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Combat Casualty Care and Lessons Learned from the Last 100 Years of War

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Combat Casualty Care and Lessons Learned from the Last 100 Years of War Author’s Accepted Manuscript Combat Casualty Care and Lessons Learned from the Last 100 Years of War Matthew Bradley, Matthew Nealiegh, John Oh, Philip Rothberg, Eric Elster, Norman Rich www.elsevier.com/locate/cpsurg PII: S0011-3840(16)30157-5 DOI: http://dx.doi.org/10.1067/j.cpsurg.2017.02.004 Reference: YMSG552 To appear in: Current Problems in Surgery Cite this article as: Matthew Bradley, Matthew Nealiegh, John Oh, Philip Rothberg, Eric Elster and Norman Rich, Combat Casualty Care and Lessons Learned from the Last 100 Years of War, Current Problems in Surgery, http://dx.doi.org/10.1067/j.cpsurg.2017.02.004 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting galley proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. COMBAT CASUALTY CARE AND LESSONS LEARNED FROM THE LAST 100 YEARS OF WAR Matthew Bradley, M.D. 1, 2, Matthew Nealiegh, M.D. 1, John Oh, M.D. 1, Philip Rothberg, M.D. 1, Eric Elster M.D. 1, 2, Norman Rich M.D. 1 1 Department of Surgery, Uniformed Services University -Walter Reed National Military Medical Center, 8901 Wisconsin Ave., Bethesda, MD 20889 2Naval Medical Research Center, 503 Robert Grant Ave., Silver Spring, MD 20910 Corresponding Author: Matthew J. Bradley, MD LCDR MC USN Trauma/Critical Care Surgeon Assistant Professor of Surgery Walter Reed National Military Medical Center/Uniformed Services University E-mail: [email protected] Author email addresses in order: [email protected], [email protected], [email protected], [email protected], [email protected], [email protected] Conflict of Interest Statement: The authors declare no conflicts of interest. Disclosure: The authors are military service members (or employees of the U.S. Government). The opinions or assertions contained herein are the private ones of the author/speaker and are not to be construed as official or reflecting the views of the Department of Defense, the Uniformed Services University of the Health Sciences or any other agency of the U.S. Government. No funding was received for this work. The views expressed in this article are those of the author and do not necessarily reflect the official policy or position of the Department of the Navy, Department of Defense, nor the U.S. Government. This work was prepared as part of their official duties. Title 17, USC, §105 provides that ―copyright protection under this title is not available for any work of the United States Government.‖ Title 17, USC, §101 defines a U.S. Government work as a work prepared by military service member or employee of the U.S. Government as part of that person‘s official duties. The study protocol was approved by the Walter Reed National Military Medical Center and the Naval Medical Research Center Institutional Review Boards in compliance with all applicable Federal regulations governing the protection of human subjects. COMBAT CASUALTY CARE AND LESSONS LEARNED FROM THE LAST 100 YEARS OF WAR KEY WORDS: military history, combat casualty care, military surgery I. INTRODUCTION From our earliest records of Western societies sending their citizens into harm‘s way, those societies have usually made some provision for their citizens‘ care. However, the organization of medical professionals in various times and places makes meaningful comparison difficult and probably not productive. The names are the eponym legends: Paré and ligature, Larrey and forward surgical care, Letterman and medically controlled evacuation, Esmarch and first aid. However, we have chosen N. Pirogoff‘s observation that ―war is an epidemic of trauma‖ to shape this discussion. For the last 15 years the U.S. military has been at war in Asia and has witnessed and treated a variety of injuries, most notably from improvised explosive devices (IEDs), which have produced injury patterns never seen before in prior combat operations. The military medical community has learned a great deal from the care of these casualties while witnessing unprecedented survival rates. As we strive to evaluate and apply this latest epidemic experience we believe the involvement of the U.S. military in various 20th century wars may provide some guidance and warnings. We have chosen to focus on the 20th century for both military and medical reasons. First, war had become an extension of the modern industrial society, fought by huge armies, mobilizing the entire resources of the nation state. Operationally, combined arms warfare is the norm; logistics is the crucial staff activity; and the 19th century humanitarian revolutions had assured social leaders would watch the care of the soldier, sailor, airman, and Marine. Medically, preventive medicine based in germ theory had begun to make cities safer and this technology was used to help reduce disease and non-battle injury in deployed forces. Even more important, the various medical professional traditions had coalesced into a common, scientifically educated general practitioner (GP), and out of that community there was emerging a new surgeon, medically qualified, scientifically educated and hospital trained. Every Western army at the beginning of the 20th century used its social power to credential this new GP as the general medical officer (GMO) and this new surgeon as its hospital-based trauma manager. Arguably, the most significant progress in the care of the combat casualty may have occurred within the last century with contributions from several nations. What follows is a detailed description of the progress in the care of battlefield casualties and lessons learned from modern conflicts with U.S. involvement. II. WORLD WAR I As the whole of Europe fell into the clutches of World War I, the U.S. was coming of age. Medicine grew out of the 19th century with widespread acceleration of learning, sharing, and scientific interest. The Nobel Prize Committee awarded its inaugural prize in 1901[1], and would soon honor Alexis Carrel‘s revolutionary vascular work in 1912; he was the first surgeon, and, at the time, the youngest Nobel Laureate in history. Soon thereafter Carrel joined the French military, making strides in wound management[2]. The burgeoning Mayo Clinic transformed into a public institution in 1915, barely three years after Drs. Will and Charlie Mayo accepted reserve commissions as first lieutenants in the U.S. Army Medical Corps[3]. Acute medical conditions still carried grave danger—C. L. Gibson‘s paper in a 1900 volume of Annals of Surgery noted nearly 50% mortality from acute intestinal obstruction [4]. With notable exceptions, however, (Major Walter Reed‘s work on mosquito vectors and yellow fever, for example,) medicine on the front lines of conflict still slogged along at the pace of the U.S. Civil War. During the Spanish-American War, 10 times more soldiers died from illness in unsanitary conditions in domestic base camps than died close to the front lines[5]. ―Necessity is the mother of invention,‖ however, and the storms of war in Europe would soon water the fertile minds of military medicine around the world. WOUNDS AND WOUND CARE Turn-of-the-century wound care ranged widely, encompassing techniques old and new. The practice of Hippocrates‘ wound suppuration still lingered centuries later. Surgical legends such as Baron Guillaume Dupuytren and Baron Dominique Jean Larrey promoted surgical wound debridement in earlier centuries, but the practice largely disappeared after the decline of Napoleonic France, flowing in and out of favor through the early 20th century[6]. The new wave of physicians at the dawn of the 20th century espoused technological advances as the panacea for all ailments, wounds included. Sir Joseph Lister‘s proposal in 1867 that chemical antibiosis in the hospital could kill the bacteria causing wound infections stands as a milestone discovery in the annals of human medicine. Translation of his techniques into forward military practice came quickly when antiseptic occlusion dressings in soldiers‘ aid kits appeared in the Spanish-American War[7]; antiseptic coverage of wounds was taught as basic care to the European armies at the outset of The Great War. Lister himself, however, avoided ―old-fashioned‖ debridement of tissue, favoring his carbolic acid tonics alone for the best treatment of soft-tissue infection, though Sir Alexander Fleming thought the long-term gangrenous damage he saw at General Hospital Number 13 in 1915 outweighed the early benefit of Lister‘s caustic antiseptics[8]. The optimal, balanced approach to Listerian implementation combined with Larrey‘s debridement would eventually be promoted by Army Colonel Antoine Depage as what we would think of now as combined therapy—sharp debridement of dead tissue with medicinal cleansing of the remaining microscopic contamination.[6] Fleming‘s discovery of penicillin had not yet opened the floodgates for systemic antibiotics, so local delivery in the Listerian paradigm served as the primary medical antibiosis of the time. Topical carbolic acid only treated the surface of the wound, and with lower efficacy than desired. Alexis Carrel, only three years removed from receiving his Nobel Prize, collaborated with English chemist Henry Dakin to advance local decontamination. They perfected targeted delivery of Dakin‘s solution (0.5% sodium hypochlorite and dichlormaine T) to damaged tissues through perforated rubber tubing implanted or tunneled through the wounded service member‘s body[2, 7]. Infusions every two hours reportedly cleansed myriad wounds, allowing better surgical debridement or closure with a purified field[9]. Tubes and chemicals provided the best antiseptic therapy for salvaging wounds—and lives—in World War I, and was adopted in civilian practice until systemic delivery of antibiotics was developed later in the century[10].
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