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27 • Vascular Surgery in the Austere Environment 345
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passed from one surgeon, as he or she leaves the mission,
to the incoming clinician who has to pick up these pieces
while wondering whether the patient would have done better with ligation and a primary amputation.
Therefore it is incumbent on the surgeon who intends
to practice in the austere environment to learn the techniques that will enable graft coverage, including the
raising of muscle aps followed by a split skin graft. The
technique of fasciocutaneous grafts is also important for
surgeons in these challenging situations to understand.
There are many opportunities to learn such techniques
through attending various ap courses, watching and assisting plastic surgical colleagues, and reading the extensive
literature that is available.
45,46
Box 27.1 summarizes the
Box 27.1 Muscle and Fasciocutaneous Flaps
Neck, supraclavicular fossa, axilla, and upper arm
Sternocleidomastoid
Pectoralis major
Latissimus dorsi
Antecubital fossa to proximal forearm
Flexor digitorum
Brachioradialis
Radial forearm flap
Forearm fasciocutaneous flap
Chest
Pectoralis major
Omentum
Rectus abdominus
Latissimus dorsi
Groin to upper thigh
Groin flap
Rectus femoris
Rectus abdominus
Tensor fascia lata
Sartorius
Popliteal fossa to ankle
Medial and lateral gastrocnemius
Cross-leg flap
Soleus
Vastus lateralis
Lateral malleolar flap
Sural artery flap
muscle aps that this author considers most useful for the
vascular surgeon to learn.
VASCULARIZED COMPOSITE MUSCLE FLAPS FOR
COVERAGE OF VASCULAR RECONSTRUCTION
Brachioradialis Flap
Fig. 27.24 depicts a gunshot wound to the distal brachial
artery whereby both the distal brachial and radial and the
ulnar arteries were signicantly damaged. A long saphenous vein graft was performed to the brachial and radial
artery and covered by the brachioradialis muscle after preserving its blood supply from the distal radial artery. The
patient subsequently underwent a split skin graft with an
excellent result.
Rectus Abdominus Flap
This is an excellent ap based on the inferior epigastric
artery and is used to cover large soft-tissue defect over the
groin when there is insufcient sartorius muscle to permit
coverage of exposed vessels. An incision is made in the groin
crease 3 cm above the inguinal ligament, and the rectus
muscle is harvested up to the interdigitations with the costal cartilage. It is mobilized off of the posterior rectus sheath
after ligation of the superior epigastric artery and is swung
down over the groin defect (Fig. 27.25).
Soleus and Gastrocnemius Muscle Flaps
Soleus muscle provides a very useful ap to cover distal leg
wounds. The soleus muscle has two pedicles from the posterior tibial and peroneal arteries, which supply the muscle
from both the proximal and distal sites. The muscle can
survive on either pedicle and can therefore be mobilized
proximally or distally. The medial or lateral gastrocnemius
muscle is also useful to mobilize to cover more proximal leg
wounds (Fig. 27.26).
Fasciocutaneous Flaps
In Fig. 27.27, a lateral malleolar ap is used to cover a
defect in the forefoot. Fig. 27.28 demonstrates a fasciocutaneous saphenous artery ap used to cover the tibia. The
anterior border of the ap includes the long saphenous vein
A B
Fig. 27.24 (A and B) Brachioradialis flap.
346 SECTION 4 • The Management of Vascular Trauma
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AA B
C D
Fig. 27.25 Rectus abdominis flap. (A) Infected groin with ligation of the femoral vessels. The sartorius was destroyed. (B) Mobilization of the rectus
abdominis muscle. (C) The tunnel was created. (D) Coverage of the wound with the muscle.
D
Cross-Leg Flap
This is a very versatile fasciocutaneous ap, receiving its
blood supply from perforating branches, mainly the posterior tibial artery. A 4-year-old boy was injured during
a barrel bomb attack in Syria. He had lost all the blood
vessels to his foot. Of course, the easiest solution would
have been to perform a primary below knee amputation.
However, a decision is made to use the long saphenous
vein of the non-injured leg and perform a tibioperoneal to
posterior tibial bypass (Fig. 27.31A). This was successful.
He also had an injury to his ankle which required external xation (Fig. 27.31B). After 24 hours, he was brought
back to the operating theatre where the distal anastomosis
was covered after harvesting a ap from the non-injured
leg based on perforating vessels. The ap was sutured to
the skin of the injured leg such that the vein graft was
covered (Fig. 27.31C). Both limbs were immobilized for
Fig. 27.26 Soleus muscle flap.
3 weeks to allow the ap to acquire a blood supply from
the donor leg. The ap was then cut and the legs separated
and the external xator removed, and the boy was walking
to preserve the saphenous artery. Fig. 27.29 shows a groin
ap based on the supercial circumex iliac artery covering
a distal ulnar artery anastomosis with signicant tissue loss.
A sural artery ap used to cover a calcaneal defect can be
very useful to cover the posterior tibial artery (Fig.27.30).
after 6 weeks.
Radial Forearm Flap
The radial forearm ap, a fasciocutaneous free ap based
on the radial artery with drainage from the cephalic vein,
27 • Vascular Surgery in the Austere Environment 347
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Fig. 27.27 (A) Lateral malleolar flap. (B) Lateral malleolar flap after 5 days.
A
B
Fig. 27.28 (A and B) Saphenous fasciocutaneous flap.
can be mobilized to cover posterior defects and any part of
the forearm or distal upper limb (Fig. 27.32). The size of the
radial artery lends itself to perhaps the only ap that can be
harvested and used as a free ap in the austere environment
as it is possible to anastomose the radial artery to any artery
using loops and therefore does not require a microscope.
Fig. 27.29 Groin flap used to cover ulna artery anastomosis.
Forequarter Amputation
Sometimes it is necessary to perform difcult amputations (Fig. 27.33), and it is always worth carrying a USB
stick containing the steps required to perform these taxing
procedures. One does not want to be caught out and to be
required to receive instructions via a text message!
47
Working in Austere Environments
This chapter has focused particularly on vascular surgery,
but, as can be seen, this specialty overlaps general, orthopedic, and plastic surgery. For the surgeon to be able to
do the best for his or her patients in the austere environment requires a degree of prociency in all of these areas.
It is true that in austere environments a vascular surgeon
must, by necessity, become the type of general surgeon seen
before the rise of superspecialization. In these challenging environments, one's hand is also likely to be turned to
urology, neurosurgery, pediatric surgery, and obstetrics and
gynecology, among other medical disciplines. To train or
to prepare for these challenging but extremely rewarding
348 SECTION 4 • The Management of Vascular Trauma
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Fig. 27.30 Sural artery flap in a child with skin loss over the calcaneum.
A
C
Fig. 27.31 (A) Tibioperoneal to posterior tibial artery reversed long
saphenous vein grafting for blast injury in a 4-year-old child. (B) Exter-
B
nal fixation. (C) Cross-leg flap.
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A
CB
Fig. 27.32 (A–C) A radial artery flap.
ABC
Fig. 27.33 (A–C) Forequarter amputation.
situations, one must commit to learning the skills and the
knowledge required, including observing and working with
colleagues, attending courses, and participating with an
experienced group during such austere missions.
One such course which the author directs is called the
Surgical Training for the Austere Environment. It is a 5-day
course which takes a surgeon through all the specialties
that are required before going on a mission. The course runs
twice a year in London. Due to its expense, the author set
up the David Nott Foundation which offers scholarships to
any surgeon in the world to attend this course. The scholarships pay for travel, food, accommodation, and course fees.
Each course for the past 4 years has had 14 scholarships
awarded. Those interested are requested to apply via www.
Davidnottfoundation.com.
Successfully completing an austere medical or surgical
mission requires mental and physical resiliency and not
just expert surgical skill and technique. Accomplishing austere missions, whether during wartime situations or Third
World medical missions, requires coping with stress associated with being away from home in a country with different cultures and different religious beliefs. In these settings,
one's team frequently consists of known partners and/or
friends but also of expats from all over the world who have
their own cultures. Because of this, one must be prepared to
adapt and to become part of a unit that is both insular and
yet diverse.
There is no doubt that it is getting more dangerous to
work abroad in conict zones and that security cannot be
guaranteed even when working for the established and wellknown agencies such as the International Committee of the
Red Cross (ICRC) and Medecins sans Frontieres (MSF). A
recent symposium in London entitled “Health Care in Danger” highlighted the problems faced by health workers.48
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It is paramount that one obeys all of the security rules of
the organization that one deploys with. Although one's
freedom of movement might be signicantly limited during
an austere surgical mission, such precaution is often necessary not only for personal safety but also for the safety and
success of the larger project.
On coming home from a deployment or a mission, it is
important to attend available debrieng sessions. These
sessions improve resiliency, draw a line under one's period
away, and help one complete the mission. If one immediately returns to a normal work and family schedule without
a period of time to decompress, it may be difcult to adapt.
It is not uncommon for surgeons who have been on medical or surgical missions to have feelings of guilt relating to
the native people cared for and left behind. If not addressed
properly and professionally, these recollections and sentiments can percolate into and even overwhelm one's work
and home life. If one has spent time in a particularly dangerous situation, it does take time to get over this, and it is
important to keep in contact with others who have been on
the mission to share experiences and improve resiliency. It
is normal for one to feel elated on return from an austere
mission, only for a more reective mood and even sadness
to follow. However, intentional steps to debrief, decompress,
and improve resiliency are generally effective.
The beauty of an austere mission lies in one's challenging
but extremely rewarding role as a physician and surgeon.
In these settings, one's job is to perform the operations and
look after the patients on the ward while being mindful that
many surgeons who have passed through the mission, as
well as the local staff, have been in that setting over a long
period of time. It is likely that these and others associated
with the mission have seen it all. As always, the surgeon
should treat the team with humility, understanding that his
or her role is only for a nite period of time whereas many
of those working in the mission will have to endure the
stresses of the situation for much longer periods of time. As
always, one should avoid engaging in the politics of the situation, should never diminish the value of a team member,
and should leave the frustrations one has at home. Medical
and surgical missions in the austere environment are truly
in a different place and time. One should engage the mission, enjoy it, and give it his or her best shot!
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G lo bal P er sp ectives on
Vascular Trauma
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Australia and New Zealand
IAN D. CIVIL
Region-Specific Epidemiology
Australia and New Zealand have a combined population
of approximately 30 million people (approximately the
population of Texas) spread over a very large land mass of
nearly 8 million square kilometers (roughly the size of the
continental United States). In Australia and New Zealand,
ownership and use of rearms and, in particular, handguns
is limited by strict laws. With large farming areas in both
countries, rearms are present but at a much lower per capita rate than in the United States (26.3 guns per 100 people
in New Zealand; 14.5 guns per 100 people in Australia;
120.5 guns per 100 people in the United States).1 Additionally, the incidence of a mass shooting events in Australia
and New Zealand has been very low but these do occur sporadically.
of knives is harder to police. Among most cultural groups
in Australia and New Zealand, interpersonal violence most
commonly involves blunt mechanisms rather than stabbings or shootings.3 As a result the vast majority (over
90%) of trauma in both Australia and New Zealand is of a
blunt mechanism with penetrating mechanisms being the
cause in less than 10% of trauma patients.4 Most vascular
trauma that occurs in the community is therefore to lower
extremity vessels in association with fractures and dislocations (Fig. 28.1), to the thoracic aorta in association with
deceleration injury (Fig. 28.2), and to the cervical vessels
in association with blunt trauma (Fig. 28.3). Penetrating
trauma occurs with the usual distribution of injury from
accidental injuries such as arms lacerated when placed
though windows and, less commonly, from interpersonal
violence with rearms. Given the increasing rate of endovascular procedures performed by a range of providers and
in areas such as in intensive care units (ICUs), a signicant
proportion of penetrating vascular trauma in Australia and
New Zealand arises from iatrogenic mechanisms (e.g., damage to the femoral, the subclavian, and the carotid vessels).
land City Hospital Trauma Registry established in 1994, and
other cumulative reports, indicate an incidence of vascular
injury comprising approximately 1.5% of trauma admissions.
of vascular injuries have occurred due to blunt mechanisms
and 25% from penetrating mechanisms. Since the 1990s,
there have been no major changes in the etiology of vascular trauma, although the absolute numbers have increased
gradually in line with population growth.
2
As in most countries, despite being illegal, the carrying
Long-established institutional registries such as the Auck-
6–8
In this extensive trauma experience, roughly 75%
9
5
land. In general, it is not well systematized, although the
state of Victoria in Australia has run an effective statewide
trauma system since the early 2000s and has been able to
demonstrate both a signicant reduction in mortality and
an improved functional outcome for survivors.
American College of Surgeons (ACS) verication system has
been adopted by the Royal Australasian College of Surgeons
(RACS), and some hospitals and regions have embraced this
process improvement strategy in systems for the delivery of
care. In general, however, trauma care is provided by a range
of hospitals whose size and capability vary widely. In the
large metropolitan centers of Australia and New Zealand,
there exist hospitals that match to a greater or lesser degree
the trauma care capabilities of an ACS level I trauma center.
In the regional and provincial areas, base hospitals usually
have the capabilities of an ACS level III center. In more rural
and remote areas, trauma capabilities are limited. In the rural
areas, most trauma patients are taken to the nearest regional
hospital, which is the only real option. In the cities and urban
areas, there is usually some form of geographic boundary
used to dene the receiving medical center. Only in Victoria
has a really effective destination policy been developed that is
highly efcient in ensuring major trauma patients are taken
to one of only two adult or one pediatric (level I) centers.
10,11
The
Surgical Training and Certification
The RACS is the only training oversight body for surgeons in
Australia and New Zealand, and the College trains in nine
surgical disciplines including vascular surgery. Prior to 1997,
vascular surgery was integral to general surgical training
with further expertise being available in post-fellowship positions, but lately there has been a separate training program
that has graduated up to 10 vascular surgeons per year. There
is no separate training program in trauma surgery, and additional expertise in this area, beyond what might be obtained
in general, orthopedic, neurosurgical, or vascular surgical
training, is only available in post-fellowship programs either
within Australia and New Zealand or overseas. Thus, it is
possible to be deemed by the registering authorities as a certied general surgeon or a certied vascular surgeon, but not a
certied trauma surgeon as this specialty is not one of those
recognized by the regulatory entities. Overall, in New Zealand
and Australia there is approximately 1 surgeon for every
6000 people. However, with respect to the specic specialties
likely to manage vascular trauma, there is 1 general surgeon
for every 16,000 persons and 1 vascular surgeon for every
145,000 (RACS surgical workforce projections 2025).
12
Region-Specific Systems of Care
There is considerable variation in the systems of care under
which trauma care is provided in Australia and New Zea-
Access to Care
In Australia and New Zealand there are private health-care
systems, but most trauma and acute care is managed within
353
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Fig. 28.3 Common carotid traumatic dissection secondary to blunt
trauma.
the hospital are managed in the public or national healthcare program.
Fig. 28.1 Dislocated knee associated with distal ischemia.
Fig. 28.2 Computed tomography (CT) showing blunt thoracic aortic
rupture.
the public or national health-care system. This system
affords a baseline of routine and emergency care for all
citizens of Australia and New Zealand. Personal, private, or
government-supported insurance allows patients to access
the private system for semi-acute and elective needs, and in
New Zealand a universal no-fault accident insurance (Accident Compensation Corporation) allows private care of
injuries after the rst 10 days postinjury (unless the patient
is still an inpatient in a public health-care facility, which is
then obligated to continue providing care). Almost all episodes of trauma signicant enough to warrant admission to
Prehospital Care
Prehospital care in New Zealand is provided by a single
prehospital provider in each geographic area. One provider, the Order of St John, is responsible for over 90% of
all prehospital care in New Zealand. There is a single emergency telephone number, and three mirrored call centers
manage all emergency ambulance calls. Although tasked
by these call centers, air ambulances are not part of the
road provider system, but, like it, they are funded largely
by the government for noninjury work. For patients suffering injury, funding is mainly by the Accident Compensation Corporation as well as by sponsorship and charitable
donations. In Australia, each state and territory has its own
ambulance system and integrated air ambulances.
Advanced Trauma Life Support (ATLS) was introduced
into Australia and New Zealand in 1988 (referred to as
Early Management of Severe Trauma), and it has been
mandatory for all surgical trainees since 1994. Since 1997,
the Denitive Surgical Trauma Care (DSTC) course has
been run in Australia and, since 2003, in New Zealand,
and there are currently four courses in Australia and one in
New Zealand each year. DTSC is strongly recommended by
the General Surgeons' associations for trainees who began
training in 2012. In 2017, the ACS ASSET course was run
in Sydney and there are plans for annual provision of this
vascular anatomic exposure course to be run using locally
trained instructors together with internationally qualied
faculty.
Region-Specific Considerations for
Diagnosis
As most vascular trauma is the result of a blunt mechanism, evidence-based contemporary diagnostic strategies
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