Medical Emergencies
In the event of a more serious injury or illness, a Role 1 BAS has very little capability in performing anything beyond the most basic interventions. Part of the art of being an effective field surgeon lies in stabilization, triage, and transport of these sometimes very ill patients. Both the decision to transport to a higher level of care (eg, Role 2 or 3 facility) as well as selection of the means of transportation falls on the field surgeon. The MEDO plays an essential role in assisting in the coordination of the transfer; however, the responsibility ultimately falls on the field surgeon.1,6 The field surgeon at the Role 2 BAS may be expected to perform more advanced medical and surgical interventions. More advanced pharmacotherapies include thrombolytics, antivenin, and vasopressors. Some procedural interventions include intubations, central lines, and laceration repairs. The Role 2 BAS has the capability to hold patients for up to 72 hours.
Case Examples
Specific conditions one of the authors (N.R.M.) treated include heat injury, myocardial infarction, disseminated tuberculosis, appendicitis, testicular torsion, malaria, suicidal ideation, burns, and status epilepticus. Over 8 months, the Role 2 BAS received 91 medical emergencies, with 53 necessitating evacuation to a higher level of care. Often, the more serious or rare conditions presented in the foreign contractor and coalition force populations working alongside US troops.
In one particular case, a 35-year-old man with an electrocardiogram-confirmed acute ST-segment elevation myocardial infarction was administered standard therapy consisting of intravenous morphine, oxygen, sublingual nitroglycerin, an angiotensin-converting enzyme inhibitor, and a beta-blocker. Given the lack of a cardiac catheterization laboratory at the next highest level of care as well as a low suspicion for aortic dissection (based on the patient’s history, physical examination, and chest radiograph), fibrinolysis with tenecteplase was performed in the deployed environment. After a very short observation for potential hemorrhage, the patient was then evacuated to the Role 3 hospital, where he made a near-complete recovery. Preparation with advanced cardiac life support courses and a thorough algorithmic review of the 10 most common causes of presentation to the emergency department helped adequately prepare the dermatologist to succeed.
Trauma Emergencies
The same principles of triage and transport apply to trauma emergencies. Mass casualties are an inevitable reality in combat, so appropriate training translating into efficient action is essential to ensure the lowest possible mortality. This training and the actions that stem from it are an additional responsibility that the field surgeon must maintain. During deployment, continued training organized by the field surgeon could quite literally mean the difference between life and death. In addition to the organizational responsibilities, field surgeons should be prepared to perform initial stabilization in trauma patients, including application of tourniquets, establishment of central lines, reading abdominal ultrasounds for free fluid, placement of chest tubes, intubation, and ventilator management. The Joint Trauma System Clinical Practice Guidelines also offer extensive and invaluable guidance on the most up-to-date approach to common trauma conditions arising in the deployed environment.7 At the Role 2 level, the field surgeon also must be prepared to coordinate ancillary services, manage the Role 2/forward surgical team intensive care unit, and serve as first assist in the operating room, as needed (Figure 2).
Figure 2. A Role 2 battalion aid station operating room after rendering care.
Case Examples
One of the authors (N.R.M.) assisted or provided care in approximately 225 trauma cases while deployed. A mass casualty event occurred, in which the Role 2 BAS received 34 casualties; of these casualties, 11 were immediate, 10 were delayed, 11 were minimal, and 2 were expectant. Injury patterns included mounted and dismounted improvised explosive device injuries (eg, blast, shrapnel, and traumatic brain injuries) as well as gunshot wounds. Direct care was provided for 13 casualties, including 10 abdominal ultrasound examinations for free fluid, placement of 2 chest tubes, 1 intubation, establishment of 3 central lines, and first-assisting 1 exploratory laparotomy. Of the casualties, 22 were evacuated to the Role 3 hospital, 8 were dispositioned to a coalition hospital, 2 were returned to active duty, and 2 died due to their injuries. The military trauma preparation as outlined in the predeployment training can help adequately prepare the military dermatologist to assist in these cases.