Combat Related Maxillofacial Injuries

Lt Col Darryl Tong RNZAMCOral and Maxillofacial Surgeon

Disclaimer and OPSEC

Role 3 MMU KAF

• Only designated Role 3 medical facility in Southern Afghanistan

• Role 3 NATO asset designation• Also Level III medical facility

• Highest level of care available within the combat zone

• ICU and ward beds• General, orthopaedic, neurosurgery,

maxillofacial • Blood bank, laboratory, x-ray and CT,

mortuary

Role 3 MMU KAF

• Nations represented include:• Canada (lead Nation)• Denmark• Netherlands• United States• United Kingdom• Australia• New Zealand

MMUCOMKAF HQ

Q

Primary care

Role 3 MMU KAF

• 2 Surgical teams each consisting of:• Anaesthetist• Nurse anaesthetist• General Surgeon• Orthopaedic Surgeon• Theatre staff

• 24 hour shifts with call-back option on off days as required

• Canadian – Danish rotation

Role 3 MMU KAF

• Neurosurgery and Maxillofacial surgery stand alone specialties

• R3 MMU is the referral centre for all neurosurgical and maxillofacial trauma for Southern Afghanistan

• 24 hour on call, 7 days a week• Neurosurgery: United Kingdom• Maxillofacial Surgery: UK, Canada, NZ

Role 3 MMU KAF

• 8 wards beds with surge capability of extra 4 beds = 12 total

• 5 ICU beds with ventilators with one extra bed often used for recovery

• 4 extra beds for ward or ICU capability• One isolation room for infectious

disease or detainees

Role 3 MMU KAF

• Extra 8 beds in primary care and surge capabilities in respective Role 1 facilities (UK, Dutch, Danish etc)

• 6 trauma bays with surge capability of 8 extra bays = total 14 trauma bays with overflow to Role 1 facilities

Role 3 MMU KAF

• 2 operating theatres • X-ray department• Laboratory and blood bank• Dental section ( 2 dentists + DAs)• Psych med section (psychiatrist and 2

MH RNs)• Prev med section• Pharmacy

Patients

• Coalition personnel• Civilian contractors• ANA and militia• ANP• Local population

• Significant paediatric patient flow• Minimal women’s health involvement

Surgeries by specialty

50 115273

648

893

Other 4%Neuro 7%Maxfax 16%General 39%Ortho 53%

Period: 01 Sep 2007 – 01 Mar 2009

N = 1675

Patient category

642 635

303

48 47

0

100

200

300

400

500

600

700

Period: 01 Sep 2007 – 01 Mar 2009

Trauma sequence

• 9- liner called through• Trauma teams notified• Specialist staff notified• Operating theatre on standby• Triaged• Primary survey: MARCHH• Secondary survey

Maxillofacial injuries in combat

• Incidence of HFN wounds from Iraq and Afghanistan currently ranges from 21-29% (US and UK data)

• Israeli data ranges from 26-54% (Lebanon, Gaza and West Bank)

• Dobson et al. 1988: 13 major conflicts from 1914-1986 Overall incidence HFN wounds 16%

including WW1, WW2, Vietnam and

Maxillofacial injuries in combat

• Second most common injuries sustained among combat personnel

• Fragment injuries >> GSW• Blunt trauma still occurs• Concomitant injuries: Cervical spine Traumatic head injury Ocular/Otologic

Maxillofacial injuries in combat

• Proportional increase in HFN injuries due to survivability from the use of CBA

• Exposed areas of extremities, face and neck are issues for CBA design

• Mobility and ability to fight versus protection

Surgical considerations

• Damage control surgery vs. definitive care

• Primary versus secondary reconstruction

• Choice of hardware• General condition of patient• Patient disposition• Antibiotics

Surgical considerations

• Life, limb, eyesight• Damage control surgery is typically

not necessary apart from airway or haemorrhage control

• UK favours early evacuation for definitive maxillofacial repair

• US study: definitive feasible in-country but following strict criteria

Surgical considerations

• Potential need for secondary surgery depends on: Patient condition Availability of tissue Surgeon skill set Demands on operating theatre Timings for STRATEVAC

Surgical considerations

• Local nationals tended to receive as much definitive surgery as possible Local expertise issues Rehab and post op care issues

• Often time delay in presentation General condition of patient Availability of medevac Tactical situation at the time

Multiple roles in trauma

• Maxillofacial trauma Soft tissue Hard tissue

• Teeth • Bones

• Ocular injuries• Advanced airway management

including surgical airway• Neck exploration

Multiple roles in trauma

• First assistant Orthopaedic surgery General surgery Neurosurgery

• Trauma team leader• Post operative care complications

Points to consider

• Combat body armour saves lives but not necessarily limbs or faces

• Head, face and neck wounds second most common injuries in combat personnel

• Surgeons with expertise in maxillofacial trauma are an integral part of the current military surgical team

Points to consider

• Maxillofacial surgeons are force multipliers• Essential that the lessons learnt in combat

trauma are passed on to other military surgeons

• Maxfax surgeons need to be familiar with other surgical specialties: Eyes / ENT Neurosurgery Orthopaedic surgery General surgery

Points to consider

• Adaptability essential (not civilian tertiary hospital-centric mentality)

• Basic maxillofacial trauma skills as part of a training module for other specialists

• Regular opportunities to share information

Acknowledgements

• AMMA/Joint Health Command• NZ Defence Force• University of Otago• Role 3 MMU KAF

““The Best Care AnywhereThe Best Care Anywhere””