April – June 2011 

Perspectives 1

MG David A. Rubenstein; COL Mustapha Debboun; Richard Burton 

1831 6

COL Lorne H Blackbourne

We Don't Know What We Don’t Know: Prehospital Data in Combat Casualty Care 11

COL Brian J. Eastridge; LTC Robert Mabry; COL Lorne H. Blackbourne; CAPT (Ret) Frank K. Butler, USN

A Prehospital Trauma Registry for Tactical Combat Casualty Care 15

LTC Russ S. Kotwal; MSG Harold R. Montgomery; Kathy K. Mechler, MS, RN

Current Concepts in Fluid Resuscitation for Prehospital Care of Combat Casualties 18

Michael A. Dubick, PhD

Evaluation of Topical Hemostatic Agents for Combat Wound Treatment 25

Bijan Kheirabadi, PhD

New Tourniquet Device Concepts for Battlefield Hemorrhage Control 38

COL John F. Kragh, Jr; Chris Murphy; Michael A. Dubick, PhD; et al

The Role of Normoventilation in Improving Traumatic Brain Injury Outcomes 49

COL Leopoldo C. Cancio; MAJ(P) Kevin K. Chung 

Advances in Prehospital Burn Resuscitation for the Combat Injured 55

MAJ(P) Kevin K. Chung; Jose Salinas, PhD; COL Evan M. Renz

Advanced Technology Development for Remote Triage Applications 61

in Bleeding Combat Casualties

Kathy L. Ryan, PhD; Caroline A. Rickards, PhD; Carmen Hinojosa-Laborde, PhD; et al

Advanced Monitoring and Decision Support for the Battlefield 73

Critical Care Environment

Jose Salinas, PhD; Ruth Nguyen, MD; Mark I. Darrah, PhD; et al

Prehospital and Emergency Care Research at the US Army Institute of 82 

Surgical Research: Enabling the Next Great Leap in Combat Casualty Survival 

LTC(P) Robert T. Gerhardt

Improving Role I Battlefield Casualty Care from Point of Injury to Surgery 87 

LTC Robert L. Mabry; COL Robert A. De Lorenzo

Sharpening the Edge: Paramedic Training for Flight Medics 92 

LTC Robert L. Mabry; COL Robert A. De Lorenzo 

Prehospital combat casualty care 

The starting point of battlefield survival 
April – June 2011 The Army Medical Department Center & School PB 8-11-4/5/6 

By Order of the Secretary of the Army: 

Official: 

1101403 

GEORGE W. CASEY, JR 

General, United States Army 

Chief of Staff

DISTRIBUTION: Special 

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Secretary of the Army 

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LTG Eric B. Schoomaker 

The Surgeon General 

Commander, US Army Medical Command 

MG David A. Rubenstein 

Commanding General 

US Army Medical Department Center and 

School 
 April – June 2011 1

Perspectives Perspectives

EDITORS’ PERSPECTIVE

COL Lorne Blackbourne opens the collection of focus 

articles with a retrospective look at the evolution of 

prehospital trauma care since 1831. Interestingly, 1831 

is significant to medical science because in that year 

occurred the first documented use of intravenous fluid. 

Technological advances in medical science, as well as 

throughout almost all aspects of human endeavor, have 

been breathtaking, and, by and large, greatly 

beneficial. However, COL Blackbourne presents a 

comparison of the technology of prehospital battlefield 

care in 1831 and today, and his conclusions reveal a 

surprising lack of significant advancement in both 

sophistication and variety in diagnosis and treatment 

over the years. His article sets the stage for the articles 

The Marine Corps has a fundamental tenet which is 

ingrained in every Marine, from the Commandant to 

the newest boot camp graduate: 

The only reason for your existence in the Corps, no 

matter your job, is that Marine rifleman in the foxhole. 

Everything you do must ultimately contribute to his 

effectiveness and survival on the battlefield. 

With regard to our ultimate purpose, a similar principle 

is applicable to most of us in the Army Medical Department. Indeed, the historical foundation for the existence 

of military medicine is management of trauma injuries 

incurred by Warfighters in combat. When reduced to its 

essence, that trauma care starts with the combat medic, 

who must call upon all of the training, skills, and 

equipment that we have given him/her to keep wounded 

Soldiers alive until they are in the hands of our superbly 

capable surgeons. Those combat medics are the core of 

prehospital care on the battlefield, that absolutely 

crucial phase of combat trauma care that can determine 

the outcome of the casualty’s journey through the 

medical care system. The survival of that combat 

casualty is the primary reason for our existence, and the 

combat medic is the starting point to make that happen. 

We in the AMEDD live and work in the real world. 

Every day presents new, "right now" crises and challenges clamoring for our time and attention. In the 

bedlam of so many complications and diversions, so 

many requirements pulling from all directions, and so 

many demands for instant responses, it is sometimes 

difficult to keep our collective concentration directed 

towards the ultimate responsibility. COL Lorne 

Blackbourne, Commander of the US Army Institute of 

Surgical Research (ISR), and his team have assembled 

this very important issue of the AMEDD Journal to 

refocus on prehospital care of combat trauma. Drawing 

on the considerable resources of the ISR’s professional 

staff and their counterparts in research and the practice 

of trauma care from across the country, this impressive 

collection of articles explores a broad spectrum of topics dealing with the current and future states of prehospital combat trauma care. The articles cover the gamut, 

including research in medications, techniques, and 

tools; data requirements, management, and value; and 

the qualifications and training of our frontline medical 

professionals. Readers may find some of the content a 

bit controversial, perhaps even provocative, but the 

Army is a learning organization, and we as leaders and 

professionals must always recognize facts for what 

they are, especially when lives may be on the line. 

The AMEDD is responsible for many varied 

disciplines encompassing nearly every aspect of 

modern medicine. Obviously, all are very important to 

the health and welfare of our Warfighters. However, 

when the urgent cry “MEDIC!” rings across the chaos 

of a battlefield, nothing is more vital at that moment 

than the capabilities that the AMEDD has given that 

Soldier and those that will assist in moving the 

casualty to the next level of care. For that reason, the 

articles in this issue should be of great interest to the 

vast majority of AMEDD medical professionals, 

whether or not you are directly involved in combat 

casualty care. All military medical professionals 

should be impressed by the dedication and focus of 

those continuously involved in working to optimize 

the odds of survival of our Warriors who go into 

harm’s way, whenever and wherever necessary. 

COMMANDER’S INTRODUCTION

MG David A. Rubenstein 
2 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

Perspectives 

that follow, which demonstrate that military medicine 

in general, and the Army Institute of Surgical Research 

in particular, has considerable resources dedicated to 

rectifying this situation as rapidly as possible, working 

to improve every facet of prehospital battlefield 

trauma care. 

COL Brian Eastridge and his team examined the 

differences between the advances of military trauma 

care in the hospital setting and that experienced in the 

prehospital environment from the perspective of the 

evidence that drives change and improvement. The 

Army has implemented sophisticated data collection 

systems and databases specifically to track injuries and 

allow thorough analysis of both successes and failures 

of treatments, including all the factors which can be 

quantified. Such analyses and implemented protocols, 

equipment, and supplies have resulted in tremendous 

advances in acute care management of the combat casualty. Unfortunately, as COL Eastridge et al describe 

in detail, such necessary data is almost never available 

from the prehospital care phase of combat trauma care. 

Without that data, those dedicated to improving the 

prehospital care capabilities are essentially hunting for 

solutions armed with suboptimal evidence, when any 

exists at all. The article describes the military’s efforts 

to address this problem, with the establishment by 

DoD of the Tactical Combat Casualty Care (TCCC) 

guidelines with participation of all the services. These 

guidelines are under constant review and modification 

based on evidence gathered from numerous sources, as 

well as unrelenting efforts to gather data from the 

actual battlefield environment. This is difficult, but the 

paramount importance of such data cannot be overemphasized. 

In the next article, LTC Russ Kotwal and his coauthors 

describe one early initiative to implement TCCC 

protocols and procedures, and directly address the lack 

of prehospital data. The 75th Ranger Regiment 

developed and implemented a regiment-wide program 

of training in TCCC basics, especially the recording of 

casualty data from the first contact with any responder, 

whether a medic or not. The Regiment created a 

Soldier’s data card specifically to capture the TCCC 

data, and ensured that command emphasis on its use 

was constant, including training classes and during 

field exercises. That data card eventually became the 

Army’s standard TCCC card (DA Form 7656). As the 

Regiment’s collection of data from the TCCC card 

improved in quality and quantity, a database for the 

TCCC data was developed: the prehospital trauma 

registry. LTC Kotwal et al discuss the evolution of that 

registry into a web-based tool that has markedly 

improved the command’s ability to devise treatment 

protocols and procedures based on evidence, one of 

the essential elements discussed previously as historically unavailable. This article is yet another example 

of the initiative, skill, and energy of our military medical professionals in pursuing the primary goal, 

survival of the Warfighter.

It is well documented that hemorrhage has historically 

been, and remains, the primary cause of death on the 

battlefield. Further, data from current combat operations indicate that two-thirds of hemorrhage-related 

deaths in those conflicts have been from noncompressible injuries. As Dr Michael Dubick describes in 

his excellent article, often there is little the combat 

medic can do for such casualties beyond infusing fluid 

to maintain blood pressure until surgical resources can 

be reached. However, even that capability faces limitations in supply, and certain types of intravenous fluids 

are not suitable for this application. The article focuses 

on the current thinking with regard to optimal fluid 

resuscitation strategies to give the combat medic the 

best chance to stabilize the combat casualty. The concept of damage control resuscitation has been developed to describe those optimal strategies as battlefield 

data and attendant research reveal what works, and 

what does not. Dr Dubick’s article details the background, data, practices, and research in progress within 

the damage control resuscitation concept, the majority 

of which is the direct result of work at the Army 

Institute of Surgical Research.

In his detailed and very informative article, Dr Bijan 

Kheirabadi discusses the research and development 

efforts to improve topical hemostatic agents that have 

been ongoing for the past 15 years or so. The need for 

a safe, effective, and easily used topical agent to 

control compressible hemorrhage has become an 

increasingly important goal for military medical 

researchers as the character of the battlefield has 

changed dramatically from that of years past. Planners 

have to anticipate longer evacuation times to surgical 

resources as current conflicts have become 

increasingly nonlinear, with dispersed locations of 

varying levels of medical and transport support. 

Statistically, the use of an effective hemostatic agent in 
 April – June 2011 3

THE ARMY MEDICAL DEPARTMENT JOURNAL

a dressing to quickly control hemorrhage in the 

prehospital phase of trauma treatment could be the 

most effective method to reduce morbidity in a 

significant percentage of casualties with compressible 

bleeding injuries. That fact, combined with the 

obvious utility of such agents in the hospital as well, 

focus the intense interest by researchers such as Dr 

Kheirabadi in developing the best product possible to 

meet our commitment to our nation’s valiant Warriors. 

COL John Kragh, Jr, and his coauthors address the 

most serious type of hemorrhage-related cause of 

death on the battlefield, the uncontrolled bleeding from 

a wound in the trunk area of the body, usually on the 

periphery of the body armor, for which tourniquet 

application is seemingly impossible. In 2009, the DoD 

Committee on Tactical Combat Casualty Care made 

truncal tourniquets a research priority. COL Kragh et 

al present a carefully developed, extensively researched discussion of the physiology of controlling 

truncal blood flow by compression, the anatomical considerations and challenges involved, the various attempts and ideas to address the problem throughout 

history, and some of the approaches under consideration in the current research. This article is an important look at perhaps the most important challenge 

facing those working to increase the survival of battlefield casualties during the prehospital phase of trauma 

care. Readers will have a thorough appreciation of the 

skills, expertise, and dedication of those addressing 

this complex and deadly, but unavoidable circumstance of combat.

Improvements in the Soldier’s individual protective 

equipment used in current combat operations have 

resulted in a decrease in the number of lethal torso and 

head injuries, which means that surviving casualties 

present with various types of serious injuries in a 

larger proportion than previously experienced. That 

survivability, combined with the concussive effects of 

blast from the enemy’s weapon of choice — the 

improvised explosive device — have resulted in a 

marked increase in diagnosed traumatic brain injury 

(TBI) among surviving combat casualties. As 

discussed in recent articles in the AMEDD Journal, 

TBI has become one of the signature injuries from the 

Iraq and Afghanistan combat theaters, and is the 

subject of extensive research and collaborative efforts 

to understand the physiology of this injury, and 

develop protocols to address it throughout the flow of 

casualty care. In their excellent, well-referenced article, COL Leopoldo Cancio and MAJ(P) Kevin Chung 

present a detailed discussion of the research and 

clinical experiences shaping current thinking about 

how to best address TBI in the prehospital phase of 

trauma care. Their article focuses on stabilizing the casualty’s respiration, ventilation, and blood pressure 

parameters within limits that have been indicated by 

studies as optimizing survivability and long-term recovery to normal brain functions. The information presented in this article is a compendium of the leading-edge of 

medical research in this increasingly important area, and 

should be of great interest to all medical professionals 

involved in any phase of combat trauma care. 

The improved torso protection and the pervasive use of 

the IED have also resulted in an increase in the number 

of surviving casualties with severe burn injuries. The 

vast majority of those casualties are brought to the 

Burn Center at the Army Institute of Surgical Research 

(ISR), which has long been recognized as one of the 

world’s premier burn care facilities. The Burn Center 

not only provides the best care possible to patients 

they receive, but it is also a major locus for research 

into all aspects of burn care, from point of injury to 

posttreatment rehabilitation. This is illustrated in the 

excellent article contributed by MAJ(P) Kevin Chung 

and his coauthors, which focuses on prehospital fluid 

resuscitation of the severely burned combat casualty. 

They investigated the actual fluid resuscitation 

practices of the prehospital providers caring for the 

burned wounded in comparison with the clinical 

standards recommended by the American Burn 

Association. Not surprisingly, they discovered that the 

complexity of fluid administration formulae and the 

close monitoring required was beyond the immediate 

capabilities of those charged with caring for multiple 

casualties in the stark surroundings of the battlefield. 

Indeed, their research found that prehospital 

responders in the United States were also not 

attempting to apply the detailed protocols to determine 

initial fluid rates. So the ISR developed and validated a 

greatly simplified methodology to calculate the initial 

fluid resuscitation rate which falls within the 

acceptable range. The patient’s response then determines adjustments to that initial rate. The ISR had 

already (2005) developed and published burn resuscitation clinical practice guidelines for en route care, 

along with a flow sheet for standardized documentation of the care received by the patient throughout 

transport to the Burn Center. MAJ(P) Chung et al 

detail these efforts, as well as the development of a 
4 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

Perspectives 

computerized decision support system to further 

monitor and standardize resuscitation fluid rates. 

These and several other initiatives described in the 

article are indicative of the dedication, initiative, and 

enthusiasm for the mission that have been the hallmark 

of those professionals of the ISR who work tirelessly 

to save the lives of American Warfighters.

The capability to remotely monitor the physiologic 

status of Soldiers in the field has long been a staple of 

science fiction books and movies. However, the 

obvious value of such a concept has also been 

recognized by real-world military medical developers 

and researchers for many years. Dr Kathy Ryan and 

her team of coauthors provide a look at the current 

state of ongoing research and developmental work to 

produce a practical, reliable, and accurate system 

which, at the most basic level, will provide the combat 

medic a capability to remotely triage bleeding 

Soldiers. Combat medics routinely place themselves in 

vulnerable circumstances while finding, evaluating, 

and treating wounded Soldiers. Unfortunately, it is not 

uncommon for the medic to find the Soldier either not 

seriously injured, or too severely injured to be saved. 

Further, since the medics must make those judgments 

“on-site” requiring time and often risking their own 

lives, other seriously wounded Soldiers may wait, a 

potentially life-threatening situation. In their detailed, 

well-presented article, Dr Ryan et al examine the 

extreme complexities — physiological, technical, functional, and ergonomic — involved in designing the 

sensors, interfaces, and algorithms to present the 

information a medic needs to make the necessary 

critical judgments. The extent of the factors that 

researchers must consider is significant, but the 

analysis of specific data elements as to their respective 

contributions to presenting the overall physiological 

status is truly impressive. The effort described in this 

article is yet another example of the extraordinary 

level of expertise and capability that is found in the 

Army Medical Department. 

As discussed from various perspectives in earlier 

articles, the scarcity of information about a casualty’s 

injuries, vital signs, and care received (including 

medications) is a continuing problem. In the absence 

of such information, each successive provider must 

take time to reevaluate the casualty as he or she moves 

through the various stages of the evacuation process, a 

delay which at any point in the process can be a very 

perilous circumstance for the wounded Warrior. 

Further, that provider evaluation itself may be problematic, because in the dynamic environment of the 

combat theater, each caregiver’s level of experience 

and access to supporting medical information can vary 

considerably. As described by Dr Jose Salinas and his 

colleagues, mitigating these information shortcomings 

is the focus of ongoing research and development at 

the ISR, with the goal of providing prehospital medical 

caregivers with advanced computer-based monitoring 

and decision support systems (DSS) to minimize 

delays and sometimes dangerous variations in rendered 

care. Their ideal system would be one with multiple 

sensors on the patient feeding data into a DSS for 

analysis and presentation to the caregiver, who could 

query the system for previous care and medications 

rendered, access recommended procedures and 

knowledge-based information about the particular 

patient’s conditions and responses, and then monitor 

the patient’s condition in real time. 

LTC(P) Robert Gerhardt provides an overview of the 

Army Institute of Surgical Research’s current efforts 

in research programs, development efforts, and 

collaborations aimed at improving casualty survival 

throughout the prehospital and transport phases of 

trauma care. Of course the ISR’s primary focus is the 

combat environment, but, as indicated by the close 

collaborations with other military services, civilian 

hospitals, trauma centers, and medical transport 

companies and agencies, the drive to optimize 

prehospital trauma care is a common goal for all 

practitioners of emergency medicine. Other articles in 

this issue have featured certain specific areas of work 

at the ISR, but LTC(P) Gerhardt’s article presents the 

scope of ongoing work across multiple areas, 

providing a perspective of the breadth and depth of the 

professional skills and capabilities which the dedicated 

people there bring to work every single day. It should 

also be obvious that the work at the ISR, although 

directed towards the survival of the Warrior on the 

battlefield, contributes greatly to the survival of trauma 

victims across the United States. 

As MG Rubenstein mentioned in his opening remarks, 

the US Army combat medic is literally the point 

person in the sequence of trauma care that exists to 

stabilize a wounded Soldier until he or she reaches a 

surgical facility. This issue of the AMEDD Journal

closes with 2 articles from LTC Robert Mabry and 

COL Robert De Lorenzo examining the training and 

certification requirements for those vitally important 
 April – June 2011 5

THE ARMY MEDICAL DEPARTMENT JOURNAL

individuals, and providing carefully-considered ideas 

and recommendations as to how to markedly improve 

their levels of skill and expertise. Of course the 

ultimate goal of any change is improved casualty 

survival rates in the prehospital phases of battlefield 

trauma care, a positive trend that is occurring, but can 

always be improved. 

In their first article, LTC Mabry and COL De Lorenzo 

look at the historical evolution of the care of battlefield 

wounded, from literally none just a century or so ago, 

to the system of trained and skillful specialists with 

ambulances, helicopters, and specially configured 

medical transport airplanes that are part and parcel of 

modern battlefield trauma care. However, as good as it 

is, it can always be better, a proposition to which the 

authors are totally dedicated, with the ultimate goal of 

more lives saved. They call for renewed emphasis in 

the specific training and qualifications for those “out 

front” in the battlefield care path, not just the combat 

medics, but also the overseeing physician assistants 

and unit surgeons upon whom those medics rely for 

mentoring, instruction, and assistance. The authors 

point out that, in the past, military medicine was able 

to “grow our own” reservoir of experienced, skilled 

field practitioners, but certain factors currently limit 

that ability. They propose a number of structural 

changes and shifts in emphasis which would reinstate 

that depth of expertise, with only positive impacts on 

the numbers of surviving wounded who arrive at 

surgical facilities in combat theaters. 

The advent of the helicopter as an evacuation vehicle 

for battlefield wounded is arguably one of the most 

significant developments in combat trauma care since 

1797, when Dominique Jean Larrey established the 

world’s first formal ambulance corps for Napoleon’s 

armies. He recognized that time is life, a truism even 

more profound today as the capabilities of military 

medical practitioners have reached unimaginable 

levels, as long as the wounded reach them in time. 

Indeed, as so often happens in history, the timing of 

the development of helicopter medical evacuation 

(MEDEVAC) was especially fortuitous in that it 

evolved in concert with momentous shifts in the nature 

of military operations. The Vietnam experience, 

followed by the collapse of the Iron Curtain, were 

strong indicators that future conflicts would probably 

not be fought over a “structured” battlefield, stretching 

back from the forward edge of the battle area through 

defined areas of support wherein vehicles could move 

via secured roads quickly and efficiently. Combat 

operations in Vietnam, Iraq, and Afghanistan have 

been, and are, dispersed, noncontiguous, and definitely 

nonlinear. Without the helicopter MEDEVAC, the 

prospects of our wounded Warriors reaching advanced 

medical facilities in time would be severely 

diminished. In their timely and important article, LTC 

Mabry and COL De Lorenzo argue that, as good as the 

military’s MEDEVAC capabilities are, they could and 

should be improved. They cite the areas where change 

would have the most significant positive results, and 

present proposals (and numbers) to enact those 

changes. They develop their recommendations based 

on the world’s most sophisticated, efficient, successful 

model of prehospital air transportation of trauma 

victims, the civilian system in the United States. As 

they point out, the irony of the situation is that the 

current US civilian emergency medical services 

system owes its existence to the success of the US 

military MEDEVAC operations in Vietnam. The 

excitement of early successes combined with 

enthusiastic state and federal support and resulted in 

rapid evolutions in sophistication, innovation, and 

capabilities, which have produced the superb system 

that benefits Americans in every state of our country. 

LTC Mabry and COL De Lorenzo present the case that 

the military’s MEDEVAC system should be closely 

and carefully reviewed with the goal of identifying and 

incorporating standards, protocols, and resources to 

optimize its lifesaving potential, and an already 

excellent system will only get better. 
6 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

INTRODUCTION

The year 1831 was very significant to the advancement 

of medical technology. It was the year of the first 

documented use of an intravenous fluid. It was 

administered to increase the intravascular volume to treat 

the signs and symptoms of hypovolemia.1-4 In 1831, 

during the cholera epidemic in England, Drs Thomas 

Latta and Robert Lewins of London injected a saline 

solution guided by the pulse of hypovolemic cholera 

patients. Dr Lewins wrote in The Lancet about his 

experience with one patient: 

The patient’s pulse at the commencement was 180, very 

small and feeble. She was excessively restless, with a 

feeling of great weakness and tormenting thirst. Before 

12 oz had been injected, the pulse began to improve; it 

became fuller and slower, and it continued to improve, 

until, after 58 oz had been injected, it was down to 110.3

Since this introduction of a saline-based intravenous 

fluid, how has the medical technology advanced that we 

are using prehospital on the battlefield prior to getting 

combat wounded to a surgical facility? 

While the technology to locate, track, and destroy our 

enemies has taken huge strides since 1831, our 

prehospital technology to help save life and limb has not 

kept pace. Satellites, global positioning systems, 

unmanned aerial vehicles, and lasers are just a few of the 

new technologies placed on the modern battlefield; the 

modern combat medic is, on the other hand, using 

technology that has barely advanced since 1831. 

Highlighting the technologic advances in combat arms to 

the individual medic level, one only need look at the 

medic’s semiautomatic sidearm, assault rifle (with 

electronic sights/laser), and night vision goggles, and 

then compare them to the flintlock rifle and flintlock 

pistol used in 1831. To illustrate the “technological 

divide,” we must look at the medical technology 

available to combat medics today. 

Guided by the tenets of Tactical Combat Casualty Care 

(TCCC), the training of medics today has greatly 

improved.5

 The equipment manufactured for use by 

combat medics is lighter and is engineered with great 

advances. In contrast, when analyzed by comparing 

anatomic injury diagnostic and treatment capabilities, the 

actual technology of the diagnostic and treatment options 

available on the battlefield does not reveal many great 

advances since 1831. 

COMBAT INJURY DEMOGRAPHICS

Retrospective analysis indicates that the major causes of 

“potentially survivable” injuries resulting in death on the 

battlefield (killed in action) and after reaching a surgical 

facility (died of wounds) are truncal hemorrhage, 

“junctional” hemorrhage (axilla, groin, neck), extremity 

hemorrhage, airway, traumatic brain injury (TBI) and 

tension pneumothorax.6,7 Other areas of concern to 

combat medics include shock diagnosis, guidance of 

shock resuscitation, pain control, and remote triage. 

COMBAT MEDIC TECHNOLOGY BY POTENTIALLY

SURVIVABLE ANATOMIC INJURY

Truncal Penetrating “Noncompressible Hemorrhage” 

Injury 

In combat, hemorrhage is the cause in 83% to 87% of all 

such potentially survivable deaths. Of these deaths, 

approximately 50% are due to noncompressible 

hemorrhage from penetrating truncal injury.6,7 The 

combat medic, when treating penetrating truncal (chest, 

abdomen, and/or pelvis) trauma on the battlefield, first 

diagnoses hemorrhagic shock by doing a manual check of 

the character of the patient’s radial pulse and/or mental 

status (in the absence of TBI).5

 Upon diagnosis of shock, 

the combat medic then administers an intravascular 

volume expander, either the starch based colloid Hextend 

(Hospira, Inc, Lake Forest, Illinois), Lactated Ringers 

(LR), or normal saline (NS) via an intravenous or 

intraosseous (IO) catheter. Since intravascular fluid 

administration is the only treatment option currently 

available to treat penetrating truncal trauma, and since 

there are no level I data that demonstrate improved 

efficacy of Hextend over LR or NS in the exsanguinating 

trauma patient in the prehospital setting, we cannot state 

that the technology to resuscitate/treat noncompressible 

truncal hemorrhage has advanced since 1831.4

 Nor can 

we say that the technology available to the combat medic 

to diagnose hemorrhagic shock was not available in 1831. 

The addition of the IO infusion route is a clear 

1831 

COL Lorne H Blackbourne, MC, USA 
 April – June 2011 7

technologic advance in the patient without an antecubital 

vein for intravenous catheter insertion (rare) or, in certain 

tactical situations, due to white light restrictions. 

Junctional Hemorrhage 

(Compressible, Nontourniquetable) 

Current management of hemorrhage from areas that can 

be manually compressed but not amenable to tourniquet 

placement are described as compressible and nontourniquetable. These areas include the proximal femoral 

artery, distal iliac artery, axillary artery, and the carotid 

artery. Current management of these injuries includes 

manual compression with a hemostatic agent (currently 

Combat Gauze (Combat Medical Systems, Fayetteville, 

NC) is recommended by TCCC).8,9 Hemostatic agents 

represent a clear advance in technology over cloth 

bandage in 1831 as evidenced by animal data. 

Extremity Exsanguination 

During the “Victory of the Nile”* in 1798, a young 

French Midshipman recalled, 

...the conflagration soon began to rage with dreadful 

fury... the French Commander-in-Chief, having lost 

both his legs, was seated with tourniquets on the 

stumps, in an armchair facing his enemy...10 

And thus, our most important prehospital technology that 

has saved thousands of wounded Warriors in current 

overseas contingency operations is based on technology 

available over 200 years ago, an example of which is 

shown in the Figure.8,11,12

Tension Pneumothorax 

Tension pneumothorax is the cause of death in 

approximately 5% of combat wounded with potentially 

survivable injuries.7

 On the battlefield today, a combat 

medic diagnoses a tension pneumothorax from observing 

the patient and, if feasible, by auscultation with a 

stethoscope. Dyspnea, distended Jugular veins, 

hypotension, and decreased unilateral breath sounds are 

the major findings for the diagnosis. 

The stethoscope was invented in 1816 by René Laënnec 

in Paris, France.13 Since that time the stethoscope has 

improved but the basic technology has not. Physical 

exam and auscultation were available in 1831. 

The treatment of a tension pneumothorax on the 

battlefield involves needle decompression by placing a 

hollow needle through the second intercostals space in 

the midclavicular line.8

The first documentation of intravenous blood transfusion 

and intravenous pain medication administration is 

credited to Sir Christopher Wren in 1665 when he 

administered Opium via a sharpened quill to a dog.14

Since that time, multiple modifications have been made, 

including the invention of a hollow metal needle by 

Francis Rynd in 1844.15

The technology of observation, radial pulse 

determination, and auscultation to diagnose a tension 

pneumothorax were all available skills and technology 

available in 1831. And while the sterile decompression 

needles used today on the battlefield are an improvement 

over a sharpened hollow quill, the basic technology of 

decompressing a pleural cavity was available in 1831. 

Hemothorax 

Current guidelines for the management of hemothorax 

include diagnosis by physical exam and auscultation, and 

treatment with intravenous fluids and ventilator 

assistance with bag valve mask.5

 The bag valve mask is 

clearly a technological advance, although there is no 

prospective data that demonstrates its use results in a 

mortality benefit in patients with a hemothorax. 

Open Pneumothorax (“Sucking” Chest Wound) 

Current management guidelines for combat medics are to 

seal an open chest wound with an occlusive dressing and 

then observe for signs of a tension pneumothorax.8

 Upon 

diagnosing a tension pneumothorax, the dressing is to be 

removed to allow for decompression. In 1823, Charles 

Macintosh applied for a patent for a waterproof cloth 

made with a rubber layer.16 And thus, a chest seal 

material technology was available before 1831. 

*In August 1798, the English fleet, under Rear Admiral Horatio 

Nelson, destroyed the French Mediterranean fleet anchored in 

Aboukir Bay at Alexandria, Egypt.

Extremity tourniquet, circa 1760. 
8 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

PAIN CONTROL

Intravenous morphine is the most common analgesic 

administered on the battlefield.17 Narcotic analgesics 

based on opium were widely available before 1831. 

REMOTE TRIAGE

...I flamed the bug and tossed a grenade and the hole 

closed up, then turned to see what had happened to 

Dutch. He was down but he didn’t look hurt. A platoon 

Sergeant can monitor the physicals of every man in his 

platoon, sort out the dead from those who merely can’t 

make it unassisted and must be picked up. But you can 

do the same thing manually from switches right on the 

belt of a man’s suit. Dutch did not answer when I called 

him. His body temperature read ninety-nine degrees, his 

respiration, heartbeat, and brain waves read zero... 

Starship Troopers18

The ability to know when soldiers are injured would help 

identify and locate wounded and maximize the time 

challenged opportunity to intervene. In 1831, as on the 

battlefields of 2010, the call of “MEDIC” is the most 

common way to remotely triage the wounded from those 

who are not. 

PREHOSPITAL DOCUMENTATION

A review of the Joint Theater Trauma Registry reveals 

that less than 10% of entered patients had any prehospital 

data, and that less than 1% had actionable information 

documented.8

 Currently, prehospital documentation is 

obtained by manually completing a TCCC card. The 

technology to fill out a TCCC card is basically a pen and 

paper—both available in 1831. 

MONITORS FOR THE DIAGNOSIS OF SHOCK

The medic on the battlefield uses physical examination to 

diagnose hemorrhagic shock and to guide resuscitation. 

Physical examination was available in 1831. 

OVERVIEW OF OPPORTUNITIES FOR BATTLEFIELD CARE

TECHNOLOGIC ADVANCES

It is certain that manufacturing, training, and some areas 

of battlefield care have advanced since 1831, but, as 

shown in the Table, the majority of anatomic injury 

diagnostic and therapeutic technologies have not. 

OPPORTUNITIES FOR TECHNOLOGIC ADVANCES IN

BATTLEFIELD PREHOSPITAL CARE

Penetrating Truncal Trauma 

Intravenous fluids that allow for life-sustaining perfusion 

and oxygen delivery while ameliorating the acute 

coagulopathy of trauma could allow for extension of time 

until exsanguination and the severe effects of ischemia 

associated with the lethal triad and subsequent risk of 

death.4,19-21

1831 

Diagnosis 

Available Diagnostic 

Technology 

1831 

Available 

Diagnostic 

Technology 

2010

Available 

Treatment 

Technology 

1831 

Available 

Treatment 

Technology 

2010 

Major 

Technologic 

Advance? 

Penetrating truncal injury Physical exam Physical exam Crystalloid Crystalloid or colloid NO 

Intravenous access Sharpened quill Intraosseous catheter YES 

Extremity arterial hemorrhage Physical exam Physical exam Tourniquet Tourniquet NO 

Junctional compressible, 

nontourniquetable hemorrhage Physical exam Physical exam Cloth packing Combat Gauze YES 

Tension pneumothorax Physical exam, 

auscultation 

Physical exam, 

auscultation 

Decompression with 

sharpened quill 

Decompression with 

hollow needle NO 

Open chest wound Physical exam Physical exam Waterproof cloth Plastic sealant NO 

Hemothorax Physical exam, 

auscultation 

Physical exam, 

auscultation Intravenous fluid Intravenous fluid, bag valve mask ventilation NO 

Traumatic Brain injury Physical exam Physical exam None None NO 

Hypothermia prevention Physical exam, 

thermometer 

Physical exam, 

thermometer Wool blanket Active warming systems YES 

Prehospital documentation Pen and paper Pen and paper NO 

Pain control Physical exam Physical exam Opium Morphine NO 

Remote Triage Voice Voice NO 

Monitors for Shock and 

resuscitation Physical exam Physical exam NO 

Comparison of available diagnostic and treatment technologies for the battlefield available in 1831 compared to 2010. 
 April – June 2011 9

THE ARMY MEDICAL DEPARTMENT JOURNAL

Junctional (Compressible, Nontourniquetable) 

Hemorrhage 

While current hemostatic agents represent a clear 

technological advance since 1831, the US military is only 

on the second generation of hemostatics. From a 

historical perspective, the future will most likely provide 

great improvement in these agents. A mechanical 

compression device for these junctional areas may also 

provide greater hemostatic capability in the near future. 

Monitors for Diagnosing Hemorrhagic Shock 

The medic on the battlefield uses physical examination, 

whereas the medic on an evacuation platform uses 

standard vital signs, both which, due to compensatory 

mechanisms, diagnose shock after significant blood loss 

(class III shock after loss of approximately one-third of 

total blood volume). With advances in resuscitation 

strategies, the ability to diagnose hemorrhagic shock 

before it is obvious and to guide that resuscitation over 

time will maximize the ability of combat medics to 

diagnose and treat combat wounded. 

Remote Damage Control Resuscitation 

As technologies for diagnosis and treatment for combat 

wounded become available, the remote presence of a 

physician, physician assistant, or any available 

professional with trauma expertise may offer an option 

for the medic. This capability option may offer the 

maximal application of the new technologies. 

Tension Pneumothorax, Hemothorax, and Open 

Thoracic Wounds 

The diagnosis of tension pneumothorax/hemothorax and 

laterality can be a major challenge to even the most 

seasoned traumatologist, especially in the face of 

concomitant blood loss. The diagnosis and treatment of 

tension pneumothorax on the battlefield today uses 

human skills and technology available in 1831. To 

improve the diagnostic accuracy and to monitor for 

recurrence, the advent of a pneumothorax/hemothorax 

detection system that is very small and of light weight 

would be a significant advance. Chest seals for open 

chest wounds with one-way valves would help decrease 

the chances of a recurrent pneumothorax and decrease the 

chances of having the medic decide whether or not to 

remove the dressing in the challenging patient with a 

sealed open chest wound. Safe methods for hemothorax/

pneumothorax release with apposition of the visceral and 

parietal pleura would seal off many sources of 

intrathoracic hemorrhage and air leak. 

Battlefield Pain Control 

Nonnarcotic pain control that allows for pain relief but 

that maintain the sensorium and judgment would turn the 

injured combatant on the battlefield from a liability to a 

potential force protection adjunct. 

Hypothermia Prevention 

Current hypothermia active warming blankets are clearly 

better than wool blankets.22 Future blankets will have 

improved ability to prevent heat loss and will 

progressively decrease in weight and volume. 

Prehospital Documentation 

Prehospital documentation of patient vital signs and 

therapeutic interventions with duration will maximize the 

admitting physician’s ability to treat combat wounded. In 

civilian trauma, the documentation of accurate 

prehospital vital signs is associated with an improved 

outcome.23 Recording prehospital vital sign trends is the 

first technologic goal. 

For process improvement, a postevent, Web-based 

thorough reporting of all actions and life saving 

interventions used by the combat medic will provide the 

data needed to assist in training and overall assessment of 

prehospital medic performance. The 75th Ranger 

Regiment has such a Web-based program, the Prehospital 

Trauma Registry. 

COMBAT REALITY OF TECHNOLOGIC ADVANCES

Our efforts to advance the technology available for 

combat medics must be made in concert with the enduser, the combat medic. “Buy-in” from medics is 

essential to the successful placement of all new devices 

and techniques. The size and volume of all advances 

must be within the capabilities of the medic and en route 

personnel to actually carry the equipment. Combat 

medics must be brought into the process of development 

of new battlefield technologies for them as early as 

possible. 

CONCLUSION

The prehospital arena represents the geographic area with 

the greatest potential to improve care with advances in 

technology for wounded Warriors as they make the long 

journey from point of injury to rehabilitation in the 

continental United States. 
10 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

REFERENCES

1. Awads AS, Lobo D. The history of 0.9% saline. Clin 

Nutr. 2008;27:179-188. 

2. Latta T. Malignant cholera. Documents 

communicated by the central board of health, 

London, relative to the treatment of cholera by the 

copious injection of aqueous and saline fluids into the 

veins. Lancet. 1832;18:274-277. 

3. Lewins R. Injection of saline solutions in 

extraordinary quantities into the veins of malignant 

cholera. Lancet. 1832;18:243-244. 

4. Blackbourne LH, Czarnik J, Mabry R, Eastridge BJ, 

Baer D, Butler F, Pruitt B. Decreasing killed in action 

and died of wounds rates in combat wounded. J 

Trauma. 2010;69(suppl 1):S1-S4. 

5. Butler FK, Giebner SD, McSwain NE, eds: 

Prehospital Trauma Life Support Manual-Military 

Edition: Tactical Field Care. 7th ed. Akron, Ohio: 

Mosby. In press. 

6. Kelly J, Ritenour A, McLaughlin D, et al. Injury 

severity and cause of death from operation Iraqi 

Freedom and Operation Enduring Freedom: 2003-

2004 versus 2006. J Trauma. 2008;64(suppl 1):S21-

S27. 

7. Holcomb J, McMullin N, Pearse L, et al. Causes of 

death in U.S. special operations forces in the global 

war on terrorism 2001-2004. Ann Surg. 2007;245:986-

991. 

8. Butler F. Tactical combat casualty care: update 2009. 

J Trauma. 2010;69(suppl 1):S10-S13. 

9. Kheirabadi BS, Scherer MR, Estep JS, et al. 

Determination of efficacy of new hemostatic 

dressings in a model of extremity arterial hemorrhage 

in swine. J Trauma. 2009;67:450-460. 

10. Jones S, Gosling J. Nelson’s Way. London: Nicholas 

Brealey Publishing; 2005. 

11. Kragh JF, Walters TJ, Baer DG, et al. Survival with 

emergency tourniquet use to stop bleeding in major 

limb trauma. Ann Surg. 2009;249:1–7. 

12. Tien HC, Jung V, Rizoli SB, Acharya SV, MacDonald 

JC. An evaluation of tactical combat casualty care 

interventions in a combat environment. J Spec Oper 

Med. 2009;9(1):65-68. 

13. Lyons AS, Petrucelli RJ. Medicine: An Illustrated 

History. New York: Abradale Press; 1987. 

14. Pearce D. Sir Christopher Wren. BLTC Research Web 

site. Available at: http://www.generalanaesthesia.com/images/christopher-wren.html. 

Accessed October 29,2010. 

15. Rosenhek J. Needle trade: believe it or not, the simple 

syringe was centuries in the making. Doctor’s Review

[serial online]. March 2009. Available at: http://

www.doctorsreview.com/history/needle-trade/. 

Accessed October 29, 2010. 

16. Charles Macintosh, chemist and inventor. Today in 

Science History [serial online]. Available at: http://

www.todayinsci.com/M/Macintosh_Charles/Mac 

intoshCharlesBio.htm. Accessed October 29, 2010. 

17. Holbrook TL, Galarneau MR, Dye JL, Quinn K, 

Dougherty AL. Morphine use after combat injury in 

Iraq and posttraumatic stress disorder. N Engl J Med. 

2010;362(2):110-117. 

18. Heinlein RA. Starship Troopers. New York: Ace 

Books; 1959. 

19. Alam HB, Bice LM, Butt MU, et al. Testing of blood 

products in a polytrauma model: results of a multiinstitutional randomized preclinical trial. J Trauma.

2009 Oct;67(4):856-864. 

20. Brohi K, Cohen MJ, Ganter MT, Matthay MA, 

Mackersie RC, Pittet JF. Acute Traumatic 

Coagulopathy: Initiated by Hypoperfusion Modulated 

Through the Protein C Pathway? Ann Surg. 2007 

May;245(5):812-818. 

21. Krishna G, Sleigh JW, Rahman H. Physiological 

predictors of death in exsanguinating trauma patients 

undergoing conventional trauma surgery. Aust N Z J 

Surg. 1998;68(12):826-829. 

22. Allen PB, Salyer ST, Dubick MA, Holcomb JB, 

Blackbourne LH. Preventing hypothermia: 

comparison of current devices used by the US Army 

in an in vitro warmed fluid model. J Trauma. 2010:69

(suppl 1):S154-S161. 

23. Laudermilch DJ, Schiff MA, Nathens AB, Rosengart 

MR. Lack of emergency medical service 

documentation is associated with poor patient 

outcomes: a validation of audit filters for prehospital 

trauma care. J Am Coll Surg. 2010;210:220–227. 

AUTHOR

COL Blackbourne is Commander, US Army Institute of 

Surgical Research, Fort Sam Houston, Texas. 

1831 
 April – June 2011 11

You can’t improve what you can’t measure, 

and you can't measure without data. 

Caring for wounded warriors on the battlefield is an 

endeavor that resonates with every person who wears 

the military uniform of their country. The care 

provided by medical personnel in combat is often 

accomplished under the most difficult conditions 

imaginable and exemplifies the utmost in selflessness 

and courage. The challenges faced by medics, corpsmen, and pararescuemen in caring for their wounded 

teammates on the battlefield are legendary, and include 

an ongoing engagement with hostile forces, darkness, 

equipment limitations, and environmental extremes.1

Process improvement in battlefield trauma care must 

focus on preventable causes of death. As with civilian 

trauma, death after injury occurs in a trimodal 

distribution with immediate, early, and late 

components. Immediate deaths are those who suffer 

overwhelming and catastrophic injury, particularly 

those in close proximity to explosive forces. Early 

mortality is characterized by mortality in minutes to 

hours and is largely the result of hemorrhage, anatomic 

and/or physiology respiratory compromise, or 

traumatic brain injury. The late spike in mortality is 

related to the sequelae of organ dysfunction. Many 

potentially lethal injuries, particularly those in the 

second phase, may be averted and late mortality 

mitigated by appropriate prehospital management of 

the injured patient.2-4 Within the context of military 

conflict, the overwhelming majority of battlefield 

casualty deaths occur before reaching a medical 

treatment facility, therefore, prehospital care is of 

paramount importance. Unfortunately, we have very 

sparse documentation of the actual care that occurs in 

the tactical setting. Of combat casualties, a recent 

analysis has extrapolated that 17% of battlefield 

fatalities could potentially survive under optimal 

circumstances.3

 Of those potentially survivable 

injuries, 79% of the mortality is secondary to 

hemorrhage, 12% to airway compromise, and 4% due 

to central nervous system injury.3,4 Mitigation 

strategies fielded to medics and corpsman are based 

upon the concepts of Tactical Combat Casualty Care 

(TCCC) and vary in some respects from those 

advocated by the civilian prehospital trauma life 

support. TCCC is focused on causes of preventable 

death on the battlefield and has a greater emphasis on 

tourniquets (combat application tourniquets), 

hemostatic dressings (Combat Gauze, Combat Medical 

Systems, Fayetteville, NC), needle decompression of 

tension pneumothoraces, and surgical airways. 

Although reports documenting the successes and 

failures of these and other TCCC interventions are 

available, the data are limited to small case series and 

individual reports.5-9

In contrast, tremendous advances in the management 

of the Wounded Warrior after he or she reaches a 

medical treatment facility have been driven by 

evidence. Derived from the necessity to improve the 

outcomes of Soldiers injured on the battlefield, US 

military forces developed and implemented the Joint 

Theater Trauma System and Joint Theater Trauma 

Registry (JTTR) using US civilian trauma system 

models. Using the civilian schema based upon the 

guidelines set forth by the American College of 

Surgeons,10 the trauma system implementation 

predicated the emplacement and evaluation of critical 

system component elements, including prehospital and 

acute care facilities, as well as infrastructure elements 

including trauma leadership, professional resources, 

performance improvement, research support, 

education, and advocacy.11 The complexity of system 

care in the battlefield environment is compounded by 

the inherently discontinuous environment, and the 

necessity to maintain the continuum of patient care 

over several thousand miles involving 3 to 5 discrete 

levels of medical care. The constant in the underWe Don't Know What We Don’t Know: 

 Prehospital Data in Combat Casualty Care 

COL Brian J. Eastridge, MC, USA 

LTC Robert Mabry, MC, USA 

COL Lorne H. Blackbourne, MC, USA 

CAPT (Ret) Frank K. Butler, MC, USN 
12 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

pinnings of success for the military trauma system has 

been evidence-based. 

During the period between October 2001 and July 

2010, 22,800 individual US military casualties were 

entered in the JTTR. Due to the inherent nature of 

active conflict, 87% of these casualties were classified 

as battle injury. The majority (66.4%) of battlefield 

casualties sustained a penetrating injury, 24.1% of all 

patients had an injury severity score of 16 or more, 

21.8% had clinical evidence of shock with a base 

deficit of 5 or more, 24% of patients required blood, 

and 4.2% required massive transfusion (more than 10 

units of red blood cells per 24 hours). Using these and 

similar data, tremendous ad-vances have been made in 

the acute care management of the combat casualty, 

including advances in resusci-tation of hemorrhage, 

burn resuscitation, and hypother-mia prevention and 

management.11-15

Collection of data regarding prehospital trauma care is 

inherently problematic. Even in the relatively mature 

civilian emergency medical service systems, there is a 

poor understanding of the effectiveness and utility of 

medical and procedural interventions in the prehospital 

management of trauma. Many therapies once dogmatically applied, such as military antishock trousers, large 

volume intravenous fluid resuscitation, and prehospital 

intubation of the traumatic brain injured patient, have 

fallen by the wayside after thorough investigation revealed that the practices were either not effective or deleterious to patient outcomes.16-18 These examples substantiate that most significant alterations in EMS management have come after thorough analysis of the data. 

The tactical environment presents yet another tier of 

challenges in the evaluation of prehospital advances in 

treatment paradigms and technology with evidence. 

Even the basic anatomic and physiologic metrics are 

uniquely difficult to obtain from the battlefield, due to 

the inherent dangers and complexities of the combat 

environment. To date, the limited, direct knowledge 

with respect to the outcomes from TCCC has only 

been obtained from the reports cited previously and 

other limited case series, as well as lessons learned 

vignettes by first responders describing their 

experiences with tactical trauma care.19 Though there 

is an evolving body of evidence that TCCC is 

responsible for saving lives on the battlefield, the vast 

majority of the published peer review literature that 

support the efficacy of the concept of TCCC is rooted 

in the post hoc analysis of prehospital therapies 

identified at the level of a surgical treatment facility.20

Tactical Combat Casualty Care is the latest evolution 

of the process of care within the hostile battlefield 

environment. The battlefield trauma care continuum is 

manifested by multiple coexistent levels of triage, 

treatment, and evacuation dissimilar to the civilian 

trauma setting. The current military combat casualty 

care paradigm consists of 5 discreet levels of injury 

care beginning at point of injury and finishing with 

casualty evacuation to the United States. The basic 

tenets of these tiered levels of battlefield injury care 

are aggressive stabilization, resuscitation, staged 

treatment, and evacuation of the wounded to 

progressively higher levels of care to improve injury 

outcomes while being sensitive to the realities of the 

resource-constrained environment of operations. 

Prehospital casualty care is initially manifest with self 

aid and may progress through a sequence of buddy aid 

to combat life saver (nonmedical). The first medically 

trained support within the chain for the injured 

combatant is the combat medic, corpsman, or more 

highly trained special operations medic. The goal of 

medical management at this echelon is to 

expeditiously stabilize the casualty for evacuation to 

the next appropriate level of care. Some of the unique 

facets of care in the combat environment include care 

under hostile fire, austere environments, potential for 

prolonged time period between injury time and 

evacuation time, limited senior medical guidance, and 

limited resources. 

However, the prehospital period is the critical missing 

link in the care of the US military combat casualty. A 

recent analysis of 3 years of trauma data from the 

JTTR, shown in the Figure, was significant in that the 

vast majority of battlefield casualties (87%) had no 

documentation at all of prehospital wounding 

mechanism, injury location, vital signs, or 

interventions. Of a sample of 4,382 casualties in the 

registry from August 2007 through March 2010, only 

8% had complete vital signs, and only 6% had any 

documentation of therapeutic intervention or attempt 

from point of injury. The net effect is that the medical 

and research and development communities will 

continue to develop new technologies to support the 

combat casualty care needs of the Warfighter based 

upon suboptimal evidence. 

We Don't Know What We Don’t Know: Prehospital Data in Combat Casualty Care 
 April – June 2011 13

THE ARMY MEDICAL DEPARTMENT JOURNAL

The acquisition of prehospital data is paramount to the 

lifesaving ability of the frontline medic, and ultimately 

to the survival of the combat casualty. The lack of 

documentation of rudimentary physiologic measures 

(ie, heart rate, systolic blood pressure, respiratory rate) 

in the field is associated with a more than 2-fold 

increased risk of mortality which was sustained even 

after adjustment for severity of injury.21 Some of this 

increased mortality risk probably results from the 

inability to study such data and implement 

performance improvement measures. Emphasis placed 

upon enhancing the quality and quantity of prehospital 

documentation within the civilian EMS community 

has proven to be efficacious and sustainable.22

There have not been, nor will there be, prospective 

randomized trials conducted in the battlefield 

environment, and yet there must be some basis for 

process improvement in prehospital combat casualty 

care. The Department of Defense Committee on 

Tactical Combat Casualty Care makes recommended 

changes to the TCCC Guidelines based on: 

 an ongoing review of the published civilian and 

military prehospital trauma literature, 

 ongoing interaction with military combat casualty 

care research laboratories, 

 direct input from experienced combat corpsmen, 

medics, and pararescuemen, 

 case reports discussed on the weekly Joint Theater 

Trauma System performance improvement trauma 

teleconferences, 

 regular interaction with the service military 

medical lessons learned centers, and 

 expert opinion from both military and civilian 

trauma leaders.1

Improved documentation of combat injuries sustained, 

treatments rendered on the battlefield and during 

evacuation, and results of interventions performed 

would be an invaluable addition to this process. 

There are effective systems available at present to 

markedly improve our ability to document the prehospital care provided to our Wounded Warriors. The 

TCCC Casualty Card and the Prehospital Trauma 

Registry, both pioneered by the 75th Ranger 

Regiment, offer the immediate availability of a 

systems improvement in this area. These options have 

been recently endorsed to the services by the Defense 

Health Board in their memorandum of August 6, 

2009.23 The TCCC Casualty Card has been recently 

designated as a standard Army form (DA7656). 

Most preventable deaths occur in the prehospital 

phase. This interval is where the next great leap 

forward in combat casualty care could be. Recommendations for the immediate way ahead: 

Line commanders take ownership of ensuring that 

their troops complete the TCCC Casualty Cards. 

Deployed medical commanders ensure that the 

data is transcribed from the cards and the registries 

into the electronic medical records and the JTTR. 

Medical research leaders provide resources for the 

data to be rapidly collated and systematically 

analyzed, and make recommendations for process 

improvement. 

Both military medical leaders and line 

commanders respond in a timely manner to 

implement improvements suggested by this newly 

available data. 

REFERENCES

1. Butler FK, Giebner SD, McSwain N, Pons P, eds. 

Prehospital Trauma Life Support Manual: Military 

Version. 7th ed. St Louis: Mosby; preface. In press. 

2. Trunkey, D. Trimodal distribution of death. Sci Am. 

1983;249(2):20-27. 

87%

8% 6%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

No prehospital

documentation

Any vital sign

documentation

Documentation of

interventions

Prehospital documentation of combat traumatic injuries from 

August 2007 through March 2010 (n=4,382). 

Source: US military Joint Theater Trauma Registry. 
14 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

3. Kelly JF, Ritenour AE, McLaughlin DF, et al. Injury 

severity and causes of death from Operation Iraqi Freedom and Operation Enduring Freedom: 2003–2004 

versus 2006. J Trauma. 2008;64(suppl 2):S21–S27. 

4. Holcomb JB, McMullin NR, Pearse L, et al. Causes 

of death in US Special Operations Forces in the 

Global War on Terrorism, 2001–2004. Ann Surg. 

2007;245(6):986–991. 

5. Kragh JF Jr, Walters TJ, Baer DG, Fox CJ, Wade CE, 

Salinas J. Holcomb JB. Survival with emergency 

tourniquet use to stop bleeding in major limb trauma.

Ann Surg. 2009;249(1):1-7. 

6. Kragh JF Jr, Walters TJ, Baer DG, Fox CJ, Wade CE, 

Salinas J, Holcomb JB. Practical use of emergency 

tourniquets to stop bleeding in major limb trauma. J 

Trauma. 2008;64(suppl 2):S38-S50. 

7. Tarpey M. Tactical combat casualty care in Operation 

Iraqi Freedom. Army Med Dept J. April-June 2005:38-

41. 

8. Tien HC, Jung V, Rizoli SB, Acharya SV, 

MacDonald JC. An evaluation of tactical combat 

casualty care interventions in a combat environment. 

J Am Coll Surg. 2008;207:174-178. 

9. Beekley AC, Sebesta JA, Blackbourne LH, et al. 

Prehospital tourniquet use in Operation Iraqi 

Freedom: effect on hemorrhage control and 

outcomes. J Trauma. 2008;64(suppl 2):S28-S37. 

10. American College of Surgeons Committee on 

Trauma. Resources for the Optimal Care of the 

Injured Patient. Chicago, IL: American College of 

Surgeons; 1999:135. 

11. Eastridge BJ, Jenkins D, Flaherty S, Schiller H, 

Holcomb JB. Trauma system development in a 

theater of war: Experiences from Operation Iraqi 

Freedom and Operation Enduring Freedom. J 

Trauma. 2006;61(6):1366-1373. 

12. McLaughlin DF, Niles SE, Salinas J, Perkins JG, Cox 

ED, Wade CE, Holcomb JB. A predictive model for 

massive transfusion in combat casualty patients. J 

Trauma. 2008;64(suppl 2):S57-S63. 

13. Borgman MA, Spinella PC, Perkins JG, et al. The 

ratio of blood products transfused affects mortality in 

patients receiving massive transfusions at a combat 

support hospital. J Trauma. 2007;63(4):805-813. 

14. Holcomb JB, Jenkins D, Rhee P, et al. Damage control resuscitation: directly addressing the early coagulopathy of trauma. J Trauma. 2007;62(2):307-310. 

15. Ennis JL, Chung KK, Renz EM, et al. Joint theater trauma system implementation of burn resuscitation guidelines improves outcomes in severely burned military 

casualties. J Trauma. 2008;64(suppl 2):S146-S152. 

16. Bickell WH, Pepe PE, Wyatt CH, Dedo WR, 

Applebaum DJ, Black CT, Mattox KL. Effect of 

antishock trousers on the trauma score: a prospective 

analysis in the urban setting. Ann Emerg Med. 

1985;14(3):218-222. 

17. Bickell WH, Wall MJ Jr, Pepe PE, Martin RR, 

Ginger VF, Allen MK, Mattox KL. Immediate versus 

delayed fluid resuscitation for hypotensive patients 

with penetrating torso injuries. N Engl J Med. 

1994;331(17):1105-1109. 

18. Davis DP, Peay J, Sise MJ, et al. Prehospital airway 

and ventilation management: a trauma score and 

injury severity score-based analysis. J Trauma. 

2010;69(2):294-301. 

19. Butler FK. Tactical combat casualty care: update 

2009. J Trauma. 2010;69(1):S10-S13. 

20. Beekley AC, Starnes BW, Sebesta JA. Lessons 

learned from modern military surgery. Surg Clin N 

Am. 2007;87:157-184. 

21. Laudermilch D, Schiff M, Nathens A. Lack of 

emergency medical services documentation is 

associated with poor patient outcomes: a validation of 

audit filters for prehospital trauma care. J Am Coll 

Surg. 2010;210(2):220-227. 

22. Joyce SM, Dutkowski KL, Hynes T. Efficacy of an 

EMS quality improvement program in improving 

documentation and performance. Prehosp Emerg 

Care. 1997;1(3):140-144. 

23. Defense Health Board. Memorandum: Tactical 

Combat Casualty Care and Minimizing Preventable 

Fatalities in Combat. Washington, DC: US Dept of 

Defense; August 6, 2009. Available at: http://

www.health.mil/dhb/recommendations/2009/2009-

05.pdf. Accessed November 9, 2010. 

AUTHORS

COL Eastbridge is Director Emeritus, Trauma and 

Surgical Critical Care, US Army Institute of Surgical 

Research, Fort Sam Houston, Texas. He is also the 

Trauma Consultant to The Army Surgeon General. 

LTC Mabry is Director, Prehospital Division, Joint 

Theater Trauma Registry, US Army Institute of Surgical 

Research, Fort Sam Houston, Texas. 

COL Blackbourne is Commander, US Army Institute of 

Surgical Research, Fort Sam Houston, Texas. 

CAPT (Ret) Butler is the Director, Tactical Combat 

Casualty Care Program. 

We Don't Know What We Don’t Know: Prehospital Data in Combat Casualty Care 
 April – June 2011 15

Historically, many combat-related deaths occur in the 

prehospital environment before the casualty reaches a 

medical treatment facility.1

 In 1996, Butler and 

colleagues outlined a novel approach to prehospital 

trauma management that would optimize casualty care 

in unique environments and circumstances encountered during combat operations.2

The 75th Ranger Regiment adopted and integrated the 

principles of Tactical Combat Casualty Care (TCCC) 

in 1999. Because all personnel on the battlefield have 

the potential to provide casualty care as first responders, and also have the potential to be a casualty, the 

75th Ranger Regiment provided TCCC training to all 

personnel assigned to the unit. The Ranger First 

Responder Course and the Casualty Response Training 

for Ranger Leaders Course were 2 TCCC-based 

programs of instruction developed and implemented at 

that time to ensure a mastery of the basics of TCCC by 

all Rangers.3

 Additionally, the Regiment integrated the 

principles of TCCC in the same manner as a battle drill 

during the conduct of training exercises and rehearsals 

for combat raids and airfield seizures. 

Documentation of prehospital care provides a 

historical record of the event on behalf of the patient 

and communicates patient status, injuries, and 

treatments as patients flow from provider to provider 

on the battlefield. Documentation of injuries and 

prehospital treatment is also required to validate and 

refine TCCC protocols and procedures. Although the 

DD Form 1380 (Field Medical Card) was the standard 

for military prehospital care documentation at that 

time, it did not adequately capture the necessary data 

fields imposed by TCCC. Thus, also in 1999, the 75th 

Ranger Regiment developed a casualty card to capture 

and document TCCC in the prehospital environment. 

This card quickly propagated throughout the US 

Special Operations Command and was used by 

multiple units in both Afghanistan and Iraq. Most 

recently (2009), this card, shown in the Figure, was 

adopted by the US Army as DA Form 7656, Tactical 

Combat Casualty Care Card. 

Once again, as all personnel on the battlefield have the 

potential to be first responders, TCCC equipment and 

supplies must be considered to be “Soldier-centric” 

and should be commensurate with ability, skills, and 

training. Thus, in 2000, basic TCCC bleeder control 

kits were provided to all Rangers and were carried in a 

A Prehospital Trauma Registry for 

 Tactical Combat Casualty Care 

LTC Russ S. Kotwal, MC, USA 

MSG Harold R. Montgomery, USA 

Kathy K. Mechler, MS, RN 

ABSTRACT

Many combat-related deaths occur in the prehospital environment before the casualty reaches a medical 

treatment facility. The tenets of Tactical Combat Casualty Care (TCCC) were published in 1996 and integrated 

throughout the 75th Ranger Regiment in 1999. In order to validate and refine TCCC protocols and procedures, a 

prehospital trauma registry was developed and maintained. The application of TCCC, in conjunction with 

validation and refinement of TCCC through feedback from a prehospital trauma registry, has translated to an 

increase in survivability on the battlefield. 

The Tactical Combat Casualty Care Card, DA Form 7656. 
16 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

standardized fashion and location to facilitate rapid 

self or buddy care, while medics carried additional 

medical equipment and supplies for more advanced 

care. It should be noted that the Ranger bleeder control 

kit subsequently became a model for the Army’s 

current individual first aid kit. 

As first responders were ultimately providing casualty 

care, and at times found themselves in combat 

formations that did not include a medic, responsibility 

for documentation of this care was shifted away from 

the medic only to all Soldiers, in contrast to the Field 

Medical Card traditionally carried solely by the medic. 

Thus, Ranger casualty cards became ubiquitous and 

were included in all bleeder control kits. As such, they 

were collocated with all potential first responders as 

well as all potential casualties. 

Prompted by the events of September 11, 2001, 

components of the 75th Ranger Regiment deployed to 

combat in Afghanistan the following month. 

Concurrently, the 75th Ranger Regiment initiated a 

casualty card collection program in order to capture 

and evaluate data on combat casualties and casualty 

treatments. The casualty card collection program 

expanded to Iraq in March 2003 as components of the 

75th Ranger Regiment also deployed in support of 

combat operations in that theater. 

Although initially a rudimentary database in its nature, 

the casualty card collection program evolved into a 

prehospital trauma registry (PHTR) in 2005 using the 

Ranger casualty card as the template for the registry. 

Post hoc PHTR casualty card entry removed battlefield 

chaos and ensured increased capture and granularity of 

injuries incurred and treatments provided. Command 

emphasis and support of the PHTR was instrumental to 

its success. Leaders viewed the casualty card collection program and PHTR as a means to answer questions in reference to personal protective equipment as 

well as tactics, techniques, and procedures. Lessons 

learned were rapidly dispersed internally throughout 

the organization and externally to other units. Integral 

to gaining and maintaining command support for the 

PHTR were the integration and front loading of instant 

data graphing products, command reports, and ad hoc 

query capabilities into the PHTR. Notable is that the 

PHTR significantly increased the success of the 

casualty card collection program. Also of note, 

utilizing the casualty card in isolation would not have 

adequately provided the purpose, justification, and 

feedback required to maintain strong command 

support for the program. 

The purpose of the PHTR was to collect combat pointof-injury data at near-real time and provide timely 

command-level data, statistics, trends, and analysis. 

Thus from 2008 to 2010, in consultation with the US 

Army Institute of Surgical Research and in collaboration with the Texas A&M Health Science Center Rural 

and Community Health Institute, the framework and 

power of the PHTR was further refined as medics and 

computer programmers worked side by side to develop 

a product that would benefit the command. The 

resulting PHTR is a web-based solution specifically 

developed in order to validate TCCC training and 

treatment protocols through an internal assessment and 

analysis of casualty wounding patterns and treatments 

rendered. This analysis would determine if appropriate 

interventions were conducted on casualties who 

needed them, if there was a lack of appropriate 

interventions on casualties who needed them, and if 

inappropriate interventions were conducted on 

casualties who did not need them. Ultimately, the 

analysis would also help to facilitate 5 major goals: 

1. Augment the commander’s decision-making 

process. 

2. Reduce morbidity and mortality through force 

protection modifications and directed 

procurement. 

3. Validate and refine the commander’s casualty 

response system. 

4. Evaluate current Tactical Combat Casualty 

Care treatment strategies. 

5. Guide needed modifications to unit medical and 

nonmedical personnel, training, and equipment 

requirements. 

Requirements for point-of-injury, tactical, and level 1 

care and documentation must reflect the fact that the 

current flow of casualty care is no longer based on 

strict adherence to historical echelons of care. 

Proposed technological solutions cannot detract from 

the combat mission, hinder combat casualty care, or 

put a task force at risk. Material solutions must remain 

simple, durable, redundant, and ubiquitous. Solutions 

must also be Soldier-centric and not medic-centric, as 

all Soldiers have the potential to be first responders. 

A Prehospital Trauma Registry for Tactical Combat Casualty Care 
 April – June 2011 17

THE ARMY MEDICAL DEPARTMENT JOURNAL

As TCCC implementation is the responsibility of 

tactical leaders, it is a “casualty response system” and 

not a “medical system.” Providing timely feedback to 

tactical leaders is a must in order to affect needed 

changes in tactical force protection and procurement 

requirements, TCCC treatment strategies, and 

resourcing of personnel-training equipment. 

The 75th Ranger Regiment has been continuously 

engaged in combat operations throughout the past 9 

years. As such, the Regiment has maintained a 

constant presence in Afghanistan since 2001 and Iraq 

since 2003. The Ranger casualty card and PHTR have 

been successfully used in both theaters throughout this 

time. As of April 1, 2010, the Regiment had sustained 

a total of 419 battle injuries, including 28 who were 

killed in action and 4 who died of wounds. None of 

these fallen Rangers passed away as a result of 

prehospital medically preventable causes. 

Tactical Combat Casualty Care must be measured, 

validated, and refined through a functional PHTR that 

provides evidence-based support for casualty care 

protocols, procedures, and training. Documentation of 

injuries and treatments in the prehospital environment 

has proven instrumental in the continuous refinement 

and improvement of TCCC treatment strategies at the 

unit level. Point-of-injury and prehospital wounding 

and treatment data captured by the PHTR can also be 

linked to patient outcomes maintained at the Joint 

Theater Trauma Registry for optimal analysis of the 

entire provided continuum of care. Innovation and 

advancement of casualty care on the battlefield is 

facilitated by a care delivery system with a data 

repository which is available for data mining by 

investigators and researchers. 

Ultimately, TCCC is not just a medical program; it is 

the framework of a casualty response system that relies 

on a mastery and immediate application of basic and 

vital lifesaving skills by all Soldiers. This is validated 

by a PHTR. The success of TCCC is directly related to 

command ownership of the program. The tactical 

commander owns and is responsible for the prehospital 

casualty response system, and all personnel in the 

command serve as the foundation for prehospital care 

on the battlefield. TCCC provides the critical protocols 

and procedures necessary for Soldiers to treat a 

casualty. Leaders ensure this training is conducted to 

standards and is rehearsed and integrated into training 

events throughout the training cycle. The PHTR 

continuously validates and refines TCCC. The end 

result is an increase in survivability on the battlefield 

and a successful completion of the mission. 

REFERENCES

1. Bellamy RF. The causes of death in conventional 

land warfare: implications for combat casualty care 

research. Mil Med. 1984;149:55-62. 

2. Butler FK, Hagmann J, Butler EG. Tactical combat 

casualty care in special operations. Mil Med. 

1996;161(suppl):3-16. 

3. Veliz CE, Montgomery HR, Kotwal RS. Ranger first 

responder and the evolution of tactical combat 

casualty care. Infantry. 2010;May-August:90-91. 

AUTHORS

LTC Kotwal is Deputy Command Surgeon, US Army 

Special Operations Command, Fort Bragg, North 

Carolina. 

MSG Montgomery is Regimental Senior Medic, 75th 

Ranger Regiment, Fort Benning, Georgia. 

Ms Mechler is Codirector and Operations Officer, Rural 

and Community Health Institute, Texas A&M Health 

Science Center, Bryan, Texas. 
18 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

INTRODUCTION

It is reported that acute hemorrhage consistently 

accounts for about 50% of battlefield deaths in 

conventional warfare, and for 30% of casualties who 

die from wounds.1

 In addition, lessons learned by the 

British, the Israelis and the Indians in their various 

conflicts and skirmishes confirmed that prompt 

resuscitation improves survival.2,3 Also, results of a 

consensus conference and studies of pulse status 

concluded that fluid resuscitation was necessary for 

any casualty with a change in mental status or who 

was unconscious, suggesting a systolic blood pressure 

less than 50 mm Hg.4,5

It is well recognized that limitations exist in providing 

sufficient fluid for resuscitation in far-forward combat 

environments. Weight and cube limitations restrict the 

availability of large volumes of crystalloid 

resuscitation fluids for far-forward use. In addition, the 

combat medic has limited training, and long evacuation times or delayed transport to forward surgical 

facilities can be expected. Future combat scenarios imply that delays of 24 hours before evacuation of casualties could be more common, particularly if evacuation 

is from urban environments, as was experienced in 

Somalia.6

 The implication is that several hours may 

pass before any surgical intervention is possible to 

treat the injured Soldier. As indicated by Bellamy,1

mortality increased from 20% to 32% when evacuation 

of casualties was delayed from immediately to 24 

hours. Yet, evidence from experimental animals 

suggests that interventions to reestablish homeostasis 

may need to be initiated within 30 minutes after injury 

to assure survival,7

 offering additional challenges to 

attempts to improve resuscitation on the battlefield and 

at higher echelons of care. 

Addressing the need for improved prehospital fluid 

resuscitation for treating traumatic hemorrhage was the 

topic of an ISR-sponsored symposium held in January 

2010. The current tactical combat casualty care guidelines were evaluated along with the goals that an ideal 

resuscitation fluid should expand and maintain circulating blood volume, and thus vital organ perfusion, 

while having a positive effect on hemostasis. The 

current state-of-the-art use of crystalloids, colloids, 

and oxygen carriers were discussed. The discussion led 

to the conclusion that current fluid resuscitation guidelines are not optimal and further research was needed 

for prehospital resuscitation. 

DAMAGE CONTROL RESUSCITATION

Autopsy data from about 1000 casualties in Operation 

Iraqi Freedom (OIF) and Operation Enduring Freedom 

(OEF) have identified hemorrhage as a cause of death 

in 85% of potentially survivable casualties, and 

bleeding could only have been controlled in 32% of 

these casualties by means presently available to the 

Current Concepts in Fluid Resuscitation for 

 Prehospital Care of Combat Casualties

Michael A. Dubick, PhD 

ABSTRACT

Historically, hemorrhage accounts for the primary cause of death on the battlefield in conventional warfare. In addition, 

hemorrhage was associated with 85% of potentially survivable deaths in the current conflicts, approximately two-thirds 

of which were from noncompressible injuries. Future combat casualty care strategies suggest the likelihood of long 

transport times or significant time delays in evacuation of casualties. In addition, there are logistical limitations to 

providing large volumes of resuscitation fluid far-forward, and current guidelines do not recommend infusing large 

volumes of fluid until bleeding is controlled. Since the medic has few options for treating noncompressible injuries 

short of infusing fluid to maintain a blood pressure, the concept of damage control resuscitation was developed to 

promote hemostatic resuscitation. Damage control resuscitation recommends limiting the amount of crystalloids or 

colloids infused and using plasma and other blood products in more optimal ratios for the treatment of severe 

hemorrhage to improve battlefield survival and to reduce or prevent early and late deleterious sequelae. Taken together, 

these efforts have important implications towards the development of optimal fluid resuscitation strategies for 

stabilization of the combat casualty. 
 April – June 2011 19

field medic, such as tourniquets and hemostatic 

dressings.8

 For the remaining 68% with noncompressible hemorrhage, the medic has few options at 

present, other than fluid to maintain blood pressure 

until the casualty can get to a surgeon. In addition, it is 

well recognized that trauma patients can develop coagulopathy. For years it has been reported that trauma 

patients can become hypothermic and acidotic which, 

along with the development of a coagulopathy, forms a 

triad known as the “bloody viscious cycle” with a high 

mortality rate.9

 Routine care has been to warm these 

patients and reverse their acidosis, which has been 

successful.10,11 However, little has been done to address their bleeding abnormalities until the patient 

went to the operating room. In addition, it has recently 

been recognized that traumatic injury can early induce 

a bleeding disorder that is independent of the development of hypothermia or a result of hemodilution, and 

is commonly seen in the most severely injured patients 

who require a massive transfusion.12-14 This 

observation initially seen in the civilian community 

was also recognized in a military population,15

representing about 38% of casualties requiring a 

transfusion. Data show that coagulopathy is related to 

severity of injury and markedly increases mortality 

rates at similar levels of injury severity. Improving 

survival at all echelons of care in these patients 

requires hemorrhage control and resuscitation to 

restore normal blood clotting capabilities and 

metabolic processes, while providing volume. Current 

guidelines provided by the Committee on Tactical 

Combat Casualty Care advocate the control of 

bleeding and limited fluid resuscitation with Hextend 

(Hospira, Inc, Lake Forest, IL), allowing the systolic 

blood pressure to rise to around 80 mm HG. Over the 

past 40 to 50 years, the treatments commonly used for 

resuscitation of hemorrhagic shock in both the civilian 

and military sector, including crystalloid solutions and 

packed red blood cells, actually dilute the remaining 

coagulation factors and platelets further which may 

increase the tendency for more bleeding. 

An evaluation of patients at Combat Support Hospitals 

from January 2004 to December 2006 revealed that 

90% suffered from penetrating trauma, with 

hemorrhage being the number one problem.15,16 Of 

these patients, 22% required a transfusion and over 8% 

required a massive transfusion, defined as 10 or more 

units of packed red blood cells (RBCs) in a 24-hour 

period. In comparison, at a major trauma center in the 

United States, 11% required a transfusion and only 

2.7% of those required a massive transfusion. 

Considering the much greater magnitude of injuries 

and the over 3 times higher need for massive 

transfusion encountered in OIF and OEF compared to 

civilian trauma,17 the requirement for more effective 

treatment is more of an urgent problem for the 

military. Since patients who require massive transfusion generally comprise the majority of in-hospital 

trauma deaths, there was a need for a revolutionary 

strategy to treat such severe injuries. 

To address the above problems, the concept of damage 

control resuscitation (DCR) was introduced as a 

resuscitation strategy primarily for the most seriously 

injured patient. It is a structured intervention that 

consists of 2 goals and was endorsed Army-wide in 

January 2007 for optimal resuscitation of severely 

injured Soldiers. The first goal is to limit fluid resuscitation to keep the patient’s systolic blood pressure at 

about 80 mm HG to minimize renewed bleeding from 

recently formed blood clots.18 The second goal is to 

restore the blood volume using plasma as the primary 

resuscitation fluid in a ratio close to 1:1 with RBCs to 

provide hemostatic resuscitation. Other blood products 

reserved for massive transfusion protocols, such as 

platelets, cryoprecipitate, and, possibly, recombinant 

activated Factor VII and fibrinogen which are available and could be used as needed. 

PERMISSIVE HYPOTENSION

Permissive hypotension, or fluid resuscitation to a 

blood pressure lower than normal, was recognized as a 

reasonable approach in the care of combat casualties in 

both World Wars I and II.19,20 Adaptation of permissive hypotension as a far-forward treatment strategy 

was renewed by US Special Operations Forces after a 

1998 conference.5

Today, fluid resuscitation practices to normalize the 

blood pressure rapidly after traumatic hemorrhage are 

no longer recommended, especially in patients with 

penetrating injuries.21,22 Rapid volume infusion even 

for blunt trauma patients is also being questioned.23 It 

has been argued that resuscitation to baseline or 

normal blood pressure can increase bleeding and 

worsen outcome because of severe hemodilution of remaining coagulation factors and hemoglobin, as well 

as disruption of newly forming blood clots. Thus, it is 

suggested that permissive hypotensive resuscitation 
20 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

can improve outcome, yet avoid these adverse 

hemostatic and metabolic effects.21,22,24,25 As an 

example, studies in both rodents and swine have 

shown that in the treatment of uncontrolled hemorrhage from a vascular injury, restoring mean arterial 

pressure to 40 mm HG or 60 mm HG, resulted in 

longer survival compared to animals resuscitated to the 

baseline mean arterial pressure of 80 mm HG, as well 

as animals that received no fluid.26,27 In addition, the 

provision of some fluid even before surgical repair of 

the injury is performed also appeared to be better than 

delaying all fluid until after surgery.26 Also, our own 

work observed that lactated Ringer’s (LR) infusion to 

a mean arterial pressure (MAP) of 70 mm HG improved hemorrhage-induced vascular hyporeactivity to 

norepinephrine better than LR resuscitation to baseline 

MAP during the 4-hour study period.28 Resuscitation 

to baseline MAP with LR resulted in severe hemodilution and deterioration of vascular responsiveness to 

norepinephrine. The medical literature contains several 

studies reporting on adverse immunologic effects of 

LR or normal saline,29,30 so efforts to reduce the 

volumes used seem prudent. However, the adequacy of 

hypotensive fluid resuscitation is not well delineated 

as some studies have suggested that hypotensive 

crystalloid resuscitation to a MAP of 60 mm HG to 70 

mm HG may be inadequate to prevent metabolic 

derangements associated with hemorrhagic shock.31,32

It should be noted that over the last decade of research 

into hypotensive resuscitation, the majority of studies 

have only monitored animals for a few hours, and LR 

or normal saline has been the primary fluid 

examined.33,34 Since not all animals in the hypotensive 

resuscitation groups survived in some of the studies, 

research into better resuscitation strategies and improved fluids seems warranted. 

BLOOD AND BLOOD COMPONENTS

As mentioned, the second major aspect of damage 

control resuscitation recommends a judicious use of 

blood products in more favorable ratios to improve 

outcome in the severely injured, particularly in patients 

requiring a massive transfusion. This aspect of DCR is 

focused on addressing the coagulopathy associated 

with traumatic injury through hemostatic resuscitation. 

Adverse effects of RBC transfusion are well 

described,35-39 so determining which patients need 

blood is another area of research at the US Army 

Institute of Surgical Research (USAISR). 

Damage control resuscitation practices in theater were 

implemented through a Joint Theater Trauma System 

Clinical Practice Guideline* (last updated February 

2009) for the use of blood products at level IIb/III. Of 

course, the use of blood by the US military is not a new 

idea and transfusion practices date back to World War I. 

Blood use in World War II,40 the Korean conflict,41 and 

in Vietnam42 have been described. This history has also 

been extensively reviewed by Hess and Thomas.43

Several retrospective reviews have analyzed military 

casualty data from combat support hospitals and have 

concluded that use of plasma, including plasma to 

RBC ratios that approached 1:1, improved the 

coagulopathy and reduced 30-day mortality compared 

to the use of more RBCs or ratios of plasma to RBCs 

greater than 1:4.44-46 Prospective studies in swine 

polytrauma models have also shown that plasma alone 

could improve coagulopathy.47 Other studies observed 

improved survival with greater use of platelets and the 

benefits of higher fibrinogen to RBC ratios.48,49 Also 

of interest is the successful use of warm, fresh, whole 

blood in theater where over 6000 units have been 

transferred over a 4 to 5 year period.16 Retrospective 

studies have seen improved 30-day survival with 

warm, fresh, whole blood compared to casualties who 

received component therapy, as well as acceptable 

benefit-to-risk ratios under situations where blood 

components are unavailable or not available in 

sufficient amounts for transfusion requirements.16,50,51 

Retrospective reviews of greater use of plasma and 

higher plasma to RBC ratios have also been assessed 

in civilian trauma patients. More aggressive use of 

plasma seems to be beneficial in improving coagulopathy.11,52 Further evaluation suggested that achieving 

near a 1:1:1 ratio of plasma, RBC, and platelets 

improved the coagulopathy and had a positive impact 

on survival.53-57 However, the optimal ratios remain 

controversial.58,59 Taken together, the data suggest that 

DCR practices improve outcomes in coagulopathic 

trauma patients by using more plasma and other blood 

components in ratios closer to whole blood, and by 

reducing the use of large volumes of crystalloids in the 

resuscitation. 

As the current use of blood products for treating 

severely injured trauma patients has occurred in 

Current Concepts in Fluid Resuscitation for Prehospital Care of Combat Casualties 

*Internal military document not normally accessible by the 

general public. 
 April – June 2011 21

THE ARMY MEDICAL DEPARTMENT JOURNAL

medical treatment facilities, interest has been 

generated regarding having plasma available in the 

prehospital or far-forward setting. It is well known that 

freeze-dried plasma was extensively used for resuscitation in forward areas during World War II, but was 

withdrawn due to high transmission rates of hepatitis.40

Efforts are currently underway to redevelop a freezedried plasma product for use in the United States. 

Recent studies in a swine polytrauma model showed 

that freeze-dried plasma was similar to fresh-frozen 

plasma in its coagulation factor levels and could 

improve the coagulopathy in this model.60,61 Currently, 

freeze-dried plasma is available through the German 

Red Cross and the French Military, and both products 

are available for use by coalition medical personnel in 

Operation Enduring Freedom (Afghanistan). 

CONCLUDING REMARKS

Prehospital resuscitation practices and the use of 

crystalloids for fluid resuscitation have not changed 

significantly in the past 40 to 50 years in either the 

military or civilian sector. Through research funded 

primarily by the US Army Combat Casualty Care 

Research Program, efforts in the past 20 years have 

been directed on improving far-forward resuscitation. 

Current investigations on fluid resuscitation strategies 

at USAISR are now focused under the concept of 

damage control resuscitation. Despite efforts to 

provide small volume resuscitation through 

development of hypertonic fluids such as hypertonic 

7.5% saline without or with Dextran-70 (hypertonic 

saline/dextran) over the past 20 years, these products 

have yet to achieve FDA approval, although a 5% 

saline solution is FDA approved for hyponatremia. 

Consequently, for the past decade the Tactical Combat 

Casualty Care committee recommended Hextend, a 

hetastarch based product in a balanced salt solution, as 

the fluid of choice for small volume resuscitation, with 

guidance to limit the total infusion to one liter based 

on the casualty’s mental status or pulse character.4

 No 

fluid is recommended if the casualty is not in shock. 

As noted, to date most fluid resuscitation studies 

evaluating this permissive hypotension have generally 

used crystalloids such as LR or normal (physiologic) 

saline. Our own studies in a swine hemorrhage model 

have indicated that similar hemodynamic and metaGeneral Resuscitation Hemostatic Agents 

Adequate Volume Dressing for external wounds 

Hypotensive resuscitation Tourniquets and junctional devices 

Temperature of fluid Intracavitary bleeding 

Choice of fluid 

Metabolic derangements Biomarker of Resuscitation 

Adjuncts (metabolic substrates, antioxidants, sex hormones, etc) Hypoxia signals and cellular susceptibility 

Immune Modulation Improvement by resuscitation? 

As related to standard therapy in patients 

Interactions with coagulation system (animals/trauma patients) Newer Blood Products (in collaboration with Blood Research Program) 

Complement components Freeze dried plasma 

Refrigerated/frozen/freeze-dried/spray-dried platelets 

Hemostatic Resuscitation Dried/freeze-dried red blood cells 

Blood products including coagulation factors Freeze-dried/recombinant fibrinogen 

Blood product ratios Hemoglobin-based oxygen carriers 

Age of blood products 

JTTR retrospective review (outcome data) 

Acquired Coagulopathy Use of blood products 

Acidosis Coagulopathy 

Hypothermic 

Anemia Clinical Studies 

Trauma Induced coagulopathy (joint program with Blood 

Research) Assessment of blood product use in trauma patients 

Resuscitation Outcomes Consortium (Joint effort of Department of 

Defense and National Institutes of Health) 

Endothelial cell function, interactions, effect of laminar flow 

Damage control resuscitation research areas at the US Army Institute of Surgical Research 
22 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

REFERENCES

1. Bellamy RF. The causes of death in conventional 

land warfare: implications for combat casualty care 

research. Mil Med. 1984;149:55-62. 

2. Dubick MA, Kramer GC. Hypertonic saline dextran 

(HSD) and intraosseous vascular access for the 

treatment of hemorrhagic hypotension in the farforward combat arena. Annals Acad Med Singapore.

1997;26:64-69. 

3. Mehrotra M, Mehrotra S. Provisions of trauma 

resuscitation and anesthesia service in an advance 

field military hospital in northern India. Trauma Care 

J. 2002;12:18-21. 

4. McManus J, Yershov AL, Ludwig D, et al. Radial 

pulse character relationships to systolic blood 

pressure and trauma outcomes. Prehosp Emerg Care.

2005;9:423-428. 

5. Butler FK, Hagmann JH, Richards DT. Tactical 

management of urban warfare casualities in special 

operations. Mil Med. 2000;165(suppl1):1-48. 

6. Mabry RL, Holcomb JB, Baker A, et al. US Army 

Rangers in Somalia: an analysis of combat casualties 

on an urban battlefield. J Trauma. 2000;49:515-529. 

7. Nelson AW, Swan H. Hemorrhage: responses 

determining survival. Circ Shock. 1974;1:273-285. 

8. Kelly JF, Ritenour AE, McLaughlin DF, et al. Injury 

severity and causes of death from Operation Iraqi 

Freedom and Operation Enduring Freedom: 2003-

2004 versus 2006. J Trauma. 2008;64(suppl2):S21-

S27. 

9. Moore EE. Staged laparotomy for the hypothermia, 

acidosis, and coagulopathy syndrome. Am J Surg.

1996;172(5):405-410. 

10. Armand R, Hess J. Treating coagulopathy in trauma 

patients. Transfus Med Rev. 2003;17(3):223-231. 

11. Gonzalez EA, Moore FA, Holcomb JB, et al. Fresh 

frozen plasma should be given earlier to patients requiring massive transfusion. J Trauma. 2007;62:112-

119. 

12. Brohi K, Singh J, Heron M, Coats T. Acute traumatic 

coagulopathy. J Trauma. 2003;54:1127-1130. 

13. Brohi K, Cohen MJ, Ganter MT, Matthay MA, 

Mackersie RC, Pittet JF. Acute traumatic 

coagulopathy: initiated by hypoperfusion: modulated 

through the protein C pathway? Ann Surg.

2007;245:812-818. 

Current Concepts in Fluid Resuscitation for Prehospital Care of Combat Casualties 

bolic responses can be achieved with about a third of 

the volume using colloids compared to crystalloids in 

swine resuscitated to 80 mm HG systolic pressure.62

However, the limits of this hypotensive resuscitation 

strategy, such as whether permissive hypotension 

would worsen the incidence of late complications that 

could arise from incomplete resuscitation, are unknown. Also, evidence does suggest that resuscitation 

to a systolic blood pressure of 80 mm HG would be 

inadequate to improve cerebral perfusion after head 

injury. Thus, a component of DCR research at 

USAISR investigates adjuncts that can be used in 

small volume resuscitation (<2 ml/kg). This work is in 

conjunction with the Defense Advanced Research 

Projects Agency Surviving Blood Loss Program. 

Preliminary studies in a swine severe hemorrhage 

model have show some benefit associated with small 

volume estrogen infusion.63 An overview of research 

projects at the USAISR under the damage control 

resuscitation program is presented in the Table. 

At present, the clinical practice guidelines for use of 

warm, fresh, whole blood or plasma and other blood 

components as part of a damage control resuscitation 

regimen are designed for level IIb/III echelons of care. 

As mentioned, the approach is to treat the most 

severely injured who present with a coagulopathy and 

have the greatest chance of dying. Typically, these are 

the patients who require a massive transfusion. 

However, efforts are underway to move this DCR 

strategy to more forward echelons of care, and current 

research efforts focus on the development of freezedried plasma and platelet-like substances, as well as 

other components derived from plasma such as 

fibrinogen concentrates and recombinant activated 

factor VII. The consensus of discussants at the 

USAISR-sponsored symposium on prehospital fluid 

resuscitation overwhelmingly favored the development 

of a dried plasma product that could expand and 

maintain blood volume while providing lost 

coagulation factors resulting from the traumatic injury. 

Thus, this further supports expanding DCR capabilities 

to the prehospital arena. Damage control resuscitation 

guidelines emerged from a recognized medical 

problem and are being addressed by preclinical and 

clinical studies to develop an evidence-based best 

practice for treating these severely injured Soldiers. It 

is hoped that early implementation of far-forward 

damage control resuscitation will result in fewer early 

deaths from hemorrhage and fewer medical 

complications, such as development of multiorgan 

failure and related sequelae, as well as overall 

reduction in blood product use. 
 April – June 2011 23

THE ARMY MEDICAL DEPARTMENT JOURNAL

14. McLeod JB, Lynn M, McKenney MG, Cohn SM, 

Murtha M. Early coagulopathy predicts mortality in 

trauma. J Trauma. 2003;55:39-44. 

15. Niles SE, McLaughlin DF, Perkins JG, et al. 

Increased mortality associated with the early 

coagulopathy of trauma in combat casualties. J 

Trauma. 2008;64:1459-1465. 

16. Spinella PC. Warm fresh whole blood transfusion for 

severe hemorrhage: US military and potential civilian 

applications. Crit Care Med. 2008;36(suppl7):S340-S345. 

17. Como JJ, Dutton RP, Scalea TM, Edelman BB, Hess 

JR. Blood transfusion rates in the care of acute 

trauma. Transfusion. 2004;44:809-813. 

18. Sondeen JL, Coppes VG, Holcomb JB. Blood 

pressure at which rebleeding occurs after 

resuscitation in swine with aortic injury. J Trauma.

2003;54(suppl5):S110-S117. 

19. Cannon WB, Fraser J, Cowell EM. The preventive 

treatment of wound shock. JAMA. 1918;70:618. 

20. Beecher HK. Preparation of battle casualties for 

surgery. Ann Surg. 1945;121:769-792. 

21. Bickell WH, Waal MJ, Pepe PE, et al. Immediate 

versus delayed fluid resuscitation for hypotensive 

patients with penetrating torso injuries. New Engl J 

Med. 1994;331:1105-1109. 

22. Shoemaker WC, Peitzman AB, Bellamy R, et al. 

Resuscitation from severe hemorrhage. Crit Care 

Med. 1996;24(suppl2):S12-S23. 

23. Hambly PR, Dutton RP. Excess mortality associated 

with the use of a rapid infusion system at a level 1 

trauma center. Resuscitation. 1996;31:127-133. 

24. Dries DJ. Hypotensive resuscitation. Shock.

1996;6:311-316. 

25. Owens TM, Watson WC, Prough DS, Uchida T, 

Kramer GC. Limiting initial resuscitation of 

uncontrolled hemorrhage reduces internal bleeding 

and subsequent volume requirements. J Trauma.

1995;39:200-207. 

26. Capone AC, Safar P, Stezoski W, Tisherman S, 

Peitzman AB. Improved outcome with fluid 

restriction in treatment of uncontrolled hemorrhagic 

shock. J Am Coll Surg. 1995;180:49-56. 

27. Stern SA, Wang X, Mertz M, et al. Underresuscitation of near-lethal uncontrolled hemorrhage: 

effects on mortality and end-organ function at 72 

hours. Shock. 2001;15:16-23. 

28. Liu LM, Ward JA, Dubick MA. Effect of crystalloid 

and colloid resuscitation on hemorrhage-induced 

vascular hyporesponsiveness to norepinephrine in the 

rat. J Trauma. 2003,54(suppl5):S159-S168. 

29. Rhee P, Wang D, Ruff P, et al. Human neutrophil 

activation and increased adhesion by various 

resuscitation fluids. Crit Care Med. 2000;28:74-78. 

30. Cotton BA, Guy JS, Morris JA Jr, Abumrad NN. The 

cellular, metabolic, and systemic consequences of 

aggressive fluid resuscitation strategies. Shock.

2006;26:115-121. 

31. Michell MW, Rafie AD, Shah A, et al. Hypotensive 

and normotensive resuscitation of hemorrhagic shock 

with Hextend or lactated Ringers (LR). Crit Care 

Med. 2003;12(suppl):A41. 

32. Wu X, Stezoski J, Safar P, Tisherman SA. During 

prolonged (6 h) uncontrolled hemorrhagic shock 

(UHS) with hypotensive fluid resuscitation, mean 

arterial pressure (MAP) must be maintained above 60-

70 mm HG in rats. Crit Care Med 2003;12

(suppl):A40. 

33. Stern SA, Dronen SC, Birrer P, Wang X. Effect of 

blood pressure on hemorrhage volume and survival in 

a near-fatal hemorrhage model incorporating a vascular injury. Ann Emerg Med. 1993;22:155-163. 

34. Kowalenko T, Stern S, Dronen S, Wang X. Improved 

outcome with hypotensive resuscitation of 

uncontrolled hemorrhagic shock in a swine model. J 

Trauma. 1992;33:349-362. 

35. Croce MA, Tolley EA, Claridge JA, Fabian TC. 

Transfusions result in pulmonary morbidity and death 

after a moderate degree of injury. J Trauma.

2005;59:19-23. 

36. Koch CG, Li L, Duncan AI, Mihaljevic T, et al. 

Morbidity and mortality risk associated with red 

blood cell and blood-component transfusion in 

isolated coronary artery bypass grafting. Crit Care 

Med. 2006;34:1608-1616. 

37. Netzer G, Shah CV, Iwashyna TJ, et al. Association 

of RBC transfusion with mortality in patients with 

acute lung injury. Chest. 2007;132:1116-1123. 

38. Silliman CC, Fung YL, Ball JB, Khan SY. 

Transfusion-related acute lung injury (TRALI): 

current concepts and misconceptions. Blood Rev.

2009;23:245-255. 

39. Sihler KC, Napolitano LM. Complications of massive 

transfusion. Chest. 2010;137:209-220. 

40. Kendrick DB. Blood program in World War II. In: 

Coates JB Jr, ed-in-chief. Medical Department 

United States Army in World War II. Washington, 

DC: Office of Medical History, US Army Medical 

Dept; 1964. Available at: http://history.amedd.army 

.mil/booksdocs/wwii/actvsurgconvoli/CH06.htm. 

Accessed February 3, 2011. 
24 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

Current Concepts in Fluid Resuscitation for Prehospital Care of Combat Casualties 

41. Artz CP, Howard JM, Sako Y, Bronwell AW, 

Prentice T. Clinical experiences in the early 

management of the most severely injured battle 

casualties. Ann Surg. 1955;141:285-296. 

42. Miller RD. Massive blood transfusions: the impact of 

Vietnam military data on modern civilian transfusion 

medicine. Anesthesiology. 2009;110:1412-1416. 

43. Hess JR, Thomas MJG. Blood use in war and 

disaster: lessons from the past century. Transfusion.

2003;43:1622-1633. 

44. Borgman MA, Spinella PC, Perkins JG, et al. The 

ratio of blood products transfused affects mortality in 

patients receiving massive transfusions at a combat 

support hospital. J Trauma. 2007;63:805-813. 

45. Spinella PC, Perkins JG, Grathwohl KW, et al. Effect 

of plasma and red blood cell transfusions on survival 

in patients with combat related traumatic injuries. J 

Truama. 2008;64(suppl2):S69-S78. 

46. Blansfield JS, Nekervis MA. A memorable Marine: 

the battle of coagulopathy. J Emer Nurs. 2007;33:545-

549. 

47. Alam HB, Bice LM, Butt MU, et al. Testing of blood 

products in a polytrauma model: results of a multiinstitutional randomized preclinical trial. J Trauma.

2009;67:856-864. 

48. Perkins JG, Cap AP, Spinella PC, et al. An evaluation 

of the impact of apheresis platelets used in the setting 

of massively transfused trauma patients. J Trauma.

2009;66(suppl4):S77-S85. 

49. Stinger HK, Spinella PC, Perkins JG, et al. The ratio 

of fibrinogen to red cells transfused affects survival 

in casualties receiving massive transfusions at an 

Army combat support hospital. J Trauma. 2008;64

(suppl2):S79-S85. 

50. Spinella PC, Perkins JG, Grathwohl KW, et al. Risks 

associated with fresh whole blood and red blood cell 

transfusions in a combat support hospital. Crit Care 

Med. 2007;35:2576-2581. 

51. Spinella PC, Perkins JG, Grathwohl KW, Beekley 

AC, Holcomb JB. Warm fresh whole blood is 

independently associated with improved survival for 

patients with combat-related traumatic injuries. J 

Trauma. 2009;66(suppl4):S69-S76. 

52. Moore FA, Nelson T, McKinley BA, et al. Is there a 

role for aggressive use of fresh frozen plasma in 

massive transfusion of civilian trauma patients?. Am J 

Surg. 2008;196:948-960. 

53. Ketchum L, Hess JR, Hiippala S. Indications for early 

fresh frozen plasma, cryoprecipitate, and platelet 

transfusion in trauma. J Trauma. 2006;(suppl6):S51-

S58. 

54. Holcomb JB, Wade CE, Michalek JE, et al. Increased 

plasma and platelet to red blood cell ratios improves 

outcome in 466 massively transfused civilian trauma 

patients. Ann Surg. 2008;248:447-458. 

55. Gunter OL Jr, Au BK, Isbell JM, Mowery NT, 

Young PP, Cotton BA. Optimizing outcomes in 

damage control resuscitation: identifying blood 

product ratios associated with improved survival. J 

Trauma. 2008;65:527-534. 

56. Maegele M, Lefering R, Paffrath T, et al. Changes in 

transfusion practice in multiple injury between 1993 

and 2006: a retrospective analysis on 5389 patients 

from the German Trauma Registry. Trans Med.

2009;19:117-124. 

57. Duchesne JC, Kimonis K, Marr AB, et al. Damage 

control resuscitation in combination with damage 

control laparotomy: a survival advantage. J Trauma.

2010;69:46-52. 

58. Kashuk JL, Moore EE, Johnson JL, et al. Postinjury 

life threatening coagulopathy: is 1:1 fresh frozen 

plasma:packed red blood cells the answer?. J 

Trauma. 2008;65:261-270. 

59. Scalea TM, Bochicchio KM, Lumpkins K, et al. 

Early aggressive use of fresh frozen plasma does not 

improve outcome in critically injured trauma patients. 

Annals of Surg. 2008;248:578-584. 

60. Shuja F, Shults C, Duggan M, et al. Development and 

testing of freeze-dried plasma for the treatment of 

trauma-associated coagulopathy. J Trauma. 

2008;65:975-985. 

61. Spoerke N, Zink K, Cho SD, et al. Lyophilized 

plasma for resuscitation in a swine model of severe 

injury. Arch Surg. 2009;144:829-834. 

62. Dubick MA, JL Sondeen, MD Prince, AG James, JJ 

Nelson, EL Hernandez. Hypotensive resuscitation 

with Hextend, Hespan or PolyHeme in a swine 

hemorrhage model. Shock. 2004;21(suppl2):42. 

63. Burns JW, LA Baer, EJ Hagerman, et al. 

Development and resuscitation of a sedated, mature 

male miniature swine severe hemorrhage model. J 

Trauma. In press. 

AUTHOR

Dr Dubick is Supervisory Research Pharmacologist and 

Task Area Manager, Damage Control Resuscitation 

Research Program, US Army Institute of Surgical 

Research, Fort Sam Houston, Texas. 
 April – June 2011 25

INTRODUCTION

In current military operations, as in the past, severe 

bleeding wounds that cannot be treated with standard 

hemostatic methods remain the number one cause of 

potentially preventable death among combat 

casualties.1-3 An early and effective method of 

controlling hemorrhage at the point of injury or after 

the casualty reaches the surgical facility can 

potentially save more lives than any other measure.4,5

Tissue trauma and hypovolemic shock caused by 

significant blood loss are additional risk factors that 

can lead to acute coagulopathy, making hemorrhage 

control and resuscitation therapy more difficult even 

after patients arrive at the hospitals.6,7 In addition to 

the need for immediate surgical intervention to control 

hemorrhage, more blood and blood products 

transfusion are required to reverse shock and restore 

normal coagulation in these patients. When the 

bleeding is eventually stopped after significant blood 

loss and resuscitation therapy, the patients are left 

more vulnerable to hypothermia, acidosis, and 

persistent coagulopathy, and are at higher risk of 

morbidity and late mortality due to sepsis and multiple 

organ failure that may occur afterwards.8,9

Battlefield mortality (killed in action) resulting from 

traumatic wounds has significantly diminished in the 

ongoing military operations as compared to previous 

conflicts.10,11 This decrease is likely due to several 

factors, including routine wear of body armor, prompt 

and efficient use of tourniquets to stop extremity 

bleeding, rapid casualty evacuation, and aggressive use 

of plasma along with red cells for fluid resuscitation.11

A recent epidemiological study of combat wounds 

received in Operation Iraqi Freedom (OIF) and 

Operation Enduring Freedom (OEF) showed that 

extremities were the most common sites of injury 

among the casualties, of which the majority were not 

lethal and amendable by tourniquet application.12 A 

review of lethal wounds in autopsy reports of 982 

combat deaths in Iraq and Afghanistan revealed that 

nearly 24% could have been potentially prevented if 

early and effective treatments had been provided. Of 

those potentially preventable deaths, 85% were caused 

by uncontrolled hemorrhage, of which two-thirds were 

noncompressible and one-third compressible 

bleeding.13 These findings once again emphasize the 

need for prompt and more effective hemorrhage 

control treatment in the field and in the combat support 

hospitals. Because of the possibility of prolonged 

evacuation times during combat operations and limited 

options before the arrival of casualties at the combat 

support hospitals, the prehospital phase offers the best 

opportunity to control hemorrhage at its early onset, 

and prevent morbidity and mortality consequences.14,15

It is clear that the natural ability of blood to clot 

rapidly and seal bleeding vessels is inadequate to stop 

a more severe hemorrhage, and that this mechanism 

Evaluation of Topical Hemostatic Agents for 

 Combat Wound Treatment 

Bijan Kheirabadi, PhD 

ABSTRACT

Uncontrolled hemorrhage remains the leading cause of potentially preventable death in combat casualties. In the 

current conflict, nearly two-thirds of these deaths occurred as a result of torso injuries with noncompressible 

hemorrhage and one-third from extremity injuries with compressible bleeding. The natural ability of blood to clot 

rapidly and stop bleeding from large vessels is far less than needed in the face of severe injuries and may even be 

diminished as a result of a massive tissue trauma (acute coagulopathy). Therefore, the use of a pressure device (ie, 

tourniquet) or topical hemostatic dressing is essential to stop compressible hemorrhage and prevent possible shock or 

death of casualties at the point of injury. To provide combat medics with the best means of treating hemorrhages, it is 

essential to understand the mechanism of action, efficacy strength, and possible adverse effects of each available 

hemostatic agent. In this article, we review the risks and benefits of the agents/dressings that have been used on the 

battlefield, the process that led to the selection of the new agents, and the present deficiencies that must be addressed in 

the development of new products. 
26 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

may even be weakened after massive tissue injuries 

and hemorrhagic shock. Therefore, the use of adjuvant 

hemostatic dressings or devices and drugs to enhance 

blood-clotting capacity are essential to stop severe 

hemorrhage and prevent the death of injured Soldiers. 

Unlike noncompressible bleeding that has no 

prehospital remedy except the administration of a 

limited volume of fluid (Hextend) to treat hypotensive 

shock in the patient and possibly exacerbate bleeding, 

several advanced hemostatic products have been 

developed in the past 15 years for treating 

compressible hemorrhage. Some of these products 

were tested extensively in the laboratories, and a few 

selected products were deployed for use by US forces 

on the battlefield. This article reviews the physical 

properties, mechanisms of action, and risks and 

benefits of hemostatic agents/dressings that have been 

used on the battlefield. The efficacy and safety studies 

that led to selection of these agents and present 

deficiencies that must be addressed by new hemostatic 

products are also discussed. 

HEMOSTATIC MECHANISMS OF TOPICAL AGENTS

There are essentially 2 mechanisms by which the 

topical hemostatic agents produce hemostasis when 

placed in bleeding wounds: 

 Physically adhering to damaged tissues in the 

wound and sealing injured blood vessels to prevent 

further blood loss (eg, chitosan dressing). 

 Accelerating and strengthening the clotting of 

blood present in the wound by incorporating into 

the developing clot and producing hemostasis. 

This mechanism is often achieved as a result of 2 

related reactions: a) rapid absorption of water from 

blood in the wound which concentrates all clotting 

elements on the injured tissues, and b) a chemical 

reaction that activates the intrinsic coagulation 

pathway and platelets and promotes clot formation. 

Therefore, the activity of these products depends on 

the intact coagulation function of patients. 

The majority of hemostatic agents, including gauze, 

facilitate hemostasis by the second mechanism. A few 

products with very high efficacy produce hemostasis 

by both mechanisms, such as WoundStat 

(TraumaCure, Bethesda, MD), a silicate-based mineral 

agent in granular form, and fibrin sealant dressing, a 

biological dressing made of plasma-derived clotting 

proteins. Although the hemostatic efficacy of a topical 

agent has high importance, the agent’s chemical 

effects on the exposed tissues and potential for causing 

greater damage in the wound or systemic 

complications must also be considered in the selection 

of an appropriate agent. There are other criteria that 

are uniquely important for the agents used in the 

military. Table 1 lists the properties of the ideal 

hemostatic dressing for tactical use, as recommended 

by a panel of military experts. 

EARLY EFFORTS IN THE DEVELOPMENT OF HEMOSTATIC

DRESSINGS 

Until the onset of OEF and OIF, the Army Field 

Bandage (AFB) was the mainstay for controlling 

external bleeding. The AFB is composed of a thick 

layer of absorbent cotton wrapped in layers of gauze 

and attached to 2 long straps for wrapping around the 

wound. It absorbs large volumes of blood and provides 

a matrix that promotes platelet aggregation and blood 

coagulation while exerting pressure on the wound. 

The early notion that up to a third of all combat deaths 

resulting from exsanguination could be prevented with 

the use of more effective hemorrhage methods4

focused the US Army’s Combat Casualty Care Research Program on the development of more effective 

hemostatic products than gauze. 

Evaluation of Topical Hemostatic Agents for Combat Wound Treatment 

Approved or cleared by the US Food and Drug Administration 

Stops severe arterial and/or venous bleeding in 2 minutes or less 

No toxicity or side effect 

Causes no pain or thermal injury 

Poses no risk to medics 

Ready to use and requires little or no training 

Durable and lightweight 

Flexible enough to fit complex wounds and is easily removed without 

leaving residues 

Stable and functional at extreme temperatures (-10°C to +40°C) for at 

least 2 weeks 

Practical and easy to use under austere conditions (low visibility, rain, 

wind, etc) 

Effective on junctional wounds not amendable by tourniquet 

Long shelf life (> 2 years) 

Inexpensive and cost-effective 

Biodegradable and bioabsorbable 

Table 1. Characteristics of the ideal hemostatic dressing for 

tactical applications. 
 April – June 2011 27

THE ARMY MEDICAL DEPARTMENT JOURNAL

Dry Fibrin Sealant Dressing 

Nearly a decade of collaborative research between the 

US Army and the American Red Cross with funding 

support by the Department of Defense resulted in the 

development in the laboratory of the first advanced 

hemostatic dressing that was significantly more 

efficacious than the AFB.16 The new product was 

developed for both prehospital and conventional 

surgical application. The dressing was the dry form of 

the existing hemostatic product known as liquid fibrin 

sealant used in routine surgical procedures. However, 

because liquid fibrin sealant preparation was 

complicated and time-consuming, it had no utility in 

trauma care. Dry fibrin sealant dressing (DFSD) 

(American Red Cross Holland Laboratory, Rockville, 

MD) was made of lyophilized clotting proteins 

purified from pooled human plasma from donated 

blood that was ready to use. Layers of fibrinogen and 

thrombin with calcium chloride were freeze-dried onto 

an absorbable backing material17 (Figure 1). Upon 

contact with blood, the proteins dissolved and the 

enzymatic reaction between thrombin and fibrinogen 

resulted in formation of a fibrin layer that adhered 

tightly to injured tissue and stopped the hemorrhage. 

In a complex wound, the dressing could be added as a 

powder that mixed with blood and accelerated the 

clotting reaction and strengthened the final clot. The 

efficacy of this dressing has been proven in a number 

of experimental models, including ballistic, extremity, 

and parenchymal injuries in normal and coagulopathic 

swine.18-24

The main safety concern with this dressing was the 

risk of viral transmission (specifically hepatitis and 

human immunodeficiency virus) from the use of 

human clotting proteins purified from pooled plasma. 

This risk, however, has been virtually eliminated 

because of stringent screening of blood donors, 

extensive testing of collected blood, and recent 

advanced methods of viral inactivation (solvent 

detergent and ultraviolet radiation) in plasma.17

Nevertheless, since the main components of DFSD are 

derived from plasma, it is considered biologic and, 

contrary to other hemostatic agents, must be tested for 

safety and efficacy in clinical trials to receive approval 

from the US Food and Drug Administration (FDA) for 

human use. Under an FDA-approved Investigational 

New Drug protocol, a number of DFSDs were 

deployed early to Iraq and Afghanistan for treating 

external hemorrhage in consenting Soldiers,25 but were 

soon withdrawn due to deployment of a new dressing 

with presumably similar potency that had received 

FDA clearance (HemCon bandage, HemCon Medical 

Technologies, Inc, Portland, OR). Dry fibrin sealant 

dressing was used on only one injured Soldier, and it 

successfully stopped the arterial bleeding where all 

other attempts had been futile.26

The necessary clinical trials required substantial 

funding which could not be secured at the time, 

therefore, further manufacturing and marketing efforts 

of this effective product were suspended in 2002. 

However, a renewed interest by larger companies may 

bring this potentially useful product to the clinics. At 

least one similar product, Fibrin Patch (Ethicon, Inc, 

Somerville, NJ), has completed phase I and phase II 

clinical trials* and the manufacturer is seeking FDA 

approval for future marketing. 

Rapid Deployment Hemostat Bandage 

The rapid deployment hemostat (RDH) dressing 

(Marine Polymer Technologies, Inc, Danvers MA), 

developed with funding support from the Office of 

Naval Research, is a chitin-based hemostatic dressing 

*http://www.clinicaltrials.gov/ct2/results?spons=%22Ethicon%

2C+Inc.%22&spons_ex=Y 

Dry Fibrin Sealant Dressing HemCon Bandage QuikClot QuikClot ACS+ 

Figure 1. Topical hemostatic products deployed during Operations Enduring Freedom and Iraqi Freedom. 
28 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

composed of poly-N-acetyl-glucosamine (fully 

acetylated), which is derived from marine microalgae. 

Although the mechanism of its hemostatic action 

remains unclear, suggested mechanisms include red 

blood cell aggregation, platelet activation, activation of 

the clotting cascade, and local vasoconstriction via 

endothelin release.27-30 The original RDH dressing 

showed the ability to control minor bleeding (3 mmdeep splenic laceration) in normal and coagulopathic 

pigs,31,32 but was ineffective against severe arterial 

(aortotomy injury22), venous (grade V liver injury33), 

and mixed (femoral artery and vein transection) 

bleeding in the studies that were conducted in our 

laboratory and other locations.34 Other investigators 

reported that the new generation of RDH dressings, 

modified RDH (mRDH) bandages, with an increase in 

active ingredient, was effective in aortic and liver 

injury models in swine.35,36 A small clinical study (10 

patients) reported successful treatment of liver 

hemorrhage in coagulopathic patients with 

intracorporeal use of mRDH bandages.37 This dressing 

has received FDA clearance as a class I medical device 

and is commercially available at the price of $1,000 

per dressing. There are no reported harmful effects 

associated with its use. This dressing has not yet been 

deployed to the combat theaters.

HemCon Bandage 

As planning for OEF and OIF developed, research 

efforts by academia and industry were accelerated to 

produce other dressings/agents which were more 

effective than gauze, easier and less expensive to 

produce, and could be licensed without the need for 

clinical trials. The results were development of 2 new 

products, the HemCon (HC) bandage and QuikClot 

(QC) (Z-Medica Corp, Wallingford, CT) granules 

(Figure 1). The HC dressing was developed by the 

Oregon Medical Laser Center (Portland, OR) with 

some funding support by the US Army. The dressing is 

made of freeze-dried chitosan, a partially deacetylated 

form of chitin (a natural polysaccharide) found 

abundantly in shellfish such as shrimp. In small animal 

studies, liquid chitosan was shown to have hemostatic 

properties.38,39 The primary mechanism of HC 

hemostatic action appears to be strong adherence to 

wet tissues and sealing of the injured vessels.40 In an 

early study, the prototype of HC was tested in our 

laboratory in a swine model with a grade V liver 

injury. The results demonstrated the superior efficacy 

of this dressing over regular gauze for controlling 

venous bleeding.40 However, in subsequent 

confirmatory studies in which the final product was 

tested in the same model, the differences between HC 

and gauze were less significant (A. E. Pusateri et al, 

unpublished data, March 2003). 

The HC bandage received FDA clearance as a 

hemostatic device in 2002 and a few months later was 

distributed among US Army personnel for use in the 

treatment of external bleeding on the battlefield. The 

efficacy of this dressing was reexamined against 

arterial bleeding in more relevant swine models. The 

results showed that the adherence of HC to the 

damaged tissues/vessels decreases with time, and that 

even initially successful dressings (70%) cannot stop 

the bleeding for more than one hour after application.24

In a groin injury model, this dressing was totally 

incapable of controlling arterial bleeding from the 

femoral artery injury.23 Since the marketing of the 

original dressing, HemCon Company has made several 

modifications to the product to improve its efficacy 

and applicability. The new generations of HC are 

thinner and more flexible and conform better to the 

wounds. One version of this dressing, ChitoFlex, has a 

ribbon-rolled shape with no backing (both sides are 

active) which can be used for packing deep penetrating 

wounds. However, none of these changes has 

substantially increased the overall efficacy of this 

product in animal model testing. There have been no 

reports of allergic reaction or any other side effects 

associated with the use of this dressing in patients. 

Currently, the HC dressing is being replaced in the 

military with a simpler and presumably more effective 

dressing called Combat Gauze. 

QuikClot 

QuikClot (QC), the first mineral-based (zeolite) 

hemostatic agent, was introduced in open granular 

form (Figure 1). This product was also developed with 

funding support from the Office of Naval Research. 

The hemostatic mechanism of this agent was 

suggested to be the rapid water absorption 

concentrating all clotting proteins and cells in the 

wound.41 The interaction of water with zeolite, 

however, caused an exothermic reaction that generated 

significant heat in the wound and often caused burning 

injuries. The heat generation may have also 

contributed to the hemostatic function of QC. The 

efficacy of QC was primarily demonstrated in 2 

studies using a swine model with a groin injury that 

Evaluation of Topical Hemostatic Agents for Combat Wound Treatment 
 April – June 2011 29

THE ARMY MEDICAL DEPARTMENT JOURNAL

included complete transection of both the femoral 

artery and the vein and limited fluid resuscitation.34,42

Treatment of this bleeding with QC resulted in a 

significantly higher survival rate (100%) compared to 

untreated animals (0% to 16%). Treatment of this 

wound with standard gauze alone also led to an 

approximately 60% survival rate. There were no 

significant differences in blood loss among groups. On 

the other hand, in a subsequent study in which QC was 

tested in our model of high-pressure arterial bleeding 

(6 mm femoral arteriotomy), it failed to provide 

hemostasis or improve survival rate, and was 

essentially no better than AFB.23 In our liver injury 

model with venous bleeding, however, QC was more 

effective than regular gauze.43

The safety of QC was a controversial issue. Burning 

injuries were quite evident on the skin, skeletal 

muscle, and blood vessels that were exposed to QC 

and included potentially irreversible damage to the 

femoral nerve.23 The abscess and necrosis of skeletal 

muscle and femoral vessels treated with QC were also 

seen in a survival study in swine one week after 

treatment.44 QuikClot received FDA clearance as a 

medical device without clinical testing, and, despite 

these safety concerns, it was widely distributed among 

US Marine and Navy personnel for treatment of 

external hemorrhage. The argument was that if QC 

could stop a life-threatening hemorrhage and save the 

life of a Warfighter, although in the process caused 

burning injuries, its benefits clearly outweighed its 

potential side effects. This argument seemed valid if 

indeed QC could stop a life-threatening hemorrhage, 

but the experimental evidence from some laboratories 

indicated otherwise.23,45 Nevertheless, anecdotal case 

reports of successful use of QC for treatment of 

injured troops supported its use in Iraq and 

Afghanistan.41 Similar successes regarding HC 

dressing use were also reported among the Army 

personnel.46 A recent report by Rhee et al described 

the use of QC in 103 documented cases in civilian and 

military settings with only a few cases of significant 

tissue burning, one of which required a skin graft.47

Tissue burning remained an issue that may have 

limited its use of QC in the field. Therefore, the 

manufacturer (Z-Medica) replaced the original QC 

zeolite granules with synthetic zeolite beads that 

produce minimum exothermic reaction48 and packaged 

them in small porous cotton bags for easy application 

and removal (QuikClot ACS+) (Figure 1). The original 

QC is no longer produced or sold by the company. 

DEVELOPMENT OF NEW HEMOSTATIC AGENTS/

DRESSINGS

Despite the positive anecdotal reports, other reports49,50

and information from combat medics implied limited 

use or avoidance of available hemostatic agents in the 

field because of either painful burning effects (QC) or 

poor efficacy in controlling severe bleeding (HC). 

Therefore, since deployment of QC and HC dressings, 

continuous research and development by industry has 

produced a number of new hemostatic products that 

were rapidly marketed as medical devices after receipt 

of FDA clearance. The clearance process was 

relatively simple; as long as the companies could 

prove that their products were equivalent to previously 

approved agents (ie, QC or HC dressing), they could 

market their products. 

At least 10 to12 new products entered the market, all 

of which were indicated for temporary control of 

external bleeding and were claimed to be safe (no 

thermal injury) and efficacious. Our laboratory and the 

Navy Research Group were tasked to conduct large 

animal studies to identify more efficacious products 

beneficial for military applications. After a few products were eliminated in preliminary screening tests, 

the more promising new agents were tested in 3 

models of extremity injury that involved complete 

transection of the femoral artery and the vein, 4 mm 

femoral artery punch with limited fluid resuscitation51,52 and 6 mm femoral artery punch and unlimited fluid resuscitation.53,54 The results reported by 

both laboratories were surprisingly consistent with one 

exception: the QuikClot ACS+ showed higher efficacy 

than average in the Navy studies, but was not different 

from the HC dressing (control treatment) in our study. 

The top 3 agents were WoundStat, Combat Gauze (ZMedica Corp, Wallingford, CT), and Celox (MedTrade 

Products Ltd, Crewe, UK) (Figure 2), which were 

significantly more effective in reducing blood loss and 

improving survival than the control dressing (HC) and 

QC, and had no immediately apparent side effects 

(Figure 3). Based on the overall results, the efficacy of 

these 3 agents could be ranked in the order (1) 

WoundStat, (2) Combat Gauze, (3) Celox. However, the differences in blood loss or survival rates 

were not statistically significant among the agents. The 

3 agents are further discussed below. Information 

about other agents tested is found in earlier 

publications.51-54 
30 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

WoundStat 

WoundStat (WS), another mineral-based granular 

agent, consists of smectite minerals and is a 

nonmetallic clay made of sodium, calcium, and 

aluminum silicates. When exposed to water or blood, 

WS granules absorb water and form a clay material 

with high plasticity that, upon compression, binds 

tightly to underlying tissues and seals the bleeding 

sites. In addition to water absorption, 

which concentrates clotting factors, the 

granules have negative electrostatic 

charges that activate the intrinsic 

clotting cascade and accelerate the bloodclotting process.45 The mineral is not 

biodegradable and therefore must be 

removed entirely from the wound site 

before definitive surgical repair is done. 

The tissue adhesiveness of this clay, 

along with its potent clotting ability, 

secured hemostasis in all the 

experiments and led to100% survival of 

pigs.45,53 Only 10% of animals treated 

with the HC dressing as control agent 

survived the experiments.52

Mixing WS granules with water did not 

generate heat and caused no thermal 

damage, however, there were other 

findings in the tissues that were safety 

concerns. For example, although 

applying and covering the wound with 

this agent was relatively easy, eventual 

removal of the clay material from the 

wound was cumbersome and required 

extensive irrigation and debridement. 

Despite these efforts, microscopic WS 

residues were found in the lumen of the 

majority of treated blood vessels.53

Given the strong clotting activity of WS 

granules, these residues could become 

the source of local or systemic 

thrombosis if blood flow were 

reestablished in the treated vessel. These anomalies 

and other changes in treated vessels led to the design 

of an experimental study to evaluate the safety of WS 

treatment, even though the agent had already been 

approved by the FDA for clinical use.55 The result is 

described later in the section, WoundStat and Combat 

Gauze Safety Studies. 

Combat Gauze 

Combat Gauze (CG) may be considered the first 

mineral-based hemostatic dressing. This dressing is a 4-

yard-long, 3-inch-wide roll of nonwoven surgical 

gauze made of 50% polyester and 50% rayon 

impregnated with kaolin, an aluminum silicate 

mineral. Kaolin is a potent activator of contact 

(intrinsic) clotting pathway that accelerates the initial 

onset and speed of clot formation. CG 

was the most effective dressing tested in 

our arterial hemorrhage model and 

resulted in 80% survival of the 

animals.54 However, unlike the adhesive 

products, this dressing often does not 

provide immediate hemostasis when 

applied over wounds, resulting in more 

blood loss than other agents. Hemostasis 

is eventually achieved when a 

hemostatic clot is formed in conjunction 

with CG on the injury site. Unlike the 

granular agents, application and removal 

of CG are easily accomplished and 

require no special procedures. Because 

the hemostatic function of CG depends 

solely on the blood-clotting activity of 

hosts, this dressing may be found to be 

less effective in patients with 

coagulopathy. 

The safety of CG was less an issue since 

kaolin particles (diameter <3 μm) are 

incorporated into the gauze. However, 

when the gauze is placed in a pool of 

blood or in other liquids, the kaolin 

particles are washed out and could 

potentially enter into the systemic 

circulation and cause thrombotic 

complication. Therefore, the safety of 

CG and WS was investigated in 

experimental studies described later in 

the section, WoundStat and Combat 

Gauze Safety Studies. 

Celox 

Celox (CX) is a chitosan-based hemostatic agent in 

granular form containing a proprietary blend of different chitosan compounds. The chitosan particles are 

positively charged, binding with negatively charged 

surfaces such as red blood cells and platelets. The heEvaluation of Topical Hemostatic Agents for Combat Wound Treatment 

WoundStat granules 

Combat Gauze 

Celox powder 

Figure 2. New, more efficacious 

topical hemostatic products. 
 April – June 2011 31

THE ARMY MEDICAL DEPARTMENT JOURNAL

mostatic mechanism of CX is mediated by a mixture 

of chemical and mechanical (adherence) linkages to 

red blood cells and tissues, forming a physical barrier around the severed vessels. Treatment of the arterial hemorrhage with CX in our model resulted in an 

approximately 50% reduction in blood loss and 60% 

survival rate of tested animals.53 It was also shown to 

be more effective than QC and HC dressing in a 

groin injury model involving transection of femoral 

vessels.56 The hemostatic activity of CX was 

inconsistent (all or none) in our experiments, but in 

successful cases, hemostasis was much more stable 

than using other chitosan products (HC). 

Although in principle chitosan is a bioabsorbable 

material, CX hemostatic powder is not considered 

bioabsorbable and therefore must be removed from the 

wound prior to surgical repair. Since it forms large 

clumps when wetted with blood, removal of CX from 

wounds is much easier than other granular/powder 

agents (ie, WS and QC). The in vitro blood tests 

(thrombelastography) also showed that CX (chitosan) 

particles do not affect the clotting activity of blood. 

The possible CX residues in the wound are likely to be 

degraded, causing no thrombotic complications. CX 

elicits stronger inflammatory reaction than other 

hemostatic products, but otherwise appears to be a safe 

agent. Some civilian first responders and a few 

military units are carrying CX for treating hemorrhage, 

however, the light powder nature of this agent, which 

is more difficult to apply in the field (especially in the 

low-visibility or windy conditions), has discouraged 

wide distribution and use of this agent on the 

battlefield. Attempts by the company to package this 

hemostatic powder in dissolvable bags for easier 

application have not been successful because of the 

loss of hemostatic activity.54 The CX as powder can be 

applied to deep penetrating wounds by a new syringe 

delivery system. 

SAFETY EVALUATION OF HEMOSTATIC AGENTS 

All the above-mentioned hemostatic products except 

DFSD have been recognized as Class I medical 

devices by the FDA and have received marketing 

clearance by proving that the new products are 

equivalent to similar agents (ie, QC) that were cleared 

by the FDA after 1976. 57 This pathway also requires 

some standard safety testing, including in vitro 

cytotoxicity using fibroblast cell culture and in vivo 

sensitivity, irritability, and systemic toxicity, all of 

which are done in small animals (rats and rabbits). 

These tests evaluate the potentially adverse effects of 

chemicals that may be eluted or extracted from a 

medical device. Although no reaction may indicate 

that a material is free of harmful extractable, it is 

certainly not evidence that the device is fully 

biocompatible and safe for applying over an external 

wound with access to systemic circulation. 

Considering that hemostatic devices are intended to 

stop bleeding from vascular injuries, it is likely that 

they will come in direct contact with endothelial cells 

in the injured vessels and inflammatory cells drawn to 

the site of injury. Therefore, the standard safety tests 

applied to most medical devices may be inadequate in 

evaluating hemostatic agents, particularly those with 

hemostatic minerals. This inadequacy was never more 

apparent than in the case of the original QC. Although 

none of the standard tests showed that the zeolite itself 

or its eluted chemicals are harmful, a simple test of 

pouring QC granules into a beaker containing blood 

would have revealed the extreme rise of temperature 

and its potential burning injury when it is applied to 

the wound. 

WOUNDSTAT AND COMBAT GAUZE SAFETY STUDIES

For the reasons explained above (histological 

evidence), it was suspected that these hemostatic 

agents, particularly WS, may have potential 

thrombogenic effects when applied to wounds with 

major vascular injuries. To test this hypothesis, we 

developed a new wound model in swine that would 

demonstrate the effect of these agents locally as well 

as detecting any systemic embolism.55 The wound 

involved partial transection of the carotid artery and 

jugular vein in the neck and was treated with either 

Figure 3. Kaplan-Meier analysis of survival time of pigs following 

arterial injury and hemostatic treatment. 

WS - WoundStat; CG - Combat Gauze; CX - Celox; QC - QuikClot ; 

HC - HemCon 

Percent Surviva l 

Time (minute s) 

WS* (100%)

CG* (80%)

CX* (60%)

QC ACS+(16%)

HC (10%) 

*P<.05 vs HC 

P<.0001 

(Log Rank test)
32 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

WS or CG to control hemorrhage for 2 hours. The 

control wounds were treated with regular gauze. 

Following treatment, the hemostatic agents were 

removed, wounds debrided extensively, vessels 

repaired by suturing, and blood flow reestablished in 

the vessels for 2 hours. 

Computed tomography (CT) angiography and direct 

observation afterwards showed that the majority of 

vessels treated with WS were occluded with large 

thrombi/clots, whereas no abnormality was seen in 

gauze- or CG-treated vessels (Figure 4). Granules of 

WS and blood clots were also found in the lung of one 

pig. Histological examination revealed significant 

endothelial and transmural damages in the WS-treated 

vessels. Microscopic residues of WS that were 

associated with arterial thrombosis were also found in 

the lung. The histological changes of gauze and CG 

treatment were similar and mild. 

A follow-up in vitro study58 using human endothelial 

and mouse macrophage-like cells substantiated the in 

vivo findings and showed severe toxic necrosis of the 

cells after direct exposure to WS minerals. However, 

epithelial HeLa cells were unaffected by WS. These in 

vivo and in vitro findings, along with the results of 

another safety study by US Air Force scientists,59

resulted in rapid suspension of WS distribution and 

permanent withdrawal of this hemostatic agent from 

the US military medical practice. To our knowledge, 

this product was not used on any of our casualties 

during the brief period that it was deployed. 

To ensure that CG with kaolin has no long-term 

detrimental effect on the wound, the dressing was also 

tested in a survival swine study using the same wound 

model. CT images showed patency and normal blood 

flow in the treated vessels of all animals 2 weeks after 

surgery. Histologically, healing progressions of 

wounds and vessel walls were similar to those of the 

control group (gauze treated) with normal endothelium 

(thrombus-free) present in all vessels (B.S.K., 

unpublished data, 2009). Because of high efficacy, 

ease of use, and proven safety, CG was recommended 

by the Tactical Combat Casualty Care Committee for 

distribution among US forces for use as the first line of 

treatment of external hemorrhage on the battlefield 

refractory to tourniquets. It has essentially replaced the 

previously deployed hemostatic agents (HC and QC). 

The initial anecdotal reports of uses of CG on the 

battlefield are very positive and encouraging. The 

properties of the new hemostatic agents are compared 

to those of the older products in Table 2. 

Evaluation of Topical Hemostatic Agents for Combat Wound Treatment 

Figure 4. Computed tomography images of pigs left (intact) and right carotid arteries treated with Combat Gauze (A) and 

WoundStat (B) 2 hours after blood reflow. WS indicates WoundStat. Reproduced from Kheirabadi et al55 with permission. 

A B
 April – June 2011 33

THE ARMY MEDICAL DEPARTMENT JOURNAL

CURRENT DEFICIENCIES IN THE TREATMENT OF

COMPRESSIBLE BLEEDING

Nearly all hemostatic agents are adjuvant to the 

patient’s own blood clotting activities. In general, 

these agents physically obstruct (decrease) the outflow 

of blood in the wound, accelerate clotting reactions, 

and provide a matrix for increased platelet interactions, 

resulting in faster and stronger fibrin clot formation 

that can bind to and seal vascular injuries. Therefore, 

the effectiveness of these agents depends heavily on 

the competent coagulation function of patients. In the 

combat environment, trauma and hemorrhage caused 

by explosion (massive tissue injuries), resuscitation 

with a synthetic colloid fluid (hemodilution), delayed 

evacuation and transport in helicopters (hypothermia), 

and hypovolemic shock (metabolic acidosis) have 

collectively created conditions that can induce early 

coagulopathy in some casualties. Among the combat 

casualties who required blood transfusion, over onethird (38%) were diagnosed with acute traumatic 

coagulopathy with an international normalized ratio 

(INR) of 1.5 or more upon arrival at a combat support 

hospital. High mortality (24%) was associated with 

early coagulopathy and acidosis in these patients.60 A 

diffuse large area of bleeding associated with multiple 

vascular injuries in coagulopathic patients is much 

harder to treat with ordinary hemostatic agents than 

defined bleeding in noncoagulopathic patients. 

We tested the efficacy of the 2 most powerful 

hemostatic products, WS and CG, to control bleeding 

in coagulopathic swine.61 The mineral 

components of these agents (smectite and 

kaolin, respectively) were found to be potent 

activators of the intrinsic clotting cascade, 

promoting faster and stronger clot formation 

when added to native blood.53,54 The additional 

sealant properties of WS clay when mixed with 

blood suggested an advantage for the treatment 

of coagulopathic bleeding that may not be 

possible with other hemostatic agents. Some in 

vitro data also supported this hypothesis,62,63

therefore, it was tested in another large-animal 

study.61

Coagulopathy was induced in pigs prior to 

injury by removal of 50% of their circulating 

blood volume and replacing it with an equal 

volume of isotonic Hextend solution 

(hemodilution) and lowering their normal body 

temperature by 5°C (≈34°C, hypothermia), resulting in 

an INR of 1.4. The pigs were then subjected to the 

same femoral artery injury as before and treated with 

WS or CG. Regular gauze was used as control 

treatment, and a new fibrin sealant dressing (FAST 

bandage) was also added to the study. Although the 

arterial bleeding in this model did not mimic a typical 

coagulopathic bleeding, it provided a standard 

condition for testing these agents under coagulopathic 

state, which could be directly compared with the 

previous results in normal animals. The results showed 

that WS and CG were generally unable to stop the 

bleeding in the coagulopathic animals. This was 

expected for CG with 40% survival rate but was 

unexpected for WS with only 13% survival rate 

because of its tissue sealant properties. Apparently, the 

tissue adherence of WS is mediated by clot formation, 

and this property is lost with preexisting coagulation 

deficiency. 

There is a need for a new class of hemostatic agent 

that can function independently of host coagulation 

function and stop bleeding in coagulopathic patients. 

Such a product will be particularly beneficial to 

casualties who develop early coagulopathy at the point 

of injury. The most successful product in our 

coagulopathic hemorrhage models has been the 

fibrinogen-based dressings.21,56,65 These dressings 

deliver the main components of blood clots, including 

fibrinogen, thrombin, CaCl2, Factor XIII, and other 

proteins, to the wound and form strong hemostatic 

fibrin clots bypassing the patients’ own clotting 

Table 2. Comparison of characteristics of available hemostatic agents. 

Characteristic QC ACS+ HemCon Celox WoundStat Combat 

Gauze 

Hemostatic efficacy + + + + + + + + + + + + + 

Side effects No No No Yes No 

Ready to use Yes Yes Yes Yes Yes 

Training requirement + + + +++ ++ 

Lightweight, durable + + + + + + + + + + + 

2-yr shelf life Yes Yes Yes Yes Yes 

Stable in extreme 

conditions Yes Yes Yes Yes Yes 

Cleared by FDA Yes Yes Yes Yes Yes 

Biodegradable No No Yes No No 

Cost ($) ≈30 ≈75 ≈25 ≈30 ≈25 

Hemostatic Agents 

NOTE: A single + symbol indicates an agent has meant the minimum requirement. 

Multiple + symbols indicate degree of exceeding the minimum requirement. 
34 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

functions. The missing platelet component is 

compensated by the high fibrinogen content of the 

dressing that increases fibrinogen concentration in the 

wound more than a factor of 10 above normal. 

Moreover, because of its biological nature, the 

fibrinogen-based dressings are fully absorbable and 

can be implanted permanently to control some 

refractory bleedings in patients. The dressing can also 

potentially eliminate the cleansing surgeries in damage 

control operations that are necessary for removing 

gauze and other nonabsorbable hemostatic materials 

used to control hemorrhage and secure hemostasis. At 

least 2 such dressings (FAST and Fibrin Patch) are 

being developed in the United States and are 

undergoing clinical trials to receive FDA approval for 

future use. 

There are other situations in which treatment of some 

external wounds might also be difficult, if not 

impossible, with available hemostatic agents. An 

example is junctional wounds that involve amputation 

of extremities at the groin or shoulder levels. These 

wounds are large with profuse bleedings, which, if not 

controlled promptly, will cause the victim to 

exsanguinate in a short time. A tourniquet, perhaps the 

most effective hemostatic device, is ineffective (cannot 

be applied properly) to control the hemorrhage 

because of the location of the injury. Other hemostatic 

dressings are also no match for these types of wounds 

and hemorrhage. A mechanical device (adjustable 

clamp) has been developed (and recently received 

FDA clearance) to exert constant and high pressure on 

proximal regions and occlude main feeding vessels 

(iliac and subclavian arteries) to slow down the 

bleeding. Large-surface-area dressings that are coated 

with different hemostatic agents with long wrapping 

strips are also being produced to be used alone or in 

conjunction with mechanical devices. 

CONCLUSION

Future combat scenarios in which troops will be more 

dispersed imply that evacuation times of casualties 

may exceed 24 hours. Even in urban environments, 

evacuation may be delayed significantly, as was 

experienced in Somalia.65 The implication is that at a 

minimum, several hours may pass before any surgical 

intervention is possible to treat injured Soldiers, and it 

is well established that mortality rates will rise with 

increasing evacuation times.66 Since the introduction 

of the Army field bandage, significant progress has 

been made in the past decade toward developing new 

hemostatic products for treating external wounds. The 

new dressing, Combat Gauze, offers the simplicity and 

convenience of regular gauze, enhanced by a potent 

hemostatic mineral (kaolin) that together stop the 

majority of compressible bleeding in noncoagulopathic 

patients. Development of even more efficacious 

products (ie, chitosan-based gauze dressings) 

continues, but the greatest need for controlling 

bleeding on the battlefield centers around 

noncompressible torso wounds.15 Other targets are 

control of bleeding in coagulopathic patients in 

prehospital and hospital settings after significant blood 

loss and fluid resuscitation. Future fibrinogen-based 

dressings may offer the best chance for stopping these 

types of bleeding. 

Our responsibilities are to: 

1. Publicize these unresolved problems and 

challenge scientific communities to propose new 

and practical solutions. 

2. Support and collaborate with research and 

development efforts that may resolve these 

medical problems. 

3. Conduct independent, unbiased research to 

assess the true safety and efficacy of newly 

developed products. 

4. Determine their relevance and potential benefit 

in combat casualty care, thereby ensuring that 

the best available treatments for control of 

hemorrhage are rendered to our Soldiers. 

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Modified rapid deployment hemostat bandage reduces blood loss and mortality in coagulopathic pigs 

with severe liver injury. J Trauma. 2003;55:275-281. 

37. King DR, Cohn SM, Proctor KG. Modified rapid 

deployment hemostat bandage terminates bleeding in 

coagulopathic patients with severe visceral injuries. J 

Trauma. 2004;57:756-759. 

38. Klokkevold PP, Subar P, Fukayama H, Bertolami 

CN. Effect of chitosan on lingual hemostasis in 

rabbits with platelet dysfunction induced by 

epoprostenol. J Oral Maxillofac Surg. 1992;50:41-45. 

39. Klokkevold PP, Fukayama H, Sung EC, Bertolami 

CN. The effect of chitosan on lingual hemostasis in 

heparinized rabbits. J Oral Maxillofac Surg. 

1999;57:49-52. 

40. Pusateri AE, McCarthy SJ, Gregory KW, Harris RA, 

Cardenas L, McManus AT, et al. Effect of a chitosanbased hemostatic dressing on blood loss and survival 

in a model of severe venous hemorrhage and hepatic 

injury in swine. J Trauma. 2003;54:177-182. 

41. Alam HB, Burris D, DaCorta JA, Rhee P. 

Hemorrhage control in the battlefield: role of new 

hemostatic agents. Mil Med. 2005;170:63-69. 

42. Alam HB, Chen Z, Jaskille A, Querol RI, Koustova 

E, Inocencio R, et al. Application of a zeolite 

hemostatic agent achieves 100% survival in a lethal 

model of complex groin injury in swine. J Trauma. 

2004;56:974-983. 

43. Pusateri AE, Delgado AV, Dick EJ, Jr., Martinez RS, 

Holcomb JB, Ryan KL. Application of a granular 

mineral-based hemostatic agent (QuikClot) to reduce 

blood loss after grade V liver injury in swine. J 

Trauma. 2004;57:555-562. 

44. Wright JK, Kalns J, Wolf EA, Traweek F, Schwarz S, 

Loeffler CK, et al. Thermal injury resulting from 

application of a granular mineral hemostatic agent. J 

Trauma. 2004;57:224-230. 

45. Ward, KR, Tiba MH, Holbert WH, et al. Comparison 

of a new hemostatic agent to current hemostatic 

agents in a swine model of lethal extremity arterial 

hemorrhage. J Trauma. 2007;63(2):276-283. 

46. Wedmore I, McManus JG, Pusateri AE, Holcomb JB. 

A special report on the chitosan-based hemostatic 

dressing: Experience in current combat operations. J 

Trauma. 2006;60:655-658. 

47. Rhee P, Brown C, Martin M, et al. QuickClot use in 

trauma for hemorrhage control: case series of 103 

documented uses. J Trauma. 2008;64:1093-1099. 

48. Arnaud F, Tomori T, Carr W, et al. Exothermic 

reaction in zeolite hemostatic dressings: QuikClot 

and ACS+. Ann Biomed Eng. 2008;36:1708-1713. 

49. Neuffer MC, McDivitt J, Rose D, et al. Hemostatic 

dressings for the first responder: a review. Mil Med. 

2004;169(9):716-720. 

50. Cox ED, Schreiber MA, McManus J, Wade CE, 

Holcomb JB. New hemostatic agents in the combat 

setting. Transfusion. 2009;49(suppl 5):248S-255S. 

51. Arnaud F, Teranishi K, Tomori T, Carr W, McCarron 

R. Comparison of 10 hemostatic dressings in a groin 

puncture model in swine. J Vasc Surg. 2009;50

(3):632-639. 

52. Arnaud F, Parreño-Sadalan D, Tomori T, et al. 

Comparison of 10 hemostatic dressings in a groin 

transection model in swine. J Trauma. 2009;67

(4):848-855. 

53. Kheirabadi BS, Edens JW, Terrazas IB, et al. 

Comparison of new hemostatic granules/powders 

with currently deployed hemostatic products in a 

lethal model of extremity arterial hemorrhage in 

swine. J Trauma. 2009;66:316-328. 

54. Kheirabadi BS, Scherer MR, Estep JS, et al. 

Determination of efficacy of new hemostatic 

dressings in a model of extremity arterial hemorrhage 

in swine. J Trauma. 2009;67:450-459. 
 April – June 2011 37

THE ARMY MEDICAL DEPARTMENT JOURNAL

55. Kheirabadi BS, Mace JE, Terrazas IB, et al. Safety 

evaluation of new hemostatic agents, smectite 

granules and kaolin-coated gauze in a vascular injury 

wound model in swine. J Trauma. 2010;68:269-278. 

56. Kozen BG, Kircher SJ, Henao J, Godinez FS, 

Johnson AS. An alternative hemostatic dressing: 

comparison of CELOX, HemCon, QuikClot. Acad 

Emerg Med. 2008;15:74-81. 

57. 501(k) Clearances information page. Food and Drug 

Administration Web site. Available at: http://

www.fda.gov/MedicalDevices/ProductsandMedical 

Procedures/DeviceApprovalsandClearances/510k 

Clearances/default.htm. Accessed January 18, 2011. 

58. Bowman PD, Wang X, Meledeo MA, Dubick MA, 

Kheirabadi BS. Toxicity of aluminum silicates used 

in hemostatic dressings toward human umbilical 

veins endothelial cells, HeLa cells, and RAW267.4 

mouse macrophages. J Trauma. In press. 

59. Gerlach T, Grayson JK, Pichakron KO et al. 

Preliminary study of the effects of smectite granules 

(WoundStat) on vascular repair and wound healing in 

a swine survival model. J Trauma. 2010;69(5):1203-

1209. 

60. Niles SE, McLaughlin DF, Perkins JG, et al. 

Increased mortality associated with the early 

coagulopathy of trauma in combat casualties. J 

Trauma. 2008;64(6):1459-1465. 

61. Kheirabadi BS, Mace JE, Terrazas IB, et al. Clotinducing minerals versus plasma protein dressing for 

topical treatment of external bleeding in the presence 

of coagulopathy. J Trauma. 2010;69(5):1062-1073. 

62. Moskowitz KA, Manly DA, Mackman N. Effect of a 

topical hemostatic agent on clotting times in a whole 

blood model of dilutional coagulopathy [PP-TH-678]. 

J Thromb Haemostasis. 2009;7(suppl s2):1161. 

Available at: http://onlinelibrary.wiley.com/doi/ 

10.1111/j.1538-7836.2009.03473_2.x/pdf. Accessed 

January 18, 2011. 

63. Moskowitz KA, Manly DA, Mackman N. Effect of 

different topical agents on clotting times in a whole 

blood model of acidosis mediated coagulopathy [PPTH-677]. J Thromb Haemostasis. 2009;7(suppl 

s2):1160-1161. Available at: http://onlinelibrary. 

wiley.com/doi/10.1111/j.1538-7836.2009.03473_2.x/

pdf. Accessed January 18, 2011. 

64. Delgado AV, Kheirabadi BS, Fruchterman TM, et al. 

A novel biological hemostatic dressing (fibrin patch) 

reduces blood loss and resuscitation volume and 

improves survival in hypothermic, coagulopathic 

swine with grade V liver injuries. J. Trauma. 

2008;64:75-80. 

65. Mabry RL, Holcomb JB, Baker A, et al. US Army 

Rangers in Somalia: An Analysis of Combat 

Casualties on an Urban Battlefield. J Trauma. 

2000;49:515-529. 

66. Bellamy RF, Maningas PA, Vayer JS. Epidemiology 

of trauma: military experience. Ann Emerg Med. 

1986;15:1392-1395. 

AUTHOR

Dr Kheirabadi is a Research Physiologist, Department 

of Damage Control Resuscitation, US Army Institute of 

Surgical Research, Fort Sam Houston, Texas. 

Articles published in the Army Medical Department Journal are indexed in 

MEDLINE, the National Library of Medicine’s (NLM’s) bibliographic database 

of life sciences and biomedical information. Inclusion in the MEDLINE 

database ensures that citations to AMEDD Journal content will be identified to 

researchers during searches for relevant information using any of several 

bibliographic search tools, including the NLM’s PubMed service. 
38 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

INTRODUCTION

In the bestselling nonfiction book and popular movie,

Black Hawk Down,

1

 Corporal James “Jaimie” Smith 

died of a gunshot wound and groin hemorrhage that 

was too proximal for a tourniquet.2 His wound was at 

the junction between his trunk and thigh just beyond 

his body armor. This type of junctional injury has 

become more common recently, partly due to better 

body armor. With the success of regular tourniquets in 

the current war, isolated limb exsanguination is no 

longer the most common cause of preventable death on 

the battlefield; hemorrhage amenable to truncal 

tourniquets now is most common.3,4 Groin hemorrhage 

is the most common type of junctional bleeding where 

regular tourniquets cannot work.5

 Pressure point 

control of hemorrhage in the groin and limbs where 

collateral blood flow is present has been called a 

“euphemistic misnomer” by investigators because 

blood flow is restored momentarily in normal volunteers.6

 The Committee on Tactical Combat Casualty 

Care recommended military antishock trousers for 

hemorrhage control about the pelvic body region,7

 but 

effectiveness is poor, and contraindications are numerous.8-13 Therefore, in 2009, the Committee made truncal tourniquets a research priority. Soon thereafter, the 

Combat Casualty Care Research Program of the US 

Army Medical Research and Materiel Command 

requested candidate devices in order to address 

junctional bleeding. Of the few candidate devices 

provided, only one as of this writing, the Combat 

Ready Clamp (Combat Medical Systems, Fayetteville, 

NC) was approved by the US Food and Drug Administration. An update on the newest challenges of combat 

casualty care now needs explicit fills of specific 

knowledge gaps, especially on delineation among the 

“knowns and unknowns” of practical hemorrhage 

control measures. For example, only 3 devices are 

evidenced to be lifesaving for extremity injured 

casualties: emergency tourniquets, Thomas’ splint, and 

pelvic binders. The purpose of the present review is to 

discuss today’s gaps in battlefield hemorrhage control 

New Tourniquet Device Concepts for 

 Battlefield Hemorrhage Control 

COL John F. Kragh, Jr, MC, USA 

Chris Murphy 

Michael A. Dubick, PhD 

David G. Baer, PhD 

James Johnson, PhD 

COL Lorne H. Blackbourne, MC, USA 

ABSTRACT

Background: Given the recent success of emergency tourniquets, limb exsanguination is no longer the most common 

cause of preventable death on the battlefield; hemorrhage amenable to truncal tourniquets now is. The purpose of the 

present study is to discuss the gaps today in battlefield hemorrhage control and candidate solutions in order to stimulate 

the advancement of prehospital combat casualty care. 

Methods: A literature review, a market survey of candidate devices, a request for devices, and an analysis of the current 

situation regarding battlefield hemorrhage control were performed. 

Results: Hemorrhage control for wounds in the junction between the trunk and the limbs and neck is a care gap in the 

current war, and, of these, the pelvic (including buttock and groin proximal to the inguinal ligament) area is the most 

common. Historical and recent reports give background information indicating that truncal tourniquets are plausible 

devices for controlling junctional hemorrhage on the battlefield. A request for candidate devices yielded few prototypes, 

only one of which was approved by the US Food and Drug Administration. 

Conclusions: In order to solve the now most common cause of preventable death on the battlefield, junctional 

hemorrhage from the pelvic area, the planned approach is a systematic review of research, device and model 

development, and the fielding of a good device with appropriate training and doctrine. 
 April – June 2011 39

and candidate solutions in order to stimulate the advancement of prehospital combat casualty care. 

JUNCTIONAL HEMORRHAGE CONTROL: AN IMPORTANT

HEALTH CARE GAP ON TODAY’S BATTLEFIELD

We use the term “junctional” to include the groin 

proximal to the inguinal ligament, the buttocks, the 

gluteal and pelvic areas, the perineum, the axilla and 

shoulder girdle, and the base of the neck. We simply 

grouped these into a succinct label as they were at the 

junctions of the trunk. We use this label to discuss 

problem-solving. The lethality of limb injuries is less 

than junctional areas as hemorrhage is less and slower, 

and so the junctional hemorrhage control challenge is 

greater than in the limbs.14

Traumatic hemorrhage is a common, well recognized, 

and lethal problem in civilian and military settings for 

which numerous countermeasures have been 

recommended, and a few of which are evidenced to be 

lifesaving.2-5,7 A major goal in caring for such 

casualties is to stop the bleeding promptly as the main 

cause of death is hemorrhagic shock.15-19 Exsanguination-related mortality associated with major 

trauma has been noted to be unacceptably high,20

especially when casualties receive nontherapeutic 

procedures such as laparotomy without arresting pelvic 

hemorrhage.21 Early trauma care is error-prone even in 

mature trauma systems, as delayed control of 

hemorrhage can lead to preventable deaths for which 

remedies can be effectively targeted.22 Delayed control 

of hemorrhage, notably pelvic, was the leading error in 

one study; most of these errors were early in care as 

clinical data were often incorrectly perceived or the 

provider formed an incorrect intent and performed a 

wrong action.22 Comprehensive and integrated health 

care is optimal when it includes the multiple essentials 

to best care, which may include use of algorithms, 

checklists, and protocols.22 Prompt diagnosis and 

comprehensive treatment are essential to an optimal 

survival rate in multiple injury casualties where damage control is effective and safe when well executed.16,23 Although many recent advancements have 

been hospital-based, most trauma deaths occur prehospital. This is especially so on the battlefield, and 

prehospital advancement is our focus in this review. 

Continued developments in prehospital care may 

improve survival by early hemorrhage control 

allowing better resuscitation.19 Additional importance 

of junctional hemorrhage control is due to the 

frequency of such bleeding in the current war. 

JUNCTIONAL BLEEDING, COMMON ON TODAY’S

BATTLEFIELD

Epidemiologically, we can estimate the number of 

casualties who might need a junctional hemorrhage 

control device in order to count the possible lives 

saved during the current war. During the current war, 

from October 1, 2001, to April 30, 2010, 6450 coalition casualties died, averaging 63 deaths per month.24

According to the most recent report of the causes of 

death in casualties during the current war, only 23% 

(232/982) were “potentially survivable,” the rest had 

severe bodily disruption that was not survivable.5

 Of 

these 23%, 20% had junctional injury and bleeding as 

a cause of death. Therefore, if all these 4.6% (20% of 

23%) of casualties were savable with a device, then the 

maximum average monthly yield of optimal use of the 

device would be 3 casualties saved (4.6% of 63 per 

month). The rates of junctional hemorrhage is not clear 

in part because the words, categorization, and coding 

are yet to be adopted widely. For example, epidemiologically speaking, it is only possible at the moment 

to estimate that junctional hemorrhage from the lower 

extremity appears less common than the upper 

extremity perhaps because of the greater body surface 

area exposed to penetrating trauma in war. Clearly, 

there remain several important knowledge gaps 

regarding the rates of these lethal injuries. 

A recent review of battle casualties that died of 

wounds indicated that 21% of cases had junctional 

bleeding possibly amenable to a truncal tourniquet.25 A 

recent presentation of a review of US battlefield 

casualty data indicated that pelvic trauma deaths 

included 44% with a pelvic arterial injury.26 The 

distribution of body regions injured in the current war 

are different than in previous wars by an increase in 

the regions not protected by body armor; the difference 

is likely related to more explosions now.27 Explosions 

account for over 75% of all combat casualties, and 

their severity coupled with thoraco-abdominal protection by body armor has resulted in more severe 

orthopaedic injuries.28 Orthopaedic trauma cases 

presenting with shock which can be refractory to 

resuscitation. Junctional lesions such as the superior 

gluteal artery hemorrhage can be difficult to control.29

In a study of war casualties with penetrating gluteal 

injuries, surgeons noted that associated vascular injuries were present in 21% of cases, and overall, 76% 

required surgical management, with 14% developing 

postoperative complications. Transfusion requirements 
40 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

were high, length of stays were long, and associated 

injuries to local structures were common.30

Further evidence that junctional hemorrhage control is 

common comes from the weekly global video teleconference on war care. Recent casualties had 15% to 

33% with junctional bleeding.* At the US Department 

of Defense Tourniquet Summit in 2010 in Stafford, 

Virginia, US Army Special Operations Command personnel gave a presentation on the need for a junctional 

hemorrhage control device on the battlefield today. 

Although the need for hemorrhage control in 

junctional body regions is now common, the challenge 

to control that bleeding is difficult. 

HEMORRHAGE CONTROL CHALLENGE: LARGE ARTERY

LESIONS WITH JUNCTIONAL BLEEDING

Numerous aspects of vessel lesions affect hemorrhage. 

Arterial lesions are generally more lethal than venous 

lesions, and higher arterial pressure can cause more 

rapid loss of blood volumes.31 Normal blood flow in 

vessels such as an artery is related to the fourth power 

of the radius, and so larger, proximal vessels such as in 

the groin or axilla therefore have greater arterial blood 

flow than distal limb arteries. Normal blood flow is 

proportional to the fourth power of the vessel radius 

(Poiseuille’s law: Q=(∆Pπr4)/(8ηl), where Q is the 

volumetric blood flow rate; ΔP is the driving pressure 

drop; π is the mathematical constant, approximately 

3.14159; r is the vessel radius; η is the dynamic viscosity; and l is the length of the vessel).32 Blood loss is 

also faster in larger than in smaller vessels. Proximal 

arterial lesions are more lethal than distal ones, 

probably because greater vessel caliber at a higher 

pressure permits larger volume and more rapid blood 

loss.14,33 Hemorrhage rate from a vessel leak is 

estimated by a derivation of Bernoulli’s equation: 

Q=A√[(2∆P)/(ρ+v2

)], where the hemorrhage rate (Q) 

is the laceration area (A) times the square root of twice 

the transmural pressure change (ΔP) divided by the 

blood density (ρ) plus the velocity (v) squared.32,34-39

Passive vessel wall tension can increase arterotomy 

area (size of the lesion opening in the artery wall) and 

the hemorrhage rate or volume. Active wall tension 

from smooth muscle contraction can further increase 

opening size and thereby worsen hemorrhage. Further, 

casualty movement, such as limb movement, may lead 

to tissue translations, clot shear, plug disruption, and 

rebleeding which have been directly observed in animal models of hemorrhage and hemorrhage control.40

Mathematical or medical bioengineering models of 

compressible tube phenomena need more practical 

applications, not just theoretical development.41 The 

science of collapsible tubes such as arteries has only 

been partly worked out, and some applications to hemorrhage control problems indicate compression may be 

helpful, but the works are preliminary or limited.42

Although some of these principles of transmural 

pressure gradients perhaps controlling bleeding have 

been described and seem plausible, their application to 

control traumatic hemorrhage control is incomplete in 

clinical care. The ideas are promising, but the specific 

mechanisms and applications have not been evidenced 

to be effective or simple. 

Given a growing understanding of the challenge of 

junctional hemorrhage control, candidate solutions 

have been proposed. 

CANDIDATE SOLUTIONS TO CONTROL JUNCTIONAL

HEMORRHAGE

Many candidates exist to control junctional 

hemorrhage, but few are likely to be practical in the 

near term. Damage control such as emergency room 

thoracotomy and aortic clamping or simple ligation of 

major vessel injury can save casualties with critical 

injuries from exsanguination, but these solutions are in 

a hospital setting.43-45 Direct pelvic packing is gaining 

in popularity, but evidence is preliminary and also 

hospital-based.46 Particularly, application of damage 

control principles to prehospital settings has been 

difficult. Selective angiographic embolization is safe 

and effective to control refractory, life-threatening 

bleeding, but this intervention is hospital-based.47,48

Use of a clinical algorithm including diagnostic 

radiology, external skeletal fixation of pelvic fractures, 

and early angiographic embolization was effective and 

safe to rapidly control hemorrhage in hemodynamically unstable trauma patients, but these interventions 

were hospital-based specialty services.49,50 Similarly, 

hospital-based surgical interventions have included 

saline-filled Penrose drains for hepatic injury 

hemorrhage control and Foley urinary catheter use for 

hemorrhage tamponade. Extravascular balloon cathe-

*General data range summarized from the Joint Theater Trauma System weekly worldwide video teleconferences over the period July 22 through 

August 18, 2010.

New Tourniquet Device Concepts for Battlefield Hemorrhage Control 
 April – June 2011 41

THE ARMY MEDICAL DEPARTMENT JOURNAL

ters inserted into hemorrhaging wounds can control 

bleeding, but the wound-balloon interface should 

conform for best tamponade.51 A balloon-based device 

inserted into a deep, penetrating wound and inflated 

quickly to stop bleeding is analogous to that with 

which experienced clinicians may be familiar: balloons 

inserted into the esophagus or stomach to control 

internal hemorrhage from esophageal varices. However, rarely are war wounds esophagus-shaped. The 

main challenge today is big, open, bleeding war 

wounds from explosions, not tunnel-like, contained 

wounds which may be seen more with lower velocity 

gunshots or civilian wounds. Along the tamponade 

idea, iatrogenic abdominal cavity insufflation has 

decreased blood loss and improved hemodynamics in a 

pig model of traumatic venous hemorrhage, so 

iatrogenic abdominal insufflation may be a plausible 

candidate for prehospital care of abdominal injury. 

However, there are numerous physiologic risks, and 

the benefits may be limited to controlling venous 

bleeding.43 Pelvic binders or circumferential compression devices in early care of patients with unstable 

pelvic fractures appear effective, but indicated fracture 

patterns are few while other patterns are 

contraindicated. A pelvic binder can reduce so called 

“open book” pelvic ring fractures, but they can overcompress and displace the fractures into the pelvic 

cavity in certain types of fracture patterns as lateral 

compression patterns are contraindicated.52 Thus, 

binder use is decided after radiographic interpretation 

of the fracture pattern and is not first aid. However, 

prospective data concerning mortality and 

complications is limited.53 One review found that early 

emergency medical care with pelvic binders reduced 

neither hemorrhage nor mortality.54 Another study 

found that in certain fracture patterns, expert use in a 

trauma system was associated with improved survival, 

less transfusion requirements, and shorter length of 

hospital stay.55 A survey of hemostatic wound dressing 

use on the battlefield indicated that dressings were 

reported to be most useful on areas where tourniquets 

could not be applied to control bleeding, while they 

were most difficult to use in extremity injuries where 

they could not be placed easily onto or into the 

wounds.46 Recent animal experiments showed lifesaving efficacy in ideal circumstances in controlled, 

reproducible models, but human lifesaving effectiveness (as opposed to controlling hemorrhage) has 

not been evidenced, perhaps because adequate data are 

rarely collected, and the circumstances of use are 

naturally haphazard and uncontrolled.56-58

Military antishock trousers were used for hemorrhage 

control about the pelvic body region,7

 but effectiveness 

is poor, and contraindications are numerous.8-13,59-61

Along a similar line of thought as pneumatic garments 

is abdominal insufflation of air, but currently this 

experimental idea has no direct prehospital data.61

There are many candidates for controlling junctional 

hemorrhage, of which many are currently 

unevidenced, but some may show promise for specific 

lesions, certain settings, or specialists. 

HISTORICAL HEMORRHAGE CONTROL DEVICES USED

FOR JUNCTIONAL BLEEDING

Historically, several surgeons have reported using 

truncal tourniquets or compression devices on large 

arteries like the common iliac in order to control 

hemorrhage and blood flow to the lower extremity or 

pelvis. Such devices have included several designs, 

such as those shown in the Figure. Pancoast’s aortic 

tourniquet had a screw and counterpressure pad 

connected by a bar, and was similar to Lister’s device, 

which was developed nearly simultaneously and 

independently.62,63 Esmarch’s bandage, Dupuytren’s 

compressor, and other devices worked in a similar 

manner by compression of the skin and underlying 

tissues to indirectly compress large vessels like the 

common iliac artery.62 These tourniquets were asymmetric in design, in that their compression was different than the circumferential tourniquet bands used 

in the limbs. Asymmetric tourniquets were aimed to 

specifically compress the arteries preferentially, rather 

Examples of historical truncal tourniquets. 

Source: Pilcher63

Pancoast’s aortic tourniquet 

Esmarch’s aortic tourniquet 

Esmarch’s aortic tourniquet in place 

Dupuytren’s compressor used in cross section 

Gross’s dual arterial compressor 
42 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

than all tissues like the symmetric tourniquets. 

Historically, the asymmetric tourniquets occluded 

arteries by pressure point compression while intending 

to permit collateral circulation.62 These asymmetric 

devices were difficult to position correctly, required 

anatomic knowledge, were difficult to maintain in 

position, were unreliable (particularly when users were 

inexperienced), and were eventually abandoned.2

Petit’s tourniquet worked well as an asymmetric 

design, probably because it had a large mechanical 

advantage. It was positioned by an expert surgeon, and 

the casualty did not move during surgery; but it too 

was eventually abandoned. Evidence indicates that 

tourniquets have been used before in truncal or junctional areas to control hemorrhage during surgery with 

at least temporary success in expert hands.62,63 Given 

the historical track record, it may now be plausible to 

make a junctional tourniquet which will control hemorrhage if used correctly. 

An important point in the historical track record is that 

the expert hands were surgeons who had a detailed 

understanding of the arterial anatomy from a clinical 

perspective which probably helped them, but made it 

difficult for nonexperts with less anatomical knowledge to reproduce results. 

ANATOMIC AREAS OF POSSIBLE PRESSURE POINT

COMPRESSION IN HEMORRHAGE CONTROL

Collateral flow to the limb can lessen ischemiareperfusion to tissues distant to bleeding. Therefore, if 

collateral flow can be maintained concurrently with 

hemorrhage control, effectiveness may be safe. 

However, if collateral flow permits retrograde blood to 

exsanguinate from the wound, then compression is 

ineffective. To find compression points without 

collateral arteries, surgeons and investigators have 

determined that the common iliac artery and its 

internal and external branches are a possible area.64

Hemorrhage control at this area has included ligation 

or embolization of the internal iliac artery, sometimes 

bilaterally.16 In the supine position, the most common 

casualty position for routine assessment and 

transportation, the common iliac artery and aortic 

bifurcation are near the underlying bony structures on 

which a device may compress the artery closed. Here 

these arteries are compressible against the posterior 

vertebral bones. In computerized tomographic scans in 

US casualties with junctional bleeding, the distance 

from the aortic bifurcation to the fifth lumbar vertebral 

bone endplate is 1.1 cm; the bifurcation is near 

midline. The inverted-Y configuration of the common 

iliac branches (left and right) has its center posterior to 

the umbilicus, the “belly button,” a skin landmark 

offering a simple point at which to place the device. 

The common iliac artery courses over the body of the 

first sacral (S1) vertebral bone, which lies at the 

opening of the bony pelvic ring. The area to compress 

is about 7 cm long for each common iliac artery, so 

compression may be effective in about 14 cm. 

Compression of either common iliac artery stops the 

pulse in the same sided limb, and not the other side. 

Therefore, there are adequate anatomic grounds on 

which to design a system for hemorrhage control based 

on pressure point compression in the pelvic area. A 

consideration of the physiology follows. 

PHYSIOLOGIC BASIS OF CONTROLLING JUNCTIONAL

BLOOD FLOW BY COMPRESSION

The physiology of aortic and common iliac artery 

compression has been studied in normal volunteers, 

and compression has shown effective control of blood 

flow to the distal extremities.64 Investigators at the 

Medical College of Georgia modeled control of 

hemorrhage in critical femoral or inguinal penetrating 

wounds in an ultrasound evaluation.64 The investigators studied a model of hemorrhage control in 

normal volunteers (9 men) by artery compression. The 

investigators noted that exsanguination from a femoral 

artery wound can occur in seconds and that it may be 

seen more often now with more body armor use. The 

investigators wrote that military physicians 

recommend compression of the common iliac arteries 

with a knee or a fist as a temporary measure. The 

supine volunteers (on the floor) had a dumbbell from a 

gymnasium placed vertically on a common bath towel 

(tightly bundled to roughly the size and shape of an 

adult knee) near the umbilicus in order to see if the 

artery blood flow was stopped. Using ultrasound, the 

investigators measured the flow with various weights. 

Flow was consistently stopped given that the weight 

was adequate and the compression was accurate. 

Aortic compression of 80 to 140 pounds led to no flow 

in the common femoral artery. For all 9 volunteers, up 

to 80 pounds of pressure over the distal iliac artery 

failed to decrease common femoral artery flow 

velocity, and no subject was able to tolerate more 

weight at that location. Therefore, there are adequate 

physiologic grounds on which to design a system for 

New Tourniquet Device Concepts for Battlefield Hemorrhage Control 
 April – June 2011 43

THE ARMY MEDICAL DEPARTMENT JOURNAL

hemorrhage control based on pressure point compression in this area, and the proximal portion of the 

common iliac arteries appears to be the target zone. 

The investigators concluded that flow to the common 

femoral artery can be stopped completely with pressure over the common iliac artery and that such pressure could be feasibly used in catastrophic wounds. 

Compression over the common iliac artery worked 

best, but a first responder still may need to apply 

upward of 120 pounds of pressure to stop arterial 

exsanguination.64 Furthermore, as the study noted no 

complications, compression may be used safely. 

A preliminary animal study, also from the Medical 

College of Georgia, examined the efficacy and safety 

of a novel, externally applied pneumatic abdominal 

tourniquet to halt blood flow from the abdominal aorta 

in 2 pigs.65 This study demonstrated the device’s 

efficacy. Although there was no sign of direct tissue 

injury, the rise in serum potassium in one animal was 

concerning, and further research was recommended.65

Therefore, the physiological evidence indicates that a 

well-designed device could plausibly control hemorrhage. A consideration of how a device would be used 

follows. 

CONCEPT OF OPERATIONS: DEVICE TRAITS FROM THE

USER’S VIEWPOINT

The concept of how a junctional tourniquet would be 

used in war is yet to be fully developed in order to 

communicate the system characteristics to 

stakeholders, but regular tourniquets are a model from 

which adaptations can be used. For example, to save 

lives, a truncal tourniquet is designed to control 

prehospital bleeding, as is the goal of regular 

tourniquets. Regular tourniquets are an integrated 

capability for far-forward medical care to reduce 

mortality and morbidity associated with major 

battlefield wounds and injuries. We aim for truncal 

tourniquets to also be such a capability. Specifically, 

novel prototype tourniquets for hemorrhage control of 

truncal injuries on the battlefield may increase, like 

regular tourniquets, the duration of survival of a 

casualty so as to permit transport to a forward surgical 

facility. Longer survival is a practical objective, which 

permits better resuscitation and life-saving 

interventions. The intended use scenario is for a senior 

medic or a physician assistant working under the 

supervision of a physician at a forward location, such 

as a battalion aid station. The intended users need 

adequate anatomic knowledge and specific device 

training to apply the device and control hemorrhage in 

the prehospital or far forward setting. The truncal 

tourniquet would permit hemorrhage control for 

casualty evacuation by occluding deep truncal vessels 

with distal bleeding by compressing sites where 

standard tourniquets cannot be applied. Desirable traits 

of candidate devices, presented in the Table, should fit 

within the needs of the user, in this case, senior medics 

in the field. Furthermore, the design of the candidate 

devices, the instructions on use, and the anatomic 

knowledge required constrain the device candidates to 

use by senior medics who are well trained in the 

specific device. The prehospital strategy was 

successful for regular tourniquets, first in special 

operations forces and then in conventional forces, and 

a similar tactic for truncal tourniquets is planned. The 

evidence of best tourniquet practice helped refine 

regular tourniquet doctrine serially, and a similar tactic 

is planned for truncal tourniquets. Current stakeholders 

include the device makers and users, the regulators 

(the US Food and Drug Administration), the researchers (Wake Forest University Medical Center, the 

Unites States Army Institute of Surgical Research), 

and the developers (United States Army Medical 

Materiel Development Agency). Interactions among 

participants have included a teleconference and 

correspondence which facilitated the regulatory 

pathway and approval of the Combat Ready Clamp as 

the first hemorrhage control device for prehospital use 

for groin hemorrhage. Orders for the Combat Ready 

Clamp have been placed for limited introduction into 

the field. Initial distribution in November 2010 was 

planned for a select unit, and if results are promising, 

Stops bleeding effectively from junctional areas such as the groin, 

pelvis, buttock, shoulder or neck 

Compresses sites where regular tourniquets cannot fit 

Safe to use 

Can be used well in prehospital on the battlefield in tactical situations 

Small 

Lightweight 

Low-cost 

Easy to use; requires minimal training or familiarization 

Quickly applied 

Does not slip on tightening or in use 

Provides easy release of compression 

Easy to reapply 

Long shelf life 

Desirable traits of candidate device. 
44 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

wider distribution will follow. The clamp is not yet 

evidenced in clinical practice, but some preliminary 

preclinical evidence, such as in cadavers, is promising. 

Given this concept of how users would operate the 

device, delimitation of research models, knowledge 

gaps, and device development challenges can help 

guide the way forward. 

ANIMAL AND HUMAN MODELS, RESEARCH GAPS, AND

DEVELOPMENT CHALLENGES

In lethal animal models of exsanguination, groin or 

junctional areas are often selected and numerous hemostatic substances or dressings have shown variable 

capacity to control bleeding, while some improve 

survival.40,66-69

Currently, there is a gap regarding the way in which 

junctional bleeding can be practically modeled and 

devices tested for efficacy in humans. For example, 

there are no well-established models to control bleeding in humans, and surrogate models such as normal 

volunteers have limitations. Current gaps in the literature include an establishment of a reliable human model of junctional hemorrhage that can be used to test 

several devices, as repeated testing in volunteers is uncomfortable. A recent Medical College of Georgia study using normal volunteers indicated that such compression by a weight (dumbbell) worked well, but testing 

was painful in one area, and numbers of tests were 

limited.64 The scalability of the pressure exerted and 

the flow stopped gave further evidence of cause and 

effect between such compression and flow control, but 

ultrasonically detected flow in a normal artery was 

only a surrogate of bleeding. Perhaps a human cadaver 

model with simulated blood pumped out of a wound 

would permit proximal pressure point control of hemorrhage. Testing of device effectiveness rates with specific repeatable bleeding wounds may then be possible. 

Human and animal data regarding the effects of 

compression on blood flow, hemorrhage, or swelling 

have some relevance to hemorrhage control solutions, 

but the works have had limited application to the real 

world. The compression of limbs decreases tissue perfusion which is most important in skeletal muscle, the 

limb tissue most sensitive to prolonged ischemia. The 

perfusion quality depends in part on the amplitude of 

the artery-venous pressure gradient.70 The hydrodynamics of arterial hemorrhage indicate that the rate of 

leakage (simulated hemorrhage) is associated both 

with the transmural pressure gradient and the area of 

the vessel opening (simulated laceration of the wall).36

The lesion size of the vessel opening of simulated 

trauma resulting in hemorrhage has been associated 

with both the amplitude of the resultant drop of blood 

pressure and the magnitude of the counterpressure 

required for control.32 For short segments of vessels 

like arteries, increasing external pressure has little to 

no effect on flow within the vessel.34 However, when 

long segments are compressed, the flow stoppage can 

occur at low or even subsystolic pressures.71 Evidence 

indicates that circumferential pneumatic compression 

of limbs at 20 to 30 mm Hg may control arterial 

bleeding and yet not interrupt limb perfusion.72

Although counterpressure at an arterial bleeding lesion 

can improve survival in animals, such benefits come at 

a physiologic cost, namely metabolic acidosis, 

particularly with prolonged duration.35 Other gaps 

include doctrine of device use, adequate lesson plans, 

user training in specific devices, and casualty 

simulator use in assessing trainee competency. 

CONCLUSION

If a candidate junctional hemorrhage control device 

can be designed from a mechanical standpoint to 

specifically compress the target tissues reliably and 

precisely, and be demonstrated as safe when tested in a 

volunteer study, then it could be a successful device 

for medics trained in its use. Fielding of such a device 

may prevent casualty deaths. Although the technology 

of a truncal tourniquet may have been available as 

long ago as 1831, the integrated systems approach that 

demonstrated the remarkable success of regular 

tourniquets recently was not. We discussed the gaps 

today in battlefield hemorrhage control, and we 

surmise that an integrated systems approach to 

junctional hemorrhage control is our current best hope 

in minimizing a current, common cause of preventable 

death on the battlefield. 

ACKNOWLEDGEMENTS

COL Kragh has consulted at no cost with Tiger 

Tourniquet, LLC; Tactical Medical Solutions, LLC; 

Combat Medical Solutions, Inc; Composite Resources 

Inc; Delfi Medical Innovations, Inc; North American 

Rescue Products, LLC; H & H Associates, Inc; Creative 

& Effective Technologies, Inc; TEMS Solutions, LLC; 

Blackhawk Products Group; Combat Medical Systems, 

LLC; Hemaclear; Tactical Development Group; 

New Tourniquet Device Concepts for Battlefield Hemorrhage Control 
 April – June 2011 45

THE ARMY MEDICAL DEPARTMENT JOURNAL

Compression Works, LLC; Tier-One Quality Solutions; 

Kforce Government Solutions; CHI Systems; and 

Entrotech, Inc. He has received honoraria for work for 

the US Food and Drug Administration for device 

consultation. He has received honoraria for trustee work 

for the nonprofit Musculoskeletal Transplant 

Foundation. He has worked as a technical 

representative to the US Government’s contracting 

officer in agreements with Physical Optics Corporation; 

Resodyn Corporation; International Heart Institute of 

Montana Foundation; Daemen College; Noble 

Biomaterials, Inc; Wake Forest Institute of 

Regenerative Medicine; National Tissue Engineering 

Center; Pittsburgh Tissue Engineering Initiative; 

University of Texas Southwestern Medical Center; 

Arteriocyte, Inc; and Kelly Space and Technology, Inc. 

The authors thank Otilia Sánchez and Roy Sanders for 

their assistance in preparation of this article.

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48 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

New Tourniquet Device Concepts for Battlefield Hemorrhage Control 

AUTHORS

COL Kragh is an Orthopedic Surgeon, US Army Institute of Surgical Research, Fort Sam Houston, Texas. 

Mr Murphy is Director of Research and Development, Combat Medical Systems LLC, Fayetteville, NC. 

Dr Dubick is a Research Physiologist, US Army Institute of Surgical Research, Fort Sam Houston, Texas. 

Dr Baer is Director of Research, US Army Institute of Surgical Research, Fort Sam Houston, Texas. 

Dr Johnson is Director, Center for Applied Learning, Wake Forest University Medical Center, Winston-Salem, NC. 

The winning poster in the Combat Medic Transition poster contest, 

submitted by Sgt Christopher Giddinge, US Army Medical Research 

Institute of Infectious Disease, Fort Detrick, Maryland. 
 April – June 2011 49

INTRODUCTION

Traumatic brain injury (TBI) is a leading cause of 

death and disability on the modern battlefield. During 

World War I, TBI was referred to as “shell shock.” 

Whether this entity was physical or psychological in 

origin was a subject of considerable debate. At the 

onset of World War II, British authorities banned use 

of the term in order to avoid contamination of the 

ranks by what was, by then, viewed as a factitious 

disorder. Resumed appreciation for the organic 

etiology of many of these injuries led to a new term 

during World War II, “postconcussion syndrome.”1

Our current definition of TBI emphasizes that it is a 

“traumatically induced structural injury and/or 

physiological disruption of brain function as a result of 

an external force” with at least one of the following 

clinical signs2,3: 

 Decreased level of consciousness 

 Amnesia for events surrounding injury 

 Changed mental state at time of injury (confusion, 

disorientation, slowed thinking) 

 Neurological deficits (weakness, loss of balance, 

change in vision, praxis, paresis/plegia, sensory loss, 

aphasia, etc.) 

 Intracranial lesion 

TBI is classified as mild, moderate, or severe2,3: 

Mild – Glasgow Coma Scale* (GCS) 13-15; loss of 

consciousness (LOC) less than 1 hour; amnesia less 

than 24 hours. 

Moderate – GCS 9-12; LOC 1 to 24 hours; amnesia 1 

to 7 days 

Severe – GCS 3-8; LOC more than 24 hours; amnesia 

longer than 7 days 

Furthermore, the confusion experienced during World 

Wars I and II concerning whether TBI was psychological or physiological in origin has been resolved, at 

least in part, by recognizing that the symptoms of 

posttraumatic stress disorder and TBI overlap 

significantly, especially in the areas of attention, 

depression, and anxiety.3,4

What is the importance of TBI on today’s battlefield? 

During the current conflicts in Iraq and Afghanistan 

(Operations Iraqi Freedom (OIF) and Enduring 

Freedom (OEF)), TBI has been a major cause of 

injury, leading some to call TBI the “signature injury” 

of these wars. Roughly half of these TBI cases are 

moderate or severe.5

 Hospitalizations for TBI were 

greater in OIF than in OEF, and the overall trend was 

for an increase in TBI admissions in both theaters 

during the period 2003 through 2007.6

 There are 

several possible explanations for an increase in survivors of TBI during OIF and OEF, compared to 

previous conflicts. Increased use of improvised explosive devices has subjected more casualties to the concussive effects of blast injury. One review indicated 

that 59% of blast injury patients admitted to the Walter 

Reed Army Medical Center had TBI.5

 Improvements 

in body armor have decreased the number of lethal torso injuries, while improvements in helmets may have 

decreased the lethality of head injuries. Improvements 

in prehospital care, such as better tourniquets, and in hospital care, such as damage control surgery, have improved the survival of patients who otherwise would 

have died from nonhead trauma. Finally, improved 

screening has likely detected more cases of mild TBI.2,5,7

Thus, a workshop cosponsored by the National 

Academy of Engineering and the Institute of Medicine 

reported that between January 2003 and April 2006, 

The Role of Normoventilation in Improving 

 Traumatic Brain Injury Outcomes 

COL Leopoldo C. Cancio, MC, USA 

MAJ(P) Kevin K. Chung, MC, USA 

*The Glasgow Coma Scale is a quick, practical, standardized system for assessing the degree of consciousness in the critically ill 

and for predicting the duration and ultimate outcome of coma, primarily in patients with head injuries. The system involves eye

opening, verbal response, and motor response, all of which are evaluated independently according to a rank order that indicates

the level of consciousness and degree of dysfunction. Source: Mosby’s Medical Dictionary. 8th ed. St Louis, MO: Mosby-Year 

Book, Inc; 2009. 
50 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

28% of combat casualties from OIF and OEF receiving 

care at Walter Reed had a TBI.3

 In a prospective study, 

nearly 15% of 2,525 infantry Soldiers from 2 combat 

brigades returning from Iraq in 2006 had an injury 

resulting in altered mental status or loss of 

consciousness.8

 Kelly and colleagues9 reported on 982 

US military deaths from OIF and OEF during the 

period 2003 through 2006. Considering the cause of 

death for those casualties deemed by the authors to 

have potentially survivable injuries, TBI constituted 

9%.9

 A study by Owens et al10 of wounding patterns in 

the same conflicts demonstrated a greater proportion 

of head and neck wounds compared to other body 

areas than in the previous 3 wars (Vietnam, Korea, and 

World War II). Specifically, head and neck wounds 

now constitute 30% of injuries. The overwhelming 

majority of these head and neck injuries are caused by 

explosions.10 Galarneau et al11 queried data from the 

Navy-Marine Corps Combat Trauma Registry for OIF 

for a 7-month period during 2004. The data revealed 

that 115 patients had TBIs, of whom 13% died (killed 

in action or died of wounds). Another 43% were 

medically evacuated.11 

PREHOSPITAL CARE OF TBI CASUALTIES

What is the current prehospital standard of care for 

head-injured patients? In contrast to the high incidence 

of TBI on the battlefield, therapeutic options for 

prehospital combat casualty care of TBI patients 

remain limited. The Brain Trauma Foundation*, under 

a grant from the Defense and Veterans Brain Injury 

Center†

, published Guidelines for Field Management 

of Combat-Related Head Trauma in 2005.12 It includes 

the following recommendations: 

 Airway: Patients with Glasgow Coma Scale score 

below 9 should be intubated, depending on operator skill. 

 Oxygenation: Hypoxemia should be prevented, 

pulse oximetry should be performed, and oxygen 

saturation (SaO2) maintained above 90%. 

 Ventilation: Use of hyperventilation should be 

minimized, and limited to those patients exhibiting 

evidence of herniation. End-tidal CO2 (ETCO2) 

monitoring should be performed to help guide 

ventilation in intubated patients, with a goal of 25-

35 mm Hg. 

 Circulation: Hypotension should be avoided, the 

blood pressure measured, and fluid resuscitation administered for all casualties with systolic blood pressure below 90 mm Hg. Hypertonic saline may be 

preferable to isotonic saline as a resuscitation fluid. 

The common theme in these prehospital guidelines is 

avoidance of further injury to the TBI patient. 

Avoidance of hypotension and hypoxia serve the goals 

of maintaining oxygen delivery to ischemic, or 

potentially ischemic, brain tissue. Avoidance of 

hyperventilation serves a similar goal, via the effect of 

the PaCO2 (partial pressure of carbon dioxide in 

arterial blood) on cerebral blood flow. It is well known 

that a primary determinant of cerebral blood flow is 

the PaCO2. A decrease in the PaCO2 causes cerebral 

vasoconstriction and a decrease in cerebral blood flow. 

Thus, the only indication for hyperventilation in the 

brain-injured patient is impending herniation. In this 

situation, hyperventilation and decreased cerebral 

blood flow may decrease intracranial pressure enough 

to forestall death, buying time for other measures such 

as diuresis, hypertonic fluid infusion, and/or decompressive craniectomy to be performed. Short of this, 

hyperventilation and hypocapnia cause decreased 

blood flow to ischemic brain tissue, worsening outcomes following TBI. Because of these concerns, 

some authors recommend against performing hyperventilation in TBI patients without monitoring the 

jugular venous oxygen saturation, partial pressure of 

oxygen in brain tissue, or cerebral blood flow.13 

CLINICAL DATA ON PREHOSPITAL VENTILATION OF

TBI PATIENTS

How successful are we at achieving these goals for 

ventilation during prehospital care? CPT John Ritchie 

and colleagues from the US Army Institute of Surgical 

Research conducted a prospective observational study 

of TBI patients admitted to a single combat support 

hospital (CSH) in Iraq during the period 2007 through 

2009. These patients were all intubated, either in the 

prehospital setting or upon arrival at the CSH 

emergency department. The partial pressure of carbon 

dioxide (PCO2) was measured either in arterial blood 

(PaCO2), or in venous blood (PvCO2) with estimation 

of the PaCO2. A PaCO2 of 35-40 mm Hg was assumed 

to be the appropriate therapeutic target range. None of 

the patients who were ventilated by bag-valve mask 

before arrival at the CSH had a PaCO2 in the target 

range, and only 41% of patients who were intubated 

(and then bag ventilated) before arrival were in the 

The Role of Normoventilation in Improving Traumatic Brain Injury Outcomes 

*Information available at: http://www.braintrauma.org/ 

†Information available at http://www.dvbic.org/ 
 April – June 2011 51

THE ARMY MEDICAL DEPARTMENT JOURNAL

target range. (No patients in this study were intubated 

and then ventilated by mechanical ventilator.) CPT 

Ritchie (oral communications, 2010) and his colleagues concluded that improvements in technology 

may be needed to improve this aspect of care. 

What is the impact of errors in ventilation and 

oxygenation on mortality? Davis and colleagues in San 

Diego have studied the problem of prehospital ventilation of head-injured civilian trauma patients for 

many years. Using data from San Diego County, they 

demonstrated that, contrary to common belief, 

paramedic-performed rapid sequence intubation was 

associated with an increase in mortality and a decrease 

in good outcomes compared with historical controls.14

In a subsequent analysis, both hyperventilation and 

severe hypoxia were shown to be independently 

associated with increased mortality.15 A trauma 

registry study of over 13,000 patients confirmed that 

prehospital intubation was associated with increased 

mortality in patients with moderate to severe head 

injury.16 Davis et al then expanded their analysis of the 

San Diego data, finding that both hyperventilation and 

hypoventilation were associated with worse outcomes 

in intubated, but not in nonintubated, head-injured 

patients. Furthermore, they found an optimal range for 

prehospital PaCO2 of 30-49 mm Hg.17 A recent publication by the same group using Trauma Injury Severity 

Score methodology refined these conclusions by documenting that intubation improved survival in a subset 

of severely injured patients with low predicted survival.18 Other authors report findings similar to those 

by Davis et al. Chi and colleagues19 prospectively enrolled patients with head injuries into an observational 

multicenter study. Of 150 patients, 57 had prehospital 

“secondary insults” of hypotension or hypoxia. Hypoxia increased mortality and the Disability Rating Scale. 

The combination of hypoxia and hypotension had an 

additive effect on these measures.19 

END-TIDAL CARBON DIOXIDE MONITORING

What can be done to improve prehospital ventilation in 

head-injured patients? The most obvious solution is to 

provide medics with an estimate of the PaCO2. The 

most immediately available measurement for this estimate is the ETCO2, available on many transport monitors in the field today (eg, Propaq MD Monitor, ZOLL 

Medical Corporation, Chelmsford, MA). The major 

problem with using the ETCO2 as an estimate of the 

PaCO2 is the fact that the difference (gradient) 

between the 2 numbers varies, depending on various 

cardiopulmonary factors. The most important of these 

factors is the physiological dead space. The physiological dead space (VD) is composed of the anatomic 

dead space and the alveolar dead space. Anatomic 

dead space is the volume of the conducting air spaces, 

ie, the trachea, bronchi, bronchioles, and other portions 

of the airway which conduct air but which do not participate in gas exchange. Alveolar dead space is the volume of unperfused spaces at the alveolar level.20,21

Wagner pointed out that in addition to unperfused 

alveoli, high ventilation-perfusion compartments (or, 

less frequently, low ventilation-perfusion compartments) also contribute to an increased alveolar dead 

space.22 Clinical conditions which increase the PaCO2 -

ETCO2 gradient include decreased pulmonary perfusion (eg, hemorrhagic shock causing decreased cardiac 

output, pulmonary embolism, cardiac arrest, air embolism), and airway obstruction (including severe bronchospasm).21,23 Acute lung injury and acute respiratory 

distress syndrome increase VD and thus the PaCO2 -

ETCO2 gradient, likely by means of pulmonary vasoconstriction, microthrombi, and/or endothelial swelling.24

Considering the fact that multiple factors present in 

trauma patients may influence the PaCO2 -ETCO2

gradient, it is evident that the ETCO2 is not a perfect 

surrogate for the PaCO2. Several of the best studies of 

this problem have been conducted in Europe, where 

physicians frequently provide prehospital care, and 

arterial blood gas analysis is therefore feasible in that 

environment. Belpomme et al25 prospectively measured PaCO2 and ETCO2 during transport of 100 

prehospital, mechanically ventilated patients with 

various diseases. The main finding was that the PaCO2 -

ETCO2 gradient varied widely among patients, but did 

not differ significantly during transport (mean values 

of 8.6 ± 13.5 mm Hg at start, and 7.3 ± 13.0 mm Hg at 

end transport).25 Helm and colleagues26 conducted a 

prospective study of 97 mechanically ventilated 

trauma patients. Patients for whom the attending 

anesthetist could see the ETCO2 monitor had a higher 

incidence of normocapnia than those in situations 

where the anesthetist was blinded. Interestingly, 

patients with severe TBI or chest trauma, hemodynamic instability, or high injury severity scores were 

more likely to be ventilated appropriately. In that 

study, the ETCO2 target was 30-35 mm Hg for regular 

patients, and 25-30 mm Hg for hemodynamically 

unstable or chest trauma patients.26 
52 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

Yamanaka and Sue,27 among others, have 

demonstrated that directly measured VD correlates 

with the PaCO2 -ETCO2 gradient. The usual method of 

measuring VD, however, requires collection of expired 

gas in a Douglas bag and is thus clinically 

impractical.27 One way to overcome the limitations of 

conventional capnography for estimation of the PaCO2

is volumetric capnography. Conventional devices 

measure the ETCO2 by analyzing the partial pressure 

of CO2 in exhaled air as a function of time. But the 

volumetric capnograph (volume-based capnograph) 

provides additional information on pulmonary function 

by analyzing the partial pressure of CO2 in exhaled air 

as a function of exhaled volume. This approach 

provides data which are independent of the expiratory 

flow rate.28 The volumetric capnograph consists of 3 

phases. Phase I is a flat, low CO2 phase and corresponds to exhalation from the anatomic dead space. 

Phase II is a steeply rising phase and corresponds to 

the exhalation of mixed air. Phase III is a plateau 

phase with a slowly rising slope which corresponds to 

exhalation of alveolar air. The different portions of this 

curve can be quantified (parameterized). It is then 

possible to estimate VD using a method called the 

“single-breath test for carbon dioxide.”29 This method 

requires simultaneous measurement of the PaCO2, and 

use of the Enghoff modification of the Bohr equation 

where PECO2 is the mixed exhaled PCO2 measured by 

the volumetric capnograph, and physiological dead 

space is expressed as a fraction of the total tidal volume (VT).30 The following data from McSwain et al 

demonstrate the relationship between VD/VT measured 

by volumetric capnography, and the PaCO2-ETCO2

gradient30: 

It can be seen that VD / VT is a function of the PaCO2 -

ETCO2 gradient (higher VD/VT is associated with higher gradient), and that within each VD / VT range, the 

correlation between PaCO2 and ETCO2 is reasonably 

high. In other words, if VD / VT is known and stable, 

ETCO2 becomes a reasonable surrogate for PaCO2. 

The problem is that calculation of VD / VT requires 

measurement of the PaCO2, and thus still remains “out 

of bounds” for prehospital combat casualty care. 

Nevertheless, it would be premature to discard 

volumetric capnography. The capnograph likely 

contains information which can be harnessed to refine 

our ability to predict PaCO2. An analogous concept 

was described by Patel and colleagues in the diagnosis 

of pulmonary embolus.31 These authors trained an 

artificial neural network (ANN) using 17 variables 

from the volumetric capnograph to estimate the 

presence or absence of pulmonary embolus (PE). In 53 

test subjects, PE was detected with a sensitivity of 

100% and a specificity of 48%.31 Rayburn also 

described an ANN which uses the volumetric 

capnograph to estimate the PaCO2.

32 This ANN was 

trained using 82 datasets from patients with a variety 

of pulmonary conditions. According to Rayburn (oral 

communication, D. B. Rayburn, 2009), the correlation 

coefficient between estimated and measured PaCO2

using this ANN was high, and the difference between 

the 2 values was no greater than ±2 mm Hg. We are 

currently validating this ANN using data from a 

porcine model of acute respiratory diseases secondary 

to pulmonary contusion. 

TRANSCUTANEOUS CO2

Are more accurate methods of estimating PaCO2

available? The closest and most promising solution is 

the direct measurement of CO2 at the level of the tissue 

in the form of transcutaneous CO2 (PTCCO2). In a 

recent study, Hinkelbein and colleagues prospectively 

measured PaCO2, ETCO2, and PTCCO2 in 34 patients 

scheduled for interhospital transport.33 This study was 

unique in that these 3 measurements were compared 

simultaneously. PTCCO2 more accurately estimated 

PaCO2 when compared to ETCO2. Not surprisingly, 

subgroups with high FiO2 (fraction of inspired oxygen) 

or with respiratory failure had significant increases in 

the PaCO2 -ETCO2 gradient, highlighting the 

limitations of ETCO2 measurement.33 The reliability of 

PTCCO2 has been described previously in other 

populations.34,35 Although very promising and 

available from multiple vendors (SenTec Digital 

Monitoring System, Therwil, Switzerland; TOSCA, 

Linde, Basel, Switzerland; Tina TCM4 device, 

Radiometer Copenhagen, Bronshoj, Denmark), 

PTCCO2 has a number of limitations which would 

make it difficult to field without some refinement. The 

greatest limitation is the relative bulk of the monitors, 

The Role of Normoventilation in Improving Traumatic Brain Injury Outcomes 

VD

VT

ൌ PaCO2 െ  PECO2

PaCO2

VD / VT Range <0.40 0.41-0.55 0.56-0.70 >0.70 

PaCO2-ETCO2

gradient 0.3±2.1 5.9±4.3 13.6±5.2 17.8±6.7

Correlation 

coefficient 

(PaCO2 vs ETCO2) 

0.95 0.88 0.86 0.78 
 April – June 2011 53

THE ARMY MEDICAL DEPARTMENT JOURNAL

which are only available as standalone devices. Frequent calibrations using a CO2 standard, incorporated 

within each device, are required. Additionally, these 

devices employ heat-generating sensors, which creates 

a potential for thermal injury. Like many noninvasive 

sensors, signal quality is significantly diminished in 

shock states such as hemorrhage. 

CONCLUSION

Traumatic brain injury, including moderate and severe 

TBI, is a significant and growing problem on the 

contemporary battlefield. In civilian studies, 

ventilation which achieves a PaCO2 within a target 

range is associated with improved survival following 

TBI. However, data from the battlefield indicate that 

such “normoventilation” is achieved in a minority of 

casualties who require ventilatory support. In order to 

address this problem, both training and technological 

improvements are needed. Medics should receive 

training directed at improving their skills in hand 

ventilation and, in particular, should be trained in the 

importance of avoiding over-ventilation in patients 

with TBI. Medics should also be provided with 

technology which increases their ability to ventilate 

their casualties in a manner which achieves the target 

PaCO2. We see 3 options for doing this: 

Measurement of the ETCO2 using traditional, timebased capnography, with use of rules for adjusting the 

rate and depth of ventilation in order to achieve a 

desired target range for the ETCO2. This was the 

method successfully performed by Helm et al.26 This 

approach has the disadvantage of adding an additional 

sensor to a future prehospital vital signs monitor, but 

small, lightweight ETCO2 monitors are now available. 

Helm’s target ranges for the ETCO2 appear reasonable 

(30-35 mm Hg for stable patients, and 25-30 mm Hg 

for unstable patients), but the impact of dead-space 

ventilation cannot be completely overcome. 

Estimation of the PaCO2 using volumetric 

capnography and an ANN or similar machine-learning 

approach.32 In addition to the points made above about 

time-based capnography, this method would require 

further validation prior to implementation. 

Estimation of the PaCO2 using another technique such 

as PTCCO2, as described by Hinkelbein and others.33

This method would require use of an additional sensor 

which is not commonly used in prehospital or critical 

care settings at present, and would also require sensor 

improvements. Also, the performance of such a sensor 

in patients with hemorrhagic shock would have to be 

validated. On the other hand, PTCCO2 has the potential 

advantage of providing an estimate of PaCO2 which is 

independent of dead-space ventilation. 

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injury. Curr Opin Cril Care. 2010;16(1):45-52. 

14. Davis DP, Hoyt DB, Ochs M, et al. The effect of 

paramedic rapid sequence intubation on outcome in 

patients with severe traumatic brain injury. J Trauma.

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15. Davis DP, Dunford JV, Poste JC, et al. The impact of 

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16. Davis DP, Peay J, Sise MJ, et al. The impact of 

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17. Davis DP, Idris AH, Sise MJ, et al. Early ventilation 

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18. Davis DP, Peay J, Sise MJ, et al. Prehospital airway 

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AUTHORS

COL Cancio is Consultant Surgeon, Combat Critical 

Care Engineering Task Area, US Army Institute of 

Surgical Research, Fort Sam Houston, Texas. 

MAJ(P) Chung is Medical Director, Burn Intensive 

Care Unit, US Army Institute of Surgical Research, 

Fort Sam Houston, Texas. 

The Role of Normoventilation in Improving Traumatic Brain Injury Outcomes 
 April – June 2011 55

INTRODUCTION

Wartime often leads to advances in medical care as 

unique problems that surface in an austere environment necessitate urgent solutions. Current combat 

operations in Iraq and Afghanistan have been no 

different in their impact on burn care, specifically with 

regard to fluid resuscitation. The influx of severely 

burned combat casualties globally evacuated to our 

burn center at the US Army Institute of Surgical 

Research in Fort Sam Houston, Texas [hereinafter 

referred to as the Burn Center], began in early 2003 

and has continued through 2010. As the flow of those 

casualties continued, we discovered processes in need 

of improvement and addressed them in a timely and 

robust manner. Such initiatives included reevaluation 

of the initial fluid resuscitation of burn casualties, as 

well as continued resuscitation during en route care. 

A SIMPLIFIED APPROACH TO FLUID RESUSCITATION IN

BURNS

Overview 

Arguably one of the more challenging aspects of the 

initial management of severe burn casualties is the 

fluid resuscitation necessary to prevent or mitigate 

burn shock and multiple organ failure. Longstanding 

recommendations provided by the American Burn 

Association (ABA) include initiating fluid 

resuscitation of the burn patient utilizing lactated 

Ringers solution, at an infusion rate of 2 to 4 cc/kg/

percentage total body surface area (TBSA) burn 

administered over the first 24 hours following the burn 

injury (postburn); providing one-half of estimated fluid 

over the first 8 hours, and the remainder over the next 

16 hours.1

 This ABA resuscitation guideline is 

intended to give the provider a prediction of how much 

fluid should be given over an entire 24-hour period. 

Although, predicting the total amount of volume that 

the patient should receive in a 24-hour period via 

formula is helpful in assessing the precision of the 

resuscitation post hoc, it should not be used to strictly 

dictate what the patient receives hour to hour. Once 

initiated, the ultimate goal of fluid resuscitation is to 

maintain end-organ perfusion by gradually restoring 

fluid balance while simultaneously replacing insensible losses and avoiding the consequences of both 

under- and over-resuscitation. Optimal care of the burn 

casualty during the early phase of resuscitation requires an attentive medic titrating fluid therapy based 

on a compilation of various endpoints centered on a 

goal of maintaining a urine output of 30-50 ml/hr. 

Urine output of between 30-50 ml/hr is generally 

accepted as a corollary of renal perfusion indicative of 

adequate initial resuscitation in casualties with isolated 

burn injuries. Thus, the practical purpose of any 

formula is to identify an appropriate starting point for 

the resuscitation, the initial infusion rate. A prediction 

of how the first 24 hours should go, the centerpiece of 

the current resuscitation guidelines, may place the 

focus of the resuscitation away from the “art” of 

resuscitation. 

Prehospital Burn Resuscitation 

Despite general instructions that the predicted fluid 

requirements are designed to serve only as guidelines, 

and that actual resuscitation should be based on patient 

response, many nonburn providers either err on the 

side of adhering strictly to the formulae regardless of 

patient response, or not utilizing them at all. A post 

hoc analysis of prehospital fluid resuscitation practices 

was performed using data collected from an 

institutional review board-approved prospective 

observational trial assessing resuscitation practices in 

the Burn Center. We reviewed the records of 39 

civilian burn patients admitted to the Burn Center with 

severe thermal injury greater than 20% TBSA. At the 

time of admission to the Burn Center, we carefully 

recorded the time of burn, total prehospital fluids 

given, weight in kilograms, and estimated percentage 

TBSA burn. We used this data to estimate initial rate 

Advances in Prehospital Burn Resuscitation 

 for the Combat Injured 

MAJ(P) Kevin K. Chung, MC, USA 

Jose Salinas, PhD 

COL Evan M. Renz, MC, USA 
56 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

of fluid begun for each patient in the first hour 

postburn. We then determined the formula, in 

cc/kg/percentage TBSA, that would have been 

used to derive that initial rate. Essentially, we 

wanted to evaluate which, if any, formula the 

pre-Burn Center providers were using, in cc/kg/

percentage TBSA, to calculate the patient’s initial fluid resuscitation rate. The results (Table 1) 

were plotted (Figure 1) and compared to current 

ABA guidelines. We discovered that only 21% 

of all patients (8/39) were being initiated on a 

fluid rate what would have been derived using 

the 2-4 cc/kg/percentage TBSA formula recommended by the ABA. Thus, we concluded that 

prehospital providers situated in a large city in 

the United States were not using a formula to 

determine the initial fluid rate. If US prehospital 

providers are not using a formula, it is highly 

unlikely that providers deployed to austere 

environments, often tending to multiple casualties 

simultaneously, are using a formula. 

The most likely reason for this lack of adherence 

among prehospital providers is the fact that the 

formulae are too complex, requiring multiple steps. 

For example, the calculated rate for a patient weighing 

70 kg who has suffered a 50% TBSA burn requires 4 

separate variables (time, weight, surface area, and 

volume) with a minimum of 4 computations that must 

be performed. Such calculation results in an initial 

fluid rate of 437 ml/hr when using the Modified 

Brooke formula (2 cc/kg/percentage TBSA).1

 The 

likelihood of a combat provider at the level I or level II 

echelon of care performing this calculation under 

duress or in the face of multiple casualties is 

exceedingly low. 

The Rule of 10 

Surely, a more simple method could be found to derive 

this initial fluid rate. Enter the “Rule of 10” (see inset 

below). Recently conceived and validated in silico 

[computer simulation] at the US Army Institute of 

Surgical Research (ISR),2

 the Rule of 10 is a 

simplified formula that calculates the initial fluid 

resuscitation rate by multiplying the estimated burn 

size by 10. In the example given above, multiplying 

the surface area of burn (50%) by 10 results in an 

Advances in Prehospital Burn Resuscitation for the Combat Injured 

12.59

1.24

7.51

2.77

20.13

0

5

10

15

20

25

Fluid Resuscitation Rates* 

Figure 1. Post hoc analysis of prehospital fluids administered to burn 

patients. Individual values for each of 39 patients shown in Table 1 

are plotted to illustrate distribution of necessary fluid resuscitation 

rates across the sample population. Certain numerical values are 

shown to provide perspective. 

*In cc/kg/percentage TBSA burned. 

Table 1. The calculated initial fluid resuscitation rates for 

39 patients. Values are plotted in Figure 1. 

cc/kg/

percentage TBSA 

Subject 

number 

cc/kg/

percentage TBSA 

Subject 

number 

0.00 CL-30 5.19 CL-16 

1.05 CL-38 5.59 CL-06 

1.18 CL-40 5.70 CL-09 

1.24 CL-05 5.79 CL-11 

1.43 CL-19 5.89 CL-14 

1.73 CL-24 6.35 CL-39 

2.30 CL-21 6.41 CL-20 

2.58 CL-02 6.85 CL-10 

2.59 CL-15 7.51 CL-23 

2.60 CL-27 7.67 CL-12 

2.71 CL-33 7.77 CL-34 

2.77 CL-35 8.30 CL-28 

3.27 CL-29 8.64 CL-36 

3.91 CL-18 8.90 CL-31 

4.17 CL-08 8.94 CL-07 

4.44 CL-26 11.82 CL-17 

4.57 CL-25 12.23 CL-01 

4.76 CL-04 12.59 CL-03 

4.88 CL-22 20.13 CL-37 

5.02 CL-13 

The US Army Institute of Surgical Research 

Rule of 10 

Estimate burn size (using the Rule of Nines) to the nearest 

10% TBSA. 

Multiply that by 10 to calculate the Initial Fluid Rate for 

patients weighing 40 to 80 kg. 

Increase fluid rate by 100 cc/hr for every 10 kg of body 

weight above 80 kg. 
 April – June 2011 57

THE ARMY MEDICAL DEPARTMENT JOURNAL

initial fluid rate of 500 ml/hr, a number falling within 

the acceptable range of 437 ml/hr (2 ml/kg/TBSA) 

and 875 ml/hr (4 ml/kg/TBSA) derived from the ABA 

consensus recommendation. Subsequent and serial 

adjustments in fluid infusion rate are then based upon 

response to resuscitation. As demonstrated by our in 

silico validation, this simplified equation provides an 

acceptable starting point for the vast majority of 

patients weighing more than 40 kg. To accommodate 

burn patients weighing over 80 kg, an increase of 100 

ml/hr is added for each 10 kg over 80 kg. 

The Rule of 10 allows the combat prehospital 

providers at levels I and II echelons of care to easily 

implement the fluid resuscitation, and then to shift the 

focus towards the patient’s response to the 

resuscitation in order to dictate the amount of fluid 

administered over the first 24 hours. Traditional 

resuscitation formulas can still be used as benchmarks 

to assess the adequacy of the resuscitation. This 

formula has recently been adopted by the Committee 

on Tactical Combat Casualty Care*, and has been 

included in a new chapter for treatment of burn 

casualties in the military version of the prehospital 

trauma life support manual published by the National 

Association of Emergency Medical Technicians.3 

EN ROUTE CARE

Identification of the problem 

For US Warriors burned in the Iraq and Afghanistan 

theaters, the initial burn resuscitation — the first 24 to 

48 hours postburn — is routinely performed by 

providers possessing variable levels of experience in 

burn care. In addition, multiple handoffs occur while 

the patient is being transported. It is common for 4 or 

more teams of providers to manage a military casualty 

with severe burns prior to the patient’s arrival at the 

Burn Center for definitive care. Given that variations 

in practice exist among different sets of providers, 

variability in the way care is delivered during the 

resuscitation is unavoidable. In addition, the teams 

rotate out of theater every 4 to 6 months, which results 

in the loss of the knowledge and experience gained 

during their deployment. Together, these issues 

provide an underpinning that makes it difficult to 

standardize care in this environment. The multitude of 

challenges faced by deployed providers with regard to 

immediate burn care has previously been described.4

Burn Guidelines 

As a result of these challenges and in an effort to 

standardize care, in November 2005, we developed the 

burn resuscitation clinical practice guidelines (Table 2), 

as well as a burn resuscitation flow sheet (Figure 2). 

Serendipitously, the Joint Theater Trauma System had 

been established in early 2005, and it became the 

vehicle that allowed us to immediately disseminate the 

guidelines and burn care flow sheet. Within weeks of 

identifying the insufficiency of documentation and 

lack of standardization of en route care, a solution was 

developed and disseminated widely throughout the 

Initiate 5% albumin early as described in the Emergency War 

Surgery Handbook.5

Check bladder pressures every 4 hours. 

If urine output (UOP)<30 cc/hr, strongly consider the placement of a pulmonary artery (PA) catheter to guide 

resuscitation with specific pulmonary capillary wedge 

pressure (PCWP) and mixed venous saturation (SvO2) goals 

(goal PCWP 10 to 12, SvO2 65% to 70%). If a PA catheter 

placement is not practical, consider monitoring the central 

venous pressure (CVP) from a subclavian or internal jugular 

vein along with central venous (ScvO2) saturations (goal 

CVP 8 to 10, ScvO2 60% to 65%). 

If CVP or PCWP is not at goal, increase the fluid rate. 

If CVP or PCWP is at goal, consider vasopressin 0.04 unit/

minute to augment the mean arterial pressure (and thus 

UOP) or dobutamine 5 mg/kg/min (titrate until SvO2 or 

ScvO2 at goal). The maximum dose of dobutamine is 20 

mg/kg/min. 

If both CVP or PCWP and SvO2 or ScvO2 are at GOAL, stop 

increasing fluids (even if UOP<30 cc/hr). The patient 

should be considered hemodynamically optimized, and the 

oliguria is likely a result of established renal insult. Some 

degree of renal failure should be tolerated and expected. 

Continued increases in fluid administration despite optimal 

hemodynamic parameters will only result in “resuscitation 

morbidity” that is oftentimes more detrimental than renal 

failure. 

If the patient becomes hypotensive along with oliguria 

(UOP<30 cc/hr), then follow the hypotension guidelines. 

Every attempt should be made to minimize fluid administration while maintaining organ perfusion. If UOP>50 cc/hr, 

decrease the fluid rate by 20%. 

After 24 hours, lactated Ringer infusion should be titrated 

down to maintenance levels and albumin continued until 

the 48-hour mark. 

At 12 to 18 hours postburn, calculate the PROJECTED 24-hour 

resuscitation if fluid rates are kept constant. If the projected 24-

hour resuscitation requirement exceeds 6 cc/kg/percentage 

TBSA, the following steps are recommended: 

Table 2. The Army Institute of Surgical Research burn 

resuscitation clinical practice guidelines. 

*A committee of the Defense Health Board, US Department of 

Defense. 
58 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

combat theater. This accomplishment is an example of 

how the system enabled us to establish guidelines very 

quickly and educate providers across the evacuation 

chain. The flow sheet has been a valuable 

documentation tool to record the first 72 hours of 

resuscitation as patients move through the various 

echelons of care. At each level of evacuation, the flow 

sheet ensures the appropriate repeated assessment of 

the resuscitation, which is vital in all difficult 

resuscitations. The flow sheet also provides our staff 

with the data necessary to evaluate the patient’s initial 

resuscitation course when patients arrive at the Burn 

Center.6

 This resuscitation tool has been important in 

providing continuity in documentation as well as 

system-wide standardization of care. 

Follow-up Data 

Improvement of outcomes as a result of this 

intervention has also been previously described by 

Ennis et al.7

 A 50% decrease in the composite 

endpoint of abdominal compartment syndrome and 

mortality was revealed when the outcomes of those 

evacuated after the release of the guidelines were 

compared to those of casualties who were evacuated 

before the guidelines were in place. This finding by 

our group illustrates how our current military trauma 

Advances in Prehospital Burn Resuscitation for the Combat Injured 

Figure 2. The burn resuscitation flow sheet developed and distributed by 

the ISR in 2005. It is used 

to document the first 72 

hours of care received by 

burn patients as they 

move through evacuation 

channels en route to the 

Burn Center. 
 April – June 2011 59

THE ARMY MEDICAL DEPARTMENT JOURNAL

landscape allows us to adapt as a system, identify 

problems, and alter the way care is delivered in an 

effort to improve outcomes.7

Decision Support 

Nonetheless, the burn flow sheet, a valuable and 

necessary tool, is not perfect. It helps document what 

was done, but does not assist the provider in the 

determination of how a resuscitation should be 

performed. Much variability still exists with regard to 

how burn resuscitation is conducted from patient to 

patient. In order to provide better guidance to nonburn 

providers and to further standardize care, we have 

developed a computer-based decision support algorithm to assist the deployed care provider.8

 As shown 

in Figure 3, urine output levels are automatically 

captured by the system hourly, which generates a 

recommendation for fluid rates based on the trend of 

the last few hourly urine outputs. Application of this 

decision support system (DSS) in our intensive care 

unit at the Burn Center was evaluated. Compared to 40 

control patients who were resuscitated without the 

DSS, resuscitation using the DSS in 26 consecutive 

patients resulted in significantly lower fluid requirements during the initial 48 hours following the burn 

injury (27±14 vs 15 ± 6 liters, P<.05). Furthermore, 

compared to control patients, the DSS was able to 

maintain patients between the urine output targets of 

30 to 50 ml/hr over a higher percentage of the time 

(22% vs 37%, P<.05).9 

THE FUTURE

One of the ISR’s primary objectives related to 

resuscitation is to facilitate the fielding of a userfriendly tool designed for prehospital and hospitalbased providers who do not routinely care for burn 

Figure 3. Reproduction of the input/output screen of the burn resuscitation decision support system developed by the Army 

Institute of Surgical Research. 

Cumulative graphs 

Input/output table 

and graphs 

Data input dialogue box 

Last hour’s urine output 

Current infusion rate 

Recommended new 

infusion rate 

Actual infusion 

rate 
60 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

casualties. The tool may ultimately be delivered in the 

form of a handheld device (Figure 4) or be 

incorporated into an intravenous fluid pump. 

Regardless of the technology used, the key objective is 

to incorporate a functional and tested version of a burn 

resuscitation DSS to assist providers in the resuscitation of burn casualties based on real-time 

physiologic parameters; to be available during all 

phases of care or evacuation. Ultimately, it is hoped 

that these efforts will result in improved resuscitation 

practice, more efficient transmission of clinical data, 

less morbidity associated with resuscitation, and 

overall improved outcomes. 

Other areas of interest include the choice of 

resuscitation fluid used in the forward environment. 

Special operations forces and other highly mobile 

combat teams are often limited in the amount of 

medical supplies immediately available to them. The 

use of colloids and plasma substitutes continues to 

spark much discussion among prehospital providers. 

Current research in this area may result in further ways 

to minimize complications associated with over- and 

under-resuscitation of the burn casualty, as well as 

other battlefield casualties. 

REFERENCES

1. Pham TN, Cancio LC, Gibran NS. American Burn 

Association practice guidelines burn shock 

resuscitation. J Burn Care Res. 2008;29:257-266. 

2. Chung KK, Salinas J, Renz EM, et al. Simple 

derivation of the initial fluid rate for the resuscitation 

of severely burned adult combat casualties: in silico 

validation of the rule of 10. J Trauma. 2010;69(suppl 

1):S49-S54. 

3. National Association of Emergency Medical 

Technicians. PHTLS: Prehosptial Trauma Life 

Support, Military Edition. 7th ed. St Louis, Missouri: 

Mosby; 2010. 

4. Chung KK, Blackbourne LH, Wolf SE, et al. 

Evolution of burn resuscitation in operation Iraqi 

freedom. J Burn Care Res. 2006;27:606-611. 

5. Burris DG, Dougherty PJ, Elliot DC, et al, eds. 

Emergency War Surgery. 3rd rev. Washington, DC: 

Borden Institute, Office of the Surgeon General, US 

Dept of the Army; 2004:28.6. 

6. Chung K, Wolf S, Cancio L, et al. Resuscitation of 

severely burned military casualties: fluid begets more 

fluid. J Trauma. 2009;67: 231-237. 

7. Ennis JL, Chung KK, Renz EM, et al. Joint Theater 

Trauma System implementation of burn resuscitation 

guidelines improves outcomes in severely burned 

military casualties. J Trauma. 2008;64(suppl 2):S146-

S152. 

8. Salinas J, Drew G, Gallagher J, et al. Closed-loop and 

decision-assist resuscitation of burn patients. J 

Trauma. 2008;64(suppl 4):S321-S332. 

9. Salinas J, Kramer GC, Mann EA, et al. Computer 

decision support system improves fluid management 

during resuscitation of burn patients. J Burn Care 

Res. 2009;30(suppl 2):S46. 

AUTHORS

MAJ(P) Chung is Medical Director, Burn Intensive 

Care Unit, US Army Institute of Surgical Research, 

Fort Sam Houston, Texas. 

Dr Salinas is Manager, Combat Critical Care 

Engineering Research Task Area, US Army Institute of 

Surgical Research, Fort Sam Houston, Texas. 

COL Renz is Director, US Army Institute of Surgical 

Research Burn Center, Fort Sam Houston, Texas. 

Figure 4. Artist drawing of a conceptual 

hand-held device to provide access to the 

burn resuscitation decision support 

system. 

Advances in Prehospital Burn Resuscitation for the Combat Injured 
 April – June 2011 61

Accurate, early diagnosis of hemorrhage to enable 

timely application of life saving interventions is a high 

priority for the Army Medical Department, since 

hemorrhage remains a leading cause of death on the 

battlefield.1,2 Survival rates increase when victims 

requiring immediate intervention are correctly and 

expeditiously identified,3

 but methods of assessing the 

severity of hemorrhage based on current triage 

algorithms are severely limited. Despite ongoing 

study, mental status and low blood pressure 

(systolic < 90 mm Hg) are still considered to be the 

best indicators of the need for life-saving 

interventions,4-6 even though the unreliability of 

arterial blood pressure as an indicator of blood loss 

was recognized as early as World War II.7,8 In trauma 

and combat casualty care medicine, a profound need 

exists for improved physiological algorithms that will 

provide a reliable early indication of hemodynamic 

instability, and provision of these algorithms has been 

the focus of our research efforts.9

 Indeed, delays in 

identification and control of hemorrhage in the 

prehospital phase of treatment accounted for a large 

percentage of potentially preventable deaths during 

Operation Iraqi Freedom.2

 In recognition of this need, 

the Combat Casualty Care Research Program of the 

US Army Medical Research and Materiel Command 

established a specific task area (Advanced Capabilities 

for Emergency Medical Monitoring) in 2002 to investigate new ways to meet capability gaps in medical 

monitoring, particularly in the prehospital phase. 

Physiologic status assessment in casualties can be 

problematic in the military setting, where physical 

access to the injured individual may be complicated by 

terrain, weather and hostile action. Likewise, some 

civil sector settings may challenge first responders, 

particularly when victims are located remotely. The 

lack of a remote triage capability may therefore result 

in the medic attending to either a) a Soldier who is 

uninjured but caught in the vicinity of combat; or b) a 

Soldier under severe fire who has an injury that is 

deemed unsalvageable.10 Indeed, a combat medic may 

place himself in harm’s way to assist a Soldier who 

may not even be injured or may be unsalvageable. 

Data collected during the Vietnam War indicate that 

the fatality rate of US Army medics was double that 

seen in infantrymen.11 Anecdotally, this risk continues 

in the current combat setting, as medics routinely place 

Advanced Technology Development for 

 Remote Triage Applications in Bleeding 

 Combat Casualties 

Kathy L. Ryan, PhD 

Caroline A. Rickards, PhD 

Carmen Hinojosa-Laborde, PhD 

LTC(P) Robert T. Gerhardt, MC, USA 

LTC (Ret) Jeffrey Cain, MC, USA 

Victor A. Convertino, PhD 

ABSTRACT

Combat developers within the Army have envisioned development of a “wear-and-forget” physiological status monitor 

(PSM) that will enhance far forward capabilities for assessment of Warrior readiness for battle, as well as for remote 

triage, diagnosis and decision-making once Soldiers are injured. This paper will review recent work testing remote 

triage system prototypes in both the laboratory and during field exercises. Current PSM prototypes measure the 

electrocardiogram and respiration, but we have shown that information derived from these measurements alone will not 

be suited for specific, accurate triage of combat injuries. Because of this, we have suggested that development of a 

capability to provide a metric of circulating blood volume status is required for remote triage. Recently, volume status 

has been successfully modeled using low-level physiological signals obtained from wearable devices as input to 

machine-learning algorithms; these algorithms are already able to discriminate between a state of physical activity 

(common in combat) and that of central hypovolemia, and thus show promise for use in wearable remote triage devices. 
62 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

themselves in potentially vulnerable positions in order 

to physically assess and treat a wounded Soldier. It is 

therefore desirable to provide a remote triage 

capability that protects combat medics while 

accurately assessing the injury severity of a wounded 

Soldier. 

WEAR-AND-FORGET MONITORING SYSTEMS

The concept of continuous, remote, physiological 

monitoring has gained traction for use by Warfighters,12,13 astronauts,14 and emergency first responders,15 and implementation systems have been actively 

pursued by military developers.12,13 In particular, the 

US Army has embarked on a program to develop a 

“wear-and-forget” monitoring system that will 

wirelessly provide continuous streams of physiological 

data from individual Soldiers to a medic-held personal 

data assistant (Figure 1). It should be noted that the 

initial impetus for development of a remote triage 

system evolved from the desire for continuous 

monitoring capabilities to assess the physiological 

status of Soldiers to determine their readiness for 

battle, thereby providing a greater degree of 

operational and situational information to tactical 

commanders. Hence, as originally envisioned, these 

monitoring systems include the capability to measure 

hydration status, body core temperature, and the 

amount of sleep obtained.13 It was realized early, 

however, that physiological responses to combat injury 

might also be measured by these systems, and could 

provide the capability for remote triage. 

The Army currently has received 2 prototypes of a 

physiological status monitor (PSM) that were 

developed under an Army Technology Objective and 

congressionally-funded programs. For the purposes of 

combat casualty care, the PSM is designed to provide 

continuous monitoring of the electrocardiogram (ECG) 

and respiration rate. We recently tested both of these 

prototype systems for their ability to accurately 

measure R-R intervals (RRI, the interval between 2 R 

waves, derived from the ECG) and respiration rate 

during central hypovolemia. Briefly, healthy human 

volunteers were exposed to lower body negative 

pressure (LBNP), which we and others have 

demonstrated to be a reliable and reproducible 

experimental model of hemorrhage that can be 

performed in conscious humans.9,16 Measurements of 

RRI and respiratory rate from both of the prototype 

systems during hypovolemia were compared with 

those derived from a standard ECG and capnograph. 

Results from these experiments demonstrated that both 

prototype systems reliably measured RRI; while the 

Hidalgo belt also measured respiration rate with high 

fidelity, the Foster Miller shirt tended to underestimate 

the true respiration rate (Figure 2). In parallel with the 

laboratory experiments, both prototypes were also 

tested under field conditions during US Army Ranger 

training at Fort Benning, Georgia, in 2008. During a 2-

day field test, the prototypes were evaluated for their 

ability to capture data as well as for their wearability 

and comfort. While data capture was acceptable from 

the Foster Miller shirt, there were some 

synchronization problems between the Hidalgo belts 

and the personal data assistant, resulting in a loss of 

data. Furthermore, there were complaints of chafing 

and discomfort from data capture devices that were 

placed on pressure points under the body armor with 

both prototypes. Clearly, further end-user testing under 

different environmental conditions will be required 

before either the current prototype or new systems are 

proposed for fielding. 

WILL CURRENT PSM MEASUREMENTS AID REMOTE

TRIAGE? 

Making the assumption that wearability and data 

capture issues can be overcome with further 

development, the question becomes whether the 

information provided by the current PSM prototypes 

will provide sufficient clinical information to properly 

assess the status of a wounded Soldier beyond that of 

being alive or dead. Unfortunately, elevated heart and 

respiration rates resulting from hemorrhage in a 

wounded Soldier may not be distinguishable from 

elevated heart and respiration rates in a Soldier 

actively participating in a military maneuver or 

Advanced Technology Development for Remote Triage Applications in Bleeding Combat Casualties 

Figure 1. Concept of wear-and forget physiological status 

monitors, with current prototype systems depicted. 
 April – June 2011 63

THE ARMY MEDICAL DEPARTMENT JOURNAL

firefight. However, the investigation of naturallyoccurring rhythmic fluctuations in RRIs obtained from 

the ECG (ie, heart period variability (HPV)) 

underscores a multitude of feedback control 

mechanisms that may lend insight into normal and 

abnormal physiology, such as reduced blood volume 

resulting from severe hemorrhage. Since the first 

suggestion in 1963 that HPV might be useful for 

clinical monitoring of patients,17 this field has literally 

exploded, with indications that HPV monitoring might 

provide useful diagnostic information for such chronic 

disease states as cardiac diseases (eg, myocardial 

infarction, congestive heart failure), sleep apnea, 

diabetes, and renal failure.18 In fact, a PubMed search 

performed in October 2010 on the term “heart rate 

variability” revealed more than 13,000 published 

papers. Despite this interest, these techniques have not 

yet been widely implemented into clinical practice or 

monitoring devices.19,20

In the laboratory environment, frequency-domain 

analyses of HPV have been used extensively to 

explore human autonomic cardiovascular rhythms, 

especially as they relate to maintenance of steady-state 

hemodynamics through activation and inhibition of the 

autonomic nervous system. Spontaneous fluctuations 

in intervals between ECG R waves (ie, R-R intervals) 

around the respiratory (high) frequency (HF) are 

Figure 2. Comparison of standard measurement of RRI and respiration rate with those from the Hidalgo belt (Panels A and B) 

and the Foster-Miller shirt (Panels C and D). Results are presented as group means ± standard error. Unless otherwise noted, 

N=5 for Hidalgo belt and N=4 for Foster-Miller shirt. 

A

B

C D
64 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

known to be mediated by parasympathetic neural 

activity,21 while oscillations occurring at frequencies 

lower than respiration (LF) are thought to be mediated 

by both parasympathetic elements and sympathetic 

modulation of vascular resistance.22,23 Furthermore, 

HF spectral power decreases progressively (ie, 

parasympathetic withdrawal) during reductions in 

central blood volume and is inversely associated with 

sympathetic activation, demonstrating the expected 

shift in sympathovagal balance during central 

hypovolemia.24,25 

Based on this understanding, we first investigated 

whether frequency domain metrics of HPV would 

provide predictive power to discriminate between 

trauma patients in the prehospital environment who 

subsequently lived or died. To test this hypothesis, we 

measured HPV from ECG data collected during 

prehospital transport of civilian trauma patients who 

sustained blunt or penetrating injuries leading to 

hemorrhage.26 RRI data were collected between 45 and 

90 minutes after injury, while the average time of 

death was 9.5 hours in those patients who were 

nonsurvivors. The results indicated that patients who 

died had statistically higher RRI HF/LF ratios than 

those patients who lived. In a subsequent analysis, 

these results were verified in a larger cohort of patients 

that included more head and blunt injuries.27 These 

initial analyses indicated that alterations in RRI HF/LF 

might be early markers of patient survival and thus 

provide clues for development of PSM-based 

algorithms to assist the combat medic with important 

remote triage decisions, particularly in a mass casualty 

scenario. Subsequently, Batchinsky et al28 extended 

these observations to demonstrate that loss of RRI 

complexity (using nonlinear analysis of RRI to 

produce entropy and fractality measurements) was 

associated with subsequent mortality. Finally, loss of 

RRI variability and complexity was shown to be 

associated with the administration of a life-saving 

intervention (LSI) in data taken from trauma patients 

during the prehospital phase of care.29,30 Recently, RRI 

complexity metrics have been specifically advocated 

for use in remote triage applications.31 It should be 

noted, however, that in the majority of these studies 

demonstrating an association between HPV and either 

the administration of a life-saving intervention29 or 

eventual mortality,26-28 at least one easily obtainable 

standard vital sign (eg, Glasgow Coma Scale motor 

score) also distinguished the 2 groups of patients (eg, 

LSI vs no LSI, lived vs died). It was therefore unclear 

whether complicated calculation of a HPV metric 

would provide “added value” in enhancing triage 

capabilities over standard vital signs, particularly in 

situations in which the medic either had physical 

access to the patient or had radio communication that 

could be used to ascertain the patient’s ability to 

respond (ie, Glasgow Coma Scale). 

The application of HPV for combat medic decision 

support has several attractive features, including: a) it 

can provide remote and continuous monitoring from a 

sensor system that can be worn by every Soldier; and, 

b) it can utilize a simple ECG signal provided by the 

current prototypes of PSM. While we26,27 and others28-31

had initially used group mean analysis for 

determination of HPV utility, several important 

questions remained before realistically proposing the 

use of HPV metrics of any kind for remote triage of 

individual Warfighters or, for that matter, clinical 

monitoring of individual patients. For example, what 

are “normal” values for HPV metrics and are these 

reproducible in the same subject? What are technical 

requirements for valid calculation of HPV metrics? 

Are alterations in HPV metrics specific only to loss of 

central blood volume? Do HPV metrics track central 

hypovolemia in any given individual? In our further 

work, we systematically sought to answer these 

questions by determining whether HPV metrics are of 

use in tracking hemorrhage in individual patients, and 

whether responses of HPV metrics are specific to 

hemorrhage rather than to other combat stressors such 

as physical activity. 

To answer the question of whether HPV metrics would 

track blood loss in individuals, we first determined 

intersubject and intrasubject variability in resting 

human subjects during the same experimental session 

to determine normal values and their reproducibility.32

While some of the complexity metrics (but not the 

time and frequency domain metrics) displayed 

reasonably low (coefficient of variation (CV) ≤8.5%) 

intersubject variability and high (CV ≤ 8.9%) 

reproducibility in our study, recent work from Tan et 

al33 demonstrated that these metrics a) are not 

reproducible within individuals during different 

experimental sessions; and b) do not reliably reflect 

autonomic mechanisms responsible for HPV. The 

authors therefore concluded that caution is warranted 

in using these metrics as diagnostic tools.33 In 

Advanced Technology Development for Remote Triage Applications in Bleeding Combat Casualties 
 April – June 2011 65

THE ARMY MEDICAL DEPARTMENT JOURNAL

agreement with the conclusions of this study, we found 

that, while group means of HPV metrics are highly 

correlated (|r|≥0.87)* with stroke volume (an index of 

central blood volume) during progressive reductions in 

central blood volume, analysis of the individual 

trajectories for HPV metrics demonstrated poor and 

inconsistent correlations (|r|≤0.49) with changes in 

stroke volume at the individual subject level (Figure 

3).34 From these data, we concluded that the HPV 

metrics do not reliably track individual reductions in 

central volume in the controlled laboratory setting and 

therefore may not be useful, even in trending analysis, 

in monitoring hemorrhagic injuries in individual 

patients.34 

In further analyses using real world data, we 

determined that 36% to 52% of trauma patients 

undergoing helicopter transport to the hospital 

demonstrate the presence of at least one ectopic beat 

within their ECG record,35 valid determination of HPV 

metrics requires ECG waveforms that are free of noise 

and ectopic beats.36 When the percentage of ECG 

waveforms rendered unusable by the presence of 

electromagnetic noise from patient movement or 

electrical interference is added, these limitations 

potentially exclude between 48% and 74% of 

prehospital trauma patients. On an individual basis, 

HPV measurements could therefore only be applied to 

approximately 26% to 52% of trauma patients.35 For 

remote triage applications, it might be 

anticipated that electromagnetic noise 

due to movement might produce an 

even larger problem. Finally, we 

determined whether HPV metrics 

provided added value to the ability to 

determine whether an individual 

patient would subsequently require a 

LSI. We analyzed ECG recordings 

collected on prehospital trauma 

patients with normal standard vital 

signs, testing the hypothesis that, if 

HPV metrics provided additional 

information above that of standard 

vital signs, these metrics would 

distinguish between those receiving a 

LSI and those that did not.37 While 

group means of some of these HPV 

metrics statistically differed between 

the groups, there was inordinately 

high (81% to 94%) overlap of individual patient HPV 

values between groups, suggesting that patients would 

have been incorrectly classified if HPV alone was used 

as a triage tool (Figure 4). This finding assumes even 

greater importance when considered in the context of 

remote triage, as ECG-derived metrics would be the 

only available resource in the absence of physical 

*|r| indicates the absolute value of the correlation coefficient. 

Figure 3. Left panel, group means for change in a representative HPV metric 

(fractal dimensions by curve length, FD-L) during LBNP. Right panel, individual 

trajectories for the same metric during LBNP. N=101. R values are correlation 

coefficients between FD-L and stroke volume (SV) for the group means as a whole 

during LBNP (left panel) and for individual changes in FD-L and SV at each LBNP 

level (right panel). Modified from Ryan et al.34 

Figure 4. Box-and-whisker plot of fractal dimension by curve 

length (FD-L) demonstrating the high degree of overlap of 

individual values between the LSI (N=32) and No-LSI patients 

(N=127). Eighty-four percent of individual LSI patient values fall 

within the No-LSI range. From Rickards et al.37 
66 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

access to the patient using currently proposed PSM 

systems. 

In order to effectively interpret an alteration in HPV 

metrics as suggestive of a casualty rather than a 

fighting Soldier in a remote situation, it is also 

necessary to distinguish the difference(s) in 

physiological responses under these conditions. To 

answer the question of specificity to hemorrhage, we 

tested the hypothesis that HPV metrics would be able 

to differentiate between subjects exposed to LBNP 

(simulating blood loss) or the same subjects 

undergoing moderate exercise.10 Figure 5 demonstrates 

that HPV metrics respond in a similar fashion during 

controlled laboratory experiments using LBNP vs 

exercise. Therefore, HPV metrics are unable to 

differentiate an active Soldier from a bleeding Soldier 

when the individual is not visible to the combat medic. 

While we used exercise as an experimental model to 

produce sympathetic activation and increase heart rate, 

it is important to note that other physiological stimuli 

occurring in combat Soldiers that increase heart rate 

(eg, anxiety, pain, heat or cold stress) might also be 

confused with blood loss if HPV metrics were used in 

a remote triage system. Indeed, Sacha and Pluta recently demonstrated that increases in heart rate of any 

etiology produce profound decreases in HPV metrics, 

purely for mathematical reasons because of the 

curvilinear relationship between heart rate and RRI.38

To summarize, current remote triage wear-and-forget 

monitoring systems (ie, PSM prototypes) measure 

ECG and respiration rate. Certainly, this information 

could be useful in assessing whether a soldier is alive 

or dead following injury and the current prototypes 

therefore meet the objective criterion of life sign 

detection. An optimal remote triage system, however, 

would additionally provide valuable information a) 

that any elevation in heart rate, respiration, or other 

physiological indicator is a result of injury 

(specificity); and b) that could aid in determination of 

severity of injury (sensitivity). Such information could 

assist combat medic decisions such as the initiation of 

treatment and prioritization of evacuation. The data 

discussed above raise profound concerns that the 

implementation of HPV metrics into a remote triage 

system could provide this information. Therefore, we 

have redirected our focus to the development of a 

novel remote triage system that does not rely solely on 

ECG-derived metrics. 

NOVEL MEASUREMENTS FOR REMOTE TRIAGE

If not HPV metrics, what should be measured to 

determine the presence and severity of hemorrhage in 

a remote triage system? From our laboratory studies, it 

is clear that stroke volume and pulse pressure (systolic 

minus diastolic blood pressure) decrease consistently 

with central hypovolemia, at least on a group mean 

basis.39 As previously described, we performed a study 

in which the ability of HPV metrics to differentiate 

between a state of central hypovolemia simulating 

blood loss (via LBNP) and physical activity was 

ascertained10 While HPV metrics could not reliably 

distinguish between these physiological conditions 

(Figure 5), we were able to identify that pulse pressure 

could differentiate the conditions of physical activity 

from LBNP (Figure 6). This was not an unexpected 

finding as pulse pressure (ie, systolic blood pressure 

minus diastolic blood pressure) tracks stroke volume, 

which increases with exercise40 and decreases with 

LBNP.34,39 Hence, both stroke volume and pulse pressure could be reasonable candidates for determination 

of central hypovolemia during hemorrhage. 

Currently, however, the only portable methods of 

measuring ambulatory blood pressure (and thereby deriving pulse pressure) or stroke volume are cumbersome and restrict movement and dexterity. Ambulatory blood pressure monitors, for example, use inflatable, restrictive cuffs around the upper arm or fingers 

in order to make blood pressure measurements. 

Additionally, for technical and comfort reasons, the 

majority of these monitors cannot take measurements 

continuously, with most providing output once every 3 

to 5 minutes. Clearly, current noninvasive blood 

pressure systems are not practicable for use in remote 

triage systems. 

Recently, the emergence of artificial intelligence 

technology has offered a potential solution to this 

issue. By definition, this scientific discipline designs 

algorithms that allow computers to evolve behaviors 

based on empirical data (eg, from sensors). In essence, 

the algorithms can “learn” to solve problems, and 

therefore show promise as being able to predict in time 

the point of cardiovascular decompensation in 

individuals subjected to central hypovolemia.41 Using 

this technology, machine-learning algorithms can be 

developed that learn to recognize patterns of responses 

in low-level physiological signals that are associated 

Advanced Technology Development for Remote Triage Applications in Bleeding Combat Casualties 
 April – June 2011 67

THE ARMY MEDICAL DEPARTMENT JOURNAL

with changes in parameters that reflect volume status 

(eg, stroke volume or pulse pressure). As an example, 

a wearable, noninvasive monitor for the indirect 

measurement of energy expenditure has recently been 

developed (SenseWear Pro2 armband (BodyMedia 

Inc, Pittsburgh, PA); Figure 7, left panel). When 

placed in the designated location on the upper arm, this 

sensor system armband is able to detect the galvanic 

skin response, heat flux, and skin temperature. Using 

these 3 inputs, a proprietary machine-learning 

algorithm has been developed to track the response of 

pulse pressure to physiological stimuli. In our 

laboratory, preliminary data indicate the ability of the 

armband algorithm to track the progressive decrease in 

pulse pressure with application of LBNP (Figure 7, 

right panel). As a result, there was a very strong linear 

relationship between conventionally measured pulse 

pressure via finger photoplethysmography (Finometer 

(Finapres Medical Systems B.V., Amsterdam, The 

Netherlands)) and the pulse pressure predicted by the 

algorithm (R2

=0.9). Furthermore, recent results indicate that the algorithm could predict actual pulse pressure or stroke volume values during either LBNP or 

exercise and that this algorithm was able to distinguish 

between LBNP and exercise with high (≥92%) 

accuracy, sensitivity, and specificity.42 While preliminary, these results suggest that machine-learning technology may be a promising component of future re01234

Heart Rate, bpm

50

60

70

80

90

100

110

Hypovolemia

Exercise

01234

RMSSD, ms

0

20

40

60

80

100 Hypovolemia

Exercise

Stage of Hypovolemia/Exercise

01234

RRI HF, ms2

0

500

1000

1500

2000

2500

3000

3500 Hypovolemia

Exercise

Stage of Hypovolemia/Exercise

01234

FD-L

1.6

1.7

1.8

1.9

2.0 Hypovolemia

Exercise

A B

D

C

Figure 5. Heart rate (HR, panel A) and representative HPV responses to 5 stages of hypovolemia induced by LBNP and 5 

stages of HR-matched exercise. Time domain (RRI root mean squared successive difference, RMSSD), frequency domain (RRI 

HF) and nonlinear complexity (fractal dimensions by curve length, FD-L) HPV metrics are depicted in Panels B-D. Panels A and 

C are from Rickards et al.10; panels B and D are previously unpublished data (K. L. Ryan et al, 2010). N=12. 
68 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

mote triage systems, as algorithms could be developed 

for distinguishing Soldiers who are active during 

combat from those who are hypovolemic due to traumatic hemorrhage. To date, all of these preliminary 

results have been acquired in a controlled laboratory 

setting with subjects who are not moving their arms 

appreciably. As development proceeds, it will be imperative to determine whether movement and other 

stressors (eg, dehydration, heat stress) produce measurement artifacts and, if so, whether 

these can be overcome. As always, 

field testing will be necessary to 

determine wearability and usefulness 

for the Warfighter. 

It should be noted that, with the 

current configuration, implementation of an armband device in a 

remote triage system requires that the 

combat casualty have at least one 

upper extremity that is not severely 

injured. We therefore queried the 

Joint Theater Trauma Registry as to 

the likelihood that Soldiers in the 

current conflict would not meet this 

criterion. In Operations Iraqi Freedom and Enduring Freedom, only 

6.47% of wounded Soldiers have 

presented with severe injury between 

the elbow and shoulder on one arm that would 

preclude effective use of an armband device. 

Therefore, a remote triage system based on an 

armband device could be used after injury in at 

least 93.5% of Soldiers. Given the equal 

probability that injury would occur to any one 

side (ie, 50% chance of an injury to the right 

arm), a remote triage system based on a single 

armband device worn on one arm alone should 

be able to capture approximately 96% of Soldier 

monitoring. 

STANDOFF REMOTE TRIAGE

In addition to wearable systems that would yield 

continuous physiological monitoring, it is also 

desirable to have a system for standoff triage of 

a wounded Soldier who can be visualized. Such 

a capability would allow a combat medic to 

ascertain the status of a wounded Soldier under 

fire before putting himself at risk, and would 

therefore decrease the probability of harm to the 

medic. In fact, a Navy corpsman presented a battle 

vignette from Operation Enduring Freedom at the US 

Army Institute of Surgical Research in 2009, in which 

he discussed how he cared for 17 wounded-in-action 

comrades while under fire. At the end of his 

presentation, he was asked for a “wish list” of 

capabilities that would help him care for wounded 

Soldiers. His highest priority was “a ray gun to check 

Advanced Technology Development for Remote Triage Applications in Bleeding Combat Casualties 

Figure 7. Left panel: current configuration of the BodyMedia SenseWear Pro2 armband. Measurements include galvanic skin response, heat flux and skin temperature. Right panel: comparison of values of pulse pressure predicted by a machinelearning algorithm using inputs from the BodyMedia SenseWear Pro2 armband 

with actual values measured by beat-to-beat finger photoplethysmography 

(Finometer). N=8. 

Figure 6. Pulse pressure response to 4 stages of LBNP up to -60 mm Hg 

and 4 stages of exercise. Asterisk(*) designates P≤.002 between the 

LBNP and exercise conditions at that stage. From Rickards et al.10 N=12. 

Stage of Hypovolemia/Exercise

01234

Pulse Pressure (mmHg)

30

40

50

60

70

80

Hypovolemia

Exercise
 April – June 2011 69

THE ARMY MEDICAL DEPARTMENT JOURNAL

out patients” (HM1 J. Torrisi, oral communication, 

2009). Indeed, the authors have heard a number of 

high-ranking individuals within the medical 

departments of the various military branches express 

their wish for a “Star Trek tricorder.” 

At this point, the capability for standoff triage has not 

been realized. Both the US Department of Homeland 

Security and the Defense Advanced Research Projects 

Agency are currently funding, or have funded, 

initiatives aimed at developing this capability, using 

such technologies as laser Doppler vibrometry43 and 

ultrawide-band radiofrequency radiation. It is quite 

conceivable that standoff technology could be 

developed to determine alive/dead status. If additional 

information concerning patient status is desired, the 

most promising signals to be measured will be those 

somehow associated with compensatory physiological 

responses to central hypovolemia. Measurement of 

such signals without contacting the body surface may 

be more challenging. 

POTENTIAL ISSUES FOR REMOTE TRIAGE

It is clear that both combat medics and injured Soldiers 

would benefit from development of a capability for 

remote triage, whether in a wearable system or a 

standoff device. The above discussion focuses on our 

efforts to determine the best physiological responses to 

be measured by such a system during hemorrhage. 

Once developed, a number of other important issues 

must be resolved before fielding a capability in a 

battlefield situation. Clearly, any wearable remote 

triage system will have to be small, lightweight, 

rugged, and comfortable, and must not impede 

movement. In every war in recorded history, Soldiers 

have littered battlefields with gear that they felt was 

either not essential or diminished their mission 

performance. From this standpoint, solicitation of 

input from end-users is essential during the early 

developmental stages of these systems. Furthermore, 

remote triage systems will have to include algorithms 

that recognize when the physiological signals being 

collected have been corrupted by artifactual noise and 

are therefore not valid for accurate decision support. 

Additionally, any wireless radiofrequency 

communication produced by such a device will have to 

be integrated into the wireless communication network 

used on the battlefield. As part of this process, data 

transmission will have to be encrypted so that the 

location and status of an injured Soldier is not made 

evident to enemy combatants. It will also be important 

to have any remote triage systems hardened to 

withstand common battlefield occurrences such as 

vibration, blast, and electromagnetic pulses, which can 

disable all electrical devices on the battlefield. Power 

supply issues should also be considered, with the 

ability to use commercially available small batteries 

(eg, AAA) for operation in remote areas without 

electricity. None of these issues are insoluble, with the 

key being integration of engineering and 

communication expertise early in the process of 

development of a system. Development of remote 

triage devices for battlefield use will also benefit from 

the recent profound commercial interest in 

development of similar devices for home healthcare 

applications. This is a very active area of research and 

development which will use similar technologies that 

could be adapted for applicability to combat casualty 

care use, and which could serve as predicate devices 

for FDA approval. Once a legitimate candidate for a 

wearable system is prototyped, it will also be essential 

to field-test the system to gather input on wearability 

and useability from both combat medics and Soldiers, 

the ultimate customers for the system. 

CONCLUSION

When making a remote triage decision without access 

to the patient, the military medic must know if a 

Soldier is wounded or simply engaged in combat. To 

assist with such decisions, it has been suggested that 

the future Warfighter will be equipped with 

physiological monitoring devices that will have the 

capability to measure ECG and respiration signals. 

However, since our research demonstrates that the raw 

and derived measurements from these signals (eg, 

heart rate, HPV, respiration rate) will not differentiate 

an active Soldier from a bleeding Soldier, new 

technologies that provide measurements that 

specifically reflect bleeding trauma will be required 

for the situation in which the Soldier is not visible. Our 

research provides new evidence that technologies exist 

with the capability to obtain surrogate information 

about the continuous status of pulse pressure or stroke 

volume, and that such technologies could provide 

essential information to the combat medic on the blood 

volume status of the Soldier and the need for prompt 

medical attention. Providing accurate and reliable 

indicators of patient status from a remote location will 

potentially protect combat medics from unnecessary 

exposure to enemy fire, and assist in the timely triage 
70 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

and evacuation of combat casualties. By producing 

new triage capabilities for use by the combat medic, 

the Advanced Capabilities for Emergency Medical 

Monitoring Task Area will also improve recognition of 

the need for early (prehospital) hemorrhage control 

and thereby reduce mortality on the battlefield.2

ACKNOWLEDGEMENTS

Funding support was provided by the US Army 

Medical Research and Materiel Command Combat 

Casualty Care Research Program, Ft. Detrick, 

Maryland. 

We thank Mr Gary Muniz for his superb technical 

assistance, and the research subjects for their cheerful 

cooperation. 

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72 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

AUTHORS

Dr Ryan is a Research Physiologist, US Army Institute of Surgical Research, Fort Sam Houston, Texas. 

Dr Rickards is a Research Assistant Professor, Department of Health and Kinesiology, University of Texas at San 

Antonio, Texas. 

Dr Hinojosa-Laborde is a Research Physiologist, US Army Institute of Surgical Research, Fort Sam Houston, Texas. 

LTC(P) Gerhardt is Chief, Prehospital and Emergency Care Research Program, US Army Institute of Surgical 

Research, Fort Sam Houston, Texas. 

LTC (Ret) Cain is a Staff Emergency Physician with QuestCare Partners, Dallas, Texas. 

Dr Convertino is a Senior Research Physiologist and Task Area Manager, US Army Institute of Surgical Research, 

Fort Sam Houston, Texas. 

Advanced Technology Development for Remote Triage Applications in Bleeding Combat Casualties 
 April – June 2011 73

INTRODUCTION

Lack of information in the battlefield critical care 

environment continues to be problematic for adequate 

patient care. Insufficient actionable data on patient 

injuries means that care providers have to reevaluate 

the patient at each level during the evacuation chain. 

This problem becomes increasingly critical when 

injury severity requires immediate action to save the 

patient’s life. When these issues are coupled with 

challenges related to treatment of injuries in a tactical, 

dynamic, and constantly shifting battlefield 

environment, effective patient care may 

become much more difficult and stressful 

on both patients and providers. 

One of the main differences between 

military and civilian critical care systems is 

the military concept of patient evacuation 

via the casualty evacuation/medical evacuation systems. In many cases, Soldiers 

injured on the front lines may face a long 

series of treatment regimens starting at the 

level I echelon of care and potentially 

progressing to level V in the United States. 

This also includes advanced critical care 

during transport and en route care phases. 

The complicated nature of the battlefield 

health care system creates a gap between 

state of the art trauma centers in the United 

States and trauma care facilities in the 

lower battlefield echelons of care (Figure 1). This gap 

is driven by many factors which include not just lack 

of specialized care providers in the battlefield setting, 

but also logistical support issues related to providing 

expert care in an austere environment.1

 Even at the 

level V facilities, the degree of patient care may be 

driven to a large extent by the experience of the care 

provider. Previous studies have shown that the addition of expert providers, such as critical care intensivists, will improve overall patient outcomes due to the 

increased availability of expert care and help to mitigate problems with provider treatment variability.2,3

Advanced Monitoring and Decision Support 

 for Battlefield Critical Care Environment 

Jose Salinas, PhD LTC Elizabeth A. Mann, AN, USA 

Ruth Nguyen, MD Steven E. Wolf, MD 

Mark I. Darrah, PhD MAJ(P) Kevin K. Chung, MC, USA 

George A. Kramer, PhD COL Evan M. Renz, MC, USA 

LTC Maria L. Serio-Melvin, AN, USA COL Leopoldo C. Cancio, MC, USA 

ABSTRACT

Automation and decision support systems are vital for improving critical patient care in the battlefield environment. 

However, advances in data management, sensor fusion, and decision support algorithms must be developed and 

incorporated into existing patient monitoring systems for this technology to improve battlefield patient care. This paper 

examines issues related to research and development of advanced monitoring and decision support systems for use both 

on the battlefield and in the civilian trauma environment. 

En Route

Critical Care Tech Gap

En Route

Medical Capability

Casualty Movement

STANDARD OF CARE

Level IIb:

Forward

Surgical  

Team

Level III:

Combat  

Support

Hospital

Level IV‐V:

Landsuhl

Walter Reed

BAMC

Level I:

Point of Injury

En Route

The goal:to creatively fill the gap between whatis available for care in CONUS

trauma systems, and whatis provided to combat casualties on the battlefield.

Figure 1. Technology gap in the military medical evacuation process. 

Level IV‐V:

Landstuhl

Walter Reed

BAMC
74 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

One approach to reduce the patient care technology 

gap and improve patient care in the battlefield critical 

care environment is the use of advanced computer 

algorithms that provide care givers with additional 

information using decision support technology. These 

algorithms harness data derived from multiple sensors 

attached to the patient to derive solutions and 

recommendations for treatment of battlefield injuries. 

Specifically, the use of multivariate vital sign indices 

derived from high performance digital signal 

processing algorithms coupled with decision support 

technology that incorporate the knowledge and 

experience of expert care clinicians provides users 

with better indicators of patient status and actionable 

medical information tailored to the patient and injury 

type. 

DECISION SUPPORT TECHNOLOGY FOR MEDICAL

DECISION MAKING

The concept of computer decision support systems 

(CDSS) involves the use of computer algorithms that 

can process raw data into useful information while 

offering a platform for embedding the expertise and 

knowledge of advanced experts in a particular field. A 

clinical CDSS is further defined as a system 

specifically designed for use by clinical personnel by 

providing a software application that includes the 

clinical care rules, information processing, or knowhow for the treatment or diagnosis of specific diseases 

or injuries. Previous studies have shown that a CDSS 

may improve patient outcomes by acting as an adjunct 

that provides additional knowledge, information, and 

recommendations to help providers at both the acute 

and routine phases of clinical care.4-6

The CDSSs can be broken down into different 

classifications or taxonomies based on their 

implementation and role within their environment.7,8

For the battlefield, 4 main taxonomies can be explored 

for use by clinical providers: data-driven, knowledgedriven, model-driven, and hybrid. Within these 

classifications, CDSSs can also be further refined 

based on their adaptive capability during use. Adaptive 

CDSSs will adjust the system recommendations based 

on responses from the patient on a case-by-case basis. 

This includes not only adjusting the value of 

parameters being controlled (ie, infusion rate), but also 

may include providing the user with different 

recommendations altogether (eg, switching from fluid 

therapy to pharmacotherapy based on the patient’s 

blood pressure response from a fluid challenge). 

Data driven CDSSs are defined as computer 

algorithms designed to exploit the computational 

capacity of the computer system to analyze, test, and 

provide summaries of data that would normally be 

beyond the capability of a user to process. Increasing 

processing capacity of modern computer systems has 

facilitated the ability for algorithms to process large 

amounts of data that can be analyzed in very short 

amounts of time. The latest Intel (Santa Clara, 

California) processors running on today’s personal 

computers have the capacity to process over 100,000 

million instructions per second (MIPS) due to their fast 

clock speeds and ability to concurrently process 

multiple instructions for every clock cycle. Many new 

processors include advanced multicore designs that 

include the ability to execute instructions in parallel to 

improve application performance. These advanced 

architectures can be further enhanced by coupling 

them with advanced digital signal processing hardware 

for further performance improvements. Even 

processors available for newer mobile phones or 

mobile use have the ability to process over 1000 MIPS 

while significantly reducing power consumption and 

improving battery life. In terms of medical use, these 

capabilities allow today’s computer systems to 

potentially analyze vast amounts of medical data for 

use by clinicians. Normally, these systems are not 

adaptive, but provide the user with grouping, trending, 

and multivariate fusion of medical and physiologic 

data that can be used as clinically meaningful 

information. Examples of data driven DSS 

applications include smart monitor alarms that use 

trending and triggers based on combinations of 

continuous multiple clinical parameters. 

On the other hand, knowledge-driven CDSSs rely on 

the use of some type of built-in knowledge base to 

derive recommendations for users. These systems are 

also called expert systems or rule-based systems 

because they attempt to embed the knowledge of a 

subject matter expert (SME) into a computer 

application using sets of rules to represent the 

knowledge of the SME. The complete set of rules 

within the system makes up the knowledge-base for a 

particular problem or domain under which the CDSS 

will operate. These systems can be designed for use by 

novice users working in a new environment or expert 

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THE ARMY MEDICAL DEPARTMENT JOURNAL

users who may have use for a validation tool. 

Knowledge bases for most rule-based systems are 

represented as a set of rules containing “IF‐THEN”

statements that cover the different situations that occur 

during the use of the CDSS. Rules of this system have 

2 main sections. For each rule, an IF section defines a 

testable condition that results in an action that must be 

processed further by the system or the user. This 

section results in either a true or false condition which 

defines if that rule gets examined and executed by the 

system. The THEN section defines an action that occurs 

should the IF section be true. For example, a subset of 

a resuscitation CDSS may have rules such as the 

following: 

 IF patient radial pulse is weak, THEN get the 

patient blood pressure. 

 IF patient blood pressure is below 90 mm Hg, 

THEN give 1000 ml bolus of normal saline. 

This type of CDSS normally includes an inference 

engine to process the rules within its knowledge base 

and choose the appropriate actions based on which 

rules are true. In many CDSS where the number of 

rules is small, the inference engine can be as simple as 

a search method that executes the rules sequentially. 

However, when the system is composed of large 

numbers of rules, the possibility exists that 2 or more 

rules may have conflicts with each other (ie, rule 1 

suggests the fluid is turned down while rule 2 suggests 

the fluid is turned up). In these cases, a more complex 

inference engine is needed, not only to optimize the 

processing of all the rules, but also provide 

deconflicting solutions in cases where actions from 

different rules contradict each other. The Rete 

algorithm is one example of a commonly available 

inference engine algorithm for rule execution.9

Model-driven CDSS systems use internal mathematical models to determine or predict the behavior of the 

underlying operational domain space. A set of 

mathematical equations are used to define how aspects 

of the environment will behave under a given set of 

conditions. Users provide the system with parameters 

that the model will use to predict the behavior of the 

environment and use the results to generate a 

recommendation. For example, a resuscitation system 

for guiding trauma resuscitation may have an internal 

model of the blood pressure response to a given level 

of fluid, patient weight, age, and height. If a patient 

has a low blood pressure, the system can use that 

information to determine the amount of fluid normally 

necessary to bring the patient to a higher and more 

acceptable blood pressure. Using this approach, the 

effectiveness of the system depends on the accuracy of 

the underlying model. For medical applications, many 

physiological changes may not be fully understood and 

use only approximate equations to model the 

fundamental factors associated with the process. These 

systems are commonly used in feedback control and 

closed-loop devices that use the response of the patient 

as feedback to adjust a patient care device. Closedloop pain sedation is an example of this type of 

system. 

In many cases, the use of machine learning or artificial 

intelligence technologies can be coupled with modelbased systems to improve their performance in situations where the model response is not well known, or 

in cases where traditional statistics-based multivariate 

analysis does not provide a good fit. Several 

technologies have been explored for use in medical 

CDSS, including Bayesian decision trees, artificial 

neural networks, and support vector machines. These 

approaches provide ways for the system to reason 

based on uncertainty and limited knowledge of the 

environment, and generate a probability distribution 

used to model the resulting problem. 

In battlefield critical care, CDSSs not only have to 

provide relevant clinical information, but also have to 

meet stricter requirements for use and deployment in a 

high conflict environment. These additional requirements include: 

Mobility. The CDSS may have to be carried by 

medics or used in facilities that are not in a fixed 

location. CDSS implementation, therefore, has to 

be as compact as possible given the potential use 

within the battlefield. 

Reliability. Use of a CDSS in this environment 

requires higher reliability to withstand deployment 

across vast geographically dispersed and austere 

environments in addition to having to operate in 

extreme temperature ranges. 

Ease of use. Human factors play an extremely 

important role when very limited training and/or 

usability information is available on the CDSS. 

Design of an intuitive graphical user interface is 

paramount in creating a system that is usable by 

military health care providers. 
76 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

Examples of CDSSs under development for use in 

military environments include the US Army Institute 

of Surgical Research Burn Resuscitation Decision 

Support System (BRDSS). This system was developed 

to optimize fluid resuscitation of acute burn patients 

from point of injury providing recommendations for 

fluid titration during the initial 48 hours postburn. 

Importantly, the user may accept or modify these 

recommendations based on clinical judgment. Each 

hour on the hour, users provide the system with current 

infusion rates, urinary output for the last hour, and 

whether the patient is hemodynamically stable. The 

system uses a model-based CDSS algorithm to 

estimate the appropriate fluid rate for the following 

hour to maintain the urinary output within acceptable 

levels and keep the patient in optimal fluid balance. 

The system provides a mechanism for assisting the 

nonburn-care provider in the field with the ability to 

more effectively resuscitate a patient with acute burn. 

Additionally, the BRDSS provides an adjunct to 

reduce interprovider variability found when resuscitating patients using standard approaches. 

Another example of a CDSS is the closed loop fluid 

management system being developed by the 

University of Texas Medical Branch, Galveston, to 

provide medics and far-forward personnel with fluid 

recommendations during trauma resuscitation. Closedloop fluid therapy has been studied in extensive animal 

research and most recently in human volunteers 

subjected to hemorrhage. Using both normotensive 

and hypotensive target levels of blood pressure, closedloop control was shown to effectively and efficiently 

resuscitate sheep subjected to uncontrolled or multiple 

hemorrhage protocols.10-12 The left panel of Figure 2 

shows the effectiveness of blood pressure maintenance 

with closed-loop titrated delivery of lactated Ringer’s 

in conscious sheep during multiple hemorrhages of 25, 

15, and 5 mL/kg. Groups compared used control algorithms based on a nonlinear decision table, proportional-integral-derivative (PID), or fuzzy logic. The 

right panel of Figure 2 shows the fluid requirements of 

6 animals per group, as well as the 3:1 volume needs 

of standard of care therapy. Note the volume savings 

of closed-loop versus standard of care, and the greater 

volume savings with the more sophisticated PID and 

fuzzy logic algorithms. 

These examples show the potential for improvement 

using CDSSs coupled with feedback and control designs. Future work will require testing of these systems 

in clinical trials that may elucidate further improvements of using this technology on injured patients. 

DATA COLLECTION FOR CDSS DESIGN AND

DEVELOPMENT

Data collection is an integral aspect of patient care and 

has evolved tremendously throughout the past century 

in the American hospital system. Additionally, 

Advanced Monitoring and Decision Support for Battlefield Critical Care Environment 

Figure 2. Performance of closed loop resuscitation fluid algorithms for blood pressure control using a decision table, proportionalintegral-derivative control, and fuzzy logic control. 

mm Hg 
 April – June 2011 77

THE ARMY MEDICAL DEPARTMENT JOURNAL

adequate data availability is critical for design, 

development, and operations of CDSS. In order to 

develop and implement accurate CDSS control rules 

and/or models, appropriate data have to be collected 

and analyzed for use during the algorithm development phase. Additionally, these data provide users 

ability to track diseases, healthcare trends, and epidemiological patterns of diseases, and have become an 

invaluable complement to the healthcare industry 

allowing healthcare providers to note trends and 

improve health outcomes. However, though most 

hospitals with a trauma center collect data through a 

data system or registry, a standardized or universal 

data collection system does not exist. 

To address the problems with current trauma databases, there have been ongoing studies to improve 

handover of critical trauma patient information by 

identifying problems that hinder accurate data transfer. 

There has been research focused on maximizing handover of patient information between paramedics and 

the receiving staff in the emergency department.13-15

Evans et al noted that only 75% of the prehospital 

setting information was documented and, even worse, 

only 67% of data was documented in the in-hospital 

handover. Moss determined the most commonly 

missed variables during handover of a trauma patient 

were: prehospital hypotension, Glasgow Coma Scale 

(GCS) score, heart rate, blood pressure, and respiratory 

rate.14 Perhaps the solution to these issues is the implementation of what the military has used in its research. 

Not only is there a better way to transfer the data from 

paramedic to emergency room team, perhaps there are 

better variables to evaluate and analyze to obtain a 

more accurate picture of the severely injured patient. 

The researchers at the Army Institute of Surgical 

Research use data from the Trauma Vitals System for 

storing data of the trauma patient from the point of 

injury until arrival to the trauma center.16 

Holcomb et al explored parameters in the prehospital 

setting which assist medical personnel with trauma 

patient triage to a trauma center for further lifesaving 

interventions (LSIs).17 The main physiologic signs 

found to significantly affect the need for LSIs were the 

GCS less than 6 and systolic blood pressure (SBP) below 90. When both GCS and SBP were abnormal, 

95% of the patients required LSIs. Holcomb et al proposed the need for specific physiologic data analysis in 

the prehospital setting to discriminate patients who 

require LSI versus those who do not. With this in effect, trauma centers, whether military or civilian, will 

become more efficient in the care of trauma patients. 

Unfortunately, as previously discussed, GCS and SBP 

often fail to make it past handoff from paramedics to 

the emergency room/trauma team. In a separate study, 

Holcomb et al17 also reviewed prehospital diagnostic 

and monitoring techniques which may best predict the 

need for prehospital LSI in nonhead-injured trauma 

patients. They had hypothesized that the addition of 

more automated systems during the treatment phase 

would increase the ability to predict if a patient 

required LSI.17 Holcomb et al proceeded to collect data 

from 3 distinct groups. All vital sign data collected 

among the 3 groups were stored and retrieved in the 

Trauma Vitals System. Group 1, the manual group 

(MG), contained only data that did not require instrumentation to obtain, ie, palpable pulse (radial, femoral, 

carotid) and either the motor or vocal component of 

the GCS score. Group 2, the semiautomated groups 

(SG), had all variables present in MG as well as vital 

signs that required minimal instrumentation. SG incorporated the eye component of the GCS and oxygen 

saturation as measured by pulse oximetry values. 

Group 3 was fully automated (AG) in data collection 

and included all variables from Groups 1 and 2, as 

well as noninvasive blood pressure, heart rate, endtidal carbon dioxide, and respiratory rate.17 In the multivariate analysis of Groups 1-3, the variables with the 

best predictive power for prehospital LSI in the MG 

were radial pulse along with the verbal and motor components of GCS.17 The only variable SG had different 

than the MG was the GCS eye component instead of 

verbal. Review of the AG demonstrated that the addition of all automated vital signs did not statistically 

improve the area under the curve for the receiver 

operating characteristic curve in predicting prehospital 

LSI.17 Holcomb determined that in an area where it is 

not possible to have the more complex electronic 

equipment for vital signs, such as in a combat zone or 

mass casualty event, one can reasonably predict the 

need for prehospital LSI using radial pulse and both 

the verbal and motor components of GCS.17 

In a retrospective study, McManus et al18 used the 

quality of prehospital radial pulses to estimate SBP, 

and also evaluated it as a method to rapidly triage a 

trauma patient. This study is similar to Holcomb et al, 

but McManus further characterizes the radial pulse in 

his patient evaluation. Pulse character as a marker for 

trauma triage is an important concept in environments 
78 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

where the ability to obtain a SBP is difficult or 

impossible secondary to time constraints, unavailability of equipment, and/or a noisy/shaking field 

environment. Subjects in this study were separated into 

3 groups. Paramedics involved with the helicopter 

teams were trained to identify the pulse as normal 

(strong, easily palpable), weak (palpable but difficult 

to find), or absent (no pulse). On review of the records, 

all patients with head injuries were excluded, as well 

as those with absent pulse as they were classified dead 

on arrival. To mimic the casualties seen in a combat 

environment, only patients from 18 to 50 years of age 

were included. In addition to radial pulse data, other 

variables collected were ones that could be rapidly 

assessed in a field environment without instrumentation: age, respiratory rate, capillary refill time, GCS, 

and gender. McManus et al completed a classification 

and regression tree analysis to predict the SBP. For 

patients with a weak pulse, the odds of mortality was 

15.2 times greater than for those with normal character 

pulse. A weak pulse correlated with a mean SBP of 

99.8 mm Hg, whereas a normal pulse correlated with a 

mean SBP of 128.7 mm Hg. After these numbers were 

obtained, the patients were split by age for those 39 

years or older, and those younger. Subjects who had 

normal pulse and younger than 39 years of age had a 

mean SBP of 126.3 mm Hg, and those aged 39 years 

or older, 134.2 mm Hg.18 The older age group was 

further split based on the initial respiratory rate, either 

more than 31.5 breaths per minute, or less than that 

rate. The group with more than 31.5 breaths per 

minute had an average SBP of 104 mm Hg, and those 

with the lower rate had an average of 139 mm Hg.18

The results indicated that pulse character is highly 

sensitive as a predictor for SBP, but not specific. Most 

of the subjects with weak radial pulse were noted to 

have low SBPs, however, not all those with normal 

pulse characters had normal SBP as older subjects with 

higher respiratory rates had low SBPs.18 McManus et 

al showed that mortality was 29% in nonhead-injury 

patients with a weak radial pulse and only 3% for 

those with normal pulse character. Additionally, those 

with the weak pulse character were 5 times more likely 

to be admitted into the intensive care unit. Using pulse 

character, SBP could be approximated for rapid 

assessment and triage in trauma patients, as well as 

partial prognosis of their outcome.18 

The Army Institute of Surgical Research has been 

active in the investigation of documentation 

completeness and accuracy in the setting of 

prehospital/hospital data collection. Missing data not 

only hinders patient care but has been seen to delay 

LSI. Additionally, the missing values can be 

detrimental when records are reviewed for quality 

analysis or research. Current prehospital electronic 

monitors obtain vital signs such as oxygen saturation, 

blood pressure, and heart rate that are not as accurate 

in predicting patient outcome. A monitoring device 

should be small, lightweight, and with the ability for 

remote, wireless access and functionality which would 

benefit both civilian and military trauma providers. 

ADVANCED MONITORING SYSTEMS FOR THE

BATTLEFIELD ENVIRONMENT

As previously stated, lack of reliable information from 

the far-forward combat setting is one of the most 

important issues related to the use of vital signs 

monitors in the battlefield critical care environment. In 

order to help alleviate this problem, the Department of 

Defense has sponsored several advanced monitoring 

initiatives to provide products capable of capturing and 

analyzing data from patients in the field. A recent 

advancement in the data driven CDSS is the 

introduction of the wireless vital signs monitor, 

WVSM (Athena GTX, Inc, Des Moines, IA). The 

company recently received clearance from the US 

Food and Drug Administration to market the device, 

which is a compact, patient-worn wireless and/or 

wired monitor. This innovative piece of equipment 

automatically measures blood pressure, pulse rate, 

blood oxygenation, and other important critical vital 

signs from point of injury through transport to a 

treatment center. The WVSM device records up to 4.5 

hours of these vital signs and is capable of wirelessly 

uploading this data to a personal digital assistant, 

mobile computer (tablet or laptop), and/or other 

computer system using a software program designed to 

search for and communicate with any WVSM device 

within range. The system uses a standard wireless 

IEEE 802.11 Wi-Fi signal, eliminating the need to 

reevaluate the patient at each level of medical care and 

providing continuous records of all vital signs 

recorded from the point of device operation. A 

rechargeable battery provides up to 7 hours of 

operation, depending on frequency of blood pressure 

measurements and status of Wi-Fi connection. To 

minimize tactical risk, all wireless functions and 

alarms can be toggled on and off as desired. 

Advanced Monitoring and Decision Support for Battlefield Critical Care Environment 
 April – June 2011 79

THE ARMY MEDICAL DEPARTMENT JOURNAL

Designed for ease of use and transport to far forward 

situations, the WVSM weighs less than 16 oz and 

incorporates a standard blood pressure cuff, a reusable 

finger clip pulse oximeter, and a 3-lead electrocardiograph (ECG). In multiple injury situations, a colorcoded and audible alarm system of critical parameters 

assists the caregiver in triage decisions, allowing 

simultaneous monitoring of multiple patients on the 

receiving station accessory software. The caregiver 

can quickly view each patient’s status at the point of 

injury in order to accurately triage the casualty. As the 

patient arrives at the treatment center and comes 

within range of the facility’s Wi-Fi network, the 

WVSM will automatically upload patient data to the 

treatment center’s computer at the rate of one minute 

of history per second, providing a real-time view of all 

current vital signs and historical trends. 

Additional equipment under development is a smaller 

vital signs monitor, the mini-Medic (Athena GTX, Des 

Moines, IA) system. The device is designed to be 

attached to the patient’s forehead and provides the 

medic with a complete set of vital signs and smart 

alarms for patient monitoring. The “band aid” 

component, the forehead accessory, provides standard 

measures of pulse oximetry, heart rate, 3-lead ECG, 

and skin temperature, among other measures. A builtin near-real-time R-wave detector provides heart rate 

measures on the device for transmission to the 

receiving station. The monitor also includes a trauma 

card where manual entry of mechanism of injury, 

drugs, and treatments can be entered. 

In contrast to the WVSM, the size of the mini-Medic 

system prevents blood pressure measures using a 

standard cuff system. However, the device provides a 

measure of the patient’s pulse wave transit time 

(PWTT) as a surrogate of patient hemodynamic stability. A proprietary algorithm is used to compute the 

PWTT and provide a real time patient blood pressure 

trend. With the continuous monitoring of PWTT, miniMedic becomes increasingly sensitive to sudden 

changes in blood pressure, as shown in Figure 3. 

Patient status is monitored via the Murphy Factor 

(Athena GTX, Des Moines, IA) smart alarm algorithm. 

The system provides the medic with decision support 

capability by combining all vital signs, trends, and 

pulse characteristics recorded by the monitor, and 

applying a multivariate sensor fusion algorithm that 

provides a combined index of the patient condition. 

Ratings are displayed as 0-1 in green, 2-3 in yellow, 

and 4-5 in red, indicating a patient who is in a normal, 

low priority, or high priority condition, respectively. 

The mini-Medic allows one medic to quickly deploy 

the sensing band-aids and begin triage decisions based 

on the easy-to-read handheld monitor displaying a 

color-coded numeric assessment. The medic can 

quickly and easily monitor up to 10 remote patients up 

to 100 meters away. 

Figure 3. The response of PWTT (green) from a hemorrhage and recovery of an animal study. 
80 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

The algorithm used to display Murphy Factor has 

undergone extensive research to show strong 

correlation to other similar summary alarms. In a 

unique application of high mobility, stress, and 

motion, the algorithm automatically compensates for 

data dropout and missed data points by summarizing 

only what is known at the time, and never infers a 

value not present. An example presented in Figure 4 

shows the Murphy Factor algorithm calculated on the 

vitals of a hemorrhage pig study. This example shows 

that the Murphy Factor jumps to a yellow and red level 

after the hemorrhage. In fact, since the algorithm picks 

up the quick drop in pressure the value jumps faster 

than the drop in actual BP. Then, as the animal 

stabilized and blood pressure measured posthemorrhage, the Murphy Factor lowered to a 3-4 range, still 

remaining elevated as the heart rate and respiratory 

rate are both elevated. In this case the dynamic nature 

of the measure is balanced by the fact that although the 

vital signs known are serious, the “patient” is stable. 

To further assist the medic, a trauma card is included 

on the handheld monitor to allow the medic to enter 

data which is then stored on the patient’s forehead 

system. This allows all patient data including current 

readings, historical information showing trends, and 

medic entered information to remain with the patient 

from the point of injury through patient disposition. 

All of this information, along with current vital signs 

readings, can be wirelessly accessed upon arrival at the 

treatment center, either through the handheld device or 

from the band-aid accessory, for printout in the format 

of the Trauma Combat Casualty Care card. 

CONCLUSIONS

Decision support and automation are critical 

technologies in the advancement of battlefield 

medicine. Nevertheless, several challenges remain to 

be addressed and resolved. Effective data collection, 

accurate models of physiology, and monitoring 

systems that can be deployed across all echelons of 

care need to be further developed and deployed. As 

computing power continues to increase, the 

availability of platforms for decision support 

technology becomes much more ubiquitous. However, 

there is still a need to tie computer systems 

engineering within an integrated framework for 

improving treatments and diagnosis that can be 

automated using state-of-the-art technology. These 

issues are currently being address through various 

research projects within the Department of Defense. 

REFERENCES

1. Salinas J, Drew G, Gallagher J, et al. Closed-loop and 

decision-assist resuscitation of burn patients. J 

Trauma. 2008;64(suppl 4):S321-S332. 

2. Grathwohl KW, Venticinque SG. Organizational 

characteristics of the austere intensive care unit: the 

evolution of military trauma and critical care medicine; applications for civilian medical care systems. 

Crit Care Med. 2008;36(suppl 7):S275-S283. 

3. Lettieri CJ, Shah AA, Greenburg DL. An intensivistdirected intensive care unit improves clinical 

outcomes in a combat zone. Crit Care Med. 2009;37

(4):1256-1260. 

Advanced Monitoring and Decision Support for Battlefield Critical Care Environment 

Figure 4. Murphy Factor (blue) follows the trend of the vitals for a hemorrhaged pig. 
 April – June 2011 81

THE ARMY MEDICAL DEPARTMENT JOURNAL

4. Garg AX, Adhikari NK, McDonald H, et al. Effects 

of computerized clinical decision support systems on 

practitioner performance and patient outcomes: a 

systematic review. JAMA. 2005;293(10):1223-1238. 

5. Kawamoto K, Houlihan CA, Balas EA, Lobach DF. 

Improving clinical practice using clinical decision 

support systems: a systematic review of trials to 

identify features critical to success. Br Med J. 

2005;330(7494):765. 

6. Morris AH. Developing and implementing 

computerized protocols for standardization of clinical 

decisions. Ann Intern Med. 2000;132(5):373-383. 

7. Guerlain S, Brown DE, Mastrangelo C. Intelligent 

decision support systems. 2000 IEEE International 

Conference on Systems, Man, and Cybernetics, 

Nashville, Tennessee, 8-11 October 2000. Vol 3. 

IEEE Web site; 2000:1934-1938. Available at: http://

ieeexplore.ieee.org/xpl/tocresult.jsp?isnum 

ber=19155. 

8. Sui L. Decision support systems based on knowledge 

management. Proceedings of the 2005 International 

Conference on Services Systems, and Services 

Management, Chongquing, China, 13-15 June 2005. 

Vol 2. IEEE Computer Society Web site; 2005:1153-

1156. Available at: http://www.computer.org/portal/

web/csdl/doi/10.1109/ICSSSM.2005.1500178. 

Accessed November 2, 2010. 

9. Forgy CL. Rete: a fast algorithm for the many 

pattern/many object pattern match problem. Artif 

Intell. 1982;19:17-37. 

10. Chaisson NF, Kirschner RA, Deyo DJ, Lopez JA, 

Prough DS, Kramer GC. Near-infrared spectroscopyguided closed-loop resuscitation of hemorrhage. J 

Trauma. 2003;54(suppl 5):S183-S192. 

11. Rafie AD, Rath PA, Michell MW, et al. Hypotensive 

resuscitation of multiple hemorrhages using 

crystalloid and colloids. Shock. 2004;22(3):262-269. 

12. Ying H, Bonnerup C, Kirschner RA, Deyo DJ, 

Michell MW, Kramer GC. Closed-loop fuzzy control 

of resuscitation of hemorrhagic shock in sheep. Paper 

presented at: 24th Annual International Conference of 

the IEEE Engineering in Medicine and Biology 

Society and the Biomedical Engineering Society; 

October 23-26, 2002; Houston, Texas. 

13. Owen C, Hemmings L, Brown T. Lost in translation: 

maximizing handover effectiveness between 

paramedics and receiving staff in the emergency 

department. Emerg Med Australas. 2009;21(2):102-107. 

14. Moss RL. Vital signs records omissions on 

prehospital patient encounter forms. Prehosp 

Disaster Med. 1993;8(1):21-27. 

15. Evans SM, Murray A, Patrick I, et al. Assessing 

clinical handover between paramedics and the trauma 

team. Injury. 2010;41(5):460-464. 

16. Salinas JM, McManus JG, Convertino VA, Holcomb 

JB. Hospital Data Warehousing System for Mining of 

Patient Data. Paper presented at: 2005 Software 

Engineering Application Conference; November 14-

16, 2005; Phoenix, Arizona. 

17. Holcomb JB, Salinas J, McManus JG, Miller CC, 

Cooke WH, Convertino VA. Manual vital signs 

reliably predict need for life-saving interventions in 

trauma patients. J Trauma. 2005;59(4):821-828. 

18. McManus J, Yershov AL, Ludwig D, et al. Radial 

pulse character relationships to systolic blood 

pressure and trauma outcomes. Prehosp Emerg Care. 

2005;9(4):423-428. 

AUTHORS

Dr Salinas is Manager, Combat Critical Care 

Engineering Research Task Area, US Army Institute of 

Surgical Research, Fort Sam Houston, Texas. 

Dr Nguyen is a Research Fellow in the Combat Critical 

Care Engineering and Clinical Trials Task Area, US 

Army Institute of Surgical Research, Fort Sam Houston, 

Texas. 

Dr Darrah is President and CEO of Athena GTX, Inc, 

Des Moines, Iowa. 

Dr Kramer is Director, Resuscitation Research 

Laboratory, University of Texas Medical Branch, 

Galveston, Texas. 

LTC Serio-Melvin is a Clinical Nurse Specialist, US 

Army Institute of Surgical Research, Fort Sam Houston, 

Texas. 

LTC Mann is a Research Scientist, US Army Institute 

of Surgical Research, Fort Sam Houston, Texas 

Dr Wolf is a Consulting Surgeon and Professor of 

Surgery, University of Texas Health Science Center, 

San Antonio, Texas. 

MAJ(P) Chung is a Medical Intensivist, US Army 

Institute of Surgical Research Burn Center, Fort Sam 

Houston, Texas. 

COL Renz is Director, US Army Institute of Surgical 

Research Burn Center, Fort Sam Houston, Texas. 

COL Cancio is Consulting Surgeon, US Army Institute 

of Surgical Research Burn Center, Fort Sam Houston, 

Texas. 
82 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

THE PROBLEM: PREVENTABLE DEATH ON THE

BATTLEFIELD AND OTHER DEPLOYED SETTINGS

In the current conflict in Iraq and Afghanistan, the theaterwide case fatality rate (defined as the sum of the number 

killed-in-action plus the number died-of-wounds, divided 

by total number of battle casualties) approximates 12%.1,2

Of these unfortunates, perhaps one-third represent 

“potentially preventable causes of death,” excluding 

catastrophic central nervous system injuries, great vessel 

injuries, and massive burns.3,4

Within this population of potentially preventable deaths, 

perhaps half die for lack of a life-saving intervention 

(LSI) performed within 10 to 20 minutes of wounding.4

LSIs include airway/ventilatory support, tourniquet or 

compression of accessible hemorrhage, and decompression of intrathoracic tension physiology, be it tension 

pneumothorax, massive hemothorax, or a combination of 

both. Retrospective studies of the implementation of 

advanced practice medics and credentialed emergency 

care practitioners have likewise decreased case fatality 

from the reported 12% to approximately 6.7% and 7.1% 

respectively, citing primarily the association between 

early performance of LSIs with this survival improvement.2,5 Preliminary data from a retrospective analysis of 

military critical care paramedic-staffed Army air 

ambulances, with a survival improvement of roughly 

50% in severely wounded service members (defined as 

injury severity scale greater than 15), provided further 

corroboration of these observations (LTC R. L. Mabry, 

oral communication, September 2010). 

The aforementioned data support the contention that a 

capability gap exists in the scope-of-practice and clinical 

competency of prehospital combat casualty care proPrehospital and Emergency Care 

 Research at the US Army Institute of 

 Surgical Research: Enabling the Next 

 Great Leap in Combat Casualty Survival 

LTC(P) Robert T. Gerhardt, MC, USA 

ABSTRACT

Minimizing preventable death continues to be a primary focus of the combat casualty care research community, and of 

the Army Medical Department as a whole. Toward that end, tremendous successes have been realized in resuscitative 

surgery, critical care, rehabilitation, preventive medicine, and in our collective ability to project effective medical care 

into the most austere locations throughout the globe. 

Innovation in the care rendered outside of theater hospitals or strategic air evacuation conveyances, however, has not 

kept the same pace. The US military experience in World War II, Korea, and Vietnam served as a prime source for the 

development of the tactics, techniques, and procedures which spawned modern civilian sector trauma care and 

emergency medical services. But this ascendance was driven by the dedicated medics, corpsmen, physicians, nurses, and 

allied health practitioners from those conflicts who left the military for the civilian sector, leaving their replacements, in 

many cases, to repeat the same mistakes, and to relearn hard lessons that otherwise might have been assimilated had 

they been effectively captured and integrated into doctrine and training. A prime example of this phenomenon is the 

recent acknowledgement of the “en route care gap” existing in tactical medical evacuation. 

The US Army Institute of Surgical Research (USAISR) and the Army emergency medicine community have made a 

significant commitment toward elucidating the requirements, capability gaps, and a way-forward in search of the development of an integrated prehospital combat casualty care system, nested within the Joint Theater Trauma System. This 

paper examines specific research programs, concept development, and collaborations with other Army, joint, and 

civilian center organizations which comprise the USAISR Prehospital and Emergency Care Research Program, 

including the Remote Damage Control Resuscitation initiative, Emergency Telemedical Direction of Role-I providers, 

Combat Medical Voice Documentation System, and establishment of the Remote Trauma Outcomes Research Network. 
 April – June 2011 83

viders, both among paraprofessional medics and corpsmen, and credentialed practitioners. Yet even were this 

capability gap to be bridged, there remains a sizeable 

subpopulation of preventable combat deaths resulting 

from the lethal combination of noncompressible truncal 

hemorrhage (NCTH), environmental effects, and protracted time intervals between initial injury and access to 

resuscitation and hemostatic surgery.6

 In reality, once LSIs 

are performed and initial intravascular boluses of colloidal 

fluids are administered, the current prehospital combat 

casualty treatment algorithm is essentially exhausted. 

Ultimately, the solution is to bring the casualty and 

surgical facility closer to each other. In lieu of that, it is 

theorized that were it possible to accurately identify the 

NCTH casualty, one might employ specific physiological and biochemical characteristics as well as tactical data to determine which casualties are at greatest 

risk for requiring massive blood transfusion, and the 

associated risks for coagulopathy, acidosis, and 

hypothermia.7

 Further, if forward-deployable blood 

components were to become available, along with a 

mechanism for clinical oversight for their use, it might 

become possible to treat those conditions, forestalling the 

onset of this “lethal triad” as the casualty undergoes 

evacuation to an operating table in a condition that might 

improve their chances of survival. 

TOWARD AN INTEGRATED COMBAT EMERGENCY MEDICAL

SERVICES SYSTEM

Presuming the premises described above to be true, the 

next steps toward meaningful reduction in combat deaths 

would encompass improved clinical competence and 

advanced scope-of-practice for prehospital combat 

casualty caregivers, the accurate, timely and accessible 

acquisition of prehospital patient care records for both 

documentation and process improvement, and a technological solution for the initial temporization of casualties 

suffering from NCTH.8

 All will require professional 

medical oversight, clinically-validated operating guidelines or protocols, and an integrated network of initial 

tactical medical care, medical evacuation with care 

continuing en route, and coordination with destination 

surgical facilities on a fluid battlefield.9

 Arguably, this 

scenario represents the integration of prehospital care 

into the Joint Theater Trauma System (JTTS) in a manner 

analogous to the integration of prehospital care into 

civilian sector trauma systems. Another way of viewing 

this scenario is the image of a combat emergency medical 

services (EMS) system.10

While such a vision is notable for its audacity, it also 

presents a viable approach to integrating critical assets 

within the Army Medical Department (AMEDD) and the 

Army as a whole toward the laudable goal of driving the 

rate of preventable combat deaths toward zero. These 

include the AMEDD Department of Combat Medic 

Training, the Army EMS Program Management Office, 

the Directorate of Combat and Doctrine Development, 

the USAISR, the Medical Communications for Combat 

Casualty Care Program Office, the US Army Aeromedical Center, and the Office of The Surgeon General, 

among others. Toward this end, the USAISR’s Prehospital and Emergency Care Research Program continues 

its labor to link doctrinal and training solutions with 

technology and clinical innovation. 

REMOTE DAMAGE CONTROL RESUSCITATION INITIATIVE

Presuming they receive required LSIs and survive the 

initial postwound period, severely wounded individuals 

with continuing hemorrhage and delayed evacuation are 

more likely to die eventually due to the cumulative 

deleterious effects of NCTH—hypothermia, acidosis, and 

coagulopathy.4

 The later conditions have become known 

as the lethal triad.11 The damage control resuscitation 

paradigm employs selected use of blood products early in 

the course of trauma resuscitation in an attempt to 

prevent or mitigate development of these conditions.12

Blood product transfusion at Role-I (prehospital combat 

casualty care) is a concept not foreign to the Israeli and 

British conventional military medical communities, 

though it is administered exclusively by credentialed 

practitioners.13,14 In likewise manner, remote damage 

control resuscitation (RDCR) is a concept envisioned for 

use in the out-of-hospital setting in cases where severely 

injured patients with continuing NCTH face delays in 

evacuation to resuscitative surgical intervention. These 

delays may result from weather conditions, time and 

distance factors, and availability of evacuation assets in 

proximity to the patient. In the setting of conflict, 

additional causes of evacuation delay might include 

hostile action, prioritization of tasks required for mission 

accomplishment, and logistical constraints.15 In such 

cases, RDCR may provide a coherent diagnostic and 

therapeutic algorithm for early intervention in the out-ofhospital phase, with the objective of delivering optimized 

preoperative patients to the military trauma surgeon. 

By projecting the concept of damage control resuscitation 

forward of the Role-II (forward surgical facility) or III 

(theater hospital) emergency medical treatment section, 

and building upon the Tactical Combat Casualty Care 

(TCCC) paradigm, RDCR might employ advanced monitors and point-of-care diagnostics to diagnose or predict 

NCTH during the tactical field care or tactical evacuation 
84 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

phases.16 Following this diagnosis, decision support devices coupled with emergency telemedical direction 

would provide the authority to employ advanced therapeutic agents by noncredentialed medics or corpsmen 

remotely. These agents might include lower volume 

intravenous colloid fluid infusion in the form of freezedried or spray-dried plasma. With the advent of fielddeployable thromboelastography, it may also become possible to administer freeze-dried platelets, targeted procoagulants, such as recombinant Factor VIIa or activated 

prothrombin complex, or antifibrinolytics such as tranexemic acid. Eventually, hemoglobin-based oxygen carriers 

or even whole-blood substitutes might become available 

for employment in a future RDCR paradigm. If one accepts the premise that the employment of hospital-based 

damage control resuscitation may improve survival from 

16% to 40% over standard trauma care, translation of 

RDCR into the Role-I setting may likewise yield 

encouraging results. 

EMERGENCY TELEMEDICAL DIRECTION

Both conventional wisdom and recent data collected from 

the Iraq theater of operations imply an improved rate of 

casualty survival resulting from the presence of emergency medicine-skilled triage, treatment, and evacuation 

decision-making in the prehospital (health service support levels I and II) phase of combat casualty care.2,5

Despite the potential significance of these preliminary 

findings, the pool of military emergency medicine practitioners (physicians, emergency medicine specialtytrained physician assistants, and advanced practice 

medics) available to deploy with conventional forces is 

unlikely to increase for the foreseeable future, and their 

current force levels are inadequate to staff a preponderance of deploying combined arms battalions or even 

brigade combat team medical treatment teams.2

 As a result, alternative methods of exporting this expertise and 

procedural competency must be sought. Preliminary studies of EMS-style medical direction and of advanced treatment protocols for combat medics under the supervision 

of military emergency physicians appear promising.10

Preliminary investigations of emergency telemedical direction of primary care physician-led resuscitation teams 

in simulated casualty care scenarios, under the auspices 

of the Emergency Telemedical Direction of Role-I Providers Project, have also been shown to be feasible, and 

in an initial pilot trial, improved the rate of completion of 

LSIs from 56% to 100% (R.T.G. et al, unpublished data, 

2010). The Army Institute of Surgical Research remains 

actively engaged in the investigation of emergency 

telemedical direction as a primary mechanism both for 

enabling RDCR by forward-deployed practitioners, 

medics, and corpsmen, and for providing the legal and 

ethical authority for out-of-hospital blood product usage. 

COMBAT MEDICAL VOICE DOCUMENTATION SYSTEM

Despite robust and accurate collection of patient care reports and clinical data initiated at forward surgical facilities (Role II) and theater hospitals (Role III), there remains a sparse record of such data collection in the prehospital combat casualty care setting (Role-I).* This capability gap not only impedes patient care, but it also prevents meaningful process improvement, which has 

contributed materially to the static case fatality rate in the 

Role-I setting. 

A combination of legacy documentation formats (written 

field medical card, form DD 1380), spotty Role-I 

casualty data documentation enforcement by battalion 

and brigade medical command structures, and a pervasive 

perception by many Role-II/III practitioners that data 

coming from Role-I providers holds little value, among 

other issues, set the conditions for failure in collecting 

this vital data. While there are isolated examples of 

success in collecting and processing Role-I data mainly 

from the Special Operations Forces setting, the majority 

of anecdotal reports from conventional forces in the field 

indicate that “completed” DA 7656/TCCC cards often 

contain incomplete data, and are often completed several 

hours retrospective to the patient care encounter.* While 

retrospective patient care report completion is common in 

the civilian sector EMS community, the general practice 

is to complete and file these patient care reports within 

the immediate posttransport period, often while the 

ambulance is being restocked for return to service. 

Understandably, the concern in the case of delayed 

completion of prehospital casualty care records (PCCR) 

centers on recall bias, as well as difficulty in linking 

these records with their respective casualties as they 

wend their way through the casualty care and evacuation 

chain. Despite these obstacles, civilian sector experience 

in EMS data collection and research has demonstrated 

that timely, accurate, and relevant out-of-hospital clinical 

data can be collected.17 Furthermore, not only is it a 

medico-legal requirement in the civilian sector that these 

data be collected as part of the medical record, but that by 

collecting, de-identifying, collating, and analyzing it, we 

may improve both the emergency medicine system itself 

and the quality of patient care delivered by it.18 Clearly, 

our combat casualties deserve nothing less. 

Prehospital and Emergency Care Research at the US Army Institute of Surgical Research: 

Enabling the Next Great Leap in Combat Casualty Survival 

*Source: Joint Theater Trauma Registry, an internal military database not readily accessible by the general public. 
 April – June 2011 85

THE ARMY MEDICAL DEPARTMENT JOURNAL

Toward this end, USAISR initiated investigations into 

threshold solutions for bridging this Role-I PCCR 

capability gap.19 A rugged, hands-free, high-fidelity voice 

recorder was considered as an effective entry-level 

mechanism for capturing the PCCR data that compose 

the DA 7656/TCCC card, as well as follow-on treatment 

interventions at forward resuscitative surgery and during 

en route care. A prototype combat medical voice 

documentation system (CMVDS) is being developed 

under the guidance of USAISR, in cooperation with the 

Medical Communications for Combat Casualty Care 

Directorate and the private sector. The CMVDS device is 

composed of a recorder capable of capturing the human 

voice after filtering-out typical background noise which 

is ubiquitous on the battlefield, coupled to a data 

recording “sled” which allows near-immediate 

downloading of the recording, permitting the combat 

medical provider to retain a copy of the recording while 

sending the recorder itself with the casualty. After arrival 

at theater hospitals, it is envisioned that CMVDS would 

be downloaded by a trauma registrar, after which it may 

be manually transcribed, or processed via a natural 

language processing software application into a standard 

word processor file. Subsequently, the clinical data could 

be uploaded to medical records, registries, and for 

command and control purposes. A corresponding natural 

language processing software system capable of 

digitizing the audio files generated by CMVDS is also 

under development, with the objective of uploading 

PCCR data into an electronic medical record, and for 

populating the prehospital segment of the Joint Tactical 

Trauma Registry.19

REMOTE TRAUMA OUTCOMES RESEARCH NETWORK

In order to be successfully developed and actualized, the 

aforementioned RDCR paradigm will require clinical 

validation and demonstration prior to translation to the 

battlefield. It is widely acknowledged that prehospital 

research is difficult to conduct; the contemporary 

operational environment adds further complications in 

terms of protracted time periods from point-of-wounding 

to resuscitative surgery.15,17,18 Thus, the identification and 

development of a relevant and sustainable test bed for 

RDCR and related out-of-hospital trauma research was 

identified as a priority by USAISR. 

The Southwest Texas Regional Advisory Council for 

Trauma (STRAC) is a robust and mature network of 

community hospitals, regional trauma centers, EMS 

units, and air medical transport organizations. It is 

affiliated with the Brooke Army Medical Center, 

USAISR, and the University of Texas Health Science 

Center–San Antonio. A preliminary review of interfacility trauma transports within this network revealed 

numerous cases of transport time intervals from 40 

minutes to an excess of 6 hours, often from outlying 

facilities without surgical capability. With the notable 

exception of hostile fire, an analysis of time-distance and 

environmental issues in this setting bore remarkable 

similarity to the contemporary operational environments 

in Afghanistan and Iraq. As such, the STRAC network 

was identified as a potentially optimal model for studying 

RDCR applications. 

Recently, USAISR was awarded congressionally-directed 

funds to support the development of the Remote Trauma 

Outcomes Research Network (RemTORN) Project. The 

stated objectives of this program are to establish the 

physical and personnel infrastructure for the collection of 

both out-of-hospital (initial response and interfacility) 

and linked inpatient clinical data for trauma patients 

undergoing initial stabilization followed by transfer to the 

Brooke Army Medical Center or University Hospital, 

both level-I trauma centers; and to initiate observational 

studies of physiologic monitoring, coagulation status, 

injury severity, and en route care in anticipation of 

subsequent clinical trials of RCDR protocols. As this test 

bed matures, RemTORN is envisioned as providing the 

translational bridge for testing and proving the 

technologies, training interventions, and clinical guidelines that will enable the mitigation of NCTH, which will 

further decrease the rate of preventable combat deaths. 

Coincidentally, it is anticipated that RDCR interventions 

will also translate into civilian sector applications, 

particularly in such settings as rural EMS, austere/wilderness emergencies, tactical medical operations, homeland and overseas disaster response, and regionalized 

trauma networks. 

BRINGING IT ALL TOGETHER

Rigorous scientific inquiry and integrated innovation at 

the Role-I level of the battlefield are relatively young and 

emerging concepts. While the obstacles and challenges 

are daunting, the potential dividends are equally 

substantial. To realize them will require innovative 

thinking, commitment, and substantial resources in terms 

of talent, fiscal support, and staff work. Collaboration 

with joint, interagency, and civilian sector partners from 

academia and industry will also be critical. Through our 

current initiatives and other cooperative efforts with 

AMEDD directorates and Navy and Air Force partners, 

the Prehospital and Emergency Care Research Program 

of the USAISR has sought to chart a coherent, relevant, 

and actionable roadmap for enabling the next great leap 

in casualty survival. 
86 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

Prehospital and Emergency Care Research at the US Army Institute of Surgical Research: 

Enabling the Next Great Leap in Combat Casualty Survival 

REFERENCES

1. Holcomb JB, Stansbury LG, Champion HR, 

Wade C, Bellamy RF: Understanding combat casualty care statistics. J Trauma. 2006;60(2):397-401. 

2. Gerhardt RT, De Lorenzo RA, Oliver JE, et al. Out-ofhospital combat casualty care in the current war in 

Iraq. Ann Emerg Med. 2009;53(2):169-174. 

3. Holcomb JB, McMullin NR, Pearse L, et al. Causes 

of death in US Special Operations Forces in the 

Global War on Terrorism, 2001–2004. Ann Surg. 

2007;245(6):986–991. 

4. Kelly JF, Ritenour AE, McLaughlin DF, et al. Injury 

severity and causes of death from Operation Iraqi 

Freedom and Operation Enduring Freedom: 2003-

2004 versus 2006. J Trauma. 2008;64(suppl 2):S21–

S27. 

5. Zoroya G. Military considers revised medical training 

for troops. USAToday.com [serial online]. September 

13, 2009. Available at: http://www.usatoday.com/

news/military/2009-09-13-save-lives_N.htm. 

Accessed January 6, 2011. 

6. Gerhardt RT, Mabry RL, DeLorenzo RA, Butler FK. 

Fundamentals of Prehospital Combat Casualty Care. 

Combat Casualty Care: Lessons Learned from OEF 

and OIF [book on DVD]. Los Angeles: Pelagique, 

LLC; 2010. 

7. MacLeod JB, Lynn M, McKenney MG, Cohn SM, 

Murtha M. Early coagulopathy predicts mortality in 

trauma. J Trauma. 2003;55(1):39-44. 

8. Gerhardt, RT, Adams BD, De Lorenzo RA, Godinez 

F, Crawford DM, Gruppo LQ, Rinnert K. Panel 

synopsis: prehospital combat health support 2010: 

what should our azimuth be?. J Trauma. 2007;62

(suppl 6):S15-S16. 

9. Gerhardt RT, McGhee JS, Cloonan C, Pfaff JA, De 

Lorenzo RA. US Army MEDEVAC in the new 

millennium: a medical perspective. Aviat Space 

Environ Med. 2001;72:660-665. 

10. Gerhardt RT, Hermstad EL, Oakes M, Wiegert RS, 

Oliver J. An experimental predeployment training 

program improves self-reported patient treatment 

confidence and preparedness of Army combat 

medics. Prehosp Emerg Care. 2008;12(3):359-365. 

11. Jansen JO, Thomas R, Loudon MA, Brooks A. 

Damage control resuscitation for patients with major 

trauma. BMJ. 2009;338:b1778. 

12. Shaz BH, Dente CJ, Nicholas J, et al. Increased 

number of coagulation products in relationship to red 

blood cell products transfused improves mortality in 

trauma patients. Transfusion. 2010;50(2):493-500. 

13. Barkana Y, Stein M, Maor R, et al. Prehospital blood 

transfusion in prolonged evacuation. J Trauma. 

1999;46(1):176-180. 

14. McLeod J. Hodgetts T. Mahoney P. Combat 

"category A" calls: evaluating the prehospital 

timelines in a military trauma system. J R Army Med 

Corps. 2007;153(4):266-268. 

15. Gerhardt RT. Tactical en route care. In: Schwartz RB, 

McManus JG, Swienton RE, eds. Tactical Emergency 

Medicine., Philadelphia, PA: Lippincott Williams & 

Wilkins; 2008:153-167. 

16. Butler F. Tactical combat casualty care: combining 

good medicine with good tactics. J Trauma. 2003;54

(suppl 5):S2-S3. 

17. Maio RF, Garrison HG, Spaite DW, et al. Emergency 

medical services outcomes project I (EMSOP I): 

prioritizing conditions for outcomes research. Ann 

Emerg Med. 1999;33:423-432. 

18. Sayre MR, White LJ, Brown LH, et al. National EMS 

research agenda. Prehosp Emerg Care. 2002;6(suppl 

3):S1-S43. 

19. Anthony L, Gerhardt RT, Sharma K, et al. Enabling 

prehospital documentation via spoken language 

understanding on the modern battlefield. Paper 

presented at: 3rd International Conference on Applied 

Human Factors and Ergonomics; July 19 – 22, 2010; 

Miami, Florida. 

AUTHOR

LTC(P) Gerhardt is Chief, Prehospital and Emergency 

Care Research Program, US Army Institute of Surgical 

Research, Fort Sam Houston, Texas. 
 April – June 2011 87

INTRODUCTION

Role I battlefield medical care is care provided in the 

prehospital environment outside of the forward 

surgical team and the combat support hospital. It 

includes aid delivered from the point of injury through 

the battalion aid station or brigade support medical 

company until the casualty is delivered to surgical 

care. Providers of casualty care at this stage include 

injured Soldiers themselves (self-aid), fellow Soldiers 

(buddy-aid and combat life-savers), combat medics, 

flight medics, battalion surgeons and physician 

assistants. 

Historically, the Army Medical Department’s 

(AMEDD) chief focus in wartime has been the 

provision of quality hospital-based and forward 

surgical care. During the current conflict, tremendous 

medical advances have been made that saved the lives 

of many Soldiers who would have died in other 

conflicts.1

 If a salvageable patient arrives alive at 

surgical care in the current conflict, the likelihood of 

survival is nearly 98%.2

 Yet 3 out of 4 deaths occur on 

the battlefield before reaching a surgeon, with as many 

as 28% of fatally injured Soldiers dying with 

potentially survivable injuries.3

 Therefore, any 

significant future improvement in saving Soldiers’ 

lives is most likely to occur in the prehospital setting. 

This will require a significant shift in AMEDD focus 

to emphasize the prehospital environment. 

It is important to recognize that while the AMEDD 

trains medical providers, establishes doctrine, and 

develops medical equipment sets for the prehospital 

environment, line commanders are ultimately 

responsible for the medical care of their Soldiers on 

the battlefield. Yet busy combat arms commanders 

receive little training on how Soldiers die in battle and 

how they as leaders can best prepare their Soldiers to 

react to casualties. Instead, line commanders have 

relied on their “Doc,” usually their battalion surgeon 

or physician assistant (PA), to advise them on medical 

training and casualty care tactics, techniques, and 

procedures. This places great responsibility on the 

battalion surgeon or PA in terms of setting the 

example for clinical excellence in the line unit, as well 

as demonstrating competence in medical staff planning 

and execution. 

The role of the battalion surgeon, PA, and combat 

medic are therefore central to the success of battlefield 

care and critical to the survival of wounded casualties. 

To advance the state-of-the-art, this article examines 

current military prehospital care policies and 

procedures and uses the highly evolved civilian 

emergency medical systems as a study of contrasts. It 

further proposes a comprehensive way to exploit 

advantages of the civilian system for the benefit of the 

US Army and, ultimately, battlefield casualties. 

HISTORICAL PERSPECTIVE

Wars are “epidemics of trauma.” These epidemics 

have historically leveraged advances in military 

surgical and trauma care that are often later applied to 

the civilian trauma setting. The most salient aspect of 

military prehospital medicine historically and today 

has been the rapid clearing of casualties from the 

battlefield. During the 18th and 19th centuries, 

exposure was the most prevalent killer of wounded 

Soldiers. Wounded Soldiers, especially those on the 

losing side, would often lie for days where they fell, 

exposed to the elements without water, food, or 

shelter.4

 Officers and those who could afford medical 

care would hire surgeons to accompany them during 

the campaign or seek care on the local economy 

following the action. 

Dominique Jean Larrey, Napoleon’s surgeon, 

recognized that delays in evacuation increased 

mortality and suffering for the wounded. He developed 

horse-drawn “flying ambulances” to rapidly treat and 

evacuate wounded soldiers from the field.4

 During the 

US Civil War, several scandals followed early battles 

Improving Role I Battlefield Casualty Care 

 from Point of Injury to Surgery 

LTC Robert L. Mabry, MC, USA 

COL Robert A. De Lorenzo, MC, USA 
88 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

after injured Soldiers remained on the field for days, 

with some left for dead and even robbed by ambulance 

drivers as they lay wounded. Public outrage enabled 

Dr Jonathan Letterman, medical director for the Army 

of the Potomac, to institute many sorely needed 

reforms, including the formation of a dedicated 

Ambulance Corps that would function similarly to 

Larrey’s system. Letterman’s reforms were adopted by 

militaries throughout world. The principle of rapid 

evacuation through “echelons of care” established by 

Larrey and Letterman is still the doctrinal model used 

by the AMEDD and most modern armies today.5

Modern warfare of the 20th century brought about 

more lethal weapons, such as precision artillery and 

machine guns, necessitating further dispersion of 

forces. Ambulances became mechanized. Specially 

trained corpsmen and medics were placed into combat 

formations for the first time to provide dedicated pointof-injury care. Medic training was rudimentary and 

traditionally had minimal involvement from 

physicians. It was thought that little could be done on 

the firing line other than basic skills, such as applying 

bandages and splints and carrying the patient to the aid 

station on a litter. 

The Korean and Vietnam eras brought helicopter 

evacuation to the fore. Indeed, the icon of modern 

battlefield medicine in the United States is the Dust-off 

helicopter. The Dust-off epitomizes modern battlefield 

care in that an injured soldier can be whisked from the 

battlefield to surgical care within minutes of 

wounding. Military trauma systems built during 

Korean and Vietnam combat steadily increased the 

survival rates of wounded Soldiers. 

In 1966, the National Academy of Sciences published 

Accidental Death and Disability: the Neglected 

Disease of Modern Society.

6

 This paper remarked that 

Soldiers wounded in Korean and Vietnam received 

better trauma care than civilians injured in automobile 

accidents in American cities. It noted that ambulances 

lacked standardization, equipment was inadequate, and 

ambulance attendants were often poorly trained. 

Millions of dollars in federal funding followed the 

publication of this paper, giving rise to our modern 

civilian emergency medical systems (EMS). 

The end of the war in Vietnam saw the birth of the 

modern EMS and the formation of a new medical 

specialty, emergency medicine. Physicians, nurses, 

and medics with significant combat experience 

demobilized and returned to the United States, 

bringing the wartime lessons learned from military 

trauma systems to the civilian sector.7

 From the 1970s 

until today, civilian EMS and the practice of 

emergency medicine have flourished, advanced, and 

developed into a unique and distinct subspecialty of 

medicine with their own body of scientific research 

and specially trained providers. 

The AMEDD’s primary focus in the post-WWII 

period has been on operating fixed medical facilities 

and providing quality healthcare to its beneficiaries. 

Military healthcare providers are trained to the highest 

civilian standards. Military physicians, PAs, and 

nurses are all required to pass the same boards and 

certification and licensing examinations as their 

civilian counterparts. Their training takes place in a 

fixed-facility hospital or clinic environment. Military 

providers in training, particularly those attending 

uniformed service programs, often have “militaryunique” medical education requirements. Because of 

the intensity of these programs and rigid accreditation 

requirements, the military unique training is necessarily provided at an introductory level.8

Newly minted physicians and PAs are then assigned as 

battalion and brigade medical officers. These providers 

are then responsible for unit medical training, 

readiness and staff medical planning, as well as 

providing care at the battalion aid station or projecting 

forward on the battlefield themselves during larger 

operations or mass casualty incidents. Predeployment 

medical training is required, but these courses are 

often just-in-time and occasionally deferred.8

It has long been a paradox of military expediency that 

the most junior and least experienced providers are the 

ones challenged to manage complex cases such as 

multiple combat trauma in a setting far from mentors 

or specialists. 

The battalion PA has traditionally served as the mentor 

for the combat medic. The PA program was started by 

physicians at Duke University who saw a group of 

individuals with a tremendous amount of hands-on 

experience, but lacked formal training and recognition. 

These were the combat medics from the armed 

services who had served in Vietnam. These physicians 

began the first formal Physician Assistant Training 

Program at Duke in 1965. The Army’s PA training 

Improving Role I Battlefield Casualty Care from Point of Injury to Surgery 
 April – June 2011 89

THE ARMY MEDICAL DEPARTMENT JOURNAL

program began in 1971, with the first class graduating 

in July 1973.9 But the character of the Army’s PA 

corps has changed since PAs became commissioned 

officers in 1992. Because of commissioning rules and 

education requirements, experienced enlisted combat 

medics are now rarely able to meet the prerequisites to 

enter into the program. Once the core of the PA 

program, former combat medics are now the exception 

in the PA course where more than 50% of the current 

candidates are prior service officers. Few new PAs 

now have experience as a medic. While the academic 

and clinical quality of the military PA has never been 

better, that key source of mentorship for a unit’s 

medics, as well as the battlefield medical expertise 

these former medics brought to the combat arms 

commander, has significantly changed. 

Training for military medics remained rudimentary 

until the 68W (the military occupational specialty 

(MOS) designation of the Army healthcare specialist) 

transition initiative in 2001 under the leadership of 

Army Surgeon General James Peake. LTG Peake, a 

decorated infantry officer who served in Vietnam 

before becoming a physician, recognized the critical 

nature of the medic’s job in combat and pushed for the 

most significant enhancement in Army medic training 

in history. Army medics are now required to pass the 

civilian National Registry of Emergency Medical 

Technicians (EMT)-Basic examination, the entry-level 

civilian certification. “Whiskey training” then follows, 

where medics are taught the principles and techniques 

of Tactical Combat Casualty Care. These skills are 

then assessed at the end of their 4 months of training in 

a sophisticated 16-day field experience that 

incorporates mounted and dismounted patrolling, 

urban operations, and forward operating base and aid 

station operations. Initial entry medic training is now 

for the first time under the supervision of emergency 

medicine physicians with subspecialty training in 

EMS. This enables the latest prehospital medical 

innovations, training techniques, and research to be 

rapidly incorporated into medic training. Army medics 

are better trained in providing point-of-injury 

battlefield care today than at any time in history. 

The enhanced level of initial entry training for combat 

medics represents a significant milestone, but more 

can be done. Civilian EMS providers follow a 

progressive professional pathway from EMT-Basic up 

to the EMT-Paramedic level. Providing paramediclevel education to Army medics would enhance their 

lifesaving skills and could remedy an anomaly among 

MOSs — medics are among rare MOSs that throughout 

their careers are required to demonstrate proficiency 

only in their basic Skill Level 10. Most other MOSs 

require increasing levels of technical competency as 

rank increases. Introducing a clinical ladder or career 

pathway that allows for increasing technical 

competence could enhance promotion and retention 

and counter the high rate of 68W attrition. 

The contemporary operational environment requires a 

broader skill set from medics than point-of-injury care 

and rapid evacuation. Conventional units and their 

medics are more dispersed in the battlespace and are in 

close contact with civilian populations. This presents 

unique challenges formerly encountered only by 

special operations medics. Such challenges include 

providing sick call in remote and isolated locations 

without a PA, caring for civilians which may include 

children and the elderly, prolonged care of the 

wounded when evacuation is delayed, and even 

veterinary and dental care. Conventional medics are 

only partially trained for these mission requirements. 

Civilian helicopter EMS has advanced tremendously 

since its origins on the battlefields of Vietnam. It has 

now evolved into the most sophisticated mobile 

prehospital care platforms in the nation and serves 

virtually all Americans. In contrast, the inflight 

medical care during military helicopter medical 

evacuation (MEDEVAC) has remained relatively 

unchanged.10 The excellence of civilian air EMS 

provides valuable lessons for military aeromedical 

evacuation systems, including flight medic training 

and skill level, equipment sets, medical direction, 

quality assurance, and the development of intratheater 

critical care transport capability. This latter capability 

would solve a major challenge in the current wars in 

Iraq and Afghanistan as doctrine does not support the 

intratheater critical care transport of patients following 

emergency surgery at the forward surgical team (FST). 

In an effort to fill the gap, deployed medical leaders 

are pressing into service nurses (from the combat 

support hospital or FST) with variable levels of critical 

care and flight training to perform the transports. One 

of the most important lessons learned from civilian 

EMS is the value added from medical direction. 

Civilian helicopter transport systems have intense 

oversight from physicians with specific training in 

prehospital and en route critical care. Raising Army 

MEDEVAC standards to this level will likely require 
90 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

supplementing the local flight surgeon with an 

emergency physician. 

A WAY AHEAD

Any improvement in battlefield care must first start 

with physicians within the AMEDD. Providing care in 

the troop medical clinic or the hospital ward are 

important and worthy missions for the military 

physician. But, of course, it is not the same as caring 

for casualties at the point of injury, running a battalion 

aid station during major combat operations, or 

transporting critically injured patients in a MEDEVAC 

helicopter. There have been several proposals over the 

years to define the “board-certified” military 

physician, but to date the precise skill set, training, and 

certification requirements for optimal battlefield 

practice have not been defined. The military should 

seek to develop physicians who specialize in 

prehospital and operational care. The closest civilian 

approximation is the emergency medicine specialist 

with subspecialty training in emergency medical 

services. This field of medicine requires unique 

training and a large body of specialized research 

centering on care outside the hospital. Training in 

EMS develops specialists who use a systems approach 

to improve prehospital care. While it would be 

difficult to place EMS-trained emergency physicians 

in every operational role, the EMS and military unique 

skills for providers operating in Role I should be 

defined and appropriately trained. The AMEDD 

should seek to systematically develop clinical experts

in the practice of prehospital battlefield medicine. 

The combat medic’s skill set should be broadened to 

incorporate the challenges of the contemporary 

operating environment. While it would be impossible 

to make every entry-level 68W into a special forces 

medic, a career pathway that increases technical 

competency as rank increases is a realistic goal. Entrylevel medics (grades E-1 thru E-4) should be focused 

on Tactical Combat Casualty Care principles and pointof-wounding care, the current focus of the 68W initial 

entry training. Midlevel medics (E-4 thru E-6) should 

have a more advanced skill set, including the ability to 

perform remote sick call, more advanced trauma skills, 

and increased preventive medicine and camp hygiene 

skills. This medic should be able to deploy with and 

provide care for up to a company-sized element in a 

remote outpost with minimal support. Senior medics 

(E-6 thru E-8) would be responsible for battalion aid 

station operations and should be able to assist the 

physicians and PAs during sick-call and mass casualty 

operations. These medics would also serve as the 

instructors at the AMEDD Center and School and 

medical simulation training centers, as well as serve as 

the “Master Medic” trainer at the brigade and division 

level. Senior medics should be trained at the civilian 

EMT-Paramedic level. 

A clear professional path based on externally validated 

standards such as the National Registry of Emergency 

Medical Technicians certification examinations would 

ensure well-qualified and technically competent 

noncommissioned officers (NCOs) reached the higher 

ranks. Additional training at the paramedic level would 

also give midcareer NCOs the college credits needed 

to apply for AMEDD commissioning programs to 

become physicians, PAs, nurses, physical therapists, 

etc, bringing their invaluable combat and deployment 

experience into the AMEDD as commissioned 

healthcare providers. 

With increased levels of training for all providers in 

Role I, sustainment training capabilities will have to 

become more robust. Current 68W sustainment is 

centered on recertification on Skill Level 10 MOS 

tasks. Sustainment should be standardized across 

different unit types and across the medical simulation 

training centers (MSTCs), available on every major 

division-sized post. These MSTCs could serve as the 

“medical range” for their respective posts, offering a 

large menu of training for Role I providers. The 

centers should be uniformly staffed and funded to 

conduct high quality training for tenant units. 

Importantly, oversight of prehospital care should have 

coordination and visibility at the highest levels of the 

AMEDD. Among the many agencies sharing 

responsibility for prehospital care are the following: 

 The Department of Combat Medic Training 

conducts initial entry training. 

 The Department of Combat and Doctrine 

Development develops equipment and doctrine. 

 Army EMS track certification currency. 

 The Center for Pre-Deployment Medicine 

conducts training for deploying medics. 

 The US Army Institute of Surgical Research 

conducts the battlefield care research. 

Improving Role I Battlefield Casualty Care from Point of Injury to Surgery 
 April – June 2011 91

THE ARMY MEDICAL DEPARTMENT JOURNAL

 The Army Training and Doctrine Command 

integrates and develops medical training 

requirements for nonmedics. 

 The Forces Command develops requirements for 

deploying units. 

 The theater surgeon synchronizes requirements in 

theater. 

 Unit medical officers execute battlefield care. 

 Finally, the line commanders are the ultimate endusers of battlefield medical care. 

Unified oversight could integrate these agencies and 

reap the benefit of improved synchrony and force 

responsiveness. 

It is interesting to note that similar models already 

exist for synchronizing requirements, conducting 

strategic planning, integrating medical research, 

advocating for resources, directing process 

improvements, and developing training standards: 

veterinary care, dental care, public health, and warrior 

transition care. Each holds a place as a major 

subordinate command of the AMEDD. 

CONCLUSION

The vast majority of Soldiers who die do so on the 

battlefield before reaching a physician. For combat 

casualty survival to improve further, the AMEDD 

must extend the investment made in FSTs, combat support hospitals, and fixed military treatment facilities to 

the prehospital and Role I setting. By taking advantage 

of a systems approach, casualty survival can be 

improved in far-forward areas of combat. 

REFERENCES

1. Pruitt BA Jr. Combat casualty care and surgical 

progress. Ann Surg. 2006;243(6):715-729. 

2. Holcomb JB, Stansbury LG, Champion HR, Wade C, 

Bellamy RF. Understanding combat casualty care 

statistics. J Trauma. 2006;60(2):397-401. 

3. Kelly JF, Ritenour AE, McLaughlin DF, Bagg KA, 

Apodaca AN, Mallak CT, et al. Injury severity and 

causes of death from Operation Iraqi Freedom and 

Operation Enduring Freedom: 2003-2004 versus 

2006. J Trauma. 2008;64(suppl 2):S21-S27. 

4. Ortiz JM. The revolutionary flying ambulance of 

Napoleon's surgeon. Army Med Dept J. OctoberDecember 1998:17-25. 

5. Ashbow P. 1861-1873. History of the Medical 

Department of the United States Army. Cambridge, 

MA: Houghton Mifflin; 1929:71-79. 

6. National Academy of Sciences. Accidental Death and 

Disability: The Neglected Disease of Modern Society. 

Washington, DC: National Academies Press; 1966. 

7. Stewart RD. History of EMS: foundations of a 

system. In: Brennan JA, Krohmer JR, eds. Principles 

of EMS Systems. 3rd ed. Sudberry, MA: Jones and 

Bartlett Publishers; 2006:2-15. 

8. De Lorenzo RA. How shall we train?. Mil Med. 

2005;17(10):824-830. 

9. Society of Army Physician Assistants. A brief history 

of the physician assistant program. Available at: 

http:www.sapa.org/. Accessed September 20, 2010. 

10. Gerhardt RT, McGhee JS, Cloonan C, Pfaff JA, De 

Lorenzo RA. US Army MEDEVAC in the new 

millennium: a medical perspective. Aviat Space 

Environ Med. 2001;72(7):659-664. 

AUTHORS

LTC Mabry is Director, Prehospital Division, Joint 

Theater Trauma Registry, US Army Institute of Surgical 

Research, Fort Sam Houston, Texas. 

COL De Lorenzo is Chief, Department of Clinical 

Investigation, Brooke Army Medical Center, Fort Sam 

Houston, Texas. 

Key Steps to Improving Battlefield Care 

Systematically train and develop clinical experts in prehospital battlefield care. 

Create a clinical ladder for the 68W MOS by providing increased training and certification as rank increases. 

Train flight medics to the civilian flight paramedic standard. 

Upgrade the medical simulation training centers to serve as the medical range for every division-sized post. 

Establish a high level battlefield care directorate or command staffed with personnel possessing appropriate and relevant 

clinical expertise. 
92 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

Sharpening the Edge: Paramedic Training 

 for Flight Medics 

LTC Robert L. Mabry, MC, USA 

COL Robert A. De Lorenzo, MC, USA 

BACKGROUND

Military physicians have long recognized that rapid 

evacuation from the battlefield decreases suffering and 

prevents death. Air medical evacuation (MEDEVAC) 

of seriously ill and injured patients during military 

operations was pioneered in the United States by the 

US Army. The first use of an aircraft to evacuate US 

Soldiers was in 1926 when the US Army Air Corps 

transported them from Nicaragua to Panama.1

Helicopter evacuation came to the fore during the 

Korea War. Although the platforms were crude and no 

medical care was given during transport, more than 

22,000 casualties were evacuated by that method.2

Helicopter MEDEVAC would undergo significant 

expansion and growth during the Vietnam era. During 

this period, dedicated MEDEVAC helicopters were 

deployed en masse to Vietnam. The Bell UH-1 was 

large enough to carry several patients and a combat 

medic who could provide care en route to the hospital. 

This rapid evacuation to surgical care was one of the 

principal reasons for the significant reduction in 

battlefield mortality during the Vietnam War 

compared to other wars of the 20th century. 

In 1966, with the Vietnam War at its peak, the 

National Academy of Sciences published a landmark 

paper entitled Accidental Death and Disability: The 

Neglected Disease of Modern Society, more commonly known as “the White Paper.

3” Researchers who 

prepared this paper noted that Soldiers injured on the 

battlefields of Vietnam and Korea received better 

medical care than residents of the United States injured 

on its highways. The White Paper led to the passage of 

the National Highway Safety Act4

 and prompted 

Congress to pour millions of dollars into the development of our modern emergency medical services 

(EMS) systems. 

Coincident with the development of modern civilian 

EMS systems were the end of the Vietnam War and 

the demobilization of the physicians, nurses, and 

medics who served there. Many of these returning 

medical providers helped develop our current EMS 

systems based on their wartime experiences. 

The first Emergency Medical Technician–Paramedic 

(EMT-P) programs were established in the late 1960s, 

and today EMT-Ps are operating in every state. In the 

early 1970s, the US military began to use its 

MEDEVAC helicopters based on wartime experience 

to transport civilians in the United States under the 

Military Assistance to Safety and Traffic program. 

Prehospital care and the development of civilian 

helicopter EMS systems underwent significant growth 

after the end of the Vietnam conflict. The civilian 

model evolved to become patient-centric, focusing on 

care delivered en route and training providers to a high 

level of care in the unique environment of the helicopter. The US Army’s model focuses on the platform, 

with greater emphasis given to aircraft performance 

and operations. En route care in the Army is generally 

provided by a single combat medic, a model rooted in 

the Vietnam War. A comparison of civilian and 

military helicopter EMS systems (Table 1) provides 

ample basis for healthy discussions on ways to 

improve Army medical evacuation care. 

As a result of progressive development, civilian EMS 

providers have evolved into North America’s most 

sophisticated system of en route care. Air EMS has 

become the gold standard in managing and 

transporting severely ill or injured patients from the 

scene of injury or between medical facilities. To 

achieve this level of excellence, civilian aircraft are 

generally staffed by a pair of highly trained flight 

paramedics or comparably trained flight nurses. 

CURRENT OPERATIONAL ENVIRONMENT

The Army currently staffs MEDEVAC helicopters 

with a single EMT-Basic (EMT-B). There are several 

reasons for this approach to staffing, including training 
 April – June 2011 93

constraints, cost, and the origins of modern medical 

evacuation doctrine —a Cold War model that anticipated large-scale combined arms battles where rapidly 

“clearing the battlefield” was paramount and an 

austere level of care was necessarily assumed.

5

The operational environment of Iraq and Afghanistan 

have challenged the traditional staffing model of one 

EMT-B medic on several fronts: a) transport of unprecedented numbers of civilians, including pediatric, 

geriatric, obstetric, and medical cases; b) transport of 

postoperative critical care patients (levels II to III or 

level III to III); and c) transport across large 

geographic areas requiring prolonged inflight care. To 

illustrate these dramatic and unprecedented changes in 

helicopter medical evacuation, a synopsis of over 600 

flights from one MEDEVAC unit’s recent experience in 

Operation Enduring Freedom is presented in Table 2. 

Soldiers injured in remote, rugged areas (eg, most of 

Afghanistan and large swaths of Iraq) have been 

almost universally transported by MEDEVAC. Many 

Requirements Army Flight Medic Civilian Flight Paramedic (% programs that require) 

EMT level EMT-Basic (MOS requirement) EMT paramedic (100%) 

Experience 1 year as MOS 68W (EMT-B) 3 yr lead paramedic busy ALS system (70%); 5 yr (30%) 

Certification/

licensure EMT-B State or nationally registered EMT paramedic 

Flight medic course Currently not required Not applicable 

Training hours No hour requirement for mission task 2120 New hire: 60 hr in classroom (75%) 

Clinical hours None New hire: 40 hr of clinical rotations (75%) 

Preceptor field hours 

No hour requirement; Task 2120 will be 

evaluated by flight or standards Instructor until 

completed proficiently 

New hire: 120 hr Preceptor Ride-Outs (50%) – based on type 

of aircraft flown and whether ride-outs can be done 

Critical care training Not required; JECC is available but not widely 

used by FM due to unit cost. Program-specific requirement (80%) 

RSI competency Task not in flight medic’s scope of practice Required (100%) 

ACLS Required for flight medic course only Required (100%) 

ITLS/PHTLS 

ITLS required for flight medic course only; 

PHTLS required by medic transition (once); no 

sustainment requirement 

Required (100%) 

PEPP/PALS PEPP required for flight medic course only Required (100%) 

Documentation No standard; often absent from medical record Legal requirement in all states; used for PI, remediation, 

workload 

Medical direction 

Unit-based flight surgeon (usually a primary 

care specialty) is responsible for oversight. Most 

often has little trauma or EMS experience. No 

formalized interaction with flight medics. No 

standard PI process. No online medical control 

Virtually all state medical practice acts require an emergency 

medical director with training in emergency medical/trauma 

or at least “extensive experience directing EMS.” Mandatory 

for ALS services; most systems use offline direction (retrospective PI review and remediation, continuing education, 

credentialing) and online direction (complex procedures, field 

declaration of death, protocol deviations, direct observation 

of EMT-Ps for validation) 

Standard protocols No standard US Army treatment protocols; unitbased Required (100%) 

Continuing medical 

education 

TC 8-800 MEDIC (annual requirement focused 

on Level 10 MOS tasks) Required (National Registry = 80 hr every 2 yrs) 

Chart review/PI/QA No standard Required (100%) 

Table 1. Comparison between civilian and military emergency medical services systems. 

GLOSSARY

ACLS – advanced cardiac life support FMC– flight medic course PHTLS – prehospital trauma life support 

ALS – advanced life support ITLS – international trauma life support PI – process improvement 

APART – annual proficiency and readiness test JECC – joint enroute care course (%) = percentage of civilian programs who require 

EMS – emergency medical services MODS – medical operational data system RL – readiness level (TC 1-210) 

EMT – emergency medical technician MOS – military occupational specialty QA – quality Assurance 

EMT-P – emergency medical technician-paramedic PALS – pediatric advanced life support RSI – rapid sequence intubation 

FM – flight medic PEPP – pediatric prehospital providers 
94 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

require advanced life support measures in order to 

survive even a brief flight to a forward surgical team 

(FST). Because FSTs are not able to hold 

postoperative patients for long periods, they in turn 

must evacuate critically ill postoperative cases 

following resuscitative surgery. These patients are 

likely to be sedated, intubated, on a ventilator, and are 

often receiving multiple medication drips and blood 

products. The knowledge and skills required to care 

for these cases unequivocally requires a paramedic or 

nurse with critical care training and experience. 

The high-intensity needs of many postoperative casualties do not match the current level of training of flight 

medics. To fill the gap, deployed medical units (eg, 

FST) are, on a case-by-case basis, pressing nurses or 

other highly-trained providers into provisional flight 

service. While this expedient measure satisfies the immediate needs of the patient, it has consequences 

including temporarily depriving the thinly-staffed FST 

of a key provider. In some cases, pressing mission needs 

all but preclude the FST from sending a nurse, and a 

wrenching decision regarding patient transport ensues. 

The case for more advanced training for flight medics 

is steadily growing. More than 40 combat-deployed 

unit after-action reports have identified Army flight 

medic training and skill level as a key issue and 

recommended paramedic level training as a solution. 

Typical examples of comments concerning flight 

medic capabilities received by the Army Medical 

Department (AMEDD) Lessons Learned Center are 

presented in the Appendix. 

As evidence mounts that improved patient outcomes 

are linked to better provider training, the Theater 

Trauma Consultants responded with a Clinical Practice 

Guideline (CPG) entitled “Intratheater Transfer and 

Transport of Level II and III Critical Care Trauma 

Patients.”6

 The CPG states, “Polytrauma patients 

require a higher level of care than normally provided 

by MEDEVAC units.”6(p1) The CPG further 

recommends that a nurse or physician trained in 

critical care accompany these patients. As a result of 

the Theater Trauma Consultants’ input, 18 critical care 

nurses have recently been deployed to Afghanistan to 

supplement the flight medics in theater. Other 

elements of the system have responded in similar 

fashion. In March 2010, the US Army School of 

Aviation Medicine recommended changes to flight 

medic training, including additional skills, tasks, and 

training to close the capability gap. Implementation of 

the recommendations, however, requires a significant 

reprioritization of resources and action is pending. 

In summary, 21st century conflicts will demand flight 

medics who can operate across the full spectrum of 

operations. Future combat operations are envisioned to 

be increasingly expeditionary in an “era of persistent 

conflict.” Forward and theater medical assets will be 

smaller and more dispersed. Forces will likely operate 

across large geographic areas requiring prolonged and 

advanced care by the flight medic. We will likely 

continue to operate among civilian populations, both 

local nationals and contractors, necessitating transport 

of pediatric, geriatric, and medical cases typical of air 

ambulance operations in the United States. 

Furthermore, consequence management operations and 

defense support to civil authorities in the United States 

related to disasters or large-scale terrorism will require 

flight medics with the same skills as their civilian 

counterparts in order be fully integrated in the medical 

response plan. 

PROPOSED SOLUTION

Meeting the unprecedented challenges of medical 

evacuation requires steps that are at once bold and yet 

familiar: training all US Army flight medics to flight 

paramedic competency and certification as described 

in the 2009 International Association of Flight Paramedics Position Statement (Table 3). The training is 

Sharpening the Edge: Paramedic Training for Flight Medics 

Table 2. Synopsis of more than 600 MEDEVAC flights in one 

region during Operation Enduring Freedom.*

Types of Cases Percentage 

of Cases Description 

Trauma 86 

Medical 14 

Includes acute myocardial infarction, chronic obstructive pulmonary disease, stroke, toxic 

exposures, overdose, psychosis, 

seizures 

Critical care 14 

Intubation, vent management, 

chest tube insertion, advanced 

medications 

EMT paramedic level 62 Includes critical care cases 

Adult 94 Aged 18 to 68 years 

Pediatric 6 

Mostly trauma but also congenital heart conditions, toxic exposures, burns, sepsis, complicated child birth 

*Data is from 91⁄2 months of MEDEVAC operations by a 3 helicopter detachment 

in Afghanistan, 2008-2009. Source of data is internal military documents not 

normally accessible by the general public. 
 April – June 2011 95

THE ARMY MEDICAL DEPARTMENT JOURNAL

bold because of the intensity and the skill level that a 

select group of combat medics will achieve. It is familiar because the AMEDD and the Army has decades of 

experience in training small groups of motivated enlisted Soldiers in highly technical and specialized medical fields, such as licensed practical nurses, cardiovascular technicians, and special forces medical sergeants. 

It is posited that this training could be rapidly 

implemented under realistic resource ceilings. Training 

could be conducted in 3 phases totaling approximately 

32 weeks. Costs are estimated at $10,000 per flight 

medic, in addition to permanent change of station costs 

for initial flight paramedic training. 

Phase I: Military Flight Medic Training 

Program Length: Currently 4 weeks. 

Location: Fort Rucker, Alabama. 

Cost: Temporary duty at Fort Rucker and associated 

course costs. 

Prerequisites: 68W with at least 3 years of experience, 

preferably at least one combat deployment, current 

BLS/EMT-B, valid flight physical, meets height, 

weight, and Army Physical Fitness standards.

Description: Program would incorporate elements of 

current Flight Medic course focusing on physical and 

mental fitness, validation of combat medic skills, 

aircraft and flight operations, and Readiness Level 

(RL) progression. This would serve as the selection 

and assessment phase to ensure that candidates are 

physically and mentally capable to perform the duties 

of a flight medic. At the end of this phase, candidates 

who successfully completed the course would return to 

their units and permanent change of station to Fort 

Sam Houston for phase II. 

Phase II: EMT-Paramedic 

Program Length: 1000 hours (20 weeks) 

Location: University of Texas Health Science Center, 

San Antonio, TX (UTHSC-SA). 

Costs: ≈$6,000 per student for course costs. Permanent 

change of station move to Fort Sam Houston for 

Phases II and III. 

Prerequisites: Completion of Phase I. 

Description: Program would model the existing San 

Antonio Fire Department Paramedic training course, a 

fully accredited EMT-P program. The current UTHSC-SA 

program can accommodate 20 to 30 US Army flight 

paramedic candidates per class, up to 60 per year. At 

the end of the course, students would achieve the National Registry of EMT–Paramedic Certification. Oncourse completion students would be eligible for 33+ 

semester hours of college credit. A historical precedent 

with UTHSC-SA and the US Special Operations Command Paramedic program exists where Special Forces 

medics trained as EMT-Ps in San Antonio. Existing 

memoranda of agreement could be modified to 

accommodate US Army flight paramedic candidates. 

Phase III: Critical Care Flight Paramedic 

Program Length: 524 hours (120 classroom, 284 

clinical, 120 field training exercise) (8 weeks) 

Location: Brooke Army Medical Center (BAMC), 

University of Texas Health Science Center-San 

Antonio, San Antonio Air Life. 

Prerequisites: Completion of Phase I and II and 

National Registry of EMT-paramedic certification. 

Costs: Would be based on cooperative agreements 

with UTSAHSC, BAMC, and Air Life. Clinical 

rotations would be conducted at BAMC, an existing 

military facility with little associated costs. 

Description: Students would learn and apply principles 

of critical care in the classroom, laboratory, clinical, 

and field settings. Student rotations will include 

operating room/anesthesia service; medical, surgical, 

cardiac, and pediatric intensive care units; the Institute 

of Surgical Research burn unit; and San Antonio Air 

Life. Clinical and didactic rotations will be followed 

by a 120-hour continuous field training exercise at 

Camp Bullis, Texas, that is reflective of the current 

contemporary operational environment. 

END STATE

Following this recommended training pathway, the US 

Army flight paramedic will: 

 Be prepared to take the Flight Paramedic 

Certification Exam. 

 Be trained to entry-level civilian flight paramedic 

proficiency/competency. 

 Be able to provide competent en route care to most 

critically ill or injured patients from the point of 

injury or between medical treatment facilities. 
96 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

Sharpening the Edge: Paramedic Training for Flight Medics 

Area Standards 

1. Experience Minimum 3 years of experience as a combat medic 

2. Education a. Primary: Successful completion of the paramedic National Standard Curriculum or equivalent. 

b. Secondary: Successful completion of a critical care education program that meets or exceeds the educational objectives of 

this position statement, including didactic sessions, practical sessions, skill proficiency demonstration, and clinical rotations 

c. Tertiary: Continuing mentored didactic education, skill maintenance, and clinical opportunities that maintain the educational 

objectives of this position statement 

3. Certifications a. Advanced Cardiac Life Support 

b. Adult and Pediatric International Trauma Life Support / Prehospital Trauma Life Support / Advanced Trauma Life Support 

c. Pediatric Advanced Life Support / Advanced Pediatric Life Support 

d. Neonatal Resuscitation Program 

e. Or an equivalent education in each of the aforementioned areas 

4. Knowledge a. Assessment of the critically ill or injured patient 

b. Advanced adult and pediatric airway management including, but not limited to: 

i. Rapid sequence induction (RSI) intubation 

ii. Alternative and rescue airways 

iii. Surgical cricothyroidotomy 

iv. Continuous waveform capnography to monitor end tidal carbon dioxide (ETCO2) 

c. Mechanical and noninvasive ventilation theory, troubleshooting, and competence 

d. Chest tube thoracostomy management and insertion (if applicable) 

e. Obtain and maintain peripheral venous, central venous (if applicable), and/or intraosseous access 

f. Administration of blood and blood products 

g. Electrocardiogram (ECG) monitoring and 12 lead ECG interpretation 

h. Defibrillation, cardioversion, and transcutaneous and transvenous pacing monitoring, maintenance, and treatment 

i. Circulatory management and support including invasive hemodynamic monitoring and intra-aortic balloon pump (IABP) 

management (theory, transport considerations, troubleshooting, and operations, if applicable) 

j. Intracranial pressure monitoring and management 

k. Pharmacology included in the National Standard Curriculum augmented by knowledge of analgesics, antibiotics, 

antidysrhythmics, antiepileptics, paralytics, sedatives, and vasoactive medications 

l. Laboratory value interpretation including arterial blood gas analysis 

m. Targeted radiology study interpretation 

5. Patient 

management 

a. Acute respiratory emergencies 

b. Cardiovascular emergencies 

c. Hypertensive emergencies 

d. Shock and multiple organ system failure 

e. Infectious diseases 

f. Neurological emergencies including stroke and intracranial hemorrhage 

g. Trauma 

h. Spinal cord injury 

i. Burn 

j. Trauma in pregnancy 

k. Pediatric trauma 

l. Critical pediatric emergencies 

m. Obstetrical emergencies 

n. Neonatal emergencies (if applicable) 

o. Environmental emergencies 

p. Poisoning / toxic exposure / hazardous material awareness 

q. Bioterrorism 

6. Transport 

medicine 

a. Safety 

i. Vehicle operations and emergency procedures 

ii. Critical care transport equipment 

iii. Patient / family factors 

iv. Human factors (including but not limited to air medical resource management (AMRM) or equivalent) 

b. Evaluation of appropriateness for transport based on required level of care 

c. Transport logistics 

d. Critical care transport equipment (ventilator, IABP, neonatal isolette, etc.) 

e. Patient packaging for safety and accessibility 

f. Radio and communication technology 

g. Transport physiology 

h. Interaction and communication with medical oversight 

i. Medical provider communication / transfer of care 

j. Documentation 

7. Quality 

management Understanding principles and best practice 

8. Certification 

examination 

Successful completion of a critical care paramedic certification examination. Along with the FP-C®, the IAFP recognizes the 

Critical Care Paramedic Certification Examination (CCP-C®) as a valid certification examination for the critical care paramedic. 

Table 3. 2009 International Association of Flight Paramedics Position Statement.7
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THE ARMY MEDICAL DEPARTMENT JOURNAL

 Provide Soldiers wounded on the battlefield with 

the same level of care as a civilian evacuated by 

helicopter receives in the United States. 

TRANSITION AND SUSTAINMENT

Although 2 classes of 25 to 30 to medics per year 

would meet the requirements of the current conflict, it 

would be insufficient over time to generate sufficient 

numbers of flight paramedics to fill every air ambulance unit in all 3 components as authorizations increase from 645 total flight medics currently to a projected end state of 1173 flight medics in the year 2017. 

Since the proposed course is conducted in different 

phases, the modular nature of the proposed course 

would make Phase II, the paramedic phase, easily 

exportable to other accredited paramedic programs 

near a flight medic’s current post. The 101st Airborne 

Division sent all of its flight medics to civilian 

paramedic training near Fort Campbell prior to their 

most recent deployment to Operation Enduring 

Freedom. The 82nd Airborne Division is also 

implementing a paramedic program with an additional 

critical care course for their flight medics. It is likely 

that a large number of flight medics, especially in the 

Army Reserve and the National Guard, are already 

qualified as EMT paramedics. A survey to determine 

the exact numbers should be conducted since this 

qualification is not currently tracked in Army 

personnel systems. 

Phase III, the critical care phase, could be reproduced 

at other medical centers with an adequate volume of 

critical care patients and at which a cooperative 

arrangement could be established with a supporting 

civilian air ambulance service. 

The proposed modular design would facilitate “off the 

street” civilian paramedics and flight paramedics 

enlisting directly into the Army flight paramedic 

program. Flight medic trainees would first attend basic 

combat training, the battlefield portion of MOS 68W 

initial entry training, and fast-track directly to the 

appropriate phases of training required to meet the US 

Army flight paramedic standard. 

To better illuminate resource issues, it is useful to 

examine the cost of training a Special Forces Medical 

Sergeant (MOS 18D), another highly-trained enlisted 

medic. Cost for class VIII supplies and temporary duty 

alone during the medical phase of training of an 18D 

are approximately $45,000 per individual trained. 

These medics treat a relatively small number of 

patients entering the evacuation system. The cost to 

train a critical care flight medic will be about one-third 

of this amount, yet flight medics touch 95% of the 

patients evacuated in Operation Enduring Freedom.

One of the reasons cited for leaving the Army 

following the initial enlistment by 68Ws is the lack of 

additional training opportunities and lack of a career 

pathway that includes additional certifications. A flight 

paramedic program would provide a career ladder for 

68Ws. While there will likely be attrition just as there 

is in the MOS 18D course, a system of bonuses and 

selection would mitigate this. The current University 

of Texas Health Science Center-San Antonio 

paramedic training program has a greater than 88% 

pass rate. 

Sustainment training for an advanced flight medic 

(Table 4) would naturally be more intensive than the 

current 68W flight medic model. However, in many 

respects sustainment can be easier for military 

paramedics given our access to military treatment 

facilities for clinical time and our medical simulation 

training centers. Sustainment is the other side of the 

advanced flight medic coin. Without a well thoughtout sustainment plan, the benefits of rigorous initial 

training would wane over time. Flight medic 

competency and sustainment should be tracked on the 

Unit Status Report, as is aircrew readiness. 

Proficiency pay and enlistment bonuses will be key 

features in attracting and sustaining highly qualified 

Frequency Activity 

Monthly 

Four intubations on simulators, cadavers, live 

patients, or animal models 

Four training scenarios on simulators, live patients, 

or animal models. One each: trauma, pediatric, 

medical, critical care 

Every 6 months One-week anesthesia rotation with a minimum of 5 

live intubations 

Every 2 years 

Recertification of ACLS, PALS, PHTLS, AMLS, or 

equivalent courses 

Two-week Medical Proficiency Training rotations in 

an intensive care unit or with a busy civilian EMS/

Air Ambulance service 

Every 4 years 

Four-week trauma center rotation 

Total of 100 Continuing Education units required 

for FP-C recertification in addition to 2-day FP-C 

recertification course 

Predeployment One-week FTX (same as final FTX in Phase III) 

Table 4. Process for sustaining flight paramedic certification. 
98 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

flight paramedics. Proficiency pay should be linked to 

passing the rigorous Flight Paramedic Certification 

Examination and maintaining this certification through 

a rigorous sustainment process (Table 4). Proficiency 

pay should bring the US Army flight paramedic’s 

salary to the civilian flight paramedic entry-level pay 

of approximately $45,000 per year. Proficiency and 

bonus pay will be key features in attracting highcaliber enlisted Soldiers into this career pathway, and 

retaining them. 

The idea to increase the training of Army flight medics 

to the civilian flight paramedic level may superficially 

appear to be a radical departure from current practice. 

In fact, the idea that has been around for more than a 

quarter century, beginning with the Division 86 

concept and advocated in several other studies 

examining MEDEVAC.8-10 A detailed review article 

made a comprehensive case for paramedic trained 

flight medics in 1997.11

Counterarguments to the concept of paramedic flight 

training must be considered. These include: a) costs 

that exceed value, b) difficulties in achieving training 

success (and consequent classroom attrition), c) combat units unlikely to embrace the change or the burden 

of sustainment, d) the sustainment tail will be expensive, e) the National Guard and Reserve will be challenged to meet the increased time commitment of training, and f) competition from civilian employers will 

increase as they seek to hire away the now highlytrained flight medics. While acknowledging these possibilities, it is instructive to consider the history of the 

then 91W (now 68W) combat medic program. During 

its inception, each of these counterarguments were postulated (some quite vigorously), but ultimately all were 

refuted. The resounding success of the 68W program 

stands as testimony to the ability of the AMEDD to 

achieve deep and lasting success in enlisted medic 

training. 

CONCLUSION

The US Army pioneered the concept of helicopter 

evacuation, and justifiably stands proud as the father 

of modern air EMS. In turn, civilian helicopter EMS 

has now come full circle since the Vietnam War and 

the publication of the White Paper3

 on trauma in the 

1960s. It is now the most sophisticated delivery 

platform for prehospital care in the United States. To 

continue the cycle, the US Army stands poised to 

combine outstanding MEDEVAC aircraft capabilities 

with the advanced training of flight paramedics.11 The 

ultimate goal is improved care for battlefield casualties 

and a more responsive and flexible medical evacuation 

system. Flight paramedic training is an important step 

in keeping combat casualty care on the cutting edge. 

REFERENCES

1. McGinnis KK, Judge T. Air Medicine: Accessing the 

Future of Health Care [Foundation for Air-Medical 

Research and Education Web site]. 2006. Available 

at: http://www/fareonline.org/FAREWhitePaper2006.pdf. 

2. Driscoll R. US Army Helicopters in the Korean War. 

Mil Med. 2001;166(4):290-296. 

3. National Academy of Sciences. Accidental Death and 

Disability: The Neglected Disease of Modern Society. 

Washington, DC: National Academies Press; 1966. 

4. The Highway Safety Act of 1966 Pub L No. 89-564, 

80 Stat 731. 

5. Burkhalter EL. Divisional support on the modern 

battlefield. Mil Med. 1984;149:561-564. 

6. US Army Institute of Surgical Research. Intratheater 

Transfer and Transport of Level II and III Critical 

Care Trauma Patients. November 2008. Available at: 

http://www.usaisr.amedd.army.mil/cpgs.html. 

Accessed November 12, 2010. 

7. International Association of Flight Paramedics. 

Critical care paramedic position statement. July 2009. 

Available at: http://www.flightparamedic.org/

documents/CriticalCareParamedicPositionPaper.pdf. 

Accessed November 8, 2010. 

8. Gerhardt RT, McGhee JS, Cloonan C, Pfaff JA, De 

Lorenzo RA. U.S. Army MEDEVAC in the new 

millennium: a medical perspective. Aviat Space 

Environ Med. 2001;72(7):659-664. 

9. Gerhardt RT, Stewart T, De Lorenzo RA, Gourley 

EJ, Schreiber MA, McGhee JS. U.S. Army air 

ambulance operations in El Paso, Texas: a descriptive 

study and system review. Prehosp Emerg Care. 

2000;4(2):136-143. 

10. De Lorenzo RA. Improving combat casualty care and 

field medicine: focus on the military medic. Mil Med. 

1997;162(4):268-272. 

11. De Lorenzo RA. Military and civilian emergency 

aeromedical services: common goals and different 

approaches. Aviat Space Environ Med. 1997;68(1):56-

60. 

Sharpening the Edge: Paramedic Training for Flight Medics 
 April – June 2011 99

THE ARMY MEDICAL DEPARTMENT JOURNAL

Observation: Flight medic training

Discussion: Like civilian EMS, many of the MEDEVAC missions involve routine patient transfers. Even the majority of 

point-of-injury patients require mainly basic life support skills, with oxygen therapy and intravenous infusions accounting 

for the majority of medical interventions. About 5% of these patients, however, are critically ill or are injured patients 

who present with unstable airways or hemodynamics requiring advanced airway management and other lifesaving 

interventions. This population of patients is precisely where skills and training need to be focused, they are the patients 

most likely to require and benefit from aggressive advanced prehospital care. Reviewing these cases made it clear that 

there were many cases in which the current flight medic training program falls short. Additionally, there was a sizable 

subset of cardiac/chest pain patients for which the medic was the only medical attendant. The current training program 

does not adequately prepare flight medics for treating cardiac patients, who were frequently transferred without 

appropriate treatment or safeguards. In the 1159th and 54th Medical Companies, many of the patients were critical-care 

interfacility transfers involving patients who were chemically paralyzed, sedated, intubated, on a ventilator with ongoing 

drug administration, chest tubes, and intensive hemodynamic monitoring. The 1159th Air Ambulance was a Guard unit in 

which about a third of their medics are civilian EMT-Ps, including 2 medics who were Critical Care EMT-Ps. 

Fortunately, this unit performed a large number of the critical-care transfers. 

While a medical attendant is often provided from the combat support hospital or forward surgical team, in the early stages 

of this conflict that was not always possible nor would it be possible in the expeditionary phase of most future conflicts. 

Lesson Learned: The current flight medic training program is not sufficient as a standalone program to provide the 

critical-care aeromedical skills necessary to treat the most severely injured patients experienced during this operation. 

Authors’ Recommendation: The flight medic needs solid MOS 91W skills supplemented by the skills of the Advanced 

Cardiac Life Support (ACLS) and Critical Care Air Transport Teams, coupled with continuous clinical practice. Excellent 

airway management and endotracheal intubation skills are essential. Although a patchwork system of courses can be 

created to try to meet this need (and it is likely to be the short-term fix), what is really needed is an EMT-P level 

certification that includes the necessary clinical experience in critical care and advanced level procedures, similar to the 

Special Operations Combat Medic program. The vast majority of flight programs in civilian air ambulance programs 

include a flight nurse and an EMT-P as the medical attendants. The key is clinical experience in addition to the enhanced 

critical care didactics. Completing an ACLS course does not mean that you adequately understand cardiac pharmacology 

or arrhythmia recognition sufficiently to provide advanced cardiac care independently. No civilian air or ground 

ambulance crew could provide that level of treatment in the United States without completing a paramedic course that 

included extensive didactic and clinical training in the relevant conditions and treatment. The curriculum from the Joint 

Enroute Critical Care course is inadequate for 91W medics, as is the civilian Critical Care EMT-P course, since they were 

designed to provide an already experienced field EMT-P with additional critical care air transport skills, not to turn an 

EMT-B provider into a Critical Care Transfer Paramedic! It is dangerous to train a medic to maintain deep sedation and 

paralysis during transfer of a ventilator patient unless he has excellent intubation skills, chest decompression skills, 

ventilator management skills, and the clinical experience to treat the potential complications. Flight medics should 

accordingly be maintained in the career field as long as they desire to do so by stabilizing assignments and allowing for 

promotion through E-7 as flight paramedics, because of the cost of training and perishable skills. Alternatively, flight 

paramedic positions could be made warrant officers, much as with other technical fields, to retain the flight medical skills 

and experience where they are needed the most. 

Deployment/Operation: Operation Iraqi Freedom

From the 3/10th IBCT Operation Enduring Freedom deployment: Flight medics require training to reach the paramedic 

skill level in order to provide the en route care necessary for critically injured casualties evacuated from the forward 

surgical team (FST) after life-sustaining surgery to Role III facilities. The Army National Guard flight medics are 

paramedic-qualified and better trained to care for potential issues when evacuating patients from the FST after surgery 

than are active-duty flight medics who are trained to the minimum qualification: EMT-B; BTLS; ACLS; PHTLS; and 

PAL standards. Flight medics also need more training on ventilation and transporting sedated patients. Flight medic 

training was identified by the unit as a top issue.

APPENDIX

Sample of comments from units deployed to Operations Iraqi Freedom and Enduring Freedom regarding flight medic 

capabilities and qualifications received by AMEDD Lessons Learned (http://lessonslearned.amedd.army.mil). 
100 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

Sharpening the Edge: Paramedic Training for Flight Medics 

APPENDIX (CONTINUED)

Observation: Need for increased medical training for flight medics.

Discussion: The war on terrorism is a new kind of war fought with mostly Special Forces. Most of the Special Forces and 

medical facilities located in Afghanistan did not want to use our medics and paramedics because they were not trained by 

Special Operations Forces (SOF). At the request of the SOF, a doctor, physician-assistant, or SF medic would accompany 

patients, taking away that medical asset from the battlefield. The MOS 68W program is a good start to the 91 series in the 

Army, but it needs to be taken to a new level for flight medics.

Lesson Learned: SOF units are reluctant to trust EMT-B trained medical personnel.

Authors’ Recommendation: In dispersed operations, MEDEVAC is always provided for more critical patients; whereas 

lower-priority patients are evacuated by ground. The current knowledge, skill set, and critical decision-making performed 

by current Army flight medics do not provide the breadth and depth of care our civilian counterparts have come to expect. 

Flight medics should be trained to the paramedic level to provide a higher level of care, so that other elements will be 

more confident in their abilities and the medic better prepared to handle an urgent MEDEVAC. 

Deployment/Operation: Operation Enduring Freedom, Afghanistan. 

From the 4/4th IBCT Operation Enduring Freedom deployment: Flight Medic Training. The unit noted that all the 

National Guard air ambulance company flight medics (68WF) had paramedic certification. As a result, the National 

Guard flight medics had superior skills to monitor and provide advance inflight care for critically injured patients when 

compared to the active-duty flight medics. Paramedic-qualified flight medics are able to intervene and handle potential 

issues that severely injured patients may experience. This issue has been noted in previous After Action Reports, and the 

AMEDD Center and School is evaluating the training requirements for the flight medics to determine whether all need to 

be trained to the paramedic level. 

AUTHORS

LTC Mabry is Director, Prehospital Division, Joint Theater Trauma Registry, US Army Institute of Surgical Research, 

Fort Sam Houston, Texas. 

COL De Lorenzo is Chief, Department of Clinical Investigation, Brooke Army Medical Center, Fort Sam Houston, 

Texas. 
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