Improvised explosive devices are the most common cause of injury or death for US soldiers involved with Operation Enduring Freedom. As a result of the prevalence and heightened power of improvised explosive devises, traumatic, multiple amputations have increased among both civilian and military populations.

“When I was deployed [in Afghanistan] in 2010, we noticed a rash of this new injury pattern with triple amputees,” Rodd J. Benfield, MD, FACS, a commander in the United States Navy, told O&P Business News. “We wanted to describe those and see if there were any clinical indicators for survival or things that we could pick up on that could guide treatment for future people going out there.”

Retrospective study

Benfield and his colleagues conducted a retrospective analysis to investigate this injury pattern further. They used the Joint Theatre Trauma Registry to identify patients who were treated at the North Atlantic Treaty Organization Role 3 combat hospital at Kandahar Airfield in Afghanistan between June 2010 and December 2010. The study included 22 patients with a mean age of 29 years who had a viable status from point of injury with at least bilateral lower extremity amputations due to improvised explosive devises (IED) blasts.

The researchers wanted to analyze how these injury patterns were initially managed and to identify clinical factors that would indicate whether a patient would need a massive blood transfusion, which is typically defined as needing 10 or more units of blood within the first 24 hours of the injury.

“In an austere environment like Afghanistan those are resources that you want to use wisely,” Benfield said. “You don’t want to activate them and then not need them, but you don’t want to wait and activate them too late.”

Clinical indicators for blood transfusions include hemoglobin levels and vital signs, but in a combat setting with limited resources, these indications can be difficult to determine.

“In a modern combat arena, it’s hard to define parameters like that,” Benfield said. “It was more useful for us to identify something you could look at in the clinical presentation rather than the lab value or a specific number.”

The researchers found that injuries affecting the perineum, buttocks, pelvis and/or gastrointestinal (GI) tract were good indicators that a massive blood transfusion would be required.

“So in any patient that had perineal or pelvic involvement or GI tract involvement, if it was obvious, we would activate the massive blood transfusion protocol,” Benfield said.

According to Benfield, better identification and management of these injuries has improved treatment in the field.

“The medics in the field have gotten really good about how they treat these patients,” Benfield said. “They are trained to control hemorrhage at the scene with tourniquets rather than starting IVs and giving them blood and resuscitating them to normal vital signs.”

Increasing survival rates

Among the patients included in Benfield’s study, 77% survived, and the overall survival rates for patients with multiple, traumatic injuries appear to be increasing. However, data is limited on this patient population, and the number of patients who do not survive this injury remains unknown.

“Our study looked at patients that made it to us, and their survival was pretty good,” Benfield said. “But the true way of knowing [the survival rate] would be knowing what the denominator is — how many people had these injuries that didn’t even make it to us.”

Despite the lack of information, it is evident that soldiers with multiple traumatic amputations are surviving at an increased rate when compared with those in past conflicts.

“If more people are surviving these injuries, and I suspect it is true, a lot has to do with the pre-hospital care,” Benfield said. “Certainly we are seeing a lot of patients with these devastating triple amputations with pelvic and torso involvement who are still alive, and in past conflicts, we haven’t seen that.”

The increasing survival rate for this injury pattern could potentially affect the civilian O&P industry as these soldiers return to the United States and seek care. Soldiers with multiple injuries, post-traumatic stress disorder and other psychological issues could present challenges for orthotists and prosthetists.

“I would suspect that these patients are going to have, aside from their physical injuries, a lot of psychological issues or complex injuries,” Benfield said. “They could have amputations at high levels, right at the shoulder or hip disarticulation, and there are a handful of patients who have had four-limb amputations.”

Benfield said that utilizing a team of specialists, which could include psychologists, social workers, surgeons, orthotists, prosthetists and physical and occupational therapists, is important when working with these patients.

“In my opinion, it seems like these patients do better when there are other patients with similar injuries around,” Benfield said. “At the Naval Medical Center in San Diego, they are treated by a whole team and the guys are still together, so they have that bond and camaraderie that they experience as part of a unit.” — by Megan Gilbride

For more information:
Benfield, RJ. Injury. 2012; doi:10.1016/j.injury.2012.06.030.

Disclosure: The authors have no relevant financial disclosures.

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