Improving Role I battlefield casualty care from point of injury to surgery.
Role I battlefield medical care is care provided in the prehospital environment outside of the forward surgical team and the combat support hospital. It includes aid delivered from the point of injury through the battalion aid station or brigade support medical company until the casualty is delivered to surgical care. Providers of casualty care at this stage include injured Soldiers themselves (self-aid), fellow Soldiers (buddy-aid and combat life-savers), combat medics, flight medics, battalion surgeons and physician assistants.
Historically, the Army Medical Department's (AMEDD) chief focus in wartime has been the provision of quality hospital-based and forward surgical care. During the current conflict, tremendous medical advances have been made that saved the lives of many Soldiers who would have died in other conflicts. (1) If a salvageable patient arrives alive at surgical care in the current conflict, the likelihood of survival is nearly 98%. (2) Yet 3 out of 4 deaths occur on the battlefield before reaching a surgeon, with as many as 28% of fatally injured Soldiers dying with potentially survivable injuries. (3) Therefore, any significant future improvement in saving Soldiers' lives is most likely to occur in the prehospital setting. This will require a significant shift in AMEDD focus to emphasize the prehospital environment.
It is important to recognize that while the AMEDD trains medical providers, establishes doctrine, and develops medical equipment sets for the prehospital environment, line commanders are ultimately responsible for the medical care of their Soldiers on the battlefield. Yet busy combat arms commanders receive little training on how Soldiers die in battle and how they as leaders can best prepare their Soldiers to react to casualties. Instead, line commanders have relied on their "Doc," usually their battalion surgeon or physician assistant (PA), to advise them on medical training and casualty care tactics, techniques, and procedures. This places great responsibility on the battalion surgeon or PA in terms of setting the example for clinical excellence in the line unit, as well as demonstrating competence in medical staff planning and execution.
The role of the battalion surgeon, PA, and combat medic are therefore central to the success of battlefield care and critical to the survival of wounded casualties. To advance the state-of-the-art, this article examines current military prehospital care policies and procedures and uses the highly evolved civilian emergency medical systems as a study of contrasts. It further proposes a comprehensive way to exploit advantages of the civilian system for the benefit of the US Army and, ultimately, battlefield casualties.
Wars are "epidemics of trauma." These epidemics have historically leveraged advances in military surgical and trauma care that are often later applied to the civilian trauma setting. The most salient aspect of military prehospital medicine historically and today has been the rapid clearing of casualties from the battlefield. During the 18th and 19th centuries, exposure was the most prevalent killer of wounded Soldiers. Wounded Soldiers, especially those on the losing side, would often lie for days where they fell, exposed to the elements without water, food, or shelter. (4) Officers and those who could afford medical care would hire surgeons to accompany them during the campaign or seek care on the local economy following the action.
Dominique Jean Larrey, Napoleon's surgeon, recognized that delays in evacuation increased mortality and suffering for the wounded. He developed horse-drawn "flying ambulances" to rapidly treat and evacuate wounded soldiers from the field. (4) During the US Civil War, several scandals followed early battles after injured Soldiers remained on the field for days, with some left for dead and even robbed by ambulance drivers as they lay wounded. Public outrage enabled Dr Jonathan Letterman, medical director for the Army of the Potomac, to institute many sorely needed reforms, including the formation of a dedicated Ambulance Corps that would function similarly to Larrey's system. Letterman's reforms were adopted by militaries throughout world. The principle of rapid evacuation through "echelons of care" established by Larrey and Letterman is still the doctrinal model used by the AMEDD and most modern armies today. (5)
Modern warfare of the 20th century brought about more lethal weapons, such as precision artillery and machine guns, necessitating further dispersion of forces. Ambulances became mechanized. Specially trained corpsmen and medics were placed into combat formations for the first time to provide dedicated point-of-injury care. Medic training was rudimentary and traditionally had minimal involvement from physicians. It was thought that little could be done on the firing line other than basic skills, such as applying bandages and splints and carrying the patient to the aid station on a litter.
The Korean and Vietnam eras brought helicopter evacuation to the fore. Indeed, the icon of modern battlefield medicine in the United States is the Dust-off helicopter. The Dust-off epitomizes modern battlefield care in that an injured soldier can be whisked from the battlefield to surgical care within minutes of wounding. Military trauma systems built during Korean and Vietnam combat steadily increased the survival rates of wounded Soldiers.
In 1966, the National Academy of Sciences published Accidental Death and Disability: the Neglected Disease of Modern Society. (6) This paper remarked that Soldiers wounded in Korean and Vietnam received better trauma care than civilians injured in automobile accidents in American cities. It noted that ambulances lacked standardization, equipment was inadequate, and ambulance attendants were often poorly trained. Millions of dollars in federal funding followed the publication of this paper, giving rise to our modern civilian emergency medical systems (EMS).
The end of the war in Vietnam saw the birth of the modern EMS and the formation of a new medical specialty, emergency medicine. Physicians, nurses, and medics with significant combat experience demobilized and returned to the United States, bringing the wartime lessons learned from military trauma systems to the civilian sector. (7) From the 1970s until today, civilian EMS and the practice of emergency medicine have flourished, advanced, and developed into a unique and distinct subspecialty of medicine with their own body of scientific research and specially trained providers.
The AMEDD's primary focus in the post-WWII period has been on operating fixed medical facilities and providing quality healthcare to its beneficiaries. Military healthcare providers are trained to the highest civilian standards. Military physicians, PAs, and nurses are all required to pass the same boards and certification and licensing examinations as their civilian counterparts. Their training takes place in a fixed-facility hospital or clinic environment. Military providers in training, particularly those attending uniformed service programs, often have "military-unique" medical education requirements. Because of the intensity of these programs and rigid accreditation requirements, the military unique training is necessarily provided at an introductory level. (8)
Newly minted physicians and PAs are then assigned as battalion and brigade medical officers. These providers are then responsible for unit medical training, readiness and staff medical planning, as well as providing care at the battalion aid station or projecting forward on the battlefield themselves during larger operations or mass casualty incidents. Predeployment medical training is required, but these courses are often just-in-time and occasionally deferred. (8)
It has long been a paradox of military expediency that the most junior and least experienced providers are the ones challenged to manage complex cases such as multiple combat trauma in a setting far from mentors or specialists.
The battalion PA has traditionally served as the mentor for the combat medic. The PA program was started by physicians at Duke University who saw a group of individuals with a tremendous amount of hands-on experience, but lacked formal training and recognition. These were the combat medics from the armed services who had served in Vietnam. These physicians began the first formal Physician Assistant Training Program at Duke in 1965. The Army's PA training program began in 1971, with the first class graduating in July 1973. (9) But the character of the Army's PA corps has changed since PAs became commissioned officers in 1992. Because of commissioning rules and education requirements, experienced enlisted combat medics are now rarely able to meet the prerequisites to enter into the program. Once the core of the PA program, former combat medics are now the exception in the PA course where more than 50% of the current candidates are prior service officers. Few new PAs now have experience as a medic. While the academic and clinical quality of the military PA has never been better, that key source of mentorship for a unit's medics, as well as the battlefield medical expertise these former medics brought to the combat arms commander, has significantly changed.
Training for military medics remained rudimentary until the 68W (the military occupational specialty (MOS) designation of the Army healthcare specialist) transition initiative in 2001 under the leadership of Army Surgeon General James Peake. LTG Peake, a decorated infantry officer who served in Vietnam before becoming a physician, recognized the critical nature of the medic's job in combat and pushed for the most significant enhancement in Army medic training in history. Army medics are now required to pass the civilian National Registry of Emergency Medical Technicians (EMT)-Basic examination, the entry-level civilian certification. "Whiskey training" then follows, where medics are taught the principles and techniques of Tactical Combat Casualty Care. These skills are then assessed at the end of their 4 months of training in a sophisticated 16-day field experience that incorporates mounted and dismounted patrolling, urban operations, and forward operating base and aid station operations. Initial entry medic training is now for the first time under the supervision of emergency medicine physicians with subspecialty training in EMS. This enables the latest prehospital medical innovations, training techniques, and research to be rapidly incorporated into medic training. Army medics are better trained in providing point-of-injury battlefield care today than at any time in history.
The enhanced level of initial entry training for combat medics represents a significant milestone, but more can be done. Civilian EMS providers follow a progressive professional pathway from EMT-Basic up to the EMT-Paramedic level. Providing paramedic-level education to Army medics would enhance their lifesaving skills and could remedy an anomaly among MOSs--medics are among rare MOSs that throughout their careers are required to demonstrate proficiency only in their basic Skill Level 10. Most other MOSs require increasing levels of technical competency as rank increases. Introducing a clinical ladder or career pathway that allows for increasing technical competence could enhance promotion and retention and counter the high rate of 68W attrition.
The contemporary operational environment requires a broader skill set from medics than point-of-injury care and rapid evacuation. Conventional units and their medics are more dispersed in the battlespace and are in close contact with civilian populations. This presents unique challenges formerly encountered only by special operations medics. Such challenges include providing sick call in remote and isolated locations without a PA, caring for civilians which may include children and the elderly, prolonged care of the wounded when evacuation is delayed, and even veterinary and dental care. Conventional medics are only partially trained for these mission requirements.
Civilian helicopter EMS has advanced tremendously since its origins on the battlefields of Vietnam. It has now evolved into the most sophisticated mobile prehospital care platforms in the nation and serves virtually all Americans. In contrast, the inflight medical care during military helicopter medical evacuation (MEDEVAC) has remained relatively unchanged. (10) The excellence of civilian air EMS provides valuable lessons for military aeromedical evacuation systems, including flight medic training and skill level, equipment sets, medical direction, quality assurance, and the development of intratheater critical care transport capability. This latter capability would solve a major challenge in the current wars in Iraq and Afghanistan as doctrine does not support the intratheater critical care transport of patients following emergency surgery at the forward surgical team (FST). In an effort to fill the gap, deployed medical leaders are pressing into service nurses (from the combat support hospital or FST) with variable levels of critical care and flight training to perform the transports. One of the most important lessons learned from civilian EMS is the value added from medical direction. Civilian helicopter transport systems have intense oversight from physicians with specific training in prehospital and en route critical care. Raising Army MEDEVAC standards to this level will likely require supplementing the local flight surgeon with an emergency physician.
A WAY AHEAD
Any improvement in battlefield care must first start with physicians within the AMEDD. Providing care in the troop medical clinic or the hospital ward are important and worthy missions for the military physician. But, of course, it is not the same as caring for casualties at the point of injury, running a battalion aid station during major combat operations, or transporting critically injured patients in a MEDEVAC helicopter. There have been several proposals over the years to define the "board-certified" military physician, but to date the precise skill set, training, and certification requirements for optimal battlefield practice have not been defined. The military should seek to develop physicians who specialize in prehospital and operational care. The closest civilian approximation is the emergency medicine specialist with subspecialty training in emergency medical services. This field of medicine requires unique training and a large body of specialized research centering on care outside the hospital. Training in EMS develops specialists who use a systems approach to improve prehospital care. While it would be difficult to place EMS-trained emergency physicians in every operational role, the EMS and military unique skills for providers operating in Role I should be defined and appropriately trained. The AMEDD should seek to systematically develop clinical experts in the practice of prehospital battlefield medicine.
The combat medic's skill set should be broadened to incorporate the challenges of the contemporary operating environment. While it would be impossible to make every entry-level 68W into a special forces medic, a career pathway that increases technical competency as rank increases is a realistic goal. Entry-level medics (grades E-1 thru E-4) should be focused on Tactical Combat Casualty Care principles and point-of-wounding care, the current focus of the 68W initial entry training. Midlevel medics (E-4 thru E-6) should have a more advanced skill set, including the ability to perform remote sick call, more advanced trauma skills, and increased preventive medicine and camp hygiene skills. This medic should be able to deploy with and provide care for up to a company-sized element in a remote outpost with minimal support. Senior medics (E-6 thru E-8) would be responsible for battalion aid station operations and should be able to assist the physicians and PAs during sick-call and mass casualty operations. These medics would also serve as the instructors at the AMEDD Center and School and medical simulation training centers, as well as serve as the "Master Medic" trainer at the brigade and division level. Senior medics should be trained at the civilian EMT-Paramedic level.
A clear professional path based on externally validated standards such as the National Registry of Emergency Medical Technicians certification examinations would ensure well-qualified and technically competent noncommissioned officers (NCOs) reached the higher ranks. Additional training at the paramedic level would also give midcareer NCOs the college credits needed to apply for AMEDD commissioning programs to become physicians, PAs, nurses, physical therapists, etc, bringing their invaluable combat and deployment experience into the AMEDD as commissioned healthcare providers.
With increased levels of training for all providers in Role I, sustainment training capabilities will have to become more robust. Current 68W sustainment is centered on recertification on Skill Level 10 MOS tasks. Sustainment should be standardized across different unit types and across the medical simulation training centers (MSTCs), available on every major division-sized post. These MSTCs could serve as the "medical range" for their respective posts, offering a large menu of training for Role I providers. The centers should be uniformly staffed and funded to conduct high quality training for tenant units.
Importantly, oversight of prehospital care should have coordination and visibility at the highest levels of the AMEDD. Among the many agencies sharing responsibility for prehospital care are the following:
* The Department of Combat Medic Training conducts initial entry training.
* The Department of Combat and Doctrine Development develops equipment and doctrine.
* Army EMS track certification currency.
* The Center for Pre-Deployment Medicine conducts training for deploying medics.
* The US Army Institute of Surgical Research conducts the battlefield care research.
* The Army Training and Doctrine Command integrates and develops medical training requirements for nonmedics.
* The Forces Command develops requirements for deploying units.
* The theater surgeon synchronizes requirements in theater.
* Unit medical officers execute battlefield care.
* Finally, the line commanders are the ultimate end-users of battlefield medical care.
Unified oversight could integrate these agencies and reap the benefit of improved synchrony and force responsiveness.
It is interesting to note that similar models already exist for synchronizing requirements, conducting strategic planning, integrating medical research, advocating for resources, directing process improvements, and developing training standards: veterinary care, dental care, public health, and warrior transition care. Each holds a place as a major subordinate command of the AMEDD.
The vast majority of Soldiers who die do so on the battlefield before reaching a physician. For combat casualty survival to improve further, the AMEDD must extend the investment made in FSTs, combat support hospitals, and fixed military treatment facilities to the prehospital and Role I setting. By taking advantage of a systems approach, casualty survival can be improved in far-forward areas of combat.
Key Steps to Improving Battlefield Care
* Systematically train and develop clinical experts in prehospital battlefield care.
* Create a clinical ladder for the 68W MOS by providing increased training and certification as rank increases.
* Train flight medics to the civilian flight paramedic standard.
* Upgrade the medical simulation training centers to serve as the medical range for every division-sized post.
* Establish a high level battlefield care directorate or command staffed with personnel possessing appropriate and relevant clinical expertise.
(1.) Pruitt BA Jr. Combat casualty care and surgical progress. Ann Surg. 2006;243(6):715-729.
(2.) Holcomb JB, Stansbury LG, Champion HR, Wade C, Bellamy RF. Understanding combat casualty care statistics. J Trauma. 2006;60(2):397-401.
(3.) Kelly JF, Ritenour AE, McLaughlin DF, Bagg KA, Apodaca AN, Mallak CT, et al. Injury severity and causes of death from Operation Iraqi Freedom and Operation Enduring Freedom: 2003-2004 versus 2006. J Trauma. 2008;64(suppl 2):S21-S27.
(4.) Ortiz JM. The revolutionary flying ambulance of Napoleon's surgeon. Army Med Dept J. October-December 1998:17-25.
(5.) Ashbow P. 1861-1873. History of the Medical Department of the United States Army. Cambridge, MA: Houghton Mifflin; 1929:71-79.
(6.) National Academy of Sciences. Accidental Death and Disability: The Neglected Disease of Modern Society. Washington, DC: National Academies Press; 1966.
(7.) Stewart RD. History of EMS: foundations of a system. In: Brennan JA, Krohmer JR, eds. Principles of EMS Systems. 3rd ed. Sudberry, MA: Jones and Bartlett Publishers; 2006:2-15.
(8.) De Lorenzo RA. How shall we train?. Mil Med. 2005;17(10):824-830.
(9.) Society of Army Physician Assistants. A brief history of the physician assistant program. Available at: http:www.sapa.org/. Accessed September 20, 2010.
(10.) Gerhardt RT, McGhee JS, Cloonan C, Pfaff JA, De Lorenzo RA. US Army MEDEVAC in the new millennium: a medical perspective. Aviat Space Environ Med. 2001;72(7):659-664.
LTC Robert L. Mabry, MC, USA
COL Robert A. De Lorenzo, MC, USA
LTC Mabry is Director, Prehospital Division, Joint Theater Trauma Registry, US Army Institute of Surgical Research, Fort Sam Houston, Texas.
COL De Lorenzo is Chief, Department of Clinical Investigation, Brooke Army Medical Center, Fort Sam Houston, Texas.
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|Author:||Mabry, Robert L.; De Lorenzo, Robert A.|
|Publication:||U.S. Army Medical Department Journal|
|Date:||Apr 1, 2011|
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