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Commander's introduction.

The Marine Corps has a fundamental tenet which is ingrained in every Marine, from the Commandant to the newest boot camp graduate:
   The only reason for your existence in the Corps, no
   matter your job, is that Marine rifleman in the foxhole.
   Everything you do must ultimately contribute to his
   effectiveness and survival on the battlefield.

With regard to our ultimate purpose, a similar principle is applicable to most of us in the Army Medical Department. Indeed, the historical foundation for the existence of military medicine is management of trauma injuries incurred by Warfighters in combat. When reduced to its essence, that trauma care starts with the combat medic, who must call upon all of the training, skills, and equipment that we have given him/her to keep wounded Soldiers alive until they are in the hands of our superbly capable surgeons. Those combat medics are the core of prehospital care on the battlefield, that absolutely crucial phase of combat trauma care that can determine the outcome of the casualty's journey through the medical care system. The survival of that combat casualty is the primary reason for our existence, and the combat medic is the starting point to make that happen.

We in the AMEDD live and work in the real world. Every day presents new, "right now" crises and challenges clamoring for our time and attention. In the bedlam of so many complications and diversions, so many requirements pulling from all directions, and so many demands for instant responses, it is sometimes difficult to keep our collective concentration directed towards the ultimate responsibility. COL Lorne Blackbourne, Commander of the US Army Institute of Surgical Research (ISR), and his team have assembled this very important issue of the AMEDD Journal to refocus on prehospital care of combat trauma. Drawing on the considerable resources of the ISR's professional staff and their counterparts in research and the practice of trauma care from across the country, this impressive collection of articles explores a broad spectrum of topics dealing with the current and future states of prehospital combat trauma care. The articles cover the gamut, including research in medications, techniques, and tools; data requirements, management, and value; and the qualifications and training of our frontline medical professionals. Readers may find some of the content a bit controversial, perhaps even provocative, but the Army is a learning organization, and we as leaders and professionals must always recognize facts for what they are, especially when lives may be on the line.

The AMEDD is responsible for many varied disciplines encompassing nearly every aspect of modern medicine. Obviously, all are very important to the health and welfare of our Warfighters. However, when the urgent cry "MEDIC!" rings across the chaos of a battlefield, nothing is more vital at that moment than the capabilities that the AMEDD has given that Soldier and those that will assist in moving the casualty to the next level of care. For that reason, the articles in this issue should be of great interest to the vast majority of AMEDD medical professionals, whether or not you are directly involved in combat casualty care. All military medical professionals should be impressed by the dedication and focus of those continuously involved in working to optimize the odds of survival of our Warriors who go into harm's way, whenever and wherever necessary.


COL Lorne Blackbourne opens the collection of focus articles with a retrospective look at the evolution of prehospital trauma care since 1831. Interestingly, 1831 is significant to medical science because in that year occurred the first documented use of intravenous fluid. Technological advances in medical science, as well as throughout almost all aspects of human endeavor, have been breathtaking, and, by and large, greatly beneficial. However, COL Blackbourne presents a comparison of the technology of prehospital battlefield care in 1831 and today, and his conclusions reveal a surprising lack of significant advancement in both sophistication and variety in diagnosis and treatment over the years. His article sets the stage for the articles that follow, which demonstrate that military medicine in general, and the Army Institute of Surgical Research in particular, has considerable resources dedicated to rectifying this situation as rapidly as possible, working to improve every facet of prehospital battlefield trauma care.

COL Brian Eastridge and his team examined the differences between the advances of military trauma care in the hospital setting and that experienced in the prehospital environment from the perspective of the evidence that drives change and improvement. The Army has implemented sophisticated data collection systems and databases specifically to track injuries and allow thorough analysis of both successes and failures of treatments, including all the factors which can be quantified. Such analyses and implemented protocols, equipment, and supplies have resulted in tremendous advances in acute care management of the combat casualty. Unfortunately, as COL Eastridge et al describe in detail, such necessary data is almost never available from the prehospital care phase of combat trauma care. Without that data, those dedicated to improving the prehospital care capabilities are essentially hunting for solutions armed with suboptimal evidence, when any exists at all. The article describes the military's efforts to address this problem, with the establishment by DoD of the Tactical Combat Casualty Care (TCCC) guidelines with participation of all the services. These guidelines are under constant review and modification based on evidence gathered from numerous sources, as well as unrelenting efforts to gather data from the actual battlefield environment. This is difficult, but the paramount importance of such data cannot be overemphasized.

In the next article, LTC Russ Kotwal and his coauthors describe one early initiative to implement TCCC protocols and procedures, and directly address the lack of prehospital data. The 75th Ranger Regiment developed and implemented a regiment-wide program of training in TCCC basics, especially the recording of casualty data from the first contact with any responder, whether a medic or not. The Regiment created a Soldier's data card specifically to capture the TCCC data, and ensured that command emphasis on its use was constant, including training classes and during field exercises. That data card eventually became the Army's standard TCCC card (DA Form 7656). As the Regiment's collection of data from the TCCC card improved in quality and quantity, a database for the TCCC data was developed: the prehospital trauma registry. LTC Kotwal et al discuss the evolution of that registry into a web-based tool that has markedly improved the command's ability to devise treatment protocols and procedures based on evidence, one of the essential elements discussed previously as historically unavailable. This article is yet another example of the initiative, skill, and energy of our military medical professionals in pursuing the primary goal, survival of the Warfighter.

It is well documented that hemorrhage has historically been, and remains, the primary cause of death on the battlefield. Further, data from current combat operations indicate that two-thirds of hemorrhage-related deaths in those conflicts have been from noncompressible injuries. As Dr Michael Dubick describes in his excellent article, often there is little the combat medic can do for such casualties beyond infusing fluid to maintain blood pressure until surgical resources can be reached. However, even that capability faces limitations in supply, and certain types of intravenous fluids are not suitable for this application. The article focuses on the current thinking with regard to optimal fluid resuscitation strategies to give the combat medic the best chance to stabilize the combat casualty. The concept of damage control resuscitation has been developed to describe those optimal strategies as battlefield data and attendant research reveal what works, and what does not. Dr Dubick's article details the background, data, practices, and research in progress within the damage control resuscitation concept, the majority of which is the direct result of work at the Army Institute of Surgical Research.

In his detailed and very informative article, Dr Bijan Kheirabadi discusses the research and development efforts to improve topical hemostatic agents that have been ongoing for the past 15 years or so. The need for a safe, effective, and easily used topical agent to control compressible hemorrhage has become an increasingly important goal for military medical researchers as the character of the battlefield has changed dramatically from that of years past. Planners have to anticipate longer evacuation times to surgical resources as current conflicts have become increasingly nonlinear, with dispersed locations of varying levels of medical and transport support. Statistically, the use of an effective hemostatic agent in a dressing to quickly control hemorrhage in the prehospital phase of trauma treatment could be the most effective method to reduce morbidity in a significant percentage of casualties with compressible bleeding injuries. That fact, combined with the obvious utility of such agents in the hospital as well, focus the intense interest by researchers such as Dr Kheirabadi in developing the best product possible to meet our commitment to our nation's valiant Warriors.

COL John Kragh, Jr, and his coauthors address the most serious type of hemorrhage-related cause of death on the battlefield, the uncontrolled bleeding from a wound in the trunk area of the body, usually on the periphery of the body armor, for which tourniquet application is seemingly impossible. In 2009, the DoD Committee on Tactical Combat Casualty Care made truncal tourniquets a research priority. COL Kragh et al present a carefully developed, extensively researched discussion of the physiology of controlling truncal blood flow by compression, the anatomical considerations and challenges involved, the various attempts and ideas to address the problem throughout history, and some of the approaches under consideration in the current research. This article is an important look at perhaps the most important challenge facing those working to increase the survival of battlefield casualties during the prehospital phase of trauma care. Readers will have a thorough appreciation of the skills, expertise, and dedication of those addressing this complex and deadly, but unavoidable circumstance of combat.

Improvements in the Soldier's individual protective equipment used in current combat operations have resulted in a decrease in the number of lethal torso and head injuries, which means that surviving casualties present with various types of serious injuries in a larger proportion than previously experienced. That survivability, combined with the concussive effects of blast from the enemy's weapon of choice-the improvised explosive device-have resulted in a marked increase in diagnosed traumatic brain injury (TBI) among surviving combat casualties. As discussed in recent articles in the AMEDD Journal, TBI has become one of the signature injuries from the Iraq and Afghanistan combat theaters, and is the subject of extensive research and collaborative efforts to understand the physiology of this injury, and develop protocols to address it throughout the flow of casualty care. In their excellent, well-referenced article, COL Leopoldo Cancio and MAJ(P) Kevin Chung present a detailed discussion of the research and clinical experiences shaping current thinking about how to best address TBI in the prehospital phase of trauma care. Their article focuses on stabilizing the casualty's respiration, ventilation, and blood pressure parameters within limits that have been indicated by studies as optimizing survivability and long-term recovery to normal brain functions. The information presented in this article is a compendium of the leading-edge of medical research in this increasingly important area, and should be of great interest to all medical professionals involved in any phase of combat trauma care.

The improved torso protection and the pervasive use of the IED have also resulted in an increase in the number of surviving casualties with severe burn injuries. The vast majority of those casualties are brought to the Burn Center at the Army Institute of Surgical Research (ISR), which has long been recognized as one of the world's premier burn care facilities. The Burn Center not only provides the best care possible to patients they receive, but it is also a major locus for research into all aspects of burn care, from point of injury to posttreatment rehabilitation. This is illustrated in the excellent article contributed by MAJ(P) Kevin Chung and his coauthors, which focuses on prehospital fluid resuscitation of the severely burned combat casualty. They investigated the actual fluid resuscitation practices of the prehospital providers caring for the burned wounded in comparison with the clinical standards recommended by the American Burn Association. Not surprisingly, they discovered that the complexity of fluid administration formulae and the close monitoring required was beyond the immediate capabilities of those charged with caring for multiple casualties in the stark surroundings of the battlefield. Indeed, their research found that prehospital responders in the United States were also not attempting to apply the detailed protocols to determine initial fluid rates. So the ISR developed and validated a greatly simplified methodology to calculate the initial fluid resuscitation rate which falls within the acceptable range. The patient's response then determines adjustments to that initial rate. The ISR had already (2005) developed and published burn resuscitation clinical practice guidelines for en route care, along with a flow sheet for standardized documentation of the care received by the patient throughout transport to the Burn Center. MAJ(P) Chung et al detail these efforts, as well as the development of a computerized decision support system to further monitor and standardize resuscitation fluid rates. These and several other initiatives described in the article are indicative of the dedication, initiative, and enthusiasm for the mission that have been the hallmark of those professionals of the ISR who work tirelessly to save the lives of American Warfighters.

The capability to remotely monitor the physiologic status of Soldiers in the field has long been a staple of science fiction books and movies. However, the obvious value of such a concept has also been recognized by real-world military medical developers and researchers for many years. Dr Kathy Ryan and her team of coauthors provide a look at the current state of ongoing research and developmental work to produce a practical, reliable, and accurate system which, at the most basic level, will provide the combat medic a capability to remotely triage bleeding Soldiers. Combat medics routinely place themselves in vulnerable circumstances while finding, evaluating, and treating wounded Soldiers. Unfortunately, it is not uncommon for the medic to find the Soldier either not seriously injured, or too severely injured to be saved. Further, since the medics must make those judgments "on-site" requiring time and often risking their own lives, other seriously wounded Soldiers may wait, a potentially life-threatening situation. In their detailed, well-presented article, Dr Ryan et al examine the extreme complexities -physiological, technical, functional, and ergonomic--involved in designing the sensors, interfaces, and algorithms to present the information a medic needs to make the necessary critical judgments. The extent of the factors that researchers must consider is significant, but the analysis of specific data elements as to their respective contributions to presenting the overall physiological status is truly impressive. The effort described in this article is yet another example of the extraordinary level of expertise and capability that is found in the Army Medical Department.

As discussed from various perspectives in earlier articles, the scarcity of information about a casualty's injuries, vital signs, and care received (including medications) is a continuing problem. In the absence of such information, each successive provider must take time to reevaluate the casualty as he or she moves through the various stages of the evacuation process, a delay which at any point in the process can be a very perilous circumstance for the wounded Warrior. Further, that provider evaluation itself may be problematic, because in the dynamic environment of the combat theater, each caregiver's level of experience and access to supporting medical information can vary considerably. As described by Dr Jose Salinas and his colleagues, mitigating these information shortcomings is the focus of ongoing research and development at the ISR, with the goal of providing prehospital medical caregivers with advanced computer-based monitoring and decision support systems (DSS) to minimize delays and sometimes dangerous variations in rendered care. Their ideal system would be one with multiple sensors on the patient feeding data into a DSS for analysis and presentation to the caregiver, who could query the system for previous care and medications rendered, access recommended procedures and knowledge-based information about the particular patient's conditions and responses, and then monitor the patient's condition in real time.

LTC(P) Robert Gerhardt provides an overview of the Army Institute of Surgical Research's current efforts in research programs, development efforts, and collaborations aimed at improving casualty survival throughout the prehospital and transport phases of trauma care. Of course the ISR's primary focus is the combat environment, but, as indicated by the close collaborations with other military services, civilian hospitals, trauma centers, and medical transport companies and agencies, the drive to optimize prehospital trauma care is a common goal for all practitioners of emergency medicine. Other articles in this issue have featured certain specific areas of work at the ISR, but LTC(P) Gerhardt's article presents the scope of ongoing work across multiple areas, providing a perspective of the breadth and depth of the professional skills and capabilities which the dedicated people there bring to work every single day. It should also be obvious that the work at the ISR, although directed towards the survival of the Warrior on the battlefield, contributes greatly to the survival of trauma victims across the United States.

As MG Rubenstein mentioned in his opening remarks, the US Army combat medic is literally the point person in the sequence of trauma care that exists to stabilize a wounded Soldier until he or she reaches a surgical facility. This issue of the AMEDD Journal closes with 2 articles from LTC Robert Mabry and COL Robert De Lorenzo examining the training and certification requirements for those vitally important individuals, and providing carefully-considered ideas and recommendations as to how to markedly improve their levels of skill and expertise. Of course the ultimate goal of any change is improved casualty survival rates in the prehospital phases of battlefield trauma care, a positive trend that is occurring, but can always be improved.

In their first article, LTC Mabry and COL De Lorenzo look at the historical evolution of the care of battlefield wounded, from literally none just a century or so ago, to the system of trained and skillful specialists with ambulances, helicopters, and specially configured medical transport airplanes that are part and parcel of modern battlefield trauma care. However, as good as it is, it can always be better, a proposition to which the authors are totally dedicated, with the ultimate goal of more lives saved. They call for renewed emphasis in the specific training and qualifications for those "out front" in the battlefield care path, not just the combat medics, but also the overseeing physician assistants and unit surgeons upon whom those medics rely for mentoring, instruction, and assistance. The authors point out that, in the past, military medicine was able to "grow our own" reservoir of experienced, skilled field practitioners, but certain factors currently limit that ability. They propose a number of structural changes and shifts in emphasis which would reinstate that depth of expertise, with only positive impacts on the numbers of surviving wounded who arrive at surgical facilities in combat theaters.

The advent of the helicopter as an evacuation vehicle for battlefield wounded is arguably one of the most significant developments in combat trauma care since 1797, when Dominique Jean Larrey established the world's first formal ambulance corps for Napoleon's armies. He recognized that time is life, a truism even more profound today as the capabilities of military medical practitioners have reached unimaginable levels, as long as the wounded reach them in time.

Indeed, as so often happens in history, the timing of the development of helicopter medical evacuation (MEDEVAC) was especially fortuitous in that it evolved in concert with momentous shifts in the nature of military operations. The Vietnam experience, followed by the collapse of the Iron Curtain, were strong indicators that future conflicts would probably not be fought over a "structured" battlefield, stretching back from the forward edge of the battle area through defined areas of support wherein vehicles could move via secured roads quickly and efficiently. Combat operations in Vietnam, Iraq, and Afghanistan have been, and are, dispersed, noncontiguous, and definitely nonlinear. Without the helicopter MEDEVAC, the prospects of our wounded Warriors reaching advanced medical facilities in time would be severely diminished. In their timely and important article, LTC Mabry and COL De Lorenzo argue that, as good as the military's MEDEVAC capabilities are, they could and should be improved. They cite the areas where change would have the most significant positive results, and present proposals (and numbers) to enact those changes. They develop their recommendations based on the world's most sophisticated, efficient, successful model of prehospital air transportation of trauma victims, the civilian system in the United States. As they point out, the irony of the situation is that the current US civilian emergency medical services system owes its existence to the success of the US military MEDEVAC operations in Vietnam. The excitement of early successes combined with enthusiastic state and federal support and resulted in rapid evolutions in sophistication, innovation, and capabilities, which have produced the superb system that benefits Americans in every state of our country. LTC Mabry and COL De Lorenzo present the case that the military's MEDEVAC system should be closely and carefully reviewed with the goal of identifying and incorporating standards, protocols, and resources to optimize its lifesaving potential, and an already excellent system will only get better.




MG David A. Rubenstein
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Article Details
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Title Annotation:Perspectives; military medicine
Author:Rubenstein, David A.
Publication:U.S. Army Medical Department Journal
Geographic Code:1USA
Date:Apr 1, 2011
Previous Article:Nutritional care of detained persons in operation Iraqi freedom.
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