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Delayed-Onset Neuropathological Complications From a Foramen Magnum and Occipital Crest Focused TBI of the Vietnam War and Other Conflicts: Part III, Critique of Existing TBI Criteria and Their Operational Controversies. Military medicine INTRODUCTION:In this report, we discuss the controversy of the diverse traumatic brain injury (TBI) categorization and taxonomy and the need to develop a new multidimensional and multidisciplinary categorization system that can be an aid in improved diagnostic and prognostic outcomes. Of interest, the heterogeneity of TBI marks the major obstacle to develop effective therapeutic interventions. Currently, the Glasgow Coma Scale has been utilized to guide in the prognosis and clinical management of TBI; it does not encompass the pathophysiological mechanisms leading to neurological deficits that can impede therapeutic interventions and consequently the failure of clinical trials. An unfortunate gap exists between advances in TBI research and existing U.S. Department of Defense (DoD) definitions, categorization, and management. Part I illustrates a unique posterior-focused TBI case report that does not fit any existing TBI definitions. Part II summarizes new animal-based TBI research that supports the case report as a legitimate TBI category. Part III critiques existing TBI criteria and their controversies. METHODS:Current DoD definitions and decision-making protocols based on concussion time alone are reviewed and compared to the myriad of additional TBI definitions that further illustrate the marked differences in definitions, especially in mild TBIs. RESULTS:The DoD definitions are not consistent with what academic research and science bring to the debate. With increasing world conflicts and wars, evaluators are not prepared to accept, evaluate, and properly manage those TBIs that are not associated with immediate levels of unconsciousness alone as the prime determinant of diagnosis and long-term severity. Despite comprehensive research, current understanding among decision-makers of progressive pathology of non-hemispheric TBIs remains limited, inconsistent, and confusing. CONCLUSIONS:This dilemma requires a multidisciplinary, science/medicine-led panel to actively reassess TBI criteria that take into consideration the latest research including non-cerebral hemispheric injuries. We recommend that DoD/Veterans Affairs establish a commission to regularly review the academic-related scientific evidence and incorporate these findings in a timely fashion into their operational definitions. This would guarantee that recognition, diagnosis, and follow-up of all TBIs are properly understood, managed, and documented. 10.1093/milmed/usab373
Head Face and Neck Surgeon Deployment in the New French Role 2: The Damage Control Resuscitation and Surgical Team. Military medicine INTRODUCTION:High-intensity conflict is back after decades of asymmetric warfare. With the increase in the incidence of head, face, and neck (HFN) injuries, the French Medical Military Service has decided to deploy HFN surgeons in the new French Role 2: the Damage Control, Resuscitation, and Surgical Team (DCRST). This study aims to provide an overview of HFN French surgeons from their initial training, including the surgical skills required, to their deployment on the DCRST. MATERIALS AND METHODS:The DCRST is a tactical mobile medico-surgical structure with several configurations depending on the battlefield, mission, and flux of casualties. It represents the new French paradigm for the management of combat casualties, including HFN injuries. RESULTS:The HFN's military surgeon training starts during residency with rotation in the different subspecialties. The HFN surgeon follows a training course called "The French Course for Deployment Surgery" that provides sufficient background to manage polytrauma, including HFN facilities on modern warfare. We have reviewed the main surgical procedures required for an HFN military surgeon. CONCLUSION:The systematic deployment of HFN surgeons in Role 2 is a specificity of the French army as well as the HFN surgeon's training.Currently, the feedback from an asymmetric conflict is encouraging. However, it will have to innovate to adapt to modern warfare. 10.1093/milmed/usac329
Military neurosurgery in operation: experience in the French role-3 medical treatment facility of Kabul. Joubert Christophe,Dulou Renaud,Delmas Jean Marc,Desse Nicolas,Fouet Mathilde,Dagain Arnaud Acta neurochirurgica BACKGROUND:In 2009, during the war in Afghanistan, the increasing number of head injuries led to the deployment of a military neurosurgeon at the Kabul International Airport (KaIA) medical treatment facility, in March 2010. The main goal of this study was to depict the neurosurgical activity in this centre and to analyse its different aspects. METHOD:A retrospective study of all the neurosurgical patients treated in KaIA from March 2010 to June 2013. RESULTS:Three hundred and seventy-three interventions performed by the neurosurgeon deployed were reported for 373 surgeries, in 335 patients, representing 10.6 % of the overall surgical activity of the centre. Among the 69 interventions performed on soldiers, 57 surgeries were undertaken in emergency (82.6 %), while 12 were elective procedures (17.4 %). On the other hand, 289 surgeries were performed in civilian Afghans, with 126 emergency procedures in (43.6 %), against 163 elective interventions (56.4 %). Among the 44.5 % (n = 149) of the traumatic casualties, cerebral lesions represented 28.7 % (n = 96) and spinal lesions 12.4 % (n = 42). Ninety patients had multiple injuries. Additionally, patients without trauma accounted for 55.5 % (n = 186) of the overall population. Thus, 49 % (n = 164) were operated on for non-traumatic lesion of the spine. These were mostly civilian Afghans treated under medical aid to the population (90.2 %, n = 148/164). CONCLUSIONS:The military neurosurgeon had two roles in KaIA: both to support the armed forces and to manage medical aid to the civilian population. This study gives food for thought on the neurosurgical needs in modern warfare, and on the skills required for the military neurosurgeon. 10.1007/s00701-016-2843-z
Surgical challenges in a new theater of modern warfare: The French role 2 in Gao, Mali. Malgras Brice,Barbier Olivier,Petit Ludovic,Rigal Sylvain,Pons François,Pasquier Pierre Injury INTRODUCTION:On January 11th 2013, France launched Operation Serval in Mali following Resolution 2085 of the Security Council of the United Nations. Between January and March 2013, more than 4000 French soldiers were deployed to support the Malian National Army and the African Armed Forces. METHODS:All of the patients who had surgery during Operation Serval were entered into a computerised database. Patients' demographic data (age, sex, status) and types of performed surgical procedures (specialties, injury mechanisms) were recorded. RESULTS:268 patients were operated on in Gao's Role 2 with a total of 296 surgeries. Among those operated on, 40% were Malian civilians, 24% were French soldiers, and 36% were soldiers of the International Coalition Forces. The majority of the surgeries were orthopaedic, and visceral surgeries were common as well, representing 43% of the total surgeries. Specialised surgical procedures including neurosurgery, thoracic, and vascular surgery were also performed. Forty percent of the surgeries were scheduled. War-related traumatic surgeries represented 22% of the surgical procedures, with non-war related surgeries and non-trauma emergency surgeries making up the rest. CONCLUSION:this analysis confirms the specific characteristic of asymmetric warfare that it results in a relatively reduced number of war-related casualties. Forward surgical teams have to deal with a wide range of injuries requiring several surgical specialties. Surgeries dedicated to medical aid provided to the population also represented an important part of the surgical activity. Because of the diversity and the technicality of the surgical procedures in Role 2, surgeons had to be trained in war surgery covering all of the surgical specialties, while they maintained their specific skills. In France in 2007, the French Military Health Service Academy (École du Val-de-Grâce, Paris, France) offered an advanced course in surgery for deployment in combat zones, with a special focus on damage control surgeries and the management of mass casualties incidents. 10.1016/j.injury.2015.07.035