Every war has its signature weapon. In Afghanistan and Iraq improvised explosive devices (IEDs) and landmines are the rebels' preferred method of attack.
These devices cause horrific injury and sometimes death. Advances in armour have increased soldiers’ survival rates, but mean they often sustain complex injuries to their faces, arms and legs.
Soft tissue and bone wounds are typical of the injuries received by military servicemen and women who are treated at University Hospitals Birmingham (UHB) NHS Foundation Trust. There, NHS staff and military medical personnel work together at the forefront of modern medicine.
Operations in warzones such as Afghanistan are pushing the boundaries of modern medicine in a range of areas including:
UHB has earned a reputation as a centre of excellence in the field of reconstructive hand surgery. This has been enhanced by its success in treating military injuries.
This expertise began with the treatment of work-related hand injuries, which were common in the West Midlands’ industrial heartland. “We’ve used our experience of dealing with crushed hand injuries and adapted it for military injuries,” says consultant plastic surgeon Garth Titley.
Dealing with never-before-seen hand injuries has led to some groundbreaking procedures.
One case was Private Neil McCallion, from the Argyll and Sutherland Highlanders, whose left hand was shattered by a shrapnel wound in Afghanistan in September 2006. Four of the five metacarpal bones (connecting the index, middle, ring and little fingers to the wrist) were missing. After the wound was painstakingly cleaned out, the back of the hand looked like a scooped-out crab shell.
There was little textbook guidance on this level of hand reconstruction. During his extensive research, Titley read about a similar procedure carried out on a foot injury by surgeons in Japan. He applied this research to his treatment of Private McCallion's hand. The technique involved rebuilding the hand using three of his ribs and muscle from the right side of his torso.
“It’s called a serratus anterior flap with ribs procedure,” says Titley. “As far as I'm aware, this has not previously been performed to this extent on a hand.”
During a 17-hour operation, the ribs were used to join the fingers to the wrist, using tiny plates and screws.
After several operations, Private McCallion could perform basic tasks with his rebuilt hand. “He can pick up a pint and he's learned to drive,” says Titley. “He has a hand that enables him to perform most of his daily activities.” He has recently had further surgery to improve mobility in the hand.
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The treatment of war wounds is complicated by the risk of potentially life-threatening infection. IEDs are often packed with shrapnel, such as steel nuts and nails, to increase the likelihood of secondary infection. Bacteria present in the soil, such as the drug-resistant Acinetobacter baumannii, and other impurities can also be driven far into the wound by the blast wind and shrapnel.
Debridement (the removal of dead, damaged or infected tissue to improve healing) is critical in infection control. “We have to make sure these wounds are very clean and that every bit of potential for infection is removed,” says consultant in burns and plastic surgery Lieutenant Colonel Steve Jeffrey. “The extent of the wounds we’re dealing with means this is particularly difficult.”
In surgery, dead tissue is removed using a new device known as Versajet. This is a high-pressure jet of sterile salt water directed through a small jet nozzle at the end of a handpiece.
“It’s more accurate than a metal scalpel. Versajet has made a significant improvement in how we are able to deal with these difficult wounds.”
To speed up the healing process, special silver-based dressings are used to prevent infection. “These dressings contain anti-microbial properties,” says Lieutenant Colonel Jeffrey. “We hope to take these dressings further into Afghanistan to apply them to wounds at an earlier stage.”
With large wounds, where the application of a traditional dressing is difficult, such as with a groin injury, a technique called topical negative pressure (TNP) is applied. A suction device is connected to the dressing to remove the wound’s impurities. TNP controls the bacteria and contains any exudate (fluid) from the wound. It also reduces the swelling associated with the injury. This enables the wound to heal more easily and makes the patient more comfortable.
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Soldiers often have multiple injuries, which means they need treatment for different types of pain. Soft tissue injuries, bone injuries, emotional pain and phantom limb pain (PLP) all hurt in different ways. "Treatment is not as straightforward as giving someone morphine until it stops hurting," says Debby Edwards, a consultant nurse in acute pain management.
Nurses have access to all the analgesic drugs available. Regional anaesthesia is used to isolate different types of pain. The technique involves injecting local anaesthetic drugs at the source of the pain.
To deal with the burning and tingling sensations that recovering service personnel often experience, the use of antidepressants in low doses is effective.
Many post-operation amputees experience PLP, a pain that seems to come from where an amputated limb used to be. “It's often excruciating and very difficult to treat," says Edwards.
In addition to analgesia, she says inviting long-term amputees to share their experience with post-operative amputees can really help in reducing PLP.
Emotional trauma can exacerbate physical pain and delay recovery. Here, the trust and bond built between nurses and the soldiers is critical. "We're realistic but always positive and supportive," says Edwards. "We help them to plan their recovery, which is good for confidence, and try to help heal the emotional pain, which speeds up recovery."
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Maxillofacial surgery is surgery to repair the face and jaw. It became a specialism during the First World War when trench warfare meant that heads were exposed and severe face and jaw injuries were common.
Today, most facial fractures are treated using internal fixation (holding bones together or in place) with titanium mini-plates. This has replaced the traditional techniques of intermaxillary fixation, which restricts jaw movement, and external fixation, which involves holding fractured bones in place using an external rod screwed into bones around the fracture.
However, external fixation, which was pioneered during the First World War, has been used during the conflicts in Iraq and Afghanistan as a result of the injuries caused by high-energy explosives with shrapnel. In some cases of injury to the face, stripping the skin from the bone to insert plates is not advised as it can increase the risk of infection and damage the bone’s blood supply. “In such cases, we’ve reverted back to external fixators,” says Group Captain Andrew Monaghan.
Not surprisingly, the materials have evolved since 1914-18. External fixators are now made of titanium instead of steel and are more malleable, increasing the range of positioning. "Trainees have little expertise in this technique because we went many years without seeing this sort of complex trauma in large numbers, but it’s a technique that the military maxillofacial surgeon needs to have among his skills,” says Group Captain Monaghan.
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Rehabilitation starts as soon as soldiers are admitted. Physiotherapists use a broad range of skills to treat injured service personnel, whose injuries can include multiple fractures, amputations, loss of sight or hearing, brain injury and sometimes a combination of the above.
Rehabilitation focuses on balance and core stability exercises. "If an amputee hasn't had good acute rehab, when it comes to fitting the prosthesis they'll have poor balance," says Jane Young, senior trauma physiotherapist. "We've had three-limb amputees who, after going through rehab at UHB, are able to get themselves in and out of bed with one arm. That's incredibly gratifying.”
Many techniques are used for pain relief. Desensitisation helps the patient become used to their wounds by touching them with different materials. Mirror therapy can be used to treat amputees with phantom limb pain (PLP). PLP occurs because the nerve endings at the site of amputation trick the brain into believing the amputated limb is still there.
With mirror therapy, an amputee uses a mirror box to mirror the missing limb. The patient exercises the existing limb and watches the movement in the mirror. The reflection creates the illusion of two limbs moving together. The mirror tricks the brain into seeing the amputated limb, overriding mismatched nerve signals.
In most patients, this results in decreasing pain in the stump. "Patients need to be psychologically ready before having mirror therapy," says Young.
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