The_Drug_of_War"--a_historical_review_of_the_use_of_Ketamine_in_military_conflicts
2014 US military Study: "The intraoperative administration of ketamine to burned U.S. service members does not increase the incidence of post-traumatic stress disorder" larger retrospective data analysis of ketamine use and PTSD development in 298 burn patients serving in the US military. This study did not find that ketamine offered PTSD-protective effects seen in previous smaller studies, but ketamine also did not worsen likelihood of PTSD development.
2021 US military study: Ketamine Use in Operation Enduring Freedom - shows increasing usage of ketamine within the US military during the Afghanistan/Iraq campaigns.
2015 Emergency Physicians Monthly article: Battle Tested: Ketamine Proves its Worth on the Front Line
2014 study: The effect of ketamine on intracranial and cerebral perfusion pressure and health outcomes: a systematic review
A review of available literature found that ketamine did not produce significant changes in
cerebral perfusion pressures, neurologic outcomes, length of ICU stay, or mortality.
A review of available literature found that ketamine did not produce significant changes in
cerebral perfusion pressures, neurologic outcomes, length of ICU stay, or mortality.
Friday, December 15, 2023
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