Diagnoses and factors associated with medical evacuation and return to duty among nonmilitary personnel participating in military operations in Iraq and Afghanistan

Background

Nonmilitary personnel play an increasingly critical role in modern wars. Stark differences exist between the demographic characteristics, training and missions of military and nonmilitary members. We examined the differences in types of injury and rates of returning to duty among nonmilitary and military personnel participating in military operations in Iraq and Afghanistan.

Methods

We collected data for nonmilitary personnel medically evacuated from military operations in Iraq and Afghanistan between 2004 and 2007. We compared injury categories and return-to-duty rates in this group with previously published data for military personnel and identified factors associated with return to duty.

Results

Of the 2155 medically evacuated nonmilitary personnel, 74.7% did not return to duty. War-related injuries in this group accounted for 25.6% of the evacuations, the most common causes being combat-related injuries (55.4%) and musculoskeletal/spinal injuries (22.9%). Among individuals with non–war-related injuries, musculoskeletal injuries accounted for 17.8% of evacuations. Diagnoses associated with the highest return-to-duty rates in the group of nonmilitary personnel were psychiatric diagnoses (15.6%) among those with war-related injuries and noncardiac chest or abdominal pain (44.0%) among those with non–war-related injuries. Compared with military personnel, nonmilitary personnel with war-related injuries were less likely to return to duty (4.4% v. 5.9%, p = 0.001) but more likely to return to duty after non–war-related injuries (32.5% v. 30.7%, p = 0.001).

Interpretation

Compared with military personnel, nonmilitary personnel were more likely to be evacuated with non–war-related injuries but more likely to return to duty after such injuries. For evacuations because of war-related injuries, this trend was reversed.In modern warfare, injuries sustained in combat have never been the leading source of attrition among soldiers. In World War I, World War II and the Korean War, respiratory and infectious diseases were the top reasons for hospital admissions among service members. By the Vietnam Conflict, non-battle injuries had supplanted respiratory illness as the leading cause of hospital admissions and have remained the leading cause ever since.^1,2The principal causes for medical evacuation of military personnel from US operations in Iraq and Afghanistan were recently described in a large four-year epidemiologic study.³ In descending order, the leading reasons were musculoskeletal conditions, combat-related injuries, neurologic symptoms and psychiatric disorders; the last category surpassed combat-related injuries as the number two reason in the latter half of both engagements. However, nonmilitary personnel were not included in that study. Over the past three years, nonmilitary members, including US Department of Defense civilians, private contractors and diplomats, have comprised about 50% of personnel serving in Iraq and about two-thirds of those serving in Afghanistan.^4,5Several reasons may explain why the types of injury and the return-to-duty rates differ between military and nonmilitary personnel. First, the motivations for overseas deployment might differ between the groups. Whereas some civilian personnel (e.g., diplomats) may be assigned to positions in Iraq and Afghanistan, virtually all private contractors volunteer for their jobs. In contrast, most military members have little choice in their deployment. Second, military and nonmilitary members assigned to war zones have different occupational specialties, living conditions and regulations to which they must adhere. Especially for junior military personnel, jobs tend to be more dangerous, living environments more austere and regulations more stringent. Finally, unlike military personnel, who are paid regardless of deployment status, most contractors’ pay is contingent upon continued employment in theatres of operation. In addition, nonmilitary personnel are generally compensated with higher salaries than service members in comparable occupational specialties.In civilian cohorts, many of these factors have been shown to influence return-to-work rates in a variety of contexts. Studies of the effect of financial compensation on work status after injury have generally shown a direct correlation between return-to-work rates and higher income levels.^6,7 Similar associations have also been found between return-to-work rates and job satisfaction and coping mechanisms, factors that may be influenced by work conditions and perceived control over one’s environment.^8–10The objectives of our study were threefold: to ascertain whether the reasons for medical evacuation from military operations differed between military and nonmilitary personnel; to determine whether return-to-duty rates differed between the two groups; and to identify factors that influence return-to-duty rates among nonmilitary members.     

The epidemiology of blast lung injury during recent military conflicts: a retrospective database review of cases presenting to deployed military hospitals, 2003-2009

Blast injuries are becoming increasingly common in military conflicts as the nature of combat changes from conventional to asymmetrical warfare and counter-insurgency. This article describes a retrospective database review of cases from the UK joint theatre trauma registry from 2003 to 2009, containing details of over 3000 patients, mainly injured in Iraq and Afghanistan. During this period, 1678 patients were injured by explosion of whom 113 had evidence of blast lung injury. Of the 50 patients who survived to reach a medical facility, 80 per cent required ventilatory support. Injuries caused by explosion are increasing when compared with those caused by other mechanisms, and blast lung represents a significant clinical problem in a deployed military setting. Management of these patients should be optimized from point of wounding to definitive care.     

Viral Hepatitis: Problems of Incidence and Control in Military Personnel

(A) Hepatitis B virus (HBV) is now the major cause of infectious viral hepatitis in U.S. military personnel and probably also in the civilian population over 15 years of age. (B) The incidence of icteric, viral hepatitis is much higher in U.S. military personnel than in comparable age groups in the civilian population. The 17-to 20-year-old enlisted men show the highest rates. (C) In parts of the world (e.g., U.S.A., Germany) where most of the inapparent infection is caused by the adw subtype of HBV, most of the acute clinical disease is caused by the ayw subtype. In the U.S.A. and Germany, 95% or more of HB_s Ag isolates from U.S. military personnel with acute hepatitis is ayw. (D) It may be many years before one can expect to have sufficient data for a decision as to the possible availability of an effective HBV vaccine. Accordingly, a decision is urgently needed regarding either the immediate use of the best practically available hepatitis immune gamma globulin, that can be prepared by modern techniques, for the prevention of hepatitis in U.S. military personnel or postponement of such use until an adequate and properly controlled trial can be carried out in active duty military personnel in an area of high incidence.     

Retrospective Cohort Analysis of Chest Injury Characteristics and Concurrent Injuries in Patients Admitted to Hospital in the Wenchuan and Lushan Earthquakes in Sichuan,China

Background

The aim of this study was to compare retrospectively the characteristics of chest injuries and frequencies of other, concurrent injuries in patients after earthquakes of different seismic intensity.

Methods

We compared the cause, type, and body location of chest injuries as well as the frequencies of other, concurrent injuries in patients admitted to our hospital after the Wenchuan and Lushan earthquakes in Sichuan, China. We explored possible relationships between seismic intensity and the causes and types of injuries, and we assessed the ability of the Injury Severity Score, New Injury Severity Score, and Chest Injury Index to predict respiratory failure in chest injury patients.

Results

The incidence of chest injuries was 9.9% in the stronger Wenchuan earthquake and 22.2% in the less intensive Lushan earthquake. The most frequent cause of chest injuries in both earthquakes was being accidentally struck. Injuries due to falls were less prevalent in the stronger Wenchuan earthquake, while injuries due to burial were more prevalent. The distribution of types of chest injury did not vary significantly between the two earthquakes, with rib fractures and pulmonary contusions the most frequent types. Spinal and head injuries concurrent with chest injuries were more prevalent in the less violent Lushan earthquake. All three trauma scoring systems showed poor ability to predict respiratory failure in patients with earthquake-related chest injuries.

Conclusions

Previous studies may have underestimated the incidence of chest injury in violent earthquakes. The distributions of types of chest injury did not differ between these two earthquakes of different seismic intensity. Earthquake severity and interval between rescue and treatment may influence the prevalence and types of injuries that co-occur with the chest injury. Trauma evaluation scores on their own are inadequate predictors of respiratory failure in patients with earthquake-related chest injuries.     

医学干预对武警某部军事训练伤的影响

目的：探讨医学干预对南方某武警部队战士训练伤发生情况的影响。方法：随机将南方某武警部队的一大队,按照干预措施施训,作为干预组;另一大队按照以往常规方法进行训练,不加任何干预措施,作为对照组。观察6个月内的两大队（干预组和对照组）的训练伤发生情况。结果：骨关节和软组织损伤为常见。实施医疗干预可有效降低军事训练伤的发生率（17．95％〈29．18％）,其主要效果在于大幅度降低了骨关节损伤的发生率（6．53％〈10.31％）和软组织损伤的发生率（5．59％〈9．92％）。结论：实施医学干预可有效降低我武警部队军事训练伤的发生率。     

Occupational injuries,illness affect 1 in 13 Canadians.

One in every 13 Canadian workers has experienced a work-related illness or injury, federal data indicate. Occupational-health clinics in Ontario report a growing number of cases of sick-building syndrome, repetitive-strain injury, asthma and chemical exposure, as well as injuries related to the use of construction equipment. In the past the medical profession assumed that men incurred most work-related injuries, but today, says an occupational-health specialist, "work-related illness and injuries are just as likely to happen to women or to white-collar professionals."     

A comparison of the characteristics of injuries between obese and non-obese inpatients

Objective: The objective was to compare characteristics of injuries between a sample of U.S. obese and non‐obese inpatients. Methods: Discharge records from the 2002 Nationwide Inpatient Sample of the Healthcare Cost and Use Project were analyzed to identify records including an International Classification of Diseases, Ninth Revision, Clinical Modification injury diagnosis code (ICD‐9‐CM). Records with an exclusive obesity comorbidity were isolated, and proportionate injury ratios with 95% confidence intervals were calculated to compare the demographics and injury characteristics between obese and non‐obese persons hospitalized for an injury. Results: A total of 160,707 discharge records were analyzed. Type and cause of injury that required hospitalization were significantly associated with obesity status (p < 0.001). Sprains, strains, and dislocations represented significantly higher proportions of injury‐related hospitalizations among obese persons compared with non‐obese persons. By cause of injury, injuries among obese persons were more frequently due to falls, overexertion, and poisonings compared with non‐obese persons. Discussion: Injuries that required hospitalization among obese persons may have injury characteristics distinct from injuries among non‐obese persons.     

Skin Injuries on the Body and Thigh of Dairy Cows: Associations with Season,Claw Health,Disease Treatment,and other Cow Characteristics

An epidemiological study was conducted in 18 dairy herds with the objective to characterize those groups of cows where skin injuries to the body and thighs occurred most frequently. Data were analyzed with multivariable logistic regression. The epidemiologic patterns were different in first and later lactations. In first lactation some degree of injury occurred among 7.7% of 1793 cows. For most cows occurrence of sole ulcer was positively associated with injury while occurrence of heel horn erosion was negatively associated with injury. The association between injury and body weight differed depending on month of calving (significant interaction). Injuries occurred most frequently among high yielding cows. Severe reproductive, metabolic, and/or infectious diseases were associated with injuries. In later lactations some degree of injury occurred among 13.4% of 832 cows in lactations 2 to 9 where severity of injury increased with lactation number. Injuries occurred least frequently at examinations made in the January to March. They occurred most frequently among cows with sole ulcers. Calving in March through October was associated with injuries especially if the cows were treated for limb disorders. Most cases of injuries occurred early or late in lactation or among high or very low yielding cows in lactations 2 to 9.     

Shiftwork and Industrial Injuries at A Chemical Plant in Southeast Texas

-A historical retrospective study of 242 shiftworker (SW) and 224 non-SW (NSW) injuries at a chemical manufacturing plant in southeast Texas (U.S.A.) was performed. Data were collected on injuries that occurred between 1 January 1982 and 31 December 1985. The SW schedule comprised an 8-hr, 7-day backward rotation program while the dayworker schedule consisted of a typical U.S.A. 40-hr work week. Injury records were matched against payroll/attendance records to substantiate the probability of isolating possible effects of the shiftwork rotation schedule on the rates, distribution and severity of injuries. Injuries in the SW sample were compared to those in the non-SW sample. The work responsibilities of dayworkers were not exactly the same as those of shiftworkers. However, the job responsibilities for males and females within the dayworker and shiftworker groups were equivalent. Overall injury incidence rates were not significantly different between SWs and non-SWs, although female SWs had significantly higher incidence rates than did male SWs and both male and female dayworkers. The occurrence of injuries, however, was not equally distributed during the day shift and the night shift, but was equally distributed during the evening shift and for non-SWs, suggesting that certain, yet to be determined, factors were affecting the distribution of injuries during the day and night shift. However, the average number of injuries was two-three times higher during the First four days of the day and night shift, yet were not elevated during the evening shift.     

Diagnosis and management of injuries from dangerous marine life

Injuries from marine life encompass a wide spectrum, from mild stings to severe bites. Fortunately most of the injuries are mild, although some may be significant, resulting in death. Most of these injuries can be treated by family physicians with a knowledge of the cause of the pathology. Over the years, there have been many treatment options. Some have actually caused an increase in severity. An important rule in treating these injuries is to inactivate the venom, treat the local reaction or injury, and treat the systemic sequelae. Jellyfish stings are the most common type of marine injury. The tentacles possess nematocysts, which are stinging units that are inactivated by the application of vinegar. Sea urchin and stingray injuries require the removal of the imbedded spines after the wound is soaked in hot water. Coral, sea bathers eruption, and swimmer's itch require thorough scrubbing and irrigation. Sea snakes, cone shells, and venomous fish possess a neurotoxin that requires close monitoring in the event of cardiopulmonary collapse. All of these injuries require tetanus status monitoring and consideration of coverage for infectious sequelae.     

Burn injuries inflicted on children or the elderly: a framework for clinical and forensic assessment

LEARNING OBJECTIVES: After studying this article, the participant should be able to: 1. Understand the difference between battery and assault in U.S. law and the concepts of the phrase "child abuse" and "elder abuse." 2. Understand that state statutes vary and can define abuse narrowly or with great specificity, and that either definition has inherent problems for physicians treating victims of abuse and neglect. 3. Know where to find the state-specific legal criteria for child or elder abuse and neglect, along with the corresponding standards for mandatory reporting and physician accountability. 4. Understand the relevant law regarding physician-patient privilege and the repercussions of incorrect but good faith reporting and of failing to report suspected abuse or neglect of children or the elderly. 5. Understand that there are no pathognomic signs for inflicted burn injury. 6. Clinically assess burned pediatric or elderly patients within a framework that will minimize the risk of missing or inappropriately suspecting injuries that stem from abuse or neglect. SUMMARY: This article deals with burns inflicted on children and the elderly, two particularly vulnerable societal groups. Though inflicted burning is a relatively rare method of inflicting physical abuse, failure to diagnose it has far-reaching ramifications. These injuries pose both medical and forensic problems for physicians, along with unique ethical dilemmas. This article is a collaboration between surgeons and lawyers providing a holistic, workable approach to the management of inflicted burn injury. The authors first describe the legal considerations that must be appreciated by U.S. physicians, then they suggest a rational and balanced clinical approach to the assessment of burn injuries that may have been inflicted intentionally or negligently on children and the elderly.     

Balance index score as a predictive factor for lower sports results or anterior cruciate ligament knee injuries in Croatian female athletes--preliminary study

Female athletes participating in high-risk sports suffer anterior cruciate ligament (ACL) knee injury at a 4- to 6-fold greater rate than do male athletes. ACL injuries result either from contact mechanisms or from certain unexplained non-contact mechanisms occurring during daily professional sports activities. The occurrence of non-contact injuries points to the existence of certain factors intrinsic to the knee that can lead to ACL rupture. When knee joint movement overcomes the static and the dynamic constraint systems, non-contact ACL injury may occur. Certain recent results suggest that balance and neuromuscular control play a central role in knee joint stability, protection and prevention of ACL injuries. The purpose of this study is to evaluate balance neuromuscular skills in healthy Croatian female athletes by measuring their balance index score, as well as to estimate a possible correlation between their balance index score and balance effectiveness. This study is conducted in an effort to reduce the risk of future injuries and thus prevent female athletes from withdrawing from sports prematurely. We analysed fifty-two female athletes in the high-risk sports of handball and volleyball, measuring for their static and dynamic balance index scores, using the Sport KAT 2000 testing system. This method may be used to monitor balance and coordination systems and may help to develop simpler measurements of neuromuscular control, which can be used to estimate risk predictors in athletes who withdraw from sports due to lower sports results or ruptured anterior cruciate ligament and to direct female athletes to more effective, targeted preventive interventions. The tested Croatian female athletes with lower sports results and ACL knee injury incurred after the testing were found to have a higher balance index score compared to healthy athletes. We therefore suggest that a higher balance index score can be used as an effective risk predictor for lower sports results and lesser sports motivation, anterior cruciate ligament injury and the ultimate decision to withdraw from active participation in sports. If the balance testing results prove to be effective in predicting the occurrence of ligament injuries during future sports activities, we suggest that prophylactic training programs be introduced during athlete training, since the prevention of an initial injury will be more effective than prevention of injury recurrence.     

Squash ball to eye ball: the likelihood of squash players incurring an eye injury.

The records of the 118 patients treated as Southampton Eye Hospital during 1978-9 for injuries incurred while playing squash, badminton, tennis, table tennis, cricket, and football show that for squash the main cause of eye injury was the player being hit by the ball. Severe eye injuries--those requiring treatment as an inpatient--were rare but much more frequent than such injuries in other sports. Less serious injuries--those requiring treatment as an outpatient--were also rare, with a frequency comparable with that of similar injuries in football and badminton. Squash players are most unlikely to incur an eye injury, but should this occur it has far-reaching consequences both in the short and the long term. Each individual player must weigh these chances and consequences against the possible inconvenience of using some form of eye protection.     

Getting past the accident: explosive devices, limb loss, and refashioning a life in a military medical center

I describe the refashioning of a sense of self and identity of a junior officer in the U.S. Army who was injured in Iraq. Ethnographic data for this article were collected between July 2006 and January 2008. The setting for this article is the U.S. Armed Forces Amputee Patient Care Program at Walter Reed Army Medical Center. Two models of rehabilitation are contrasted in the rehabilitation program. The first focuses on the refashioning of identity through a sports model of rehabilitation emphasizing physical functioning. The second approaches rehabilitation by emphasizing individual interests and the concern of a person who has a future life to develop. I conclude by arguing that understanding the process of rehabilitation from traumatic injury would benefit from a perspective that melds multiple dimensions, taking into account both the physical body and the social world that patients have inhabited and will inhabit.     

The effect of damage to the lateral collateral ligaments on the mechanical characteristics of the ankle joint--an in-vitro study

Injuries to the lateral collateral ligaments of the ankle joint are among the most frequently occurring injuries at the lower limb. The present study was conducted for the purpose of establishing the basis for the development of a quantitative diagnostic procedure for such injuries. To achieve this goal, the effect of four types of ligament injuries on the three-dimensional mechanical characteristics of the ankle were investigated. These types of injuries consisted of: 1) isolated tear of the anterior talofibular ligament; 2) isolated tear of the calcaneofibular ligament; 3) isolated tear of the posterior talofibular ligament; and 4) combined tear of both the anterior talofibular ligament and the calcaneofibular ligament. The experiments were conducted on 31 amputated lower limbs and consisted of comparing the three-dimensional load-displacement and flexibility characteristics of the ankle joint prior to and following sectioning of selected ligaments. The experimental and analytical procedures used to derive these characteristics was developed previously by the authors. From the results of this study it was concluded that the three-dimensional flexibility characteristics of the ankle joint are strongly influenced by damage to the lateral collateral ligaments. Furthermore, it was found that each type of ligament injury produced unique and identifiably changes in the flexibility characteristics of the ankle. These unique changes, which are described in detail in this paper, can be used to discriminate between the different types of ligament injuries. Consequently, it was concluded that it is feasible to develop a quantitative diagnostic procedure for ankle ligament injuries based on the effect of the injury on the flexibility characteristics of the ankle.     

Injury response checkpoint and developmental timing in insects

In insects, localized tissue injury often leads to global (organism-wide) delays in development and retarded metamorphosis. In Drosophila, for example, injuries to the larval imaginal discs can retard pupariation and prolong metamorphosis. Injuries induced by treatments such as radiation, mechanical damage and induction of localized cell death can trigger similar delays. In most cases, the duration of the developmental delay appears to be correlated with the extent of damage, but the effect is also sensitive to the developmental stage of the treated animal. The proximate cause of the delays is likely a disruption of the ecdysone signaling pathway, but the intermediate steps leading from tissue injury and/or regeneration to that disruption remain unknown. Here, we review the evidence for injury-induced developmental delays, and for a checkpoint or checkpoints associated with the temporal progression of development and the on-going efforts to define the mechanisms involved.     

The injured lung: clinical issues and experimental models

Exposure of military and civilian populations to inhaled toxic chemicals can take place as a result of deliberate release (warfare, terrorism) or following accidental releases from industrial concerns or transported chemicals. Exposure to inhaled toxic chemicals can result in an acute lung injury, and in severe cases acute respiratory distress syndrome, for which there is currently no specific medical therapy, treatment remaining largely supportive. This treatment often requires intensive care facilities that may become overwhelmed in mass casualty events and may be of limited benefit in severe cases. There remains, therefore, a need for evidence-based treatment to inform both military and civilian medical response teams on the most appropriate treatment for chemically induced lung injury. This article reviews data used to derive potential clinical management strategies for chemically induced lung injury.     

Injury response checkpoint and developmental timing in insects

In insects, localized tissue injury often leads to global (organism-wide) delays in development and retarded metamorphosis. In Drosophila, for example, injuries to the larval imaginal discs can retard pupariation and prolong metamorphosis. Injuries induced by treatments such as radiation, mechanical damage and induction of localized cell death can trigger similar delays. In most cases, the duration of the developmental delay appears to be correlated with the extent of damage, but the effect is also sensitive to the developmental stage of the treated animal. The proximate cause of the delays is likely a disruption of the ecdysone signaling pathway, but the intermediate steps leading from tissue injury and/or regeneration to that disruption remain unknown. Here, we review the evidence for injury-induced developmental delays, and for a checkpoint or checkpoints associated with the temporal progression of development and the on-going efforts to define the mechanisms involved.     

入伍新训中膝关节损伤的特点与防治研究

目的：通过对某部新入伍官兵训练中膝关节损伤发生原因、特点进行流行性病学调查和分析,为合理训练,预防损伤发生和 治疗相关伤病提供指导依据。方法：对某部2013 年度450 名新入伍官兵的训练伤发病情况进行统计分析,重点分析膝关节损伤 发生率、伤病类型和致伤原因,并对其严重者进行关节镜治疗,观察和分析术后随访效果。结果：某部新兵的训练伤发生率为 20.0%。以关节急性扭伤最为多见,占81.1%。其中膝关节损伤共发生32 例,占训练伤发病率为7.1%,占训练伤发病率43.8%,其 中膝关节周围肌肉损伤20 例、交叉韧带损伤1 例、半月板损伤9 例、侧副韧带损伤2 例。致伤率最高的前3 位科目是5000 米负 重跑、跨越障碍训练、格斗训练,共27 例,占膝关节训练伤总数的84.4%。所有受伤患者中,12 例行手术治疗,20 例给予石膏、支具 固定、休息等保守治疗。经随访所有患者均得到较好的功能恢复。结论：对于新兵膝关节训练伤预防工作非常重要,避免致残;关 节镜手术技术的进步对于膝关节军事训练伤治疗有良好的效果。     

Shaping the military wound: issues surrounding the reconstruction of injured servicemen at the Royal Centre for Defence Medicine

The conflict in Afghanistan has produced injuries similar to those produced from military conflicts for generations. What distinguishes the modern casualty of the conflict in Afghanistan from those of other conflicts is the effectiveness of modern field medical care that has led to individuals surviving with injuries, which would have been immediately fatal even a few years ago. These patients present several challenges to the reconstructive surgeon. These injured individuals present early challenges of massive soft-tissue trauma, unstable physiology, complex bony and soft-tissue defects, unusual infections, limited reconstructive donor sites, peripheral nerve injuries and traumatic amputations. Late challenges to rehabilitation include the development of heterotopic ossification in amputation stumps. This paper outlines the approach taken by the reconstructive team at the Royal Centre for Defence Medicine in managing these most difficult of reconstructive challenges.