Trauma in Conflict: Wartime Happenings - Essay Example

? Trauma in Conflict According to FitzPatrick and Hartsock, trauma nursing, as a profession, has seen significant changes in the past few decades. Looking at the past, one can see that scores of talented, multi-faceted and dedicated nurses have helped to transcend the profession to the level it is today (Flint et al. 2007). Trauma nursing is closely linked to wartime happenings. From the time of Florence Nightingale, who is regarded as the founder of the profession of nursing, to modern day conflicts, nursing has played an imperative role in the delivery of care to the injured. FitzPatrick and Hartsock observe that throughout history military nurses have stood with physicians and assisted them in carrying out emergency medical interventions. Nurses have served as care providers in many regions of conflict such as Somalia, Croatia, Desert Storm and recently in Iraq and Afghanistan (Flint et al. 2007). The evolution in trauma nursing has opened up new roles for nursing such as injury prevention, data management and the use of new technologies for dealing with trauma injuries. One such medical intervention is the military tourniquet. The military tourniquet is used for supporting poly-trauma patients. The Combat Application Tourniquet (CAT) is a common military tourniquet used by military nurses. This essay will discuss the potential dilemmas arising out of the use of tourniquets, particularly CAT. The issues will be considered in the context of trauma conflict situations. Patients in military operations in Afghanistan will be considered too. According to Beachley, military nurses have contributed significantly towards the effective management and care of severe injuries. Amongst such measures are triage rapid evacuation, stabilization and surgical procedures (Flint et al. 2007). It is necessary for military nurses to master the interventions that are required for dealing with blast and gunshot victims. The frequency of such injuries has increased significantly over the past few decades owing largely to the fact that they are not confined to the military anymore. The proliferation of weaponry and its use out of the military has made the civilian population yet more susceptible to trauma. The role of nurses has become increasingly important in managing trauma ever since the Crimean War. Effective management of penetrating trauma, which has occurred in wars and military operations, requires the nurse to be apt at the working knowledge of the interventions (O'Shea 2005). A critical aspect of emergency care of trauma victims is gaining control of and stopping haemorrhage. It has been reported that taking measures to prevent deaths occurring from blood loss from the limbs are the most vital means of saving lives. Haemorrhage has been cited as the most important reason for death after trauma (Lerner & Soudry 2011). In the protocol used for managing a trauma patient, circulation is now being given increased importance. The treatment procedure has changed from ABC to ABC to highlight the significance of controlling blood loss (Brodie et al. 2007). These changes are also being introduced into training programs for military trauma nurses. A device used in such cases is tourniquet. Tourniquets are devices which can reduce arterial and venous flow by compressing it. In the UK, tourniquets are a part of the personal first aid kits of soldiers going to the field. They are encouraged to make use of tourniquets when faced with excessive amounts of blood loss. Despite the effectiveness of tourniquets on stopping blood loss, their use in conflict situations is subject to debate. There are strong arguments both favouring and discouraging the use of tourniquets in critical situations in the war zone. The arguments against the use of tourniquets are that they lead to the unnecessary loss and amputation of limbs. This highlights the gravity of the issue and the medicolegal aspects surrounding their use. Tourniquets are used for medical or tactical reasons. They help to deliver care-under-fire, which pertains to the management of trauma cases while they are being evacuated and brought out of critical, life-threatening situations. When the patients are in relatively safer surroundings, the tactical tourniquet is taken off while the medical tourniquet is made loose. The wound is then analyzed and further bleeding from the wound is prevented by using direct pressure or a pressure dressing; this refers to tactical field care. Tourniquets were earlier home-made but the ones used by the British army are not home-made. These tourniquets, referred to as the Combat Application Tourniquet, are subject to a lot of controversy arising out of their use in indicative and contra-indicative situations and their effectiveness in saving lives (Parker & Clasper 2007). In the Afghan War, there was an increased use of tourniquets amongst the soldiers. For instance, every soldier of the Canadian Forces was given knowledge regarding the provision of combat-casualty care and each one of them carried tourniquets (National Defence and the Canadian Forces 2008). It has been seen that tourniquet use for preventing blood loss has increased greatly after it was introduced as a component of the personal first aid kit of soldiers. Research documents that ever since the introduction of Combat Application Tourniquet in the first aid kits, its use has incremented dramatically (Brodie et al. 2007). To some degree, this depicts the ease of use of the device for preventing bleeding from open wounds. Learning from lessons from history, the US made hurried endeavours to provide every soldier in Iraq and Afghanistan with a tourniquet, with data indicating the unnecessary death of soldiers resulting from not using tourniquets (Little 2005). Currently, soldiers are given adequate training regarding casualty care. Before they are sent out to the war zone, they are given pre-deployment instructions about the indications and contra-indications of tourniquets. Moreover they are also taught how to carry out a treatment paradigm for trauma patients, incorporating the proper use of tourniquets to stop haemorrhage. Although the pre-deployment training follows a strict regimen of planned and monitored guidelines, it is seen that suggestions from external sources can impact the use of the device. These suggestions maybe misleading and incorrect; for example ‘the tourniquet should only be used over one bone’. In such cases, there is a chance that soldiers do not follow the prescribed measures and cause unintentional injury to the patient. The argument that is presented in favour of the use of tourniquets is that they can be an essential means of averting death and morbidity, given that they are put into place by knowledgeable and expert nurses or physicians. Tourniquets have been in use since the times of the Roman and over the time have become light and easy to use. It is documented in literature that tourniquets are a reliable way of stopping bleeding. In the Vietnam War, every tenth trauma patient who had penetrating wounds died due to compressible haemorrhage. This serves to highlight that the use of tourniquet could have saved the lives of these patients. In the military setting, tourniquets are indicated at two particular instances. Firstly, tourniquets can be used when the trauma patient is under enemy fire and direct pressure cannot be applied to stop the bleeding. At that instant, it is necessary to prevent blood loss by using tourniquets before the victim can be evacuated to safety. The second indication for the use of tourniquets is when bleeding does not stop despite putting pressure on pressure points. In this case, it is seen that tourniquets can stop haemorrhage quicker than direct pressure, thereby stopping blood loss till the required dressings can be accessed. If there is only one nurse or doctor available to stop bleeding, tourniquet use is even more productive and handy. The strategic location at which the tourniquet is placed allows attendants to deal with severe injuries first. Also, by application of tourniquets, the nurse or the physician has both his/her hands free, and can use them easily to apply the dressings. In a comparative study on commercial tourniquets available in the market, it was seen that the CAT had the most ideal combination of compactness and lightweight and did not cause much pain. Moreover it was quickly able to stop bleeding as measured by Doppler (Schwartz? McManus & Swienton 2007). Correct application of the tourniquet is necessary in order to prevent complications. It has been stated in literature that the use of tourniquets prevented 7% of combat deaths of US soldiers and army staff in the conflict zones of Somalia and Vietnam (Walters & Mabry 2005). Hilary Jaeger, one of NATO’s accomplished doctors in Afghanistan, reports that the tourniquet was able to save the lives of thousands of soldiers who had become victims of IEDs. Countering the argument levelled against tourniquet use, Jaeger observes that “in Afghanistan, IEDs have been so powerful that whether a soldier was on foot or in an armoured vehicle, the instant of the explosion, amputation had usually already taken place” (Fisher 2010). In such cases, tourniquets have been indicated to treat trauma patients when pressure, elevation or dressing does not stop bleeding and the patient is in a life-threatening position (Sheridan 2004). When analyzing the statistics of the war in Afghanistan, it is seen that there was a marked increase in US combat casualties in 2010. This was attributed to greater deployment of troops in the region. However, the survival rates of wounded soldiers were seen to have fallen. Chivers (2011) observes that this was primarily due to quicker access to medevac helicopters and the widespread use of tourniquets in life-threatening situations. More than 400,000 tourniquets have been deployed in the conflict zones of Iraq and Afghanistan (Beekley 2008). Working in the Leatherneck camp in Afghanistan, Solano (2011) reports that the marines and sailors effectively used the tourniquet to save trauma patients in combat situations; the tourniquet has 100% effectiveness and can be very useful in stopping haemorrhage. A tourniquet can be applied for a maximum of two hours without causing morbidity. However, if the tourniquet is left in place for more than 6 hours, it greatly elevates the chances of limb amputation. A tourniquet applied for more than 2 but less than 6 hours can also cause complications; however the progression of such complications is influenced by a number of factors. The recommended application of tourniquet is 1 to 2 inches proximal to the site of haemorrhage. After application, the wound is inspected and the required dressing is done. Then the tourniquet can be slackened to check if there is any further bleeding (Schwartz? McManus & Swienton 2007). If the tourniquet is not applied properly for the right duration of time, it can cause complications such as compartment syndromes. Such was the case in a conflict situation where the surgeon applied the tourniquet on the trouser which had a book in its pocket. Another complication that had been seen due to application of tourniquet is ulna nerve palsy. This occurred in a patient who had widespread soft tissue injury due to a ballistic wound (Brodie et al. 2007). Hamlin, Richardson-Tench and Davies (2008) contend that tourniquet use poses a risk to the patient. It not only makes the limb tissue ischemic but also puts strain on the soft tissue. This can lead to soft tissue injury, nerve injury, post-tourniquet syndrome, digital necrosis, pressure sores, toxic reactions, and pulmonary embolism. In a study conducted by Clasper, Brown and Hill (2009), prehospital tourniquet was seen as an aggravating factor for limb complications. However the authors suggest that there is a need to prospectively assess the risk and benefits of tourniquet use and further research should be carried out to determine its effectiveness. Richey (2007) contends that the arguments presented against or in favour of tourniquet use are not completely without ground. Tourniquet use has been decried or advocated by surgeons based on their experiences in the battlefield. Richey argues that in a life-threatening position, saving the life of the trauma patient is more important than the potential risk of limb amputation. However this does not mean that the nurse or physician should not make an effort to decrease complications arising out of tourniquet use and to minimize the time the tourniquet is in place. Prolonged use of a tourniquet can cause intense pain arising out of ischemia of the limb. There is a general perception rife amongst the soldiers that if definitive care is delayed, loosening the tourniquet can cause recurrent haemorrhage. Therefore they apply the tourniquet tightly for long periods of time despite the potential risk of limb ischemia. Otis and Huntington (1883) observe that many soldiers used to come to their military camp with tightly applied extemporaneous tourniquets and swollen limbs; this is representative of the fear in soldiers stemming from incorrect perceptions about blood loss. The extremely liberal and incorrect use of tourniquets in the Civil War by inadequately trained soldiers led many of the surgeons to disparage tourniquets. This was based on the fact that the use of tourniquets was followed by a dramatic increase in limb amputations. However a point in defence of tourniquet use could be that the soldiers had to wait for days before they were rescued and given definitive care. In such cases, tourniquets were applied for excessively long periods of time than recommended. Therefore Richey (2007) is of the view that the complications that arise due to tourniquet use can be attributed to lack of proper training. For this he recommends that soldiers should be given sufficient training regarding the proper use of tourniquets. Attention to details relating to the use of tourniquets can prevent complications (Hentz & Chase 2001). Weaver (2010), who taught EMT as a Lab Instructor, argues that trauma management personnel should resort to the use of tourniquets without any fear since it is not a deciding factor of whether the limb should be amputated or not. However he asserts that not using a tourniquet can be a deciding factor of the person’s survival. He recommends the use of tourniquet when the attendant is in doubt, particularly in the rapid-evacuation stage. He observes that “all 50 states have "good Samaritan" protections, and that as long as you do not exceed your limits of training, you may well be sued (anyone can sue anyone else for anything) but that you will not lose - and probably won't even go to trial”. Therefore he recommends the use of tourniquets in extreme life-threatening situations. Salvucci (2011) observes that tourniquets have been used extensively in the wars in Iraq and Afghanistan. When looking at the figures closely, particularly the research conducted by Kragh (2009) on combat units in Baghdad, on survival rates with use of tourniquets, it was seen that tourniquets were strongly correlated with greater survival rates in trauma patients where shock was absent. Prehospital use was also a major factor in preventing morbidity due to hemorrhage. The study also concluded that no limb amputations were carried out as a result of tourniquet use. Kalish et al. (2008) also came to the conclusion that tourniquet use did not lead to neurovascular complications. Keeping this in consideration, Salvucci (2011) advocates the use of tourniquets by the military to for managing limb injuries. Where the UK military trains soldiers regarding both the benefits and possible risks of tourniquet use, wartime experiences have provided evidence regarding the effectiveness of the tourniquet in preventing deaths when applied correctly (Hodgetts & Mahoney 2007). Given the research findings, the US and UK military advocate the use of tourniquets in life-threatening situations. This has implications for tourniquet use by civilian EMS too. Given the recent military experiences in Iraq and Afghanistan, the use of tourniquets is now being recommended for civilian use (Stuke 2010). 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