The History—and Future—of Combat Care
Throughout history there have been numerous medical advances on the battlefield. During Alexander the Great’s military campaigns in the 4th century B.C., soldiers with bleeding extremity wounds were taken care of through the use of tourniquets. Tourniquets were also employed by the Romans during amputations. The practice of using an early stretcher made from wicker and placed on a frame was recorded in a 1380 A.D. manuscript. Simple stretchers were used to transport casualties during wartime through the mid-20th century. The practice of triage was pioneered during the Napoleonic Wars. American Civil War surgeon Maj. Jonathan Letterman developed modern methods of medical organizations within armies.
Battlefield medicine, also known as combat casualty care, developed a great deal between World War I and World War II. In the former, about four of every 100 wounded men who received treatment could be expected to survive; in the latter, the rate improved to 50 of every 100.
Comparison of statistics for battlefield casualties from 1941–2005 indicate the U.S. casualty survival rate in the global war on terrorism has been the best in our nation’s history. The percentage of those wounded who died in World War II, Vietnam and Operation Iraqi Freedom/Operation Enduring Freedom was 19.1 percent, 15.8 percent and 9.4 percent, respectively.
‘Golden Hour’ Crucial
Multiple studies of historical casualty rates have indicated that nearly 50 percent of military personnel killed in action died from excessive blood loss and about 80 percent go on to expire within an hour after initial injury. This hour is crucial to survival of the casualty and is known as the “golden hour.” The death of the casualty can best be prevented by immediate treatment of the hemorrhage within an hour after initial injury. One of the major reasons why we are doing better in casualty survival is due to tactical combat casualty care. This is essentially a set of best-practice, pre-hospital trauma care guidelines custom-made for battlefield use.
Up to 90 percent of combat deaths occur before the casualty reaches a medical treatment facility. The fate of an injured soldier often lies in the hands of the person who provides the initial care to the casualty. However, there may not be any combat medical personnel available when the casualty occurs. Pre-hospital care is the most important factor in assuring the survival of the casualty. The goal of tactical combat casualty care is to identify and treat casualties with preventable causes of death and keep them alive to reach the hospital. Tactical combat casualty care has helped keep our wounded warriors alive.
Causes of Preventable Death
The three most common causes of preventable death on the battlefield are: hemorrhage from extremity wounds, tension pneumothorax (secondary to a penetrating injury to the chest) and airway problems. There are several factors that may interfere with a medic’s ability to provide care in the tactical environment. These factors are: hostile fire, darkness, extreme environments, limited medical equipment, possible prolonged evacuation time, unit mission and tactical flow.
Over the past decade, combat medicine has improved considerably with an overhaul of everything from training to gear. Enlisted military training for the U.S. armed forces is located under one command—the Medical Education and Training Campus at Fort Sam Houston, Texas. After completing the basic medical course, students go on to advanced training in tactical combat casualty care, a set of evidence-based, best-practice, pre-hospital trauma care guidelines.
Tactical combat casualty care is becoming the standard for tactical management of combat casualties within DoD. It has been a major factor in U.S. forces having the highest casualty survival rate in American history. Tactical combat casualty care is built around three definitive phases of casualty care: care under fire, provided while the medic and casualty are under hostile fire; tactical field care, provided once the casualty is no longer under hostile fire; and tactical evacuation care, provided while the casualty is evacuated to a higher echelon of care. The improvement in how combat casualties are managed has resulted in significantly lower death rates in combat.
Innovation is an ideal way to find solutions for old problems. Military units that have trained all their unit members in tactical combat casualty care have registered the lowest incidence of preventable deaths in the history of modern warfare. The U.S. military achieved extraordinary success in casualty survival during the wars in Afghanistan and Iraq.
Combat Medic Training
Combat medics or field medics are military personnel who have been trained to at least an Emergency Medical Technician-Basic level (a 16-week course in the Army) and are responsible for providing first aid and front line trauma care on the battlefield. They hold the primary MOS of a Health Care Specialist (68W) and are also responsible for providing medical care in the absence of an available physician. Combat medics are vital to combat operations and have one of the most stressful military occupations. They are eager to be soldiers and fight while also charged with preserving life on and off the battlefield. “Forging loyalty” describes the main process of combat medics to adjust to severe stress and trauma during deployment.
Advances in battlefield medicine also have been possible through virtual health care. It connects patients with physicians using a computer, tablet or smartphone.
Injured trauma patients are transported by way of the U.S. military trauma system. The medical care provided to these patients has been organized into four “roles” of care, with each higher numbered category having more medical and surgical treatment capabilities. Role 1 medical treatment facilities consist of emergency first responder and tactical combat casualty care; Role 2 facilities offer limited hospital capability; Role 3 facilities have full but short-term hospital capability (e.g., a combat support hospital); and Role 4 medical treatment facilities are located in safe areas inside or outside the continental U.S.
An analysis provided a comprehensive examination of pre-hospital trauma patients by type and mode of transport from Role 1 to Role 2 facilities in Afghanistan. The most common injury was penetrating and the dominant injury mechanism was explosion. The mode of transport in this study was by medical evacuation. Finally, this study highlights the need to support the continued emphasis on tactical combat casualty care training. Moreover, there is also a need for standardized qualifications for non-medical and medical personnel in providing reliable transportation care.
Another study evaluating battle injuries from IEDs and mines encountered by a mechanized Marine Corps battalion in Iraq provided insight into injury profiles and prevention. Upper extremity and head injuries were common, suffered by 70 percent of those injured. Ear injury was the most common single injury (23 percent). It is believed that combat earplugs could reduce these injuries. Eye injuries were rare (0.5 percent) because of ballistic eye protection.
Injury to the torso was mild because of body armor vests. Since most of these wounds were minor, 80 percent of those injured Marines returned to duty.
A more recent and comprehensive analysis indicates about 52,200 U.S. service members were injured during Operation Iraqi Freedom and Operation Enduring Freedom from 2001–2009. More than 10,000 service members were evacuated due to battle injuries. From 2001 through 2005, 78 percent of injuries in OIF/OEF were blast-related. Those injuries were caused by the enemy’s increased use of IEDs. When an IED detonates under a vehicle, the event is called an underbody blast. Underbody blasts were a significant cause of morbidity and mortality among service members in Iraq and Afghanistan. Forty-one percent of the wounded-in-action injuries endured were in the pelvis, thigh, lower leg, ankle and foot. Twenty-two percent of service members killed in action had significant injuries to the lower half of the body, but the more frequent body regions affected were the head and torso.
This injury analysis suggests additional studies must be conducted to guide research to develop lifelike modeled response curves, human injury criteria and injury assessment reference curves, which assess injury using laboratory dummies that mimic human response to physical injury.
Battlefield Trauma Care Redefined
The combined published data and battlefield experience have resulted in the services using tactical combat casualty care to care for their combat wounded. Through collected efforts, the U.S. military has redefined battlefield trauma care.
Future research should strive to better account for and understand the need to reassess battlefield medicine. It also should focus on introducing methods to advance presurgical care on the battlefield. DoD’s Tactical Combat Casualty Care Working Group has established a methodology in which DoD can ensure battlefield medicine and trauma care are ongoing educational processes that can adapt swiftly to new data and combat experience.
Additionally, it is interesting to observe reports of the proliferation of robotic surgeons, unmanned vehicles and technologies worth exploring when researching battlefield medicine. Development of the robotic telesurgery system, for example, was supported in part by NASA and the Defense Advanced Research Projects Agency. These technologies will carry on and multiply in ground medical operations. They will certainly have potential to reduce combat fatalities.
What must be accomplished is the preservation of military medicine advances made for our nation’s wounded. Medical advances brought about from lessons learned must not become lessons lost.