J. B. Lundy, L. C. Cancio

autograft is performed to close wounds. Cadaver allograft is used for temporary closure of excised burn wounds when adequate autograft is not available. In Chapman’s review of long-term outcomes after combat-related burns, out of 285 combat-related burn patients, 35 % had an associated traumatic injury [24]. Fractures, large soft tissue defects, and traumatic amputations are some of the more common injuries. These associated injuries make definitive wound closure challenging, increase the open surface area at risk for infection, and complicate long-term rehabilitation.

Military burn casualties remain inpatients at the USAISR Burn Center until all wounds are closed, inpatient rehabilitation needs are met, and nonmedical attendants (typically family members) have been educated in wound care and activities of daily living. Military personnel are then assigned to the Fort Sam Houston Warrior Transition Unit and discharged to local housing. Many blast-injured casualties suffer traumatic amputations and require fitting and rehabilitation with extremity prostheses. The newly constructed Center for the Intrepid provides a state-of- the-art amputee rehabilitation center for these personnel.

Wolf et al. reviewed the outcomes of burned combatants and civilians treated at the USAISR between April 2003 and May 2005 [15]. The authors hypothesized that due to the delays in evacuation and associated traumatic injuries, outcomes would be worse for the military burned casualties. Of 751 total patients cared for at the USAISR during the period studied, 273 were military personnel. Overall, the mortality of the US military personnel sustaining burns in the combat theaters was no different from locally evacuated civilians. Of the 285 patients in Chapman’s return to duty study mentioned above, 190 patients were categorized as having returned to duty [24]. A total of 95 burned military casualties were medically discharged. Patients who were medically discharged had larger TBSA and full thickness burn size, more frequently suffered inhalation injury and associated traumatic injuries, and had a higher injury severity score [24]. An earlier study by Kauvar et al. noted that 10 % (n=13) of military burn casualties that were able to return to duty required limitations due to their injuries [5].

Care of host-nation burn patients

One challenging aspect of military medical care in the deployed setting is the care of host-nation casualties. Host-nation civilians and military personnel during wartime are frequently evacuated to US military medical treatment facilities on the battlefield. The impetus for caring for these patients at US facilities stems from several sources. Article 56 of the 4th Geneva Convention of 1949 states that “the Occupying Power has the duty of ensuring and maintaining, with the cooperation of national and local authorities, the medical and hospital establishments and services, public health and hygiene in the occupied territory.” Similarly, U. S. Army FM 8–10–14, Employment of the Combat Support Hospital, states that “Only urgent medical reasons will determine priority in the order of treatment to be administered. This means that wounded enemy soldiers may be treated before wounded Americans or allies (. . .) Civilians who are wounded or become sick as a result of military operations will be collected and provided initial medical treatment in accordance with theater policies and transferred to appropriate civilian authorities as soon as possible.” In practice, this means that host-nation patients presenting to U. S. forces with life-, limb-, or eyesight-threatening injuries have received initial care at U. S. medical treatment facilities.

Whereas resuscitation and lifesaving surgery might conceivably be completed within roughly two days of injury for patients with non-thermal injuries, in the case of burn patients the threat to life continues until the wounds are fully closed. Evacuation out of the combat zone (i. e., evacuation to echelons higher than Role III hospitals) has not been available to hostnation patients. Furthermore, host-nation facilities on the current battlefield, whether in Iraq or in Afghanistan, have not been equipped to provide burn care comparable to that available in U. S. Role III hospitals. This constellation of factors–the Geneva Convention moral imperative, the duration of the threat to life caused by thermal injury, and the discrepancy between U. S. and local capabilities–has made the disposition of host-nation burn patients problematic, and motivated U. S. Role III hospitals to provide definitive care. It would be incorrect to conclude that Role III hospitals were capable of providing the same level of

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