When the Going Gets Tough, the Tough Get Going: Improving the Disaster Preparedness of Health Care Providers: A Single Center's 4-Year Experience.

OBJECTIVE: Operation based exercises represent simulation activities, which are of great importance for emergency preparedness, as they simulate real experiences in a guided manner. Whereas their primary purpose is to address the organizational emergency preparedness, little is known about the personal benefits of involved participants and whether these positive changes endure over time. METHODS: Immediate and medium term assessment of the effectiveness on individual preparedness and benefits of participants, based on self-perception, after participating in a set of 4 interdisciplinary field exercises organized as part of the MSc in Global Health-Disaster Medicine of the Medical School of the National and Kapodistrian University of Athens, Greece. The field exercises were carried out yearly, from 2016 to 2019. Data were collected via questionnaires pre- and post-exercise (1 week and 10 months after participation). The sample size was 228 trainees, with a response rate of 88%. RESULTS: The majority (95%) stated that Mass Casualty Incident (MCI) exercises are appropriate for disaster management training in terms of comprehending theory, and for team-building training. In the case of a real MCI, 22% of the participants declared themselves to be ready to respond prior to MCI exercises. Upon completion, the overall perception of readiness among the participants increased to 77%. Trainee feedback indicated enhancement of both technical and non-technical skills (87%), which were persistent over time, and revealed a high level of satisfaction with the training. CONCLUSION: This study shows a positive immediate and medium-term impact of operation-based exercises on technical, non-technical skills, and self-perception of participants.

Vascular Surgery in the Pacific Theaters of World War II: The Persistence of Ligation Amid Unique Military Medical Conditions.

: Although multiple sources chronicle the practice of vascular surgery in the North African, Mediterranean, and European theaters of World War II, that of the Pacific campaign remains undescribed. Relying on primary source documents from the war, this article provides the first discussion of the management of vascular injuries in the island-hopping battles of the Pacific. It explains how the particular military, logistic, and geographic conditions of this theater influenced medical and surgical care, prompting a continued emphasis on ligation when surgeons in Europe had already transitioned to repairing arteries.

A contemporary, 7-year analysis of vascular injury from the war in Afghanistan.

OBJECTIVE: Vascular injury is a leading cause of death and disability in military and civilian trauma. Although a previous interim study defined the distribution of vascular injury during the wars in Iraq and Afghanistan, a contemporary epidemiologic assessment has not been performed. The objective of this study was to provide a current analysis of vascular injury during the final 7 years of the war in Afghanistan, including characterization of anatomic injury patterns, mechanisms of injury, and methods of acute management. METHODS: The Department of Defense Trauma Registry was analyzed to identify U.S. military service members who sustained a battle-related vascular injury and survived to be treated at a surgical facility in Afghanistan between January 1, 2009, and December 31, 2015. All battle-related injuries (nonreturn to duty) were used as a denominator to establish the injury rate. Mechanism and anatomic distribution of injury as well as the acute management strategies of revascularization, ligation, and use of endovascular techniques were defined. RESULTS: Of 3900 service members who sustained a battle-related injury, 685 patients (17.6%) had 1105 vascular injuries (1.6 vascular injuries per patient). Extremity trauma accounted for 72% (n = 796) of vascular injuries, followed by the torso (17%; n = 188) and cervical (11%; n = 118) regions. Lower extremity vascular injury was the most prevalent anatomic location (45%; 501/1105). Explosion with fragment penetration accounted for 70% (477/685) of injuries, whereas gunshot wounds accounted for 30% (205/685). Open repair was performed in 559 cases (57%; 554/981), whereas ligation was the initial management strategy in 40% (395/981) of cases. In addition, 374 diagnostic endovascular procedures were completed, 27 therapeutic endovascular interventions to include stent placement and angioplasty were performed and 55 inferior vena cava filters were placed. Mortality of the vascular injury cohort was 5%. CONCLUSIONS: The rate of vascular injury in modern combat is higher than that reported in previous wars. Open reconstruction is performed in half of cases, although ligation is an important damage control option, especially for minor or distal vessel injuries. Angiographic techniques are increasingly being used and documented within wartime registries more than ever. Proficiency with open and endovascular methods of vascular injury management remains a critical need for the U.S. military and will require partnership with civilian institutions to attain and maintain.

Fifty-year anniversary of the Vietnam Vascular Registry and a historic look at vascular registries.

The management of arterial injuries has evolved from simple cauterization of the time of Ambrose Paré to the more complex repairs of today. Through history there has been much learned from combat regarding the management of vascular injuries. Starting in World War I, vascular registries have been established to further study and refine the management of these injuries. One of the most pivotal registries was the Vietnam Vascular Registry established by Dr Norman Rich. The lessons learned from these registries have been carried on to the current conflicts with the establishment of the Global War on Terror Vascular Initiative. We compare 100 lower extremity vascular injuries from the Vietnam Vascular Registry to 100 injuries in the Global War on Terror Vascular Initiative database as we continue to improve the future with lessons from our past.

Consensus recommendations for essential vascular care in low- and middle-income countries.

OBJECTIVE: Many low- and middle-income countries (LMICs) are ill equipped to care for the large and growing burden of vascular conditions. We aimed to develop essential vascular care recommendations that would be feasible for implementation at nearly every setting worldwide, regardless of national income. METHODS: The normative Delphi method was used to achieve consensus on essential vascular care resources among 27 experts in multiple areas of vascular care and public health as well as with experience in LMIC health care. Five anonymous, iterative rounds of survey with controlled feedback and a statistical response were used to reach consensus on essential vascular care resources. RESULTS: The matrices provide recommendations for 92 vascular care resources at each of the four levels of care in most LMICs, comprising primary health centers and first-level, referral, and tertiary hospitals. The recommendations include essential and desirable resources and encompass the following categories: screening, counseling, and evaluation; diagnostics; medical care; surgical care; equipment and supplies; and medications. CONCLUSIONS: The resources recommended have the potential to improve the ability of LMIC health care systems to respond to the large and growing burden of vascular conditions. Many of these resources can be provided with thoughtful planning and organization, without significant increases in cost. However, the resources must be incorporated into a framework that includes surveillance of vascular conditions, monitoring and evaluation of vascular capacity and care, a well functioning prehospital and interhospital transport system, and vascular training for existing and future health care providers.

Vascular Surgery in World War II: The Shift to Repairing Arteries.

Vascular surgery in World War II has long been defined by DeBakey and Simeone's classic 1946 article describing arterial repair as exceedingly rare. They argued ligation was and should be the standard surgical response to arterial trauma in war. We returned to and analyzed the original records of World War II military medical units housed in the National Archives and other repositories in addition to consulting published accounts to determine the American practice of vascular surgery in World War II. This research demonstrates a clear shift from ligation to arterial repair occurring among American military surgeons in the last 6 months of the war in the European Theater of Operations. These conclusions not only highlight the role of war as a catalyst for surgical change but also point to the dangers of inaccurate history in stymieing such advances.

Traumatic ulnar artery pseudoaneurysm following a grenade blast: report of a case.

Vascular injuries comprised a small percentage of total injuries requiring medevac in the Iraq and Afghanistan conflicts; however, their impact cannot be overstated. This case highlights an individual who sustained a grenade blast injury leading to hemorrhage, and forearm compartment syndrome. He was initially treated with irrigation and debridement, forearm fasciotomy, and delayed primary closure. The patient developed persistent ulnar neuropathy and hypothenar atrophy despite a normal initial vascular examination. During reconstructive surgery, he was discovered to have a proximal ulnar artery pseudoaneurysm. Upper extremity pseudoaneurysms are a rare sequelae following vascular injury, but have significant consequences for the patient and are identifiable by imaging.

One Example of a Model Humanitarian Mission.

This paper describes a model humanitarian mission to Guyana; it illustrates the value of excellent ongoing care in collaboration with local physicians and surgeons, cooperation with local government and medical officials, and frequent periodic follow-up missions (always to the same hospital, working with the same staff). This effort has largely avoided the so-called "Seven Sins of Humanitarian Medicine".

Female military medical school graduates entering surgical internships: are we keeping up with national trends?

BACKGROUND: Ratios of women graduating from the only US military medical school and entering surgical internships were reviewed and compared with national trends. METHODS: Data were obtained from the Uniformed Services University of the Health Sciences graduation announcements from 2002 to 2012. RESULTS: There were 1,771 graduates from 2002 to 2012, with 508 female (29%) and 1,263 male (71%) graduates. Female graduates increased over time (21% to 39%; P = .014). Female general surgery interns increased from 3.9% to 39% (P = .025). Female overall surgical subspecialty interns increased from 20% in 2002 to 36% in 2012 (P = .046). Women were represented well in obstetrics (57%), urology (44%), and otolaryngology (31%), but not in neurosurgery, orthopedics, and ophthalmology (0% to 20%). CONCLUSIONS: The sex disparity between military and civilian medical students occurs before entry. Once in medical school, women are just as likely to enter general surgery or surgical subspecialty as their male counterparts. Increased ratio of women in the class is unlikely to lead to a shortfall except in specific subspecialties.