Has Current French Training for Military Orthopedic Surgeons Deployed in External Operations Been Appropriately Adapted?

Has Current French Training for Military Orthopedic Surgeons Deployed in External Operations Been... Abstract Introduction The current evolution of surgical practices is increasingly trending toward hyper-specialization. For military surgeons, their practice in France does not differ from their civilian counterparts. In contrast, in external operations, they have to deal with specific war injuries in austere conditions. They are also required to take care of local populations. Therefore, specific training is necessary, and the French Military Health Service Academy (Ecole du Val-de-Grâce) Paris has set up a specific training called Advanced Course for Deployment Surgery (ACDS) in 2007. The aim of this study is to assess the relevance of this teaching regarding pathologies encountered during current conflicts. Materials and Methods The activity of deploying orthopedic surgeons during the three recent major external operations (Afghanistan, Mali, and Central African Republic) has been retrospectively recorded in terms of global volume, types of trauma, status of patients who had been operated on, and indications. These data have been compared with teaching during the ACDS. Results Our study found a high variability in terms of operating volume, types of trauma, patients’ statuses, and types of operations performed depending on the operation theaters. The volume of surgical activity carried out within Role 3 is much more important than that in Role 2 with more than half of the surgeries performed as scheduled surgery to the benefit of the local population. Within advanced Role 2 surgical structures deployed in Mali and Central Africa, more than 70% of the activity was performed as emergencies. Surgical indications were varied, ranging from emergency surgery to limb reconstructive surgery. A lot of non-orthopedic procedures such as vascular repairs and decompressive craniotomies were also performed. All of the encountered pathologies were taught during ACDS. Discussion The large variety and technical nature of the performed operations requires the training of highly qualified military orthopedic surgeons with both experience in war surgery and management of after-effects and complications. Orthopedists are also required to carry out procedures dealing with neurosurgery, general, and/or vascular surgery on missions. These data highlight the complexity of military surgeons’ training along with the hyper-specialization of the civilian medical world. For more than 10 yr, French military surgeons have benefited from a training program called ACDS to meet these objectives. This initial training seems to be appropriated adapted in view of the managed pathologies. Introduction Nowadays, the evolution of surgical practices is toward specialization and hyper-specialization. Surgeons are no longer general surgeons but mono-specialists. Regarding military orthopedic surgeons, their practice in the mainland does not differ from their civilian counterparts. They work in military hospitals and perform prosthetic surgery, arthroscopic surgery, and traumatology. In external operations, orthopedic surgeons are deployed within Role 2 or 3 and have to deal with specific war traumas whose severity represents real surgical challenges and to confront a massive influx of injured people with the necessity of triage. They also ensure the elementary operational support of deployed servicemen, treat all types of surgical emergencies, and often take part in care provided to local populations (Table I). Therefore, a specific type of training is fundamental in order to acquire all of the necessary specific skills. However, maintaining military orthopedic surgeons’ versatility is a complex requirement. It rests at the moment on initial general surgical training associated with specific military training for surgeons before their deployment has set up in 2007 by the French Military Health Service Academy (Ecole du Val-de-Grâce) Paris. This training includes the following:1,2 - A semester in a department of general (abdominal and/or thoracic) surgery, a semester in vascular surgery, and a semester in neurosurgery. - A 2-mo mission abroad within a Role 2 or 3 with an experienced surgeon. - Validation of the Basic Advanced Trauma Life Support (ATLS) course. - Validation of the individual specific Advanced Course for Deployment Surgery (ACDS) followed during the last 2 yr of training. It includes five 3-d modules (Table II). The aim is to teach the basics of war trauma surgery and the principles of medical aid to populations (MAP). Each module is composed of theoretical teaching (conferences, clinical cases, and feedback) and practical simulation exercises on cadavers or bioreactors. - Taking part in a collective course of work in surgical teams, with simulation exercises of triage and technical procedures. Table I. Difference Between Civilian and Military Surgeons Civilian Practice War Practice Hyper-specialized Schedule surgery One-stage surgery Minimal invasive and arthroscopic surgery Evidence-based Medicine Asepsis Polyvalence/neurosurgery/vascular surgery Traumatology External fixation Triage Damage control surgery Large approach No evidence-based medicine Austere conditions Civilian Practice War Practice Hyper-specialized Schedule surgery One-stage surgery Minimal invasive and arthroscopic surgery Evidence-based Medicine Asepsis Polyvalence/neurosurgery/vascular surgery Traumatology External fixation Triage Damage control surgery Large approach No evidence-based medicine Austere conditions Table I. Difference Between Civilian and Military Surgeons Civilian Practice War Practice Hyper-specialized Schedule surgery One-stage surgery Minimal invasive and arthroscopic surgery Evidence-based Medicine Asepsis Polyvalence/neurosurgery/vascular surgery Traumatology External fixation Triage Damage control surgery Large approach No evidence-based medicine Austere conditions Civilian Practice War Practice Hyper-specialized Schedule surgery One-stage surgery Minimal invasive and arthroscopic surgery Evidence-based Medicine Asepsis Polyvalence/neurosurgery/vascular surgery Traumatology External fixation Triage Damage control surgery Large approach No evidence-based medicine Austere conditions Table II. Description of Courses During CACHIRMEX Module Objectives Module 1 Generality about war surgery and the French Health service during deployment Presentation of devices available during deployment Module 2 Soft tissue lesions and limb injuries War damage control orthopedics Burn lesions Modules 3 and 4 Damage control abdominal surgery Craniotomy Tracheotomy Sternotomy/thoracotomy Vascular trauma Module 5 Medical aid to population Module Objectives Module 1 Generality about war surgery and the French Health service during deployment Presentation of devices available during deployment Module 2 Soft tissue lesions and limb injuries War damage control orthopedics Burn lesions Modules 3 and 4 Damage control abdominal surgery Craniotomy Tracheotomy Sternotomy/thoracotomy Vascular trauma Module 5 Medical aid to population Table II. Description of Courses During CACHIRMEX Module Objectives Module 1 Generality about war surgery and the French Health service during deployment Presentation of devices available during deployment Module 2 Soft tissue lesions and limb injuries War damage control orthopedics Burn lesions Modules 3 and 4 Damage control abdominal surgery Craniotomy Tracheotomy Sternotomy/thoracotomy Vascular trauma Module 5 Medical aid to population Module Objectives Module 1 Generality about war surgery and the French Health service during deployment Presentation of devices available during deployment Module 2 Soft tissue lesions and limb injuries War damage control orthopedics Burn lesions Modules 3 and 4 Damage control abdominal surgery Craniotomy Tracheotomy Sternotomy/thoracotomy Vascular trauma Module 5 Medical aid to population The aim of this work is to analyze the relevance of their present training in view of pathologies met by surgeons during recent conflicts. Materials and Methods We have retrospectively collected all of the operating procedures performed by orthopedic surgeons during the three major external missions. Data were retrospectively analyzed from an electronic database File Maker (Pro File Maker Inc., Santa Clara, CA, USA) prospectively completed by deployed surgeons and containing the operating reports of operations performed. The data were gathered on Excel databases (Microsoft Corporation). Analyzed variables included the percentage of operational activity carried out by orthopedic surgeons against the global activity, patients’ demographic data (age and status), and the surgical procedures performed. Statuses of patients were classified into four categories: French servicemen, foreign servicemen, local civilians, and others (contractors and workers in embassies or non-governmental organizations). The surgical activity was subdivided into four categories: war-related injuries, non-war-related injuries (principally accidents from sports and road accidents), non-traumatic-related emergencies, and elective surgery. These data were compared with the teaching issued during the ACDS. Results Pamir’s Operation, Afghanistan (2009–2013) Between July 2009 and July 2013, 3,215 patients were managed in French Role 3 in Kabul. This Role 3 included three operating theaters, with a 6-bed resuscitation room and a 50-bed ward. Modern technical means (nail and plates) and a computed tomography (CT) scan were available. The activity of orthopedic surgeons represented 42% of the overall activity (1,319 patients). The mean age of the patients was 31 yr (range 1–78 yr) and 17% were children (<15 yr). Forty-seven percent of patients were Afghan civilians, French servicemen represented 17%, and foreign servicemen 14%. The activity of elective surgery represented 44% of patients, war-related traumas 38%, and 18% corresponded to non-war-related injuries. The indications were numerous and concerned all anatomical regions. Half of the procedures concerned soft tissues (wound debridement, skin grafts, and dressings under general anesthesia). Bone fractures represented 18% of procedures including exofixations and internal fixation. Hand surgery represented 9.6% of all procedures (Tables III and IV). Table III. Status of Patients Afghanistan Mali Central African Republic War-related injuries 38% 32% 32% Non-war-related injuries 10% 30% 48% Non-trauma-related emergencies 8% 8% 18% Elective surgery 44% 30% 2% Afghanistan Mali Central African Republic War-related injuries 38% 32% 32% Non-war-related injuries 10% 30% 48% Non-trauma-related emergencies 8% 8% 18% Elective surgery 44% 30% 2% Table III. Status of Patients Afghanistan Mali Central African Republic War-related injuries 38% 32% 32% Non-war-related injuries 10% 30% 48% Non-trauma-related emergencies 8% 8% 18% Elective surgery 44% 30% 2% Afghanistan Mali Central African Republic War-related injuries 38% 32% 32% Non-war-related injuries 10% 30% 48% Non-trauma-related emergencies 8% 8% 18% Elective surgery 44% 30% 2% Table IV. Procedures Performed in Each Theater Theater Afghanistan Mali Central African Republic Bone fixation  Internal fixation 11.1% 3.7% 6%  External fixation 7.2% 18.6% 8% Soft tissue procedures (hand excluded)  Flap transfers 1.9% 0.6% 3%  Debridement 18.2% 22.5% 66%  Skin grafting 3.2% 1.9%  Dressing 23% 14.9%  Abscess/arthritis 3.8% 4.2% Hand lesions 9.6% 15.5% 4% Bone grafting/reconstruction 4% 1.2% 0% Fasciotomies 0.7% 1.2% 1% Amputation 3.4% 3.1% 3% Osteomyelitis treatment 0.7% 0.6% Material removal 5.3% 5% 4% Reconstructive surgery 2.7% 1.9% 1% Orthopedic selective surgery 5.2% 0.6% 0% Vascular surgery 0% 1.9% 2% Craniotomies 0% 2.5% 1% Intermaxillar block 0% 0% 1% Theater Afghanistan Mali Central African Republic Bone fixation  Internal fixation 11.1% 3.7% 6%  External fixation 7.2% 18.6% 8% Soft tissue procedures (hand excluded)  Flap transfers 1.9% 0.6% 3%  Debridement 18.2% 22.5% 66%  Skin grafting 3.2% 1.9%  Dressing 23% 14.9%  Abscess/arthritis 3.8% 4.2% Hand lesions 9.6% 15.5% 4% Bone grafting/reconstruction 4% 1.2% 0% Fasciotomies 0.7% 1.2% 1% Amputation 3.4% 3.1% 3% Osteomyelitis treatment 0.7% 0.6% Material removal 5.3% 5% 4% Reconstructive surgery 2.7% 1.9% 1% Orthopedic selective surgery 5.2% 0.6% 0% Vascular surgery 0% 1.9% 2% Craniotomies 0% 2.5% 1% Intermaxillar block 0% 0% 1% Table IV. Procedures Performed in Each Theater Theater Afghanistan Mali Central African Republic Bone fixation  Internal fixation 11.1% 3.7% 6%  External fixation 7.2% 18.6% 8% Soft tissue procedures (hand excluded)  Flap transfers 1.9% 0.6% 3%  Debridement 18.2% 22.5% 66%  Skin grafting 3.2% 1.9%  Dressing 23% 14.9%  Abscess/arthritis 3.8% 4.2% Hand lesions 9.6% 15.5% 4% Bone grafting/reconstruction 4% 1.2% 0% Fasciotomies 0.7% 1.2% 1% Amputation 3.4% 3.1% 3% Osteomyelitis treatment 0.7% 0.6% Material removal 5.3% 5% 4% Reconstructive surgery 2.7% 1.9% 1% Orthopedic selective surgery 5.2% 0.6% 0% Vascular surgery 0% 1.9% 2% Craniotomies 0% 2.5% 1% Intermaxillar block 0% 0% 1% Theater Afghanistan Mali Central African Republic Bone fixation  Internal fixation 11.1% 3.7% 6%  External fixation 7.2% 18.6% 8% Soft tissue procedures (hand excluded)  Flap transfers 1.9% 0.6% 3%  Debridement 18.2% 22.5% 66%  Skin grafting 3.2% 1.9%  Dressing 23% 14.9%  Abscess/arthritis 3.8% 4.2% Hand lesions 9.6% 15.5% 4% Bone grafting/reconstruction 4% 1.2% 0% Fasciotomies 0.7% 1.2% 1% Amputation 3.4% 3.1% 3% Osteomyelitis treatment 0.7% 0.6% Material removal 5.3% 5% 4% Reconstructive surgery 2.7% 1.9% 1% Orthopedic selective surgery 5.2% 0.6% 0% Vascular surgery 0% 1.9% 2% Craniotomies 0% 2.5% 1% Intermaxillar block 0% 0% 1% Operation Serval, Mali (2013–2015) During the 18 mo of the operation Serval in Mali, 268 patients were operated on in Gao’s Role 2. The Role 2 was located in a tent containing a single operating theater, two beds in resuscitation, and eight beds for hospitalization. The patients’ mean age was 29 yr (range 0.7–60 yr). Half of the patients were civilians, 17% were French servicemen, and 33% were foreign servicemen. The orthopedic surgical activity represented 53% of the overall activity and selective surgery represented 30%. The use of reconstructive surgery was low with only one lateral gastrocnemius flap and three skin grafts. War-related traumas represented 32% of patients. The war wounded were 49% of cases affecting French servicemen and in other the cases foreign servicemen (Malians and United Nations forces). Bone fixation represented 23% of procedures and were mainly performed with external fixators. The rate of amputations was 3%. Three vascular repairs and three decompressive craniotomies were performed by the orthopedic surgeon. Non-war-related traumas represented 30% of patients. They corresponded to soft tissue wound debridement (25%) and hand surgeries (31%). Several open and closed fractures were managed with 6 fixations using K-wires and 11 exofixations. A foreign serviceman with skull trauma secondary to a fall required a decompressive craniotomy. Non-traumatic-related emergencies represented 8% of procedures (Tables III and IV). Sangaris’ Operation, Central African Republic (2013–2015) During the first 18 mo of the French intervention in Central African Republic, 431 surgical operations were performed in a Role 2 built under a tent. During this study period, the orthopedic surgeon performed 34% of surgical operations, mainly during the first months of the conflict. Patients’ mean age was 34 yr. One quarter of orthopedic procedures dealt with local patients, one quarter with foreign servicemen, and half with French servicemen. Surgical procedures for war-related traumas represented 32% of the surgical activity and 2% elective surgery. Surgical procedures for non-war-related traumas represented 48% and 13% of global activity, respectively. The majority (69%) of procedures performed by orthopedic surgeons involved injuries to extremity soft tissue and 14% of them were devoted to the surgical management of fractures. Only nine internal fixations were performed by using K-wires for wrist fractures (6%) and 13 exofixations (8%) were performed. Four acute amputations for mangled extremity were carried out. Hand injuries with tendon sutures were performed in six patients (4%) and six patients benefited from material removal (4%). A fasciotomy was carried out. The orthopedic surgeon also performed one craniotomy, one inter-maxillary block, three (2%) vascular repairs, and four (3%) flaps (Tables III and IV). Discussion Orthopedic surgeons can be deployed in different contexts according to their missions. Role 2 has mobile structures close to combat zones whose purpose is to stabilize wounded soldiers according to the principles of damage control surgery. Role 3 is better equipped (with a CT scan and internal fixation devices) and is used primarily and secondarily to manage wounded individuals but also to carry out scheduled surgery and MAP.3–6 This comparative analysis of the surgical activity of orthopedic surgeons within different structures reveals a wide discrepancy in the operating volume, the types of surgery, and the procedures performed. These data are comparable with those from other series in the literature in terms of operating volume, patients, and injuries. In Role 3, global surgical activity is much more important than within Role 2 with possible scheduled surgery.7–9 On the contrary, Role 2 carry out more than 70% of their activity in emergencies.3–6 For orthopedic surgeons, war-related traumas represent between a third and half of their activity. This particularity can be explained by the quality of the present equipment of protection-limiting injuries to trunks and heads, but leaving limbs still vulnerable. Therefore, the better medicalization of the forward post and its capacities of fast evacuation10–15 result in surgeons being confronted with survivors with high limb mutilations that represent surgical challenges.16–18 Moreover, asymmetric present conflicts are responsible for a lot of civilian casualties, which explains the importance of MAP and particularity the important task of operated on children (about 20% of the activity19–21 because they are often collateral victims of explosions). The diversity of procedures is important, ranging from emergencies to reconstructive surgery (skin grafting, flap transfers, and bone reconstruction).22,23 Nearly 50% of procedures deal with soft tissues (wound trimmings, dressings, and skin grafts), whereas fractures represent a little less than 20% of operations.11 Internal fixation devices are available only in Role 3 structures where aseptic conditions are sufficient. The place of hand surgery and of pediatrics is also important.24,25 In addition, orthopedic surgeons in Role 2 must be able to perform vascular repairs and decompressive craniotomies (contrary to those in Role 3 with more specialized surgeons). This versatility is also well reported in the literature by American Role 2 in Iraq and Afghanistan.3,13,26,27 In view of these data, the diversity of operations and varied contexts, deployed military orthopedists must be highly qualified and have experience in general surgery and complex traumas. Knowledge of neurosurgery and general and/or vascular surgery are necessary. Skills in hand surgery and pediatric surgery are useful. These data highlight the complexity of military surgeons’ training along with the hyper-specialization of the civilian surgical world.28–30 In France, in 2007, the French Military Health Service Academy (Ecole du Val-de-Grâce) Paris has set up an ACDS1,2 in order to provide all military surgeons with tools to manage severely hemorrhagic wounded individuals. This practical training appears to be more than necessary in view of these data and the literature29 in order to close the gap between theoretical knowledge and low surgical experience. The comparison of ACDS objectives with operations shows that this course is perfectly adapted to the training objectives for operational military surgeons. However, this training only occurs in the pre-deployment period and is based on the acquisition of knowledge with theoretical lessons, of know-how with practical workshops, and of know-how-to-be, that is the capacity to establish a good indication at the right time by stepping back from experienced situations with feedback from surgeons coming back from missions. On the other hand, no additional training is offered during and after deployment. Maintaining technical surgical skills between missions is necessary.30 Modern tools of training and teaching could be useful. The development of online teaching, called e-training or e-learning, or even massive open online courses, can be accessible by any deployed surgeon.31–35 The use of new technologies with the development of virtual reality and serious games, as has already been done for salvage in combat, would be an interesting perspective.36,37 Conclusion Present training of orthopedic surgeons is complex and fits between the need to adapt to a civilian world geared to an early hyper-specialization and the need to acquire specific skills for the management of the war wounded and to confront the diversity of procedures that they may be led to perform in the field. Therefore, specific training is required for a modern military orthopedic surgeon to prepare for the job during future missions. 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Has Current French Training for Military Orthopedic Surgeons Deployed in External Operations Been Appropriately Adapted?

Military Medicine , Volume 183 (9) – Sep 1, 2018

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Abstract

Abstract Introduction The current evolution of surgical practices is increasingly trending toward hyper-specialization. For military surgeons, their practice in France does not differ from their civilian counterparts. In contrast, in external operations, they have to deal with specific war injuries in austere conditions. They are also required to take care of local populations. Therefore, specific training is necessary, and the French Military Health Service Academy (Ecole du Val-de-Grâce) Paris has set up a specific training called Advanced Course for Deployment Surgery (ACDS) in 2007. The aim of this study is to assess the relevance of this teaching regarding pathologies encountered during current conflicts. Materials and Methods The activity of deploying orthopedic surgeons during the three recent major external operations (Afghanistan, Mali, and Central African Republic) has been retrospectively recorded in terms of global volume, types of trauma, status of patients who had been operated on, and indications. These data have been compared with teaching during the ACDS. Results Our study found a high variability in terms of operating volume, types of trauma, patients’ statuses, and types of operations performed depending on the operation theaters. The volume of surgical activity carried out within Role 3 is much more important than that in Role 2 with more than half of the surgeries performed as scheduled surgery to the benefit of the local population. Within advanced Role 2 surgical structures deployed in Mali and Central Africa, more than 70% of the activity was performed as emergencies. Surgical indications were varied, ranging from emergency surgery to limb reconstructive surgery. A lot of non-orthopedic procedures such as vascular repairs and decompressive craniotomies were also performed. All of the encountered pathologies were taught during ACDS. Discussion The large variety and technical nature of the performed operations requires the training of highly qualified military orthopedic surgeons with both experience in war surgery and management of after-effects and complications. Orthopedists are also required to carry out procedures dealing with neurosurgery, general, and/or vascular surgery on missions. These data highlight the complexity of military surgeons’ training along with the hyper-specialization of the civilian medical world. For more than 10 yr, French military surgeons have benefited from a training program called ACDS to meet these objectives. This initial training seems to be appropriated adapted in view of the managed pathologies. Introduction Nowadays, the evolution of surgical practices is toward specialization and hyper-specialization. Surgeons are no longer general surgeons but mono-specialists. Regarding military orthopedic surgeons, their practice in the mainland does not differ from their civilian counterparts. They work in military hospitals and perform prosthetic surgery, arthroscopic surgery, and traumatology. In external operations, orthopedic surgeons are deployed within Role 2 or 3 and have to deal with specific war traumas whose severity represents real surgical challenges and to confront a massive influx of injured people with the necessity of triage. They also ensure the elementary operational support of deployed servicemen, treat all types of surgical emergencies, and often take part in care provided to local populations (Table I). Therefore, a specific type of training is fundamental in order to acquire all of the necessary specific skills. However, maintaining military orthopedic surgeons’ versatility is a complex requirement. It rests at the moment on initial general surgical training associated with specific military training for surgeons before their deployment has set up in 2007 by the French Military Health Service Academy (Ecole du Val-de-Grâce) Paris. This training includes the following:1,2 - A semester in a department of general (abdominal and/or thoracic) surgery, a semester in vascular surgery, and a semester in neurosurgery. - A 2-mo mission abroad within a Role 2 or 3 with an experienced surgeon. - Validation of the Basic Advanced Trauma Life Support (ATLS) course. - Validation of the individual specific Advanced Course for Deployment Surgery (ACDS) followed during the last 2 yr of training. It includes five 3-d modules (Table II). The aim is to teach the basics of war trauma surgery and the principles of medical aid to populations (MAP). Each module is composed of theoretical teaching (conferences, clinical cases, and feedback) and practical simulation exercises on cadavers or bioreactors. - Taking part in a collective course of work in surgical teams, with simulation exercises of triage and technical procedures. Table I. Difference Between Civilian and Military Surgeons Civilian Practice War Practice Hyper-specialized Schedule surgery One-stage surgery Minimal invasive and arthroscopic surgery Evidence-based Medicine Asepsis Polyvalence/neurosurgery/vascular surgery Traumatology External fixation Triage Damage control surgery Large approach No evidence-based medicine Austere conditions Civilian Practice War Practice Hyper-specialized Schedule surgery One-stage surgery Minimal invasive and arthroscopic surgery Evidence-based Medicine Asepsis Polyvalence/neurosurgery/vascular surgery Traumatology External fixation Triage Damage control surgery Large approach No evidence-based medicine Austere conditions Table I. Difference Between Civilian and Military Surgeons Civilian Practice War Practice Hyper-specialized Schedule surgery One-stage surgery Minimal invasive and arthroscopic surgery Evidence-based Medicine Asepsis Polyvalence/neurosurgery/vascular surgery Traumatology External fixation Triage Damage control surgery Large approach No evidence-based medicine Austere conditions Civilian Practice War Practice Hyper-specialized Schedule surgery One-stage surgery Minimal invasive and arthroscopic surgery Evidence-based Medicine Asepsis Polyvalence/neurosurgery/vascular surgery Traumatology External fixation Triage Damage control surgery Large approach No evidence-based medicine Austere conditions Table II. Description of Courses During CACHIRMEX Module Objectives Module 1 Generality about war surgery and the French Health service during deployment Presentation of devices available during deployment Module 2 Soft tissue lesions and limb injuries War damage control orthopedics Burn lesions Modules 3 and 4 Damage control abdominal surgery Craniotomy Tracheotomy Sternotomy/thoracotomy Vascular trauma Module 5 Medical aid to population Module Objectives Module 1 Generality about war surgery and the French Health service during deployment Presentation of devices available during deployment Module 2 Soft tissue lesions and limb injuries War damage control orthopedics Burn lesions Modules 3 and 4 Damage control abdominal surgery Craniotomy Tracheotomy Sternotomy/thoracotomy Vascular trauma Module 5 Medical aid to population Table II. Description of Courses During CACHIRMEX Module Objectives Module 1 Generality about war surgery and the French Health service during deployment Presentation of devices available during deployment Module 2 Soft tissue lesions and limb injuries War damage control orthopedics Burn lesions Modules 3 and 4 Damage control abdominal surgery Craniotomy Tracheotomy Sternotomy/thoracotomy Vascular trauma Module 5 Medical aid to population Module Objectives Module 1 Generality about war surgery and the French Health service during deployment Presentation of devices available during deployment Module 2 Soft tissue lesions and limb injuries War damage control orthopedics Burn lesions Modules 3 and 4 Damage control abdominal surgery Craniotomy Tracheotomy Sternotomy/thoracotomy Vascular trauma Module 5 Medical aid to population The aim of this work is to analyze the relevance of their present training in view of pathologies met by surgeons during recent conflicts. Materials and Methods We have retrospectively collected all of the operating procedures performed by orthopedic surgeons during the three major external missions. Data were retrospectively analyzed from an electronic database File Maker (Pro File Maker Inc., Santa Clara, CA, USA) prospectively completed by deployed surgeons and containing the operating reports of operations performed. The data were gathered on Excel databases (Microsoft Corporation). Analyzed variables included the percentage of operational activity carried out by orthopedic surgeons against the global activity, patients’ demographic data (age and status), and the surgical procedures performed. Statuses of patients were classified into four categories: French servicemen, foreign servicemen, local civilians, and others (contractors and workers in embassies or non-governmental organizations). The surgical activity was subdivided into four categories: war-related injuries, non-war-related injuries (principally accidents from sports and road accidents), non-traumatic-related emergencies, and elective surgery. These data were compared with the teaching issued during the ACDS. Results Pamir’s Operation, Afghanistan (2009–2013) Between July 2009 and July 2013, 3,215 patients were managed in French Role 3 in Kabul. This Role 3 included three operating theaters, with a 6-bed resuscitation room and a 50-bed ward. Modern technical means (nail and plates) and a computed tomography (CT) scan were available. The activity of orthopedic surgeons represented 42% of the overall activity (1,319 patients). The mean age of the patients was 31 yr (range 1–78 yr) and 17% were children (<15 yr). Forty-seven percent of patients were Afghan civilians, French servicemen represented 17%, and foreign servicemen 14%. The activity of elective surgery represented 44% of patients, war-related traumas 38%, and 18% corresponded to non-war-related injuries. The indications were numerous and concerned all anatomical regions. Half of the procedures concerned soft tissues (wound debridement, skin grafts, and dressings under general anesthesia). Bone fractures represented 18% of procedures including exofixations and internal fixation. Hand surgery represented 9.6% of all procedures (Tables III and IV). Table III. Status of Patients Afghanistan Mali Central African Republic War-related injuries 38% 32% 32% Non-war-related injuries 10% 30% 48% Non-trauma-related emergencies 8% 8% 18% Elective surgery 44% 30% 2% Afghanistan Mali Central African Republic War-related injuries 38% 32% 32% Non-war-related injuries 10% 30% 48% Non-trauma-related emergencies 8% 8% 18% Elective surgery 44% 30% 2% Table III. Status of Patients Afghanistan Mali Central African Republic War-related injuries 38% 32% 32% Non-war-related injuries 10% 30% 48% Non-trauma-related emergencies 8% 8% 18% Elective surgery 44% 30% 2% Afghanistan Mali Central African Republic War-related injuries 38% 32% 32% Non-war-related injuries 10% 30% 48% Non-trauma-related emergencies 8% 8% 18% Elective surgery 44% 30% 2% Table IV. Procedures Performed in Each Theater Theater Afghanistan Mali Central African Republic Bone fixation  Internal fixation 11.1% 3.7% 6%  External fixation 7.2% 18.6% 8% Soft tissue procedures (hand excluded)  Flap transfers 1.9% 0.6% 3%  Debridement 18.2% 22.5% 66%  Skin grafting 3.2% 1.9%  Dressing 23% 14.9%  Abscess/arthritis 3.8% 4.2% Hand lesions 9.6% 15.5% 4% Bone grafting/reconstruction 4% 1.2% 0% Fasciotomies 0.7% 1.2% 1% Amputation 3.4% 3.1% 3% Osteomyelitis treatment 0.7% 0.6% Material removal 5.3% 5% 4% Reconstructive surgery 2.7% 1.9% 1% Orthopedic selective surgery 5.2% 0.6% 0% Vascular surgery 0% 1.9% 2% Craniotomies 0% 2.5% 1% Intermaxillar block 0% 0% 1% Theater Afghanistan Mali Central African Republic Bone fixation  Internal fixation 11.1% 3.7% 6%  External fixation 7.2% 18.6% 8% Soft tissue procedures (hand excluded)  Flap transfers 1.9% 0.6% 3%  Debridement 18.2% 22.5% 66%  Skin grafting 3.2% 1.9%  Dressing 23% 14.9%  Abscess/arthritis 3.8% 4.2% Hand lesions 9.6% 15.5% 4% Bone grafting/reconstruction 4% 1.2% 0% Fasciotomies 0.7% 1.2% 1% Amputation 3.4% 3.1% 3% Osteomyelitis treatment 0.7% 0.6% Material removal 5.3% 5% 4% Reconstructive surgery 2.7% 1.9% 1% Orthopedic selective surgery 5.2% 0.6% 0% Vascular surgery 0% 1.9% 2% Craniotomies 0% 2.5% 1% Intermaxillar block 0% 0% 1% Table IV. Procedures Performed in Each Theater Theater Afghanistan Mali Central African Republic Bone fixation  Internal fixation 11.1% 3.7% 6%  External fixation 7.2% 18.6% 8% Soft tissue procedures (hand excluded)  Flap transfers 1.9% 0.6% 3%  Debridement 18.2% 22.5% 66%  Skin grafting 3.2% 1.9%  Dressing 23% 14.9%  Abscess/arthritis 3.8% 4.2% Hand lesions 9.6% 15.5% 4% Bone grafting/reconstruction 4% 1.2% 0% Fasciotomies 0.7% 1.2% 1% Amputation 3.4% 3.1% 3% Osteomyelitis treatment 0.7% 0.6% Material removal 5.3% 5% 4% Reconstructive surgery 2.7% 1.9% 1% Orthopedic selective surgery 5.2% 0.6% 0% Vascular surgery 0% 1.9% 2% Craniotomies 0% 2.5% 1% Intermaxillar block 0% 0% 1% Theater Afghanistan Mali Central African Republic Bone fixation  Internal fixation 11.1% 3.7% 6%  External fixation 7.2% 18.6% 8% Soft tissue procedures (hand excluded)  Flap transfers 1.9% 0.6% 3%  Debridement 18.2% 22.5% 66%  Skin grafting 3.2% 1.9%  Dressing 23% 14.9%  Abscess/arthritis 3.8% 4.2% Hand lesions 9.6% 15.5% 4% Bone grafting/reconstruction 4% 1.2% 0% Fasciotomies 0.7% 1.2% 1% Amputation 3.4% 3.1% 3% Osteomyelitis treatment 0.7% 0.6% Material removal 5.3% 5% 4% Reconstructive surgery 2.7% 1.9% 1% Orthopedic selective surgery 5.2% 0.6% 0% Vascular surgery 0% 1.9% 2% Craniotomies 0% 2.5% 1% Intermaxillar block 0% 0% 1% Operation Serval, Mali (2013–2015) During the 18 mo of the operation Serval in Mali, 268 patients were operated on in Gao’s Role 2. The Role 2 was located in a tent containing a single operating theater, two beds in resuscitation, and eight beds for hospitalization. The patients’ mean age was 29 yr (range 0.7–60 yr). Half of the patients were civilians, 17% were French servicemen, and 33% were foreign servicemen. The orthopedic surgical activity represented 53% of the overall activity and selective surgery represented 30%. The use of reconstructive surgery was low with only one lateral gastrocnemius flap and three skin grafts. War-related traumas represented 32% of patients. The war wounded were 49% of cases affecting French servicemen and in other the cases foreign servicemen (Malians and United Nations forces). Bone fixation represented 23% of procedures and were mainly performed with external fixators. The rate of amputations was 3%. Three vascular repairs and three decompressive craniotomies were performed by the orthopedic surgeon. Non-war-related traumas represented 30% of patients. They corresponded to soft tissue wound debridement (25%) and hand surgeries (31%). Several open and closed fractures were managed with 6 fixations using K-wires and 11 exofixations. A foreign serviceman with skull trauma secondary to a fall required a decompressive craniotomy. Non-traumatic-related emergencies represented 8% of procedures (Tables III and IV). Sangaris’ Operation, Central African Republic (2013–2015) During the first 18 mo of the French intervention in Central African Republic, 431 surgical operations were performed in a Role 2 built under a tent. During this study period, the orthopedic surgeon performed 34% of surgical operations, mainly during the first months of the conflict. Patients’ mean age was 34 yr. One quarter of orthopedic procedures dealt with local patients, one quarter with foreign servicemen, and half with French servicemen. Surgical procedures for war-related traumas represented 32% of the surgical activity and 2% elective surgery. Surgical procedures for non-war-related traumas represented 48% and 13% of global activity, respectively. The majority (69%) of procedures performed by orthopedic surgeons involved injuries to extremity soft tissue and 14% of them were devoted to the surgical management of fractures. Only nine internal fixations were performed by using K-wires for wrist fractures (6%) and 13 exofixations (8%) were performed. Four acute amputations for mangled extremity were carried out. Hand injuries with tendon sutures were performed in six patients (4%) and six patients benefited from material removal (4%). A fasciotomy was carried out. The orthopedic surgeon also performed one craniotomy, one inter-maxillary block, three (2%) vascular repairs, and four (3%) flaps (Tables III and IV). Discussion Orthopedic surgeons can be deployed in different contexts according to their missions. Role 2 has mobile structures close to combat zones whose purpose is to stabilize wounded soldiers according to the principles of damage control surgery. Role 3 is better equipped (with a CT scan and internal fixation devices) and is used primarily and secondarily to manage wounded individuals but also to carry out scheduled surgery and MAP.3–6 This comparative analysis of the surgical activity of orthopedic surgeons within different structures reveals a wide discrepancy in the operating volume, the types of surgery, and the procedures performed. These data are comparable with those from other series in the literature in terms of operating volume, patients, and injuries. In Role 3, global surgical activity is much more important than within Role 2 with possible scheduled surgery.7–9 On the contrary, Role 2 carry out more than 70% of their activity in emergencies.3–6 For orthopedic surgeons, war-related traumas represent between a third and half of their activity. This particularity can be explained by the quality of the present equipment of protection-limiting injuries to trunks and heads, but leaving limbs still vulnerable. Therefore, the better medicalization of the forward post and its capacities of fast evacuation10–15 result in surgeons being confronted with survivors with high limb mutilations that represent surgical challenges.16–18 Moreover, asymmetric present conflicts are responsible for a lot of civilian casualties, which explains the importance of MAP and particularity the important task of operated on children (about 20% of the activity19–21 because they are often collateral victims of explosions). The diversity of procedures is important, ranging from emergencies to reconstructive surgery (skin grafting, flap transfers, and bone reconstruction).22,23 Nearly 50% of procedures deal with soft tissues (wound trimmings, dressings, and skin grafts), whereas fractures represent a little less than 20% of operations.11 Internal fixation devices are available only in Role 3 structures where aseptic conditions are sufficient. The place of hand surgery and of pediatrics is also important.24,25 In addition, orthopedic surgeons in Role 2 must be able to perform vascular repairs and decompressive craniotomies (contrary to those in Role 3 with more specialized surgeons). This versatility is also well reported in the literature by American Role 2 in Iraq and Afghanistan.3,13,26,27 In view of these data, the diversity of operations and varied contexts, deployed military orthopedists must be highly qualified and have experience in general surgery and complex traumas. Knowledge of neurosurgery and general and/or vascular surgery are necessary. Skills in hand surgery and pediatric surgery are useful. These data highlight the complexity of military surgeons’ training along with the hyper-specialization of the civilian surgical world.28–30 In France, in 2007, the French Military Health Service Academy (Ecole du Val-de-Grâce) Paris has set up an ACDS1,2 in order to provide all military surgeons with tools to manage severely hemorrhagic wounded individuals. This practical training appears to be more than necessary in view of these data and the literature29 in order to close the gap between theoretical knowledge and low surgical experience. The comparison of ACDS objectives with operations shows that this course is perfectly adapted to the training objectives for operational military surgeons. However, this training only occurs in the pre-deployment period and is based on the acquisition of knowledge with theoretical lessons, of know-how with practical workshops, and of know-how-to-be, that is the capacity to establish a good indication at the right time by stepping back from experienced situations with feedback from surgeons coming back from missions. On the other hand, no additional training is offered during and after deployment. Maintaining technical surgical skills between missions is necessary.30 Modern tools of training and teaching could be useful. The development of online teaching, called e-training or e-learning, or even massive open online courses, can be accessible by any deployed surgeon.31–35 The use of new technologies with the development of virtual reality and serious games, as has already been done for salvage in combat, would be an interesting perspective.36,37 Conclusion Present training of orthopedic surgeons is complex and fits between the need to adapt to a civilian world geared to an early hyper-specialization and the need to acquire specific skills for the management of the war wounded and to confront the diversity of procedures that they may be led to perform in the field. Therefore, specific training is required for a modern military orthopedic surgeon to prepare for the job during future missions. 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For permissions, please e-mail: journals.permissions@oup.com. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model)

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Military MedicineOxford University Press

Published: Sep 1, 2018

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