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Introduction: Deployments abroad pose an occupational risk for mental disorders and reduced quality of life among military personnel. This study examines the question of whether a relevant predictor for the frequency of mental disorders after deployments abroad can be found. It is postulated that soldiers who experience a military-specific critical event develop more symptoms and their quality of life decreases., Methods: This study included n=370 combat troops deployed to Afghanistan as part of the International Security Assistance Force (ISAF) operation. Using questionnaires, data on psychological symptoms and quality of life were collected before and after deployment. The discriminator was whether a critical military-specific event, defined as a type A criterion of PTSD according to ICD-10 (F43.1), was experienced during the deployment., Results: It was shown that soldiers who experienced a critical event (n=81; 21.9%) developed significantly more depressive, somatic and stress symptoms. When evaluating the questionnaires on the quality of life, significant deteriorations were found in all areas, apart from environmental quality of life. In the study group without a critical event, there were significant improvements in stress experience and environmental quality of life after deployment. When the entire group was included, a time x group interaction effect was found with deterioration in soldiers with critical events in all of the above-mentioned areas, apart from the environmental quality of life., Conclusion: In summary, it can be postulated that critical events during a deployment abroad have a significant impact on the mental health and quality of life of soldiers. This can be used for more specific pre- and post-operation measures as well as for de-stigmatization programs., Competing Interests: Die Autorinnen/Autoren geben an, dass kein Interessenkonflikt besteht., (Thieme. All rights reserved.)

Operation Allies Refuge started in July 2021 with implications for critical care nurses, both military and civilian, serving at the US Army's Landstuhl Regional Medical Center in Landstuhl, Germany. Cultural and logistical concerns and complications were at the forefront of care provided to Afghan evacuees during the operation and were exacerbated by a mass casualty event on August 26, 2021, when a suicide bomber attacked the Abbey Gate of Hamid Karzai International Airport in Kabul, Afghanistan. This article discusses the issues that affected care, including language barriers, supply shortages, cultural differences, mass evacuation during a pandemic, and management of the mass casualty event by the critical care team. The information is compiled into a summary of lessons learned to assist in future management of emergency evacuee care within our military and civilian health care systems., (©2024 American Association of Critical-Care Nurses.)

The current war in Ukraine has drawn public attention to the treatment of war injuries. Follow-up treatment in Germany is portrayed the clover leaf of the TraumaNetzwerke DGU, is largely based on the demands of the Federal Ministries for Defence and Health and is intended to enhance resilience in war.The present article presents the special features of the care of severely injured patients during hostilities and should provide insights into the expected results of treatment and the actual procedures. We emphasise the unpredictability of the care of the severely injured during hostilities.On the basis of a search of the literature for the deployment of the German Army in Afghanistan and for the current war in Ukraine, we present the challenges and the typical patterns of injuries. We discuss the factors that can influence the procedures and the quality of the results during hostilities and how these may differ from civil polytrauma care in Germany - which is well established and standardised.Even during deployment of the Federal Army or (as planned) NATO, care of the severely injured is under standardised conditions, as based on the algorithmic ATLS care and which is concentrated on bleeding control. The corresponding equipment and personnel are well established, well prepared and well trained.However, there may be special local conditions or special deployments that make it inevitable that emergency medical care will be more delayed than in the civil system in Germany and can only take place after protracted transport. The objective is always that soldiers in combat should be able to receive medical care that is equivalent to that received by all accident victims in Germany, whatever the time and site of the accident., Competing Interests: Die Autorinnen/Autoren geben an, dass kein Interessenkonflikt besteht., (Thieme. All rights reserved.)

The aim of the present study was to investigate the effect of experiencing potentially traumatic events during deployment on post-deployment sleep quality as measured by the Pittsburgh Sleep Quality Index (PSQI) and the Addendum for Post-Traumatic Stress Disorder (PTSD) of the Pittsburgh Sleep Quality Index (PSQI-A). Deployment related experiences were quantified on a standardised list of the Mental Health Advisory Team of the U.S. armed forces. The original sample consisted of 118 soldiers of the German armed forces who were deployed to Afghanistan for six months. The present analyses focused on data assessed after deployment (n = 70) and in a three-month follow-up (n = 51). Results indicate that immediately after return experiences during deployment had an independent significant effect on sleep quality but not three months later. Immediately after return depressive and stress symptoms significantly affected sleep quality while three months later somatic symptoms were significant. At both time points sleep prior to deployment was a significant predictor of sleep quality following deployment. Given the importance of sleep quality prior to deployment as a known independent risk factor for newly occurring mental disorders after deployment, these results underline the need to improve sleep quality already at an early stage., (Copyright © 2018 Elsevier B.V. All rights reserved.)

Background: The Senior Visiting Surgeon (SVS) program at Landstuhl Regional Medical Center (LRMC), Germany, was developed during the wars in Afghanistan and Iraq as a measure to build military-civilian interaction in trauma care and research. The objective of this study was to provide a summary of the program including workload and experiences. An additional objective was to identify factors needed for sustainment of this program during an interwar period., Methods: An electronic, 34-question survey was distributed to 192 surgeons who participated in the SVS program at LRMC, either through the American Association for the Surgery of Trauma or the Society of Vascular Surgery between 2005 and 2012. The survey was composed of multiple-choice and open-ended questions., Results: The response rate was 61% (n = 118), with 24% (n = 28) indicating previous military service. These 117 respondents provided 24.5 months of volunteer coverage at LRMC, with 22% (n = 26) performing multiple, 2-week rotations. Visiting surgeons participated in two to five operative cases per week, with the majority of operations related to the management of soft tissue wounds and burns followed by abdominal and vascular procedures, conducted daily multidisciplinary intensive care unit rounds, and collaborated with military surgeons in research projects resulting in 22 publications. More than half (n = 59) of the respondents maintained contact with military colleagues during the 12 months following the rotation. The majority of surveyed surgeons support continuation of the SVS at military facilities in the United States and hosting military surgeons at their civilian trauma center., Conclusion: This study is the first to quantify the SVS program during the wars in Afghanistan and Iraq. Visiting surgeons provided more than 2 years of combat casualty care during these, the longest wars in US history. Continuation of this program will require expanded military-civilian interaction in trauma care, training, and research during any interwar period.

International studies suggest a growing risk of posttraumatic stress disorder (PTSD) with an increasing duration of deployment. There are no data available for the German armed forces that would allow an assessment of the average mission duration of about 4 months. Analyses are based on a stratified random sample of 1,483 ISAF soldiers. Standardized diagnostic interviews were conducted about 12 months after soldiers returned from mission. Deployment duration was categorized into 1-2 months, 3-5 months, and 5-8 months. Additionally, dimensional analyses of deployment duration were performed. Deployment duration was associated with the number of stressful and traumatic events. Notwithstanding, we found no linear relationship between mission duration and PTSD risk, neither in the total sample nor in the defined subgroups. However, we found a bimodal distribution suggesting an increased PTSD risk in the first 2 months and - less pronounced and limited to the Kunduz location - for deployment durations of at least 6 months. There was no general increase in PTSD risk with increasing deployment durations for German soldiers in this naturalistic study. The higher risk for soldiers with short deployments might be explained by selection of vulnerable subjects and different deployment characteristics. Further, there is some evidence of an increased PTSD risk for soldiers deployed for longer periods to high-risk locations (e.g., Kunduz).

Background: Little is known about the frequency of traumatic event exposure and the development of post-traumatic stress disorder (PTSD) among German soldiers serving in Afghanistan., Methods: We studied a random sample consisting of 1599 soldiers who had served in the 2009/2010 ISAF mission in Afghanistan, stratified by deployment location and unit. Twelve months after their return to Germany, the soldiers were assessed with a Composite International Diagnostic Interview (CIDI) to establish the diagnoses of mental disorders and PTSD according to the DSM-IV. 889 similar soldiers who had not been deployed abroad were assessed in the same way., Results: 49.2% (95% confidence interval [CI]: 46.4 to 52.1) of the deployed soldiers experienced at least one traumatic event during their deployment, and 13% experienced more than three. The 12-month prevalence of PTSD among returning soldiers was 2.9% (95% CI: 2.1 to 4.1), while the service-related incidence after deployment was 0.9% (95% CI: 0.5 to 1.6). These figures imply a two- to fourfold elevation of the risk of PTSD. The risk of PTSD was highest among soldiers who had served in Kunduz (Afghanistan) and in combat units. Only half of all soldiers with PTSD sought professional help., Conclusion: Deployment abroad is associated with a high frequency of traumatic experiences and a two- to fourfold elevation of the risk of PTSD. Each year, about 300 cases of PTSD develop for every 10 000 soldiers who return to Germany; thus, the cumulative number of returnees with PTSD from the beginning of German deployment abroad may currently run into the thousands. 45% of all PTSD cases, or about one in two, are neither diagnosed nor treated. Deployment abroad also substantially increases the risk of developing a number of other mental disorders.

Introduction: Military missions abroad carry a high risk of psychological traumatization. In this study, we examined the reasons for increased utilization of the treatments offered to soldiers by the German armed forces' psychiatric services., Method: We analyzed trends in initial contacts with psychiatrists and psychotherapists among German soldiers participating in missions to Afghanistan and the Balkans. To this end, we evaluated existing data from the psychiatric services of all German Armed Forces Military Hospitals with respect to sociodemographic factors (sex, area of mission) and the underlying psychiatric disorders over an 18-month period (January 2010 to June 2011)., Results: 615 soldiers made an initial contact with the psychiatric and psychotherapeutic services during the study period. The total number of first contacts did not change significantly (p = 0.195), but there was a notable rise in the number of first contacts by female soldiers with deployment-related stress (p = 0.003). Mission-specific statistics revealed a significant increase in the number of first contacts only for soldiers deployed to the Balkans (p = 0.017). 91% of soldiers making a first contact were given the diagnosis of a stress reaction (ICD-10: F 43); the second most common diagnosis (8.9%) was an affective disorder (ICD-10: F 32.0, F 32.1)., Conclusion: Despite psychological prevention efforts, military missions abroad often lead to mental disorders. Our findings indicate that the mild observed increase in incidence is both sex-specific and deployment-area-specific.

Background: Explosive blasts are common in the modern military environment. These blasts incorporate a concussive component (primary blast injury) and a penetrating component (secondary blast injury). Penetrating injuries are the leading cause of death and injury in these attacks. This review characterizes the vascular injuries associated with penetrating blast injuries to the neck and provides recommendations on the early management of these casualties for the surgeon unfamiliar with these injuries., Methods: The Landstuhl Regional Medical Center Trauma Registry was queried for admissions from January 1, 2006, to June 30, 2010, coded for a penetrating injury to the neck caused by a blast mechanism. Medical records were abstracted from the patient's initial presentation and care through the deployed military medical system. We recorded the vascular injuries, diagnostic studies, operative events, and early postinjury course for all identified patients., Results: Query of the Landstuhl Regional Medical Center Trauma Registry initially identified 252 patients, of which 53 were excluded because their injuries arose from other mechanisms or were only superficial. Among the remaining 199 patients, 38 (19.1%) sustained 44 vascular injuries requiring treatment. Compelling physical examination findings ("hard signs") were present in 15 (7.5%), who underwent immediate neck exploration. Another 12 patients also underwent neck exploration without any prior imaging studies. Computed tomography (CT) or CT angiography (CTA) examinations were done in 172 patients without hard-sign physical examination findings. Of these, the result of the imaging study was negative in 106 patients, and no further investigation or treatment for cervical vascular trauma was initiated. Of 66 patients who underwent CT/CTA before operative neck exploration, CT/CTA identified a vascular injury in 26 that was later confirmed on neck exploration. The combination of physical examination and CT/CTA resulted in a sensitivity of 96.3% and a specificity of 97.2% in diagnosing cervical vascular injury., Conclusions: Penetrating cervical wounds from war-related blast trauma are associated with potentially life-threatening vascular injuries. The presenting physical examination, availability of CT/CTA, local surgical expertise, and tactical combat situation all contribute to surgical decision making in these patients. In patients without hard signs of vascular trauma and a normal CT/CTA of the neck, there is no evidence to support mandatory surgical neck explorations or further immediate diagnostic studies to exclude cervical vascular injury., (Published by Mosby, Inc.)

A basic understanding of the ballistic behaviour of projectiles or fragments after entering the human body is essential for the head and neck surgeon in the military environment in order to anticipate the diagnostic and therapeutic consequences of this type of injury. Although a large number of factors influence the missile in flight and after penetration of the body, the most important factor is the amount of energy transmitted to the tissue. Long guns (rifles or shotguns) have a much higher muzzle energy compared to handguns, explaining why the remote effects beyond the bullet track play a major role. While most full metal jacket bullets release their energy after 12-20 cm (depending on the calibre), soft point bullets release their energy immediately after entry into the human body. This results in a major difference in extremity wounds, but not so much in injuries with long bullet paths (e.g. diagonal shots). Shrapnel wounds are usually produced with similarly high kinetic energy to those caused by hand- and long guns. However, fragments tend to dissipate the entire amount of energy within the body, which increases the degree of tissue disruption. Of all relevant injuries in the head and neck region, soft tissue injuries make up the largest proportion (60%), while injuries to the face are seen three times more often than injuries to the neck. Concomitant intracranial or spinal injury is seen in 30% of cases. Due to high levels of wound contamination, the infection rate is approximately 15%, often associated with a complicated and/or multiresistant spectrum of germs.

Background: The success of US Air Force Critical Care Air Transport Teams (CCATT) in transporting critically ill and injured patients enabled changes in military medical force deployment and casualty care practice. Even so, a subset of casualties remains who exceed even CCATT capabilities for movement. These patients led to the creation of the Landstuhl Acute Lung Rescue Team (ALeRT) to close the "care in the air" capability gap., Methods: The ALeRT Registry was queried for the period between November 1, 2005, and June 30, 2010. Additionally, Landstuhl Regional Medical Center critical care patient transfers to host nation medical centers were reviewed for cases using extracorporeal lung support systems., Results: For the review period, US Central Command activated the ALeRT on 40 occasions. The ALeRT successfully evacuated patients on 24 of 27 missions launched (89%). Three patients were too unstable for ALeRT evacuation. Of the 13 remaining activations, four patients died and nine patients improved sufficiently for standard CCATT movement. The ALeRT initiated pumpless extracorporeal lung assistance six times, but only once to facilitate evacuation. Two patients were supported with full extracorporeal membrane oxygenation support after evacuation due to progressive respiratory failure., Conclusions: ALeRT successfully transported 24 casualties from the combat zones to Germany. Without the ALeRT, these patients would have remained in the combat theater as significant consumers of limited deployed medical resources. Pumpless extracorporeal lung assistance is already within the ALeRT armamentarium, but has only been used for one aeromedical evacuation. Modern extracorporeal membrane oxygenation systems hold promise as a feasible capability for aeromedical evacuation.

Introduction: In 2010, the world witnessed 32 wars and other armed conflicts. Epidemiological analyses of mechanisms and patterns of injury of soldiers sent into these conflicts can be utilised to identify the surgical expertise that is required in a combat setting providing important parameters to adjust medical infrastructure and training requirements for future Military Surgeons., Experiences: Today in 2011, the German Bundeswehr runs a combat support hospital (role 3) in Mazar-e-Sharif in Northern Afghanistan providing a multidisciplinary capability profile. Furthermore, there are two role 2 medical treatment facilities (rescue centres) in Kunduz and Feyzabad for life-saving procedures and damage control operations in order to enable rapid evacuation to a higher level of care. Epidemiological analyses of injury patterns and mechanisms have shown that 2,299 soldiers of the coalition forces have been killed in Afghanistan until January 15, 2011. Of these, 21.4% died in non-hostile action (2010). The leading causes of injury were explosive devices (up to 60%) followed by gunshot wounds. Chest or abdominal injuries (40%) and traumatic brain injuries (35%) were the main causes of death for soldiers killed in action. The analysis of all surgical procedures performed in Northern Afghanistan demonstrates that most of the patients who underwent surgery until 2009 were local civilians. Most of these operations involved osteosynthesis and soft tissue debridement. Due to the recently aggravated tactical situation within the theatre, a significant increase of mass casualty situations and combat-related injuries was noticed., Discussion: The casualties in this military conflict present with injury patterns that are not seen in routine surgical practice at home. In an era of increasing surgical sub-specialisation, the deployed military surgeon needs to acquire and maintain a wide range of skills including a variety of surgical fields. In order to create this kind of military surgeon, the so-called DUO plus model for the training of military surgeons (specialisation general surgery plus a second sub-specialisation either in visceral surgery or orthopaedics/trauma surgery) has been developed in the Joint Medical Service of the German Bundeswehr. Other relevant skills, such as emergency neurotraumatology, battlefield surgery with integrated oral and craniomaxillofacial surgery, and emergency gynaecology are also integrated into this concept and will be addressed in special courses. On successful completion of this training programme, military surgeons will be officially appointed as "Einsatzchirurg" for a duration of 5 years. After this time, it will be obligatory to renew this "combat ready" status., Conclusion: The buildings and materials in German military medical treatment facilities provide for excellent working conditions. The training programme for military surgeons in its end-2010 version has been designed specifically with data about injury pattern and non-battle diseases as well as the political situation and professional requirements in the civilian sphere in mind.

Objective: To develop a validated mortality prediction score for children with traumatic injuries., Patients and Methods: We identified all children (<18 years of age) in the US military established Joint Theater Trauma Registry from 2002 to 2009 who were admitted to combat-support hospitals with traumatic injuries in Iraq and Afghanistan. We identified factors associated with mortality using univariate and then multivariate regression modeling. The developed mortality prediction score was then validated on a data set of pediatric patients (≤ 18 years of age) from the German Trauma Registry, 2002-2007., Results: Admission base deficit, international normalized ratio, and Glasgow Coma Scale were independently associated with mortality in 707 patients from the derivation set and 1101 patients in the validation set. These variables were combined into the pediatric "BIG" score (base deficit + [2.5 × international normalized ratio] + [15 - Glasgow Coma Scale), which were each calculated to have an area under the curve of 0.89 (95% confidence interval: 0.83-0.95) and 0.89 (95% confidence interval: 0.87-0.92) on the derivation and validation sets, respectively., Conclusions: The pediatric trauma BIG score is a simple method that can be performed rapidly on admission to evaluate severity of illness and predict mortality in children with traumatic injuries. The score has been shown to be accurate in both penetrating-injury and blunt-injury populations and may have significant utility in comparing severity of injury in future pediatric trauma research and quality-assurance studies. In addition, this score may be used to determine inclusion criteria on admission for prospective studies when accurately estimating the mortality for sample size calculation is required.

Since the beginning of the Overseas Contingency Operation, more than 45,000 ill and wounded service members have been evacuated from the battlefield to Landstuhl Regional Medical Center (LRMC) in western Europe. LRMC is a stopover for these service members, where they are further assessed, treated, and stabilized before they return to the United States. This process requires coordination between different military services, health care teams, and modes of transportation. These processes can be complicated given the severity of the wounded. Nurses at LRMC have learned how to streamline services, providing efficient, comprehensive care for wounded service members and their families., (Published by Elsevier Inc.)

Since 1992 the German Bundeswehr has been deployed for securing peace and peacekeeping abroad. Since then 83 German soldiers have been killed and overall 129 wounded in action as of 07.12.2009. In Northern Afghanistan the German Bundeswehr runs a combat support hospital (role 3) in Mazar-e-Sharif providing a multidisciplinary capability profile. Furthermore, there are two role 2 medical treatment facilities for primary surgical trauma care located in Kunduz and Feyzabad. In these role 2 facilities life saving procedures and damage control operations are performed in order to enable rapid evacuation to a higher level of care. Thereby military surgeons are often confronted with various medical and logistic challenges. The German Navy also has two equivalent role 2 medical treatment facilities (Naval Rescue Centers) aboard its two combat support ships (CSS) "Berlin" and "Frankfurt am Main" to support maritime task groups operating worldwide. These floating field hospitals provide an indispensable asset in the medical emergency care of naval operations with difficult space-time factors. Due to the specific operating alliance between CSS and Naval Rescue Center, special operations as well as evacuation and humanitarian missions following disasters near the coastline can be effectively accomplished.

Management of combat-related major vascular injuries is a challenge to all surgeons and a vascular specialist will not always be available in a wartime setting; therefore, every surgeon deployed to a war setting must be able to cope with these life and limb-threatening injuries. Data obtained from searching Medline and Google on the localization and treatment of combat-related vascular injuries of the USA strike forces in Afghanistan and Iraq were analyzed and adjusted to the requirements of the German Armed Forces. A total of 5-7% of casualties sustained major vascular injuries. After initial treatment using damage control measures to control the bleeding and restore perfusion definitive repair with vascular reconstruction must be performed in a facility with a higher level of care. Basic vascular surgical techniques which all military surgeons need to know are presented taking the austere conditions of a wartime environment into consideration. Preparation of all surgeons for deployment to a wartime situation must include basic knowledge and skills in vascular surgery including emergency and vascular reconstruction techniques.

The Joint Theater Trauma System (JTTS) is a formal system of trauma care designed to improve the medical care and outcomes for combat casualties of Operation Iraqi Freedom and Operation Enduring Freedom. This article describes the JTTS Trauma Performance Improvement Plan and how JTTS personnel use it to facilitate performance improvement across the entire continuum of combat casualty care.