Trauma-induced coagulopathy and treatment in Kosovo

Military Medicine, Apr 2001 by O'Sullivan, Joseph

The 67th Combat Support Hospital at Camp Bondsteel, Kosovo, treated victims of trauma on an almost daily basis at the beginning of U.S. peacekeeping efforts in the region. Military health care personnel must respond quickly and efficiently when confronted with patient wounds resulting in massive blood losses. The limited medical resources of a field hospital often complicate efforts to treat the most severe injuries. One such case involved a young farmer riddled with gunshot wounds. Early volume/blood resuscitation before, during, and after surgery led to a massive blood coagulopathy. This case study describes the actions the physicians and nurses initiated to save this victim of violence. The subsequent discussion delineates methods to reduce intraoperative blood losses, blood transfusion alternatives, and technological advances in trauma resuscitation.

Introduction

All at the 67th Combat Support Hospital (CSH) called him "Mad Max" because of his striking resemblance to the main character (Mel Gibson) in the Road Warrior films. This 33-yearold farmer sustained gunshot wounds to the chest, abdomen, ear, and hand. The members of Trauma Team One of the 67th CSH assigned to Task Force Med Falcon, Camp Bondsteel, Kosovo, were amazed at his initial presentation to the emergency medical treatment area. He had lost huge quantities of blood before arrival but he was conscious, oriented, and verbalizing, and he did not appear to be in acute distress.

This type of trauma is an everyday occurrence in major metropolitan areas throughout the United States. Urban health care providers with state-of-the-art equipment are involved in trauma resuscitation through the preoperative, perioperative, and postoperative phases. This case is unique because it occurred, without advance blood bank capabilities, in the austere environment of Kosovo.

NATO air strikes and ethnic cleansing had ended not long before the arrival of the 67th CSH in Kosovo. The trauma continued, however, even as peacekeeping forces entered the area. Vengeful members of the local population used every means possible to inflict suffering on one another. Gunshot wounds, severe beatings, stabbings, and the use of land mines, grenades, bombs, and mortar were the preferred means of carnage. From June 1999 to April 2000, the 67th CSH, as part of the 30th Medical Brigade, treated almost all of the trauma that occurred in the U.S. sector of this corner of the Balkans.

As the Yugoslavian Army retreated in June 1999, it became apparent that the civilian medical system in the region had been left crippled. The exiting army took a majority of Kosovo's medical equipment. Compounding these physical problems was the lack of trained, experienced personnel remaining in the region. This was attributable to the fact that from 1989 to 1999, the Albanian Kosovars had been strongly discouraged from seeking any kind of medical training and/or employment. In response to these losses, the United Nations, the U.S. Department of Defense, and international volunteer organizations were and are supporting the acquisition of medical supplies as well as the development of a local civilian medical staff. The goal remains to revitalize the indigenous hospitals so that they will have the ability to provide capable and reliable medical care to the region's population.

Case Study

The day before Mad Max was attacked, a skirmish near the border of Kosovo between Macedonian soldiers and an unknown militia group had resulted in Macedonian casualties. According to follow-up investigations, Max was unknowingly tending his livestock in this volatile area and was guilty of being in the wrong place at the wrong time. He fell victim to a retaliatory assault by the embittered Macedonian soldiers.

Mad Max's case was an outstanding example of the efficiency of the 67th CSH. He arrived via helicopter and was rushed to the 67th's emergency medical treatment area. The primary trauma assessment determined that he had suffered five gunshot wounds: one to the ear, one to the abdomen, one to the hand, and two to the thorax. One of the thoracic injuries resulted in a massive left hemothorax/pneumothorax.

The assessment process continued. Prehospital blood losses were estimated at 2,000 mL. Upon admission, lactated Ringer's solution was infused rapidly through a large-bore intravenous tube. Max's initial hematocrit was 21.6%, with a platelet count of 136,000/(mu)L. Preliminary chest and abdominal radiographs were taken, resulting in the insertion of a left chest tube. An additional 1,600 mL of poorly clotting blood poured from this thoracostomy, and the decision was made to proceed expediently to a surgical setting. Estimated blood losses were now greater than 3,500 mL (Table I).

Once in the operating room, an exploratory thoracotomy was performed. Upon examination of the chest cavity, 1,000 mL of additional blood was expressed despite the accurate placement of the left chest tube. Brisk parenchymal bleeding was identified, necessitating stapled wedge resections of the left lobe and lingula. With apparent stabilization of the chest bleed, surgery progressed with a midline celiotomy. A perforated jejunum was discovered that resulted in its resection and a stapled, functional end-to-end anastomosis. Surgery concluded with repair of the still bleeding left ear and incision and irrigation of the right hand.