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He who wishes to be a surgeon must first go to war.

Hippocrates (460-377 BC)

How varied was our experience of the battlefield and how fertile the blood of warriors in rearing good surgeons.

Thomas Clifford Allbutt (1836–1925)

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.


MEDEVAC helicopter loading (top left), air drop of supplies (top right), the operating room tent (bottom left), and medical personnel of the 67th Forward Surgical Team (Airborne); FOB Todd/Bala Murghab, Afghanistan.

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 ...

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