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Contents lists available at ScienceDirect

Injury

journal homepage: www.elsevier.com/locate/injury

Editorial

In a stable battlefield, avoid using austere surgical units to meet the

golden hour of trauma time to care goal

Introduction Care at R3s likely superior to care at R2s

The North Atlantic Treaty Organization (NATO) categorizes While R2s provide superb care, a review of the existing

combat casualty care facilities according to their capabilities. Role literature reveals that care at R3s is likely to be superior to care at

1 (R1) is the most basic and delivers primary care and basic R2s. There have been two studies directly comparing mortality

resuscitation. A Role 2 (R2) facility has basic resuscitative and between R2s and R3s. The first study found no difference in

emergency surgical capability. Role 3 (R3) is generally the most mortality between patients initially seen at R2s compared to

comprehensive theatre medical asset with the most robust patients initially seen at R3s [2]. In contrast, the second study,

resources. In the United States, both the Army and the Marine which was five times as large, found the mortality rate was 6.6%

Corps have R2s; the Army has the Forward Surgical Team (FST) lower for critically injured casualties initially treated at an R3 [3].

while the Marine Corps has the Forward Resuscitative Surgical R3s are likely to provide better care because of their robust

System (FRSS). resources and the high volume of care they provide. The benefit of

R2s are ideal on a dynamic battlefield. They can be set up and robust resources was established with the introduction of civilian

taken down within an hour, and are highly mobile on the modern trauma systems. Trauma systems coordinate pre-hospital, acute

maneuver battlefield covering up to 50 to 100 kilometers in a day care, and rehabilitation assets to ensure timely access to

[1]. They provide timely surgical capability where there otherwise appropriate care. In these systems, seriously injured trauma

would be none. Many R2 assets were embedded with combat units patients are directed to trauma centers where resources, inter-

during the attack phase of Operation Iraqi Freedom (OIF). They are ventions, and specialized staff are concentrated. Studies have

also useful when the risk of casualties is low, number of troops found that the introduction of trauma systems is associated with

small, or presence transient, as to make establishing an R3 resource decreased mortality [4–7].

prohibitive. Militarily, R3s have more resources than R2s. R2s usually have

Once the battlefield stabilizes R3s are established. However R2s two to four general and orthopedic surgeons, anesthesiologists,

often stay in place, surrounding R3s to ensure compliance with the nursing support and basic blood bank support. In addition to these

American operational planning principle of the “Golden Hour of resources, R3s have specialists, CAT scans, intensive care units, and

Trauma” (GHT). This GHT concept holds that if a severely injured robust blood transfusion, pharmaceutical and operating room

patient can receive resuscitative surgery within an hour, his or her assets. These assets are important in the operational setting, as the

chances of survival are improved. US ground forces now operate modern care of IED injured patients often involves 5–8 surgeons

within an hour of surgical capability if possible. and 3 anesthesiologists working simultaneously [8].

By using forward R2s, time to treatment—as defined by early In addition to having robust resources, data from civilian

access to surgery—is decreased. However, this practice emphasizes trauma centers reveal a benefit from seeing a high-volume of

early access to surgery over treatment at a well-resourced, high- critically injured trauma patients. That is, with repetition, hospitals

volume center – such as an R3. improve. This relationship—improved quality of care with in-

Using R2s to satisfy the Golden Hour of Trauma time to creased patient volume—is well established in health care and

treatment goal, after R3s and en route care assets have been trauma care specifically [9–14]. Because severely injured patients

established, is misguided. Care at R3s should be emphasized as the have better outcomes at high-volume centers, the American

weight of the published evidence shows that treatment at a well- College of Surgeons requires advanced trauma centers to admit at

resourced, high-volume center is likely more important than time least 1200 trauma patients yearly, 240 of which must be severely

to treatment. Furthermore, time to treatment goals can be injured [15].

achieved with robust casualty evacuation resources, and important In a medically mature battlefield, R2s do not see many patients.

acute treatments can be done en route to R3 facilities with new, Our data from USMC units in Afghanistan reveal that our R2s

advanced evacuation platforms. While R2s play a critical role in performed one surgical case every two months; compare that to

certain operational settings, when the battlefield matures care at 158 surgical cases per month at R3s (Table 1) [8,16–20]. Some R2s

an R3 should be prioritized. saw only one injured patient every two weeks.

http://dx.doi.org/10.1016/j.injury.2017.08.048

0020-1383/© 2017 Published by Elsevier Ltd.

Please cite this article in press as: R. Childers, P. Parker, In a stable battlefield, avoid using austere surgical units to meet the golden hour of

trauma time to care goal, Injury (2017), http://dx.doi.org/10.1016/j.injury.2017.08.048

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JINJ 7378 No. of Pages 4

2 R. Childers, P. Parker / Injury, Int. J. Care Injured xxx (2017) xxx–xxx

Table 1

Comparison of volumes at Role 2 versus Role 3 in OIF/OEF in stable battlefields with established R3s and robust CASEVAC.

d c

Setting Months of Data Median Trauma Patients/Mo Median Trauma Operative Cases/Mo

a

Role 2 Unpublished 65 2.6

a

Role 2 Unpublished 53 0.6

Role 2 Published [16–19] 52.5 54.4 23.4

Role 3 Published [20] 15 173.3

b

Role 3 Published [8,20] 48 157.9

a

C Alvarado, G Demers, A Elliot, J Liang J. Moore, P Woodson. Personnel Communication 2013–2014 all from US Navy units serving in Helmand Province Afghanistan 2010–

2014. We were able to obtain 65 months of data for trauma cases, and 53 months for operative cases, from two Role 2 units.

b

Role 3 operative cases included specialty fields including neurosurgery, OMFS, and ophthalmology.

c

Operative cases may, especially at role 3 facilities, include multiple operative procedures.

d

Trauma patient definition varied according to publication; some met Joint Theater Trauma Registry inclusion criteria, others were defined loosely as trauma resuscitations

tracked in individual databases. In general, all patients regardless of acuity were included.

Time to care in trauma patients should not be overemphasized continually improved over the course of the last 15 years.

Increased tourniquet use [24], the introduction of hemostatic

Many would agree that care at R3s might be better, but argue dressings [25], decreased hypothermia in the prehospital setting

that decreased time to treatment makes up for this difference. The [26], advances in prehospital care capabilities [27], implementa-

existing literature is all observational, so definitive conclusions tion of damage control resuscitation [28], the introduction of an

cannot be made; however, what exists reveals only a weak organized military trauma system [29], more robust combat

association between transport time and mortality in trauma trauma research [30], improved training [31], the use of

patients. tranexamic acid [32], and improved diagnostic capabilities [33]:

The effect of prehospital time on mortality in trauma patients these are just some of the advances in combat casualty care made

has been examined in both the civilian and military sector. in the last conflict. These improvements, as well as unseen factors,

Harmsen recently published a systematic review examining the confound our ability to make causal inferences from Kotwal’s

influence of prehospital time on outcome in civilian trauma observational data.

patients [21]. Sixteen studies of total prehospital time (TPT) met The available evidence is consistent with the conclusion that

their inclusion criteria. In six studies examining total prehospital short transport time probably decreases mortality in a small

time in undifferentiated trauma patients, only one showed a portion of patients. While the evidence to support an association

clinically significant association between TPT and mortality. Only between pre-hospital time and mortality is weak, we are not

one of three studies of penetrating trauma showed an increase in arguing against a short transport time per se. Rather, we are against

mortality with increased TPT. None of the three blunt-trauma using forward surgical assets to accomplish transport time goals

patient studies showed a benefit to short prehospital time. Only because it minimizes the greater importance of being seen at a

one of three studies looking at traumatic brain injury (TBI) showed well-resourced, high-volume center, and because there are better

a statistically significant decrease in mortality with early transport. ways to shorten pre-hospital time.

The one study in TBI patients that is cited as showing decreased

mortality with shortened prehospital time had mixed results and is Robust casualty evacuation resources: the best way to shorten

emblematic of the studies on the subject [22]. While a statistically time to treatment

significant association with mortality with each incremental

minute of patient arrival was found, it is unlikely to be clinically The best way to decrease time to treatment is by increasing

significant. The hazard ratio (HR) was 1.002, 95% CI 1.001–1.004, evacuation assets, not by placing forward R2 surgical assets. In

p = 0.001. A HR of 1 would represent no association. There was no 2009, after Secretary Gates mandated the GHT policy, air assets

survival benefit observed for patients arriving within 60 min of were increased to meet this mandate [34]. The result was

injury time (HR 0.77, 95% CI 0.50–1.18, p = 0.22) but an apparent decreased time to treatment, with a simultaneous decrease in

benefit for those presenting within 2 h of injury time (HR 0.31, 95% the percent of patients seen at R2s. The percent of casualties

CI 0.15–0.66, p = 0.002). There is therefore a hint of effect, but initially seen at R3s increased from 42.4% to 48% with a

certainly nothing convincing. corresponding decrease in the percent of patients initially seen

When using observational literature to determine causation, first at R2s [3].

consistency is required; it is absent on this subject. Most of the The use of the MV22 Osprey is also an intriguing option to

studies on the subject are negative. It is important to remember decrease time to treatment. With a max speed of 316 mph, the

that in observational literature, a study that finds no association is casualty could be over 100 miles away from an R3 and still be

more likely true than a study that does find an association [23]. If delivered within an hour [35]. Using MV22 as an evacuation

there were a strong association between TPT and mortality, then in platform has been explored and we are curious to see more data

all the negative studies there would have to be a confounder that [36,37].

exactly counteracted the benefit of a shortened prehospital time. The recent conflicts in Iraq and Afghanistan saw advances in

In 2009 Secretary of Defense Robert M. Gates mandated pre-hospital care that can mitigate longer transport time. One

prehospital helicopter transport of critically injured combat example of improved patient evacuation was the British Medical

casualties in 60 min or less. In 2015 Kotwal published an important Emergency Response Team (MERT). In the MERT system, a team

study examining the effect of this golden hour policy on combat consisting of a physician, nurse, and two paramedics operating

casualty mortality [3]. within a large CH-47 Chinook helicopter were able to administer

The investigators found that after the mandate, transport time advanced care typically not available in conventional en route care.

decreased and mortality rate improved even in the setting of more Some of these important interventions that can be completed en

severely injured casualties. While this is an encouraging finding, it route to higher care include compressible hemorrhage treatment,

does not necessarily follow that the decreased transport time airway control, chest decompression, blood product administra-

caused the decreased mortality. Combat casualty care has tion, and hypothermia control [26,27]. There is evidence that, in

Please cite this article in press as: R. Childers, P. Parker, In a stable battlefield, avoid using austere surgical units to meet the golden hour of

trauma time to care goal, Injury (2017), http://dx.doi.org/10.1016/j.injury.2017.08.048

G Model

JINJ 7378 No. of Pages 4

R. Childers, P. Parker / Injury, Int. J. Care Injured xxx (2017) xxx–xxx 3

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Richard Childers*

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* Corresponding author.

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E-mail address: [email protected] (R. Childers).

Please cite this article in press as: R. Childers, P. Parker, In a stable battlefield, avoid using austere surgical units to meet the golden hour of

trauma time to care goal, Injury (2017), http://dx.doi.org/10.1016/j.injury.2017.08.048