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]. Depage, also by then the director of the Belgian Red Cross, presented illustrative data to the American Surgical Association‘s 1919 meeting based on his hospitals‘ treatments in the later stages of the war. The decrease in amputations was astounding, especially after the addition of arthrotomies with Carrel-Dakin‘s irrigation, followed by immediate closure when the wound included a major joint capsule.[11]
Even centuries before the bacteriological model of infection, military surgeons knew that infected or gangrenous wounds killed patients. Unfortunately for the injured soldier or sailor, this often meant amputating the offending limb. While Lister, Carrel, Fleming, and others worked to manage the infection, surgical contemporaries devised better interventions for source control.
The prevailing thought for projectile-wound infections, almost since the debut of powder-fired weapons, was that of poisoning by gunpowder or poison-laden projectiles themselves. New observations by military physicians in far-flung global wars advanced the corporate knowledge of wounds through the tragedy of soldiers injured in those conflicts. One U.S. surgeon, Navy Commander A. M. Fauntleroy, wrote about this prolifically, as a result of his assignment as a forward medical observer in Europe before the U.S. entered the war. Fauntleroy presented a paper at the 1916 American Surgical Association meeting proposing contaminated clothing as an infectious source, and that wounds reflected the environment in which they were incurred. His experience treating the injured from the Boer Wars on the dry veldts of South Africa noted quick recoveries for soldiers with open but minimally contaminated wounds. When open wounds met the muck of trench warfare throughout Western Europe, results differed.
The wet fields of France and Germany, heavy with manure fertilizer, held different threats than the veldts.[12] Even warfare itself changed the microbial profiles of wounds. Trench warfare‘s stagnation meant injured men could sometimes lay for days in the contaminated No Man‘s Land between trenches. Fleming worked tirelessly at the Institut Marie Depage in the years prior to his revolutionizing discovery of penicillin. His studies of wounded soldiers‘ clothing yielded numerous bacteria, most of them terribly virulent, including C. perfringens and C. tetani.[6] As Thomas Helling notes in his treatise on Depage, ―[t]he dead were sometimes left indefinitely to rot before the trenches and often became part of the terrain as artillery pulverized them into the dirt and mud, adding to the microbial morass.‖[6] Dirt is the soldier‘s constant companion, and the wounds of ongoing wars continue to vex modern medicine. Similar work regarding invasive fungal infections from blast injuries is ongoing at America‘s leading military medical center, and carries direct relevance to the conflicts of today[13].
The new projectiles of higher-powered rifles and fragments of thousand-pound shells could lodge deep into the muscles of battle-hardened soldiers. Prevailing practices in earlier conflicts taught surgeons only to explore the wound in search of the offending missile if easily accessible or if arterial bleeding ensued. With the realization of Roentgen‘s X-ray technology, new devices and techniques arrived for accurate localization and removal of foreign objects. Joseph Flint, professor of surgery at Yale, served in several hospitals in France. His staff variously used a vibrating magnet and the ring compass (and developed modifications that allowed it to be molded and hinged, useful on any location on the body), finally settling on their modification of the Sutton Localizer. A piano wire, eventually modified to a more robust wire with a harpoon-style tip, was inserted under fluoroscopic guidance through a blunt obturator until contacting the bullet. The obturator allowed manipulation under the fluoro screen without sharp dissection or perforation concerns. This effectively established wire/needle localization as a technique for preoperatively defining a deep-tissue target for surgeons[14]. Flint credited these targeted removals for low rates of sepsis in his hospitals.
BURNS
Late 1800s burn care had changed little in the centuries prior that is in all but the most avant-garde surgeons. Balms, oils, tinctures of all sorts and sources—many had been in use since medieval days. The technologically advanced treatments essentially replaced solutions of steeped plants or animal products with picric or boric acid solutions. A Minnesota surgeon, Haldor Sneve, presented a paper that was decades ahead of its time when he suggested salt solution clysis for resuscitation and even xenografts of chicken skin to replace lost tissue. [15]
Fauntleroy turned tragedy into progress with his analysis of burn treatments. Late in the War, a coal ship explosion severely burned 32 men who presented within hours to Fauntleroy‘s hospital. His team essentially instituted a randomized, controlled crossover trial by starting half the victims with ―non- interference,‖ meaning without debridement, and the rest with standard removal of damaged tissue. All patients received the World War I version of treatments we recognize today—external heat, fluid resuscitation (done by Fauntleroy with rectal clysis using dextrose 4% with normal saline), dressing changes, and pain control. Interestingly, Fauntleroy concluded that burns healed best without debridement. Other aspects sound strikingly similar to the Clinical Practice Guidelines and leading research published by today‘s U.S. Army Institute of Surgical Research Burn Center, a world leader in burn care and research at the San Antonio Military Medical Center: early fluid resuscitation prevents burn shock, burn sepsis sets in quickly, and extensive body surface area burns do poorly.[16] Fauntleroy‘s paper stands as one of the first in a distinguished, ongoing line of military burn research.
LABORATORY MEDICINE
Entering World War I, laboratory medicine meant completing one‘s own tests with the office microscope or chemical kit, or contracting out to a local private chemist. Few hospitals offered laboratory services in- house. Residents or researchers provided the service for hospitals lucky enough to have the funding required. Private chemists were in short supply on the battlefields of Europe, however, so the Army provided lab services with speed and quality unexpected to deployed physicians. Pathologist Army Colonel Joseph Siler, M.D., managed a network of laboratories headquartered at the Central Medical Laboratory in Dijon, France. Notably, Siler exercised significant autonomy directing his labs, particularly because of confusion surrounding his chain of command. For many months early in the War, laboratory services ostensibly fell under the Division of Sanitation, managed by the Army‘s supply corps.
Physicians employed the labs with such gusto that efficiency became key. Army Colonel Louis Wilson served as Siler‘s assistant director of the Allied Expeditionary Force‘s laboratories. He served while on leave from his civilian role as director of laboratories at the Mayo Clinic. Wilson instituted a report detailing which ordered tests turned positive to determine appropriate utilization. This may be the first documented use of a ―Physician Report Card‖ for practice adjustment.[17]
Army labs offered wide-ranging tests, including the first forward-deployed pathogen testing. Typhoid and syphilis, specifically, ran rampant through troop encampments; testing and treating these infections effectively increased combat readiness of the force. So accustomed were physicians to the support of Siler and Wilson‘s labs that returning physicians soon demanded their home hospitals develop similar programs.[3] National societies soon joined the movement. The American College of Surgeons required in-house labs as part of their post-war accreditation package.[17]
Pathologists within range of the front also meant routine autopsies on deceased soldiers. Many young surgeons learned trauma care through the pathologist‘s knife, turning those tragedies to successes when treating future wounds. These autopsies also enhanced development of protective gear used by Allied troops, with real-time feedback available for commanders.[17]
BLOOD BANK
One of the military‘s greatest medical legacies from World War I is the blood bank. Leading surgery and hematology experts from around the world entered the Allied countries‘ services with an impassioned focus on saving lives through transfusion.
Almroth Wright described citration for the storage of blood in 1897. Physicians at Harvard/Massachusetts General Hospital stood on his shoulders in support of the war in Europe. Dr. Oswald H. ―Robby‖ Robertson widely advocated for typed blood to be available for transfusion at hospitals near the battlefront, citrated in a modification of Wright‘s method. Tremendous support came in the person of Harvey Cushing and Base Hospital 5, (known throughout the theater as ―Cushing‘s Hospital‖) especially after Cushing and other Harvard staff visited Carrel and staff working under Depage. With input from Carrel, Robertson and Cushing‘s staffs developed improved apparatus for administering the blood in a deployed setting. British physicians immediately embraced the practice, inviting Robertson to travel and teach.[7] Hundreds of physicians and nurses received training from Robertson‘s crew, spreading this lifesaving capability throughout the European fronts. As Hedley-Whyte notes in his review of transfusions and war, ―[b]y 1918 each base-hospital and casualty clearing station hospital was transfusing about 50 to 100 pints of blood to an average of 50 wounded each day on the Western Front.‖[18]
Robertson‘s impassioned drive to care for the troops yielded another world first—the blood bank. ―Robby‖ could often be found treating patients near or on the front battle lines—even once barely escaping German capture when his unit was overrun. During 1917‘s Battle of Cambrai, in far-northern France, Robertson fashioned an ice chest from ammunition cases to personally transport 22 units of blood to a clearing station within range of the fight. The blood survived the trip, treating Canadian shock casualties, and the blood bank was born.[19] Refrigerated banks became the rule throughout the Western Front.[20]
SHOCK
Army General J.M.T. Finney, a future American College of Surgeons (ACS) president, served as the Chief Surgical Consultant to the American Expeditionary Force for much of The Great War. In an act of visionary leadership, he established a Central Laboratory for focused, translational research on topics immediately applicable to battlefield medicine. Finney chose another future ACS president, Army Major George Crile, to head the Central Laboratory. Crile established early fame in the 1890s for his research in shock and surgical physiology, performed the first human-to-human blood transfusion in 1906, and would go on to found the Cleveland Clinic after being promoted to brigadier general in the inter-war years.
Walter Cannon, Harvard‘s eminent physiologist, researched and published prolifically from the Finney- Crile Laboratory. Cannon realized the detrimental effects of hypothermia on patients in shock, and was among the first to advocate active, artificial rewarming of trauma patients.[21] Cannon also proposed that shock resulted from blood and plasma loss, and was not purely a condition of nerves. He supported the use of intravenous fluids for treatment; earlier in the century, rectal clysis or subcutaneous (―under the breast‖[22]) was the quickest parenteral entry. Edward Archibald and W. S. McLean, two Canadian medical officers serving in Europe, followed Cannon‘s lead. They observed excellent resuscitation results with saline, even proposing an idea decades ahead of its time—―hypertonic salt solution at twice decinormal strength‖ for volume expansion. Their conclusions that the response to saline is important, but fleeting, also led to proposals of adding colloid to resuscitations. Further, they even noted some mechanism for blood being ―sucked away‖ from the circulation during shock, perhaps foreshadowing the widened intracellular junction model of today.[22]
MEDICAL EVACUATION Long before World War I, surgeons realized the basic fact that casualty survival increased as injury-to- surgeon time decreased. Larrey‘s ―flying ambulance‖ model had not been fully espoused by military planners, so most medical care comprised first aid by line medics, with advanced care waiting until after the battle subsided. This led to high mortality rates for intra-abdominal injuries, even leading some surgeons to avoid abdominal operations.[12] In Russia, Dr. Viera Gedroitz (a Russian princess and surgeon) refused to operate on abdominal injuries older than three hours. To access more soldiers inside that critical window, Gedroitz outfitted a railcar as a mobile operating suite, moving treatment toward the fight.[7] Another Russian pioneer instituted a continent-wide trauma treatment and evacuation system that became the basis for major wars of the next 100 years. Vladimir Oppel‘s system was based on his emphatic belief—―[t]he wounded patient needs to undergo the right operation at the right time and in the right place.‖ As a surgeon on his first assignment early in the war, he lamented inefficiencies in medical care, where injured soldiers only received cursory treatment on the line; others, less injured, might evacuate more easily and arrive at collecting stations, using resources meant for their comrades dying in the field. Dismal results followed—the Russian army was losing a war of attrition, returning only 40% to 60% of its casualties to duty, while on the western fronts, nearly 80% returned to fight. Oppel proposed an integrated trauma treatment and evacuation system recognizable to today‘s military surgeons, with the first decisions of care being made immediately in a maximum of six hours. In Echelon 1, wound debridement cleaned the wound and provided lifesaving treatment; Echelon 2 allowed major operative treatment with definitive procedures; Echelon 3 began rehabilitation, serial procedures, and other long- term treatments.[23] Adaptations on Oppel‘s plan form the basis of today‘s Joint Trauma System, itself a modification of the World War II structure.[23] The Royal College of Surgeons so appreciated his accomplishments that they accepted Oppel as an honorary fellow.
In the Allied forces, the Belgian surgeon Depage pushed care toward the line, setting up postes avances des hopitaux du front (advance posts of the front hospitals). Depage was already revered as one of the leading surgeons of northern Europe in 1912 when as a colonel in the Belgian army, he and Marie—his wife, anatomy illustrator, and research partner—traveled to the Balkans to set up hospitals for Belgian soldiers. Only months after delivering his 1914 presidential address, “Les enseignements de la chirurgie de la guerre” (―Instructions in the surgery of war‖) at the New York meeting of the Societe Internationale de Chirurgie, he and Marie separately escaped the German invasion of Belgium, soon reuniting to found an ambulance (military hospital) at the personal request of Belgium‘s Queen Elisabeth.[6] From his main Ambulance de l'Ocean at La Panne, on the North Sea coast of Belgium, Depage deployed his first postes avances in the paradigm of Gedroitz, but on motorcars instead of rail. Depage focused most of his forward care on abdomen and chest casualties, or massive hemorrhage. Patients stable for duty could return from there, gaining back time previously lost to long round-trip transport; those requiring further care traveled back to an ambulance. He reported that placing these mobile stations within 2 km of the active battlefront reduced abdominal wound mortality from 65% to 45%. Fauntleroy, the multi-war veteran renowned for burn care, supported this structure, noting when ―the patient could receive prompt attention, the results from operative treatment had been most encouraging‖ when compared with the expectant policies of prior conflicts.[12] When Marie died in the sinking of the Lusitania, he renamed Ambulance de l’Ocean the Institut Marie Depage in her honor. She was returning to his side from a lecturing and recruiting tour in the U.S. when she perished in the event that changed public opinion about U.S. involvement in the War.[6] It was out of Ambulance de l’Ocean that Fleming and Carrel produced so much military medical literature.
BIRTH OF PLASTIC SURGERY Plastic surgery blossomed in World War I. Sir Harold Gillies, an otolaryngologist by training, so impressed his seniors with skill and vision for the treatment of facial wounds that they chose him to open one of the first plastic surgery units in the world. Widely regarded as the ―father of plastic surgery,‖ Gillies treated nearly 11,000 patients in the United Kingdom‘s military service over two World Wars.[24] His impassioned care of ―our boys‖ changed the lives of his patients. Sir Harold developed numerous facial reconstructive techniques, perhaps the most famous being the ―tubed pedicle‖ graft.[25] Here he succeeded in maintaining robust blood flow to facial grafts with notably lower infection rates than prior techniques. He also championed the psychological impact of plastics, encouraging peer support and multiple follow-up visits to boost patient morale. Among those he trained would be his cousin and burn plastics pioneer, Sir Archibald McIndoe, whose newfound skills would bloom in World War II.[26]
VASCULAR SURGERY
Carrel led the world in vascular surgery techniques at the turn of the century. His triangulation-and-fill suture technique enabled consistently successful end-to-end arterial repair for the first time in history. Surgeons throughout the U.S. and Europe began implementing this technique, but military applications came slowly; ligation or amputation remained standard practice throughout World War I. Dr. Bertram Bernheim quotes poor transport times and high infection rates that prevented widespread use of arterial repair techniques. Most vascular repair work involved ligating pseudoaneurysms that had formed over injured vessels in the weeks after injury, when collateral circulation had already developed to help salvage the injured limb.[27]
SURGICAL SPECIALTY CARE
―[T]he one agent of successful surgery, whether war surgery or civil surgery, is the good surgeon.‖[28] Crile‘s classic proverb arrived at the 1919 meeting of the American College of Surgeons. Crile, along with several other pillars of American surgery, integrated civilian medicine into military structure and advanced the surgical care of our casualties.[29]
American Surgical Association President Robert G. LeConte encouraged military training for physicians, especially surgeons, knowing that surgeons in uniform encounter patients and environments not seen in civilian practice. ―The duties of the military surgeon are vastly different from those of a civil practitioner, and no one in civil life can take the place of a trained medical officer.‖[5] Even simple topics like hygiene contained inherent differences. During the Spanish-American War, for example, 3,681 mortalities were attributed to disease—2,649 of which were in stateside encampments. Only 293 men died from battle wounds. The risk of death was 10 times higher for those living at ―home‖ than fighting on the front line. To permanently remedy that civilian-military medical chasm, Will Mayo formally proposed a standing military medical school in 1919, just after the end of World War I.[3]
As the war brewed in Europe, Cushing, the Mayo brothers, and other medical giants prepared for America‘s contribution. Will and Charlie Mayo began formal service for their country when they accepted commissions as Army first lieutenants in 1912 at ages 51 and 46, respectively. Will Mayo chaired a committee of national medical leaders (Charlie Mayo also joined the board) who advised President Woodrow Wilson beginning in 1916. The Mayo brothers and committee began to assemble plans for mobilizing American medical expertise for war. Much help was needed, as the U.S. Army Medical Corps consisted of only 443 medical officers prior to World War I. Politically, Charlie Mayo championed the Owens-Drier bill, allowing medical officers to be promoted as high as major general to provide parity in operational planning. Prior to this time, regular Army physicians could only promote to colonel, and reservists (including Cushing, Crile, et al.,) could only attain the rank of major. The Mayo brothers eventually rose from 1st lieutenants to brigadier generals.
Meanwhile, Cushing led a team of Harvard physicians on a fact-finding and advising trip to Europe. The training and camaraderie this group developed became the de facto first reserve hospital unit. Western Reserve University and University of Pennsylvania soon followed suit as the concept spread.[7] The training paid dividends in battle—Cushing‘s hospital in France treated 499 patients in 27 hours during one particularly fierce battle.
III. WORLD WAR II
World War II saw major advances in surgery, blood transfusion, rapid patient transportation, and decreasing mortality from combat injuries. The U.S. military was thrust in the middle of a war already in progress across continents including Europe, Asia, Africa, and South America. While casualty statistics vary widely, the total number of battle wounded exceeded 25,000,000 and battle deaths numbered around 15,000,000.[30] At the time, the medical corps of the Army, Air Force, and Navy did not have enough medical officers ready for the volume of patients they would be receiving. Therefore, the Department of Defense (DoD) relied heavily on the direct commissioning of civilian physicians.
In his 1949 Presidential Address to the American Surgical Association, Fred W. Rankin, who had served in the U.S. Army in both world wars, reviewed his experience as an Army general and director of the surgery division of the U.S. Army in World War II.[31] Rankin cited four factors as being most important in the reduction of mortality and morbidity rates for battle injuries in World War II. These included the availability of excellently trained young surgeons who could perform surgery in combat areas; improved methods of resuscitation, including the ready availability of blood and blood plasma; the availability of antibiotics and chemotherapeutic agents used as adjuncts to surgery; and improved means of transportation, including aircraft, for movement of convalescent patients over long distances, even to the continental U.S.[31] As a result of those improvements in care, the percentage of combat casualties dying of wounds was reduced to 3.3% from the World War I level of 8.1%.[31] Furthermore, the mortality rates of patients with life-threatening wounds of the head, chest, and abdomen were reduced to approximately one-third of the rates in World War I.[31]
SURGICAL CONSULTANTS AND AUXILIARY SURGICAL GROUPS (ASG)
During the inter-war period, the U.S. Army Medical Department‘s strength after World War I was reduced from a peak of 340,000 to 11,500 officers and enlisted personnel by 1939.[32] To prepare for World War II, the Army Medical Department relied heavily on reserve and National Guard units to supplement the medical corps. In addition, the Medical Department shortened the length of the medical officer basic training course from five to three months and expanded the size of training classes. Due to the need to rapidly deploy medical personnel, much of the training, including specialized medical training required for the support of combat troops, occurred ―on the job.‖[32] While the efficacy of this new pre- war training regimen was not well documented, one can imagine that personnel experienced in war wounds, complex surgical procedures, and leadership were in high demand.
In response, the Office of the Surgeon General created the Professional Consultants Division within the office of the Army Surgeon General.[33] These consultants were academic surgical luminaries who were commissioned into the Army and served full time in their roles in uniform. These consultants became full-time medical and surgical advisors to the surgeon general. This is in distinct contrast to World War I where the consultants only served part time, or were only called upon when needed while they maintained their civilian duties as their primary roles. The responsibilities of the surgical consultants included promotion of the highest standards of surgery. The surgical consultants included Army Brigadier General Fred Rankin, Army Brigadier General Elliott Cutler, Army Colonel Edward Churchill, and Army Colonel Michael DeBakey. Through their observations of combat injuries and application of best surgical techniques within this challenging environment, practice guidelines and best practice solutions were devised that resulted in a 25-% to 50% decrease in case fatality rates from previous wars.[33] In addition, the assignment of appropriately trained young surgical specialists to forward combat areas as recommended by the consultants was key to the successes of the military medical department in reducing mortality from war wounds.
In distinction from the static trench warfare of World War I, the Second World War was far more kinetic with rapidly moving front lines. Churchill advocated that the best-trained surgeons needed to be toward the front to perform the most demanding procedures in the most unforgiving environment in the most severely injured patients.[23] The consultants group was tasked to provide a solution to get surgical care as close to the point of injury as possible. In response, the Auxiliary Surgical Groups (ASG) were proposed by the Surgical Consultants Division to push surgical care forward.[33] This novel concept was endorsed by Rankin, who was head of the surgical consultants group, and General Norman T. Kirk, the Army surgeon general at the time.
At the beginning of World War II, the field hospitals, which were large, fixed, 400-bed facilities, were the Army‘s primary surgical facility. These hospitals had to be placed close to airfields outside of the combat zone in order to evacuate patients out of theater. ASGs formed under Army Colonel James Forsee at Lawson General Hospital, Atlanta, were designed as mobile units that could bring surgical specialty care to the front and fluidly augment surgical care where it was most needed.[7, 33] Originally, four teams were created. Each specialty team in the group initially consisted of a chief surgeon, assistant surgeon, anesthesiologist, surgical nurse, and two enlisted technicians.[33] Eventually, specialist teams were also created to augment the ASGs. These teams included general, thoracic, neuro, plastic, maxillofacial, and orthopedic surgeons. These teams proved extremely valuable as they were surgical assets that could be moved around where needed most.[33] The initial ASG in combat (2nd ASG) deployed with 5th Army in 1943 to the North Africa, Sicily, and Italy campaigns.[21]
As with any novel concept, there was initial resistance to their implementation, primarily from the administrative side of the Army as the ASGs were not part of the official military inventory. In addition, many hospital personnel felt outsiders were supplanting them. However, the ASGs were eventually embraced because of the expertise of the surgeons deployed with them and their outstanding outcomes. Most importantly, their ability to pass on skills and best practices learned during combat proved invaluable. The ASGs compiled thorough medical records which were eventually analyzed.[33] Attachment of these teams was credited with decreasing mortality from penetrating abdominal mortality from a high of 66% in World War I to 24% in World War II.[7]
BLOOD TRANFUSIONS
Between the two world wars, the U.S. military gained much needed experience in blood storage, transportation, and transfusion. While blood and plasma transfusions were used in the latter years of World War I, it was during the Spanish Civil War (1936–1939) where the practicability of stored blood transported to severely wounded soldiers was proven. During this time, the Barcelona Blood Transfusion Service under General Francisco Franco‘s nationalist movement provided blood stored in citrated solutions to forward-deployed medical facilities. The blood was maintained under refrigeration and transported in insulated containers.[34] These techniques in blood storage and delivery would become a revolution in the resuscitation of victims of hemorrhagic shock.
With German aggression and the threat of war looming on the European continent, the British Ministry of Defense in 1938 established a committee in London to devise a solution for blood transfusion support to military hospitals. This led to the formation of the Army Blood Transfusion Service and the opening of the Army Blood Supply Depot in 1939, becoming the first military transfusion service in the world.[35] Prior to the U.S. involvement in World War II, the British experience with blood transfusion in the North Africa theater was already accumulating. It was their experience with transfusion of seriously wounded casualties that showed the ―oxygen carrying capacity [of whole blood] was essential during anesthesia and initial wound surgery.‖[34]
The problems of delivering large volumes of whole blood to the front during World War II were numerous. Obstacles included providing equipment for collection, storage, and delivery. Techniques to provide a prolonged shelf life as well as techniques for proper blood group typing were just being developed. Therefore, plasma, and later albumin, although not substitutes for whole blood, were widely used as the preferred resuscitation product. Plasma was being used in large quantities during World War II, primarily due to its ease of procurement, storage, and transportation in comparison to whole blood. During the early part of the war, the techniques for freeze-drying plasma were refined, and large volumes of it were transported to the front lines. While the ability to store frozen plasma existed at the time, freeze dried plasma could be preserved and stored for years under extreme heat and cold conditions. Furthermore, it would also be reconstituted with a simple kit and then transfused to the recipient with few adverse reactions.[34]
However, it was recognized by the Red Cross Subcommittee on Blood Substitutes that plasma was only a temporary solution without the availability of whole blood. Churchill, the North Africa consultant to the surgeon general, reported during the North Africa campaigns that whole blood was the resuscitation fluid of choice, and that it was the only therapeutic fluid for preparing seriously injured casualties for surgery, lowering both mortality and infection rates. In addition, he stated that plasma should only be used as a supplement to whole blood, and not a substitute for it. The experiences in the North African theater, as well as the subsequent campaigns in Italy, provided ample evidence for the efficacy of whole blood and plasma transfusions in severely wounded casualties prior to the large-scale engagements in the latter part of the European theater campaigns.
ANTIBIOTICS AND SURGICAL CARE
Sulfonamide antibiotics, discovered in Germany prior to the conflict, were first used in World War II. They were mass produced in preparation for the war and used by both the British and U.S. military. Sulfonamides were used in powder, oral, and parenteral forms to treat infected wounds as well as gonorrhea. Initially, there was widespread enthusiasm for sulfa antibiotics, and it was even issued as a powder inside the first aid kits that were given to every American soldier. They were instructed to place the powder on open wounds immediately after injury.
Sulfonamides were credited with significantly decreasing the incidence of gas gangrene in wounds as compared to World War I, although the principle of early surgical debridement contributed significantly.[36] Unfortunately, sulfonamides had significant adverse effects, to include agranulocytosis and nausea when taken in oral form. By 1943, sulfonamides were phased out as treatment for gonorrhea due to the development of bacterial resistance.[37] Penicillin soon replaced sulfonamides for the treatment of all infections. During the war, it was soon realized that penicillin was active against gonorrhea, syphilis, streptococcal, and staphylococcal infections with greater potency and less tissue toxicity. As a result, penicillin completely replaced sulfonamides for the treatment of infections during World War II.[38] While the use of antibiotics during the war was a vital supplement to surgical care, it was emphasized that it was not a replacement for good surgical technique.
Churchill summarized the revolutionary management of major war wounds after his experience in the Mediterranean theater.[23] He proposed the concept of ―phased wound management,‖ involving three surgical stages, similar to what Oppel proposed in Russia during World War I.[23, 39] The initial and reparative phases occurred in-theater, and the third, the reconstructive phase, occurred in the interior zone. The initial phase of wound surgery involved procedures designed to save life or limb and prevent or eradicate wound infection. This included closure of chest wounds or hollow viscous injuries and thorough debridement of grossly damaged tissue. In addition, the prompt setting of fractures was advocated, as the ―exact maintenance of the reduction of fractures by precise methods is precluded by the necessity for evacuation to the rear…‖[23] Surgeries during this phase took place close to the front lines at the ASGs or field hospitals.
The reparative surgery phase occurred in the zone of communication, typically in the larger general hospitals. Procedures performed during this phase were designed to abbreviate wound healing, restore function, and minimize disability. The closure of wounds intentionally left open at the initial surgery typically happened on or after the fourth post-injury day. If there remained any hint of infection, it was debrided surgically or with application of moist dressings. Wound closure was then re-attempted on subsequent days. It was recognized here that quantitative culture of the wounds was not helpful in determining the timing of wound closure, and that all open wounds would demonstrate varied aerobic and anaerobic flora.[23] Rather, it was the gross appearance of the wound itself that determined whether it was ready for healing by primary intention. In addition, the use of topical sulfonamides or penicillin was found to be ineffective, and parenteral penicillin was used only for established infections or complex injuries involving bones, joints, and viscera. The recognition of ―secondary anemia‖ from chronic infections and indolent wound healing occurred during this time, and was corrected with whole blood transfusions. Early closure of small bowel fistulae, repair of end colostomies, and the implementation of loop sigmoid colostomies to protect anal and perineal open wounds occurred during this phase as well. Reduction and internal fixation of fractures and debridement of infected joint capsules were also undertaken during this stage.[23]
Of particular note, the active management of retained hemothorax and organizing empyema was addressed during the reparative phase. In contrast to management of thoracic trauma in World War I, thoracic splints were abandoned, and the evacuation of large thoracic clots through thoracotomy and decortication was advocated. Churchill described this as ―… one of the significant advances of World War II.‖[23] By removing the clot burden, it was recognized during the Mediterranean campaign that this avoided the subsequent complications of empyema and fibrosis, allowing for early healing and full lung expansion. Again, penicillin was an important adjunct to this procedure. Once patients were sent to the contiguous U.S. (CONUS), correction of deformities (reconstructive phase) were undertaken and rehabilitation started.
VASCULAR TRAUMA
With the use of high-velocity weapons and high-impact explosives, major vascular injuries were also common during World War II. Vascular surgery techniques for acutely injured vessels were still in the early stages prior to the beginning of World War II. Previous attempts at arterial anastomosis and vein grafts were limited to case reports and small series, primarily for non-acute injuries to the vessels, consisting primarily of pseudo-aneurysms or arteriovenous fistula. Vascular surgery for trauma during World War I was poor, largely attributed to prolonged evacuation times combined with the high frequency of infections. As a result, most arterial sutures were doomed to rupture with secondary exsanguination.[27]
After World War II, Dr. Michael DeBakey co-authored a review of 2,471 cases of arterial injury. Nearly all of the arterial injuries were treated by ligation, resulting in an amputation rate of 49%. Repair of the artery was attempted in only 81 recorded procedures, the majority consisting of lateral suture repair. In this small subset, the amputation rate was decreased to 35%. In addition, the use of vein grafts was also disappointing. In 40 cases of vein homolog grafts, the amputation rate was 58%.[40] The official policy was to forego formal arterial repair in favor of ligation primarily due to the poor clinical results. DeBakey concluded that arterial ligation ―is of stern necessity, for the basic purpose of controlling hemorrhage. …‖[27, 40] The lack of efficacy in vascular repair may also have been due to prolonged transportation times to the first surgical facility. While the time to first surgery improved compared to previous conflicts with ASGs, this time averaged over 10 hours, likely precluding any successful revascularization.[27]
CASUALTY TRANSPORT
Churchill ―emphasized…the importance of minimizing the time lag between initial surgery and early reconstructive procedures…Thereby extending the role of the ‗field trauma center‘ into the rehabilitation phase.‖[15] The term ―golden period‖ was used to describe the importance of the time lag between wounding and initial surgery. Just as importantly, Churchill also stressed the importance of minimizing the time between initial and reparative surgery.[23]
World War II provided the Army Air Force with a large-scale experience in aeromedical evacuation of over 1 million patients by the end of World War II. The C-47, a large, fixed-wing cargo plane, became the primary method of moving patients in and out of the combat theater. These planes were originally designed to move cargo, and there was initial resistance to utilizing them for patient transportation.[41]
Near the beginning of U.S. involvement in the war in 1942, aeromedical evacuation was in its infancy, and the concept of being able to take injured patients to altitude for prolonged flights was unproven. In 1943, the first trans-oceanic aeromedical evacuation occurred with five patients from Karachi, India (now Pakistan) to Bolling Field, District of Columbia. This flight was heralded as proof of concept that a global aeromedical evacuation system was feasible.[41]
By the time of the Battle of the Bulge from 1944-1945, casualties were flown directly to the U.S. as early as three days after being wounded. General Dwight D. Eisenhower touted air evacuation as a major medical advancement in World War II saving thousands of lives.[41] In later wars, many of the obstacles of aeromedical evacuation would be solved, such as standardization of litter and patient carry systems, high-altitude physiology, provision of advanced medical treatments and monitoring in flight, and probably most importantly, crew rest and rotation.
IV. KOREAN WAR
The post-World War II period, while largely peaceful for most Americans, was marked by increasing tensions between the U.S. and the Soviet Union. The predominant foreign policy at the time was focused on the containment of communism, both at home and abroad. The U.S. clearly concerned with communism spreading throughout Europe, formulated the Truman documents and the Marshall Plan, and the Berlin Airlift. America‘s foreign policy of containment also extended to Asia and in 1950 the Korean Conflict would be the first major battle the U.S. waged against the spread of communism, a mere five years after the end of World War II. Publications from the U.S. DoD reported 36,574 deaths and 103,284 wounded in action during this three-year conflict.[42] Tragically, though, the Korean Conflict is also known as the ―Forgotten War,‖ overshadowed by the support for and overwhelming victory of World War II. However, it should never be forgotten that 1.8 million service members fought in Korea, and major lessons in the practice of surgery were learned there. These included advancements in medical evacuation and mobile hospital support, vascular and burn surgery, and dialysis in forward locations.
HELICOPTER EVACUATION
The rugged, impassable terrain in Korea led to the edict that ―A man dies in a period of time, not over a distance of miles.‖[43] In order to evacuate casualties efficiently, a helicopter evacuation platform was needed, as ground transportation was near impossible in certain inaccessible locations. On Aug. 3, 1950, the first official demonstration for helicopter medical evacuation was established by the Eighth Army Surgeon, Army Colonel Chauncey Dovell, and Army Captain Leonard Crosby at Taegu Teachers College in what is now South Korea.[43, 44] The demonstration was a success and by August 10 this platform was authorized for use to evacuate casualties. In addition to the efficiency of transport, the smooth ride of the aircraft compared to a hand-carried litter over rugged terrain or the jostling of a jeep over dirt roads made aeromedical transport the vehicle of choice for injured patients.[43]
In 1951, the 8063rd Mobile Army Surgical Hospital (MASH) was the first unit to use helicopters to evacuate casualties. The Bell H-13 was the primary helicopter used for medical evacuation, or "medevac.‖ Up to two patients were transported on skids placed outside on either side of the helicopter, limiting the treatment each patient could receive during transport. In 1952, the Army medevac helicopter units were organized and assigned to the Eighth Army medical command. The identification change of the helicopter units to officially being known as MEDEVAC units, mandated by Army Surgeon General Major General George Armstrong in December 1952, meant they were now under medical control.[43]
There were several limitations to work around with helicopter transport. Because there were no lights and only basic instrument gauges, most helicopter flights occurred during daylight.[43] Despite these limitations, many intrepid pilots would risk their own lives to fly at night in order to save the lives of severely injured service members. As patients were attached to the outer skids of the aircraft, patients would occasionally freeze, so crews made tubes to divert engine heat to patients. In addition, small openings in the aircraft doors were made so that resuscitation fluids, whole blood, and plasma could be stored inside the cockpit. This kept the fluid from freezing in the intravenous tubing as the patients were resuscitated in flight.[43, 44] The medevac pilots during the Korean Conflict had no medical training. These pilots would take improvisational courses on basic medical knowledge from the medical and surgical units when they could. Anecdotally, many pilots were so dedicated to the mission that they would assist in the casualty care in field hospitals and even assisted in the operating rooms between flights.[43] In 1953, Medical Service Corps officers became the primary pilots for medevac flights. These officers were chosen for their expertise in transporting the wounded.[21] However, by then, most of the fighting was over. Between Jan. 1, 1951 and the end of active hostilities in July 1953, Army helicopter teams evacuated 17,690 patients, with USMC helicopters adding thousands more for a total of nearly 22,000.[43, 44]
MOBILE ARMY SURGICAL HOSPITALS
The first Mobile Army Surgical Hospitals were established on paper on Aug. 23, 1945.[44] These units were based upon the ASG concept of World War II in order to move surgery to the patient, rather than moving the patient to surgery.[33, 44] By doctrine, there were 14 physicians, 12 nurses, two medical service corps officers, one warrant officer, and 97 enlisted personnel assigned to the MASH. The MASH facility was a 60-bed, truck-borne hospital designed to be taken down to move within six hours and set up again within four hours.
By the time hostilities broke out on the Korean peninsula in 1950, there were no active MASH units available, although five existed on paper. Furthermore, the Eighth Army had less than half the medical officers it required assigned to it.[44] As a result, the Army relied heavily upon the reserves, as well as a physician draft system, known at the time as the ―Berry Plan.‖ At the onset of conflict, casualty levels were extremely high, and hospital activity was brisk.
Monthly admission rates of over 3,000 casualties were routine.[21] The famed 8076th MASH was cited for treating over 15,000 patients in only a nine-month period. During this time, the unit also moved between 13 different locations. The MASH units performed spectacularly during the Korean War, and were credited with decreasing the case fatality rate for Army troops to 2.5% from 4.5% during World War II.[45]
VASCULAR TRAUMA
During World War II and the first years of the Korean Conflict, all arterial injuries in combat were treated with ligation. This was primarily due to the experience from poor outcomes with arterial repairs in World War II.[27] In addition, the proper, atraumatic surgical instruments and techniques for arterial repair did not exist at the time.
In 1952, Navy Lieutenant, Junior Grade (Dr.) Frank Spencer went against the current surgical dogma, and against official orders, and began repairing arterial injuries. His resolve to initiate a project on arterial repair started while observing a young Marine develop a gangrenous foot from a simple, mid-thigh, superficial femoral artery injury that was treated with ligation.[46] Despite the official rule that all arterial injuries must be treated by ligation, Dr. Spencer decided that attempting a repair, and potentially salvaging an extremity, was better than watching a dying limb. He gained experience with vascular surgery as a resident at Johns Hopkins under the tutelage of Dr. Alfred Blalock and Dr. Helen Taussig, who developed a novel surgery for tetralogy of fallot or blue baby syndrome. His first repair and subsequent repairs requiring interposition grafts involved the use of arterial homografts from casualties that were killed in action. Their femoral arteries were harvested and maintained in a tissue bank that he devised which consisted of placing the harvested arteries in a suspension of plasma. Degradation of the grafts did not become a problem as they were routinely used within a few days.[46, 47]
Despite Spencer‘s innovation, most combat medical facilities lacked the proper instruments to perform arterial repairs. Army Captain John Howard and his team were initially using modified hemostats that the Eighth Army engineers adjusted (creating interdigitating rather than opposed teeth) in an attempt to minimize intimal damage. However, the clamps still crushed tissue and caused thrombosis.[48] Potts clamps were only recently developed in the late 1940s and were used for the Blalock-Taussig procedure. These fine-toothed, multi-point clamps provided secure traction while minimizing intimal trauma. These and other desperately needed instruments weren‘t readily available until they were hand-delivered to MASH (and to other units) by vascular pioneer Army Colonel Carl Hughes.[46, 48]
Through Spencer‘s experience, he learned the rule that ―as long as the calf muscles were soft and the patient could move his toes, arterial repair was feasible because the gastrocnemius muscle was viable and functioning.‖[46, 47] Delayed primary closure was performed after the arterial repairs were initially covered by a viable soft tissue flap in order to avoid infection. He also noted that if the vascular exam did not improve in four to six hours, return to the operating room was needed.[47] Using principles of early and complete wound debridement, along with new antibiotics (aureomycin, chloramphenicol, and terramycin) combined with refined techniques in arterial vascular repair, the incidence of gangrenous wounds, particularly from Clostridial species, was as low as 0.08% in one published series.[49]
SURGICAL RESEARCH TEAMS AND RENAL FAILURE
The Army Medical Service Graduate School Surgical Research Team in Korea organized by Army Colonel William Stone, Commandant of the Army Medical Service Graduate School, identified high output renal failure as well as resuscitation and physiologic responses to injury during its 20-month existence in the Korean Conflict.[50] In particular, the resuscitation of burn patients was closely studied. The research team noted that prompt fluid resuscitation reduced the incidence of renal failure in burn injury. Prior to the development of resuscitation guidelines for burn injury developed in Korea, the incidence was over 35%.
Renal support teams were deployed near the Korean front during the war. Army Major Paul Teschan from the Walter Reed Army Institute of Research and his team brought Brigham-Kolff rotating drum dialyzers to Korea and established the first forward-deployed dialysis unit at the 11th Evacuation Hospital.[51] Teschan and his team documented an incidence of acute renal failure in 0.5% of all combat casualties with an increase in expected mortality from 5% to over 90% with renal failure. Teschan also documented the direct correlation with severity of trauma to degree of renal failure.[51] Teschan and his team performed prophylactic dialysis for severely injured patients in order to mitigate the adverse effects of renal failure.[52, 53]
V. VIETNAM WAR
The Vietnam War spanned 20 years—the longest active conflict in our nation‘s young history. During those two decades, military surgeons made continued improvements in the organization, equipment and execution of worldwide trauma care; military scientists and physicians collaborated on a major discovery for burn care; and new vascular surgery techniques saved lives and limbs near the front lines.
TRAUMA EVACUATION
Helicopter evacuation came of age in Vietnam. Korea‘s one- and two-man evacuations in small-boy helicopters grew to the mighty Huey in Vietnam. Officially designated the UH-1 Iroquois, the Huey‘s powerful jet-powered rotors could carry up to nine patients on each mission.[21, 43, 44] Call signed ―DUSTOFF‖ due to the amount of dust and dirt blown from the rotors, each team consisted of a flight crew along with a medic.
Evacuations became so efficient that even major arterial trauma could reach the operating table quickly, with most surgeries starting less than an hour after first treatment by a line medic.[54] As a result, this led to rising mortality statistics at military hospitals—care improved, but sicker patients reached the hospital. Critically burned patients, in particular, benefitted from formalizing the rapid transport chain from the battlefield to the U.S. The U.S. Army Institute of Surgical Research burn flight team ―accomplished 103 intercontinental flights with over 824 critically ill, severely burned patients from the burn holding unit in the U.S. Army hospital at Kashine Barracks in Japan to the U.S. Army Burn Center in San Antonio with only one in-flight death.‖ [55]
BURN CARE
Since the advent of intravenous fluid delivery, burn care remained essentially stagnant. Severely burned patients surviving the initial shock faced burn sepsis, the overwhelming infection grown in vivo in the wounds themselves. Pseudomonas aeruginosa proved particularly deadly, until Army Colonel John Moncrief and Army Major (later, colonel and president of the American Surgical Association) Basil Pruitt manipulated sulfamylon cream for human topical use. Leading the U.S. Army Surgical Research Unit (now the U.S. Army Institute of Surgical Research) in San Antonio, Moncrief and Pruitt collaborated with Army Colonel Douglas Lindsey at the U.S. Army Chemical Laboratory in Edgewood, Maryland, to base mafenide acetate in an absorbable cream (Sulfamylon Burn Cream). This allowed an effective anti- pseudomonal drug to be delivered directly to the burn; deeply damaged tissue loses or thromboses blood vessels, rendering intravenously delivered medications ineffective. Lindsey‘s team chose a base easily broken down by blood enzymes and readily excreted in the urine. Burn centers around the world still widely employ sulfamylon today.[55, 56]
VASCULAR TRAUMA
Treatment of vascular injuries continued evolution in Vietnam. Viewed purely through the lens of amputation rates after major vascular injury, the 13% rate from Korea improved to 8% in Vietnam‘s early months, eventually falling below 4% by war‘s end.[21] Hughes, Spencer, Howard and others‘ mentoring fueled improved technical acumen of deployed surgeons. Army Captain Sidney Levitsky and Army Colonel Robert Hardaway described one series of 55 consecutive major arterial injuries at the Army 3rd Surgical Hospital, which confirmed Spencer‘s ―viable calf, viable limb‖ rule, noting that amputations were only required after infrapopliteal injuries.[46, 47, 54] Levitsky and others polished Korean War techniques, specifically arterial debridement. Practice shifted from the standard 1cm debridement on each side of the damaged vessel, instead only removing enough to see a grossly normal intima layer, thereby preserving valuable vessel length. Embolectomy catheters, unavailable to Korean War surgeons, came to widespread use. Wound care over vascular repairs evolved as well, with n-butyl monomers of cyanoacrylate—―vessel glue‖—widely implemented for leak and infection prophylaxis. Glue used in prior eras showed notable local tissue toxicity, contributing to, rather than protecting from, wound complications. Arterial grafts banked by Spencer during Korea gave way to saphenous vein grafts, yielding better viability; routine muscle flap coverage of all grafts added protection. Many surgeons implemented standard penicillin coverage (alternatively chloramphenicol or streptomycin) until wound closure for further prophylaxis. [54]
One of vascular surgery‘s landmark resources, the Vietnam Vascular Registry, emerged through the impassioned drive of Army Major Norman Rich, a vascular surgeon who later became the first chairman of the Uniformed Services University of the Health Sciences Department of Surgery. Rich meticulously logged detailed notes about his cases, even providing his patients with a registry card for reference and further research at future visits. His impeccable documentation of venous repair began a massive swing in standard therapy. Previously, surgeons routinely ligated major venous injuries to concentrate on the limb‘s arterial inflow. Rich‘s experimental work, matched with registry data, showed drastically decreased morbidity after vascular injury if major venous wounds underwent repair along with their arterial counterparts. Limb edema, for example, dropped from over 50% with venous ligation to 13% with venous repair, clearly illustrating the ―inflow/outflow‖ pillar of vascular surgery. The Vietnam Vascular Registry continues to grow even today, adding long-term veteran information to the growing volumes of vascular research, as well as exemplifying the tradition of ―the military takes care of its own.‖ Enrolled veterans ―feel someone still cares,‖ a sentiment not always felt by Vietnam warriors.[27, 57, 58] Walter Reed National Military Medical Center, now the public interface for registry members, continues to receive queries from registry cardholders regarding their care. Rich, meanwhile, would rise to the rank of colonel in the Army; among myriad other honors, the Department of Surgery at the Uniformed Services University of the Health Sciences and a surgical fellowship at the Walter Reed National Military Medical Center bear his name.
VI. MAJOR CONFLICTS OF THE LATE 20TH CENTURY American interventions in Iraq and Somalia (Operation Desert Storm and Operation Restore Hope) were the major contributors to military surgical research in the late 20th century. Though both of these conflicts were short and involved relatively modest deployments of American troops, much was learned that would later be applied in future engagements.
OPERATION DESERT STORM AND OPERATION RESTORE HOPE On Aug. 2, 1990, Iraqi forces invaded Kuwait and rapidly routed the Kuwaiti government. An international coalition of armed forces opposing the Iraqi military interventions would be built up over the next six months. An aggressive air campaign against Iraqi-held military targets and positions began in early January of 1991.[59] On Feb. 24, 1991, a ground combat campaign began. Within four days, ground troops had liberated Kuwait and forced Iraq to surrender. [60]
A few years later during the Somali Civil War, the U.S. led a multinational mission, Operation Restore Hope, initially to secure delivery of humanitarian aid and later to stabilize a nascent democratic Somali state.[61, 62] The results of the mission led to a mass-casualty incident among U.S. troops that would lay clear the need for change among casualty care. The high-intensity urban warfare seen in this conflict represented a shift from frontline field battles to blurred lines of battle with challenging conditions and rapidly changing tactical situations, which exposed deficiencies in combat casualty care.[63]
A prospective research effort to gather data regarding care of combat casualties during the conflict in Somalia was not supported. However, Air Force Lieutenant Colonel Robert Mabry, now a military emergency department physician, was a Special Forces medic and directly participated in the care of casualties in Somalia. Mabry and co-authors later wrote a retrospective review of injuries sustained and outcomes from that engagement. Data was derived from medical, flight, and pathology records, as well as available media and eyewitness reports.[64]
The review identified potential areas of improvement, including body armor design and medical care, training, and education. Specifically, the medical initiative focused on the addition of prehospital prophylaxtic antibiotics, the utility of tourniquets in preventing extremity exsanguination, hypothermia prevention, and the potential benefit of a trauma registry.[64] Assertions in that study were supported by other prominent experts in trauma, emergency medicine, and battlefield tactics.
The Special Operations Medical Association held a panel discussion in 1998 to discuss combat casualty care amid urban warfare. This discussion became the basis for the paper ―Tactical Management of Urban Warfare Casualties in Special Operations‖[63], which recapitulated many of Mabry et al‘s observations mentioned above. Numerous conferences were held after Somalia to absorb lessons from the conflict and plan for future engagements. [64-66] The findings of these conferences and lessons learned from Operations Desert Storm and Restore Hope are discussed in the following sections.
Tactical Combat Casualty Care The events of the ―Battle of Mogadishu‖ were chronicled in the historical nonfiction book ―Black Hawk Down‖ and the subsequent film of the same name. In this engagement, many American service members were injured and the ability to care for them was paralyzed by the tactical situation.[67] The joint special operations task force, ―Task Force Ranger,‖ entered downtown Mogadishu on Oct. 3, 1993 to capture high-ranking members of General Aidid‘s militia[67]. The task force suffered an early casualty in which a soldier fast-roping from a helicopter fell and suffered a severe traumatic brain injury. As a result, three of the 12 Humvees in the ground element of the task force were diverted to transport the casualty to medical care. The remainder of the task force came under heavy attack by Somali militiamen, resulting in the downing of two Black Hawk helicopters. The inability of U.S. forces to control the tactical situation in the setting of mounting casualties hindered delivery of casualty care and critically delayed patient evacuation.[63, 67]
Two fundamental deficiencies were identified following the Somalia conflict. First, the military had no specific combat trauma medical training, so procedures for field care of combat casualties followed Advanced Trauma Life Support guidelines.[68] The guidelines had been designed for the care of civilian trauma patients and therefore did not consider the needs of the concurrent tactical situation. Second, during non-combat assignments, medics and corpsmen were often assigned to large military hospitals that saw few, if any, acute trauma patients, limiting their experience to the care of wounded patients.[69, 70] These shortfalls in training and caring for casualties while in a volatile combat situation spurred the Naval Special Warfare Command (NSWC) to revisit how special operations medical providers prepared for combat casualty care.[68] This NSWC inquiry, which involved an extensive literature search and consensus panel of subject matter experts, laid the foundation for the development of Tactical Combat Casualty Care (TCCC). Overall, the goal of TCCC was to develop a set of guidelines that incorporated the care of combat casualties while managing the tactical requirements of a mission.[68] Initially, TCCC was taught to physicians attached to Navy SEAL units, but it was quickly adopted by the other military branches and taught to combat first responders (Army medics, Navy corpsmen, Air Force pararescuemen).[68]
TCCC has remained the key training platform and is now a mandatory course for deploying medical personnel. TCCC consists of three phases that govern the care that may be given during the corresponding tactical situation.[71] The priority of the first phase of TCCC, Care Under Fire, is directed at attaining fire superiority. It is the period of time during enemy contact when the team remains under effective enemy flak and it is expected that all available team members, including the injured casualty (-ies) if possible, return fire. Because the focus is on engaging the enemy, the extent of care in this phase includes removing the casualty from potential further injury and controlling life-threatening external hemorrhage through the use of an extremity tourniquet if tactically feasible.
The second phase, Tactical Field Care, begins once fire superiority is achieved or the casualty is removed from further immediate danger. In this phase, providing airway support and securing a definitive airway are stressed. During the TCCC course, students are taught airway adjuncts, how to perform a cricothyroidotomy, how to assess for and treat a tension pneumothorax using a needle thoracostomy, how to place intravenous or intraosseous lines, and techniques for preventing hypothermia and splinting orthopedic injuries. Appropriate application of various junctional tourniquets is also stressed during this phase of care. Finally, medical first responders are taught how to appropriately document patient status and care rendered while awaiting the arrival of an evacuation platform. [72] The emphasis on documentation has been beneficial to treatment in later stages of care as well as contributing to the data available for analysis in the Department of Defense Trauma Registry (DoDTR).
In the third and final phase of TCCC, Tactical Evacuation, the casualty is loaded into an evacuation platform for transport to higher echelons of care. Evacuation platforms can be ground or air vehicles with different levels of resources depending on the intent and staffing of the vehicle. Tactical vehicles adapted for casualty evacuation may offer no medical equipment or expertise other than that of the treating medic. More advanced medical evacuation platforms may offer advanced monitoring, mechanical ventilation, blood products, and other life-saving equipment. The guiding principle of tactical evacuation is ensuring that previous interventions (tourniquets, definitive airways, needle thoracotomies) remain in place and function properly. During this phase a provider must remain vigilant for evidence of treatable decompensation.[72]
The merits of TCCC would not be widely proven until Operation Enduring Freedom and Operation Iraqi Freedom, which began in 2001 and 2003, respectively. The low mortality rates of these conflicts observed in the setting of devastating complex injuries would be a true testament to the importance of TCCC in saving lives.[73]
Tourniquets Extremity tourniquets were available during the Somalia campaign; however, their carriage and use was not widely prescribed. In his analysis of combat casualties in Somalia, Mabry cites only one example of a tourniquet application in the field after an RPG blast that caused a partial through-knee amputation of a soldier‘s leg.[64] However, tourniquets were more frequently placed for extremity wounds after arrival of casualties at a Role II facility. The successful (and in one case, lifesaving) role of tourniquets in this conflict reaffirmed the original TCCC guidelines regarding tourniquet use and spurred renewed interest in their use in subsequent conflicts.[74] Additional experience with extremity tourniquets during the Global War on Terrorism (GWOT) led to unprecedented distribution of manufactured tourniquets to all deployed service members.[75]
One particular death that was potentially survivable during the Somalia Campaign occurred when a soldier suffered a penetrating femoral artery and vein injury. Due to the proximal extent of the injury, an extremity tourniquet could not be effectively applied and the patient exsanguinated despite direct pressure and wound packing.[76] This junctional hemorrhage sparked the development of a number of junctional tourniquet devices over the next decade.[77]
Theater Medical Research and Data Collection The value of data gathering regarding combat injuries was well understood prior to the start of Operation Desert Storm. This was a lesson learned from Rich, creator of the Vietnam Vascular Registry. To ensure a robust effort of prospectively collected data, a 30-member Casualty Data Assessment Team (CDAT) was originally organized for deployment to Iraq to gather details on combat casualty care. The CDAT was a cooperative venture between the Division of Military Trauma Research-Letterman Army Institute of Research and the Army‘s Medical Research and Development Command.[78] Unfortunately, this plan was stymied by the Army Office of the Surgeon General, and instead a four-member team was directed to gather data by reviewing medical records and interviewing patients that had already been evacuated to Germany.[78] The smaller CDAT sent to Germany decried the loss of detailed information on initial injury care and resuscitation and a cross-sectional appraisal of the medical evacuation system that could have been gathered if the entire complement of team members had been sent into the theater.[78]
Though the CDAT admitted it was not possible to gather much crucial data about the conflict, some recommendations were generated from their experience. First, it was recommended that a fully complemented CDAT be formed and instituted prior to the next conflict to ensure complete data collection and analysis. In addition, it was noted that orthopedic injuries made up a significant contingent of injuries suffered and additional effort should be devoted to research on treatment of these wounds. Furthermore, non-medical providers were frequently found to be the initial combat casualty care providers. These fellow soldiers with rudimentary medical training delivered the majority of point-of- injury care during the conflict, and their utilization reinforced the need for advanced training. Finally, the Personal Armor System, Ground Troops (PASGT) fragmentation vest and helmet system was found to prevent penetrating injury in covered areas. Although this system was initially issued to U.S. Army troops in the 1980s, it had not been widely tested in a combat environment until Operation Desert Storm. It was also suggested that additional armor protecting the neck and shoulders should be developed, which was lacking in the current vest.[79]
The legacy of the medical experience in Operation Desert Storm was to underscore the need for and potential benefits of large-scale data collection on combat injury to guide research and product development for future conflicts.
Impact of Modern Body Armor During the Vietnam War, the primary form of torso protection for the dismounted soldier was the flak jacket. They provided some protection against low-velocity bullets but did not provide protection against high-velocity bullets fired from rifles.[80] The PASGT mentioned above provided greater coverage to the thorax, and initial animal testing suggested improvements in protection from projectiles as compared to the flak jacket.[79]
During Operation Desert Storm, the overwhelming majority of combat injuries suffered by U.S. service members were a result of penetrating trauma, specifically that of blast fragmentation.[81] The most common cause of death in this conflict was from junctional extremity hemorrhage rather than penetrating head, thoracic, or abdominal injury. This change in distribution of injuries from head and torso to extremity proved the effectiveness of the coverage of the body armor issued to warfighters during the conflict.
Mabry examined the effectiveness of body armor at preventing injury during Operation Gothic Serpent in Somalia. His study noted that modern body armor was effective at decreasing penetrating chest and abdominal injuries when compared to previous conflicts.[64] The PASGT helmet likely saved the life of a soldier injured by a bullet to the occiput; unfortunately, 36% of deaths in this conflict were the result of penetrating head wounds to areas not covered by the helmet.[64]
Intercontinental Aeromedical Evacuation and Critical Care Air Transport Teams (CCATT) Numerous after-action reports decrying deficits in staffing and supply chain were submitted by senior medical officers after Operation Desert Storm. Units tasked with running hospitals or evacuating combat casualties were found to lack the appropriate personnel or skills, physical and mental fitness, and training to complete their missions.[82] Supplies were outdated, unavailable, not mission-appropriate, or in short supply.[82] The report noted that if casualties during the conflict had risen to the level expected, appropriate care would not have been able to be provided to the wounded.[82] These reports forced the General Accounting Office to investigate the state of medical care provided during the conflict. Based on their findings, the office and the Air Force comprehensively reviewed delivery of medical care and developed numerous initiatives to improve readiness prior to the next conflict.[82]
At the time of the conflict in Somalia, aeromedical evacuation platforms provided by the U.S. Air Force did not have the native personnel or resources to care for critically ill patients. Staff and equipment for grievously wounded patients had to be drawn from host facilities and borrowed for the duration of transport. In Operation Desert Storm, for example, teams capable of providing early resuscitation to burn victims were transferred from the U.S. Army Institute of Surgical Research in San Antonio or Landstuhl Regional Medical Center in Germany.[83] This limitation in aeromedical capabilities sparked a renewed interest in adding equipment and physicians capable of caring for critically ill casualties in flight. This led to the development of the Critical Care Air Transport Team (CCATT) program by Air Force Lieutenant General (Dr.) Paul K. Carlton, Jr. and Air Force Colonel (Dr.) J. Christopher Farmer. The medical assets intrinsic to each team consisted of a critical care-trained physician, a critical care nurse, and a respiratory therapist with the expected capability of taking care of up to three critically ill ventilator-dependent patients or up to six non-critically ill casualties. By 1994, the CCATT program would be fully operational to sustain high-level care for critically ill patients during intercontinental evacuation. However, its utilization would be limited until the onset of Operation Enduring Freedom in October 2001.
New Perspectives in Fluid Resuscitation Prehospital fluid resuscitation during Operation Desert Storm and Operation Gothic Serpent consisted only of crystalloids, as blood products were not readily available prior to casualty arrival to a combat support hospital. However, the value of pure crystalloid resuscitation, especially in large volume, was brought back into question following these conflicts because of deleterious consequences, such as pulmonary fluid overload, congestive heart failure, prolonged ileus and impaired anastomotic healing, coagulopathy, and bleeding.[84-88] Aggressive crystalloid resuscitation was also found to be a major cause of abdominal compartment syndrome.[89] Data from animal models over the ensuing years suggested improved mortality with judicious, rather than aggressive, use of crystalloid.[90-92] Likewise, clinical data in a prospective trial of early and aggressive crystalloid resuscitation compared to delayed infusion of crystalloids until operation demonstrated improved survival and earlier hospital discharge in the delayed group.[93] Studies comparing the tonicity of crystalloids (isotonic versus hypertonic) also failed to demonstrate a mortality benefit between tonicities.[94]
Furthermore, carrying a large volume of crystalloid for resuscitation was prohibitive for combat medics and corpsmen, thus alternative fluids, such as various colloids, were considered. Although comparisons of colloid versus crystalloid resuscitation failed to show that one had a significant advantage over others, the hetastarch colloids were pursued given their relatively small volume, hemodynamic effects, and ability to be stored at room temperature.[95] In particular, the hetastarch Hextend (Biotime Inc., Berkeley, California) was selected as the prehospital fluid of choice given its suitable side effect profile compared with other colloids.[96] With its plasma-expanding potential, Hextend given in smaller volumes by combat medical first responders achieved similar hemodynamic effects as compared to much larger volumes of crystalloids.[65, 97] Despite its side effect profile on coagulopathy and acute kidney injury, Hextend would remain the recommended prehospital option in the absence of blood product availability until the later years of GWOT.[95, 98, 99]
VII. OPERATION IRAQI FREEDOM, OPERATION ENDURING FREEDOM, AND THE GLOBAL WAR ON TERRORISM
One month after the horrific terrorist attack on Sept. 11, 2001, Operation Enduring Freedom officially commenced in Afghanistan, initiating what would become the longest war in U.S. history. On March 19, 2003, the U.S along with coalition allies, primarily from the United Kingdom, initiated war in Iraq, in what would be known as Operation Iraq Freedom. Together, these conflicts would fall under the GWOT mission.
As GWOT progressed, the majority of combat in Iraq and Afghanistan became unconventional warfare. Enemy tactics evolved from conventional small-arms fire and explosives to more extensive use of improvised explosive devices (IEDs)[100]. Injuries, often complex wounds, caused by these blasts accounted for nearly three-quarters of all combat wounds.[101] Even so, survival was the highest compared with all other U.S. conflicts largely due to improvements in first responder care, evacuation times, and resuscitation practices.
I. ADVANCEMENTS IN POINT-OF-INJURY CARE a) Tactical Combat Casualty Care Revisited
OEF/OIF marked the first major conflicts in which TCCC was widely instituted throughout the DoD. Since initial publication in 1996, the TCCC guidelines have undergone multiple revisions as a process improvement to address the evolution of combat casualty care.[73]
A review of casualty mortality in GWOT found that 90% of potentially survivable battlefield deaths were caused by hemorrhage with the majority the result of truncal hemorrhage, followed by junctional and extremity hemorrhage.[102] In an attempt to improve on potentially survivable deaths, under the TCCC guidelines use of extremity and junctional tourniquets was emphasized as the primary tool for hemostasis in the field.[103] For hemorrhage that could not be controlled with tourniquets, TCCC guidelines advocated the use of hemostatic dressings and hemostatic adjuncts such as tranexamic acid.[104-107] These interventions will be further discussed in later sections.
Airway compromise was identified as the second most common cause of potentially survivable battlefield death.[100] Thus, aggressive use of cricothyroidotomies by prehospital providers, especially for patients with maxillofacial trauma, was stressed with TCCC providers.[108] Needle decompression was also emphasized as tension pneumothorax had been cited as another cause of potentially survivable battlefield death with current guidelines now recommending all patients with chest trauma and cardiovascular collapse receive a needle decompression.[72]
Fluid resuscitation in the TCCC guidelines changed drastically over the past 10 years. Knowledge from previous wars as well as ongoing research combined to significantly change combat resuscitation strategies. Hypotensive resuscitation and ratio-driven resuscitation, or 1:1:1, replaced large-volume crystalloid infusion.[95] In addition, standardized antibiotic prophylaxis regimens to be given in the field for open wounds were instituted. Battlefield analgesia, which had previously consisted primarily of intramuscular morphine, was revamped to include Tylenol, NSAIDs, intranasal or intramuscular Ketamine, and buccal Fentanyl lozenges.[109]
Most significantly, subsequent updates to TCCC guidelines were included in the military edition of the Prehospital Trauma Life Support (PHTLS) textbook and taught exhaustively to all prehospital military providers and most deploying members of the military.[106, 110]
b) Extremity Tourniquets In GWOT At the start of GWOT, tourniquets were not widely used among U.S. service members in combat due to concerns about potential effectiveness and complications. Experiences in World War II, the Vietnam War, and civilian trauma literature had led to tourniquets being relegated to a hemostatic measure of last resort for extremity hemorrhage.[111, 112] Controversies regarding the use of tourniquets for hemorrhage were centered around the risks associated with intentionally inducing limb ischemia.[113] In addition to local tissue damage downstream from the tourniquets, limb ischemia has been shown to have a negative global effect through the release of systemic inflammatory mediators causing splanchnic hypoperfusion and subsequent mesenteric ischemia.[114-116]
Early resurgent evidence for the effectiveness of tourniquets was contemporaneous with the start of GWOT. Data from the Israeli Defense Force, which had been using tourniquets since the 1980s, demonstrated a high rate of appropriate and effective tourniquet placement in combat by prehospital providers with low rates of complications. This helped influence the use of tourniquets in GWOT.[74] Subsequently, in 2003, the Advanced Technology Applications for Combat Casualty Care Conference convened an expert panel that discussed ideal tourniquet construction and created guidelines for use in theater.[74]
As a result, the widespread use of extremity tourniquets among injured U.S. service members would provide compelling evidence that tourniquets saved lives on the battlefield. A review of admitted trauma patients at a U.S. combat support hospital in Iraq looked at tourniquet use and determined that 57% of potentially survivable deaths may have been prevented by judicious tourniquet use in the prehospital setting.[117] A similar prospective study at a Baghdad combat support hospital demonstrated a significant mortality benefit when tourniquets were placed prior to patient deterioration into hemorrhagic shock. This same study also demonstrated 0% survival among casualties with indications for tourniquets and no tourniquets placed; conversely, 87% survival was demonstrated among casualties that received indicated tourniquets.[118]. These data demonstrating tourniquets effectiveness lead to the universal distribution to all service members deploying to theaters of combat by 2005.[75] c) Hemostatic Dressings Due to the destructive nature of blast injuries and the difficulty in achieving hemostasis in certain extremity and junctional wounds, a focus on alternative or adjuncts to tourniquets were sought. With the emphasis on hemostatic agents that could be placed in the field to obtain hemostasis, several products were developed by both private companies and joint corporate-military ventures.
QuikClot hemostatic agent (Z-Medica, Wallingford, Connecticut) became the dressing of choice as it was found to be the most efficient product. QuikClot uses the naturally occurring mineral kaolin to concentrate and activate factor XII in the intrinsic clotting pathway to generate clot.[119] It was initially formulated as a powder containing zeolite, which produces an exothermic reaction, but led to significant unintended burns. Because of this adverse reaction, it was reengineered with kaolin into its current gauze medium, QuikClot Combat Gauze.
These agents were extremely helpful to the medical first responders because they provided a quick and simple method of achieving hemostasis in large wounds that would otherwise not have been amenable to tourniquet placement. The U.S experience in Iraq and Afghanistan with kaolin- and chitosan-based hemostatics found these products to be highly effective at controlling hemorrhage (95% to 97% success rate) when used in the field.[120, 121] Likewise, two series from the Israeli Defense Force Medical Corps showed 88% to 92% effectiveness in stopping hemorrhage when QuikClot Combat Gauze was used.[122, 123]
Their ease of use was demonstrated in a study performed at Naval Medical Center Portsmouth in which novice U.S. Navy corpsmen were given a 15-minute PowerPoint presentation on use of topical hemostatics. At the conclusion of training, the students were told to apply a topical hemostatic agent to a pig with an exsanguinating femoral artery injury. All of the students were able to obtain hemostasis even with the brief training and unfamiliarity with use of the product.[124] Combat Gauze became the favored hemostatic dressing for control of external hemorrhage by the Committee on Tactical Combat Casualty Care because of its handling and effectiveness compared to other agents.[72, 104, 125] d) Prehospital Transfusion and the Golden Hour Container Prior to the start of combat in Iraq and Afghanistan, only case reports existed of prehospital transfusion of whole blood and blood products. The difficulties of storing, typing, and transfusing blood made this treatment logistically prohibitive. The model for carrying blood products on aeromedical evacuation platforms and transfusing them en route was developed in Operation Enduring Freedom. Exploration of prehospital transfusion in Afghanistan began in 2010. Flight medics on medevac helicopters were able to carry and transfuse packed red blood cells and/or thawed plasma to trauma patients. Specific indications for transfusions in flight were tachycardia, hypotension, or multiple amputations.[126] This capability has influenced civilian regional trauma systems which have begun pilot programs to evaluate the value of this potential therapeutic option.[127]
The biggest challenge in prehospital transfusion was the inability to store blood in a cooled environment for a prolonged period. Products left at room temperature for too long a period of time will become unusable.[128] The development of the Golden Hour Container (Pelican BioThermal, Plymouth Minnesota), a thermal transport container that is rated to keep products at a set temperature for up to 168 hours, has made the long-term prehospital storage of blood products feasible.[129, 130]
e) Instituting A Hypothermia Clinical Practice Guideline
Hypothermia has long been known to increase mortality in trauma patients; in fact, it is likely an independent predictor of mortality in trauma.[131-133] War-wounded patients were no exception to this.[134] Early in GWOT, 7% to 18% of combat casualties were arriving to Role III theater hospitals with hypothermia.[134, 135] In response, a Clinical Practice Guideline (CPG) for the prevention of hypothermia was released in 2006.[136] By 2008, only 1% to 3% of casualties arriving at medical care were hypothermic.[136].
The current CPG recommends a combination of passive and active rewarming devices in both the hospital and prehospital setting. At the point of injury, it is recommended that providers utilize the Hypothermia Prevention and Management Kit (HPMK) (North American Rescue Products, Greer, South Carolina). The HPMK consists of a self-heating shell liner, a waterproof and windproof Heat Reflective Shell, a self- heating Ready Heat shell liner, and heat-conserving reflective headpiece.[137] Upon arrival to medical care, more potent hypothermia prevention and treatment modalities such as warmed bedclothes, rapid infusers, warmed operating rooms and Bair Hugger devices are used.[138]
Although laboratory data has suggested that the CPG-recommended HPMK is superior to other methods of rewarming, the same study noting the drastic decrease in hypothermia patients on arrival to medical care noted that the standard wool Army blanket remained the most common method used to prevent hypothermia.[139, 140] Some of the benefits seen with the decreased incidence of hypothermia were hypothesized to result from increased awareness to hypothermia facilitated by the CPG even if its recommendations were not explicitly followed.[140] f) Golden Hour
The widely stated idea of the ―golden hour‖ originated in the 1970s by Dr. R Adams Cowley, a Maryland trauma surgeon responsible for developing the first regional trauma system and founding of the R Adams Cowley Shock Trauma Center.[141] The ―golden hour‖ refers to the 60-minute window in which intervention after critical injury may be lifesaving, a statement Cowley made and stood by.[142] Clinical evidence of the validity of this concept has been mixed, although, unnecessary delays in transport have been universally discouraged.[143, 144] Rapid evacuation from the point of injury remained the standard of care among civilian trauma systems.
In 2009, based on the golden hour concept, then-Secretary of Defense Robert Gates instituted a policy that time from point of injury to definitive care should be no more than 60 minutes. This halved the previous goal of two hours.[145] Army Colonel (Dr.) Russ Kotwal and colleagues performed a large retrospective analysis of U.S. casualties in Afghanistan from 2001 until 2014. The major point of interest in this study was a change in mortality after institution of this ‗golden hour‘ policy. Interestingly, it was found that the overall case fatality rate did decrease. The percentage of casualties that expired before they reached definitive medical care (killed in action) also decreased. The percentage of casualties that died after reaching a medical facility (died of wounds) remained unchanged. This suggests that mortality is likely improving rather than the burden simply being shifted temporally by earlier transport.[145] It should be noted; however, that significant improvements in care of combat casualties over the preceding years may confound the improved survival from 2009 onward.[145] g) Prehospital Transportation
The long distances, rugged terrain, and potential for roadside IEDs in Afghanistan favored use of helicopters for aeromedical evacuation of wounded patients. The level of care available en route to a medical treatment facility differed by the medical evacuation platform available for a given mission. The three most commonly used rotary wing evacuation platforms used in GWOT belonged to the U.S. Army, the U.S. Air Force, and the British Royal Air Force. The U.S. Army medevac primary platform was HELICOPTER, which operated under the historic call sign ―DUSTOFF‖ and was manned by an EMT-B trained flight medic. The U.S. Air Force flew Sikorsky HH-60 Pave Hawks under the call sign ―PEDRO,‖ manned by two pararescuemen with EMT-P training. The RAF aeromedical evacuation team, called the Medical Emergency Response Team or ―MERT‖, flew Boeing CH-47 Chinooks. MERT teams consisted of a physician with a critical care subspecialty, a critical care nurse, and a respiratory therapist.
During Operation Iraqi Freedom, distances and evacuation times from point of injury to definitive care were relatively short due to the geography of the theater. This made feasible both rotary wing and ground evacuation. In contrast, longer evacuation distances and greater risk in ground transport in the operation compelled almost exclusive rotary wing evacuation for injured casualties. Because of this dilemma, transport care became a target for improvement by the DoD. Using data from the DoDTR, outcomes were compared between critically injured patients transported by the different platforms. Critical care flight paramedics (CCFP) from U.S. Army National Guard units provided medevac services during their deployments in eastern Afghanistan. Outcomes of injured patients transported by these CCFP-manned medevac units were compared with DUSTOFF flight medics in southern Afghanistan during the same period. Forty-eight-hour mortality rates of battlefield casualties transported by CCFP medevac were one- third of those transported by DUSTOFF.[146] The unique reasons behind the success of CCFP medevac units were the higher level of medical training, the use of standardized protocols, and a process improvement initiative via case reviews. The U.S. Army has recently mandated CCFP training for all flight medics.[147] Similar data were presented in a prospective study from Afghanistan from 2008 to 2011 in which the mortality of more seriously injured patients (ISS >15) transported by MERT decreased by one-third.[148]
II. SURGICAL CARE IN THEATER a) Damage Control Surgery (DCS) and Damage Control Resuscitation (DCR)
Damage Control Surgery (DCS) emerged in the 1990s as a three-stage technique for management of major trauma. The first phase was rapid laparotomy in the operating room to control hemorrhage and temporize sources of contamination. The second phase occurred in the intensive care unit in which fluid resuscitation was delivered to optimize tissue perfusion and reverse acidosis, coagulopathy, and hypothermia. Once physiologic parameters normalized, the third phase of DCS involved returning to the operating room for definitive repair and management of non-life-threatening injuries.[149]
DCS was criticized for delaying resuscitation and reversal of the lethal triad of hypothermia, coagulopathy, and acidosis. Conventional wisdom at the time was that coagulopathy was consumptive or dilutional, resulting from resuscitation. This perception would lead to a delay in resuscitation of plasma, platelets, and cryoprecipitate until the second phase of DCS. Research would soon demonstrate that most trauma patients in shock were coagulopathic upon initial evaluation in the trauma bay rather than only after resuscitation.[150] More so, early coagulopathy was found to be a significant independent predictor of mortality. Deranged PT and PTT increased the odds of death in major trauma by 35% and 326%, respectively.[151] Compounding this, prehospital management of traumatic shock involved liberal use of crystalloid resuscitation which further diluted clotting factors.[84]
In the early 2000s, the concept of Damage Control Resuscitation (DCR) emerged as a treatment strategy to be used in conjunction with DCS and massive transfusion protocols. The basic tenants of DCR— permissive hypotensive, balanced blood product transfusion, and minimizing crystalloid resuscitation— expand upon the role of DCS by treating the acute coagulopathy of trauma.[152] Permissive hypotension was recommended to the first responders by the TCCC giving them a targeted systolic blood pressure of 90mmHg and recommending administering fluid only with the manifestation of shock.[72] While blood products became the preferred resuscitative fluid, storage requirements made their routine presence on combat missions prohibitive. Therefore, combat medics and corpsmen continued to carry Hextend due to its light weight and effects on volume expansion.[95] However, by the end of the Afghanistan campaign prehospital, en route, blood transfusion was made possible when operational tempo was at its lowest.[148]
b) Hypotensive Resuscitation Large volume resuscitation with crystalloids causes serious complications and increases mortality in severely wounded trauma patients.[84] Early in the war; however, this was still the standard of care in forward combat hospitals. The military medical community underwent a drastic change starting in 2006 that eschewed large volumes of crystalloids and favored a more restrictive policy of fluid resuscitation. The largest study of its kind demonstrated significant improvements in mortality among patients who received hypotensive resuscitation and ratio-driven blood product resuscitation when compared to those that received large volume crystalloid resuscitation.[153]
As mentioned above, blood product use in the prehospital environment is a relatively recent practice and typically only available on certain aeromedical evacuation platforms.[154] However, forthcoming research on en route resuscitation including the Control of Major Bleeding after Trauma and Prehospital Use of Plasma in Traumatic Hemorrhage trials to assess plasma in prehospital resuscitation may provide further clarity as to the most appropriate prehospital resuscitation strategy.[155, 156]
c) Ratio-Driven Resuscitation The strategy of ratio-driven blood product resuscitation has the potential benefits of improved survival, early fascial closure, and prevention of acute respiratory distress syndrome, especially among the most severely injured patients.[157-159] Early evidence for a mortality benefit of a balance blood product resuscitation (1:1:1, PLT:FFP:pRBC ratio) in combat casualties came from several retrospective analyses of service members receiving blood product transfusions at several combat support hospitals in Iraq from 2003 to 2005. In one such study, mortality improved by greater than 50% in patients who received a high ratio of FFP to pRBC (1:1.4) when compared to patients receiving a low ratio (1:1.8).[160] In another review of combat casualties receiving pRBCs, it was found that each unit of FFP transfused was independently associated with improved survival suggesting that early and increased transfusion of FFP may decrease mortality.[161] Likewise, other studies from the GOWT mission demonstrated the mortality benefit with high platelet to pRBC ratios.[162] d) Warm Fresh Whole Blood Warm fresh whole blood (WFWB) transfusion was common practice among trauma patients beginning in World War I.[163] WFWB transfusion became less popular in the 1970s as individual blood components allowed for more tailored therapy.[164] The benefits of WFWB include the logistic ease of collection from a ―walking blood bank,‖ lack of storage artifact, and greater in vivo efficacy.[165, 166] WFWB has a higher hematocrit, smaller volume, higher platelet counts, and greater clotting factor activity than single units of pRBC, FFP, and PLT.[167] WFWB transfusion was associated with improved survival when compared to patients receiving pRBC and FFP at Forward Surgical Teams in Afghanistan.[168] However, WFWB is not without its disadvantages; it carries the risk of transmission of infectious diseases such as HIV and hepatitis B and C.[167] This risk is lower due to routine screening of U.S. service members for infectious diseases; however, coalition allies were part of the donor pool and screening processes may not be as stringent as in the U.S. A program is in place to monitor for potential disease transmission in patients that received WFWB.[169] e) Apheresis Platelet Collection Capability
In the past, collection of platelets was challenging because a unit of platelets would need to be pooled from up to six donors.[170] Adding to this difficulty is the short half-life, on the order of five days, which limits shelf life and utilization.[171] To address the demand for platelets while limiting the donor pool and pitfalls of storage, apheresed platelets from a single donor were used. In addition, smaller, more rugged platelet collection systems such as the MCS+ 9000 Mobile Platelet Collection System (Haemonetics, Braintree, Massachusetts) allowed scalable in-theater collection of platelets for transfusion.[172]
The ability to bring platelet apheresis machines closer to the front lines helped to ensure that supply of platelets matched critical demand. Unfortunately, though, apheresis platelets were not available in theater early on so casualties did not benefit from this capability at the start of Operation Enduring Freedom or Operation Iraqi Freedom.[173] f) Hemostatic Adjuncts
Recombinant factor VIIa (rFVIIa) was originally used for treatment of patients with hemophilia or acquired anti-factor VIII antibodies.[174] However, the role of rFVIIa had expanded into the treatment of coagulopathy of trauma by early 2000 based on case reports of its use in hemorrhage control in critically injured patients.[175-178] This research was backed up by the findings that rFVIIa improved blood loss and survival in swine models of hemorrhagic shock.[179-181] Small civilian series subsequently noted improved hemostasis with the use of rFVIIa in coagulopathic trauma patients.[177, 178] Unfortunately, studies of rFVIIa in combat trauma were not as encouraging. A series examining 22 U.S. service members seriously injured in Iraq who received rFVIIa did not demonstrate a survival benefit when compared to case-matched controls.[182] The failure to show improved mortality in the rFVIIa group may be due to physician bias of selecting the most severely injured patients to receive rFVIIa and comparing them to an unmatched case-control group.[183]
Tranexamic acid (TXA) is an anti-fibrinolytic that also emerged as a beneficial adjunct in traumatic shock. A synthetic lysine analog, TXA was found to be a more potent inhibitor of fibrinolysis than its predecessor, ϵ-aminocaproic acid.[184] Its clinical use dates back to the 1960s and has been used in the prevention or treatment of bleeding in hereditary coagulopathies, oral surgery, elective cardiac and orthopedic surgeries, ruptured intracranial aneurysms, and gastrointestinal hemorrhage.[185-192] However, minimal data existed in 2004 about patient outcomes after use of TXA in trauma.[193]
Renewed interest in the use of TXA in trauma came about in 2010 with the publication of the CRASH-2 trial, a randomized, controlled, multi-center trial that found TXA significantly decreased risk of death in bleeding trauma patients with the most pronounced effect when TXA is given within three hours of injury.[194] It was subsequently introduced into practice in coalition combat casualties after 2010.
The MATTERs study, the military‘s experience with TXA, was then published in 2012. MATTERs was a retrospective cohort study that examined severely injured combat patients at a NATO hospital in Afghanistan. Patients requiring blood transfusion were given TXA in the study group and compared to historic controls. The TXA group demonstrated significant improvement in 24-hour mortality post-injury; an effect that was increased in the subgroup requiring massive transfusion.[195] Despite the limitations from these studies, their results placed an emphasis on TXA usage, including its administration in the field by the first responders.
III. INTERCONTINENTAL CASUALTY TRANSPORTATION a) Critical Care Air Transport Team (CCATT)
In previous conflicts hospitals were located behind friendly lines in or near the country of active hostilities. Patients often underwent the entirety of their convalescence at these hospitals without repatriation to their country of origin. During World War II and Vietnam, aeromedical patient evacuation platforms allowed the battlefield-injured patient to be returned to the continental U.S. for treatment. Critically ill patients, however, could be evacuated only if critical care providers accompanied them. The needs of GWOT resulted in robust utilization of a safe system of intercontinental aeromedical evacuation in which the intrinsic aircrew was capable of caring for critically ill patients.[196] During GWOT, patients were rapidly evacuated from point of injury to in-theater Role II and III military treatment facilities before being evacuated to higher echelons of care in other countries. Casualties injured in Operation Enduring Freedom and Operation Iraqi Freedom typically arrived at the Landstuhl Regional Medical Center (the Role IV facility in Landstuhl, Germany) within 24 to 48 hours of injury. Within 48 to 96 hours, many patients were returned to the U.S. and cared for at CONUS Role V military hospitals such as the former Walter Reed Army Medical Center and National Naval Medical Center (now the Walter Reed National Military Medical Center) and the former Brooke Army Medical Center (now the San Antonio Military Medical Center).[197]
CCATTs, as previously mentioned, consist of a critical care-trained physician, a critical care nurse, and a respiratory therapist.[196] A full complement of vasoactives, antibiotics, sedatives, and anesthetic medications are available for use in-flight.[198] Crews are capable of inserting advanced airway, managing portable mechanical ventilation, administering blood products and drawing basic labs.[198] A standard CCATT is capable of simultaneously caring for six critically ill patients, up to three of whom can require mechanical ventilation.[196]
Barriers to widespread adoption of a CCATT program had included the concern that patients would be at risk of adverse events. During intercontinental evacuation, major diagnostic and therapeutic modalities are not available for the duration of transport. In a review of over 600 CCATT missions, the most common serious events were hypotension, decreased urine output, decreased oxygen saturation, and changes in mental status.[199] No deaths or loss of invasive adjuncts such as chest tubes or artificial airways were noted[199] and anemia did not contribute to worse outcomes when undergoing intercontinental evacuation.[200, 201] Proper timing of evacuation was also a concern; the largest review of CCATT data did not find any relationship between timing of evacuation and mortality.[202] A significant amount of basic science research on aeromedical evacuation and its effects on immunology and physiology has taken place as a result of the recent conflicts. Makley and colleagues found no significant increase in systemic inflammatory response in a hemorrhagic mouse model subject to simulated aeromedical evacuation.[203]
CCATTs have also been deployed in support of more recent civilian disasters. Most notably, critically ill patients were evacuated from New Orleans by CCATT in 2005 after Hurricane Katrina overwhelmed hospitals in the city.[198] The CCATT platform has been proven to be a safe and reliable method of aeromedical evacuation that has revolutionized the care of the combat casualty.
IV. TRAUMA RESEARCH, QUALITY IMPROVEMENT, AND INTERCONTINENTAL COMMUNICATION a) Joint Trauma System (JTS)
Civilian regional trauma systems were codified by the U.S. Congress in the late 1960s after a report from the National Academy of Sciences shed light on the health burden of traumatic injury.[204] As part of a quality assurance/process improvement initiative, the armed services began creating trauma systems and accompanying trauma registries in the early years of GWOT using civilian regional trauma systems as a model. In 2004 representatives of the Joint Theater Trauma System (JTTS) (now the Department of Defense Trauma System[125]) were first able to begin inspecting the medical care delivery systems of the U.S. military.[205] The initial JTTS team assigned to assess trauma capability among DoD forward medical treatment facilities consisted of a single trauma surgeon and six trauma nurse coordinators.[205] This team was tasked to inspect in-theater hospitals to assess their potential to deliver quality trauma care. At the same time, data collection regarding ill and injured patients in-theater began to be added at the Joint Theater Trauma Registry (now DoDTR).[205]
The DoDTR, and subsequently the Department of Defense Trauma System, was termed a ―continuous learning health system,‖ a system in which all data and intent are geared toward improving patient outcomes.[206] Under the auspices of the Combat Casualty Care Research Program, U.S. military researchers have analyzed data from the DoDTR for evidence-based process improvement and trauma research. This knowledge takes the form of 43 combat-trauma-relevant CPGs for the care of the combat wounded. These CPGs undergo annual review and revision to ensure that they reflect the most current state of trauma research.[207] b) Video Teleconference (VTC)
In 2005, a weekly video teleconference was developed that would enable communication through the continuum of the military healthcare system so that a real-time patient sign-out and quality assurance could occur.[208] These sessions were attended by providers worldwide at medical treatment facilities in combat theaters of operation in Germany and in the U.S. Today, video teleconferences are multidisciplinary, incorporating many members of the care team rather than only the physicians. Operation Iraqi Freedom and Operation Enduring Freedom were the first conflicts in which it was feasible to implement this technology. Prior to these conflicts, no standardized voice communication system existed to allow providers to discuss care of combat casualties throughout all phases of treatment and rehabilitation. Weekly video teleconferences permitted consensus decisions about individual patient care and allowed for the rapid, global dissemination of guidelines and policies to all involved providers.[209]
V. CONUS CARE AND REHABILITATION a) Venous Thromboembolism (VTE)
It is well accepted that severe trauma such as that seen in combat injuries places patients at increased risk of venous thromboembolism (VTE).[210] Clot emboli from deep vein thrombosis may cause pulmonary embolism, a major cause of death in trauma patients.[211, 212] Researchers at Brooke Army Medical Center looked at factors influencing VTE among combat-wounded patients. They performed a retrospective record review of over 26,000 combat casualties over a 10-year period. In that review, bilateral and/or proximal lower extremity amputations demonstrated significant increases in risk of deep vein thrombosis and pulmonary embolism.[213] A smaller retrospective study performed at Walter Reed Army Medical Center from 2009 to 2011 demonstrated that massive transfusion predicted an increased risk of deep vein thrombosis and pulmonary embolism. The same study also demonstrated that low molecular weight heparin, such as enoxaparin (Lovenox, Sanofi, Bridgewater, New Jersey), when given at doses of either 30 mg twice a day or 40 mg daily, was equally effective at VTE prophylaxis, which was in contradistinction to most civilian trauma literature.[214] Low molecular weight heparin was also found to be superior to both unfractionated heparin and no pharmacologic prophylaxis in preventing VTE.[214] Likewise, in a study by Dr. Joseph Caruso and colleagues, once daily dosing of Lovenox 40 mg, often used in the setting of regional anesthesia in these complex trauma casualties, did not demonstrate an increase in VTE or bleeding complications when compared with traditional twice-daily 30 mg Lovenox dosing.[215, 216]
Inevitably, some injured combat trauma patients at high risk of VTE (or with known VTE) would have a contraindication to medical prophylaxis or anticoagulation or would fail anticoagulation. Retrievable inferior vena caval filters were placed to prevent death from large pulmonary embolus. Inferior vena cava filters were placed either prophylactically (in patients at high risk of VTE) or therapeutically (in patients with known VTE disease in which anticoagulation failed or was contraindicated). A 2009 study looking at placement of the filters in military trauma patients found an overall retrieval rate of only 18%.[217] Poor retrieval rates spurred creation of an inferior vena cava filter registry in which tracked patients were afforded a much improved filter retrieval rate of 60%.[218] b) Traumatic Brain Injury (TBI)
The relative frequency of exposure to blasts in the form of improvised explosive devices as well as increased screening led to an increase in the incidence of traumatic brain injury (TBI) during GWOT. The DoD estimated that since 2000 over 300,000 U.S. service members have suffered from a TBI. Of these, 82.4% were mild, 8.5% were moderate, and 1% were severe.[219] Long-term effects of TBI vary significantly depending on the severity of the injury. Among patients with mild TBI, 15% will experience a post-concussive syndrome consisting of headache, sleep disturbances, mood disturbances, cognitive disorders, and neurologic deficits.[220] Patients with even mild TBI carry an increased long-term risk of suicidal ideation.[221]
Diagnosis of TBI begins with combat medics and corpsmen in a forward setting. Combat medics and corpsmen were trained to follow a standardized algorithm in the diagnosis and management of TBI. These algorithms are available in Military Acute Concussion Evaluation pocket cards and the accompanying Concussion Management in Deployed Settings pocket cards. These algorithms were developed by the Defense and Veterans Brain Injury Center (DVBIC) to improve early screening and management of TBI.[222-224] Novel methods of TBI diagnosis were discovered during GWOT. Evidence from U.S. service members in Afghanistan has demonstrated that brain diffusion tensor imaging can provide acute evidence of mild TBI by demonstrating attenuated signal in the right superior longitudinal fasciculus.[225]
Technology and experience in the treatment of TBI improved significantly during GWOT. The DVBIC has established an Emerging Consciousness Program to return patients to their highest possible level of function. Interventions to aid in recovery of consciousness were both pharmacologic treatments and sensory stimulation. Medications used included amphetamines, dopaminergic medications, and eugeroics.[226] Sensory stimulation techniques are individualized practices designed to improve measurable responses to stimuli of all sensory modalities.[227] c) Prostheses and Composite Tissue Allografts
Traumatic amputation represented a significant portion of musculoskeletal injuries during GWOT. Limb amputations represented approximately 6% of all wounds sustained in combat.[228] Innovative new ―powered‖ prosthetic technology was developed to maximize function in injured service members. Indeed, evidence has borne out that GWOT service members with traumatic lower extremity amputations as a result of combat report higher levels of function and statistically increased participation in high- impact activities when compared to Vietnam veterans without access to advanced technology prosthetics.[229]
Historically, technology for functional upper-extremity prostheses has lagged behind that of lower extremity prostheses; in fact, the functional component of upper extremity prostheses for the majority of U.S. service members consisted of a hook mechanism.[230] In 2006, the Defense Advanced Research Projects Agency created the Revolutionizing Prostheses program to develop prostheses that provide amputees with fine motor control and sensory output. One such prosthetic, the DEKA Arm, (DEKA Integrated Solutions Corp., Manchester, New Hampshire) offered users the ability to articulate about the fingers, wrists, elbows, and shoulders.[231] The DEKA Arm was well received by veterans with upper- extremity amputations that were selected to test the device; it was specifically noted that users were able to perform tasks that were not possible with their prior prosthetics.[232] The DEKA Arm recently received Food and Drug Administration approval based on its success.[233]
Another prosthetic, the Modular Prosthetic Limb developed by the Johns Hopkins University Applied Physics Laboratory (Laurel, Maryland) allowed users to control the limb through electrocorticographic electrodes implanted on the motor cortex of the brain.[234, 235] Trials of the device with wounded warriors began at the Walter Reed National Military Medical Center in 2012.[236] Air Force Master Sergeant Joseph Deslauriers, Jr., a three-limb amputee from an IED and a user of the device, testified in front of the House Committee on Science, Space and Technology Subcommittee on Research and Technology in 2013. His testimony praised the ability of the limb to offer finger movements and wrist rotation that allowed him to function more independently.[237]
Extremity transplant has been successfully performed in a small number of combat wounded patients with traumatic amputations. In 2009, a 24-year-old male injured by a blast received a distal right forearm transplant.[238] In late 2012, a 26-year-old soldier injured by an IED received a bilateral upper-extremity transplant as well as a bone marrow transplant to prevent rejection.[239, 240] Long-term outcomes of function for both prostheses and transplanted extremities are promising.
VIII. CONCLUSION
Significant advances in casualty care and combat trauma surgery occurred over the past 100 years. Improvements in aeromedical evacuation, surgical techniques, and resuscitation strategies, as well as a better understanding of the physiologic response to injury have led to increased survival despite rising injury severity scores. However, there are still gaps to fill in order to improve upon previous successes. Lessons learned from previous conflicts cannot be forgotten and ongoing basic science and translational research is necessary to truly understand and manage complex combat trauma patients. Process improvement reviews of the DoDTR and refinements to the combat CPGs are essential for successful patient outcomes. Likewise, ongoing DoD trauma readiness training is crucial to maintain preparedness for the next conflict.
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Author Biography
Matthew Bradley: LCDR Bradley received his undergraduate degree from the Pennsylvania State University and attended Temple University School of Medicine in Philadelphia, PA where he received his Doctor of Medicine. After medical school, Dr. Bradley completed his residency in General Surgery at the Walter Reed National Military Medical Center (WRNMMC) in Bethesda, MD. Following residency he was assigned as the Ship‘s Surgeon on board the George HW Bush, CVN 77 during its maiden deployment in support of Operation Enduring Freedom. He completed his fellowship training in Trauma/Critical Care at the R Adams Cowley Shock Trauma Center in Baltimore, MD. Following fellowship he was transferred to the Naval Medical Research Center in Silver Spring, MD serving as the Department Head for the Regenerative Medicine Department where he concentrates his research efforts on battlefield injuries. In addition to his position at NMRC he also holds an academic position as an Assistant Professor of Surgery at the Uniformed Services University and as an Attending Trauma/Critical Care Surgeon at WRNMMC while continuing to work as a volunteer staff trauma surgeon at the Shock Trauma Center. During LCDR Bradley‘s last deployment he served as the Chief of Trauma at the NATO Role III Multinational Medical Unit in Kandahar, Afghanistan in support of Operation Enduring Freedom and the Resolute Support Mission. Dr. Bradley is a Fellow of the American College of Surgeons, a member of the Eastern Association for the Surgery in Trauma, the Southeastern Surgical Congress, the Society of Critical Care Medicine, and the Association for Academic Surgery. In addition, he is an instructor for Advance Trauma Life Support (ATLS), Fundamentals of Critical Care Support (FCCS), Advanced Trauma Operative Management (ATOM), and Advanced Surgical Skills for Exposure in Trauma (ASSET).
Matthew Nealeigh: LT Nealeigh earned his Bachelor‘s degree in Biology from Wayne State College, Nebraska, and earned his commission through Officer Candidate School aboard Naval Air Station Pensacola in October 2004. He served for six years as a Cryptologist and Information Warfare Officer in support of multiple government intelligence agencies, including a deployment to Iraq supporting special operations teams. He also served tours on the Admiralty staff at the Pentagon and Commander, U.S. Fleet Cyber Command/U.S. TENTH Fleet. Dr. Nealeigh earned his medical degree from Lincoln Memorial University (Tennessee), and is a third-year general surgery resident at Walter Reed National Military Medical Center, Bethesda, MD. He was appointed a surgical teaching fellow with the Uniformed Services University of Health Sciences.
John Oh: COL Oh is a trauma critical care surgeon at the Walter Reed National Military Medical Center and chief of general surgery. Dr. Oh received his undergraduate degree at the United States Military Academy at West Point in 1993. He attended New York Medical College in Valhalla, New York graduating in 1998. After completing a residency in general surgery in 2003 at the William Beaumont Army Medical Center, Dr. Oh served at the 121st General Hospital in Seoul, Korea, as well as Carl R. Darnall Army Medical Center at Fort Hood, TX. He served in operational tours in Afghanistan and Iraq, earning the Soldiers Medal for heroism in 2006 after removing an unexploded rocket from a wounded soldier. In 2010, Dr. Oh completed a surgical critical care fellowship at Brooke Army Medical Center and then served as the trauma medical director at Landstuhl Regional Medical Center (LRMC) in Germany, the military‘s sole level IV treatment center which received nearly 100% of the evacuated combat casualties from Afghanistan and Iraq. During this time, Dr. Oh supervised the trauma research department and was active in clinical research in combat casualty care, traumatic brain injury, and prehospital injury care. Dr. Oh was instrumental in collaborating with German critical care physicians in order to establish and maintain a military Extra-Corporeal Membrane Oxygenation Team. This team augmented the Air Force Critical Care Air Transport Teams and was capable of flying into combat theaters in Afghanistan and Iraq as well as throughout Europe and Africa to support patients with severe respiratory distress syndrome. These patients were transported on the aircraft on ECMO and returned to Germany for further management. His interests are in global surgery and injury care. Dr. Oh is currently the chief of general surgery at Walter Reed and the Director for the Division of Global Surgery at USUHS.
Philip Rothberg: Dr Rothberg received his undergraduate degree from the University of Maryland and his MPH and MD degrees from Tulane University. He is currently a fourth-year surgical resident at the Walter Reed National Military Medical Center and was appointed a surgical teaching fellow with the Uniformed Services University of Health Sciences.
Eric Elster: Dr. Elster received his undergraduate and medical school degrees from the University of South Florida in Tampa as a recipient of the U.S. Navy‘s Health Professionals Scholarship Program. Upon graduation, Dr. Elster completed a general surgery residency at the National Naval Medical Center in Bethesda, MD. During Operation Iraqi Freedom, Dr. Elster served as ship‘s surgeon aboard the USS Kitty Hawk while stationed in the Persian Gulf. Upon returning, Dr. Elster completed a solid organ transplantation fellowship at the National Institutes of Health and then was stationed at the Naval Medical Research Center in Silver Spring, MD, where he directed a translational research program focused on the development of improved diagnostics and therapies for serious traumatic injuries, transplantation and advanced operative imaging. CAPT Elster now serves as the 3rd Chairman and Professor of the Department of Surgery at the Uniformed Services University of the Health Sciences & the Walter Reed National Military Medical Center, a department which includes 89 staff surgeons across all surgical specialties, 135 surgical residents and fellows, and supports 170 medical students per year (of which 40 last year matriculated in surgical residency programs). This robust academic department has a research portfolio across the spectrum of surgery with peer review funding from DoD and the NIH and publishes more than 250 papers per year in high-impact journals. Dr. Elster is also the Director of the Surgical Critical Care Initiative, a joint military and civilian program developing clinical decision support tools for critically ill patients. Dr. Elster was last deployed as a surgeon and Director of Surgical Services at the NATO Role 3 Military Medical Unit in Kandahar, Afghanistan. Dr. Elster is a member of several key organizations including a fellow of the American College of Surgeons, Society of University Surgeons, American Society of Transplant Surgeons, the Southern Surgical Association, the Halsted Society and the American Surgical Association. Dr. Elster and has published over 130 scientific manuscripts in leading journals such as JAMA, Annals of Surgery, American Journal of Transplantation, and Science Translational Medicine, and has received numerous research grants across all aspects of surgery.
Norman Rich: Dr Rich received his undergraduate and medical degrees from Stanford University. He completed his surgical internship and surgical residency at Tripler Army Medical center and Letterman Army Medical Center, respectively. He was the first vascular fellow and vascular chief at the Walter Reed Army Medical Center in Washington D.C. Dr. Rich is a member of an extensive number of societies, has won numerous awards and honors, and authored hundreds of manuscripts. Most notably he started, and remains the Director of, the Vietnam Vascular Registry, which continues to provide lessons learned and guidance for management of vascular injuries. In addition, he was the first chairman of the Department of Surgery, which now bears his name, at the Uniformed Services University.