Chapter 52: Modern Combat Casualty Care

The military trauma surgeon has the seemingly contradictory task of preservation in an environment of destruction. History dictates the time and location of war, each occurrence with its share of casualties. Wounded warriors provide a service to their country and in their time of sacrifice improve a generation of surgeons. The price of lessons learned is severe and many times complete.

The Global War on Terrorism (GWOT) spanning over a decade including operations in Afghanistan and Iraq represents the longest continuous period of war in the US history. During this period much has been learned—providing advances in hemostasis, resuscitation, evacuation, damage control surgery, and transfusion strategies. Unfortunately, some lessons from previous conflicts had to be relearned such as the use of whole blood and hypotensive resuscitation. It is the duty of our generation to look back in time to glean from the experience of those before us and provide a surgical time capsule to be opened when needed.

Regardless of the nation, era, or location, combat casualty care has several qualities that separate it from its civilian counterpart. It tends to occur in austere, resource limited environments. The structures, equipment, supplies, and personnel are often required to be both mobile and few. By nature, ongoing hostile gunfire may threaten treatment activities for patient and provider alike. Additionally, the mechanisms of injury are disproportionately penetrating and blast associated.

Proximity drives much of modern combat casualty care. Warfighters are often in remote locations in today’s unconventional dispersed battlefield. With the purpose of decreasing evacuation times and distances first line surgical care is pushed further forward with a smaller footprint of facilities and personnel. Figure 52-1 is typical of this type of unit, in this case a forward surgical team (FST). At these locations damage control resuscitation and surgery is implemented with the goal of stabilization to the next higher levels of care. A chain of medical treatment is established from the point of injury to the final medical treatment facility (MTF) in the United States. Currently this chain of treatment and transport evacuation is typically completed within 72 hours.

Over the course of the following pages this chapter will endeavor to convey the current state of combat casualty care. The structure of prehospital interventions, en route care, facilities, and data management will be addressed. Special attention is devoted to recent discoveries and newly implemented practices. Throughout, there remains a close relationship between military and civilian trauma care, each constantly informing the other with expertise and innovation.

Benchmarking and Progress

The ability to evaluate outcomes of combat casualties is necessary to assess the capabilities of casualty care and determine areas for improvement. Trended over time these outcomes also provide a perspective of improvements and setbacks. Such information frames the foundation of evidenced based care. Wounded and injury rates require standardization in order to make comparisons, though such a reference has been lacking until the past decade. Holcomb et al developed a standardized measure which is referred to in Fig. 52-2 and expanded upon in the remainder of this section.¹

Wounded in Action and Killed in Action

Battlefield injuries (BI) are initially classified based on their survival to the first MTF. In the deployed setting this MTF is usually a battalion aid station, FST or combat support hospital (CSH) (see the section “Roles of Care” further). Those who do not survive the initial injury and transport are considered killed in action (KIA). Those who survive to the MTF are considered wounded in action (WIA). Those who return to duty (RTD) within 72 hours are typically not included in the final WIA figures. The gross number of killed and injured troops provides general information regarding the battle characteristics, initial care, and evacuation. As injury severity increases it is expected that the ratio of KIAs would increase. Likewise evacuation times and the effectiveness of first responder efforts can result in variations in the WIA/KIA ratio. Efforts to decrease the KIA rate include body and vehicle armor, field care advances, and decreased evacuation times.

Died of Wounds

The died of wounds (DOW) rate provides a measure of mortality after arrival at the MTF. Measured as a percentage, it is determined by the fraction of those WIA who do not survive (not including RTD). As the DOW rate includes only those who survive to the MTF, it is a useful measure of the treatment effectiveness at the MTF. Key to its use as a comparative measure is the exclusion of those patients who RTD. The inclusion or exclusion of RTD in the DOW rate calculation has been variable until recently standardized. Also, the expediency and efforts of the medical evacuation crew (MEDEVAC) may result in more patients with fatal injuries surviving to arrive at the MTF only to die shortly thereafter decreasing the KIA rate and increasing the DOW rate. Thus, advances at any point in the evacuation chain can affect measures elsewhere in the system.

Case Fatality Rate

The case fatality rate (CFR) provides another proportional measure of battlefield lethality. Deaths from both KIA and DOW are included. The denominator includes all those injured on the battlefield—KIAs and WIA (not excluding RTD). It is expressed alongside the other equations in Fig. 52-3. When used to compare scenarios with similar battlefield characteristics it can provide additional insights into the aggregate effectiveness of pre-MTF and post-MTF arrival casualty care.

Research comparing the current operations with prior conflicts has been limited due to variation in amount of data, how those data are recorded, and inconsistency of terminology. It became clear that a benchmarking measure was required to have more meaningful and standardized data collection and reporting at a systems level. The civilian methods for benchmarking and capturing data for analysis on a large scale are civilian trauma registries performed at local and regional levels, the National Trauma Data Bank and the Trauma Quality Improvement Program. The Department of Defense Trauma Registry (DoDTR) was created with these civilian models in mind. Since 2004 all comprehensive, standardized data are collected from the point of injury onward and maintained by the US Army Institute of Surgical Research.²

Injury Patterns

The improvised explosive device (IED) has become the characteristic weapon of the recent conflicts in Iraq and Afghanistan. The IED and the countermeasures to mitigate its effects have shaped the distribution of injuries sustained. This transition from gunshot wounds (GSWs) to blast injuries has been in evolution since the US Civil War.³ Other explosive devices, besides IEDs, and GSWs still remain a significant source of morbidity and mortality.

IEDs have become common in the current Global War on Terrorism and recent terrorist events. Increased adoption of their use has been driven by a combination of available materials and destructive power. While their forms vary widely they all share four essential components denoted by the acronym “PIES”; P-power source, I-initiator, E-explosive, and S-switch (Table 52-1).^4,5 Adjuncts, such as formed charges or fragments are often added. All items required for construction are readily available, making their creation easy and prevention problematic.

A common utilization of IEDs has been in the form of roadside bombs. As the recent conflicts progressed, efforts were made to decrease the high number of injuries sustained in high mobility multipurpose wheeled vehicles (HMMWVs). This spurred the development of the mine-resistant ambush protected (MRAP) vehicle with characteristic armor and a V-shaped hull to deflect blast energy (Fig. 52-4).

As coalition troops became less susceptible to roadside bombs with the advent of improved vehicle armor the use of IEDs shifted. “Dismounted” IEDs became more common, targeting soldiers on foot patrols. IEDs have also been used via a variety of delivery devices, to include vehicle (vehicle-borne IED or VBIED) and suicide bombers. This interplay between development of weapons and defenses has persisted throughout history.

The torso is particularly vulnerable to penetrating projectiles such as IED created fragments or firearm rounds. In response, modern body armor provides protection to this area (Fig. 52-5). The effectiveness of body armor used by the US military has changed the distribution of combat injuries. Areas without protection, such as the extremities, are the more common sites of injury. The increased use of explosive devices by insurgent forces described earlier has also evolved in response to weaknesses in armor coverage. A recent review of 5 years of injuries in Iraq and Afghanistan revealed the presence of extremity injuries in 51.9% of combat casualties, the vast majority of wounds (74.4%) were due to explosive devices.⁶

Education and Resources

Clinical Practice Guidelines

As initial surgical interventions for combat casualties occur over a wide variety of dispersed locations, the challenge of standardization and education increases. As a response, the joint theater trauma system (JTTS) has created a series of clinical practice guidelines (CPGs). These guidelines are modeled after civilian guidelines published by several of the national trauma associations. As of this writing there are over 40 evidence-based CPGs created by subject matter experts on a wide variety subjects (Table 52-2). The CPGs are updated routinely based on the available literature. The complete list is readily available at the USAISR Web site and is available as a portable device application.⁷

Tactical Combat Casualty Care

Warfighters who sustain injuries while under fire are treated with first-aid administered by self-aid, buddy aid, or a combat lifesaver. A combat lifesaver is a nonmedical team member who has enhanced first aid training. If the injured warfighter requires more advanced care, the combat medic or medical corpsman trained in tactical combat casualty care (TCCC) provides treatment.

TCCC was developed initially as a research project in the US Special Operations Command in the early 1990s. During this period, the trauma care was reviewed, revised, and then published in Military Medicine in 1996. Guidelines for TCCC are continually reviewed and revised by the Committee on TCCC (CoTCCC; Fig. 52-6). Trauma surgeons, emergency medicine physicians, combat medics, and corpsmen with combat deployment experience from all branches of the US military participate on the CoTCCC. TCCC is partnered with many other organizations such as prehospital trauma life support (PHTLS) and the US Army Institute of Surgical Research (USAISR). TCCC describes basic management plans for care under fire, tactical field care, and tactical evacuation care.

Care Under Fire

While providing care under fire, the medic or corpsman must (1) return fire and take cover, (2) direct or expect the casualty to remained engaged as a combatant if appropriate, (3) direct the casualty to move to cover and apply self-aid if able, (4) keep the casualty from sustaining additional wounds, (5) extricate casualties from burning vehicles or buildings and move them to places of safety and stop the burning process, (6) defer airway management until tactical field care phase, and (7) stop life-threatening external hemorrhage if tactically feasible with self-aid or tourniquets and move the casualty to cover.

Tactical Field Care

Once the injured warfighter is no longer under fire or has been moved to an area providing cover, the combat medic or corpsman then provides tactical field care. The evaluation and treatment of injuries in this phase of case is similar to the care provided by civilian prehospital care providers (with a few exceptions). Any warfighter with altered mental status must be disarmed of their weapons immediately. The usual airway and breathing assessment and treatments are carried out. In the assessment and treatment of bleeding, Combat Gauze (Celox Gauze or ChitoGauze if Combat Gauze is not available) is applied with a minimum of 3 minutes of direct pressure. If the medic or corpsman is unable to apply direct pressure or the bleeding cannot be controlled with direct pressure, the placement of a tourniquet is recommended. The administration of tranexamic acid (TXA) is recommended if the casualty is in hemorrhagic shock, receiving multiple transfusions, has one or more amputations, or penetrating torso injuries. For those casualties who are awake, alert, and have a palpable radial pulse; no intravenous fluids are administered. However, if the casualty is in hemorrhagic shock, resuscitation should be initiated with the following fluids (in order of preference): whole blood; plasma, RBC, and platelets in 1:1:1 ratio; plasma and RBC in 1:1 ratio; plasma or RBC alone; Hextend; crystalloid (Lactated Ringers or PlasmaLyte A). If there are no blood products available and crystalloids must be administered, only a 500-mL bolus is recommended followed by reassessment. If the casualty regains a palpable radial pulse or improved mental status, the fluid resuscitation is stopped. There are three options for providing analgesia to injured warfighters on the battlefield. For mild to moderate pain in the warfighter who is still able to fight acetaminophen and meloxicam (nonsteroidal anti-inflammatory drug) are given. For the casualty in moderate to severe pain who is not at risk for respiratory compromise or shock, oral fentanyl lozenges can be used. If the casualty is deemed to be in hemorrhagic shock or respiratory distress, ketamine is used for moderate or severe pain.^8,9

Role 1

The first medical care a warfighter receives is provided at Role 1. First-aid can be administered by nonmedical personnel on an individual level via self-aid or buddy aid. Each warfighter is issued an individual first-aid kit containing bandages, an advanced hemostatic dressing, a nasopharyngeal airway, a combat application tourniquet (Fig. 52-7), gloves, and tape. Combat lifesavers, nonmedical personnel with enhanced first-aid training, can provide additional care prior to arrival of the combat medic/corpsman. The combat medic/corpsman is trained in tactical combat casualty care (TCCC), which includes maintaining the airway, stopping bleeding, preventing shock, protecting wounds, and immobilizing fractures. The injured warfighter is then taken to the battalion aid station or Shock Trauma Platoon.

The BAS is similar for the US Army and US Marine Corps (USMC). At the BAS, a physician, physician assistant, or medic/corpsman makes triage, treatment, and evacuation decisions. The goal of treatment is to return to duty or to stabilize and allow for the evacuation to the next role of care. There is no surgical or patient holding capacity at Role 1.

The Shock Trauma Platoon is a small emergency medical unit that supports the Marine Expeditionary Force. Like the BAS, it has no surgical capacity; however the Shock Trauma Platoon is staffed by two emergency medicine physicians and can hold patients for up to 48 hours.

Role 2

At this role of care, basic primary care can be provided to warfighters. Optometry, dental care, combat and operational stress control, behavioral health, laboratory services, radiology services, and surgical capabilities are frequently available in a Role 2 facility. Each branch of the Armed Forces has slightly different organization and capabilities.

For the US Army, the Role 2 MTF is operated by the medical treatment platoon of medical companies. The medical company is assigned to support a brigade or division. Here, the warfighter is examined and evaluated. Those who can be treated and return to duty within 72 hours or require immediate damage control surgery to preserve life, limb, or eyesight are held for treatment. The warfighter can receive packed red blood cell transfusion, dental care, limited radiographic studies, clinical laboratory services, combat and operational stress control, and preventive medicine. The FST is a 20-person team with three general surgeons, one orthopedic surgeon, two nurse anesthetists, critical care nurses, surgical scrub technicians, and combat medics. It is designed to provide lifesaving resuscitative general and orthopedic surgery. An FST is deployed by ground, fixed or rotor wing aircraft, or via airborne operations. A fully supplied FST can operate continuously for 72 hours on two operating tables for a maximum of 30 cases. However, an FST is not designed or equipped for stand-alone operation and thus must rely on the medical company for logistical support (electricity, water, and fuel) and security. In the last few years of Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF), FSTs have been split to create two teams.

In the US Air Force (USAF), the Mobile Field Surgical Team (MFST) is comprised of five team members: a general surgeon, orthopedic surgeon, anesthetist, emergency medicine physician, and an operating room nurse or technician. Much like an FST, the MFST cannot participate in stand-alone operations and supports an aid station or flight line clinic. The 10-person Small Portable Expeditionary Aeromedical Rapid Response (SPEARR) team is a MFST with an additional three person Critical Care Air Transportation Team (CCATT) and two-person preventive medicine team. A SPEARR team is stand-alone capable for 7 days and can perform up to 10 surgeries in 48 hours. The SPEARR team is designed to provide care during the early phase of deployment and is highly mobile. The Expeditionary Medical Support (EMEDS) Basic team builds on the SPEARR team, with an additional 15 personnel. In addition to resuscitative surgery, EMEDS Basic can provide 24-hour sick call, dental care, and limited radiology and clinical laboratory services. There are four holding beds, two operating room tables, and three climate controlled tents. An EMEDS+10 facility has 6 additional holding beds for a total of 10 beds and 56 personnel but retains the same surgical capability as an EMEDS Basic.

For the US Navy (USN), Role 2 care consists of a Casualty Receiving and Treatment Ship (CRTS) or aircraft carrier battle group. The CRTS is part of a three-ship Amphibious Ready Group (ARG). With 45 ward beds, 4 operating rooms, and 17 intensive care unit (ICU) beds, the CRTS has a 176-person Fleet Surgical Team with 1 surgeon, 1 nurse anesthetist, 1 ICU nurse, 1 operating room nurse, 1 general medical officer, and 12 support staff. The CRTS can be augmented with an additional two orthopedic surgeons and one oral maxillofacial surgeon. Support services include frozen blood availability, radiology, and clinical laboratory capabilities. The CRTS can triage up to 50 patients and can only hold patients for 72 hours. The aircraft carrier battle group Role 2 assets do not typically support ground forces and are not casualty receiving ships. The 52 ward beds, three ICU beds, and single operating room are staffed by one surgeon and five additional medical officers.

The USMC Role 2 care consists of a surgical company that provides surgical care for one infantry regiment of the Marine Expeditionary Force. The surgical company is comprised of four Forward Resuscitative Surgical Systems (FRSS), four shock trauma platoons (Role 1 providers), and four en route care teams. The FRSS is the basic surgical capability module which can provide resuscitative surgery for 18 patients for 48 hours without resupply. Each FRSS has 2 surgeons, 1 anesthetist, 1 ICU nurse, 2 operating room technicians, and 2 corpsmen. Like the US Army FST, the FRSS is not a stand-alone unit and relies on the main unit for resupply and logistical support. The en route care team is comprised an ICU nurse and corpsman. They can transport and care for up to two critically injured warfighters (one requiring mechanical ventilation).

Role 3

The treatment available at this role of care encompasses the entire range of medical care to all categories of patients. The US Army Role 3 care platform is the CSH, which provides services for all categories of patients within theater. Two complete hospital companies provide resources, personnel, and equipment to care for up to 248 patients. Four ICUs and support staff can care for up to 48 critically ill patients and 10 wards with intermediate nursing care for up to 200 patients. In terms of surgical capability, the CSH has six operating room tables for general, orthopedic, thoracic, urological, gynecological, and oral maxillofacial surgery. In addition to surgical expertise, radiology, clinical laboratory, blood banking, psychiatry, public health, pharmacy, and nutrition support are usually available at this role of care. Medical teams, medical detachments, or hospital augmentation teams can augment capabilities of the CSH. Augmented services can include hemodialysis, clinical pathology, infectious disease, and head and neck surgery (neurological surgery, ophthalmology, and otolaryngology). Typically, only the head and neck surgery augmentation team is authorized a CT scanner.

In the USAF, Role 3 care consists of EMEDS+25 and the Air Force theater hospital. With 84 support personnel, two operating room tables, and 25 patient beds, EMEDS+25 can provide up to 20 operations in 48 hours. Additional modules with subspecialty capabilities such as otolaryngology, neurological surgery, ophthalmology, cardiothoracic, and vascular can be added to the EMEDS+25. The Air Force theater hospital provides the largest USAF surgery capability and critical care support in theater.

Role 3 care for the USN consists of expeditionary medical facilities and the USNS Mercy and USNS Comfort hospital ships. Each hospital ship has 12 operating rooms and 999 beds with 68 ICU, 20 postanesthesia care unit, 11 respiratory isolation, 400 intermediate care, and 500 minimal care beds. These minimal care beds are usually upper bunk beds reserved for patients ready to return to full duty; 273 officers and 943 enlisted personnel staff the ship with full clinical laboratory, radiology (with CT scanner), and blood banking services with frozen blood stores. The expeditionary medical facility has four operating rooms, 40 ICU and 110 ward beds. Clinical support services and surgical specialties for the expeditionary medical facility are similar to the US Army CSH.

Role 4

Medical centers outside the theater of operations at Landstuhl Regional Medical Center in Kaiserslautern, Germany, and other regional medical centers in the continental United States (Darnall Army Medical Center, Eisenhower Army Medical Center, Madigan Army Medical Center, San Antonio Military Medical Center, Womack Army Medical Center, William Beaumont Army Medical Center, and Walter Reed National Military Medical Center) provide Role 4 care.^10,11

Evacuation and transport of combat casualties is a multiservice and often multinational endeavor. The current doctrine of US military evacuation from the point of injury is centered on the “golden hour” concept. All battlefield injuries must be transported to the nearest Role 2 or Role 3 facility within 60 minutes. In the rare events that this does not occur, the case is formally reviewed for avoidable causes. Evacuation vehicles and surgical assets are geographically placed to meet these demands. Patients are transported from the point injury serially to higher echelons of care. An arrangement of various transport platforms has been assembled and a nonexhaustive list follows (Fig. 52-8).

• Casualty evacuation (CASEVAC) refers to patient movement in any vehicle not specifically designated for medical care and by personnel who may have little if any medical training. This vehicle of opportunity is often a helicopter, but can be any form of transportation. CASEVAC platforms are chosen when speed is more important than en route medical equipment or capabilities.

• Medical Evacuation (MEDEVAC) pertains to vehicles which are in effect military ambulances—either by air or ground. The MEDEVAC platform most used in recent operations is the HH-60M “Black Hawk” helicopter (Fig. 52-9). Nicknamed “Dust Off,” a title coined during the Vietnam era, MEDEVAC helicopter crews are designed to expediently bring patients from the point of injury to the nearest surgical capability. Early in the conflicts, these vehicles were manned by basic medics but they are now manned by advanced paramedics and intensive care unit nurses. Resuscitation and stabilization of the patient continues while in the air. Hostile fire is often encountered in this process and as a medical transport minimal defense capabilities are available for protection.

• Aeromedical Evacuation (AE) is the term for US Air Force fixed-wing aircraft used to transport patients either within theater or out of theater. Examples would be from a Role 2 facility to a Role 3 (intratheater) or from Afghanistan to Germany. Physiologic capacity for flight and appropriate triage of patients via AE is determined by the flight surgeon who is familiar with the demands and restrictions of care at altitude. The most common air frames used for AE include the C-130 and C-17 (Fig. 52-10). AE is used for patients who would generally meet criteria for ward or outpatient status within a hospital setting, they may be ambulatory or “litter patients” (named for the lightweight transport cot used).

• Critical Care Air Transport Team (CCATT) refers to the augmented AE-type platform with specific capabilities for ICU care. Each team is consists of an intensivist physician, a critical care nurse and a cardiopulmonary technician (for ventilator and invasive monitor management). They are able to provide en route care for 3–6 critical patients for periods ranging from under an hour to over 16 hours. Specifically designed low profile and air/altitude worthy equipment, such as ventilators and monitors, are cleared for use prior to employment as part of the CCATT tool set. Despite the severity of injuries, long transport times and additional constraints of providing care at altitude, the CCATT program has had an en route mortality of less than 0.02%.^11,12,13,14

Medical Emergency Response Team—Enhanced

As the military continues to push high level care further forward the logical next step is physician presence on evacuation aircraft. The United Kingdom’s Medical Emergency Response Team—Enhanced (MERT-E) represents this capability. It operates out of a CH-47 Chinook, a larger two rotor helicopter. The team is designed to meet the needs of the most critically injured patients when evacuation times and distances may be long. A study evaluating the period from July to November 2008 recorded 324 missions for 429 patients. A physician was present for 90% of missions. A total of 64 physician interventions were performed including tube thoracostomy, death pronouncements, sedation, and blood product administration. The benefit of physician presence overall is unclear as the decision not to perform advanced interventions can sometimes be important and is more difficult to measure. Additionally, the MERT-E model is equipment and personnel resource intensive in environments that often have minimal resources.¹⁵ A comparative evaluation of forward aeromedical evacuation platforms found lower mortality for all ISS groups with the MERT platform.¹⁶

The refinement of damage control resuscitation (DCR) principles represents one of the major advances in trauma surgery during recent years. The high tempo and large volumes of causalities during combat operations lasting over a decade has provided a crucible for this change. Patients with trauma necessitating a massive transfusion require vigilant attention throughout their treatment—from point of injury, to the first MTF, definitive surgery, and throughout transport. This paradigm is focused on three tenets (1) minimizing crystalloid use during early resuscitation, (2) permissive hypotension, and (3) transfusion of blood products which resemble whole blood as closely as possible.¹⁷

Damage Control Criteria Recognition—The Lethal Triad

Acute coagulopathy of trauma (ACT) is caused by the combination of severe tissue injury and shock and it is mediated by activated protein C.¹⁸ The infusion of high chloride containing crystalloid solutions exacerbates ACT by inducing the lethal triad producing trauma induced coagulopathy (TIC). The lethal triad is defined by the presence of acidosis, hypothermia, and coagulopathy in the setting of traumatic hemorrhage. It is a vicious cycle of clinical findings associated with increased mortality compared with noncoagulopathic patients.¹⁹ Once this vicious cycle is induced, it is difficult to reverse as each component of the triad results in worsening of the others. There is tremendous interest in developing criteria to identify patients who require DCR early. Unfortunately, there is no single scoring system which will distinguish all traumatic coagulopathy patients requiring DCR.²⁰ Mechanism and clinical suspicion remain important factors for early recognition. Current predictors used by the US military as established by the Clinical Practice Guideline on DCR at forward facilities are included in Table 52-3 and will be discussed below.⁷

Acidosis

Acidosis, generally recognized as a pH less than 7.25, represents part of the lethal triad. A base deficit of greater than 6 has been demonstrated as an independent risk factor for coagulopathy and is associated with increased mortality.²¹ Recognized via a rapid laboratory value acidosis provides early indication of metabolic derangements from profound hemorrhage. Acidosis impairs both platelet function and the coagulation cascade.²⁰

Coagulopathy

Coagulopathy is concerning in the setting of trauma as both an indicator of increased mortality and a barrier to hemorrhage control. An INR greater than 1.5 is an independent predictor of massive transfusion and is usually available in the resuscitation bay.²² Impaired coagulation requires replacement of clotting factors and platelets rather than red cells alone.

Hemoglobin and Hematocrit

Anemia secondary to acute blood loss is another measure easily determined in the trauma bay. Traditional teaching dictates that the hemoglobin and hematocrit will not initially change immediately after hemorrhage as red cells and plasma are lost in equal proportions. Based on this premise anemia would not be evident until after plasma levels equilibrate for the lost whole blood volume. However, when hemoglobin measures are obtained within the first 30 minutes of arrival to the emergency department, nearly 90% of trauma patients with major bleeding will be identified.²³ A hemoglobin less than 11 g/dL has been determined to be an independent predictor of massive transfusion.²²

Systolic Blood Pressure

The presence and degree of hypotension provide measures for diagnosis, prognosis, and treatment in the bleeding trauma patient. Systolic blood pressure less than 90 mm Hg is commonly used as the definition of shock. Advanced Trauma Life Support teaching also advocates for the use of blood pressure in its classification of hemorrhage. However, once a systolic blood pressure below 90 mm Hg is reached this already corresponds to a 40% loss of circulating volume—a late finding.²⁴ Earlier changes in blood pressure have been demonstrated to be indicative of changes in prognosis. A large study of NTDB patients found the prognostic cutoff below 110 mm Hg, below which mortality increased by 5% for every decrement of 10 mm Hg.²⁵ An important note, however, is that prognostic criteria cutoffs do not necessarily translate into therapeutic goals. Permissive hypotension is an example of this. A goal of DCR is to keep the SBP at approximately 90 mm Hg prior to definitive surgical hemorrhage control. Previous experiences with SBP goals at normal levels translated into increased mortality.²⁶ While a SBP of less than 110 mm Hg is useful to determine severity of hemorrhagic insult, it should not be used as an early resuscitation target.

Damage Control Intervention—Resuscitative Fluid Strategies

Crystalloid Minimization and Selection

Crystalloids have long been used in trauma as volume expanders to support blood pressure. However, select resuscitative fluids can propagate acidosis and normotension may exacerbate hemorrhage. Rather than being resuscitative as intended, crystalloids can increase morbidity and mortality.

In far forward prehospital settings, blood products are rarely available and crystalloids remain one of the options available for fluid resuscitation. In these situations it is important to consider which type of crystalloid to utilize. The most common fluids used are normal saline (NS) and lactated Ringer’s (LR). There are several key differences between the two, but the most notable is the fluid pH.

Saline infusions were developed in 1831 after observed “decreased fluidity” of blood among cholera patients. Despite the widespread use of NS, there is no available scientific basis for its initial use. The closest evidence is an in vitro study by a Dutch chemist, Jakob Hamburger, in 1888 noting a shared freezing point between human plasma and 0.9% NS of –0.52°C.²⁷ Ringer’s solution was developed in the 1880s by Sydney Ringer with the purpose of maintaining activity of a frog myocardium using electrolyte constituents resembling plasma.²⁸ Later, lactate was added to Ringer’s original solution (by Alexis Hartmann) to combat the effects of acidosis through conversion to bicarbonate in the liver.

Several animal studies over the past decade have supported improved outcomes with LR over NS.^29,30,31 Counter-intuitively, hyperkalemia is increased with NS as opposed to LR. Hyperkalemia is attributed to extracellular shift of potassium due to the low pH of 5.0 found in NS (Table 52-4).³² In both LR and NS there is concern for dilution of clotting factors compounding coagulopathy. There are situations when judicious crystalloid resuscitation is appropriate. Part of this strategy includes the target blood pressure for resuscitative efforts.

Permissive Hypotension

Walter Cannon, a US Army trauma surgeon during the World War I, noted that restricting fluid administration prior to surgery limited bleeding. Similarly during World War II, anesthesiologist Henry Beecher noted improved outcomes in patients whose SBP was maintained in the 1980s between injury and the OR.²⁶ These early observations have been reconfirmed in current DCR practices.

Permissive hypotension is designed to avoid clot destabilization prior to definitive hemorrhage control. Fluid restriction contributes to permissive hypotension and avoids acidosis, hypothermia, and coagulopathy caused by high-chloride-containing fluids infused at room temperature.

Blood Transfusion Strategies

The third tenet of DCR is transfusion of blood products in ratios resembling whole blood. This strategy comes directly from the military experience after observing mortality trends associated with blood product ratios. Borgman et al reviewed 246 patients at a US Army Combat Support Hospital in Iraq evaluating ratios of plasma to red cell units and association with mortality rates.³³ This study revealed a significant decrease in mortality as the ratio approached 1:1. Results of Borgman’s study provided confirmation for changes in the CPGs, which had already taken effect during 2004. The basis for the CPG changes in 2004 had mainly been expert opinion.

The move away from transfusion of low plasma to red cell ratios marked an important transition from previous practice. The use of individual blood product components had been dictated by laboratory parameters rather than the patient’s clinical situation.¹⁷ Patients would receive plasma for an elevated INR or PTT rather than the presence of severe hemorrhage. Similarly, platelet administration had been guided by measured thrombocytopenia. The transition to lower ratios was based on a paradigm shift toward matching the whole blood that was being lost. Despite changes in both military and civilian DCR guidelines, the ideal ratio remains elusive.

The goal of the Prospective Observational Multicenter Major Trauma Transfusion (PROMMTT) study was to provide further evidence regarding blood component ratios, particularly early transfusion of plasma and platelets. A total of 1245 patients from 10 US level 1 trauma centers receiving at least 1 unit of RBCs within 6 hours of admission were in the original study group. Multiple separate subgroup analyses have been published from the data obtained. Among 905 patients from the main study group who also received greater than or equal to 3 component unit transfusions, increased plasma: RBC ratios were independently associated with decreased 6-hour mortality. Hemorrhagic deaths predominated in the first 6 hours. Patients with high ratios either tended to receive a 1:1:1 or 1:1:2 ratio (plasma to platelets to red blood cells).^34,35

The Pragmatic, Randomized Optimal Platelet and Plasma Ratios (PROPPR) trial further addressed the question of ideal transfusion ratios. A total of 680 patients were randomized to a 1:1:1 versus a 1:1:2 ratio during active resuscitation at 12 level 1 trauma center in the United States. There was no statistically significant difference in 24 hour or 30 day mortality. However, the 1:1:1 group achieved hemostasis more frequently and were less likely to die of hemorrhage in the first 24 hours.³⁶

First In First Out versus Last In First Out

There is increasing evidence that increased age of blood is associated with worse outcomes due to the “storage lesion” attributed to decreased 2,3-DPG, depletion of nitric oxide, and impaired RBC conformational change.^37,38,39 A correlation has been established between RBC age and infection, organ dysfunction and mortality among trauma patients.⁴⁰ Thus, it is appealing to use the youngest blood available for the sickest patients.

Traditionally, blood banks have used a strategy of “first in first out” (FIFO) for blood product allocation. This concept is similar to stocking milk at the grocery store—even though younger cartons may be available older ones are sold first to prevent waste due to expiration. The unit closest to the expiration date of 42 days will always be given first.

Due to recognized risks of aged blood, alternative allocation strategies have been proposed. One group of investigators from Stanford was able to create a model which allowed for an RBC age cutoff of 14 days and a “last in, first out” strategy without increased unit utilization or waste. Success of their model resulted from a supply excess with a supply (donations) to demand (blood products used) ratio of 1.06.⁴¹ Due to documented improvements in survival and recent feasibility studies, current military experts and the US Army CPGs advocate for a last in first out (LIFO) strategy during massive transfusion (cite DCR CPG).¹⁸ This strategy does result in a significant waste of blood product but the benefit to the patient is believed to outweigh the cost of the wasted blood products. Two recently published prospective randomized trials performed in critical care patients and cardiac surgery patients (ABLE and RECESS published this week in NEJM) revealed no differences in clinical outcomes in patients who received older red blood cells versus younger red blood cells but a similar trial has not been performed in trauma patients.

Adjuncts and Alternatives to Component Therapy—Lyophilized Plasma and Cryopreserved Red Blood Cells

Storage conditions remain a limiting constraint on the availability of blood products during military operations. For the combat medic weight is paramount as everything needs to be carried and refrigeration is rarely available. At the FST or CSH the refrigerated shelf life of PRBCs can limit availability of this product.

The benefits of early plasma transfusions have been recognized with new information on component therapy ratios. The most common form of plasma, fresh frozen plasma (FFT), must be stored at –18°C and then undergo a thawing process in a warming bath for approximately 15–20 minutes.⁴² Both of these processes require specialized bulky equipment which is difficult to house or completely absent at far forward facilities and for first responders. However, lyophilized (freeze dried) plasma represents a light-weight, easily carried option which can be stored at room temperature. Lyophilized plasma represents another rediscovery of previous military advances finding new uses again today. In World War II lyophilized plasma was used due to the same concerns as today—transport and shelf life. Unfortunately, pooled plasma that was not screened for viral pathogens was used at that time—with associated increased viral infection risk. Thus, the practice was abandoned. With the ability to screen and test for disease more effectively, lyophilized plasma is being reinvented. Recent work evaluating the properties of lyophilized plasma have demonstrated 86% of prelyophilization coagulation factor activity (18) and decreased blood loss compared with FFP in a combat relevant swine model.^43,44 European production of lyophilized plasma has continued in recent years with notable use by the French and Germans in overseas military activities at Roles 1, 2, and 3 facilities and MEDEVAC platforms.⁴⁵

Cryopreserved red blood cells (CPRBC) were first used on a large scale use by the US military during the Vietnam War after large volumes of standard PRBC preparations were being discarded due to age. The technique currently approved for use by the FDA involves the use of a glycerol buffer to prevent crystal formation associated membrane disruption and cellular damage due to large temperature changes. The red cells are stored at –80°C with 40% glycerol weight/volume within 6 days of collection. They can be stored for up to 10 years before they are thawed and deglycerolized for patient use.^46,47 The storage lesion is minimized while also allowing for larger inventories of blood in settings with sporadic or unpredictable use. Despite these benefits, including FDA approval, CPRBCs are only being employed in rare specific situations today. This is likely attributed to the increased time (~90 minutes) and cost associated with the thawing and deglycerolizing process. They have been used increasingly in current military operations with hundreds of units provided and are used in an equivalent manner to PRBCs. They are also part of the response plan for potential large-scale natural or man-made disasters domestically.

Whole Blood versus Component Therapy

Historically, the first blood transfusions in the early 1900s were whole blood as opposed to component therapy (CT) in common use today.⁴⁸ During the first two world wars a combination of warm fresh whole blood (WFHB) and stored whole blood was used with a peak of 2000 units per day in 1945.⁴⁹ Military medicine played a significant role in the initial transition to component therapy during the Vietnam era when long distances and transport times were associated with expiration of whole blood units. However, this transition to CT occurred in the absence of evidence comparing its risks, benefits or efficacy with whole blood.⁵⁰ Despite this paucity of initial evidence, CT has become the standard for blood banking.

The reexamination of WFHB in the current era was also led by the military community. Logistical restraints are imposed on effective CT transfusion at forward operating bases owing to long supply chains and limited processing and storage of components. Platelets have a very short shelf life (5 days) and require constant agitation. FFP and cryoprecipitate must be stored at –20°C and require the capacity for thawing. Additionally, the storage capacity for all components is limited.⁵¹ WFHB addresses many of these limitations.

The theoretical clinical benefits of WFHB include avoidance of dilution, absence of anticoagulant additives, consistency with damage control surgery principles and blood product age. As discussed earlier, the ideal transfusion ratio for RBCs, platelets, and plasma is 1:1:1 and WFHB intrinsically matches this ratio. The “storage lesion” is a concern with whole blood that is distributed centrally due to long transit times. However, negligible storage time is present when WFHB is obtained locally.

In practice, WFHB requires a “walking blood bank” consisting of volunteer donors who are not needed immediately for warfighting activities or active resuscitation of the patient(s). The operating base must be of sufficient size to have enough blood donors who meet the above criteria. The most forward and remote facilities which could benefit most from WFHB capabilities often do not have enough personnel to maintain a walking blood bank. Additionally, coalition forces frequently have their own rules regarding who can either donate or receive WFHB, citing the inability to perform robust serologic testing of transmissible disease. It is not uncommon for a participating force to restrict donation and transfusion of WFHB to their own nationality. Current US practice is guided by the US Army Institute of Surgical Research Clinical Practice Guideline for Massive Transfusions.⁷

WFHB transfusion was instituted due to the need for blood early in resuscitation at remote locations. More recently the outcomes of this decision have been reported with encouraging findings. In a retrospective review of 354 patients comparing those who received WFHB versus those who received CT alone in a deployed setting both 24-hour and 30-day mortality were significantly decreased supporting findings from a previous study by the same author.^48,52 Prospective trials comparing WFHB versus CT have not been performed. However, excitement regarding early results has been tempered by the inherent limitations of comprehensive transmissible disease donor screening.

Damage Control Interventions: Temporary and Definitive Direct Hemorrhage Control

The general principle of damage control in the combat environment is to provide only the interventions required to safely get the patient to the next echelon/role of care. This approach begins at the point of injury with the teachings of TCCC including tourniquets and topical hemostatic agents. It continues through the FST with a variety of vascular control and repair techniques. The goal is to salvage potentially survivable injuries, over 90% of which are associated with hemorrhage.⁵³

Topical Hemostatic Agents

Research and development of novel topical hemostatic agents has seen much interest during the current era of combat casualty care. Initially based on chitosan (treated crustacean shell) or clay derived powders these hemostatic agents undergo an exothermic reaction when exposed to hemorrhagic wounds. When used as a straight powder or impregnated gauze these agents can provide hemorrhage control alone or as an adjunct to tourniquet use. As addressed in the “Tactical Field Care” section earlier, Combat Gauze is used as the primary hemostatic by the first responder based on CoTCCC guidelines. The gauze has been selected over powder formulations for ease of use and ability to provide compression in cavitary wounds. Hemostatic gauze products continue to be useful in the operating room as well and have become commonplace in civilian settings. There has been an explosion of improvements and options for topic hemostatic agents in recent years with several new agents in being investigated currently.

Self-expanding foam represents a promising new technique to provide hemostasis for otherwise noncompressible intra-abdominal hemorrhage. A polyurethane foam is under investigation which can be delivered in an intracavitary manner and increase in volume to temporize hemorrhage until definitive surgical control.⁵⁴

Expandable sponges under the label XSTAT (RevMededx, Wilsonville, OR) have also been developed through military research with FDA approval for use in 2014 (Figure 52-11). The device consists of a large syringe that can deliver many pill-sized, nonabsorbable, radio-opaque sponges, which expand within 20 seconds of contact with moisture. The volume of material delivered and the size of the delivery device provides tamponade control of junctional wounds in the groin and axilla.

Tranexamic Acid

The Clinical Randomization of an Antifibrinolytic in Significant Hemorrhage (CRASH-2) study, an international prospective randomized trial of over 20,000 trauma patients, demonstrated a mortality benefit.⁵⁵ When studied in a military Role 3 hospital, the Military Application of Tranexamic Acid in Trauma Emergency Resuscitation (MATTERs) study also revealed a mortality advantage.⁵⁶ In both studies the benefit was seen only if provided early after injury (less than 3 hours). As such, tranexamic acid (TXA) is advocated by the current DCR guidelines from the Joint Trauma System (reference DCR CPG).

Traumatic Arrest and Profound Shock

Combat casualties have a high frequency of penetrating injury from mechanisms designed to be lethal. Traumatic arrest or profound shock en route to the first surgical facility are realities which must be anticipated. Aortic occlusion represents a means to limit hemorrhage and maintain perfusion to neurologic and central structures. However, this remains a very aggressive maneuver and patient selection is paramount.

Resuscitative Thoracotomy

The indication for resuscitative thoracotomy is usually loss, or impending loss, of vital signs in the initial resuscitation setting after penetrating trauma. The specific indications for this extreme measure vary between institutions and remain an area of contentious debate. It is promoted as the “last opportunity” to save a life. However, the nature of the procedure poses risk to medical personnel in terms of infectious disease exposure from sharp rib fractures or instruments. A large series of emergency thoracotomies during a 4-year period in Iraq revealed an overall survival rate of 11%.⁵⁷ The current US military indication for emergency thoracotomy is limited to penetrating trauma, without isolated head injury and not if vital signs have been lost for over 10 minutes.⁷

Resuscitative Endovascular Balloon Occlusion of the Aorta

The use of intra-arterial balloon occlusion of the aorta was first reported in 1954 by Colonel Carl Hughes.⁵⁸ However, it has only recently gained popularity in the current era of expanded endovascular technologies. Resuscitative endovascular balloon occlusion of the aorta (REBOA) has several potential advantages over emergent thoracotomy. In terms of risk to providers, this catheter-based technique reduces the opportunities for direct exposure to biohazardous materials through puncture by broken ribs. As the balloon can be inflated at different locations, selective occlusion—either in the chest or inferior to the renal arteries can be performed. Particularly for the patient with exsanguinating isolated pelvic trauma the benefits of aortic occlusion while maintaining renal and visceral blood flow is possible. REBOA does require a specialized skill set and equipment that may not be available in all circumstances. Recent promising experiences with REBOA have prompted the creation of military-specific indications for its use (CPG).⁵

Operative Resuscitation

Operative intervention in the setting of DCR is an extension of prehospital and initial MTF intervention goals of hemorrhage and coagulopathy management. Unlike most civilian settings both tactical and physiologic considerations mush be considered. A prime example is the FST which often operates in a split-based configuration (2 general surgeons or 1 general surgeon/1 orthopedic surgeon) with 1 OR and only 6 hours of holding capacity postsurgery. The focus includes rapidly assessing the patient, controlling hemorrhage, minimizing contamination, and facilitating evacuation to the next higher level (role/echelon) of care. As time and resources are limited only those interventions which are required to stabilize the patient for transport to the next level of care are performed.

Damage control laparotomy is a familiar component of DCR in the setting of intra-abdominal or lower extremity junctional hemorrhage. Hemorrhage is controlled by ligation, repair, compression, or shunting. Injured bowel requiring resection is left in discontinuity. The abdomen is packed and left open in a nearly universal manner. This allows for an abbreviated operative time, facilitating expedient return to the ICU for further resuscitation. Additionally, the OR is made available more rapidly for the next patient(s)—who regularly arrive in multiples. The chaos inherent in a war zone can adversely affect communication concerning the patient’s injuries. An open abdomen allows the next-higher receiving MTF the ability to directly visualize the injuries sustained when communication is impaired. The abdominal pack dressing is routinely labeled with indelible ink as an additional means to ensure the full extent of injuries is recognized and can be appropriately treated (Fig. 52-12).

Major arterial injury presents conflicting priorities of control to prevent exsanguination and preservation of flow to maintain viability of tissues distant to the injury. The primacy of life over limb remains. When the limb can be salvaged while preserving the patient’s life the intervention used is contingent upon the resources available. Extra time spent on a formal repair may place other casualties needing operative intervention at unacceptable risk. Generally speaking, at Role 2 facilities, the employment of temporary vascular shunts is encouraged over formal repair—which is best left to the Role 3 or higher. Exploration, proximal and distal control, thrombectomy, and local heparinization are still utilized for shunting (CPG of vascular injuries). Not all vessels can or should be shunted, a list of major vessel considerations for shunting is provided in Table 52-5.¹¹ When an extremity’s vascular inflow is maintained through shunting or repair a fasciotomy is currently recommended. The amount of soft tissue compartment swelling after injury in young, muscular patients is often profound.

Acute Lung Rescue Team/Extracorporeal Membrane Oxygenation in Transport

Combat trauma-associated acute lung injury (ALI) and acute respiratory distress syndrome (ARDS) are present in 26–33% of critically ill casualties.^59,60,61 ALI/ARDS among combat wounded patients are attributed to sources including blast injury, pulmonary contusion, transfusion complications, fat/marrow emboli, pneumonia, inhalation injuries, sepsis, near-drowning, and large overall injury burden. CCATT had been established for the transport needs of critical patients out of the theater of operations. Most patients with ALI/ARDS are responsive to standard low-volume ventilation lung protective strategies based on ARDS Network guidelines.⁶² However, there remains a subset of patients with such severe pulmonary injury that they either had to wait for improvement to meet CCATT criteria or expire prior to evacuation. In 2005 the acute lung rescue team (ALeRT), a joint service endeavor, was implemented to meet the needs of these patients. The ALeRT involves an intensivist-led team available for consults from the combat zone and capable of activating a team to meet and transport severely lung injured patients. Comprised of two critical care physicians, two critical care nurses, and two respiratory therapists with specialized experience the ALeRT team is able to provide over 24 hours of continuous care. Adjuncts to standard mechanical ventilator support employed include prone positioning, buffer therapy, inhaled prostacyclin, and use of the Volumetric Diffusive Respiratory (VDR-4) (Percussionaire Corporation, Sandpoint, ID).⁶³

Despite the advanced capabilities of the ALeRT there are still patients with such poor oxygenation that more aggressive measures are required such as extracorporeal therapies. In response to this need, a relationship was established between Landstuhl Regional Medical Center (LRMC) and the University Hospital Regensburg (UHR). LRMC is the principal receiving facility for all casualties from the US Central Command activities including operations in Iraq and Afghanistan. UHR is an academic center in Germany with extracorporeal life support (ECLS) capabilities including regional transport. Initially, the NovaLung (NovaLung GmbH, Heilbronn, Germany), an arteriovenous pumpless ECLS system was employed, typically using femoral arterial and venous cannulas placed immediately upon arrival at LRMC. The NovaLung is not currently approved by the US Food and Drug Administration and only available for investigational use, though is commonly used in Europe and the United States. Eventually, pump-driven veno-venous extracorporeal membrane oxygenation (ECMO) has been employed with cannulations being performed at the Role 3 hospital in Afghanistan with evacuation to LRMC followed by transport to the San Antonio Military Medical Center (Fig. 52-13). The miniaturization of the ECMO filter and circuit combined with improvement in the electrical/computer interface have made these advances possible.^59,64,65

Care of the Military Working Dog

Military working dogs (MWDs) are regularly employed for detection of explosives and illicit materials. They are an integral component of special operations and military police activities, often involved in far-forward activities. In the setting of injury or illness the ideal responders are military veterinary personnel. However, other health care providers (HCPs) may be the only available resource for preservation of life, limb, or eyesight. The scope of this chapter does not allow for an exhaustive description of battlefield canine care but there are some cogent considerations below (all according to Joint Theater Trauma System Clinical Practice Guidelines).⁶⁶ Upon stabilization the MWD should be evacuated to a military veterinarian at the earliest convenience.

• Demographics and clinical information should be confidential, similar to MWDs’ human counterparts.

• The MWD’s handler should be present during care for the protection of the animal and the treating staff (Fig. 52-14). Muzzles should be used during examination and treatment.

• Direct communication with a military veterinarian should occur prior to any surgical procedure to provide guidance.

• A thin or fenestrated mediastinum is present in dogs, requiring bilateral chest tubes in the setting of a unilateral pneumothorax.

• Pulse oximetry can be placed on the tongue in a sedated dog.

• Gastric dilatation-volvulus syndrome (GDV) is a common canine surgical emergency. Prophylactic gastropexy is performed in most MWDs, but not all and is still subject to failure. Clinical presentation includes abdominal distention, ineffective vomiting, and signs of shock (due to decreased venous return). Lateral thoracic radiography aids in the diagnosis. Treatment consists of immediate decompression by percutaneous gastric trocar (14–18 gauge IV) decompression. Definitive therapy requires exploratory laparotomy, detorsion, gastropexy and resection of ischemic tissue—preferably performed by a veterinarian if urgent evacuation is possible after decompression.⁶⁷

• Acetaminophen and ibuprofen can cause liver toxicity in MWDs—DO NOT USE.

• MWDs are subject to canine post-traumatic stress disorder-like syndrome, listen to the handler for changes in behavior after significant events.

• “MWDs may be euthanized in the case of catastrophic wounding with poor prognosis for recovery and in order to relieve the MWD from undue suffering.”

Recent evidence confirms that MWDs can be adequately resuscitated and/or treated by nonveterinarians. A study of gunshot wounds sustained by MWDs in Iraq and Afghanistan revealed 29 such injuries. Half of the wounds were thoracic, but otherwise had a similar distribution to humans. The “died of injury” rate was 38%, 17 of the 18 MWDs killed died prior to evacuation or treatment. Of the 11 survivors, all were returned to duty.⁶⁸

Joint Theater Trauma System and Joint Theater Trauma Registry

Trauma care has advanced through the exchange of innovation and experience between civilian and military medicine going back to antiquity. In more recent history, during the Vietnam War, prehospital interventions and decreased evacuation times due to aeromedical platforms informed later civilian care. During the same era the American College of Surgeons shaped civilian trauma management through the publications Early Care of the Injured Patient followed by Optimal Resources for Care of the Injured Patient.^69,70 These resources became the guide for the development of civilian trauma centers which have been associated with improved outcomes. The Trauma system is defined as “an organized effort in a geographic region to deliver a full range of trauma care.”⁷¹ Organization within an area of operations or activity allows for increased oversight and information availability across from the prehospital setting through definitive care. Areas covered by an integrated trauma system have shown a decrease mortality of 15–20%.⁷¹ Upon the next era of military activities, in the Middle East, leaders and military commanders looked toward the successes of civilian trauma systems.⁷²

The Joint Trauma System (JTS) was launched in 2004 with the goal of capturing the lessons learned and benefits obtained from their civilian counterparts. The stated mission of the JTS is “to improve trauma care delivery and patient outcomes across the continuum of care utilizing continuous performance improvement (PI) and evidence-based medicine driven by the concurrent collection and analysis of data maintained in the Department of Defense Trauma Registry (DoDTR).”

In order to achieve this mission the JTS has outlined three specific areas of focus described below.^73,74

DoDTR

Previously the Joint Theater Trauma Registry (JTTR), after the USAISR program was adopted by all military services, it became the DoDTR. It was initially launched the same year as the JTS (2004) and it is a civilian trauma registry database that has been modified for military use. Some of the strengths of civilian programs were the ability to compare outcomes to each other and over time in order to make incremental improvements and, when necessary, abandon nonbeneficial practices. The DoDTR electronically captures data in the following categories: demographics, mechanism/circumstances of injury, diagnosis, treatment and outcomes. The patients included are comprehensive—regardless of US citizenship, military/civilian status, or presence of wartime environment. This store of information is used for official activities, monitoring of continuous metrics, and as a source for queries (similar to the NTDB).

Trauma Care Delivery

JTS data is contemporary across the points of treatment and evacuation. Currently this information is used to ensure that the current standards for initial evacuation from the point of injury are met with the intent of also verifying those standards. Additional efforts are being made to obtain increased granularity of the data with a specific interest in gathering detailed prehospital and en route care (regardless of means of conveyance).

Performance Improvement

Inherent in all of the JTS activities is the aspect of PI. Whereas this is a general motivation behind the comprehensive data acquisition and management activities of the DoDTR, specific activities and positions within the JTS are organized around PI. The development and monitored implementation of the Clinical Practice Guidelines are one of the more visible PI initiatives. The effect of CPG use has been measured with reassuring results including decrease in mortality from 32% preimplementation to 21% post-CPG for the damage control resuscitation guidelines addressed earlier.⁷¹ A form of ongoing PI has been the use of the weekly video teleconference. This conference connects providers from every aspect of care including prehospital, the FST, CSH, Landstuhl and military hospitals in the United States to discuss current critically ill patients to assess the quality of care and provide 360° follow-up. Also under the umbrella of PI is the constant education and readiness efforts of the JTTS including predeployment training to continuing medical education.

The amount of research generated by the recent conflicts has been voluminous. The DoDTR has contributed greatly to both the quality and number of publications, which is currently in excess of 200 peer-reviewed manuscripts. The clinical practice guidelines are regularly updated and informed by the most recent evidence. Several titles are available through The Borden Institute and the US Military which detail specific difficult combat casualty cases and their management. Valuable lessons have been learned from prior conflicts, but the records of those lessons are too often incomplete. There has been a concerted effort of both PI and preservation during this generation. Ultimately, preservation of the many costly lessons learned is contingent upon continuation of the systems and ideals instituted through the JTS and DoDTR.

However, continuing research and data preservation will not completely address the experience gap. Maintenance of trauma surgery skills in a period when the military tempo decreases is a challenge. There are already relationships between the various services and select large US trauma centers, mostly used for predeployment activities. If the United States enters an “inter-war” period the military may need to expand upon these relationships for the maintenance of skills and improved readiness.