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Chapter 33 TACTICAL MEDICINE Tactical Medicine Chapter 33 TACTICAL MEDICINE LANNY F. LITTLEJOHN, MD,* and BRENDON G. DREW, DO† INTRODUCTION BACKGROUND Tactical Environment History of Combat Death Statistics Wounding Patterns TACTICAL COMBAT CASUALTY CARE OVERVIEW Origins Definitive Proof of Effectiveness Phases of Care Contrast to Civilian Prehospital Care HEMORRHAGE CONTROL Tourniquets Hemostatic Dressings Junctional Hemorrhage AIRWAY MANAGEMENT CHEST TRAUMA DAMAGE CONTROL RESUSCITATION Fresh Whole Blood Stored Constituents of Blood Artificial Colloids Crystalloids Best Strategies for Fluid Resuscitation Emerging Adjuncts to Damage Control Resuscitation MEDICATIONS Tranexamic Acid Pain Control Antibiotics CASE REVIEW CONCLUSION *Commander, Medical Corps, US Navy; Command Surgeon, Naval Special Warfare Development Group, Dam Neck, Virginia Beach, Virginia †Commander, Medical Corps, US Navy; Chairman of Emergency Medicine, Naval Medical Center San Diego, San Diego, California 477 Fundamentals of Military Medicine INTRODUCTION Medical practice in a limited-resource operational such as those delineated in the Tactical Combat Ca- environment frequently differs from “standard” sualty Care (TCCC) guidelines and the Prehospital practice in a fully resourced hospital in the United Trauma Life Support (PHTLS) manual.1 Thorough States. Battlefield trauma care is based partly on appreciation of these concepts is important not only standard US guidelines, such as the Advanced for the practice of individual military medical officers Trauma Life Support (ATLS) course, but also with an (MMOs), but also for MMOs’ oversight and empow- eye toward the unique considerations of a forward erment of further forward deployed providers (eg, deployed environment. This chapter will highlight corpsmen and medics) who provide care close to the important operational medical skills and guidelines, point of injury. BACKGROUND Tactical Environment tions can be expected to eventually fail. Blood products may rapidly be rendered useless when generators fail Delivering medical care in the tactical environ- or blood reefers (refrigerators) simply cannot maintain ment is one of the most daunting tasks an MMO will products at 0°C to 10°C indefinitely. be asked to prepare for and accomplish. This care To prepare for success in the tactical setting, takes place at the confluence of several challenging mindset is a fundamental consideration for MMOs. situations, including austere environments, limited In addition to normal US practice standards of care, resources (in both personnel and equipment), un- MMOs must also know how to handle the unique usual and severe wounds, and the possible presence wounding patterns, resource limitations, and tactical of a dangerous enemy. Exhibit 33-1 provides a more considerations common in this setting. There are three complete listing of conditions and concerns in this main objectives in providing care to a casualty during environment. a tactical or combat mission: Considering these factors, MMOs must prepare to care for the severely injured while also considering 1. Provide the best possible care for the casualty. human performance issues related to environmental 2. Minimize additional casualties. extremes. In extreme and austere settings, the human 3. Maximize the probability of mission success body is required to operate outside its normal daily for the unit. training pattern and adjust to the effects of high alti- tude, cold, heat, or other factors. Each of these condi- Mindset is also enhanced by remembering the tions involve a host of problems and medical treatment differences between principles and preferences, as options, including the very real concerns of infectious described in the PHTLS manual.1(xxi) “Principles” are disease. Health problems caused by these threats, col- medical care goals that must be accomplished to best lectively referred to as disease and nonbattle injury take care of the patient. “Preferences” are how these (DNBI), have been the leading cripplers of fighting forces throughout history. These topics are further discussed in Chapter 20, Physical Fitness; Chapter 21, Performance Nutrition; Chapters 22 through 24, on EXHIBIT 33-1 environmental extremes; and Chapter 40, Preventive Medicine in the Deployed Environment. CHALLENGES OF THE TACTICAL Environmental elements affect not just the human ENVIRONMENT body, but also the equipment required to care for it. The battlefields of Operation Enduring Freedom • Hostile fire (OEF) have seen temperatures from below freezing, • Darkness in January at Bagram Airfield in Parwan Province, to • Altitude upwards of 137°F, in August in Helmand Province. In • Weather extremes • Prolonged evacuation the Hindu Kush mountains, to the extreme northeast, • Limited resources operations reportedly took place as high as 15,000 to • Provider training level 17,000 feet, higher than any peak in the continental • Mission completion United States. In both Iraq and Afghanistan, fine dust • Tactical considerations penetrates nearly any container except a tightly sealed • Local disease prevalence zip-lock bag. Thus, any equipment used in these condi- 478 Tactical Medicine goals are accomplished in the context of the entire MMOs should study their unit’s various missions casualty care scenario. For example, in hemorrhage in depth prior to deployment, because not all tactical control, the principle is to stop the bleeding. The medicine will occur on combat missions. For example, preference will depend on the unique casualty care Exhibit 33-2 lists the numerous possible missions of scenario and the tactical setting. One might choose to a Marine expeditionary unit deployment. Lastly, the immediately place a tourniquet while under effective MMO should thoroughly study the environment of hostile fire, even if there is only moderate bleeding, care and resources available in the specific area of whereas in a safer environment, a provider might ap- operations. Limited treatment and rapid evacuation ply a pressure dressing as the initial action. to a higher level of care may quite possibly be the best To deliver the very best care in challenging envi- option for a given patient and tactical scenario. ronments, MMOs must have a strong font of knowl- edge and a wider breadth of skills than their civilian History of Combat Death Statistics counterparts. A provider should have multiple ways of accomplishing tasks such as securing an endotra- To understand the basic statistics involved in cheal tube. MMOs must also understand the tactics, describing combat casualties, the terms “killed in techniques, and procedures unique to their unit; be action” (KIA), “died of wounds” (DOW), and “case thoroughly versed in the unit mission; and develop a fatality rate” (CFR) must be defined. Up to 90% of all collegial working relationship both with the command casualties who do not survive die on the battlefield and with the medics or corpsmen working under their before arriving at a dedicated field hospital. These supervision. The joint operational environment US casualties are described as KIA. KIA has classically forces commonly work in requires an understanding of served as an indicator of weapon lethality and the all other medical capabilities—those in other US units, utility of protective measures, both of which have interagency organizations, and coalition partners. De- increased steadily over time. If a casualty survives cisions must be made about which medical capability to be admitted to a field hospital, but then later dies will be placed where during unit operations. Casualty from injury, they are described as DOW. DOW has scenarios almost always involve both medical and been seen as an indicator of the effectiveness of com- tactical problems. Thus, the MMO must communicate bat casualty care. A combination of KIA and DOW is TCCC principles to unit leaders throughout their as- the CFR, which is an indicator of the overall lethality signment to the unit so that appropriate management of the battlefield. and evacuation plans can be developed in the context Organized prehospital trauma care had its birth on of the overall tactical situation. the 19th century battlefields of the Napoleonic wars. Before discussing specific injuries in the combat With each major conflict since, lessons learned were environment, some further broad principles must be covered. Predeployment training for the differ- ent services continues to differ significantly, even for similar missions. It is incumbent on providers to pay close attention in training and to seek further training EXHIBIT 33-2 early once they are informed of a pending deployment. POSSIBLE MISSION PROFILES FOR A On their initial deployment, MMOs are rarely fully MARINE EXPEDITIONARY UNIT prepared to experience and manage combat trauma; thus, exposure to actual trauma, as well as contact • Amphibious assault with providers who recently returned from combat • Security, stability, transition, and reconstruc- operations, is essential. Examples of in-depth trauma tion operations training for military providers can be found at the • Support theater security cooperation activities Navy Trauma Training Center at Los Angeles County/ • Humanitarian assistance University of Southern California Medical Center, • Noncombatant evacuation operations the Air Force Center for Sustainment of Trauma and • Tactical recovery of aircraft, equipment, per- Readiness Skills program at the University of Cincin- sonnel nati Medical Center, and the Army Trauma Training • Airfield operations from expeditionary sea
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