A Retrospective Review of Clinical Admissions to Afghan National Security Forces Health Care Institutions.

BACKGROUND: Few published reports have examined the numbers of civilian injuries treated at Military Treatment Facilities in the Afghan Theater of Operations. However, review of Department of Defense Trauma Registry revealed a persistent percentage of civilians treated by NATO, and this study compares the proportion of civilians served by Afghan and Coalition military hospitals between 2009 and 2013. METHODS: A retrospective review of records from Department of Defense trauma Registry for Coalition data, and Afghan data from the Office of the Inspector General. We assessed changes in the proportion of civilians served between 2009 and 2013 at Afghan and Coalition hospitals. RESULTS: There was a significant percentage (≥21.55%) of civilians served at both Afghan and Coalition hospitals. Although the total population of Afghan Nationals treated remained steady, the number of total civilians decreased over this time period. To account for this, the percentage of military personnel increased at Afghan military hospitals. In Coalition hospitals, the civilian population increased between 2009 and 2011 and then decreased between 2011 and 2013. CONCLUSIONS: For all hospitals, whether Afghan or Coalition hospitals, there was a persistent level of civilian admissions. A downward trend for civilian patients in the Coalition hospitals and a similar increase in Afghan hospitals was expected. However, the numbers for Afghan hospitals instead showed a downward trend, potentially from the loss of logistical assistance provided by Coalition forces in transferring patients to Afghan hospitals. As evidenced by our data, future missions should plan to provide care for this civilian population, by allocating funding and appropriately training personnel. Additionally, logistical concerns of transferring to host-nation facilities and training host-nation providers will require foresight, planning, and diplomatic overtures, not always included in tactical decision-making.

Evaluation of Factors Associated with Death in Patients with Necrotizing Fasciitis of the Abdominal Wall.

BACKGROUND: Necrotizing fasciitis (NF) is a rapidly progressing, life-threatening soft tissue infection. The prognostic factors associated with death from abdominal wall NF are not well understood. METHODS: The medical records of 61 patients with abdominal wall NF were reviewed retrospectively. Demographic, co-morbidity, laboratory, and clinical data were collected and compared for patients who survived and who did not. RESULTS: Sixty-one patients met the inclusion criteria, with eight deaths (13.11%). Elevated blood urea nitrogen (BUN) concentration, elevated total bilirubin, and prolonged intensive care unit (ICU) stay were correlated with a greater risk of death. CONCLUSIONS: Presentation with elevated markers of liver and renal dysfunction, as well as prolonged post-operative ICU stay were associated with a higher risk of death in patients with NF of the abdominal wall.

A Retrospective Case Series of Surgical Implant Generation Network (SIGN) Placement at the Afghan National Police Hospital, Kabul, Afghanistan.

In Afghanistan, adequate and cost-effective medical care for even routine conditions is lacking; especially for complex injuries like long-bone fractures. The Surgical Implant Generation Network (SIGN) intramedullary nail is used for treatment of long-bone fractures from blunt injuries and does not require imaging. We are reporting for the first time results of the SIGN intramedullary nail at the Afghan National Police Hospital, a tertiary care facility in Kabul. 71 records from the SIGN Online Surgical Database were reviewed for gender, age, date of injury, implant date, patient's home of record, and type/ mechanism of injury. Mean age was 26.7 years, all but one being male; time from injury to implant ranged 1 to 401 days, with mean of 40.6 days. Long-bone fractures from motor vehicle accidents remained constant, and war injuries peaked in summer. Follow-up is limited because of security and financial burdens of travel. However, personal communication with Afghan National Police Hospital surgeons suggests that patients included in the current study have not experienced any adverse outcomes. While it remains to be seen if the SIGN Online Surgical Database will facilitate more comprehensive outcome studies, our results provide support for the efficacy of SIGN nails in treating long-bone fractures from war injuries.

Autologous Internal Iliac Artery Graft in a Popliteal Artery Injury Defect in War Surgery.

A 23-year-old Afghan National Policeman sustained a right popliteal artery injury secondary to a ground-based blast. Initial treatment was an application of a tourniquet, and after triage at a local civilian hospital a shunt was placed, 3 hours after the initial injury, and then was transferred to Kabul for definitive care, 24 hours after injury. Extensive trauma to both legs precluded use of greater saphenous vein as a graft. To avoid an above-the-knee amputation, a branch of the internal iliac artery was harvested for grafting. Postoperative computed tomography angiography indicated the presence of excellent flow, and he was discharged fully ambulatory on postoperative day 17. Autologous arterial grafting has only been used infrequently, and in this case represents innovation in a low-resource environment. Surgical training in Afghanistan has seen great strides at the National Hospital. If this patient were treated at any other facility, he likely would have had a high amputation. Without advising or direction of coalition surgeons, the Afghan Trauma Team independently made the decision to harvest the artery and salvage the limb, and this is one example of how coalition support has bolstered the confidence of Afghan surgeons to develop unconventional solutions to conventional problems.

Cholecystoduodenal fistula in a patient post-Roux-en-Y gastric bypass.

We presented a case of a cholecystoduodenal fistula in a patient 4 years post-Roux-en-Y gastric bypass. The patient presented with biliary colic symptoms after a stone became impacted in the fistula and outflow through the cystic duct was intermittently obstructed by a second stone. The fistulous tract was taken down with a cholecystectomy and duodenum repaired with a modified Graham patch.

Conversion of laparoscopic cholecystectomy to open surgical procedure due to complete fibrosis of the gallbladder.

We present a case of transmural fibrotic gallbladder in a patient with previously undiagnosed gallbladder disease and describe our surgical approach to treating this patient.

Clostridium tertium isolated from a necrotizing soft tissue infection in a diabetic but otherwise nonimmunocompromised patient.

Clostridium tertium has historically been regarded as nonpathogenic, and its implication as the primary microbe in infectious etiologies remains unclear. Although there have been several reports of C tertium isolated from blood, tissue, and other specimens, largely this population has consisted of patients with neutropenia, hematologic malignancies, or gastrointestinal disorders. Here we describe a case of a 39-year-old nonimmunocompromised man with a history of type 1 diabetes mellitus and intravenous drug use who presented to our institution with a necrotizing soft tissue infection involving his right upper extremity. The infection had developed after the patient had injected methamphetamines. At surgery, tissue was obtained for Gram stain and culture, yielding C tertium, after an initial misidentification as Lactobacillus species. After undergoing extensive surgical debridement and treatment with an appropriate antibiotic regimen, the patient was able to be discharged home with retained function of his extremity. Although not common, infections involving C tertium can produce severe, potentially life- and limb-threatening disease processes, which may require aggressive therapy even in the nonimmunocompromised patient.