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A Military-Specific Injury Scoring System to Aid in Understanding the Golden Hour

A Military-Specific Injury Scoring System to Aid in Understanding the Golden Hour To the Editor The study by Kotwal et al1 demonstrating a lower case fatality rate and (adjusted for Injury Severity Score) a lower killed in action rate after the 2009 mandate to transport wounded US military casualties from the battlefield in Afghanistan is a resounding endorsement of the potential benefit of policy change at the highest level. While transporting critically wounded patients to the hospital quickly makes logical sense, there remain opportunities for more nuanced study. Presumedly owing to the changing nature of the conflict, the proportion of patients wounded by explosion increased from 55.0% before to 67.0% after (P < .001) the intervention.1 The Injury Severity Score is an imperfect instrument to adjust for risk of death at time of injury, even in homogenous populations,2 but is particularly problematic when comparing patients with penetrating blast-fragmentation trauma with patients with other types of wounds. Blast fragmentation typically involves penetration of several body parts with low-energy debris, increasing the anatomically based Injury Severity Score without necessarily affecting risk of death as much as might other types of penetrating trauma. An increasing proportion of blast-fragmentation wounds may account for the decreasing case fatality rate, and Injury Severity Score–adjusted results are a relatively weak argument against this possibility. The observed case fatality rate inflection point after the “golden hour” mandate does suggest an additional effect of quicker prehospital times, but it would be interesting to know whether there was a similar inflection point in the trauma mechanism around this time. The study1 highlights the intuitively logical possibility that patients treated by austere forward surgical teams have a higher died of wounds rate than those initially taken to larger hospitals, a finding that, if true, would have profound policy implications for deployed medical care. Testing this conclusion would be most convincingly performed using a military-specific trauma risk prediction model that, in particular, takes into account the unique effects of blasts. With more than 55 000 patients, the US Department of Defense Trauma Registry3 should have sufficient information to design such a model. The resulting increase in the power to analyze this historically unique data set could also answer another pressing question: does a 1-hour transit to a surgical hospital really sit at the inflection point in the case fatality rate, or are there further benefits to be gained? Ignoring this question risks engendering a false sense of security in future combat casualty care planning. Back to top Article Information Corresponding Author: Michael C. Reade, MBBS, MPH, DPhil, FCICM, Australian Defence Force Joint Health Command and University of Queensland, Australia, Level 9, Health Sciences Bldg, Royal Brisbane and Women’s Hospital, Queensland, Australia 4029 (m.reade@uq.edu.au). Published Online: January 13, 2016. doi:10.1001/jamasurg.2015.4915. Conflict of Interest Disclosures: None reported. References 1. Kotwal RS, Howard JT, Orman JA, et al. The effect of a golden hour policy on the morbidity and mortality of combat casualties [published online September 30, 2015]. JAMA Surg. doi:10.1001/jamasurg.2015.3104.PubMedGoogle Scholar 2. Tohira H, Jacobs I, Mountain D, Gibson N, Yeo A. Systematic review of predictive performance of injury severity scoring tools. Scand J Trauma Resusc Emerg Med. 2012;20:63.PubMedGoogle ScholarCrossref 3. Langan NR, Eckert M, Martin MJ. Changing patterns of in-hospital deaths following implementation of damage control resuscitation practices in US forward military treatment facilities. JAMA Surg. 2014;149(9):904-912.PubMedGoogle ScholarCrossref http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png JAMA Surgery American Medical Association

A Military-Specific Injury Scoring System to Aid in Understanding the Golden Hour

JAMA Surgery , Volume 151 (5) – May 1, 2016

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Publisher
American Medical Association
Copyright
Copyright © 2016 American Medical Association. All Rights Reserved.
ISSN
2168-6254
eISSN
2168-6262
DOI
10.1001/jamasurg.2015.4915
Publisher site
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Abstract

To the Editor The study by Kotwal et al1 demonstrating a lower case fatality rate and (adjusted for Injury Severity Score) a lower killed in action rate after the 2009 mandate to transport wounded US military casualties from the battlefield in Afghanistan is a resounding endorsement of the potential benefit of policy change at the highest level. While transporting critically wounded patients to the hospital quickly makes logical sense, there remain opportunities for more nuanced study. Presumedly owing to the changing nature of the conflict, the proportion of patients wounded by explosion increased from 55.0% before to 67.0% after (P < .001) the intervention.1 The Injury Severity Score is an imperfect instrument to adjust for risk of death at time of injury, even in homogenous populations,2 but is particularly problematic when comparing patients with penetrating blast-fragmentation trauma with patients with other types of wounds. Blast fragmentation typically involves penetration of several body parts with low-energy debris, increasing the anatomically based Injury Severity Score without necessarily affecting risk of death as much as might other types of penetrating trauma. An increasing proportion of blast-fragmentation wounds may account for the decreasing case fatality rate, and Injury Severity Score–adjusted results are a relatively weak argument against this possibility. The observed case fatality rate inflection point after the “golden hour” mandate does suggest an additional effect of quicker prehospital times, but it would be interesting to know whether there was a similar inflection point in the trauma mechanism around this time. The study1 highlights the intuitively logical possibility that patients treated by austere forward surgical teams have a higher died of wounds rate than those initially taken to larger hospitals, a finding that, if true, would have profound policy implications for deployed medical care. Testing this conclusion would be most convincingly performed using a military-specific trauma risk prediction model that, in particular, takes into account the unique effects of blasts. With more than 55 000 patients, the US Department of Defense Trauma Registry3 should have sufficient information to design such a model. The resulting increase in the power to analyze this historically unique data set could also answer another pressing question: does a 1-hour transit to a surgical hospital really sit at the inflection point in the case fatality rate, or are there further benefits to be gained? Ignoring this question risks engendering a false sense of security in future combat casualty care planning. Back to top Article Information Corresponding Author: Michael C. Reade, MBBS, MPH, DPhil, FCICM, Australian Defence Force Joint Health Command and University of Queensland, Australia, Level 9, Health Sciences Bldg, Royal Brisbane and Women’s Hospital, Queensland, Australia 4029 (m.reade@uq.edu.au). Published Online: January 13, 2016. doi:10.1001/jamasurg.2015.4915. Conflict of Interest Disclosures: None reported. References 1. Kotwal RS, Howard JT, Orman JA, et al. The effect of a golden hour policy on the morbidity and mortality of combat casualties [published online September 30, 2015]. JAMA Surg. doi:10.1001/jamasurg.2015.3104.PubMedGoogle Scholar 2. Tohira H, Jacobs I, Mountain D, Gibson N, Yeo A. Systematic review of predictive performance of injury severity scoring tools. Scand J Trauma Resusc Emerg Med. 2012;20:63.PubMedGoogle ScholarCrossref 3. Langan NR, Eckert M, Martin MJ. Changing patterns of in-hospital deaths following implementation of damage control resuscitation practices in US forward military treatment facilities. JAMA Surg. 2014;149(9):904-912.PubMedGoogle ScholarCrossref

Journal

JAMA SurgeryAmerican Medical Association

Published: May 1, 2016

References