Editor’s note: This morning, in Bethesda MD, the Executive Director of the American College of Surgeons, Dr. David Hoyt, presented the leadership of Walter Reed National Military Medical Center with a plaque recognizing its designation as an ACS-certified Level II Trauma Center. Walter Reed Bethesda is part of extraordinary chain of military health system facilities, providers, organizations, and techniques that have dramatically improved an injured service member’s odds of survival and recovery. As the authors of this post note, lessons learned during more than a decade of war are now being adopted into civilian care, to the benefit of children and adults in every corner of the United States and beyond. For more on emergency care, read the December Health Affairs issue, “The Future of Emergency Medicine: Challenges And Opportunities.“
Out of the ashes of 9-11 and the two wars that followed, a new paradigm has emerged that has benefited more than 50,000 injured warfighters and is transforming civilian trauma care. During the past decade of war, strategic investments in research and clinical care, coupled with contributions from world-class clinician-scientists, have produced the lowest case-fatality rate among combat casualties in the history of armed conflict.
At the beginning of Operations Enduring Freedom (OEF) and Iraqi Freedom (OIF), the combat injury case-fatality rate was approximately 18 percent. Over the subsequent decade, it steadily decreased to 5 percent despite an overall increase in injury severity. This remarkable achievement is grounded in advances in all aspects of trauma care, from the point of injury to optimum treatment in military rehabilitation centers.
As with all previous conflicts throughout history, clinical knowledge generated in the civilian setting was rapidly adapted in innovative ways to address challenges encountered on the battlefield. Now, it is coming full circle to improve the care and decrease the mortality of both injured warriors and civilian trauma victims. This reciprocal relationship between military and civilian medicine, recently highlighted in domestic terrorism attacks such as the Boston Marathon bombing and the mass shootings at Aurora and Tucson, is visible in daily practice in trauma centers throughout the country.
These improvements didn’t happen by accident; the military invested in relevant translational research and developed a flexible, evidence-based trauma system that rapidly developed, assessed, deployed, and refined new advances in trauma care and rehabilitation. In this post we highlight a number of these advances and the science behind them, and we offer a roadmap to ensure that these advances are not only preserved for use in future conflicts, but evolve to benefit all patients — military and civilian alike.
What Has Been Accomplished
Tactical combat casualty care. One of the first important advances was recognition, based on experience gained in the First Gulf War, that combatants themselves are the true “first responders” on the battlefield. Combatants are trained to recognize and promptly respond to life-threatening injuries, and medics and corpsmen are now trained in a realistic, scenario-based, and standardized fashion, based on the principles of tactical combat casualty care (TCCC). TCCC provides the training for the effective use of topical hemostatic agents (bandages with the ability to accelerate blood clotting) and, when necessary, tourniquets to control severe bleeding, along with other skills such as rapid assessment of injuries, airway control, treatment of traumatic pneumothorax (collapsed lung), and immediate pain control.
TCCC is divided into three phases that are relevant in both the combat and civilian mass casualty settings: care under fire, tactical field care, and tactical evacuation care. “Tactical” refers to individual and small unit activities, such as direct care rendered by a first responder at the point of injury, in contrast to “operational” and “strategic” activities, which involve larger units and broader geographic space. This coordinated approach achieved exceptional success; when adopted by elite units of the US military, it resulted in the near elimination of preventable deaths on the battlefield. Today, civilian emergency medical systems (EMS) are adopting the TCCC approach using a course offered by national organizations representing the EMS community.
Bleeding control. Early hemorrhage (bleeding) control, using tourniquets and topical hemostatic agents, are a prime example of how new or improved techniques on the battlefield can produce profound benefits at home. Previously tourniquets were not advocated for routine use for fear of limb loss. However, the need for tourniquets was quickly recognized as essential in modern warfare where severe extremity injuries are common and evacuation is often both timely and fast. Widespread adoption of tourniquets saved many lives in combat without secondary limb loss.4 As an adjunct, the use of topical hemostatics, was more than 90 percent effective. Over the course of the conflicts, these agents were modified several times. This allowed military doctors to optimize their effectiveness while minimizing side effects.
Both of these approaches to hemorrhage have quickly made their way to civilian settings, moving “from the sandbox to the street.” This was most clearly seen following the Boston Marathon bombings, where “without a doubt, tourniquets were a difference-maker and saved lives.”
Massive transfusion protocols. Advances in care did not end on the battlefield; they accelerated upon arrival at hospital settings. This began with new approaches to replacing blood loss from trauma. Prior to our experience in Iraq and Afghanistan, the most severely injured casualties were resuscitated in a step-wise fashion, first with saline solutions, followed by a gradual escalation to the use of blood products. Faced with less than ideal outcomes, military surgeons challenged this approach and looked for better ways to replace blood loss. Based upon solid lab research, these surgeons introduced the concept of “balanced resuscitation”, by immediately countering blood loss with key components of blood when the injured soldier or marine’s injury profile suggested the need for massive transfusion (unstable patients or those with severe injury patterns). This approach not only improved survival, it reduced the rate of complications in combat-wounded patients.
Adoption of “massive transfusion protocols” has become one of the most swiftly adopted changes in care coming from the battlefield. Today, a majority of Level I trauma centers in the US have shifted to this practice. This approach is also being adopted in surgical education, where trainees are taught to activate “massive transfusion protocols” to counter severe injuries.
“Damage control” surgery. The next major advance took place in the operating room where prompt surgical control of bleeding, closure of perforated bowel injuries, and early debridement of damaged tissue are key steps. Focusing on these priorities up front, leaving the abdomen “open” with temporary dressings, and deferring more complex definitive surgery for subsequent procedures has avoided the secondary insult of prolonged periods in the operating room. This led to a practice called “damage control surgery.” This concept was first introduced in the civilian trauma world (utilizing a term adopted from the military, where “damage control” refers to maneuvers to save a ship so it can continue to be effective). The technique caught on with military surgeons, many of whom who had trained in civilian trauma centers, and was swiftly refined under wartime conditions. As with the other advances discussed, the widespread application of damage control surgery has benefited military and civilian populations alike.
Neurocritical care. Patients with specific injuries, most notably penetrating head and extremity injuries, have also benefited from military medicine. In previous conflicts, many of these patients were assumed to have non-survivable injuries and were treated as “expectant” (i.e., only comfort care). Now, they are aggressively managed using techniques similar to those applied in damage control surgery.
For example, in cases of massive head trauma, a portion of the skull is temporarily removed to allow the brain to swell without creating a lethal rise in pressure that would stop blood flow to the brain. This is particularly important for patients faced with long medical evacuation times. Another technique involves preventing the spasm of major blood vessels that are necessary to support brain survival and function. Although this practice has not yet been widely adapted in civilian trauma, it may come to be widely used in future mass casualty events and conflicts.
Treatment of badly damaged limbs. Another advance that has seen widespread use is an integrated approach to early limb salvage versus amputation in patients suffering from massive extremity injuries with significant tissue loss and neurovascular damage. Military and civilian researchers have found that, for certain patients, early amputation results in better long-term functional outcome. For patients who remain good candidates for limb salvage, the innovations in soft tissue reconstruction have produced survivors who not only recovered, but in many instances returned to full duty and extremely active lifestyles.
Two key adjuncts to the successful treatment of severe extremity wounds are adequate pain control and aggressive, early rehabilitation. The adoption of regional pain control and integrated pain management teams has allowed rehabilitation to start while the patient is still in the hospital. All of these efforts come together in the treatment of the multi-limb amputees who face substantial challenges. Without these approaches, the amazing functional results that have been seen would not be achievable. Many of these techniques are now working their way into civilian practice, such as treatment of victims of the Boston Marathon bombings.
Rapid evacuation to tertiary care centers. Transporting injured personnel to centers capable of providing advanced levels of care required comparable innovations in tactical and strategic casualty evacuation. In conflict zones, tactical evacuation is largely accomplished by medical evacuation helicopters, while inter-theatre strategic evacuation over thousands of miles is achieved with large Air Force fixed wing aircraft outfitted with ICU pallets and staffed by specially trained Critical Care Air Transport Teams (CCATTs). This integrated approach has resulted in a reduced medical footprint in the conflict area as compared to previous conflicts. Equally important, improvements in hand-offs of care were devised to assure seamless transitions between the military, the U.S. Public Health Service, the Veterans Health Administration, and, ultimately, civilian trauma and rehabilitation facilities. The collective impacts of these advances in care are unprecedented in military history.
How It Was Done
Almost as remarkable as this progress is the manner in which it was done. Normally, progress in patient care is achieved through painstaking, incremental research, often tested and refined through large-scale randomized trials involving thousands of patients. It’s been written that the average time frame for research to reach the bedside and be widely adopted into care is measured in decades. The military health system didn’t have that sort of time. Lives depended on swift and sure decisions, backed by the best available evidence.
Much of the progress was made possible through creation of the Joint Trauma System (JTS), whose mission is to improve trauma care delivery across the continuum of care through careful data collection and analysis, to improve clinical outcomes in near real-time. This effort represents the largest combat registry ever created. In addition to monitoring the quality and outcomes of care, the JTS develops and implements clinical practice guidelines system-wide, and identifies the training and research needs for trauma care in the military.
The ability of the JTS to rapidly identify emerging injury patterns, develop best practices and research-based CPG’s, and subsequently disseminate and track such guidelines represents a paradigm shift away from costly, multi-year clinical studies to “focused empiricism” and continuous process improvement. Driven to address challenges identified by the JTS, the DoD continues to invest in mission-relevant research focused on biomarker-based care, regenerative medicine, and advanced approaches to hemorrhage control. While many civilian centers have adopted similar models with a degree of success, the widespread implementation of this approach could serve as a model for other large health care systems.
Early in what has proven to be the longest armed conflict fought by the U.S. to date, military medicine recognized that it needed to fundamentally change how it approached the care of wounded warriors. It did this by implementing data-driven decisions at every step in the continuum of care, from battlefields in two nations across 8000 miles and three continents to world-class hospitals and rehabilitation centers in Germany and the United States. Importantly, this work was done while the individuals involved were doing their utmost to provide the best possible care to every injured combatant and civilian they touched. As was true following the conflicts in Korea and Vietnam, lessons learned in the crucible of war are beginning to transform care in civilian hospitals in the U.S. and around the world.
The progress that has been made over the past decade is tenuous at best. Some of those who led these efforts have retired from the military, and others are struggling to contend with budget cuts, furloughs and funding constraints. It won’t be easy to maintain surgical skills honed over a decade of conflict. But this is essential to assure that military healthcare in any future conflict will be as good, and ideally better, than in the most recent ones. There is little doubt that thousands of service members and veterans are alive today thanks to the work of dedicated military and civilian health care professionals. Many of the insights they developed are beginning to transform care in the civilian world and millions will benefit.
The knowledge gained over a decade of war cannot be taken for granted. Continued work is needed to identify and manage challenges that are only faintly understood today. The progress that is made will not only help our warfighters in future conflicts, it will help save the lives of civilians as well.