Managing Infection in Combat Casualty Care

In this episode of Frontline Surgery: Mastering Military Trauma Care, hosts Dr. Joshua Dilday and Dr. Jeff Connor are joined by Dr. Mary Ford, infectious disease expert and the podcast's first non-surgeon guest, to tackle one of the most persistent threats in combat casualty care: battlefield infections. From contaminated blast wounds at the point of injury to multi-drug resistant organisms acquired along the evacuation chain, the episode breaks down why infection risk evolves at every stage of care and why what is in the wound on day one looks very different from what threatens the patient on day ten.

Dr. Ford walks through the spectrum of pathogens surgeons will encounter, the growing threat of invasive fungal infections in blast trauma, and why the fundamentals of infection prevention including hand hygiene and bundle-based care remain the most powerful tools available even in austere environments. The episode closes with clear takeaways for deploying surgeons: prevention is key, common things are common, operate early and often, and advocate at the command level because that is where the standards are set and where they fall apart.

Transcript

SPEAKER_00 0:01

The major cause of death for an injured service member outside of that first 24 hours are infection and associated complications. So over a third, depending on what you're looking at, of patients who have combat trauma will have an infectious complication during their initial hospitalization. And the severity of tissue damage scales with infection risk.

SPEAKER_01 0:32

Brought to you by the AST Military Committee. Join us as we engage in conversations with field experts, examine critical battlefield scenarios, and uncover the strategies that keep surgeons ready for anything.

SPEAKER_03 0:44

Stay prepared and stay sharp with Frontline Surgery, where every episode provides key insights into mastering military trauma care. Welcome again to Frontline Surgery, Mastering Military Trauma Care. I'm Joshua Dilday, joined by my co-moderator, Jeff Connor. Jeff, good to have you again. Great episode today. Yeah, good to be back. Excited for it. And for the listeners, just a reminder, this series is designed to prepare those early career military surgeons for the realities of deployed trauma care. And one of those realities is something that is certain as I don't think we talk about enough. So today's episode is kind of focused on one of the most persistent and dangerous threats in combat casualty care, and that's battlefield infections. While we know hemorrhage may kill early, infection often threatens survivability later in the patient's course. Whether it's a contaminated blast wound or multidrug-resistant organisms in the prolonged field care environments, infectious disease remains a major challenge in modern warfare. And today we are honored to have frontline surgery's first non-surgeon clinical expert, Dr. Mary Ford. Dr. Ford is an infectious disease expert who has managed complex combat casualty care and wounds infections. Dr. Ford, thank you so much for joining us.

SPEAKER_00 2:01

Thank you so much for having me. It truly is an honor. You know, I love working with all of our surgical colleagues. So I'm really grateful for the opportunity to be here and chat with you guys today.

SPEAKER_02 2:10

All right. Let's set the stage a little bit, kind of moving forward here. So I'm going to give a little bit of scenario just to kind of set what we're going to talk about throughout this episode. All right. So let's um we're at a Ford surgical facility during some sustained combat operations. We've got a casualty that arrives after a jump drone strike with terrible, terrible lower soft tissue extremity destruction. Open fractures, we've got contamination from who knows what, soil, debris, burned material. We do initial damage control surgery to stop hemorrhage and wash things out as much as possible. And we get the patient to survive to the next level of care. But several days later, we've got, you know, despite repeated debreedments, the pay the patient develops worsening fevers, tissue necrosis, signs of sepsis, and the cultures eventually reveal multi-drug-resistant organisms. I'm sure this is a scenario as old as time, but let's uh let's kind of jump off from there.

SPEAKER_03 3:10

So, Dr. Ford, these are increasingly common. And I think they're becoming even more common in the recent conflicts. What's so challenging about this? And is this different than the everyday infection we see at our MILSID partnerships where Jeff and I are?

SPEAKER_00 3:23

Yeah, so I think the difference between combat trauma infections and civilian trauma infections is, you know, there's the difference can't be overstated, right? So I think that the main problem here is that we have someone who's experienced a significant blast injury. So that blast injury is not characteristic in our civilian um hospitals, thankfully, but it does create a lot of challenges for us. So these blast injuries are pretty uniquely destructive, right? Kind of simultaneously compromise the body's physical barriers while also creating an environment that's ideal for bacterial replication, right? You have a ton of necrotic debris, you have the severe tissue damage that is destroying all of the local blood vessels, meaning the normal immune cells and the system, the like systemic antibiotics that you're going to try to give to the patient can't get to the infected site. And then you have all of these, you know, foreign bodies, you have clots, you have fluid collections, you have contaminations from all sorts of bacterial sources, including the patient themselves, the environment, and ultimately, as we're seeing with the patient in this scenario, the healthcare system, all of this creates this infection that can be extremely hard to treat. And, you know, Josh, you're exactly right. We are seeing this more now, it seems, although this really is a tale as old as time, right? We know that outside of that kind of initial traumatic blood loss, the major cause of death for an injured service member outside of that first 24 hours are infection and its associated complications. So over a third, depending on what you're looking at, of patients who have combat trauma will have an infectious complication during their initial hospitalization. And the severity of tissue damage scales with infection risk. So patients with traumatic amputations, there are some studies that show that almost 50% of them will have an infectious complication associated with their trauma. These are deeply hard, and we haven't even talked about the fact that the MDR organism that this person has is going to make this even harder to treat.

SPEAKER_03 5:14

Wow. Now, I I mean, it seems because everything is worse in war and everything is worse in surgeons or surgeries that happen in war. You just described why these are so bad. Is every bacteria that that these patients are going to be infected with in DRS? Like, should we just automatically assume that's the worst of the worst every time?

SPEAKER_00 5:33

Man, isn't that a great question? So it really depends on where in the stage of injury you are talking about the infection. So I think when you look at all of the literature on this, and a lot of this work has been done by Tito's, which is the trauma infectious disease outcome study. So that may be something that's familiar to some of your lessons and listeners. It may not be. But Tito's is basically a big observational study that evaluates short and long-term infectious disease complications following deployment-related trauma. Started back in 2009, finishing up their 17th year. But when you look at, you know, both this literature, but also literature going back to Vietnam and even earlier, we know that at the point of injury, what is in the wound is causing problems, are mostly the things that were on the patient's skin, right? It's staph species, it's strep species, including group A strep, you know, strep pyogenes, and then maybe some stuff from the environment, things that are going to cause gas gangrene like clostridium porfynes, but mostly it is the things that are on the patient's skin, not things that you're worried about being super drug resistant. That's part of why, you know, if you look at the updated TCCC antibiotic prophylaxis guidelines that just came out, they have actually narrowed the spectrum of the antibiotics that they are recommending you give at point of injury. So it's down to recommending cefidroxyl, if you have someone who can tolerate oral or ceftriaxone, if you have someone who needs it, you know, via IV, IM, or IO. And that's really because at point of injury, the problem is what was on the patient's skin itself, for the most part. But as we watch people go through these EVAC chains, right? You get them away from the point of injury to a roll one, to a rule two. Maybe you're lucky enough to get them back to Germany, although in our current conflict, we know that's taking a really long time. But what we see is that people are picking up these MDRs along that EVAC train. And so it is at point of injury, it's not a problem. But by the time we get people back into our hospitals, that's when we're really seeing by that seven to 10 day mark, those gram negatives are starting to predominate. And so when you look at the literature from that's coming out now, it's super scary, right? Like you're seeing organisms that they're isolating for which there are no antibiotics. We have no antibiotics that we can treat these organisms. Very, very scary. But we are seeing that these are oftentimes, you know, we find one patient who had this on the battlefield, and then that same exact organism, you know, genetically sequenced, is showing up in six different patients in a hospital. So at the point of injury, not worst case scenario. But as you start to get people home after several rounds of damage control surgery, that's when we're starting to see things are not going as well.

SPEAKER_03 8:06

You started by putting my mind at ease by saying that it was just normal stuff. And then you ended with this apocalyptic. We don't have antibiotics for that. Thank you for the the tease. You started with the beauty and the beast quote tales all the time, and then you went true apocalyptic. So, Jeff, I don't I we're clearly out of our lane here in non-surgical stuff here, but it affects us. I mean, clearly it affects us.

SPEAKER_02 8:27

Yeah, and I I guess one of my this may sound like a very easy question or it just may be common sense, but have any studies or have you guys seen throughout lessons learned is time in each particular role, does that correlate with incidents of these bad infections? You know, because I'm just thinking about our current con, you know, current conflicts where evac times are, you know, really variable, right? And getting to a place where we have definitive surgical treatment or to a traditional, you know, roll three type setting. Is there any indication as to, you know, how to manage these at a roll two with these longer evacu times?

SPEAKER_00 9:07

Yeah. So I think to kind of the first question with are there studies that, you know, are looking at number of days at each facility and whether or not that matters to acquisition. Not that I'm aware of. That doesn't mean that they're not out there. There was a study done back in OEF OIF. It was actually patients in Iraq. And basically they screened them as they were leaving Iraq. And of these 54 patients screened, only one of them had an MDR. One patient had MERSA. But then as they march along, you know, we start to see just higher and higher numbers of patients who have MDRs. And you also start to see that shift from, you know, the first one was MERSA, right? A gram positive. That person probably was colonized with MERSA. But then by the time you get home, of these 54 patients who are screened in a rock, nine of them have infections. And it's mostly acinetobacter and klebsiella. So things that, again, are not necessarily colonizers of human skin, but are things that they picked up, nosocomially. But and then to your second question, things that we can do to kind of deal with the risk of infection in these prolonged care situations. That's really challenging. But I think it all comes down to the basics as much as we can. You know, kind of like I said in the beginning, these are lessons that we have learned over and over again. And at the end of the day, what we can do that really matters are just infection prevention and control principles. So what that equates to is good hand hygiene, right? Wash your hands. And it sounds silly and it sounds like maybe there are places that you wouldn't be able to do that. But, you know, even in a combat support hospital somewhere in Iraq, you can put hand sanitizer at the end of a bed and hand sanitize after you finish taking care of one patient before you walk in the open bay to the next bed. And we have studies that, you know, my mentors and colleagues did during OEF OIF that showed what a big difference these very simple measures make. To the tune of there was a hospital that was having a ton of ventilator associated pneumonias. So what did they do? They implemented a ventilator-associated pneumonia bundle, right? Like doing CHG baths and head of bed at 30 degrees and putting literally just taping hand sanitizer to the end of the bed. And at the end of this, they were having VAP rates that were lower than vap rates at in ICUs in the US. It's like you can do it. It's possible, but there is this kind of when you look at these studies too, and you talk to people when they're deployed, it's not your norm, right? It's not the way you're practicing medicine at home. You're not resourced in the same way. And there's a lot of just the inherent disruption of being in a combat zone. And so we start to get not complacent, but we accept a lower level of adherence to these practices because we're like, well, we're deployed. You know, we can't do X, Y, or Z. Um But the reality is that, you know, we can do the best we can with the resources that we have. Again, even if that's just taping hand sanitizer to the end of your bed.

SPEAKER_02 11:55

I think that's a great point. I mean, such an easy thing to do that's not even, you know, from a surgical standpoint, has nothing to do with how much tissue we're removing, how many times we go to the operating room, what antibiotics we're using. I mean, uh starting with simple things that we do every day in the hospital, and then we don't even really think about it. And making sure that we implement that downrange as much as we can and as much as possible. But like you said, these are simple things.

SPEAKER_03 12:25

Yeah. Dr. Ford, you talked about Kleb Ciella, you talked about MERSA, you talked about Astinobacter, and I'm glad you reviewed the antibiotics with septraxin or something that's easily available, easy done with a little bit narrow coverage. What about fungal infections? I know that is something that we kind of, I don't want to say it snuck up on us, but something that has been increasingly talked about as everything from the war climate changes to delayed evacuation to LISCO, whatever it is, fungal infections seem to be a significant amount of conversation started right now. What do I need to know for that? Does that change? What's going on with these fungal infections in the surgical field?

SPEAKER_00 13:04

Yeah, you know, fungal infections are different, right? So I think I said before we started recording that like one of my, you know, basic things that I want people to take away is that for these gram-negative pathogens, they're not in the dirt. This didn't come from the initial injury, right? This came from the things we did to them along the way. The fungal infections are different. Like that's that's probably from the dirt. And we what we know is that these invasive fungal infections, it is really the nature of the blast injury, the velocity of that injury and the significant tissue damage of the injury that matters. That is what's allowing these fungal organisms to seed into the tissue and really cause a problem. Because we didn't really start to see a lot of these until we started having a lot of dismounted blast trauma in Afghanistan, right? Like people were doing foot patrols, they were stepping on IEDs, they had this horrible, you know, lower extremity and perineal trauma, and we started seeing these bad invasive fungal infections. Um, we also know that there's some, you know, association here, the at least the infections in Afghanistan, they were characterized by folks who are at lower elevation, people who are at warmer temperatures, near waterways. So again, there is something environmental that is allowing these organisms to exist where they are. And then we have these bad blast injuries and they get into the patients. Um as you guys know, IFIs are devastating, right? They are quick. They patients have increased mortality, morbidity, limb loss, significantly prolonged hospitalizations. Um, you know, civilian literature reports mortality as high as 38%. A lot of that encompasses invasive fungal infections that are very different than the ones we're dealing with, right? That's more thinking like a diabetic patient with mucore. We're thinking a young, healthy 20-year-old who just, you know, stepped on an IED and now has fungus in their thigh. I think this comes to one of the other, you know, like my three things that I would want people to take away is like if you are thinking you need to go to the OR, you need to go to the OR. If you have any questions about it, you need to go to the OR. And I understand that that is really hard because particularly for many of these folks, you are trying to preserve as much tissue as you can for better functional outcomes, which is always our goal for our active duty soldiers, right? We want them to have the best functional outcome after these devastating injuries as we can. But IFIs just move so fast. And if you have any question that there is any sort of, you know, you something kind of says boo, right? You take down a dressing and you're like, it doesn't look great. It doesn't look terrible, but it doesn't look great. You probably need to investigate that further. And this is where the team dynamic really comes in because we need you guys to have the suspicion, you to go to the OR, you need the folks in our microbiolab to be able to actually identify the fungus. You need the pathologist to look at it under the microscope and tell us, well, is this fungus just sitting in the dead tissue that you cut off where we would expect to find fungus? Or has it actually invaded into the blood vessels, which means it is continuing to march up this person's leg or their arm? And then ideally, us infectious disease doctors are also on the team so we can help you manage the antifungals. Although at first, I'll tell you, spoiler alert, it's two antifungals. Look at the GTS guidelines. You want two, because we don't know what it is, and we're probably not gonna know what it is for a while.

SPEAKER_03 16:11

You just made a bunch of fans from surgeons by you basically saying, hey, surgeons, go operate. We're we're not gonna argue with you on that. So well done. Mary Ford is the uh the most popular infectious disease doctor for the podcast right now. So I think you hit it on the head and I love this. Your takeaway so far from what I'm understanding, Jeff, is it sounds like prevention is key. It's the common things being common and operate early and often. I mean, that seems straightforward, and yet we can't give up the vigilance on the virulence because the longer these patients are in the system, whether it's the evacuation chain or the definitive level of surgical care, as that continuity expands, they're at increased risk for worse actors, whether that's IFI, invasive fungal infection, or multidrug resistant, or whatever scary thing is underneath the sheets. So those were great takeaways.

SPEAKER_02 16:58

So one a couple things before before we uh end here, I I wanted to ask, you know, what are what are a few just, if you would say, pitfalls or or not or mistakes, I guess, things that we want to avoid. You know, I've got a deployment coming up um to the Middle East. What are some things that you have seen in the past or have heard in the past of trying to avoid?

SPEAKER_00 17:22

Yeah, you know, I think a lot of that comes back to to some of what you just summarized for us. I think it's really that, you know, the basics are doable and they're hugely impactful. So infection prevention and control, you know, washing your hands, and also having someone on your team who is skilled in those principles. It doesn't have to be you, right? Like your job as the surgeon is going to be a whole host of other things. But it's good to know who's on your team and who has that kind of skill set. Veering from the standard puts patients at risk, right? So anything that you can do in terms of getting them to surgery in a timely fashion, again, those infection prevention and control principles, I can't say it enough. That's really the most important thing. But doing the best we can to adhere to the standards that we know would want back home within reason is going to create the best outcomes. And then I also think this is important for, you know, a young active duty surgeon who's just graduated from training, who's going to their first unit, who's going to deploy, you need to have buy-in from your leadership. You know, you need to be able to speak to your commander and help them understand why the things that you're advocating for are important. And you can't, you know, you have to use terms that they're going to understand, right? You the, but the leader, your leadership is buying the risk here. And so if you want to get someone on your team trained in infection prevention and control before you go, you know, there are short trainings that the army can give you and your leadership is not supportive of that. Well, here's the risks, right? Here's the risks if we don't have someone who understands these principles before we deploy. And then also ask the questions, right? If it, if you are not measuring something, you may not be doing it correctly. So if you are not actually making sure that people are washing their hands after they go from bed to bed, they're probably not. And so making sure that anything you and your team can within reason like measure and monitor, do that because it's the simple things that fall by the wayside first.

SPEAKER_02 19:21

I think I think that was great. Josh, do you have anything else to add?

SPEAKER_03 19:26

I think Dr. Ford showed exactly why she's an expert in the field. One, obviously, she's popular surgeons by saying go ahead and operate. But you talked about, Dr. Ford, you talked about everything from prevention is key. It's not going to improve unless you measure it. And then one of our favorite topics on frontline surgery is getting the truth of where the change is going to happen at the command level. This was phenomenal. This is exactly what we wanted to have on this episode. Infectious disease is such a nebulous topic for a lot of surgeons because we we just a lot of times we are so separate in the continuity of care. We see patient at point A, and by the time they get to point D, it's either the cat is out of the bag or we've already moved on. And with the joint trauma system, which we've also discussed here on this podcast, there are ways to continue to attract that. And you've shown one of these reasons why it's so important. Because throughout the continuity of that patient's care, these things become so infectious. So thank you so much. I love the takeaways of prevention is key. It's the common things being common. Operate early and often. And I'll have a fourth one that you mentioned at the last one is continue to advocate at the highest level possible because that's where the change matters. So, Jeff, this was an awesome episode. We just want to thank so much, Dr. Ford, for being again the first non-surgeon on frontline surgery. Hopefully, maybe a repeat guest. We'll have to do something as well. Infection remains one of the enduring threats that we see in combat casualty care. And the next conflict may magnify in these challenges even further. We know that with delayed evacuation and prolonged field care, we're seeing it already. Preparation, diligence, disciplined surgical principles will remain critical. And because of that, we're going to ask everyone to stay ready, stay sharp.

SPEAKER_01 20:59

Thank you so much. Thank you for tuning into this episode of Frontline Surgery. We hope today's discussion has provided valuable insights into military trauma care. Be sure to join us next time for more expert perspectives and battlefield ready knowledge.

SPEAKER_03 21:14

Until then, stay ready.