Journal of Health Education Research & Development, 2017
Figure 1: Combination of Combat Gauze and iTClamp to control hemorrhage in a penetrating neck inj... more Figure 1: Combination of Combat Gauze and iTClamp to control hemorrhage in a penetrating neck injury from a stab wound.
Military surgeons have gained familiarity and experience with mass casualty events (MCEs) as a ma... more Military surgeons have gained familiarity and experience with mass casualty events (MCEs) as a matter of routine over the course of the last two conflicts in Afghanistan and Iraq. Over the same period of time, civilian surgeons have increasingly faced complex MCEs on the home front. Our objective is to summarize and adapt these combat surgery lessons to enhance civilian surgeon preparedness for complex MCEs on the home front. The authors describe the unique lessons learned from combat surgery over the course of the wars in Afghanistan and Iraq and adapt these lessons to enhance civilian surgical readiness for a MCE on the home front. Military Damage Control Surgery (mDCS) combines the established concept of clinical DCS (cDCS) with key combat situational awareness factors that enable surgeons to optimally care for multiple, complex patients, from multiple simultaneous events, with limited resources. These additional considerations involve the surgeon's role of care within the de...
We present an unusual case of a single gunshot to the genitalia in which the bullet trajectory in... more We present an unusual case of a single gunshot to the genitalia in which the bullet trajectory injured the urethra, corpus cavernosum, and both testicles. All injuries were successfully repaired during initial exploration. Our report serves as a reminder to clinicians to have a high index of suspicion in this circumstance and consider immediate exploration of all the injured areas. We also demonstrate the use of a dartos fascia interposition flap to cover and separate the concomitant urethral and corporal sutures lines. Our dartos flap bolstered the urethral and cavernosal repairs and helped prevent postoperative corporourethral fistula formation.
The philosophy of damage control surgery has developed tremendously over the past 10 years. It ha... more The philosophy of damage control surgery has developed tremendously over the past 10 years. It has expanded outside the original boundaries of the abdomen and has been applied to all aspects of trauma care, ranging from resuscitation to limb-threatening vascular injuries. In recent years, the US military has taken the concept to a new level by initiating a damage control approach at the point of injury and continuing it through a transcontinental health care system. This article highlights many recent advances in damage control surgery and discusses proper patient selection and the risks associated with this management strategy.
Intra-abdominal packing with laparotomy pads (LP) is a common and rapid method for hemorrhage con... more Intra-abdominal packing with laparotomy pads (LP) is a common and rapid method for hemorrhage control in critically injured patients. Combat Gauze™ and Trauma Pads™ ([QC] Z-Medica QuikClot(®)) are kaolin impregnated hemostatic agents, that in addition to LP, may improve hemorrhage control. While QC packing has been effective in a swine liver injury model, QC remains unstudied for human intra-abdominal use. We hypothesized QC packing during damage control laparotomy (DCL) better controls hemorrhage than standard packing and is safe for intracorporeal use. A retrospective review (2011-2014) at a Level-I Trauma Center reviewed all patients who underwent DCL with intentionally retained packing. Clinical characteristics, intraoperative and postoperative parameters, and outcomes were compared with respect to packing (LP vs. LP+QC). All complications occurring within the patients' hospital stays were reviewed. A p≤0.05 was considered significant. 68 patients underwent DCL with packing; (LP n=40; LP+QC n=28). No difference in age, BMI, injury mechanism, ISS, or GCS was detected (Table 1, all p>0.05). LP+QC patients had a lower systolic blood pressure upon ED presentation and greater blood loss during index laparotomy than LP patients. LP+QC patients received more packed red blood cell and fresh frozen plasma resuscitation during index laparotomy (both p<0.05). Despite greater physiologic derangement in the LP+QC group, there was no difference in total blood products required after index laparotomy until abdominal closure (LP vs LP+QC; p>0.05). After a median of 2days until abdominal closure in both groups, no difference in complications rates attributable to intra-abdominal packing (LP vs LP+QC) was detected. While the addition of QC to LP packing did not confer additional benefit to standard packing, there was no additional morbidity identified with its use. The surgeons at our institution now select augmented packing with QC for sicker patients, as we believe this may have additional advantage over standard LP packing. A randomized controlled trial is warranted to further evaluate the intra-abdominal use of advanced hemostatic agents, like QC, for both hemostasis and associated morbidity.
BACKGROUND: Use of transthoracic echocardiography (TTE) in documenting cardiac disorders is well ... more BACKGROUND: Use of transthoracic echocardiography (TTE) in documenting cardiac disorders is well accepted. This study reviews institutional experience with TTE in the clinical setting of pulmonary embolism (PE). STUDY DESIGN: Retrospective review of surgical ICU patients who underwent TTE within 72 hours of diagnosis of PE, from January 2005 to March 2007. Collected data included symptoms, clinical suspicion of PE, preexisting conditions, operative procedures, TTE findings, presence of deep venous thrombosis, and treatments used for PE. Preexisting TTEs, when available, were compared with those obtained after acute PE. TTEs subsequent to the first post-PE study were analyzed for change in severity of findings. RESULTS: Thirty-one patients (12 men, 19 women, mean age 66 years, APACHE II 18.1) were included. Twenty-two had high, and nine had moderate, clinical suspicion for PE. Radiographic diagnosis of PE was made by computed tomography (25 of 31) and by ventilation-perfusion scans (6 of 31). Twelve of 31 patients had extremity deep venous thrombosis by duplex ultrasonography. Tricuspid regurgitation was the most common TTE finding (28 of 31), followed by pulmonary hypertension (24), dilated right ventricle (23), right heart strain (19), and underfilled, hyperdynamic left ventricle (17). Seventeen patients had previous or "baseline" echocardiograms, and when compared with the post-PE TTE, all patients demonstrated worsening in at least one TTE finding. CONCLUSIONS: This study identified findings that can be used in prospective evaluation of TTE for suspected PE. The importance of baseline TTE has also been emphasized. Additional prospective evaluation of TTE in diagnosis of suspected PE in the ICU is warranted. (J Am Coll Surg 2008;206: 42-47.
Transthoracic echocardiography (TTE) is an established part of modern medical practice, and its u... more Transthoracic echocardiography (TTE) is an established part of modern medical practice, and its use in documenting cardiac disorders has long been recognized. Since the introduction of 2-dimensional TTE, the right-sided heart chambers have become amenable to fairly accurate analysis, enabling the evaluation of morphologic and functional abnormalities associated with many cardiopulmonary diseases, including pulmonary embolism (PE). The availability of small, portable echocardiographic units combined with an increasing number of intensive care specialists trained in echocardiography makes TTE an attractive modality for the diagnosis of PE in the intensive care unit (ICU). In the ICU setting, prompt decision-making and appropriate triage of critically ill patients can facilitate early institution of therapy for PE while awaiting patient stabilization and further definitive testing. Although several prior reviews incorporate TTE in the overall approach and clinical decision algorithms pertaining to the diagnosis and treatment of pulmonary embolism, no dedicated review exists that focuses purely on TTE. We attempt to fill that gap by reviewing the available literature pertaining to use of TTE in the diagnosis of suspected PE, and by better defining the use of TTE in the ICU setting. Emphasis is placed on the use of TTE as a clinical triage tool for suspected PE.
The philosophy of damage control surgery has developed tremendously over the past 10 years. It ha... more The philosophy of damage control surgery has developed tremendously over the past 10 years. It has expanded outside the original boundaries of the abdomen and has been applied to all aspects of trauma care, ranging from resuscitation to limb-threatening vascular injuries. In recent years, the US military has taken the concept to a new level by initiating a damage control approach at the point of injury and continuing it through a transcontinental health care system. This article highlights many recent advances in damage control surgery and discusses proper patient selection and the risks associated with this management strategy.
Journal of Health Education Research & Development, 2017
Figure 1: Combination of Combat Gauze and iTClamp to control hemorrhage in a penetrating neck inj... more Figure 1: Combination of Combat Gauze and iTClamp to control hemorrhage in a penetrating neck injury from a stab wound.
Military surgeons have gained familiarity and experience with mass casualty events (MCEs) as a ma... more Military surgeons have gained familiarity and experience with mass casualty events (MCEs) as a matter of routine over the course of the last two conflicts in Afghanistan and Iraq. Over the same period of time, civilian surgeons have increasingly faced complex MCEs on the home front. Our objective is to summarize and adapt these combat surgery lessons to enhance civilian surgeon preparedness for complex MCEs on the home front. The authors describe the unique lessons learned from combat surgery over the course of the wars in Afghanistan and Iraq and adapt these lessons to enhance civilian surgical readiness for a MCE on the home front. Military Damage Control Surgery (mDCS) combines the established concept of clinical DCS (cDCS) with key combat situational awareness factors that enable surgeons to optimally care for multiple, complex patients, from multiple simultaneous events, with limited resources. These additional considerations involve the surgeon's role of care within the de...
We present an unusual case of a single gunshot to the genitalia in which the bullet trajectory in... more We present an unusual case of a single gunshot to the genitalia in which the bullet trajectory injured the urethra, corpus cavernosum, and both testicles. All injuries were successfully repaired during initial exploration. Our report serves as a reminder to clinicians to have a high index of suspicion in this circumstance and consider immediate exploration of all the injured areas. We also demonstrate the use of a dartos fascia interposition flap to cover and separate the concomitant urethral and corporal sutures lines. Our dartos flap bolstered the urethral and cavernosal repairs and helped prevent postoperative corporourethral fistula formation.
The philosophy of damage control surgery has developed tremendously over the past 10 years. It ha... more The philosophy of damage control surgery has developed tremendously over the past 10 years. It has expanded outside the original boundaries of the abdomen and has been applied to all aspects of trauma care, ranging from resuscitation to limb-threatening vascular injuries. In recent years, the US military has taken the concept to a new level by initiating a damage control approach at the point of injury and continuing it through a transcontinental health care system. This article highlights many recent advances in damage control surgery and discusses proper patient selection and the risks associated with this management strategy.
Intra-abdominal packing with laparotomy pads (LP) is a common and rapid method for hemorrhage con... more Intra-abdominal packing with laparotomy pads (LP) is a common and rapid method for hemorrhage control in critically injured patients. Combat Gauze™ and Trauma Pads™ ([QC] Z-Medica QuikClot(®)) are kaolin impregnated hemostatic agents, that in addition to LP, may improve hemorrhage control. While QC packing has been effective in a swine liver injury model, QC remains unstudied for human intra-abdominal use. We hypothesized QC packing during damage control laparotomy (DCL) better controls hemorrhage than standard packing and is safe for intracorporeal use. A retrospective review (2011-2014) at a Level-I Trauma Center reviewed all patients who underwent DCL with intentionally retained packing. Clinical characteristics, intraoperative and postoperative parameters, and outcomes were compared with respect to packing (LP vs. LP+QC). All complications occurring within the patients' hospital stays were reviewed. A p≤0.05 was considered significant. 68 patients underwent DCL with packing; (LP n=40; LP+QC n=28). No difference in age, BMI, injury mechanism, ISS, or GCS was detected (Table 1, all p>0.05). LP+QC patients had a lower systolic blood pressure upon ED presentation and greater blood loss during index laparotomy than LP patients. LP+QC patients received more packed red blood cell and fresh frozen plasma resuscitation during index laparotomy (both p<0.05). Despite greater physiologic derangement in the LP+QC group, there was no difference in total blood products required after index laparotomy until abdominal closure (LP vs LP+QC; p>0.05). After a median of 2days until abdominal closure in both groups, no difference in complications rates attributable to intra-abdominal packing (LP vs LP+QC) was detected. While the addition of QC to LP packing did not confer additional benefit to standard packing, there was no additional morbidity identified with its use. The surgeons at our institution now select augmented packing with QC for sicker patients, as we believe this may have additional advantage over standard LP packing. A randomized controlled trial is warranted to further evaluate the intra-abdominal use of advanced hemostatic agents, like QC, for both hemostasis and associated morbidity.
BACKGROUND: Use of transthoracic echocardiography (TTE) in documenting cardiac disorders is well ... more BACKGROUND: Use of transthoracic echocardiography (TTE) in documenting cardiac disorders is well accepted. This study reviews institutional experience with TTE in the clinical setting of pulmonary embolism (PE). STUDY DESIGN: Retrospective review of surgical ICU patients who underwent TTE within 72 hours of diagnosis of PE, from January 2005 to March 2007. Collected data included symptoms, clinical suspicion of PE, preexisting conditions, operative procedures, TTE findings, presence of deep venous thrombosis, and treatments used for PE. Preexisting TTEs, when available, were compared with those obtained after acute PE. TTEs subsequent to the first post-PE study were analyzed for change in severity of findings. RESULTS: Thirty-one patients (12 men, 19 women, mean age 66 years, APACHE II 18.1) were included. Twenty-two had high, and nine had moderate, clinical suspicion for PE. Radiographic diagnosis of PE was made by computed tomography (25 of 31) and by ventilation-perfusion scans (6 of 31). Twelve of 31 patients had extremity deep venous thrombosis by duplex ultrasonography. Tricuspid regurgitation was the most common TTE finding (28 of 31), followed by pulmonary hypertension (24), dilated right ventricle (23), right heart strain (19), and underfilled, hyperdynamic left ventricle (17). Seventeen patients had previous or "baseline" echocardiograms, and when compared with the post-PE TTE, all patients demonstrated worsening in at least one TTE finding. CONCLUSIONS: This study identified findings that can be used in prospective evaluation of TTE for suspected PE. The importance of baseline TTE has also been emphasized. Additional prospective evaluation of TTE in diagnosis of suspected PE in the ICU is warranted. (J Am Coll Surg 2008;206: 42-47.
Transthoracic echocardiography (TTE) is an established part of modern medical practice, and its u... more Transthoracic echocardiography (TTE) is an established part of modern medical practice, and its use in documenting cardiac disorders has long been recognized. Since the introduction of 2-dimensional TTE, the right-sided heart chambers have become amenable to fairly accurate analysis, enabling the evaluation of morphologic and functional abnormalities associated with many cardiopulmonary diseases, including pulmonary embolism (PE). The availability of small, portable echocardiographic units combined with an increasing number of intensive care specialists trained in echocardiography makes TTE an attractive modality for the diagnosis of PE in the intensive care unit (ICU). In the ICU setting, prompt decision-making and appropriate triage of critically ill patients can facilitate early institution of therapy for PE while awaiting patient stabilization and further definitive testing. Although several prior reviews incorporate TTE in the overall approach and clinical decision algorithms pertaining to the diagnosis and treatment of pulmonary embolism, no dedicated review exists that focuses purely on TTE. We attempt to fill that gap by reviewing the available literature pertaining to use of TTE in the diagnosis of suspected PE, and by better defining the use of TTE in the ICU setting. Emphasis is placed on the use of TTE as a clinical triage tool for suspected PE.
The philosophy of damage control surgery has developed tremendously over the past 10 years. It ha... more The philosophy of damage control surgery has developed tremendously over the past 10 years. It has expanded outside the original boundaries of the abdomen and has been applied to all aspects of trauma care, ranging from resuscitation to limb-threatening vascular injuries. In recent years, the US military has taken the concept to a new level by initiating a damage control approach at the point of injury and continuing it through a transcontinental health care system. This article highlights many recent advances in damage control surgery and discusses proper patient selection and the risks associated with this management strategy.
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Papers by John Chovanes