      Members of our Editorial Board have recommended the      following books, publications, and articles for those interested in the      history of military surgery and its impact on the surgical profession as a      whole. You will find that not as much has changed as you might think in      caring for casualties, as new surgeons find &#8216;new wounds&#8217; and      rediscover old lessons.   

Anesthesia and Perioperative Care of the Combat      Casualty

 (Textbook of      Military Medicine: Surgical Combat Casualty Care, Part IV)   

     by the Department of the Army, Office of the Surgeon      General  

     R.F. Bellamy and R. Zajtchuk, eds; 1995  

Battle casualties: Incidence, Mortality, and Logistic      Considerations 

     by M.E. DeBakey and G.W. Beebe; 1952.  

Bleeding Blue and Gray: Civil War Surgery and the      Evolution of American Medicine

Conventional Warfare: Ballistic, Blast and Burn      Injuries

 (Textbook of Military Medicine:      Warfare, Weaponry, and the Casualty, Volume 5 Part I)   

     by the Department of the Army, Office of the Surgeon      General   

     R.F. Bellamy and R. Zajtchuk, eds; 1991.  

     T.E. Bowen and R.F. Bellamy, eds; 1988.  

Emergency War Surgery: First United States Revision of      the Emergency War Surgery NATO Handbook

Emergency War Surgery: Third United States Revision of      the Emergency War Surgery NATO Handbook

     by N.G. Kirby and G. Blackburn; 1981.  

     Hamish Hamilton Medical books; 1941.  

Larrey: Surgeon to Napoleon&#8217;s Imperial Guard

     by Otto F. Apel and Pat Apel; 1998.  

Surgeon to Soldiers: Diary and Records of the Surgical      Consultant, Allied Force Headquarters, World War II

     by T.H.J. Goodwin and A.J. Hull; 1918.  

     Surgery in World War II: Vascular Surgery   

     by US Army Medical Department, Historical Division  

     M.E. DeBakey and D.C. Elkin, eds; 1955.  

Surgery in World War II: Volume      II—General Surgery

     by the Office of the Surgeon General  

United States Army in the Korean War: The Medics War  

     by N.M. Rich and F.C. Spencer; 1978.  

     By N.M. Rich, K.L. Mattox, and A. Hirshberg; 2004.  

     by J.C. Beyer, J.B. Coates, L.D. Heaton; 1962.  

Battle injuries of the arteries in World War II  

Military Surgery in World War II—a      backward glance and a forward look  

The Mobile Army Surgical Hospital (MASH): a military      and surgical legacy  

Articles

Surgical Rounds

Suggested reading from our Editorial Board on military surgery throughout history

     Each month, Dr. Maria Flynn issues a Radiology      Challenge, presenting images from one of a variety of imaging modalities      and a case report. Can you diagnose the condition? Follow the link to find      out whether your answer was correct, what was really wrong with the      patient, and how the patient was treated. Then, come back next month to  test your radiographic reading skills on a new case!

 Edward Via Virginia College of Osteopathic Medicine

Dr. Maria Flynn is Chief of Genitourinary Imaging and      Radiology Intern/Medical Student Program Director at the Naval Medical      Center Portsmouth, as well as a Lieutenant Commander in the US Navy Medical      Corps. She received her medical degree from Tulane Medical School in 1994      and completed her radiology residency at the National Capital Consortium in      2003. She is certified by the American Board of Radiology and has been      appointed Adjunct Assistant Professor of Radiology and Radiological      Sciences at the F. Edward H?bert School of Medicine.

     A 42-year-old woman presented to the emergency      department complaining of crampy abdominal pain, nausea, and vomiting that      worsened with eating. She reported experiencing similar episodes, which      occurred at approximately 6-month intervals over the previous 6 to 7 years. Her surgical history included multiple ventral hernia repairs, a laparoscopic Roux-en-Y      gastric bypass (RYGB) in 1996, abdominoplasty, and an abdominal      hysterectomy.  

     Prior medical records were unavailable; however, the      patient claimed to have been admitted to the hospital on three occasions      for abdominal pain. During one admission, she underwent an exploratory      laparotomy, which was significant for a volvulus within an internal hernia.       

     A physical examination found the patient to be      hemodynamically stable. Her abdomen was diffusely tender and distended,      with no peritoneal signs. Bowel sounds were hyperactive. Laboratory tests      found a white blood cell (WBC) count of 13.1 x 103/?L, and urinalysis      findings were noncontributory. Contrast-enhanced computed tomography (CECT)      of the abdomen and pelvis was performed (Figures 1-4).   

 What is causing the patient's intra-abdominal pain?

 Intussusception with partial small bowel obstruction

Maria Flynn, Chief of Genitourinary Imaging and Radiology Intern/Medical Student Program Director, Department of Radiology, Naval Medical Center Portsmouth, Portsmouth, VA; Robert C. Scalise, MS4, Edward Via Virginia College of Osteopathic Medicine, Blacksburg, VA

 Acute abdomen secondary to perforated ileal diverticulitis — Ehab Elakkary, Igor Sincos, Steven Bolton 3:125

	Acute aortic occlusion form heparin-induced thrombocytopenia — Wesley P. Francis, Lisa G. Hall, Martin Tuma 12:589

	Acute gangrenous appendicitis associated with 

—induced toxic shock syndrome — Daniel Shibru, Christopher Newton, Jonathan Svahn 11:530

	Adenocystic breast cancer — Melhem Solh, Sabir Mubashir, Linda Dubay, et al 4:178

	Adrenal hematoma presenting as a large left upper quadrant mass — Marie Catherine Lee, Mitchell I. Chorost, Jonathan Earle 5:227

	Analytic uncertainty and clinical impact of HER2/

 testing — Richard M. Peterson, Armando Sardi, Michael Ballo 7:317

	Appendiceal intussusception caused by villous adenoma — Matthew S. Pugliese, Steven F. Counter 9:417

	Appendiceal mucocele — Nora L. Yip, Wayne A.I. Frederick 1:26

	Appendiceal mucocele: Benign or malignant? — Jonathan P. Lopez, Emad Kandil, Alexander Schwartzman, et al 11:540

	Applying the principles of Larrey’s Flying Ambulance: An international military MedEvac mission — David R. Welling, Norman M. Rich, John E. Hutton, et al 12:582

	Apricot phytobezoar lodged at omental band: A unique case of small bowel obstruction — Meghan C. O’Bryan, Cabot Murdock 3:112

	Bleeding gastric varices and a mesenteric fibroma in a gravid patient — Brent Keeling, Dana Osborne, Natasha Luckey, et al 3:117

	Carcinoma of unknown primary origin presenting as adult intussusception — Nicole Schimke, Dennis Whitmer 9:423

	Chilaiditi’s syndrome with incarcerated hepatodiaphragmatic small bowel hernia of unknown etiology — Kashaf Sherafgan, Sergey Khaitov, Fred Silvestri 9: 430

	Comparing wound closure techniques in laparoscopic surgery: Tissue adhesive versus standard sutures — Azul S. Jaffer, Eric K. Osborne, Robert D. Fanelli 1:16

	Complications of ingesting metallic objects and a magnet — Scott F. Reed 3:120

	Conservative management of an esophageal disruption in a septic patient — Albeir Mousa, Courtney Lee, Michael Sanusi, et al 2:73

	Cystic adventitial disease of the popliteal artery — Amit J. Dwivedi, Eric Nguyen, C. Cherukupalli, et al 7:311

	Diagnostic laparoscopy for intussusception sec&shy;&shy;ondary to metastatic lung cancer — Weesam Alkhatib, Michael Moncure, Rosane Achcar 9:404

	Endocarditis and splenic abscess — Erica Giblin, Michael Ganey 7:327

	ERCP findings of Mirizzi’s type II syndrome — Henry Talus, Sitaram Pillarisetty 4:175

	Eversion carotid endarterectomy illustrated: Tips and tricks of the procedure — N. Saratzis, A. Saratzis, S. Miliaras, et al 8:383

	Follicular variant papillary thyroid carcinoma arising in a struma ovarii — Jody Johnson, John Ketner 10:483

	Gallstone ileus — Erika Fellinger, Frederick Rogers 1:34

	Giant hydatid cystic liver disease: A challenging problem for Western surgeons — Ronald Barbosa, Ahmed Mahmoud, Nathaniel Matolo, et al 5:211

	Glomus tumor of the stomach — Christopher M. Larson, Erick R. Ratzer, Janet K. Stephens, et al 6:269

	Hypothenar hammer syndrome — Mojtaba Gasht 10:473

	Incidental adrenal pseudocyst — Gilbert Chang, Andy Sharobeim, Maria Ozeata, et al 5:231

	Inflammatory myofibroblastic tumor of the small bowel mesentery mimicking ectopic pregnancy — Ali Elhorr, Ehab Elakkary, Wissam Bleibel, et al 1:30

	Intraperitoneal hemorrhage after endovascular embolization of a cerebellar hemangioblastoma — Luz P. Angel, Moses DeGraft-Johnson, Kambhampaty Krishnasastry, et al 7:334

	Intussusception after Roux-en-Y gastrojejunostomy: Sequela of the Roux stasis syndrome? — Kongkrit Chaiyasate, Melhem Solh, Vijay Mittal 6:286

	Intussusception of the small intestine through an ileostomy: A rare cause of intestinal necrosis — David B. Chessin, David R. Stern, Tomas M. Heimann 9:410

	Laparoscopic management of intestinal perforation by a fish bone, mimicking acute appendicitis — Billy J. Kim, Josh E. Roller, Mark Watson 11:522

	Laparoscopic repair of retrosternal hernia of Morgagni — Mahesh S. Sharma, Desmond H. Birkett, Paresh C. Shah, et al 6:261

	Laparoscopic resection of gastrointestinal stromal tumors of the stomach — Andrew J. Morse, Christopher Evans 2: 66

	Laparoscopic resection of a giant adrenal cyst — Jodi Widner, Margaret Schrieber, Nita Ellis 5:219

	Lymphoepithelial cyst of the pancreas in a young woman — Dimitris P. Korkolis, Dana Osborne, Brian A. Boe, et al 1:21

	MALT lymphoma of the lung presenting with an IgM monoclonal gammopathy — Scott M. Schulze, Mathew M. Edavettal, Louis Fares II, et al 10:476

	Massive pneumoperitoneum from pulmonary barotrauma: A rare complication — Rose Ayoob, Michael Subit, Bryan Richmond 6:281

	Mesenteric volvulus presenting as right lower quadrant pain — Arie E. Pelta, Jay Yelon 2:82

	Mycobacterium avium complex causing intra-abdominal abscess and fibropurulent peritonitis in an AIDS patient — Mark A. Mueller, Michael Zdon 4:185

	Necrotizing Fournier’s gangrene from a perforated rectal carcinoma — Neil R. McMullin, Scott Gering, Thomas Levoyer 6:275

	Novel treatment of candidal cholecystitis using amphotericin B cholecystostomy irrigation — Shalini R. Anne, Peter L. Faries, Gregg S. Landis 8:37

	Obturator hernia: clinically elusive and radiologically effortless — Sergio A. Carrillo, David Varnagy, Donald Minervini 8:377

	Pancreaticoduodenectomy for metastatic ocular melanoma — Joseph DiNorcia III, Beth A. Schrope 5:235

	Perforated jejunal diverticulitis — Parviz Goshtasby, Vasudevan Tiruchelvam, Thomas Nicholson 8:361

	Petersen’s hernia after Roux-en-Y gastric bypass — Arnold H. Belgraier 10:488

	Popliteal artery entrapment syndrome — N. Saratzis, A. Lioupis, N. Melas, et al 1:12

2006

Baron Larrey and the evolution of medical transport 

	The fascinating history of transporting the injured can be traced to innovators such as Baron Dominique-Jean Larrey, the prominent French surgeon who established the “Flying Ambulance” organization during the early Napoleonic Wars.

 Larrey developed his Flying Ambulance unit for what was then a novel purpose: rapidly transporting injured soldiers from the battlefield to a more secure location, where they could receive medical care for their wounds.

	He realized that this could be accomplished only through preparedness and organization, and so he devised a fleet of lightweight, functional wagons that were pulled by horses (Figure 1). In one of the earliest examples of triage in practice, his medics were directed to attend first to the most grievously injured soldiers, regardless of rank, who were placed in the wagons and carried from the scene of the fighting to safety. When horses and wagons were unavailable, Larrey used great ingenuity for transport and at times used camels, or even wheelbarrows, for his wounded.

	America’s ‘Father of Battlefield Medicine’ and medical director of the Union’s Army of the Potomac, Dr. Jonathan Letterman adopted Larrey’s principles of triage and transport when he organized medical support for the northern soldiers during the Civil War. Among Dr. Letterman’s many reforms, he instituted an ambulance system that was responsible for triaging and evacuating thousands of wounded troops from the front lines, saving numerous lives.

	As technology has evolved, so has emergency transport of the war’s wounded. The horse-drawn wagons and carriages have been replaced by automobiles, trains, ships, and, ultimately, airplanes and helicopters. During World War II, which saw hundreds of thousands of wounded over a large geographic spread, medical transport became essential, and the C-47 Skytrain was the workhorse of that conflict. In the wars of Korea and Vietnam, helicopters ferried casualties to hospitals or aid stations in record time, significantly reducing the percentage of soldiers who succumbed to their wounds and hugely impacting the prosecution of those engagements (Figure 2). Following Vietnam, the US military’s ability to transport large numbers of wounded would not be tested on a large scale until the present conflicts in Afghanistan and Iraq, which began shortly after September 11, 2001.

 One Air Force surgeon, in particular, had much to do with envisioning and organizing the military’s current methods of transporting the wounded. In 1982, Paul K. Carlton, MD, was stationed in Wiesbaden, Germany, as a young lieutenant colonel. He realized that no effective, formal plan existed to facilitate medical transport in the event of an emergency. The procedure at that time was to appropriate aircraft of opportunity and dispatch small medical teams where needed, but there was no established organization or dedicated equipment. Instead, military physicians, nurses, and medics were assigned in a somewhat random fashion to carry out missions throughout Europe and Africa, retrieving sick and injured soldiers and conveying them to a US military hospital in Germany.

	Determined to change this haphazard system, Dr. Carlton lobbied to secure dedicated medical equipment, which was pre-positioned and at the ready on pallets. He fought for the establishment of organized, trained teams that were always prepared to be dispatched to rescue patients in need.  Dr. Carlton originally named this new organization the Flying Ambulance Surgical Trauma (FAST) Team, in honor of Larrey and his historic Flying Ambulance.

	Over the years, as Dr. Carlton rose in rank and assumed greater responsibility, he continued to work on the issue of medical evacuation, always refining and improving his ideas. In 1999, Dr. Carlton was appointed Surgeon General of the US Air Force and was positioned to implement the well-researched aerovac program that he had formulated over the years, and which had been organized in the late 1990s as the Critical Care Aeromedical Transport Team (CCATT).

	A basic CCATT is comprised of one physician, at least one critical care nurse, and a pulmonary specialist. The CCATT physician must be either a surgeon or a critical care specialist. All members of a CCATT undergo a training program that lasts several weeks, and those who successfully complete the program earn the right to wear the unique CCATT emblem on a shoulder of their flight suit. These specialized teams are noted for their members’ professionalism and can-do attitudes.

	Each CCATT is supplied with state-of-the-art medical equipment, such as lightweight, reliable ventilators; infusion machines; pulse oximeters; high-quality monitors; and basic laboratory kits. After acquiring patients, the CCATT need only ensure that the patient is physically stabilized, although perhaps not medically stable, before taking to the skies. After all, the airplane has been transformed into a flying intensive care unit, where damage control is the rule and ‘care in the air’ is the mantra.

	CCATTs have distinguished themselves on the battlefields of Afghanistan and Iraq by successfully retrieving thousands of wounded. It has been remarkable to see how well the CCATTs have performed and how thoroughly Dr. Carlton’s ideas have been validated.

—An early test of the CCATT occurred in response to the bombing of the U.S.S. Cole. Thursday, October 12, 2000, was a beautiful autumn day in Landstuhl, Germany, where several CCATTs were based. Landstuhl is home to a regional US military hospital, which even in 2000 had a busy patient load, although it was not the hot bed of activity it has since become. Landstuhl Regional Medical Center currently serves as the European center of patient care for those wounded in the Iraq and Afghanistan conflicts.

	The U.S.S. Cole is a navy destroyer, and on that day in October, it had approximately 200 sailors aboard (Figure 3). In the early afternoon, personnel at Landstuhl received word that the U.S.S. Cole had been attacked by suicide bombers while refueling at Aden Harbor in Yemen. As always happens when such catastrophes occur, we began receiving conflicting reports on the number of deaths, extent of injuries, and the degree of damage. Some reports turned out to be correct, some incorrect. Eventually, it was confirmed that 17 sailors had died from the bombing and another 39 were injured. While the ship had a medic and an aid station, it had no physician. However, all the Cole’s survivors actively tended to their injured compatriots even as they struggled valiantly to keep the ship from sinking.

	We received an immediate request to get a CCATT ready to proceed to Yemen and retrieve our injured sailors, many of whom had been taken to local hospitals in Aden, where sophisticated medical care was lacking. Fortunately for our sailors, the French military had established a modern hospital about 200 miles away, across the Strait of Aden, in the little country of Djibouti. On their own initiative, the French flew a C-160 Transall to Yemen and evacuated the 11 most seriously wounded patients to the Djibouti hospital, where they were cared for most professionally.

— Because the patients were now separated into two different groups in two different countries, planners at Ramstein Air Force Base (AFB) decided to dispatch two MedEvac missions to ferry all the injured back to Germany. Each plane was to have an augmented CCATT to deal with the high number of casualties.

	Each mission involved a C-9 Nightingale, which until its recent replacement by the C-17, was the aerovac airplane of choice for many years (Figure 4). It is a twin-engine jet, the military equivalent of the DC-9, and specifically designed for MedEvac missions. The aircraft is plumbed and wired to care for multiple casualties; features such as suction, oxygen, and litter stanchions are built into the plane. A side door on the Nightingale folds outward to become a ramp, which makes on- and off-loading patients faster and more efficient.

	The first mission, 10E1, flew from Ramstein AFB to Cairo, and then on to Aden. The second mission, 10E2, went from Ramstein AFB to Cairo to Djibouti (Figure 5); one of the authors, Dr. David Welling, was a member of the CCATT on 10E2. Because of international aviation restrictions, the need to obtain clearances from foreign governments to traverse their airspace, and the “fog of war,” the missions did not leave Ramstein AFB until early in the morning on October 13, a full day after the attack. While the CCATTs were prepared to leave 12 hours earlier, the tremendous planning and coordination the missions required took half a day to accomplish. This detailed planning was to pay dividends later. For example, on the way to their respective destinations, each mission had a scheduled stop in Cairo, Egypt, to refuel. Planners ensured that ‘fresh’ pilots were staged in Cairo so that the C-9 Nightingales could make the roundtrip without violating crew-rest restrictions.

At the French military hospital in Djibouti

—The Republic of Djibouti is a poor Muslim country in eastern Africa. We arrived there in the afternoon of October 13, in brutally hot and humid weather. The plane taxied into a secure, fenced area, patrolled by French soldiers with automatic weapons and dogs. Some concern existed about whether we, too, might become terrorist targets.

	The French military hospital was approximately 5 miles away, and we drove there in vans, forming a military convoy. On arrival, we visited the 11 patients with haste. We found 2 who were critically injured and on respirators; the other 9 had major fractures and various severe injuries. We determined that the patients’ conditions were stable enough for us to take all 11 back to Landstuhl with us.

	Several on our team were able to converse with our hosts in French, and this facilitated better planning and patient care. Some of us also knew French surgeons known to the physicians at Djibouti, which established common ground and put everyone at ease. The visit illustrated the significant benefits of international cooperation and studying foreign languages. It must be stated that the French physicians did a marvelous job treating our patients and deserve tremendous credit for their initiative and excellent work.

— Once our rounds had been completed and our plans were set, we commandeered every ambulance in Djibouti to caravan our patients back to the airplane. It was dark by the time everyone was loaded securely aboard and we were prepared to take off, at 6:29 pm. The effort had left us soaked with perspiration, and we relished the modern jet’s air-conditioned coolness. The smell inside the aircraft was unforgettable: a pungent mixture of sweat and  draining wounds. The trip itself was also memorable. We were surrounded by brave and wonderful young people who, despite having undergone a traumatic experience that had left them badly injured, were as eager to help us as we were to help them. Those who were awake did their best to assist us in moving and repositioning them, and although some sailors were grieving over friends who had died in the explosion, they endeavored to comfort their surviving shipmates.

	One patient began showing signs of sepsis after the plane got underway, so several internal medicine physician members of our CCATT inserted a central line and initiated antibiotic treatment. Most of our 11 patients were on oxygen; many had open, draining wounds. The most critically injured patient had nearly 11 broken bones, bilateral pneumothorax, and a ruptured stomach. He was being ventilated, and we were able to keep him stable throughout the trip. A young woman with pulmonary burns was also on a ventilator. Because of a lack of equipment, the Yemeni doctors had been unable to perform endotracheal intubation and ventilation, and she was found 

 by the French doctors, who quickly realized her desperate situation, intubated her, and put her on a respirator, thereby saving her life.

	Mission 10E2 again stopped to refuel in Cairo, Egypt. After takeoff from Cairo, we continued up the Mediterranean towards southern Italy. It became apparent that our liquid oxygen supplies were getting dangerously low, so we diverted to Sigonella, Sicily, where we took on more fuel and replenished our oxygen reservoir. We then proceeded to Ramstein AFB; the atmosphere was foggy, but we had just enough visibility to land “at minimums” at 7:15 am on October 14, 2000, less than 24 hours after being dispatched. We felt great relief as all 11 patients were carried safely up the hill to the hospital at Landstuhl, where we were greeted by an enthusiastic team of rested colleagues. They assumed responsibility for our patients at that point and subsequently gave them the best of care.  

	Mission 10E1 had arrived at Ramstein AFB several hours before 10E2, just before midnight on October 13, but the plane was diverted to Frankfurt, Germany, because of the impenetrable fog. The medical team and its multitude of patients made the hour-long journey from Frankfurt to Landstuhl by bus and arrived early in the morning on October 14.

—All of our 11 patients recovered, most without any long-term health complications. The damaged U.S.S. Cole was hauled on the back of a heavy Norwegian transport ship named the 

 to Pascagoula, Mississippi, where it was repaired and put back into service.

	The Air Force selected the combined missions of 10E1 and 10E2 as “Mission of the Year” for 2000 and awarded the prestigious MacKay Trophy to the 39 crew and CCATT members who were present on the two flights. Dr. Carlton attended the ceremony and expressed his pride in the team members “for their professionalism and skill in bringing back our wounded warriors.” The MacKay Trophy rests in the Smithsonian Air and Space Museum in Washington, DC.

	CCATTs are still performing magnificently, and the lessons learned from the U.S.S. Cole rescue mission have been applied repeatedly in transporting large numbers of critically injured troops from Iraq and Afghanistan. The principles of Larrey’s Flying Ambulance continue to soar.  

This article contains the opinions of the authors and does not necessarily reflect the doctrine of the United States Department of Defense or the Uniformed Services University. 

 1. Burris DG, Welling DR, Rich NM. Dominique-Jean Larrey and the principles of humanity in warfare.

	2. Gillet MC. Army Historical Series—The Army Medical Department 1818-1865, Center of Military History United States Army, Washington DC, 1987, p. 228.

David R. Welling, Colonel USAF MC (ret); Norman M. Rich, Colonel USA MC (ret); John E. Hutton, Brigadier General USA MC (ret); David G. Burris, Colonel USA MC, Norman M. Rich Department of Surgery, F. Edward H?bert School of Medicine, USUHS, Bethesda, MD

Applying the Principles of Larrey's Flying Ambulance: an International Military Medevac Mission

• High-sulfur coal stocks are on the rise 

	Always a popular target for criticism in the past, high-sulfur coal has recently drawn an approving eye, attracting the attention—and wallets&mdash;of investors. Even though high-sulfur coal burns hotter than low-sulfur coal, enabling it to generate more electricity, coal buyers and utility companies avoided high-sulfur coal because it was associated with acid rain and other environmental problems that could prove costly.

	According to a recent Wall Street Journal article, stricter environmental regulations and costlier pollution emission credits have compelled facilities to invest in “scrubbers.” These are seven-story facilities that are placed next to smokestacks to capture sulfur as it comes out of the plants. The scrubbers allow high-sulfur coal to be used without the previous pollution risks.

	Companies that sell high-sulfur coal, like Consol Energy, Inc, are predicted to grab market shares from coal competitors over the next few years. The Journal says that while currently only 30% to 40% of the nation’s coal-fired electricity output is generated by facilities using scrubbers, that figure is expected to jump to about 60% over the next 5 years.

	Ordering online has made purchasing products extremely convenient, especially for busy surgeons with little time to hit up the mall. What could be any more convenient? Purchasing via cell phone.

	According to a recent article in Advertising Age, PayPal has introduced a mobile payment system that allows people to purchase items, transfer money, or make charitable donations using a cell phone. PayPal Mobile’s “Text to Buy” feature can be utilized by members who register their phone numbers with the service and choose a PIN number to secure their payments. Transactions are conducted by text-messaging product codes directly to an eBay-owned payment company. Once a merchant receives a mobile payment, it will ship purchased items to the buyer at the address PayPal has on file. A few of the media-sector launch partners include 20th Century Fox Home Entertainment, Bravo, MTV, and the NBA store.

	4.5%—Percentage of total US Web site visits racked up by top-ranked MySpace.com during the week ending July 8, ahead of Yahoo Mail. (Newsweek, 2006)

	$877—Amount of online retail spending per US consumer in 2005. (Entrepreneur, 2006)

	$1,512—Amount of online retail spending per US consumer anticipated in 2009. (Entrepreneur, 2006)

	38%—Percentage of “avid” NBA fans that are women. (Change Agent, 2006)

	70%—Percentage of American parents who consider it absolutely essential to teach their children to save and spend carefully. (Renaissance, 2006)

	31%—Percentage of family businesses worldwide that will change ownership within the next 10 years. (Citigroup Pursuits, 2006)

	49%—Percentage of family businesses worldwide without succession plans. (Citigroup Pursuits, 2006)

	1,100—Number of college students who commit suicide each year. (Time, 2006)

	$140 million—Amount said to have been paid for No. 5, 1948 by Jackson Pollack, the highest price ever paid for a painting. (USA Today, 2006)

	46—Number of states where immigrant population has grown since 2000; South Carolina leads with an estimated 47% growth rate. (Time, 2006)

	$2.8 billion—Amount political campaigns and special interest groups spent on the 2006 midterm elections. (Newsweek, 2006)

• Dog owners howling mad at insurance companies 

	For years insurance companies have refused to write homeowners’ policies for families who own dog breeds that are considered dangerous. The Wall Street Journal reports that animal-welfare organizations are teaming up with lawmakers to institute a ban on this insurance industry prejudice. There are nine states—Kentucky, Maine, Michigan, New Hampshire, New Jersey, New York, Tennessee, Vermont, and Wisconsin&mdash; with bills pending that would prohibit insurance companies from denying homeowners’ coverage based on the breed of dog residing in the home. Among “vicious breeds” commonly included on insurance liability lists are German shepherds, Akitas, Siberian huskies, Alaskan malamutes, Chow Chows, Doberman pinschers, and American pit bull terriers. While the insurance industry’s distrust of these breeds is not wholly unfounded (800,000 dog bites occur in the United States annually that are serious enough to require medical attention) breed-advocates state emphatically that these controversial canines are only as dangerous as the manner in which they’re raised.

• More news on Internet phishing and avoiding the bait 

	It is getting increasingly difficult to decipher a valid e-mail from an e-mail scam. Con artists are pulling out all the stops to manipulate people into falling for their gimmicks. According to BusinessWeek, hackers have become slyer than ever and are preying on people’s worst fears—in some cases, sending e-mails that accuse the recipient of sending SPAM and threatening a lawsuit. A 2005 survey by Gartner Inco, quoted in BusinessWeek, finds that although the number of people victimized through Internet phishing declined from 3% in 2004 to 2.5% in 2005, the amount of money lost due to this kind of fraud rose from $690 million to $1.5 billion. Even if you are someone who is never tempted to reply to the most trustworthy appearing e-mails with personal information, you may still be at risk. BusinessWeek describes one program recently discovered on a Russian Web site by security firm Sophos, Inc that sends out SPAM appearing to promote news stories. The program attempts to turn off PC firewalls and install a keystroke-logger, which records each and every keystroke you make, collecting any information you type on your computer regardless of which Web site or program you are using. What it comes down to is this: never open e-mails or click on links sent by unfamiliar individuals.

• Separating financial advising from hustling 

	The financial advising niche has attracted a number of untrustworthy salespeople, who try to swindle unsuspecting surgeon investors into shifting their portfolio into investments they themselves are soliciting. Money magazine cautions investors to be wary of advisors whose advice strays from how to create a financial plan and shifts toward selling your current investments and buying new ones from them. Make sure the advisor you are consulting is registered with your state securities department (

) and has not received a list of complaints. Also, familiarize yourself with the value behind each credential; some may be marketing gimmicks. Take, for example, the popular CSA credential. While it does come from a real organization—the Society of Certified Senior Advisors&mdash; Money says it merely means that your advisor took a self-study course or a 4-day course whose only requirement is passing a 100-question multiple-choice exam. More abbreviations appended to a name do not necessarily mean more expertise. Obtaining referrals from trusted friends or colleagues is a safe way to choose an advisor, or you can consult respected industry groups like the Financial Planning Association (

) and the National Association of Personal Financial Advisors (

• Different financial assistance options 

	If you are trying to decide whether you should hire a full-service broker, an independent advisor, or someone in between, it is important to take time to figure out which one matches your needs the best. The Wall Street Journal advises you to research the strengths and weaknesses of stockbrokers, financial advisors, and financial planners, and the Journal provides an overview of each:

	• Stockbroker—Stockbrokers trade securities and receive commission or fees based on the product sold if they are brokerage-based; they may also charge annual fees. Independent stockbrokers may have a broader selection of investment options and fewer reasons to push particular products.

	• Financial advisor—Financial advisors manage the big picture for financial planning and asset management. They have an obligation to their clients to be reliable and trustworthy. They take responsibility in managing your financial life, and you generally pay an annual fee of 1% to 2% of the assets under management. If they are brokerage-based, like some stockbrokers, they may try to push in-house products.

	• Financial planner—They offer services similar to those of financial advisors. Financial planners create a financial plan that you execute yourself through a traditional or online brokerage firm. The cost is typically a one-time fee.

•IRS releases audit figures for rich Americans 

	If you made over $1 million per year, there’s a good chance you could face an audit. The IRS recently disclosed that in 2005 they performed 11,715 audits (5.2%) on the 225,000 Americans who reported incomes of $1 million or more in 2005. According to the Wall Street Journal, this rare data revelation occurred after Syracuse University released a report stating that the IRS had conducted a mere 30 face-to-face audits on households with $1 million-plus incomes. Agency officials state that the discrepancy was due to a change in the way they keep their records, and they recently added a new audit classification of $1 million or more. For Americans earning $100,000 or more, which includes a good chunk of surgeons, the IRS says it audited 221,426 of these tax filers in 2005, up from 166,221 in 2004.

• Tour college campuses from your living room 

	Most surgeons had their share of medical school nightmares, the first one being deciding where to attend. If your children are preparing for college and want to consider a variety of different schools around the country, you may have to relive this nightmare. Flying from state to state and staying in hotels as you visit various campuses with your child can be incredibly expensive, but it’s a useful way to determine whether the school is the right one for your child to attend for the next 4 years. If you don’t want to shell out up to $1,000 per campus visit, there is another option. Some companies are offering college campus tours on DVD. College Choice Walking Tours (

) is one such company. You can tour one of 350 campuses for a mere $15 per hour-long DVD. These onscreen tours present all of the sights and sounds you would experience if you were actually there and can help you and your child to eliminate some colleges from the list immediately, thereby eliminating another time-consuming and costly trip to campus.

• Plan ahead for high nursing home costs 

	The cost of putting an elderly parent in a nursing home can be staggering. Fortunately, most retirees won’t face significant long-term care costs, but an unfortunate few will be hit with steep expenses. According to the New York Times, a recent study concluded that 69% of Americans aged 65 will eventually require some form of long-term care. That may just mean help with bathing, dressing, or going to the bathroom, tasks that do not require a nursing home stay because family members can provide assistance.

	The study projects that 37% of 65-year-olds will eventually need long-term care in a nursing home or assisted living facility, with 11% of men and 28% of women requiring more than 5 years of care. This can be incredibly expensive. To help ease the cost, consider purchasing longevity insurance, a relatively new type of policy that pays an income for life during your later years. For example, MetLife has a product that allows carriers aged 55 and older to invest a lump sum that guarantees an income which kicks in at age 85. Unlike long-term care insurance, your health is not an issue when withdrawing the money, so you can use it to help pay nursing home costs. 

Surgeon's Bulletin Board

 is      pleased to introduce two developments that the Editorial Board believes      will enhance our publication. In this issue, we present a new feature      entitled Casualty Surgery Series. This series deals with trauma surgery,      prehospital care, management of major calamities, and military medicine.      The feature's editor, Norman Rich, MD, Colonel, US Army Medical Corps      (Ret.), has long been a leader in the care of injured patients and an      outstanding surgical educator. He will be assisted most ably by the      Editorial Board and especially by David Burris, MD, a colonel in the US      Army Medical Corps and Chair of the Department of Surgery at the F. Edward      H?bert School of Medicine, Uniformed Services University of the      Health Sciences.  

began including self-assessment questions and answers for the lead article of each issue. The      feedback so far has been very positive. With      this preliminary for?ay into continuing surgical education, 

 has decided      to commit to a broader-based, more extensive self-assessment program.  

     Beginning with the January 2007 issue, you will find a      series of questions related to general surgery topics. The questions will      also be available on the Web site, 

, along with the answers and brief explanations of the      correct responses. These questions will be very similar, although not      identical, to those asked on the American Board of Surgery Recertification      Examination and can be used in preparation. They will also serve to help      you document learning to meet the requirements of the multiple Maintenance      of Competence programs continually being developed by medical societies,      etc. Finally, they offer you an exciting way to keep current with surgical      developments and present you with an opportunity to pursue knowledge long      after the formal requirement for study has passed.  

 hopes you      will enjoy and utilize these new developments, and we would very much      appreciate your feedback. Visit 

 and click on "Contact Us" in the upper      right corner to send an e-mail to the editor about this or any other  question or comment you may have concerning the journal. 

Rib fracture causing delayed aortic laceration 

     I suggest that an endovascular approach in the event of      descending thoracic injury would be better than a "rapid      thoracotomy." Femoral arterial access could be obtained and a wire      placed in the thoracic aorta prior to mobilization of the fractured rib. If      major hemorrhage occurred, an occlusion balloon could be temporarily placed      while an endograft was being prepared.      

 An      endovascular stent may have a role in this condition, if a perforation of      the aorta is recognized but catastrophic bleeding has not yet occurred. In      our case the aortic injury was suspected but not confirmed. It would be      hard to advocate inserting a stent for what may end up being a normal      aorta.  

Needless to say, a stent would not be the procedure of      choice in the presence of acute intrathoracic bleeding. Immediate control      through a rapid thoracotomy would be necessary. A stent could be used prior      to reducing the fractured rib if diagnostic imaging revealed a sealed      perforation. 

     This was eloquently written and needs to be read by      the public. Political opportunism ruthlessly damaging the careers of good      people!      

					Assigned 47th Combat Support Hospital

					Assigned 274th Forward Surgical Team

Surgeons whose patients are the victims of terror bombings are likely to be confronted with unique and challenging injury patterns. These patients are at high risk for having their injuries missed during evaluation, which can be devastating in terms of morbidity and mortality. Reducing the incidence and impact of overlooked injuries requires a carefully thought-out and disciplined plan that incorporates close observation, repeated trauma surveys, and close coordination between multidisciplinary treatment teams. Surgeons at home or abroad may find themselves directing treatment for these complex trauma patients. To illustrate the difficulties described, the authors present three cases typical of those encountered at a combat support hospital deployed in Iraq.

	Victims of terror bombings sustain unique patterns of injury and present particular diagnostic and treatment challenges. These blasts can originate from a variety of sources, including an improvised explosive device (IED), a vehicle-born IED, or a suicide bombing. Although the delivery system may vary, the perpetrator’s goal is fixed: to cause the greatest degree of damage to the largest number of victims. Casualties are indiscriminate and may encompass both military and civilian targets. While caring for casualties of these asymmetric weapons continues to evolve, there are multiple reasons why these patients remain at high risk for missed injuries. To illustrate some of those reasons, we report three cases that are typical of those encountered at a combat support hospital deployed in Iraq.

—A 35-year-old man sustained blast injuries from a suicide bombing during a mass casualty (MASCAL) event. In an attempt at damage control, he underwent an immediate laparotomy at another institution before being transferred by military helicopter to our combat support hospital. The patient arrived intubated and sedated, with his abdomen packed to control a grade III penetrating liver injury and a bladder injury repaired using a suprapubic catheter. His initial vital signs were a heart rate of 142 beats per minute, blood pressure of 142/64 mm Hg, a respiratory rate of 21 breaths per minute, and a core temperature of 101.1°F. Physical examination revealed abdominal distension with skin closure and numerous penetrating injuries on his lower back, buttocks, and thighs, inflicted by spherical pellets (Figure 1). A laboratory evaluation was significant for a base deficit of &mdash;11 mmol/L, prothrombin time of 22.6 seconds, and hematocrit of 31%.

	The patient underwent 12 hours of resuscitation, after which a second exploratory laparotomy was performed. This found a spherical missile at the junction of his anterior rectum and the posterior bladder, with a 1.5-cm hematoma at the peritoneal reflection. Rigid proctoscopy identified blood but no discrete rectal injury. After a rectal washout, an end colostomy with a Hartmann’s pouch was created and the bladder was revised over a Foley catheter for anatomic drainage. An attempt to remove the liver packs was unsuccessful, and the liver had to be repacked with administration of whole blood and activated factor VIIa.

	Over the next 48 hours, a limited neurological examination observed a complete motor deficit in flexion and extension of the patient’s right foot and loss of strength at hip flexion, but preserved sensation throughout the limb. Four days after presentation, the patient’s liver was unpacked, the fascia was closed, and several ball bearings were removed through a right hip arthrotomy. Once the patient was hemodynamicallystable and could tolerate transfer and movement, a computed tomography (CT) scan of the abdomen and pelvis was performed. The CT scan revealed the severity of penetrating injuries to the spinal column at vertebrae L4 and caudal (Figure 2), which prompted transfer of the patient to a higher care facility with neurosurgical capabilities.

—A 32-year-old man was the victim of an IED during a MASCAL event and sustained multiple penetrating injuries to his right flank, arm, and leg. Despite a negative FAST (Focused Assessment by Sonography in Trauma) examination, his abdomen was tender on palpation. A portable radiograph of the patient’s chest did not identify any pneumothorax, but a spherical pellet was noted at the level of the right hemidiaphragm. Other injuries included a right ulnar fracture with massive tissue loss, an intra-articular foreign body in the right knee, and a through-and-through, penetrating injury to the right calcaneus.

	A laparotomy was performed, and five colotomies in the mid-transverse colon were repaired, while a ball bearing was retrieved from within the posterior falciform ligament. Further mobilization of the triangular ligaments had to be halted due to a contained hematoma. Investigation of the right superficial femoral and popliteal arteries revealed no arterial compromise, and a right knee arthrotomy was performed to retrieve an intra-articular ball bearing. The extent of tissue destruction in the patient’s leg and degree of resuscitation mandated a four-compartment fasciotomy.

	His right arm had to be amputated at the elbow because of tissue loss and nonviability. During the 12 hours that followed, his right leg lost distal pulses, necessitating an arterial thrombectomy of the popliteal artery followed by reverse saphenous vein graft bypass around the injured segment of the posterior knee. A postoperative arteriogram administered prior to the patient’s departure from the operating room (OR) demonstrated bypass patency.

	Several weeks later, radiographs of the patient’s chest were taken, and everything appeared normal; however, 72 hours after these radiographs were taken, attempts to insert a routine subclavian central line were complicated by the withdrawal of bilious fluid from the right pleural space. This prompted a tube thoracostomy.

	A postoperative radiograph of the patient’s chest subsequent to his departure from the OR revealed the degree of bilious effusion that had developed in this 72-hour interim (Figure 3). After 5 days of drainage, a right thoracotomy for empyema revealed a penetrating injury through the hepatic diaphragm (Figure 4), which had been overlooked.

—A 28-year-old man was involved in an IED blast in which his right arm was shattered and nonviable to the shoulder. A tourniquet and chest tube were placed while the patient was in the field.

	The patient arrived obtunded, with an initial heart rate of 99 beats per minute, blood pressure of 95/32 mm Hg, respiratory rate of 22 breaths per minute, and a core temperature of 97.4°F. Physical examination revealed his lungs were clear and his abdomen was soft on palpation.An initial FAST examination was normal, and a rectal examination was negative for blood.

	The right upper extremity was mangled beyond salvage to the humeral head, with active arterial hemorrhage. No other entrance or exit wounds were identified. A portable chest radiograph showed both lungs inflated with a properly positioned chest tube and a large, dense foreign body over the right hemidiaphragm, although it was difficult to differentiate this foreign body from other debris littering the stretcher and patient (Figure 5). The patient’s laboratory results were significant for a pH of 7.2, lactate of 6.2 mmol/L, and hematocrit of 38%.

	A right shoulder disarticulation was performed immediately for vascular control, and wounds were packed open. An intraoperative fluoroscopy examination did not identify the foreign object noted earlier, but a postoperative CT scan of the chest confirmed a dense, disk-shaped object measuring 5 x 5 x 2 cm in the inferior right hemidiaphragm (Figure 6).

	After 36 hours of resuscitation, a large metal missile was retrieved through a right thoracotomy, and a missed diaphragmatic injury was repaired. Serial washouts with eventual myodesis and skin closure were performed on the right shoulder, and the patient was discharged to an allied hospital for further rehabilitation.

 Much has been written about blast injuries in the medical literature, and it is well known that these injuries can be particularly devastating. A blast has five mechanisms for causing injury, categorized as follows: primary from the blast wave, secondary from projectiles, tertiary from the victim being thrust against stationary objects, quaternary from the generated heat, and quinary from the explosive material’s toxicity.

Jeffrey Musser, Assigned 47th Combat Support Hospital, Mosul, Iraq, and Medical Director, ICU, Madigan Army Medical Center, Tacoma, WA; Edward M. Falta, Assigned 274th Forward Surgical Team, Mosul, Iraq, and Chief, Organ Transplant Surgery, Walter Reed Army Medical Center, Washington, DC

December 2006

2006

Applying the Principles of Larrey's Flying Ambulance: an International Military Medevac Mission

Surgeon's Bulletin Board

Strategies to reduce the incidence and impact of overlooked traumatic injuries in blast victims

So you want to be a surgeon

Acute aortic occlusion from heparin-induced thrombocytopenia

Solid Pseudopapillary Pancreatic Tumor Remains Asymptomatic for 30 Years