The High Price of Knowledge

The following is a good article about the increase in the medical field that we have gained from our recent conflicts:

The Laboratory Of War: How Military Trauma Care Advances Are Benefiting Soldiers And Civilians

By Eric Elster, Eric Schoomaker, and Charles Rice

Editor’s note: This morning, in Bethesda MD, the Executive Director of the American College of Surgeons, Dr. David Hoyt, presented the leadership of Walter Reed National Military Medical Center with a plaque recognizing its designation as an ACS-certified Level II Trauma Center. Walter Reed Bethesda is part of extraordinary chain of military health system facilities, providers, organizations, and techniques that have dramatically improved an injured service member’s odds of survival and recovery. As the authors of this post note, lessons learned during more than a decade of war are now being adopted into civilian care, to the benefit of children and adults in every corner of the United States and beyond. For more on emergency care, read the December Health Affairs issue, “The Future of Emergency Medicine: Challenges And Opportunities.“

Out of the ashes of 9-11 and the two wars that followed, a new paradigm has emerged that has benefited more than 50,000 injured warfighters and is transforming civilian trauma care. During the past decade of war, strategic investments in research and clinical care, coupled with contributions from world-class clinician-scientists, have produced the lowest case-fatality rate among combat casualties in the history of armed conflict.

At the beginning of Operations Enduring Freedom (OEF) and Iraqi Freedom (OIF), the combat injury case-fatality rate was approximately 18 percent. Over the subsequent decade, it steadily decreased to 5 percent despite an overall increase in injury severity. This remarkable achievement is grounded in advances in all aspects of trauma care, from the point of injury to optimum treatment in military rehabilitation centers.

As with all previous conflicts throughout history, clinical knowledge generated in the civilian setting was rapidly adapted in innovative ways to address challenges encountered on the battlefield. Now, it is coming full circle to improve the care and decrease the mortality of both injured warriors and civilian trauma victims. This reciprocal relationship between military and civilian medicine, recently highlighted in domestic terrorism attacks such as the Boston Marathon bombing and the mass shootings at Aurora and Tucson, is visible in daily practice in trauma centers throughout the country.

These improvements didn’t happen by accident; the military invested in relevant translational research and developed a flexible, evidence-based trauma system that rapidly developed, assessed, deployed, and refined new advances in trauma care and rehabilitation. In this post we highlight a number of these advances and the science behind them, and we offer a roadmap to ensure that these advances are not only preserved for use in future conflicts, but evolve to benefit all patients — military and civilian alike.

What Has Been Accomplished

Tactical combat casualty care. One of the first important advances was recognition, based on experience gained in the First Gulf War, that combatants themselves are the true “first responders” on the battlefield. Combatants are trained to recognize and promptly respond to life-threatening injuries, and medics and corpsmen are now trained in a realistic, scenario-based, and standardized fashion, based on the principles of tactical combat casualty care (TCCC). TCCC provides the training for the effective use of topical hemostatic agents (bandages with the ability to accelerate blood clotting) and, when necessary, tourniquets to control severe bleeding, along with other skills such as rapid assessment of injuries, airway control, treatment of traumatic pneumothorax (collapsed lung), and immediate pain control.

TCCC is divided into three phases that are relevant in both the combat and civilian mass casualty settings: care under fire, tactical field care, and tactical evacuation care. “Tactical” refers to individual and small unit activities, such as direct care rendered by a first responder at the point of injury, in contrast to “operational” and “strategic” activities, which involve larger units and broader geographic space. This coordinated approach achieved exceptional success; when adopted by elite units of the US military, it resulted in the near elimination of preventable deaths on the battlefield. Today, civilian emergency medical systems (EMS) are adopting the TCCC approach using a course offered by national organizations representing the EMS community.

Bleeding control. Early hemorrhage (bleeding) control, using tourniquets and topical hemostatic agents, are a prime example of how new or improved techniques on the battlefield can produce profound benefits at home. Previously tourniquets were not advocated for routine use for fear of limb loss. However, the need for tourniquets was quickly recognized as essential in modern warfare where severe extremity injuries are common and evacuation is often both timely and fast. Widespread adoption of tourniquets saved many lives in combat without secondary limb loss.4 As an adjunct, the use of topical hemostatics, was more than 90 percent effective. Over the course of the conflicts, these agents were modified several times. This allowed military doctors to optimize their effectiveness while minimizing side effects.

Both of these approaches to hemorrhage have quickly made their way to civilian settings, moving “from the sandbox to the street.” This was most clearly seen following the Boston Marathon bombings, where “without a doubt, tourniquets were a difference-maker and saved lives.”

Massive transfusion protocols. Advances in care did not end on the battlefield; they accelerated upon arrival at hospital settings. This began with new approaches to replacing blood loss from trauma. Prior to our experience in Iraq and Afghanistan, the most severely injured casualties were resuscitated in a step-wise fashion, first with saline solutions, followed by a gradual escalation to the use of blood products. Faced with less than ideal outcomes, military surgeons challenged this approach and looked for better ways to replace blood loss. Based upon solid lab research, these surgeons introduced the concept of “balanced resuscitation”, by immediately countering blood loss with key components of blood when the injured soldier or marine’s injury profile suggested the need for massive transfusion (unstable patients or those with severe injury patterns). This approach not only improved survival, it reduced the rate of complications in combat-wounded patients.

Adoption of “massive transfusion protocols” has become one of the most swiftly adopted changes in care coming from the battlefield. Today, a majority of Level I trauma centers in the US have shifted to this practice. This approach is also being adopted in surgical education, where trainees are taught to activate “massive transfusion protocols” to counter severe injuries.

“Damage control” surgery. The next major advance took place in the operating room where prompt surgical control of bleeding, closure of perforated bowel injuries, and early debridement of damaged tissue are key steps. Focusing on these priorities up front, leaving the abdomen “open” with temporary dressings, and deferring more complex definitive surgery for subsequent procedures has avoided the secondary insult of prolonged periods in the operating room. This led to a practice called “damage control surgery.” This concept was first introduced in the civilian trauma world (utilizing a term adopted from the military, where “damage control” refers to maneuvers to save a ship so it can continue to be effective). The technique caught on with military surgeons, many of whom who had trained in civilian trauma centers, and was swiftly refined under wartime conditions. As with the other advances discussed, the widespread application of damage control surgery has benefited military and civilian populations alike.

Neurocritical care. Patients with specific injuries, most notably penetrating head and extremity injuries, have also benefited from military medicine. In previous conflicts, many of these patients were assumed to have non-survivable injuries and were treated as “expectant” (i.e., only comfort care). Now, they are aggressively managed using techniques similar to those applied in damage control surgery.

For example, in cases of massive head trauma, a portion of the skull is temporarily removed to allow the brain to swell without creating a lethal rise in pressure that would stop blood flow to the brain. This is particularly important for patients faced with long medical evacuation times. Another technique involves preventing the spasm of major blood vessels that are necessary to support brain survival and function. Although this practice has not yet been widely adapted in civilian trauma, it may come to be widely used in future mass casualty events and conflicts.

Treatment of badly damaged limbs. Another advance that has seen widespread use is an integrated approach to early limb salvage versus amputation in patients suffering from massive extremity injuries with significant tissue loss and neurovascular damage. Military and civilian researchers have found that, for certain patients, early amputation results in better long-term functional outcome. For patients who remain good candidates for limb salvage, the innovations in soft tissue reconstruction have produced survivors who not only recovered, but in many instances returned to full duty and extremely active lifestyles.

Two key adjuncts to the successful treatment of severe extremity wounds are adequate pain control and aggressive, early rehabilitation. The adoption of regional pain control and integrated pain management teams has allowed rehabilitation to start while the patient is still in the hospital. All of these efforts come together in the treatment of the multi-limb amputees who face substantial challenges. Without these approaches, the amazing functional results that have been seen would not be achievable. Many of these techniques are now working their way into civilian practice, such as treatment of victims of the Boston Marathon bombings.

Rapid evacuation to tertiary care centers. Transporting injured personnel to centers capable of providing advanced levels of care required comparable innovations in tactical and strategic casualty evacuation. In conflict zones, tactical evacuation is largely accomplished by medical evacuation helicopters, while inter-theatre strategic evacuation over thousands of miles is achieved with large Air Force fixed wing aircraft outfitted with ICU pallets and staffed by specially trained Critical Care Air Transport Teams (CCATTs). This integrated approach has resulted in a reduced medical footprint in the conflict area as compared to previous conflicts. Equally important, improvements in hand-offs of care were devised to assure seamless transitions between the military, the U.S. Public Health Service, the Veterans Health Administration, and, ultimately, civilian trauma and rehabilitation facilities. The collective impacts of these advances in care are unprecedented in military history.

How It Was Done

Almost as remarkable as this progress is the manner in which it was done. Normally, progress in patient care is achieved through painstaking, incremental research, often tested and refined through large-scale randomized trials involving thousands of patients. It’s been written that the average time frame for research to reach the bedside and be widely adopted into care is measured in decades. The military health system didn’t have that sort of time. Lives depended on swift and sure decisions, backed by the best available evidence.

Much of the progress was made possible through creation of the Joint Trauma System (JTS), whose mission is to improve trauma care delivery across the continuum of care through careful data collection and analysis, to improve clinical outcomes in near real-time. This effort represents the largest combat registry ever created. In addition to monitoring the quality and outcomes of care, the JTS develops and implements clinical practice guidelines system-wide, and identifies the training and research needs for trauma care in the military.

The ability of the JTS to rapidly identify emerging injury patterns, develop best practices and research-based CPG’s, and subsequently disseminate and track such guidelines represents a paradigm shift away from costly, multi-year clinical studies to “focused empiricism” and continuous process improvement. Driven to address challenges identified by the JTS, the DoD continues to invest in mission-relevant research focused on biomarker-based care, regenerative medicine, and advanced approaches to hemorrhage control. While many civilian centers have adopted similar models with a degree of success, the widespread implementation of this approach could serve as a model for other large health care systems.

Early in what has proven to be the longest armed conflict fought by the U.S. to date, military medicine recognized that it needed to fundamentally change how it approached the care of wounded warriors. It did this by implementing data-driven decisions at every step in the continuum of care, from battlefields in two nations across 8000 miles and three continents to world-class hospitals and rehabilitation centers in Germany and the United States. Importantly, this work was done while the individuals involved were doing their utmost to provide the best possible care to every injured combatant and civilian they touched. As was true following the conflicts in Korea and Vietnam, lessons learned in the crucible of war are beginning to transform care in civilian hospitals in the U.S. and around the world.

The progress that has been made over the past decade is tenuous at best. Some of those who led these efforts have retired from the military, and others are struggling to contend with budget cuts, furloughs and funding constraints. It won’t be easy to maintain surgical skills honed over a decade of conflict. But this is essential to assure that military healthcare in any future conflict will be as good, and ideally better, than in the most recent ones. There is little doubt that thousands of service members and veterans are alive today thanks to the work of dedicated military and civilian health care professionals. Many of the insights they developed are beginning to transform care in the civilian world and millions will benefit.

The knowledge gained over a decade of war cannot be taken for granted. Continued work is needed to identify and manage challenges that are only faintly understood today. The progress that is made will not only help our warfighters in future conflicts, it will help save the lives of civilians as well.

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Combat Casualties

Here is another article by Max Velocity, I just find his articles so good I have to put them up for you guys. I just bought his books by the way, I will read them and do book reviews here when I am done.


SHTF Combat Casualty - Considerations & Realities

On my CRCD class, I don't have time to do a full class on TC3 (Tactical Combat Casualty Care). However, what I do is give a few pointers as to how causalities will fit into the game in a real SHTF contact situation.

When I train people in patrol break contact drills, I explain that it is like practicing a fire emergency drill. The fire alarm goes off, we all head downstairs and rally in the parking lot. Simple. But in the reality of a fire, we may not all get out, it may be a smoke and flame filled confusion, and we may take casualties. It's the same for break contact drills.

So, we practice our choreographed drills and at the level of the CRCD class I don't even throw in casualties. The worst case reality of a break contact drill, facing a well sited enemy ambush, is that you may get out crawling down a creek bed dragging your wounded buddy. Or you may not get out at all. But that is worst case.

Break contact drills are 'Oh Shit' emergency drills and there are worst case scenarios. The other side of that is that with a well executed drill, even though you are doing the drill to ultimately get away, you may react and hit the enemy in such an effective way that you leave them reeling, wondering what happened as you "faded away into the woods."

In the immortal words of Captain Jack Sparrow of 'Pirates of the Caribbean' fame: "We will fight them, to run away."

The main point that I want to bring out today is firstly the effect of casualties on your drill, and secondly the effect that SHTF will have on your TC3 procedures.

Firstly, the hardest thing you will do is going to probably be evacuating a casualty under enemy fire. Moving a casualty is very hard. Initially, you will be dragging the casualty by his gear every bound back that you make. You will move, dragging the casualty, covered by the other buddy pair. Then, you will stop, take a fire position, and fire to cover the withdrawal of the other buddy pair. As you get further away from the contact, creating a breathing space, you can consider reorganizing slightly so that, depending on the size of your team, there is an element moving the casualty and an element fire and moving back to cover that. For a four man team with one casualty, that will mean one person moving the casualty, whether by dragging or the Hawes carry, and the other two bounding back to cover that move.

Once you rally up out of contact, you can reorganize, again your numbers will determine exactly how you do that (are you a team or a squad?), to create a litter carry party and a security party to cover the move out.

Secondly, let's look at the reality of TC3 in an SHTF situation:

There are three phases to TC3:

1) Care under fire
2) Tactical Field Care
3) Evacuation

In the Care under Fire phase, the primary thing you must concentrate on is fighting the battle. If you are breaking contact that means do that. Don't do anything that will cause more casualties, such as running out in the open to get that downed point man, unless you have first suppressed the enemy.

Th only intervention you, or the casualty, can do in the Care under Fire phase is to apply a hasty tourniquet 'high and tight' on a wounded limb to stop imminent death from extremity bleeding. As a team you will be going through your individual RTR drills, reacting to the contact, and then flowing into the break contact drill as appropriate. If you have a man down, you will simply have to grab him and drag him back on each bound you make back as part of your fire and movement.

Even in the care under fire phase, don't try and put a tourniquet on in an exposed position. Drag the guy into a semblance of cover, be practiced so you can whip it on and tighten it down quick either in the groin or armpit area, and then get on with firing and moving. If you kneel in the open to apply a tourniquet, you will be shot down.

If you are in some other contact situation where you are not actually moving and breaking contact, and you are engaged in a firefight with a casualty exposed in the open, then don't risk all to go to them. Concentrate on suppressing the enemy and winning the firefight. There are pretty much four things you can shout to them under TC3:

1) Can you return fire?
2) Can you apply self-aid? (i.e. hasty tourniquet high and tight)
3) Can you crawl to me?
4) Lay still! (so as not to draw more fire - don't tell them to "play dead", it's not good psychologically!)

But, dependent on the situation you find yourself in SHTF, there are some other considerations. You probably don't have back-up and there is no 'dust-off' medevac on the way. If the guy is obviously dead, grey matter on the ground or whatever, then look to the greater good of the team and fight out of there. SHTF will make you face some hard decisions. You may not be able to bring them all home. The other side of that is that wounds can be horrific and look a lot worse than they are. So long as the guy is breathing, even better screaming, then do your best to get him out of there, even though you may be repulsed and unsure how you could ever take care of such a nasty wound.

The next phase to look at is the Tactical Field Care phase. This is where training can diverge from the SHTF reality. In training, once you have suppressed the enemy and got the casualty to cover, then you can go into Tactical Field Care, which means taking care of H-ABC (now MARCH, same thing) and then the full assessment before packaging up the casualty (thermal blanket to prevent hypothermia, even in hot weather) and monitoring them for evacuation. This is where a whole bunch of interventions are possible. However, in SHTF I can't tell you who your enemy will be. Worst case, they are an aggressive force that will follow you up, potentially even a Regime style 'enemies foreign or domestic' hunter-killer force. If so, you will not be able to hang around in the rally point for longer than it takes to do a personnel check, tactical reloads, and maybe a quick intervention on the casualty. Other than that, if you hang around and they follow up into your hasty ambush established as part of the rally, you will be back in contact and will have to roll back into the break contact drills again, back to another rally point. Don't hang about after breaking contact.

In that sort of situation, you will have to do what you can for the casualty as you move back, creating further distance as you E&E away from the contact point. But here we hit another dilemma. You need to have equipment with you, and personnel, to carry the casualty. If you are using a litter, one casualty will take a squad to move - four on the litter at any one time, struggling, and the others pulling security as you move. You could use other methods, such as the ruck-style carry straps allowing one person to carry the casualty, but all this is going to be really hard work and make you slow.

Enter: more hard decisions: how badly wounded is the casualty? Do you have definitive care to get him back to? How hard are you being pursued? Can you take care of the pursuit with a hasty ambush, or are you in serious trouble? Can you move fast enough to get away while moving the casualty? Will the casualty survive the evacuation (which as non-medically trained personnel you may not even know)? If you leave the casualty, what will the enemy do to him? Maiming, torture, cannibals, interrogation? Is leaving the casualty a security risk to your teams operations and ultimate survival? Do you have a contingency plan for team members falling into enemy hands - can you move your FOB location faster than you expect him to break to interrogation?

No, I'm not advocating that you shoot your guy and leave him, or that he shoot himself. But this may be a time for a little volunteer heroics from the casualty, which always carries a risk of capture. It all just depends on the situation, and no doubt an SHTF or civil war/resistance type situation is going to throw up some really hard choices. Some of this ties in with comments that I have made before about dumping gear to get away, running off naked through the woods after having dumped all your gear to escape. The key here is to carry a load that you can move with, and shuffle-run out with if necessary, so you never have to dump all your weapons, ammo and gear even if you dump your patrol pack. If you are being closely pursued, whether you have a casualty or not, then you may face a choice of dumping everything and running, or you may turn and fight, hasty ambush, get close to the enemy negating indirect fire weapons, and maybe survive in the chaos, in the gaps. That is your choice and largely depends on what you are about i.e. what you see as your mission.

There is a time to live, a time to fight, and a time to die. All that really matters is how much it's going to hurt, right? If you are going to go out like a fighting bear, go out like a grizzly.

This leads us on to the last part, which is evacuation. The whole point, in a nutshell, of the TC3 protocols is basically to stabilize the casualty and keep them alive so that they can be evacuated back to definitive care, in military terms at the CASH (Combat Hospital). But in SHTF you will only have whatever medical care you have. Whether that is a medically trained person, or yourself having read up and taken some courses.

The interventions that you do under TC3 protocols rely on further definitive interventions back at the hospital to take care of the problem. You have to take that tourniquet off some time right? Are you going to clamp that artery? Do you have the equipment? You have to get a chest tube in to take care of the sucking chest wound and tension pneumothorax (collapsed lung), right? Can you get over your own feelings of revulsion at the gore and blood in order to be effective in helping your buddy or family member?

So ultimately, keeping the guy alive until you can get him out will then rely on being able to keep him further alive by definitive interventions. You may be back to an 1860's level of medicine, giving him a bottle of whisky to drink while you do what you can. So, you need to be able to clean, debride and suture wounds. You need to consider antibiotics, because back in the day infection was the major killer of those who initially survived their wounds. Think about use of betadine/sugar poultices and similar, as used by vets on horses.

So, ultimately what is my point? Like all military style doctrine, it has to be assessed and looked at from the perspective of an SHTF situation. TC3 is no different. It is really useful to train as a combat lifesaver or combat medic and to learn to do TC3. But make sure you have assessed the use of it in a non-military SHTF environment and consider the potential absence of definitive care as well as the need for people in your group to step into those gaps with useful skills.

Live Hard, Die Free.

MV

http://maxvelocitytactical.blogspot.com/2013/09/shtf-combat-casualty-considerations.html

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