J

April–September 2016

OURNAL

THE UNITED STATES ARMY

MEDICAL DEPARTMENT

AMEDD at WAR:

Lessons Learned

2001-2015
JOURNAL

A Professional Publication

of the AMEDD Community THE UNITED STATES ARMY

MEDICAL DEPARTMENT

Online issues of the AMEDD Journal are available at http://www.cs.amedd.army.mil/amedd_journal.aspx

April–September 2016 US Army Medical Department Center & School PB 8-16-4/5/6/7/8/9

The Army Medical Department Journal [ISSN 1524-0436] is published

quarterly for The Surgeon General by the AMEDD Journal Office, USAMEDDC&S, 

DoTAA, 3630 Stanley RD STE B0204, JBSA Fort Sam Houston, TX 78234-6100.

Articles published in The Army Medical Department Journal are listed and 

indexed in MEDLINE, the National Library of Medicine’s premier bibliographic 

database of life sciences and biomedical information. As such, the Journal’s 

articles are readily accessible to researchers and scholars throughout the 

global scientific and academic communities.

CORRESPONDENCE: Manuscripts, photographs, official unit requests to 

receive copies, and unit address changes or deletions should be sent via 

email to usarmy.jbsa.medcom-ameddcs.list.amedd-journal@mail.mil, or by 

regular mail to the above address. Telephone: (210) 221-6301, DSN 471-6301

DISCLAIMER: The AMEDD Journal presents clinical and nonclinical 

professional information to expand knowledge of domestic & international 

military medical issues and technological advances; promote collaborative 

partnerships among Services, components, Corps, and specialties; convey 

clinical and health service support information; and provide a peer-reviewed, 

high quality, print medium to encourage dialogue concerning healthcare 

initiatives.

Appearance or use of a commercial product name in an article published 

in the AMEDD Journal does not imply endorsement by the US Government.

Views expressed are those of the author(s) and do not necessarily reflect 

official policies or positions of the Department of the Army, Department of 

the Navy, Department of the Air Force, Department of Defense, nor any other 

agency of the US Government. The content does not change or supersede 

information in other US Army Publications. The AMEDD Journal reserves the 

right to edit all material submitted for publication (see inside back cover).

CONTENT: Content of this publication is not copyright protected. Reprinted 

ma-terial must contain acknowledgement to the original author(s) and the 

AMEDD Journal.

OFFICIAL DISTRIBUTION: This publication is targeted to US Army Medical 

Department units and organizations, other US military medical organizations, 

and members of the worldwide professional medical community.

By Order of the Secretary of the Army:

Official:

GERALD B. O’KEEFE

Administrative Assistant to the 

Secretary of the Army

Mark A. Milley

General, United States Army

Chief of Staff

DISTRIBUTION: Special 1607401

LTG Nadja Y. West

The Surgeon General

Commander, US Army Medical Command

MG Steve Jones

Commanding General

US Army Medical Department Center and School

US Army Health Readiness Center of Excellence
April – September 2016 i

Army Medical Department at War: Lessons Learned ........................................................................ 1

COL Clinton K. Murray, MAJ Scott R. Hitter, MG Stephen L. Jones

SETTING THE STAGE

Planning for Organizational Success: Hope is Not a Method ............................................................ 4

MG (Ret) David Rubenstein

Data-driven Casualty Estimation and Disease Nonbattle Injury/Injury Rates

in Recent Campaigns ........................................................................................................................... 8

 Babara E. Wojcik, Rebecca J. Humphrey, Brandon J. Hosek, Catherine R. Stein

Surveillance of Disease and Nonbattle Injuries During US Army Operations

in Afghanistan and Iraq .................................................................................................................... 15

 Keith G. Hauret, LTC(P) Laura Pacha, Bonnie J. Taylor, Bruce H. Jones

CHANGES IN EQUIPMENT AND TECHNIQUES/TACTICS/PROCEDURES

THAT IMPACTED CARE AND OUTCOMES

Dismounted Complex Blast Injuries Including Invasive Fungal Infections .................................. 24

 COL Clinton K. Murray, COL Kirby Gross, Col Robert J. Russell, Ruth A. Haslett

Battlefi eld Tourniquets: Lessons Learned in Moving Current Care Toward Best Care

in an Army Medical Department at War .......................................................................................... 29

 John F. Kragh Jr, Michael A. Dubick

Lessons Learned for the Resuscitation of Traumatic Hemorrhagic Shock ..................................... 37

 Philip C. Spinella, COL Jeremy G. Perkins, LTC Andrew P. Cap

PERSONNEL CHANGES THAT IMPACTED CARE AND OUTCOMES

Theater Blood Support in the Prehospital Setting........................................................................... 43

 LTC Audra L. Taylor, LTC Jason B. Corley

Shaping the Flight Paramedic Program ........................................................................................... 48

 LTC Neil B. Davids

US Army Physical Therapist Roles and Contributions in Operations

Enduring Freedom and Iraqi Freedom ............................................................................................. 52

COL Scott W. Shaffer, COL (Ret) Josef H. Moore

The Role of Army Nurse Practitioners Supporting Wars in Iraq and Afghanistan........................ 58

COL Paul C. Lewis, COL Edward Yackel, COL Richard M. Prior

Advances in Anesthesia Delivery in the Deployed Setting .............................................................. 62

 MAJ John E. Wilson Jr, COL William P. Barras

Roles of Occupational Therapists in Theater, Past and Present ..................................................... 66

 LTC Enrique V. Smith-Forbes, LTC Charles D. Quick, LTC Katherine M. Brown

WOUNDED WARRIOR CARE

Wounded, Ill, and Injured Challenges .............................................................................................. 71

 MG Stephen L. Jones

Rehabilitation of the Combat Casualty: Lessons Learned from Past and Current Confl icts ........ 77

 COL (Ret) Paul F. Pasquina, COL (Ret) John C. Shero

US ARMY MEDICAL DEPARTMENT AT WAR:

LESSONS LEARNED

2001-2015
ii http://www.cs.amedd.army.mil/amedd_journal.aspx

PROGRAMMATIC IMPLEMENTATIONS TO IMPROVE HEALTH

Battlefi eld Documentation of Tactical Combat Casualty Care in Afghanistan .............................. 87

 MAJ John B. Robinson, Michael P. Smith, COL Kirby R. Gross, COL Samual W. Sauer,

 COL James J. Geracci, MAJ Charlie D. Day, COL (Ret) Russ S. Kotwal

Abstract: Lessons Learned, Saving Lives on the Battlefi eld ........................................................... 95

 COL Samual W. Sauer

Traumatic Brain Injury Clinical Recommendations: Impact on Care and Lessons Learned ........ 97

 COL Sidney R. Hinds II, Scott C. Livingston

Acute and Chronic Pain on the Battlefi eld: Lessons Learned from Point of Injury

to the United States ......................................................................................................................... 102

 COL Scott M. Croll, LTC(P) Scott R. Griffi th

Leveraging Trauma Lessons from War to Win in a Complex Global Environment ..................... 106

 LTC Kyle N. Remick

Infection Prevention in the Deployed Environment ...................................................................... 114

 Lt Col Heather C. Yun, COL Clinton K. Murray

OPERATIONAL SYSTEM CHALLENGES

Medical Logistics Lessons Observed During Operations

Enduring Freedom and Iraqi Freedom ........................................................................................... 119

 COL Mark J. Dole, COL (Ret) Jonathan M. Kissane

Planning Staff and Space Capacity Requirements during Wartime ............................................. 124

 Elisa B. Kepner, Rachel Spencer

OPERATIONAL PATIENT HEALTHCARE

Military Sleep Management: An Operational Imperative ............................................................. 128

 COL Vincent Mysliwiec, MAJ Robert J. Walter, LTC Jacob Collen, Nancy Wesensten

Evolution of Military Combat Eye Protection ................................................................................ 135

 LTC James R. Auvil

The US Army Medical Department Email Teleconsultation Program.......................................... 140

 Charles M. Lappan

Cardiovascular Complaints Among Military Members During

Operation Enduring Freedom ......................................................................................................... 148

 LTC James A. Watts, Capt Frank D. Russo, LTC Todd C. Villines, COL Samuel O. Jones,

 Lt Col Gilberto Patino, Maj Javed M. Nasir, Robert E. Eckart, Lt Col Kevin E. Steel

Pediatric Wartime Injuries in Afghanistan and Iraq: What Have We Learned?.......................... 153

 Capt Xiaoming Shi, COL Mary J Edwards

VETERINARY CARE

Role of Human Health Care Providers and Medical Treatment Facilities in Military

Working Dog Care and Accessibility Diffi culties with Military Working Dog Blood Products .... 157

 LTC James T. Giles III

US ARMY MEDICAL DEPARTMENT AT WAR:

LESSONS LEARNED

2001-2015

THE ARMY MEDICAL DEPARTMENT JOURNAL
April – September 2016 iii

THE ARMY MEDICAL DEPARTMENT JOURNAL

PUBLIC HEALTH CHALLENGES

Select Public Health and Communicable Disease Lessons Learned During

Operations Iraqi Freedom and Enduring Freedom ....................................................................... 161

 LTC Eric C. Garges, MAJ Kevin M. Taylor, LTC Laura A. Pacha

Deployment Exposures and Long-term Health Risks: The Shadow of War ................................. 167

 Coleen Baird

Deployment-related Respiratory Issues ......................................................................................... 173

 COL (Ret) Michael J. Morris, Capt Frederic A. Rawlins, MAJ Damon A. Forbes,

 Maj Andrew J. Skabelund, COL Pedro F. Lucero

Impact of North Atlantic Treaty Organization Policies and Procedures on

Combined Medical Operations: Food and Water Safety and Veterinary Support ........................ 179

 COL Timothy H. Stevenson, LTC Nicole A. Chevalier, CW4 Gregory R. Scher, LTC Ronald L. Burke

Water for Warfi ghters in Iraq and Afghanistan: A Summary of Lessons Learned ....................... 182

 Steven C. Richards, Arthur H. Lundquist, Todd E. Richards

DOCTRINE AND TRAINING PROGRAMS

Surgical and Resuscitation Capabilities for the “Next War” Based on

Lessons Learned from “This War” ................................................................................................... 188

 LTC David Freel, MAJ Bradley J Warr

Predeployment Medical Training for Providers ............................................................................. 192

 MAJ Michael D. Holloway

Lessons Learned: Employment and Tactical Use of the Combat Medic

During Stability Support Operations.............................................................................................. 195

 MSG Michael S. Eldred

CONCLUSION

Army Medical Department at War: Healthcare in a Complex World............................................ 199

 COL Clinton K. Murray, MG Stephen L. Jones

US ARMY MEDICAL DEPARTMENT AT WAR:

LESSONS LEARNED

2001-2015
iv http://www.cs.amedd.army.mil/amedd_journal.aspx

The US Army Health Readiness Center of Excellence

The Army Medical Department Center and School

ENVISION, DESIGN, TRAIN, EDUCATE, INSPIRE

Joint Base San Antonio Fort Sam Houston, Texas
April – September 2016 1

On July 27, 1775, the Continental Congress established 

a hospital for an Army of 20,000 and appointed the 

following offi cers and attendants: one director general 

and chief physician, 4 surgeons, one apothecary, 20 surgeon’s mates, one clerk, 2 storekeepers and one nurse 

for every 10 patients. This marks the organization of the 

Army Medical Department (AMEDD).

The following 240 years included many signifi cant contributions to the nation and the fi eld of medicine. When 

the AMEDD immunized the Army against smallpox 

during the Revolutionary War, the AMEDD proved 

that mass immunization was effective, and subsequent 

global campaigns eradicated the disease. The history of 

AMEDD is replete with distinguished fi gures who have 

contributed greatly to the fi eld of medicine. MAJ William Beaumont, a Medical Corps offi cer, is not only the 

father of gastroenterology but also of the discipline of 

physiology. MAJ John Shaw Billings established The 

Surgeon General’s Library, which is now The National 

Library of Medicine. MAJ Walter Reed demonstrated 

that the mosquito was the vector of transmission for yellow fever. COL William Gorgas, who led the campaign 

against mosquitos in Panama, made the construction 

of the Panama Canal possible by controlling the outbreaks of yellow fever and malaria that threatened its 

completion.

Among the many advances achieved in the last century, 

a number of which are shown in the Table, the AMEDD 

has produced major advances in trauma management, 

blood transfusions, and the treatment of shock. During the Korean War, the AMEDD developed innovative 

techniques used for renal dialysis; and during the Vietnam War, it made signifi cant improvements in the treatment of acute respiratory failure. Throughout its illustrious history, AMEDD continues to progress and evolve 

by learning from each war and applying that knowledge 

in future confl icts. The lessons we learned in the trenches of the 2 World Wars, the frontlines of Korea, and the 

rice paddies of Vietnam made AMEDD stronger in the 

towns of Somalia, the deserts of Iraq, and the mountains 

of Afghanistan. The lessons we have learned in the most 

recent confl icts in the Middle East will make us stronger, 

wiser, and more effective in the confl icts to come. The 

knowledge gained from confl icts in the past has been 

applied in many ways. We have developed the Combat 

Lifesaver and 68 W Programs, Tactical Combat Casualty Care, damage control resuscitation, and damage control surgery. Through the years, the AMEDD has also 

developed new treatments and rehabilitation methods in 

all disciplines of medicine that have allowed Soldiers 

and Families to lead productive lives.

During the past 14 years of war, the AMEDD helped 

raise casualty survival rates from 76% in Vietnam to 

over 92% during the wars in Iraq and Afghanistan.3

That means that over 8,000 casualties who would have 

died in previous confl icts returned home to their families. Our Warfi ghters fi ght more effectively knowing 

that AMEDD is on the battlefi eld to care for them if injured, and they take comfort in knowing that AMEDD 

is caring for their Families back home.

The quality of medical care markedly advanced during 

the wars in Iraq and Afghanistan due to evidence-based 

medicine.4-6 In addition, the advances in body armor, 

fi re retardant clothing and vehicles, vehicle survivability, evacuation assets, and communication prominently 

enhanced patient outcomes. Finally, since 80% of initial 

care is done by the patient himself or buddy aid, trauma 

medical management training of entire units—especially nonmedical personnel—can signifi cantly impact 

overall morbidity and mortality.7

Substantial efforts to codify and document care have 

proved that signifi cant improvement has occurred over 

the last 14 years. Despite the statutory prohibition on 

the performance of randomized controlled trials in the 

combat zone (10 USC 980, Limitations on Use of Humans as Experimental Subjects), many lessons have still 

been learned, rapidly disseminated, and effectively applied. Initially, the Advanced Technology Applications 

to Combat Casualty Care annual meeting allowed sharing of trauma-related lessons. The meeting transitioned 

to the Military Healthcare System Research Symposium to broaden the lessons learned across all military 

healthcare issues. Peer-reviewed journal supplements 

Army Medical Department at War:

 Lessons Learned

 COL Clinton K. Murray, MC, USA

 MAJ Scott R. Hitter, SP, USA

 MG Stephen L. Jones, MC, USA
2 http://www.cs.amedd.army.mil/amedd_journal.aspx

ARMY MEDICAL DEPARTMENT AT WAR: LESSONS LEARNED

AMEDD Advances in Combat Casualty Care.*

World War I

Use of intravenous fluids and blood transfusions

Motorized ambulances

Laparotomy for penetrating abdominal wounds

Use of surgical specialists

Effective topical antisepsis: Carrel-Dakins wound irrigation system

Antitetanus serum

Radiologic localization of foreign bodies

Neurosurgical trauma databank

Characterized the bacteria and infection rates associated with wounds

World War II

General availability of whole blood and plasma

Formulaic resuscitation of burn patients

Availability of “well trained” surgeons and use of specialty specific Auxiliary Surgical Groups

Hierarchical organization of trauma care

Use of antibiotics

Use of fixed wing aeromedical evacuation

Identification of “Wet Lung in War Casualties”

Korean War

Fluid resuscitation adequate to correct shock and prevent organ failure

Availability of board certified surgical specialists

Forward availability of definitive surgery

Use of helicopters for patient transport

Primary repair and vascular grafts for injured vessels

Use of hemodialysis in theater of operations

Identification of high output renal failure

Recognition of seasonal variation in bacteria recovered from battle wounds

Vietnam War

General use of helicopters for patient transport

Monitoring of organ function in theater of operations

Blood gas measurements

Serum chemistries

Portable radiology equipment

Use of mechanical ventilators in theater of operations

Effective topical antimicrobial chemotherapy for burns

Staged intercontinental aeromedical transport of burn patients

Identification of Acute Respiratory Distress Syndrome

Established Vietnam Vascular Registry

Operation Desert Storm/Shield

Burn team augmentation of evacuation hospitals to provide theater-wide burn care

Reactivation of intercontinental burn patient transport system

Operations in Iraq and Afghanistan

Development of a military trauma registry

“Low volume” resuscitation fluids – colloids and red blood cells

Hemostatic agents

Systemic

Topical

Use of “damage control” initial surgery

Use of endovascular stents

Common use of external fixators

Improved tourniquets

CAD/CAM limb prostheses

Pain control

Concussion care

Established clinical practice guidelines for combat casualty care

Identification of coagulopathy in injury

Challenges of treating infections with fungus and multidrug-resistant bacteria

Deployed Electronic Health Record

Reach back capability with telehealth and programmatic email communication

*Data from Pruitt,1 Pruitt et al.2
April – September 2016 3

THE ARMY MEDICAL DEPARTMENT JOURNAL

and Borden Institute textbooks (http://www.cs.amedd.

army.mil/borden/) have been published for wide dissemination of the information. In addition, guidelines 

have been developed through collaborative military and 

civilian subject matter expertise with regular revisions 

as new lessons are learned.8-12

A 3-day meeting was held September 9-11, 2015, in San 

Antonio, TX, to address key lessons across all of the 

AMEDD Corps that had not been consistently captured 

in previous publications. Forty-seven lectures* were 

delivered with a focus on Setting the Stage; Equipment 

and Techniques; Tactics and Procedures Changes that 

Impacted Care and Outcomes; Personnel Changes that 

Impacted Care and Outcomes; Wounded Warrior Care; 

Programmatic Implementations to Improve Health; 

Operational System Challenges; Veterinary Care; Public Health Challenges; and Doctrine and Training Programs. Thirty-six lectures were developed into manuscripts that are presented in this issue of the AMEDD 

Journal. These articles highlight key aspects of the lessons learned and address aspects of Doctrine, Organization, Training, Material, Leadership, Personnel, Facilities, and Policy to ensure the lessons are incorporated 

throughout the Army and Army Medicine.

REFERENCES

1. Pruitt BA. The symbiosis of combat casualty care 

and civilian trauma care: 1914-2007. J Trauma and 

Acute Care Surg. 2008;64:S4-S8.

2. Pruitt BA, Rasmussen TE, Gueller G. The formula 

for success in military medical research. J Trauma 

and Acute Care Surg. 2015;79:S64-S69.

3. Eastridge BJ, Mabry RL, Seguin P, et al. Death on 

the battlefi eld (2001-2011): implications for the future of combat casualty care. J Trauma and Acute 

Care Surg. 2012;73:S431-S437.

4. Blyth DM, Yun HC, Tribble DR, Murray CK. Lessons of war: combat-related injury infections during the Vietnam War and Operation Iraqi and Enduring Freedom. J Trauma and Acute Care Surg. 

2015;79:S227-S235.

5. Murray CK, Hinkle MK, Yun HC. History of infections associated with combat-related injuries. J 

Trauma and Acute Care Surg. 2008;64:S221-S231.

6. Kotwal RS, Howard JT, Orman JA, et al. The effect of a golden hour policy on the morbidity 

and mortality of combat casualties. JAMA Surg. 

2016;151(1):15-24.

7. Kotwal RS, Montgomery HR, Kotwal BM, et al. 

Eliminating preventable death on the battlefi eld. 

Arch Surg. 2011;146:1350-1358.

8. Tactical Combat Casualty Care Guidelines for 

Medical Personnel. Fort Sam Houston, Texas: US 

Army Institute of Surgical Research; June 2015. 

Available at: http://www.usaisr.amedd.army.mil/

pdfs/TCCC_Guidelines_for_Medical_Person

nel_150603.pdf. Accessed December 4, 2015.

9. TCCC-MP Guidelines and Curriculum [internet]. National Association of Emergency Medical 

Technicians; 2016. Available at: http://www.naemt.

org/education/TCCC/guidelines_curriculum. Accessed December 4, 2015.

10. JTS Clinical Guidelines [internet]. Fort Sam Houston, Texas: US Army Institute of Surgical Research; 

2015. Available at: http://www.usaisr.amedd.army.

mil/cpgs.html. Accessed December 4, 2015.

11. Murray CK, Hospenthal DR. Prevention and management of combat-related infections clinical practice guidelines consensus conference: overview. J 

Trauma. 2008;64:S207-S208.

12. Hospenthal DR, Murray CK. Preface: Guidelines 

for the prevention of infections associated with 

combat-related injuries: 2011 update. J Trauma. 

2011;71(2 suppl 2):S197-S201.

AUTHORS

COL Murray is Deputy Chief of the US Army Medical 

Corps and Medical Corps Specifi c Branch Proponent Offi cer, AMEDD Center & School, Joint Base San Antonio 

Fort Sam Houston, Texas.

MAJ Hitter is an Associate Professor, Interservice Physician Assistance Program, AMEDD Center & School, 

Joint Base San Antonio Fort Sam Houston, Texas.

MG Jones is the Commanding General, AMEDD Center 

& School, US Army Health Readiness Center of Excellence, Joint Base San Antonio Fort Sam Houston, Texas.

*Available at https://www.milsuite.mil/book/groups/ameddcs-hrcoe-lessons-lessoned-conference-2015/overview
4 http://www.cs.amedd.army.mil/amedd_journal.aspx

Hope is Not a Method

Gordon R. Sullivan and Michael V. Harper1

THE PERSPECTIVE

Admiral Sergei Gorshkov of the former USSR knew the 

American military well when he said “the most diffi cult 

thing about planning against the Americans is that they 

do not read their own doctrine, and they would feel no 

particular obligation to follow it if they did.” 2

 An anonymous American Soldier unknowingly supported the Admiral’s observation with the comment “as a former Soldier, let me assure you, ain’t none of us ever read those 

damn things. Field manuals just take up space in some 

back offi ce and go untouched for years before someone 

throws them out.”3

THEY SEE US AS DIFFERENT

A nonhealthcare Army colleague once 

expressed to me his sympathy for the 

plight of the military healthcare leader. “You healthcare leaders,” he said 

“work by committee, always want to 

talk, are constrained by guilds, feel a 

need to reach consensus, try to infl uence others instead of giving orders, 

and lead people who want to govern 

themselves.” His conclusion: “I don’t 

envy you one bit.”

In this article, I do not argue the point 

that leadership skills are both similar 

and different across a range of specialties within the Army and the military. We must, though, understand that 

some of our colleagues see us military 

healthcare leaders, and our organizations, as dramatically different from them and their organizations. Unfortunately, this opinion can put our work and our organizations at a disadvantage when trying to get approval of or 

simple synchronization to operational plans.

BUT WE ARE THE SAME

The Army’s foundational doctrinal publication, Army 

Doctrine Publication 3-0 (ADP 3-0),4

 defi nes “Army 

doctrine [as] a body of thought on how Army forces 

operate as an integral part of a joint force.” 4(p1) This 

capstone doctrine establishes “the Army’s view of the 

nature of operations, the fundamentals by which Army 

forces conduct operations, and the methods by which 

commanders exercise mission command.” 4(p1)

The family tree for ADP 3-0 goes back 

to 1923 and the Army’s publication 

of its Field Service Regulations. This 

publication was “designed especially 

for the government of the operations 

of large units and of small units forming a part of larger units.”5

 In it, the 

Army outlines the underlying doctrine 

to guide the decisions and actions of 

commanders and staffs in land operations. Sanitation, hospitalization and 

evacuation have a prominent place 

in Field Service Regulations: Chapter 

X (Shelter) of Part I (Operations) and 

Chapter II (Hospitalization and Evacuation) of Part II (Administration).

The 1923 Field Service Regulations

served as the precursor to Field 

Planning for Organizational Success:

Hope is Not a Method

 MG (Ret) David Rubenstein, MS, USA

ABSTRACT

The foundational requirement for US Army Medical Department (AMEDD) organizational success on the 

battlefi eld is proper planning in accordance with Army doctrinal and tactical guidance. The same can be said 

for every type of AMEDD garrison-based organization. Commanders and leaders of AMEDD garrison-based 

organizations must be familiar with and rehearsed in the military decision making process, and use it to their 

advantage in support of the Warfi ghter and his or her family.

SETTING THE STAGE
April – September 2016 5

THE ARMY MEDICAL DEPARTMENT JOURNAL

Manual 100-5, Field Service Regulations, Operations, 

published in 1941 to disseminate Army doctrine broadly 

across an Army rapidly expanding for future operations, 

which were realized as World War II. In the Preface of 

the 1992 reprint by the US Army Command and General Staff College, historian Christopher Gabel points out 

that “The 1941 version of FM 100-5 has long been recognized as a classic piece of doctrine writing, remarkable for its clarity of concept and prose.”6

 However, unlike its predecessor, health services were not addressed 

in that publication.

Through the intervening years, Field Manual 100-5 was 

continuously updated based on contemporary thinking 

developed from lessons of past and current efforts and 

expectations of future efforts. The current state of that 

evolution is now vested in ADP 3-0 which, in addition 

to presenting the Army’s capstone doctrine, “serves 

as the basis for decisions about [Army] organization, 

training, leader development, materiel, Soldiers, and 

facilities.” 4(p1)

Nowhere in the various editions of publications defi ning Army operations do we see that capstone doctrine 

as intentionally limited to fi eld units or warfi ghting 

operations. In fact, “operational art is not associated 

with a specifi c echelon or formation, nor is it exclusive to theater and joint force commanders. Instead, it 

applies to any formation that must effectively arrange 

multiple, tactical actions in time, space, and purpose to 

achieve a strategic objective, in whole or in part.” 4(p9)

Garrison-based Army Medical Department units and 

organizations certainly operate in “multiple, tactical actions in time, space, and purpose to achieve a strategic 

objective....” 4(p9)

As the discussion of ADP 3-0 above demonstrates, 

knowledge and application of Army doctrine applies 

to all Army organizations, those in the fi eld operating 

at the tip of the spear, those in fi eld and garrison locations planning the operations, and those uniquely in garrison locations supporting the fi ght and the Warfi ghter. 

Whether Soldiers in combat arms, combat support, and 

combat service support, all are held to the same philosophy, thinking, and expectations when it comes to Army 

operations within our construct called Army doctrine.

DOCTRINE AS IT APPLIES TO PLANNING

In ADP 3-0, Army capstone doctrine defi nes an operations process as “a commander-centric activity, informed 

by the mission command approach to planning, preparing, executing, and assessing military operations.” 4(p10)

From that foundation, ADP 3-0 tells us “planning is the 

art and science of understanding a situation, envisioning 

a desired future, and laying out effective ways of bringing about that future.” 4(p10) To understand, envision, and 

develop solutions to unfamiliar problems requires that 

“leaders integrate this methodology with the detailed 

planning typically associated with the military decisionmaking process to produce executable plans.”4(p10)

The concept of mission command is not unique to the 

combat arms commander, leader, or organization. Nor 

does it intend to exclude the medical commander, leader, 

or organization. From our own Army doctrine we learn 

“the medical commander exercises mission command 

(authority and direction) over his subordinate medical 

resources. As discussed in Army doctrine on unifi ed 

land operations, “the commander is the focus of mission 

command....”7

Army health system support doctrine to the warfi ghter 

and tactical units is outlined in Army Techniques Publication 4-02.3 (ATP 4-02.3).8

 While the primary focus for ATP 4-02.3 is for “Army Health System (AHS) 

support to maneuver forces,” it specifi cally applies to 

[author’s emphasis] “all commanders and their staffs, 

command surgeons, AHS planners, and Army Medical 

Department (AMEDD) personnel and units.”8(pvi) The 

reasoning for this emphasis is unambiguous: in its ultimate design, all AMEDD support is to the commander 

and Warfi ghter in the fi eld. Within the AMEDD, garrison-based leaders, staffs, and organizations are as important as colleagues in tactical fi eld-based healthcare 

organizations in accomplishing the AMEDD responsibility “to effectively execute AHS operations to support the tactical commander [requires] comprehensive 

planning....”8(p3-1)

That comprehensive planning, to ensure the tip of the 

spear is well supported by both AMEDD tactical units 

and AMEDD garrison-based units, requires AHS planning on par with those being supported. To that end, 

commanders and units being supported by the AMEDD 

use the military decisionmaking process to develop 

comprehensive plans. It stands to reason, then, that 

AMEDD garrison-based organizations should also use 

the military decisionmaking process.

The linkage is clear. Army doctrine applies to all Army 

organizations; Army operations come from mission 

command focused planning; Army operational planning is a result of the military decisionmaking process; 

tactical and garrison-based AMEDD organizations are 

a part of the Army; and the AMEDD commander, like 

his nonhealthcare peers, exercises mission command. It 

stands to reason, therefore, that AMEDD operational 

planning in both fi eld and garrison-based organizations 
6 http://www.cs.amedd.army.mil/amedd_journal.aspx

should be based on the military decisionmaking process (MDMP).

THE MILITARY DECISIONMAKING

PROCESS

Field Manual 6-0 “applies to the 

Active Army, the Army National 

Guard/Army National Guard of 

the United States, and the United 

States Army Reserve unless otherwise stated.” 9(pvi) It presents the 

military decisionmaking process, 

one of the Army’s 3 planning 

methodologies.9(p9-1) Key to this article, the manual makes no exclusion for garrison-based AMEDD 

units. It provides guidance for 

planning across all components 

and branches of the Army.

To that end of inclusivity, “Effectively conducting the 

military decisionmaking process requires leaders who 

understand the fundamentals of planning.” 9(p9-1) Operational planning in support of the commander and Warfighter is not an activity for amateurs. Nor is it an activity 

for a small subsection of the staff with knowledge of the 

characteristics, steps, and plans. Instead, the “process 

helps commanders, staffs, and others think critically 

and creatively while planning.” 9(p9-1)

Also, to be involved in the process means one understands the process. The MDMP is taught to offi cers and 

noncommissioned offi cers alike during professional 

military education. The depth and complexity of that 

exposure varies depending on the curriculum of the 

specifi c course. Further, continuing practice with the 

elements of the MDMP is dependent on the expectation 

of the commander and senior leaders. In fact, “the commander is the most important participant in the MDMP. 

More than simply decisionmakers in this process, commanders use their experience, knowledge, and judgment 

to guide staff planning efforts.” 9(p9-2)

THE CHALLENGE OF DOCTRINE, ORGANIZATION, TRAINING, 

MATERIAL, LEADERSHIP, PERSONNEL, FACILITIES

This returns us full circle to the opening paragraph of 

this article and the realization that many of our colleagues, rightly or wrongly, see colleague leaders in 

garrison-based AMEDD organizations as being different. Unless those in garrison-based organizations learn, 

understand, practice, and use Army doctrine related to 

operations planning, they will be outsiders and, as outsiders, minimized. Garrison operations to support the 

warfi ght and the Warfi ghter are not business as usual, 

just at a bigger scale or faster rate. 

Garrison operations to support the 

warfi ght and the Warfi ghter are 

different than day-to-day healthcare operations. The population 

is unique, their needs are unique, 

the universe of interested people 

is unique, and the intense scrutiny 

given to the process is unique.

As a result, these unique garrison 

operations by AMEDD organizations in support of the warfi ght and 

the Warfi ghter require planning. 

Published Army doctrine describing effective planning requires 

use of the MDMP. Implementing MDMP requires commanders, 

leaders, and staff who are schooled 

and comfortable with it. Schooling 

comes from attending professional military education; 

comfort comes from routine use of the process.

There are at least 4 results that accrue from knowing, 

practicing, and using the MDMP, three of which are: 

plans that our line colleagues understand; plans that can 

be easily integrated with those plans developed by other 

Army and military organizations; and plans that lead to 

successful mission command and successful missions. 

The fourth result can best be voiced in the negative: 

MDMP-developed plans ensure that commanders, leaders, and staffs do not rely on hope as a method to a successful outcome. Hope is Not a Method.

1

From the perspective of Doctrine, Organization, Training, Material, Leadership, Personnel, Facilities (DOTMLPF), what is the commander, the staff leader, the 

AMEDD to do? The answer to the doctrine, training, 

and leadership elements of the DOTMLPF challenge 

is 2-fold: schooling and use. First, the MDMP must be 

schooled at all AMEDD professional military education. 

Then, the MDMP must be inculcated into the planning 

DNA of all AMEDD organizations and their people. Its 

schooling and its use are not limited to fi eld-based, tactical units alone. Commanders and leaders of AMEDD 

garrison-based organizations must be familiar with and 

rehearsed in the military decision making process and 

use it to their advantage in support of the Warfi ghter and 

his or her family.

REFERENCES

1. Sullivan GR, Harper MV. Hope Is Not a Method. 

New York, NY: Times Books; 1996.

SETTING THE STAGE
April – September 2016 7

THE ARMY MEDICAL DEPARTMENT JOURNAL

2. Military Quotes Mohandas K. Gandhi – Herman Göring [internet]. Available at: http://www.military-quotes.com/

database/g.htm. Accessed September 1, 2015.

3. askReddit [internet]. Available at: https://www.reddit.com/r/AskReddit/comments/12z7hs/has_anyone_here_ever_

been_a_soldier_fi ghting/c6zk7mg. Accessed September 1, 2015.

4. Army Doctrine Publication 3-0: Unifi ed Land Operations. Washington, DC: US Department of the Army; 2011. 

Available at: http://www.army.mil/e2/rv5_downloads/info/references/ADP_3-0_ULO_Oct_2011_APD.pdf. Accessed January 26, 2016.

5. Field Service Regulations [obsolete]. Washington, DC: War Department; 1923:iii.

6. Field Manual 100-5, Field Service Regulations, Operations [obsolete]. Washington, DC: War Department; 1941:i. 

Available at: http://ibiblio.org/hyperwar/USA/ref/FM/FM100-5/index.html. Accessed January 26, 2016.

7. Field Manual 4-02: Army Health System. Washington, DC: US Department of the Army; 2013:2-30. Available at: 

http://armypubs.army.mil/doctrine/DR_pubs/dr_a/pdf/fm4_02.pdf. Accessed January 26, 2016.

8. Army Techniques Publication 4-02.3. Army Health System Support to Maneuver Forces. Washington, DC: US Department of the Army; 2014. Available at: http://armypubs.army.mil/doctrine/DR_pubs/dr_a/pdf/atp4_02x3.pdf. 

Accessed January 26, 2016.

9. Field Manual 6-0: Commander and Staff Organization and Operations. Washington, DC: US Department of the 

Army; 2014. Available at: http://armypubs.army.mil/doctrine/DR_pubs/dr_a/pdf/fm6_0.pdf. Accessed January 26, 

2016.

AUTHOR

MG (Ret) Rubenstein, a former Commanding General of the AMEDD Center & School, is a Clinical Associate Professor 

of Health Administration, Texas State University, San Marcos, 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 identifi ed to researchers during searches for 

relevant information using any of several bibliographic search tools, 

including the NLM’s PubMed service.
8 http://www.cs.amedd.army.mil/amedd_journal.aspx

An important task of medical planning involves the 

inevitable occurrence of disease and nonbattle injury 

(DNBI) hospitalizations in deployed troops. Historically, DNBIs have exceeded combat-related injuries in 

every major US military operation.1-5 In 2002, the Offi ce 

of The Surgeon General noted that existing projection 

models based on subject matter expert opinions produced admission rates much higher than those recorded during recent operations and asked the Center for 

Army Medical Department (AMEDD) Strategic Studies 

(CASS) to study the DNBI issue.6

 The Statistical Analysis Cell (previously Statistical Analysis Branch, CASS) 

was given the task to provide a new methodology for 

casualty estimation and to calculate DNBI rates for recent operations. Our approach was to develop a datadriven methodology based on deployed population and 

administrative healthcare data collected in theater and 

to analyze profi les of DNBI rates over time.

In this article, we briefl y describe 2 distinct disease and 

nonbattle injury/battle injury (DNBI/BI) methodologies, one for deployed US Army Soldiers and one for 

other groups of patients treated at Role 3 Army military treatment facilities (MTFs) in theater. We present 

variability in daily DNBI/BI rates over time, show how 

DNBI/BI rates changed through the campaign, describe 

which diagnoses mainly contributed to the volume of incidence rates, and provide recommendations for future 

analyses.

DEVELOPMENT OF DNBI RATES METHODOLOGY

The study of DNBI admission rates was conducted by 

merging records from existing military databases, including US Army Soldier deployment data from the 

Contingency Tracking System fi les from the Defense 

Manpower Data Center (DMDC) and hospitalization 

data from the Standard Inpatient Data Record (SIDR) 

fi les acquired from the Army’s Patient Administration Systems and Biostatistics Activity (PASBA). The 

DMDC data identifi ed all Soldiers who were deployed 

to the various operations by date of arrival in theater 

and date of departure from theater. Battle injuries were 

identifi ed through use of NATO Standardization Agreement (STANAG) 2050 trauma indicator “0” (direct result of war) or “1” (other battle injuries) and cause of 

injury codes 300-479 (injuries caused by enemy action). 

Note that the SIDR variables for STANAG codes are 

well-populated and provide a fairly reliable identifi cation for cause of injury.7

 For the remaining records, we 

determined disease cases and nonbattle injury cases 

using the principal diagnosis code. A hospital admission record was identifi ed as disease if the 3-digit 

Data-driven Casualty Estimation and Disease

 Nonbattle Injury/Battle Injury Rates

 in Recent Campaigns

 Barbara E. Wojcik, PhD

 Rebecca J. Humphrey, MA

 Brandon J. Hosek, MA

 Catherine R. Stein, MS

ABSTRACT

To ensure Soldiers are properly equipped and mission capable to perform full spectrum operations, Army 

medical planners use disease nonbattle injury (DNBI) and battle injury (BI) admission rates in the Total Army 

Analysis process to support medical deployment and force structure planning for deployed settings. For more 

than a decade, as the proponent for the DNBI/BI methodology and admission rates, the Statistical Analysis 

Cell (previously Statistical Analysis Branch, Center for Army Medical Department Strategic Studies) has provided Army medical planners with DNBI/BI rates based upon actual data from recent operations. This article 

presents the data-driven methodology and casualty estimation rates developed by the Statistical Analysis Cell 

and accredited for use by 2 Army Surgeon Generals, displays the top 5 principal International Classifi cation of 

Disease, 9th Revision, Clinical Modifi cation (ICD-9-CM) diagnoses for DNBI/BI in Operation Iraqi Freedom/

Operation New Dawn (OIF/OND), and discusses trends in DNBI rates in OIF/OND during the stabilization 

period. Our methodology uses 95th percentile daily admission rates as a planning factor to ensure that 95% of 

days in theater are supported by adequate staff and medical equipment. We also present our DNBI/BI estimation methodology for non-Army populations treated at Role 3 US Army medical treatment facilities.
April – September 2016 9

THE ARMY MEDICAL DEPARTMENT JOURNAL

ICD-9-CM* principal diagnosis code was between 001-

799 or 960-999. Nonbattle injury included ICD-9-CM 

codes 800-959.

We identifi ed 2 types of operations: warfi ghting and 

peacekeeping.7

 Statistical Analysis Cell (SAC) analysts 

performed extensive data mining of deployment data 

in Operations Desert Shield/Desert Storm (the Persian 

Gulf War) and Operation Endeavor (peacekeeping in 

Bosnia and Kosovo). Admission rates were determined 

by merging the healthcare data records with the US 

Army Soldier population data. Daily rates were expressed as the number of admissions per 1,000 Soldiers 

present in theater on that day. Overall rates expressed 

as the number of admissions per 1,000 Soldier-days 

were calculated by taking the total number of hospital 

admissions that occurred within the analyzed period 

of time divided by the total number of Soldier-days at 

risk (present in theater) during the time examined. During the peacekeeping operation, rates varied over time 

seasonally or with geographic location.8

 Analysis of the 

Persian Gulf War data indicated that DNBI admission 

rates vary during the 3 phases of a warfi ghting operation—build up, ground combat, stabilization—when 

these phases can be identifi ed.

Additionally, the Statistical Analysis Cell determined 

that the traditional use of mean or overall DNBI admission rates in previous medical planning processes 

carried a signifi cant risk of failing to provide suffi cient 

medical resources for approximately half of the deployed days. To counter this problem, we developed an 

alternate method to using the mean. The SAC examined 

daily admission rates using percentile analysis and selected the 95th percentile daily DNBI admission rate as 

a planning factor. The 95th percentile cutoff point identifi es the daily admission rate at which 95% of days had 

hospital admissions at or below this rate. Only 5% of 

days had admissions above this planning factor. Note 

that we examined daily diagnosis profi les and found no 

statistically signifi cant difference between the top 5% of 

days with the highest admissions and the bottom 95% of 

days with lower admissions.9

Results of the SAC analysis addressing warfi ghting operations were approved by The Army Surgeon General, 

LTG James Peake, and Director, Force Management, 

Army G-37/FM, MG Dennis Hardy in December 2002. 

The DNBI 95th percentile admission rates were provided by the SAC to the Center for Army Analysis for 

DNBI modeling and force structure planning in the Total Army Analysis 2011 process (TAA 11). The analysis 

results were published by Wojcik et al.9

 Throughout this 

paper we refer to the term 95th percentile daily DNBI/

BI admission rate as a DNBI/BI admission rate.

METHODOLOGY FOR EXPANDED ADMISSION ANALYSIS

The Director, Force Management, concurred with the 

Offi ce of The Surgeon General that the DNBI analysis 

should be a continuous process culminating in an annual analysis and report to Army leadership.

In response, the Statistical Analysis Cell embarked upon 

a project to analyze the rates of hospital admission for 

disease and nonbattle injuries during recent troop deployments and use the analysis to develop data-driven 

DNBI web applications for medical deployment and 

force structure planning. The resulting web tool separately addresses peacekeeping (Bosnia, Kosovo) and 

warfi ghting operations ( Desert Shield/Desert Storm, 

Operation Enduring Freedom, Operation Iraqi Freedom/Operation New Dawn), and takes into account 

the geographic location, phase of the operation (if applicable), and the size and composition of the deployed 

force. Composition variables include Soldier age, gender, unit type, force component, and enlisted/offi cer status. The SAC further expanded the admission analyses 

to include disease, nonbattle injury, battle injury, combat stress, and behavioral disorder rates in addition to 

combined DNBI rates for US Army Soldiers. In 2005, 

the DNBI rates were accredited by LTG Kevin Kiley for 

use as a planning tool by the AMEDD and Army medical planners.10 In 2011, Army planners made the decision to replace DNBI rates based upon Desert Shield/

Desert Storm with admission rates estimated from data 

collected in Operation Iraqi Freedom.

Also in 2011, the Statistical Analysis Cell received a request to provide the Center for Army Analysis a casualty estimation methodology and estimated admission 

rates for nontraditional populations (patients other than 

US Army Soldiers) treated at Role 3 Army MTFs in 

theater. A different methodology was proposed to estimate DNBI/BI rates for these patients. Admission data 

records include the patient benefi ciary category which 

indicates the basis under which individuals are provided 

care at MTFs. Using the benefi ciary category, the following groups of patients were identifi ed in collaboration with the Center for Army Analysis: other US uniformed services; coalition forces NATO; coalition forces 

non-NATO; US government agencies and civilians; contract employees; indigenous population; detainees; and 

others. Since the populations at risk were not available 

for these patient groups, the traditional method of rate 

calculation could not be used. Rates for these patients 

were defi ned in terms of US Army Soldier population at *International Classifi cation of Disease, 9th Revision, Clinical 

Modifi cation
10 http://www.cs.amedd.army.mil/amedd_journal.aspx

risk. The new estimation method was accomplished by 

calculating ratios of the number of admissions for each 

group of patients to the number of Soldier admissions at 

Army Role 3 MTFs during the same period of time. Next, 

these ratios were multiplied by the 95th percentile Army 

Soldier daily admission rate during the examined period 

of time to estimate the rates for nontraditional groups of 

patients treated at Role 3 Army facilities (expressed per 

1,000 Soldiers). Results of this analysis were incorporated into the TAA processes starting with TAA 14-18.

ILLUSTRATION OF DNBI/BI RATE METHODOLOGY

Data and admission rates presented in this paper were 

obtained using the sources and methods described above. 

For this illustration, US Army Soldier deployment data 

and US Army Role 3 hospitalization data were summarized for the entire campaign of Desert Shield/Desert 

Storm (DS/DS), for Operation Enduring Freedom for 

the period September 11, 2001, through December 31, 

2012, and for Operations Iraqi Freedom and New Dawn 

(OIF/OND) for the period September 1, 2002 through 

December 31, 2011. Three distinct phases were identifi ed for OIF/OND: buildup (September 1, 2002, to 

March 19, 2003), ground combat (March 20, 2003, to 

April 30, 2003), and stabilization (May 1, 2003, to December 31, 2011).

Data used by the Statistical Analysis Cell were obtained 

and analyzed following strict data governance rules approved by the Army Human Research Protection Offi ce: 

records were limited in scope to variables needed for the 

stated purposes and de-identifi ed. All datasets were protected on secure DoD servers. Data analyses were performed using SAS version 9.1.3 software (SAS Institute, 

Inc, Cary, NC). P-values less than .05 were considered 

statistically signifi cant.

The variability in 95th percentile daily DNBI/BI rates 

during the stabilization phase in OIF/OND was presented as percentage change compared to the fi rst year of the 

stabilization phase. The overall change was presented 

as a fl uctuation ratio between the largest and smallest 

DNBI/BI admission rates during the entire stabilization 

period. The top 5 principal ICD-9-CM diagnoses for 

each category of disease and injury type for US Army 

Soldiers hospitalized during the OIF/OND campaign 

were identifi ed.

Because nontraditional populations were unknown, rates 

for these patients were defi ned in terms of US Army Soldiers population at risk. Using the new methodology developed by the SAC, ratios of the number of admissions 

for each group of patients to the number of Army Soldier 

admissions were multiplied by the 95th percentile Army 

Soldier daily admission rate to estimate rates for nontraditional groups of patients (expressed per 1,000 Soldiers).

RESULTS

Rates for US Army Soldiers

Figures 1 and 2 present profi les of DNBI admissions and 

admission rates during buildup, ground combat, and the 

fi rst year of stabilization in Operation Iraqi Freedom. 

These graphs reveal daily variability in the size of deployed troops and also in the number of hospital admissions during each phase of the campaign. Note that low 

admission counts (Figure 1) during the build-up phase 

equate to high admission rates (Figure 2) due to the relatively small number of deployed troops. Admissions and 

admission rates demonstrate descending trends for the 

stabilization phase. Results of the analysis performed 

for this phase show that each year’s 95th percentile daily 

admission rate is more than 25% lower than the DNBI 

rate during the fi rst year of stabilization. A fl uctuation 

ratio of 1.45 illustrates an almost 50% difference between the lowest and the highest DNBI rate during the 

stabilization period. For the same period of time, the BI 

rates demonstrated much higher variability (fl uctuation 

ratio was 4.3), and the 95th percentile daily BI admission rates for the last 3 years of OIF/OND decreased, on 

average, by almost 60%.

Table 1 presents 95th percentile daily admission rates 

for 3 recent campaigns. The DNBI rates for Iraq and 

Afghanistan are 47% and 27% lower than the DNBI rate 

for Desert Shield/Desert Storm. Table 2 presents the top 

5 principal diagnoses in OIF/OND for each category: 

disease, nonbattle injury, and battle-injury. The top diagnosis for NBI is concussion, for BI is fracture of tibia 

and fi bula, and for disease is symptoms involving chest 

and respiratory system.

Rates for Nontraditional Populations

Table 3 presents results of the casualty estimation for 

nontraditional populations for the entire OIF/OND campaign. Analysis conducted by phase showed that for each 

Soldier admitted during the stabilization period, there 

was over one patient from the nontraditional categories 

admitted to Role 3 Army MTFs. This ratio is even more 

pronounced for BI patients (more than 2 nontraditional 

patients admitted for each admitted US Army Soldier).

COMMENT

This paper presents the methodology behind the current 

DNBI/BI medical planning factors accredited by the 

Army Surgeon Generals and used in consecutive Total 

Army Analysis requirements for over a decade. Use of 

data from actual deployments as the basis for the casualty estimation of DNBI/BI rates greatly improved their 

SETTING THE STAGE
April – September 2016 11

THE ARMY MEDICAL DEPARTMENT JOURNAL

accuracy compared with previous planning tools which 

relied primarily on subject matter expert opinions. The 

DNBI/BI casualty estimation rates were validated by 

comparison to the most recently available data from current deployments. The methodology along with the SAS 

programming code was internally and externally verifi ed and validated. The Center for Army Analysis used 

these rates to update Combat Support Hospital Rules of 

Allocation. As a consequence, the total number of beds 

and the total number of medical staff were corrected to 

account for nontraditional groups of patients. Prior to 

the analysis performed by the Statistical Analysis Cell, 

these patients were not included in the TAA process and 

the medical workload did not account for treating patients other than US Army Soldiers.

The continuous update of DNBI/BI rates is crucial for 

the accuracy of the casualty estimates. Our analysis is 

based on both healthcare administrative data from the 

SIDR housed by PASBA, and the Contingency Tracking 

System fi les capturing the US Army deployed Soldier 

population from DMDC. Both fi les are still subject to 

updates, changes, and corrections to the existing records. 

As a result, our estimates change, which is refl ected in 

planning factors for consecutive TAA cycles.

Comparison of the DNBI/BI rates currently in use to 

the rates originally used in the TAA 11 based on the 

Desert Shield/Desert Storm experience emphasizes the 

effectiveness of the recent strategic approaches regarding force health protection, including Soldier readiness, 

Buildup

Ground

Combat

Stabilization

Figure 1. Daily admissions of US Army Soldiers for disease and nonbattle injuries and daily Soldier population at risk in Operation 

Iraqi Freedom through fi rst year of Stabilization (April 30, 2004).

190,000

180,000

170,000

160,000

150,000

140,000

130,000

120,000

110,000

100,000

90,000

80,000

70,000

60,000

50,000

40,000

30,000

20,000

10,000

0

60

50

40

30

20

10

0

Admission Count

Population

Daily Soldier Population

Daily DNBI Admissions

09/01/2002 01/01/2003 05/01/2003 09/01/2003 01/01/2004 05/01/2004
12 http://www.cs.amedd.army.mil/amedd_journal.aspx

new and/or improved personal protection equipment, 

personal physical fi tness, camp sanitation measures, improved medical screening, environmental surveillance 

of the deployment destination, and more.11 For example, 

for TAA 11, the 95th percentile daily DNBI rate for the 

ground combat phase based on DS/DS was 0.590/1,000 

Soldiers. In recent TAA analysis, this rate is 0.287/1,000 

Soldiers. The 95th percentile daily DNBI rate for stabilization was 0.370/1,000 Soldiers for DS/DS and now is 

0.202/1,000 Soldiers based on OIF/OND data.

During the last decade, DNBI rates in OIF/OND decreased by 25% compared to the fi rst year of stabilization, and BI rates decreased in the last 3 years of the 

campaign by almost 60%. These decreasing trends 

demonstrate the effectiveness of Army initiatives to 

protect deployed Soldiers.

To fully embrace challenges regarding readiness of deployed troops, dental emergency encounters or D-DNBI 

incidence rates must be included in the planning process. 

In recent campaigns, dental emergency rates exceeded 

medical DNBI rates.12,13 Dental emergencies in a deployed setting may compromise combat effectiveness of 

deployed Soldiers, which is why medical planners need 

accurate estimates of D-DNBI rates to properly determine the amount of equipment, supplies, and manpower.

The DNBI casualty estimation methodology allowed us 

to conduct numerous epidemiological studies regarding 

Buildup

Ground

Combat

Stabilization

Figure 2. Daily admission rates (per 1,000 Soldiers) for disease and nonbattle injuries and daily Soldier population at risk in Operation Iraqi Freedom through fi rst year of Stabilization (April 30, 2004), with 95th percentile (PCTL) phase rates. Admission RatePopulation

190,000

180,000

170,000

160,000

150,000

140,000

130,000

120,000

110,000

100,000

90,000

80,000

70,000

60,000

50,000

40,000

30,000

20,000

10,000

0

1.2

1.1

1.0

0.9

0.8

0.7

0.6

0.5

0.4

0.3

0.2

0.1

0.0

09/01/2002 01/01/2003 05/01/2003 09/01/2003 01/01/2004 05/01/2004

Buildup

95th PCTL=0.471

Stabilization

95th PCTL=0.202

Ground Combat

95th PCTL=0.287

Daily Soldier Population

Daily DNBI Rates

SETTING THE STAGE
April – September 2016 13

THE ARMY MEDICAL DEPARTMENT JOURNAL

Soldiers’ readiness in both OEF and OIF/OND. These 

studies cover a wide spectrum of healthcare topics, including behavioral health,14 traumatic brain injury,15,16

spinal cord injury,17 and dental emergencies.18

Continuation of the surveillance and updated analysis 

of both DNBI and BI hospital admission rates in recent 

theaters should provide more accurate estimates of both 

planning factors which are integral to AMEDD doctrine, 

organization, training, materiel, leadership and education, personnel, and facilities development, and crucial 

for success of future operations.

REFERENCES

1. Peake JB. Refl ections on injuries in the military. 

The hidden epidemic. Am J Prev Med. 2000;18(suppl 3):4-5.

Table 1. Campaign Comparison of 95th Percentile Daily Admission Rates (per 

1,000 US Army Soldiers).

Campaign Disease NBI DNBI Population at Risk

(total Soldier days)

Desert Shield/Desert Storma 0.307 0.110 0.392 55,757,089

Operations Iraqi Freedom/New Dawnb 0.166 0.071 0.208 404,439,909

Operation Enduring Freedomc 0.227 0.122 0.285 130,098,331

aEntire campaign

bThrough 31 Dec 2011 (the end of OND) cThrough 31 Dec 2012

Table 3. OIF/OND DNBI Admission Ratios and Ratesa for all Patient Populations 

Compared to US Army Soldiers.

Patient Category Ratio to

Army

Admissions

95% Army Daily

Admission

Rate per

1,000 Soldiers

Rate

per

1,000

US Army 

Soldiers

US Army 0.208

Other US uniformed services 0.166 0.035

Coalition forces NATO 0.069 0.014

Coalition forces non-NATO 0.014 0.003

US government agencies and civilians 0.019 0.004

Contract employees 0.274 0.057

Indigenous population 0.174 0.036

Detainees 0.278 0.058

Other 0.0004 0.0001

Total (excluding US Army) 0.9944 0.207

aThrough 31 Dec 2011 (the end of OND)

Table 2. Top 5 Principal Diagnosesa for In-theater Admissions in Operations Iraqi Freedom/New Dawnb by Admission Category.

Disease Nonbattle Injury Battle Injury

Diagnosis % Diagnosis % Diagnosis %

786 Symptoms involving respiratory 

system and other chest symptoms

6.81 850 Concussion 5.74 823 Fracture of tibia and fibula 5.11

592 Calculus of kidney and ureter 4.72 802 Fracture of face bones 4.37 863 Injury to gastrointestinal 

tract

4.69

682 Other cellulitis and abscess 4.22 824 Fracture of ankle 3.88 891 Open wound of knee, leg 

[except thigh], and ankle

4.35

540 Acute appendicitis 4.19 959 Injury, other and 

unspecified

3.88 890 Open wound of hip and thigh 4.28

780 General symptoms (Alteration 

of consciousness)

4.02 823 Fracture of tibia and fibula 3.78 873 Other open wound of head 3.65

a3-digit ICD-9-CM diagnosis code

bThrough 31 Dec 2011 (the end of OND)
14 http://www.cs.amedd.army.mil/amedd_journal.aspx

2. Kotwal RS, Wenzel RB, Sterling RA, Porter WD, Jordan NN, Petruccelli BP. An outbreak of malaria in U.S. Army 

Rangers returning from Afghanistan. JAMA. 2005;293(2):212-216.

3. Blood CG, Jolly R. Comparisons of disease and nonbattle injury incidence across various military operations. Mil 

Med. 1995;160(5):258-263.

4. Jones BH, Hansen BC. An Armed Forces Epidemiological Board evaluation of injuries in the military. Am J Prev 

Med. 2000;18(suppl 3):14-25.

5. Belmont PJ, Goodman GP, Waterman B, DeZee K, Burks R, Owens BD. Disease and nonbattle injuries sustained 

by a U.S. Army Brigade Combat Team during Operation Iraqi Freedom. Mil Med. 2010;175:469-476.

6. Lynch LC, Elliott CW, McMurry P. Disease and nonbattle injury forecasting. US Army Med Dep J. July-September 

1999:2-8.

7. Amoroso PJ, Smith GS, Bell NS. Qualitative assessment of cause-of-injury coding in U.S. military hospitals: NATO 

standardization agreement (STANAG) 2050. Amer J Prev Med. 2000;18(suppl 3):174-187.

8. Wojcik BE, Davis JM, Humphrey RJ, Stein CR, Hassell LH. AMEDD Disease And Non-battle Injury Models., Fort 

Sam Houston, TX: United States Army Medical Department Center and School; January 2005. RP 05-001.

9. Wojcik BE, Hassell LH, Humphrey RJ, Davis JM, Oakley CJ, Stein CR. A disease and non-battle injury model 

based on Persian Gulf war admission rates. Am J Ind Med. 2004;45(6):549-557.

10. Wojcik BE, Humphrey RJ, Czejdo B, Hassell LH. U.S. Army disease and nonbattle injury model, refi ned in Afghanistan and Iraq. Mil Med. 2008;173(9):825-835.

11. Hyams KC, Riddle J, Trump DH, Wallace MR. Protecting the health of United States military forces in Afghanistan: applying lessons learned since the Gulf War. Clin Infect Dis. 2002;34(suppl 5):S208-S214. 

12. Wojcik BE, Szeszel-Fedorowicz W, Humphrey RJ, et al. Risk of dental disease non-battle injuries and severity of 

dental disease in deployed U.S. Army personnel. Mil Med. 2015;180(5):570-577.

13. Simecek JW, Colthirst PM, Wojcik BE, Eikenberg S, Guerrero AC, Fedorowicz A, Szeszel-Fedorowicz W, DeNicolo P. 

The incidence of dental disease non-battle injuries in deployed U.S. Army personnel. Mil Med. 2014;179(6):666-673.

14. Wojcik BE, Akhtar FZ, Hassell LH. Hospital admissions related to mental disorders in U.S. Army soldiers in Iraq 

and Afghanistan. Mil Med. 2009;174(10):1010-1018.

15. Wojcik BE, Stein CS, Bagg K, Humphrey RJ, Orosco J. Traumatic brain injury hospitalizations of U.S. Army soldiers deployed to Afghanistan and Iraq. Amer J Prev Med. 2010;38(suppl):S108-S116.

16. Wojcik BE, Stein CS, Orosco J, Bagg K, Humphrey RJ. Creation of an expanded Barell Matrix to identify traumatic 

brain injuries of U.S. military members. Journal of Defense Modeling and Simulation: Applications, Methodology, 

Technology. 2010;7:157-166. Available at: http://dms.sagepub.com/content/7/3.toc. Accessed January 19, 2016.

17. Wojcik BE, Curley KC, Szeszel-Fedorowicz W, Stein CR, Humphrey RJ. Spinal injury hospitalizations among U.S. 

Army soldiers deployed to Iraq and Afghanistan. Mil Med. 2015;180(2):216-223.

18. Colthirst PM, Wojcik BE, Humphrey RJ, Hosek B, Stein CR, Landt C. Longitudinal Analysis of Dental Emergencies in Overseas Contingency Operations. Poster presented at: National Oral Health Conference; April 27-29, 2015; 

Kansas City, MO.

AUTHORS

Dr Wojcik is Chief, Statistical Analysis Cell, US Army Medical Department Center and School, Joint Base San Antonio 

Fort Sam Houston, Texas.

Ms Humphrey, Mr Hosek, and Ms Stein are Health Statisticians, Statistical Analysis Cell, US Army Medical Department 

Center and School, Joint Base San Antonio Fort Sam Houston, Texas.

SETTING THE STAGE
April – September 2016 15

Historically, disease was the greatest threat to Soldiers’ 

health and the leading cause of death in early American wars, including World War I. During World War 

II, there was a transition to a more mechanized Army. 

There were also signifi cant advances in sanitary and 

medical control of infectious diseases.1,2 As a result, for 

the fi rst time in history, the Army fatality rate for disease and nonbattle injury (DNBI) combined (74/10,000 

Soldiers) was much lower than the rate for battle injury 

(209/10,000 Soldiers).3

Unlike the fatality rate, the hospitalization rate for DNBI 

in World War II was still much higher (669/1,000 personyears [p-years]) than the rate for battle injury (29/1,000 

p-years), due primarily to disease (592/1,000 p-years).4

Even though DNBI and battle injury rates dropped signifi cantly in Viet Nam and again in Operations Desert 

Shield and Desert Storm (the Gulf War, 1990-1991), the 

DNBI hospitalization rate was still higher than the battle injury rate in the Gulf War (152/1,000 p-years and 

6/1,000 p-years, respectively).4,5 Of the DNBI hospitalizations in the Gulf War, the 2 leading diagnosis categories were acute nonbattle injury and conditions of the 

musculoskeletal system, accounting for 25% and 13% of 

hospitalizations, respectively.6

After 13 years of continuous military operations in Afghanistan and Iraq, the Army is rapidly transforming 

from a force focused on counterinsurgency operations 

to a smaller force that will be more adaptable, mobile, 

and responsive to global threats.7,8 In the future, there 

will be an ever greater dependence on the personal medical readiness of every Soldier. In this rapidly changing 

operational setting, every casualty, whether from battle 

injury or DNBI, will impact unit and mission readiness. 

Even more than now, commanders will rely on near-real 

time DNBI surveillance to assess medical readiness of 

the force and identify emerging medical threats.1,2,9

In past military deployments and confl icts, up to and 

including Operations Desert Shield and Desert Storm, 

the military services had no systematic, theater-wide 

DNBI surveillance.5

 Reported DNBI patterns, rates, and 

trends were based on analysis of hospitalization records 

that were centrally collected after the deployments ended.5

 The absence and importance of a systematic DNBI 

surveillance program were realized when there were insuffi cient medical and environmental surveillance data 

to evaluate possible causes of adverse health effects reported by veterans of the Gulf War.10

In 1993, the Joint Staff mandated medical surveillance 

with weekly DNBI reporting on future joint deployments.5,11 A theater-wide program for collecting outpatient data for DNBI surveillance was in place for deployments to Somalia (Operation Restore Hope, 1992-1993), 

Surveillance of Disease and Nonbattle Injuries

 During US Army Operations in Afghanistan

 and Iraq

 Keith G. Hauret, MSPH, MPT

 LTC (P) Laura Pacha, MC, USA

 Bonnie J. Taylor, PhD

 Bruce H. Jones, MD, MPH

ABSTRACT

Disease and nonbattle injury (DNBI) are the leading causes of morbidity during wars and military operations. However, adequate medical data were never before available to service public health centers to conduct DNBI surveillance 

during deployments. This article describes the process, results and lessons learned from centralized DNBI surveillance by the US Army Center for Health Promotion and Preventive Medicine, predecessor of the US Army Public 

Health Command, during operations in Afghanistan and Iraq (2001-2013).The surveillance relied primarily on medical evacuation records and in-theater hospitalization records. Medical evacuation rates (per 1,000 person-years) for 

DNBI were higher (Afghanistan: 56.7; Iraq: 40.2) than battle injury rates (Afghanistan: 12.0; Iraq: 7.7). In Afghanistan 

and Iraq, respectively, the leading diagnostic categories for medical evacuations were nonbattle injury (31% and 34%), 

battle injury (20% and 16%), and behavioral health (12% and 10%). Leading causes of medically evacuated nonbattle 

injuries were sports/physical training (22% and 24%), falls (23% and 26%) and military vehicle accidents (8% and 

11%). This surveillance demonstrated the feasibility, utility, and benefi ts of centralized DNBI surveillance during 

military operations.
16 http://www.cs.amedd.army.mil/amedd_journal.aspx

Haiti (Operation Uphold Democracy, 1994), and Egypt 

(Bright Star training exercise, 1994). But these surveillance data were incomplete and nonspecifi c.5

 This same 

Joint Staff DNBI surveillance was still in place in October 2001 when Operation Enduring Freedom began in 

Afghanistan.

IMPROVEMENTS IN DNBI SURVEILLANCE DURING

OPERATIONS IN AFGHANISTAN AND IRAQ

In 2003, the Deployment Health Support Directorate 

(Offi ce of the Secretary of Defense) fi elded the Theater Medical Information Program (TMIP), a layered 

force health protection data system.10 The Joint Medical 

Workstation (JMeWS), an element of TMIP fi elded in 

January 2003, provided online, near real-time medical 

surveillance and analysis derived from patient records 

and DNBI reports.10,12 Later, TMIP added the Medical 

Situational Awareness in the Theater (MSAT) and Theater Medical Data Store (TMDS) web-based applications that allow both classifi ed and unclassifi ed access 

to theater medical records and other medical data.13-15

Numerous system updates contributed to improvements 

in the theater medical surveillance capability during 

the operations in Afghanistan and Iraq.15 Updates to 

components of the electronic health record, including 

AHLTA-Theater and Theater Composite Health Care 

System Cache, improved the capture of outpatient and 

inpatient medical encounters, respectively. Improvements in the theater informatics infrastructure allowed 

greater connectivity and access to these systems. But 

even with these improvements, concerns persisted about 

the completeness and accuracy of the in-theater DNBI 

surveillance capability and the medical encounters in 

the electronic health record.

In early 2004, the US Army Center for Health Promotion 

and Preventive Medicine (USACHPPM), predecessor of 

the US Army Public Health Command (USAPHC) developed and implemented a plan for centralized DNBI 

surveillance for the operations in Afghanistan and Iraq. 

This surveillance plan included identifying and coding 

causes of nonbattle injury to monitor rates and trends 

over time. This article describes the process used by the 

USACHPPM and USAPHC for centralized DNBI surveillance for operations in Afghanistan and Iraq; summarizes fi ndings from the surveillance; and describes 

surveillance lessons learned.

METHODS

The Injury Prevention Program at USACHPPM identifi ed and evaluated medical and nonmedical data systems 

for their potential contribution to centralized, systematic DNBI surveillance. It evaluated the data systems 

initially in 2004, and reevaluated them periodically as 

changes and improvements were made. Using data completeness, accuracy, accessibility, timeliness, and utility 

as criteria, the following data systems were evaluated:

 Medical encounter data from theater accessed 

through MSAT and TMDS

 Standard Inpatient Data Records (SIDR) from intheater hospitalizations provided by the Patient 

Administration System and Biostatistics Activity 

(PASBA), Offi ce of the Surgeon General

 Medical evacuation records from the Transportation Command Regulating and Command & Control Evacuation System (TRAC2ES)

 Casualty records from the Defense Casualty Information Processing System

 Accident records from the Army Safety Management Information System

The USACHPPM concluded from this evaluation that 

TRAC2ES and hospitalization records were best suited 

for centralized surveillance. The data from TRACE2S 

were complete (all medical evacuations from theater), 

accurate, accessible (through the TRAC2ES portal), 

timely (data entered at the time of evacuation), and useable (ie, unique personal identifi ers, ICD-9-CM* diagnosis codes, and patient histories from which causes of 

nonbattle injury could be determined). Also considered 

was the fact that Soldiers requiring evacuation from 

theater have serious medical conditions and are a “loss” 

to their unit until they return to theater or are replaced. 

Each loss negatively affects the unit’s mission readiness 

related to the operational tempo and special skills of 

each Soldier. While hospitalization records were judged 

to be accurate and useable, they were not accessible until 4 to 6 months after the hospitalization occurred.

The USACHPPM evaluation of the remaining data 

sources (ie, theater outpatient encounters, casualty records, and accident records) determined that they should 

be used only as secondary data sources. Due to theaterrelated issues, the outpatient encounter data were incomplete and the representativeness of available data could 

not be determined. These encounter data were used to 

investigate some specifi c medical problems, but were not 

used in the centralized surveillance. Casualty and accident records were valuable in providing additional details about the causes and mechanisms of some injuries.

For rate calculations used in the surveillance, the Armed 

Forces Health Surveillance Center provided the denominator data (number of deployed person-months) for each 

month of the deployments. These data were based on the 

*International Classifi cation of Diseases, 9th Revision, Clinical 

Modifi cation

SETTING THE STAGE
April – September 2016 17

THE ARMY MEDICAL DEPARTMENT JOURNAL

Contingency Tracking System data from the Defense 

Manpower Data Center.

RESULTS OF CENTRALIZED DNBI SURVEILLANCE

Medical Evacuations

Overall, 20,702 Soldiers were medically evacuated from 

Operation Enduring Freedom (OEF: October 2001 to December 2013) and 47,647 Soldiers were evacuated from 

Operation Iraqi Freedom-New Dawn (OIF-OND: March 

2003 to December 2011). Medical evacuation rates in 

OEF for disease, nonbattle injury, and battle injury were 

28.6/1,000 p-years, 18.1/1,000 p-years, and 12.0/1,000 pyears, respectively. In OIF-OND, these rates were lower 

than in OEF (24.0/1,000 p-years, 16.3/1,000 p-years, and 

7.7/1,000 p-years, respectively).

Figures 1A and 1B show the monthly rates for DNBI 

(blue line) and battle injury (red line) medical evacuations from OEF and OIF-OND, respectively. Monthly 

rates were highest during the initial phases the operations. After the initial phases, monthly DNBI rates in 

OEF were generally higher (range after 2002: 21/1,000 

p-years to 93/1,000 p-years) than in OIF (range after 

2003: 20/1,000 p-years to 70/1,000 p-years). Monthly 

battle injury rates in OEF were lower prior to May 2006 

compared to the period June 2006 to December 2011. 

Battle injury rates after June 2006 in OEF followed a 

seasonal pattern with higher rates between April and 

September refl ecting higher levels of hostile action during the warmer months. In OIF-OND, monthly battle 

injury rates were higher during the fi rst half of the operation (March 2003 to May 2008; range: 5 to 25/1,000 

p-years) compared to the period June 2008 to December 

2011 (range: 0 to 5/1,000 p-years).

Figures 2A and 2B show the distribution of medical 

evacuations for each operation by primary diagnosis 

groups in the ICD-9-CM. The pattern for distribution 

is similar for both operations. The 2 leading diagnosis 

categories for OEF and OIF-OND were nonbattle injury 

(ie, acute injuries and injury-related musculoskeletal 

conditions) accounting for 31% and 34%, respectively, 

of medical evacuations, and battle injury, accounting 

for 20% and 16%, respectively, of evacuations. The next 

3 leading categories for OEF and OIF-OND were behavioral health (12% and 10%, respectively), ill-defi ned 

conditions (8% and 9%, respectively), and digestive disorders (6% for both operations).

Figures 3A and 3B show the annual percentage of all 

medical evacuations for each of the 6 leading diagnosis 

groups from Figures 2a and 2b. Evacuations for nonbattle injury fl uctuated in both operations. The percentage 

of battle injury evacuations in OEF increased starting in 

2006, whereas the battle injury percentage in OIF-OND 

was increasing from 2003 to 2007 and then dropped 

from 2008 to 2013. For both operations, the percentage 

of evacuations for behavioral health increased beginning in 2007, peaking at 18% in OEF (2012) and 21% in 

OIF-OND (2010).

Figure 4 shows the leading causes of nonbattle injuries 

that required medical evacuation, as determined from 

the patient history in TRAC2ES records. The leading 

causes of nonbattle injury were similar for both operations, though the rank order of the causes differed by operation. Sports and physical training accounted for 24% 

and 22% of nonbattle injury evacuations in OIF-OND 

and OEF, respectively. Falls and near-falls accounted for 

23% of evacuations in OIF-OND and 26% in OEF. Military motor vehicle accidents accounted for 11% and 8% 

of nonbattle injury evacuation in OIF-OND and OEF, 

respectively.

In-theater Hospitalizations

Overall, there were 12,251 hospitalizations in OEF and 

23,299 hospitalizations in OIF-OND. Hospitalization 

rates for disease, nonbattle injury, and battle injury in 

OEF were 16.1/1,000 p-years, 6.2/1,000 p-years, and 

12.3/1,000 p-years, respectively. In OIF-OND, hospitalization rates for disease and nonbattle injury (26.3/1,000 

p-years and 8.8/1,000 p-years, respectively), were higher 

than in OEF, but the rate for battle injury (9.1/1,000 pyears) was lower.

The distribution of primary diagnosis groups for intheater hospitalizations differed from the distribution 

for medical evacuations. For OEF and OIF-OND, the 4 

leading diagnosis groups for hospitalizations were battle injury (36% and 21%, respectively), nonbattle injury 

(18% and 19%, respectively), digestive disorders (11% 

and 15%, respectively) and ill-defi ned conditions (10% 

for both operations). Whereas behavioral health ranked 

third for medical evacuations in both operations (18% to 

21%), it ranked eighth for OEF hospitalizations (3.0%) 

and sixth for OIF-OND hospitalizations (6%).

The distribution of causes of nonbattle injuries hospitalized in-theater also differed from the distribution for 

nonbattle injuries that were medically evacuated. The 

2 leading causes of nonbattle injury hospitalizations 

for OEF and OIF-OND were military vehicles (21% for 

both operations) and falls (21% and 15%, respectively). 

Inhalation or ingestion of toxic substances (intentional 

injuries) ranked fourth for OEF (11%) and third for OIFOND (13%). Sports and physical training ranked fi fth 

for hospitalizations but was the leading category for 

nonbattle injury medical evacuations.
18 http://www.cs.amedd.army.mil/amedd_journal.aspx

Figure 1. Monthly rates (per 1,000 person-months) for medical evacuation of battle injuries and disease/nonbattle injuries for 

Operation Enduring Freedom (1A) and Operation Iraqi Freedom – New Dawn (1B).

1A. Operation Enduring Freedom (July 2002 - October 2013). July 02 Oct 02 Jan 03 Jan 04 Jan 05 Jan 06 Jan 07

Jan 08

Jan 09

Jan 10

Jan 11

Jan 12

Jan 13

Apr 03

Apr 04

Apr 05

Apr 06

Apr 07

Apr 08

Apr 09

Apr 10

Apr 11

Apr 12

Apr 13

July 03

July 04

July 05

July 06

July 07

July 08

July 09

July 10

July 11

July 12

July 13

Oct 03

Oct 04

Oct 05

Oct 06

Oct 07

Oct 08

Oct 09

Oct 10

Oct 11

Oct 12

Oct 13

140

120

100

80

60

40

20

0

Month

Air Evacuation Rates Per 1,000 Person-years

Disease & Nonbattle Injury

Battle Injury

1B. Operation Iraqi Freedom – New Dawn (March 2003 - December 2011). Air Evacuation Rates Per 1,000 Person-years

Month

120

100

80

60

40

20

0

Mar 03

Mar 04

Mar 05

Mar 06

Mar 07

Mar 08

Mar 09

Mar 10

Mar 11

Jun 03

Jun 04

Jun 05

Jun 06

Jun 07

Jun 08

Jun 09

Jun 10

Jun 11

Sep 03

Sep 04

Sep 05

Sep 06

Sep 07

Sep 08

Sep 09

Sep 10

Sep 11

Dec 03

Dec 04

Dec 05

Dec 06

Dec 07

Dec 08

Dec 09

Dec 10

Dec 11

Disease & Nonbattle Injury

Battle Injury

SETTING THE STAGE
April – September 2016 19

THE ARMY MEDICAL DEPARTMENT JOURNAL

2B. Operation Iraqi Freedom – New Dawn (2003 - 2011).

Percentage

(N=47,647 medical evacuations)

Ill-defi ned conditions

Nonbattle injury

Battle Injury

Behavioral health

Digestive

Genitourinary

Nervous System

Circulatory

Musculoskeletal

Respiratory

Endocrine

Infectious

Neoplasms

Skin

Other

Unknown

34.0%

16.0%

10.1%

8.7%

5.9%

4.7%

3.6%

3.1%

2.1%

1.8%

1.6%

1.6%

1.5%

1.5%

3.7%

0.2%

0 20 25 5 10 35 15 30

Nonbattle Injuries

Battle Injuries

Disease

Figure 2. Distribution of primary diagnosis categories for US Army medical evacuations from Operation Enduring Freedom (2A) and 

Operation Iraqi Freedom – New Dawn (2B).

2A. Operation Enduring Freedom (2001 - 2013).

31.1%

19.6%

12.1%

8.3%

5.6%

4.7%

3.4%

3.4%

3.1%

1.3%

1.2%

1.0%

0.9%

0.8%

3.5%

0.1%

Nonbattle Injuries

Battle Injuries

Disease

Percentage

(N=27,207 medical evacuations)

Ill-defi ned conditions

Nonbattle injury

Battle Injury

Behavioral health

Digestive

Genitourinary

Nervous System

Circulatory

Musculoskeletal

Endocrine

Respiratory

Skin

Neoplasms

Infectious

Other

Unknown

0 20 25 5 10 35 15 30
20 http://www.cs.amedd.army.mil/amedd_journal.aspx

Nonbattle Injury

Battle Injury

Behavioral Health

Ill-Defi ned Conditions

Digestive

Genitourinary

Year

Percentage of All Evacuations

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013

35

45

40

30

25

20

15

10

5

0

3A. Operation Enduring Freedom (2001 - 2013).

3B. Operation Iraqi Freedom–New Dawn (2003 - 2011). Percentage of All Evacuations

Year

35

40

30

25

20

15

10

5

0

2003 2004 2005 2006 2007 2008 2009 2010 2011

Figure 3. Percentages of US Army medical evacuations for the leading primary diagnosis categories from Operation Enduring Freedom (3A) and Operation Iraqi Freedom – New Dawn (3B). 

SETTING THE STAGE
April – September 2016 21

THE ARMY MEDICAL DEPARTMENT JOURNAL

COMMENT

The USACHPPM/USAPHC conducted centralized DNBI surveillance during the operations 

in Afghanistan and Iraq. This surveillance used 

medical evacuation and in-theater hospitalization 

records as primary data sources. A unique component of the surveillance was coding causes of 

nonbattle injuries based on the narrative patient 

history in TRAC2ES records. This surveillance 

demonstrated the feasibility and utility of identifying causes of nonbattle injury from medical evacuation and hospitalization records.

Operation Enduring Freedom and OIF-OND were 

the fi rst Army operations of this scale in which 

data were available to conduct centralized DNBI 

surveillance during the operations. This surveillance provided an additional means of monitoring health of the force and identifying emerging 

medical threats. As for nonbattle injuries, this surveillance helped to focus attention on potentially 

preventable causes of injury such as falls from tactical vehicles, rollover tactical vehicle accidents, 

and injuries from sports and physical training.

Distributions for the primary diagnosis groups for 

medical evacuations were similar for both operations. The 3 leading diagnosis groups were nonbattle injury, battle injury, and behavioral health. The 

leading diagnosis groups for in-theater hospitalizations were also similar for both operations (ie, 

battle injury, nonbattle injury, and digestive), but 

the rank order and proportion for the leading diagnosis 

groups were different for hospitalizations compared to 

medical evacuations. In-theater medical capabilities and 

individual prognosis likely infl uenced these differences.

LESSONS LEARNED FROM DNBI SURVEILLANCE IN

AFGHANISTAN AND IRAQ

As the Army transforms to a smaller, yet more adaptable, mobile, and responsive force, senior leaders and 

commanders will have a greater expectation for near 

real-time DNBI surveillance to accurately assess the 

medical readiness of the force and identify emerging 

medical threats.1,2,9 Lessons learned from surveillance 

during OEF and OIF-OND should guide efforts in the 

Department of Defense and Army as they work toward a 

more robust and informative DNBI surveillance for the 

future. Lessons learned from this surveillance follow:

 Central DNBI surveillance was achieved using 

medical evacuation (TRAC2ES) and in-theater hospitalization (SIDR-PASBA) records.

 Utility of MSAT for centralized DNBI surveillance 

was limited because it could only be accessed on 

the classifi ed network. As such, MSAT data could 

not be analyzed or linked to other medical and nonmedical surveillance data that reside on unclassifi ed systems.

 Air evacuation records from TRAC2ES were used 

to identify and code causes of nonbattle injury. Intheater SIDR hospitalization records from PASBA 

included coded causes of injury.

 The deployment outpatient encounter data in MSAT 

did not have coded causes of injury. Currently, injury cause coding in the electronic health record 

by medical providers is not mandatory in the electronic health records. As a result, causes of injury 

are unknown for injuries treated at levels I and II 

where the majority of injured Soldiers receive medical care. Finding a solution to this important shortfall in the health record should be a priority.

 Nonbattle injury was the leading diagnostic category of medical evacuations in both operations, 

Figure 4. Causes of US Army nonbattle injuries requiring medical evacuations from Operation Enduring Freedom (OEF), 2001-2013, and Operation Iraqi Freedom – New Dawn (OIF–OND), 2003-2011. 

Sports and

Physical Training

Falls and

Near Falls

Motor 

Vehicle

Crushing and

Blunt Trauma

Lifting/Pushing/

Pulling

Shoes/Clothes,

PPE

Weapons

Related

Cutting and

Piercing

Boarding and

Alighting

Environmental

23.8%

22.0%

22.7%

26.2%

11.2%

8.1%

8.7%

11.3%

7.4%

5.9%

3.7%

1.2%

3.1%

3.2%

2.6%

2.0%

2.5%

2.4%

2.1%

1.2%

0% 10% 20% 30%

OIF–OND (n=11,063) OEF (n=4,870)

Percentage of Nonbattle Injuries
22 http://www.cs.amedd.army.mil/amedd_journal.aspx

followed by battle injury. Of in-theater hospitalizations, battle injury was the leading category, followed by nonbattle injury. These data show that injuries are a leading medical problem during deployments and affect unit and mission readiness.

 Leading causes of nonbattle injury during deployments were the same as leading causes among Soldiers in garrison. Whether in garrison or on deployment, the 3 leading causes of injury for hospitalized 

nonbattle injuries are motor vehicle accidents, falls, 

and sports/physical training.16 The leading cause of 

air evacuated nonbattle injuries was sports/physical 

training, which is also the leading cause of injuries 

among Soldiers in garrison.17,18

CENTRAL AND IN-THEATER DNBI SURVEILLANCE ISSUES

RELATED TO DOCTRINE, ORGANIZATION, TRAINING, 

MATERIEL, LEADERSHIP & EDUCATION, PERSONNEL, 

AND FACILITIES

Doctrine

 Policy and directives should include the requirement 

for entering medical care in the electronic medical 

record at all levels of medical care in theater. Despite improvements during OEF and OIF-OND, no 

outpatient medical encounters were entered in the 

electronic medical record during the most recent 

operation in Africa (Operation United Assistance, 

2014-2015).

 Consideration should be given to allow greater access to deployment medical encounter and population data from MSAT on unclassifi ed systems to 

support military public health centers in medical 

surveillance and force health protection work.

Training

 Active and reserve component medical units should 

receive predeployment training on the medical 

information technology systems they will use in 

theater (for example, Medical Communications for 

Combat Casualty Care [MC4] and JMeWS).

Facilities

 In-theater support for JMeWS/MSAT/MC4 systems is essential for data fl ow throughout the enterprise to those with a need-to-know. Reliable intheater and central DNBI surveillance at all levels 

of care can only be achieved when the medical encounter data are complete and representative of the 

deployed population.

Leadership & Education

 Given the magnitude of the injury problem for the 

Army, senior medical and safety leaders should support mandatory cause-coding of injuries in the electronic health record.

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April – September 2016 23

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injury risk factors among US Army wheel vehicle 

mechanics. Mil Med. 2007;172:988-996.

AUTHORS

Mr Hauret is with the Injury Prevention Program, Army 

Public Health Center-Provisional, Aberdeen Proving 

Ground, MD.

Dr Pacha is Director, Epidemiology and Disease Surveillance Portfolio, Army Public Health Center-Provisional, 

Aberdeen Proving Ground, MD.

Dr Taylor is with the Injury Prevention Program, Army 

Public Health Center-Provisional, Aberdeen Proving 

Ground, MD.

Dr Jones is Program Manager, injury Prevention Program, Army Public Health Center-Provisional, Aberdeen 

Proving Ground, MD.
24 http://www.cs.amedd.army.mil/amedd_journal.aspx

BACKGROUND

Unprecedented knowledge and advances during the 

wars in Iraq and Afghanistan have improved survival 

rates, but at the same time led to increased morbidity.1

 As the enemy adjusted to US countermeasures, the 

military medical response had to adjust accordingly. 

Mechanisms of injury transitioned between small arms 

fi re, mortars, rocket-propelled grenades and improvised explosive devices (IED). In addition, the military 

had to adjust from mounted to dismounted operations 

and from centralized larger bases to widely distributed smaller bases as the wars transitioned from ground 

combat operations to counterterrorism/counterinsurgency. This required utilization of the Combat Medic 

for unparalleled care at the point of injury. There was 

also the implementation of evacuation from time of injury to surgical care within an hour, leading to improved 

outcomes.2

 In addition, the US military developed advanced care nearer to the point of injury through fl ight 

paramedics and fl ight critical care nurses, refl ecting 

the British Medical Emergency Response Team. The 

operational environment also changed from deserts in 

Iraq to rocky mountains and lush waterways in parts of 

Afghanistan. The culminations of these changes led to 

alterations in injury types and infecting pathogens requiring continual medical response adjustments.

Examples of military adjustments included equipment; 

tactics, techniques and procedures (TTPs); and clinical 

training and guidelines. Equipment advances to improve survival included tourniquet fi elding with training, improved body armor, improved uniform design to 

survive thermal injury and improved vehicular design 

to minimize injury. New training courses such as the 

Tactical Combat Medical Care and the implementations 

of Clinical Practice Guidelines led to standardization of 

care and rapid fi elding of the most current information 

and practices. Vital to every decision was the ability to 

collect information to improve the entire continuum of 

casualty care. The Department of Defense Trauma Registry (DoDTR) in combination with the Joint Trauma 

System allowed for rapid data collection, analysis, and 

distribution of new care guidelines. As infections occur 

in approximately 50% of casualties that were injured severely enough to be admitted to an ICU, the Infectious 

Disease (ID) Module was developed for the DoDTR 

with a separate Trauma Infectious Disease Outcome 

Study to analyze and collect 5-year outcome data.3

The recognition of the challenges with dismounted complex blast injuries in southwest Afghanistan were fi rst 

noted by the British military as this was their primary 

area of responsibility prior to the US Army and Marine 

Dismounted Complex Blast Injuries

 Including Invasive Fungal Infections

 COL Clinton K. Murray, MC, USA

 COL Kirby Gross, MC, USA

 Col Robert J. Russell, FRCEM, L/RAMC

 Ruth A Haslett

ABSTRACT

Large blast injuries during dismounted operations in southwest Afghanistan causing major limb amputations 

and perineal injuries associated with large blood volume resuscitation were associated with invasive fungal, 

primarily mold, infections. This article outlines the interventions undertaken to mitigate excess morbidity and 

mortality associated with invasive fungal infection. These interventions include defi ning the problem and associated risk with systemically collected and analyzed information, developing improved protective body armor 

for the thigh and perineal region, standardizing management through clinical practice guidelines that outlined 

risk, diagnostic and treatment recommendations with enhanced discussions on the weekly Theater Combat 

Casualty Care Conference that includes personnel from the combat zone, Germany, and the United States. 

The article concludes by explaining the key way forward with regarding an inner-war approach to sustained 

knowledge and skills.

CHANGES IN EQUIPMENT AND TECHNIQUES/TACTICS/

PROCEDURES THAT IMPACTED CARE AND OUTCOMES
April – September 2016 25

THE ARMY MEDICAL DEPARTMENT JOURNAL

Corps transitioning to the area.4

 The British referred to 

this area as the “Green Zone” because of the vegetation and waterways which was often confused with the 

Green Zone in downtown Baghdad, Iraq. Once the US 

military was in the region a similar recognition of severe injury pattern with associated complications was 

recognized. A US Army task force was established to 

summarize and analyze information to develop recommendations of care.5

 At the same time, the infectious 

disease and surgical community noted increased rates 

of mold infections in these patients.6

In order to address the problem, numerous parallel programs were developed, including defi ning the problem, 

developing equipment to address the injury pattern, 

modifi cation of TTPs to avoid the injury, and clinical 

practice guidelines to standardize care.

DEFINING THE PROBLEM

Once the risk was identifi ed to be fundamentally due 

to large blast injuries associated with dismounted operations in southwest Afghanistan causing major limb 

amputations and perineal injuries, the next goal was to 

further stratify the patients to develop diagnostic and 

treatment protocols to minimize excess morbidity and 

mortality. Data collected from the DoDTR and ID Module was able to defi ne regions of Afghanistan at highest 

risk, including case control analysis with 10-digit coordinates linked with geographic information system 

to identify other regions that were at potential risk if 

similar care and injury patterns developed.7

 The overall evaluation allowed for the identifi cation of risks for 

infections and poor outcomes.8-12 Key characteristics included type of mold, region of the country, presence of 

ongoing necrotic tissue, blast injury, dismounted at time 

of injury, above the knee amputation, and large-volume 

packed red blood cell (greater than 20 units) transfusion 

within the fi rst 24 hours. All of this information was 

able to assist in the development of equipment, TTPs, 

and guidelines to address the issue.

EQUIPMENT

Implementation and modifi cation of body armor has 

greatly affected casualty outcomes. As such, a similar 

program was developed for this new injury pattern. The 

 British led the way developing a 3 Tier system. Tier 1, 

issued in 2010, included layered synthetic silk cycling 

shorts that were thicker than previous issued cycling 

short-type underwear with some antimicrobial activity. Tier 2 was an over garment diaper appearing device 

with some ballistic protection that covered the perineal 

region to be worn with Tier 1. It was issued in February 2011 to all British troops to wear when operating 

outside the wire to apply in moderate IED threats. Tier 

3 was issued in November 2011 with over-trousers that 

are 3⁄4 length extending from the Tier 2 device to above 

the knee to be combined with Tier 1 and 2 worn mainly 

by the point men operating the metal detector. After November 1, 2010, the British military assessed adherence 

with overall 81% wearing any combination of Tier 1/2/3 

when injured. They found that 78% were wearing Tier 

1, 66% were wearing Tier 2, 6% were wearing Tier 3. 

Overall, 10% were not wearing pelvic protection with 

12% injured in the fi rst 2 months of Tier 1 issue; 71% 

were within the base not required to wear pelvic protection; and 16% were outside the wire. No documentation 

was available for 9% of casualties.

As US Marines moved into the area, there was an opportunity to compare the British to US Marine equipment as the British mostly used Tier 1 and 2 while the 

Marines had only Tier 1. The information was collected 

from trauma logs from Bastion, Afghanistan, between 

April 1 and September 30, 2011. Overall, there were 45 

US and British casualties in a high amputation group 

with unilateral or bilateral at or above the knee traumatic amputations, plus several with unilateral below 

knee or above ankle amputation. A comparison group 

of low amputations included 31 US or British casualties 

with unilateral or bilateral below knee or above ankle 

amputations, but no through the knee or above the knee 

amputations. There were 59 US and 17 British casualties 

(N=76) with decreased rates of genitourinary injuries 

of those wearing more protective equipment as shown 

in the Table. Ongoing analysis is required to continue 

to validate utility of this Tiered system, but the DoDTR 

does not collect this information and limited data from 

autopsy fi ndings are released.

TACTICS, TECHNIQUES, AND PROCEDURES

There was a recognition from the line that the IEDs associated with dismounted blast injuries were placed along 

major valley paths with vegetation and waterways. However, the trigger mechanism was often present up in the 

rocky edges along the valley walls and was frequently 

human controlled to avoid indiscriminate injuring of 

animals or local personnel. Given this recognition, there 

was a switch to moving US military personnel away from 

Genitourinary injury rate based upon Tier of protection at 

Bastion, Afghanistan between April 2, 2011 and September 

30, 2011.

Level of

Tier Protection

High Lower Extremity

Amputation with

Genitourinary Injury

n=45

Low Lower Extremity

Amputation with

Genitourinary Injury

n=31

Tier 1 and 2 17% 0%

Tier 1 only 56% 25%

None 68% 21%

Unknown (n=11) ---- -----
26 http://www.cs.amedd.army.mil/amedd_journal.aspx

the valley paths with vegetation and waterways to operate along the valley and rocky environment. Although 

there is no available data regarding implementation of 

this change or direct evidence of decreased injuries with 

its implementation, it does highlight that close communication of medical fi ndings to the line allows a collaborative, multidisciplinary approach to address the problem 

using each group’s unique perspective and skill set.

CLINICAL PRACTICE GUIDELINES

A number of standard clinical approaches were developed to ensure optimal delivery and standardization of 

care. A 2011 meeting to develop Combat-related Injury 

Practice Guidelines for Extremity Care identifi ed fungal 

infections as a major gap with regards to information and 

care.13 After this meeting, Landstuhl Regional Medical 

Center established a standard approach to screening for 

invasive mold infection resulting in an ability to assess 

the utility of this clinical change in standard practice.14

There were 44 patients available for analysis pre-protocol 

and 30 postprotocol. Although there was less angioinvasive cases, fewer days to invasive mold infection diagnosis, fewer days to initiating antifungal therapy, and more 

patients receiving antifungal therapy after implementation of the protocol change, there were no changes in 

hospital days, ICU duration stay, operating room visits, 

high level amputations, or deaths. As such, there is likely 

more specifi c information required to clearly identify at 

risk patients, which likely includes host parameters and 

wound parameters such as ongoing necrotic tissue.

Infectious disease, orthopaedic surgeons, and trauma 

surgeons collaborated to develop a standard clinical 

practice guideline to address risk stratifi cation of patients and management plans in and out of the combat 

zone.15 The development of the CPG demonstrates the 

value of a trauma system involved in combat casualty 

care from point of injury to return to the United States. 

During the weekly Thursday Theater Combat Casualty 

Care conference, colleagues at Walter Reed National 

Military Medical Center reported on casualties with 

progressively invasive fungal infections. This feedback 

to theater prompted a series of teleconferences moderated by the Joint Theater Trauma System Director. These 

teleconferences linked surgeons in theater, surgeons at 

Landstuhl Regional Medical Center, surgeons at Walter 

Reed National Military Medical Center, orthopaedic surgeons, and infectious disease specialists. Data from the 

Trauma Infectious Disease Outcomes Study group was 

reviewed for trends. From this collaboration, the Management of Suspected Invasive Fungal Infection CPG 

was formed. The trauma system demonstrated value in 

this circumstance as (1) a means to sense an evolving 

clinical issue, (2) enhancing communication by linking 

subject matter experts of several disciplines and several 

locations, (3) reviewing data, (4) developing a clinical 

practice guideline, and (5) providing feedback to care 

providers along the continuum during weekly Thursday Theater Combat Casualty Care conferences. Most 

of these recommendations predated any of the publications that supported the initial conclusions that led to 

the document. These guidelines allowed for defi ning the 

problem, evaluating and treating the patient, and establishing a built in performance improvement monitoring 

process including standard notes and care. Although 

the clinical practice guidelines were implemented, the 

drastic changes in injury rates prevented any adequate 

powered analysis of the effect of the clinical practice 

guideline implementation to be undertaken.

Other research endeavors undertaken after recognizing 

the challenges was determining the ideal therapy for injuries, including agents such as Dakins solution or novel 

therapies such as tea tree oil.16,17 Although therapy recommendations for modifying Dakins solution to lower 

concentration were recommended in the guidelines, 

outcomes studies with adequate power were not possible. These studies should be conducted to validate that 

clinical changes affect outcomes similar to the lack of 

outcome changes associated with changing the diagnostic approach. It is important to notice that these studies 

were developed and carried out in military treatment facilities (MTFs) and not within the Medical Research and 

Material Command (MRMC) research programs. This 

refl ects the ability of astute clinicians to recognize the 

problem and link to an answer. Overall, better collaboration with research commands is a priority as some research programs were reluctant to shift away from standard research focus areas.

WAY FORWARD

In order to continue to make advances for the next war, 

key issues within Doctrine, Organization, Training, Materiel, Leadership and education, Personnel, Facilities 

Policy (DOTMLPF-P) must occur to advance clinical 

care:

1. Maintaining the DoDTR with an ID Module is required as the ID module took 8 years from the 

onset of the war to become fully running in 2009, 

and a number of years after that for data analysis 

and publication of fi ndings. This program needs 

to be written into Doctrine with clearly defi ned 

Organizational responsibility to monitor, assess, 

develop, deliver and then collect data based upon 

any changes to validate improvement. These validated improvements then are further codifi ed into 

the appropriate section of DOTMLPF-P.

CHANGES IN EQUIPMENT AND TECHNIQUES/TACTICS/PROCEDURES

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April – September 2016 27

THE ARMY MEDICAL DEPARTMENT JOURNAL

2. Vital to decreasing traumatic injuries and infections is avoidance of the injury in the fi rst place. 

Key equipment is vital to this change and continue assessments of lessons learned through autopsy analysis of equipment and the DoDTR are required to transition to equipment studies, whether 

it be a tourniquet, eye covering, uniform, or vehicle. Once the equipment is placed into a system to 

fund, then training is required with incorporation 

across the Army as a whole, meaning not only the 

medical community.

3. Experts in the full spectrum of care from point 

of injury to rehabilitative specialty care are vital. 

The recognition of invasive fungal infection complication was detected in level V care facilities by 

clinically experienced subspecialists. However, it 

is incumbent that a pathway for communication 

throughout the organization be established as 

these lessons were not known or even managed 

in the dedicated research lanes such as MRMC. 

This requires better leadership links among casualty care across the full spectrum of operations, 

research, and clinical communities. General offi -

cer level responsibility for combat-casualty care 

within the AMEDD or at a joint assignment that 

links FORSCOM to MEDCOM and within MEDCOM MRMC to MTFs should be considered.

4. Establish the Joint Trauma System as the lead 

agency for trauma in the Department of Defense 

with authority to establish and assure best-practice trauma care guidelines to the Director of Defense Health Agency, the 3 services, and the combatant commanders.18

REFERENCES

1. Blyth DM, Yun HC, Tribble DR, Murray CK. 

Lessons of war: combat-related injury infections 

during the Vietnam War and Operation Iraqi and 

Enduring Freedom. J Trauma Acute Care Surg.

2015;79:S227-S235.

2. Kotwal RS, Howard JT, Oman JE, et al. The effect 

of a golden hour policy on the morbidity and mortality of combat casualties. JAMA Surg. 2015;DOI: 

10.1001/jamasurg.2015.3014.

3. Tribble DR, Conger NG, Fraser S, et al. Infectionassociated clinical outcomes in hospitalized medical evacuees following traumatic injury- Trauma 

Infectious Disease Outcome Study (TIDOS). J 

Trauma Acute Care Surg. 2011;71:S33-S42.

4. Sharma DM, Webster CE, Kirkman-Brown J, Mossadegh, Whitbread T, on behalf of the Genitourinary Working Group (Trauma). J Royal Army Medical Corps. 2013;159Suppl:i1-i3.

5. Ficke JR, Eastridge BJ, Butler FK, et al. Dismounted complex blast injury report of the army dismounted complex blast injury task force. J Trauma 

Acute Care Surg. 2012;73:S520-S532. 

6. Warkentien T, Rodriguez C, Lloyd B, et al, for the 

IDCRP TIDOS group. Invasive mold infections 

following combat-related injuries. Clin Infect Dis. 

2012;55:1441-1449.

7. Tribble DR, Rodriguez CJ, Weintrob AC, Shaikh F, 

Aggarwl D, Carson ML, Murray CK, Masuoka P, 

and IDCRP TIDOS. Environmental factors related 

to fungal wound contamination following combat 

trauma in Afghanistan (2009-2011). Emerg Infect 

Dis. 2015;21:1750-1760.

8. Rodriguez CJ, Weintrob AC, Shah S, et al, and IDCRP TIDOS Group. Risk factors associated with 

invasive fungal infections in combat trauma. Surg 

Infect. 2014;15:521-526.

9. Rodriguez C, Weintrob AC, Dunne JR, et al, 

and IDCRP TIDOS Investigative Team. Clinical relevance of mold culture positivity with and 

without recurrent wound necrosis following combat-related injuries. J Trauma Acute Care Surg. 

2014;77:769-773.

10. Weintrob AC, Weisboror AB, Dunne JR, et al, 

and IDCRP TIDOS. Combat trauma-associated 

invasive fungal wound infections: epidemiology and clinical classifi cation. Epidemiol Infect. 

2015;143:214-224.

11. Warkentien TE, Shaikh F, Weintrob AC, et al, and 

IDCRP TIDOS Study Group. Impact of mucorales 

and other invasive molds on clinical outcomes of 

polymicrobial traumatic wound infections. J Clin 

Microbiol. 2015;53:2262-2270.

12. Lewandowski LR, Weintrob AC, Tribble DR, et al, 

and the IDCRP TIDOS Study Group. Early complications and outcomes in combat injury related 

invasive fungal wound infections: a case-control 

analysis. J Orthop Trauma. 2015 (Epub ahead of 

publication).

13. Murray CK, Obremskey WT, Hsu JR, et al, and the 

Prevention of Combat-related Infectious Guidelines Panel. Prevention of infections associated 

with combat-related extremity injuries. J Trauma 

Acute Care Surg. 2011;71:S235-S257.

14. Lloyd B, Weintrob AC, Rodriguez C, et al, and the 

IDCRP TIDOS Investigative Team. Effect of early 

screening for invasive fungal infections in US Service Members with explosive blast injuries. Surg 

Infect. 2014;15:619-626.

15. Treatment of suspected invasive fungal infection 

in war wounds [internet]. Joint Theater Trauma 

System Clinical Practice Guidelines. November 

2012. Available at: http://www.usaisr.amedd.army.

mil/cpgs/Invasive_Fungal_Infection_in_War_

Wounds_1_Nov_12.pdf. Accessed October 9, 2015.
28 http://www.cs.amedd.army.mil/amedd_journal.aspx

16. Homeyer DC, Sanchez CJ, Mende K, Beckius ML, 

Murray CK, Wenke JC, Akers KS. In vitro activity 

of Melaleuca alternifolia (tea tree) oil on fi lamentous fungi and toxicity to human cells. Med Mycol. 

2015;53(3):285-294.

17. Barsoumian A, Sanchez CJ, Mende K, et al. In 

vitro toxicity and activity of Dakin’s solution, 

mafenide acetate, and amphotericin B on fi lamentous fungi and human cells. J Orthop Trauma. 

2013;27(8):428-436.

18. Combat Trauma Lessons Learned from Military 

Operations 2001-2013 [internet]. Defense Health 

Board Reports. Available at: http://www.health.mil/

About-MHS/Other-MHS-Organizations/DefenseHealth-Board/Reports. Accessed March 9, 2015.

AUTHORS

COL Murray is Deputy Chief of the US Army Medical 

Corps and Medical Corps Specifi c Branch Proponent Offi cer, AMEDD Center & School, Joint Base San Antonio 

Fort Sam Houston, Texas.

COL Gross is with the Joint Trauma System, US Army 

Institute of Surgical Research, Joint Base San Antonio 

Fort Sam Houston, Texas.

Col Russell is the Defence Consultant Advisor Emergency Medicine, Royal Centre for Defence Medicine, 

Birmingham Research Park, Vincent Drive, Birmingham, 

United Kingdom.

Ms Haslett is a Casualty Analyst, Defence Science and 

Technology Laboratory, Porton Down, Wiltshire, United 

Kingdom.

CHANGES IN EQUIPMENT AND TECHNIQUES/TACTICS/PROCEDURES

THAT IMPACTED CARE AND OUTCOMES
April – September 2016 29

Tourniquets today have come far from where they were 

on September 11, 2001. When war came to the United 

States on 9-11, tourniquets were a means of last resort 

in bleeding control. Today, tourniquet use is a means of 

fi rst aid. The scientifi c evolution of tourniquets among 

the US military services since 9-11 has had one main 

fi nding: tourniquet use provides a signifi cant survival 

benefi t.1-5 However, little is known about that benefi t: 

what is its size; who receives that benefi t, and does it apply to both military and civilians? 6

 Other gaps include 

how to optimize performance of tourniquet users.3

 A reminder of our current need to know such things may aid 

ongoing efforts of key leaders to maintain a scholarly 

focus within the US Army Medical Department so that 

it does not drift. “No drift” is a mantra of stewards of 

combat casualty care research so that the military goes 

to the next war without having to relearn lessons of past 

wars, i.e., without the need to improve caregiving to 

reach levels of the last war.4

In an effort to maintain a scholarly focus on improving 

fi rst aid, the present update gives a basic understanding 

of the recent scientifi c evolution of tourniquets in the 

US military. The present review documents such lessons not only to improve doctrine and policy today, but 

also—and especially—to prevent such drift and thereby 

improve care in future wars. Furthermore, the lessons 

learned by the military may guide improvements in civilian fi rst aid.

UPDATE ON CURRENT USE OF TOURNIQUETS

IN THE US ARMY

Tourniquet use in the military services today incorporates 4 key lessons learned over the last 14 years of 

war. The fi rst lesson about tourniquet use the military 

learned in the current war was that we should not forget to focus on what we need to know; that is to say, 

what is not already in the lesson plans of medics. Although we have learned much recently, such as if surviving casualty percentages are compared between 

those with fi rst tourniquet use after shock onset and 

those who are not in shock at fi rst use, the fact remains 

that shock onset is associated with more mortality—as 

much as 80% to 92%.2 ,7 However, such a difference is 

not a treatment effect of tourniquets, it is a difference 

in shock effect.6

 Such a need to know more about fi rst 

aid is a still a well-established knowledge gap; tourniquet use provides a ready example of such gaps.5,6 Some 

such gaps are discovered by trying to answer questions 

such as, what is the effect size of tourniquet treatment?5

 Battlefield Tourniquets: Lessons Learned in

 Moving Current Care Toward Best Care in an

 Army Medical Department at War

 John F. Kragh, Jr, MD

 Michael A. Dubick, PhD

ABSTRACT

Bleeding prevention and control by tourniquet use by out-of-hospital caregivers is a major breakthrough in 

military medicine of current wars. The present review documents developments in tourniquet practices since 

2001 among the US military services for aid in improving doctrine, policy, and especially care in wars to come. 

Tourniquets are an adjunct for resuscitation in self-care and buddy aid and today are issued to all military 

servicepersons who deploy into a combat zone. In the US Army, virtually every Soldier is trained in fi rst aid 

tourniquet use; since 2009 they are instructed early and often to use them early and often. Despite substantial 

knowledge gains among the services in tourniquet use and resulting improvements in casualty survival, current 

evidence shows persistent diffi culties in achieving best care with tourniquet use for individual trauma patients. 

Nevertheless, contemporary tourniquet use incorporates key lessons learned over the last 14 years of war that 

include: (1) tourniquet use reliably stops bleeding from limb wounds and prevents mortality in prehospital 

settings; and (2) brief tourniquet use appears to be safe. These 2 lessons have become so evident that civilian 

emergency medical systems have begun using them, albeit unevenly. Collection and interpretation of data of 

casualties with tourniquet use have showed that such intervention has lifesaving benefi t through 2 mechanisms: 

control of both ongoing hemorrhage and shock severity. The next generation of interventions in bleeding control involves developing the skill sets, education, and standards of tourniquet users which may improve hemorrhage control in wars to come.
30 http://www.cs.amedd.army.mil/amedd_journal.aspx

A military survey reported in 2015 that tourniquet use 

was associated with worse shock and more transfusion 

requirements among hospital-admitted casualties, yet 

those who received tourniquets had survival rates similar to those of comparable, transfused casualties who 

did not receive tourniquets.5,6 Does effectiveness vary 

by clinical setting (use out-of-hospital vs emergency department)? Surveys of military casualties have shown 

that fi rst use of tourniquets in such settings is associated 

with improved survival if use is earlier; specifi cally, survival has been associated with prehospital application 

(89% vs 78% hospital, P<.01) and application before the 

onset of shock (96% vs 4% after).2,7 But such surveys began at the emergency department, not at the time of indication which is a better, albeit harder, way of surveying 

the need for intervention.2,6,7 Does effectiveness vary by 

condition of the casualty (degree of shock or injury severity)?5,6 An evaluation of tourniquet use for patients 

treated at forward surgical (Role 2) facilities revealed an 

association with improved survival and reduced shock 

index on arrival; a 20% reduction of mortality was associated with each increase of 0.2 unit of shock index 

(odds ratio [OR], 1.27; 95% confi dence interval [CI], 

1.12-1.42) in tourniquet use vs nonuse (OR, 1.46; 95% CI, 

1.37-1.56).8

 However, in this study the time-course of individuals casualties was not tracked for shock control 

as the data were not paired in 2 times for an individual; 

such cohort data are more like epidemiology of large 

groups rather than treatment of individual patients—the 

difference between public health of populations and 

health care of individuals.

What should fi rst aid instructors teach about how and 

when to use tourniquets, for example, at a marathon 

bombing or at a shooting in a movie theater? Such questions are basic to how and when caregiving is needed.5,6

Data gathered regarding improvised tourniquets has 

advanced rapidly since 2013, and improvised strap-andwindlass tourniquets have been shown to be more effective than those with no windlass, as a windlass allowed 

the user to gain mechanical advantage. However, improvised strap-and-windlass tourniquets fail to control 

hemorrhage often (ie, 32% of tests), even in a laboratory 

setting.9,10 In a second laboratory study of improvised 

tourniquets, the commercial Combat Application Tourniquet (CAT) was a control for the US Army improvised 

tourniquet and a bandana-windlass tourniquet; CAT 

performed fastest (P<.0001, both), but both improvised 

techniques were not statistically different from each 

other. All time-of-application results in the commercial group were less than the minimums of either improvised group.11 In a third laboratory study of improvised windlasses, effectiveness, windlass turn numbers, 

time to stop bleeding, the number of windlasses, and 

the under-tourniquet pressure were associated inversely 

with breakage.12 The windlass type was associated with 

breakage; only chopsticks were without breakage at 2 

windlasses. Of those windlass types that broke, 21% 

were chopsticks, 26% were pencils, and 53% were craft 

sticks; such data showed differential value of various 

items used together as one working windlass.12 In a 

fourth laboratory study of a standard issue military tourniquet, tourniquet effectiveness rates were uniformly 

100% irrespective of whether the windlass position was 

medial, lateral, anterior, or posterior.13 Presently, much 

other information is lacking about what fi rst aid instructors should teach about how and when to use tourniquets, 

and a focus on user development is needed if we are to 

optimize user performance.

The second lesson the military learned about tourniquet 

use was that its use provided a survival benefi t while 

safety was also provided.1,2 A tourniquet survey began 

in Baghdad was made in 3 sequential parts and observed 

casualties with tourniquet indications.14 Altogether, the 

survey included 727 patients with 1,212 tourniquets 

used on 952 limbs.2,7,10,14-17 This large survey was useful 

by dispelling theories that were wrong and confi rming 

theories that were right.2,17 The performance improvement aspect of the large survey was emphasized in the 

third time period surveyed which showed increased usage of tourniquets within the US military trauma system 

in Baghdad in 2007 (Figure 1).17 This survey over 466 

days showed that (1) the appropriate wound indication 

rose from 96% to 99%, (2) fi rst usage before shock onset 

for individual casualties rose from 96% to 99%, and (3) 

the prehospital (fi rst use before hospital) usage rose from 

84% to 97%.17 All of these changes were signifi cant. A 

newly refi ned concept of bleeding control by tourniquet 

use emerged that indicated the patient’s status regarding hemorrhagic shock at the time of fi rst tourniquet use 

was the main determinant of survival. If shock onset 

had not occurred, tourniquet use was associated with 

high survival rates as documented by both a higher 

proportion of surviving patients and a longer duration 

of patient survival.2

 Much like emergency room thoracotomy, shock onset (as indicated by loss of a palpable 

peripheral pulse) before tourniquet use was associated 

with low survival rates.2

 Furthermore, minor morbidity 

during tourniquet use was empirically confi rmed as few, 

temporary, and incomplete.15 Such a refi ned understanding led to renewed efforts to use tourniquets early and 

often, and tourniquet trends showed good results such 

as improving survival (decreasing case fatality rates of 

all-causes) despite increasing injury severity.5,6,8,15,17

The third lesson about tourniquet use that the military 

learned in the current war was that the users’ concepts 

CHANGES IN EQUIPMENT AND TECHNIQUES/TACTICS/PROCEDURES

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April – September 2016 31

THE ARMY MEDICAL DEPARTMENT JOURNAL

of tourniquets changed. Early in the war, a tourniquet 

was a device, a materiel item issued within an individual’s fi rst aid kit. Since tourniquets were devices made 

of materials familiar to Soldiers like nylon webbing and 

a metal rod, early in the war Soldiers innately thought 

of them as a mechanical means of compressing limbs 

and underlying blood fl ow to control bleeding from 

wounds. Such mechanistic thinking was easy to teach 

and learn, as illustrated in Figure 2, and there was little action needed to develop user training (eg, learning 

curves, skill decay measurement, or differentiating user 

skillsets by experience level). Situational concerns were 

more apparent at the beginning of the war. For example, 

strategies concerning tourniquet use might change in an 

environment-dependent manner: Care Under Fire (tourniquets could be tried fi rst) versus Tactical Field Care 

(tourniquets were to be tried last). Tourniquets applied 

in the fi eld were often found later to be relatively loose 

by physicians, and the looseness problem was thought 

to be caused by the tourniquet user applying them too 

loose. However, the problem was eventually understood 

and explained better through research from Iowa.19,20

Diffi culty in achieving arterial compression was explained by civilian researchers who showed that persons 

with tourniquets applied changed over time during tourniquet use; the individual’s limb changed.19,20 A person 

who self-applied their tourniquet to their arm, for example, soon relaxed their arm muscles which altered the 

Figure 1. Improvement in use of tourniquets by time period 

in a Baghdad combat support hospital during 2006-2007. 

The time span is separated into 3 distinct, sequential periods: 1-Precondition; 2-Preparation; 3-Execution of the Surge. 

Data source: Kragh et al.17 Count

Time Period

2.0

3.5

2.5

1.5

0.5

3.0

4.0

1.0

0.0

1 2 3

Tourniquets/day

Limbs with tourniquets/day

Casualties with tourniquets/day

Figure 2. Learning curve for a user of a fi rst aid tourniquet (on a manikin). For this subject, the data indicates that the user 

learned to achieve better bleeding control by becoming faster. The variance tended to decrease, but the maximum variance in 

use-to-use was in use number 68, surprisingly late and after almost half of the experience. This chart was generated for this 

article using data from Davinson et al.18

0 40 60 80 100 120 140 20

20

0

40

60

80

100

120

140

Use Number

Time to Stop Bleeding (seconds)

y=62.31x-0.228

 R2=0.3556

 Time

 Power (Time)
32 http://www.cs.amedd.army.mil/amedd_journal.aspx

tourniquet effectiveness from arterial to venous control 

within minutes.19,20 Further research showed that there 

was variance in applied pressures under tourniquets 

even of the same model applied by the same person.19,20

More research showed that compression of the limb 

changed the underlying limb itself by extruding blood 

from all vessels and lymph from the lymphatic system.19-21 Such fl uid extrusion altered effectiveness of the 

tourniquet as its pressure applied to the skin dropped 

within minutes, which in turn allowed arterial fl ow to 

recur while venous fl ow remained blocked; a bad situation—a venous tourniquet. Moreover, the blood and 

lymph responses differed over time; the blood effects 

were faster and the lymph effect was slower.19-21 From 

such science, refi nements were subsequently made to 

caregiving guidelines to underscore the importance and 

to increase the frequency of users reassessing casualties with tourniquets.22 Given such subtle science, a refi ned understanding occurred to change the tourniquet 

concept from mechanistic to probabilistic. That is to say, 

tourniquet use was not a simple, mechanistic, yes-no intervention. Rather, each use had a probability of success 

that could be partial, change over time, or be altered by 

the specifi c situation. The mechanistic concept changed 

to a tetrad concept wherein the 4 interrelated parts of 

the tetrad are a user, a patient, an intervention, and a 

situation, as shown by Figure 3. This new concept is 

dynamic as all elements can change, and such change 

means that empiric results are probabilistic and not 

purely mechanistic; empiric outcomes of tourniquet use 

indicate that the probability of better outcomes is associated with improvements in care delivered. In another 

example of improved caregiving from the large, 3-part 

Baghdad survey, the rate of limbs with only one tourniquet used increased from 66% to 74% to 89%; while 

tourniquet models themselves did not change, and while 

injury numbers and severity increased, improvements 

appeared to come from users as use, experience, and 

effi ciency improved.10 Such new knowledge involving 

best tourniquet practices is continuously and incrementally added. Given battlefi eld experience over a decade, 

knowledge of wear and tear of tourniquets has increased 

in part through scientifi c inquiries.23-26 For one example, 

in a study of heat exposure, prolonged dry heat was not 

associated with change in tourniquet effectiveness rates 

(P=.32); when adjusted for the effects of user and model, the comparisons of time to effectiveness and total 

blood loss were statistically signifi cant (P<.0001), but 

the comparison of pressure was not (P=.0613) as user 

effects appeared to affect outcomes while exposure did 

not.18 The military changed its concept of the tourniquet 

to become a concept of dynamic interrelation among 

users-situations-patients-tourniquets.

What the military teaches Soldiers in tourniquet application is substantial in breadth and occasionally in 

depth. In an example of breadth, all new Army recruits 

learn tourniquets upon initial entry training, receive 

further detailed training during subsequent advanced 

individual training in a combat lifesaver course, and get 

predeployment refresher training. (and data to support 

why when available) gaps that remain. Another example 

of breadth: medics receive training in greater specifi city for their more advanced skillset than other Soldiers, 

and they often are taught about troubleshooting diffi cult 

cases and converting tourniquets to pressure dressings. 

Specifi c information about what Soldiers are taught 

about tourniquet application is included in the Combat 

Lifesaver course.27 Specifi c information that military 

medics are taught about tourniquet application is presented in Figure 4.

Intervention Patient

Caregiver

Situation

Figure 3. A new schema of tourniquet science developed recently includes the dynamic interaction among components of 

a tetrad that include a patient, a caregiver, an intervention, and 

a situation, represented schematically as a tetrad. Each item in 

the tetrad can change. The caregiver may also be the patient in 

self-applied tourniquet use. Each item is interrelated with the 

others. For example, if a casualty (patient) is wounded in a limb 

in combat, a Soldier (caregiver) provides fi rst aid with tourniquet 

use (intervention) during Care Under Fire (situation). Soon after 

the end of active combat, the situation changes to Tactical Field 

Care (a new situation) wherein Soldiers are taught to convert 

the tourniquet use to use of a pressure dressing. The schema 

alters the perception of the challenges for looking just at the 

device (the tourniquet) to invite looking at each item and each 

interrelation. The tourniquet is a tool, and it its use is the intervention; deemphasizing other items makes the problem simpler 

than reality, an over-simplifi cation which generates unintended 

problems such as under-emphasizing patient reassessment. 

The patient changes because of the intervention. The patient 

also changes over time and requires rechecking if the limb under the tourniquet gets smaller from applied pressure.

CHANGES IN EQUIPMENT AND TECHNIQUES/TACTICS/PROCEDURES

THAT IMPACTED CARE AND OUTCOMES
April – September 2016 33

THE ARMY MEDICAL DEPARTMENT JOURNAL

The fourth lesson the military learned about tourniquet 

use in the current war was that today, in developing the 

way ahead for military medicine, civilians may also 

improve their use of tourniquets. Such implementation 

gaps also apply to civilian fi rst aid situations wherein 

similar risks occur (eg, external hemorrhage associated 

with penetrating trauma).4,22 Such application led civilian medical authorities to reverse course and recommend tourniquet use.28-30 An increasing number of clinical studies from civilian settings have been published 

since 2014 indicating that several of the military fi ndings about tourniquet use are supported by comparable 

civilian fi ndings such as lifesaving benefi t and safety of 

use.31-37 However, civilian adoption of tourniquet use is 

currently uneven.38 Defense research in out-of-hospital 

use of tourniquets paved the way for civilian use, and 

both military and civilian investigators are considering 

extension of other interventions to control hemorrhage, 

such as prehospital use of pelvic binders. On the road 

from current care toward best care, the lessons that the 

military learned about what is necessary for a large 

trauma system to work well is also improving civilian 

caregiving.

CURRENT STATUS OF TOURNIQUET USE

IN ALL US MILITARY SERVICES IN 2015

As a result of one of the longest wars in US history in 

which combat still continues, the military is keenly 

aware of existing knowledge gaps. Another important 

gap relevant to the military services presently being addressed by ongoing research is junctional hemorrhage, 

ie, bleeding from wounds at the torso-appendage junctions where limb tourniquets cannot fi t.39-42 Presently, 

there are few clinical trials, junctional case reports, or 

case series of hemostatic dressing use, but there are 

some laboratory and preclinical studies.43-47 Additionally, the hydraulic or mechanical effects of wound packing 

in bleeding control are becoming better understood.48,49

The principles of controlling hemorrhage early by mechanical methods appear to apply to all portions of the 

extremities: the limbs where limb tourniquets fi t and 

junctional parts of extremities where junctional tourniquets fi t. Furthermore, tourniquets have been proposed 

in prolonged fi eld care for mitigation of reperfusion after limb crush syndrome, although limited experience is 

available for decision-making.10,50-52 The topics of junctional bleeding and crush syndrome require further research to provide evidence of effectiveness and safety.

Tourniquets in 2015 are issued to all military service 

personnel who deploy into a combat zone. In the US 

Army, virtually every Soldier is trained in tourniquet 

use—early and often. For example, since 2009 all recruits (new enlisted Soldiers) irrespective of specialty 

(1) To maintain fi repower supremacy, only extremity bleeding 

should warrant any intervention during Care Under Fire.

(a) Casualty blood sweeps are not recommended 

during this phase of care. The assessment takes a 

considerable amount of time to complete and leaves 

the care giver vulnerable to the enemy.

(b) Visual inspection is not necessary until both the care 

provider and the casualty are behind cover.

(c) When approaching the casualty, if blood is apparent 

on the shirt sleeve or the pant leg, that is all the proof 

necessary to warrant application of a tourniquet.

(2) When the tactical situation dictates, no intervention 

should be employed unless and until:

(a) The unit can afford to have the provider drop out of 

the fi re fi ght long enough to intervene.

(b) Efforts to direct the self-aid/buddy aid have failed.

(3) Tourniquets are the only recommended treatment for 

extremity hemorrhage during this phase. (Remember: 30

seconds on the “X” is 25 seconds too many. Even if it take 

only a few seconds to apply a tourniquet, that is enough 

time for the enemy to take aim and fi re on both you and 

the casualty.)

(a) Intervention should take place under suitable cover or 

concealment. This may require that you initially move 

the casualty before placing a tourniquet.

(b) The intervention should be tactically feasible as to 

avoid a circumstance where the care giver is an 

additional casualty.

(c) For obvious life threatening extremity hemorrhage.

1) You may not really know if hemorrhage is life 

threatening until Tactical Field Care phase when 

the wound can be exposed and evaluated.

2) The suspicion of life threatening hemorrhage is 

the only required criteria during Care under Fire.

(4) All tourniquets placed during Care Under Fire should be 

Hasty Tourniquets.

(a) Place over the clothing.

(b) As high on the extremity as possible (without 

capturing the shoulder or the buttock).

1) Rarely are combat wounds clean incisions 

perpendicular through the extremity.

2) This placement is preferred during Care under 

Fire because of the inability to properly expose 

and assess the wound.

3) High application ensures the tourniquet is placed 

completely above any possible damaged/injured 

tissue.

(c) As tightly as possible (due to the limitations during 

this phase of care, pulse checks are not required).

(5) Hasty Tourniquets should be converted to an alternative 

form of hemorrhage control prior to evacuation, typically 

during the Tactical Field Care Phase.

Figure 4. Excerpt from student handout for US Army Medic: 

Tourniquet Use During Care under Fire.
34 http://www.cs.amedd.army.mil/amedd_journal.aspx

have been trained in tourniquet use in Basic Combat 

Training (also known as Initial Entry Training) that 

includes a Combat Lifesaver Course in fi rst aid skills. 

Soon thereafter in Advanced Individual Training, more 

tourniquet training is again provided. Further training 

may be given when Soldiers are assigned to their units, 

and refresher training occurs before deployments. Such 

a systematic and long-standing program has changed 

the US Army’s fi rst-aid culture. Before 2009, tourniquets were new, a new way of doing things; after 2009, 

they were old. Prior to 2009, such a culture change was 

made in miniature by individual units like the 75th 

Ranger Regiment and Special Operations Forces. After 

their success, leaders of other organizations used it as 

a template for expanding this critical knowledge to all 

Soldiers.2

NEXT GENERATION OF BLEEDING CONTROL

INTERVENTIONS

 Current evidence shows that user development is important to best performance in bleeding control interventions.18,53,54 Moreover, an emphasis on the quality of 

training should be recognized, understood by key leaders, planned for in military units, and made a priority. 

Among all areas associated with improvement of tourniquet use (ie, Doctrine, Organization, Training, Material, Leadership, Personnel, Facilities [DOTMLPF]), 

training is today the quintessential item to be addressed 

for tourniquet use: optimal user development is the most 

likely of all factors to improve outcomes. The path from 

current care toward best care is challenging; may we 

journey with knowledge, hope, and determination.

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7. Kragh JF Jr, Littrel ML, Jones JA, Walters TJ, Baer 

DG, Wade CE, Holcomb JB. Battle casualty survival with emergency tourniquet use to stop limb 

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8. Le TD, Kragh JF Jr, Gross KR, et al. Impact of 

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Florida; August 17-20, 2015.

9. Altamirano MP, Kragh JF Jr, Aden JK III, Dubick 

MA. Role of the windlass in improvised tourniquet 

use on a manikin hemorrhage model. J Spec Oper 

Med. 2015;15(2):42-46.

10. 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-S49; discussion S-50.

11. Lyles WE III, Kragh JF Jr, Aden JK, Dubick 

MA. Testing tourniquet use in a manikin model: 

two improvised techniques. J Spec Oper Med. 

2015;15(4):21-26.

12. Kragh JF Jr, Wallum TE, Aden JK III, Dubick MA, 

Baer DG. Which improvised tourniquet windlasses 

work well and which ones won’t?. Wilderness Environ Med. 2015;26(3):401-405.

13. K ragh JF Jr, Wallum TE, Aden JK III, Dubick MA, 

Baer DG. Emergency tourniquet effectiveness in 

four positions on the proximal thigh. J Spec Oper 

Med. 2014;14(1):26-29.

14. K ragh JF Jr, Walters TJ, Westmoreland T, et al. 

Tragedy into drama: an American history of tourniquet use in the current war. J Spec Oper Med. 

2013;13(3):5-25.

15. K ragh JF Jr, O’Neill ML, Walters TJ, et al. Minor 

morbidity with emergency tourniquet use to stop 

bleeding in severe limb trauma: research, history, 

and reconciling advocates and abolitionists. Mil 

Med. 2011;176:817-823.

16. K ragh JF, O’Neill ML, Beebe DF, Fox CJ, Beekley A, Cain J, Parsons D, Mabry R, Blackbourne 

L. Survey of the indications for use of emergency 

tourniquets. J Spec Oper Med. 2011;11(1):30-38.

17. K ragh JF, Beebe DF, O’Neill ML, Beekley AC, 

Dubick MA, Baer DG, Blackbourne LH. Performance improvement in emergency tourniquet 

use during the Baghdad surge. Am J Emerg Med. 

2013;31:873-875.

18. D avinson J, Kragh JF Jr, Aden J III, DeLorenzo R, 

Dubick M. Laboratory testing of emergency tourniquets exposed to prolonged heat. J Spec Oper 

Med. 2015;15(1):34-38.

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THAT IMPACTED CARE AND OUTCOMES
April – September 2016 35

THE ARMY MEDICAL DEPARTMENT JOURNAL

19. Slaven SE, Wall PL, Rinker JH, Halub ME, Hopkins JW, Sahr SM, Buising CM. Initial tourniquet 

pressure does not affect tourniquet arterial occlusion pressure. J Spec Oper Med. 2015;15(1):39-49.

20. S laven SE, Gildemaster Y, Rometti M, Hopkins 

JW, Sahr SM, Buising CM, Wall PL. Pattern of 

pressure loss under strap tourniquets immediately 

following application. Poster presentation at: 2014 

Special Operations Medical Association Scientifi c 

Assembly; December 8-11, 2014; Tampa, Florida.

21. W all PL, Coughlin O, Rometti M, et al. Tourniquet pressures: strap width and tensioning system 

widths. J Spec Oper Med. 2014;14(1):19-29.

22. S hackelford SA, Butler FK Jr, Kragh JF Jr, Stevens 

RA, Kotwal RS, Mabry RL, Bailey JA. Optimizing the use of limb tourniquets in tactical combat 

casualty care: TCCC Guidelines Change 14-02. J 

Spec Oper Med. 2015;15(1):17-31.

23. K ragh JF Jr. Use of tourniquets and their effects on 

limb function in the modern combat environment. 

Foot Ankle Clin. 2010;15:23-40.

24. C hilders R, Tolentino JC, Leasiolagi J, Wiley N, 

Liebhardt D, Barbabella S, Kragh JF Jr. Tourniquets exposed to the Afghanistan combat environment have decreased effi cacy and increased breakage compared to unexposed tourniquets. Mil Med. 

2011;176:1400-1403.

25. K ragh JF Jr, O’Neill ML, Walters TJ, et al. The 

military emergency tourniquet program’s lessons learned with devices and designs. M il Med. 

2011;176:1144-1152.

26. K ragh JF Jr, Burrows S, Wasner C, et al. Analysis 

of recovered tourniquets from casualties of Operation Enduring Freedom and Operation New Dawn. 

Mil Med. 2013;178:806-810.

27. US Army. Combat Lifesaver Course: Student Self 

Study Manual, Subcourse ISo871. ed C. Fort Sam 

Houston, TX: US Army Medical Department Center & School; September 2013.

28. F ox N, Rajani RR, Bokhari F, et al. Evaluation and 

management of penetrating lower extremity arterial trauma: an Eastern Association for the Surgery 

of Trauma practice management guideline. J Trauma Acute Care Surg. 2012;73(5 suppl 4):S315-S320.

29. B ulger EM, Snyder D, Schoelles K, et al. An evidence-based prehospital guideline for external 

hemorrhage control: American College of Surgeons Committee on Trauma. Prehosp Emerg 

Care. 2014;18:163-173.

30. J acobs LM Jr. Joint Committee to Create a National 

Policy to Enhance Survivability from Mass Casualty Shooting Events: Hartford Consensus II. J Am 

Coll Surg. 2014;218:476-478.

31. P assos E, Dingley B, Smith A, et al. Tourniquet use 

for peripheral vascular injuries in the civilian setting. Injury. 2014;45:573-577.

32. Z ietlow JM, Zietlow SP, Morris DS, Berns KS, Jenkins DH. Prehospital use of hemostatic bandages 

and tourniquets: translation from military experience to implementation in civilian trauma care. J 

Spec Oper Med. 2015;15(2):48-53.

33. O de G, Studnek J, Seymour R, Bosse MJ, Hsu JR. 

Emergency tourniquets for civilians: can military 

lessons in extremity hemorrhage be translated?. J 

Trauma Acute Care Surg. 2015;79:586-591.

34. S chroll R, Smith A, McSwain NE Jr, et al. A multiinstitutional analysis of prehospital tourniquet use. 

J Trauma Acute Care Surg. 2015;79:10-14.

35. I naba K, Siboni S, Resnick S, et al. Tourniquet 

use for civilian extremity trauma. J Trauma Acute 

Care Surg. 2015;79:232-237.

36. M eizoso JP, Valle EJ, Allen CJ, et al. Decreased 

mortality after prehospital interventions in severely injured trauma patients. J Trauma Acute Care 

Surg. 2015;79:227-231.

37. A lpert EA, Lipsky AM, Elie ND, Jaffe E. The contribution of on-call, volunteer fi rst responders to 

mass-casualty terrorist attacks in Israel. Am J Disaster Med. 2014;10:35-39.

38. H aider AH, Piper LC, Zogg CK, et al. Military-tocivilian translation of battlefi eld innovations in operative trauma care. Surgery. 2015;158:1686-1695.

39. T ovmassian RV, Kragh JF Jr, Dubick MA, Baer 

DG, Blackbourne LH. Combat ready clamp medic 

technique. J Spec Oper Med. 2012;12(4):72-78.

40. K ragh JF Jr, Murphy C, Dubick MA, Baer DG, 

Johnson J, Blackbourne LH. New tourniquet device concepts for battlefi eld hemorrhage control. 

US Army Med Dep J. April-June 2011:38-48.

41. K ragh JF Jr, Mann-Salinas EA, Kotwal RS, et 

al. Laboratory assessment of out-of-hospital interventions to control junctional bleeding from 

the groin in a manikin model. Am J Emerg Med. 

2013;31(8):1276-1278.

42. K ragh JF Jr, Parsons DL, Kotwal RS, et al. Testing of junctional tourniquets by military medics to 

control simulated groin hemorrhage. J Spec Oper 

Med. 2014;14(3):58-63.

43. M ann-Salinas EA, Kragh JF Jr, Dubick MA, Baer 

DG, Blackbourne LH. Assessment of users to control simulated junctional hemorrhage with the combat ready clamp (CRoCTM). Int J Burns Trauma. 

2013;3(1):49-54.

44. K ragh JF Jr, Dubick M, Aden J III, McKeague A, 

Rasmussen T, Baer D, Blackbourne L. U.S. military 

experience with junctional wounds in war from 

2001 to 2010. J Spec Oper Med. 2013;13(4):76-84.
36 http://www.cs.amedd.army.mil/amedd_journal.aspx

45. K ragh JF Jr, Johnson JE, Henkel CK, Dubick MA. 

Technique of axillary use of a combat ready clamp 

to stop junctional bleeding. Am J Emerg Med. 

2013;31(8):1274-1276.

46. J ohnson JE, Sims RK, Hamilton DJ, Kragh J. 

Safety and effectiveness evidence of SAM? Junctional tourniquet to control inguinal hemorrhage 

in a perfused cadaver model. J Spec Oper Med. 

2014;14(2):21-25.

47. K lotz JK, Leo M, Anderson B, et al. First case 

report of SAM? Junctional tourniquet use in Afghanistan to control inguinal hemorrhage on the 

battlefi eld. J Spec Oper Med. 2014;14(2):1-5.

48. K ragh JF Jr, Steinbaugh J, Parsons DL, Mabry RL, 

Kheirabadi BS, Dubick MA. A manikin model 

for study of wound packing interventions to control out-of-hospital hemorrhage. Am J Emerg Med. 

2014;32(9):1130-1131.

49. K ragh JF, Aden JK, Steinbaugh J, Bullard M, 

Dubick MA. Gauze vs XSTAT in wound packing for hemorrhage control. Am J Emerg Med. 

2015;33(7):974-976.

50. P orter K, Greaves I. Crush injury and crush syndrome: a consensus statement: Keith Porter and 

Ian Greaves review the fi ndings of a consensus 

meeting on crush injury and crush syndrome held 

in Birmingham on May 31 2001 and co-ordinated 

by the faculty of pre-hospital care of the Royal 

College of Surgeons of Edinburgh. Emerg Nurse. 

2003;11:26-30.

51. S chwartz DS, Weisner Z, Badar J. Immediate lower 

extremity tourniquet application to delay onset of 

reperfusion injury after prolonged crush injury. 

Prehosp Emerg Care. 2015;19(4):544-547.

52. K ragh JF Jr, Baer DG, Walters TJ. Extended (16-

hour) tourniquet application after combat wounds: 

a case report and review of the current literature. J 

Orthop Trauma. 2007;21:274-278.

53. C lumpner B, Polston R, Kragh JF Jr, et al. Single 

versus double routing of the band in the combat application tourniquet. J Spec Oper Med. 

2013;13(1):34-41.

54. P olston RW, Clumpner BR, Kragh JF Jr, Jones 

JA, Dubick MA, Baer DG. No slackers in tourniquet use to stop bleeding. J Spec Oper Med. 

2013;13(2):12-19.

AUTHORS

Dr Kragh and Dr Dubick are with Damage Control Resuscitation, US Army Institute of Surgical Research, 

Joint Base San Antonio Fort Sam Houston, Texas.

CHANGES IN EQUIPMENT AND TECHNIQUES/TACTICS/PROCEDURES

THAT IMPACTED CARE AND OUTCOMES

Combat Application Tourniquet

Special Operations Forces

Tactical Tourniquet
April – September 2016 37

Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF) in Afghanistan have proven to be 

crucibles of learning for combat casualty care. This 

brief review will summarize recent advances in our understanding of the epidemiology of combat trauma, the 

importance of shock and coagulopathy, the concept of 

damage control resuscitation, the limits of hypotensive 

resuscitation, the central role of blood products in hemostatic resuscitation, and the role of systemic hemostatic 

adjuncts.

EPIDEMIOLOGY

Recent evidence from the Iraq and Afghanistan confl icts indicates that 90% of combat deaths occur in the 

prehospital phase of care, and that 25% of these deaths 

are potentially preventable with existing medical technology. Signifi cantly, 90% of medically preventable 

deaths occur due to hemorrhage.1,2 Although major advances in hemorrhage control have been made with the 

reintroduction of tourniquets, noncompressible hemorrhage remains a major challenge. There were 4,596 

combat deaths in a 10-year period from 2001 to 2011, of 

which about 1,000 were due primarily to hemorrhage 

and were potentially preventable. Overall, when patients 

requiring massive transfusion during their initial resuscitations are considered, it is apparent that about 10% of 

combat wounded are at high risk of early exsanguination and require aggressive, early hemorrhage control 

and blood-based resuscitation beginning in the prehospital phase of care to reduce morbidity and mortality.3

SHOCK AND COAGULOPATHY

On average, OIF/OEF patients requiring blood transfusion presented to combat support hospitals with an 

International Normalized Ratio (INR) of 1.5; nonsurvivors averaged an INR of 2.2 on admission.4

 Oxygen 

debt due to ischemia during hemorrhagic shock causes 

organ dysfunction and ultimately death if not reversed 

with timely resuscitation. Shock causes endothelial dysfunction and this has been associated with the development of a primary or endogenous coagulopathy which 

includes activation of fi brinolysis. In addition, mechanisms such as autohemodilution from mobilization of 

interstitial fl uid, catecholamine release, proinfl ammatory signaling, and other poorly understood pathways, 

such as the unique contribution of traumatic brain injury 

(TBI), contribute to this endogenous coagulopathy.5,6

Primary coagulopathy occurs early after injury and is 

more severe with increased amount of tissue injury. In 

early primary coagulopathy, thrombin generation is 

typically elevated compared to uninjured subjects; the 

degree to which thrombin is a limiting factor in hemostatic function for these patients is thus debatable.7

 Over 

time, with resuscitation and ongoing bleeding, a secondary or exogenous coagulopathy occurs as a result of further dilutional and consumptive etiologies. Thrombin 

Lessons Learned for the Resuscitation

 of Traumatic Hemorrhagic Shock

 Philip C. Spinella, MD

 COL Jeremy G. Perkins, MC, USA

 LTC Andrew P. Cap, MC, USA

ABSTRACT

The lessons learned regarding the resuscitation of traumatic hemorrhagic shock are numerous and come from 

a better understanding of the epidemiology, pathophysiology, and experience in this population over 10-plus 

years of combat operations. We have now come to better understand that the greatest benefi t in survival can 

come from improved treatment of hemorrhage in the prehospital phase of care. We have learned that there is an 

endogenous coagulopathy that occurs with severe traumatic injury secondary to oxygen debt and that classic 

resuscitation strategies for severe bleeding based on crystalloid or colloid solutions exacerbate coagulopathy 

and shock for those with life-threatening hemorrhage. We have relearned that a whole blood-based resuscitation strategy, or one that at least recapitulates the functionality of whole blood, may reduce death from hemorrhage and reduce the risks of excessive crystalloid administration which include acute lung injury, abdominal 

compartment syndrome, cerebral edema, and anasarca. Appreciation of the importance of shock and coagulopathy management underlies the emphasis on early hemostatic resuscitation. Most importantly, we have learned 

that there is still much more to understand regarding the epidemiology, pathophysiology, and the resuscitation 

strategies required to improve outcomes for casualties with hemorrhagic shock.
38 http://www.cs.amedd.army.mil/amedd_journal.aspx

generation can be reduced as a result of this secondary 

or exogenous coagulopathy.8

 Since it is diffi cult to rapidly identify primary or secondary coagulopathy with 

current clinically available measures of hemostasis, 

goal-directed therapy is diffi cult to achieve. In principle, 

the rapid treatment and prevention of both shock and 

coagulopathy with early surgical control of bleeding 

and hemostatic resuscitation with blood products that 

deliver the functionality of whole blood provides the 

best currently available resuscitation strategy to reduce 

death from hemorrhage. This approach, which includes 

the use of resuscitation to blood pressure targets slightly 

below normal levels (80 mm to 90 mm Hg systolic) in 

order to minimize pressure-induced rebleeding—socalled “hypotensive resuscitation,” and the avoidance 

of crystalloids and colloids has been termed damage 

control resuscitation (DCR).9

 It should be noted that our 

understanding of shock and coagulopathy continues to 

evolve and that optimizing patient monitoring in order 

to adjust ratios of blood products and hemostatic adjuncts, as well as their delivery over time, remains an 

area of active research.

HYPOTENSIVE RESUSCITATION

The duration of time from injury to surgical control of 

bleeding is an important factor in the appropriateness 

of applying hypotensive resuscitation strategies. Hypotensive resuscitation, particularly the avoidance of largevolume crystalloid use, has been shown to reduce death 

from hemorrhage for patients with penetrating injuries 

and with evacuation times under 30 minutes.10 It is unknown if this practice is advantageous for patients with 

evacuation times of over 60 minutes. The risk of shock 

and coagulopathy increases with a low cardiac output 

state, especially as the oxygen content of blood drops 

over time with bleeding and the loss of red blood cells 

(RBCs). As a result, caution is necessary when contemplating the appropriateness of hypotensive resuscitation in prolonged fi eld care situations, as well as in 

particular clinical scenarios such as TBI. The validity 

of the current hypotensive resuscitation thresholds has 

also been questioned in the light of transfusion-based 

strategies that deliver improved hemostasis compared to 

crystalloid. In short, it is not clear whether hypotensive 

resuscitation offers any advantages if hemostatic blood 

products are available in the prehospital environment. 

Conversely, there is fairly strong evidence supporting 

avoidance of excess crystalloid through permissive hypotension when blood is not available and bleeding is 

not controlled.11

HEMOSTATIC RESUSCITATION

A whole blood-based resuscitation with either whole 

blood or whole blood approximated with a 1:1:1 unit ratio 

of RBCs, plasma, and platelet units provides a balanced 

treatment of both the shock and coagulopathy that together increase the risk of hemorrhagic death. It should 

be noted for planning purposes that the platelet units in 

“1:1:1” refer to platelet concentrate volumes from wholeblood derived platelets (imagine literally reconstituting 

a unit of whole blood that has been separated by centrifugation into red cells, plasma and platelets – with 

anticoagulant and red cell additive solution added, thus 

diluting fi nal product concentrations by about a third). 

Given that modern component use in the US military 

is exclusively based on platelets collected by apheresis, 

it might be more accurate to use the ratio of 6:6:1 (red 

cell units: plasma units: one apheresis platlet unit), but 

for the purposes of consistency with the literature, we 

retain the “1:1:1” terminology. In austere environments, 

whole blood is available through walking blood banks, 

where donors are typically screened with abbreviated 

questionnaires, and in some situations pre-screened for 

transfusion transmitted diseases prior to deployment. In 

this situation, the whole blood is collected and transfused within a very short period of time; therefore, it is 

termed warm fresh whole blood (WFWB). The rationale for the use of WFWB for resuscitation compared to 

the use of blood components is that it is more concentrated than one unit each of RBCs, plasma, and platelets, 

which contain three times the volume of anticoagulants 

and additive solutions and is more convenient in the prehospital setting. Warm fresh whole blood also has not 

developed the various storage lesions that reduce the effi cacy and safety of stored blood components such as 

the well-known loss of labile coagulation factors and 

thrombin generation potential in thawed plasma, the 

loss of aggregation response in standard room temperature-stored platelets and the increased risk of bacterial 

growth in room temperature-stored platelets.12,14

In an effort to increase the availability of whole blood, 

the effects of storage at 4°C have been re-evaluated. 

Whole blood has been found to retain most of its hemostatic function for up to 14 days.15 A potential advantage of this product compared to the approximation of 

whole blood with blood products in a 1:1:1 unit ratio is 

that the platelets in whole blood will be stored at 4°C 

and the platelet units used in approximated whole blood 

will be stored at 22°C. Previously published trial data in 

adults and children have indicated that platelet-containing products stored at 4°C are more hemostatically active compared to when they are stored at 22°C.14 Whole 

blood at 4°C would still be more concentrated than blood 

components in a 1:1:1 unit ratio, reducing the risk of dilutional coagulopathy.16,19 To further increase the availability of whole blood, particularly in emergency situations when cross-matching is diffi cult or impossible, it 

CHANGES IN EQUIPMENT AND TECHNIQUES/TACTICS/PROCEDURES

THAT IMPACTED CARE AND OUTCOMES
April – September 2016 39

THE ARMY MEDICAL DEPARTMENT JOURNAL

is possible to use low anti-A, anti-B titer Group O whole 

blood as a universal donor product.20

The widespread adoption of hemostatic resuscitation 

is evident in the fi ndings of a recent survey of 132 US 

trauma centers, which reported that for adult trauma 

management, 88% of sites target high (1:2 or greater) 

plasma-to-RBC ratios. Likewise, 79% of sites target 

high platelet-to-RBC ratios. To facilitate the early transfusion of plasma, 69% of sites indicated that they have 

plasma immediately available for massive transfusion 

protocols (MTP) activation. A similar survey of MTP 

policies in children’s hospitals revealed that 78% of centers targeted a high plasma:RBC ratio in children with 

life-threatening bleeding, whereas 65% of centers targeted a high ratio of platelets:RBCs. These survey data 

indicate that most adult and pediatric medical centers 

are attempting to deliver the functionality of whole 

blood with components.21

A meta-analysis of retrospective studies that evaluated 

the effect of high plasma ratios on outcomes in trauma 

patients indicated a survival benefi t with early and increased plasma administration.22 However, as these 

types of studies are prone to several types of biases, 

including survivor bias and confounding by indication, 

the fi nal word on the effect of high ratios on survival is 

unknown. There has been less data published regarding high platelet to RBC ratios, although most reports 

indicate improved survival, similar to the plasma:RBC 

ratio data.23,24

Recently, the Pragmatic Randomized Optimal Platelet 

and Plasma Ratios (PROPPR) trial, a large prospective 

randomized trial compared a 1:1:1 ratio versus 1:1:2 in 

which the latter group received fewer platelets that were 

given later in resuscitation.25 The study, while limited by 

the similarity of the treatment arms and which was determined by fading equipoise in the fi eld, provided higher quality evidence than retrospective studies to support 

equal ratio component use and was able to show a difference in secondary outcomes of reduced death from 

hemorrhage at 24 hours and reduced time to hemostasis. 

Primary outcomes of mortality at 24 hours and 30 days 

were not different between the 2 study groups.

Further improvements in hemostasis and overall resuscitation outcomes may be possible since platelets stored 

at 22°C, the current standard of care, are less hemostatically functional than platelets stored at 4°C, and are also 

less safe due to the risk of bacterial contamination.26,27

Efforts are underway to make platelet units at 4°C available for patients with traumatic bleeding. The FDA 

and AABB in 2015 have permitted the use of apheresis 

platelet units stored unagitated between 1°C and 6°C at 

the Mayo Clinic Trauma Center in Rochester, MN, for 

bleeding patients. In addition, clinical trials comparing 

platelets stored at 4°C vs 22°C are underway in Bergen, Norway, in patients undergoing complex cardiac 

surgery and experiencing severe bleeding. Cold-stored 

platelets have been designated an Army Strategic Technology Objective and could soon be deployed in support 

of combat operations.

In addition to improvements in platelets, the development of dried plasma products, such as freeze-dried 

(FDP) or spray-dried plasmas may provide important 

opportunities for improving prehospital resuscitation, particularly in austere settings where other blood 

products may be unavailable or inconvenient to collect 

on-site. While FDP was fi rst fi elded by US Forces in 

World War II and used as a bridge to whole blood transfusion, reintroduction of such a product to the clinical 

armamentarium requires FDA approval. The US Army 

Medical Research and Materiel Command, in partnership with the US Navy’s Offi ce of Naval Research and 

the Department of Homeland Security, has spearheaded 

efforts to obtain dried plasma products for trauma resuscitation. Development is advancing and clinical trials 

are currently underway. For the time being, US Army 

Special Operations Command troops have access to 

FDP manufactured by the French Army under an Expanded Access Investigational New Drug (IND) protocol. Execution of this protocol in the deployed setting 

is extremely cumbersome due to data management and 

reporting requirements and use has been extremely limited. The true utility of FDP and similar products will 

only be assessed once they are available off the IND 

protocol.

SYSTEMIC HEMOSTATIC ADJUNCTS

The logistical challenges of resuscitating trauma patients in remote settings often limit administration of 

blood products and have prompted the evaluation of hemostatic adjuncts. These medications may be particularly useful if intravascular volume is supported with 

crystalloid fl uids, which cause dilutional coagulopathy.

Hemorrhage may be better controlled by improving 

clot stability. The CRASH-2 trial demonstrated that 

tranexamic acid (TXA), a lysine analog inhibitor of 

fi brinolysis, administered upon admission to hospital 

within 3 hours of injury, reduced all-cause mortality 

and death due to hemorrhage in trauma patients without causing an increase in venous thromboembolism.28

The MATTERS and MATTERS-2 studies retrospectively evaluated TXA use in OEF combat casualties 

and found evidence of improved survival, although a 
40 http://www.cs.amedd.army.mil/amedd_journal.aspx

higher rate of venous thromboembolism was identifi ed 

in unadjusted data in patients receiving TXA.29,30 Since 

earlier administration of TXA resulted in improved outcomes in CRASH-2, use in the prehospital setting is a 

reasonable extrapolation of the available clinical data.31

Furthermore, TXA has been shown to be stable across 

a wide range of environmental conditions that account 

for even very severe military operational settings.32,33

Tranexamic acid has thus been endorsed by the Blood 

Advisory Group of the North Atlantic Treaty Organization34 as part of a protocol for the resuscitation of patients in hemorrhagic shock.35

Another approach to hemorrhage control is centered 

on providing substrate for clot formation. Fibrinogen 

conversion to fi brin is the fi nal common pathway of the 

coagulation system. Fibrinogen is rapidly depleted in 

the setting of massive trauma and hemorrhage due to 

hemodilution, consumption, and fi brino(geno)lysis.36-38

Fibrinogen concentrates appear to be relatively safe and 

can rapidly restore hemostatic function in some circumstances, thus reducing bleeding and transfusion requirements.39,40 In a large observational study of severely injured patients, the early use of fi brinogen concentrate 

was associated with signifi cantly lower 6-h mortality 

and an increased time to death, but also a greater incidence of multiple organ failure.41 Randomized trials, 

particularly in the prehospital setting, are urgently needed to guide appropriate use of fi brinogen concentrates in 

trauma resuscitation.

Finally, increased thrombin generation has been suggested as an approach to improve hemorrhage control. 

Recombinant human factor VIIa has been evaluated in 

trauma and in other bleeding patient populations. While 

rFVIIa unquestionably increases thrombin generation 

and may reduce bleeding and RBC transfusion requirements to some extent, no mortality benefi t has been 

demonstrated with use of this drug, and it associated 

with increased thromboembolic risk in certain patient 

populations (eg, elderly, active atherosclerotic vascular 

disease).42,43 Its use in trauma cannot be recommended 

outside of a clinical trial setting. Prothrombin complex 

concentrates (PCCs) have become the new standard of 

care in managing hemorrhage in patients receiving warfarin anticoagulation.44 Use of PCCs in a broader population of trauma patients has not been evaluated in randomized controlled trials and may excessively increase 

thromboembolic risks due to the long half-lives of 

procoagulant factors in these products.45 Animal studies suggest that PCCs may reduce blood loss but may 

also increase the risk of developing DIC and death.46,47

Randomized controlled trials are required before the use 

of PCCs can be recommended for the broader trauma 

population.

CONCLUSION

The central tenets of damage control resuscitation, aggressive hemorrhage control, early treatment of shock 

and coagulopathy with blood products that deliver the 

functionality of whole blood, early administration of 

TXA,48 and avoidance of crystalloid and colloid infusions have become the standard of care in combat casualty management. Further improvements in outcomes 

are possible with incorporation of products like coldstored platelets, freeze- or spray-dried plasma, and fi -

brinogen concentrate, but the most important gains will 

be made through translation of DCR principles to the 

prehospital setting with therapies like point-of-injury 

whole blood transfusion. Additional gains will be possible through acquisition of a deeper understanding of 

the physiology of shock and coagulopathy which will 

permit enhanced patient selection and goal-directed 

therapy. Overall, reducing the time between an injury 

and hemostatic resuscitation remains the great challenge of battlefi eld medicine.

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20. Strandenes G, Berseus O, Cap AP, et al. Low titer group O whole blood in emergency situations. 

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21. Camazine MN, Hemmila MR, Leonard JC, Jacobs 

RA, Horst JA, Kozar RA, et al. Massive transfusion policies at trauma centers participating in the 

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22. Murad MH, Stubbs JR, Gandhi MJ, et al. The effect of plasma transfusion on morbidity and mortality: a systematic review and meta-analysis. Transfusion. 2010;50(6):1370-1383.

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24. Perkins JG, Cap AP, Spinella PC, et al. An evaluation of the impact of apheresis platelets used in 

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S84-S85.

25. Holcomb JB, Tilley BC, Baraniuk S, et al. Transfusion of plasma, platelets, and red blood cells in a 

1:1:1 vs a 1:1:2 ratio and mortality in patients with 

severe trauma: the PROPPR randomized clinical 

trial. JAMA. 2015;313(5):471-482.

26. Reddoch KM, Pidcoke HF, Montgomery RK, et al. 

Hemostatic function of apheresis platelets stored at 

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27. Nair PM, Pidcoke HF, Cap AP, Ramasubramanian 

AK. Effect of cold storage on shear-induced platelet aggregation and clot strength. J Trauma Acute 

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28. de Guzman R, Polykratis IA, Sondeen JL, Darlington DN, Cap AP, Dubick MA. Stability of 

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29. Morrison JJ, Dubose JJ, Rasmussen TE, Midwinter MJ. Military Application of Tranexamic Acid 

in Trauma Emergency Resuscitation (MATTERs) 

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30. Morrison JJ, Ross JD, Dubose JJ, Jansen JO, Midwinter MJ, Rasmussen TE. Association of cryoprecipitate and tranexamic acid with improved survival 

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32. Floccard B, Rugeri L, Faure A, et al. Early coagulopathy in trauma patients: an on-scene and hospital admission study. Injury. 2012;43(1):26-32.

33. Darlington DN, Craig T, Gonzales MD, Schwacha 

MG, Cap AP, Dubick MA. Acute coagulopathy of 

trauma in the rat. Shock. 2013;39(5):440-446.

34. Heier HE, Badloe J, Bohonek M, et al. Use of 

tranexamic acid in bleeding combat casualties. Mil 

Med. 2015;180(8):844-846.

35. Schlimp CJ, Voelckel W, Inaba K, Maegele M, 

Ponschab M, Schochl H. Estimation of plasma fi -

brinogen levels based on hemoglobin, base excess 

and Injury Severity Score upon emergency room 

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36. Schochl H, Schlimp CJ. Trauma bleeding management: the concept of goal-directed primary care. 

Anesth Analg. 2014;119(5):1064-1073.

37. Rahe-Meyer N, Solomon C, Hanke A, et al. Effects of fi brinogen concentrate as fi rst-line therapy 

during major aortic replacement surgery: a randomized, placebo-controlled trial. Anesthesiology. 

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38. Wafaisade A, Lefering R, Maegele M, et al. Administration of fi brinogen concentrate in exsanguinating trauma patients is associated with improved 

survival at 6 hours but not at discharge. J Trauma 

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39. Lin Y, Stanworth S, Birchall J, Doree C, Hyde C. Recombinant factor VIIa for the prevention and treatment of bleeding in patients without haemophilia. 

Cochrane Database Syst Rev. 2011;16(2):CD005011.

40. Yank V, Tuohy CV, Logan AC, et al. Systematic 

review: benefi ts and harms of in-hospital use of 

recombinant factor VIIa for off-label indications. 

Ann Intern Med. 2011;154(8):529-540.

41. Patriquin C, Crowther M. Treatment of warfarinassociated coagulopathy with vitamin K. Expert 

Rev Hematol. 2011;4(6):657-665; quiz 666-667.

42. Honickel M, Rieg A, Rossaint R, et al. Prothrombin complex concentrate reduces blood loss and 

enhances thrombin generation in a pig model 

with blunt liver injury under severe hypothermia. 

Thromb Haemost. 2011;106(4):724-733.

43. Grottke O, Braunschweig T, Spronk HM, et al. Increasing concentrations of prothrombin complex 

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44. Kragh JF Jr, Walters TJ, Baer DG, et al. Practical use of emergency tourniquets to stop bleeding 

in major limb trauma. J Trauma. 2008;64(suppl 

2):S38-S49; discussion S50.

45. Schochl H, Voelckel W, Maegele M, Kirchmair L, 

Schlimp CJ. Endogenous thrombin potential following hemostatic therapy with 4-factor prothrombin 

complex concentrate: a 7-day observational study 

of trauma patients. Crit Care. 2014;18(4):R147.

46. Dickey NW. Combat Ready Clamp Addition to the 

Tactical Combat Casualty Care Guidelines 2011-07. 

Falls Church, VA: Defense Health Board: September 23, 2011. Available at: http://www.health.mil/

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2016.

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48. Ausset S, Glassberg E, Nadler R, et al. Tranexamic 

acid as part of remote damage-control resuscitation in the prehospital setting: A critical appraisal 

of the medical literature and available alternatives. J Trauma Acute Care Surg. 2015;78(6 suppl 

1):S70-S75.

AUTHORS

Dr Spinella is Director, Pediatric Critical Care Translational Research Program and Associate Professor, 

Department of Pediatrics Washington University in St 

Louis School of Medicine, St Louis, Missouri.

COL Perkins is Chief, Hematology-Oncology Service at 

the Murtha Cancer Center, Walter Reed National Medical Center, Bethesda, Maryland, where he is also Chair 

of the Institutional Review Board. He is the Hematology/

Oncology Consultant to The Army Surgeon General and 

Associate Professor of Medicine at the Uniformed Services University of the Health Sciences.

LTC Cap is Chief, Coagulation & Blood Research, US 

Army Institute of Surgical Research, Joint Base San Antonio-Ft Sam Houston, Texas.

CHANGES IN EQUIPMENT AND TECHNIQUES/TACTICS/PROCEDURES

THAT IMPACTED CARE AND OUTCOMES
April – September 2016 43

The overall mission of the Armed Services Blood Program (ASBP) is to provide quality blood products and 

services for all worldwide customers in peace and war. 

The standard blood distribution system used by ASBP 

provides a solid framework for the 3 service blood programs to move blood and blood products to designated, 

in-theater medical care activities, treatment facilities, 

and first responders as illustrated in Figure 1.1,2 While 

the distribution system works very well when established in support of theater operations, stringent storage and shipping requirements, inventory management, 

and limited potency periods have a continuous influence 

on the ability to provide this required support.2

 Despite 

these constraints and in response to documented lessons 

learned, several improvements on the blood program 

have already been made. Supporting units have become 

more flexible, inventory management has been enhanced, Hemacool refrigerators and freezers (AcuTemp 

Thermal Systems, Moraine, Ohio) are found at Role 2, 

apheresis platelets are collected in theater, aggressive 

collections in the United States have resulted in fresher 

blood on the shelf in theater, and protocols have been established to standardize transfusion ratios and the emergency collection of whole blood. These efforts alone 

have contributed immensely to the noted improved survival rates on the battlefield. However, the work and advances must continue in order to sustain current practice 

with our conventional forces as well as continue to focus 

on extending the required support beyond the current 

distribution system to those closest to the point of injury—the first responders. The determination of blood 

types through use of Eldon ABO cards and development 

of the Micronics ABORh card (both approved by the 

Food and Drug Administration (FDA) for educational 

use) has allowed the capability to determine blood types 

of donors and closed the gap of depending on dog tags 

with a known error rate of 3%-5%.3

 A capability gap 

in ensuring safe blood products led to the whole blood 

pathogen reduction device (PRD) development effort. 

As of 2011, PRD is an official Program of Record for 

the Department of Defense (DoD) which will enhance 

blood safety efforts in support of future capabilities.

Freeze Dried Plasma

While the theater blood management of FDA licensed 

products has been successful, frozen plasma products 

are only available doctrinally at Role 2 and Role 3 MTFs 

due to logistical constraints. With the long logistical tail, 

breakage rates of fresh frozen plasma (FFP) sometimes 

exceeded 25%, rendering a precious product useless. 

Research and development efforts have been vital to the 

future success in combating these constraints and supporting damage control resuscitation (DCR). The development of a dried plasma product would eliminate the 

need for shipping at ultra-low temperatures and unacceptable loss of product due to breakage. Freeze dried 

Theater Blood Support in the

 Prehospital Setting

LTC Audra L. Taylor, MS, USA

LTC Jason B. Corley, MS, USA

Abstract

The Army Blood Program (ABP) is charged with the responsibility of supporting the Warfighter on the battlefield, in 

addition to meeting garrison hospital blood requirements on a daily basis. Blood support concepts developed in response to Operation Iraqi Freedom/Operation Enduring Freedom combat operations are the cornerstone to maintaining current capabilities and shaping future endeavors.. The ABP is actively engaged with research, advanced development of blood products and medical technology to improve blood safety and efficacy for both our conventional and 

operational forces. The feasibility of frozen/deglycerolized red blood cell use in theater has been demonstrated. The 

use of Blood Group A plasma in the place of Blood Group AB plasma has been successful. Placement of cryoprecipitate at Role 2 medical facilities and the placement of blood products on MEDEVAC (Vampire Program missions) 

have proven invaluable in moving transfusion therapy closer to the point of Injury. The improved patient outcomes 

from earlier transfusion of blood products has driven the requirement for far-forward blood support. Now (more than 

ever), there are products and processes in place to meet the requirements for blood use in the prehospital setting.

Personnel Changes that Impacted Care and Outcomes
44 http://www.cs.amedd.army.mil/amedd_journal.aspx

a. Information paper. Subj: Relationship Between the French Military Blood Program and the US Army; November 4, 2013. Internal military 

document not readily accessible by the general public.

plasma (FDP) provides tremendous advantages in battlefield DCR beginning at the POI. Once reconstituted, 

this product combats the coagulopathy of trauma and 

restores circulatory volume.

Freeze dried plasma will be used to treat life threatening, severe hemorrhage arising from injuries sustained 

during contingency operations in remote, austere environments where access to standard blood products 

and immediate damage control surgery is not readily 

available. The US military has identified an operational 

need for an FDP product on the battlefield as noted in 

an approved Capabilities Development Document. Department of Defense requirements have been identified 

and collaboration efforts are underway with private industry to develop a product approved by the FDA. In 

the meantime, the US Army Special Operations Command has an immediate need and, under an Expanded 

Access Investigational New Drug (IND) protocol, has 

been granted permission from the FDA to procure this 

type of product from the French Military Blood Bank 

(also referred to as Centre de Transfusion Sanguine des 

Armees (CTSA)).a

 The CTSA provides a very limited 

amount of FDP due to a limited donor pool in France. 

A novel collaborative approach among the Special Operations Command, the Army Medical Research and 

Material Command, the Army Blood Program (ABP), 

and CTSA has been in the works to amend the Expanded Access IND to provide apheresis plasma collected 

by the ABP as the source material for CTSA to manufacture FDP. To date, 5 ABP Blood Donor Centers are 

collecting plasma for this program. Freeze dried plasma 

will provide blood support at the POI, will reduce current wastage of FFP due to breakage and outdating, does 

not require cold chain management, and can be used by 

both conventional and special operations forces.

Blood Group O Low Titer Whole Blood

The requirement for the collection and transfusion benefits of whole blood in emergency conditions is well 

known and documented. The evolution of this practice 

has resulted in the development of a Clinical Practice 

Guideline for Fresh Whole Blood Collections4

 by the 

US Central Command and identified the need for a standardized training platform. Current practice includes 

the collection and transfusion of type specific whole 

Figure 1. US Military Blood Distribution and Reporting System. Adapted from Technical Manual TM 8-227-12: Joint Blood Program 

Handbook.

1

Glossary

ASBBC - Armed Services Blood Bank Center AJBPO - Area Joint Blood Program Officer

BDC - Blood Donor Center BTS - Blood Transshipment System

ASBPO - Armed Services Blood Program Office BPD - Blood Product Depot

ASWBPL - Armed Services Whole Blood Processing Laboratory BSU- Blood Supply Unit

JBPO - Joint Blood Program Officer FSSG - Force Service Support Group

personnel Changes that Impacted Care and Outcomes
April – September 2016 45

The Army Medical Department Journal

blood, however, the ability to obtain the blood type of 

a potential donor can be problematic. The 75th Ranger 

Regiment Trauma Management Team (Tactical) at Fort 

Benning, Georgia, has partnered with the ABP to deploy 

with identified low titer Group O donors. This program 

has evolved throughout FY15 and includes completion 

of the DD Form 572 (Donor Screening Record) and interview process for volunteer low titer Group O Soldiers 

assigned to the regiment, the collection of tubes for the 

required viral marker and titer testing, establishment of 

the unit in the Theater Medical Data Store (TMDS) for 

theater access by the Regimental Surgeon of results, and 

appropriate donor follow-up and counseling in the event 

of a positive test. This collaborative effort was initiated 

in conjunction with the Sullivan Memorial Blood Donor 

Center at Fort Benning. The Fort Benning donor collection team has worked to streamline the process and 

develop a standard operating procedure to be used in 

support of Rangers assigned to Joint Base Lewis McChord and Hunter Army Air Field.b

 This program also 

involves the Department of Pathology at each location 

in order to process, ship, and enter the requested titer 

results in the Composite Health Care System. Group O 

Rangers with a titer of 1:256 or greater are considered 

“high titer” and will not be used as donors. Group O 

Rangers with a titer less than 1:256 are considered “low 

titer” and may be used as donors. Titer results of the first 

3 collections are shown in Figure 2.c

 Donor interview 

is documented on the DD Form 572: Blood Donation 

Record. Transfusion transmitted disease testing, and 

titer testing results are entered into TMDS by the donor center staff. This step closes the loop and provides 

visibility to the Regimental Surgeon or designee. As this 

program continues to mature, approximately one half of 

the potential blood Group O donors should be identified 

as low titer.

The Vampire Program

The current Vampire Program, established in 2012, allows the transfusion of blood products on MEDEVAC 

rotary wing aircraft during combat operations by flight 

medics, registered nurses, physicians, and physician assistants for patients with appropriate indications.d

 These 

MEDEVAC medical personnel are authorized to administer blood products in accordance with the approved 

protocol in theater. Identified personnel must complete 

the initial training program, which provides familiarization with the indications for transfusion, recognition, 

and treatment of reactions and administrative requirements. Refamiliarization is required every 3 months.

Standard blood products used in this program include 

Group O packed red blood cells (pRBCs) and group A 

thawed FFP. Both products require refrigeration and 

are issued and transported in the approved “golden 

hour box.” Upon issue, MEDEVAC medical personnel assume all responsibility for the products and the 

appropriate documentation. Transfusions must be ordered by a physician and appropriately documented in 

the patient’s chart. Transfusion activities must be documented in TMDS and documentation placed in the patient’s medical record. The medical detachment blood 

support (MDBS) commander also maintains oversight 

of this program and reports any problems to the joint 

blood program officer on a weekly basis. Approximately 

320 units of pRBCs and 20 units of thawed FFP have 

been transfused as of this writing. There will be a continued need for this program as one avenue to provide 

life-saving measures in the prehospital setting. As new 

FDA approved blood products are made available within 

industry, a future product menu for the Vampire Program may include FDP, cold stored apheresis platelets, 

and cold stored whole blood.

Cold Products: Whole Blood, Apheresis Platelets

and Liquid Plasma

Whole blood is a product that is not routinely stored in 

theater beyond 24 hours. The current initiative to identify Group O low titer donors with the 75th Ranger Regiment will lay the foundation for the collection and storage of Group O low titer units to support our conventional forces. The current Clinical Practice Guidelines 

Sources are internal military documents not readily accessible by the general public:

b. Draft Standard Operating Procedure: Ranger Titer Testing. Fort Benning, GA: Sullivan Memorial Blood Center; August 2015.

c. Ranger Titer Results and Graph. Fort Benning, GA: Sullivan Memorial Blood Center; July 2015.

d. Malsby RF, Shackelford S, Coots NV. SOP for Management and Administration of Blood Products on Army MEDEVAC Missions, 

version 3. US Forces – Afghanistan; August 2012.

Figure 2. Titer results from the first 3 collections at Fort Benning. BD indicates blood draw. Data provided by S. Rudesheim, 

Sullivan Memorial Blood Center, Fort Benning, GA.

*Positive results for the FDA mandated Transfusion Transmission Disease Testing.

41 41

80

19

71

22

36

9 5 1 0 0

20

0

40

60

80

100

BD 1 BD 2 BD 3

No. Drawn No. Positive* No. High Titer No. Low Titer
46 http://www.cs.amedd.army.mil/amedd_journal.aspx

allow for the transfusion of type-specific whole blood. A 

shift to the collection, testing, storage, and distribution 

of Group O whole blood in theater at Role 2 facilities will 

have a huge effect on current inventory constraints and 

allow the ASBP to provide the right product to the right 

patient.4

 Fresh whole blood contains platelets and may 

also be incorporated into the current Vampire Program.

Apheresis platelets are collected in theater due to their 

5-day expiration, Upon collection, platelet products are 

maintained at room temperature in an incubator (with 

gentle agitation) while a deployed Role 3 medical facility 

provides microbiology support for bacterial contamination testing. Despite being collected in theater, the availability of this product is still limited to Role 3 medical facilities and the MDBS.2

 As operations move to more austere environments and efforts continue to provide blood 

support in these locations, storing this resource-intensive 

product in a refrigerator will assist in this endeavor. The 

blood industry has noted that specific platelet products 

may target specific clinical indications. Room temperature platelets are important for those patients with chronic conditions, while cold stored platelets are good for 

trauma patients. In addition to the significant decrease 

in required resources to maintain this blood component, 

the Army Institute of Surgical Research has conducted 

a tremendous amount of research with this product and 

noted that cold stored platelets provide better hemostatic function.5

 The FDA has recently approved the use of 

3-day, apheresis cold stored platelets. This is definitely 

a significant step in the right direction as research continues to focus on extending the expiration date of cold 

stored platelets with the addition of platelet additive solutions. The ability to store cold apheresis platelets that are 

fully tested and FDA licensed would create the capability 

to ship this product to the theater of operations through 

the Armed Services Blood Distribution System.

The ASBP has received a few requests for liquid plasma 

to support exercises and operations. This whole blood 

derived product has a 26-day expiration date, is ideal 

for those Role 2 medical facilities without thawing 

capability, and is stored in a refrigerator at the same 

temperature as pRBCs and thawed FFP. Since this 

product is not widely used, the procurement of it by 

ASBP requires a significant amount of lead time. The 

3 service blood programs are currently working on licensure packets to routinely provide this product. Once 

licensed with ASBP, this product will be more readily 

available with less lead time required for collection and 

distribution

Predeployment Training

Training plays a vital role in the successful execution of 

donor collections and transfusion activities. In the absence of a formalized training platform, laboratory officers and the service blood programs will work together 

to facilitate training for laboratory personnel preparing 

to deploy. This process will work for active duty personnel, but does not capture reserve personnel and, as a 

result, a significant amount of training is completed in 

theater. The ABP submitted a request in 2011 to develop 

a formalized training course to provide training on the 

collection of whole blood, collection of apheresis platelets, and deglycerolization of frozen blood. Future plans 

include the availability of the course in the Army Training Requirements and Resource System and attendance 

by personnel from the Army, Navy, and Air Force.

Conclusion

As the ABP continues to be engaged with research and 

advanced development, partnerships with industry and 

other alliances are vital to the continued success and efforts to provide blood support in the prehospital setting. 

Freeze dried plasma is available to US Army Special 

Forces, the 75th Ranger Regiment can now deploy with 

known Blood Group O low titer donors, and the FDA 

has approved cold stored apheresis platelets. This collaborative type of effort must continue as we work diligently to decrease cold chain management requirements, 

provide pathogen reduction technology, and move blood 

products further forward on the battlefield into the prehospital setting. Lessons learned by the ABP will have 

significant effect on future doctrine and training.

personnel Changes that Impacted Care and Outcomes
April – September 2016 47

The Army Medical Department Journal

References

1. Technical Manual TM 8-227-12: Joint Blood Program Handbook. Falls Church, VA: Armed Services Blood Program Office; December 1, 2011. Available at: http://armypubs.army.mil/med/DR_pubs/

dr_a/pdf/tm8_227_12.pdf. Accessed February 12, 

2016.

2. Joint Publication 4-02: Health Service Support. 

Washington, DC: Office of the Chairman, Joint 

Chiefs of Staff; July 2012. Available at: http://www.

dtic.mil/doctrine/new_pubs/jp4_02.pdf. Accessed 

February 11, 2016.

3. Rentas FJ, Clark PA. Blood type discrepancies on military identification cards and tags: a 

readiness concern in the US Army. Mil Med. 

1999;164(11):785-787.

4. Joint Trauma System Clinical Practice Guideline: Fresh Whole Blood Transfusion. Fort Sam 

Houston, Texas: US Army Institute of Surgical 

Research; 2012. Available at: http://www.usaisr.

amedd.army.mil/cpgs/Fresh_Whole_Blood_Trans

fusion_24_Oct_12.pdf. Accessed February 26, 

2016.

5. Cap AP. Platelet storage: a license to chill!. Transfusion. 2016;56(1):13-17.

Authors

LTC Taylor is the Army Blood Program Director, US 

Army Medical Command, Joint Base San Antonio-Fort 

Sam Houston, Texas.

LTC Corley is the Army Blood Program Deputy Director, US Army Medical Command, Joint Base San Antonio-Fort Sam Houston, Texas.
48 http://www.cs.amedd.army.mil/amedd_journal.aspx

Shaping the Flight Paramedic Program

 LTC Neil B. Davids, MC, USA

BACKGROUND

After September 11, 2001, the Army transitioned from 

a peacetime Army to one in continuous wartime operations. As our confl icts have continued, there have been 

many signifi cant changes and improvements in combat 

casualty care from the point of injury to rehabilitation 

of Wounded Warriors to the fi rst ever critical care transport by Army combat medics. This manuscript attempts 

to capture the observations and decisions that led to the 

creation of the Army’s Critical Care Flight Paramedic 

(CCFP) Program and how it is being shaped to meet future requirements.

At the initiation of the confl icts after 9/11, Army Aeromedical Evacuation units were staffed with one medical 

provider for en route care. This provider (fl ight medic) 

was trained with the certifi cation level of an Emergency Medical Technician (EMT) Basic. Additionally, the 

fl ight medic received training at the Army School of 

Aviation Medicine on aircrew functions and Advanced 

Cardiac Life Support, Pediatric Education for Prehospital Professionals, and International Trauma Life Support. 

This training was 6 weeks long and upon completion the 

medic became a fl ight medic with the skill qualifi cation 

identifi er of “F.”

The experiences, advice, and decisions that led to the 

creation of the program occurred over the course of several years. Initially, anecdotal evidence and after action 

reviews from providers in Iraq and Afghanistan noted 

that during the course of medical evacuation, postoperative patients transferred from a forward surgical 

team were critically ill and required signifi cant infl ight 

medical management, such as ventilator management, 

provision of multiple medications, and blood administration. The fl ight medic was not trained to deliver this 

level of care and although many would learn these skills 

on the job, it was not a stated requirement to do so. Because medics were not trained in en route care, another 

medical provider, ie, physician, physician assistant, or 

critical care nurse, would have to accompany the patient 

during medical evacuation. This caused several potential problems: new providers were typically not familiar 

with aircrew procedures which could potentially cause 

issues while in fl ight, were unfamiliar with providing 

care in a nonhospital environment, and most importantly, were lost to the units for a lengthy period of time 

before they could make their way back.

Medical leaders identifi ed these gaps through various 

channels and initiated efforts to change the paradigm. 

One of the Army solutions was the creation of the En 

route Critical Care Nurse (ECCN) program, which 

trained critical care nurses to accompany critically ill patients during intrafacility transport. The ECCNs were initially assigned to one of the medical treatment facilities, 

however, as time progressed, the ECCNs were eventually attached to the air ambulance units where they could 

develop relationships with the fl ight medics and aircrews, 

to great success. This change in assignment contributed 

greatly to the success of the program because the ECCN 

became more familiar with the providers and other unit 

personnel and could assist with point of injury responses.

Although the employment of the ECCN markedly enhanced the level of en route care, a larger issue remained. 

Because ECCNs were never assigned to air ambulance 

units, there was no guarantee that ECCNs would be 

ABSTRACT

Over the past 14 years of confl ict, the Department of Defense medical community has made signifi cant strides 

in patient care. As the confl icts developed, many sources identifi ed a critical gap in en route care, specifi cally 

the need for critical care trained personnel for point of injury and intrahospital transfers, as well as improved 

outcomes for patients who received care from critical care trained providers. As stopgap measures were implemented, the US Army instituted the Critical Care Flight Paramedic Program in order to meet this need of 

life saving critical care transport. Execution of both an institutional training model as well as a home station 

training option allows for increased numbers of personnel trained, as well as fl exibility for National Guard and 

Army Reserve units to keep personnel in their area. The Critical Care Flight Paramedic Program’s educational 

outcomes have been exceptional, with National Registry Paramedic pass rates well above the national average. 

As the program develops, recertifi cation and sustainment of knowledge and skills will be challenges, and novel 

approaches and fl exibility will become critical for continued success.
April – September 2016 49

THE ARMY MEDICAL DEPARTMENT JOURNAL

trained and available for deployment in future confl icts. 

The logical solution to this problem was to ensure that 

the provider assigned to the unit, the fl ight medic, has 

the necessary skills and knowledge to perform the essential en route care, which is standard practice within 

the US civilian air evacuation community.

Anecdotal evidence from after action reports assessing en route care continued to mount over the course of 

combat operations. However, there was little evidence 

to support that staffi ng evacuation platforms with medical providers who had a level training above that of a 

fl ight medic resulted in improved patient outcomes.1 

This changed in 2011, when the Journal of Trauma published the paper “Impact of critical care trained fl ight 

paramedics on casualty survival during helicopter evacuation in the current war in Afghanistan”.2

 The study 

showed patient survival at 48 hours was 66% higher 

when patients were transported by critical care trained 

crews as compared to patients transported by crews who 

were not trained in critical care. This strongly supported 

the recommendation that critical care training should 

become the standard for MEDEVAC medical providers.

In 2010, the Army Medical Department Center and 

School (AMEDDC&S) and the US Army School of Aviation Medicine convened a Flight Medic Critical Task 

selection board which determined that the requisite skill 

level for a fl ight medic should be a paramedic with certain additional skills. Shortly thereafter, The Army Surgeon General, based upon a recommendation from the 

AMEDDC&S Commanding General, decided that the 

fl ight medic would be trained as a paramedic with critical care training. The Army codifi ed this series of decisions in ALARACT* 061/2012 which provided notifi cation of the requirement and intent to train 68W Flight 

Medics to NREMT-P† standards with critical care training. Additionally, the FY13 National Defense Authorization Act 3

 (NDAA) directed the Secretary of the Army 

to implement a requirement to have “all in-fl ight medical care providers to be critical care fl ight paramedic 

(CCFP) certifi ed within the next 3 years.”

ESTABLISHMENT

The development of the institutional model started with 

the creation of the Critical Care Flight Paramedic Program at AMEDDC&S in late 2011. The fi rst pilot course 

for National Registry Paramedic (NRP) certifi cation 

was conducted at the University of Texas Health Science 

Center San Antonio (UTHSCSA) from February to August of 2012. This course follows the National Registry 

of Emergency Medical Technician guidelines for the 

medical curriculum taught by the faculty at UTHSCSA. The fi rst time pass rate of the NRP exam was 92% 

(historical average across the United States in 2012 was 

74%), and since inception has always remained above 

90%. Upon completion of the NRP course, students 

transitioned directly to the critical care course, with the 

didactic portion conducted at UTHSCSA, and critical 

care clinical rotations at the San Antonio Military Medical Center. Each student completed 240 hours of clinical rotations which signifi cantly exceeded the number 

of hours in civilian critical care courses for paramedics. 

The justifi cation for this number of hours was that in the 

civilian air ambulance community, a paramedic generally will not be considered for hire with less than 3-5 

years of experience as a ground paramedic. Given the 

potential for an Army Medic to not have the clinical patient experience that a full time paramedic would have, 

the increase in patient encounters during training would 

provide an equivalent experience that a civilian would 

accumulate in 3 to 5 years.

The third training course was the integration of medical 

training in the aviation environment coupled with aircraft crewmember training. Given that the initial paramedic students were already MEDEVAC crewmembers 

and therefore been to the legacy fl ight medic course 

(with the additional skill identifi er (ASI) of F3), crewmember training would not be a requirement for them. 

However, natural attrition of medics required that new 

medics, who were not trained as MEDEVAC crewmembers, must attend this training. Initially, these students 

went to the legacy fl ight medic course until a new course 

could be created for the fl ight paramedics.

HOME STATION TRAINING

As the institutional model was created, it became apparent that it would not be possible to meet the throughput 

necessary to meet the FY13 NDAA directive. Given that 

the civilian community has many facilities to provide 

the training necessary to obtain NRP certifi cation and 

critical care training, the Army created the Home Station Training option. This option, outlined in ALARACT 

028/2013 and updated in ALARACT 301/2013, allowed 

units to send Soldiers to an accredited civilian NRP 

program as well as civilian critical care programs (with 

the approval of the director of the CCFP Program). This 

provides fl exibility for units and Soldiers to obtain the 

training without having to change duty stations. This 

is extremely benefi cial to Soldiers assigned to air ambulance units that may be pending a deployment cycle. 

Additionally, this option is advantageous for National 

*All Army Activities: a message transmitted to all US Army activities 

throughout the world, providing announcements, notifi cations, 

and other information of import requiring rapid dissemination 

Army-wide.

†National Registry of Emergency Medical Technicians-Paramedic
50 http://www.cs.amedd.army.mil/amedd_journal.aspx

Guard and Reserve unit Soldiers whose civilian employment would be severely disrupted for an individual 

training event. This model may become more attractive 

in the years to come as we try to meet the goal of having 

every infl ight provider be a CCFP.

CURRENT TRAINING

The current institutional model consists of contracted 

courses from UTHSCSA. The NRP course is 6 months 

in length and culminates with the student taking the 

NRP exam. Upon passing the exam, the student transitions to the critical care course, which is 8 weeks long. 

The current contracted course differs from the pilot in 

that the clinical rotations are done with civilian facilities 

and agencies, broadening the students’ experience.

The third course required for those students who have 

not received the ASI F3 in the past is the new AMEDD 

Aviation Crewmembers Course. The purpose of this 

course is twofold: fi rst to “operationalize” the medical 

knowledge that the students have in the aircraft environment, and second, to introduce the student to the aviation environment and the crewmember skills necessary 

to become an effective crewmember on an aircraft. The 

fi rst pilot of this course was conducted in July 2015, and 

student feedback has been overwhelmingly positive.

FUTURE

As stated earlier, the initial goal of the program was to 

transition all Army fl ight medics to CCFP by FY 2017. 

For a variety of reasons (deployments, funding for pay 

and allowances for National Guard/Reserve, throughput 

capability), the likelihood of meeting this goal is low. 

However, signifi cant progress has been made, and attention is being focused at the highest levels to ensure the 

program continues to provide for training of this critical 

skill set.

As the program matures, there will likely be a transition of the contracted courses to bring the training into 

the AMEDDC&S. One advantage of this would be that 

the instructors will be primarily CCFPs with deployment experience which would bring real world experience to students. Another advantage would be the ability 

to integrate training in the aircraft cabin environment 

using the newly constructed Transport Medical Training Lab (TMTL) at AMEDDC&S. The TMTL enables 

students to integrate all the skills learned using high fi -

delity patient simulators in a realistic aircraft environment. Instructors are able to record all of the students’ 

interventions with the simulated patient ensuring a 

thorough evaluation is provided. Additionally, there is a 

forward surgical team “suite” in which the student will 

be able to hand over and receive patients from hospital 

providers, so the fi rst time they conduct such handovers 

will not be in a deployed environment. This will also 

allow other providers to rehearse and train in a more 

realistic environment while at AMEDDC&S. The San 

Antonio Military Medical Campus, as well as civilian 

hospitals and other civilian agencies, will still be part 

of the CCFP training through the use of Medical Training Agreements in order to ensure the students have a 

breadth of clinical experience prior to seeing a critically 

ill or injured patient on their own. Finally, the ability to 

integrate the other agencies at AMEDDC&S, such as 

the veterinary instructors, allow for integration of military specifi c training requirements into the program.

CHALLENGES

One of the main challenges in creating the CCFP is the 

“tail” of sustainment and recertifi cation training. Army 

Emergency Medical Service currently has an interim 

recertifi cation policy that is outlined in ALARACT 

071/2014, which meets the requirements of NREMT 

recertifi cation for NRP. Although it meets the requirements, many of the interventions and much of the 

knowledge outlined in the policy fail to address the 

needs for sustainment of the CCFP. Currently the CCFP 

Program is working on a solution through the creation 

of a training circular (TC) similar to TC8-800 for 68Ws 

(combat medics), but focused on the CCFP needs. Additionally, getting sustainment clinical training in a high 

acuity environment (ICU level care) will be necessary 

to maintain clinical acumen. This will require medical 

training agreements (MTA) between units and military 

treatment facilities (MTF) or civilian hospitals, as many 

local MTFs do not have the patient level of acuity for the 

CCFP to maintain clinical knowledge and skills. This 

will require leaders at separate posts to take the lead 

in integrating with the outside community, which is already happening at locations like Fort Hood, where the 

leadership has approved MTAs with civilian agencies, 

enabling their medics to acquire patient care experience.

As the transition to Critical Care Flight Paramedics continues to progress, other challenges will become evident. 

Given the successful history of the rapid development 

of this program, these challenges will likely become 

opportunities to improve on the program and allow for 

future success. Early identifi cation of the gaps in en 

route care, followed by parallel initiatives from multiple 

sources, have shown that developing a highly skilled en 

route care provider can be done effectively. Challenges 

in the future, primarily concerning sustainment of these 

skills, will likely be met through innovative institutional 

and organizational solutions in order to maintain the capability to take care of the most critically ill and injured 

patient.

PERSONNEL CHANGES THAT IMPACTED CARE AND OUTCOMES
April – September 2016 51

THE ARMY MEDICAL DEPARTMENT JOURNAL

REFERENCES

1. Cearnal L. Emergency physicians highlight, ‘‘Army-wide emergency medical care defi ciency’’ in training of fl ight 

medics. Ann Emerg Med. 2008;52:522-524.

2. Mabry RL, Apodaca A, Penrod J, Orman JA, Gerhardt RT, Dorlac WC. Impact of critical care-trained fl ight paramedics on casualty survival during helicopter evacuation in the current war in Afghanistan. J Trauma Acute Care 

Surg. 2012;73(2 suppl 1):S32-S37.

3. Pub L No. 112-239, National Defense Authorization Act for Fiscal Year 2013; January 2, 2013.

AUTHOR

LTC Davids is Medical Director, Critical Care Flight Paramedic Program, Center for Prehospital Medicine, AMEDD Center & School, Joint Base San Antonio-Fort Sam Houston, San Antonio, Texas.
52 http://www.cs.amedd.army.mil/amedd_journal.aspx

PROBLEM STATEMENT: IMPACT OF MUSCULOSKELTAL

INJURIES

Musculoskeletal injuries (MSI) are the primary cause 

for healthcare visits, lost duty days, decreased readiness, 

medical evacuation, and disability in the military.1-8

Musculoskeletal injuries resulted in 2.5 and 2.2 million 

healthcare visits in 2010 and 2012, respectively.2,3 Additionally, approximately 68,000 military members are 

injured on an annual basis, resulting in 25 million injury 

related lost duty days and healthcare costs exceeding 

$700 million a year.4,5 The estimated annual salary cost 

alone for nondeployable Soldiers exceeds $3 billion.5

The long-term costs of musculoskeletal disabilities are 

staggering with the Veterans Administration reporting 

annual compensation exceeding $5.5 billion for service 

members with musculoskeletal disabilities.5,6 Musculoskeletal injuries during deployment are also extremely 

common with reports of 87% of all nonbattle injuries involving the musculoskeletal system.7 Further, nonbattle 

MSI was the leading cause of medical evacuations from 

theater from 2001 to 2010.7

ARMY PHYSICAL THERAPY PRIOR TO SEPTEMBER 2001

The roles and contributions of US Army physical therapists (PTs) have evolved since formal military physical 

therapy education and practice started in 1922. In particular, Army PTs have served in every major military 

confl ict since World War II.8-10 Prior to the Vietnam War, 

Army PTs typically served in fi eld or general hospitals 

outside the combat zone (Level 4 care) or in large medical centers in the United States (Level 5 care) providing rehabilitative care. During Vietnam, the roles and 

responsibilities of Army PTs were expanded to include 

serving as physician extenders for the evaluation and 

treatment of neuromusculoskeletal conditions, with 43 

Army PTs serving in 3 of 4 combat zones.8,9 Two key 

factors contributing to the use of Army PTs in a direct 

access role was the overwhelming MSI and orthopaedic 

surgical caseload during and following Vietnam.9,11-12

Various studies prior to 2001 examined the impact of PTs 

in direct access and deployment settings.9,13-14 In particular, during Operation Desert Storm, return to duty rates 

for Soldiers evaluated by an Army PT were 90%.9,13 Research by Teyhen14 during peacekeeping operations in 

Bosnia reported that 19% of all patients seeking care at 

the combat support hospital (Level 3 care) were managed by physical therapy, with only 2% of all PT patients 

requiring lost duty, hospitalization, or medical evacuation. In 2000, Army PTs were assigned to Army Ranger battalions. The original PTs assigned to these units 

demonstrated immediate value for operational readiness 

and within a 10 month period, deployment readiness for 

Ranger Battalions shifted from 88% to 95%.9,13 The improvements in readiness were attributed to Ranger PTs 

focus on a Soldier sports medicine (SSM) model which 

defi ned 6 roles Army PTs, shown in the Figure, within 

the following 3 areas: (1) injury surveillance/prevention, 

US Army Physical Therapist Roles

 and Contributions in Operations

 Enduring Freedom and Iraqi Freedom

 COL Scott W. Shaffer, SP, USA

 COL (Ret) Josef H. Moore, SP, USA

ABSTRACT

Musculoskeletal injuries are a leading cause of health care utilization, medical evacuation, and disability. US 

Army physical therapists (PTs) have served as physician extenders for the management of nonsurgical neuromusculoskeletal injuries since the Vietnam confl ict. The roles and evidence supporting US Army physical 

therapy continue to evolve. This article discusses the different levels of care and roles of US Army PTs, the contributions and evidence regarding US Army physical therapy, and physical therapy lessons learned during Operations Enduring Freedom and Iraqi Freedom. Since 2001, US Army PTs and enlisted physical therapy technicians have provided care from Levels 1 to 5 and assignments have expanded to special operations and brigade 

combat teams. Evidence suggests US Army PTs serving both in referral and direct access roles provided safe 

and defi nitive care that maximized readiness while reducing evacuation. Key physical therapy lessons learned 

include: (1) a continued focus on a Soldier sports medicine forward care model, (2) a need for injury risk assessment, physical performance screenings, and reconditioning programs that optimize readiness, and (3) continued 

support for physical therapy structure, training, and research that maximizes Soldier readiness and health.
April – September 2016 53

THE ARMY MEDICAL DEPARTMENT JOURNAL

(2) early identifi cation and rehabilitation of MSI, and (3) 

reconditioning/human performance optimization.9

 The 

SSM approach using this concept continues to be the 

foundation of Army PT outpatient practice today, both 

in garrison and deployment.9

ARMY PHYSICAL THERAPY AFTER SEPTEMBER 2001

The growing evidence of Army PT’s effect on readiness 

prior to September 2001, and the employment of the 

SSM model by US Army Rangers set the stage for expanded assignments and utilization of Army PTs during 

Operations Enduring Freedom and Iraqi Freedom (OEF/

OIF). Specifi cally, Army PTs and enlisted physical 

therapy technicians started serving in US Special Operations Command (SOCOM) units and brigade combat 

teams (BCTs) in 2003 and 2005, respectively. During 

deployment, these assignments provided an immediate forward presence for Army PTs and PT technicians 

and allowed for an expansion of neuromusculoskeletal 

evaluation and treatment to Level 1 and 2 care facilities 

(forward operating base battalion aid stations).9,15 Army 

PTs serving in these assignments consistently traveled 

to Soldiers at various locations within their area of operation, thus reducing Soldiers’ travel to a higher level of 

care at a combat support hospital (CSH).15 The combination of the number of MSI sustained during OEF/OIF, 

ill-defi ned enemy locations, and geographic separation 

between operating bases also necessitated the augmentation of one to 2 additional physical therapists for each 

deployed CSH. Collectively, from 2001 to 2011, 162 

Army PTs deployed in support of OEF/OIF,9

 and in 2011, 

approximately 80% of all deployment qualifi ed active 

duty Army PTs had deployed at least once.

CONTRIBUTIONS OF ARMY PHYSICAL THERAPY SINCE

SEPTEMBER 2001

Early Identification and Management of 

Musculoskeletal Injuries

Since the beginning of the OEF/OIF confl ict, Army PTs 

have embraced the SSM model and commitment to Soldier readiness. Research by Moore et al9

 in 2013 provides 

descriptive data of patient encounters and management 

by deployed Army PTs from July 2004 to March 2011, 

presented in the Table. Findings from deployed BCTs 

and CSHs (N=74) reported that over one-third (38%) of 

all outpatient workload was completed by physical therapy with 45% of all physical therapy encounters being 

new evaluations. Additionally, almost half (45%) of new 

evaluations were seen on a direct access basis with CSH 

specifi c data confi rming that 91% of military personnel 

with MSI at Level 3 care were managed by physical therapy. Overall, the low ratio of new evaluations to overall 

visits (71,310/157,337; 1 new evaluation per 2.3 overall 

encounters) suggests most military personnel required 

The Soldier Sports Medicine Model encompasses 6 key roles across 3 areas. All roles are interrelated and are a collaborated effort by the Soldier, command team, master fi tness trainers, physical therapists, physical therapy technicians and medical staff 

is required to maximize readiness and Soldier health.

AREA 3

RECONDITIONING AND

HUMAN PERFORMANCE OPTIMIZATION

ROLES

5. Reconditioning programs for injured Soldiers transitioning back to full training 

status 

6. Individual and/or command guidance 

on human performance optimization 

techniques

AREA 1

MUSCULOSKELETAL INJURY

SURVEILLANCE AND PREVENTION

ROLES

1. Musculoskeletal injury surveillance 

2. Injury prevention strategies in the form 

of screening and education

READINESS

AND

HEALTH

AREA 2

EARLY IDENTIFICATION AND

REHABILITATION OF INJURIES

ROLES

3. Early identifi cation of musculoskeletal 

injuries 

4. Rehabilitation of musculoskeletal 

injuries
54 http://www.cs.amedd.army.mil/amedd_journal.aspx

minimal visits and almost all (97%) were 

returned mission capable.9

Moore et al9 also examined CSH and BCT 

data in isolation, and of the 71,310 BCT/

CSH PT new evaluations reported, 69% 

(48,879) were evaluated by PTs serving 

in BCTs. These fi ndings emphasize the 

forward shift of Army PTs and refl ect that 

the majority of physical therapy patients 

were managed by PTs organic to the brigade. In consultation with brigade physician assistants, it was also reported that 

31% (15,084/48,879) of patients seen by 

BCT PTs would have required evacuation 

to the CSH had a PT not been assigned 

to the brigade. Combat support hospital 

physicians also reviewed physical therapy 

new evaluations and determined that 18% 

of patients seen by CSH PTs would have 

been evacuated from theater had a PT not been present. 

Collectively, these fi ndings suggest that Army PTs serving as part of the CSH or BCT healthcare teams during 

OEF/OIF diagnosed and treated a signifi cant percentage 

of MSIs, maintained readiness, and minimized evacuation for additional care.9,15

A survey of primary care BCT healthcare providers 

(N=107) also reported BCT PTs signifi cantly decreased 

medical evacuations within (68%) and out of theater 

(73%). Brigade providers also felt that PTs positively affected the overall mission (97%), patient prognosis (83%), 

and PTs were considered the local expert in musculoskeletal pathology (92%), including radiology (79%).16

The clinical diagnostic accuracy of military PTs as compared to magnetic resonance imaging has also been assessed among military PTs, orthopaedic surgeons, and 

nonorthopaedic healthcare providers. Findings demonstrated that the diagnostic accuracy for military PTs and 

orthopaedic surgeons was superior to nonorthopaedic 

providers.17 Finally, the safety of direct access military 

physical therapy care was evaluated across 25 DoD 

healthcare sites and involved 112,653 new patient evaluations with 50,799 (45%) of the patients seen through 

direct access without physician referral. Over the 

40-month data collection period, there were no reported 

or documented adverse events, probation or reduction 

of privileges, state licensure disciplinary actions, or litigation cases involving DoD credentialed PTs.18 United 

States military PTs in garrison and during deployment 

are deemed by their counterparts to provide safe and 

critical expertise with regards to the prevention, diagnosis, and management of musculoskeletal conditions. 

Serving in a direct access role to identify and manage 

musculoskeletal conditions appears to enhance physical 

therapy care closer to the point and time of injury while 

allowing other members of the healthcare team to focus on complex medical and surgical patients sustaining 

traumatic injuries.

Musculoskeletal Injury Surveillance

A concentrated effort was made by Army PTs during 

OEF/OIF to conduct MSI surveillance with a specifi c focus on body regions involved and mechanisms of injury.9

Three separate physical therapy studies examining MSI 

injuries by body region have consistently demonstrated 

the top 5 involved regions as lumbar spine, knee, leg/

foot/ankle, shoulder, and cervical spine.9,19,20 Research 

by Roy et al19,20 also reported on occupational and gender differences for body regions and mechanisms of injuries for deployed BCT Soldiers. The authors identifi ed 

that female Soldiers deployed in support of OEF had a 

higher percentage of lower extremity (women: foot/ankle=22%, knee=17%, hip=11%; men: foot/ankle=19%, 

knee=8%, hip=1%) injuries as compared to male Soldiers who sustained higher rates of low back injuries 

(men=32%; women=22%).19 Roy20 also demonstrated 

variability in body region injured, diagnosis, and mechanism of injury based on occupational specialty and authors emphasized a need for specifi c occupational injury 

prevention strategies.

Injury Prevention, Reconditioning, and Human 

Performance Optimization

Since 2008, Army PTs have led a DoD funded project 

examining military power, performance, and injury 

prevention.21-23 This trial involved injury prevention (IP) 

and physical performance screening of over 1,400 US 

Data Comparing Outpatient Physical Therapy Encounters From Combat Support 

Hospital and Brigade Combat Teams During Operation Iraqi Freedom/Operation 

Enduring Freedom From July 2004 to March 2011.

Description of Workload Outpatient 

Encounters

Percentage

of Total

Physical therapy encounters/total of patient 

encounters for organization (CSH/BCT)

157,337/416,987 37.7

Physical therapy new evaluations/physical therapy 

total encounters (CSH/BCT)

71,310/157,337 45.3

Direct access evaluations/total physical therapy 

evaluations (CSH/BCT)

31,769/71,310 44.6

Musculoskeletal injuries managed by PTs compared with other providers (CSH only)

34,009/37,332 91.1

Soldiers returned to duty treated by physical 

therapists/total physical therapy evaluations 

(CSH/BCT)

69,454/71,310 97.4

CSH Soldiers who would have required theatre 

evacuation had a PT not been present (CSH only)

 3,979/22,431 17.7

BCT Soldiers requiring evacuation to a CSH or out 

of theatre had a PT not been present (BCT only) 

15,084/48,879 30.9

Data are from Moore et al.9

CSH indicates combat support hospital; BCT, brigade combat team; PT, physical therapist.

PERSONNEL CHANGES THAT IMPACTED CARE AND OUTCOMES
April – September 2016 55

THE ARMY MEDICAL DEPARTMENT JOURNAL

Army Rangers, special operations and BCT Soldiers. To 

date this research has outlined advances in musculoskeletal screening, provided normative data for various 

physical performance screening measures, and identifi ed multiple potential predictors of MSI sustained by 

US Army Rangers.21-23 Additional research is required 

to refi ne MSI screening for the Army but this area holds 

great potential for mitigating injuries and optimizing 

readiness.

The contribution of Army PTs to IP, reconditioning, 

and human performance optimization (HPO) efforts 

in response to OEF/OIF are also highlighted by collaborative efforts with the US Army Fitness Institute, 

Public Health Command, US Army Research Institute of Environmental Medicine, and the Offi ce of the 

Army Surgeon General. In particular, these collaborative efforts led to injury prevention programs in initial 

entry training that resulted in decreased femoral neck 

stress fractures, integration of physical readiness training, reconditioning programs, and recommendations 

for pre-enlistment physical performance screening.24,25

Additional research by Lester et al26 was also integral 

for defi ning the impact of deployment on BCT Soldiers’ 

body composition and physical fi tness and the potential 

importance of additional targeted HPO physical training postdeployment. The importance of high intensity 

reconditioning or “bridge program to return to duty” 

was also demonstrated by an Army PT serving with SOCOM. Following rehabilitation, Soldiers who completed 

a 6-week functional training program exhibited statistically signifi cant pre- to posttraining improvements in 

agility, vertical jump height, timed and distance hop 

testing, kip-ups, and body fat.27 Although promising, 

additional research examining the effect of reconditioning programs on injury prevention, Soldier specifi c occupational tasks, and readiness are needed.

ARMY PHYSICAL THERAPY LESSONS LEARNED

It is important to point out that for this article the focus was limited to Army PTs’ impact on the surveillance, prevention, early assessment, rehabilitation, and 

reconditioning of MSI in an outpatient setting. This 

manuscript does not address the countless contributions 

Army physical therapy has provided in the areas of polytrauma, amputee, limb salvage, burn and neurologic (eg, 

traumatic brain injury, spinal cord injury, vestibular 

dysfunction) rehabilitation during OIF/OEF. A systematic review of the affect that Army PTs had on these 

conditions and lessons learned is warranted.

With regard to MSI, the opportunities, contributions, 

and lessons learned by US Army Physical Therapy 

since 2001 are numerous and diverse. First, Army PTs 

were integral to the early identifi cation and management 

of MSIs during OEF/OIF, and PTs directly contributed 

to maintaining Soldier readiness and decreased medical evacuations within and outside the theater of operations.9

 Second, despite the expansion of Army PTs into 

the BCTs, full integration of a SSM model, and specifi -

cally, adequate resources (currently 1 PT/1 PT enlisted 

per 3,500 BCT Soldiers) to address the IP, reconditioning, and HPO roles remain a challenge. Future BCT PT 

staffi ng models similar to those in Ranger and SOCOM 

units (1 PT and 1 PT technician per 600-1000 personnel) would allow Army PTs to address the IP, reconditioning, and HPO needs of BCT Soldiers. The third 

lesson learned involves a need for continued development, standardization, and policy/leadership support 

for physical training, reconditioning, and employment 

of an annual musculoskeletal physical performance 

screening assessment.5,21 It is also important that the 

selected screening measure(s) and reconditioning/HPO 

programs nest with critical occupational and physical 

readiness tasks.5,21 Improvements in these areas will 

require continued collaboration with multiple organizations, but ultimately hold great potential for maximizing 

readiness and the health of the force. Additional support 

for physical therapy clinical outcomes research, including integration within the electronic health record, is 

critical for analyzing current practice and optimizing 

care. Military physical therapy is a leader within evidence-based physical therapy practice, as demonstrated 

by over 400 military PT publications since 2001.28 Finally, Army physical therapy’s success has developed 

since 1922 secondary to a long-standing commitment 

to education/training across the career lifespan of offi cers, enlisted, and civilian PT team members. Since 

2001, Army physical therapy has expanded entry-level 

physical therapy education to the doctoral level, established 2 doctor of clinical sciences fellowships (sports 

medicine and orthopaedic manual therapy), developed 

2 postprofessional short courses (joint operational deployment course and forward musculoskeletal screening 

course), integrated a military physical therapy residency, 

and expanded educational opportunities for PhD and 

training with industry. Future commitment to these programs and expansion of enlisted and civilian training 

are required to enhance the health and readiness of the 

future force.

REFERENCES

1. Hauret KG, Jones BH, Bullock SH, Canham-Chervak M, Canada S. Musculoskeletal injuries description of an under-recognized injury problem among 

military personnel. Am J Prev Med. 2010;38(1 

suppl):S61-S70.
56 http://www.cs.amedd.army.mil/amedd_journal.aspx

2. Ambulatory visits among members of the active 

component, U.S. Armed Forces, 2010. MSMR. 

2010;18:16-21.

3. Army Medical Surveillance Activity. Absolute and 

relative morbidity burdens attributable to various 

illnesses and injuries, U.S. Armed Forces, 2012. 

MSMR. 2013;20:5-10.

4. Ruscio BA, Jones BH, Bullock SH, et al. A process 

to identify military injury prevention priorities 

based on injury type and limited duty days. Am J 

Prev Med. 2010;38(suppl 1):S19-S33.

5. Nindl BC, Williams TJ, Deuster PA, Butler NL, 

Jones BH. Strategies for optimizing military physical readiness and preventing musculoskeletal injuries in the 21st century. US Army Med Dep J. October-December 2013:5-23.

6. Gilchrist J, Jones BH, Sleet DA, Kimsey CD. Exercise-related injuries among women: strategies 

for prevention from civilian and military studies. 

MMWR Recomm Rep. 2000;49(RR-2):15-33.

7. Armed Forces Health Surveillance Center (AFHSC). Causes of medical evacuations from Operations Iraqi Freedom (OIF), New Dawn (OND) and 

Enduring Freedom (OEF), active and reserve components, U.S. Armed Forces, October 2001-September 2010. MSMR. 2011;18(2):2-7.

8. Hartwick AMR. The Army Medical Specialist 

Corps. Washington, DC: US Army Center of Military History; 1993.

9. Moore JH, Goffar SL, Teyhen DS, Pendergrass TL, 

Childs JD, Ficke JR. The role of U.S. military physical therapists during recent combat campaigns. 

Phys Ther. 2013;93:1268-1275.

10. Benson CJ, Schreck RC, Underwood FB, Greathouse DG. The role of Army physical therapists as 

nonphysician health care providers who prescribe 

certain medications: observations and experiences. 

Phys Ther. 1995;75:380-386.

11. Greathouse DG, Schreck RC, Benson CJ. The 

United States Army physical therapy experience: 

evaluation and treatment of patients with neuromusculoskeletal disorders. J Orthop Sports Phys 

Ther. 1994;19(5):261-266.

12. Army Regulation 40-68: Clinical Quality Management. Washington, DC: US Department of the 

Army; 2004 (revised 2009).

13. Garber MB, Baxter RE. Physical therapy in the US 

Army combat health support system. A research 

paper presented to the US Army Command and 

General Staff College in partial fulfi llment of the 

requirements for A462: Combat Health Support 

Seminar; 2003; Fort Leavenworth, KS.

14. Teyhen DS. Physical therapy in a peacekeeping operation: Operation Joint Endeavor/Operation Joint 

Guard. Mil Med. 1999;164(8):590-594.

15. Rhon DI. A physical therapist experience, observation, and practice with an infantry brigade combat 

team in support of Operation Iraqi Freedom. Mil 

Med. 2010;175:442-447.

16. Rhon DI, Gill N, Teyhen D, Scherer M, Goffar 

S. Clinician perception of the impact of deployed 

physical therapists as physician extenders in a combat environment. Mil Med. 2010;175:305-312.

17. Moore JH, Goss DL, Baxter RE, DeBerardino TM, 

Mansfi eld LT, Fellows DW, Taylor DC. Clinical diagnostic accuracy and magnetic resonance imaging of patients referred by physical therapists, orthopaedic surgeons, and nonorthopaedic providers. 

J Orthop Sports Phys Ther. 2005;35:67-71.

18. Moore JH, McMillian DJ, Rosenthal MD, Weishaar 

MD. Risk determination for patients with direct access to physical therapy in military health care facilities. J Orthop Sports Phys Ther. 2005;35:674-678.

19. Roy TC, Ritland BM, Sharp MA. A description of 

injuries in men and women while serving in Afghanistan. Mil Med. 2015;180:126-131.

20. Roy TC. Diagnoses and mechanisms of musculoskeletal injuries in an infantry brigade combat 

team deployed to Afghanistan evaluated by the brigade physical therapist. Mil Med. 2011;176:903-908.

21. Teyhen DS, Shaffer SW, Umlauf JA, et al. Automation to improve effi ciency of fi eld expedient 

injury prediction screening. J Strength Cond Res. 

2012;26(suppl 2):S61-S72.

22. Teyhen DS, Shaffer SW, Butler RJ, et al. What risk 

factors are associated with musculoskeletal injury 

in US Army Rangers? A prospective prognostic 

study. Clin Orthop Relat Res. 2015;473:2948-3958.

23. Teyhen DS, Riebel MA, McArthur DR, et al. 

Normative data and the infl uence of age and gender on power, balance, fl exibility, and functional 

movement in healthy service members. Mil Med. 

2014;179:413-420.

24. Scott SJ, Feltwell DN, Knapik JJ, Barkley CB, 

Hauret KG, Bullock SH, Evans RK. A multiple 

intervention strategy for reducing femoral neck 

stress injuries and other serious overuse injuries 

in U.S. Army Basic Combat Training. Mil Med. 

2012;177:1081-1089.

25. Molloy JM, Feltwell DN, Scott SJ, Niebuhr DW. 

Physical training injuries and interventions for 

military recruits. Mil Med. 2012;177:553-558.

26. Lester ME, Knapik JJ, Catrambone D, Antczak 

A, Sharp MA, Burrell L, Darakjy S. Effect of a 

13-month deployment to Iraq on physical fi tness 

and body composition. Mil Med. 2010;175:417-423.

PERSONNEL CHANGES THAT IMPACTED CARE AND OUTCOMES
April – September 2016 57

THE ARMY MEDICAL DEPARTMENT JOURNAL

27. Goss DL, Christopher GE, Faulk RT, Moore J. Functional training program bridges rehabilitation and return to duty. 

J Spec Oper Med. 2009;9:29-48.

28. Published Research Articles. The US Army Baylor University Doctoral Program in Physical Therapy Web Site. 

Available at: http://www.baylor.edu/graduate/pt/index.php?id=34391. Accessed October 1, 2015.

AUTHORS

COL Shaffer is Dean of the Graduate School, AMEDD Center and School, Joint Base San Antonio-Fort Sam Houston, 

San Antonio, Texas. He is also Chief of Army Physical Therapy and Assistant Chief, Army Medical Specialist Corps.

COL (Ret) Moore is a Professor of the US Army-Baylor University Doctoral Program in Physical Therapy, AMEDD 

Center and School, Joint Base San Antonio-Fort Sam Houston, San Antonio, Texas.
58 http://www.cs.amedd.army.mil/amedd_journal.aspx

In 2015, Army nurse practitioners celebrate 50 years of 

providing high-quality, patient-centered primary and 

specialty care as part of the military medical team.1

Over this time, facility-based Army nurse practitioners have seen a gradual yet steady increase in roles 

and responsibilities. Today, nurse practitioners in nondeployed settings enjoy a predominantly autonomous 

practice with a clearly delineated role in caring for patients within patient centered medical homes. In fact, 

the Army has been granted a special waiver by the National Committee for Quality Assurance to allow Army 

nurse practitioners to be patient-centered medical home 

team leaders. Within the military medical system, the 

combat mission remains paramount. While the role of 

nurse practitioners in nondeployed settings has matured, 

the “go to war” roles for them have expanded at a slower pace. This article explores the maturing role for the 

nurse practitioner in Army medicine.

EVOLVING ROLES FOR THE NURSE PRACTITIONER

The nurse practitioner role has evolved differently between the peacetime and wartime missions. The Army 

was quick to incorporate nurse practitioners into medical care being provided within the United States. The 

fi rst advanced practice nurses in primary care, called 

nurse clinicians in ambulatory care, were recognized 

in June 19721 and assigned to select military medical 

facilities.2

 This was very progressive as the fi rst nurse 

practitioner academic program had begun only 7 years 

previously and the American Nurses Association would 

not establish the Council of Primary Care Nurse Practitioners until 1974.3

 Nurse practitioners were incorporated into the Army Medical Department, growing and 

expanding in role and scope of practice. Today, over 170 

family nurse practitioners (FNPs) serve on active duty 

in the Army.

The evolution of the role of FNPs during deployment 

or combat has been less methodical. The reasons are 

unclear but may be due in part to the relatively recent 

introduction of nurse practitioners into the combat environment. Incorporating a new nursing specialty into 

the go-to-war mission requires both a clear need and 

display of essential skills to meet that need. While the 

role of Army nurse practitioners in noncombat positions 

has become an integral part of normal patient care, the 

opportunity to explore the role in combat has been limited until very recently. Combat action in Vietnam concluded in 1975, only 3 years after FNPs were introduced 

into the Army, which did not allow time to evaluate the 

role of nurse practitioners in that confl ict. Between 1975 

and 1990 there were several minor combat deployments 

to Grenada and Panama. These confl icts were brief and 

did not strain the medical system, resulting in little interest in changing the accepted models of care. The fi rst 

major troop deployment that required full fi elding of 

all medical assets occurred with the advent of Desert 

Shield/Desert Storm in 1990. A number of nurse practitioners were deployed with the rest of the medical assets. 

The exact number is unknown because there existed no 

specifi ed combat role for an Army nurse practitioner nor 

institutional method to track them during a deployment. 

These nurse practitioners were unrecognized in the Professional Filler System (PROFIS) and subsequently deployed into combat hospital nursing specialties of medical/surgical, emergency, or critical care nursing. Despite 

The Role of Army Nurse Practitioners

 Supporting Wars in Iraq and Afghanistan

 COL Paul C. Lewis, AN, USA

 COL Edward Yackel, AN, USA

 COL Richard M. Prior, AN, USA

ABSTRACT

Family nurse practitioners are an essential member of the military medical team. They were incorporated into 

the Army medical system almost as soon as there was an academic program to develop the role in primary care 

settings. The role for nurse practitioners during deployment has not been as clear. Even though they have been 

around for 50 years, the specifi c role nurse practitioners provide is still evolving. This article explores the incorporation of nurse practitioners into Army medicine with a focus on deployed medicine. Nurse practitioners 

have been shown to be very versatile providers with the requisite skill sets to meet the demands of the combat 

environment and are able to substitute for other medical assets that are critically short due to sustained confl ict. 

Clarifying the value a nurse practitioner brings to medical care in the combat environment is essential to insure 

all assets are being employed to provide the best medical care to the US fi ghting force.
April – September 2016 59

THE ARMY MEDICAL DEPARTMENT JOURNAL

this limitation, a select few nurse practitioners were able 

to make their debut in this confl ict. These nurse practitioners self-identifi ed as providers to their respective 

units once deployed. As nurse practitioners were an integral part of patient care in CONUS, the skills they were 

offering were known to the leadership. The nurse practitioners were given permission to become credentialed 

providers in theater. However, the decision remained on 

a case-by-case basis handled at the unit level.

The recognition of a role for nurse practitioners in a 

combat environment led to a broader discussion of how 

to institutionalize the role. However, Desert Shield/Desert Storm also ended quickly with the medical system 

having suffi cient medical resources to meet the demand. 

This short combat action was followed by a rapid redeployment back to the United States which once again 

relegated consideration of the role of nurse practitioners 

in the combat environment into an academic discussion 

with no clear answers.

The commencement of protracted combat operations in 

Afghanistan and Iraq taxed the Army medical system 

in terms of the length and frequency of deployments for 

healthcare providers. As a result of the high operational 

tempo with resultant strain from frequent deployments 

on physicians and physician assistants, nurse practitioners were once again evaluated for a permanent role on 

the Table of Organization and Equipment* (TO&E).

THE EMERGENCE OF ARMY FNPS DURING OPERATIONS IN

IRAQ AND AFGHANISTAN

In 2001, the United States entered into a series of confl icts which have lasted over a decade. At the commencement of hostilities, troops and medical assets 

were deployed into Afghanistan using the same medical 

deployment model employed in Desert Storm. Deployed 

FNPs once again found themselves working in traditional roles such as staff nurses on medical-surgical wards 

or using previously acquired skills in specialty areas 

such as critical care or emergency nursing. There were, 

however, some indications that FNPs were beginning to 

be recognized in theater. In 2003, the 28th Combat Support Hospital (CSH) was deployed to Iraq with a compliment of nurses that included nurse practitioners. While 

awaiting movement orders into Iraq, it became evident 

that medical support was signifi cantly limited at a staging base located in Kuwait. Two nurse practitioners 

from the 28th CSH were selected to lead the mission of 

establishing a troop medical clinic. Through close coordination with the leadership of the 28th CSH and 21st 

CSH, the nurse practitioners garnered the appropriate 

approvals to allow nurse practitioners to provide primary care within the newly established Troop Medical 

Clinic at Camp Victory, Kuwait. The clinic employed 8 

nurse practitioners and other members of the healthcare 

team who successfully provided round-the-clock care 

for over a month to an estimated 1,956 service members 

that presented with a wide variety of disease and nonbattle injuries.4

As the confl icts intensifi ed, the need to offi cially recognize the role and combat functionality for nurse practitioners grew. The FNP Consultant to The Surgeon 

General began to push for recognition of FNPs prior to 

deployment in order to assign them to provider roles as 

well as maintain visibility of where the FNPs worked 

and to which units they were assigned within the theater 

of operations. This effort met with success in 2004 when 

the fi rst offi cial FNP TO&E slot was approved within a 

combat support hospital. Assignment to a hospital unit 

represents the most direct translation of an FNP’s skills 

between nondeployed hospitals in the United States to 

deployed hospitals in a combat zone. Notably, the broad 

utility of the FNP skill set offered many other avenues 

for FNPs in the combat environment. At the beginning 

of 2005, 6 nurse practitioners were specifi cally designated to deploy as FNPs, but with dramatically different 

roles. Four deployed to function as general practitioners conducting routine patient care in the rear echelon. 

They were assigned with family practice physicians to 

conduct routine sick call as well as physicals for troops 

headed to theater. The 2 others, however, were sent to 

act as medical advisors to the Multinational Security 

Transition Command–Iraq. The 2 FNPs embedded 

within Iraqi military units in order to teach them how 

to provide medical care. Perhaps due to the success of 

these 2 individuals or perhaps just a recognition of the 

versatility of the FNP skill set, FNPs were soon being 

considered to assist with other critical shortages being 

seen in theater. The pool of forward deployed physician 

assistants in battalion aid stations became strained due 

to the continued high operational tempo and relatively 

limited supply of physician assistants available for deployments. Having similar skill sets and more availability, nurse practitioners began to be substituted for 

a select number of physician assistant positions. These 

substitutions were soon followed by nurse practitioners 

also being employed to fi ll vacant slots for a family physician in the combat support hospital (W. Bester, oral 

communication, January 22, 2011) and to replace a physician in the 549th Area Support Medical Company.4

The continued integration of FNPs into combat continued to evolve slowly with nurse practitioners substituting for physicians and physician assistants as shown in 

the Table. However, 2 years after the policy changes *A Table of Organization and Equipment defi nes the structure and 

equipment for a military organization or unit.
60 http://www.cs.amedd.army.mil/amedd_journal.aspx

were made and 7 years after initiation of combat action, 

25% of deploying nurse practitioners were still being assigned to noncredentialed nursing positions.5

THE ROLE OF FNPS IN A COMBAT ENVIRONMENT

As the wars in Iraq and Afghanistan are drawing to 

a close, the role for the family nurse practitioner in a 

combat support hospital has been validated. While this 

seems a simple translation of current peacetime FNP 

utilization into a combat environment, recent literature 

would suggest that the skills may not be entirely similar.

Lewis et al6

 surveyed 50 Army FNPs with deployment 

experience to elucidate their clinical practices while deployed. Only two-thirds (62%) of the nurse practitioners 

reported clinical care as their primary duty with various 

other leadership positions accounting for the other third. 

Those in clinical care saw typical primary care complaints such as musculoskeletal complaints, back pain, 

gastrointestinal issues and psychiatric issues. These 

FNPs practiced independently with over 80% reporting 

a need to collaborate with a physician “only occasionally” or “not at all.” Interestingly, 

44% of the nurse practitioners surveyed reported having credentials 

to admit to observational hold status and 12% having full hospital 

admission privileges.

While the FNP’s practice seemed 

to be traditional in many respects, 

there are some indications that 

many also experienced a practice 

which was more intense than that seen in peacetime 

when practicing outside the primary care setting. One 

study (R. M. P., unpublished data, 2012) found that 

47.8% of surveyed FNPs reported independently assessing trauma and 30.4% reported independently managing 

trauma. According to Lewis et al,6

 about 20% of surveyed FNPs reported participating in combat patrols, 

68% reported coming under direct or indirect fi re, and 

24% report encountering improvised explosive devices 

or land mines. Currently, there is limited research on the 

evolving role for the FNP in combat.

CONCLUSION

The wars in Iraq and Afghanistan are the fi rst confl icts 

in US history that have offi cially recognized the role of 

the deployed nurse practitioner. At the commencement 

of hostilities in 2001, nurse practitioners were deployed 

in a range of roles from bedside medical surgical nurses 

to advanced practice nurses. In 2005, the Army Medical 

Department offi cially recognized that FNPs are force 

multipliers and possess the requisite skills and scope of 

practice to accomplish the mission. Over the course of 

14 years of confl ict, nurse practitioners have become vital members of deployed medical teams with expanded 

roles and responsibilities.

In 2012, The Surgeon General of the Army commissioned a RAND Corporation study7

 that explored methods to improve the Army’s deployment augmentation 

system (PROFIS) to fi nd ways of ensuring that healthcare needs are effi ciently met both in garrison and on 

the battlefi eld. One of the recommendations was to 

improve the utilization of nurse practitioners and physician’s assistants in direct support of maneuver units. 

A revision in the military regulations governing nurse 

practitioner practice will be required to fully implement 

that recommendation. Credentialing for nurse practitioners is delineated within Army Regulation 40-68.

8

 There 

is ambiguity within the regulation regarding the authority of a nurse practitioner to delegate medical tasks such 

as administration of controlled substances to unlicensed 

personnel (for example, medics). This authority is seen 

as critical in a war environment. If 

nurse practitioners are deployed to 

level I echelon of care, such authority is necessary to allow medics to 

perform the duties they have been 

assigned in a combat environment.

There are many anecdotal stories 

regarding the exceptional performance of nurse practitioners who 

have been deployed to various 

clinical and leadership positions during the wars in 

Iraq and Afghanistan. Unfortunately, there is little scientifi c research investigating the roles of nurse practitioners during deployments. Confl icts are cyclical and 

it is expected that, at some point in the future, the US 

Army will once again be called upon to protect our nation. The Army Medical Department will be ready and 

able to care for the sick and wounded. As the history of 

the confl icts in Operations Enduring Freedom and Iraqi 

Freedom are written, the effect of nurse practitioners 

on the provision of battlefi eld healthcare will become 

more apparent. Leveraging the capability and capacity 

of all members of the healthcare team is of paramount 

importance in a time of diffuse threats and diminishing 

medical resources.

REFERENCES

1. Sarnecky MT. A Contemporary History of the U.S. 

Army Nurse Corps. Fort Sam Houston, Texas: The 

Borden Institute; 2010.

Roles of US Army Family Nurse Practitioners 

During Deployments to Combat Theaters, 

2003-2015.

Role AOC Number

Performing

Role

Family Nurse Practitioner 66P 133

Physician Assistant 65D 54

Family Medicine Physician 61H 18

AOC indicates Area of Concentration, the alphanumeric designator of the medical specialty.

PERSONNEL CHANGES THAT IMPACTED CARE AND OUTCOMES
April – September 2016 61

THE ARMY MEDICAL DEPARTMENT JOURNAL

2. Sarnecky MT. A History of the U.S. Army Nurse 

Corps. Philadelphia, PA: University of Pennsylvania Press; 2004.

3. American Association of Nurse Practitioners. Historical Timeline [internet]. Available at: https://

www.aanp.org/about-aanp/historical-timeline. Accessed November 30, 2015.

4. Dargis J, Horne T, Tillman-Ortiz S, Scherr 

D, Yackel EE. Expanding the role of the nurse 

practitioner in the deployed setting. Mil Med. 

2006;171(8):770-773.

5. Franklin BE, Carr KV, Padden DL. Self-assessment of trauma competencies among army family 

nurse practitioners. Mil Med. 2008;173(8):759-764.

6. Lewis PC, Stewart D, Brown W. Deployment experiences of Army nurse practitioners. Mil Med. 

2012;177(8):889-893.

7. Sobero ME, Olmsted SS, Morganti KG, Burns RM, 

Haas AC, Biever K. Improving the Deployment of 

Army Health Care Professionals: An Evaluation 

of PROFIS. Santa Monica, CA: RAND Corporation; 2013. Technical Report TR-1227-A. Available 

at: http://www.rand.org/pubs/technical_reports/

TR1227.html. Accessed November 30, 2015.

8. Army Regulation 40-68: Clinical Quality Management. Washington, DC: US Department of the 

Army; 2004 [revised 2009]:29. Available at: http://

www.apd.army.mil/pdffi les/r40_68.pdf. Accessed 

November 30, 2015.

AUTHORS

COL Lewis is Senior Nurse Scientist, Womack Army 

Medical Center, Fort Bragg, North Carolina.

COL Yackel is Senior Staff Offi cer, Clinical Performance 

Assurance Directorate, US Army Medical Command, 

Joint Base San Antonio-Fort Sam Houston, Texas.

COL Prior is Deputy Commander for Nursing, Ireland 

Army Community Hospital, Fort Knox, Kentucky.
62 http://www.cs.amedd.army.mil/amedd_journal.aspx

In August 2015, the Chief of Staff of the Army, GEN 

Mark A. Milley, emphasized the importance of listening and learning from the Army itself and preparing for 

the fi ght tomorrow. It is imperative to capture the lessons learned from the current confl ict while the subject 

matter experts are still able to provide the necessary 

feedback to implement change. Preparation for future 

confl ict is replete with new and innovative ideas, however, these initiatives should be informed by listening 

to previous lessons learned. The determination of anesthetic capability begins prior to any patient ever showing up on an operating table. The anesthesia provider, 

as part of a medical planning team, is key to any successful deployment or humanitarian mission. A working 

knowledge of the number of personnel supported, expected casualties rate, and logistical support available 

to the surgical team will always infl uence the anesthesia 

plan that can be sustained. For example, some supported 

units may have insuffi cient lift or ground capability to 

move a fully manned and equipped surgical team. This 

places a limitation on the mobility of the surgical team 

unless they are able to reduce their weight and cubic 

requirements. These limitations directly affect the type 

of anesthetic that a forward deployed provider can deliver. Although there have been numerous developments 

in volatile anesthesia equipment for the deployed setting, 

total intravenous anesthesia (TIVA) has emerged as a 

safe alternative with additional physiologic advantages. 

Ideally, the optimal anesthetic kit for any mission is 

based on durability, dependability, weight, and volume. 

An anesthetic packing plan centered on a TIVA capability fulfi lls these requirements.

DEPLOYABLE ANESTHESIA EQUIPMENT

The evolution of mission requirements and the fl uid nature of the battlefi eld has directed surgical and advanced 

resuscitation capability to move increasingly forward. 

Often located within minutes of the point of injury, surgical teams are frequently deployed in elements smaller 

than the traditional Role 2 forward surgical team. Military anesthesia providers have consistently sought to 

fi nd the optimal anesthesia equipment set to meet mission requirements, increase mobility, and still maintain 

the highest standard of anesthetic care. The traditional 

combat anesthetic is a balanced technique of volatile inhalation gas and intravenous anesthetic adjuncts. In the 

early phases of Operation Enduring Freedom and Operation Iraqi Freedom, many anesthesia providers deployed with the Ohmeda Universal Portable Anesthesia 

Complete (PAC) draw-over anesthesia system to deliver 

volatile inhalation anesthetics. The draw-over meets the 

requirements discussed above. Since its development in 

the 1970s, the PAC has proven to be durable, dependable, 

and relatively lightweight. Additionally, it does not require power or gas fl ow to deliver an anesthetic. However, 

the draw-over does have limitations, which include the 

requirement to scavenge waste gases and the potential, as 

with all volatile gases, to trigger malignant hyperthermia, 

Advances in Anesthesia Delivery

 in the Deployed Setting

 MAJ John E. Wilson Jr, AN, USA

 COL William P. Barras, AN, USA

ABSTRACT

Lessons learned over the past decade and a half of combat casualty management has brought about numerous 

advances in trauma anesthesia practice. In the post-Vietnam era, deployable anesthesia equipment centered 

on the capability to provide a balanced anesthetic technique, utilizing a combination of volatile gas and intravenous anesthetic adjuncts. The evolution of the modern battlefi eld has forced anesthesia providers across the 

military to adapt to mission requirements that often dictate a surgical capability that is more rapidly mobile and 

less reliant on logistical support. Institutional medical equipment development has focused on fi elding a lighter, 

more mobile volatile gas delivery method. Despite numerous advances in anesthetic gas delivery, many veteran 

anesthesia providers have come to recognize the value of alternative anesthetic techniques in the deployed setting. One of the most appealing advances in combat anesthesia practice is the emergence of total intravenous 

anesthetics (TIVA) for trauma management and resuscitation. Although there have been numerous developments in anesthetic equipment for use in the deployed setting, TIVA has many advantages over volatile gas 

administration. Future research, development, and education should focus on TIVA and the ability to provide 

this as an alternative safe anesthetic for patients in austere environments. It is imperative to retain the lessons 

we have learned in order to adapt more effectively in future confl icts. This accumulation of knowledge must 

inform future innovative solutions to the challenges of casualty management in a deployed setting.
April – September 2016 63

THE ARMY MEDICAL DEPARTMENT JOURNAL

a potentially lethal metabolic crisis in susceptible individual. Perhaps the greatest barrier to the continued use 

of this device is that it is no longer being manufactured 

by Ohmeda and no commercial vendor has offered a replacement; meanwhile, stockpiles of replacement parts 

are rapidly being depleted. A similar problem occurred 

with the Narkomed M anesthesia machine (Drägerwerk 

AG, Lübeck, Germany) secondary to the manufacturer 

discontinuing its production. The device was simple and 

safe and similar in design to anesthesia machines familiar to providers used in the United States. Unfortunately, the Narkomed M failed to meet the criteria for agile 

surgical teams on many levels. First, the machine and 

its components weigh close to 200 pounds. Secondly, it 

requires compressed gas and power for sustained operations. Consequently, the Narkomed M was limited to use 

by Role 2 (forward surgical team) and Role 3 (combat 

support hospital/fi eld hospital) medical facilities.

In response to continued requirements for a suitable fi eld 

anesthesia machine, the Defense Medical Standardization Board convened a Theater Care Anesthesia Working Group to evaluate commercial, off the shelf, anesthesia machines suitable for use in austere environments. 

The purpose was to quickly fi eld a unit that would replace the Narkomed M while maintaining the standards 

for safety and mobility. The recommendation forwarded 

was the Dräeger Fabius Tiro M. The most noticeable differences from the Narkomed M was that the Tiro M provided alternative ventilation modes and integrated safety 

features absent in earlier generations of fi eld anesthesia 

machines. The familiar technology provided by the Trio 

M appealed to most anesthesia providers, however, once 

again this device was designed for Role 2 and higher 

medical facilities with limited requirements for mobility. 

The newly fi elded Tiro M weighs 200 pounds, has regular maintenance requirements, and requires electrical 

power to operate the ventilator (battery charge limited 

to 45 minutes.) There are similar limitations found with 

the Magellan anesthesia machine. Although it weighs 

only 45 pounds, which makes it more appealing for fi eld 

anesthesia, the protective case required for transport 

adds an additional 65 pounds. As with all other volatile 

gas machines, this makes the Magellan suitable for Role 

2 medical facilities but not practical for mobile surgical teams with weight and cubic restrictions. For these 

reasons, TIVA, rather than volatile gas anesthetics, may 

be a more desirable method for providing anesthesia in 

deployed mobile surgical teams.

OXYGEN CONCENTRATORS

The development and implementation of commercially 

available oxygen concentrators have reduced many 

of the requirements to maintain large quantities of 

compressed gas. All commercially available anesthetic 

machines, however, require a compressed gas source. 

Most mobile surgical units deploy with E size compressed gas cylinders, which weigh on average 8 pounds 

empty. Some Role 2 (forward surgical team) facilities 

deploy with H size compressed gas cylinders, which are 

over 100 pounds each. The use of compressed gas by 

surgical teams can create a burdensome logistical problem by introducing the requirement for a robust infrastructure with capability to refi ll and procure replacement cylinders. In some cases, a local vender may be 

available, however, a quality control issue is introduced 

when relying on an outside source.

Patient air and ground transport add an additional consideration when using compressed gas. A traditional 

alloy-encased bottle may become compromised and 

suffer catastrophic failure. The explosive release of 

metal fragments can create safety concerns for air and 

ground crew personnel.1

 Consequently; the use of Kevlar oxygen bottles has gained support for long distance 

transport. Kevlar is approximately half the weight of 

an ordinary, alloy-encased oxygen cylinder. Additionally, the Kevlar casing may help reduce ductile failure, 

limiting cylinder disintegration and the risk of fragmentation if compromised.1

 However, the unacceptable 

risk of fragmentation remained, especially for patient 

transport via aircraft. In an effort to reduce reliance on 

compressed gas, US Army Medical Department leadership invested in systems that actually generate oxygen 

through room air concentration at the point of use. This 

initiative ensured that the supply of oxygen was uninterrupted on the battlefi eld.2

 Portable oxygen concentrators 

were subsequently developed, including the Eclipse and 

Saros (Sequal Technologies, Ltd, Taipei City, Taiwan). 

The implementation of oxygen concentrators resolved 

several problems created by compressed gas cylinders. 

First and foremost, they clearly reduced explosive risk 

and personnel endangerment. Secondly, they reduced 

or eliminated logistical requirements incumbent with 

the use of compressed oxygen cylinders. Finally, the 

concentrators that have been fi elded have demonstrated 

their ability to remain functional in extreme temperatures and harsh environments, which make them a perfect complement for TIVA administration.

TOTAL INTRAVENOUS ANESTHESIA

The technique or specifi c drugs used when designing 

an anesthesia plan for a trauma patient may often appear irrelevant.3

 Experienced providers argue that the 

best results are achieved by familiarity and experience 

of the anesthetist. Based on the modality of administration, anesthetics agents can be divided into 2 subclasses: those delivered by inhalation via volatile gases and 
64 http://www.cs.amedd.army.mil/amedd_journal.aspx

those delivered intravenously (TIVA).3 Whether using 

TIVA or inhalation, either technique must be carefully 

titrated to the hemodynamic profi le while assuring adequate sedation/hypnosis and analgesia.4

 Unfortunately, 

in some percentage of patients it is nearly impossible 

in early resuscitation efforts to adequately address all 

pillars of anesthesia while maintaining hemodynamic 

stability. Total intravenous anesthesia provides the anesthetist with a unique fl exibility. The provider can select 

individual intravenous agents and concentrations that 

address analgesia, amnesia, and akinesia with reduced 

detriment to the patient’s hemodynamic stability.

Historically, a typical trauma anesthetic may have been 

accomplished using 2 simple intravenous medications, 

scopolamine and a narcotic. However, in the past year, 

the manufacture of intravenous scopolamine has become very limited leaving anesthesia providers in search 

of alternative agents for trauma patients in extremist. Intravenous anesthetic management of the trauma patient 

is still preferred over volatile anesthetic management for 

emergent airway facilitation and damage control surgery. There are several alternative intravenous agents 

that have been implemented with varied success. Intravenous medications such as propofol, etomidate, midazolam, and fentanyl have been administered alone and 

in combination for induction and anesthetic maintenance 

during trauma resuscitation. One of the most promising 

intravenous anesthetic agents for trauma is ketamine, an 

older medication that was previously avoided because of 

undesired side effects. However, as the clinical management of ketamine administration improves and renewed 

research provides refutable evidence from previous 

claims, anesthesia providers have taken a second look at 

ketamine use in trauma.5

 In fact, some evidence suggests 

that ketamine may provide a neuroprotective quality by 

improving cerebral perfusion in neurologic injury.6

A number of studies have compared TIVA and volatile 

anesthetics. The results demonstrated in Englehart et al 

showed that a TIVA regimen produced less pronounced 

hypotension then isofl urane in uncontrolled hemorrhagic shock.6

 The study suggested that in circumstances 

of limited resources, such as mobile surgical teams, a 

ketamine-based TIVA regimen might be a viable option. Ketamine is a noncompetitive antagonist of the Nmethyl-D-Aspartate (NMDA) receptor. It demonstrates 

several benefi cial pharmacodynamic effects in the setting of hypotension due to the fact that it increases sympathetic tone, which leads to an increase in heart rate, 

blood pressure, and cardiac output.7

 This is a signifi cant 

advantage in a cohort of trauma patients including adults, 

children, and polytrauma patients who are hypotensive 

secondary to hypovolemia.7 A popular medication used 

in the induction of anesthesia and maintenance of general anesthesia is propofol. Propofol is a short acting, 

hypnotic/amnestic agent. Although propofol has an appealing pharmacokinetic profi le, it has been associated 

with hypotension. Shearin et al 8

 determined that 16.5% 

of trauma patients who were administered propofol only 

infusions developed hypotension. Therefore, an alternative to propofol alone is the mixture of ketamine with 

propofol known as “ketofol”. According to Smischney 

et al,9

 propofol was more likely to generate a 20% reduction in systolic blood pressure compared to “ketofol” which was associated with signifi cantly improved 

hemodynamic stability.

Total intravenous anesthesia in the deployed setting has 

additional practical advantages over volatile anesthetics. 

In wartime trauma resuscitation, the ability to continue 

to provide anesthesia despite loss of power or equipment 

failure is crucial. A total intravenous technique can be 

accomplished without additional equipment or power 

supply. Occasionally, the deployed setting introduces additional tactical considerations such as environments that 

require light and noise discipline. An intravenous anesthetic may prove to be a better option than a cumbersome 

anesthesia machine. The total intravenous technique also 

allows the anesthesia provider the ability to continuously 

provide en route patient transport by litter, ground, or air 

without interruption of amnesia and analgesia.

Recent changes in tactical combat casualty care doctrine 

have increased the recognition and availability of ketamine in the deployed setting. First line medics are now 

more familiar with ketamine and frequently include it as 

a fi rst line adjunct in their medic aid kits. The consorted 

use of ketamine across the continuum of combat care 

enables the consolidation of resources in extreme conditions where resupply may be constrained.

CONCLUSIONS

The discussion about anesthesia in the deployed austere 

environment is not a new concept. In 2009, Barras et 

al 10 summarized many of the same discussion points 

made in this paper. New paradigms in Army medicine 

and emergent tactical requirements necessitate smaller, 

more agile surgical teams to conduct missions with a 

reduced logistical footprint. Complacency with current practice and equipment should not be status quo 

for the next confl ict. An increased investment in time 

and resources should be expended on predeployment 

training and the continued pursuit of alternative anesthetic techniques. Demonstrated success with total intravenous anesthesia remains one of the most promising developments from years of combat lessons learned. 

Continued educational and training efforts should focus 

PERSONNEL CHANGES THAT IMPACTED CARE AND OUTCOMES
April – September 2016 65

THE ARMY MEDICAL DEPARTMENT JOURNAL

on ensuring that every military anesthesia provider is 

comfortable delivering TIVA in an unstable trauma patient. Doctrine should support formal TIVA education 

in military anesthesia curricula for both nurse anesthetist and physician anesthesiologists. Prior to deployment, 

anesthesia providers should demonstrate profi ciency in 

the administration of TIVA to trauma patients as part of 

predeployment training.

The effectiveness of any anesthesia provider, however, is 

also dependent on the effectiveness of the tools they have. 

Research and development should focus on new and innovative ways of delivering combat anesthesia. Promising investigative projects such as closed loop inhalation 

anesthesia and racemic versus +S isomer ketamine have 

been documented in anesthesia journals, however, continued research is necessary. The increased interest in 

TIVA across the fi eld of anesthesia has prompted several 

biomedical manufactures to develop target controlled 

infusers. Target controlled infusers use specifi cally programmed syringe drivers to enable a more precise titration of anesthetic medication. The infuser operates on 

algorithms based upon pharmacokinetic and pharmacodynamic data to an estimated target concentration in 

blood.11 With continued development and clinical trials, 

this type of infuser shows tremendous promise for future military use in the deployed setting.

Collaborative triservice efforts should guide future studies and focus on the effectiveness of different anesthetics throughout the continuum of care on the battlefi eld. 

Future education and deployment training should focus 

on physiological endpoints and be informed by clinical 

outcomes. Numerous technological advances have occurred in anesthetic delivery throughout the past decade 

of war. It is now imperative that we retain these lessons, 

learn from our missteps, and continue to develop techniques that allow for quicker adaptation to meet future 

battlefi eld requirements.

REFERENCES

1. More Durable Aerospace, Marine, and Rail 

Equipment [internet]. Du Pont Corporation 

Website; 2014. Available at: http://www.dupont.com/products-and-services/fabrics-fibersnonwovens/fibers/uses-and-applications/aero

space-marine-rail.html. Accessed September 24, 

2015.

2. Arnold M. US Army Oxygen Generation System 

Development. Defense Technical Information 

Center Website; 2010. Report RTO-MP-HFM-182. 

Available at: http://dtic.mil/dtic/tr/fulltext/u2/

a581789.pdf. Accessed September 24, 2015.

3. Schifi lliti D, Grasso G, Conti A, Fodale V. Anaesthetic-related neuroprotection: intravenous or inhalational agents?. CNS Drugs. 2010;24:893-907.

4. Joint Theater Trauma System Clinical Practice 

Guideline [internet]. Fort Sam Houston, TX: US 

Army Institute of Surgical Research; 2014. Available at: http://www.usaisr.amedd.army.mil/cpgs/

Trauma_Anesthesia_16Jun2014.pdf. Accessed 

September 24, 2015.

5. Himmelseher S, Durieux ME. Revising a dogma: 

ketamine for patients with neurological injury? 

Anesth Analg. 2005;101:524-534.

6. Englehart MS, Allison CE, Tieu BH, et al. Ketamine-based total intravenous anesthesia versus 

isofl urane anesthesia in a swine model of hemorrhagic shock. J Trauma. 2008;65:901-909.

7. McDermott P, Sebastian J. Should Ketamine be 

used as an induction agent in traumatic brain injury? Br J Hosp Med. 2013;74(9):538.

8. Shearin AE, Patanwala AE, Tang A, Erstad BL. 

Predictors of hypotension associated with propofol 

in trauma patients. J Trauma Nurs. 2014;21(1):4-8.

9. Smischney NJ, Beach ML, Loftus RW, Dodds TM, 

Koff MD. Ketamine/propofol admixture (ketofol) 

is associated with improved hemodynamics as an 

induction agent: a randomized, controlled trial. J 

Trauma Acute Surg. 2012;73:94-101.

10. Barras P, McMasters J, Grathwohl K, Blackbourne 

L. Total intravenous anesthesia on the battlefi eld. 

US Army Med Dep J. January-March 2009:68-72.

11. Morton NS. Total intravenous anesthesia (TIVA) 

and target controlled infusion (TCI) in children. 

Paediatr Anaesth. 2013;3:37-41.

AUTHORS

MAJ Wilson is assigned to the San Antonio Military 

Medical Center, Joint Base San Antonio-Fort Sam 

Houston, Texas.

COL Barras is Chief, Clinical Operations, US Army 

Forces Command Surgeon’s Offi ce, Fort Bragg, North 

Carolina.
66 http://www.cs.amedd.army.mil/amedd_journal.aspx

Occupational therapy (OT) is defi ned as “the art and 

science of helping people do day-to-day activities important and meaningful to their health and well-being 

through occupational engagement.” 1

 Since its inception, OT was grounded on the concept of engagement 

in therapeutic activities to promote health. Today, there 

is a growing multidisciplinary appreciation for occupational engagement and its associated well-being, which 

highlights the health effects of participating in multiple 

activities and occupations.2

MILITARY OCCUPATIONAL THERAPY WARTIME ROLES

The involvement of occupational therapists as reconstruction aides during World War I created national 

professional recognition. The executive order of 1917 

authorized the Civil Service Commission to employ occupational therapists as civilians in the Army Medical 

Department for the duration of the war emergency and 

to accompany hospitals for overseas duty.3

 The aim was 

to employ medical aides and teachers in the reconstruction of the injured Soldier. The intent was for this curative phase to allow Soldiers to return to active duty 

rather than “be discharged to live reliant upon a pension, 

as an economic drain on the country.” 4

 Since the early 

1800s, training individuals in activities of daily living 

and remedial work were used in the rehabilitation therapy of mentally ill patients.3

By the advent of World War II (WWII), OT’s presence 

in the military had diminished. There were only 5 Army 

hospitals providing OT services and only 8 occupational 

therapists serving as civilians in the Army.3

 However, 

due to the war escalation, by 1945 there were 899 civil 

service occupational therapists, including 452 apprentices, serving in the United States.3

 Following the WWII 

carnage resulting in over 40 million casualties worldwide, departments of physical medicine were developed 

which laid the foundation for OT practice in physical disabilities and orthopedics. By 1947, occupational therapists were granted military designation with the creation 

of the Women’s Medical Specialist Corps. In 1955, Public Law No. 84-294 allowed the Army Medical Specialist 

Corps (AMSC) to commission men into the Corps.3

The Army OT support for the Vietnam War was provided primarily in Japan, Hawaii, and the continental 

United States. In 1971, MAJ Hetty Ricker became the 

fi rst AMSC OT offi cer assigned to the combat zone in 

South Vietnam where she served as the OT consultant to 

the US Army, Vietnam Surgeon.3

 Her 3 missions were 

to assist in establishing a drug abuse treatment program 

at the 3,000-bed convalescent center at Cam Ranh Bay, 

to strengthen rehabilitation programs in 13 other Army 

drug control treatment facilities, and to evaluate OT 

support and education in the medical civil assistance 

programs aiding the Vietnamese population.

During Operations Desert Storm and Desert Shield, occupational therapists were represented in the fi rst hospitals to deploy to Southwest Asia. This was in marked 

contrast to medical support mobilizations during the 

Korean and Vietnam Wars. In October 1990, MAJ Mary 

Laedtke, and an enlisted OT assistant became the fi rst 

occupational therapists to be assigned to a Combat Stress 

Roles of Occupational Therapists in Theater,

 Past and Present

 LTC Enrique V. Smith-Forbes, SP, USA

 LTC Charles D. Quick, SP, USA

 LTC Katherine M. Brown, SP, USA

ABSTRACT

The impetus to deploy occupational therapy (OT) assets into theaters of operation lies in the occupational 

therapist’s ability to evaluate the effect of physical and/or behavioral symptoms on functional performance and 

effectively develop individualized interventions. Occupational therapy utilization has been robust during 14 

years of continuous deployments in Iraq and Afghanistan. Occupational therapy’s indoctrinated role in combat 

is solely with the combat and operational stress control missions, however, the skills and capabilities of this 

profession have demonstrated effi cacy in other specializations, including concussion care. The effectiveness 

of OT interventions is demonstrated with improved return to duty (RTD) rates for casualties suffering with 

combat and operational stress reactions where OT was a major component of a restoration and reconditioning 

program. As well, postconcussion RTD rates have been linked to the broad skill sets inherent in OT that allow 

casualties to remain in theater from the point of injury to complete recovery and RTD.
April – September 2016 67

THE ARMY MEDICAL DEPARTMENT JOURNAL

Control Team deployed to Operation Desert Storm. The 

team’s task was to evaluate, in the combat environment, 

the success of methods and techniques developed to 

manage combat stress.3

OCCUPATIONAL THERAPY UNIQUE ROLES

Occupational therapists perform multiple functions in 

the combat or garrison environments. Apart from a 

background in orthopedics and physical dysfunction 

rehabilitation, occupational therapists train in neurology and behavioral health rehabilitation. Occupational 

therapists evaluate the effects of physical, cognitive, 

neurologic, or psychosocial symptoms on functional 

performance in the deployed environment. Because 

of the unique ability to conduct analysis, occupational 

therapists are skilled to develop activities of increasing 

challenge (grading) to facilitate healing and effective 

return to duty (RTD). The ability to make environmental modifi cations enables occupational therapists to facilitate cognitive, emotional, and physical rehabilitation. 

Finally, occupational therapists address physical, cognitive, and psychosocial symptoms in conjunction with 

job analysis to ensure successful RTD.

OCCUPATIONAL THERAPY AND CONCUSSION CARE

IN THEATER

Mild Traumatic Brain Injury (mTBI) is also known as 

a concussion. It is important to note that “mild” does 

not refer to symptoms, but rather injury severity. Concussion is the preferred term when communicating with 

service members. Concussion became the signature 

injury for the Operations Iraqi Freedom and Enduring 

Freedom due to the prevalence of improvised explosive 

devises. This is in contrast to posttraumatic stress disorder that was the signature injury for the Vietnam War. 

Prior to 2010, up to 90% of concussed service members 

remained undiagnosed, redeployed, and/or were evacuated from theater. The condition was not well understood 

and there was a lack of standardized training, facilities, 

staffi ng, and medical documentation. Since 2010, an 

increased awareness of injury events, evaluation, and 

treatment has occurred. Department of Defense Instruction 6490.115

 was published to provide policy guidance 

for the management of mTBI/concussion care in the deployed setting. In theater, concussion treatment resulted 

in an improved RTD rate (92%-95%).

The OT role in concussion care is threefold: evaluate, 

treat, and educate. First, evaluation of cognitive, psychosocial, physical, and vestibular injuries is required to assess effect on functional performance. Second, treatment 

is provided by graded activities and environmental modifi cation. Service members begin with rest and gradually 

progress through various phases of recovery in which 

treatments are designed to provide increasing physical, 

cognitive, and vestibular challenges that simulate individual occupational demands until performance does not 

trigger symptoms. The appearance of no new symptoms 

at rest and with exertion is the cue to evaluate the service 

member for readiness to RTD. Recommendations are 

given to the service member’s provider who ultimately 

determines fi tness for duty. Third, occupational therapists provide detailed education in 3 primary venues: (1) 

to concussed service members on how to facilitate healing and the expectation for recovery; (2) to commanders 

and line leaders on the expected recovery from mTBI as 

well as the line leader’s roles and responsibilities; and 

(3) to medics and medical providers on concussion care, 

current policies, and treatment algorithms.

Concussion recovery is a physiological recovery. When 

deployed in the combat theater, occupational therapists 

act as force multipliers by enabling service members 

to recover from concussion and remain with their unit 

following injury. Due to closely monitoring symptoms, 

providing cognitive and physical rest, and ensuring Soldiers are fi t to perform occupational tasks before returning to work, occupational therapists preserve the force 

for combat readiness and maintain unit integrity. Occupational therapists are an asset for both service members 

and line leaders.

COMBAT STRESS CONTROL

Serving in a combat environment exposes service members to demands and inherent dangers that result in experiencing physiological and emotional stress which is 

defi ned as combat stress.6 Combat occupational stress 

reactions (COSR) are the predictable, expected, emotional, intellectual, physical, and/or behavioral reactions 

of service members who have been exposed to stressful events in combat or military operations other than 

war.6

 Combat operational stress control (COSC) aims 

to identify, prevent, and manage adverse combat and 

operational stress reactions.6,7 There are 4 Army tactical tasks taken from Army Doctrine Reference Publication 1-038

 that guide COSC doctrine: ART 4.3.1 Provide Combat Casualty Care8(p4-90); ART 4.3.1.5 Provide 

Behavioral Health Neuropsychiatric Treatment8(p4-94); 

ART 6.7 Provide Force Health Protection8(p6-51); and 

ART 6.7.3 Provide Combat and Operational Stress Control Prevention.8(p6-54) Occupational therapists within the 

COSC detachment return service members to duty by 

accomplishing 3 objectives:

1. Assist the service member to develop a sense of belonging. Occupational therapists facilitate the reestablishment of the service members’ relationships 

with their leaders and their peers.
68 http://www.cs.amedd.army.mil/amedd_journal.aspx

2. Help the service member develop an internal locus 

of control, mediated through the stress of graded activities. Occupational therapists provide purposeful 

activities to enhance functional performance.

3. Facilitate the improvement of communication skills 

using cognitive behavior therapy facilitated by each 

occupational therapist’s therapeutic use of self.9

OCCUPATIONAL THERAPIST ROLES IN THE FITNESS/

RESTORATION TEAM

Although occupational therapists contribute in the 9 

functional roles of COSC,6

 they are a stronger force 

multiplier when employed in the functional areas of restoration10 and reconditioning, and during the conduct of 

unit needs assessments. Occupational therapists work to 

identify stressors (physical) and assess performance (reactions), teach prevention to facilitate adapting coping 

and social skills, and engage service members in meaningful, purposeful activities.

COSC POPULATIONS AND OCCUPATIONAL

THERAPY’S FOCUS

During Operations Iraqi Freedom and Enduring Freedom, occupational therapists learned that COSC operations were dictated by the populations needs. This was 

accomplished by coupling Maslow’s hierarchy of needs 

theory11 to the maturation of the battlefi eld to determine 

the focus of intervention as illustrated in the Figure. Cohesive teams are developed through extensive training 

opportunities and that is what was delivered early in the 

confl ict to occupy immature battlefi elds. Immature battlefi elds necessitate predominately combat operations 

that are time and energy intensive. In this stage, service 

members require restoration to meet Maslow’s fundamental physiological needs and a safe environment to ensure recovery (rest, sleep, etc). As the confl ict protracts, 

extensive training is replaced by personnel turnover and 

hasty operational deployment, generating a population 

with fragmented criterion to occupy a mature battlefi eld, 

who now require the development of team cohesion. 

The mature battlefi eld requires predominately stabilization and reconstruction operations in a relatively safe environment where their basic physiological needs (food, 

shelter, sleep) are met. These service members require 

reconditioning, as the primary needs in this population 

are a sense of belonging and esteem, which coincides 

with Maslow’s higher levels of self-esteem (M. Callison 

et al, unpublished data, 2012).

COSC RECOVERY OF ACUTE COSR

The Restoration program is typically a 24-72 hour 

program.6(p10-1) The focus is on nutrition, sleep hygiene, 

personal hygiene, graded activities, and a structured 

military environment. Evaluation is conducted to 

determine adaptive versus maladaptive behaviors. Reconditioning involves Restoration and additional training up to 7 days.6(p12-1) Life skills classes are conducted 

daily and service members receive behavioral health offi cer follow-up. Service members are provided a structured, scheduled environment to prevent them from 

adopting a patient role.10 The aim is to restore resiliency 

through physical, emotional, spiritual, and cognitive 

skills. The Table presents data concerning the patients 

seen in one year at a Restoration center.

OCCUPATIONAL THERAPY UNIQUE SKILLS

APPLIED IN THE COSC

Occupational therapy’s intake focus is on service members’ functional performance.12 It is the only discipline 

on the interdisciplinary team assessing work skills/

abilities. Other providers have commented on the value 

of this particular skill. Occupational therapists use the 

same unique skills used in concussion care. However, in 

COSC, the graded tasks and environmental modifi cations vary based on the specifi c needs of each service 

member. Treatments are designed to provide increasing 

Combat operational stress control operations dictated by 

population needs.

Battlefi eld Population Focus

Immature Cohesive Team Basic Needs

Mature Fragmented Team Belonging

VARIABLES

Battlefi eld:

Immature=restoration: low level needs

Mature=reconditioning: higher level needs

Population:

Early=Psychosocially equipped

Late=Psychosocially wanting

SELF

ACTUALIZATION

SELF ESTEEM

achievement, respect

SENSE OF BELONGING

unit, friends, family, partner

SAFETY

safety and security of self and family

PHYSIOLOGICAL

breathing, food, water, rest

PERSONNEL CHANGES THAT IMPACTED CARE AND OUTCOMES
April – September 2016 69

THE ARMY MEDICAL DEPARTMENT JOURNAL

physical, cognitive, and psychosocial challenges that 

simulate individual occupational demands until they are 

able to perform occupational demands, illustrated in the 

Figure. For example, while in concussion care, treatment 

begins with modifi cations to create a quiet environment; 

in restoration, the environment is modifi ed to maintain 

a structured military environment to prevent service 

members from adopting a “patient role.” In a comparison of restoration/reconditioning, units using both behavioral health-directed and OT-directed intervention, 

there was a 17% greater likelihood of RTD when compared to those restoration/reconditioning teams that did 

not include occupational therapists (T. L. Brininger et al, 

unpublished data, 2013).

OCCUPATIONAL THERAPY RECOMMENDATIONS FOR

CONCUSSION CARE

Doctrine: Occupational therapy services and other behavioral health disciplines are not written in the TBI 

doctrine. It is important that the distinctive roles for each 

provider be written in the TBI doctrine similar to that of 

the COSC doctrine in order to provide a thorough understanding of roles and responsibilities for future confl icts.

Manning: The Occupational Therapist (Area of Concentration (AOC) 65A) listed on the TDAa be added to TBI 

doctrine.

Training: Training is available and requirement is necessary. This includes the Interdisciplinary TBI Training 

for Deploying Providers NCAT(ANAM).b Each deploying provider is to be a graduate of the Captain’s Career 

Course (at a minimum).

OCCUPATIONAL THERAPY LESSONS LEARNED IN COSC

Doctrine: The current COSC doctrine contained in Field 

Manual 4-02.516

 works well when it is employed. An 

update is needed to refl ect current occupational therapy 

nomenclature. Currently, service members referred to 

Restoration require an evaluation by a behavioral health 

provider in order to avoid Restoration misuse.

Manning: There is no occupational therapy asset at the 

main support medical company level. Recommend fi lling the established COSC OT position with a Major (O4) as listed in the TOE.c

Training: Train as a team with other COSC providers 

to have cohesiveness and gain insight on provider roles. 

There are current occupational therapy efforts to support garrison behavioral health programs. The Management of Combat and Operational Stress Control Casualties postprofessional behavioral health course currently 

trains AOC 65A (Occupational Therapist), and military 

occupational specialties 68L (Occupational Therapy 

Specialist) and 68X (Behavioral Health Specialist). Ensuring all receive the training required to vet for suicidal 

or homicidal tendencies is very important.

REFERENCES

1. Cohn ES, consulting ed; Schell BAB, Gillen G, eds. 

Willard and Spackman’s Occupational Therapy. 

12th ed. Philadelphia, PA: Lippincott Williams & 

Wilkins; 2003:50.

US Military Service

Service No. %N

Army 277 84%

Air Force 34 10%

Navy 15 5%

Marine Corps 2 1%

Posttraumatic

Stress Disorder

Diagnosed No. %N

Yes 19 6%

No 302 92%

Unknown 7 2%

Experienced

Combat?

Response No. %N

Yes 71 22%

No 248 76%

Unknown 7 2%

Gender

No. (%N)

Male Female

275 (84%) 53 (16%)

5 Highest Percentages 

of Patient Military 

Occupational Specialties

MOS No. %N

Infantry 54 17%

Military Police 27 8%

Truck Driver 27 8%

Mechanic 16 5%

Cook 15 5%

5 Most Cited Reasons

for Seeking Treatment

MOS No. %N

Occupational 133 17%

Adjustment

Disorder 50 8%

Relationship 41 8%

PTSD 19 5%

Leadership 11 5%

Number of

Individual Patient

Combat Deployments

Deployment No. %N

1st 176 55%

2nd 84 26%

3rd 31 10%

4th 17 5%

5 or more 12 4%

5 Most Listed Patient 

Deployment Locations

Location No. %N

Bagram 

Airfield 155 48%

Shank 19 6%

Stone 14 4%

Salerno 12 4%

Gardez 9 3%

US military service members seen from February 6, 2010 to 

February 9, 2011 at the Freedom Restoration Center in Afghanistan. N=328; Return to duty rate of this period, 97%.

Data provided by CPT Jason Judkins, SP, USA.

a Table of Distribution and Allowances: Prescribes the organizational structure, personnel, and equipment authorizations, and requirements of a military unit to perform a specifi c mission for which there is no appropriate table of organization and equipment (defi ned in 

note c below).

bNCAT indicates neurocognitive assessment tool; ANAM, Automated Neuropsychological Assessment Metrics.

c Table of Organization and Equipment: Defi nes the structure and equipment for a military organization or unit.
70 http://www.cs.amedd.army.mil/amedd_journal.aspx

2. Stav WB, Hallenen T, Lane J, Arbesman M. Systematic review of occupational engagement and 

health outcomes among community-dwelling older 

adults. Am J Occup Ther. 2012;66(3):301-310.

3. Hartwick AMR. The Army Medical Specialist 

Corps: The 45th Anniversary. Washington, DC: US 

Army Center of Military History; 1993. Available at: 

http://www.history.army.mil/html/books/085/85-2/

index.html. Accessed February 18, 2016.

4. Gutman SA. Infl uence of the U.S. military and occupational therapy reconstruction aides in World 

War I on the development of occupational therapy. 

Am J Occup Ther. 1995;49(3):256-262.

5. Department of Defense Instruction 6490.11: Policy Guidance for Management of Mild Traumatic 

Brain Injury/Concussion in the Deployed Setting. 

Washington, DC: US Dept of Defense; 2012. Available at: http://www.dtic.mil/whs/directives/corres/

pdf/649011p.pdf. Accessed February 18, 2016.

6. Field Manual 4-02.51: Combat and Operational 

Stress Control. Washington DC: US Dept of the 

Army; July 2006.

7. Field Manual 4-02: Army Health System. Washington DC: US Dept of the Army; August 2013:12-2.

8. Army Doctrine Reference Publication 1-03: The 

Army Universal Task List. Washington DC: US 

Dept of the Army; October 2015.

9. Holmqvist K, Holmefur M, Ivarsson AB. Therapeutic use of self as defi ned by Swedish occupational therapists working with clients with cognitive impairments following acquired brain injury: A 

Delphi study. Aust Occup Ther J. 2013;60(1):48-55.

10. Smith-Forbes E, Najera C, Hawkins D. Combat operational stress control in Iraq and Afghanistan: Army occupational therapy. Mil Med. 

2014;179:279-284.

11. Maslow AH. A dynamic theory of human motivation. In: Stacey CL, DeMartino M, eds. Understanding Human Motivation. Vol XV. Cleveland, 

OH: Howard Allen Publishers; 1958:26-47.

12. Gerardi S, Newton S. The role of the occupational 

therapist in CSC operations. US Army Med Dep J. 

July-September 2004:20-27.

AUTHORS

LTC Smith-Forbes is Director, DScOT Program, Graduate School, Army Medical Department Center & School, 

Joint Base San Antonio-Fort Sam Houston, Texas.

LTC Quick is Chief, Army Medical Specialty Corps/Veterinary Corps Education Branch, Army Medical Department Center & School, Joint Base San Antonio-Fort Sam 

Houston, Texas.

LTC Brown is Deputy for Healthcare Delivery and the 

Occupational Therapy Consultant to The Army Surgeon 

General, Falls Church, Virginia.

PERSONNEL CHANGES THAT IMPACTED CARE AND OUTCOMES
April – September 2016 71

BACKGROUND

From the onset of the wars in Afghanistan and Iraq, the 

National Capital Region (NCR) served as America’s primary reception site for returning casualties and trauma 

care. Flights from Landstuhl Regional Medical Center 

landed at Joint Base Andrews where the 779th Medical Group operated an aeromedical staging facility. Almost all critical casualties were evacuated to Ladhstuhl 

Army Medical Center with 50% of all inpatients being 

taken to Walter Reed Army Medical Center (WRAMC) 

or National Naval Medical Center (NNMC) or Brooke 

Army Medical Center/San Antonio Military Medical 

Center with most stayed for outpatient rehabilitation at 

WRAMC.

The Washington Post articles published in February 

2007 led to a close examination of the care provided 

the wounded Warriors at WRAMC.1,2 In these articles, 

Dana Priest described the lodging conditions in Building 18 and diffi culties faced by outpatients. The President’s Commission led by Bob Dole and Donna Shalala 

found high quality clinical care, but noted problems 

with handoffs between inpatient and outpatient care, between the separate Department of Defense and Veterans 

Administration health care systems, and the separate 

disability systems.3

 The Independent Review Group established by the Secretary of Defense found fi rst class 

care from the battlefi eld to the tertiary medical facility 

which set a recognized standard of excellence in trauma 

care.4

 However, they noted that a breakdown in health 

services and care management occurred once the service member transitioned from inpatient to outpatient 

status. Other key fi ndings were that comprehensive care, 

treatment, and administrative services were not provided in an interdisciplinary, collaborative manner. A clear 

standard was lacking for the qualifi cations and training 

of outpatient case managers, there were insuffi cient behavioral health staff, and more work was needed in the 

diagnosis and treatment of traumatic brain injury and 

posttraumatic stress disorder. Signifi cant improvements 

arose from the lessons learned. The Army increased 

funding for WRAMC, constructed new facilities including a state of the art amputee center, and implemented 

efforts to retain staff leaving because of the impending closing of Walter Reed. It established the Warrior 

Transition Command and implemented new policies to 

provide better support to wounded (ie, combat related 

injured), ill, and injured (ie, noncombat related injuries) 

along with their families.

The Base Realignment and Closure Commission 

(BRAC) recommendation to close WRAMC and establish the Walter Reed National Military Medical Center 

(WRNMMC) and Fort Belvoir Community Hospital 

(FBCH) also led to an evaluation of Warrior care. Senior military and elected leaders closely examined plans 

to transfer patients during the height of the fi ghting 

season in Afghanistan when casualty fl ows were expected to peak. The recommendations from this second 

evaluation, like the fi rst, brought further resources and 

Wounded, Ill, and Injured Challenges

 MG Stephen L. Jones, MC, USA

ABSTRACT

The Washington Post articles of February 2007 led to a close examination of the care provided Wounded Warriors at Walter Reed Army Medical Center. Subsequent reports by the President’s Commission, Independent 

Review Group, and Defense Health Board all recommended ways to improve care. Joint Task Force National 

Capital Region Medical was established to implement the recommended improvements in Warrior care, and 

the recommendations of the Base Realignment and Closure Commission to close Walter Reed and realign the 

staff into a new Walter Reed National Military Medical Center and Fort Belvoir Community Hospital. It accomplished these tasks, maintained existing wounded, ill, and injured care, and safely transferred patients during the height of the fi ghting season in Afghanistan. It successfully accomplished its mission through engaged 

leadership, establishing an appropriate environment for Warrior care, careful management of casualty fl ow, 

and robust communication with all parties affected by the changes. The lessons learned in Warrior care should 

be considered when planning future military medical operations.

WOUNDED WARRIOR CARE
72 http://www.cs.amedd.army.mil/amedd_journal.aspx

additional improvements. Joint Task Force National 

Capital Region Medical was established to implement 

the BRAC recommendations, apply these lessons, and 

those learned during execution of their mission. The 

challenges they faced, and their approach to overcoming those challenges are presented below.

THE MILITARY PROBLEM

Joint Task Force National Capital Region Medical (JTF 

CapMed) was tasked to continue existing wounded, ill, 

and injured operations in the NCR while constructing 

new facilities, building new teams, and establishing new 

patient care processes. Staff would have to prepare for a 

projected increase in casualty fl ow, ensure patient safety 

throughout the transfer, overcome Army, Navy, Marine 

Corps, and Air Force culture and policy differences, 

and maintain standards of multiple accrediting organizations. Components of the solution included engaged 

leadership, an appropriate environment for Warrior care, 

careful management of casualty fl ow, and robust communication with all parties affected by the changes.

ENGAGED LEADERSHIP

Engaged leadership requires far more than regular casualty visits. Leaders must take the time to gather facts 

and truly understand the situation. Effective leaders 

provide more than purpose, direction, and motivation; 

they also ensure careful planning is conducted and adequate resources are provided. They change overly bureaucratic policies that hinder care, develop solutions to 

the challenges that arise, and monitor implementation 

of the solutions. Senior civilian and military leadership 

accomplished this through the reviews noted above, and 

a follow-up evaluation by the Defense Health Board 

(DHB) entitled “Achieving World Class.”5

 The latter 

review examined the planned integration of military 

medical facilities in the NCR, and plans for WRNMMC 

and FBCH to determine if they were being designed 

and constructed to be world-class medical facilities. 

The fi rst recommendation of the DHB provided a defi nition of world-class medical facility which was codifi ed 

in the 2010 National Defense Authorization Act. The 

second was to empower one offi cial with singular organizational and budgetary authority and be staffed appropriately to manage and lead the healthcare integration efforts and operations in the NCR. The third was to 

develop a Comprehensive Master Plan for an NCR integrated delivery system and for WRNMMC. Additional 

recommendations focused on facility and infrastructure 

improvements.

The JTF CapMed staff followed the standard military 

planning process to implement the recommendations 

discussed above. They developed a concept of operations 

(Table 1) and clearly assigned responsibilities to the hospital, military service, and installation (Table 2). They 

integrated the efforts of the many agencies that played 

a role in Warrior care and applied a single standard of 

care to all military services. They analyzed every aspect 

of care from the patient and family’s perspective, and 

provided additional services like child care, transportation, and internet access which supported the Warrior’s 

rehabilitation and reintegration. During execution of 

the BRAC recommendations, JTF CapMed adapted to 

many challenges: increasingly severe casualties, signifi -

cant construction delays, a telecommunications strike, 

and even an earthquake. At the last minute they transferred patients a day early because of an approaching 

hurricane.

Table 1. Joint Task Force National Capital Region Medical 

Concept of Operations.

Integrated system of care for Wounded, Ill, and Injured comprised of Service and Military Treatment Facility programs, with 

Installation/Base, Veterans Affairs, and Volunteer Organization 

support.

One standard of clinical care, rehabilitation and recovery that 

is patient-centered, holistic and builds independence and 

resiliency.

Walter Reed National Military Medical Center Unique Capabilities

Amputee and complex battle trauma

Severe traumatic brain injury and neurosurgery

Eye trauma

Cardiothoracic surgery

Fort Belvoir Community Hospital Unique Capabilities

Residential substance abuse treatment

Dual diagnosis with substance abuse

Table 2. Responsibilities of Joint Task Force National Capital 

Region Medical.

Military Treatment Facility Responsibilities

Provide patient/family-centered clinical care and rehabilitation.

Operate a Warrior Family Coordination Cell.

Conduct timely and responsive Medical Evaluation Board (MEB) 

system.

Administer military Service-specific MEB.

Contribute to an optimal healing environment.

Provide other support services as required.

Service Responsibilities

Maintain command and control over Warriors to include but not 

limited to the Uniform Code of Military Justice, transfer authority, movement, and family support.

Maintain personnel accountability.

Administer Service-specific personnel services.

Maintain Service Wounded, Ill and Injured Warrior Programs.

Assure personnel availability for continuity of healthcare and 

rehabilitation.

Installation/Base Responsibilities

Provide base operation services (eg, childcare, dining, lodging, 

and on-campus transportation).

Ensure campus is compliant with Americans with Disabilities Act 

Accessibility Guidance.

Operate fitness center, morale, welfare & recreation activities, 

the Exchange/PX, and related entities.

Contribute to an optimal healing environment.

WOUNDED WARRIOR CARE
April – September 2016 73

THE ARMY MEDICAL DEPARTMENT JOURNAL

ENVIRONMENT FOR WARRIOR CARE

The DHB defi nition of a World Class Medical Facility 

addressed 6 domains shown in Table 3. The recovery, 

rehabilitation and reintegration of Warriors also required a campus specifi cally designed for that purpose; 

the elements of the campus are outlined in Table 3. The 

environment for Warrior care considered far more than 

facilities. It included the exchange of clinical information while casualties were still in theater, an appropriate reception at Joint Base Andrews, and transfer to the 

medical facility in a mobile ICU if required. The interaction with families during and after casualty notifi cation was equally important in establishing a supporting 

environment. Families experienced less stress when 

provided information about their service members’ conditions, their progress en route home, and what to expect 

upon arrival at Walter Reed.

Facility lessons learned at WRAMC were applied during construction of WRNMMC and FBCH.8

 The JTF 

CapMed modifi ed the standard Army Warrior Complex 

plans to better suit more severely wounded casualties. 

Warrior lodging was constructed with 2-bedroom suites 

that included a kitchen, laundry facilities, and living 

area. Each bedroom had a separate bathroom and large 

closet. They provided amputees additional storage space 

for prosthetics, electrical outlets to recharge batteries, 

and allowed more privacy for nonmedical attendants. 

Wounded Warriors assisted in the selection of furniture 

and suggested modifi cations. Postconstruction modifi cations included installation of tubs to bathe children and 

to allow amputees to soak themselves. Staff personally 

navigated the campus in wheel chairs and spent much 

time with casualties and families to discover remaining 

accessibility obstacles. This guided improvements to 

fl ow within the hospital, modifi cation of sidewalks, addition of more automatic door openers and handicapped 

parking. The installation developed plans to improve access to athletic fi elds and build biking and running trails.

The Independent Review Group, Defense Health Board, 

 Army Dismounted Complex Blast Injury Task Force, 

and Pain Management Task Force all recognized multidisciplinary care was a critical element of the clinical 

environment.4-7 It was particularly important for pain 

management, treatment of multiple amputees, casualties with complex abdominal and genitourinary injuries, 

and managing transitions in care. The transition from 

inpatient to outpatient status was a high risk event. A 

multidisciplinary approach involving inpatient and outpatient clinical staff, Warrior Transition Unit cadre, case 

managers, and administrative personnel was essential to 

a smooth transition. Clinical details were shared where 

needed and occupational therapy staff evaluated lodging for suitability. Discharges at night and on weekends 

were avoided, especially for high risk behavioral health 

patients. Finally, inpatient staff were required to make 

personal contact with Warrior Transition Unit cadre at 

discharge and not rely on email to transmit information. 

Once Warriors transitioned to outpatient status, nonmedical attendants assisted those who were unable to 

perform activities of daily living. Since many were not 

otherwise eligible, policy changes allowed nonmedical 

attendants to receive health care at the medical facility. 

When Warriors did not have a suitable family member 

to serve as a nonmedical attendant, the Army designated another Soldier to assist.

The Warrior Transition Unit cadre contributed signifi -

cantly to the environment for Warrior care. They provided support to casualties and families that was normally 

the responsibility of the home station chain of command. 

Families required even greater assistance after abruptly 

moving to assist in the rehabilitation of their Warrior. 

Squad leaders were the fi rst line of support for Warriors 

and families. The ratio of squad leaders to Warriors 

was standard across the Army and adequate for most 

medical facilities. It was not adequate, however, for the 

medical centers caring for those with the devastating injuries seen in Afghanistan after 2009. A typical squad 

at WRNMMC in September 2011 included 10 Warriors; 

of these 7 were amputees, and over half of them were 

multiple amputees. Six of the 7 amputees were accompanied by families who also required support. Severely 

wounded Warriors averaged 3-5 clinic appointments a 

day, requiring squad leaders to track 150 to 250 appointments per week. The more complex casualties required 

more medications, behavioral health care, intense case 

Table 3. Environment for Warrior Care

World-Class Medical Facility

Basic Infrastructure

Leadership and Culture

Processes of Care

Performance

Knowledge Management

Community and Social Responsibility

Holistic Wounded Warrior Campus

Outpatient Rehabilitation that encourages reintegration into the 

community

Lodging specifically designed for Warrior and Family needs

Dining

Childcare and playgrounds

Transportation

Outpatient medical care for nonmedical attendants and families

Service Wounded, Ill and Injured Programs

Family and other support services

Veterans Affairs and Charitable Organizations

Social programs

Internet access in Military Treatment Facility, Lodging and Gym

Designed for accessibility
74 http://www.cs.amedd.army.mil/amedd_journal.aspx

management, and more administrative support. Since 

many had served in Afghanistan and Iraq 3 or 4 times, 

they and their families were recovering from the cumulative stress of multiple deployments.

The social environment is a key element of both rehabilitation and reintegration. Warriors and families developed a sense of camaraderie at WRAMC’s outdoor 

barbeque and playground which was the center of social life. This environment was diffi cult to duplicate at 

WRNMMC. The increasing severity of wounds, cumulative stress from multiple deployments, and more comfortable lodging at WRNMMC led many Warriors to remain isolated in their rooms. The activities sponsored by 

private organizations on and off campus assisted with 

their reintegration into society. As they progressed with 

rehabilitation, Warriors were moved to leased apartments in the community to learn to live independently 

before returning home.

MANAGEMENT OF CASUALTY FLOW

As casualties declined in 2007 following the surge in 

Iraq, Army surgical leadership concentrated acute amputee care at WRAMC to maintain expertise. Burn casualties decreased as well, so there were fewer direct casualty fl ights to San Antonio. As a result, by 2010 92% 

of all critically injured Warriors were taken to the NCR. 

In the summer of 2010, a signifi cant increase in casualties from Afghanistan was noted. Many were severely 

wounded by improvised explosive devices during dismounted operations and sustained high lower extremity 

amputations, pelvic, genital, and spine injuries. In 2009, 

there were 49 single and 13 multiple major limb amputations in Afghanistan and Iraq. This rose to 77 single and 

25 multiple major limb amputations in 2010.9

 The peak 

in casualty fl ow during those years occurred from July 

through October. The closure of WRAMC was scheduled for August 2011 when casualty fl ow was projected 

to be high, and planned operating room renovations at 

WRNMMC in accordance with DHB recommendations 

would severely limit capacity at the same time.

The JTF CapMed leadership recognized this challenge 

in the summer of 2010 and coordinated with the US 

Transportation Command (TRANSCOM) to redistribute critically injured patients to Brooke Army Medical 

Center, which was also undergoing a BRAC evolution 

at Lackland Air Force Base which involved reduction in 

services at Wilford Hall Medical Center. The change required reopening of the Aeromedical Staging Facility at 

Joint Base San Antonio–Lackland, and was implemented in January 2011. It allowed better use of the Military 

Health System capacity to treat amputees, and moved 

many Warriors closer to home, families and friends. 

During the fi rst 3 months of 2011, 145 casualties were 

regulated to the NCR rather than the projected 424.

To determine the facility and staff required to support 

the increasing casualty fl ow, JTF CapMed staff developed a model as described by Kepner and Spencer elsewhere in this issue.* The model estimated the number 

of ICU beds, medical surgical beds, and operating room 

hours needed for different levels of casualty fl ow. The 

capacity for amputee care at Brooke Army Medical Center and Naval Medical Center, San Diego, were included 

to better inform decisions on medical regulation. The 

model was adjusted after the 2011 casualty season to account for the increased numbers of and requirements for 

multiple amputees. The JTF CapMed also projected requirements for outpatient rehabilitation staff and lodging 

which were increasing as the average length of stay for 

casualties with multiple extremity amputations rose to 2 

years. On August 2, 2011, as the NNMC approached capacity limits, JTF CapMed requested temporary staffi ng 

augmentation from the military services for its operating 

rooms, intensive care unit, medical surgical wards, radiology, and occupational therapy sections. It made contingency plans for additional lodging, including Americans 

with Disabilities Act (Pub L No. 101-336, 104 Stat 328 

(1990)) compliant rooms, and transportation. Requirements were projected well in advance to allow time for 

the movement of personnel and execution of contracts.

COMMUNICATION

Communication of clinical information assisted staff 

to prepare for a casualty’s arrival. The web based Joint 

Patient Tracking Application (JPTA) provided patient 

information once a casualty reached the combat support 

hospital. The application which was developed by the 

Landstuhl Regional Medical Center and implemented 

across the Military Health System in 2004 provided information earlier and in more detail than the TRANSCOM Regulating and Command & Control Evacuation 

System, commonly known as TRAC2ES. The Landstuhl Medical Center staff also participated in Joint Theater Trauma System conferences to discuss the clinical 

status of casualties en route.

Communication of information to families after casualty notifi cation is equally as important, but was limited 

in the fi rst years of the confl ict. Families were provided 

limited details of a casualty’s condition during initial 

notifi cation, then often heard nothing for days. Implementation of JPTA allowed providers at the home station to keep families better informed. The Warrior and 

Family Quick Reference Guide helped families prepare 

*See article on page 124.

WOUNDED WARRIOR CARE
April – September 2016 75

THE ARMY MEDICAL DEPARTMENT JOURNAL

for travel to the NCR. It was placed on the hospital’s 

web site and included checklists for preparing to leave a 

household, travel, packing lists, caring for children, and 

what to expect upon arrival at the facility. The handbook 

eased a family’s transition and allowed them to better 

support their casualty.

Families are overwhelmed with information upon initial 

arrival at a medical center and retain little of what they 

are initially told. They are also signifi cantly affected 

when they fi rst see their critically injured Warrior in 

the intensive care unit. These issues were addressed by 

providing information in writing and repeating it often. 

Warriors well along in their rehabilitation met with new 

families and provided encouragement. Seeing a multiple amputee walking on his prostheses provided hope to 

families during this diffi cult time. An Integrated Warrior Care Roadmap was developed to show casualties 

and families the phases and milestones of their recovery. 

Originally developed by the Marine Corps Wounded 

Warrior commander, it was refi ned using length of stay 

data and tailored to each Warrior based on their injuries. 

The roadmap allowed families to plan, demonstrated to 

casualties they were making progress, and gave them 

events to look forward to, such as convalescent leave. 

A Nonmedical Attendant/Family Member Advisory 

Group met monthly with senior JTF CapMed leadership. 

These meetings kept senior leadership informed of issues and allowed them to discuss progress in resolving 

them. Monthly town hall meetings with Warriors and 

families served the same purpose and allowed presentation of information by the many agencies support 

wounded Warriors.

Regular updates to other interested parties including senior military and civilian leaders, non-Federal entities, 

the media, and even residents of local neighborhoods 

were important to the mission. This demonstrated that 

JTAF CapMed leadership was aware of and were addressing issues, reduced questions, and maintained confi dence in the effort.

CONSIDERATIONS FOR THE FUTURE

Two areas of Warrior care require further improvement. 

First, Warrior Transition Unit, hospital, and installation staff should be provided training in how to support families recovering from the cumulative stress of 

multiple deployments and rehabilitating from devastating injuries. The second area requiring improvement is 

the intra-United States medical evacuation system using C-130 aircraft. The vibration, noise, and cold make 

C-130 medical evacuation fl ights far less comfortable 

than those on C-17s. Intra-United States fl ights on the 

slower C-130 aircraft are long, as the fl ight from Joint 

Base Andrews to Fort Bragg could take 10 hours with 

stops at West Point, Fort Drum, Fort Benning, Fort 

Stewart, and Fort Gordon along the way. Evacuation 

to the Naval Medical Center, San Diego or Joint Base 

Lewis McChord could take a week with multiple stops 

where casualties remained overnight. Army senior leader involvement is required to effect this change with 

TRANSCOM.

Army Medicine should include the entire continuum of 

casualty care in the DOTMLPF-P domains and lessons 

learned process. Casualty care begins in garrison with 

development of a fi t and healthy force, continues in theater and ends in garrison with rehabilitation and reintegration. The collection of lessons learned should not 

focus only on battlefi eld care, but include those learned 

in hospitals, clinics, by support staff, and those crafting 

policies and programs. Warrior care should be addressed 

with the same systematic approach as a military operation. Finally, the expertise gained through hard work 

over years should be sustained by continuing to care for 

those severely injured rather than referring them to the 

Department of Veterans Affairs health care system.

The Dole-Shalala Commission noted that making signifi cant improvements in casualty care “requires a sense 

of urgency and strong leadership. The tendency to make 

systems too complex and rule-bound must be countered 

by a new perspective, grounded in an understanding of 

the importance of patient-centeredness.” We must consider this lesson as we prepare for the new challenges 

ahead.

REFERENCES

1. Priest D, Hull A. Soldiers face neglect, frustration 

at army’s top medical facility. Washington Post. 

February 18, 2007:A01.

2. Priest D, Hull A. Inside the Mologne House, survivors of war wrestle with military bureaucracy and 

personal demons. Washington Post. February 19, 

2007:A01.

3. Dole R, Shalala D. Serve, Support, Simplify: Report of the President’s Commission on Care 

for America’s Returning Wounded Warriors. 

Washington, DC: July 2007. Available at: http://

www.cnas.org/sites/default/files/Dole_Shalala_

July_30_2007report.pdf. Accessed February 22, 

2016.

4. West T, Marsh J. Rebuilding the Trust: Report on 

Rehabilitative Care and Administrative Processes 

at Walter Reed Army Medical Center and National 

Naval Medical Center. Washington, DC: Independent Review Group. April 2007.
76 http://www.cs.amedd.army.mil/amedd_journal.aspx

5. Kizer K, McGowan M, Bowman S. Achieving 

World Class: An Independent Review of the Design 

Plans for the Walter Reed National Military Medical Center and the Fort Belvoir Community Hospital. May 2009. Available at: http://www.dtic.mil/

cgi-bin/GetTRDoc?Location=U2&doc=GetTRD

oc.pdf&AD=ADA519453. 

6. Ficke JR, Eastridge BJ, Butler FK, et al. Dis mounted complex blast injury: report of the Dismounted 

Complex Blast Injury Task Force. J Trauma Acute 

Care Surg. 2012;73(6suppl5):S520-S532.

7. Pain Management Task Force. Final Report: Providing a Standardized DoD and VHA Vision and 

Approach to Pain Management to Optimize the 

Care for Warriors and their Families. Washington, 

DC: Offi ce of The Army Surgeon General. May 

2010.

8. Mateczun J. Comprehensive Master Plan for the 

National Capital Region Medical: Creating a 

World-Class, Integrated Healthcare Delivery System in the National Capital Region. Washington, 

DC: Defense Health Board; April 2010.

9. Carino M. Presentation on Emerging Medical 

Trends. Washington, DC: Offi ce of The Army Surgeon General. Data source: April 2011. Amputee 

Patient Care Service, WRAMC.

AUTHOR

MG Jones is Commanding General, AMEDD Center 

& School, US Army Health Readiness Center of Excellence, and Chief, US Army Medical Corps, Joint Base 

San Antonio-Fort Sam Houston, Texas.

WOUNDED WARRIOR CARE
April – September 2016 77

As you know, you go to war with the Army you have. 

They’re not the Army you might want or wish to have

at a later time.

Secretary of Defense Donald Rumsfeld1

Although this quote by Secretary Rumsfeld may evoke 

considerable criticism and debate, more importantly 

his words should help us focus our attention to make 

certain that our future fi ghting forces are well trained, 

resourced, and equipped to respond to its nation’s call 

for action, whether in peacetime or at war. In order to 

meet this goal, however, it is critically important that 

the lessons learned from prior confl icts be preserved, 

documented, and taught to future generations. Nowhere 

is this more important than within the Military Healthcare System (MHS), whose fundamental mission is to 

assure the readiness of its military forces 2

 and to ensure 

that the existing healthcare system has both the capacity 

and the competency to ensure that service members and 

their families receive the highest quality of care. This is 

particularly true for those who have sustained combat 

related injuries; or, as President Abraham Lincoln described in his second inaugural address, “to care for him 

who shall have borne the battle.”3

 In fact, evidence suggests that independent of what Army you might go to 

war with, the expectation of the American public is that 

those men and women who place themselves in harm’s 

way in defense of this nation receive only the highest 

quality of medical care available.4

Over the past decade, tremendous advances have taken 

place in the acute resuscitative trauma care, changes to 

combat medical tactics, techniques, and procedures, and 

systemic improvements in medical response to battlefi eld polytrauma, along with the rapid evacuation of 

combat casualties. Coupled with the protection provided 

by enhanced body armor, these changes have resulted 

in historically high survival rates.5,6 Mortality rates 

have been reduced from approximately 24% in the Vietnam confl ict to approximately 20% in Operation Iraqi 

Freedom and Operation Enduring Freedom (OIF/OEF). 

Survivability of those injured on the battlefi eld is at an 

unprecedented historical level of 90%, compared with 

84% in Vietnam and 80% in World War II.7

 Survival on 

the battlefi eld, however, is just the fi rst step. The MHS 

should be committed to not just helping service members “survive” after injury, but to “thrive” as they recover from their wounds and reintegrate with their military 

units and among family, friends, and communities. This 

is particularly true for those combat casualties who are 

challenged with overcoming signifi cant physical, cognitive, or psychological impairments. This capability is 

especially relevant and important for those who have 

sustained severe blast injuries, such as those described 

by the Army Dismounted Complex Blast Injury Task 

Force.8

The term “rehabilitation” can be used in many different 

contexts, but in healthcare, the term is generally used 

when discussing the programs or processes for returning an individual to health after an injury, illness, or 

addiction. More specifi cally, “rehabilitation medicine” 

refers to the evaluation, diagnosis, and management of 

Rehabilitation of the Combat Casualty:

 Lessons Learned from Past and

 Current Conflicts

 COL (Ret) Paul F. Pasquina, MC, USA

 COL (Ret) John C. Shero, MS, USA

ABSTRACT

The fi eld of rehabilitation is deeply rooted in military medicine, especially in promoting the restoration of function 

and community reintegration of injured service members returning from war. Since military operations began in 

Iraq and Afghanistan over a decade ago, rehabilitative care programs have been integral in supporting the Military 

Healthcare System in providing high quality comprehensive care for combat casualties and their families, particularly those with complex blast injuries resulting in conditions such as amputation and other limb dysfunction, traumatic brain injury, and spinal cord injury. Fundamental to a successful rehabilitation program is the coordination of 

interdisciplinary care that not only crosses multiple medical specialties and disciplines, but also promotes ongoing 

education, research, quality improvement and readiness. This brief article is intended to highlight some of the most 

important lessons learned from current and past confl icts in delivering the highest quality rehabilitative care to our 

nation’s heroes.
78 http://www.cs.amedd.army.mil/amedd_journal.aspx

individuals of all ages with a physical and/or cognitive 

impairment, to maximize recovery and quality of life. It 

is through rehabilitation and the restoration of functional 

independence that many individuals regain dignity and 

even discover personal growth, which can propel them 

to discover new meaning and purpose within their lives. 

Ultimately, rehabilitative efforts are not solely limited 

to achieving independence or adaptive strategies to promote daily functional activities, but to promote active 

participation in society and, whenever possible, return 

to active military service.

The fi eld of Rehabilitation Medicine is deeply rooted in 

military medicine, especially concerning the restoration 

of function and community reintegration of injured service members returning from war. Signifi cant advances 

in the diagnosis and treatment of numerous conditions 

have largely resulted from rehabilitation programs developed after World Wars I and II. Furthermore, technological advances after Vietnam, particularly in orthotics, prosthetics, and mobility aids have had a profound 

impact on the care of individuals with limb loss and 

neuromuscular disorders, not just in the military but 

also across the globe. Since combat operations began in 

Iraq and Afghanistan, military medicine has been at the 

forefront of advancing the knowledge of rehabilitation 

sciences. As the threat of terrorism continues to be of 

top priority for the United States, the military and public 

healthcare systems must be prepared to provide state-ofthe-science care to individuals suffering from the acute 

and chronic effects of terrorist-related injuries.9,10

Although rehabilitative care has been long considered 

to be the principal responsibility of the Department of 

Veterans Affairs,11 lessons learned during OIF/OEF and 

Operation New Dawn (OND) indicate the need for the 

MHS to maintain competence and capacity in providing rehabilitative care, particularly for combat casualties 

with complex blast injuries.8

 Service members exposed 

to blasts commonly sustain injuries to multiple organ 

systems. Injuries such as limb loss, soft tissue wounds, 

paralysis, traumatic brain injury, and vision and/or hearing impairment commonly happen in combination and 

are frequently also accompanied by complex pain and 

infection, as well as psychological complications such 

as depression, anxiety, and posttraumatic stress.12 It is 

therefore fundamental to provide aggressive and coordinated care for each of these conditions early in the 

acute setting, because not addressing these issues immediately may lead to secondary problems and poorer 

outcomes.13-16

Rehabilitative efforts are largely accomplished through 

the work of an interdisciplinary team of specialists 

representing a multitude of disciplines. These specialists employ an array of interventions, modalities, and 

assistive technologies to help maximize functional independence and successful reintegration or participation in 

society. Because of the complex nature and spectrum of 

needs of combat casualties, an expanded list of interdisciplinary team members is required to sustain wartime 

operations. An example of this list is provided in the 

Table. In addition, the patient and patient’s family are 

also vital members of the rehabilitative team and remain 

critical to the successful engagement of rehabilitation 

throughout the various phases of recovery. An individualized treatment plan can then be established with input from all team members, which addresses the unique 

characteristics of each patient. This also includes short 

and long-term goal setting with the team to reinforce 

treatment objectives, facilitate motivation, and measure 

outcomes.

Over the course of providing and overseeing rehabilitative care for thousands of combat casualties, the following lessons are offered for the reader to consider in 

maintaining both competence and capacity for the ongoing and future missions of the MHS.

LESSONS LEARNED

Rehabilitation Must Start in the Acute Care Setting

As reported by COL Paul Brown (MC, USA) regarding 

his experiences in Vietnam, rehabilitative interventions 

need to start as early as possible.17 The paradigm of 

waiting until all medical and surgical issues are stabilized or resolved before engaging rehabilitative services is fraught with complications and poorer outcomes. 

This is especially true for casualties with complex blast 

The Amputee Care Program is dependent upon an interdisciplinary team consisting of many specialties, an example 

of which is shown below. The specialists and a coordinated 

team approach are absolutely necessary to provide the highest quality of care and ensure that all needed services are 

readily available. 

Surgery (Access to Subspecialties) Behavioral Health

Physiatry Neuropsychology

Infectious Disease Social Work

Pain Management Peer Support

Nursing Nutrition

Physical Therapy Gait Lab

Occupational Therapy Database, IT support

Speech Language Pathology Public Affairs Office 

Prosthetics/Orthotics VA Counselors

Assistive Technology Vocational Rehabilitation

Sports/Recreational/Art Therapy Driving Rehabilitation

Physical Evaluation Board Liaison Offi cer Integrative Medicine

WOUNDED WARRIOR CARE
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THE ARMY MEDICAL DEPARTMENT JOURNAL

injuries, where the frequency of multiple comorbid injuries is high. It is well know that there are numerous negative effects of immobility, which early rehabilitation 

interventions can help mitigate. These negative effects 

include bone loss leading to osteopenia and osteoporosis, joint contractures which impair mobility and function, metabolic abnormalities, cardiovascular deconditioning, electrolyte and fl uid imbalances, orthostatic 

hypotension, muscle weakness and atrophy, skin breakdown and pressure ulcers, increased risk of infection, 

poor wound healing, and vascular thrombus formation. 

In addition to their adverse repercussions on functional 

recovery, all of these negative effects are also likely to 

lengthen hospital stays and subject patients to higher 

rates of morbidity and mortality. Furthermore, delays 

in engaging patients in therapeutic interventions to improve independence in activities of daily living, such as 

self-feeding, bathing, dressing, and toileting, or not assisting patients to be more functionally independent in 

terms of mobility with a wheelchair, prosthesis, or other 

assistive device, will likely also have profound negative 

effects on an injured service member’s psychological 

well-being, motivation, outlook on recovery, and quality 

of life. Therefore, when designing comprehensive care 

programs for combat casualties, the simultaneous delivery of state-of-the-science rehabilitative methods is as 

important as providing advanced medical, surgical, and 

behavioral health care.18,19

Nowhere is this better illustrated than in the combat casualty who sustains extensive blast injuries, as shown 

in Figure 1. Combat casualties often sustain multiple 

injuries, many requiring multiple surgical procedures 

over a protracted hospital course, during which time 

each of their associated injuries must be addressed simultaneously, in a coordinated fashion. Surgical reconstruction techniques for vascular, soft-tissue, and nerve 

repair have dramatically improved over the past decade 

and offer great hope in restoring function for even the 

most severely injured service members. Fortunately, the 

MHS has continued to invest in having some of the most 

highly trained surgical subspecialists to perform these 

techniques, not to just save lives, but preserve limbs 

and function. Their contributions to the care of combat 

casualties over the past decade have been enormous. 

Equally important to the mission, however, is the same 

investment in rehabilitative medicine. As illustrated in 

Figure 1, while this Wounded Warrior underwent multiple reconstructive procedures to save his upper limbs, 

our team simultaneously began extensive rehabilitation 

for his lower limb amputations. This rehabilitation care 

included preprosthetic education, mobility, and activities of daily living training, core and limb strengthening, 

range of motion exercises, wound management, residual 

limb care, and comprehensive pain management. Coupled with these interventions, were appropriate design, 

fi tting, and training for use of his wheelchair and prostheses, followed by extensive training in transfers, standing, 

balance, level ground ambulation, and eventual training on stairs, ramps, obstacle negotiation, running, and 

sports participation. All of these interventions happened 

simultaneously with his upper limb reconstruction and 

associated upper limb rehabilitation, which included 

scar management, neuromotor recovery facilitation, 

muscle strengthening, range of motion exercises, as well 

as gross and fi ne motor training to perform functional 

Figure 1. A Wounded Warrior recovering from extensive 

blast injuries. As he underwent multiple reconstructive procedures to save his upper limbs, the specialist team began 

the extensive rehabilitation for his lower limb amputations. 
80 http://www.cs.amedd.army.mil/amedd_journal.aspx

activities of daily living. As illustrated in this case, combat casualties with limb loss often experience multiple 

complex challenges. Evidence suggests, however, that 

the implementation of a comprehensive rehabilitation 

care program is effective in improving outcomes.20

Centers of Excellence

While considerable debate may exist over the defi nition 

of what composes a “center of excellence,” there is little 

argument regarding their importance in delivering the 

highest quality of care to combat casualties. In response 

to the rehabilitative needs for injured service members 

from OIF/OEF within the Extremity Trauma and Amputation Center of Excellence (EACE), several advanced 

rehabilitation centers (ARC) have been established within the DoD system. Their coordinated efforts help support specifi c geographic regions within the United States 

in order to provide accessible, highly specialized care to 

the most complex patients. Given the complexities of the 

problems encountered by combat casualties, the integrated team includes physicians, nurses, medics, corpsmen, 

social workers, case managers, behavioral health providers, pain specialists, therapists, prosthetists, orthotists, 

technicians, plastic surgeons, dermatologists, ophthalmologists, audiologists, pharmacists, and dentists across 

numerous disciplines who must collaborate to provide 

interdisciplinary care. In addition to healthcare providers, numerous support structures must be in place within 

the institution to ensure access to expert intensive critical care and reconstructive surgery; highly specialized 

diagnostics; 3D printing and fabrication; state-of-the-art 

prosthetic and orthotic fi tting and adjustment; computer 

assistive accessibility for patients with vision, hearing, 

or extremity impairment; interventional pain suites to 

apply novel interventions for complex pain syndromes; 

highly sophisticated gait, motion analysis, and virtual 

reality platforms; as well as access to complementary 

and alternative medicine. Of equal importance to having trained and experienced providers with cutting edge 

technology is having engaged and effective leadership 

teams with supportive administrative staff. Unless the 

providers are resourced and supported appropriately by 

their leadership, effi cient and effective care cannot be 

delivered. Issues such as infection control policies, effi -

cient scheduling of operating rooms, logistical support to 

ensure supplies are delivered on time, along with timely 

and effi cient provider privileging and credentialing are 

all critical functions of the leadership within military 

treatment facilities (MTF). Facilitating these actions is a 

well-coordinated performance/quality improvement program. Having a mechanism where the members of the 

interdisciplinary team and leadership can meet regularly 

to critically evaluate what processes and interventions 

work well and which should be improved can greatly 

enhance the effectiveness and effi ciency of the care program. Ongoing performance/quality improvement programs are increasingly important during times of war, 

especially when the MTF experiences frequent staff 

turnover along with a continuous infl ux of casualties.

The importance of having access to highly specialized 

care cannot be overstated. The advanced rehabilitation 

centers and other centers of excellence in the MHS provide an environment for bringing specialists together and 

allowing them to work in a coordinated fashion, while 

also further developing their skills through collaborative 

experience. This can only be achieved by caring for a 

high volume of patients with similar complex problems. 

It must also be recognized that the complex set of problems commonly encountered by Wounded Warriors with 

limb loss and their families are unique and not often seen 

in civilian settings. For example, nearly all amputations 

that are performed in the United States in both civilian 

and Veteran Affairs affi liated hospitals are the result 

of vascular disease and/or diabetes, not from blast injuries. Further, most amputations performed in civilian 

hospitals are to the lower limb below the knee, whereas 

among our military amputee population, a signifi cant 

percentage of combat casualties sustained upper limb 

(≈20%), multiple limb (≈30%), and above knee (≈40%) 

amputations.21 Combat casualties with limb loss are 

also generally younger than their civilian counterparts, 

and the mechanism of blast injuries makes them more 

prone to develop complications, such as heterotopic ossifi cation (≈60%)22 as well as comorbid brain injury and 

psychological stress. In summary, the medical, surgical, 

rehabilitative, and behavioral health care needs of combat casualties are different than those generally seen in 

civilian practice, so without having centers of excellence 

within the MHS, expertise in their unique care requirements would not otherwise exist.

Centers of excellence bring medical experts together, as 

well as patients, families, and often former patients who 

serve as peer mentors. This construct is enormously 

powerful in promoting healing, recovery, and quality 

of life. There are tremendous benefi ts in the development of a therapeutic milieu for a group of Wounded 

Warriors going through their rehabilitation, recovery, 

and reintegration as a team. Military service members 

are trained to be part of a unit and function as a member of a team. After injury, they are taken from their 

combat team through medical evacuation and now must 

join another team—a team motivated to recover and 

rejoin the fi ght. Serving as a peer mentor allows team 

membership to continue, even after discharge. Our collective experiences during OIF, OEF, and OND within 

the MHS’s Advanced Rehabilitation Centers at Walter 

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THE ARMY MEDICAL DEPARTMENT JOURNAL

Reed National Military Medical Center (WRNMMC) 

in Bethesda Maryland, the Center for the Intrepid (CFI) 

in San Antonio, Texas, and the Comprehensive Combat 

and Complex Casualty Care (C5) program in San Diego, 

California, demonstrate the positive effect of having 

combat casualties who have successfully completed the 

program return to motivate others to do the same. Peer 

mentors motivate fellow Wounded Warriors throughout 

their rehabilitation. This is a very effective method of 

proving to those still in rehabilitation that there is life 

after injury and that they can also achieve great success, no matter what the challenge. Evidence supports 

this approach, as graduates of the program have consistently lauded their care and specifi cally described the 

peer support that they received as benefi cial.23

Role of Families and Nonmedical Attendants

Differentiating the MHS from the Veteran’s Healthcare 

Administration and other civilian healthcare organizations is the Department of Defense’s ability and authority to provide comprehensive care for the families of 

Wounded Warriors, independent of geographical boundaries. During OIF, OEF, and OND, DoD policy changed 

to allow family members or other designated nonmedical attendants (NMAs) to stay on the campus of MTFs, 

as well as receive a stipend to offset the cost of their 

missing work to stay by the side of their Wounded Warrior to assist them through their recovery. This unprecedented practice has had an enormously positive effect 

on the rehabilitation of Wounded Warriors. As previously reported in caring for Vietnam Veterans,14 promoting independence is critical to successful rehabilitation. 

Creating situations where an injured service member 

becomes dependent on a loved one for basic functions, 

such as feeding, dressing, and hygiene, can have a negative effect on self-esteem and motivation. While therapists work daily with patients to teach and train independent skills, reinforcement by family members during 

times when the patient is not in therapy can greatly enhance the effectiveness of rehabilitation. Having family 

members or NMAs participate in rehabilitation sessions 

with the Wounded Warrior has had substantial benefi ts. 

In addition, the importance of the support and love for 

the Wounded Warrior during an incredibly emotionally 

challenging time cannot be underestimated.

Access to Technology

A comprehensive discussion of all the technological advances that are currently available for Wounded Warrior 

care is beyond the scope of this article. In support of rehabilitation, however, the technological advances in diagnosis, therapeutics, and functional independence have 

been tremendous, even over the past decade. Advances 

in prosthetic sockets and components, such as computer 

controlled knees, ankles, and hands allow much greater 

functionality for individuals with limb loss. Microprocessor controlled variable dampening prosthetic knees 

(Figure 2) are able to sense how fast an individual is walking and adjust knee stiffness during stance and swing 

Figure 2. Microprocessor controlled variable dampening prosthetic knees are able to sense how fast an individual is walking and adjust knee stiffness during stance and swing phases 

of gait nearly instantaneously to accommodate a variable cadence.

Figure 3. Specialized motorized wheelchairs enable even 

those with severe physical impairments to more independently perform pressure reliefs, stand, transfer, and control.
82 http://www.cs.amedd.army.mil/amedd_journal.aspx

phases of gait nearly instantaneously to accommodate a 

variable cadence. Lighter weight materials allow service 

members to have access to ultralight, high performance 

wheelchairs that have been shown to reduce secondary 

problems, such as overuse shoulder, elbow, wrist, and 

hand injuries. Furthermore, currently available specialized motorized wheelchairs (Figure 3) enable even those 

with severe physical impairments to more independently perform pressure reliefs, stand, transfer, and control. 

Computer interfaces, tablet devices, and other technologies create greater opportunities for those with vision 

and hearing loss to communicate. Three-dimensional 

printing enhances reconstruction procedures for fabrication of customized devices for adaptive equipment. 

Finally, advances in virtual reality and simulation platforms create even more opportunities to enhance our 

diagnostic and therapeutic rehabilitative interventions.24

Clarifying Roles and Relationships Between

the DoD and Department of Veterans Affairs

Meeting the rehabilitative needs of injured service members during a time of war is not only a challenge to the 

DoD, but a challenge for the nation. Therefore, a strong 

partnership with the Department of Veterans Affairs 

(VA) as well as civilian organizations is important to 

expand the capacity of care for Wounded Warriors, particularly during a protracted war or when there is a high 

volume of casualties. Although expertise in various areas of rehabilitative medicine exists within civilian care 

settings, the DoD and VA are specifi cally resourced and 

trained to care for the complex issues pertaining to service members and Veterans. Understanding each other’s 

roles can help clarify patient movement within the 2 systems, as well as improve access to care and enhance effi -

ciencies in care delivery through resource sharing agreements. Finally, sharing lessons learned and partnership 

in education and research can act as a tremendous force 

multiplier. An example of this has been the partnership 

between WRNMMC, the Uniformed Services University of the Health Sciences and the Human Engineering 

Research Laboratories within the VA Pittsburgh Healthcare System. These entities have partnered to present 

quarterly state-of-the-science workshops over the past 

10 years, bringing nationally recognized experts in all 

aspects of rehabilitative medicine and science to share 

experiences and new discoveries to elevate the care of 

service members, families, and Veterans. Similar workshops and educational experiences have been organized 

by many other joint efforts between the DoD and VA, including those coordinated by the Defense and Veterans 

Brain Injury Center, Center for Integrated Pain Management, EACE, Vision and Hearing Centers of Excellence, 

and others.

While a detailed description of all the programs that exist between the DoD and VA in providing healthcare services for Wounded Warriors is beyond the scope of this 

article, several are worth noting. Of signifi cant importance is the relationship that exists between the designated 5 Polytrauma Rehabilitative Centers within the VA 

system and those within the DoD system (WRNMMC, 

CFI, and C5). In combination, these 8 complex patient 

care programs are distributed geographically throughout the United States and improve access to high quality 

care for combat casualties independent of the location of 

their home of record or duty station. Coordinating patient transfers from one facility to another is facilitated 

by embedded DoD and VA liaisons at each of these centers. Coordination between the 2 systems better meets 

the acute, subacute, and chronic care needs of Wounded 

Warriors, whether they remain on active duty or retire. To 

better facilitate patient movement between the DoD and 

VA systems, additional work is still needed to improve 

the interoperability between the 2 clinical information 

technology systems. This would signifi cantly enhance 

sharing of medical records, especially radiographic, 

laboratory, and pharmacy information. Throughout OIF, 

OEF, and OND, numerous service members and Veterans have moved back and forth between DoD and VA 

healthcare organizations. Sharing electronic medical 

records is important not only to facilitate continuity of 

care, but also to enhance patient safety.

Another important aspect of caring for combat casualties is navigating the medical disability process. Many 

injured service members remain on active duty after 

completing their rehabilitation. Many of these Wounded 

Warriors undergo medical review board evaluations to 

determine if they meet military medical retention standards. If they do, they return to duty status, although 

it may be with limitations due to permanent physical 

disabilities. For those who do not meet military medical retention standards, they may apply for a Continuation on Active Duty or Continuation on Active Reserves 

waiver, which would allow them to remain on active 

duty despite their medically disqualifying injury or disease. Unfortunately, there remains a cohort of Wounded Warriors who will be medically separated from the 

military, even though they would prefer to continue to 

serve. For these men and women, a system should be in 

place to conduct disability evaluations and compensation ratings in a manner that is both comprehensive and 

expeditious. Sharing resources between the DoD and 

VA is critical to accomplish this challenging mission. 

Medical compensation and life-long access to continued medical care for injuries sustained during war are 

important elements of the trust established between the 

WOUNDED WARRIOR CARE
April – September 2016 83

THE ARMY MEDICAL DEPARTMENT JOURNAL

nation and our volunteer military force. Since the majority of injured service members who go through the 

medical evaluation board (MEB) process are also actively engaged in rehabilitative services, rehabilitation 

processionals must be aware of the process and provide 

pertinent information to the patient and MEB providers. 

Because of the potential for perceived confl ict of interest, providers who are intimately involved with treating 

patients should not also be involved in the adjudication 

of medical compensation decisions. Lessons learned 

over the past decade indicate that independent providers 

should fulfi l this role within both the DoD and VA systems. Ideally, an integrated disability and compensation 

system should be established between the DoD and VA 

systems, with clear roles and responsibilities delineated 

to avoid confusion for providers and patients.

Promote Reintegration and Community Participation

A key aspect of recovery after war injury is returning to 

active participation. The term “participation” may mean 

different things to different people, but has been highlighted by the World Health Organization as an important aspect of International Classifi cation of Functioning, Disability and Health. Essentially it recognizes that 

quality of life is often dependent on an individual’s ability to be an active participant in society, either through 

vocation, avocation, volunteer work, or engagement 

with family and friends. Limitations to participation include such issues as a “nonaccessible” community with 

barriers to mobility, poor transportation systems, lack of 

communication aids or provisions for those with vision 

or hearing loss, as well as limited access to rehabilitative 

services. These issues become very relevant in caring 

for Wounded Warriors, particularly those with multiple 

complex injuries and resultant impairments. Therefore, 

active community reintegration programs are needed to 

care for combat casualties and should be well coordinated between the DoD and VA systems. Over the past 

decade, many of these programs were developed within 

the DoD system to meet the demands of our Wounded 

Warriors and their families. While it is clear that these 

services are a shared responsibility of both the DoD and 

VA, experience suggests the importance of their ongoing presence within the DoD system.

Peer support, adaptive sports and recreation, creative 

arts, and service dog programs have all been critical elements for many Wounded Warriors during their 

fi rst steps towards successful community reintegration. These programs not only build opportunities for 

socialization and initial transition out of the hospital, 

but greatly facilitate confi dence building, motivation, 

and improved self-effi cacy, which are fundamental to 

the successful rehabilitation and recovery of injured 

service members. Disfi guring wounds, impaired mobility, psychological injuries (eg, posttraumatic stress, 

depression, anxiety) and loss of many normal bodily 

functions are extremely challenging for young service 

members, independent of their gender, race, or ethnic 

diversity. Therefore, programs that promote activities to 

help overcome these challenges continue to prove benefi cial in Wounded Warrior care. In fact, many of the 

national and international disabled athletic programs, 

adaptive sports and recreational activities, or great art 

contributions, have come from the efforts of Veterans of 

current or prior wars.

Similar to sports, creative arts, or other activity programs, 

Driving and Vocational Rehabilitation services are also 

fundamental for improving ultimate community participation for recovering Wounded Warriors. Adaptive 

devices for improving accessibility and independence 

in driving are often cited by many Wounded Warriors 

as one of the most important aspects of their care. The 

ability to drive decreases social isolation, promotes vocational and active life-roles within the community, and 

improves access to care for patients who need to return 

to medical facilities for ongoing rehabilitation, wellness 

visits, or complications that may arise. Vocational rehabilitation is also important and should be conducted by 

trained professionals who are skilled at both counseling 

and evaluating Wounded Warriors based on their interests, talents, and abilities. Vocational opportunities may 

include retraining, additional schooling, internships, or 

job placement with the appropriate adaptive devices or 

accommodations established to ensure success. Vocational rehabilitation counselors are not solely focused 

on fi nding a job for Wounded Warriors, but helping 

Wounded Warriors fi nd a career path that will be sustainable as well as professionally fulfi lling.

Finally, programs such as Project C.A.R.E.* (Comprehensive Aesthetic Restorative Effort) at Naval Medical 

Center San Diego (NMCSD) provide state of the art 

multidisciplinary medical and surgical care designed to 

reconstruct complex wounds, improve appearance, and 

enhance emotional recovery after trauma. The CARE 

Program is a highly specialized team of “restorative” 

disciplines including plastic surgery, dermatology, oral 

surgery, oculoplastic surgery, facial plastic surgery, and 

orthopaedic hand surgery. Together, they augment the 

MTF rehabilitation program by fi nding advanced solutions for the most severely injured Wounded Warriors. 

In addition to coordinating care and providing emotional 

support for patients and their families, the CARE team 

helps advance the art and science of restorative care 

*http://www.med.navy.mil/sites/nmcsd/Pages/Services/ProjectC-A-R-E.aspx
84 http://www.cs.amedd.army.mil/amedd_journal.aspx

through education, training, and research. This includes 

collaborating with civilian Centers of Excellence to facilitate hand and face transplantation, along with hosting an annual educational summit featuring military and 

civilian experts from around the world specializing in 

advanced prosthetics, tissue engineering, regenerative 

medicine, and other emerging technologies. The CARE 

Program at NMCSD is a cutting edge initiative, serving 

to break down recovery barriers and expedite the return 

of optimal form, function, and emotional wellbeing after 

injury to remove the fi nal barriers for Wounded Warriors 

to return to full community participation.

Ongoing Education and Research

Military medicine has a long-standing tradition in medical education and cutting edge research. To sustain warrelated combat casualty care for current and future confl icts, ongoing educational programs are necessary to 

meet competency and capacity demands, as well as for 

building tomorrow’s leaders of military medicine. Educational programs should support the entire spectrum 

of medical specialties and disciplines, ranging from 

the combat medic to highly specialized nurses, dentists, 

physicians, and therapists. These educational programs 

must address the unique and specifi c needs of the military through designated specialized curricula. Ongoing educational activities are important for staff within 

military treatment facilities, either within or outside 

the continental United States. Issues such as provider 

recruitment and retention must be continually assessed 

by leaders to ensure current and future capacity needs 

are met. Moreover, care and attention must be available 

for our caregivers. The stress of caring for Wounded 

Warriors, while also balancing one’s own physical, psychological, and emotional health, can be extremely challenging. It should also be recognized that most of the 

healthcare providers in uniform are also frequently deployed overseas during war, which only further contributes to the likelihood of excessive stress on caregivers. 

These factors should be recognized by peers and leaders 

at the local and national level—support programs can 

be extremely helpful in maintaining a healthy medical 

force.

The federal government invests a tremendous amount 

of resources each year in medical research. Institutes 

such as the National Science Foundation, National Institutes of Health, and others have been responsible for 

many breakthroughs in modern medicine and science. 

However, the DoD and VA also support critical ongoing 

research with the specifi c and explicit mission to focus 

on military and Veteran needs. Institutes such as the 

Army Medical Research and Material Command, Naval 

Medical Research Center, Defense Advanced Projects 

Agency, and Walter Reed Army Institute of Research 

are just some of the examples of DoD’s investment in 

advancing the protection and care of military service 

members. The efforts of these groups help sustain the 

military’s capabilities to perform both its wartime and 

peacetime healthcare missions, whether in prevention of 

disease, mitigation of injury risk, providing life or limb 

saving interventions on the battlefi eld, or developing 

novel prosthetic and orthotic devices.25 These entities 

collaborate with national and international partners to 

bring the best technology, equipment, and supplies to 

the warfi ghter. A correlate of these efforts is the anticipation of the military’s future needs. In terms of rehabilitation, much is already known about the long-term 

risks of sustaining a combat injury, particularly an injury that results in an amputation.26 Combat casualties 

with limb loss are at much greater risk for early morbidity and mortality, whether related to cardiovascular disease, diabetes, bone health, arthritis, or overuse injuries. 

Research efforts must therefore address the long-term 

medical challenges of caring for individuals with combat-related injury, by both mitigating their risks as well 

as discovering novel treatments. Regenerative medicine, 

robotics, neural-prosthetics, personalized medicine, and 

advanced diagnostics are just some examples of current fi elds of study in which investment will likely have 

an enormous impact on the future of healthcare. Given 

the relatively young age of our current Veterans from 

Iraq and Afghanistan, technologies that may be 20, 30, 

or even 40 years away from clinical implementation 

would still have a signifi cant impact on their health and 

well-being.

Embrace and Harness Public Support

Unlike prior reports from the Vietnam era, during the 

current confl icts the American public has been able to 

separate their political views of war from the injured 

Warrior. Over the last decade of treating combat casualties from OIF, OEF, and OND, our staff has not encountered anyone in our private or professional lives 

who was not sensitive to and supportive of the needs of 

our Wounded Warriors. Currently there are numerous 

federal and state-sponsored programs, as well as countless nonprofi t organizations that have been established 

to help Wounded Warriors. Despite this, however, enormous challenges still exist for individuals with disabilities (military and civilian) to obtain the same access to 

care, technologies, or employment as their able-bodied 

counterparts. Part of the challenge, therefore, is fi nding 

ways to increase awareness of the support programs that 

currently exist for those in need. Many nonprofi t groups 

and private donors are well-positioned to help enhance 

care programs for Wounded Warriors. While their support should be embraced, it cannot happen without local 

WOUNDED WARRIOR CARE
April – September 2016 85

THE ARMY MEDICAL DEPARTMENT JOURNAL

leaders establishing policies and procedures to ensure 

that all legal requirements are met. Issues such as a perceived DoD endorsement of one private organization 

over another create signifi cant challenges for personnel trying to coordinate Wounded Warrior care. While 

these challenges may be substantial, the benefi ts regularly outweigh the risks.

In addition, given the public’s interest in our Wounded Warrior needs, frequent media requests are often 

made to MTFs and providers. Department of Defense 

providers must be reminded that their words or actions 

represent the overall institution, not just themselves. 

Therefore, a skilled public affairs offi ce/offi cer should 

be part of the staff of any MTF responsible for caring 

for Wounded Warriors. While managing all media invitations/requests may be overwhelming and challenging, 

in general they should be embraced by the DoD. Media 

requests should be treated as part of the constant effort 

to improve awareness of the challenges Wounded Warriors face, and also as an inspiration and demonstration 

to the nation and our allies of the incredible courage, 

spirit, and resilience of our Nation’s Heroes.

REFERENCES

1. Kristol W. The Defense Secretary we have. Washington Post. December 15, 2004;A33.

2. Evans P. Strategy Management in the Military 

Health System: Achieving the Quadruple Aim. 

Washington, DC: Offi ce of Strategy Management, 

Offi ce of the Assistant Secretary of Defense for 

Health Affairs; 27 July 2010. Available at: https://

www.meprs.info/fi les/2010_presentations/Quadru

ple_Aim.ppt. Accessed February 29, 2016.

3. Lincoln A. Second Inaugural Address of Abraham 

Lincoln. New Haven, CT: Lillian Goldman Law Library, Yale University; March 4, 1865. Available at: 

http://avalon.law.yale.edu/19th_century/lincoln2.

asp. Accessed February 29, 2016.

4. Burgess L, Shane L. Army Secretary Francis J. 

Harvey resigns amid Walter Reed fallout. Stars 

and Stripes. March 2, 2007.

5. Gerhardt R, De Lorenzo R, Oliver J, Holcomb 

J, Pfaff J. Out-of-hospital combat casualty care 

in the current war in Iraq. Ann Emerg Med. 

2009;53:169-174.

6. Ling G, Rhee P, Ecklund J. Surgical innovations 

arising from the Iraq and Afghanistan Wars. Annu 

Rev Med. 2010;61:457-468.

7. Holcomb JB, Stansbury LG, Champion HR, Wade 

C, Bellamy RF. Understanding combat casualty 

care statistics. J Trauma. 2006;60:397-401.

8. Carvalho J. Dismounted Complex Blast Injury Report of the Army Dismounted Complex Blast Injury 

Task Force. Fort Sam Houston, TX: The Army Surgeon General; June 18, 2011.

9. Foster D. Preparing for the next terrorist attack in 

America [internet]. American Military University; 

October 1, 2015. Available at: http://inhomelandse

curity.com/preparing-for-the-next-terrorist-attackin-america/. Accessed November 15, 2015.

10. Pasquina PF, Scoville CR, Belnap B, Cooper RA. 

Introduction: developing a system of care for the 

combat amputee. In: Lenhart MK, ed-in-chief. 

Textbook of Military Medicine: Care of the Combat Amputee. Washington, DC: Borden Institute, 

2009:1-18.

11. MacLennan D, Clausen S, Pagel N, Avery JD, Sigford B, MacLennan D, Mahowald R. Developing 

a polytrauma rehabilitation center: a pioneer experience in building, staffi ng, and training. Rehabil 

Nurs. 2008;33:198-204, 213.

12. Reiber G, McFarland L, Hubbard S, et al. Servicemembers and veterans with major traumatic limb 

loss from Vietnam war and OIF/OEF confl icts: 

Survey methods, participants, and summary fi ndings. J Rehabil Res Dev. 2010;47:275.

13. Mackay LE, Bernstein BA, Chapman PE, Morgan 

AS, Milazzo LS. Early intervention in severe head 

injury: long-term benefi ts of a formalized program. 

Arch Phys Med Rehabil. 1992;73:635-641.

14. Semlyen JK, Summers SJ, Barnes MP. Traumatic 

brain injury: effi cacy of multidisciplinary rehabilitation. Arch Phys Med Rehabil. 1998;79:678-83.

15. Pezzin L, Dillingham T, MacKenzie E, Ephraim 

P, Rossbach P. Use and satisfaction with prosthetic 

limb devices and related services. Arch Phys Med 

Rehabil. 2004;85:723-729.

16. McFarland L, Winkler S, Heinemann A, Jones M, 

Esquenazi A. Unilateral upper-limb loss: satisfaction and prosthetic-device use in veterans and servicemembers from Vietnam and OIF/OEF confl icts. 

J Rehabil Res Dev. 2010;47:299.

17. Brown P. Rehabilitation of the combat-wounded 

amputee. In: Burkhalter WE, Ballard A, eds. Orthopedic Surgery in Vietnam. Washington, DC: Department of the Army, Offi ce of the Surgeon General and Center for Military History; 1994:189-209.

18. Pasquina P. Optimizing care for combat amputees: 

experiences at Walter Reed Army Medical Center. 

J Rehabil Res Dev. 2004;41(3B):vii-xii.

19. Sayer NA, Cifu DX, McNamee S, Chiros CE, Sigford BJ, Scott S, Lew HL. Rehabilitation needs 

of combat-injured service members admitted to 

the VA polytrauma rehabilitation centers: the role 

of PM&R in the care of wounded warriors. PM R. 

2009;1:23-28.
86 http://www.cs.amedd.army.mil/amedd_journal.aspx

20. Doukas WC, Hayda R, Frisch HM, et al. The Military Extremity Trauma Amputation/Limb Salvage 

(METALS) Study: Outcomes of amputation versus 

limb salvage following major lower-extremity trauma. J Bone Joint Surg. 2013;95:138-145.

21. Extremity Trauma and Amputation Center of Excellence. Washington, DC: Department of Veterans 

Affairs and Department of Defense; 2015. Available at: http://www.health.mil/About-MHS/OtherMHS-Organizations/Extremity-Trauma-and-Amputation-Center-of-Excellence.

22. Potter BK, Burns TC, Lacap AP, Granville RR, 

Gajewski DA. Heterotopic ossifi cation following 

traumatic and combat-related amputations: prevalence, risk factors, and preliminary results of excision. J Bone Joint Surg Am. 2007;89:476-486.

23. Pasquina PF, Tsao JW, Collins DM, Chan BL, 

Charrow A, Karmarkar AM, Cooper RA. Quality 

of medical care provided to service members with 

combat-related limb amputations: report of patient 

satisfaction. J Rehabil Res Dev. 2008;45(7):953-960.

24. Isaacson BM, Swanson TM, Pasquina PF. The 

use of a computer-assisted rehabilitation environment (CAREN) for enhancing wounded warrior rehabilitation regimens. J Spinal Cord Med. 

2013;36:296-299.

25. Rasmussen TE, Rauch TM, Hack DC. Military trauma research: answering the call. Preface. J Trauma Acute Care Surg. 2014;77(3 suppl 

2):S55-S56.

26. Robbins CB, Vreeman DJ, Sothmann MS, Wilson 

SL, Oldridge NB. A review of the long-term health 

outcomes associated with war-related amputation. 

Mil Med. 2009;174:588-592.

AUTHORS

COL (Ret) Pasquina is Chair, Department of Physical 

Medicine & Rehabilitation, School of Medicine, Uniformed Services University of the Health Sciences, and 

Residency Program Director, Physical Medicine & Rehabilitation, Walter Reed National Military Medical Center.

COL (Ret) Shero is Director, DoD-VA Extremity Trauma 

and Amputation Center of Excellence.

WOUNDED WARRIOR CARE

A US Army Wounded Warrior injured in Iraq and a physical therapist at the Center for the Intrepid participate in the 15th Annual Around 

the World 5K Run at Lackland Air Force Base, Texas, May 7, 2007. Photo courtesy of the Center for the Intrepid.
April – September 2016 87

BACKGROUND

In 2006, the Joint Trauma System (JTS) established the 

Joint Theater Trauma System (JTTS) in Afghanistan with 

a hospital data collection system and a database (formerly the Joint Theater Trauma Registry, now the Department of Defense Trauma Registry), that was specifi cally 

designed to capture, consolidate, and analyze combat 

casualty care provided in deployed military hospitals (eg, 

combat support hospital). Data from this registry have 

subsequently produced evidence-based performance improvement recommendations that have optimized clinical practice guidelines, supported equipment and supply 

requirements, and ultimately advanced emergency and 

surgical care for severely and critically injured combat 

casualties. Throughout this process, there have been 44 

JTS clinical practice guidelines developed to improve 

care for combat casualties.1

 These efforts have contributed to survival rates as high as 98% for those arriving 

alive at military hospitals in Afghanistan,2

 however, it 

has been both tactical and medical efforts that have signifi cantly contributed to the reduction of case fatality 

rate to less than 10% for the entire confl ict.3

Performance improvement initiatives and implementation of lifesaving interventions during prehospital 

helicopter transport have also benefi tted from the availability of adequate data, particularly infl ight casualty 

care data. Notable was the study by Mabry and colleagues4

 that demonstrated survival benefi t in casualties who were transported and treated by critical care 

fl ight paramedics as compared to basic fl ight medics. As 

a result of this study, the US Army adopted the critical care fl ight paramedic as a standard for prehospital 

helicopter transport, and provided the commensurate 

funding, support, and training required to achieve this 

level of expertise. Additionally, infl ight blood transfusion protocols and capability were made available for 

prehospital helicopter transport.3

 As each prehospital 

helicopter transport unit developed their own format for 

documenting infl ight care, data points captured would 

subsequently vary from unit to unit. In response to this 

issue, the JTS developed and standardized a prehospital transport patient care record (PCR) and after action 

report (AAR) to improve data captured from infl ight 

casualty care.5

 The PCR data was then entered into an 

evacuation care database and also scanned into the patient record on the Theater Medical Data Store (TMDS).

During the confl icts in Afghanistan and Iraq, more than 

87% of US military combat casualty deaths occurred 

Battlefield Documentation of Tactical

 Combat Casualty Care in Afghanistan

MAJ John B. Robinson, SP, USA COL James J. Geracci, MC, USA

Michael P. Smith, NREMT MAJ Charlie D. Day, SP, USA

COL Kirby R. Gross, MC, USA COL (Ret) Russ S. Kotwal, MC, USA

COL Samual W. Sauer, MC, USA

ABSTRACT

Performance improvement is reliant on information and data, as you cannot improve what you do not measure. 

The US military went to war in 2001 without an integrated trauma care system to collect and analyze combat 

casualty care data. By 2006, the confl ict in Afghanistan began appreciating the capture and consolidation of 

hospital care documentation into the Department of Defense Trauma Registry. In contrast, a paucity of documentation has existed for prehospital or tactical combat casualty care (TCCC). Using the 75th Ranger casualty documentation model established in 2005, the Joint Trauma System developed a casualty data collection 

system for prehospital care using the TCCC Card, the TCCC After Action Report (AAR), and the Prehospital 

Trauma Registry. In 2013, this system was mandated for use by US forces in Afghanistan. The Joint Trauma 

System also created and deployed a prehospital team to be an integral part of the Joint Theater Trauma System 

in Afghanistan. This prehospital team provided prehospital training and facilitated prehospital data capture. 

Described and analyzed in this report are prehospital data captured in Afghanistan from 2013 to 2014 using the 

TCCC Card and the TCCC AAR.

PROGRAMMATIC IMPLEMENTATIONS TO IMPROVE HEALTH
88 http://www.cs.amedd.army.mil/amedd_journal.aspx

during the prehospital phase of care6 prior to arriving 

at a hospital with surgical capability, and it is in this 

phase of care that casualty care documentation is lacking. By the year 2007, more than 30,000 casualties had 

already resulted from the confl icts in Iraq and Afghanistan; however, less than 10% of these casualties had adequate prehospital documentation.7

 Although inherently 

diffi cult to capture, this “gap” in documentation was a 

signifi cant missing link in efforts to optimize combat 

casualty care. Without this requisite data, those dedicated to improving prehospital care are essentially hunting 

for solutions while armed with suboptimal evidence.7

 As 

more than 24% of prehospital deaths on the battlefi eld 

are categorized as “potentially survivable,”6,8 prehospital data capture is a must for global performance improvement of combat casualty care.

Having successfully refi ned its operations in Afghanistan, and having long recognized the gap in prehospital 

care and documentation, in 2013 the JTS developed and 

deployed a prehospital directorate for the JTTS in Afghanistan. In addition, novel data collection tools were 

developed for the capture, consolidation, and analysis of prehospital or Tactical Combat Casualty Care 

(TCCC).1,9-12 These tools included the TCCC Casualty 

Card, the TCCC After Action Report (AAR), and the 

Prehospital Trauma Registry (PHTR). All of these products use the MIST (mechanism of injury, injury, signs 

and symptoms, and treatment) format.

During the tactical fi eld care phase of TCCC, a TCCC 

Card is completed by the medical or nonmedical fi rst 

responder and attached to the casualty prior to transport to the next higher role of care. This provides critical treatment information to personnel providing care 

during transport, and to the medical team receiving the 

casualty at the hospital. In order to provide documentation of care in the medical record, the TCCC Card was 

scanned into the patient record on TMDS.

The more comprehensive TCCC AAR was also completed by the fi rst responder and submitted or transmitted to the JTTS within 72 hours of injury. The TCCC 

AAR has the same basic format and design as the TCCC 

Card but has more data entry points which provide for a 

more detailed report for analysis. The TCCC AAR affords the opportunity for senior medical providers to 

mentor fi rst responders on their prehospital care and to 

recognize the effect of providing such care in the context of the tactical environmental. From a performance 

improvement perspective, it is absolutely critical to 

know and understand the tactical situation when interpreting prehospital care documentation. Those who are 

experienced in tactical care can optimize feedback and 

insight. The TCCC AAR was entered into the PHTR, 

the exclusively performance improvement section was 

then removed, and only the injury and treatment section 

was scanned into the patient record on TMDS.

During 2013, JTTS personnel traveled throughout Afghanistan training medical leaders and fi rst responders 

on the new prehospital documentation system, starting fi rst at main forward operating bases (FOBs) with 

Role 3 and Role 2 medical treatment facilities, and then 

to smaller FOBs and combat outposts with only Role 

1 personnel. Additionally, the Commander, US Forces–

Afghanistan issued Fragmentary Order 13-139* in July 

2013 which mandated the use of the TCCC Card and the 

TCCC AAR for all combat casualties in Afghanistan.

Assessment of adequacy of prehospital care has historically been relatively subjective. We do not know if casualties have received the standard of care in accordance 

with the TCCC Guidelines at the point of injury. The 

analysis of data captured in TCCC Cards (Figure 1) and 

TCCC AARs (Figure 2) permit the initiation of critical 

performance improvement projects. These performance 

improvement projects will be presented in this report 

and will demonstrate the value of data capture and 

analysis. The JTTS prehospital team evaluated compliance with documentation and use of the TCCC Card and 

TCCC AAR. This team also provided “near real time” 

performance improvement feedback and recommendations to unit commanders, medical leaders, and fi rst responders using PHTR (Figure 3) data and analysis. This 

report describes those initiatives.

PERFORMANCE IMPROVEMENT PROJECT ONE

Methods

From July 1, 2013, to March 31, 2014, the patient records 

of all US military qualifi ed casualties were reviewed 

on TMDS for a TCCC card. The US Central Command 

Commander’s Daily Casualty Report was used to provide accurate casualty counts. Trauma casualties evacuated from prehospital to hospital care (from Role 1 to 

a Role 2 or Role 3) qualifi ed for TCCC Cards, TCCC 

AARS, and entry into the PHTR.

All qualifi ed TCCC Cards were categorized as legible 

if greater than 80% of the card could be read and understood. The number of data fi elds completed on the 

TCCC Card gave a percentage for completeness. Additionally, casualties evacuated out of theater were compared to their respective TCCC Card annotated evacuation precedence; “urgent,” “priority,” and “routine.”

PROGRAMMATIC IMPLEMENTATIONS TO IMPROVE HEALTH
April – September 2016 89

THE ARMY MEDICAL DEPARTMENT JOURNAL

Results

A total of 363 US military casualties qualifi ed for TCCC 

card reporting. Only 7% (24/363) had a TCCC card, of 

which 96% (23/24) were legible and 88% (21/24) were 

complete. Of casualties with TCCC cards, 92% (22/24) 

were battle injuries, and 8% (8/24) were nonbattle injuries (eg, motor vehicle collision). When the 18 casualties 

who were evacuated out of theater were compared to 

their respective TCCC card annotated evacuation precedence, it was noted that 72% (13/18) were urgent, 28% 

(5/18) were priority, and 0% (0/18) were routine.

Comment

Ninety three percent of casualties did not get a TCCC 

Card. When TCCC Cards are provided, they are generally legible and complete, and fi rst responders are triaging casualties correctly for evacuation.

PERFORMANCE IMPROVEMENT PROJECT TWO

Methods

Beginning in August of 2013, all qualifi ed TCCC AARs 

received by the JTTS prehospital team were entered 

into the PHTR. For the period October 1, 2013, to April 

30, 2014, the PHTR was queried for US casualty TCCC 

AAR compliance.

Results

Refer to Figure 4. From October 2013 to April 2014, total TCCC AAR compliance was 50% (93/186) with the 

last 4 months at 84% (57/68).

Comment

Compliance with TCCC AAR submission was directly 

related to JTTS staff efforts and coordination with the 

casualty chain of command. During this study time 

period, the US military initiated retrograde actions for 

the Afghanistan campaign, and enemy fi ghting tapered 

down during the winter months. Both of these factors 

contributed to a decrease in US military casualties, 

while JTTS prehospital team efforts and commander involvement most likely accounted for increased compliance with AARs.

Figure 1. Tactical Combat Casualty Care Card.
90 http://www.cs.amedd.army.mil/amedd_journal.aspx

PERFORMANCE IMPROVEMENT PROJECT THREE

Methods

The TCCC guidelines recommend specifi c analgesia 

medications—fentanyl, ketamine, and IV morphine—

for casualties in moderate to severe pain and do not recommend IM morphine.13 As many casualties who incur 

a gunshot wound or an amputation injury experience 

moderate to severe pain, from July 2013 to March 2014, 

the PHTR was queried to assess prehospital pain management in this casualty population within US military 

forces. Patients who were noted to be “unresponsive” on 

the AVPU scale were excluded.

Results

Refer to Figure 5. Of 49 casualties who met study criteria, 47% (23/49) did not receive analgesics in the prehospital fi eld setting. Additionally, 14% (7/49) of casualties 

who received analgesics received IM morphine which is 

not a recommended medication.

Comment

In contrast to TCCC guidelines, medics continue to be 

issued and use analgesics that are not recommended. 

Prehospital medical directors should issue and train 

their medics in accordance with current guidelines and 

standards for prehospital care on the battlefi eld.

PERFORMANCE IMPROVEMENT PROJECT FOUR

Methods

For hypothermia prevention, the TCCC guidelines recommend the use of the Ready Heat blanket with the heat 

refl ective shell (HRS). To assess compliance with this 

device, the PHTR was queried from July 2013 to March 

2014 identifying US military casualties who were treated with a hypothermia prevention device.

Results

Refer to Figure 6. Of 253 casualties who met study criteria, 51% (129/253) were treated with the Hypothermia Prevention and Management Kit, which contains 

the Ready Heat blanket with the HRS, and 4% (11/253) 

were treated using the Ready Heat blanket with the Blizzard blanket. The remaining 45% (113/253) of casualties 

were treated through improvised measures and did not 

receive the heat producing Ready Heat blanket.

Figure 2. Tactical Combat Casualty Care After Action Report.

PROGRAMMATIC IMPLEMENTATIONS TO IMPROVE HEALTH
April – September 2016 91

THE ARMY MEDICAL DEPARTMENT JOURNAL

Comment

Hypothermia in combination with coagulopathy and 

acidosis is designated the “lethal triad.” Blood loss can 

signifi cantly affect a patient’s ability to generate body 

heat, especially in the stressful combat environment. 

The TCCC guidelines recommend the use of the Ready 

Heat blanket with the HRS for combat casualties, and 

it should be made accessible during combat operations 

when possible.

PERFORMANCE IMPROVEMENT PROJECT FIVE

Methods

Eastridge and colleagues6 identifi ed 19% of potentially 

survivable prehospital deaths were due to junctional 

hemorrhage. Between January 1, 2013, and March 22, 

2014, 541 casualties were entered into the PHTR. The 

PHTR provided insight into the use of junctional tourniquets in the fi eld.

Results

The data from the PHTR query showed that 178 casualties had either been injured in the junctional region 

or did not have adequate control of extremity hemorrhage after application of a tourniquet. Nineteen of 

these 178 casualties required a massive transfusion. To 

ensure other sources of hemorrhage were not the source 

of blood loss, casualties with injuries to other body regions (6 patients) were excluded. This left a cohort of 

13 patients who demonstrated the potential need for a 

junctional tourniquet. In this group of 13 patients, only 

one (7%) was managed with a junctional tourniquet.14

Comment

Although the investigators could not quantitate the specifi c number, several of the casualties received care at 

locations that did not have junctional tourniquets available. Subsequently, the Army added a junctional tourniquet to medical sets.

GENERAL COMMENT

A survey conducted by Sauer and colleagues2 in Afghanistan in 2013 showed that deployed US military 

personnel confi rmed that they had received predeployment training, including TCCC card training: 88% of 

Figure 3. Joint Trauma System prehospital trauma registry.
92 http://www.cs.amedd.army.mil/amedd_journal.aspx

nonmedics had attended the Combat Lifesaver (CLS) 

course; 88% of medics had completed Brigade Combat 

Team Trauma Training, and 69% of medical offi cers 

had completed the Tactical Combat Medical Course or 

Combat Casualty Care Course. Additionally, 92% of 

US military personnel carried an Individual First Aid 

Kit containing a TCCC card which is usually prefi lled 

with the service member’s name, unit, and battle roster 

number as per unit standard operating procedure. The 

Commander, US Forces–Afghanistan issued an order 

in July 2013 directing the documentation of prehospital 

casualty care using the TCCC card and the TCCC AAR. 

However, even with trained end-users, TCCC card availability, and an order issued by the senior commander in 

Afghanistan, after 9 months the JTTS prehospital team 

still reported only 7% of prehospital casualty care had 

been documented to the patient record on a TCCC card. 

The missing element was leadership enforcement of the 

mandate.

McGarry and colleagues 15 conducted a study on whether there was a training defi ciency on using the TCCC 

Card by military medical providers at the Tactical 

Combat Medical Course (TCMC) course. Their study, 

conducted between January and April of 2013, demonstrated the contrary as their results showed prehospital 

medical documentation compliance of 99% (130 cards 

for 131 manikins) and accuracy of information of 83% 

(1300 of 1560 fi elds completed correctly).

Over a 2-year period, 60 midlevel and senior US Army 

Medical Department and Department of Defense medical trainers, many of whom were senior noncommissioned offi cers (NCO) with prior combat deployments 

as a front-line medic, were approached and asked why 

TCCC cards were not being used for prehospital documentation.* These medical trainers reported that the 

tactical situation—multiple casualties, rapid helicopter 

transport times, the need to complete the mission—was 

the main reason for the lack of documentation. The 

TCCC card was otherwise not considered a treatment 

priority as it does not directly contribute to saving a casualty’s life. Many of those interviewed also acknowledged that TCCC card completion is not an enforced or 

reportable event. As there are no consequences if the 

card is not completed, many also admitted to not even 

attempting to fi ll out the card during prehospital care.

Count

CasualƟ es

Treated

45% 

Improvised

51% Primary

Hypothermia

PrevenƟ on

Management 

Kit

4% Alternate:

Ready

Heat/Blizzard

20

0

40

50

30

60

10

Treated for Hypothermia Prevention No Ready Heat Blanket

TCCC Recommended

20

113

129

253

Figure 6. Hypothermia prevention using Tactical Combat Casualty Care recommended Ready Heat Blanket; July 2013–March 

2014.

Figure 5. Analgesia administered to amputation or gunshot 

would casualties not unconscious; July 2013–March 2014. Count

20

0

40

50

30

60

10

CasualƟ es Morph IV Ketamine Morph IM

(14%)

No Meds

(47%)

Fentanyl

Lozenges

49

23

11 10

7

3

Amp/GSW & AVPU>U No Meds TCCC Meds Not Recommended

Figure 4. Tactical Combat Casualty Care After Action Report 

compliance; October 2013–April 2014. Count

20

0

40

50

30

60

10

Nov

(45%)

Oct

(8%)

Dec

(48%)

Jan

(83%)

Feb

(95%)

Mar

(78%)

Apr

(69%)

49

4

38

17

31

15

24

20 22 21

9 7

13

9

Jan–Apr 84%

Casualties Reported TCCC AARs Submitted

*Author J. B. Robinson: conversations with NCO Instructors at the 

AMEDD Advance Leaders Course, Ft Sam Houston, TX, June 2014; 

Combat Casualty Care Course Instructor Course, Camp Bullis, TX, 

August 2014; 32D Medical Brigade Training Support Company 

Best Medic competition rehearsals at Camp Bullis, TX, October 

2014; Brigade Combat Team Trauma Training at Camp Bullis TX, 

March 2015; Soldier Medic Training Site, Camp Bullis, TX, May to 

September 2014.

PROGRAMMATIC IMPLEMENTATIONS TO IMPROVE HEALTH
April – September 2016 93

THE ARMY MEDICAL DEPARTMENT JOURNAL

There is no standard location or recommendation for 

TCCC Card attachment to the combat casualty. TCCC 

Card placement is left to the discretion of the individual units and thus will vary from unit to unit. The 

CLS Course Student Self Study Manual trains Soldiers 

to “attach the TCCC Card to the casualty or place the 

card in the upper left sleeve or the left trouser pocket of 

the casualty clothing.”16 In 2012, the Combat Casualty 

Care Course (C4) and TCMC courses trained Soldiers 

to tape the TCCC Card to the outside of the casualty’s 

hypothermia blanket.† The TCCC handbook does not 

indicate where the completed TCCC Card should be attached but does provide the alternative of using 3-inch 

white tape on the casualty’s chest and an indelible pen 

as an alternative to TCCC Card documentation.17 Additionally, in Afghanistan in 2014, it was noted that some 

units chose to annotate care information directly onto 

the casualty’s chest instead of using a TCCC Card.

By incorporating a standard location for attaching the 

TCCC Card to the casualty in the fi eld, those who transport casualties or receive them at a treatment facility can 

anticipate and expect the TCCC Card. Thus, ensuring 

the card does not get discarded with clothing, blankets, 

and dressings. Based on C4 course training observations and discussions with members of the Committee 

on Tactical Combat Casualty Care and the Department 

of Combat Medic Training, the TCCC Card should be 

attached to the casualty’s wrist or the ankle.

CONCLUSION

In respect to DOTMLPF (Doctrine, Organization, 

Training, Material, Leadership, Personnel, Facilities), 

and in contrast to those who believe that money and 

technology are the ultimate solutions to this problem, 

prehospital documentation and data capture is a Doctrine and Leadership issue. A mandate and policy for 

prehospital documentation and data capture, and the 

enforcement of this mandate through leadership, is required. Throughout most of the confl ict in Afghanistan, 

the US military has collected minimal prehospital data. 

Updated prehospital documentation tools and a prehospital trauma registry is now in place; however, command 

ownership and leadership enforcement of this process is 

a requisite for achieving success. Leaders are accountable for the tactical combat casualty care given to their 

wounded Soldiers; consistent documentation of this care 

will permit performance improvement to thrive.

REFERENCES

1. US Army Institute of Surgical Research. Joint 

Trauma System [internet]. Available at: http://

www.usaisr.amedd.army.mil/10_jts.html. Updated 

March 16, 2015. Accessed September 8, 2015.

2. Sauer SW, Robinson JB, Smith MP, et al. Saving 

lives on the battlefi eld (part II)–one year later a 

Joint Theater Trauma System and Joint Trauma 

System review of prehospital trauma care in Combined Joint Operations Area–Afghanistan (CJOAA) Final Report, 30 May 2014. J Spec Oper Med. 

2015;15(2):25-41.

3. Kotwal RS, Howard JT, Orman JA, et al. The effect 

of a golden hour policy on morbidity and mortality 

of combat casualties. JAMA Surg; 2016;151(1):15-24.

4. Mabry RL, Apodaca A, Penrod J, Orman JA, 

Gerhardt RT, Dorlac WC. Impact of critical caretrained fl ight paramedics on casualty survival 

during helicopter evacuation in the current war in 

Afghanistan. J Trauma Acute Care Surg. 2012;73(2 

suppl 1):S32-S37.

5. Nohrenberg JL, Tarpey BW, Kotwal RS. Data 

informs operational decisions: the tactical evacuation project. United States Army Aviation Digest. 

October-December 2014:17-19. Available at: http://

www.rucker.army.mil/aviationdigest/images/OctDec_100114.pdf. Accessed January 29, 2016.

6. Eastridge BJ, Mabry RL, Seguin P, et al. Death on 

the battlefi eld (2001-2011): implications for the future of combat casualty care. J Trauma Acute Care 

Surg. 2012; 73(6 suppl 5):S431-S437.

7. Eastridge BJ, Mabry RL, Blackbourne LH, Butler 

FK. We don’t know what we don’t know: prehospital data in combat casualty care. US Army Med Dep 

J. April-June 2011:11-14.

8. Kotwal RS, Butler FK, Edgar EP, Shackelford SA, 

Bennett DR, Bailey JA. Saving lives on the battlefi eld: a Joint Trauma System review of pre-hospital 

trauma care in Combined Joint Operating Area–

Afghanistan (CJOA–A) executive summary. J Spec 

Oper Med. 2013;13(1):77-85.

9. Kotwal RS, Montgomery HR, Mechler KK. A prehospital trauma registry for tactical combat casualty care. US Army Med Dep J. April-June 2011:15-17.

10. Kotwal RS, Montgomery HR, Kotwal BM, et al. 

Eliminating preventable death on the battlefi eld. 

†Combat Casualty Care Course, March Arch Surg. 2011;146(2):1350-1358. 2012, Camp Bullis, TX; Tactical Combat Medicine Course, July 2012, JBSA Ft Sam Houston TX.
94 http://www.cs.amedd.army.mil/amedd_journal.aspx

11. Kotwal RS, Butler FK, Montgomery HR, et al. The 

Tactical Combat Casualty Care Casualty Card: 

TCCC Guidelines Proposed - Change 1301. J Spec 

Oper Med. 2013;13(2):82-87.

12. Geracci JJ, Kotwal RS, Day CD, Bailey JA, Costello CN. Implementation of a Joint Trauma System 

Pre-hospital Trauma Registry in Afghanistan: 

Cracking the Code on Data Capture for Tactical 

Combat Casualty Care. Oral presentation at the 

Special Operations Medical Association Scientifi c 

Assembly; Tampa, Florida; December 2013; and 

the Military Health System Research Symposium; 

Fort Lauderdale, Florida; August 2014.

13. Butler FK, Kotwal RS, Buckenmaier CC 3rd, et al. 

A triple-option analgesia plan for tactical combat 

casualty care: TCCC guidelines change 13-04. J 

Spec Oper Med.2014;14:13-25.

14. Marcozzi D, Smith MP, Witte SM, Burrell E, Curtis RA, Gross KR. A 2013-2014 comparison of the 

potential benefi t versus actual use of junctional 

tourniquets in a theater of operations. Poster presented at : The Special Operations Medical Association Scientifi c Assembly; Tampa, Florida; December 2014.

15. McGarry AB, Mott JC, Kotwal RS. A study of prehospital medical documentation by military medical providers during precombat training. J Spec 

Oper Med. 2015;15:79-84.

16. US Army. Combat Lifesaver Course: Student Self 

Study Manual, Subcourse ISo0871. ed C. Ft Sam 

Houston, TX: US Army Medical Department Center & School; September 2013:7-18.

17. US Army. Tactical Combat Casualty Care Handbook. Ft Leavenworth, KS: Center for Army Lessons Learned; March 2012 No. 10-44:18. Available 

at: http://www.globalsecurity.org/military/library/

report/call/call_12-10.pdf. Accessed January 29, 

2016.

AUTHORS

MAJ Robinson is with the Mission Command Training 

program, Fort Leavenworth, Kansas.

Mr Smith is with Southern Illinois University Edwardsville, Edwardsville, Illinois.

COL Gross and COL (Ret) Kotwal are with the Joint 

Trauma System, US Army Institute of Surgical Research, 

Joint Base San Antonio Fort Sam Houston, Texas.

COL Sauer is Director, Joint Trauma System Strategic 

Programs, Naval Air Station, Pensacola, Florida.

COL Geracci is with the Offi ce of the Corps Surgeon, III 

Corps, Fort Hood, Texas.

MAJ Day is the Interservice Physician Assistant Program Coordinator, Irwin Army Community Hospital, 

Fort Riley, Kansas.

PROGRAMMATIC IMPLEMENTATIONS TO IMPROVE HEALTH
April – September 2016 95

Based on peer-reviewed literature, up to 25% of deaths 

on the battlefi eld were potentially preventable and most 

preventable deaths occurred in the prehospital environment. Further advances toward signifi cant improvements in combat trauma survival must occur at the point 

of wounding and during tactical operations. Strict adherence to the evidence-based Tactical Combat Casualty 

Care (TCCC) guidelines are proven to reduce morbidity 

and mortality on the battlefi eld, but full implementation 

across the entire force has been variable. Commitment to 

full implementation from both line and medical leadership continues to face ongoing DOTMLPF* challenges. 

This condition of variability has been described as “islands of excellence in a sea of mediocrity.” Two formal 

prehospital trauma care delivery assessments were conducted in Combined Joint Operations Area–Afghanistan 

(CJOA-A) by the US Central Command Joint Theater 

Trauma System (JTTS). The fi rst occurred in November 

2012 followed by the second from December 2013 thru 

January 2014. During the second assessment, the JTTS 

Prehospital Division directly interviewed deployed prehospital providers, medical leaders, and combatant leaders at 26 deployed locations while physically examining 

the available equipment and discussing the reviewed 

unit’s techniques, tactics, and procedures related to 

TCCC. It was notable that signifi cant progress had occurred between the 2 assessments with the establishment 

of a Prehospital Care Division within the JTTS, development of a prehospital trauma registry, weekly prehospital 

trauma conferences, and CJOA-A theater guidance and 

enforcement of prehospital documentation. Specifi c national level prehospital trauma care achievements include 

expansion of transfusion capabilities forward to the point 

of injury, junctional tourniquets, and universal approval 

of tranexamic acid. However, without the enforcement of 

centralized doctrinal and policy endorsements, the military services and their subordinate prehospital trauma 

care delivery organizations continued to struggle to adequately and fully organize, train, and equip their forces 

to meet TCCC guidelines. Among other issues, this variability in capability and implementation as evidenced in 

a lack of adoption of the TCCC’s recommended triple 

option analgesia, contraindicated medical material for 

traumatic eye care, and a lack of universal compliance 

with US Forces Fragmentary Orders concerning TCCC 

care delivery. Additionally, 27% of licensed prehospital care delivery medical leaders had not completed the 

Combat Casualty Care Course or training such as the 

Tactical Combat Medical Care Course. Finally, 12% 

of the supervising licensed healthcare medical leaders 

stated that there were TCCC recommended skills that 

they would neither train nor allow their enlisted medical 

personnel to provide. Among conventional US forces in 

the entire CJOA-A, only a single Role I had fully implemented the TCCC guidelines with all the necessary materials and scope of practice. These fi ndings existed despite a standing memorandum and recommendations by 

the Assistant Secretary of Defense for Health supporting the incorporation of the published TCCC guidelines 

into both training and practice. In contrast, US Special 

Operations Command and US Army Special Operations 

Command have codifi ed TCCC compliance as policy 

and reduced prehospital case-fatality rates. Also noted 

across multiple medical leadership levels were partial rejection or nonconcurrence and nonsupport of the TCCC 

guidelines. The evaluating team’s interactions with these 

leaders indicated the presence of a culture driven by hospital-based experiences and decision-making affected 

the capability of combat health care delivery at the organizational and unit level. Without understanding the 

unique nature of prehospital combat realities, this culture is unsuitable for ensuring a highly reliable delivery 

of fi eld and combat medical care to our wounded. The 

team believed that this culture directly led the both the 

intentional and unintentional degradation of trauma care 

delivery in the theater among conventional forces:

1. The lack of standardized TCCC capability may represent a causal factor for the increased number of 

service members killed in action and of preventable 

Abstract: Lessons Learned,

 Saving Lives on the Battlefield

 COL Samual W. Sauer, MC, USA

This abstract summarizes information presented to the Defense Health Board–Federal Committee to the Secretary of 

Defense, August 11, 2014, in Falls Church, Virginia, and later published in the Journal of Special Operations Medicine: 

Sauer SW, Robinson JB, Smith MP, Gross KR, Kotwal RS, Mabry RL, Butler FK, Stockinger ZT, Bailey JA, Mavity ME, 

Gillies DA 2nd. Saving Lives on the Battlefi eld (Part II) One Year Later A Joint Theater Trauma System and Joint Trauma 

System Review of Prehospital Trauma Care in Combined Joint Operations Area Afghanistan (CJOA-A) Final Report, 30 

May 2014. J Spec Oper Med. 2015;15(2):25-41.

*Doctrine, organization, training, materiel, leadership & education, 

personnel, facilities
96 http://www.cs.amedd.army.mil/amedd_journal.aspx

deaths, and the increased case-fatality rate seen in 

conventional forces when compared with Special 

Operations Forces.

2. Absent a validated joint requirement which is captured doctrinally, the prevailing resource-constrained environment will challenge military services to fully organize, train, and equip to TCCC 

standards.

3. There is no evidence that the DoD or CJOA-A has 

policies or procedures in place to validate or enforce 

prehospital care within an organization. Servicespecifi c doctrine requiring unit surgeons to each 

establish a standard of care allows for variant, nonstandard delivery of battlefi eld trauma care across 

the force. Furthermore, even within a single command, rotation of unit surgeons introduces and magnifi es discontinuity of unit trauma-care standards.

4. The requirements to perform and support prehospital TCCC could be standardized across the military services (universally or at the combatant command level) with the specifi c means to achieve these 

train-and-equip standards left up to the respective 

services.

5. As with elements of prehospital care, organization 

structures are highly variant, with a number of atrisk forces not having adequately manned/trained/

equipped medical support.

6. Units with a tactical evacuation mission requirement should be task organized to be able to provide 

advanced en route resuscitative care from the point 

of injury.

7. Robust training platforms exist for prehospital trauma care, though not all course syllabi keep pace 

with current best practices. Suffi cient information 

technologies exist to rapidly and widely disperse 

new TCCC guidelines as they become immediately 

available.

8. Unit equipment sets and supporting medical logistics systems have not kept pace with evolving 

prehospital care TCCC guidelines. Outdated items 

remain within the supply chain and newly required 

items have not yet been incorporated into standard 

confi gurations.

9. In the absence of a widely mandated policy that establishes TCCC guidelines as the standard for prehospital battlefi eld care and accountability for deviations from this standard, the degree of penetrance 

and acceptance of TCCC guidelines will remain episodic and dependent upon individual (surgeon and 

commander) commitment.

10. Neither line nor operational medical leaders are optimally prepared to recognize the importance of a 

robust prehospital care system or equipped with the 

requisite knowledge, skills, or experience to build or 

sustain such a system within their unit.

We must continue to embrace and explore emerging capabilities to deliver far-forward resuscitative care. History teaches that the lessons we have learned regarding 

combat casualty care may be lost if we fail to attend 

to them in the coming years. Even in a resource-constrained future, the Military Health System has the necessary personnel, organization, and experience to retain 

and refi ne our current best practices. With continued 

efforts aimed at (1) formalizing TCCC Guideline compliance across the force, (2) embracing evidence-based 

methods to continually improve upon these guidelines, 

and (3) selecting, developing, and retaining operational 

medical personnel dedicated to prehospital trauma care, 

the Military Health System will ensure an organizational 

culture that fully embraces prehospital combat casualty 

care as a core competency. We have a moral obligation 

to ensure that the advertised and expected capability is 

present at the point of injury for our service members.

COL Sauer is Director, Trauma Care Delivery, Joint Trauma System, DoD Center of Excellence for Trauma. He is stationed 

at the US Naval Air Station, Pensacola, Florida.

PROGRAMMATIC IMPLEMENTATIONS TO IMPROVE HEALTH
April – September 2016 97

More than 330,000 service members serving on active 

duty during Operations Iraqi Freedom (OIF), Enduring 

Freedom (OEF), and Noble Endeavor (OND) have experienced a traumatic brain injury (TBI) since 2000.1

When the confl icts in Iraq and Afghanistan began, the 

military medical community did not fully recognize 

the effect that improved body armor and combat vehicle modifi cations would have on traumatic brain injury—these advances in military armor decreased the 

incidence of moderate and severe TBI in comparison to 

previous military confl icts. The majority of TBIs in the 

US military are classifi ed as mild (82.4%) and the remaining 17.6% categorized as moderate (8.5%), severe 

(1.0%), penetrating (1.5%), or other (6.6%).1

 The early 

recognition of TBI ensures that prompt treatment is initiated and maximizes the chances for a full recovery.2

Military and Veterans Affairs medical practitioners rely 

on published guidance by the civilian medical community to aid them in the diagnosis, treatment, and return 

to activity decisions following TBI. It is imperative to 

understand how the military medical community translates the strongest medical and scientifi c evidence, expert opinion, and military experience (including combat) into timely and usable clinical tools to enable providers to offer the best care for TBI.

The Defense and Veterans Head Injury Program, later 

renamed Defense and Veterans Brain Injury Center 

(DVBIC), was established by Congress in 1992 to enable 

research, treatment, training, and rehabilitative services 

for care of head injury as the Department of Defense 

(DoD) TBI Center of Excellence. Congressional mandates for care and reporting of concussion required setting a standard of care for the deployed setting that was 

evidence-based with special consideration of operational requirements and capabilities. Since 2012, DVBIC has 

served as the TBI operational component of the Defense 

Centers of Excellence (DCoE) for Psychological Health 

and Traumatic Brain Injury. In 2006, the DoD recognized the need for systematic guidelines for screening, 

diagnosis, and symptom management following acute 

concussion (Concussion Management in Deployed Setting/Concussion Management Algorithm (CMA)).3

 The 

congressional mandate for care and reporting of concussion required setting a standard of care that was 

evidence-based for the deployed setting with special 

consideration of operational requirements and capabilities. This included the development and implementation 

of the Military Acute Concussion Evaluation (MACE)4

and the In-Theater Clinical Practice Guidelines.5

 Medical surveillance data from DoD as well as existing medical literature identifi ed mild TBI/concussion as having 

increased incidence with several associated symptoms 

requiring improved monitoring and management. Feedback from in-theater medical providers indicated that 

the previous version of the CMA was too complex, too 

diffi cult to read, and was not being widely implemented. 

Additionally, at that time, guidance for management of 

Traumatic Brain Injury Clinical

 Recommendations: Impact on

 Care and Lessons Learned

 COL Sidney R. Hinds II, MC, USA

 Scott C. Livingston, PhD, PT, ATC, SCS

ABSTRACT

Over 330,000 service members have been diagnosed with traumatic brain injury (TBI) since 2000. The Defense 

and Veterans Brain Injury Center (DVBIC) is uniquely positioned to identify knowledge gaps and disseminate 

information related to TBI to assist service members, clinical providers, and military families. The DVBIC utilizes a standardized process based on Institutes of Medicine and World Health Organization recommendations for 

the development of evidenced-based clinical guidelines. This presentation provided an overview of the need and 

process for developing TBI-specifi c clinical recommendations (CRs) related to diagnosis and treatment issues, and 

the lessons learned throughout their development. The development of CRs provides evidence-based, standardized 

guidance for symptom management and treatment recommendations following TBI. Included within the DVBIC 

process are site-specifi c adjustments that address the needs and requirements of our military stakeholders, including 

the operational challenges of the deployed setting. The identifi cation of the need for TBI diagnosis and treatment 

guidelines within the Military Health System and the consideration of military service-specifi c and Department of 

Defense policy are integrated within an evidenced-based, systematic CR development process.
98 http://www.cs.amedd.army.mil/amedd_journal.aspx

concussion was only available for the subacute phase 

(less than 7 days) in the VA/DoD Clinical Practice 

Guidelines.6 As a result, developing and updating clinical 

recommendations (CRs) based on these identifi ed needs 

from the fi eld became a priority for DVBIC. The issuance of Directive-Type Memorandum (DTM) 09-0337

in June 2010 by the Deputy Secretary of Defense and 

later DoD Instruction 6490.118

 (which replaced DTM 

09-033) in September 2012 directed mandatory processes for identifying those service members involved in potentially concussive events (ie, exposed to blast, vehicle 

collision, witnessed loss of consciousness, or other head 

trauma) to be screened for TBI. These new requirements 

for deploying units marked a signifi cant transition from 

symptom-driven reporting to incident-driven reporting 

of suspected TBI. Incident-driven screening clarifi ed for 

unit leadership and medical personnel all those personnel needing formal concussion screening. The desired 

result of this DoD guidance is the mitigation of the effects of potential concussive events on service member 

health, readiness, and ongoing operations, directly in 

keeping with a fundamental principle of patient care: 

early identifi cation leads to early diagnosis, early treatment, and the best possible outcomes.

As the TBI operational component of DCoE and DoD’s 

TBI CoE, DVBIC optimizes clinical care by combining 

evidence from medical literature, health care research, 

and expert opinion to develop and provide clinical 

guidelines to help military and VA healthcare providers 

deliver evidence-based treatment and address the challenges associated with TBI. Clinical guidelines for the 

management of conditions such as TBI can be classifi ed 

as clinical practice guidelines (CPGs) or CRs. The Institute of Medicine (IOM) defi nes CPGs as:

Statements that include recommendations intended to 

optimize patient care which are informed by a systematic 

review of evidence and an assessment of the benefi ts and 

harms of alternative care options.9

CPGs are trustworthy guidelines which are based on a 

systematic review of the evidence, are developed by a 

panel of multidisciplinary experts, provide a clear explanation of the logical relationships between alternative care options and health outcomes, and provide ratings of both the quality of evidence and the strength of 

the recommendations. In comparison, CRs are defi ned 

as a systematically developed clinical guidance that 

provides evidence-based recommendations, including 

consensus, to guide the practitioner in the identifi cation 

and treatment of specifi ed clinical diagnoses, process, 

or procedure.* Clinical recommendations are developed 

t o fi ll an identifi ed gap in knowledge or to provide clinical guidance for diagnosis, treatment, and evaluation of 

medical conditions. They promote evidence-based practice and standardized care, and they provide a mechanism for rapid translation of knowledge into clinical 

practice in the form of timely and practical clinical recommendations, a critical need for practitioners and leaders throughout the Military Health System (MHS). Consistency in development of CRs has advanced DVBIC 

participation and value within the MHS and its community of practitioners.

The development process for CRs includes 4 initial main 

steps as defi ned by the IOM9

 and the World Health Organization10: (1) identify and defi ne a clinical problem, 

(2) develop systematic reviews, (3) assemble a working 

group to develop clinical recommendations through 

appraisal of evidence and incorporate expert opinion, 

patient preferences and characteristics, and (4) use the 

guidance to make better informed decisions to improve 

health outcomes. Gaps or needs are identifi ed through 

various means including the military (stakeholders), 

Quad Services Working Group (WG), government reports (such as the IOM or RAND Corporation), and current research. Requests may also come from the armed 

services, gap analyses, RAND studies, DVBIC/DCoE 

as the managers of the TBI Pathway of Care, or established committees and task forces. The DVBIC Clinical 

Affairs Division, Clinical Practice and Clinical Recommendations Offi ce conducts ongoing reviews of existing products within the VA Health System, DCoE, and 

DVBIC to determine need for a CR, conducts a business case analysis once a need is identifi ed, and determines an appropriate course(s) of action(s). A CR working group is established and includes representation 

from all services (Army, Navy, Air Force, Marines) and 

key government agencies (DCoE, Deployment Health 

Clinical Center, Center for Telehealth and Technology, 

National Intrepid Center of Excellence, Force Health 

Protection & Readiness/DHA Health Care Operations, 

US Central Command, and the VA) as well as subject 

matter experts from the civilian nongovernment sector. 

Consultants from civilian academia and research as well 

as the military are invited to participate in CR working 

groups. These working groups are multidisciplinary and 

well balanced with representation from all populations 

expected to be affected by the guidelines. 

The next step in the CR development process is the 

identifi cation of an internal DVBIC project team; this 

*Internal DoD documents not readily accessible by the general public:

Standard Operating Procedure. Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury

Standard Operating Procedure. Defense and Veterans Brain Injury Center

PROGRAMMATIC IMPLEMENTATIONS TO IMPROVE HEALTH
April – September 2016 99

THE ARMY MEDICAL DEPARTMENT JOURNAL

includes an action offi cer, co-action offi cer, DVBIC 

Clinical Affairs and Education Division representatives, VA liaison, and component center representatives 

as appropriate. The WG conducts systematic reviews 

and evidence synthesis related to the TBI-specifi c topic 

(eg, sleep management following mild TBI). A literature review is conducted as part of an ongoing process 

throughout the development stage. The DVBIC Research 

Division conducts a literature search using set terms applied to databases of nationally and internationally recognized organizations to obtain research-based support 

documents. Additional military-specifi c information is 

reviewed from surveillance data. Identifi cation of key 

clinical questions is used to guide the development of 

the CR. The evidence is appraised and incorporated 

into expert opinion, patient preferences and characteristics toward answering the key clinical question(s) related to the CR topic. A meeting summary is produced 

that refl ects the discussions and agreements within the 

group for clinical questions when there is a gap in the 

literature or weak evidence to support a recommendation. The Core WG develops specifi c guidelines into a 

draft CR narrative document. The outcomes of these 

expert discussions and agreements during the meeting 

are incorporated into the CR narrative paper. The draft 

CR includes 4 elements: (1) the CR narrative (a detailed 

description of the clinical need/question, evidence review, and recommendations), (2) a clinical support tool 

(typically a laminated card consisting of a management 

algorithm for the defi ned clinical question), (3) provider 

training slides, and (4) patient education information in 

the form of a patient fact sheet. An expert subject matter group and all military services review and provide 

comments on all 4 components of the CR. The recommended edits are adjudicated and incorporated into fi nal 

CR. The draft documents are further vetted internally 

through all services prior to completion. The CR is reviewed against DoD and military service-specifi c policies before fi nal release.

One of the most recently created CRs is titled “Progressive Return to Activity Following Acute Concussion/

Mild TBI: Guidance for the Primary Care Manager in 

Deployed and Non-Deployed Settings.” This CR is novel and clinically effective because it represents the fi rst 

step-wise approach for clinicians and patients to use to 

obtain maximal recovery using a supervised treatment 

regimen. This is an excellent example of how expertise 

gained by military occupational therapists, occupational 

therapy technologists, primary care physicians, and other 

specialists at the 11 concussion care centers in Afghanistan were integral to the CR-development process to provide an effective clinical tool. The success of this CR 

was recognized during development and a supplemental 

(and related) CR for rehabilitation specialists was added 

to the CR portfolio. Additionally, these CRs are undergoing research studies to validate their effectiveness.

To date, DVBIC has released 11 CRs related to TBI as 

shown in Table 1. An overview of the CR content is presented in Table 2. All clinical recommendations can be 

downloaded or ordered as printed documents by accessing the DVBIC Educational Materials webpage: https://

dvbic.dcoe.mil/resources.

The DVBIC process for the development of CRs is a 

dynamic methodology subject to recurring process improvement and has many challenges for an international, 

large organization as well as typical guideline implementation barriers. Beginning with the Sleep Management 

CR (released in 2014), pilot testing was conducted with 

primary care providers. In October 2014, DVBIC initiated a process improvement pilot as part of a larger effort 

by DCoE to assess and improve knowledge translation 

processes. The pilot was centered on the rapid knowledge translation into clinical practice of a timely and 

practical CR on sleep disturbances following mild TBI. 

The primary objective of the pilot was to assess the effectiveness of an educational program on the CR in terms of 

disseminating information to providers and subsequent 

implementation of the knowledge (ie, provider behavior 

change). Lessons learned from this initial pilot testing 

Table 1. Defense and Veterans Brain Injury Center Clinical 

Recommendations for Traumatic Brain Injury.

Clinical Recommendation Title Release 

Date

Military Acute Concussion Evaluation (MACE) and 

Clinical Management Algorithms 

June 2006

Dec 2006

Cognitive Rehabilitation Apr 2009

Driving Following TBI Jul 2009

Indications and Conditions for In-Theater Post-Injury 

NCAT Testing 

May 2011

Indications and Conditions for Neuroendocrine

Dysfunction Screening Post mTBI 

Mar 2012

Assessment and Management of Dizziness

Associated with mTBI 

Sep 2012

Assessment and Management of Visual Dysfunction 

Associated with mTBI (in collaboration with the

Vision Center of Excellence) 

Jan 2013

Neuroimaging Following Mild TBI in the 

Non-Deployed Setting 

Jul 2013

Progressive Return to Activity Following Acute 

Concussion/mTBI: Guidance for the Primary Care 

Manager in Deployed & Non-deployed Settings 

Jan 2014

Progressive Return to Activity Following Acute 

Concussion/mTBI: Guidance for the Rehabilitation 

Provider in Deployed & Non-deployed Settings 

Jan 2014

Management of Sleep Disturbances Following 

Concussion/mTBI 

Jun 2014

TBI indicates traumatic brain injury; NCAT, neurocognitive assessment 

tool; mTBI, mild traumatic brain injury.
100 http://www.cs.amedd.army.mil/amedd_journal.aspx

focused on technology utilization, logistics, participants 

involved, content, and delivery of the training. Two of the 

most signifi cant lessons learned were that pilot testing 

should be conducted on all future CRs developed within 

DVBIC, and that additional training delivery methods 

(eg, interactive/web-based training) should be explored. 

Overall conclusions from the Sleep CR pilot testing to be 

applied to additional CR development processes include 

evaluation and effectiveness research for the CR and the 

development an effective process of dissemination and 

implementation of CRs across the MHS.

CONCLUSION

Clinical recommendations, which provide a rapid translation of knowledge into clinical practice to fi ll an identifi ed gap in knowledge or provide practical clinical guidance for diagnosis, treatment, and evaluation of medical 

conditions, are a critical need for practitioners and leaders throughout the MHS. Clinical recommendations also 

promote evidence-based practice and standardized care 

though out the uniformed services medical community 

and its healthcare providers. The DVBIC has developed 

multiple CRs and TBI educational products over the 

past decade using a process that incorporates best practices and military medical requirements. Best practices 

for the development of evidence-based CRs and education information are well defi ned within DVBIC. The 

process, which includes the implementation and evaluation of CR and education products, is met with complex 

challenges when applied across an international clinical 

setting such as the MHS. The process, challenges, and 

outcomes of creating and disseminating CRs were reviewed in this article.

REFERENCES

1. DoD Worldwide Numbers for TBI. Defense and 

Veterans Brain Injury Center Website. 2015. Available at: http://dvbic.dcoe.mil/sites/default/fi les/

DoD-TBI-Worldwide-Totals_2000-2015Q1-Q2-

Aug18-2015.pdf. Accessed March 2, 2016.

Table 2. Summary of the Defense and Veterans Brain Injury Center Clinical Recommendations.

MACE: The Military Acute Concussion Evaluation is a concussion screening tool for the acute assessment of service members involved 

in a potentially concussive event. Available as pocket card & wallet card.

Cognitive Rehabilitation: This clinical recommendation addresses cognitive assessment and recommendations for interventions for 

persistent postconcussion cognitive symptoms. Outcome measures (program-based and patient-based) and core elements of cognitive rehabilitation program implementation are also addressed. 

Driving Following TBI: The purpose of this consensus statement is to provide clinical recommendations to healthcare professionals 

within the Military Health System regarding the assessment of the ability to drive following traumatic brain injury, regardless of severity. It describes the TBI driving evaluation process to include recommendations for key elements for clinical providers to include in the 

comprehensive driving assessment following TBI.

Indications and Conditions for In-Theater Post-Injury Neurocognitive Assessment Tool (NCAT) Testing Clinical Recommendation:

This clinical recommendation provides background of predeployment neurocognitive testing and the use of automated neuropsychological assessment metrics.

Neuroendocrine Dysfunction Screening Post Mild TBI Clinical Recommendation: This clinical suite serves as a reference tool offering 

medical guidance following indications from postinjury neuroendocrine screening.

Assessment and Management of Dizziness Associated with Mild TBI Clinical Recommendation: The Assessment and Management 

of Dizziness Associated with Mild TBI Clinical Recommendation and Reference Card provide primary care providers with an approach 

to evaluate dizziness following mild TBI and offers guidance on referral for further vestibular evaluation and care.

Assessment and Management of Visual Dysfunction Associated with Mild TBI: This clinical suite provides providers an approach 

to evaluate visual dysfunction following mild TBI and offers guidance regarding referral for further eye or visual evaluation and care.

Neuroimaging Following Mild TBI in the Non-Deployed Setting Clinical Recommendation: The Neuroimaging Following Mild TBI in 

the Non-Deployed Setting clinical recommendation and reference card offers guidance for a standard approach for imaging from the 

acute through chronic stages following mild TBI in the nondeployed setting.

Progressive Return to Activity Following Acute Concussion/Mild TBI: Guidance for the Primary Care Manager in Deployed and NonDeployed Settings Clinical Recommendation: The Progressive Return to Activity clinical recommendation details the importance of 

aiding service members to progressively return to pre-injury activity and promotes the standardization of Military Health System care 

following a concussion. The recommendation can be downloaded individually or ordered as a part of the PRA suite for primary care 

managers.

Progressive Return to Activity Following Acute Concussion/Mild TBI: Guidance for the Rehabilitation Provider in Deployed and 

Non-Deployed Settings Clinical Suite: The Progressive Return to Activity clinical recommendation details the importance of aiding 

service members to progressively return to pre-injury activity and promotes the standardization of care following a concussion. The 

recommendation can be downloaded individually or ordered as a part of the PRA suite for rehabilitation providers.

Management of Sleep Disturbances Following Concussion/Mild TBI: Guidance for Primary Care Management in Deployed and 

Non-Deployed Settings: This clinical suite provides guidance regarding assessing and managing sleep disturbances associated with 

mild TBI and includes specific recommendations for helping service members and veterans in deployed and non-deployed settings 

manage symptoms of insomnia, circadian rhythm sleep-wake disorder and obstructive sleep apnea.

PROGRAMMATIC IMPLEMENTATIONS TO IMPROVE HEALTH
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2. Ponsford J, Willmott C, Rothwell A, Cameron P, 

Kelly AM, Nelms R, Curran C. Impact of early 

intervention on outcome following mild head injury in adults. J Neurol Neurosurg Psychiatry. 

2002;73:330-332.

3. Combat Medic/Corpsman Algorithm, Ver 4.0. Defense and Veterans Brain Injury Center Website. 

2012. Available at: http://www.dcoe.mil/Content/

Navigation/Documents/DCoE_Concussion_Man

agement_Algorithm_Cards.pdf. Accessed March 

2, 2016.

4. MACE-Military Acute Concussion Evaluation. 

Defense and Veterans Brain Injury Center Website. 2012. Available at: https://dvbic.dcoe.mil/sites/

default/fi les/DVBIC_Military-Acute-ConcussionEvaluation_Pocket-Card_Feb2012.pdf. Accessed 

March 2, 2016.

5. Defense and Veterans Brain Injury Center Working Group on the Acute Management of Mild Traumatic Brain Injury in Military Operational Settings. 

Clinical Practice Guideline and Recommendations. 

Deployment Health Clinical Center Website. 2006. 

Available at: http://www.pdhealth.mil/downloads/

clinical_practice_guideline_recommendations.

pdf. Accessed March 2, 2016.

6. VA/DoD Clinical Practice Guidelines: Management of Concussion/Mild Traumatic Brain Injury. 

US Department of Veterans Affairs Website. 2009. 

Available at: http://www.healthquality.va.gov/

guidelines/Rehab/mtbi/. Accessed March 2, 2016.

7. Deputy Secretary of Defense. Directive-Type 

Memorandum (DTM) 09-033, “Policy Guidance 

for Management of Concussion/Mild Traumatic 

Brain Injury in the Deployed Setting.” Washington, 

DC: US Dept of Defense. June 21, 2010. Available 

at: http://www.govexec.com/pdfs/062510bb1.pdf. 

Accessed March 2, 2016.

8. Department of Defense Instruction 6490.11: DoD 

Policy Guidance for Management of Mild Traumatic Brain Injury/Concussion in the Deployed Setting. 

Washington, DC: US Dept of Defense; 2012. Available at: http://www.dtic.mil/whs/directives/corres/

pdf/649011p.pdf. Accessed March 2, 2016.

9. Institute of Medicine. Clinical Practice Guidelines 

We Can Trust. Washington, DC: National Academies Press; 2011. Available at: http://iom.nation

alacademies.org/Reports/2011/Clinical-PracticeGuidelines-We-Can-Trust.aspx. Accessed March 

2, 2016.

10. World Health Organization Handbook for Guideline Development, 2nd ed. Geneva, Switzerland; 

World Health Organization; 2014. Available at: 

http://www.who.int/entity/kms/handbook_2nd_

ed.pdf?ua=1. Accessed March 2, 2016.

AUTHORS

COL Hinds is National Director, Defense and Veterans 

Brain Injury Center, Silver Spring, MD.

Dr Livingston is Director, Education Division, Defense 

and Veterans Brain Injury Center, Silver Spring, MD.
102 http://www.cs.amedd.army.mil/amedd_journal.aspx

Inadequately treated trauma pain in combat unleashes 

a cascade of adverse physiological and psychological 

insults.1

 Numerous medical advancements occurred 

within the international medical community that were 

independent from but concurrent with the global war 

on terrorism (GWOT). Many of these exciting developments in medicine such as ultrasound-guided regional 

anesthesia and advanced regional anesthesia were leveraged within combat casualty care early in GWOT to 

improve Soldiers’ battlefi eld pain control and potentially 

reduce chronic pain in wounded veterans.

Several pharmacologic, nonpharmacologic, technologic, 

and strategic advances which signifi cantly reduced acute 

pain on the battlefi eld emerged and were successfully 

fi elded during GWOT.2,3 Immediate and sustained air 

superiority enabled continued adherence to previously 

learned lessons from Vietnam and Desert Storm such as 

rapid evacuation of the combat wounded. Rapid evacuation in concert with early multimodal pain management 

has signifi cantly improved combat casualty care from 

the point of injury through rehabilitation efforts months 

and years following combat injury. One commonly advanced narrative suggests that Soldiers injured early 

in GWOT received Civil War era analgesia (morphine 

monotherapy).1,4,5 The alternative view counters with 

eyewitness accounts of wartime anesthetics performed 

as early as April 2003 when powerful synthetic opioids, sedatives, and regional anesthetics (axillary nerve 

blocks) were used near the front lines to provide multimodal analgesia in a combat support hospital on the outskirts of Baghdad, Iraq. Further buoying these assertions 

are reports from the 1960s when Army Anesthesiologist 

CPT Gale Thompson pioneered and published the repeated use of axillary regional anesthetics for battlefi eld 

pain control during the Vietnam War.6

 While acknowledging the limitations of morphine monotherapy and an 

overreliance on opioids, the authors recognize that morphine has for centuries proved to be an excellent analgesic for acute trauma victims. Recently, morphine was 

lauded by Holbrook and colleagues in their observational study7

 which suggested the use of morphine in US 

military personnel during combat-related trauma may 

reduce the risk of subsequent development of PTSD after serious injury. Considering approximately 17% of all 

returning Soldiers in GWOT experience PTSD and an 

even higher prevalence exists among injured Soldiers, 

acute pain control with morphine or other multimodal 

regimens will clearly have a positive effect on GWOT 

Soldiers’ long-term health.8

One of the greatest advances in pain control during 

GWOT was the introduction and management of advanced regional anesthetic techniques, specifi cally, 

continuous peripheral nerve block (CPNB) catheters 

and infusions. In light of the enemy’s continual use of 

improvised explosive devices and the subsequent tsunami of traumatic extremity amputations that ensued, 

CPNBs proved vital for acute and chronic battlefi eld 

pain control throughout the entire medical evacuation 

chain. COL Jack Chiles, a forward-thinking Anesthesiology Consultant to The Army Surgeon General, prioritized education and training by sending Army anesthesiologists MAJ Trip Buckenmaier and MAJ Scott Croll 

Acute and Chronic Pain on the Battlefield:

 Lessons Learned from Point of Injury to

 the United States

 COL Scott M. Croll, MC, USA

 LTC(P) Scott R. Griffi th, MC, USA

ABSTRACT

Historically, war tends to accelerate innovation within military medicine. In this article, the authors argue this 

truism has recurred in the case of acute and chronic pain management for combatants in the global war on terrorism (GWOT). Advances in regional anesthesia techniques and multimodal acute pain care are highlighted in 

light of the typical weapons, injuries, and comorbid conditions of the modern combat era. Reported success of 

providing chronic pain care in the war theater during GWOT is discussed in the context of operational requirements for current and future wars. A description is provided of the Pain Management Task Force (PMTF) and 

Pain Campaign Plan which was initiated during GWOT. The PMTF effort enhanced pain education and clinical 

pain care through leadership and organizational changes, which created broader access to pain treatments for 

patients and more standardized treatment capabilities across the enterprise.
April – September 2016 103

THE ARMY MEDICAL DEPARTMENT JOURNAL

to Duke University in 2001 and 2003 respectively to 

perfect these novel techniques. Completion of this training set in motion a cascade of educational and strategic 

advances for current and future US Army anesthesiology trainees and propelled advanced regional anesthesia to the forefront of the battlefi eld beginning in October 2003 with the fi rst combat CPNB.9

 In 2004, Walter 

Reed Army Medical Center (WRAMC) established the 

sole Department of Defense (DoD) fellowship in Acute 

Pain Medicine. Immediately, WRAMC anesthesiology 

residents and fellows rocketed into the 99th percentile 

nationally in advanced regional anesthetic techniques, 

which included CPNBs and the use of multimodal 

analgesia.

Signifi cant improvement has been achieved in the combat trauma-related perioperative use of multimodal analgesia, yet signifi cant obstacles still exist to achieving 

high quality, consistent use of intravenous adjuncts such 

as ketamine, propofol, benzodiazepines, clonidine, ketorolac and acetaminophen between Roles 2 and 5. Progress is often fl ush with unforeseen challenges and barriers to success, and the implementation of multimodal 

analgesia is a case in point. Even the infusion pumps 

used to administer such medications (patient-controlled 

analgesia and CPNBs) along the air evacuation system 

required offi cial USAF certifi cates of airworthiness, 

which took considerable effort and time to obtain. A 

lack of familiarity with some of these medications or 

techniques led to signifi cant resistance to implementation but was eventually overcome with education, training and persistence.

The relationship between the battlefi eld and chronic pain 

remains a complex one. It is diffi cult to predict which 

patients will develop chronic pain from an acute injury 

in the war zone and even more diffi cult to predict how 

such pain will affect the overall quality of life of such 

a casualty. The biopsychosocial (BPS) model emphasizes the role mental health and social milieu play in the 

overall experience of diseases, including chronic pain.10

Evidence from the wars in Iraq and Afghanistan support 

the application of such a model to pain on the modern 

battlefi eld. Some Soldiers injured in battle do not develop chronic pain even when signifi cant injuries intuitively suggest they would. Many who develop chronic pain 

are able to manage it well enough to preserve a high 

quality of life. Epstein’s 2010 study of quality of life for 

amputees from both Vietnam and GWOT illustrates the 

importance of psychosocial factors. He showed that patients with multiple amputations had a higher qual ity of 

life, while factors such as depression and poor prosthesis satisfaction predicted lower quality of life.11 On the 

other hand, nonbattle musculoskeletal injuries, similar 

to those seen in military training and civilian vocational 

settings, are a leading cause of evacuations from the war 

zone, with such Soldiers rarely returning to the battlefi eld.12 Each circumstance emphasizes the importance of 

the psychosocial milieu through which a pain event is 

experienced.

Some meaningful outcome and risk factor data has 

emerged regarding the prevalence of chronic pain, opioid therapy, patient risk factors, and comorbidities. Toblin showed Soldiers develop more chronic pain than 

a similar civilian population when he studied 2,876 of 

3,076 Soldiers from a brigade combat team (BCT) returning from the war. Forty-four percent of the BCT 

participants reported chronic pain versus 26% from a 

civilian population he studied prior. 13,14 Almost 3 times 

as many from the BCT population were treated with opioids. Certain risk factors for chronic pain were noted, 

including female sex, aged 30 years or more, a history 

of current or prior marriage, lower rank, higher combat 

intensity, and combat injury.14 Seal found that veterans 

are at greater risk for complications of opioid therapy 

but are more likely to be treated with opioids than civilian counterparts.15 These and similar studies suggest 

that while opioid concerns in the military have been a 

refl ection of trends in the civilian population, the efforts 

of military leaders to limit opioids where appropriate 

and develop integrative pain treatment approaches are 

grounded in science and a practical need to preserve a 

fi ghting force that is at higher risk for complications of 

opioid therapy.

A full understanding of the patient factors and treatment paradigms that affect the conversion of acute to 

chronic pain for a signifi cant subset of Soldiers with either battle or nonbattle injuries has not emerged. What 

is clear from existing literature is that poorly managed 

acute pain contributes to development of chronic pain 

such that a systematic approach to acute pain within the 

battlefi eld evacuation system should have a favorable effect.16-18 The subject rightfully remains a major focus of 

future research within the military and beyond. Just as 

with the evolution of acute pain management including 

advanced regional anesthetics and multimodal medication therapy, some useful advances have emerged in 

the treatment of chronic pain.9,19 Clinics to treat chronic 

pain in theater have emerged at times when personnel 

and time allowed, and the retrospectively published experiences of such clinics show encouraging results in 

terms of treatments allowing Soldiers to continue missions in theater.20 Prospective studies could guide future 

doctrine and policy decisions in terms of deciding the 

personnel and capabilities that should be available in 

theater for chronic pain management in the future.
104 http://www.cs.amedd.army.mil/amedd_journal.aspx

As we continue current combat efforts and consider future confl icts, improved management of Soldiers with 

common, nonbattle injuries such as musculoskeletal 

pain may be as important as casualty care in preserving combat power. An increasingly complex and technologically advanced battlefi eld has increased the need 

for Soldiers with specialized and, in some cases, unique 

training. Reserve forces have remained a key element 

of overall force structure supplying such expertise. Soldiers are older on average than in previous wars. As the 

Army continues to shrink and Soldiers become more 

specialized, the need for chronic pain services on the 

modern battlefi eld will take on added importance for 

the Army to succeed in keeping key leaders and personnel in the fi ght. Several news stories emerged during the mid to late 2000s documenting both abuse and 

diversion of opioids as well as instances of inadequate 

pain control in some wounded warriors. Organizations 

internal to the Army such as the Defense and Veterans 

Center for Integrative Pain Management likewise began 

to document the need to modernize and integrate pain 

management from point of injury to defi nitive care. By 

August 2009, then Army Surgeon General LTG Schoomaker chartered the Army Pain Management Task 

Force (PMTF) to

make recommendations for a MEDCOM [Army medical command] comprehensive pain management strategy 

that was holistic, multidisciplinary, and multimodal in 

its approach, utilized state of the art/science modalities 

and technologies, and provided optimal quality of life 

for Soldiers and other patients with acute and chronic 

pain.21(pE-1)

The PMTF had broad representation from the DoD, Veterans Administration (VA), and civilian pain treatment 

communities and assessed the state of pain care at the 

time. LTG Schoomaker emphasized standardizing pain 

treatment capabilities without stifl ing innovation. In 

May 2010 his offi ce published the fi nal report from that 

effort.21 The report offered 109 recommendations in 4 

areas:

1. Provide tools and infrastructure that support and 

encourage practice and research advancements in 

pain management.

2. Build a full spectrum of best practices for the 

continuum of acute and chronic pain, based on a 

foundation of best available evidence.

3. Focus on the warrior and Family-sustaining the 

force.

4. Synchronize a culture of pain awareness, education, and proactive intervention.

The PMTF results led to a Pain Campaign Plan that 

recognized the importance of primary care providers 

(PCPs) and their teams in pain management, noting 

the majority of patients receive their pain care from the 

physicians, physician assistants, and nurse practitioners 

working as primary care providers across the force. A 

stepped care model that existed within the VA was adopted and led to organization and leadership changes affecting both pain education and clinical care by adapting 

and evolving existing local, regional, and enterprise level clinical and command capabilities.21 Pain education 

was noted to be inadequate at most levels and televideo 

capabilities were leveraged to provide better support of 

the PCPs. In addition, Primary Care Champions were 

designated and given multimodal training including 

televideo, in-person training, and development of more 

comprehensive skills through courses such as medical 

acupuncture with associated certifi cation. Finally, clinical leaders at newly identifi ed regional interdisciplinary pain management centers transitioned to leading 

broader clinical teams including physical, occupational, 

and behavioral health specialists, integrative medicine 

physicians, exercise specialists, and chiropractors and 

acupuncturists who would rarely work so closely in traditional pain practices. Functional restoration programs 

have emerged and early outcomes support such efforts 

to treat Soldiers with chronic pain more comprehensively as the effort has led to encouraging return-to-duty 

rates.22

Acute and chronic pain care within military medicine

has evolved signifi cantly as a result of the GWOT. Prioritizing pain education coupled with organizational 

and leadership emphasis have advanced treatment techniques and paradigms in both arenas. As the operational 

tempo of combat decreases and treatment of combat 

associated pain becomes less common, it is imperative 

that the knowledge and skills acquired be retained. With 

reasonable attention, regional anesthesia, multimodal 

analgesia, and management of chronic pain for service 

members in deployed settings and beyond will be here 

to stay. Yet much of the research to defi ne the best pain 

treatments for war is yet to be accomplished. Policy 

updates to codify what has been learned cannot be neglected during periods of decreased operational tempo. 

We can little afford to repeat the current lessons learned 

given the research, education, and leadership challenges 

we need to further understand and master. For the next 

war has always come, and experience suggests it is usually sooner than expected.

PROGRAMMATIC IMPLEMENTATIONS TO IMPROVE HEALTH
April – September 2016 105

THE ARMY MEDICAL DEPARTMENT JOURNAL

REFERENCES

1. Joshi GP, Ogunnaike BO. Consequences of inadequate postoperative pain relief and chronic persistent postoperative pain. Anesth Clin North America. 

2005;23(1):21-36.

2. Buckenmaier CC, Mahoney PF, senior eds. Textbooks of Military Medicine: Combat Anesthesia: 

The First 24 Hours. Fort Sam Houston, TX: Borden 

Institute; 2015:205-244.

3. Malchow RJ, Black IH. The evolution of pain management in the critically ill trauma patient: Emerging concepts from the global war on terrorism. Crit 

Care Med. 2008;36:S346-S357.

4. Buckenmaier CC, Bleckner L. Military Advanced 

Regional Anesthesia and Analgesia Handbook. 

Fort Sam Houston, TX: Borden Institute; 2008:1. 

Available at: http://www.dvcipm.org/clinical-re

sources/dvcipm-maraa-book-project. Accessed 

March 9, 2016.

5. Talan J. On the front lines: learning from Iraq, military physicians craft new strategies for managing 

chronic pain. Neurology Now. 2008;4:33-34.

6. Thompson GE. Anesthesia for battle casualties in 

Vietnam. JAMA. 1967;201:215-219.

7. Holbrook TL, Galarneau MR, Dye JL, et al. 

Morphine use after combat injury in Iraq and 

post-traumatic stress disorder. N Engl J Med. 

2010;362:110-117.

8. Hoge CW, Casto CA, Messer SC, et al. Combat duty 

in Iraq and Afghanistan, mental health problems 

and barriers to care. N Engl J Med. 2004;351:13-22.

9. Buckenmaier III CC, McKnight GM, Winkley JV, 

et al. Continuous peripheral nerve block for battlefi eld anesthesia and evacuation. Reg Anesth Pain 

Med. 2005;30:202-205.

10. Engel GL. The need for a new medical model: a challenge for biomedicine. Science. 1977;196:129-136.

11. Epstein RA, Heinemann AW, McFarland LV. Quality of life for veterans and service members with 

major traumatic limb loss from Vietnam and OIF/

OEF confl icts. J Rehab Res Dev. 2010;47:373-386.

12. Cohen SP, Griffi th S, Larkin TM, Villena F, Larkin 

R. Presentation, diagnoses, mechanisms of injury, 

and treatment of soldiers injured in Operation Iraqi 

Freedom: An epidemiological study conducted at 

two military pain management centers. Anesth 

Analg. 2005;101:1098-1103.

13. Toblin RL, Mack KA, Perveen G, Paulozzi 

LJ. A population-based survey of chronic pain 

and its treatment with prescription drugs. Pain.

2011;152:1249-1255.

14. Toblin RL, Quartana PJ, Riviere LA, Walper KC, 

Hoge CW. Chronic pain and opioid use in US soldiers after combat deployment. JAMA Intern Med. 

2014;174(8):1400-1401.

15. Seal KH, Shi Y, Cohen G, Cohen BE, Maguen S, 

Krebs EE, Neylan TC. Association of mental health 

disorders with prescription opioids and high-risk 

opioid use in US veterans of Iraq and Afghanistan. 

JAMA. 2012;307(9):940-947.

16. Apkarian AV, Baliki MN, Farmer MA. Predicting transition to chronic pain. Curr Opin Neurol. 

2013;26:360-367.

17. Feizerfan A, Sheh G. Transition from acute to 

chronic pain. Contin Educ Anaesth Crit Care Pain. 

2015;15(2):98-102.

18. May A. Chronic pain may change the structure of 

the brain. Pain. 2008;137:7-15.

19. Jennings PA, Cameron P, Bernard S, et al. Morphine 

and ketamine is superior to morphine alone for outof-hospital trauma analgesia: a randomized controlled trial. Ann Emerg Med. 2012;59(6):497-503.

20. White RL, Cohen SP. Return-to-duty rates among 

coalition forces treated in a forward-deployed pain 

treatment center: a prospective observational study. 

Anesthesiology. 2007;107(6):1003-1008.

21. Pain Management Task Force. Providing a Standardized DoD and VHA Vision and Approach to 

Pain Management to Optimize the Care for Warriors and Their Families. Final Report. Washington, DC: Offi ce of The Army Surgeon General; 

May 2010. Available at: http://www.regenesisbio.

com/pdfs/journal/pain_management_task_force_

report.pdf. Accessed March 9, 2016.

22. Tiede JM, Earwood ME, Teuton KA. Functional 

Restoration in Active Duty Service Members: Initial Outcomes in Pain, Function and Opioid Utilization. Poster presented at: 30th Annual Meeting of 

the American Academy of Pain Medicine; March 

8, 2014; Phoenix, AZ. Abstract available at: http://

www.painmed.org/2014posters/abstract-202/. Accessed March 9, 2016.

AUTHORS

COL Croll, the Anesthesiology Consultant to The Army 

Surgeon General, is assigned to Evans Army Community 

Hospital, Fort Carson, Colorado.

LTC(P) Griffi th, the Pain Consultant to The Army Surgeon General, is assigned to Walter Reed National Military Medical Center, Bethesda, Maryland.
106 http://www.cs.amedd.army.mil/amedd_journal.aspx

This is not the end. It is not even the beginning of the 

end. But it is, perhaps, the end of the beginning.

Sir Winston Churchill, Novermber 1942

As the US Army winds down from a decade of conflict 

involving 2 major theaters of war, we are naturally inclined to emit a sigh of relief. As he did in November of 

1942 after the victory at the Second Battle of El Alamein, 

the insightful Sir Winston Churchill would remind us 

that the enemy is not dead, the threat is still real, and we 

have only just begun.

Even as we close over a decade of conflict in Afghanistan, we are faced with the threat of ISIS in Iraq. In 

Eastern Europe, Russia has flexed its military power 

in Ukraine by annexing Crimea. In Asia, North Korea 

continues to be an unfriendly nuclear presence. In the 

eastern Mediterranean and Middle East, the conflict between Israel and Palestine continues without a clear end 

in sight. A civil war in Syria is ongoing with spillover 

into Jordan and Lebanon causing increased unrest. Iran 

continues to seek nuclear technology for military use. 

Al-Qaeda in the Arabian Peninsula has been strengthened by the instability in Yemen. In Africa, Al-Shabab 

continues to launch terror attacks from Somalia into 

surrounding countries. There is violence and political 

instability in Egypt and Libya. The Seleka in the Central 

African Republic has created violence and mass atrocities as the insurgency continues. The internal political 

struggle in South Sudan has left 10,000 people dead and 

more than a million displaced. In the Western Hemisphere, we remain on alert for terrorist attacks such as 

that in Paris in November 2015. There is drug-related 

violence in Mexico that spills over into the United States. 

Following a decade of conflict, the reality is far from 

what we would like to imagine as “the end.” This evidence demonstrates that the world is still dangerous and 

perhaps increasingly complex.

The US Army Operating Concept 2020-20401

 charges 

the Army to be prepared to operate in these environments 

in order to “win in a complex world.” The overarching 

strategy for success involves a global reach, while maintaining a regional relevance. Our military objectives 

may not be geographic locations such as a capital city, 

but a group of dispersed operations that contribute to the 

same overarching objective. To “mass on the objective” 

may involve coordinated efforts with other instruments 

of national power such as informational, economic, and 

diplomatic. Our success as an Army may be measured 

as much by our finesse as by our military might.

Despite significant success and advancements in combat casualty care (CCC) over the last 14 years, including the achievement of the lowest case fatality rate in 

our history2

 as shown in Figure 1, our future success 

as an Army is not guaranteed by our past performance. 

Certainly our future success is informed and led by the 

momentum that has been gained since 2001, but now is 

not the time to rest in regards to CCC. As leaders within 

the Army Medical Department, we are compelled to leverage CCC knowledge and technology advancements 

to win in an increasingly complex global environment. 

This article reviews these CCC lessons with an eye towards providing optimal CCC for future complex operational environments.

Creation of the Joint Trauma System

Most of the success in CCC over the past decade can 

in some way be linked to the establishment of the Joint 

Trauma System. From the earliest published literature 

reviews, we discovered that Soldiers were dying from 

potentially survivable hemorrhage from the extremities, 

junctional areas of the groin and axilla, and noncompressible torso hemorrhage.3 At the time, there was no 

readily apparent solution to junctional and torso hemorrhage aside from rapid evacuation to surgical care. But 

Leveraging Trauma Lessons from War to

 Win in a Complex Global Environment

LTC Kyle N. Remick, MC, USA

Abstract

The US military has made great strides in combat casualty care since 2001. As the Army concludes combat 

operations in Iraq and Afghanistan, it faces new operational challenges in trauma care. The military medical 

community must stay ahead of the curve through sustaining current investments in combat casualty care research. This article describes lessons learned at war from a Joint Trauma System perspective in order to place 

in context how we should proceed in order to provide optimal care for our Warfighters in the future.
April – September 2016 107

The Army Medical Department Journal

early in the last series of combat deployments, we realized the value of tourniquets in preventing death from extremity 

hemorrhage, and we sought to procure, 

train, and field this device.

As Iraq became increasingly a hard fought 

counterinsurgency and stability operation, 

many deployed surgeons realized that injury severity was increasing. In a comparison of potentially survivable injuries from 

2003 and 2004 with those in 2006, the 

Injury Severity Score increased from 27 

to 37 over that period, most likely secondary to blast injuries. Furthermore, hemorrhage (extremity 33%, torso 49%, and 

junctional 21%) still accounted for 87% 

of potentially survivable deaths.4

 Frustratingly, Warfighters continued to die from 

exsanguinating extremity hemorrhage. It 

was apparent that we had not successfully 

trained and fielded tourniquets. The recommendation to 

the operational commanders for tourniquet use and the 

implementation of this recommendation was slowed by 

a lack of a feedback mechanism to make this happen.

In 2004, a group of trauma surgeons with clinical foresight and operational experience set out to create a 

trauma system for war.5

 We knew from the accumulated 

civilian trauma literature over the prior 20 to 30 years 

that trauma systems decrease mortality from trauma by 

15% to 20%.6-10 Furthermore, they recognized that the 

US military needed a formal trauma system to effectively implement changes that would lead to optimal care 

for our wounded. Based on the public health model, all 

essential components for a trauma system of care were 

addressed in the system but adapted to “patient care” in 

the unique battlefield environment as illustrated in Figure 2. Currently, the US Military Health System (MHS) 

Joint Trauma System (JTS) seeks to solidify itself as the 

standing body for global delivery of the MHS trauma 

system through approval of its JTS manual as joint doctrine.11 The following are key examples by system component of successful JTS efforts since its inception.

Information Systems and Research

The JTS, first and foremost, was and still is a data-driven 

organization. The purpose of the Information Systems 

and Research components are to collect and analyze 

data. Thus, research teams were sent to each of the theaters to collect data in real-time. Early in this effort, research teams focused primarily on collecting data from 

the major trauma hospitals (Role 3 facilities), but as the 

JTS matured later in the war, the research teams were 

able to reach out to many of the Role 2 surgical facilities 

as well. The Joint Theater Trauma Registry (JTTR, now 

renamed the Department of Defense Trauma Registry) 

was developed as the repository for this data. Shortly after data were collected, it was analyzed in order to identify gaps in care or processes that could be improved 

within the trauma system. This data was fed to research 

and development programs of the US Army Medical 

Research and Materiel Command (MRMC) such as the 

Combat Casualty Care Research Program (CCCRP). 

This program could then guide intramural and extramural trauma research sites to focus on aspects important to combat casualty care. Knowledge and material 

solutions to these gaps were then transferred to the user 

community through the JTS.

Prevention

The Prevention component used data from the JTTR to 

feedback to other programs at MRMC such as the Joint 

Trauma Analysis and Prevention of Injury in Combat 

program (www.jtapic.amedd.army.mil) for the improvement of body armor to protect the torso, pelvic, and 

groin regions, as well as improved eye protection. In coordination with multiple other groups, the development 

of mine-resistant and up-armored vehicles was also in 

part driven by data collected, analyzed, and presented 

through the work of the JTS.

Education

The Education component sought to improve the trauma 

care readiness of US military medical personnel deploying to both theaters of operation. The Joint Combat 

Trauma Management Course was developed to provide 

0%

10%

2005 2007 2009 2011 2013

20%

30%

Case Fatality Rate

Injury Severity Score

12

8

4

0

16

Injury Severity Score

Case Fatality Rate - Afghanistan

Figure 1. Case Fatality Rate (CFR) as compared to Injury Severity Score (ISS). The 

data demonstrates that as ISS was increasing between 2009 and 2013, the CFR 

was decreasing over the same time period. The data lends evidence to support 

the statement that military medical care decreased deaths in combat operations 

during that period. Source: Joint Trauma System. Reprinted with permission, 

CAPT Z. Stockinger, USN, Director.
108 http://www.cs.amedd.army.mil/amedd_journal.aspx

surgeons and others with “just-in-time” trauma refresher training prior to deployment. The services developed 

service-specific trauma training centers. For example, 

the Army developed the Army Trauma Training Center, 

first briefly in Houston and then in Miami, Florida, at 

the Ryder Trauma Center where it remains. This training center provided and still provides predeployment 

organization, skills, and knowledge training for Army 

Forward Surgical Teams. The Air Force also developed 

a program at the University of Maryland Shock Trauma 

Center in Baltimore, Maryland, and the Navy developed 

their trauma training center at the Los Angeles County–

University of Southern California Medical Center. At 

the most fundamental levels, lessons from the JTS were 

transferred by individual returning surgeons to military 

surgical residents and to medical students of the joint 

Uniformed Services University School of Medicine. In 

this way, these lessons could not only serve the next 

round of deploying surgeons but could form the operational foundational experiences for potential future surgeons and trauma providers for all services.

From the early days, there were topics of trauma concern that called for effective clinical practice guidelines 

(CPG). Guidelines involving such issues as damage control resuscitation (DCR), use of fresh whole blood, treatment guidelines for burns, fasciotomy, and many other 

topics of clinical importance were created to guide the 

deployed surgical workforce. Concurrently, the JTS initiated weekly telephone conferences with all stakeholders of the JTS. This truly phenomenal weekly morbidity and mortality review spanned the entire continuum 

of care from the point of injury (POI), to the various 

locations within the 2 theaters, to Landstuhl Regional 

Medical Center, our regional Role 4 facility, to military 

hospitals in the United States such as Walter Reed Army 

Medical Center, Naval Hospital Bethesda, and Brook 

Army Medical Center, and finally to the Veteran’s Affairs (VA) rehabilitation centers. This all-inclusive, allhands-on teleconference truly brought medical personnel working within a global continuum of care together 

as one trauma system of care. The resulting feedback 

to and from all points in the continuum of the trauma 

Figure 2. The Joint Trauma System. This schematic presents the components of a model trauma system that integrate 

and collaborate to make a system of care that is trauma patient-centric. Source: Joint Trauma System. Reprinted with 

permission, CAPT Z. Stockinger, USN, Director.

Programmatic Implementations to Improve Health
April – September 2016 109

The Army Medical Department Journal

system was of immense benefit in improving the care 

provided.

Leadership

As mentioned previously, direct access to operational 

leadership was a key factor in making the JTS an effective mechanism to improve outcomes within the US 

military. The Leadership component advocated for and 

deployed a Joint Theater Trauma Director who was 

responsible for the in-country research team in both 

theaters, and for compiling, analyzing, and presenting 

current data from the JTTR directly to the Commander, 

US Central Command on a monthly basis. This was the 

access needed to ensure that the JTS voice was heard 

and was effective in the implementation of important 

changes.

Prehospital Care

Prehospital Care, controlled by the medical evacuation 

commanders and physician-consultants known as flight 

surgeons, was integrated into the education portion of 

the JTS through its involvement in the weekly telephone 

conferences and the process of CPG creation. For example, when data showed that patients were becoming 

hypothermic during transport, operational leadership 

facilitated communication to the medical evacuation 

units regarding using hypothermia prevention kits and 

temperature “dots” on patient foreheads to monitor temperature during transport.

Performance Improvement

Performance Improvement was woven throughout the 

JTS components. As data was collected and analyzed, 

feedback was immediately provided to all elements of 

the JTS, to and from the medic at the POI to the flight 

medic on the helicopter, to the surgical teams and combat support hospitals, and onward out of theater. Any 

point along the continuum was empowered to provide 

constructive feedback to improve the JTS.

Applying the Joint Trauma System to

a Theater of War

The JTS, with its components, was then overlaid onto 

the established Roles of Care within the theaters of Afghanistan and Iraq, as shown in the Table. Along with 

the components needed to create an effective trauma 

system, there was also a need for a geographically organized physical system of care. The NATO roles of care 

were already in place but were not an established part 

of an overarching system of care. As data was gathered, 

important and timely feedback was given to the medics and trauma teams working within the JTS at these 

roles of care. So although geographically dispersed in 

2 theaters, the units working these roles of care were 

still connected by the JTS. Shared lessons learned from 

one role of care in one theater often had applicability to 

trauma care provided at similar roles in the other theater. 

The JTS provided the medical leadership necessary to 

stay focused on providing care within each respective 

role within the overall trauma system. Furthermore, the 

JTS enabled CCCRP clinicians and scientists to assess 

data and feedback from the battlefield and translate this 

directly into material and knowledge products that improved CCC in near real time. It is important to understand the perspective of the Roles of Care on the battlefield to fully appreciate these improvements in care.

Role 1

At Role 1 (POI to battalion aid station), the Committee 

on Tactical Combat Casualty Care (CoTCCC) has advised the sequence of care for patients injured on the 

battlefield since the late 1990s. Providing hemorrhage 

control was the most critical life-saving intervention, 

even above the standard civilian teaching of “airway, 

breathing, and circulation” (ABC). Thus, initial external 

hemorrhage control prior to ABCs was institutionalized 

to save lives by stopping life threatening hemorrhage 

prior to any other medical concerns. To that end, tourniquets were fielded to deploying Warfighters within newly designed individual first aid kits (known as IFAKs) 

with the priority of extremity hemorrhage control. The 

concept of “hypotensive resuscitation,” providing intravenous (IV) fluids only when absolutely necessary in order to allow a clot to form and prevent too high of a blood 

pressure from dislodging the clot, was added to medic 

training. Based on CoTCCC guidelines, Army medics 

learned advanced techniques to open and maintain airways, such as surgical cricothyroidotomy. Another significant cause of death on the battlefield, tension pneumothorax from chest wounds, was likewise addressed in 

CoTCCC guidelines and medics were taught to relieve 

the pneumothorax using a long, large bore IV catheter. 

Providing analgesia for pain management and giving 

antibiotics at or near the POI were also concepts that 

were derived from this committee. The best solution for 

junctional or noncompressible hemorrhage was initially 

tightly packed dressings and then hemostatic dressings, 

until junctional tourniquets were recently made available to deployed medics.13

Medical Evacuation from POI

Flight medics were limited in scope of practice although additional resources could be carried onboard 

helicopters. Recommendations by CoTCCC for care 

during evacuation involved reevaluation of the patient 

with hemorrhage control remaining the highest priority, followed by an airway intervention only when 

absolutely necessary, and decompression of a tension 
110 http://www.cs.amedd.army.mil/amedd_journal.aspx

pneumothorax if detected. Intravenous fluids were given only to maintain patient consciousness in line with 

the hypotensive resuscitation training. Towards the end 

of the conflicts from 2012 to 2014, medical evacuation 

units began to carry blood in “golden hour” cooler boxes and to use tranexamic acid (TXA) to promote blood 

clotting in those likely to require massive transfusions. 

Furthermore, review of outcomes revealed that the severely injured benefited from paramedic trained flight 

medics, USAF Pararescuemen, and United Kingdom 

Military Emergency Response Teams (with critical care 

flight nurses, anesthesiologists and emergency physicians) when compared to basic, entry-level US flight 

medics.14,15

Role 2–Surgical

At Role 2-Surgical facilities, we learned that damage 

control involved resuscitation for physiologic improvement alongside the surgery for anatomic control of 

bleeding and contamination. We learned to understand 

our role of care within the JTS, including the importance of personnel and equipment resources, postoperative critical care capacity, and medical evacuation availability remaining continuously ready for more casualties. 

We learned to maintain a situational awareness of the 

battlefield effects that might influence military surgical 

decision-making for each individual casualty and for 

multiple casualties. These included a knowledge of the 

ongoing operations in the area, types of weaponry used 

by the enemy (for example, blast versus high velocity 

rifle), number of friendly and enemy troops engaged 

or at risk, etc. These mission and operational variables 

could affect our capacity and capability to function.

Surgeons at the Role 2-Surgical facilities used simple 

x-ray and portable ultrasound along with patient physiology to determine the need for immediate surgery and 

in which cavity or extremity it was needed. Surgeons 

shunted vascular injuries to maintain perfusion. They 

used temporary abdominal wound closures to rapidly 

get the patient out of the operating room (OR) and to 

the intensive care unit (ICU), rapidly clearing the OR 

table for the next patient. They gave packed red blood 

cells (PRBC) and fresh frozen plasma (FFP) to resuscitate severely injured patients per the Damage Control 

Resuscitation CPG when available. These teams also organized “walking blood banks” to collect fresh whole 

blood when components failed or were not available.

Intratheater Transfers

Flight medics were often required to transport complex, 

postoperative patients who had undergone damage control surgery (DCS). These patients were often intubated, ventilated, and sedated, with an ongoing need for 

resuscitation. This essentially was an interfacility ICU 

patient transfer which exceeded the training of the standard US Army flight medic. In 2009, we began to train 

Army Nurses at the Joint Enroute Care Course and then 

to deploy critical care flight nurses to perform this higher complexity, interfacility transport mission.

NATO Roles of Care.a

Role of Care Personnel Details of Intervention

Role 1 “Buddy aid,”

Medical technician/corpsman

Flight medic 

Aid station physician or PA

Initial life-saving care rendered at and near point of injury

Involves Tactical Combat Casualty Care: care under fire, tactical field 

care, care during evacuation

Role 2 General or emergency physician

PA

Nurse

Medical support personnel

Basic resuscitation and stabilization for transport to surgical location 

or Role 3

Usually has basic x-ray, laboratory, blood capability, and small holding 

capability

Role 2-Surgicalb Surgeons for general and orthopedic 

trauma care

OR, ER, ICU nurses

Medical support personnel

Advanced resuscitation and stabilization and damage control surgery 

capability

Trauma/ED, OR, and ICU sections

Usually has blood capability and small holding capability

May have basic x-ray and laboratory capability

Role 3 General and subspecialty surgeons

ED, ICU, radiology physicians

Specialty nurses

Medical support personnel

Most robust trauma hospital in theater of operations, usually with 

neurosurgery, ENT, and ophthalmology support

CT scanner with radiologist

Full operating rooms and ICU care

Full laboratory support

Full blood bank

Role 4 Full hospital personnel Outside theater of operations; a full trauma hospital that provides 

care from admission to rehabilitation.

aDerived from NATO publication AJP-4.10(A)-Allied Joint Medical Support Doctrine.12

bRole 2 - Surgical is a US military term for a Role 2 with surgical capability in distinction from a US military Role 2 without surgical capability. 

This differs from NATO doctrine which always defines Role 2 with surgical capability.12(p1-9)

Programmatic Implementations to Improve Health
April – September 2016 111

The Army Medical Department Journal

Role 3

At Role 3, DCR was more robust due to increased manpower, a larger blood supply, and the availability of 

platelets. In 2007, Borgman et al16 published their findings from deployment to an Army combat support hospital. They determined from their data that those severely injured patients receiving a high ratio of FFP:PRBC 

had a decreased overall mortality compared to the use 

of low ratios or no FFP at all (19% vs 65%, respectively). 

Mortality due to hemorrhage in this same high to low 

ratio resuscitation population was 37% vs 92%, respectively. This was followed by numerous civilian center 

blood product ratio studies, most of which showed decreased mortality from severe trauma with early and 

rapid transfusion of 1:1:1 ratio of blood, plasma, and 

platelets in those patients requiring a massive transfusion (more than 10 Units PRBC in the first 24 hours).17-20

The Military Application of Tranexamic Acid in Trauma 

Emergency Resuscitation Study conducted at the United 

Kingdom Role 3 surgical hospital in Bastion, Afghanistan, showed that the use of TXA for patients requiring 

a massive transfusion decreased mortality to 14% from 

28% in 896 retrospectively studied patients.21

In the combat support hospitals, the presence of neurosurgeons and a CT scanner allowed for rapid diagnosis 

and life-saving surgery for traumatic brain injury. Multiple other subspecialists were available as well, including vascular surgeons, ENT surgeons, plastic surgeons, 

and orthopedic surgeons to provide ongoing DCS with 

second look procedures, vascular reconstructions, and 

complex pelvic stabilizations.

A fully functional ICU staffed with a board certified 

intensivist facilitated management of complex multisystem critical care prior to evacuation from theater. 

Finally, development and implementation of the mobile 

Burn Resuscitation Decision Support System allowed 

for forward optimal burn resuscitation at the Role 3 theater hospitals.

As we saved more severely injured patients, we had to 

develop new techniques for limb salvage, flap reconstruction, restoration, prosthetics, and rehabilitation at 

VA rehabilitation centers and military medical centers 

in the United States.

Transport from Theater

The Air Force Critical Care Air-Transport Team revolutionized theater medical evacuation, expanding evacuation to a global scale. The most severely injured patients 

could now be transported to the United States within 

days of injury. Similarly, the Army Burn Transport Team 

transported burned, multisystem injured casualties to 

the Burn Unit at San Antonio Military Medical Center. 

En route care capability included the care of complex 

critically injured patients requiring ventilation, medications to augment blood pressure, various tubes and 

drains, temporary abdominal and wound closure devices, and even extra-corporeal membrane oxygenation.

Requirements-Driven Combat

Casualty Care Research

We have made great strides in the past 14 years of prolonged conflict in 2 theaters of war. The Joint Trauma 

System was forged from necessity during war and its 

success is documented by the improvement in CCC as 

its initial legacy. However, our past success does not 

guarantee future performance. We must not drift back 

to the CCC of 2001, and we must not be naïve in thinking that we can now rest on our recent success. We must 

continue the momentum that took us so long to gather in 

order to stay ahead of the curve. As in a past generation, 

we must take heed of Winston Churchill’s wisdom and 

press on with the knowledge that there are more challenges to be faced and overcome. Our goal should be to 

begin the next conflict better prepared than we are today.

The Combat Casualty Care Research Program is postured to set a heading for success. To succeed, we must 

answer the question, “How does the Military Health 

System, and specifically the US Army, win in a complex 

world?” The answer is to create simplified DCR interventions (DCRi) that can be applied to future operations.

Near Term (2-5 Years)

In the near term, this means we capitalize on our current 

science and technology investments by seeing products 

from current research through to completion and into 

the hands of the Warfighters. We seek technology to 

bring whole blood and freeze-dried plasma to the POI. 

We look to bring expandable foam technology for junctional and abdominal hemorrhage to the battlefield. We 

will implement novel advanced physiologic monitoring 

solutions for use in triage and resuscitation.

We will focus on new operational challenges to trauma 

care such as prolonged DCR scenarios, including prolonged field care, delayed evacuation, prolonged evacuation, remote operations, or challenging megacities. Prolonged DCR solutions must include new technology for 

blood resuscitation, advanced physiologic monitoring, 

and control of junctional and torso hemorrhage. In the 

near future, we hope to deliver critical medical supplies 

to remote locations with unmanned aircraft.

At Role 2 DCS teams, we aim to become lighter and more 

versatile by leveraging totally intravenous anesthesia, 
112 http://www.cs.amedd.army.mil/amedd_journal.aspx

next generation vascular shunts, and integrated, closed 

loop patient physiology monitors that translate data 

throughout the continuum of care. We envision airbased surgical teams and simplified surgical interventions that can be brought forward to the patient. At the 

Role 3, we will see the use of endovascular balloon hemorrhage control devices and portable extracorporeal life 

support for lung, renal, and potentially cardiac support.

Mid- to Long-Term (5-10 Years and Beyond)

At the same time, we must seek the next generation of 

“leap-forward” type science and technology that will allow us to create knowledge and material products for 

Future Forces 2025 and beyond. We will invest in the 

S&T that will allow us to simplify DCRi capabilities, 

allowing them to be brought forward to the POI. We will 

seek simplification and forward deployment of endovascular torso hemorrhage control, improved blood resuscitation solutions, and organ support devices with inflammatory modulation technology. We will leverage rapidly 

emerging and developing unmanned vehicle technology 

for capability delivery and eventually self-sustained casualty care and evacuation platforms.

Summary

In summary, sustained investment in CCC research will 

keep the US military’s combat casualty care ahead of 

the curve for future operational challenges. The JTS 

encompasses the full continuum of trauma care from 

TCCC at the POI and during medical evacuation to damage control resuscitation and surgery at Role 2 and 3 to 

long range global evacuation of the critically injured to 

Role 4 care and to definitive care facilities in the United 

States. It should, therefore, be solidified into joint doctrine as a standing organization. The JTS manages all 

aspects of a global military trauma system to optimize 

casualty care in theaters of war and in increasingly complex operational environments around the world.

The Combat Casualty Care Research Program manages the combat casualty care research equity for the 

Department of Defense. Similarly, the United States 

would benefit from a more robust national investment 

in trauma care guided by a national research action plan. 

Military-civilian partnerships within national trauma 

organizations, surgical societies, and civilian academia 

would foster a model of collaborative training and research with common goals that would benefit both the 

US military and the civilian population.

References

1. The U.S. Army Operating Concept: Win in a Complex World 2020-2040. Fort Eustis, Virginia: US 

Army Training and Doctrine Command; October 

31, 2014. TRADOC Pamphlet 525-3-1. Available at: 

http://minerva.dtic.mil/doc/McMaster_AOC_full.

pdf. Accessed January 20, 2016.

2. Rasmussen TE, Gross KR, Baer DG. Where 

do we go from here?. J Trauma. 2013;75(suppl 

2):S105-S106.

3. Holcomb JB, McMullin NR, Pierce L, et al. Causes 

of death in US Special Operations Forces in the 

Global War on Terrorism 2001-2004. Ann Surg. 

2007:245:986-991.

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:S21-S27.

5. Eastridge BJ, Jenkins D, Flaherty S, et al. Trauma 

system development in a theater of war: experiences from Operation Iraqi Freedom and Operation 

Enduring Freedom. J Trauma. 2006;61:1366-1373.

6. Haas B, Jurkovich GJ, Wang J, et al. Survival advantage in trauma centers: expeditious intervention 

or experience? J Am Coll Surg. 2009;208:28-36.

7. Celso B, Tepas J, Langland-Orban B, Pracht E, 

Papa L, Lottenberg L, Flint L. A systematic review 

and meta-analysis comparing outcome of severely 

injured patients treated in trauma centers following the establishment of trauma systems. J Trauma. 

2006;60:371-378.

8. MacKenzie EJ, Rivara FP, Jurkovich GJ, et al. A 

national evaluation of the effect of trauma-center 

care on mortality. N Engl J Med. 2006;354:366-378.

9. Barringer ML, Thomason MH, Kilgo P, Spallone 

L. Improving outcomes in a regional trauma system: impact of a level III trauma center. Am J Surg. 

2006;192:685-689.

10. Nathens AB, Jurkovich GJ, Maier RV, Grossman 

DC, MacKenzie EJ, Moore M, Rivara FP. Relationship between trauma center volume and outcomes. 

JAMA. 2001;285:1164-1171.

11. Bailey J, Spott MA, Costanzo GP, Dunne JR, Dorlac W, Eastridge B, eds. Joint Trauma System: 

Development, Conceptual Framework, and Optimal Elements. JBSA Fort Sam Houston, TX: US 

Army Institute for Surgical Research; 2012. Available at: http://www.usaisr.amedd.army.mil/pdfs/

Joint_Trauma_System_final_clean2.pdf. Accessed 

January 20, 2016.

Programmatic Implementations to Improve Health
April – September 2016 113

The Army Medical Department Journal

12. AJP-4.10(A) Allied Joint Medical Support Doctrine. 

Brussels, Belgium: North Atlantic Treaty Organization; May 2011:1-8 through 1-13.

13. Sauer SW, Robinson JB, Smith MP, et al. Saving 

lives on the battlefield (part II): one year later a 

Joint Theater Trauma System and Joint Trauma 

System review of prehospital trauma care in Combined Joint Operations Area–Afghanistan (CJOAA) Final Report, 30 May 2014. J Spec Oper Med. 

2015;15(2):25-41.

14. Morrison JJ, Oh J, DuBose JJ, et al. En-route 

care capability from point of injury impacts 

mortality after severe wartime injury. Ann Surg. 

2013;257:330-334.

15. Mabry RL, Apodaca A, Penrod J, et al. Impact of 

critical care-trained flight paramedics on casualty 

survival during helicopter evacuation in the current 

war in Afghanistan. J Trauma. 2012;73:S32-S37.

16. 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.

17. Holcomb JB, Tilley BC, Baraniuk S, et al. Transfusion of plasma, platelets, and red blood cells in a 

1:1:1 vs a 1:1:2 ratio and mortality in patients with 

severe trauma - the PROPPR Randomized Clinical 

Trial. JAMA. 2015;313:471-482.

18. Dente CJ, Shaz BH, Nicholas JM, et al. Improvements in early mortality and coagulopathy are 

sustained better in patients with blunt trauma 

after institution of a massive transfusion protocol in a civilian level I trauma center. J Trauma. 

2009;66:1616-1624.

19. Zink KA, Sambasivan CN, Holcomb JB, et al. A 

high ratio of plasma and platelets to packed red 

blood cells in the first 6 hours of massive transfusion improves outcomes in a large multicenter 

study. Am J Surg. 2009;197:565-570.

20. Duchesne JC, Hunt JP, Wahl G, et al. Review of 

current blood transfusions strategies in a mature 

level I trauma center: were we wrong for the last 60 

years? J Trauma. 2008;65:272-278.

21. Morrison JJ, DuBose JJ, Rasmussen TE, Midwinter MJ. Military Application of Tranexamic Acid 

in Trauma Emergency Resuscitation (MATTERs) 

Study. Arch Surg. 2012;147(2):113-119.

Author

LTC Remick is Military Deputy, Combat Casualty Care 

Research Program, US Army Medical Research and Materiel Command, Ft Detrick, Maryland.
114 http://www.cs.amedd.army.mil/amedd_journal.aspx

Throughout history, infectious complications have reliably followed combat injuries. Increased survival rates 

from recent confl icts have resulted in increasing numbers of seriously injured patients who are at high risk for 

postinjury infections. Recent data demonstrated a 27% 

rate of infectious complications in combat-injured US 

troops evacuated to a Level V facility; this number increases to 50% among intensive care unit (ICU) patients.1

These have predominantly involved multidrug-resistant 

(MDR) pathogens, including Acinetobacter baumanniicalcoaceticus (ABC), extended-spectrum beta-lactamase (ESBL) producing Escherichia coli and Klebsiella 

pneumoniae, and MDR Pseudomonas aeruginosa and 

Enterobacter spp. By defi nition, these are healthcare 

associated infections (HAI), since they present during 

the course of medical care and were not present or incubating on admission. These remain one of the leading 

causes of preventable death in this population, and lead 

to prolonged hospitalizations, repeat operative takebacks, 

and amputations. Observations from recent confl icts provide 5 categories of generalizable knowledge which can 

be applied to current and future operations.

LESSON #5. IF IT INVOLVES MDR GRAM-NEGATIVE

BACTERIA, IT IS PROBABLY HEALTHCARE ASSOCIATED

Soon after combat operations began in Iraq in Afghanistan, clinicians caring for casualties in Level IV 

and V facilities observed the unusual occurrence of 

MDR gram-negative rods (GNR) causing wound infections, osteomyelitis, pneumonia, and bloodstream 

infections. The fi rst publication described 102 patients 

from 2002-2004 with bloodstream infections caused by 

ABC.2

 These were identifi ed at military hospitals treating combat casualties from Iraq and Afghanistan, and 

83% were associated with OIF and Operation Enduring 

Freedom (OEF). Three major hypotheses were formulated as to the source of these bacteria: pre-injury colonization with resistant organisms (presumably as a result 

of climate differences, austere environments; changes 

in personal hygiene during deployment); direct inoculation by contaminated soil/debris at the time of injury; or 

via nosocomial transmission.

Numerous studies evaluated the potential role of pre-injury colonization with MDR ABC and/or environmental 

contamination as the source. These included an assessment of colonization of Army medic trainees who had 

never deployed or come into patient contact, in patients 

evacuated from theater for disease nonbattle injury, and 

in uninjured troops during deployment.3-5 None demonstrated pre-injury colonization with MDR ABC. Evaluations of fresh wounds were also performed at the time 

of injury; these demonstrated predominantly skin fl ora 

with no evidence of MDR GNR.6

 Soil specimens were 

collected at various sites across Iraq and Afghanistan; 

no MDR pathogens were demonstrated, and the GNR 

which were isolated from wet soil samples in Afghanistan were genotypically unrelated to those characterized 

from infected combat casualties.7

However, genotypic analysis of ABC demonstrated 

some consistent strains identifi ed from Levels III to V; 

Infection Prevention in the

 Deployed Environment

 Lt Col Heather C. Yun, USAF, MC

 COL Clinton K. Murray, MC, USA

ABSTRACT

Up to 50% of combat injured patients from recent confl icts have suffered infectious complications, predominantly with multidrug-resistant (MDR) bacteria acquired nosocomially in the chain of tactical combat casualty 

care. These bacteria have ranged from MDR Acinetobacter baumannii-calcoaceticus associated with Operation Iraqi Freedom (OIF), to extended spectrum beta-lactamase producing Enterobacteriaceae from operations 

in Afghanistan. Experience from interventions at Level III facilities demonstrate that basic infection control 

(IC) procedures, such as improvements in hand hygiene, use of ventilator associated pneumonia bundles, and 

antimicrobial stewardship, can improve outcomes even in austere environments. While some systematic interventions have been implemented to mitigate this risk, including development of the Deployed Infection Control 

Course, the Multidrug-Resistance Surveillance Network, and the Trauma Infectious Disease Outcomes Study, 

ongoing vulnerabilities remain. Deployed microbiology capabilities should be strengthened, theater-level IC 

standard operating procedures should be implemented, and a joint, theater-level expert IC consultant should be 

appointed to be responsible for directing IC activities from Levels I to IV.
April – September 2016 115

THE ARMY MEDICAL DEPARTMENT JOURNAL

these have also been recovered from British and Canadian combat casualties.5,8 While clinical cultures from 

US troops in a Level III grew predominantly gram-positives, those recovered from local nationals admitted in 

the same facility were disproportionately represented 

by ABC, K. pneumoniae, and P. aeruginosa.

9

 Level 

III hospital census and the local national length of stay 

correlated with the ABC colonization rate.10 It was also 

demonstrated that in both Iraq and Afghanistan, local 

patients are frequently colonized with MDR GNR during the course of hospitalization, including high rates on 

admission.11,12 Taken together, these data demonstrate 

that the predominant source of MDR GNR colonization 

and healthcare associated infection in US combat casualties is nosocomial. This means that a fatalistic attitude 

about infectious complications cannot be assumed, and 

places responsibility on the chain of tactical combat casualty care to minimize this risk through careful attention to IC precautions.

LESSON #4. DIFFERENT THEATERS, DIFFERENT KINETICS, 

DIFFERENT ORGANISMS

When one pathogen eclipses others in order of importance, there is a tendency to drive research and interventions at that specifi c pathogen; in IC literature this is 

termed a “vertical” approach. ABC was the predominant organism through OIF, garnered much media and 

political attention as “Iraqibacter”, and most of the fi rst 

5 years of research focused on this pathogen specifi cally. 

Returning combat casualties were screened for colonization with ABC on arrival at Levels IV and V, and overall 

colonization rates began to downtrend after 2006, initially appearing to indicate success. However, when in 

2008 active surveillance was expanded to include other 

MDR pathogens, it became clear that colonization rates 

remained fairly stable in the range of 15% (Level V).13

With the shift in major combat operations from Iraq 

to Afghanistan, the predominant pathogen changed to 

ESBL producing E coli and other Enterobacteriaceae. 

Additionally, with changes in tactics and increased frequency of dismounted patrols in the provinces of southern Afghanistan, the mechanisms of injury changed to 

include higher traumatic above the knee amputations 

and major complex blast injuries, setting the stage for 

emergence of invasive fungal infections in the 2009-

2010 timeframe.14 The implication of these changes in 

microbiology with changes in theater and kinetics is that 

broad assumptions about empiric therapy and vertical 

IC measures (such as screening and decolonization for 

one organism or another) are likely to be dated and met 

with limited success. It also means that microbiology 

expertise in the deployed environment must be available and supported, so that changes in microbiology can 

be met with real-time interventions such as changes in 

prophylaxis and empiric therapy. A fl exible approach to 

prevention is necessary, both by incorporating lessons 

learned and maintaining relevant research such that interventions can be focused.

LESSON #3. EXPERTISE MUST BE DEVELOPED AND

DEPLOYED

The IC community in the Department of Defense (DoD) 

is a small one, largely consisting of a handful of nearly 

exclusively civilian IC offi cers assigned to Level IV and 

US-based MTFs, and a few active duty infectious disease 

physicians who have experience as medical directors of 

IC at their hospitals. Level III facilities currently task one 

nurse with directing IC activities as an additional duty, 

but this individual rarely has prior experience. In 2008, 

in order to provide directed training to those deploying 

in this role, the Infection Control in the Deployed Environment Course was developed and initiated through the 

Army Medical Department Center & School at Brooke 

Army Medical Center (BAMC).15 In 2010, an Army Execution Order was published directing that one person be 

identifi ed to perform this duty at Level IIIs and to ensure 

predeployment training. Uptake of predeployment training was irregular by Air Force personnel deploying in 

this role until 2012. Current records dating from 2011 indicate that 89 Army (77 active, 12 reserve), 18 Air Force 

(16 active, 2 reserve), 1 Navy, 2 Canadian military and 

6 civilian personnel have attended the course, with deployments to Afghanistan (40), Kuwait (11), and several 

to Africa, Central and South America (R. SantaMaria, 

unpublished data). We recommend that this course (or 

equivalent) be mandated for those deploying to Level III 

facilities in the role of IC offi cer. Serious consideration 

should also be given to the general structure of the IC 

community in the DoD with regard to the authorized 

numbers of active duty, certifi ed infection preventionists. 

Ideally, those deploying in the role would have experience in the fi eld. Additionally, while telehealth support 

exists for IC through Army Knowledge Online email 

consults, this currently exists as a question-answering 

service. It would be strengthened by expanding its role 

to include a proactive fact-fi nding and active mentoring 

component, ideally helmed by a joint, theater-level consultant with accountability and authority to develop and 

direct infection prevention activities theater-wide.

LESSON #2. SYSTEMS FOR RESEARCH AND SURVEILLANCE

MUST BE IN PLACE AND ONGOING

The “Iraqibacter” crisis during OIF demonstrated the 

absence of a systematic, structured approach to capturing combat-related infection events or organisms for 

characterization. Although this need was quickly recognized, multiple barriers toward meeting research gaps 

existed, including logistical and legal constraints related 
116 http://www.cs.amedd.army.mil/amedd_journal.aspx

to performing operational research. For years, research 

was limited to retrospective data analyses performed 

after a proactive clinician’s deployment, or collected 

outside the combat zone altogether and performed in a 

fragmented fashion by different investigators in different organizations, limiting generalizability. The Army 

ultimately arranged some deployments specifi cally for 

research, including infectious disease research, and the 

DoD Trauma Registry (DoDTR) was modifi ed to better capture infectious disease events. In 2008, the fi rst 

set of clinical practice guidelines relating to prevention 

of infection in combat casualties was published, and a 

signifi cant update was published in 2011 and endorsed 

by the Surgical Infection Society and the Infectious Disease Society of America.16 In 2009, the Trauma Infectious Disease Outcomes Study (TIDOS), a project of the 

Infectious Disease Clinical Research Program, was initiated and began prospectively enrolling evacuated combat casualties. At the same time, the Multidrug-resistant 

Organism Repository and Surveillance Network began 

collecting isolates to evaluate relatedness and resistance, 

and conduct global molecular epidemiology. The fi rst 

generalizable knowledge extracted from either of these, 

however, was 2011, approximately 9 years into combat 

operations. Systems such as these require ongoing funding and support even in the interconfl ict period to prevent similar delays in the next confl ict.

LESSON #1. THE STATUS QUO IS UNACCEPTABLE; BUT

IC MEASURES ARE EFFECTIVE IN THE OPERATIONAL

ENVIRONMENT

As previously stated, 27% to 50% of US casualties 

evacuated from the combat zone develop HAI (National 

Healthcare Safety Network-defi ned), an astonishingly 

high rate for largely preventable complications, with 

serious effect on these patients.1

 Direct comparison to 

HAI in US-based civilian trauma is challenging based 

on different mechanisms of injury and population as 

well as methodologies of TIDOS versus other prospective trauma infectious disease studies. However, trauma 

registry studies were conducted out of BAMC, a Level 

I trauma center, and the DoDTR, with nearly identical methodologies. The BAMC study, which excluded 

combat casualties, demonstrated an 8% infection rate 

vs the DoDTR study, which demonstrated infection in 

one-third of subjects.17,18 Notably, the DoDTR’s median 

injury severity score was higher, but the population at 

BAMC was older and had a higher proportion of medical comorbidities. Infections in combat casualties occur 

a median of 7 days after injury, well after evacuation out 

of theater. Therefore, the practitioners in Level II and III 

facilities may remain largely unaware of the complications their patients are developing, and attitudes toward 

IC in theater may be similarly uninformed.1

Fortunately, basic IC interventions are effective in the 

operational environment, just as they are in garrison. A 

study evaluating the effects of basic interventions including hand hygiene attention and surveillance, implementation of ventilator-associated pneumonia (VAP) 

bundles, and antimicrobial stewardship, was performed 

by Landrum et al 19 at Balad Air Force Theater Hospital, 

Iraq. At the time, this facility was a series of interconnected tents. This demonstrated a rapid reduction in the 

VAP rate from 60 to 11 per 1000 ventilator days and improvement in the facility’s antibiogram, with improvements in ABC susceptibility to both amikacin and meropenem. In 2011, similar interventions were conducted 

at Craig Joint Theater Hospital, Bagram, Afghanistan, 

during OEF’s peak in combat casualties, with approximately 600 ICU patients treated from June to December. 

With basic interventions such as ensuring widespread 

availability of alcohol-based hand rub and conducting 

hand hygiene surveillance, we observed an increase in 

adherence from 28% to 80% in the ICU in one month 

which was sustained over those 6 months. The VAP rate 

was reduced from 40 to 13 per 1000 ventilator days over 

the course of 6 months; both these were sustained at 

6-month follow up in 2012. Adherence to CPG recommendations for antimicrobial prophylaxis was evaluated, 

with feedback given locally in areas of concern, and the 

admission overprint revised to guide more appropriate 

prescribing. Theater-wide errors in microbiology reporting of ESBL producing pathogens were also detected and corrected, and antibiograms revised accordingly 

(H. C. Y., unpublished data).

However, there is considerable room for progress in 

the formulation and implementation of IC policies and 

procedures in the operational environment. Successful interventions have been fragmented, limited to one 

hospital or another at various times, and often “targets 

of opportunity” driven by clinicians deployed for other 

purposes. Dedicated deployments of experts in 2008, 

2009, and 2012 to assess IC demonstrated ongoing inconsistencies in a number of areas. These included predeployment training of IC offi cers; development and 

application of theater-wide IC and bloodborne pathogen 

exposure policies; deployed microbiology capabilities; 

and contracts, supplies, and equipment relating to IC 

and hospital cleaning. It is also clear from experience 

that if little attention is paid to IC during stability operations, even less may be present during entry. These 

represent ongoing threats and vulnerabilities.

RECOMMENDATIONS

Recommendations about further investment in IC have 

been previously published and are summarized in the Table. These relate to command support and administrative 

PROGRAMMATIC IMPLEMENTATIONS TO IMPROVE HEALTH
April – September 2016 117

THE ARMY MEDICAL DEPARTMENT JOURNAL

controls, and offer a view to prioritization of specifi c 

interventions. However, our most primary recommendation moving forward relates to leadership: we support 

development of a systematic, command-supported process to address IC in the deployed environment. This 

would be best accomplished through establishing a joint, 

theater-level consultant with the skills and experience 

to develop theater-level standard operating procedures, 

perform annual risk assessments and plans, coordinate 

with microbiology capabilities, establish theater-level 

antibiograms, conduct surveillance, support deployed 

IC offi cers, communicate with commanders, and assist 

with related research and quality improvement projects.

REFERENCES

1. Tribble DR, Conger NG, Fraser S, et al. Infection-associated clinical outcomes in hospitalized medical 

evacuees after traumatic injury: trauma infectious 

disease outcome study. J Trauma. 2011;71:S33-S42.

2. Centers for Disease Control and Prevention. Acinetobacter baumannii infections among patients 

at military medical facilities treating injured U.S. 

service members, 2002-2004. MMWR Morb Mortal Wkly Rep. 2004;53:1063-1066.

3. Griffi th ME, Ceremuga JM, Ellis MW, Guymon 

CH, Hospenthal DR, Murray CK. Acinetobacter 

skin colonization of US Army Soldiers. Infect Control Hosp Epidemiol. 2006;27:659-661.

4. Griffi th ME, Lazarus DR, Mann PB, Boger JA, 

Hospenthal DR, Murray CK. Acinetobacter skin 

carriage among US army soldiers deployed in Iraq. 

Infect Control Hosp Epidemiol. 2007;28:720-722.

5. Scott P, Deye G, Srinivasan A, et al. An outbreak 

of multidrug-resistant Acinetobacter baumanniicalcoaceticus complex infection in the US military 

health care system associated with military operations in Iraq. Clin Infect Dis. 2007;44:1577-1584.

6. Murray CK, Roop SA, Hospenthal DR, et al. Bacteriology of war wounds at the time of injury. Mil 

Med. 2006;171:826-829.

7. Keen EF III, Mende K, Yun HC, et al. Evaluation of 

potential environmental contamination sources for 

the presence of multidrug-resistant bacteria linked 

to wound infections in combat casualties. Infect 

Control Hosp Epidemiol. 2012;33:905-911.

8. Turton JF, Kaufmann ME, Gill MJ, et al. Comparison of Acinetobacter baumannii isolates from the 

United Kingdom and the United States that were 

associated with repatriated casualties of the Iraq 

confl ict. J Clin Microbiol. 2006;44:2630-2634.

9. Yun HC, Murray CK, Roop SA, Hospenthal DR, 

Gourdine E, Dooley DP. Bacteria recovered from 

patients admitted to a deployed U.S. military hospital in Baghdad, Iraq. Mil Med. 2006;171:821-825.

10. Griffi th ME, Gonzalez RS, Holcomb JB, Hospenthal DR, Wortmann GW, Murray CK. Factors associated with recovery of Acinetobacter baumannii 

in a combat support hospital. Infect Control Hosp 

Epidemiol. 2008;29:664-666.

11. Sutter DE, Bradshaw LU, Simkins LH, et al. High 

incidence of multidrug-resistant gram-negative 

bacteria recovered from Afghan patients at a deployed US military hospital. Infect Control Hosp 

Epidemiol. 2011;32:854-860.

Specifi c Infection Prevention Areas for Prioritization in Deployed Military Treatment Facilities.*

Focus area Recommendation

Command Support/

Administrative Controls

 Establish joint, theater-level expert consultant responsible for directing IC activities from Levels I-IV, 

including annual risk assessments and plans.

 Establish theater-level IC SOPs.

 Commit to deployed expert microbiology support and integrated surveillance for HAIs and MDROs.

 Commit to ongoing education for deploying and deployed infection preventionists and clinicians.

 Commit to resourcing clinically relevant IC/HAI research in theater.

 Commit to resourcing updated clinical practice guidelines.

Essential IC Tactical 

Priorities

 Follow national and international guidelines for prevention and treatment of HAI.

 Implement robust hand hygiene programs and monitor adherence.

 Implement VAP bundles and monitor adherence.

 Implement evidence-based SSI prevention measures.

 Emplace BBP occupational exposure protocols and ensure available prophylaxis.

 Ensure cohorting of short-term vs long-term patients.

 Standardize environmental disinfection, including both low- and high-level disinfection, and processing 

of sterile supplies.

 Implement antimicrobial stewardship programs and monitor adherence with published guidelines.

*Data source: Hospenthal et al.20

IC indicates infection control; SOP, standard operating procedure; HAI, healthcare-associated infection; MDRO, multidrug-resistant organism;

VAP, ventilator-associated pneumonia; SSI, surgical site infection; BBP, bloodborne pathogen.
118 http://www.cs.amedd.army.mil/amedd_journal.aspx

12. Ake J, Scott P, Wortmann G, et al. Gram-negative 

multidrug-resistant organism colonization in a US 

military healthcare facility in Iraq. Infect Control 

Hosp Epidemiol. 2011;32:545-552.

13. Hospenthal DR, Crouch HK, English JF, et al. Multidrug-resistant bacterial colonization of combatinjured personnel at admission to medical centers 

after evacuation from Afghanistan and Iraq. J 

Trauma. 2011;71:S52-S57.

14. Warkentien T, Rodriguez C, Lloyd B, et al. Invasive 

mold infections following combat-related injuries. 

Clin Infect Dis. 2012;55:1441-1449.

15. Crouch HK, Murray CK, Hospenthal DR. Development of a deployment infection control course. Mil 

Med. 2010;175:983-989.

16. Hospenthal DR, Murray CK, Andersen RC, et al. 

Guidelines for the prevention of infections associated with combat-related injuries: 2011 update: endorsed by the Infectious Diseases Society of America and the Surgical Infection Society. J Trauma. 

2011;71:S210-S234.

17. Murray CK, Wilkins K, Molter NC, et al. Infections 

in combat casualties during Operations Iraqi and 

Enduring Freedom. J Trauma. 2009;66:S138-S144.

18. Yun HC, Blackbourne LH, Jones JA, et al. Infectious complications of noncombat trauma patients 

provided care at a military trauma center. Mil Med. 

2010;175:317-323.

19. Landrum ML, Murray CK. Ventilator associated 

pneumonia in a military deployed setting: the impact of an aggressive infection control program. J 

Trauma. 2008;64:S123-S127; discussion S127-S128.

20. Hospenthal DR, Green AD, Crouch HK, et al. 

Infection prevention and control in deployed 

military medical treatment facilities. J Trauma. 

2011;71:S290-S298.

AUTHORS

Lt Col Yun is assigned to the Infectious Disease Service, San Antonio Military Medical Center, Joint Base 

San Antonio-Fort Sam Houston, Texas. She is also the 

Director of the San Antonio Uniformed Services Health 

Education Consortium Infectious Disease Fellowship 

Program.

COL Murray is Deputy Chief of the US Army Medical 

Corps and Medical Corps Specifi c Branch Proponent Offi cer, AMEDD Center & School, Joint Base San Antonio-Fort Sam Houston, Texas.

PROGRAMMATIC IMPLEMENTATIONS TO IMPROVE HEALTH
April – September 2016 119

Healthcare delivery relies intensively on medical products and specialized logistics services provided by medical logistics (MEDLOG). Under the best of conditions, 

MEDLOG is a complex and challenging discipline. In 

unifi ed land operations, the demands of Health Service 

Support (HSS) and the nature of its materiel requirements have resulted in common observations as far back 

as the American Civil War 1

:

 Preferred medications were not on table of supplies.

 Military doctors lacked knowledge of military 

procedures.

 Transportation of medical materiel had low priority.

 Medical supplies were left behind in order not to 

affect movement.

 Equipment and supplies were required to care for indigent volunteers, displaced persons, and refugees.

After a decade of HSS support during Operations Enduring and Iraqi Freedom (OEF/OIF), there are numerous examples of Army MEDLOG challenges as well as 

accomplishments. In particular, experiences during the 

early days of these confl icts—before mature forward 

operating bases could sustain communications and distribution channels—may be especially relevant to the 

future operating environment envisioned in the Army 

Operating Concept (AOC) 2

 and the Joint Concept for 

Health Services (JCHS).3

MEDICAL LOGISTICS CHALLENGES

The following observations from OEF/OIF demonstrate 

the complexity of medical logistics, its need for agility 

to respond to the dynamic demands of HSS operations, 

the perishability of MEDLOG skills, and its often low 

priority in planning and/or in expeditionary operations.

Modularity

The Army medical capabilities deployed into Kuwait, 

Afghanistan, Iraq, and the Horn of Africa included sophisticated medical technologies distributed across the 

battle space in small, modular elements. Combat support hospitals and forward surgical teams, regardless 

of formal organization, were split-based into 2 or more 

operating locations with varying support relationships. 

This means of employment is consistent with the future 

operating environment described in the AOC and JCHS, 

where joint forces will be expected to deploy long distances to and from dispersed locations and operate in 

often austere and contested environments. The need for 

redundancy in equipment to support such modularity, 

both clinical and logistical (eg, power, shelter, mobility), will be considered in Army Medical Department 

(AMEDD) force design updates; however, the implications for synchronizing and delivering medical supplies and maintenance support are equally profound. In 

OEF/OIF, small and dispersed medical elements generated signifi cant, specialized supply and maintenance demands but had limited self-suffi ciency and minimal (if 

any) organic personnel to manage logistics. Future medical capabilities, especially at the prehospital levels, will 

likely incorporate even more advanced trauma management capability with associated specialized logistics 

requirements. This has major implications for the theater HSS system’s ability to gain visibility of MEDLOG 

Medical Logistics Lessons Observed

 During Operations Enduring Freedom

 and Iraqi Freedom

 COL Mark J. Dole, MS, USA

 COL (Ret) Jonathan M. Kissane, USA

ABSTRACT

Medical Logistics (MEDLOG) is a function of the Army’s integrated System for Health that provides the medical products and specialized logistics services required to deliver health protection and care under all operational conditions. In 

unifi ed land operations, MEDLOG is an inherent function of Health Service Support (HSS), which also includes casualty 

care and medical evacuation. This paper focuses on a few key lessons observed during Operations Enduring Freedom and 

Iraqi Freedom with direct implications for the support of HSS in future operations as envisioned in the Army Operating 

Concept and the Joint Concept for Health Services. It also examines a few key enablers that helped mitigate these challenges that are not yet fully acknowledged in Army Medical Department doctrine, policy, and planning.

OPERATIONAL SYSTEM CHALLENGES
120 http://www.cs.amedd.army.mil/amedd_journal.aspx

requirements, make timely and informed decisions for 

prioritization, and allocate necessary resources through 

available distribution channels.

Variation

The majority of OEF/OIF medical materiel demands 

did not match items in unit medical assemblages or the 

Class VIII (medical) supplies prepositioned in the theater to sustain those assemblages. Allowance standards 

for Army medical assemblages are designed to provide 

specifi c capabilities for 72 hours of combat operations. 

During 2003, only 32% of Class VIII demands generated by joint medical forces matched the Medical Contingency File, a database maintained by the Defense 

Logistics Agency (DLA) listing supply items in the military services’ medical allowance standards.4

 As a consequence, medical units commenced line item ordering 

of additional, unanticipated items almost immediately 

upon arrival in theater. Based on the authors’ observations, medical units’ demands for materiel above allowance standards began during joint reception, staging, 

and onward integration (JRSOI) when demands were 

predominantly driven by primary care to US personnel, and continued with the advent of casualty care. Unit 

allowance standards were particularly inadequate for 

the breadth of patient populations treated; eg, enemy 

prisoners of war, displaced persons, and other civilians, 

especially children. Similarly, unit assemblages did not 

accommodate the preference/experience of initial and 

rotating clinicians, particularly for specialized capabilities such as neurosurgery. Furthermore, the processes 

for service-specifi c joint urgent operational needs introduced additional medical technologies with minimal 

consideration for theater standardization, repair parts, 

or maintenance training. Given the operational and fi -

nancial constraints in medical set design, it is unlikely 

unit assemblages can ever meet the breadth of medical 

materiel requirements associated with the range of possible HSS missions; yet there will continue to be little 

tolerance for failure in meeting these requirements. This 

has signifi cant implications for the AMEDD’s ability to 

anticipate, identify, and respond to medical supply and 

maintenance requirements beyond the initial capabilities offered by unit allowance standards.

Perishable Skills

Medical logistics is a skilled discipline that requires experience to maintain competence in systems, procedures, 

and problem solving. Given the modular and dispersed 

nature of current MEDLOG capabilities, there are limited opportunities for technical mentorship of deployed 

logisticians as well as for nonlogisticians who must engage the logistics system for support. In the early months 

of OEF/OIF, it was clear that home station training and 

experience did not adequately prepare Soldiers and 

units to meet the MEDLOG challenges of actual HSS 

operations. Garrison tasks for medical units are generally limited to set maintenance, with little exposure to the 

dynamics of sustaining healthcare operations. Few, if 

any, Army medical logistics companies have opportunities to perform supply support activity functions while 

at their home station. As a consequence, the authors observed that many MEDLOG Soldiers (and leaders) arrived unprepared to connect and use automated systems 

and instead relied on manual (such as paper, phone, or 

email) processes. The US HSS assessment conducted in 

2011 in the Afghanistan combined joint operations area 

also noted the need for rigorous professional development for medical logisticians through active garrison 

mission or more specialized training.5

 The nature of the 

future operating environment and rapid employment of 

modular, highly sophisticated medical capabilities have 

signifi cant implications for maintaining ready skills of 

medical logisticians to quickly establish and synchronize medical supply and maintenance support.

Priority

Medical materiel frequently did not have suffi cient priority to compete for available transportation. Although 

OEF/OIF distribution channels ultimately became suffi ciently robust that MEDLOG priority was seldom an 

issue, this was not the case in 2003 when MEDLOG 

capabilities as well as materiel often experienced lower 

priority for movement in both strategic and intratheater 

channels. The MEDLOG battalion with the mission to 

establish Class VIII distribution for JRSOI arrived in 

Kuwait with capabilities needed to receive cold chain 

and controlled substances barely 10 days before the invasion commenced on March 19. This created backlogs 

in the United States and Europe for planned shipments 

of pharmaceuticals, vaccines, and laboratory reagents, 

and further burdened strategic air channels with additional medical materiel needed to support healthcare to 

gathering forces. A lower priority for medical materiel 

could be attributed to the fact that combat and combat support capabilities, as well as commodities such 

as ammunition, repair parts, food, and water routinely 

have transportation precedence as mission commanders 

build and sustain combat power. However, the lack of 

medical priority often resulted because mission commanders did not have suffi cient awareness of the actual 

state of medical readiness. A contributing reason was 

a lack of Class VIII visibility in logistics systems used 

for Army sustainment; however, status reporting by 

medical units frequently did not refl ect medical supply 

or maintenance as constraints for mission readiness. In 

future operations, US forces may not have uncontested 

access into an area of operations or ready availability of 

OPERATIONAL SYSTEM CHALLENGES
April – September 2016 121

THE ARMY MEDICAL DEPARTMENT JOURNAL

commercial carriers; therefore, competition for distribution resources will likely remain the norm throughout 

all phases of operations. This has signifi cant implications for the AMEDD’s ability to identify and manage 

its requirements in order to optimize use of available 

distribution resources, and to provide accurate and timely situational awareness of medical materiel constraints 

to mission commanders who set movement priorities.

MEDICAL LOGISTICS ACCOMPLISHMENTS

 Prior to 2002, there was no MEDLOG infrastructure 

in the US Central Command (CENTCOM) for sustaining HSS in land operations. The 3rd Medical Command (Deployment Support (DS)), as the senior Army 

medical mission command for the 3rd US Army, was 

tasked to plan and execute single integrated medical logistics management responsibilities for the support of 

joint medical forces. The Medical Materiel Readiness 

Assessment conducted in 2007 for the DLA provides a 

succinct overview of how the 3rd Medical Command 

(MEDCOM) (DS) established and adapted MEDLOG 

support from theater opening through the beginning of 

the “surge” in 2007.6

Despite the signifi cant challenges, the AMEDD was remarkably successful in its MEDLOG support of Army 

and joint medical forces during OEF/OIF. The dedication and skill of medical logisticians across the force 

were indispensable in establishing a responsive and agile support framework; however, of equal importance 

were a few key decisions and enablers not yet fully acknowledged in AMEDD doctrine, policy, and planning.

6th Medical Logistics Management Center

The 3rd MEDCOM effectively used the 6th Medical Logistics Management Center (MLMC) to establish a responsive, adaptable, and enduring framework for theater 

MEDLOG support. The MLMC provided senior, skilled 

leadership to organize and establish a provisional medical materiel center (MMC), the US Army Medical Materiel Center, Southwest Asia (USAMMC-SWA) to serve 

as a theater-level platform for the intratheater medical 

supply chain and maintenance support. The 3rd MEDCOM facilitated this by assigning the MLMC commander (grade O6) operational control of 2 MEDLOG 

battalions (388th and 428th) to allow optimal allocation 

of personnel and skills between a primary theater distribution center in Qatar and a forward distribution point 

for JRSOI in Kuwait. While USAMMC-SWA manning 

has changed consistent with the Army’s theater posture, it continues to serve as a provisional organization, 

commanded by a medical logistician (grade O5). The 

USAMMC-SWA still provides CENTCOM a stable and 

capable platform for managing intratheater distribution 

of critical Class VIII supplies, including cold chain and 

controlled substances, and for staging specialized medical maintenance capabilities provided by the US Army 

MEDCOM. Experiences in OEF/OIF demonstrated 

the importance of an AMEDD capability to establish a 

theater MMC, led by senior medical logisticians, to effectively open and sustain HSS in distant land theaters. 

With the removal of medical logistics battalions from 

the AMEDD force structure, the 6th MLMC’s modular, theater-aligned organization and centralized MEDLOG management mission are critically important for 

projecting this capability. This important role may be 

implied, but is not specifi cally refl ected in Army MEDLOG doctrine.

Medical Supply Automation

Key medical logistics systems at user (DCAMa) and 

enterprise (TEWLSb) levels enabled an end-to-end supply chain between customers and theater/strategic Class 

VIII sources. In OEF/OIF, nearly all deployed medical 

units below theater hospital used DCAM to perform 

user-level Class VIII supply functions. In view of challenges previously discussed (modularity, variance, perishable skills), DCAM was valued for its simplicity (especially for use by nonlogistics personnel), access to 

supplier catalogs, and “store and forward” utility with 

intermittent communications. It should be noted that 

its most signifi cant challenge, fi rewall barriers that impede access to communications networks, will soon be 

addressed using enterprise capabilities of the Defense 

Information Systems Agency. In 2009, the AMEDD 

replaced its legacy materiel management system at 

USAMMC-SWA with TEWLS, an enterprise resource 

planning solution integrating Class VIII management 

across all Army MMCs. The TEWLS enabled centralization of key medical materiel management functions 

and improved synchronization of data among customers, 

MMCs, and commercial suppliers. It also facilitated the 

balancing of stocks and workload driven by changes in 

theater operations between USAMMC-SWA and the US 

Army Medical Materiel Center-Europe (USAMMCE). 

These observations are not intended to endorse specifi c 

systems; rather, they highlight the enterprise capabilities critically needed by the AMEDD to effectively and 

effi ciently manage MEDLOG in future HSS operations. 

The dispersion of small, highly sophisticated medical 

capabilities (including MEDLOG) will require logistics 

and nonlogistics personnel alike to have reliable access 

to MEDLOG information, and for theater logistics managers to have near real-time visibility of MEDLOG requirements and resources to optimize use of constrained 

aDefense Medical Logistics Standard Support Customer Assistance 

Module

bTheater Enterprise Wide Logistics System
122 http://www.cs.amedd.army.mil/amedd_journal.aspx

distribution channels. It will also require the ability to 

apply skilled management and technical oversight of 

MEDLOG capabilities distributed in companies and 

teams across the battlespace.

Theater Support by MEDCOM Organizations

Institutional (TDAc) organizations of the US Army 

MEDCOM have provided CENTCOM critical MEDLOG capabilities in direct support of theater operations 

from the onset of OEF/OIF. The USAMMCE served as 

the strategic MEDLOG platform for opening the theater 

and assisted the 6th MLMC in establishing USAMMCSWA. It remains in direct support of USAMMC-SWA, 

performing most materiel management functions including master data, customer order processing, and 

commercial supplier relations, as well as providing technical training for personnel rotating into USAMMCESWA and other key theater positions. The US Army 

Medical Materiel Agency (USAMMA) has provided 

specialized medical maintenance capabilities through 

Forward Repair & Maintenance-Medical teams as an 

extension of its national maintenance program. Also, 

during early phases of OEF/OIF, Army medical centers in the United States provided “reach” supply support for selected products required by clinical specialists, especially for neurosurgery and burn care. These 

observations are signifi cant because they demonstrate 

essential MEDLOG capabilities that are not resident 

in operating forces; that is, Army and joint medical 

forces deployed in land operations will require MEDLOG capabilities provided only by Army MEDCOM’s 

institutional organizations. This direct support of operating forces by MEDCOM organizations leverages and 

extends business processes, systems, and supplier relationships honed for effi cient peacetime operations in the 

Department of Defense direct care system, and “blurs 

the line” between the AMEDD’s institutional and operating units and functions.

SUMMARY

These lessons from the opening phase of OEF/OIF highlight challenges applicable to HSS in future operations 

characterized by tailored, modular, medical forces operating far from sustaining capabilities in austere environments. They also demonstrate the importance of MEDLOG capabilities resident in institutional MEDCOM organizations to provide the operational reach and agility 

necessary to establish and sustain HSS in unifi ed land 

operations. The key DOTMLPFd implications of MEDLOG lessons observed from OIF/OEF are presented in 

the Table.

REFERENCES

1. Wichtendahl K. Dr. Jonathan Letterman: Father of 

Modern Emergency Medicine [internet]. National 

Museum of Civil War Medicine Website. Available 

at: http://www.civilwarmed.org/letterman-dinner/

letterman-father-of-battlefi eld-medicine/. Accessed 

March 4, 2016.

2. Army Operating Concept, TRADOC Pamphlet 

525-3-1. Fort Monroe, VA: US Army Training and 

Doctrine Command; October 31, 2014:15-19. Available at: http://www.tradoc.army.mil/tpubs/pams/

TP525-3-1.pdf. Accessed March 4, 2016.

3. Joint Concept for Health Services. Washington, 

DC: Joint Staff, US Dept of Defense; August 31, 

2015:2. Available at: http://dtic.mil/doctrine/con

cepts/joint_concepts/joint_concept_health_servic

es.pdf. Accessed March 4, 2016.

c Table of Distribution and Allowances: Prescribes the organizational structure, personnel and equipment authorizations, and requirements 

of a military unit to perform a specifi c mission for which there is no appropriate table of organization and equipment (the document which 

defi nes the structure and equipment for a military organization or unit).

dDoctrine, organization, training, materiel, leadership & education, personnel, facilities

 Key DOTMLPFa Implications for MEDLOG Lessons Observed.

Doctrine

and Policy

 Recognize in AMEDD doctrine (eg, ATP 4-02.1b) and policy (eg, AR 40-61c) the role of key MEDCOM organizations 

(MMCs, USAMMA, Installation Medical Supply Activities) in direct support of operating forces.

 Recognize in AMEDD doctrine the requirement to establish, when necessary, a provisional MMC to provide theaterlevel MEDLOG, and the role of the MLMC in enabling that capability. Recognize in AMEDD doctrine the technical alignment of supply support functions provided by Army MEDLOG Companies with medical materiel management that is 

centralized at theater-level MMC or MLMC.

Training  Ensure rigorous professional development for medical logisticians through active garrison missions for MEDLOG 

units and medical profi ciency training in the Army’s Health Readiness Platforms.

Leader

Development

 Ensure leader development of medical mission commanders and staff promotes their ability to plan, manage, and 

appropriately advocate for MEDLOG support in HSS operations.

Materiel  Leverage existing and emerging enterprise information technologies to connect deployed medical elements with MEDLOG sustainment capabilities and enable effective management of theater MEDLOG requirements and resources. 

aDoctrine, organization, training, materiel, leadership & education, personnel, facilities

bArmy Techniques Publication 4-02.1: Army Medical Logistics7

cArmy Regulation 40-61: Medical Logistics Policies8

OPERATIONAL SYSTEM CHALLENGES
April – September 2016 123

THE ARMY MEDICAL DEPARTMENT JOURNAL

4. Cocrane RM, Mervis SA. Medical Materiel Readiness Assessment. Tysons, VA: Logistics Management Institute; October 2003: 3-8. Report DL207R1.

5. MEDCOM Support to ATO HSS Assessment: US 

Health Service Support Assessment Team. ANNEX F to OPORD 12-01; October 20, 2011:22.

6. Addison D, Cocrane R, Costello P, Johnson M, Kissane J. Medical Materiel Readiness Assessment 

(2007). Tysons, VA: Logistics Management Institute; May 2008:4-17,4-18. Report DL207R1.

7. Army Techniques Publication 4-02.1: Army Medical Logistics. Washington, DC: US Dept of the 

Army; October 29, 2015.

8. Army Regulation 40-61: Medical Logistics Policies. 

Washington, DC: US Dept of the Army; January 

28, 2005.

AUTHORS

COL Dole is the Deputy G-4, Headquarters, US Army 

Medical Command, Joint Base San Antonio-Fort Sam 

Houston, Texas.

COL (Ret) Kissane is a Senior Consultant, Logistics 

Management Institute, Tysons, Virginia.
124 http://www.cs.amedd.army.mil/amedd_journal.aspx

SITUATION

As a planner, you are required to determine how many 

people, how much space, and how much money you 

need to meet the projected caseload demand. In the best 

case, you build out your caseload demand (most likely 

and worst case), estimate full time equivalents based 

on established ratios, and secure space, equipment, and 

funding. Then you execute the plan and hope your estimates are correct. In the worst case, you take any staff, 

space, and funding you can get and make it work hoping 

your team never runs out of medical capacity when it is 

needed most.

As a planner you know many of your planning factors 

change frequently. Number and type of cases, number 

of clinical spaces, and availability of types of clinicians 

and support staff fl uctuate in the military medical environment. Maybe you are conservative and usually estimate that you need more staff and more funding to meet 

the worst-case planning scenario. Perhaps you tend to 

believe your team can handle large fl uctuations in caseload and underestimate the staff, space, and funding 

needed to meet caseload demand.

Then things change: confl icts arise, war breaks out, natural disasters occur, or other humanitarian support is 

required. Now you have to plan for a new set of requirements. How do you forecast your needs? How do you 

know what your actual capacity is with the current staff, 

space, and funding available to your team given the type 

of cases you are likely to see?

How do you plan, then manage, your operational capacity effi ciently, effectively, and quickly?

PLANNING METHODS FOR COMPLEX OPERATIONS

Current Planning Methods

Planning has come a long way from the days of simplifi ed estimation techniques. Over the last 40 years the operations research and systems analysis (ORSA) community has developed a variety of complex modeling techniques making it possible to accurately predict many 

planning factors. Planning outcomes account for cumulative variability across the process. Complex computer 

simulation models must be used to approximate overall 

system capacity given the variability of the steps within the processes. Input parameters such as processing 

Planning Staff and Space Capacity

 Requirements during Wartime

 Elisa B. Kepner, MSSE

 Rachel Spencer, MSN

ABSTRACT

Determining staff and space requirements for military medical centers can be challenging. Changing patient 

populations change the caseload requirements. Deployment and assignment rotations change the experience 

and education of clinicians and support staff, thereby changing the caseload capacity of a facility. During 

wartime, planning becomes increasingly more complex. What will the patient mix and caseload volume be by 

location? What type of clinicians will be available and when? How many beds are needed at each facility to 

meet caseload demand and match clinician supply? As soon as these factors are known, operations are likely to 

change and planning factors quickly become inaccurate. Soon, more beds or staff are needed in certain locations to meet caseload demand while other locations retain underutilized staff, waiting for additional caseload 

fl uctuations. This type of complexity challenges the best commanders. As in so many other industries, supply 

and demand principles apply to military health, but very little is stable about military health capacity planning. 

Planning analysts build complex statistical forecasting models to predict caseload based on historical patterns. 

These capacity planning techniques work best in stable repeatable processes where caseload and staffi ng resources remain constant over a long period of time. Variability must be simplifi ed to predict complex operations. This is counterintuitive to the majority of capacity planners who believe more data drives better answers. 

When the best predictor of future needs is not historical patterns, traditional capacity planning does not work. 

Rather, simplifi ed estimation techniques coupled with frequent calibration adjustments to account for environmental changes will create the most accurate and most useful capacity planning and management system. The 

method presented in this article outlines the capacity planning approach used to actively manage hospital staff 

and space during Operations Iraqi Freedom and Enduring Freedom.
April – September 2016 125

THE ARMY MEDICAL DEPARTMENT JOURNAL

times and other planning factors are calculated by developing statistical distributions through highly complex 

statistical analysis of historical data. These input factors 

are then used in the simulation to determine a single 

outcome or set of planning parameters.

This approach can be time consuming, costly, and infl exible to changing environmental factors. Cumulative 

variability becomes cumulative error when input parameters are changing or unknown. Flexibility, accuracy, 

and speed are key to wartime capacity planning. When 

current ORSA planning methods do not meet these requirements, what other methods exist?

Updated Planning Methods for Complex Systems

It appears the planners from many years ago may have 

had it right: estimation techniques work. Many years 

before computers, planners used high level measures to 

estimate staff and space requirements. Today, planning 

capacity using simplifi ed estimation techniques has 

proven to be more accurate, more fl exible, and less time 

consuming than newer planning methods. Combining 

estimation techniques with new insight around behavior of complex systems allows planners to predict and 

manage operational parameters accurately and quickly. 

These planning methods work in many different environments and are better suited for wartime planning 

activities.

This approach to planning focuses on fi nding key operational driver(s) most closely correlated to the capacity 

metrics. As drivers change, so do the capacity requirements. This method removes the need to collect extensive data on all processes, staff, and patient caseload. 

Instead, planners can now focus on monitoring and 

controlling only a few key factors that will accurately 

predict capacity. Given that complex systems frequently 

change, drivers will likely change as well. Continued 

model calibration and validation is critical when using 

this simplifi ed planning approach.

Simplified Capacity Planning

The following section outlines the 5 key steps to implementing a simplifi ed capacity planning approach. Examples from Operations Iraqi Freedom and Enduring 

Freedom are documented below.

1. Understanding the planning request and related 

metrics.

 What are you trying to predict?

 How much capacity will be available?

 How many staff members are needed?

 How much money is needed?

 How many operating room hours are needed?

2. Determine drivers that predict metrics.

What factors effect what you want to predict?

What factor or type of case(s) use the greatest 

quantities of staff and/or space because of 

volume, time, and intensity?

What type of case(s) have a wide range of volume, 

time, and intensity requirements?

3. Create predictive algorithm.

f(driver)=predicted metric

f(driver)=driver(a+b)

SIMPLE EXAMPLE (1)

Description

The facility needs to manage intensive care unit (ICU) 

utilization for all wounded, injured, or ill (WII) and has 

a simple way to measure incoming WII rates.

There are 36 ICU beds and the facility targets an 80% 

or less utilization to ensure emergency surge capacity in 

the ICU.

Predicted metric: needed number of ICU beds 

occupied by WII or ICU

Driver: Mean of WII arriving weekly: μ=12, σ=6

Where: WII weekly mean=μ=12

WII likely worst case: μ+1σ =12+(16) = 18/week

WII today=10

Note: The factor of μ+1σ is a good approximation of the 

“most likely worst case” value, meaning that this capacity requirement will likely occur a few times during a 

planning season, such as the summer.

Using 1σ is key. Any higher σ factors will plan too many 

staff, space, and budget requirements for the majority 

of the operations. Instead, use 1σ to ensure staff is effi ciently used and develop a management control dashboard to quickly identify upcoming surges in caseload 

where operational adjustments may be necessary.

a=mean length of stay in weeks: μ=1.8 weeks

b=0

f(12)=(12 

f(12+6)=(16  

f(10)=(10  

Outcome: The ICU has capacity for the current rate and 

the mean rate of WII and will likely begin to run out of 

capacity under predicted higher demands as displayed 

in Table 1.
126 http://www.cs.amedd.army.mil/amedd_journal.aspx

MORE COMPLEX EXAMPLE (2)

Description

The facility needs to manage ICU utilization for all WII 

but does not have a way to measure incoming WII rates 

easily. Amputees are more than 50% of the caseload of 

WII patients because of volume and bed days. Additionally the facility needs to use some of beds for non-WII 

patients.

There are 36 ICU beds and the facility targets an 80% 

or less utilization to ensure emergency surge capacity 

in the ICU.

Predicted metric: needed number of ICU beds 

occupied by WII or ICU

Driver: Mean of amputees (Amp) arriving weekly: 

μ=9, σ=4

Where: WII weekly mean=μ=9

WII likely worst case=13 per week

WII today=7

a=scaling factor: μ=1.6

Scaling factor considers the length of stay (LOS) for amputees in weeks, LOS for nonamputees, and ratio of WII 

to amputees.

Note: The scaling factor is most easily developed by 

taking periodic samples of the key factors including 

the predicted metric and likely drivers. After collecting 

multiple samples, develop an equation to determine the 

scaling factor. If the driver has been accurately identifi ed, this step is easy. If the driver is a combined set of 

drivers, analytic support will likely be required to perform correlation analysis and develop the scaling factor.

b=mean number of beds used by non-WII: μ=7 beds

f(9)=(9 

f(9+4)=(13

f(7)=(7

Outcome: The ICU has capacity for 

the current rate and the average rate of 

WII and will likely almost run out of 

capacity multiple times during a planning season as displayed in Table 2.

The recommendation is to divert or 

postpone non-WII patient care when 

the average number of amputees begins to increase in preparation of the 

“likely worst case” levels.

NATIONAL CAPITAL REGION EXAMPLE

Table 3 is an example of the model used by JTF National 

Capital Region Medical during 2010 through 2013 to 

manage capacity in that region. The red 12 represents 

the number of amputees arriving on a weekly basis with 

a moving average of 4 weeks. The model accurately predicted the number of WII in the ICU, medical surgical, 

and operating rooms on a weekly basis. The model was 

calibrated for low season and high season fi ghting twice 

a year and remained accurate throughout the years.

Table 1. Example 1 Output.

WII ICU

Amputees

per

Week

Daily

Census

(mean)

6 11

8 14

Today 10 18

Mean 12 22

14 25

16 29

Likely worst case 18 32

20 36

Table 2. Example 2 Output.

WII Total ICU

Census 

(WII+non-WII)

Amputees

per

Week

Daily Census

(mean)

2 10

3 12

5 15

Today 7 18

Mean 9 21

11 25

Likely worst case 13 28

Table 3. National Capital Region 

Example.

WII ICU Med 

Surg

OR

Hours

Amputees

per

Week

Daily 

Census

(mean)

Daily WII 

Census

(mean)

WII

Hours

per 

Week

2 1 10 48

4 2 19 96

6 3 29 143

8 4 39 191

10 5 49 239

12 5 58 287

14 6 68 335

16 7 78 383

18 8 87 430

20 9 97 478

22 10 107 526

24 11 117 574

26 12 126 622

28 13 136 670

30 14 146 717

32 15 155 765

34 16 165 813

36 16 175 861

38 17 185 909

40 18 194 957

OPERATIONAL SYSTEM CHALLENGES
April – September 2016 127

THE ARMY MEDICAL DEPARTMENT JOURNAL

4. Establish reporting and forecasting tools to manage 

operations.

The examples from step 3 represent one of the many 

types of management tools that can be developed using this methodology. Thresholds for drivers should be 

determined and tracked in weekly operational reports. 

As thresholds are exceeded, action should be taken to 

adjust available capacity through adding resources and/

or adjusting caseload requirements.

5. Track accuracy of algorithm and calibrate as 

necessary.

It is important to check the accuracy of the algorithm. In 

the beginning, the accuracy should be validated weekly 

until the model moves towards steady state. Afterwards, 

algorithm validation should occur monthly or quarterly 

to ensure the driver and scaling factor are still correct. 

Adjustments such as types of cases, number of cases, 

types of available clinicians, and changes in available 

space can all change the driver or scaling factor. 

Validating the algorithm follows the same steps outlined 

in this article.

APPLICATIONS

The basic approach can be applied to predict many different capacity factors. Some areas studied during 2010 

to 2013 include:

 Locations: Walter Reed Army Medical Center, National Naval Medical Center, Fort Belvoir Community Hospital, San Antonio Military Medical Center, 

San Diego Naval Medical Center, National Intrepid 

Center of Excellence for Traumatic Brain Injury, 

and Kimbrough Ambulatory Care Center.

 Areas of Study: WII inpatient and outpatient care, 

mental health inpatient and outpatient care, rehabilitation staff and space requirements, orthopedic staffi ng requirements, housing requirements, 

Wounded Warrior roadmap, and regulation of WII 

patients to medical facilities.

CONCLUSION

Complex operations can be managed through simple 

estimation models. It is often no longer necessary to 

spend excessive amounts of time and money estimating operational capacity if the dynamics of the system 

do not require it. Several elements of the DOTMLPF* 

could use this approach: organization, materiel, leadership, personnel, facilities.

AUTHORS

Mrs Kepner is Principal Operations System Engineer, 

Joint Task Force National Capital Region Medical, 

Bethesda, Maryland.

Ms Spencer is Lead Operations Planner, Joint Task Force 

National Capital Region Medical, Bethesda, Maryland.

*Doctrine, organization, training, materiel, leadership & education, 

personnel, facilities
128 http://www.cs.amedd.army.mil/amedd_journal.aspx

Decades of research have demonstrated conclusively 

that sleep sustains cognitive abilities ranging from 

simple speed of responding to problem solving, fl exible 

thinking, and the ability to integrate new information 

into a common mental model.1,2 These mental processes 

underlie successful military operations. Thus, sleep is 

a vital military resource. However, military operations 

are usually prolonged, stressful, and take place in austere environments, predisposing Soldiers to insuffi cient 

sleep.

Sleep planning and management are force multipliers. In 

contrast, when sleep is not prioritized and appropriately 

managed, consequences are not limited to decreased 

military readiness but also include degraded mental and 

physical health. Lack of sleep planning and management appears to drive a negative feedback loop in which 

overall sleep health is degraded by maladaptive sleep 

habits and practices. The consequences of inadequate 

sleep planning and management were highlighted in 

the recent RAND report, Sleep in the Military,

3

 where 

nearly 50% of military personnel screened positive for 

disturbed sleep.

Operation Iraqi Freedom, Operation Enduring Freedom, 

and Operation New Dawn (OIF/OEF/OND) posed unprecedented challenges for sleep management prior to, 

during, and after deployment. All branches of the military saw a signifi cant increase in the diagnosis of sleep 

disorders in the active duty and veteran populations over 

the course of these operations.4

 The etiology of these 

sleep disorders is multifactorial: substandard sleep environments; continuous operations; preexisting poor sleep 

practices; and perhaps most importantly, the lack of recognition at the individual and organizational level of the 

importance of maintaining healthy sleep practices.

In this article, we review factors that affect sleep in the 

deployed setting and their relationship to sleep disorders 

diagnosed in Soldiers who deployed in support of OIF/

OEF/OND. We also describe associations between sleep 

and behavioral health disorders as well as other comorbidities. We discuss appropriate treatment of sleep disorders in the military population. Our objective is to 

provide recommendations to improve sleep in future operational environments not only as critical operational 

enablers but also as preventive measures to reduce the 

likelihood of Soldiers developing sleep disorders as a 

consequence of their deployment.

SLEEP PROBLEMS IN THE DEPLOYED ENVIRONMENT

Despite years of anecdotal evidence that deployed military personnel experience sleep problems, it is only recently (within the past 10 years) that deployed Soldiers 

 Military Sleep Management:

 An Operational Imperative

 COL Vincent Mysliwiec, MC, USA

 MAJ Robert J. Walter, MC, USA

LTC Jacob Collen, MC, USA

Nancy Wesensten, PhD

ABSTRACT

Sleep is critical for military operational readiness but is commonly disregarded during operational planning. 

The start of combat operations with Operation Iraqi Freedom saw a dramatic rise in diagnosis rates of clinically signifi cant sleep disorders among offi cers and enlisted. This coincided with a parallel rise in behavioral 

health disorders. In this article, the etiology of sleep problems and sleep disorders in our military population 

is reviewed, and guidance is provided for improving sleep health in our military population. It is our view that 

appropriate sleep planning and management affords military units and commanders a near-term tactical advantage in terms of maintaining alertness, a midterm tactical advantage of decreasing susceptibility to sleep 

and behavioral health disorders, and a long-term strategic advantage with increased readiness and resiliency 

of their Soldiers.

OPERATIONAL PATIENT HEALTHCARE
April – September 2016 129

THE ARMY MEDICAL DEPARTMENT JOURNAL

were asked about sleep habits and problems as part of 

the periodic in-theater behavioral health surveys (Mental Health Advisory Team (MHAT)). Sleep may have 

been ignored because the theoretical model of Soldier 

well-being that served as the basis for these surveys did 

not include sleep as a critical factor.5

 For MHATs 5-9 

conducted between 2007 and 2013 , military personnel 

were asked how many hours of sleep they obtained per 

day, and in a separate item, how many hours of sleep 

per day they needed in order to feel well-rested.6-9 The 

response data are presented in Table 1. For MHAT-5, 

Solders reported obtaining an average of 5.6 hours of 

sleep per day and needing 6.4 hours sleep to feel well 

rested; substantially below the 7-8 hours amounts established as necessary for maintaining alertness and mental 

performance.10 The operational consequences of insuffi cient sleep are not fully known; however, in MHAT-9,8

it was reported that almost 50% of personnel reported 

they had fallen asleep on a convoy (a monotonous condition under which sleepiness would be unmasked) and 

18.4% on guard duty where vigilance is required and 

could pose risks to the unit as well as the potential for 

punishment in accordance with Article 113 of the Uniform Code of Military Justice.*

The occurrence of an unintended sleep episode requires 

a different construct than what is currently viewed as 

weakness or laziness. Sleep is a biologic requirement. 

Without adequate sleep, the brain does not function optimally, predisposing Soldiers to becoming a sleep casualty. The consequences of acute insuffi cient sleep range 

from minimal (ie, sleeping in a convoy while a passenger) to catastrophic (ie, unavoidably falling asleep while 

driving a convoy vehicle and causing an accident with 

loss of life and property). The long-term consequences of insuffi cient sleep, or chronic casualties, include 

cardiovascular disease, hypertension, and obesity.11 The 

overall effect of insuffi cient sleep, in both the short and 

long term, is decreased readiness of the force.

Factors contributing to insuffi cient sleep in deployed environments were assessed in MHAT surveys conducted 

in 2010, 2012, and 2013. Consistently, as shown in Figure 1, the 2 factors most frequently reported as interfering with sleep were nighttime duties and poor sleep 

environment. Specifi c components of a poor sleep environment that were identifi ed include a lack of adequate 

noise and light control, suboptimal physical sleep environment (lack of adequate bedding materials and uncontrollable temperature variations) and the use of the sleep 

quarters for nonsleep activities. For example, nighttime 

construction projects (to avoid extreme daytime heat) in 

the vicinity of sleeping quarters were frequently cited 

as a contributor to a poor sleep environment.12 Additionally, standard military practice is to assign sleep quarters by rank rather than by shift worked. This results in 

disrupted sleep, especially for night-shift workers due to 

lack of noise and light controls. Other behaviors, based 

on anecdotal reports, which likely contributed to insuffi cient sleep included communications with family (due 

to time zone differences, most service members used 

software applications during their nocturnal sleep period) and computer games; thereby, service members 

would sacrifi ce sleep for family obligations and leisure 

time. Lastly, the deployed setting, which is inherently 

dangerous, likely plays a role in disrupting sleep as it 

can cause a hyperaroused state.13 Hyperarousal may persist upon redeployment and contribute to the development of insomnia.

In order to compensate for insuffi cient sleep, Soldiers 

might use caffeine. In MHAT-7 for example, over 40% 

of personnel indicated that they used energy drinks, 

noting that in many units energy drinks were part of 

the regular unit supply. However, most reported using 

2 or fewer per day (the survey did not contain additional 

questions about consumption of other forms of caffeine 

*The Uniform Code of Military Justice (UCMJ), a federal law (64

Stat. 109, 10 USC, chap 47), is the judicial code which pertains 

to members of the United States military. Under the UCMJ, military personnel can be charged, tried, and convicted of a range 

of crimes, including both common-law crimes (eg, arson) and 

military-specifi c crimes (eg, desertion).

Table 1. Mental Health Advisory Team (MHAT) in-theatre surveys of deployed personnel cited in the text. “J” indicates “joint,” meaning the MHAT survey was administered to more than one branch of military service.

Report 

Number

Year(s)

Conducted

Year

Published

Operations Personnel

Surveyed

Documents Available At

V 2007 2008 OIF, OEF Soldiers http://armymedicine.mil/Pages/Mental-Health-AdvisoryTeam-V-Information-.aspx

VI 2008-2009 2009 OIF Soldiers http://armymedicine.mil/Pages/Mental-Health-AdvisoryTeam-VI-Information.aspx

VI 2009 2009 OEF Soldiers http://armymedicine.mil/Pages/Mental-Health-AdvisoryTeam-VI-Information.aspx

VII 2010 2011 OEF Soldiers, Marines http://armymedicine.mil/Documents/J_MHAT_7.pdf

VIII 2012 2013 OEF Soldiers, Marines http://armymedicine.mil/Documents/J_MHAT_8_OEF_Report.pdf

IX 2013 2013 OEF Soldiers http://armymedicine.mil/Documents/MHAT_9_OEF_Report.pdf
130 http://www.cs.amedd.army.mil/amedd_journal.aspx

such as coffee, sodas). Stress related to combat, personal 

life, and illness were associated with consuming 3 or 

more energy drinks per day.14 It is likely that insuffi cient 

sleep resulted in higher caffeine use as well as the reports of stress.

In sum, evidence from MHAT surveys indicates that the 

main sleep problem in-theatre is insuffi cient sleep driven by night operations and the poor sleep environment. 

It is probable that what initially constitutes acute sleep 

problems evolves into a chronic sleep disorder over time. 

Behavioral factors that developed during deployment 

such as the inability to maintain consistent sleep routines, hyper-arousal, and caffeine consumption likely 

contribute to the development of chronic insomnia in 

some Soldiers.

SLEEP DISORDERS IN MILITARY PERSONNEL

For a variety of reasons including increased awareness 

of sleep disorders and enhanced sleep medicine services, the number of sleep study procedures and personnel tested for sleep disorders increased from 2003 

through 2013. Concurrently and for the fi rst time in 

modern warfare, Soldiers with diagnosed obstructive 

sleep apnea (OSA) were allowed to deploy and their 

continuous positive airway pressure (CPAP) treatment 

was safely and successfully managed in-theater. The 

latter substantially increased the number of deployable 

personnel. In contrast, diffi culties sleeping 

(both acute and chronic) in Soldiers proved 

challenging to manage in theater and following redeployment. A common feature 

of most sleep disorders is that they reduce 

total recuperative sleep time, thus degrading waking function, operational readiness, 

and quality of life. Similar to OSA, successfully managing other sleep disorders 

would increase the readiness of the force.

Insomnia

Insomnia is characterized by diffi culties 

falling asleep and/or staying asleep that 

persist for at least 3 months.15 During OIF/

OEF/OND, diagnosis rates of insomnia increased dramatically in all military service 

branches.16 In the Army, rates increased 

from less than 3.6 per 10,000 person-years 

in 1998 to almost 432 per 10,000 personyears in 2012. Insomnia is currently the 

most common sleep-related complaint 

among military personnel.17 Results from 

several studies demonstrated that insomnia which develops during active service is 

often resistant to pharmacotherapy and comorbid with other conditions, notably behavioral health 

disorders and traumatic brain injury.18,19 Sedative hypnotics were the most commonly prescribed treatment 

for sleep disturbances in theater, with up to 11.4% of 

military personnel reporting they had taken medication 

for a sleep problem.8

While sedative hypnotics are often prescribed for the 

treatment of insomnia, cognitive behavioral therapy 

for insomnia (CBTi) consisting of sleep restriction and 

stimulus control administered by behavioral sleep medicine specialists is recognized as the standard of care.20

These techniques train the individual on sleep-promoting practices and avoid the side effects of sedative hypnotics. Results from clinical trials have shown that CBTi 

is superior to prescription sleep medications and can be 

completed successfully in 4-12 weeks.21 Evidence is accumulating that CBTi is effective for improving sleep in 

veterans.22 Further research is required to determine if 

CBTi is equally effi cacious in active duty personnel in 

garrison and operational environments when administered remotely.

Obstructive Sleep Apnea

Obstructive sleep apnea is characterized by repetitive 

collapse of the upper airway during sleep, resulting in 

disrupted breathing that lowers oxygen levels and causes 

brief awakenings that contribute to daytime sleepiness. 

Figure 1. Percentage of respondents reporting sources of sleep disturbance in 

the deployed environment listed on Mental Health Advisory Team (MHAT) surveys. Results are shown for MHATs conducted in 2010, 2012, and 2013. “J” indicates “joint,” meaning the MHAT survey was administered to more than one 

branch of service. % Reporting 20

30

0

40

10

J-MHAT-7 (2010) J-MHAT-8 (2012) MHAT-8 (2013)

Illness

Stress related to combat

Poor sleep environment

Stress related to personal life and problems

Other

Off-duty leisure activities

High Optempo

Nighttime Duties

OPERATIONAL PATIENT HEALTHCARE
April – September 2016 131

THE ARMY MEDICAL DEPARTMENT JOURNAL

Untreated OSA not only negatively affects the patient, 

but the patient’s loud snoring can disrupt sleep in those 

sleeping nearby. Notably, moderate and severe OSA 

which are not adequately treated can limit a service 

member’s ability to deploy.23 It is common in the general 

population, but prevalence is higher among males, obese 

patients (body mass index greater than 30), and those 

with posttraumatic stress disorder and/or traumatic brain 

injury (TBI).24 The standard therapy for OSA is CPAP, 

although mandibular advancement devices are effective 

in mild cases. Military personnel who adhere to CPAP 

show improved alertness and sleep quality.25

Parasomnias

Parasomnias are unwanted complex behaviors occurring during sleep. In Soldiers, these nocturnal behaviors 

typically arise from slow-wave sleep (which increases 

with insuffi cient sleep). Sleepwalking is common in 

children but usually abates in adolescence. Sleep walking that persists beyond adolescence is considered 

pathologic, and it places the affl icted Soldier at risk of 

unintended self-injury. During OIF/OED/OND, there 

were increased clinical reports of this disorder, which 

is likely linked to insuffi cient sleep.26 Other factors that 

can exacerbate sleepwalking include sedative medications and undiagnosed OSA. The primary treatments 

are ensuring adequate sleep duration and a safe sleeping 

environment (Table 2).

SLEEP DISORDERS AND SLEEP INSUFFICIENCY

The most common sleep disorders in the military (summarized above) are characterized by insuffi cient recuperative sleep and decreased readiness. Chronic insuffi cient sleep is consistently reported by deployed personnel. This can precipitate parasomnias, contribute 

to conditioned arousal associated with insomnia, and 

potentially exacerbate sleep disordered breathing. Further, sleep disorders are comorbid with numerous other 

behavioral health problems, and evidence suggests that 

failure to treat the sleep disorder reduces the effi cacy of 

Table 2. Symptoms/comorbidities, preferred modes of treatment, and operational considerations regarding the most common 

sleep disorders in active duty personnel.

Disorder Symptoms/Comorbidities Treatment Operational Considerations

Chronic severe

insufficient 

sleep (not due 

to underlying 

sleep or other 

disorder)

Sleepiness during waking 

period.

Attention lapses/degraded

mental performance.

Irritability, negative mood.

Increase sleep to 7-8 hours per 

24 hours via increased nightly 

time in bed, naps, etc.

If due to poor sleep environment, 

institute light/sound/temperature controls.

Until sufficient sleep is restored, Soldier waking performance will remain impaired although subjective 

alertness may improve.

Systemic problems related to poor sleep environment must be addressed at the appropriate 

echelon of command.

Insomnia Difficulty falling asleep.

Difficulty staying asleep.

Hyperarousal/rumination/

racing thoughts.

Sleepiness during waking

period.

Cognitive behavioral therapy 

(CBTi) administered by trained 

professional (can be accomplished remotely via telephone).

Short-term (<4 weeks) use of 

nonbenzodiazepine hypnotic 

under healthcare provider 

supervision.

CBTi may take up to 6 weeks to show efficacy; during 

that time, Soldier waking performance may be 

impaired.

Soldier should relinquish weapon while using 

hypnotics.

If symptoms which impair duty performance do not 

improve after 4 weeks, Soldier should be evacuated to definitive care.

Obstructive

sleep apnea

(OSA)

Extreme sleepiness during 

waking period.

Gasping during sleep.

Loud snoring (not always 

present).

Continuous positive airway pressure is standard therapy.

Mandibular advancement devices for treating mild OSA.

Prescription stimulants to treat 

residual sleepiness are not 

recommended.

Mild asymptomatic OSA (with or without CPAP) does 

not require a waiver to deploy.

Any degree of symptomatic OSA requires evaluation 

and waiver for deployment.

Moderate and Severe OSA require evaluation to 

document CPAP effectiveness, resolution of symptoms, adherence/compliance prior to issuance of 

waiver for deployment.

Other forms of sleep apnea (eg, complex sleep apnea and central sleep apnea) are nondeployable.

Mandibular advancement devices as adjunct or 

potential replacement for CPAP in moderate and 

severe in deployment requires study.

Parasomnias Walking during sleep.

Nightmares.

Trauma Associated Sleep 

Disorder.

Ensure 7-8 hours sleep per 24 to 

rule out insufficient sleep as 

cause.

Safe sleeping environment without access to weapons, locked 

door.

Assess for other comorbid disorders to include post-traumatic 

stress disorder.

Parasomnias pose a safety concern anywhere weapons are in close proximity to sleeping quarters.

Service members with documented parasomnias 

should be removed from deployed setting and 

referred for appropriate specialty evaluation.

Because adequate sleep cannot be ensured 

during deployment, documentation of such an 

episode should be a discriminator for operational 

assignments.
132 http://www.cs.amedd.army.mil/amedd_journal.aspx

treatment aimed at the behavioral health issue (Figure 

2). Appropriate sleep planning and treatment of sleep 

disorders in the deployed and nondeployed setting are 

required to maximize military medical readiness.

ANALYSIS AND RECOMMENDATIONS

Insuffi cient sleep poses a direct threat to military readiness and Soldier health. In order to implement the changes for military appropriate sleep practices and sleep 

health, the Department of Defense (DoD) and Department of the Army must have guidance on this topic. In 

the US Central Command personnel policy for deployment fi tness standards, sleep deprivation and sleep disturbance are listed as environmental extremes and that 

“... if maintaining an individual’s health requires avoidance of these extremes or conditions, she/he should not 

deploy....”23 Although some sleep deprivation and disturbance are at times unavoidable, results from MHAT 

reports and other studies suggest insuffi cient sleep is in 

part preventable, notably that which is caused by lack of 

sleep planning and the poor sleep environment.

Solution 1: DoD Policy Guidance on Military 

Appropriate Sleep Practices are Required

Throughout the DoD there currently are appropriate 

policies, awareness, and management of TBI. This occurred as a direct result of DoD Instruction 6490.11.

27

Similar expert guidance issued by the DoD would ensure that that all military branches develop organizational changes to manage sleep.

Solution 2: Recategorize Sleep Management within the 

Army Universal Task List

Sleep management is viewed as a commander’s responsibility. Within the Army Universal Task List 28 unit 

sleep plans are listed in Chapter 5 (Conduct Mission 

Command), Section II, ART 5.2.3 Execute Sleep Plans. 

It should be noted that Field Manual 6-22.5 cited in ART 

5.2.3 is now obsolete, superseded by Army Techniques 

Publication 6-22.5,

29 (ATP 6-22.5) in which Chapter 2, 

Section 1 provides guidance in sleep management, sleep 

environment, and sleep loss. There appears to be no 

specifi c requirement for a sleep management plan in the 

Mission Essential Task List (METL), and whether sleep 

plans are routinely included in METLs is unknown. We 

suggest that sleep planning be recategorized within the 

Army Universal Task List as a logistical function (Chapter 4, Section I (Provide Logistical Support) 28(p4-2) identical to planning for suffi cient food, water, etc.

So lution 3: Unit Level Sleep Trainers

To ensure the guidance contained in ATP 6-22.5, is 

understood and considered in training and operational 

planning, the Army needs Soldiers specifi cally trained 

in sleep education, planning, and management who 

are tasked with providing guidance to commands and 

developing the unit sleep plan. These Soldiers would 

serve as resources to the commander for implementing 

changes required for a military appropriate sleep practice. 

The other aspect is training Soldiers on appropriate sleep 

practices, such as sleep discipline. The inherent stress of 

working in the military with shift changes, 24-hour duty, 

and frequent moves makes developing a sleep practice 

diffi cult. Similar to the master fi tness trainer who teaches 

Soldiers how to perform physical training, a sleep trainer 

is required to provide the same level of education to 

help Soldiers develop their military appropriate sleep 

practice. In addition, focused education regarding sleep 

planning and management should be incorporated into 

military professional development courses, including 

the Offi cer Basic Course, Captain’s Career Course, and 

the Advanced Noncommissioned Offi cer Course.

Figure 2. Model demonstrating how lack of sleep planning and management decreases readiness and deployability of Soldiers.

POOR SLEEPING 

ENVIRONMENT

(Light/Noise/Temp/Timing)

NIGHT OPERATIONS

(Circadian Desynchrony)

HIGH OP TEMPO

(Anxiety/Stress)

PRE-EXISTING

POOR SLEEP HABITS

NONDEPLOYABLE

IMPAIRED

READINESS

INSOMNIA

OBSTRUCTIVE

SLEEP APNEA

PARASOMNIAS

TRAUMA-ASSOCIATED

SLEEP DISORDER

BEHAVIORAL HEALTH

PROBLEMS

DEGRADED SLEEP

(Decreased Sleep Duration and Quality)

OPERATIONAL PATIENT HEALTHCARE
April – September 2016 133

THE ARMY MEDICAL DEPARTMENT JOURNAL

CONCLUSION

While periods of insuffi cient sleep are unavoidable during sustained operations, proper planning ensures adequate recovery sleep and minimize sleep casualties. 

Embedding sleep education and management in the 

military will (1) help Soldiers develop appropriate sleep 

practices in garrison, (2) improve sleep during deployment and thus directly improve operational readiness, 

and (3) reduce the likelihood of Soldiers developing 

sleep and behavioral health disorders while deployed, 

thus improving the health of the force and reducing 

overall healthcare costs to the military.

REFERENCES

1. Dinges DF, Pack F, Williams K, et al. Cumulative 

sleepiness, mood disturbance and psychomotor 

vigilance performance decrements during aweek 

of sleep restricted to 4-5 hours per night. Sleep. 

1997;20(4):267-277.

2. Van Dongen HP, Maislin G, Mullington JM, Dinges DF. The cumulative cost of additional wakefulness: dose-response effects on neurobehavioral functions and sleep physiology from chronic 

sleep restriction and total sleep deprivation. Sleep. 

2003;26: 117-129.

3. Troxel WM, Shih RA, Pedersen ER, et al. Sleep 

in the Military. Santa Monica, CA: RAND Corporation; 2015. Report RR-739-OSD. Available 

at: http://www.rand.org/pubs/research_reports/

RR739.html. Accessed March 9, 2016.

4. Armed Forces Health Surveillance Center. Insomnia, active component, U.S. armed forces, January 

2000-December 2009. MSMR. 2010;17(5):12-15.

5. Bliese PD, Castro CA. The soldier adaptation model (SAM): applications to peacekeeping research. 

In: Britt TW, Adler, AB, eds. Psychology of the 

Peacekeeper: Lessons from the Field. Westport, 

CT: Praeger Publishers; 2003:185-203.

6. Mental Health Advisory Team (MHAT) V: Operation Iraqi Freedom 06-08, Iraq; Operation Enduring Freedom 8, Afghanistan. Washington, DC: Offi ce of The Surgeon General, US Dept of the Army; 

February 14, 2008.

7. Joint mental health advisory team 7 (J-MHAT 7) 

Operation Iraqi Freedom 2010. Washington, DC: 

Offi ce of The Surgeon General, US Dept of the 

Army; February 22, 2011. Available at: http://ar

mymedicine.mil/Documents/J_MHAT_7.pdf. Accessed March 8, 2016.

8. Mental Health Advisory Team 9 (MHAT 9) Operation Enduring Freedom (OEF) 2013 Afghanistan.

Offi ce of The Surgeon General, US Dept of the 

Army; October 10, 2013.

9. Operation Iraqi Freedom (OIF) Mental Health 

Advisory Team (MHAT) Report. Washington, DC: 

Offi ce of The Surgeon General; Headquarters, 

Department of the Army, G-1; 2003. Available 

at: http://www-tc.pbs.org/wgbh/pages/frontline/

shows/heart/readings/mhat.pdf. Accessed September 11, 2008.

10. Consensus Conference Panel. Joint Consensus 

Statement of the American Academy of Sleep Medicine and Sleep Research Society on the Recommended Amount of Sleep for a Healthy Adult: Methodology and Discussion. Sleep. 2015;38:1161-1183.

11. Ferrie JE, Shipley MJ, Cappuccio FP, et al. A prospective study of change in sleep duration: associations with mortality in the Whitehall II cohort. 

Sleep. 2007;30:1659-1666.

12. Peterson AL, Goodie JL, Satterfi eld WA, Brim 

WL. Sleep disturbance during military deployment. 

Mil Med. 2008;173(3):230-235.

13. Bonnet MH, Arand DL. Hyperarousal and insomnia: state of the science. Sleep Med Rev. 

2010;14(1):9-15.

14. Centers for Disease Control and Pevention. Energy 

drink consumption and its association with sleep 

problems among U.S. service members on a combat deployment-Afghanistan, 2010. MMWR Morb 

Mortal Wkly Rep. 2012;61:895-898.

15. International Classifi cation of Sleep Disorders–

Third Edition (ICSD-3). Darien, IL: American 

Academy of Sleep Medicine; 2014.

16. Armed Forces Health Surveillance Center. Risk of 

Type II Diabetes and Hypertension Associated with 

Chronic Insomnia Among Active Component, U.S. 

Armed Forces, 1998-2013. MSMR. 2014;21:613.

17. Mysliwiec V, Gill J, Lee H, et al. Sleep disorders 

in US military personnel: a high rate of comorbid insomnia and obstructive sleep apnea. Chest. 

2013;144(2):549-557.

18. Mysliwiec V, Roth B. Pharmacotherapy refractory 

insomnia in soldiers with traumatic brain injury. 

Chest. 2013;143(2):582-583.

19. Bramoweth AD, Germain A. Deployment-related 

insomnia in military personnel and veterans. Curr 

Psychiatry Rep. 2013;15:1-8.

20. Jacobs GD, Pace-Schott EF, Stickgold R, Otto 

MW. Cognitive behavior therapy and pharmacotherapy for insomnia: a randomized controlled 

trial and direct comparison. Arch Intern Med. 

2004;164(17):1888-1896.

21. Sivertsen B, Omvik S, Pallesen S, et al. Cognitive behavioral therapy vs zopiclone for treatment of chronic primary insomnia in older 

adults: a randomized controlled trial. JAMA. 

2006;295(24):2851-2858.
134 http://www.cs.amedd.army.mil/amedd_journal.aspx

22. Germain A, Richardson R, Stocker R, et al. Treatment for insomnia in combat-exposed OEF/OIF/

OND military veterans: preliminary randomized 

controlled trial. Behav Res Ther. 2014;61:78-88.

23. US Central Command. PPG-Tab A: Amplifi cation of the Minimal Standards of Fitness for Deployment to the CENTCOM AOR; To Accompany 

MOD Twelve To USCENTCOM Individual Protection And Individual/Unit Deployment Policy. No 

document date. Available at: http://cpol.army.mil/

library/mobil/MOD12-TabA.pdf. Accessed March 

9, 2016.

24. Collen J, Orr N, Lettieri CJ, Carter K, Holley AB. Sleep disturbances among soldiers with 

combat-related traumatic brain injury. Chest. 

2012;142(3):622-630.

25. Mysliwiec V, Capaldi VF 2nd, Gill J, Baxter T, 

O’Reilly BM, Matsangas P, Roth BJ. Adherence to 

positive airway pressure therapy in U.S. military 

personnel with sleep apnea improves sleepiness, 

sleep quality, and depressive symptoms. Mil Med. 

2015;180(4):475-482.

26. Joncas S, Zadra A, Paquet J, Montplaisir J. The value of sleep deprivation as a diagnostic tool in adult 

sleepwalkers. Neurology. 2002;58(6):936-940.

27. Department of Defense Instruction 6490.11: DoD

Policy Guidance for Management of Mild Traumatic Brain Injury/Concussion in the Deployed Setting. 

Washington, DC: US Dept of Defense; September 

2012. Available at: http://www.dtic.mil/whs/direc

tives/corres/pdf/649011p.pdf. Accessed March 9, 

2016.

28. Army Doctrine Reference Publication 1-03: The 

Army Universal Task List. Washington DC: US 

Dept of the Army; October 2015. Available at: 

http://armypubs.army.mil/doctrine/DR_pubs/dr_a/

pdf/adrp1_03.pdf. Accessed March 9, 2016.

29. Army Techniques Publication 6-22.5: A Leader’s 

Guide to Soldier Health and Fitness. Washington, 

DC: US Dept of the Army; February 2006:2-1. 

Available at: ht tp://armypubs.army.mil/doctrine/

DR_pubs/dr_a/pdf/atp6_22x5.pdf. Accessed 

March 9, 2016.

AUTHORS

COL Mysliwiec is Program Director, Sleep Medicine 

Fellowship, San Antonio Uniformed Services Health 

Education Consortium, San Antonio Military Medical 

Center, Texas.

MAJ Walter is with Pulmonary, Sleep, and Critical Care 

Medicine, San Antonio Military Medical Center, Texas.

LTC Collen is Program Director, Sleep Medicine Fellowship NCC, Pulmonary, Critical Care, and Sleep Medicine, 

Walter Reed National Military Medical Center, Bethesda, 

Maryland.

Dr Wesensten is with the Air Traffi c Organization, Federal Aviation Administration, Washington, DC.

OPERATIONAL PATIENT HEALTHCARE
April – September 2016 135

HISTORY

Routine Army-issued eye protection began during World 

War II for certain specialties and steadily progressed 

over the past 60 years into the current Military Combat 

Eye Protection (MCEP) program. The most signifi cant 

progress and positive impact occurred beginning in 2003 

despite the lack of applied technological breakthroughs 

in protective eyewear materials. The dramatic improvement was largely due to style and comfort which drove 

wear compliance rates up across the military services. 

This article provides only a brief historical review of 

the MCEP program. A thorough history of combat eye 

protection can be found elsewhere.1,2 Products derived 

from experiences in World War I, World War II, Korea, 

Vietnam and the Iran/Iraq war drove many technical eye 

protection improvements. Beginning in 1962, the Army 

began researching materials, ballistics, and human performance factors which led to the concept of a ballistic 

spectacle.1

 In 1983, the Army replaced the acetate shield 

in the M-1944 Sun, Wind and Dust goggle with polycarbonate and added laser protection in 1990. The Army 

also developed the Ballistic Laser Protective System 

(BLPS) and began limited procurement in 1989. The 

BLPS optical devices supported a prescription insert. 

The requirements for the Special Protective Eyewear 

Cylindrical System (SPECS) were not formalized until 

1984, 22 years after the initial concept, and the product 

did not become standard issue until 1995. SPECS optical devices did not support a prescription insert. Soldiers rejected BLPS and SPECS, and the force protection improvements were largely lost on the force prior to 

2004 due to poor wear compliance.3

 These devices were 

ugly, bulky, and uncomfortable, but they worked.

In 2003, the 10th Mountain Division submitted an urgent 

request for enhanced eye protection. Prior to 2004, Soldiers largely deployed with limited ballistic eyewear and 

typically wore commercial sunglasses, goggles or tinted 

prescription spectacles issued by the Army. Decision 

makers were keenly aware of the 11 year SPECS effort 

to deliver an unpopular and rarely worn Army-designed 

ballistic spectacle manufactured under contract. Representatives in Program Executive Offi ce (PEO) Soldier, 

the optometry consultant to the Army Surgeon General, members of the Tri-Service Vision Conservation 

and Readiness Program (TSVCRP) and various other 

subject matter experts were not interested in repeating 

the SPECS experience. Instead, these leaders evaluated 

commercially available eye protection against military 

ballistic standards. Optical devices that met the standards were authorized for wear beginning July 8, 2003. 

These products included clear and tinted lenses, cleaning cloths, and carrying cases.4

 These devices formed 

the fi rst Authorized Protective Eyewear List (APEL) 

in 2004 and were issued to Soldiers through the Rapid 

Fielding Initiative mechanism. By the end of 2004, every 

deployed or deploying Soldier had an APEL-approved 

MCEP device, and soon thereafter Soldiers began to receive MCEP devices upon accession.

EFFICACY

MCEP devices clearly protect the wearer and prevent 

eye injuries, but they are not designed to stop a bullet or 

protect the wearer just 3 meters from a massive blast.5

MCEP devices protect the wearer from fragments and 

minor blunt force and have been extremely effective in 

this capacity for decades. A 1982 study on eye injuries 

Evolution of Military Combat Eye Protection

 LTC James R. Auvil, MS, USA

ABSTRACT

Appreciation for combat eye protection steadily increased following World War II. Products derived from experiences in World War I, World War II, Korea, Vietnam, and the Iran/Iraq war drove technical improvements 

throughout the 1980s and 1990s. Dismal wear compliance prior to 2004 indicates Soldiers and their leaders 

did not appreciate these improvements and found little value in the bulky, ugly, and uncomfortable products. 

In 2003, the 10th Mountain Division requested enhanced eye protection. Program Executive Offi ce Soldier, 

the optometry consultant to the Army Surgeon General, members of the Tri-Service Vision Conservation and 

Readiness Program, and other subject matter experts selected and tested commercial off-the-shelf eye protection against military ballistic impact standards. Optical devices that met ballistic standards formed the fi rst 

Authorized Protective Eyewear List and were fi elded beginning in 2004. Wear compliance rose dramatically 

for the stylish protective eyewear, reaching 85% to 95% and eye injuries decreased across the Department of 

Defense even as the incidence of attacks in Iraq increased. Researchers continue to evaluate new materials and 

designs to increase the capabilities, features and level of protection of future ballistic eyewear.
136 http://www.cs.amedd.army.mil/amedd_journal.aspx

during the Lebanon War found not a 

single eye injury occurred to Soldiers 

who had ballistic eye protection properly placed over the eyes at the time 

of injury.6

A 2005 study on injuries suffered by 

Marines performing a convoy security mission found that the Marines 

suffered 188 injuries in 32 attacks 

over 6 months. Upper extremities 

suffered 22% of the injuries and 53% 

were head injuries. Despite these 

large numbers, the Marine unit suffered only one eye injury (0.5%). This 

low eye injury rate is remarkable 

when you consider 75% of the injuries were to the upper body and head. 

The authors attribute this remarkably 

low eye injury rate to the “nearly 100% conformity to...

ballistic eye protection” use.7

 The authors also noted a 

number of patients presented with shrapnel and debris 

damage to their protective eyewear which implies the 

devices prevented ocular injuries.

A British study from 2011 reviewed hospital records of 

medically evacuated British service members as well 

as postmortem reports of all British service members 

killed in action or who died of wounds during active 

service. The authors mapped all the facial wounds and 

concluded that combat eye protection “...could have prevented 7 deaths and visors 19 deaths” had the service 

members worn them.8

In 2013, another British study reviewed all the injuries 

treated at Camp Bastion (Afghanistan) due to improvised explosive devices (IEDs). The authors compared 

the incidence of eye injuries between International 

Security Assistance Force (ISAF) Soldiers who were 

equipped with eye protection and Afghan National Security Force (ANSF) Soldiers who were not. There were 

41 injured ISAF patients with three total eye injuries 

compared to 53 injured ANSF patients with 24 total eye 

injuries.9

 Clearly eye protection reduces the incidence of 

eye injuries.

The modern MCEP program began fi elding APEL products in 2004. The Department of Defense realized a 

near-immediate reduction in eye injuries. Injuries began to increase again between 2005 and 2006 and then 

steadily declined. The remarkable effect of MCEP in the 

reduction of eye injuries despite the 2006-2007 increase 

in frequency of attacks is demonstrated in the Figure.

COMPLIANCE

Style remains the most signifi cant modern MCEP wear 

compliance driver. MCEP style achieved user buy-in 

faster and better than education or mandates from leaders. Service members wanted to wear APEL devices because they looked good. Education efforts attempted to 

convince troops to wear MCEP based on the force protection benefi t, but most of the convincing was already 

done through style. Prior to the APEL, service members 

and units could order and use BLPS and SPECS, which 

met the same ballistic protection standards of current 

APEL products. Users rejected BLPS/SPECS because 

they were ugly, uncomfortable, and bulky. Mechanized 

and motorized units still used the M1944 Sun, Wind 

and Dust goggle, but training habits resulted in their use 

only when on the move in unprotected conditions such 

as traveling in an open hatch. Nonmechanized units deployed with sunglasses and ski goggles that carried virtually no capacity to protect the wearer from explosive 

fragments. Infantry forces and those performing Infantry tasks were the most vulnerable to eye injuries from 

IEDs and enemy attacks.

MCEP wear compliance rates are diffi cult to measure, 

so assessment largely depends on documented wear at 

the time of injury, survey results, and other forms of 

analysis. Compliance also appears to vary based on unit 

policy, leader direction or example, duty location, and 

perceived threat. Eye protection use at the time of injury is poorly documented. Frequently patients cannot 

remember if they were wearing eye protection at the 

time of injury and “...recording of eye protection is not 

the fi rst responder’s...priority.”11 Reports include wear 

compliance rates of just over 9%, 14%, 28.9%, and 41% 

MCEP Effectiveness: Eye injuries vs frequency of attacks in Iraq, 2002-2011.

DoD eye injury data provided by the Armed Forces Health Surveillance Center.

Data for frequency of attacks from DoD Report to Congress, June 2010.10

DoD Eye

Injuries

Number of Attacks

Eye Injuries

Attacks by Week

Mortar, rocket, and surface to air attacks

Sniper, ambush, grenade, other small arms

Bombs (IEDs and mines), found and detonated

Infrastructure and government organizations

2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

19500

12500

18500

17500

16500

15500

14500

13500

1800

1600

1400

1200

1000

800

600

400

200

OPERATIONAL PATIENT HEALTHCARE
April – September 2016 137

THE ARMY MEDICAL DEPARTMENT JOURNAL

at the time of injury.4,10,12,13 Weichel found 24% of OIF/

OEF related eye trauma cases evacuated to Walter Reed 

Army Medical Center between October 2001 and September 2006 were documented to have been wearing 

MCEP at the time of injury.14 Thirty-four percent were 

documented without MCEP use at the time of injury, 

and 41% lacked MCEP wear documentation. Gondusky 

reported “near 100% wear compliance” in the Marine 

unit he studied.7

COL (Ret) David Hilber conducted 3 Army-wide MCEP 

surveys in 2008, 2010, and 2011 while assigned to the 

Tri-Service Vision Conservation and Readiness Program, Army Public Health Command.* The 2008 survey 

received 4900 responses and indicated 78% of Soldiers 

reported MCEP was mandatory during deployment and 

65% reported MCEP use was mandatory on home station weapons ranges. Eighty-six percent of respondents 

deployed to OIF/OEF wore MCEP on convoys and missions outside forward operating bases and 54% wore 

MCEP anytime they were outdoors while deployed. Sixty-seven percent reported using MCEP during training, 

35% reported using MCEP while performing maintenance, and 20% reporting using MCEP at home. In 2008, 

the Army issued an All Army Activities message* to 

boost wear compliance and remind Soldiers to wear only 

APEL-approved devices. The results of Dr Hilber’s surveys in 2010 and 2011 indicated Soldier wear compliance 

while deployed rose to 84% in 2010 and to 95% in 2011.

LTC Jose Capo-Aponte and researchers at the Army 

Aeromedical Research Laboratory analyzed photos of 

deployed Soldiers outside forward operating bases from 

2002 through 2010 and determined the percentage of 

random, observable MCEP wear increased from approximately 20% to 95% over that time period (unpublished data).

THREAT/PROTECTION MISMATCH

Following Operation Desert Storm, the Army reviewed 

and updated ballistic impact standards. In 1996, the 

Army published updated performance specifi cations for 

the SPECS devices. The fragmentation standard remains 

today and applies to APEL products.15,16 The current ballistic standard requires eye protection to withstand the 

impact from a .15 caliber, 5.7 grain, T37 shaped (nonspherical) projectile traveling between 640 and 660 feet 

per second. This standard is based on experiences and 

assumptions from previous confl icts as well as protective material and cost limitations. Ballistic test methods 

for armor published on December 18, 1997, updated the 

previous 10-year old standard.17

The threat from IEDs infl uenced force protection design and materials across many systems over the past 

decade, but has not yet prompted increased eye protection standards. There are too many variables involved 

for a precise threat/protection comparison, but a general comparison is quite easy. The fragments from an 

IED built with a 155 mm artillery shell have an initial 

velocity between 1,200 and 1,800 meters per second.18

The fragments are highly variable in size, but assuming 

there are fragments roughly similar to the standard T37 

shaped, 5.7 grain, .15 caliber projectile, the initial velocity of IED fragments carry anywhere from 6 to 9 times 

greater energy than the current eye protection ballistic 

standard.

There is a physical limit for spectacle and goggle based 

eye protection above which additional protection is 

pointless. The current MCEP standard is well below 

that physical limit and should be increased to provide 

improved protection. The current standard relies heavily on material properties of polycarbonate, a soft but 

strong material capable of absorbing tremendous impact 

without fracturing. Newer materials such as polyamides 

(Trivex, Trogamid) outperform polycarbonate in ballistic tests.19 These materials are generally lighter and 

stronger than polycarbonate, but manufacturing challenges, cost, and the existing standard prevent the market from offering improved eye protection with these 

materials. Other options include aluminum oxynitride 

(ALON), a ceramic frequently described as “transparent 

aluminum.”20

A revolutionary material may provide much more than 

just increased protection. Graphene is a recently discovered material with incredible physical properties.21

Graphene is 200 times stronger than steel by weight, it 

conducts electricity, is transparent, fl exible, and selfhealing. Protective goggles with a thin graphene fi lm 

could theoretically charge a battery and provide a heads 

up display or quickly switch between clear and electrically tinted while providing dramatically increased ballistic protection.

BRANDING

Proper branding attracts users and improper branding 

repels them. When the APEL fi rst came out, the proponent wanted to put the Army Strong star logo on each 

product. Subject matter experts and TSVCRP members 

challenged this effort and successfully overturned it. 

The fi nal products carry a nonparochial “APEL” marking to avoid repelling non-Army personnel. Navy, Air 

Force, and Marine personnel would not want to wear 

equipment with an Army logo on it and no one wanted to 

see a service member injured because he or she refused *Internal military documents not readily accessible by the general 

public.
138 http://www.cs.amedd.army.mil/amedd_journal.aspx

to wear eye protection due to the logo. All services use 

some variation of the products on the APEL. This is an 

important lesson when developing joint products.

LOGISTICAL EFFICIENCY

For the fi rst decade, each APEL-approved MCEP device that supported a prescription lens carrier required 

a unique insert specifi c to the product’s manufacturer. 

This created a logistical burden for Soldiers, leaders, clinicians, and the ophthalmic labs that generated prescription spectacle inserts. In 2015, the Universal Prescription 

Lens Carrier (UPLC) became the standard insert with 

the release of the March 2015 APEL. The UPLC replaced 

8 unique APEL inserts, greatly simplifying the logistical 

support. More importantly, the UPLC empowers the end 

user to change APEL products without adding a burden 

to the optometry team, clinic, or ophthalmic production 

system by ordering a unique spectacle insert for the new 

APEL item. The UPLC only works with APEL products and does not extend to various chemical protective 

masks currently in use. Protective mask manufacturers 

may design and fi eld an adaptor for future use.

EXCESSIVE CHOICE

The March 2015 APEL consists of 31 options. There 

are 16 spectacle choices and 15 goggle choices. Seven 

spectacles and 10 goggles support a prescription lens 

carrier. The current large APEL selection is the result 

of contracting rules, not an Army desire for extensive 

choice. The Army predominantly uses 3 spectacle varieties and 4 goggles. An APEL of seven to twelve options is required to meet the fi t and function requirements of a very diverse force. One size does not fi t all 

and the Services should resist the temptation to simplify 

and standardize protective eyewear down to just one or 

two choices. The importance of proper fi t for every user 

outweighs the convenience and aesthetic appeal of an 

artifi cially limited product line.

DOTMLPF* APPLICATION

The MCEP program is primarily a materiel function 

and secondarily a training function. The materiel function should be addressed by updating the protective 

standards through collaboration among the Army Public Health Center (Provisional), Army Medical Command, PEO-Soldier, Natick Research Development 

and Engineering Center, Research Development and 

Engineering (RDE) Command and industry. Advances 

in applied materials and technology should be coordinated with PEO-Soldier, RDE Command, and the Defense Advanced Research Projects Agency. The training 

function should be addressed by uniform requirements 

to wear eye protection during training. Survey results 

from 2008, 2010, and 2011 revealed inconsistent force 

protection policy and/or enforcement which may result 

in preventable injuries.

CONCLUSION

The effectiveness of Military Combat Eye Protection 

has increased over the past decade due to vastly improved wear compliance. Military leaders recognized 

the eye injury threat and strongly supported this force 

protection element. Through that process, the subject 

matter experts appreciated the power of style and comfort on user acceptance and deliberately sought those 

features in products that met military ballistic impact 

standards. Policy, branding, and universal components 

matured over the past 10 years to improve awareness, 

choice, and effi ciency. The decades-old technology of 

polycarbonate lenses still provides effective protection 

from fragments and small projectiles, but newer materials may provide improved protection with less weight. 

The existing ballistic protection standards should be reviewed and likely increased to better address the threat 

of eye injuries from improved explosive devices. Future 

advances with recently discovered materials may dramatically expand the functionality of protective eyewear with integrated digital overlays and electronically 

controlled tints, while increasing or maintaining the required level of protection.

REFERENCES

1. LaPiana FG, Ward TP. The development of eye 

armor for the American infantryman. Ophthalmol 

Clin North Am. 1999;12:421-434.

2. Ari AB. Eye injuries on the battlefi elds of Iraq and 

Afghanistan: public health implications. Optometry. 2006;7:329-339.

3. Heier JS, Enzenauer RW, Wintermeyer SF, Delaney 

M, LaPiana FP. Ocular injuries and diseases at a 

combat support hospital in support of Operations 

Desert Shield and Desert Storm. Arch Ophthalmol. 

1993;111:795-798.

4. US Department of the Army. Memorandum; Subject: Authorization to Requisition and Use Commercial Eyewear as Alternatives to the Sun, Wind 

and Dust (SWDG) for Non-Laser Missions and 

Training Scenarios. Washington DC: US Dept of 

the Army, Program Manager Soldier Equipment; 

July 8, 2003.

5. Mader TH, Carroll RD, Slade CS, George RK, 

Ritchey JP, Neville SP. Ocular war injuries of the 

Iraqi insurgency, January-September 2004. Ophthalmology. 2006;113:97-104.

6. Belkin M, Treister G, Dolan S, Eye injuries and 

ocular protection in the Lebanon War, 1982. Isr J 

Med Sci. 1984:20:333-338. * Doctrine, organization, training, materiel, leadership & education, 

personnel, facilities.

OPERATIONAL PATIENT HEALTHCARE
April – September 2016 139

THE ARMY MEDICAL DEPARTMENT JOURNAL

7. Gondusky JS, Reiter MP. Protecting military convoys in Iraq: An examination of battle injuries sustained by a mechanized battalion during Operation 

Iraqi Freedom II. Mil Med. 2005;170:546-549.

8. Breeze J, Allanson-Bailey LS, Hunt NC, et al. Surface wound mapping of battlefi eld occulo-facial injury. Injury. 2011;43(11):1854-1860.

9. Parker P, Mossadegh S, McCrory C. A comparison 

of the IED-related eye injury rate in ANSF and 

ISAF forces at the UK R3 Hospital, Camp Bastion, 

2013. J R Army Med Corps. 2015;160:73-74.

10. US Department of Defense. Measuring Stability 

and Security in Iraq, Report to Congress, June 2010. 

Washington, DC: US Dept of Defense; 2010:27. 

Available at: http://www.defense.gov/Portals/1/

Documents/pubs/June_9204_Sec_Def_signed_20_

Aug_2010.pdf. Accessed March 11, 2016.

11. Vlasov A, Ryan DS, Ludlow S, Weichel ED, Colyer MH. Causes of combat ocular trauma-related 

blindness from Operation Iraqi Freedom and Enduring Freedom. J Trauma Acute Care Surg. 2015; 

79(4 suppl 2):S210-S215.

12. Thach AB, Johnson AJ, Carroll RB, et al. Severe 

eye injuries in the war in Iraq, 2003-2005. Ophthalmology. 2008;115(2):377-382.

13. Thomas R, McManus JG, Johnson A, Mayer P, 

Wade C, Holcomb JB. Ocular injury reduction 

from ocular protection use in current combat operations. J Trauma. 2009;66(suppl 4):S99-S103.

14. Weichel, ED, Colyer MH, Ludlow SE, Bower 

KS, Eiseman AS. Combat ocular trauma visual outcomes during operations Iraqi Freedom and Enduring Freedom. Ophthalmology. 

2008;115(12):2235-2245.

15. Defense Logistics Agency. Performance Specifi cation: Spectacles, Special Protective Eyewear 

Cylindrical System (SPECS). Washington, DC: US 

Dept of Defense; April 25, 1996. MIL-PRF-31013.

16. Defense Logistics Agency. Performance Specifi cation: Military Combat Eye Protection (MCEP) System. Washington, DC: US Dept of Defense; January 9, 2013. MIL-PRF-32432(GL).

17. Department of Defense Test Method Standard: V50 

Ballistic Test for Armor. Aberdeen Proving Ground, 

MD: US Army Research Laboratory; December 18, 

1997. MIL-STD-662F.

18. Karpenko A, Ceh M. Experimental simulation of 

fragmentation effects of an improvised explosive 

device. Presented at the 23rd International Symposium on Ballistics, Tarragona, Spain; April 2007.

19. Song JW, Lofgren J, Hart KD, et al. Aromatic Nylons for Transparent Armor Applications. Natick, 

MA: Soldier Systems Center, US Army Research, 

Development and Engineering Command; November 2006. Available at: http://www.dtic.mil/cgi-bin/

GetTRDoc?AD=ADA481774. Accessed March 11, 

2016.

20. Goldman, LM, Hartnett TM, Wahl JM, Ondercin RJ, Olson KR. Recent advances in aluminum 

oxynitride (ALON) optical ceramic. SPIE Proceedings. Vol 4375; September 7, 2001. Available 

at: http://spie.org/Publications/Proceedings/Pa

per/10.1117/12.439195. Accessed March 11, 2016.

21. Geim AK, Novoselov KS. The rise of graphene. Nat 

Mater. 2007;6(3):183-191. Available at: http://www.

nature.com/nmat/journal/v6/n3/full/nmat1849.

html. Accessed March 11, 2016.

AUTHOR

LTC Auvil is Program Manager, Tri-Service Vision Conservation and Readiness, Army Public Health Center 

(Provisional), Aberdeen Proving Ground, Maryland.
140 http://www.cs.amedd.army.mil/amedd_journal.aspx

Background

In 2003, a study of dermatological evacuations from 

the Middle East showed that some conditions could 

have been managed at the forward operating base if the 

provider had access to a formal reach-back program.1

 A 

team of clinicians along with information management, 

quality assurance, and operations management personnel developed an email teleconsultation program. A pilot 

program began in April 2004. Deployed providers sent 

an email with or without photographs to an email utility account using the Army Knowledge Online (AKO) 

domain. Emails were forwarded to a contact group using the amedd.army.mil domain populated with the consultants’ military email addresses. The standard was to 

answer a consultation within 24 hours of receipt. 

The program was an immediate success. Ophthalmology was added in July 2004 with burn-trauma and infectious diseases joining in January 2005. To prepare for 

the end-of-life-cycle of the AKO utility accounts, the 

program transitioned to utility accounts using the Defense Information Systems (DISA) domain.

The program is available to deployed healthcare providers of all branches of the US military. In October 2008, 

the US Army Medical Command and the Supreme 

Headquarters Allied Powers Europe signed a memorandum of understanding to permit North Atlantic Treaty 

Organization healthcare providers deployed to Afghanistan to use the program.* Deployed providers include 

physicians, physician assistants, nurses, independent 

duty medical technicians, and Special Forces medics.

There are 20 specialties with utility accounts and contact 

groups. The dental specialty is divided into 7 subgroups. 

If the provider does not know which specialty to use, 

the consultation is submitted to a generic email account. 

Table 1 lists specialties using DISA contact groups. Specialties which do not have a DISA contact group are 

shown in Table 2. These specialties are reached using 

the generic email account.

Figure 1 illustrates the teleconsultation program using 

the DISA utility account configuration.

The US Army Medical Department

 Email Teleconsultation Program

Charles M. Lappan, MPA, MBA

Abstract

The US Army Surgeon General authorized the formation of an email based teleconsultation program in 2004 

to support deployed healthcare providers in Iraq and Afghanistan. The program, which began its 12th year of 

operation in April 2015, was originally viewed as a temporary solution until a robust system was fielded. Although future of the program as a going concern has not been determined, there is the possibility it could be 

incorprated into the critical care consultation program managed at an Army Medical Center.

Table 1. Specialties With E-mail Utility Accounts and Month 

and Year of Inclusion in the Program.

Burn-Trauma Jan 05

Cardiology Sep 05

Dental Nov 08

 Dental - Endodontic / Root Canal Issues

 Dental - General Dentistry

 Dental - Implants, crowns, partial or full dentures

 Dental - Pathology in / around oral cavity

 Dental - Periodontal involving gums & transplants

 Dental - Removal of teeth, infections, implants, or fractures

 Dental involving children

Dermatology Apr 04

Infection Control Sep 08

Infectious Diseases Jan 05

Internal Medicine Nov 06

Microbiology Sep 08

Nephrology Apr 05

Neurology Oct 06

Ophthalmology Jul 04

Orthopedics Jul 07

Pain Management Sep 11

Pediatrics May 05

Preventive Medicine Jul 06

Rehabilitation Apr 06

Rheumatology May 06

TBI Mar 08

Toxicology Jan 06

Urology Jul 07

*Internal military document not readily accessible by the general Generic/All Purpose/Program Help Sep 07

public.
April – September 2016 141

The Army Medical Department Journal

To ensure compliance with the Health Insurance Portability and Accountability Act of 1996, personally identifiable information (PII) is not transmitted. Deployed 

providers update the patients’ healthcare record with 

the consultants’ recommendation(s). Consultants do 

not receive workload credit because PII is not in the 

consultation.

Program Benefits

The major benefit to the deployed provider is its ease of 

operations and rapid response. The average reply time 

for consultations between April 2004 and June 2015 was 

5 hours 15 minutes. Figure 2 shows the average reply 

times.

Feedback from providers has been positive. The following is a sample of comments from deployed providers:

`` I have found teledermatology to be a great idea. I was 

able to send my patient back to performing his duties 

in an environment where commanders cannot afford 

to lose Soldiers for long periods of time. By getting 

brigade surgeons to email the program prior to sending them to the CSH will keep Soldiers doing their 

duty.

`` I did not plan to do the biopsy in the field. The infection rates out here are very high, therefore we do not 

do anything that is elective. I will recommend to the 

patient that he get it removed when he gets back if 

it bothers him. The program has been very well received out here and has helped tremendously in the 

management of patients. P.S., when this Soldier came 

in, he had his bags with him assuming he would have 

to go to Germany for a biopsy; He would have if I 

could not have reassured him.

`` This service is a real life saver! It’s like having my own 

personal team of specialists...this is outstanding. I do 

not know how I did it before this service was created.

`` I was truly amazed [at the response of the consultants]. 

The consultants jumped on the consult and the first 

response by Dr S got to me in the blink of an eye before I could even make my way to our TOC to run the 

case by the XX eye specialists. Not only did I avoid 

waking up the XX eye specialists last night, but more 

importantly avoided an unnecessary MEDEVAC.

`` Wow! I only sent the consult out 10 minutes ago! 

Thank you!

`` I am redeploying shortly, but I want to tell you how 

valuable this system has been. My first deployment 

was to XX in 2000 and if this system had been available then, medical care would have vastly improved.

The program benefits facilities that answer consultations. 

Internal medicine residents at the Walter Reed National 

Military Medical Center conduct the initial review of 

internal medicine consultations. Dermatologists at the 

Uniformed Services University of the Health Sciences 

and the San Antonio Military Medical Center use case 

studies to expose their staff to diseases they may not see 

at their clinics.

Several professional papers and posters have been published by military and Department of Defense civilian 

consultants. Many of the primary authors are the senior 

consultants for their specialty. Thirty-one papers, posters and presentations have been published since 2003. 

Some of the more prominent papers are included in this 

article’s reference list.2-12

Challenges to Management of the Email Teleconsultation Program: What We Could Have

Done Differently

Managing the program had its set of problems. The majority are back-end issues. The task of the program manager is to ensure these issues do not affect the service 

given to the deployed provider.

Life-cycle management was not considered when the 

program began. At the onset, we assumed a robust program would be developed, negating the need to include 

life-cycle management features. In 2005, a team studied several options. Many users requested the follow-on 

program include an email option. A decision was made 

to retain the email program in its original configuration. 

We did not consider what event(s) would terminate the 

program or how to end it in a logical manner. The program had to be renewed every 2 years through Army 

Medical Command memorandums.

Data is manually collected, entered, and analyzed using 

a combination of software in lieu of a dedicated scalable/

searchable system. When the program began, only a 

few data elements were tracked. Information from each 

consultation is placed in an MS Excel file with up to 

30 data points. Excel was chosen because the program 

Table 2. Specialties Supported by the Generic 

E-mail Utility Account

Administrative Oncology

Allergy Pathology

Behavioral/Mental Health Pharmacy

Diving Physical Therapy

Endocrinology Plastic Surgery

Flight Medicine Pulmonary Diseases

Gastroenterology Radiology

Hematology Speech Pathology

Judge Advocate General Surgery

Neurosurgery Vascular Surgery

Nutrition Veterinary Medicine

OB-GYN
142 http://www.cs.amedd.army.mil/amedd_journal.aspx Figure 1. Process chart: Teleconsultation Program Business Practice for Deployed Providers. Consultant retrieves and reviews teleconsultation

emails consultationDeployed Provider

Teleconsultation

emailed to 

med.consult.army@

Finds 

mail.mil

consultant(s) 

with

appropriate

expertise

Specialty 

with

Contact 

Group

Yes No

questions/info to groupProvider sends f/u or

Include

charles.m.lappan.civ@mail.mil

in the “cc” address

Teleconsultation

is routed to the

appropriate

specialty group Consultant emails recommendation

to the deployed

physician

confirms teleconsultationCopy furnished to specialty group... 

is answered 

and enables collaboration

Operational patient healthcare
April – September 2016 143

The Army Medical Department Journal

Time %

0.0 min to 1 hour 0 min 25.02%

1 hour 1 min to 2 hours 14.09%

2 hours 1 min to 3 hours 10.43%

3 hours 1 min to 4 hours 7.85%

4 hours 1 min to 5 hours 6.91%

5 hours 1 min to 6 hours 5.95%

6 hours 1 min to 7 hours 5.19%

7 hours 1 min to 8 hours 4.15%

8 hours 1 min to 9 hours 3.95%

9 hours 1 min to 10 hours 2.74%

10 hours 1 min to 11 hours 2.08%

11 hours 1 min to 12 hours 1.77%

12 hours 1 min to 13 hours 1.67%

13 hours 1 min to 14 hours 1.12%

14 hours 1 min to 15 hours 0.89%

15 hours 1 min to 16 hours 0.68%

16 hours 1 min to 17 hours 0.53%

17 hours 1 min to 18 hours 0.44%

18 hours 1 min to 19 hours 0.41%

19 hours 1 min to 20 hours 0.37%

20 hours 1 min to 21 hours 0.24%

21 hours 1 min to 22 hours 0.22%

22 hours 1 min to 23 hours 0.33%

23 hours 1 min to 24 hours 0.38%

24 hours 1 min to 25 hours 0.24%

25 hours 1 min to 26 hours 0.32%

26 hours 1 min to 27 hours 0.18%

27 hours 1 min to 28 hours 0.15%

28 hours 1 min to 29 hours 0.12%

29 hours 1 min to 30 hours 0.15%

30 hours 1 min to 39 hours 0.79%

More than 40 hours 0.64%

Year Average 

Reply Time

Median 

Reply Time

2004 5 hr 9 min 3 hr 55 min

2005 5 hr 16 min 3 hr 32 min

2006 5 hr 12 min 3 hr 30 min

2007 5 hr 8 min 3 hr 4 min

2008 4 hr 58 min 3 hr 11 min

2009 5 hr 11 min 3 hr 10 min

2010 5 hr 13 min 3 hr 23 min

2011 5 hr 12 min 3 hr 22 min

2012 5 hr 36 min 2 hr 57 min

2013 5 hr 58 min 2 hr 54 min

2014 4 hr 1 min 1 hr 38 min

2015 4 hr 51 min 1 hr 5 min

Program 5 hr 15 min 3 hr 4 min

25%

30%

5%

20%

15%

10%

0%

1 hr 1 min to 2 hr2 hr 1 min to 3 hr3 hr 1 min to 4 hr4 hr 1 min to 5 hr5 hr 1 min to 6 hr6 hr 1 min to 7 hr7 hr 1 min to 8 hr8 hr 1 min to 9 hr

9 hr 1 min to 10 hr

10 hr 1 min to 11 hr

11 hr 1 min to 12 hr

12 hr 1 min to 13 hr

13 hr 1 min to 14 hr

14 hr 1 min to 15 hr

15 hr 1 min to 16 hr

16 hr 1 min to 17 hr

17 hr 1 min to 18 hr

18 hr 1 min to 19 hr

19 hr 1 min to 20 hr

20 hr 1 min to 21 hr

21 hr 1 min to 22 hr

22 hr 1 min to 23 hr

23 hr 1 min to 24 hr

24 hr 1 min to 25 hr

25 hr 1 min to 26 hr

26 hr 1 min to 27 hr

27 hr 1 min to 28 hr

28 hr 1 min to 29 hr

29 hr 1 min to 30 hr

30 hr 1 min to 39 hr

0.0 min to 1 hr 0 min

97.41% of all teleconsultations 

with formal groups were 

answered in 24 hours or less

15 min or less 6.6%

16 to 30 min 7.3%

31 to 45 min 6.1%

45 to 60 min 5.0%

Total ≤60 min 25.0%

manager was familiar with it. Data is extracted for monthly and ad hoc reports using pivot 

tables from 21 Excel workbooks. It takes from 

6 to 8 hours to complete a monthly report. Ad 

hoc reports used to prepare the papers such 

as those listed as references 2-12 can take 12 

hours or more to compile. A database program 

would have simplified this process.

Program management is a time-consuming 

process. Emails for each consultation are 

placed in an MS Word document. The document contains the consult text and all attachments such as photographs, electrocardiograms, x-rays, and ultrasounds. The 

majority of the documents are only 2 or 3 pages long. However, a number have 5 

to 10 pages of emails, and a few contain 30 or more pages. The busiest period was 

in Fiscal Year 2011 with 1,819 consultations as shown in Table 3. The program 

has received consultations from 69 countries and 79 US Navy ships at sea as illustrated by Figure 3.

The program is not centrally funded. To minimize costs, the program manager 

performed his work as an additional duty. The US Army Telemedicine and Advance Technology Research Center (TATRC) transferred funds to the Southern 

Regional Medical Command, (now Regional Health Command, Central (Provisional) (RHC-C (P)), where the program manager is assigned, to offset his 

management of the program. Funding ceased with the drawdown from Iraq and 

Figure 2. Reply times summary,

April 2004 thru June 2015
144 http://www.cs.amedd.army.mil/amedd_journal.aspx

Afghanistan. The RHC-C (P) continues to support the 

program without reimbursement from the Army Medical Command. The hospitals of the consultants are not 

reimbursed for their work, nor is there any way for the 

consultants to account for their time.

The program manager does not have a formal backup.

During long absences, a staff member at the RHC-C 

(P) monitors but does not actively manage the program. 

This leaves a backlog of work for the program manager. 

It creates a single point-of-failure if the program manager is not able to fulfill his duties. A formal backup 

would permit the program manager to disengage from 

his duties and reduce the likelihood of burnout.

Lack of awareness of the program by deployed providers.

Creating awareness of the program to deployed providers is an ongoing issue. Several organizations said they 

were not interested in the program. The Army Medical 

Department Center and School (AMEDDC&S), Joint 

Forces Trauma Conference (JFTC) is the program’s 

biggest supporter. The program manager has spoken 

at almost every JFTC conference for the last 5 years. 

Briefings are conducted at the AMEDDC&S Medical 

Corps and Physician Assistant courses. Many providers 

learn about the program from their colleagues after they 

arrive at their deployed location. Most providers send 

only a few consultations. A few “super-users” have sent 

over 50 consultations.

The program cannot accept classified consultations. The 

potential to mix classified with unclassified consultations is an unacceptable risk.

The program is not linked to the patient’s healthcare record. Deployed providers are responsible to update the 

patients’ healthcare records. There is no formal way to 

determine if the consultant’s advice is followed and if 

the patient is evacuated or managed in theater.

Bandwidth issues. Early in the program, some providers had difficulty submitting consultations of more than 

2 MB in size. Several facilities in the United States 

blocked emails that were greater than 10 MB. When 

large consultations were received, the program manager 

compressed and retransmitted them to the consultants.

Spam and phishing. Well-meaning users posted the 

email addresses of the utility accounts in public facing websites. There were several instances in which 

spammers sent emails to every group. Over 600 consultants participated at the height of the program. If the 

Table 3. Total Consults By Fiscal Year.

2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 Program

Totals

% Consults

Program

Burn-Trauma 23 24 19 32 31 13 17 10 12 7 2 190 1.5%

Cardiology 2 67 41 61 67 84 51 32 30 36 23 494 3.9%

Dental 14 15 21 5 11 3 5 74 0.6%

Dermatology 321 543 528 468 562 526 560 543 281 231 291 154 5,008 39.1%

Infection Control 11 11 16 4 14 21 7 84 0.7%

Infectious Diseases 82 110 106 100 110 110 100 69 66 60 32 945 7.4%

Internal Medicine 34 50 57 64 70 53 29 24 15 396 3.1%

Microbiology 8 7 3 1 3 1 1 24 0.2%

Nephrology 13 18 33 30 29 20 19 19 6 9 10 206 1.6%

Neurology 78 123 145 123 129 69 40 28 21 756 5.9%

Ophthalmology 10 51 38 54 70 65 56 81 49 56 33 27 587 4.6%

Orthopedics 11 105 169 142 227 137 117 105 93 1,106 8.6%

Pain Management 3 6 9 0.07%

Pediatrics 8 21 27 24 20 15 7 6 2 2 1 133 1.0%

Preventive Medicine 3 13 13 25 26 25 23 14 12 1 155 1.6%

Rehabilitation 1 Group Discontinued 1 0.01%

Rheumatology 13 26 20 21 32 35 19 16 17 9 208 1.6%

Sleep Medicine 12 5 16 4 3 3 3 46 0.4%

Toxicology 2 19 15 14 8 14 15 11 5 4 2 109 0.9%

Traumatic Brain Injury 8 42 63 74 34 8 16 5 250 2.0%

Urology 6 69 108 114 125 64 45 39 27 597 4.7%

Other Specialties 7 62 124 178 185 180 245 136 110 113 96 1,435 11.2%

Totals 331 731 903 1,055 1,459 1,653 1,654 1,819 1,026 818 827 537 12,813

Average Per Month 55 61 75 88 122 138 138 152 86 68 69 60 95

Operational patient healthcare
April – September 2016 145

The Army Medical Department Journal

Figure 3. Locations submitting teleconsultations.

http://www.cia.gov/cia/publications/factbook/reference_maps/pdf/time_zones.pdf Map as of July 1, 2015

Supported 

Facility
146 http://www.cs.amedd.army.mil/amedd_journal.aspx

consultant placed an out-of-office reply in their email 

box, the spammer/phisher knew the utility account was 

valid.

Diversion of consultations into Outlook Junk email files.

Sometimes a teleconsultation was diverted to the consultant’s junk email. If the consultant does not monitor the junk email box, he/she is not aware they have a 

consultation to answer. Modifying the Outlook rules of 

what is/is not junk has had mixed results. 

Consultants may not respond to the specialty group 

when answering a consultation. A consultation is considered as “not answered” until the program manager 

receives a reply from a consultant. If the consultation is 

not answered within 12 to 20 hours, the program manager retransmits the consultation. Consultants who respond directly to the deployed providers are instructed 

to forward their reply to the group.

Deployed providers may not respond to the entire group 

when a consultant asks for additional information. If a 

consultant requests additional information from the deployed provider and the provider does not respond to the 

entire group, the consultant forwards the reply to the 

entire group.

There is no consistency among specialties on the management of their groups. Some groups have a gatekeeper who forwards consultations to specific consultants. 

Some groups have consultants who answer all consultations for a specific period. Other groups place specific 

hospitals on call for a specific month(s). The majority 

of the specialties do not place specific consultants on 

call. The first consultant to answer a consultation retains 

control of it.

Poorly-focused patient photographs. Most deployed 

providers use their personal camera or camera phone 

to take photographs. They may not be skilled in fundamental digital photography techniques. When a poorly 

focused photograph is received, the program manager 

determines the camera make and model and its settings from the Exchangeable Image File Format (EXIF) 

embedded in the photograph. He instructs the provider 

how to take diagnostically acceptable photographs. In 

several instances, this has resulted in a change to the 

consultant’s diagnosis. There is no way to know whether 

legal authorizations to take and transmit photographs of 

patients have been observed. There is no way to prevent 

personally identifying information from being included 

in photos.

DOTMLPF* Assessment/Lessons Learned

Doctrine: The program began in 2004 with minimal 

fanfare. The first comprehensive Office of The Surgeon General/US Army Medical Command (OTSG/

MEDCOM) Policy Memorandum was published in May 

2004.13 Two subsequent OTSG/MEDCOM Policy Memorandums renewed the program through June 2011.14,15

The program was addressed in OTSG/MEDCOM policy Memorandum 13-009 (2013) and OTSG/MEDCOM 

Policy Memo 15-020,16,17 (2015) and incorporated into 

the current OTSG/MEDCOM telehealth policy in 2013.18

Organization: The program relies on volunteers participating as an additional duty. Because the program was 

envisioned as an interim solution, long-term sustainability was not considered. 

Training: Only a few mobilization stations briefed deploying providers on the program. On several occasions, 

the program manager was informed that the premobilization training schedule did not have any time available/

allocated to brief healthcare providers concerning the 

teleconsultation program. A 50-minute briefing is presented to deploying providers at the Joint Forces Trauma 

Course at Fort Sam Houston, Texas.

Materiel: TATRC purchased laminated credit card size 

cards to distribute to deploying and deployed providers. 

Funding for the cards ceased when TATRC was no longer able offset the program managers’ expenses.

Leadership and Education: The AMEDDC&S schedules 

telehealth presentations to the Medical Corps and Physician Assistants officer basic and career courses. 

Personnel: Not applicable.

Facilities: Not applicable.

References

1. Pak H. Presentation at Dermatology Conference, 

Great Plains Regional Medical Command Headquarters, Fort Sam Houston, Texas; August 2003.

2. Poropatich RK, DeTreville, Robert, Lappan 

Charles M, Barrigan, Cynthia, The U.S. Army 

telemedicine program: general overview and current status in Southwest Asia. Telemed J E Health. 

2006;12(4):396-408.

*Doctrine, organization, training, materiel, leadership & education, 

personnel, facilities.

Operational patient healthcare
April – September 2016 147

The Army Medical Department Journal

3. Morgan AE, Lappan CM, Fraser SL, Hospenthal 

DR, Murray CK. Infectious disease teleconsultive 

support of deployed healthcare providers. Mil Med. 

2009;174(10):1055-1060.

4. Rand ER, Lappan CM, Lee JC, Furgerson JL. 

Paging the worldwide cardiology consultant: 

the Army Knowledge Online Telemedicine 

Consultation Program in cardiology. Mil Med. 

2009;174(11):1144-1149.

5. Mines MJ, Bower KS, Lappan CM, Mazzoli RA, 

Poropatich RK. The United States Army Occular 

Teleconsultation Program 2004 through 2009. Am 

J Ophthalmol. 2011;152(1):126-132.

6. Blank E, Lappan C, Belmont PJ Jr, Machen MS, 

Ficke J, Pope R, Owens BD. Early analysis of 

the United States Army’s telemedicine orthopaedic consultation program. J Surg Orthop Adv. 

2011;20(1):50-55.

7. Schmidt T, Lappan CM, Hospenthal DR, Murray CK. Deployed provider satisfaction with 

infectious disease teleconsultation. Mil Med. 

2011;176(12):1417-1420.

8. McKoy K, Norton S, Lappan C. Quick Guide to 

Store-Forward Teledermatology for Referring Providers [internet]. American Telemedicine Association; April 2012. Available at: https://accessderm.

aad.org/img/ATA_Telederm_Guidelines.pdf. Accessed March 15, 2016.

9. Yurkiewicz IR, Lappan CM, Neely ET, Hesselbrock RR, Girard PD, Alphonso AL, Tsao JW. Outcomes from a US military neurology and traumatic 

brain injury telemedicine program. Neurology. 

2012;79(12):1237-1243.

10. Hwang JS, Lappan CM, Sperling L, Meyerle JH. 

Utilization of telemedicine in the U.S. military in a 

deployed setting. Mil Med. 2014;179(11):1347-1353.

11. McManus J, Salinas J, Morton M, Lappan C, Poropatich R. Teleconsultation program for deployed 

soldiers and healthcare professionals in remote 

and austere environments. Prehosp Disaster Med. 

2009;23(3):210-216; discussion 217.

12. Alphonso AL, Lappan CM, Tsao JW. Military telemedicine. In: Tsao JW, Demaerschalk BM, eds. Teleneurology in Practice A Comprehensive Clinical 

Guide. New York, NY: Springer Science & Business Media; 2015:27-37.

13. Office of The Surgeon General/US Army Medical 

Command Policy Memorandum 04-003: Use of 

Teledermatology Consults Prior to Patient Evacuation from Operation Iraqi Freedom (OIF) and 

Operation Enduring Freedom (OEF) Locations. 

Fort Sam Houston, Texas: US Army Medical Command; May 2004.

14. Office of The Surgeon General/US Army Medical 

Command Policy Memorandum 07-009: Use of 

Army Knowledge Online (AKO) Email in Support 

of Electronic Telehealth Medical Consultation by 

Deployed Providers. Fort Sam Houston, Texas: US 

Army Medical Command; March 2007.

15. Office of The Surgeon General/US Army Medical 

Command Policy Memorandum 09-034: Use of 

Army Knowledge Online (AKO) Email to Conduct 

Electronic Medical Consultation. Fort Sam Houston, Texas: US Army Medical Command; June 4, 

2009. Available at: https://www.qmo.amedd.army.

mil/credentialing/09_034.pdf. Accessed March 15, 

2016.

16. Office of The Surgeon General/US Army Medical Command Policy Memorandum 13-009: Use 

of Telehealth in the United States Army Medical 

Command (MEDCOM). Fort Sam Houston, Texas: 

US Army Medical Command; February 20, 2013.

17. Office of The Surgeon General/US Army Medical Command Policy Memorandum 15-020: Use 

of Telehealth in the United States Army Medical 

Command (MEDCOM). Fort Sam Houston, Texas: 

US Army Medical Command; February 10, 2015.

18. Office of The Surgeon General/US Army Medical 

Command. Telehealth All-Specialty Standard Operating Procedures. Fort Sam Houston, Texas: US 

Army Medical Command; May 13, 2013.

Author

Mr Lappan is a Health Systems Specialist, Regional 

Health Command, Central (Provisional) Joint Base San 

Antonio-Fort Sam Houston, Texas. He is Project Manager for Teledermatology and Telehealth, and is the OTSG 

AKO Teleconsultation Program Manager.
148 http://www.cs.amedd.army.mil/amedd_journal.aspx

The US military is not immune to the global scourge 

of cardiovascular disease. Cardiovascular disease has 

affected service members throughout history and continues into the current war on terror. Autopsies of US 

service members killed in the Korean and Vietnam wars 

demonstrated an 8.5% prevalence of coronary atherosclerosis.1

 Unfortunately, coronary artery disease is not 

uncommon in military members and only increases 

with age and traditional cardiovascular risk factors.

Operation Enduring Freedom (OEF) Afghanistan is 

a United States-led coalition military action focused 

within Afghanistan that took place from October 2001 

to 31 December 2014. The involvement of the US military in Afghanistan remains ongoing under Operation 

Freedom’s Sentinel. This operation functions alongside 

the International Security Assistance Force which is 

supported by the North Atlantic Treaty Organization. 

There have been over 1 million deployments of US service members in support of OEF, and 3,495 fatalities of 

US and coalition forces.2

 Based on limited data from 

Operation Iraqi Freedom (OIF), evacuation from the operational theater for known or suspected disease of the 

cardiovascular system is not uncommon.3

Rates of clinically evident cardiovascular disease in OIF 

have been evaluated. A pilot study was performed to 

evaluate the value of a forward-deployed cardiologist in 

the operational theater. The cardiologist was equipped 

with exercise testing equipment, an ambulatory electrocardiographic monitoring system, and transthoracic 

echocardiography capabilities. Results from this study 

demonstrated a marked increase in return to duty rates 

ranging from 85% to 89% when a cardiologist determined disposition of the servicemember.3,4 To further 

validate these fi ndings and mitigate the morbidity and 

mortality risks associated with acute cardiovascular disease, the US military began deploying a theater cardiology consultant to Afghanistan in 2010. The theater cardiology consultant was stationed at Bagram Air Field, 

a strategically placed casualty collection point near the 

primary site for air evacuations out of Afghanistan. The 

theater cardiology consultant is able to perform electrocardiograms, ambulatory electrocardiographic event 

recording, graded exercise stress testing, transthoracic 

and transesophageal echocardiograms, and stress echocardiography. We prospectively categorized patients referred for theater cardiology evaluations based on their 

primary cardiovascular complaint and assessed the disposition of those service members involved with OEF 

from 2010 to 2013.

METHODS

Study Population and Setting

Data were collected prospectively from all patient encounters seen by the theater cardiology consultant from 

November 2010 to September 2013 at the Role III medical 

facility at Bagram. The data set included demographics, 

Cardiovascular Complaints Among

 Military Members During Operation

 Enduring Freedom

 LTC James A. Watts, MC, USA Lt Col Gilberto Patino, USAF, MC

 Capt Frank D. Russo, USAF, MC Maj Javed M. Nasir, USAF, MC

 LTC Todd C. Villines, MC, USA Robert E. Eckart, DO

 COL Samuel O. Jones, MC, USA Lt Col Kevin E. Steel, USAF, MC

ABSTRACT

During Operation Enduring Freedom, the US military began deploying a dedicated theater cardiology consultant to Afghanistan in an effort to increase rates of return to duty in service members with cardiovascular complaints. This study was designed to categorize these complaints and determine the effect on both aeromedical 

evacuation and return to duty rates during a 2.5 year observation period. A total of 1,495 service members were 

evaluated, with 43% presenting due to chest pain followed by arrhythmias/palpitations (24.5%) and syncope 

(13.5%). Eighty-fi ve percent of individuals returned to duty, most commonly with complaints of noncardiac 

chest pain, palpitations, or abnormal electrocardiograms. Fifteen percent were evacuated out of theater, most 

often with acute coronary syndrome, pulmonary embolus, or ventricular tachycardia. The forward-deployed 

theater cardiology consultant is vital in the disposition of military members by effectively parsing out life 

threatening cardiovascular conditions versus low risk diagnoses that can safely return to duty.
April – September 2016 149

THE ARMY MEDICAL DEPARTMENT JOURNAL

primary cardiac diagnoses, and disposition (evacuation or return to duty). 

Enrollment criteria included all foreign and American military members 

who presented to this facility with a 

cardinal manifestation of possible 

cardiovascular disease. Afghani nationals and children were excluded 

from analysis. The theater institutional review board approved the protocol.

Cardiac diagnoses were selected by 

the theater cardiology consultant 

using a list of standard cardiovascular diagnostic terms. Diagnoses 

were grouped into diagnostic related 

groups if the overall incidence of 

disease was low. Clinically relevant 

arrhythmias were analyzed using 

the most specifi c diagnosis reported 

by the theater cardiologist. Ischemic 

evaluations were categorized as those 

with nonischemic chest pain, acute coronary syndrome, 

or ischemic heart disease and analyzed regardless of 

presenting symptoms. Acute coronary syndrome was 

diagnosed clinically using standardized published criteria.3

 Specifi c arrhythmias included atrial fi brillation, 

atrial fl utter, supraventricular tachycardia, ventricular 

tachycardia, sinus bradycardia, ectopic beats, and sudden cardiac death. Abnormal electrocardiogram included diagnoses such as bundle branch block, ventricular 

hypertrophy, and atrial enlargement.

The disposition of each patient was clinically determined at the time of the fi nal encounter by the theater 

cardiology consultant. Patients were either allowed to 

return to their units and resume their mission (return 

to duty), or were evacuated out of theater, often with a 

medical attendant (aeromedical evacuation).

Statistical Analysis

Statistical analysis was performed using SPSS Statistics 

for Windows (version 22.0; IBM Corp, Armonk, New 

York). Categorical variables (frequencies) were compared using χ 2

 statistics. A P-value less than .05 was 

considered signifi cant.

RESULTS

Participants

Patient demographic data are summarized in Table 1. A 

total of 1,495 service members were evaluated over a 

34-month observation period. The US Army constituted 

the largest segment of the population with 1,106 patient 

encounters accounting for 74% of the total population. 

Enlisted soldiers and noncommissioned offi cers accounted for 1,034 

patient encounters. The mean age of 

the population was 36±10 years.

Primary Findings

Table 2 delineates the frequency of 

each specifi c diagnosis. The most 

common reason for evaluation by 

the theater cardiologist was to determine the presence of ischemic heart 

disease. A total of 646 chest pain 

evaluations were performed in theater, comprising 43% of the total cardiovascular evaluations. Of the chest 

pain evaluations, 34 were determined 

to have acute coronary syndrome 

(2.2%) including ST or non-ST elevation myocardial infarction. The next 

most common diagnoses were related to primary rhythm issues such as 

aborted sudden cardiac death, palpitations, ectopic beats, atrial fi brillation, ventricular preexcitation or ventricular tachycardia (24.5%). This was 

followed by syncope (13.5%), abnormal resting electrocardiogram (7.1%), risk factor assessment (4.3%), structural heart disease (2.7%), and perimyocarditis (2.5%).

Overall, 225 (15%) of all individuals evaluated by the 

theater cardiologist were evacuated out of theater and 

did not return to duty. The return to duty rate after being evaluated by the theater cardiology consultant was 

85%. Once categorized with a specifi c diagnosis, the 

incidence of evacuation for patients with a cardiovascular diagnosis signifi cantly exceeded the overall 15% 

evacuation rate for perimyocarditis (46%), pulmonary 

embolism (87%), acute coronary syndrome (100%), 

supraventricular tachycardia (43%), ventricular tachycardia (67%), and atrial fi brillation/fl utter (37%). Conversely, the incidence of evacuation for patients who 

were diagnosed with abnormal resting ECG (4%), risk 

factor assessment (3%), noncardiac chest pain (8%), and 

palpitations (6%) were signifi cantly less than the overall 

15% evacuation rate (P<.05).

COMMENT

This study is the fi rst to describe the spectrum of cardiovascular disorders evaluated by a dedicated forwarddeployed cardiologist during wartime operations. The 

most frequent encountered complaint involved concerns 

for myocardial ischemia (43%). Complaints of this nature are evaluated with a thorough history and physical, electrocardiogram, and often a gated exercise stress 

test with or without echocardiographic imaging. While 

Table 1. Patient Demographics.

Branch of Service Frequency

(Total:

N=1,495)

%N

Coalition Soldier 81 5.4

US Forces

Army 1,106 74.0

Air Force 103 6.9

USMC 30 2.0

Navy 48 3.2

Unknown branch 127 8.5

Mean Age: 36 years (range 18-64)

Rank Frequency

(Total:

N=1,495)

%N

None indicated 84 5.6

E-1 to E-4 379 25.4

E-5 to E-9 656 43.9

W1 to W5 74 4.9

O-1 to O-4 206 13.8

O-5 to O-9 94 6.2

Unknown 2 0.1
150 http://www.cs.amedd.army.mil/amedd_journal.aspx

many primary care physicians are able 

to perform exercise stress testing, the 

cardiologist’s experience in evaluating 

chest pain syndromes aids in the decision to return these service members 

to full duty. Noncardiac chest pain was 

the most frequently used diagnostic category (40.7%), but included among those 

were service members with true obstructive cardiovascular disease and acute 

coronary syndrome (2.3%). The risk to 

the service member that returns to duty 

with coronary obstruction or acute coronary syndrome is high, despite its rare 

occurrence. This is where the cardiovascular specialist is adept at detailed risk 

stratifi cation and evaluation.

The next most common diagnostic category includes those with cardiac rhythm 

complaints or syncopal symptoms. In 

addition to the history and physical, 

evaluation may include an electrocardiogram, echocardiogram and ambulatory 

electrocardiographic monitoring. The 

theater cardiologist is able to perform 

and interpret the appropriate tests and 

make a rapid disposition with up to an 

85% return to duty rate, including some 

who presented with higher risk arrhythmias such as atrial fi brillation.

A forward-deployed cardiologist serving as the theater cardiology consultant 

plays a vital role in maintaining a battleready military force, while minimizing 

out of theater medical evacuations. Over 

a 3-year period, 85% of all deployed individuals referred with a cardiovascular 

complaint were returned to duty. The 

availability of forward-deployed, fi rstline cardiovascular diagnostic tools, 

such as echocardiography, stress testing, 

ambulatory electrocardiography, and a 

board-certifi ed cardiovascular disease 

specialist appeared to be an effective tool in discriminating life-threatening diagnoses from benign conditions that may have resulted in inappropriate evacuation. This data suggests that the presence of an equipped 

cardiovascular subspecialist in the theater of operations 

provides military commanders a vital tool to maintain 

readiness; however, continued analysis is necessary to 

determine the optimal risk assessment tools needed in 

theater. In addition, the volume of patients encountered 

by a forward deployed cardiologist suggests that in largescale confl icts, cardiovascular complaints are commonplace and a cardiovascular specialist strategically placed 

near an evacuation hub will be highly utilized. Furthermore, given the broad spectrum of cardiovascular conditions that the theater cardiology consultant can expect to 

encounter during a deployment, there is a requirement 

to ensure that military cardiologists are facile at a broad 

range of invasive and noninvasive tasks.

Table 2. Frequency of diagnostic categories and effect on evacuation frequency. 

active duty patients displayed by diagnostic category, relative percentage of total 

active duty patients, number of patients receiving aeromedical evacuation (AE), 

and aeromedical evacuation rates by diagnostic category. P-value represents 

signifi cant difference of evacuation rate from expected rate by χ2 analysis. Odds 

ratio refl ects odds of aeromedical evacuation by diagnostic category.

 Diagnostic Category Patients (n)

(Total:

N=1,495)

%N AE AE

Frequency

(%n)

P

Value

Odds

Ratio

Ischemia

Noncardiac Chest Pain 609 40.7% 48 8% <.05 0.34

Acute Coronary 

Syndrome

34 2.3% 34 100% <.05 458

Ischemic Heart Disease 3 0.2% 2 67% <.05 11.4

Total 646 43.2% 84 13% .05 0.75

Rhythm

Aborted Sudden

Cardiac Death

3 0.2% 3 100% <.05 40

Bradyarrythmia 11 0.7% 3 27% .25 2.13

Palpitations 197 13.2% 11 6% <.05 0.27

Ventricular Tachycardia 3 0.2% 2 67% <.05 11.4

Atrial Fibrillation/Flutter 71 4.7% 26 37% <.05 3.3

Supraventricular 

Tachycardia

23 1.5% 10 43% <.05 4.5

Ectopic Beats 48 3.2% 4 8% .19 0.50

Pre-Excitation 12 0.8% 2 17% .87 1.13

Total 368 24.5% 61 17% .35 1.2

Syncope

Presyncope/Syncope 202 13.5% 29 14% .77 0.94

Electrocardiogram

Abnormal ECG 106 7.1% 4 4% <.05 0.21

Risk Factor Assessment 65 4.3% 2 3% <.05 0.17

Structural

Cardiomyopathy/Hf/

Suspected

17 1.1% 5 29% .10 2.4

Valvular Heart Disease 23 1.5% 0 0% <.05 0.12

Congenital 1 0.1% 0 0% .67 1.8

Total 41 2.7% 5 12% .60 0.78

Pericarditis/Myocarditis

Myocarditis 9 0.6% 9 100% <.05 111

Pericardial Disease 28 1.9% 8 29% .04 2.3

Total 37 2.5% 17 46% <.05 5.1

Other

Vascular Disease 6 0.4% 2 33% .21 2.8

Pulmonary Embolism 15 1.0% 13 87% <.05 38.8

Chest Trauma 9 0.6% 8 89% <.05 46.8

Total 30 2.0% 23 77% <.05 20.5

OPERATIONAL PATIENT HEALTHCARE
April – September 2016 151

THE ARMY MEDICAL DEPARTMENT JOURNAL

Although the theater cardiology consultant position can 

signifi cantly augment a comprehensive cardiovascular 

prevention and treatment program for the deployed active duty service member, it is insuffi cient in addressing 

the complete need to mitigate cardiovascular risk. Premobilization assessment of cardiovascular risk is also 

a critical component. Cardiovascular screening is not 

routinely assessed in all military members preparing for 

deployment, despite the presence of traditional clinical 

risk factors. Military members are required to undergo 

periodic health screening to assess fi tness standards on a 

biannual to annual basis. Service members over the age 

of 40 also undergo a tiered cardiovascular risk screening 

program. Those individuals not meeting set medical fi tness standards are advised not to deploy. The cardiovascular risk screening program consists of an initial risk 

assessment using the Framingham risk score and resting electrocardiogram. Service members with elevated 

risk or a coronary disease risk equivalent are referred for 

functional assessment with exercise or pharmacologic 

stress testing. Despite these screening efforts, chest pain 

remained a predominant complaint in theater. With the 

advent of more comprehensive risk assessment tools and 

multimodal imaging, efforts are underway to modernize cardiovascular screening and prevention programs.

The forward-deployed cardiovascular specialist has 

been shown to have a signifi cant effect on the rates of 

return to duty. Our results demonstrating an 85% return 

to duty rate during OEF are consistent with prior studies that utilized a theater cardiologist during Operation 

Iraqi Freedom.3

An increased return to duty rate results in minimal time 

lost by the military member and almost immediate continuation of the military mission. Individuals who are 

evacuated out of theater are unlikely to return, which 

results in compromise of the mission until that military 

member can be replaced. The success of the theater 

cardiologist requires that they are collocated with fi xed 

wing aeromedical evacuation services, have the proper 

diagnostic tools to assess the most common cardiovascular complaints (treadmill, electrocardiogram, echocardiographic machine, ambulatory ECG monitor), have 

immediate access to emergency medical services and 

have direct control over the disposition of the patients 

whom they evaluate. We feel that future staffi ng models 

and doctrine should consider adding a supplementary 

position for a theater cardiologist in select, strategically 

located Role III facilities involved in large-scale theater 

combat operations.

LIMITATIONS

The data presented in this study underrepresents the 

total encounters seen and evaluated by the theater cardiologist. Additional duties of the theater cardiologist 

included providing humanitarian care for the Afghani 

population; these patients were excluded from data collection. These encounters would likely have affected the 

overall rates of diagnosis due to the prevalence of third 

world cardiovascular conditions in this population. In 

addition, baseline demographics, results of noninvasive 

and laboratory testing were not available for this analysis. Finally, a comparator arm of patients assessing evacuation rates of deployed subjects prior to the initiation 

of the theater cardiology program was not performed. 

Such data would have allowed for a more robust assessment of the effect of a theater cardiology program.

CONCLUSION

Cardiovascular complaints are common in the deployed 

setting. Many service members who have a cardiovascular concern are able to return to duty after evaluation 

due to the lack of a clinically signifi cant disorder. There 

are a few, however, with signifi cant life threatening 

cardiac disease who must be teased out from the large 

numbers of low risk patients. When given the proper 

tools to evaluate cardiovascular complaint, the forwarddeployed theater cardiologist effectively performs this 

role and is vital in the disposition of military members.

REFERENCES

1. Webber BJ, Seguin PG, Burnett DG, Clark LL, Otto JL. Prevalence of and risk factors for autopsy-determined atherosclerosis among US service members, 2001-2011. JAMA. 2012;308(24):2577-2583.

2. Coalition Military Fatalities By Year [internet]. Operation Enduring Freedom iCasualties web page, iCasualties.org 

website. Available at: http://www.icasualties.org/oef/. Accessed September 29, 2015.

3. Sullenberger L, Gentlesk PJ. Cardiovascular disease in a forward military hospital during Operation Iraqi Freedom: 

a report from deployed cardiologists. Mil Med. 2008;173(2):193-197.

4. Nayak GS. Military cardiology under a tent. Cardiology. 2007;107:395-98.
152 http://www.cs.amedd.army.mil/amedd_journal.aspx

AUTHORS

LTC Watts is Cardiovascular Diseases Associate Program Director, San Antonio Military Medical Center, Joint Base 

San Antonio-Fort Sam Houston, Texas.

Capt Russo is a Cardiovascular Fellow, San Antonio Military Medical Center, Joint Base San Antonio-Fort Sam Houston, 

Texas.

LTC Villines is Cardiovascular Diseases Program Director, Walter Reed National Military Medical Center, Bethesda, 

Maryland.

COL Jones is Staff Electrophysiologist, San Antonio Military Medical Center, Joint Base San Antonio-Fort Sam Houston, 

Texas.

Lt Col Patino is Chief, Cardiovascular Division, San Antonio Military Medical Center, Joint Base San Antonio-Fort Sam 

Houston, Texas.

Maj Nasir is a Staff Cardiologist, Keesler Medical Center, Keesler Air Force Base, Biloxi, Mississippi.

Dr Eckart is a Staff Electrophysiologist in private practice, Sarasota, Florida.

Lt Col Steel is Cardiovascular Diseases Program Director, San Antonio Military Medical Center, Joint Base San AntonioFort Sam Houston, Texas.

OPERATIONAL PATIENT HEALTHCARE
April – September 2016 153

Wherever there is armed confl ict, the potential for injury 

to children exists. In Iraq and Afghanistan, the urban 

battlefi eld environment and use of improvised explosive 

devices have resulted in a signifi cant amount of pediatric penetrating and blast injuries. While the primary 

mission of deployed combat hospitals is to care for combatants, the humanitarian care of noncombatants is inevitable. This is particularly the case in countries with 

a very limited medical infrastructure to handle not only 

both civilian combat injuries, but disease and nonbattle 

injury as well. Military providers deployed during the 

past decade cared for a signifi cant number of children at 

Role 3 facilities with a broad spectrum of injuries and 

diseases. This experience has been documented in the 

Patient Administrative Systems and Biostatistics Activity (PASBA) database and the Department of Defense 

Trauma Registry, formerly the Joint Theater Trauma 

Registry (JTTR).

SCOPE OF THE PEDIATRIC MISSION

A total of 6,273 patients aged 14 years and under were 

hospitalized from 2002-2012 at US military hospitals in 

Iraq and Afghanistan.1

 The majority of those patients in 

Iraq over this period were due to combat injuries. The 

majority of patients in Afghanistan were due to noncombat related trauma and medical/congenital conditions. The primary mechanism weapon of combat injury 

to children in Iraq was the gunshot wound, followed 

closely by the improvised explosive device (IED) and 

other explosives. In Afghanistan, most combat injuries 

were due to the IED/blast injuries. Frequent indications 

for admission for noncombat trauma were not unlike 

those seen in the United States: motor vehicle collisions, falls, and burns. Admission for combat injury was 

signifi cantly more likely in children over the age of 4 

years. Toddlers and preschoolers were more likely to be 

admitted for noncombat trauma, and infants most likely 

to be admitted with congenital and acquired disease.

Admissions for these patients were resource intense. 

Combat trauma carried a particularly high transfusion 

rate (greater than 25%) and need for invasive surgical 

procedures (more than one per patient on average). Due 

to data capture limitations in available data bases and 

limited civilian access to follow up at the military treatment facilities, outcome analysis is exceedingly limited. In-hospital mortality was 11% for combat injured 

children in Iraq and 8% for noncombat injured children 

in Afghanistan.1

 Average hospital stays were 3-5 days 

depending on reason for admission, combat injury being longer than noncombat injury. Nontrauma mortality was 5% in both countries.1

 Surgical procedures for 

noncombat injuries carried a collective mortality of less 

than 1%; congenital conditions requiring operation were 

most commonly hernia and splenectomy for congenital 

hemoglobinopathy.2

 An additional analysis of data inclusive of all patients aged less than 19 years captured 

through JTTR and PASBA reported 7,505 encounters 

between 2002 and 2011, representing 5.8% of all Role 

3 admissions during that time.3

 Once again, the major 

etiology of these pediatric injuries was blast (37%). The 

length of admission was inversely proportional to age, 

with the longest stays belonging to pediatric patients. 

Wound debridement and skin grafting were noted to be 

the most common procedures performed on these patients. Approximately 10% of patients required transfusions and 16% and 17% required ventilator support 

in Operation Enduring Freedom (OEF) and Operation 

Iraqi Freedom (OIF) respectively.3

In the above mentioned report which included older 

teenagers (up to age 19), notable differences were found 

Pediatric Wartime Injuries in Afghanistan

 and Iraq: What Have We Learned?

 Capt Xiaoming Shi, USAF, MC

 COL Mary J Edwards, MC, USA

ABSTRACT

The majority of the documented experience in pediatric trauma care during the past decade of confl ict is from 

the inpatient Role 3 mission. Pediatric patients (defi ned as 14 years of age or less) accounted for 5% to 10% 

of combat admissions. Care for these patients was resource intensive and mortality rates signifi cantly higher 

than those seen in pediatric hospitals in the United States. The largest documented experience to date with 

explosive injuries and massive transfusions in children were reported from this confl ict. Improvements in 

logistic and personnel support was seen throughout the decade of confl ict, however long-term outcomes and 

clinical practice guidelines to direct future care for these children are lacking.
154 http://www.cs.amedd.army.mil/amedd_journal.aspx

when children younger than 8 years were compared 

with those 8 years and older. Patients younger than 8 

years were admitted more for medical/burn/blunt injuries, while the penetrating/blast injuries occurred more 

often in the older group, which likely included some 

combatants. Female patients were the signifi cant majority in the younger group, while male patients were the 

majority in the older group. Both groups’ injury severity scores (ISS) did not differ signifi cantly, and ISS was 

noted to be higher in Iraq than Afghanistan. In keeping with a prior report,4

 patients younger than 8 years 

of age had a higher mortality of 9.9% (trauma mortality 

was 10.3%), than children aged 9 years and older (5.3% 

overall and 7.3% trauma). The overall mortality of both 

groups was 8.5%.

Pediatric admission rates clearly followed the severity 

of the confl icts, with the majority of both combat and 

noncombat related admissions seen during troop surges 

(2008 in Iraq and 2010 in Afghanistan).1

 This implies 

that the need for pediatric care was not only due to the 

rate of children injured from the confl ict, but an inability 

of the local community to care for children with disease 

and noncombat injury during these periods of time. The 

vast majority of children were also lost to follow up after 

discharge. What is also clear from the 2 studies is that 

while traumatic injuries carried high mortality rates for 

children, nontrauma admission mortality rates are also 

high, suggesting defi ciencies in the baseline health of 

this population and local healthcare infrastructure. This 

data is signifi cantly limited by selection bias, as admissions were largely at the discretion of the medical treatment facility, and also subject to theater medical rules of 

engagement. Data is further limited by absence of available age for a signifi cant number of patients entered into 

the database.1-3

BLAST INJURIES

A study of blast injuries for all civilians treated in military 

treatment facilities in Iraq and Afghanistan from 2002 

and 2010 found a large portion of patients were children 

under age 15 (24.5%). Detonation of IEDs and injury 

secondary to unexploded ordinance detonation were the 

most common cause of blast injury. Seventy percent of 

these blast injuries were noted to affect multiple body regions.4

 Burns and external injuries were noted to be the 

most frequently body region injured (70%). Death most 

strongly associated with severe burn injury, followed by 

injuries to head and cervical spine. This study showed a 

mortality for children 15 years and younger to be 7.8%. 

Analysis of the surgical interventions performed for 

these blast injuries was also performed, documenting 

the care for 1,213 patients who were 14 years or younger.6

 Once again; wound debridement and wound closure 

were the most common procedures and were followed 

by vascular access, exploratory laparotomy, and thoracostomy. Most of the procedures performed on pediatric 

patients were for patients aged 4 to 14 years. Children 

aged 9 to 14 years had the highest number of interventions and the highest ISS. Children younger than 3 years 

of age did not receive operative treatment comparable 

to older groups even though their injury severity and 

mortality were higher.5

Fragments from blast injuries resulted in a signifi cant 

experience with pediatric vascular injury. In a report 

of 155 pediatric vascular injuries from the wars, 58% 

were attributed to blast mechanism.7

 Lower extremity 

wounds were the most prevalent, followed by upper extremity and torso. Torso vascular injuries were double 

the rate seen in adult studies, and were 4 times more 

lethal than other injury patterns, accounting for 70% of 

the mortalities due to these injuries. Pediatric mortality 

in this study was 9%, similarly to previously reported 

fi gures.1-7 The rate of limb salvage was 95% and consistent with prior pediatric literature; however, long-term 

outcome data for the revascularization procedures is 

unavailable.

Blast injuries in OEF an OIF were common and accounted for a major portion of injuries suffered by children. These injuries have unique combination of penetrating, burn, and blunt mechanisms in addition to the 

tissue damage sustained from atmospheric overpressure. 

Children are particularly susceptible to these injuries. 

Unfortunately, this mechanism is likely to be seen outside of the battlefi eld in future terrorist attacks.

RESUSCITATION AND TREATMENT OF HEMORRHAGIC

SHOCK IN CHILDREN

Data from OEF/OIF captured 1,113 pediatric admissions 

who received blood transfusion in the fi rst day of their 

hospital stay.8

 Multivariate analysis evaluated mortality 

against the amount of blood products transfused. This 

revealed that approximately 40 ml/kg of blood products transfused provided a clear cut point for increase 

in mortality. The group receiving less than 40 ml/kg 

was compared against the group receiving more. The 

high volume transfusion group was signifi cantly more 

likely to suffer from explosion injuries, higher ISSs, 

lower GCS, and shock. This is confi rmed by previous 

studies reporting 9.6% transfusion rate in all pediatric 

injuries and 14% to 17% transfusion rate for blast injuries.1,3 Mortality during the fi rst 24 hours and totals in 

hospital mortality were signifi cantly higher in the group 

transfused more than 40 ml/kg.8

 This data provides a 

possible starting point to defi ne massive transfusion 

in pediatric trauma patients that is independent of the 

OPERATIONAL PATIENT HEALTHCARE
April – September 2016 155

THE ARMY MEDICAL DEPARTMENT JOURNAL

injuries they sustained and may serve to be an indicator 

for increased mortality. This data is limited by poor capture of weights in 40% of these patients, as well lack of 

data from point of injury, failure to include severe head 

injuries, and retrospective design.

Further analysis of patients aged under 15 years who received transfusion at military treatment facilities looked 

at the effect of balanced component blood product resuscitation and crystalloid avoidance as a resuscitation 

strategy. Two hundred twenty-four patients received 

more than 40 ml/kg of packed red blood cells (PRBCs) 

or whole blood, and 77 received more than 70 ml/kg. 

Balanced component resuscitation with a 1:1 ratio of 

PRBCs to fresh frozen plasma did not improve mortality in either of these groups, and, when all transfused 

patients were considered, was independently associated with increased mortality. Use of crystalloid in excess of maintenance requirements was associated with 

increased hospital and ICU stays in both the 40 ml/kg 

and 70 ml/kg groups. This data is also subject to the 

limitations listed in the prior study, but underscores the 

need of clinical practice guidelines specifi c to pediatric 

patients for the initiation of damage control resuscitation strategies.9

Finally, tranexamic acid (TXA) has been shown reduce 

mortality in adult patients with hemorrhagic shock.10 Although pediatric literature exists for use of TXA in elective and nontrauma related settings, less is known about 

the utility and safety of its use in pediatric trauma.11-13

Data obtained during 2008-2012 from Camp Bastion, a 

Role 3 hospital in Afghanistan, found that 9% of 766 

pediatric trauma admissions received TXA. Characteristics of the group that received TXA revealed a signifi -

cantly higher portion of penetrating injuries, a higher 

ISS, and lower GCS.14 This retrospective study reported 

a reduced mortality for the TXA cohort that was independent of mechanism of injury and injury severity. The 

authors did not report any thromboembolic complications resulting from TXA administration. The optimal 

dose of TXA for pediatric administration still needs to 

be identifi ed, but this early evidence seems to indicate 

that pediatric TXA administration may improve outcomes for pediatric patients with traumatic injuries due 

to hemorrhage.

CONCLUSION

Over the past decade, combat hospitals were forced to 

respond to an unanticipated amount of pediatric admissions during the confl icts in Iraq and Afghanistan. The 

use of IEDs and the urban environment has led to a high 

proportion of pediatric blast and penetrating injuries 

to multiple body regions that has not been previously 

reported in military literature. The data from this large 

sample of pediatric patients has increased our knowledge of pediatric blast injury and resuscitation from 

hemorrhagic shock. As the medical capabilities in the 

2 theatres of war matured, logistical support and availability of personnel trained in pediatric care improved. 

However, given limited data from point of injury and 

short- and long-term outcomes, the development of evidence-based clinical practice guidelines for pediatrics 

has signifi cantly lagged behind the profound advances 

in care for coalition forces. One lesson learned from this 

confl ict is that pediatric care will be a signifi cant portion of the military medical mission of the future. More 

robust data collection and outcome analysis, as well as 

training and logistical support, will be essential to care 

for the smallest and most innocent victims of war.

REFERENCES

1. Edwards MJ, Lustik M, Burnett MW, Eichelberger 

M. Pediatric inpatient humanitarian care in combat: Iraq and Afghanistan 2002 to 2012. J Am Coll 

Surg. 2014;218:1018-1023.

2. Cole W, Edwards MJ, Burnett MW. Providing 

care to children during times of war. Mil Med. 

2015;180:609-611.

3. Borgman M, Matos R, Blackbourne L, Spinella P. 

Ten years of military pediatric care in Afghanistan 

and Iraq. J Trauma Acute Care Surg. 2012;73(6 

suppl 5):S509-S513.

4. Matos RI, Holcomb JB, Callahan C, Spinella PC. 

Increased mortality rates of young children with 

traumatic injuries at a US Army combat support hospital in Baghdad, Iraq, 2004. Pediatrics. 

2008;122:e959-e966.

5. Edwards MJ, Lustik M, Eichelberger M, Elster E, 

Azarow K, Coppola C. Blast injury in children: An 

analysis from Afghanistan and Iraq, 2002-2010. J 

Trauma Acute Care Surg. 2012;73:1278-1283.

6. Edwards MJ, Lustik M, Carlson T, Tabak B, Farmer D, Edwards K, Eichelberger M. Surgical interventions for pediatric blast injury: an analysis from 

Afghanistan and Iraq 2002 to 2010. J Trauma Acute 

Care Surg. 2013;76:854-858.

7. Villamaria C, Morrison J, Fitzpatrick C, Cannon 

J, Rasmussen T. Wartime vascular injuries in the 

pediatric population of Iraq and Afghanistan 2002-

2011. J Pediatr Surg. 2014;49:428-432.

8. Neff L, Cannon J, Morrison J, Edwards MJ, Spinella P, Borgman M. Clearly defi ning pediatric 

massive transfusion: cutting through the fog and 

friction with combat data. J Trauma Acute Care 

Surg. 2014;78:22-29.
156 http://www.cs.amedd.army.mil/amedd_journal.aspx

9. Edwards MJ, Lustik MB, Clark ME, Creamer KM, 

Tuggle D. The effects of balanced blood component 

resuscitation and crystalloid administration in pediatric trauma patients requiring transfusion in Afghanistan and Iraq 2002 to 2012. J Trauma Acute 

Care Surg. 2015;78:330-335.

10. Shakur H, Roberts I, Bautista R, et al, and the 

Crash-2 Trial Collaborators. Effects of tranexamic 

acid on death, vascular occlusive events, and blood 

transfusion in trauma patients with signifi cant 

haemorrhage (CRASH-2): a randomised, placebocontrolled trial. Lancet. 2010;376(9734):23-32.

11. Crantford JC, Wood BC, Claiborne JR, Ririe DG, 

Couture DE, Thompson JT, David LR. Evaluating 

the safety and effi cacy of tranexamic acid administration in pediatric cranial vault reconstruction. J 

Craniofac Surg. 2015;26:104-107.

12. Tzortzopoulou A, Cepeda MS, Schumann R, Carr 

DB. Antifi brinolytic agents for reducing blood loss 

in scoliosis surgery in children (review). Cochrane 

Database Syst Rev. 2008;16(3):26.

13. Faraoni D, Goobie S. The effi cacy of antifi brinolytic drugs in children undergoing noncardiac surgery: a systematic review of the literature. Anesth 

Analg. 2014;118:628-636.

14. Eckert M, Wertin T, Tyner S, Nelson D, Izenberg S, Martin M. Tranexamic acid administration to pediatric trauma patients in a combat setting: the pediatric trauma and tranexamic acid 

study (PED-TRAX). J Trauma Acute Care Surg. 

2014;77:852-858.

AUTHORS

Capt Shi is with the General Surgery Service, San Antonio Military Medical Center, Joint Base San AntonioFort Sam Houston, Texas.

COL Edwards is Chief of Pediatric Surgery and the General Surgery Residency Program Director, San Antonio 

Military Medical Center, Joint Base San Antonio-Fort 

Sam Houston, Texas. COL Edwards is the General Surgery Consultant to The Army Surgeon General.

OPERATIONAL PATIENT HEALTHCARE
April – September 2016 157

Role of Human Health Care Providers and

 Medical Treatment Facilities in Military

 Working Dog Care and Accessibility

 Difficulties with Military Working

 Dog Blood Products

 LTC James T. Giles III, VC, USA

ROLE OF THE MILITARY WORKING DOG

Military working dogs (MWDs) are used in unprecedented numbers in current military operations, and play 

a vital role in both protecting human lives and supporting 

military objectives.1,2 Military working dogs are trained 

to perform a variety of roles such as explosive, mine, 

and narcotic detection, patrol/attack work, special operations support, and animal assisted therapy for physical and emotional injuries, to name just a few.1

 Similar 

to the human service members they serve, MWDs are 

susceptible to both combat and noncombat related injuries in the operational environment. Contract working dogs (CWDs), which are owned by a private entity 

and perform a Department of Defense (DoD) mission, 

are also used extensively, typically performing a noncombat security mission. The need for effective MWD 

teams has increased signifi cantly with the prevalence of 

improvised explosive devices (IED) in recent years. In 

2008, GEN David Petraeus aptly noted:

The capability that military working dogs bring to the 

fi ght cannot be replicated by man or machine. By all 

measures of performance, their yield outperforms any 

asset we have in our inventory. Our Army would be remiss if we failed to invest more in this incredibly valuable resource.3

At a time when IEDs represent one of the most signifi -

cant threats to our service members, MWDs remain our 

greatest countermeasure to that threat. It is important to 

remember that the purpose of the MWD is to save human lives, and maintaining their health and profi ciency 

is critical to military operations. Anytime an MWD 

team detects an explosive device before it detonates, the 

result is that humans are not killed, maimed, or injured.

OVERVIEW OF MILITARY WORKING DOG CARE IN AN

OPERATIONAL ENVIRONMENT

Veterinary care in a developed operational environment is provided by the Medical Detachment Veterinary Service Support (MDVSS). This organization has 

ABSTRACT

The use of military working dogs (MWDs) in support of military operations has increased dramatically over 

recent years, as they have proven to be our most reliable deterrent to improvised explosive devices. Healthcare delivery for MWDs in combat presents unique challenges and requires extensive collaboration between 

veterinarians and human health care providers (HCPs). A successful example is the incorporation of MWD 

emergency care for nonveterinary HCPs into the Joint Trauma System Clinical Practice Guidelines, which has 

proven to be a helpful product. Additional challenges that need further solutions include MWDs as patients in 

human medical treatment facilities (MTFs) and the procurement of appropriate canine blood components in an 

operational environment. It is often necessary for MWDs to be treated as patients in human MTFs, however, 

there is no Department of Defense guidance to support this activity. Access to MWD blood products is limited to collection of fresh whole blood in the operational setting. Similar to humans, specifi c blood component 

therapy, such as fresh frozen plasma, is often indicated for sick or injured MWDs. Currently there is no formal 

system in place to deliver any blood products for MWDs or to facilitate collection in theater.

VETERINARY CARE
158 http://www.cs.amedd.army.mil/amedd_journal.aspx

5 Veterinary Service Support Teams with one general 

practitioner veterinarian (AOC* 64A) and one animal 

care specialist (MOS* 68T) each, to provide Role 1 and 

Role 2 veterinary care. There is one Veterinary Medicine and Surgery Team with a veterinary clinical medical offi cer (AOC 64F) and 3 animal care specialists providing Role 1-Role 3 veterinary care. As delineated in 

Field Manual 4-02,

4

 Role 1 care is nonsurgical treatment 

by an animal care specialist or veterinarian for minor 

wounds, injuries, or illnesses, preventive medicine, analgesia, emergency intervention for airway, hemorrhage, 

and fracture immobilization. Role 2 veterinary care 

includes veterinarian-directed resuscitation and stabilization and may include advanced trauma management, 

emergency medical procedures, and emergency resuscitative surgery. Role 3 veterinary care includes consultation and referral for advanced veterinary diagnostic, 

therapeutic, and surgical procedures. This level of care 

requires a veterinary clinical medical offi cer with training in surgery, internal medicine, or critical care. In the 

combat theater, this facility is typically collocated with 

a Role 3 human hospital for equipment and technical 

support. There is frequently only one or a partial MDVSS in a combat theater. At the height of Operation Enduring Freedom, there were 2 MDVSS units deployed 

to Afghanistan. Consequently, there are typically very 

limited numbers of veterinary providers in theater, and 

MWDs are often geographically separated from immediate veterinary support. The doctrinal basis of allocation is one MDVSS per 60,000 troops or 50 MWDs, 

which is rarely met based on the MWD numbers. Additionally, the ratio of MWDs to troops has increased 

dramatically in recent years due to the widespread use 

of IEDs.

Both MWDs and CWDs are eligible for veterinary 

care and medical evacuation within the combat theater 

(CWDs based on the provisions of the government contract). Military working dogs are also eligible or aeromedical evacuation (AE) out of the theater, however, for 

CWDs it is the responsibility of the owning entity to 

evacuate them from theater. Similar surgical principles 

for combat injuries are followed for MWDs and human 

service members, in that defi nitive care for signifi cant 

trauma and for high-energy and contaminated wounds 

is often delayed until the patient is out of the combat 

theater. This is not the case for CWDs as they often receive defi nitive care and recover in theater. Procedures 

are occasionally performed on CWDs in theater as an 

alternative to euthanasia due to the expense and delay 

that accompanies private transport out of theater. While 

there is not a provision for AE of CWDs out of theater, 

there is a mechanism for AE of human contractors when 

medically indicated.

HISTORY OF THE MILITARY WORKING DOG CLINICAL

PRACTICE GUIDELINES

Early in the operations in Afghanistan and Iraq, it became apparent that human medicine health care providers (HCPs) frequently encounter sick or injured MWDs 

before veterinary providers. Consequently, each veterinary detachment developed an MWD care SOP to 

provide guidelines for HCPs treating working dogs in 

the absence of veterinary personnel. With this system, 

the veterinary guidance and authorized HCP scope of 

practice for MWDs varied with each rotation. The fi rst 

MWD clinical practice guideline (CPG) was published 

in 2011, entitled “Canine Resuscitation,” and posted on 

the Joint Trauma System CPGs.5

 This document served 

as a provisional MWD CPG until a comprehensive product could be developed. In March of 2012, the “Clinical 

Management of Military Working Dogs” was published 

replacing the initial CPG.6

 This document is a comprehensive CPG consisting of 106 pages and 16 appendices, 

which contains the full range of MWD medical topics 

within one CPG. The DoD Military Working Dog Veterinary Service (DoDMWDVS) served as the MWD 

CPG proponent and the initial tasks were authored by 

the instructors from the Animal Health Branch, Department of Veterinary Science, US Army Medical Department Center and School (AMEDDC&S). The CPG 

received extensive peer review from a broad range of 

veterinary corps offi cers (VCOs), animal care specialists, and HCPs. The DoDMWDVS continues to serve 

as the proponent for the MWD CPGs. The next revision 

will be published in 2016.

The MWD CPG begins by outlining the conditions 

in which an HCP should provide emergent care to an 

MWD, namely, in the absence of veterinary personnel 

when MWD life, limb, or eyesight are at risk, and to 

prepare the dog for emergency evacuation to defi nitive 

veterinary care.6

 Healthcare providers are not authorized 

to perform routine medical, surgical, or dental care to 

MWDs without prior veterinary coordination and approval. Healthcare providers are cautioned that many 

MWDs are trained to attack and any animal that is ill or 

injured may respond to treatment with aggression. Military working dogs should always be accompanied by a 

handler. However, handlers may be killed or injured in 

combat and MWDs, injured or not, are a signifi cant risk 

when separated from a handler. If the assigned handler 

is not present, it is important to identify an alternate handler as soon as possible. The MWD CPG provides information on normal clinical parameters and includes management of a number of emergency conditions, such as 

VETERINARY CARE

*AOC indicates area of concentration (an Army designation); MOS 

indicates military occupational specialty.
April – September 2016 159

THE ARMY MEDICAL DEPARTMENT JOURNAL

airway, CPR, shock, gastric dilation volvulus, anesthesia, 

analgesia, and even humane euthanasia, to name a few.6

Healthcare providers are cautioned to only perform procedures on MWDs that fall within their clinical skill set.

ARE THE MILITARY WORKING DOG CLINICAL PRACTICE

GUIDELINES USEFUL?

Anecdotally, the MWD CPGs are very helpful in providing appropriate guidance to HCPs on managing MWD 

emergencies. However, it is unknown how many times 

HCPs have provided emergent care to MWDs. Appendix Q of the CPG mandates that providers complete an 

after-action review (AAR) within 48 hours and provide 

it to the supporting veterinary unit. This self-reporting 

either does not occur or, if it does, is not reported to the 

DoDMWDVS. As part of the MWD CPG revisions going forward, AARs should go to the Defense Trauma 

Registry, formerly Joint Theater Trauma Registry, and 

DoDMWDVS.

MILITARY WORKING DOG CLINICAL PRACTICE TRAINING

VENUES

The VCOs in theater are active in providing training 

to HCPs in MWD care. It is also common for HCPs to 

spend time in the veterinary hospital to gain experience. The AMEDDC&S Joint Forces Combat Trauma 

Management Course includes an introduction to the 

MWD CPGs. In recent years, VCOs have been invited 

to military medicine trauma symposia for MWD training. Training is always available to units, both in garrison and deployed, upon request from local or supporting veterinary units. A new development in 2015 was 

the addition of 15 MWD emergency critical tasks to the 

Critical Care Flight Paramedic (CCFP) critical task list. 

This is the fi rst time HCPs have been formally assigned 

MWD emergency tasks and it is incorporated into the 

CCFP Course.

MILITARY WORKING DOGS IN MILITARY TREATMENT

FACILITIES

Military working dogs in deployed settings are frequently treated in human medical treatment facilities (MTFs). 

This is often a necessity due to lack of veterinary facilities or existing veterinary facilities may lack needed 

equipment. The MWDs may require MTF support for 

imaging, laboratory, surgery, medical procedures, or instrument sterilization. Currently there is no DoD policy 

outlining MWD access to care in MTFs. While most 

hospitals are extremely supportive, there is often confusion and MWD access may be dependent upon case by 

case negotiation with MTF leadership or departmental 

staff. Military working dogs in garrison typically only 

require MTF access for advanced imaging modalities, 

such CT and MRI, which are beyond the scope of the 

military veterinary facilities. There are Centers for Disease Control and Prevention recommendations for animals as patients in healthcare facilities which may serve 

as a basis for a DoD policy.7

 Military working dogs are 

a crucial life-saving asset to humans serving in harm’s 

way and it is important to ensure they have MTF facility 

and equipment support when the need arises.

MILITARY WORKING DOG BLOOD MANAGEMENT IN AN

OPERATIONAL ENVIRONMENT

Management of MWD blood products differs greatly 

from the human counterpart in there is no feasible means 

to ship MWD blood components into the operational 

theater. The military logistical chain exists for coldchain shipping of human blood components, but animal 

blood products are not permitted to accompany those 

shipments. Private transport of canine blood components is too cost prohibitive to be a solution. The organic 

capability of the MDVSS only supports the collection 

and administration of fresh whole blood (FWB). Fresh 

whole blood is suitable for many clinical conditions in 

the MWD, however, there are times when fresh frozen 

plasma (FFP) or platelets are a critical need. There are 

currently no shelf stable canine blood components available that serve as a suitable substitute.

The FWB need has been reasonably met by the MDVSS 

instituting a walking blood bank and prescreening donors to be available when the need for transfusion arises. 

This obviously takes more time than would be required 

if packed RBCs were available. Previously, MWDs were 

screened for infectious disease according to the American College of Veterinary Internal Medicine guidelines 

for blood donors, which involved sending out serology 

to Germany.8

 The cost to support the laboratory analysis 

for MWDs in OIF/OEF was initially absorbed by Dog 

Center Europe, the Role 3 veterinary referral center located at Pulaski Barracks in Kaiserslautern, Germany. 

Due to fi scal constraints of the Public Health Command, 

that was no longer funded as of 2013. The MDVSS in Afghanistan could not secure funding by any other means 

for donor screening. Consequently, after 2013, MWDs 

selected for blood donors only received a limited disease screening based on point of care tests available to 

the MDVSS, putting the blood supply at greater risk for 

infectious disease. It is not known if any diseases have 

been transmitted to MWDs through this process.

The need for FFP was temporarily abated in OEF by 

use of plasma apheresis. In 2011, initial efforts began 

to develop an FFP collection and distribution program 

out of Kandahar Airfi eld (KAF). In 2012, the MDVSS obtained their own apheresis unit and it was designated for animal use only. The KAF apheresis team 
160 http://www.cs.amedd.army.mil/amedd_journal.aspx

was instrumental in helping to establish this capability in training veterinary personnel to operate the unit. 

This enabled the collection and storage of FFP at KAF 

and subsequent distribution to other veterinary sites 

throughout Afghanistan. Additionally, this apheresis 

unit was used to collect platelets when the clinical need 

occurred. This capability has been a tremendous asset 

for treating sick and injured MWDs in Afghanistan, 

however, it is an ad hoc capability that only exists in 

Afghanistan. It is not organic to the MDVSS for other 

operational environments.

At a recent Veterinary Equipment Set (VES) review 

conducted by the Capability Development Integration 

Development (formerly the Directorate for Combat Doctrine and Development) in 2015, no additional equipment or capability to support FFP collection was added 

to the set due to limitations in cost and weight of the 

VES. A plausible suggestion by the review panel was to 

establish an apheresis equipment push-package at Fort 

Sam Houston, TX, that could be shipped to a deployed 

MDVSS upon request.

CONCLUSION

In this article, several aspects of Doctrine, Organization, Training, Material, Leadership, Personnel, Facilities are relevant. The MWD CPGs pertain to doctrine 

and training. The advent of the MWD CPGs are a very 

useful tool to HCPs and this practice should continue. 

Additionally, we should maximize hands-on training 

opportunities for HCPs that are likely to encounter or 

treat MWDs. The issue of MWDs as patients in MTFs 

pertains to doctrine. Currently, there is no DoD policy 

regarding access for MWDs to MTFs. A baseline policy will ensure MWDs have appropriate access when 

needed, and that MTFs can implement proper infection control measures. Establishing the capability for 

the MDVSS to generate blood components for MWDs, 

most importantly FFP, relates to materiel. While it is not 

currently feasible to outfi t every MDVSS with apheresis 

capability, establishing a centralized push-package is a 

reasonable solution until alternate shelf-stable products 

become available.

REFERENCES

1. Giles JT. Treatment of battlefi eld injuries in the 

military working dog: initial stabilization. Veterinary Symposium. American College of Veterinary 

Surgeons 2014 Surgery Summit. Red Hook, NY: 

Curran Associates, Inc; May 2015:423-425. Available at: http://www.proceedings.com/24966.html. 

Accessed March 21, 2016.

2. Giles J. Medical evacuation of the military working dog. In: Military Veterinary Services. Borden 

Institute: Joint Base San Antonio-Ft Sam Houston, 

TX. In press.

3. Crippen L. Military working dogs: guardians of the 

night [internet]. US Army website news archives. 

May 23, 2012. Available at: http://www.army.mil/

article/56965/Military_Working_Dogs__Guard

ians_of_the_Night/?con=&dom=pscau&src=syndi

cation. Accessed September 26, 2015.

4. Field Manual 4-02: Army Health System. Washington, 

DC: US Department of the Army; August 2013:11-

2–11-5 Available at: http://armypubs.army.mil/doc

trine/DR_pubs/dr_a/pdf/fm4_02.pdf. Accessed 

March 21, 2016.

5. Joint Theater Trauma System Clinical Practice 

Guideline. Canine Resuscitation. Fort Sam Houston, 

TX: US Army Institute of Surgical Research; April 

18, 2011. Available at: http://usaisr.amedd.army.

mil/cpgs/Canine_Resuscitation_18_Apr_2011.pdf. 

Accessed September 26, 2015.

6. Joint Theater Trauma System Clinical Practice 

Guideline. Clinical Management of Military Working Dogs. Fort Sam Houston, TX: US Army Institute of Surgical Research; March 12, 2012. Available at: http://usaisr.amedd.army.mil/cpgs/Clini

cal_Mgmt_of_Military_Working_Dogs_Com

bined_19_Mar_12.pdf. Accessed September 26, 

2015.

7. Schulster L, Chinn RYW. Guidelines for environmental infection control in health-care facilities. 

Recommendation of CDC and Healthcare Infection 

Control Practices Advisory Committee (HICPAC). 

MMWR. 2003;52(RR-10):28-30. Available at: http://

stacks.cdc.gov/view/cdc/32395. Accessed March 

21, 2016.

8. Wardrop KJ, Reine N, Birkenheuer A, et al. Canine 

and Feline Blood Donor Screening for Infectious 

Disease. J Vet Intern Med. 2005;19(1):135-142.

AUTHOR

LTC Giles is Chief of Surgery, DoD Military Working 

Dog Veterinary Service, Joint Base San Antonio-Lackland Air Force Base, Texas.

VETERINARY CARE
April – September 2016 161

In the deployed environment, the prevention, identifi cation, and response to communicable disease threats play 

a critical role in maintaining combat power. The recent 

wartime experiences in Iraq and Afghanistan provide 

no shortage of lessons learned in all of these areas of 

operational public health. Here we will focus on the prevention of and response to select infectious diseases of 

public health importance in the deployed environment. 

The lessons learned from these events fall into key areas of disease prevention and control, disease reporting, 

medical threat assessment, and risk communication. 

The topics chosen for discussion address lessons learned 

from multiple focus areas.

IMMUNIZATION

Military science is a powerful force multiplier on the 

battlefi eld. Immunization, for example, has been a 

staple of deployment readiness since General George 

Washington ordered variolation against smallpox for 

the Continental Army in 1777.1

 A shining example of 

the application of military vaccine science to the battlefi eld is the Hepatitis A vaccine. Hepatitis A has a long 

history of negatively impacting deployed forces. A successful partnership between the Walter Reed Army 

Institute of Research and SmithKline brought the fi rst 

hepatitis A vaccine to Federal Drug Administration approval in 1995.2

 In the absence of this immunization, 

military operations in Southwest Asia would have been 

at high risk for hepatitis A infection. According to the 

National Center for Medical Intelligence, hepatitis A 

virus poses a year round, high operational risk to nonimmunized forces.* Despite this endemic disease threat, 

there were no evacuations of US service members for 

hepatitis A infection in Operations Iraqi Freedom (OIF) 

or Enduring Freedom (OEF). This was not the case for 

other coalition partners who reported hepatitis A infection leading to lost duty time.3

 The lesson learned is that 

military science is important for disease prevention on 

the battlefi eld. Hepatitis A vaccine would not have come 

to market without the efforts of military scientists. Research and development of vaccines, medications, and 

military specifi c health programs are critical for force 

health protection.

Smallpox vaccine in the recent confl icts provides lessons in threat assessment and vaccine adverse event 

reporting. During the recent confl icts, approximately 

175,000 service members were immunized annually 

with the current smallpox vaccine.4

 The occurrence of 

Select Public Health and Communicable

 Disease Lessons Learned During Operations

 Iraqi Freedom and Enduring Freedom

 LTC Eric C. Garges, MC, USA

 MAJ Kevin M. Taylor, MC, USA

 LTC Laura A. Pacha, MC, USA

ABSTRACT

History has taught us that the threat of communicable diseases to operational readiness should not be underestimated. The unique operational challenges of a decade at war in Southwest Asia have left us with many new 

lessons about prevention and mitigation of disease. The successes of military immunization programs demonstrated the successful application of military science to modern combat. Historic maladies such as tuberculosis 

and malaria continue to challenge our Army health leadership while new challenges with diseases like Q fever 

and rabies led to questions about our preparedness. These confl icts also brought awareness of issues about the 

broader deployed community, and the often unique risks that arise when US service members interact more 

frequently with foreign militaries, local nationals, and third country nationals. Application of these lessons to 

predeployment training and integration into leadership decision-making will improve our ability to maintain 

force readiness in future confl icts and adapt Army policy to current evidence and intelligence.

*Internal military document not accessible by the general public.

PUBLIC HEALTH CHALLENGES
162 http://www.cs.amedd.army.mil/amedd_journal.aspx

myocardial signs and symptoms secondary to the vaccine were well described in the literature with a reported 

incidence of 1% to 3%.5

 As increasing numbers of service members received vaccination, case reports of myocarditis and pericarditis increased, leading to a prospective study of the use of smallpox vaccine in the deploying population.6

 This work demonstrated an incidence of 

myocardial effects at a rate much higher than previously 

reported (10%). Of note, there was no mortality reported due to myocardial or pericardial effects of smallpox 

vaccine use, but the overall effect on medical readiness 

due to unrecognized vaccine side effects could be signifi cant, given the number of doses administered. As the 

largest user of smallpox vaccine, the DoD has the responsibility to monitor vaccine safety and make recommendations on future use. The identifi cation of higher 

rates of cardiac effects will lead to improved screening 

of cardiopulmonary risk factors for those receiving the 

vaccine. The question as to whether smallpox was ever 

a credible threat on the battlefi eld is debatable. However, 

the time, expense, and high rate of adverse events from 

smallpox immunization demonstrates a lesson that careful and deliberate risk assessment must be used for force 

health protection vaccination.

SELECT INFECTIONS OF PUBLIC HEALTH IMPORTANCE

Rabies

In 2011, a Soldier died after contracting rabies from 

a presumed dog bite in Afghanistan, the fi rst rabies 

death in a service member since 1974.7,8 Rabies prevalence among feral dogs and cats was known to be high 

throughout much of Afghanistan.* Despite instructions contained in US Central Command (CENTCOM), 

General Order 01.C, prohibiting the harboring of pets 

or mascots while in theater, it was not uncommon for 

service members to keep dogs or cats as companion 

animals. In addition, risk was assumed in some situations when local dogs were used as sentries in remote 

outposts and forward operating bases, or when service 

members were collocated with Afghan police or military units that used canines for such purposes. Anecdotal reports from Soldiers in theater also suggested that 

some combat stress control offi cers implied that having 

pets or mascots was a benefi cial form of stress relief and 

that commanders may have tolerated animal presence 

for morale and protection purposes. Regardless of the 

reasons behind such frequent interaction with feral animals, the death of a service member due to rabies made 

it clear that the risk from this highly lethal infection was 

largely underappreciated among service members and 

their supporting medical providers, perhaps due to the 

rarity of animal-to-human rabies transmission in the 

United States or a lack of knowledge about the endemic 

risk in Afghanistan. Nevertheless, emphasis on prevention of exposure must continue to be a priority. Theater 

directives prohibiting the harboring of pets and mascots 

remain essential and commanders must ensure compliance though good order and discipline. When operational requirements place personnel at higher risk, service 

members must be aware of appropriate management of 

potential exposures, including immediate wound irrigation and medical evaluation. Medical providers must be 

fully trained on conducting a rabies exposure assessment. This is necessary both in operational setting and 

the postdeployment setting, as the inclusion of questions 

specifi c to rabies risk in the Postdeployment Health Assessment has increased the ability to detect possible exposures following deployment.

Malaria

Malaria is another infection with a historic effect on 

military operations. The literature is replete with case 

reports and epidemiologic studies defi ning the negative 

impact of malaria on combat operations. It was therefore appropriate that the military health leadership took 

a conservative approach to malaria prevention in Iraq. 

Initial prevention policy included 100% chemoprophylaxis at all times in both theaters of operations in the 

early stages of the Iraq and Afghanistan confl icts. Doxycycline was chosen primarily as it was also being carried as a chemoprophylactic for anthrax. Early negative 

experiences with this medication due to altitude and sun 

exposure in Afghanistan led to a curtailment of its use. 

The medical threat from malaria in Iraq was known to 

be limited. Saddam Hussain’s draining of the swampy 

areas in Iraq had nearly eliminated the threat. Malaria 

in Afghanistan was focal and limited to well-defi ned 

areas. To complicate the picture, there was no standardized regimen for chemoprophylaxis across the services 

in the early years of the confl icts, which led to confusion, misunderstanding, or mistrust among unit providers, service members, and commanders. Chemoprophylaxis itself was suboptimal, as the medications available 

at the outset of combat operations, doxycycline hyclate 

and mefl oquine, both have signifi cant adverse effect 

profi les. Issues of noncompliance and adverse effects 

are well documented in the medical literature.9-12 In Iraq, 

this led to an under-appreciation of malaria chemoprophylaxis as a Marine unit went from Iraq (very low 

risk) to Liberia (very high risk) and, in the absence of 

compliance with chemoprophylaxis, incurred 80 cases 

of falciparum malaria, leading to multiple hospital ICU 

admissions and an estimated cost of $1.2 million to the 

Military Health System (MHS).13

*Internal military document not accessible by the general public.

PUBLIC HEALTH CHALLENGES
April – September 2016 163

THE ARMY MEDICAL DEPARTMENT JOURNAL

By 2006, malaria chemoprophylaxis was removed 

from the OIF force protection plan, but cases of Plasmodium vivax malaria began to accumulate from OEF. 

Although vivax malaria poses a readiness threat to deployed forces, the low mortality and absence of drug 

resistance cloud the direct threat of malaria as a mortal 

risk to Soldiers deployed to Afghanistan, particularly 

considering the 30% prevalence of adverse effects from 

chemoprophylaxis.12

Mefl oquine was removed as a primary chemoprophylactic medication primarily due to concern for the ability 

to adequately screen all service members for behavioral 

health contraindications.14,15 Fortunately, combination 

atovaquone/proguanil (Malarone) became readily available for use as primary chemoprophylaxis during that 

same time period. The low adverse effect profi le of 

atovaquone/proguanil would improve compliance with 

chemoprophylaxis across the MHS.16

Multiple lessons were learned with malaria during OIF/

OEF. Unfortunately, many of these lessons were in fact 

relearned from previous engagements, such as the notion that compliance with chemoprophylaxis depends 

largely on command emphasis. A new lesson learned 

is that being overly risk averse may negatively effect 

readiness. Better and faster translation of medical intelligence data into deployment policy and the ability 

to apply malaria prophylaxis policies below the theater 

level may have reduced both malaria infection and the 

adverse effects of chemoprophylactic medications on 

the battlefi eld. Other malaria lessons including the use 

of rapid diagnostic tests, empiric therapy, permethrintreated uniforms, and public health surveillance are all 

equally important, and will be captured in later articles.

Tuberculosis/Latent Tuberculosis Infection

Rates of active tuberculosis (TB) transmission are high 

among civilian populations in both Iraq and Afghanistan. Based on this, initial force health protection measures included pre- and postdeployment placement of TB 

skin tests (TST) in order to identify deployment-related 

latent TB infection. However, the realized infection risk 

among US service members during OIF/OEF was quite 

low. The use of TSTs in low risk populations inevitably 

results in a large number of false positive cases. In addition, improper placement and interpretation of TSTs and 

variability in the biologic products used can contribute to 

false readings. These factors led to a number of pseudooutbreaks of TB in which signifi cant proportions of redeploying units were misidentifi ed as being infected with 

Mycobacterium tuberculosis.

17 In reality, despite tens of 

millions of contact hours with local civilians in these 

countries, very few cases of active TB attributable to exposure in theater were identifi ed. As the wars progressed, 

the use of risk stratifi cation to conduct targeted testing 

on only those at high risk was recognized as a more appropriate approach.18 While this reduced the amount of 

postdeployment TB testing, returning service members 

were still frequently misclassifi ed as high risk, resulting 

in continued testing within a recognized low risk population. MEDCOM policy eventually removed TB risk assessment from the Postdeployment Health Assessment, 

which proved critical in reducing the over-diagnosis and 

treatment of those deployed to CENTCOM areas of operation. This evolving policy highlights a misconception 

and a key lesson learned about tuberculosis in the operational setting. While this highly prevalent and contagious disease must always be a consideration, deployment to a country with high rates of TB on its own does 

not necessarily place service members at signifi cant risk 

of infection. Overestimation of TB risk has notable consequences, resulting in unnecessary testing and treatment. While the adage of “a decision to test is a decision 

to treat” still holds true, the decision of whom to test 

clearly remains the more critical and diffi cult decision.

Human Immunodeficiency Virus

Human immunodefi ciency virus (HIV) has been of limited risk to Soldiers in theater because of the systematic screening process in garrison and predeployment 

screening requirements. However, in 2006 and 2007 

Army public health offi cers became aware of an increasing number of cases of HIV diagnosed on the postdeployment HIV screening test. An investigation conducted by the Military HIV Research Program and the Army 

Public Health Command revealed most of the infections 

were acquired in the predeployment window between 

the required predeployment screening test and the actual 

deployment. Other cases were acquired during mid-tour 

leave or immediately postdeployment. Most importantly, 

no infections were due to exposure within CENTCOM, 

including through the use of blood products in theater, 

particularly the battlefi eld blood supply (walking blood 

bank).19 The investigation of the HIV cluster revealed a 

gap in the screening process that led to deployment of 

HIV-infected service members. Shortening the predeployment screening window did not eliminate but did 

signifi cantly decrease the risk of deploying HIV-infected 

service members. There are a few lessons learned from 

the HIV cluster. First, predeployment screening programs should consider the biology of the disease process. 

Given that at the time HIV testing was dependent on a 

positive ELISA test, and tests could have been conducted 

one year before deployment, exposures up to 14 months 

prior to deployment could have led to deployment with 
164 http://www.cs.amedd.army.mil/amedd_journal.aspx

HIV. In addition, this study suggests an increase in STD 

risk activity in the predeployment period. This may be 

a target for risk reduction counseling. Finally, although 

the assumption is made that no service members with 

HIV deploy into the operational environment, we know 

this to not be true. There are, and will continue to be, 

pathways by which HIV-infected Soldiers end up on the 

battlefi eld. Healthcare providers at all levels should keep 

this in mind in the care they provide in theater.

Q Fever

Coxiella burnetti infection, also known as Q fever, was 

another communicable disease that should have received 

greater predeployment consideration. Both Iraq and Afghanistan are countries with documented endemic Q 

fever risk. Exposure to this zoonotic pathogen typically 

occurs through the ingestion or inhalation of soil or dust 

contaminated by the body fl uids of infected livestock. 

With many service members operating in agricultural 

regions, often in conditions that predispose to dust inhalation such as helicopter rotor wash, exposure for some 

was conceivable. Q fever fi rst came to the attention of 

public health offi cials during an outbreak investigation of 

severe pneumonia in service members deployed to Iraq 

in 2003-2004.20 Diagnosis of Q fever is challenging in 

the operational setting, as symptoms of acute infection 

are often nonspecifi c and diagnostic tests are typically 

not considered or are not readily available. While acute 

infection usually resolves spontaneously, there is a risk 

of chronic infection, which threatens those who remain 

undiagnosed. Recognition of Q fever in deployed service 

members led to the development of new military practice 

guidelines, which subsequently informed new national 

guidelines published by the US Centers for Disease Control and Prevention.21,22 The work of clinicians and public 

health offi cers led to the identifi cation of over 150 cases of 

Q fever exposure in service members. Fortunately, there 

have been no cases of severe outcomes from chronic Q 

fever in US service members to date. The lesson learned 

with Q fever is that laboratory-based surveillance can 

play an important role in identifying endemic disease in 

deployed service members. However, it can only be useful if medical providers are aware of the endemic disease 

risks and have the appropriate tests available to make a 

diagnosis. Current and accurate infectious disease risk 

assessments are essential for guiding public health efforts, but they are equally important for training medical 

providers predeployment and identifying key diagnostic 

capabilities to be made available in theater.

Leishmaniasis

The early OIF experiences with leishmaniasis were well 

documented in the medical literature as well as in the 

lay press. Environmental exposure to the sandfl y vector 

in Iraq led to over 800 cases of cutaneous leishmaniasis. 

The Army Medical Department (AMEDD) struggled 

with how to manage these cases, including questions 

about evacuation, treatment, and long-term care. Despite cutaneous disease having few long-term adverse 

health outcomes, the large number of initial cases in service members, treatment diffi culties, and media attention strained the MHS. Delayed diagnosis, delayed treatment, lack of approved diagnostics and treatments in 

theater led to hundreds of evacuations and lengthy treatments with a toxic investigational new drug (IND).23,24

The notable rise and fall of leishmaniasis cases among 

US service members early in OIF contributed to a new 

understanding about how environmental changes in the 

operational setting can signifi cantly alter the ecology 

of this disease. As US Forces entered the country, new 

construction and human traffi c likely contributed to a 

disruption of sand fl y habitats, exposing a large population of immunologically naïve service members. However, the trend soon reversed as the maturing theater of 

operations resulted in more hardened structures and air 

conditioned lodging for those deployed to the region, 

reducing their level of exposure. The experience with 

leishmaniasis in OIF also changed the clinical management of cases in the deployed setting. While early cases 

were often medically evacuated for treatment, it became 

clear that conservative management of mild cases, often 

with a “watch and wait” approach, was a reasonable alternative that allowed many service members to remain 

in theater with minimal effect on long-term morbidity.

Surveillance

Given the direct relationship between health and operational readiness, accurate and timely information about 

disease and injury (D&I) data is critical to medical planners as well as commanders. Signifi cant challenges were 

met as attempts were made to automate the collection of 

surveillance data. Assumptions about the use of electronic health records, training of medical providers, lack 

of appropriate denominator data, and bandwidth limitations posed an insurmountable barrier to systematic 

accurate D&I data collection in theater. Data such as 

hospital admissions or medical and casualty evacuation 

data became commonplace in reporting of D&I rates by 

leadership. Although easy to calculate, these metrics had 

limited scope and are neither useful nor actionable at the 

operational level. As each theater matured and medical 

care moved into brick and mortar structures at all levels of care, electronic health systems allowed for better 

capture of medical event data. However, these were still 

plagued by the lack of population data that would allow for the determination of rates of disease and injury. 

PUBLIC HEALTH CHALLENGES
April – September 2016 165

THE ARMY MEDICAL DEPARTMENT JOURNAL

Lack of training at the Role I level on basic collection 

of health surveillance data in the absence of electronic 

systems left a gap in our knowledge of the disease and 

injury picture from the earlier years of both confl icts. In 

the same way that Soldiers learn basic land navigation in 

the era of the GPS, operational medical providers should 

learn the importance of data collection and reporting in 

the absence of automated systems to monitor the health 

of the deployed force.

THE DEPLOYMENT COMMUNITY

The individuals and organizations that interact with 

the Warfi ghter in theater make up the deployment community. While much effort is placed on the reduction 

of communicable disease among service members and 

other US government personnel, as the theater of operations matures, greater numbers of local nationals, 

contractors, and third country nationals become an integral part of the deployment occupational environment. 

In the same way that disease surveillance, prevention, 

and response are important for force health protection, 

the same issues within the non-DoD members of the 

deployment community are important given the close 

interactions with deployed forces and other US government personnel. As contracts were put in place to 

hire local nationals to work on US forward operating 

bases, issues of occupational health screening became 

apparent. Third country nationals and other contractors 

may have had organic medical care available, but the 

extent of that care, the sharing of public health data, or 

the capacity to respond to communicable disease was 

unclear to Army public health offi cers in theater. Army 

preventive medicine physicians assisted with outbreaks 

or evaluations for disease clusters among contractors for 

suspected tuberculosis, varicella, meningitis, and acute 

diarrheal disease. The different interacting populations 

with disconnected medical oversight created challenges 

in the surveillance of diseases. The lesson learned is 

consideration must be made for the deployment community as a whole. Occupational health controls and 

disease surveillance must be ensured for all personnel 

working with or in proximity to US forces as a matter of 

force health protection.

INTEGRATION OF LESSONS LEARNED

Most of the lessons cited here are related to DOTMLPF* 

areas of leadership and training. Decisions about investing or maintaining military science, adherence to or 

command support for prevention policy, and appropriate use of risk assessments are all themes repeated in 

the above lessons learned. There is no doubt that Army 

leaders understand the connection between readiness 

and disease prevention, but leaders must enforce prevention policy and the associated health behaviors in 

the deployed force. Additionally, leaders at all levels 

must use the appropriate resources, including preventive medicine assets at all levels, to make informed decisions about health risk and engage Army technical 

experts where such expertise exists. Army deployment 

policy should be based on solid medical evidence and 

intelligence. Finally, leaders must have the fl exibility to 

adapt to the changing operational environment.

Training opportunities include training for all levels 

of medical providers in endemic disease risk as highlighted by the above discussion of rabies, malaria, and 

Q fever. Training medics and medical commanders on 

basic disease surveillance procedures while in garrison 

would greatly reduce the surveillance gap that we face 

during initial phases of deployment.

The Army doctrine related to many of these public health 

issues is valid, but the application on the battlefi eld is 

often diffi cult. As the Army moves forward towards 

AMEDD 2025 to support a force that is leaner, more 

effi cient, and more integrated, commanders cannot presume that technology and medical advances will render 

basic military preventive medicine obsolete. The basic 

tenants of preventive medicine, including fi eld sanitation, 

disease surveillance, and reporting, risk communication, 

and health risk assessment will continue to be critical to 

mission success. The Army must continue to fi eld a combat force that can identify and prevent or mitigate the 

effect of disease and injury on deployed forces. When 

applied correctly, Army doctrine can achieve just that.

REFERENCES

1. Artenstein AW, Opal JM, Opal SM, Tramont EC, 

Peter G, Russell PK. History of US military contributions to the study of vaccines against infectious 

diseases. Mil Med. 2005;170(suppl 4):3-11.

2. Hoke CH Jr, Binn LN, Egan JE, et al. Hepatitis A in 

the US Army: epidemiology and vaccine development. Vaccine. 1992;10(suppl 1):S75-S79.

3. Green CA, Ross DA, Bailey MS. Acute hepatitis 

A virus infections in British Gurkha soldiers. J R 

Army Med Corps. 2013;159:240-242.

4. Montgomery JR, Engler R, Allan-Martinez 

F, Morse A, Duran L. Case report: chest pain in 

service members following smallpox vaccination. 

MSMR. 2012;19:6-7.

5. Halsell JS, Riddle JR, Atwood JE, et al. Myopericarditis following smallpox vaccination among 

vaccinia-naive US military personnel. JAMA. 

*Doctrine, organization, training, material, leadership, personnel, 2003;289(24):3283-3289.

and facilities.
166 http://www.cs.amedd.army.mil/amedd_journal.aspx

6. Engler RJ, Nelson MR, Collins LC Jr, et al. A prospective study of the incidence of myocarditis/pericarditis and new onset cardiac symptoms following smallpox and infl uenza vaccination. PLoS One. 

2015;10(3):eCollection 2015.

7. Fester JM. Public health aspects of rabies. Aviat 

Space Environ Med. 1975;46:1194-1195.

8. US Centers for Disease Control and Prevention. 

Imported human rabies in a U.S. Army soldierNew York, 2011. MMWR. 2012;61:302-305.

9. Saunders D, Garges E, Kosmowski A, et al. Doxycycline hyclate tolerability and compliance as daily 

oral malaria prophylaxis in fi eld conditions: experience of the 10th Mountain Division (LI), OEF VII 

[abstract]. American Journal of Tropical Medicine 

and Hygiene. Abstract 1008 (page 288). Available 

at: https://www.astmh.org/ASTMH/media/Docu

ments/pages_250-299.pdf. Accessed March 22, 

2016.

10. Brisson P, Woll M, Brisson M. Improving compliance with malaria chemoprophylaxis in Afghanistan. Mil Med. 2012;177:1539-1542.

11. Kotwal RS, Wenzel RB, Sterling RA, Porter WD, 

Jordan NN, Petruccelli BP. An outbreak of malaria 

in US Army Rangers returning from Afghanistan. 

JAMA. 2005;293:212-216.

12. Saunders DL, Garges E, Manning JE, et al. Safety, tolerability, and compliance with long-term 

antimalarial chemoprophylaxis in American 

Soldiers in Afghanistan. Am J Trop Med Hyg. 

2015;93(3):584-590.

13. Whitman TJ, Coyne PE, Magill AJ, et al. An outbreak of Plasmodium falciparum malaria in U.S. 

Marines deployed to Liberia. Am J Trop Med Hyg. 

2010;83(2):258-265.

14. Nevin RL. Low validity of self-report in identifying recent mental health diagnosis among U.S. service members completing Pre-Deployment Health 

Assessment (PreDHA) and deployed to Afghanistan, 2007: a retrospective cohort study. BMC Public Health. 2009;9:376.

15. Nevin RL, Pietrusiak PP, Caci JB. Prevalence of 

contraindications to mefl oquine use among USA 

military personnel deployed to Afghanistan. Malar 

J. 2008;7:30.

16. Kersgard CM, Hickey PW. Adult malaria chemoprophylaxis prescribing patterns in the military 

health system from 2007-2011. Am J Trop Med Hyg. 

2013;89:317-325.

17. Mancuso JD, Tobler SK, Keep LW. Pseudoepidemics of tuberculin skin test conversions in the U.S. 

Army after recent deployments. Am J Respir Crit 

Care Med. 2008;177:1285-1289.

18. Sanchez JL, Sanchez JL, Cooper MJ, Hiser MJ, 

Mancuso JD. Tuberculosis as a Force Health Protection Threat to the United States Military. Mil 

Med. 2015;180(3):276-284.

19. Scott PT, Hakre S, Myles O, et al. Short communication: investigation of incident HIV infections 

among U.S. Army soldiers deployed to Afghanistan and Iraq, 2001-2007. AIDS Res Hum Retroviruses. 2012;28(10):1308-1312.

20. Shorr AF, Scoville SL, Cersovsky SB, et al. 

Acute eosinophilic pneumonia among U.S. military personnel deployed in or near Iraq. JAMA. 

2004;292:2997-3005.

21. Hartzell JD, Gleeson T, Scoville S, Massung RF, 

Wortmann G, Martin GJ. Practice guidelines for 

the diagnosis and management of patients with Q 

fever by the Armed Forces Infectious Diseases Society. Mil Med. 2012;177:484-494.

22. Anderson A, Bijlmer H, Fournier PE, et al. Diagnosis and management of Q fever - United States, 

2013: recommendations from CDC and the Q 

Fever Working Group. MMWR Recomm Rep. 

2013;62(RR-03):1-30.

23. Weina PJ, Neafi e RC, Wortmann G, Polhemus M, 

Aronson NE. Old world leishmaniasis: an emerging 

infection among deployed U.S. military and civilian workers. Clin Infect Dis. 2004;39:1674-1680.

24. Aronson NE, Sanders JW, Moran KA. In harm’s 

way: infections in deployed American military 

forces. Clin Infect Dis. 2006;43:1045-1051.

AUTHORS

LTC Garges is Director, Preventive Medicine Residency Program, US Army Public Health Center, Aberdeen 

Proving Ground, Maryland.

MAJ Taylor is Associate Director, Preventive Medicine 

Residency Program, US Army Public Health Center, Aberdeen Proving Ground, Maryland.

LTC Pacha is Director, Epidemiology and Disease 

Surveillance Portfolio, US Army Public Health Center, 

Aberdeen Proving Ground, Maryland.

PUBLIC HEALTH CHALLENGES
April – September 2016 167

THE SHADOW OF WAR

A legacy of 1990-1991 Operation Desert Shield/Desert 

Storm (DS/DS) was the realization that the public health 

toll of a military confl ict is not known at the time of 

redeployment. Beyond combat-related deaths or injuries 

and disease nonbattle injury (DNBI) that occur during 

the confl ict, concerns regarding delayed health effects 

resulting from environmental exposures may extend the 

medical mission for years after the confl ict has ended. 

The operation was considered a victory with the surprisingly low total of 145 service members dying in combat 

and 225 lives claimed by nonhostile actions.1

 Nonetheless, over 60,000 individuals eventually sought an evaluation as part of registry programs open to DS/DS veterans and their families.2,3 Widespread somatic symptoms 

such as pain, fatigue, rashes, and cognitive defi cits were 

raised with concerns about their relationship to environmental exposures. Multiple expert boards and committees reviewed health consequences of service in the 

Gulf; none were able to defi ne the medical nature and 

cause or causes of a “Persian Gulf War Syndrome,” nor 

identify any cause and effect relationships between putative exposures and undefi ned illness.1,3,4 The Institute 

of Medicine (IOM) and the Presidential Advisory Committee noted that registries established by Department 

of Defense (DoD) and the Veterans Administration 

(VA) to provide free medical evaluation to concerned 

Persian Gulf War veterans were not designed to answer 

epidemiological questions. Furthermore, available scientifi c evidence did not support a causal link between 

the symptoms/illnesses reported and exposures while 

in the Gulf to oil well fi res, smoke, petroleum products, 

pesticides, chemical warfare agents, biological warfare 

agents, immunizations, pyridostigmine bromide, infectious diseases, or depleted uranium. However, the 

investigation of possible exposures of troops was considered “superfi cial and inadequate.” 1

 It was noted that 

very little personalized exposure information was available, thus it would be extremely diffi cult to defi ne relevant control groups and obtain data for them. The lack 

of exposure data limited even the most expert and wellfunded investigation to identify health outcomes linked 

to specifi c exposures or risk factors.4

 The General Accounting Offi ce stated that:

Without accurate exposure information, the investment 

of millions of dollars in further epidemiological research 

on the risk factors or potential causes for veterans’ illnesses may result in little return.5

The IOM noted that the victory in the Gulf was overshadowed by questions regarding long-term health and 

exposures that were known or possible for the deployed.3

This understanding is the primary public health legacy 

of DS/DS, and resulted in the 2000 Institute of Medicine report, Protecting Those Who Serve: Strategies to 

Protect the Health of Deployed U.S. Forces 6

 with recommended improvements.

DEPLOYMENT EXPOSURE ASSESSMENT

Presidential Review Directive 5 published in 1998 by the 

Clinton administration called protection of the health of 

our service members while deployed a “national obligation.” 7

 It directed DoD to:

...identify and minimize or eliminate the short and longterm health effects of military service, especially during 

deployments (including war) on the physical and mental 

health of veterans.

The IOM responded and recommended strategies to protect those who serve, including environmental exposure 

Deployment Exposures and Long-term

 Health Risks: The Shadow of War

 Coleen Baird, MD, MPH

ABSTRACT

The victory in Operations Desert Shield/Desert Storm has been “shadowed” by long-term health concerns 

among returning troops. During Operations Iraqi Freedom, New Dawn, and Enduring Freedom, the Department of the Army and Department of Defense implemented recommendations of the Institute of Medicine 

relating to environmental exposure assessment, hazard response, documentation of exposures, and risk assessment using environmental sampling data to evaluate potential health risks among deployed troops. Recommendations regarding risk communication proved more diffi cult to implement, however. Exposure to particulate 

matter and airborne hazards including burn pit emissions and chemical warfare agents have received attention 

from service members, the media, and in some cases, Congress. A combination of lack of clear and consistent 

messages, imperfect and sometimes seemingly contradictory science, and strong perceptions suggest that questions related to these exposures and their potential long-term health effects will persist.
168 http://www.cs.amedd.army.mil/amedd_journal.aspx

assessments in deployment locations.6 They noted that 

the spectrum of health concerns was broadening from 

acute illness and injury due to pathogens and accidents 

to possible infl uences of low-level chemical exposures 

which can manifest in chronic illnesses years later. 

The IOM also noted that a useful management scheme 

must address all the threats that deployed forces face, 

so integration is particularly needed. In addition, “risk 

information must be presented in a way that permits 

rapid decisions to be made by fi eld commanders with 

little pertinent expertise.” 6

 Necessary to this process are 

clear guidelines appropriate for deployed forces; a way 

to assess risk that takes into account competing risks 

and mission requirements. In addition, risk communication must occur on the ground. Sampling is conducted 

to answer questions, and those who are affected typically want to know the answers or they may draw their 

own conclusions. While the desire to disseminate all 

relevant exposure information to the affected group is 

strong, it is important to deliver it in an understandable 

way that causes neither unwarranted concern nor undue 

complacency.

Assessing acute risk is fairly straightforward, and 

the military developed both acute exposure guidelines 

and those considered protective for a one-year exposure 

for lower but continuous exposures.8

 “Dose” relates to 

the magnitude, duration, and frequency of exposure. 

During deployment, exposure concentrations may be 

variable over time. Some may be for a short period but 

at levels high enough to immediately affect health or 

even degrade the mission. Regarding lower concentrations and long-term health effects: concentrations above 

the long-term guidelines do not necessarily pose longterm risk if the levels are intermittent. However, there is 

rarely suffi cient monitoring information to assess levels 

over time in dynamic locations since sampling episodes 

are brief. Therefore, health risk associated with these 

intermittent exposures is almost always uncertain and 

rarely actionable, unless the action is to conduct more 

sampling. This can be frustrating for preventive medicine personnel and for commanders who have to choose 

among courses of action. The risk matrix for operational 

risk management classifi es risk in a table as green, amber, red, and black as the risk increases.8

 Gray (unclear 

results) is not in the matrix. While the IOM recommended risk communication down to the level of those 

exposed, the lack of clear risk and clear messages at this 

level interfered with this goal. In many cases, sampling 

was done at a unit level, but sent out of country for analysis. In most cases, a clear interpretation of the results 

was not available at the unit level, leaving the opportunity for inconsistent messages. According to the IOM, the 

acknowledgement of uncertainty does not erode trust 

and confi dence in leaders; instead, it fosters confi dence 

in the reliability of the information deemed to be more 

certain and valid.6

EXPOSURE TO AIRBORNE HAZARDS

Early into Operations Iraqi Freedom and New Dawn 

(OIF/OND), it was recognized that particulate matter (PM) was likely to be a ubiquitous hazard.9

 Shamal 

winds cause dust storms, and daily windblown dust, diesel exhaust, local pollution, and open burning were potential additional sources. It had been demonstrated that 

PM2.5 levels (representing the respirable fraction of PM) 

in the region had been measured at twice the US National Ambient Air Quality Standards. Exposure to PM 

affects the health of children, the elderly, and those with 

cardiopulmonary disease. The risk of various adverse 

health outcomes increases with exposure concentration, 

and there is little evidence of a threshold below which 

no adverse health effects are expected.9

 The nature and 

probability of health effects are also dependent upon 

the size fraction, chemical composition, and the duration of exposure. In short, health effects were plausible, 

but there was a paucity of information as to the health 

effects of Southwest Asia (SWA) PM on a relatively 

young and healthy population. On the basis of concerns 

about the potential health effects, US Central Command 

(CENTCOM) approval was obtained to design and implement sampling to characterize and quantify the PM 

in the ambient environment at 15 deployment sites.10

While the sampling effort was remarkably successful 

given that the every sixth-day schedule was conducted 

at 15 sites and generated much information, it was diffi -

cult to tie the results to health effects. One epidemiological effort was a case-crossover study to evaluate the association between daily average PM2.5 and PM10 concentrations at the 15 sites and acute cardiovascular and respiratory medical visits.11 Results were limited because 

the study lacked statistical power due to the paucity of 

health-outcome events, and since those that occurred 

were not always associated with a sampling day. Another used a retrospective cohort design to examine the 

association between time-weighted average PM2.5 and 

PM10 concentration and postdeployment cardiovascular 

or respiratory diagnoses in cohorts defi ned by deployment location.12 No increased diagnoses rates with higher PM was found after adjustment for many confounding 

variables. The data were limited by potential exposure 

and outcome misclassifi cation and by a relatively short 

follow-up period after deployment. In addition, it was 

recognized that base camps differ in other sources of 

potential airborne hazards such as industrial pollution, 

vehicles and fuel exposures, trash burning, and other 

individual contributions to respiratory or other effects. 

PUBLIC HEALTH CHALLENGES
April – September 2016 169

THE ARMY MEDICAL DEPARTMENT JOURNAL

The Committee on Toxicology of the National Research 

Council reviewed the available sampling information 

and studies and concluded that it is indeed plausible that 

exposure to ambient PM in SWA is associated with adverse acute and chronic health effects.10 However, the 

question of whether this was occurring remained. Later 

publications have looked at trends in respiratory conditions in the Army.13,14 Others have demonstrated increases in symptoms and small increases in respiratory 

conditions postdeployment, particularly asthma. Those 

studies included comparisons such as those exposed to 

a sulfur mine fi re (Mishraq), locations with high background pollution (Kabul), and locations with and without open trash burning.15-17 Postdeployment respiratory 

effects of airborne hazards continue to be studied and 

are the subject of a recently published book.18

BURN PIT EMISSIONS

Once the perception of a health hazard exists, it is diffi cult to reassure individuals that the risk is low. Characterization of the deployed environment and health 

concerns of those deploying should be used to develop 

force protection measures and risk communication tools. 

Joint Base Balad (JBB) was one of the largest air bases 

in Iraq and was home at one point to 25,000 military, 

civilian and coalition personnel. Since 2003, burn pits 

or areas designated for burning trash were used to facilitate solid waste disposal at Balad.19 In the absence 

of a waste disposal infrastructure, the options for expedient disposal of trash in operational environments are 

burial, incineration, or a combination of the two. Tactical security considerations often limited the options to 

incineration as it did at JBB.20 Wind roses constructed 

by the Air Force 14th Weather Squadron demonstrated 

that prevailing winds carried smoke away from locations where personnel were located. However, black 

smoke was often visible rising from the burn site. Under 

some weather conditions, such as low winds and inversions, the smoke from the burn pit lingered over areas 

of the base, generating complaints and health concerns 

amongst service members from 2003 until open burning ceased in 2009. Air sampling conducted from summer 2004 to summer 2006 demonstrated the occasional 

presence of volatile organic compounds and polycyclic 

aromatic hydrocarbons and dioxins, all of which may 

be associated with the open burning of trash.19 The potential health risk was estimated to be low, based on the 

limited detections in the small number of samples, but a 

more formal sampling plan was jointly developed. Four 

rounds of air sampling were completed; Spring and Fall 

2007, Spring 2009, and Spring 2010. These air sampling 

efforts coincided with the introduction of initiatives to 

reduce exposure to burn pit smoke. Primary measures 

included the installation and operation of 4 solid waste 

incinerators and the start of a program to segregate 

waste, with emphasis on the elimination of plastic water 

bottles from the waste stream. Two incinerators became 

operational in May 2007, a third in April 2008, and the 

last during the summer of 2009. The JBB burn pit offi cially closed on October 1, 2009.

Risk assessments conducted using the results of the 4 

aforementioned air sampling efforts estimated cancer 

risk in the range considered to be “acceptable” per the 

US Environmental Protection Agency standards, but 

some volatile organic compounds were measured at levels that might be associated with acute irritation.19 These 

effects were consistent with health conditions reported 

by some personnel. It took some time for the reports to 

be published, and it is uncertain how well the fi ndings 

were disseminated or understood by those with concerns. The VA requested assistance from the Institute 

of Medicine to assess air sampling data and risk assessment information from JBB. The IOM concluded that 

none of the individual chemicals were likely to be associated with adverse health outcomes, but that monitoring 

data suggests particulate matter from local and regional 

sources other than burn pits appeared to be of greatest 

concern.21 Risk assessments do not address mixtures of 

chemicals and their potential for adverse effects.20,22 The 

IOM was unable to conclude whether long-term health 

effects are expected from exposure to burn pit emissions. 

While this may be the state of the science, it does not reassure those who develop subsequent illness and might 

reasonably wonder if it is associated with the exposure. 

Congress addressed the issue in the fi scal year 2013 National Defense Authorization Act by requiring the VA to 

establish a registry for veterans with potential exposure 

to burn pits.23 The DoD elected to expand this to service members. Participation is voluntary, and eligibility is based on deployment to OIF, Operation Enduring 

Freedom (OEF), and OND. Confi rmation of potential 

exposure or deployment to specifi c camps or locations is 

not required as DoD was unable to specifi cally list dates 

and locations where trash was burned. While the actual 

health risk associated with burning trash may still be 

under study, service members, the media, and Congress 

viewed the billowing, thick smoke as demonstrating a 

lack of consideration for service members’ health, which 

heightened the concern. Over 50,000 service members 

and veterans have signed up for this registry to date, and 

the IOM is currently assessing the data.

CHEMICAL WARFARE AGENT EXPOSURE

Exposure to chemical warfare agents (CWA), particularly nerve agents, was a major concern after the fi rst Gulf 

War due to reports of alarms, the use of the pyrdostigmine bromide tablets as a nerve agent pretreatment, and 
170 http://www.cs.amedd.army.mil/amedd_journal.aspx

lingering health concerns after the war. Due to this, a 

massive research effort to address effects of low-level 

chemical warfare agents 24 was undertaken. Once again, 

over a decade later, CWA exposure is also an issue of 

lingering concern. On October 14, 2014, the New York 

Times published an in-depth investigation, “The Secret 

Casualties of Iraq’s Abandoned Chemical Weapons,”25

that initiated a landslide reaction and innovative response. The report alleged that from 2004-2011, American troops who deployed in support of OIF/OND:

...repeatedly encountered, and on at least 6 occasions 

were wounded by, chemical weapons remaining from 

years earlier in Saddam Hussein’s rule.

The article noted that none of the exposed veterans 

were receiving long-term health monitoring. While this 

was not necessarily correct, there was no centralized 

tracking of these exposures and most of the exposure 

incidents were classifi ed. The US Army Public Health 

Command (USAPHC) responded and by October 20, 

2014, the USAPHC began contacting service member 

and veterans identifi ed in the article; 17 Soldiers, 6 Marines, and 3 Sailors reported to have had symptomatic 

exposure to CWA, either sulfur mustard or nerve agent. 

The immediate task was to contact and interview these 

individuals and identify their exposure and their symptoms at the time, and to discuss current health concerns. 

Exposures for the 26 individuals occurred between 2003 

and 2011, most typically from handling old leaking munitions. These munitions were either being transported 

for destruction, or handled during excavation, with a few 

exposures occurring during destruction. Mustard exposures may injure the skin (blisters), the eyes, and/or the 

respiratory tract depending on the dose and the route of 

exposure. Nerve agent exposure may cause miosis from 

vapor exposure to the eye, sweating, nausea, vomiting, 

muscle twitching, involuntary urination and defecation, 

or seizures and death as dose increases.

Beyond the original 26 individuals in the New York 

Times article, the USAPHC reviewed the medical records of individuals who were known to have been in 

the same unit of a previously identifi ed exposed service 

member. In addition, in coordination with the Armed 

Forces Health Surveillance Center, a review of those 

who had identifi ed exposure to a CWA on their PostDeployment Health Assessment or Reassessment was 

initiated. By October 30, 2014, the DoD had established 

a toll-free hotline (1-800-497-6261) for service members and veterans to report potential chemical weapons 

exposure and seek a medical review. On November 7, 

2014, the Under Secretary of Defense (Personnel and 

Readiness) designated the Army as lead agent for this 

response and directed the Army to develop and publish 

implementation guidance for the identifi cation and evaluation of current and former service members who had 

CWA exposures during their deployment to Iraq in support of OIF/OND, to be executed by all branches. On 

March 20, 2015, the Under Secretary of the Army issued 

guidelines under which service members and veterans 

identifi ed as possibly exposed to a chemical weapon 

were to be contacted by their military service, evaluated 

in a structured interview, and invited for a full medical examination if they had symptomatic CWA exposure.26 The participants were also to be provided with 

documentation of their exposure and have their medical 

records updated. This information was to be shared with 

the VA to help veterans receive follow-up care or submit 

claims for potentially related medical conditions. The 

medical examinations are being conducted at Walter 

Reed National Military Medical Center and Secretarial 

Designee status is requested for those not on active duty 

so that invitational travel orders may be used to pay for 

travel and expenses. Progress through the process and 

dispositions are tracked for each individual in a special 

module of the Defense Occupational and Environmental 

Health Readiness System, access to which is available 

to the VA. In addition, dispositions, medical history, and 

physical examination are documented in the individual’s electronic health record.

As of October 2015, there were approximately 7,000 service members or veterans in all phases of the process 

of evaluation for potential CWA exposure. At the time 

of this writing, roughly 150 individuals were identifi ed 

with symptomatic CWA exposure, all of whom have 

been offered a medical examination. In the vast majority of cases, no evidence of symptomatic exposure 

is found, although an additional 62 current and former 

service members were authorized a medical examination upon plainly requesting one. To date over 100 individuals have completed the medical examination process and among the completed medical examinations, 

no signifi cant correlation between acute CWA exposure 

and chronic health effects has been identifi ed. Nearly all 

exposure effects were mild (C. P. B. unpublished data). 

A clear lesson developed from this effort: in some exposure scenarios, testing and or monitoring resulted in 

mixed results. Confi rmatory testing was conducted in 

laboratories in the United States, but service members 

rarely learned of the results, and the results were classifi ed. In many cases, service members were not sure 

about to what they had been exposed, and thus were not 

sure of the potential risk that might be associated with 

the exposure. This resulted in both anger and frustration. 

The most benefi cial part of the effort was that many service members had the opportunity to ask questions and 

come away with a better idea of their future health risk.

PUBLIC HEALTH CHALLENGES
April – September 2016 171

THE ARMY MEDICAL DEPARTMENT JOURNAL

CONCLUSION

As in previous confl icts, many personnel returning from 

deployment to Iraq and Afghanistan have concerns about 

environmental exposures and their potential health. Exposure assessments have helped to gauge the risk, but 

typically are insuffi cient to negate risk. Transparency 

regarding the use and limitations of the data collected, 

and communication of the risks to those it affects is 

recommended.6

 To support on-the-ground risk communication, the actions triggered by specifi c sampling results and the uncertainty surrounding these assessments 

should be identifi ed prior to data collection. To the degree that results are inconclusive, it should be acknowledged that an “unclear risk” is not the same as “clear 

lack of risk.” It is recognized that service connection 

and other issues complicate these matters. Operations 

Iraqi Freedom, Enduring Freedom, and New Dawn were 

the fi rst military operations for which specifi c exposure 

scenarios have resulted in relatively early recognition of 

and response to concerns in the form of a registry or 

other process. Registries have been developed to allow 

individuals to come forth and report both exposure and 

health concerns. These initiatives will gather information that is potentially useful to service members and 

their healthcare providers, as well as public health professionals who are endeavoring to protect the health of 

deployed troops. Though there are structural limitations 

to the data (for example, self-reported exposures and 

outcomes, and limited generalizability to unenrolled 

personnel), registries can be used to generate hypotheses for further evaluation. That said, it is unlikely that 

any amount of environmental sampling will be suffi -

cient to completely characterize environmental health 

risks and alleviate all future health concerns. Awareness, 

assessment, documentation, and early risk communication may help reassure those deploying, whom we are 

obligated to protect. In order to provide meaningful risk 

communication, we must know how the collected information will be used to assess risk, and how to clearly 

communicate it to those who have the right to know.

REFERENCES

1. Presidential Advisory Committee on Gulf War 

Veterans’ Illnesses. Special Report. Washington 

DC: US Government Printing Offi ce; December 

1996. Available at: http://www.gulfl ink.osd.mil/

gwvi/toc-f.html. Accessed March 23, 2016.

2. Gray GC, Hawksworth AW, Smith TC, Kang HK, 

Knoke JD, Gackstetter GD. Gulf War Veterans’ 

health registries. Who is most likely to seek evaluation?. Am J Epidemiol. 1998;148(4):343-349. 

3. Committee on the DoD Persian Gulf War Syndrome Comprehensive Clinical Evaluation Program. Evaluation of the U.S. Department of Defense Persian Gulf Syndrome Comprehensive 

Clinical Evaluation Program. Washington, DC: 

National Academies Press; 1996. Available at: 

http://www.nap.edu/read/9057/chapter/1. Accessed 

March 23, 2016.

4. Committee to Review the Health Consequences of 

Service During the Persian Gulf War Medical Follow-up Agency. Health Consequences of Service 

During the Persian Gulf War: Recommendations 

for Research and Information Systems. Washington, DC: National Academies Press; 1996. Available at: http://www.nap.edu/read/5272/chapter/1. 

Accessed March 23, 2016.

5. US General Accounting Offi ce. Gulf War Illnesses: Improved Monitoring of Clinical Progress and 

Reexamination of Research Emphasis are Needed. 

Washington, DC: US Government Accountability 

Offi ce; June 23, 1997. Report GAO/NSAID-97-163. 

Available at: http://www.gao.gov/assets/230/224299.

pdf. Accessed March 23, 2016.

6. Institute of Medicine. Protecting Those Who Serve: 

Strategies to Protect the Health of Deployed U.S. 

Forces. Washington, DC: National Academies 

Press; 2000:47. Available at: http://www.nap.edu/

read/9976/chapter/8#47. Accessed March 23, 2016.

7. Executive Offi ce of the President. A National Obligation –Planning for Health Preparedness for 

and Readjustment of the Military, Veterans, and 

Their Families after Future Deployments. Washington, DC: Executive Offi ce Presidential Review 

Directive 5; August 1998:8,19. Available at: http://

clinton5.nara.gov/textonly/WH/EOP/OSTP/NSTC/

html/directive5.html. Accessed April 1, 2016.

8. US Army Public Health Command. Technical 

Guide 230: Environmental Health Risk Assessment 

and Chemical Exposure Guidelines for Deployed 

Military Personnel. Aberdeen Proving Ground, 

MD: US Army Public Health Center (Provisional). 

2013. Available at: https://phc.amedd.army.mil/

PHC%20Resource%20Library/TG230.pdf. Accessed March 23, 2016.

9. Weese CB, Abraham JH. Potential health implications associated with particulate matter in deployed settings in Southwest Asia. Inhal Toxicol. 

2009;21:291-296.

10. Abraham JH, Baird CP. A case-crossover study of 

ambient particulate matter and cardiovascular and 

respiratory medical encounters among US military 

personnel deployed to Southwest Asia. J Occup 

Environ Med. 2012;54(6):733-739.
172 http://www.cs.amedd.army.mil/amedd_journal.aspx

11. Abraham JH, DeBakey SF, Reid L, Zhou J, Baird 

CP. Does Deployment to Iraq and Afghanistan affect respiratory health of US military personnel?. J 

Occup Environ Med. 2012;54(6):740-745.

12. National Research Council. Review of Department 

of Defense Enhanced Particulate Matter Surveillance Program Report. Washington, DC: National 

Academies Press; 2010. Available at: http://www.

nap.edu/catalog/12911/review-of-the-departmentof-defense-enhanced-particulate-matter-surveil

lance-program-report. Accessed March 23, 2016.

13. Baird CP. Res piratory disease and deployment: 

What do we know? What do we think?. US Army 

Med Dep J. July-September 2011:80-86.

14. Abraham JH, Clark LL, Sharkey JM, Baird CP. 

Trends in rates of chronic obstructive respiratory 

conditions among US military personnel 2001-2013. 

US Army Med Dep J. July-September 2014:33-43.

15. Baird CP, DeBakey S, Reid L, Hauschild VD, Petruccelli B, Abraham JH. Respiratory health status of US Army personnel potentially exposed to 

smoke from 2003 Al-Mishraq sulfur plant fi re. J 

Occup Environ Med. 2012;54(6):717-723.

16. Armed Forces Health Surveillance Center. Epidemiological Studies of Health Outcomes Among 

Troops Deployed to Burn Pit Sites. Silver Spring, 

MD: Armed Forces Health Surveillance Center; 

2010. Available at: http://fhp.osd.mil/pdfs/100604_

FINAL_Burn_Pit_Epi_Studies.pdf. Accessed 

March 23, 2016.

17. Sharkey JM, Abraham JH, Clark LL, Rohrback 

P, Ludwig S, Hu Z, Baird CP. Postdeployment respiratory health care encounters following deployment to Kabul, Afghanistan: a retrospective cohort 

study. Mil Med. 2016;181(3):265-271.

18. Baird CP, Harkins DK, eds. Airborne Hazards Related to Deployment. Fort Sam Houston, TX: Borden Institute; 2015.

19. Vie tas AJ, Taylor G, Rush V, Deck A. Screening Health Risk Assessment, Burn Pit Exposures, 

Balad Air Base, Iraq and Addendum Report. Aberdeen Proving Ground, MD: US Army Center for 

Health Promotion and Preventive Medicine; May 

2008. USACHPPM 47-MA-08PV-08; AFIOH IOHRS-BR-TR-2008- 0001. Available at: http://www.

dtic.mil/cgi-bin/GetTRDoc?AD=ADA493142. Accessed March 23, 2016.

20. Weese CB. Issues related to burn pits in deployed settings. US Army Med Dep J. April-June 

2010:22-28.

21. Institute of Medicine. Long-Term Health Consequences of Exposure to Burn Pits in Iraq and Afghanistan. Washington DC: National Academies 

Press; 2011. Available at: http://www.iom.edu/Reports/2011/Long-Term-Health-Consequences-ofExposure-to-Burn-Pits-in-Iraq-and-Afghanistan.

aspx. Accessed March 23, 2016.

22. Weese CB. Review of the Institute of Medicine report: long-term health consequences of exposure to 

burn pits in Iraq and Afghanistan. US Army Med 

Dep J. July-September 2012:43-47.

23. Dignifi ed Burial and Other Veterans’ Benefi ts Improvements Act of 2012. Pub L No. 112-260, 126 

stat 2417.

24. Somani S, Romano JA. Chemical Warfare Agents: 

Toxicity at Low Levels. Boca Raton, FL: CRC Press. 

2001.

25. Chivers CJ. The secret casualties of Iraq’s abandoned chemical weapons [archives]. New York 

Times. October 14, 2014. Available at: http://www.

nytimes.com/interactive/2014/10/14/world/mid

dleeast/us-casualties-of-iraq-chemical-weapons.

html. Accessed March 23, 2016.

26. Under Secretary of the Army. Memorandum: 

Iraq Chemical Warfare Agent Exposure Review 

Implementation Guidance. Washington, DC: US 

Department of the Army; March 20, 2015. Avail

able at: https://assets.documentcloud.org/docu

ments/1694786/chemguidelines.pdf. Accessed 

March 23, 2016.

AUTHOR

Dr Baird is Manager, Environmental Medicine Program, 

US Army Public Health Center (Provisional), Aberdeen 

Proving Ground, Maryland.

PUBLIC HEALTH CHALLENGES
April – September 2016 173

Among numerous reported health issues related to deployment, respiratory effects may occur due to the austere nature of theaters in Southwest Asia (SWA), primarily Iraq and Afghanistan.1

 Foremost of these are the 

potential airborne hazards due to higher levels of ambient particulate matter (PM) from suspended geologic 

dusts, frequent sand storms, industrial air pollution, and 

burn pit smoke from the incineration of military waste 

materials.2

 Numerous sources have implied a direct relationship between PM exposure during deployments 

with the development of serious and debilitating chronic 

pulmonary disease. Likewise, anecdotal cases of military personnel with respiratory symptoms are detailed 

in media articles suggesting there is a systemic problem with undiagnosed pulmonary disease in returning 

service members. The initial 2011 Institute of Medicine 

report, Long-Term Health Consequences of Exposure to 

Burn Pits in Iraq and Afghanistan3

 concluded there was 

no established link between burn pit exposure and lung 

disease based on the available limited evidence.

The US Army Medical Department, Veterans Administration, and other research agencies within the Department of Defense (DoD) began actively pursuing scientific investigations into respiratory symptoms associated 

with deployment to better defi ne the types, prevalence, 

and severity of both acute and chronic respiratory disease.4

 Several important questions have been raised 

about airborne hazards, in particular burn pit smoke, 

and other environmental exposures during deployment:

 What is the current scientifi c evidence linking 

chronic lung disease related to military deployment?

 What are the current investigations into deployment-related respiratory disease?

 How should the clinical evaluation of the postdeployment service member with respiratory symptoms proceed?

 What is the role of increased smoking?

 Are there any specifi c approaches to help potential 

mitigate development of chronic lung disease by 

identifying susceptible individuals or use of personal protective equipment?

RESPIRATORY SYMPTOMS

There are reported increases in respiratory symptoms 

such as cough and dyspnea during deployment dating 

back to Operations Desert Shield/Storm. From initial 

reports on the health effects of the Kuwait oil fi res of 

1991 among US troops, surveys by Army investigators 

found increases in reported symptoms of upper respiratory tract irritation, dyspnea, and cough associated with 

proximity to these fi res. Further survey research in a 

cohort of 1,560 veterans based on oil-fi re proximity 5 

years after the First Gulf War could not fi nd a correlation in self-reported symptoms of asthma and bronchitis 

and modeled proximity exposures.5

 Long-term respiratory outcomes 10 years postdeployment demonstrated 

no differences in pulmonary function testing (PFT) in 

a deployed First Gulf War cohort.6

 More recently, initial 

Deployment-related Respiratory Issues

COL (Ret) Michael J. Morris, MC, USA

Capt Frederic A. Rawlins, USAF, MC

MAJ Damon A. Forbes, MC, USA

Maj Andrew J. Skabelund, USAF, MC

COL Pedro F. Lucero, MC, USA

ABSTRACT

Military deployment to Southwest Asia since 2003 in support of Operations Enduring Freedom/Iraqi Freedom/

New Dawn has presented unique challenges from a pulmonary perspective. Various airborne hazards in the deployed environment include suspended geologic dusts, burn pit smoke, vehicle exhaust emissions, industrial air 

pollution, and isolated exposure incidents. These exposures may give rise to both acute respiratory symptoms 

and in some instances development of chronic lung disease. While increased respiratory symptoms during 

deployment are well documented, there is limited data on whether inhalation of airborne particulate matter is 

causally related to an increase in either common or unique pulmonary diseases. While disease processes such 

as acute eosinophilic pneumonia and exacerbation of preexisting asthma have been adequately documented, 

there is signifi cant controversy surrounding the potential effects of deployment exposures and development 

of rare pulmonary disorders such as constrictive bronchiolitis. The role of smoking and related disorders has 

yet to be defi ned. This article presents the current evidence for deployment-related respiratory symptoms and 

ongoing Department of Defense studies. Further, it also provides general recommendations for evaluating pulmonary health in the deployed military population.
174 http://www.cs.amedd.army.mil/amedd_journal.aspx

surveys from Operations Iraqi Freedom/Enduring Freedom (OIF/OEF) of 15,000 redeploying military personnel estimated that 69.1% reported experiencing respiratory illnesses, of which 17% required medical care.7

 The 

Millennium Cohort Study is an ongoing Naval Health 

Research Center survey designed to evaluate the longterm health effects of military service members. Initial 

data from the baseline and follow-up surveys of 46,077 

military personnel (10,753 deployed) found higher rates 

of newly reported respiratory symptoms in deployed 

compared to nondeployed personnel (14% vs 10%), although similar rates of chronic bronchitis/emphysema 

(1% vs 1%) and asthma (1% vs 1%) were observed.8

Despite the increase in respiratory symptoms, short 

term respiratory health effects due to specifi c exposures 

have not been identifi ed. Epidemiologic research conducted by the Army Public Health Command of the enhanced PM surveillance sites found no association with 

increased PM exposures and acute cardiorespiratory 

events requiring medical encounters.9

 Further analysis 

was conducted by the Public Health Command to evaluate trends in rates of chronic lung diseases in the military population from 2001 through 2013. Investigators 

observed decreases in the rates of asthma and chronic 

bronchitis over the 13-year study period, while the reported rates of nonspecifi c bronchitis tended to drive the 

overall trends in chronic respiratory disease.10

LUNG DISEASE ASSOCIATED WITH DEPLOYMENT

Acute Eosinophilic Pneumonia

There is published evidence for a cluster of acute eosinophilic pneumonia (AEP) cases related to deployment 

in military personnel. Eighteen cases were initially reported from 2003 to 2004 among 183,000 military personnel deployed in or near Iraq.11 Acute eosinophilic 

pneumonia is an unusual disease of unknown etiology 

characterized by acute illness, respiratory failure, bilateral pulmonary infi ltrates, hypoxia, and predominant 

eosinophilia (25%) on bronchoalveolar lavage (BAL). 

New-onset smoking was a defi nite risk factor as all 

were active smokers with 78% reporting recent onset of 

smoking.11 Continued collection of data from Landstuhl 

Regional Medical Center now shows there have been 

44 diagnosed cases with an average BAL eosinophilia 

of 36.8%±20.9%. Ninety-three percent of the patients 

were smokers and 65% required mechanical ventilation.12 Bronchoscopy to demonstrate pulmonary eosinophilia has become a primary intervention in evaluating 

hypoxia in evacuated patients due to the increased incidence of AEP in this population.

Asthma

Asthma remains a common fi nding in military personnel that may mirror the incidence in the general population. The extreme climate conditions in SWA along 

with high PM exposures due to dusts or burn pit smoke 

could contribute to poor asthma control with increased 

exacerbations. A survey of deploying Army personnel identifi ed 5% of troops deployed to SWA reported 

a previous diagnosis of asthma.13 While the asthmatics 

had poor baseline control of symptoms, there were no 

differences compared to nonasthmatics as both groups 

reported increased respiratory symptoms. A review of 

6,000 Veterans Administration medical records (based 

on ICD-9 diagnostic codes with limited PFT data) noted 

higher rates of “new-onset” asthma in deployed military 

between 2004 and 2007 compared to non-deployed personnel (6.6% versus 4.3%).14 A review by DoD investigators on 400 asthmatics undergoing a formal medical 

fi tness for duty evaluation could not establish a defi nitive relationship between the diagnosis of asthma and 

deployment. In reviewing patient records, the diagnosis was objectively confi rmed by testing in only 78% of 

the patients. Fifty percent of the cohort never deployed, 

25% were diagnosed predeployment, and 25% of the 

asthmatics were diagnosed postdeployment. There was 

inadequate data to determine if this was undiagnosed 

preexisting disease in the postdeployment group. No 

differences in PFTs or asthma severity were noted based 

on time of diagnosis or deployment history.15 Similar 

fi ndings were identifi ed in a cohort of patients with a 

diagnosis of chronic obstructive pulmonary disease.16

Constrictive Bronchiolitis

Constrictive bronchiolitis (CB) is a lung disease characterized by fi xed airways obstruction and fi brosis of the 

distal airways or bronchioles, with extrinsic narrowing 

or obliteration of the bronchiolar lumen. It is associated 

with environmental and occupational inhalation exposures such as diacetyl and may follow exposure to nitrogen and sulfur dioxides. Spirometry typically shows 

airfl ow obstruction without postbronchodilator increase 

and high resolution computed tomography (HRCT) of 

the chest often shows heterogeneous air trapping most 

prominent on expiratory imaging, sometimes with areas 

of patchy ground glass opacities and scattered cylindrical bronchiectasis.17 In 2011, King et al 18 reported on a 

case series of 80 previously deployed military personnel, 49 of whom underwent surgical lung biopsy which 

resulted in 73% of those so examined receiving a pathologic diagnosis of CB. The patients comprising the case 

series had varied deployment exposures; less than half 

PUBLIC HEALTH CHALLENGES
April – September 2016 175

THE ARMY MEDICAL DEPARTMENT JOURNAL

of the entire cohort had exposure to the 2003 sulfur fi re 

in Mishraq, Iraq. No standardized evaluation was employed and most patients did not undergo a comprehensive evaluation to rule out common etiologies such as 

asthma prior to lung biopsy. Few patients met the established defi nition of CB as the majority had exertional 

dyspnea, normal PFTs without fi xed obstruction, and 

normal high resolution CT imaging. The pathological 

fi ndings of this study have not been validated. Furthermore, an epidemiologic comparison demonstrated no 

increase in postdeployment medical encounters among 

military personnel exposed to the 2003 sulfur fi re compared to unexposed personnel.19 An ongoing review of 

lung biopsy reports (unpublished to date) by the Joint 

Pathology Center demonstrated few active duty military 

with small airways disease and no increase in deployed 

individuals compared to nondeployers (5.1% vs 5.6%).

THE STAMPEDE STUDIES

STAMPEDE I

After the development of the DoD Pulmonary Working 

Group in 2010, several research studies were initiated 

to better defi ne types of respiratory disease identifi ed 

immediately post deployment, utility of pre-and postdeployment spirometry, and types of respiratory disease 

associated with chronic respiratory symptoms. The 

initial “Study of Active Duty Military for Pulmonary 

Disease related to Environmental Deployment Exposure” (STAMPEDE) began recruiting in 2010 and enrolled 50 patients with new onset respiratory symptoms 

within 6 months after returning from deployment.20

This prospective standardized evaluation included full 

PFTs, chest HRCT, methacholine challenge testing 

(MCT), and fi beroptic bronchoscopy with BAL. A large 

percentage (42%) remained undiagnosed including 12% 

with normal testing and an isolated increase in lavage 

neutrophils or lymphocytes. Twenty (40%) patients 

demonstrated some evidence of airway hyperreactivity (AHR) to include eight who met asthma criteria and 

two with fi ndings secondary to gastroesophageal refl ux. 

No patients were identifi ed with diffuse parenchymal 

disease on the basis of HRCT imaging. Interestingly, a 

signifi cant number (66%) of this cohort had documented 

underlying mental health and sleep disorders.20

STAMPEDE II

STAMPEDE II is a recently completed prospective 

study using pre- and postdeployment spirometry and 

impulse oscillometry (IOS) to determine if there is an 

objective decrease in pulmonary function following deployment. The deploying population consisted of nearly 

1,700 active duty Army, National Guard, and Reserve 

personnel deploying to SWA from Fort Hood, Texas. 

All participants completed a brief respiratory survey 

and completed both spirometry and IOS pre- and postdeployment. Analysis of predeployment fi ndings noted 

a mean age of 32 years with a body mass index of 27 kg/

m2

. Nearly 40% reported a smoking history and 6% reported a history of asthma or bronchodilator use. Mean 

spirometry values, presented in Table 1, refl ect signifi -

cant percentages of Soldiers with obstructive spirometry 

predeployment. These abnormalities did not correlate 

with asthma history, prior deployments, or reported 

symptoms.21 Initial analysis of postdeployment spirometry demonstrated increases in all spirometry values 

(both FEV1

 and FVC) irrespective of smoking history, 

reported symptoms, or PM exposures.22

STAMPEDE III

STAMPEDE III is an ongoing comprehensive study of 

deployed military personnel with chronic pulmonary 

symptoms. All participants undergo a standardized 

evaluation to include full PFTs, allergy testing, chest 

imaging with HRCT, IOS, exhaled nitric oxide, MCT, 

exercise laryngoscopy, echocardiography, cardiopulmonary exercise testing (CPET), and bronchoscopy with 

BAL. Preliminary data analysis of the fi rst 200 patients 

enrolled has identifi ed an older population with a mean 

age of 37 years and a variety of comorbidities including 

obstructive sleep apnea. Diagnoses, the distribution of 

which is presented in the Figure, show a similar trend to 

the 2002 exertional dyspnea study with asthma, nonspecifi c AHR, and vocal cord dysfunction (VCD) as common fi ndings.23 Diffuse lung disease is very uncommon, 

but several individuals have been diagnosed with cardiac abnormalities and excessive dynamic airway collapse. 

The utility of CPET, HRCT, and BAL analysis has not 

yet been determined in this group of patients.

Table 1. STAMPEDE II Predeployment Spirometry 

Values.

All Not

Deployed

Prior

Deployed

N 1,693 809 884

FEV1 (% pred) 93.2±12.4 92.7±12.3 95.6±12.7

FVC (% pred) 94.4±11.7 93.6±11.3 98.4±12.8

FEV1 /FVC 81.1±6.6 80.9±6.5 82.2±6.9

FEF25-75 (% pred) 94.0±25.5 94.1±25.3 93.5±26.9

Reduced FEV1 /FVC 143 (13%) 122 (13.2%) 21 (11.7%)

FEV1 indicates forced expiratory volume at one second.

FVC indicates forced expiratory capacity.

FEF25-75 indicates mid-expiratory flow.
176 http://www.cs.amedd.army.mil/amedd_journal.aspx

EVALUATION OF DEPLOYED MILITARY PERSONNEL

The evaluation of deployed military personnel can be 

challenging. Environmental exposures are ubiquitous 

and varied, and susceptible individuals may either develop new pulmonary symptoms or exacerbate preexisting disease. A comprehensive evaluation of exertional 

dyspnea in military personnel in 2002 by Morris et al 24

demonstrated the unique nature of their pulmonary disease. As expected, nearly half of the study population 

had either asthma or exercise-induced bronchospasm, 

while 10% had evidence of VCD. A more interesting 

fi nding was the 25% of evaluated patients with chronic dyspnea who had no abnormalities despite testing.24

Most important in the initial pulmonary evaluation 

should be documentation of deployment exposures, relationship of deployment to symptoms, and any specifi c 

respiratory symptoms related to an acute exposure. At 

the primary care or initial evaluation, the minimum required tests should include at least baseline spirometry, 

bronchodilator response, and a chest radiograph. Referral for comprehensive testing at designated centers 

should be considered for unexplained symptoms (Table 

2).25 Further evaluation is primarily based on PFT and 

imaging fi ndings.25

After numerous meetings and review of the published 

literature since 2010, the Defense Health Board issued 

its statement on Deployment Pulmonary Health in 

February 2015 and made a series of recommendations 

based partially on the results of the STAMPEDE studies.1

 Several of the applicable clinical recommendations 

are summarized here:

1. Increase the number of pulmonary questions on preand postdeployment surveys and conduct routine 

analysis of responses.

2. Conduct predeployment spirometry in selected individuals if there is signifi cant risk of airborne hazards due to location or required duties.

3. Develop a consistent and tiered approach to patients 

with unexplained postdeployment dyspnea.

4. Implement an enterprise-wide clinical registry of 

service members with postdeployment chronic pulmonary symptoms.

5. Conduct prospective cohort study of unexplained 

chronic dyspnea (including the cohort of service 

members who have undergone surgical lung biopsy) 

to determine longitudinal outcomes.

6. The DoD should continue research to develop respiratory personal protective equipment appropriate for 

fi eld or combat use.

CONCLUSION

Presently, available data does not establish a specifi c 

link between the development of pulmonary disease and 

SWA deployment. However, specifi c causative factors 

(dust, burn pit smoke, etc) may have an effect on chronic 

respiratory symptoms of certain individuals. How best 

can the Army Medical Department prepare to mitigate 

potential effects of airborne hazard exposures? From a 

doctrinal standpoint, several changes should occur. First, 

the Army Public Health Center (Provisional) should be 

prepared to conduct routine testing of theater locations 

and in particular, known 

locations with a higher propensity for developing respiratory disease (such as the 

2003 Al-Mishraq sulfur fi re 

or burn pit sites). This would 

include specifi c pulmonary 

evaluation of exposed individuals soon after the time 

of exposure. Second, the 

deploying force as a whole 

should be better screened for 

potential respiratory illness 

via predeployment questions on the predeployment 

health assessment. Those 

with chronic symptoms, 

known respiratory illness 

such as asthma, or inhaler 

use should undergo a basic 

pulmonary evaluation such 

as examination, spirometry, 

Asthma AHR GERD VCD Cough SAR Cardiac EDAC COPD

Nondiagnostic Diffuse Lung

30%

20%

10%

15%

0%

25%

5%

STAMPEDE III diagnoses. AHR indicates airway hyperreactivity; GERD, gastroesophageal refl ux 

disease; VCD, vocal cord dysfunction; SAR, seasonal allergic rhinitis; EDAC, excessive dynamic 

airway collapse; COPD, chronic obstructive pulmonary disease.

PUBLIC HEALTH CHALLENGES
April – September 2016 177

THE ARMY MEDICAL DEPARTMENT JOURNAL

and chest radiograph. Third, those individuals with 

postdeployment respiratory symptoms (including those 

evacuated for respiratory illnesses) should be evaluated 

at designated DoD centers of excellence and be included 

on a clinical registry to determine long-term outcomes.

REFERENCES

1. Defense Health Board. Memorandum: Deployment 

Pulmonary Health. Falls Church, VA: Offi ce of the 

Assistant Secretary of Defense Health Affairs; February 11, 2015.

2. Weese CB, Abraham JH. Potential health implications associated with particulate matter exposure 

in deployed settings in Southwest Asia. Inhal Toxicol. 2009;21:291-296.

3. Institute of Medicine. Long-term health consequences of exposure to burn pits in Iraq and Afghanistan. Washington, DC: The National Academies Press, 2011. Available at: http://www.iom.edu/

Reports/2011/Long-Term-Health-Consequencesof-Exposure-to-Burn-Pits-in-Iraq-and-Afghani

stan.aspx. Accessed March 23, 2016.

4. Morris MJ, Zacher LL, Jackson DA. Investigating 

the respiratory health of deployed military personnel. Mil Med. 2011;176:1157-1161.

5. Lange JL Schwartz DA, Doebbeling BN, Heller 

JM, Thorne PS. Exposures to the Kuwait oil fi res 

and their association with asthma and bronchitis 

among Gulf War veterans. Environ Health Perspect. 2002;110:1141-1146.

6. Karlinsky JB, Blanchard M, Alpern R, Eisen SA, 

Kang H, Murphy FM, Reda DJ. Late prevalence 

of respiratory symptoms and pulmonary function 

abnormalities in Gulf War I veterans. Arch Intern 

Med. 2004;164(22):2488-2491.

7. Sanders JW, Putnam SD, Frankart C, et al. Impact 

of illness and non-combat injury during Operations 

Iraqi Freedom and Enduring Freedom (Afghanistan). Am J Trop Med Hyg. 2005;73(4):713-719.

8. Smith B, Wong CA, Smith TC, Boyko EJ, Gacksetter GS, Ryan MAK. Newly reported respiratory 

symptoms and conditions among military personnel deployed to Iraq and Afghanistan: a prospective population-based study. Am J Epidemiol. 

2009;170:1433-1442.

9. Abraham JH, Baird CP. A case-crossover study of 

ambient particulate matter and cardiovascular and 

respiratory medical encounters among US military 

personnel deployed to Southwest Asia. J Occup 

Environ Med. 2012;54(6):733-739.

10. Abraham JH, Clark LL, Sharkey JM, Baird CP. 

Trends in rates of chronic obstructive respiratory conditions among US military personnel, 

2001-2013. US Army Med Dep J. July-September 

2014:33-43.

11. Shorr AF, Scoville SL, Cersovsky SB, et al. 

Acute eosinophilic pneumonia among US military personnel deployed in or near Iraq. JAMA. 

2004;292:2997-3005.

12. Sine C, Allan P, Haynes R, Scoville S, Shuping E, 

Hultman A, Osborn E. Case series of 44 patients 

with idiopathic acute eosinophilic pneumonia in 

the deployed military setting. Chest. 2011;140(4_

meeting abstracts):675A.

13. Roop SA, Niven AS, Calvin BE, Bader J, Zacher 

LL. The prevalence and impact of respiratory 

symptoms in asthmatics and non-asthmatics during deployment. Mil Med. 2007;172:1264-1269.

14. Szema AM, Peters MC, Weissinger KM, Gagliano 

CA, Chen JJ. New-onset asthma among Soldiers 

serving in Iraq and Afghanistan. Allergy Asthma 

Proc. 2010;31:67-71.

15. Delvecchio SP, Collen JF, Zacher LL, Morris MJ. 

The impact of combat deployment on asthma diagnosis and severity. J Asthma. 2015:52:363-369.

16. Matthews T, Abraham J, Zacher LL, Morris MJ. 

The impact of deployment on COPD in active duty 

military personnel. Mil Med. 2014;179:1273-1278.

17. Garg K, Lynch DA, Newell JD, King TE Jr. Proliferative and constrictive bronchiolitis: classifi cation and radiologic features. AJR Am J Roentgenol. 

1994;162(4):803-808.

18. King MS, Eisenberg R, Newman JH, et al. 

Constrictive bronchiolitis in Soldiers returning from Iraq and Afghanistan. N Engl J Med. 

2011;365(3):222-230.

19. Baird CP, Debakey S, Reid L, Hauschild VD, Petruccelli B, Abraham JH. Respiratory health status of US Army personnel potentially exposed to 

smoke from 2003 Al-Mishraq sulfur plant fi re. J 

Occup Environ Med. 2012;54(6):717-723.

Table 2. Indications for Referral for Specialty Evaluation.

1. Abnormal chest radiograph (interstitial changes, lung mass, 

hilar adenopathy, lung infiltrate, pleural effusion).

2. Restrictive indices on spirometry (both FEV1 and FVC<70%).

3. Resting pulse oximetry below 95% or decrease of 4% with 

ambulation during a 6 minute walk test.

4. Need for bronchoprovocation testing to confirm asthma or 

exercise-induced bronchospasm.

5. Symptoms greater than 3 months with no response to 

treatment.

6. Prior treatment with oral steroids, hospitalization, or endotracheal intubation.

7. Unexplained dyspnea, cough and/or sputum production.

8. Symptomatic individuals with normal basic evaluation (spirometry and chest radiograph).
178 http://www.cs.amedd.army.mil/amedd_journal.aspx

20. Morris MJ, Dodson DW, Lucero PF, Haislip GD, 

Gallup RA, Nicholson KL, Zacher LL. Study of active duty military for pulmonary disease related to 

environmental dust exposure (STAMPEDE). Am J 

Respir Crit Care Med. 2014;190:77-84.

21. Skabelund A, Morris M. Baseline symptoms 

and pulmonary function of military personnel 

prior to deployment. Chest. 2013;144(4_meeting 

abstracts):480A.

22. Skabelund AJ, Morris MJ. The effect of deployment on the pulmonary function and respiratory 

symptoms of military personnel. Am J Respir Crit 

Care Med. 2015:Abstract Issue;A2577.

23. Morris M, Skabelund A, Haislip G, Lucero P. Comprehensive evaluation of military personnel with 

post-deployment respiratory symptoms. Chest. 

2014;145(suppl 3):568A.

24. Morris MJ, Grbach VX, Deal LE, Boyd SY, Johnson JE, Morgan JA. Evaluation of exertional dyspnea in the active duty patient: the diagnostic approach and the utility of clinical testing. Mil Med. 

2002;167:281-288.

25. Morris MJ, Negrescu C, Bell DG, Tinklepaugh CN. 

Discussion summary: basic diagnosis and workup 

of symptomatic individuals. In: Baird CP, Harkins 

DK, eds. Airborne Hazards Related to Deployment. Fort Sam Houston, TX: Borden Institute; 

2015:121-130.

AUTHORS

COL (Ret) Morris, Capt Rawlins, MAJ Forbes, Maj Skabelund, and COL Lucero are with the Pulmonary/Critical Care Service, San Antonio Military Medical Center, 

Joint Base San Antonio-Fort Sam Houston, Texas.

PUBLIC HEALTH CHALLENGES
April – September 2016 179

Although few individuals questioned the importance of 

North Atlantic Treaty Organization (NATO) during the 

height of the Soviet Union’s power and the Cold War, 

some wondered about the relevance of NATO after the 

collapse of the Soviet Union and its power over its Eastern European satellite countries. The Warsaw Pact’s 

dissolution in 1991, however, has not reduced the need 

for military cooperation among NATO nations. Instead, 

NATO has grown to include over a half-dozen new 

members since 1991, and in 1994, NATO launched its 

Partnership for Peace program to foster trust and cooperation among European states.1

 This cooperation has 

supported numerous multilateral military operations 

including the Bosnian air campaign, the peacekeeping 

force in Serbia and Kosovo, the Afghanistan security 

mission, earthquake relief in Pakistan, and the counterpiracy mission in the Indian Ocean.2

 These recent 

examples highlight the transition in the past 2 decades 

from unilateral operations to multinational efforts, and 

underscore the increasing importance of effective and 

effi cient multinational operations within NATO (28 nations) and its cooperative security initiatives such as 

Partnership for Peace (22 nations), Mediterranean Dialogue (7 nations), and Istanbul Cooperation Initiative (4 

nations).3

 Indeed, military reductions in many NATO 

countries and in the United States may make unilateral 

action virtually impossible, especially if the operation 

endures for an extended period of time.

Unlike Cold War plans, which often divided the area 

of operations into sectors where an individual nation 

operated independently, current operations often require partner nations to combine functions from many 

countries to provide one required capability. For example, one nation provides hospital holding beds, another 

provides laboratory support, and a third provides surgical care, resulting in a defi ned medical capability. This 

type of “plug and play” combined operations requires 

well-defi ned roles of support and procedures (ie, interoperability) to ensure no capability gaps exist. Failure 

to develop interoperability standardization parameters 

prior to deployments leads to the initial identifi cation of 

these gaps during combat operations (rather than during predeployment), which jeopardizes the health of service members and successful completion of operational 

missions. One example, described below, of this lack of 

early synchronization between NATO partners during 

Operation Enduring Freedom and Operation Freedom’s 

Sentinel greatly elevated the food protection risk to coalition forces in Afghanistan.

COALITION FOOD SERVICE ESTABLISHMENTS IN

AFGHANISTAN IN 2014

In December 2014, the United States assumed NATO 

food protection responsibilities in the Transitional Advisory and Assist Command-Central (Kabul). Simultaneously, Turkey replaced France as the Base Operations 

Support Integrator authority for the Hamid Karzai International Airport (HKIA) multinational force. Separate 

dining facilities (DFACs) operated by Turkey, NATO, 

and the United States were open on HKIA, serving coalition forces from all nations. Another DFAC, operated 

by NATO, served all coalition forces at Resolute Support Headquarters (RS HQ), the other major forward 

operating base in Kabul.

Impact of North Atlantic Treaty Organization

 Policies and Procedures on Combined

 Medical Operations: Food and Water Safety

 and Veterinary Support

 COL Timothy H. Stevenson, VC, USA

 LTC Nicole A. Chevalier, VC, USA

 CW4 Gregory R. Scher, VC, USA

 LTC Ronald L. Burke, VC, USA

ABSTRACT

Effective multilateral military operations such as those conducted by the North Atlantic Treaty Organization (NATO) 

require close cooperation and standardization between member nations to ensure interoperability. Failure to standardize policies, procedures, and doctrine prior to the commencement of military operations will result in critical interoperability gaps, which jeopardize the health of NATO forces and mission success. To prevent these gaps from occurring, 

US forces must be actively involved with NATO standardization efforts such as the Committee of the Chiefs of Medical Services to ensure US interests are properly represented when NATO standards are developed and US doctrine and 

procedures will meet the established NATO requirements.
180 http://www.cs.amedd.army.mil/amedd_journal.aspx

Initial inspections of food service establishments by US 

Veterinary Service and Preventive Medicine personnel 

revealed critical defi ciencies, the most serious of which 

was the use of unapproved sources for potentially hazardous food items. The US policy, which is consistent 

with the NATO Food Protection Standardization Agreement (STANAG), requires Veterinary Service personnel to audit food processors to help ensure subsistence 

is safe and free of accidental and intentional contaminants.4

 The Turkish DFAC at HKIA received most of 

their food from unapproved sources (ie, not audited in 

accordance with US or NATO standards) in Turkey, but 

they also procured some dairy products from local Afghan sources. Likewise, the NATO contracted DFAC at 

the RS HQ compound did not use NATO recognized 

approved sources, and inspections were not coordinated 

using a common standard. Similarly, many of the retail 

food vendors on both HKIA and RS HQ did not use 

approved sources (eg, dairy products, raw meat, eggs, 

bottled water, and ice were procured from local Afghan 

markets or other local sources). The interim solution to 

address the immediate risk was to temporarily restrict 

the Turkish DFAC to only Turkish personnel until they 

came into compliance with applicable NATO STANAGs, and to ensure that HKIA and RS HQ food concessionaires stopped using local Afghan sources. Personnel 

of the US Army Veterinary Service addressed the RS 

HQ DFAC contractual issues as described below.

The fi rst effort to bridge this gap in 2003 was the development and ratifi cation of a STANAG4

 by the Food and 

Water Safety and Veterinary Support panel (FWSVS). 

This STANAG identifi ed the requirements for approving 

food establishments wishing to sell to NATO. Later, the 

FWSVS learned that the original DFAC that was contracted by the NATO Maintenance and Supply Agency 

(now NATO Support Agency (NSPA)) did not require 

approved food sources. A review of the process revealed 

that NSPA had invited the United States to participate 

in the contract proposal meeting, but the logistician did 

not attend and did not consult the US Army Veterinary 

Services for food protection advice. Consequently, another country that attended the meeting provided their 

national food safety regulation as a template. Unfortunately, no provisions existed in the original contract 

for approved food sources or for DFAC inspections by 

any of the coalition nations. Although there was a separate NATO contract to address quality assurance at the 

DFAC, there was no procedure to harmonize inspection 

criteria by participating nations. Consequently, inspectors from various nations were inspecting the DFAC 

using their own national standards, which varied from 

country to country.

When these gaps were discovered, the US Army Veterinary Service delegate to the FWSVS worked closely 

with other NATO countries to address the issues. Delegates from Norway, Belgium, and the US (at that time, 

former, current and future chairs of the FWSVS, respectively) visited NSPA leadership in 2010 to discuss food 

protection concerns. The NSPA was happy to discuss 

these issues and to work toward solutions that would be 

agreeable to the wider NATO community. The subsequent NSPA dining facility contract referenced applicable NATO STANAGs (approved food sources, food 

safety and defense, DFAC inspections, and bottled water 

requirements) which largely mirrored US regulations.5,6

Unfortunately, in 2014 Allied Joint Force Command 

(JFC) Brunssum, Netherlands, did not contract with the 

NSPA, which had food safety experts aware of NATO 

food protection STANAGS, to draft or coordinate the 

food service contract for the DFAC at RS HQ in Kabul. 

Many of the initial gaps (eg, unapproved food sources, 

no unifi ed national DFAC inspection criteria, failure to 

reference applicable STANAGs) and some new gaps appeared in the new contract for RS HQ, which was implemented at the end of 2014.

Because of the previous work of FWSVS to harmonize 

NATO procedures, the Chair of the FWSVS (US) was 

able to work more effectively with Allied JFC to modify 

their initial contract using existing STANAGs (ie, food 

protection, potable water). During this process, NATO 

JFC explained that although their contracting regulations 

allow best value considerations, this DFAC contract was 

awarded to the cheapest bidder (ie, lowest price/technically acceptable). Without best value considerations, the 

process is to develop and offer the contract requirements. 

Any contractor that can fulfi ll the requirements may be 

awarded the contract, based solely on price. In contrast, 

“best value” criteria allow the contracting offi cer to consider other variables, including, but not limited to, price. 

This distinct difference between best value and lowest 

price contracting principles underscores the importance 

of food protection expertise involvement in NATO contract development. The involvement of food protection 

expertise in contract development is also critical to ensure applicable NATO STANAGs are implemented by 

the multitude of involved agencies in the coalition defense contracting network.

The risks associated with multinational operations are 

greatest at the beginning and at the end of operations. 

During the peak sustainment of operations, when troop 

numbers are high and logistics processes are well established, many nations tend to provide their own support functions (medical, logistics, etc.). However, during initial entry and retrograde, nations tend to rely on 

whoever is there. For instance, most of the US-operated 

DFACs in Afghanistan have closed. The only establishment feeding US troops at RS HQ is the NATO JFC 

PUBLIC HEALTH CHALLENGES
April – September 2016 181

THE ARMY MEDICAL DEPARTMENT JOURNAL

contracted DFAC; at HKIA, most of the remaining 

DFACs are nationally operated.

Because of existing and appropriate NATO STANAGS, 

US Army Veterinary Service personnel were able to 

work with the RS HQ surgeon’s cell to redraft the theater 

food protection policies to incorporate NATO standards, 

including provisions for approved sources and DFAC 

food protection standards that were more consistent with 

the broader community of participating nations.

WAY AHEAD FOR THE UNITED STATES: POTENTIAL

ASPECTS OF DOTMLPF* TO BE ADDRESSED

For the United States to be effective during NATO operations, it must be fully engaged in NATO policy, planning, and procedure development. Medical standardization within NATO falls under the auspices of the Committee of the Chiefs of Medical Services (COMEDS). 

The US Joint Staff Surgeon typically represents the 

specifi c service Surgeons General at COMEDs meetings, which sets the strategic vision and objectives and 

directs and monitors the work of the subordinate (working groups and panels) activities. The working groups 

and panels are the committees where most of the policies and procedures are written and where the fi erce 

work of standardization occurs. In order to ensure US 

and NATO procedures are integrated, the United States 

must be deeply engaged with these committees. Unfortunately, this is where the United States has failed to 

participate effectively on many occasions in the past.

Ensuring the proper assignment of personnel is critical 

for US success. While there have been instances where 

the United States has failed to send a representative to 

the committee meetings, the more common practice has 

been inclusion of personnel based simply on assignment 

to the European theater. This leads to the frequent rotation of US representatives due to reassignment, leaving 

the new representative little time to gain an understanding of NATO procedures or the ongoing work of the 

committee. This legacy has limited the US potential to 

make meaningful contributions to the groups and has 

not served US or NATO interests.

Instead of rotating representatives every 2-3 years 

based on their geographic assignment, the United States 

should select representatives who can serve longer 

terms (ie, 5 years or more). This will ensure representatives are knowledgeable on current NATO standardization efforts so US and NATO policies, procedures, and 

doctrine can be harmonized to the greatest extent possible. Importantly, travel funding for the representatives 

should be programmed by the organization primarily responsible for that function to ensure personnel are properly resourced. Failure to centralize funding jeopardizes 

US interests; individual commands may not appreciate 

the importance of the mission and therefore not support 

the travel, or may not be aware of the risk associated 

with using rotating, local personnel.

Training on NATO organization and policies will also 

help improve US-NATO interoperability by increasing 

awareness among our leaders. Training should not be 

limited to entry level courses (ie, Basic Offi cer Leader 

Course) but rather a continual process. At a minimum, 

leaders should receive predeployment refresher training 

on NATO policies and procedures that could affect their 

mission. Only by increasing exposure and knowledge of 

coalition processes will the United States develop leaders that are prepared and agile enough to excel in multicultural operations.

REFERENCES

1. North Atlantic Treaty Organization. NATO timeline [internet]. Available at: www.nato.int/docu/

posters/timeline-eng.pdf. Accessed September 27, 

2015. 

2. North Atlantic Treaty Organization. NATO operations and missions [internet]. Available at: http://

www.nato.int/cps/en/natolive/topics_52060.htm. 

Accessed September 27, 2015.

3. North Atlantic Treaty Organization. NATO partners [internet]. Available at: http://www.nato.int/

cps/en/natolive/51288.htm. Accessed September 

27, 2015. 

4. North Atlantic Treaty Organization Standardization Offi ce. STANAG 2541: Audit Principles and 

Risk Assessment of Food Processors and Suppliers 

Associated with Military Deployment. NATO Standardization Offi ce Website; 2010 [restricted access: 

https://nso.nato.int/protected].

5. North Atlantic Treaty Organization Standardization Offi ce. STANAG 2556: Food Safety, Defense, 

and Production in Support of NATO Operations. 

NATO Standardization Offi ce Website; 2014 [restricted access: https://nso.nato.int/protected].

6. North Atlantic Treaty Standardization Offi ce. 

STANAG 2136: Minimum Standards of Water Potability During Field Operations and in Emergency 

Situations. NATO Standardization Offi ce Website; 2015 [restricted access: https://nso.nato.int/

protected].

AUTHORS

COL Stevenson and LTC Chevalier are with the Defense Health Agency Veterinary Services, Falls Church, 

Virginia.

CW4 Scher is assigned to the 72nd Medical Detachment 

(Veterinary Service Support), Fort Campbell, Kentucky.

LTC Burke is with the Public Health Command District-

*Doctrine, organization, training, material, leadership, personnel, Joint Base Lewis McChord, Washington.

facilities
182 http://www.cs.amedd.army.mil/amedd_journal.aspx

Safe drinking water is a critical component of Warfighter 

deployment health. Those who are inadequately hydrated or who incur gastrointestinal illness from drinking 

contaminated water are unable to perform their duties 

effectively, particularly in battle. Historically, when deployed Soldiers were responsible for obtaining their own 

drinking water, dehydration and waterborne diseases 

were common among the forces, and took their toll. In 

the modern Army, an abundant quantity of safe drinking water is provided to all personnel during deployments, courtesy of modern equipment and the combined 

efforts of Corps of Engineers, Quartermaster (QM), 

and Preventive Medicine (PM) personnel. The Corps of 

Engineers identifies and develops water sources, while 

the QM treats, disinfects, and, after PM personnel test 

and approve it, distributes the treated water. The QM’s 

Water Planning Guide 1

 specifies the water volumes 

required for various activities during deployment, and 

Technical Bulletin Medical 577 2

 contains field drinking 

water quality standards.

Following are 5 scenarios in which lessons in field water 

management that were learned over the past 12 years led 

to or will lead to improvements in the US military’s abilities to meet the water needs of deployed personnel.

Assessment of Central Command Reverse Osmosis

Units’ Prefilter, Product, and Reject Water

Current Army reverse osmosis water purification units 

(ROWPU) are pictured in Figure 1, and a simplified flow 

diagram is shown in Figure 2. After the source water 

is strained, it is variously prefiltered by cartridge and 

multimedia filters (600 gallons per hour (GPH) and 

3000 GPH ROWPUs), membrane microfilters, or membrane ultrafilters. Prefiltration removes particulate and 

microbiological contaminants and prepares the water to 

be pumped at high pressure through the reverse osmosis (RO) vessels, which remove viruses, dissolved salts, 

and other contaminants from the water. Finally, calcium 

hypochlorite disinfectant is added to the product water, 

and it is ready for PM testing, distribution, and drinking. 

Only 40% to 70% of the influent water passes through 

the RO membranes and becomes product water, while 

dissolved and other contaminants removed by the membranes flow out of the system in the 30% to 60% of the 

water that is rejected as brine. In 2003, Army doctrine 

directed that reject water, or brine, should be disposed 

of as wastewater.

Water was scarce in the desert, and some Army and contract operators recognized brine as a valuable resource, 

disinfected it, and provided it to Warfighters to use for 

personal hygiene and sanitation in lieu of disposing of 

it. Due to some Warfighter complaints and at least one 

contractor who reported the actions, the Department of 

Defense Inspector General (IG) initiated an audit of potable and nonpotable water in Iraq in September 2006, 

with the technical support of the US Army Center for 

Health Promotion and Preventive Medicine (CHPPM).*

Raw, pretreated, and reject water qualities from 6 different Army and contractor-operated water treatment operations were evaluated by CHPPM over a 6-month period 

in Iraq. Depending on the quality of the source water, 

Water for Warfighters in Iraq and Afghanistan:

 A Summary of Lessons Learned

Steven C. Richards, PhD, PE, BCEE

Arthur H. Lundquist, PE, BCEE

Todd E. Richards, PE

Abstract

The Army is the Department of Defense executive agent for land-based field water supplies. The Army Corps of 

Engineers, Army Quartermaster Corps, and Army Medical Department coordinate to provide the necessary support 

to obtain, treat, disinfect, certify, distribute, and monitor drinking water during deployments. This collaboration is 

necessary to ensure that an adequate quantity of acceptable quality drinking water is available for deployed personnel at all base camps and in all operations. Important lessons were learned from the beginning of operations in Iraq 

in 2003 continuing throughout 2 wars. These included lessons about the employment and management of bottled 

water during deployments, the quality and potential usefulness of “wastewater” from the reverse osmosis water purifiers, the usefulness and acceptability of military packaged water, and our lack of preparedness to readily address 

the drinking water needs of small squad and platoon-sized operations lasting more than a few days. The lessons we 

learned have and will continue to enhance our ability to readily meet Warfighters’ requirements for that most critical 

of supplies—sustaining a supply of safe, aesthetically pleasing drinking water.

*CHPPM has been disestablished and its mission assumed by 

the Army Public Health Center (Provisional).
April – September 2016 183

The Army Medical Department Journal

the pretreated water in many cases met field drinking 

water standards and could have been disinfected and 

consumed (avoiding the 30% to 60% loss in volume 

resulting from RO filtration). Even the RO reject water 

was in some cases superior in quality to the source water, and could have been chlorinated and used in ablution systems with negligible health risk.

The IG report found that some units were not performing all required quality control tests, and that water suppliers exposed US forces to unmonitored and potentially 

unsafe water. The report also found that there was no 

way to determine whether water provided by the contractor and military water purification units caused disease, and that contractors and military units responsible 

for water operations must always ensure that water provided to the forces meets all established standards.3

Lesson learned: depending on the 

source water quality, all water streams 

produced by military RO purification 

equipment could be useful after disinfection, if the use is supported by verification testing and comprehensive 

monitoring.

Use of Bottled Water During

Deployments

Prior to 2003, bottled water was to be provided only during the early stages of deployments until military water supplies could be established and bulk water could 

be distributed using unit water trailers. However, in 

2003, some National Guard units deployed to Kuwait 

expecting to receive a continuous and unlimited supply of bottled water, and left their unit water trailers in 

Kuwait as they moved forward. Subsequently, the unit 

commanders complained that the QM had unnecessarily rationed their bottled water supplies. Bulk water 

points had been established, but those units had no way 

to pick up bulk water, since they no longer had their water trailers. Although QM leadership reacted quickly to 

procure additional bottled water, the bottles that they 

had with them had to be rationed for a short period of 

time until sufficient quantities could be obtained. This 

change in bottled water policy—drinking it throughout 

Figure 2. General schematic of water flow through a typical Army reverse osmosis 

water treatment unit.

Raw Water

Strainer Coagulant Prefilters Antiscalant RO Vessels Disinfection

Prefiltered Product Brine

A B

C D

Figure 1. US Army reverse osmosis water purification equipment:

A. 600 GPH ROWPU B. 3000 GPH ROWPU C. Tactical water purification system D. Lightweight water purifier
184 http://www.cs.amedd.army.mil/amedd_journal.aspx

deployments—increased the cost of drinking water and 

strained transportation assets, requiring as much as 50% 

to 60% of available vehicles to haul bottled water versus 

ammunition, equipment, repair parts, and other supplies.

Lesson learned: if leaders continue to support its use, 

we must plan and prepare to provide bottled water for 

drinking throughout deployments, and to use bulk field 

water for other purposes.

Evolution in PM Bottled Water Surveillance

To meet the increased demand for bottled water, it was 

procured from sources in the United States as well as 

from nations surrounding the area of operations (AO). 

To sell water to the military, bottled water producers’ facilities, operations, and water quality had to be audited 

and approved by US Army Veterinary Service (VS) personnel, and added to the list of approved food sources.4

While these requirements ensured that the bottled water 

was safe at the production sources, PM leaders, concerned for possible contamination during transit and in 

storage locations, established robust bottled water quality monitoring requirements. An “All Army Activities” 

notification* was issued that required PM to inspect and 

test 10 bottles from every production lot when it entered 

the AO, and at 30-day intervals at every storage location 

in the AO. This requirement became a nearly impossible 

task for PM units. It was not clear what constituted a 

“lot,” and bottles were stored in huge quantities in warehouses and storage yards, and in small quantities at innumerable locations on facilities throughout the AO as 

shown in Figure 3, all of which required periodic inspections. Inspections and testing were time consuming, 

and they added no apparent value over the duration of 

the deployments.

Lesson learned: the safety of bottled water was adequately protected by source and periodic inspections 

performed by VS personnel and storage management by 

QM personnel. The new policy is that PM personnel are 

only required to respond to requests for bottled water 

testing when a need is identified.

“The Grand Experiment” of Military Packaged Water

Drinking primarily commercial bottled water throughout the deployment posed several problems. As much 

as 60% of transportation assets were used to deliver it. 

Truck driving was considered one of the most dangerous 

military occupational specialties, and there was concern 

that intentional contamination opportunities existed 

during transportation and storage. At one point, the fully burdened cost of bottled water, including fuel, convoy 

security, management, and storage costs, was estimated 

at more than $25 per gallon.

The Marine Corps generated an operational needs statement for a mobile water packaging system that could be 

set up wherever an RO system was located. Anticipated 

benefits included that the water would be:

 produced by the Army, reducing procurement costs;

 packaged near its point of consumption, reducing 

transportation costs and risks;

 under the control of the Army at all times, reducing 

intentional contamination opportunities;

 and consumed shortly after production, reducing 

storage requirements.

Additionally, the mobile packaging system would allow 

the elimination of normally required chlorine residual 

levels, significantly improving the taste of the water—

an important improvement.

Research Development and Engineering Command’s 

Product Manager for Petroleum and Water Systems 

(PM-PAWS) purchased a Kärcher (Alfred Kärcher, 

GmbH and Co, Winnenden, Germany) mobile water 

bottling system (Figure 4) that could package 700 oneliter plastic bottles of water per hour. The PM-PAWS, 

Army Test and Evaluation Command, VS, and CHPPM 

jointly tested and evaluated the system at Aberdeen 

Proving Ground, MD, in Germany, and at Forward Operating Base Delta in Iraq, and determined its use was 

feasible. Detailed standing operating procedures were 

developed to ensure the packaged water would consistently meet the military field water standards in Technical Bulletin Medical 577.

2(p35) Seven systems were set 

up and operated at various locations in Afghanistan, *Internal military document not readily accessible by the general 

public.

Figure 3. Examples of large and small, indoor and outdoor bottled water storage.

Public Health Challenges
April – September 2016 185

The Army Medical Department Journal

all fed by contractor-operated RO water treatment systems. The RO-treated and disinfected water was passed 

through carbon filters to remove the chlorine residuals, 

and immediately packaged in one-liter bottles. The primary differences between the packaged water and commercial bottled water were the shape of the bottles and 

the brand names on the labels. Soldier acceptability was 

exceptional. Between August 15, 2010, and December 

30, 2012, a period when all 7 systems were operational, 

more than 20 million bottles of water were produced for 

deployed personnel. The estimated cost was $4 per gallon. With appreciable PM and VS oversight, the grand 

experiment was deemed a success.

Lesson learned: military packaged water is much less 

expensive, and is as safe and desirable as commercially 

bottled water during deployment operations.

Distributed Water Operations

Figure 5 illustrates the spectrum of field water requirements and the equipment available to meet those requirements. At one end 

of the spectrum, bulk water purification systems provide drinking water for large units. 

All of these systems require skilled operators and logistics support for maintenance 

and to move the treated water to the point of 

consumption, as well as PM personnel and 

equipment to test the quality of the water. 

At the other end of the spectrum, individual 

water purifiers (IWP) can supply microbiologically-safe water during emergencies and 

short-term missions. Preventive medicine 

personnel assist units with IWP device selection, based on the mission.

A capabilities gap exists for units performing small-unit operations lasting longer than 

a week. Operations at small forward operating bases and command outposts, and village stability operations complicate water 

supply issues as shown in Figure 6. Fielded 

water treatment systems that address the 

needs of these low-density locations do 

not currently exist. Bulk and bottled water 

transports to these locations are often targeted by enemy forces, and limited travel 

capabilities and high force protection issues 

often prevent PM from visiting to provide 

oversight of water quality.

The Army is working to develop systems 

and procedures that will better suit the 

needs of Soldiers in these operations, and 

the use of commercial off-the-shelf (COTS) systems 

such as those shown in Figure 7 are one consideration. 

However, problems with their use include the lack of 

trained operators, the lack of logistical support for repair 

parts, and the lack of adequate water quality monitoring 

equipment and personnel trained to use it. Their use in 

small unit operations clearly increases health risk, and 

all members of the military field water community are 

engaged in dealing with these issues to enhance water 

capabilities for these operations.

Lesson learned: preventive medicine resources should 

be aggressively involved in all aspects of small unit 

COTS water purifier applications and work with combat 

developers to minimize the Warfighter health risk inherent in their use.

Blow molder, filler, capper, labeler in one transportable container.

Capacity of 700 bottles per hour.

Semiautomatic system,

reliable in field conditions

Figure 4. Kärcher WB 700 water bottling system.
186 http://www.cs.amedd.army.mil/amedd_journal.aspx

Division

(3 Brigades)

10,000 - 18,000 Soldiers

Field Army

(2-5 Corps)

Corps

(2-5 Divisions)

Company

(3-5 Companies)

100-200 Soldiers

Battalion

(3-5 Companies)

500-600 Soldiers

Platoon

(3-4 Squads)

16-40 Soldiers

Squad

4-10 Soldiers

Brigade

(3 or more Battalions)

3,000-5,000 Soldiers

3,000 GPH ROWPU

600 GPH ROWPU

1,500 GPH

Tactical Water

Purification

System

Asymmetric, battlefield-created

gap in water treatment materiel

125 GPH

Lightweight Water

Purification System

Individual Water

Purification Set

Figure 5. The spectrum of Army combatant command field water requirements and equipment available to meet them.

Conclusion

The availability of adequate quantities of acceptable 

quality drinking water is essential for deployed personnel to be effective across the spectrum of military 

operations. Preventive medicine, Corps of Engineers, 

and QM personnel overcame many challenges in Iraq 

and Afghanistan to ensure that availability at all levels 

of operations. Lessons were learned and changes were 

implemented to enhance all aspects of water treatment, 

delivery, testing, and monitoring. Continued Army 

modernization will necessitate concurrent evolution of 

field water supply practices and procedures to meet the 

changing needs of all deployed personnel and operations. Medical community participation in the application of the Doctrine, Organization, Training, Material, 

Leadership, Personnel, and Facilities problem-solving 

construct to meet those needs and preserve the health of 

deployed personnel is imperative. In the final analysis, 

the Army’s ultimate weapon does indeed run on water.

References

1. US Army Combined Arms Support Command 

CASCOM, 25 November 2008, Water Planning 

Guide, Force Development Directorate, Fort Lee, 

VA Available at: http://www.quartermaster.army.

mil/pwd/publications/water/Water_Planning_

Guide_rev_103008_dtd_Nov_08_(5-09).pdf.

2. Technical Bulletin Medical 577: Sanitary Control 

and Surveillance of Field Water Supplies. Washington, DC: Departments of the Army, Navy, and 

Air Force; May 2010. TB MED 577/NAVMED P50-

10/AFMAN 48-138_IP. Available at: http://armypubs.army.mil/med/DR_pubs/dr_a/pdf/tbmed577.

pdf. Accessed March 30, 2016.

Public Health Challenges
April – September 2016 187

The Army Medical Department Journal

3. Deputy Inspector General for Auditing. Inspector General Report No. D-2008-060: Audit of Potable and Nonpotable Water in Iraq. 

Washington, DC: US Department of Defense; 

March 7, 2008. Available at: http://www.dodig.

mil/audit/reports/fy08/08-060.pdf. Accessed 

March 30, 2016.

4. US Department of Defense. Worldwide Directory of Sanitarily Approved Food Establishments for Armed Forces Procurement. Aberdeen Proving Ground, MD: US 

Army Public Health Center (Provisional), 

2016. Available at: https://phc.amedd.army.

mil/topics/foodwater/ca/Pages/DoDAp

provedFoodSources.aspx. Accessed March 30, 

2016.

Authors

Dr Richards is Field Water Section Chief, Drinking Water and Sanitation Program, Environmental Health Engineering Directorate, Army Public 

Health Center (Provisional), Aberdeen Proving 

Ground, Maryland.

Mr Lundquist is an Environmental Engineer, 

Drinking Water and Sanitation Program, Environmental Health Engineering Directorate, Army Public 

Health Center (Provisional), Aberdeen Proving Ground, 

Maryland.

Mr Richards is Program Manager, Drinking Water and 

Sanitation Program, Environmental Health Engineering 

Directorate, Army Public Health Center (Provisional), 

Aberdeen Proving Ground, Maryland.

Figure 6. A shower, handwashing station, and a well, typical of water supply situations at village stability operation locations.

Figure 7. Examples of commercial off-the-shelf small unit water purification equipment.
188 http://www.cs.amedd.army.mil/amedd_journal.aspx

Over the past 14 years at war, knowledge pertaining to 

casualty care has expanded exponentially. The lessons 

learned and strategic guidance such as “Army 2020 and 

Beyond”1

 call for a “modular, scalable, networked and 

fl exible health service support force structure.” Additionally, the importance of expedited medical care on 

the battlefi eld was prioritized in 2009 by the Secretary 

of Defense mandate that injured service members receive treatment at a military medical facility within 60 

minutes of a call, ie, “the golden hour.”2

 This requirement and strategic guidance caused a reevaluation of 

existing medical unit structure that led to 3 recent organizational changes in Army medicine. These approved 

changes were suggested after detailed analysis and recommendations that resulted from the work of several 

 integrated process action teams (IPATs), each chartered 

specifi cally to study the organization.

The IPATs followed the process outlined by the Joint 

Capabilities Integration Development System. In order 

to address medical capability gaps identifi ed during the 

ongoing war, IPATs were composed of subject matter 

experts including, but not limited to clinicians; senior 

offi cers and noncommissioned offi cers; experts in doctrine, organizational, personnel and equipment management; and representatives from the Center of Army Lessons Learned. The IPAT conducted a thorough analysis 

in an effort to determine the requirements to meet mission demands, current capabilities, the gaps in the ability to meet these demands, and a myriad of potential 

solutions to fi ll those gaps.

All 3 changes discussed in this article are aimed at providing the casualty an enhanced level of trauma management as close to the point of injury as possible. The 

fi rst change is a personnel substitution that assigns 

a trained emergency medicine clinician in place of a 

general medical offi cer in the brigade support medical 

company (BSMC) treatment squad. The second modifi cation is a force design update (FDU) of the forward 

surgical team (FST) resulting in a forward surgical and 

resuscitative team (FRST), which allows for 2 identical 

teams with the same capabilities to operate in different 

locations. The third change to be discussed is the FDU of 

the combat support hospital (CSH) that results in a more 

scalable and modular deployment of CSH assets to meet 

mission demands. These 3 changes will lead to more effi cient deployment of medical assets to the point of need, 

bringing a higher level of care closer to the patient as opposed to bringing the patient to care. The Army projects 

that these modifi cations will begin taking place in fi scal 

year (FY) 2016 and will be complete by FY 2022, based 

on mission demands and available resourcing.

Surgical and Resuscitation Capabilities for

 the “Next War” Based on Lessons Learned

 From “This War”

 LTC David Freel, SP, USA

 MAJ Bradley J Warr, SP, USA

ABSTRACT

The Army gleaned many lessons regarding the provision of medical care to casualties during the past 14 years of 

combat. Using these lessons learned in the Joint Capabilities and Integration Development process and through 

the analysis of an integrated process action team, the Army recently approved 3 changes to medical organizations that are intended to provide trauma management farther forward on the battlefi eld. These changes include 

the substitution of an emergency medicine trained physician and emergency medicine physician assistant (PA) 

in lieu of a general medical offi cer and primary care PA within the brigade combat team; reorganization of the 

forward surgical team into a forward surgical and resuscitative team; and the modularization of the traditional 

248 bed combat support hospital. The Army anticipates that these changes related to personnel, organizations, 

doctrine, and materiel will enable Army medicine to provide enhanced trauma management closer to the point 

of a combatant’s injury. These modifi cations are projected to begin in fi scal year 2016.

DOCTRINE AND TRAINING PROGRAMS
April – September 2016 189

THE ARMY MEDICAL DEPARTMENT JOURNAL

ADVANCED TRAUMA MANAGEMENT/DAMAGE CONTROL

RESUSCITATION TEAM IN THE BRIGADE COMBAT TEAM

At divisional level and below, the Army has lacked the 

ability to provide specialized advanced trauma management (ATM)/far-forward damage control resuscitation 

(DCR) at or near the point of injury to prevent deterioration and death in the urgent presurgical patient and 

reduce the number of deaths with potentially survivable wounds.3

 There is a lack of specialized clinicians at 

Roles 1 and 2 who possess trauma management training 

and skill. Further confounding this problem is the inability of the assigned clinicians to receive and sustain 

the appropriate training relevant to current standards for 

trauma management.

It is recognized that advances in battlefi eld trauma care 

and the institution of the Tactical Combat Casualty Care 

guidelines have resulted in the saving of many lives 

from the point of injury through the continuum of care. 

Tourniquets, hemostatic dressings, nonprotein colloids, 

intraosseous access devices, and hypothermia prevention systems have contributed signifi cantly to decreased 

morbidity and mortality; however, battlefi eld resuscitation of major hemorrhage remains a high priority. From 

a retrospective analysis, the majority of “potentially 

survivable” injuries resulting in death on the battlefi eld 

and after reaching a surgical facility are caused by hemorrhage. In a hemorrhage situation, “resuscitation” refers to the restoration of circulation after blood loss. Resuscitation is vital because restoration of blood volume 

and blood pressure are the main methods for preventing hemorrhagic shock. Hemorrhagic shock is a severe 

life-threatening condition which, if left untreated, will 

promote the dysfunction or complete failure of the vital organs, causing the patient to die. According to Joint 

Theater Trauma Registry data, over 21% of military casualties are in shock upon admission to the CSH or FST, 

and over 25% require a blood transfusion. In combat, 

hemorrhage is the cause in 85% of all such potentially survivable deaths. Other signifi cant causes of death 

among potentially survivable casualties are central nervous system injury (ie, head, neck, spinal cord), airway 

compromise due to obstruction or injury, and multisystem organ failure related to shock and the lethal triad of 

hypothermia, coagulopathy, and acidosis. By projecting 

a higher capability of medical care such as ATM/DCR 

forward to the casualty, the subsequent enhancement of 

treatment of these injuries will improve the likelihood 

of stabilizing the casualty and potentially extend patient 

survival time before surgical intervention.

In 2015, Kotwal et al 4

 published data that supports the 

2009 Secretary of Defense’s institution of the “golden 

hour” for patient care. There was a signifi cantly lower 

percentage killed in action among those casualties who 

received a blood transfusion (6.8% vs 51%; P<.001) and 

those who were transported to defi nitive care within the 

60 minute requirement (25.7% vs 30.2%; P<.01). A recommendation was submitted in 2015 by the Advanced 

Trauma Management IPAT, endorsed by the Commanding General, AMEDD Center and School and Health 

Readiness Center of Excellence, through the US Army 

Training and Doctrine Command, and approved by the 

Department of the Army that provides standardized resuscitative teams capable of supporting forward DCR, 

comprised of specifi c key tasks performed by expert 

emergency medicine clinicians who are assigned organically for employment by commanders and medical 

planners within a brigade combat team.5

The approved solution to enhance the ATM/DCR capability calls for the substitution of the previously assigned 

area of concentration (AOC) 62B (fi eld surgeon/general 

medical offi cer) and AOC 65D (primary care physician 

assistant) with AOC 62A (emergency medicine physician) and AOC 65DM2 (emergency medicine physician 

assistant) in one treatment squad within the BSMC. 

This change provides the brigade surgeon guidance 

and direction regarding the trauma system, and moves 

enhanced ATM/DCR capable teams closer to the point 

of injury to provide advanced trauma care. Enhanced 

ATM/DCR will be focused within the medical company 

that is organic to the brigade combat team.

FORWARD RESUSCITATIVE AND SURGICAL TEAM

The second change is based on an identifi ed requirement 

to provide a standardized, rapidly deployable, modular, 

and scalable resuscitative and surgical team capable of 

supporting short (less than 72 hours) or extended (more 

than 72 hours) operations. The FST, originally envisioned and designed in the 1990s, was based on the then 

current operating concepts and standards of care. The 

doctrinal employment of these units required they remain intact in their 20-person confi guration. When FST 

split-based operations were attempted during the current 

war, erosion in both capability and capacity occurred.6

*

The new FRST design is based on current lessons 

learned, enforcement of current policy, and input and 

mission support requirements from US Army Special 

Operations Command (SOCOM) and Forces Command 

commanders and medical planners/providers.2,6,7* The 

opinions and experiences of clinical subject matter experts as well as former and current FST Chiefs were 

also weighed. These recommendations were made with 

*R. Espinosa, 274th FST after action report, memorandum for the 

record; 2006. Internal military document not readily accessible by 

the general public.
190 http://www.cs.amedd.army.mil/amedd_journal.aspx

consideration of future operating concepts and environments. Modifi cations to this team focused on the ability of the team to simultaneously operate in 2 locations 

with the team’s organic personnel and equipment. Moving to a more modular force created a need for more 

fl exible support elements. A more fl exible design and 

revised surgical skill competencies are intended to meet 

the combatant commanders’ need for independent operations while expanding damage control capabilities 

across the battlefi eld, especially closer to the point of 

injury.

An approved force design update of the forward surgical 

team resulted in the new FRST. The design update revised and streamlined the surgical procedure list into 8 

specifi c damage control surgeries (DCS) the team could 

perform, while reorganizing the personnel in an effort 

to accommodate a balance of surgical skill sets during split-based operations. The emergence of DCR as 

an important adjunct to the forward surgical capability 

was recognized in the new design. This resulted in 

the addition of emergency physicians and emergency 

nursing personnel who will be able to focus on DCR 

interventions in the pre- and postoperative areas while 

the surgical teams perform DCS in the operating suites. 

Modelling and experimentation suggest a capability that 

combines DCS and DCR will increase both capability 

and throughput of the FRST vice a resuscitative and 

surgical capability employed by surgeons alone. The 

postresuscitative holding section of the FRST has been 

enhanced to include a more robust postresuscitation 

capability and skill set (Figure 1). At the request of 

SOCOM, a 6-man element was designed to provide 

short-term, mission-specifi c DCR/DCS in support 

of unconventional operations. Additionally, materiel 

additions including additional generators, information 

technology systems, and radios enable the FRST to 

conduct split-based operations without dependency 

upon or collocation with a Role 2 medical company.

COMBAT SUPPORT HOSPITAL

As previously indicated, a more modular combatant 

force creates a need for more fl exible support elements. 

This includes a requirement for the CSH to be scaled and 

tailored to support unifi ed land operations. After action 

reviews documented the inability of the traditional CSH 

to conduct split-based operations due to personnel and 

equipment limitations.* Through analysis and review of 

past operations, a CSH required augmentation in order 

to function in multiple locations simultaneously. In an 

effort to mitigate this capability gap, a FDU was submitted and approved. The redesigned unit is capable of 

*Internal military documents not readily accessible by the general 

public:

Memorandum for the record: After Action Review for 86th 

Combat Support Hospital Operation Desert Eagle in Support

of Operation New Dawn (Sep 2010-Sep 2011); 2011.

AMEDD Lessons Learned Observation Summary #933;

July 28, 2010 [restricted access].

Figure 1. Organizational structure of the Forward Resuscitative and Surgical Team. Total manning: 13 offi cers, 7 enlisted.

Administration/Supply Section

1 Healthcare Administrative Assistant

(offi cer, AOC 70B)

1 Healthcare Specialist

(enlisted, MOS 68W)

Surgical Section

1 General Surgeon

(offi cer, AOC 61J)

1 Orthopedic Surgeon

(offi cer, AOC 61M)

1 Critical Care Nurse

(offi cer, AOC 66S)

1 Nurse Anesthetist

(offi cer, AOC 66F)

1 Practical Nursing Specialist

(enlisted, MOS 68C)

1 Operating Room Specialist

(enlisted, MOS 68D)

Surgical Section

1 General Surgeon

(offi cer, AOC 61J)

1 Orthopedic Surgeon

(offi cer, AOC 61M)

1 Critical Care Nurse

(offi cer, AOC 66S)

1 Nurse Anesthetist

(offi cer, AOC 66F)

1 Practical Nursing Specialist

(enlisted, MOS 68C)

1 Operating Room Specialist

(enlisted, MOS 68D)

Resuscitative Section

1 Emergency Medicine Physician

(offi cer, AOC 62A)

1 Emergency Nurse

(offi cer, AOC 66T)

1 Healthcare Specialist

(enlisted, MOS 68W)

Resuscitative Section

1 Emergency Medicine Physician

(offi cer, AOC 62A)

1 Emergency Nurse

(offi cer, AOC 66T)

1 Healthcare Specialist

(enlisted, MOS 68W)

Figure 2. Modularized Combat Support Hospital.

HOSPITAL CENTER

Headquarters &

Headquarters 

Detachment

FIELD HOSPITAL

(32 bed)

Surgical

Augmentation

Detachment

(24 bed)

Medical

Augmentation

Detachment

(32 bed)

Intermediate

Care Ward

Augmentation

Detachment

(60 bed)

DOCTRINE AND TRAINING PROGRAMS
April – September 2016 191

THE ARMY MEDICAL DEPARTMENT JOURNAL

modular deployment enabling it to conduct split-based 

operations and enhanced early entry healthcare. These 

capabilities were added by redesigning the single 248 

bed CSH into 5 separate units that maintain the ability 

to be deployed independently as needed (Figure 2). The 

new design offers combatant commanders the ability to 

call for early entry trauma capabilities, but allows for 

the expansion of hospital based capabilities for enduring operations. Additionally, the redesign was intended 

to increase selective surgical and emergency medicine 

capabilities; increase intensive care capability; and integrate organic computer tomography (CT) scanners and 

microbiology lab capabilities into the unit.

CONCLUSION

The 3 changes discussed here demonstrate how lessons 

learned from the ongoing war have led to solutions in 

doctrine, personnel, organization, and materiel. Both 

the substitution of specialized providers at in the brigade support medical company and the reorganization 

of FST into the FSRT are intended to provide a higher 

level of ATM/DCR or DCR/DCS farther forward during operations. Additionally, the new FSRT and modularized CSH are enabled to conduct split-based operations and deploy assets as needed to support the mission. 

The materiel additions that include an organic CT scanner will further expand the capabilities of the CSH. As 

these solutions are implemented, there will be continuous review and analysis of their effectiveness.

REFERENCES

1. Combined Arms Support Command. Army 2020 

and Beyond Sustainment White Paper. Fort Lee, 

VA: US Army Combined Arms Support Command; August 30, 2013. Available at: http://www.

cascom.army.mil/ [Sustainment White Paper link]. 

Accessed March 30, 2016.

2. Shanker T. Gates seeks to improve battlefi eld trauma care in Afghanistan. New York Times. January 27, 2009. Available at: http://www.nytimes.

com/2009/01/28/washington/28military.html?_

r=0. Accessed October 7, 2015.

3. Gerhardt RT, De Lorenzo RA, Oliver J, Holcomb 

JB, Pfaff JA. Out-of-hospital combat casualty 

care in the current war in Iraq. Ann Emerg Med. 

2009;53:169-174.

4. Kotwal RS, Howard JT, Orman JA, et al. The effect of a golden hour policy on the morbidity 

and mortality of combat casualties. JAMA Surg. 

2016;151(1):15-24.

5. Gardiner H, Forslund M, Freel DA. Army DOTmLPF-P Integrated Capabilities Recommendation 

(DICR) for Advanced Trauma Management/Damage Control Resuscitation (ATM/DCR). Joint Base 

San Antonio-Fort Sam Houston, TX: Advanced 

Trauma Management Integrated Process Action 

Team; 2015.

6. Patel TH, Wenner KA, Price SA, Weber MA, Leveridge A, McAtee SJ. A US Army forward surgical team’s experience in Operation Iraqi Freedom. 

J Trauma Acute Care Surg. 2004;57:201-207.

7. Moore T. Memorandum: Extraction and Analysis 

on Medical Team, Forward Surgical (FST) Splitbased Operations. Joint Base San Antonio-Fort 

Sam Houston, TX: Directorate for Combat and 

Doctrine Development, US Army Medical Department Center and School; 2014.

AUTHORS

LTC Freel and MAJ Warr are with the Capabilities Development and Integration Directorate, Army Medical 

Department Center and School Health Readiness Center 

of Excellence, Joint Base San Antonio-Fort Sam Houston, Texas.
192 http://www.cs.amedd.army.mil/amedd_journal.aspx

Military healthcare provider training programs primarily train their doctors, physician assistants, and nurse 

practitioners using civilian institutional training mechanisms. This consists of classroom lectures, skills training as well as hospital and clinic based practice. Providers in these environments have access to a support team 

of skilled nurses, technicians, laboratory, radiology, and 

pharmacy professionals. They work in controlled environments with a ready availability of a wide variety of 

surgical equipment sets and medical supplies. Most will 

continue to practice in these environments after graduation until they are called upon to deploy. While this is 

both appropriate for peacetime medicine and provides a 

strong foundation, for the deploying provider within the 

military system of healthcare, it does not go far enough. 

The medical equipment sets, conditions, and expectations of Tactical Combat Casualty Care (TC3) present 

a potentially steep learning curve. It is important that 

providers’ fi rst encounter with TC3 not be during deployment with a combat unit caring for actual casualties.

In the years leading up to the Global War on Terrorism, there was no structured course to prepare medical 

providers for assignment to Role 1 and Role 2 environments. With increased focus on the importance of tactical combat casualty care (TCMC) to reduce morbidity 

and mortality, the TCMC course was instituted.

COURSE HISTORY

In 2003, a number of physician assistants assigned to 

Fort Sam Houston, Texas, joined units scheduled for 

deployment to Iraq. They identifi ed signifi cant knowledge gaps related to deployment and prehospital care 

among providers, as well as lessons learned on the rapidly changing battlefi elds. To strengthen the preparation 

of recently commissioned and often newly graduated 

physician assistants likely to deploy shortly after arrival 

at their units, the TCMC course was created as part of 

the corps-specifi c track of the Basic Offi cer Leadership Course. The goal was to familiarize them with the 

equipment used by their future unit and prepare them 

to provide medical care in an austere environment. The 

course was initially presented approximately 3 times per 

year. As the pace of deployments increased, it expanded 

up to 26 classes per year and opened its doors to deploying physicians, nurse practitioners, nurses, and senior 

noncommissioned offi cers in addition to the physician 

assistants for whom it was originally targeted.

The Tactical Combat Medical Care course served as 

the basis for creation, refi nement, and improvement of 

other predeployment preparation courses for addressing additional echelons of care and experience levels 

of providers. These include the Brigade Combat Team 

Trauma Training course supporting combat medics, licensed practical nurses, and fl ight medics, the Military 

Transition Team course for Soldiers assigned to Military 

Transition Teams, and the Joint Forces Combat Trauma 

Management course for those assigned to combat support hospitals.

As of this writing, over 4,000 providers have received 

training in the TCMC course. During the peak training period, which operated until September 30, 2014, 

2 classes were presented per month, 30 seats per class, 

with a total of 26 classes per year. However, although 

predeployment medical training has been a requirement 

since 2009 and class availability was greatly expanded, medical providers were still deployed without the 

mandated courses. Factors cited in the failure to attend 

training include appropriate window for course timing, 

short-notice deployment, availability of providers to 

leave other duties, command support, and the provider’s 

perception of his or her own knowledge and competence.

Predeployment Medical Training for Providers

 MAJ Michael D. Holloway, SP, USA

ABSTRACT

Following the attacks of September 11, 2001, the United States became simultaneously engaged in military 

confl icts in 2 theaters of operation. At that time there was no organized program to train medical providers assigned to deployable Role 1 or Role 2 aid stations. To fi ll this gap, the Tactical Combat Medical Care (TCMC) 

course was developed and instituted at Fort Sam Houston, Texas, in 2004 to provide the training platform for 

providers in preparation for assignment to and deployment with combat units. The TCMC course has become 

the standard for prehospital wartime care training. All military healthcare providers (physicians, physician 

assistants, nurses, combat medics) requiring training to supplement their basic medical education and facilitybased experiences are eligible to attend this course.
April – September 2016 193

THE ARMY MEDICAL DEPARTMENT JOURNAL

CURRENT COURSE CONTENT

Currently, the TCMC course is a 5-day predeployment 

course conducted at Fort Sam Houston, Texas. There are 

12 classes per year with funding for 10 students per class. 

The goal is to train providers at least 90 days prior to 

deployment, with priority given to those deploying to an 

austere or combat environment. The timing window is 

to help ensure that providers deploy with the most current knowledge and that it remains fresh in their minds. 

Nurses, senior medics, and fl ight paramedics are allowed 

to attend on a space available basis. The course is a predeployment requirement for all Role 1 and 2 providers 

per Headquarters, Department of the Army Execution 

Order 096-09HQDA* and US Forces-Afghanistan Fragmentary Order 14-067*.

In addition to preparation for battlefi eld medicine, the 

TCMC course also contributes to certifi cation requirements by providing over 40 hours of Category 1 Continuous Medical Education (CME) credits. The course is 

comprised of didactic and hands-on training. There are 

151⁄2 hours of didactic covering TC3 based off the Committee on Tactical Combat Casualty Care guidelines and 

updates, Army Medical Department (AMEDD) lessons 

learned, feedback from the fi eld, the Joint Theater Trauma Services weekly conference, and interaction with 

the Army Institute of Surgical Research.

The course also provides 27 hours of hands-on training 

to reinforce skills and muscle memory. Subjects demonstrated with hands-on training including rapid trauma 

assessment; fresh whole blood transfusion (the process 

of giving blood drawn recently (under 24 hours) and 

not separated into its components); pediatric trauma; intraosseous infusion devices currently in use such as the 

FAST 1 and EZ-IO; airway management including intubation and surgical cricothyroidotomy; thoracic trauma; 

junctional tourniquets; and emergency surgical skills 

performed in an environment simulating a deployed 

setting.

Providers will often be faced with providing healthcare 

outside the aid station as well as training and refi ning 

the skills of his or her medics. The TCMC course takes 

a crawl, walk, run method to training the providers on 

care under fi re and tactical fi eld care. This helps to ensure that they perform the right intervention at the right 

time in the continuum of care. The TCMC course places 

providers in situations similar to deployment to provide 

the most realistic training possible within the confi nes 

of available resources, and help them test their newly 

trained skills and assess their profi ciency.

As the battalion aid station is the primary treatment location for our deploying providers, TCMC also works 

to teach the team concept, each team member’s role, 

and train them to be the team leader. This is done in a 

coached environment during the week, further helping to 

refi ne this skill. As the culminating event, the providers 

put their new or refi ned skills to action in a simulated deployed aid station, building confi dence and competence.

One important area of training is trauma medication. 

In the hospital setting, providers prescribe medications 

and give instructions for their administration. The order 

itself is generally carried out by a licensed nurse; either 

a licensed practical nurse or registered nurse who has 

knowledge of drug preparation, dosing, administration, 

and side effects. In the deployed environment, the provider does not have that same trained staff. He or she is 

now taking on the responsibility not only for the order, 

but for the whole administration process. This can be a 

challenge. To ameliorate this, the TCMC course has a 

hands-on skills station for training and practicing common trauma medication preparation and administration. 

It also gives the provider a chance to ask any questions 

he or she may have in a safe environment with minimal 

risk.

Although providers are exposed to TC3 in the point of 

injury and Role 1 and Role 2 environment training, because of their varied experience and baseline knowledge 

they will not all leave the training completely profi cient. 

To gain profi ciency, the skills provided will require 

continued refi nement once they arrive at or return to 

their unit. Postdeployment feedback from providers returning from deployment have lauded the training that 

TCMC provided, and commented about how much better prepared they felt to treat combat casualties in austere environment.

THE FUTURE

The Global War on Terrorism, the umbrella under which 

military operations following the attacks of September 

11, 2001, were conducted, including Operation Iraqi 

Freedom and Operation Enduring Freedom as well as 

several other regional actions, had the lowest case fatality rate of all wars in which the United States was involved.1-3 The TCMC course contributed to that statistic 

as the fi rst conventional forces course to train TC3. Provider reports from the fi eld demonstrate the importance 

of their new skills in combat casualty care, including the 

use of the walking blood bank during the battle of Combat Outpost Keating (Afghanistan, October 3, 2009).

The war on terrorism demonstrated early on that many 

providers are not familiar with Tactical Combat Casualty *Internal military documents not readily accessible by the general 

public.
194 http://www.cs.amedd.army.mil/amedd_journal.aspx

Care, austere medicine, and military medical equipment 

sets. Future loss of the hard-fought gains in institutional 

knowledge learned from this confl ict would be devastating, considering that approximately 90% of combatrelated deaths occur prior to the casualty reaching a 

medical treatment facility.4,5 As such, the TCMC course 

should transition from a predeployment medical course 

to a provider sustainment course. It is necessary for it to 

become not only a requirement for all providers assigned 

to Role 1 and Role 2 locations prior to arriving at their 

unit and then every 2 years thereafter, but a priority. Part 

of this sustainment should include an evaluated training 

event 90 days prior to deployment to an austere environment to ensure profi ciency in specifi c medical tasks.

The TCMC course also has an important role for physicians and physician assistants that are fi rst entering the 

AMEDD as providers. True to the program’s roots, the 

physician assistant and medical corps tracks in the Basic 

Offi cer Leadership Course are invaluable opportunities 

to provide this training so they report to their fi rst assigned unit prepared. Accomplishing this will require 

funding and staff above the current levels.

Standardization of point of injury, Role 1 and Role 2 

care across the brigade combat team and military is paramount; this can be done by providing TC3 training to 

all providers being assigned to a brigade combat team 

in the Brigade Healthcare Provider Course. Following 

this, physicians and physician assistants can attend a 

more in-depth hands-on track providing training and 

reinforcement as it relates to battalion aid station operations and skills.

Knowing that the military is moving from the current 

large pool of providers with deployment experience into 

a time of fewer numbers of them, extending and expanding this course is paramount. It will allow not only exposure to the fi eld sets, skills and knowledge, but will 

allow for training and evaluation to move from exposure to profi ciency and confi dence. The extended course 

will also allow the addition of important content such as 

prolonged fi eld care and tactical training.

The creation of a TCMC/TC3 web page will allow providers access to the most current TC3 guidelines and 

updates to help keep everyone up-to-date to provide 

consistent, evidence-based care. It will also serve as a 

platform for articles and learning activities that will provide CME credits related to tactical medicine. Course 

read ahead material coupled with a pretest on training 

day 1 would reduce some of the didactics and give way 

for more hands-on time and expansion into new topics.

Looking toward the expansion and refi nement of tactical 

medicine, specifi c tracks will become necessary. Currently, the training is the same across the board for all 

attendees. The TCMC program can specialize course 

content to help providers at different stages across the 

continuum to further their knowledge.

CHALLENGES AND OPPORTUNITIES

O ur military operates under constantly changing conditions in funding, resources, and battlefi eld environments. 

The TCMC program will continue to refi ne its instruction, continuing to provide the most realistic training 

and simulation coupled with the latest standards of care 

related to battlefi eld medicine. The transition of this 

course to a readiness and sustainment program ensures 

providers will continue to have the skills and knowledge 

necessary to deploy with a forward unit to a combat environment. A failure to adapt and transition the program 

now will result in closing of the doors at the end of the 

current confl ict, ready for resurrection at the beginning 

of the next confl ict, requiring resources, time, and the 

risk of unprepared providers. The program’s transition will help ensure that the nation’s most precious resource—its sons and daughters—return home.

REFERENCES

1. Holcomb JB, Stansbury LG, Champion HR, Wade 

C, Bellamy RF. Understanding combat casualty 

care statistics. J Trauma. 2006;60:397-401.

2. 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;245:986-991.

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 vs 2006. J Trauma. 2008;64(suppl):S21-S27.

4. Bellamy RF. The causes of death in conventional 

land warfare: implications for combat casualty care 

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

5. Champion HR, Bellamy RF, Roberts CP, Leppaniemi A. A profi le of combat injury. J Trauma. 

2003;54(suppl):S13-S19.

AUTHOR

MAJ Holloway is Chief, Department of Tactical Medicine, Center for Pre-Hospital Medicine, Army Medical Department Center and School, Health Readingess 

Center of Excellence, Joint Base San Antonio-Fort Sam 

Houston, Texas.

DOCTRINE AND TRAINING PROGRAMS
April – September 2016 195

TRAINING AND EMPLOYMENT

From Baron Larrey to COL Letterman to the present 

day, the Combat Medic has continually evolved in many 

ways. From hospital stewards to litter bearers and Corpsmen, they have become ever more deeply ingrained into 

the very skin of the fi ghting element.1

 A Medic has been 

involved in every action from the start of WWI to every 

contemporary battle and hit and run action by the enemy, 

establishing a deeply developed level of trust from the 

Soldiers for whom they are responsible. It is the Combat 

Medic who fi rst builds the bonds that enable the Flight 

Medic to deliver the Wounded to the surgeon. It is the 

Medic whom the Wounded Warriors remember most, or 

fi rst, or last. It is the Medic that fi ghts the sickle welding 

hooded beast and holds back the inevitable to send his 

comrade away; so the troops have hope—the platoon, 

the squad, the leaders do not yield to despair. The Combat Medic provides that foundation of confi dence until 

the diffi cult job is done.

The last decade has seen a transformation of Combat 

Medics in both positive and a negative ways. Positive 

because of the advances in using evidence-based decisional processes which have resulted in an organized 

tactical care platform that is trusted throughout the 

world. Negative because training has been relegated to 

a centralized system of predeployment training using 

outside sources. This has eliminated the need for medical noncommissioned offi cers (NCOs) to be prepared to 

teach, coach, and mentor their Medics, Combat Lifesavers, and Soldiers in medical skills and evacuation processes. The system has provided multiple, externally 

provided training sources, meaning that NCOs are no 

longer required to resource, prepare, or use the 8-step 

training model. In many ways, we have stopped developing Combat Medics who are capable of mounting a 

platform and instructing.

COMBAT MEDIC EMPLOYMENT IN STABILITY OPERATIONS

AND COUNTERINSURGENCY

The last 14 years of armed confl icts have been challenging for Combat Medics, both tactically and technically. 

Their ability to operate in the new confl ict paradigm has 

seen skill adaptations from Special Forces skill sets in 

the areas of affected population care management, use 

of organic medical assets by the mission commander to 

shape local government cooperation, and host nation 

asset evaluation for Civil Affairs and State Department 

missions. None of those functions are found in the Critical Task List of the Combat Medic.

Skill Level 10 tasks that 68W* Combat Medics have 

used in the current stability operations and counter-insurgency environment:

 Civilian primary care including assessment and 

treatment for common injuries and illness, identifi cation and care for complex systemic problems, 

inoculations, and preventive care.

 Responding to farming and vehicular accidents in 

civilian sectors.

 Assessing civilian medical assets and recommending improvements to structures, manpower, training, and equipment.

Lessons Learned: Employment and

 Tactical Use of The Combat Medic

 During Stability Support Operations

 MSG Michael S. Eldred, USA

ABSTRACT

It is the intent of this article to defi ne the strategy by which Combat Medics have been employed in contemporary stability operations and counterinsurgency confl icts. This article describes the advances in training 

based on Tactical Combat Casualty Care and how training evolved into an evidence-based model. Training 

platforms evolved with shifts in mission requirements, new technology, improved medical techniques, and 

changing protocols. The last portion of this article details recommendations in doctrine, materiel, and training 

that could enable optimal sustainment standards while retaining operational capability across a wide variety of 

combat and peace operations. Lessons learned and changes adapted for Medics that are addressed: (1) advances 

in training and employment of the Combat Medic necessitated by tactics and strategy of current confl icts, (2) 

Combat Medic regulatory requirements and centralized, just-in-time training, and (3) changes in sustainment 

training driven by certifi cation requirements and use of medical simulation training centers.

*Military occupational specialty (MOS) 68W10 is the Army designator for Soldiers who are Combat Medics.
196 http://www.cs.amedd.army.mil/amedd_journal.aspx

 Primary care for other US government and nongovernmental organizations.

 OB/GYN care provided by female Medics assigned 

to Special Operations Special Response Teams.

The most signifi cant shift in the roles of Combat Medics has been the employment of individual Medics in 

austere, distant outposts. These forward operating posts 

are not readily accessed by ground evacuation assets 

and are therefore highly dependent on air evacuation. 

Given the generally good weather and unchallenged air 

superiority of our forces during the current confl icts, 

evacuation times to reach dispersed forward surgical or 

far forward resuscitative assets have been decreased to 

less than an hour. A prolonged weather event or the introduction of highly mobile, shoulder-fi red antiaircraft 

weapons would sharply effect our skill requirements. 

The ability to provide prolonged fi eld care and hold critically injured patients for possibly extended periods due 

to this tactical shift is essential to the future needs of 

our Warfi ghters. This capability could include use of advanced resuscitative medication, invasive surgical and 

dental care, and critical care skills in antibiotics drugs 

and anesthesiology.

Another important change is that asset development of 

the medical plan has not been limited to preventing illness, injury, and treating trauma in combat forces. It has 

expanded to assist in mission accomplishment through 

leveraging the ability of the Combat Medic to gain the 

trust of civilians and local government offi cials.

Shaping expectations of what we do to assist in the mission often falls on very junior leaders. They rarely understand the complexities of what they are allowed to do 

and what is ethically acceptable for exploitation by the 

mission command. Beyond that, junior leaders usually 

have no concept of what effect they could have on the civilian services when they circumvent the civilian medical system.2

 As explained in Joint Publication 3-07:

The effi ciency and effectiveness with which US forces 

can deliver humanitarian assistance, particularly medical 

and dental care, can have the unintended consequence of 

decreasing the population’s confi dence in the HN’s [host 

nation’s] ability to provide basic care. Possibly even 

worse, excessive US humanitarian assistance may delay 

and undermine the reconstitution of existing medical 

and other basic needs infrastructure in the HN.3(pIII-22)

This does not mean we should not prepare our Combat 

Medics for this mission, or even that it is unethical to 

shape civilian opinion through improving their medical 

care. The United States has had a high level of success 

in changing the level of medical care wherever our forces have been stationed. From epidemiological disease 

control to extending the average lifespan by providing 

preventive care, clean water, and improved agriculture, 

the United States has exported healthcare improvements 

to every country in which it had occupation forces, or 

maintains current bases of convenience or treaty obligation.4

 This was recently evidenced in the adaptation of a 

new emergency medical system in Iraq while the war in 

that theater was at its peak.2

 As Gresser points out:

Before military leaders probe a situation to discover solutions, they must determine what is morally required.5(p75)

An excellent example of this kind of mission solution 

is the strategic use of medical personnel by then MG 

Petraeus in Mosul, Iraq, from 2003 to 2004 when he 

recognized that moral obligation based on the Geneva 

Convention to establish the “security and well-being of 

the Iraqi people in his area of responsibility.” 6

In future confl icts, we can expect not only the tactics 

and strategy to change, but also dramatic shifts in demographics coupled with emerging technologies to cause 

fundamental changes in the types of skills the military 

medical system will need to cultivate. Allenby characterizes this shift in perspective as:

...rather than rely on the aggression, emotion, and physical stamina of youth to rely more on the judgment, wisdom, and patience of older age.7

This shift could involve recruiting older enlistees, causing an even more dramatic shift in medical support of 

the force. The results would also guarantee more lessons 

learned from and changes made to our medical system.

CHANGES IN SUSTAINMENT TRAINING

Early in the last decade, the Combat Medic qualifi cations converted to a Department of Transportation 

(DOT) emergency medical technician (EMT) based 

certifi cation, EMT-Basic (EMT-B). This was due in part 

as a solution to the issue of sustainment training and to 

align with the other services that had moved towards the 

DOT EMT program for ease of tracking training and 

perceived readiness. As the Army entered the current 

War on Terror confl icts throughout the world, it became 

obvious that EMT-B was never an adequate measure of 

Combat Medic readiness.

The issue is the certifi cation level chosen for the Combat 

Medic. The EMT-B is the lowest level of certifi cation for 

emergency medical service (EMS) personnel. They are 

normally limited to driving or preparing the ambulance 

for calls and are never assigned solo. They are always 

coupled with intermediate or paramedic level certifi ed 

EMS members who have the experience and training 

to deal with complex urgent situations. This was part 

DOCTRINE AND TRAINING PROGRAMS
April – September 2016 197

THE ARMY MEDICAL DEPARTMENT JOURNAL

of the plan in the initial stages of the Army’s program. 

When the DOT EMT standard was adopted, the plan 

was for progression of medical certifi cation skills as 

NCOs were promoted.8

 In this way, an EMT-B would 

be partnered with an EMT-I or P. Testing of Soldiers in 

Initial Enlisted Training (IET) indicated that the pass 

rate of personnel straight out of school would be disastrous. Even though the plan was for the experienced 

NCO to assume those roles, a hold was placed on the 

ladder process, and then the war started. The immediate 

requirements for Medics in combat operations has seen 

the complete demise of the ladder process, and NCOs 

have almost no advanced medical skills training other 

than administrative.

In 1996, working within the Special Operations medical 

community, USN CAPT Frank Butler helped develop 

the Tactical Combat Casualty Care (TC3) initiative. 

The Special Operations Command implemented TC3 

throughout its force, and it has quickly become the basis 

of all Combat Medic training over and above EMT-B. 

In IET, a Combat Medic (MOS 68W10) must pass the 

national registry EMT-B and then attend an additional 

8 weeks of TC3 training. This provides a very substantial level of combat medical skills through the evidencebased process of the Committee on Tactical Combat Casualty Care (CoTCCC) oversight.

Most NCOs have not been trained in higher level medical skills and many have lost the skills needed to keep 

their Soldiers medically qualifi ed. As a result, it has become necessary to create a centralized training program 

that ensures 90% of all medical personnel are “trained” 

prior to assignment in a current theater of operation. The 

Army Medical Department Center and School sends a 

mobile training team to train Medics at their home station in the United States or brings them to Camp Bullis, 

Texas, for training if they are in the National Guard or 

stationed outside of the United States. This “just in time” 

training program is not providing an adequate level of 

TC3 for units as they then do not train further on these 

skills as previously stated.

Currently, this “just in time” training is causing many 

second and third order effects. Most signifi cantly is that 

Medics are not training their combat lifesavers, and physician assistants (PAs) are not training their Medics. The 

effects are noticeable when Medics try to use their combat lifesavers in casualty collection points, or when PAs 

working on trauma tables have to rely on their Medics 

for assistance. Additionally, battalion surgeons are not 

familiar with TC3, and are reluctant to allow their Medics to carry approved medications and equipment that is 

in the TC3 Guidelines and is taught in TC3 courses.

MISSION COMMAND AND OWNERSHIP OF CASUALTY

CARE AND THE EVACUATION SYSTEM

Control and focus of lethality in the area of operations requires one centralized mechanism of control, one place 

through which all orders, reports, and requests must 

go. This includes casualty care and evacuation. Commanders must thoroughly plan, train, and rehearse, and 

completely own the process. No commander should take 

a unit into an active combat zone without full comprehension of casualty care and evacuation effectiveness. If 

commanders do not understand this system, they fail to 

uphold the standards of mission command. By failing 

to train, prepare, and understand this system, they are 

not prepared to take command of it in the battle space, 

causing them to lose overall visibility of the full combat 

operating situation.

During the last decade of operations, the 75th Ranger 

Regiment has effectively demonstrated combat casualty care and evacuation success. It has proven that TC3 

must be rehearsed and supervised as part of the entire 

combat plan. Their efforts have resulted in less than 3% 

died of wounds rate during their operations.9

 This is a 

direct result of the command taking ownership of the 

casualty care system and ensuring that everyone knows 

the process. The Commanding General, Joint Special 

Operations Command, then LTG Stanley McChrystal, 

implemented directives that made medical training and 

planning part of every Ranger’s operational knowledge. 

He directed that every training event would incorporate 

TC3 and all live fi res would build a TC3 event into the 

mission. It was a surprise to the Special Operations personnel, requiring them to deal with the mission and the 

casualty simultaneously. As a result, the 75th Ranger 

Regiment trains their combat lifesavers to EMT-B level, 

and their Combat Medics who are trained above a paramedic level are ingrained in every aspect of combat operations. No operations order is complete without a fully 

developed and supported casualty evacuation plan, and 

each aspect of medical operations is rehearsed throughout the planning phase.

CONCLUSIONS AND RECOMMENDATIONS:

A clinical ladder should be established which returns 

NCOs to technical applications and improves their 

prehospital medical capabilities.1,3,8,10 Throughout the 

Army, NCOs are regarded as technical experts in their 

respective specialty fi eld. Yet Combat Medic NCOs stop 

receiving advanced training after the Advanced Leadership Course (ALC) when promoted from sergeant to 

staff sergeant. No training for emergency management 

is provided other than that received in Basic EMT in IET, 

and mass casualty operations in ALC. Senior NCOs are 

assigned to leadership roles that consume their time and 
198 http://www.cs.amedd.army.mil/amedd_journal.aspx

do not place them in contact with patients frequently 

enough to maintain primary care skills.

Collaborative development of curriculum must be enhanced and broadened with evidence-based guidelines provided through the Joint Training System and 

CoTCCC. A fully developed centralized system should 

be developed and marketed as the single true source 

from which all Combat Medics obtain their skill improvement, education, doctrine, sustainment, and qualifi cation certifi cates. This should be in conjunction with 

establishment of a direct chain of leadership for prehospital medicine. Combat Medics need a support line 

that provides a consultant, a subject matter expert, and 

a system for building their healthcare knowledge and 

direction.

Even though it is the only evidence-based battlefi eld 

trauma system, TC3 is still not accepted by every commander, by every brigade surgeon, or members of the 

decision-making team in the tactical element. As a result, commanders do not train their medical teams as 

integrated assets in the operation; medics are not trained 

and issued analgesics other than morphine and evacuation assets are not devoted to support rapid transport to 

the closest higher level of care.

The 75th Ranger Regiment has had amazing success 

in decreasing preventable deaths with outcomes better than 3%. This is directly attributable to the mission 

commander making medical care a priority and owning 

it as a system of battle. The entire team, Ranger rifl emen, gunners, drivers, cooks, and offi cers are all trained 

in TC3. Every time they train, they consider safety, and 

they rehearse TCCC. It has become an exercise as inherent as breathing.

REFERENCES

1. Ortiz JM. The revolutionary fl ying ambulance of 

Napoleon’s surgeon. US Army Med Dep J. OctoberDecember 1998:17-25.

2. Donaldson RI, Hasson T, Aziz S, Ansari W, Evans 

G. The development of civilian emergency medical 

care during an insurgency: current status and future 

outlook in Iraq. Ann Emer Med. 2010;56:172-177.

3. Joint Publication 3-07: Stability Operations. Washington, DC: Joint Staff, US Dept of Defense; September 29, 2011. Available at: http://www.dtic.mil/

doctrine/new_pubs/jp3_07.pdf. Accessed April 5, 

2016.

4. Hudson W. Army Diplomacy: American Military 

Occupation and Foreign Policy after World War 

II. Lexington, KY: University Press of Kentucky; 

April 16, 2015.

5. Gresser RC. Macro-ethics and tactical decision 

making. Mil Rev. September-October 2014:72-

80. Available at: http://usacac.army.mil/CAC2/

MilitaryReview/Archives/English/MilitaryRe

view_20141031_art013.pdf. Accessed April 5, 2016.

6. Lundberg K. The Accidental Statesman: General 

Petraeus and the City of Mosul, Iraq. Cambridge, 

MA: Harvard University; 2006. Kennedy School of 

Government Case Program, C15-06-1834.0. Cited 

by: Gresser RC. Macro-ethics and tactical decision 

making. Mil Rev. September-October 2014:72-80.

7. Allenby BR. Senior soldiers: the thin gray line. Bull 

At Sci. 2014;70(5):86-95. Available at: http://thebulletin.org/2014/september/senior-soldiers-thin-grayline7594. Accessed April 5, 2016.

8. De Lorenzo RA. Improving combat casualty care: 

focus on the military medic. US Army Med Dep J. 

January-February 1998:24-30.

9. Kotwal RS, Montgomery HR, Kotwal BM, et al. 

Eliminating preventable death on the battlefi eld. 

Arch Surg. 2011;146(12):1350-1358.

10. Mabry RL, De Lorenzo RA. Improving role I battlefi eld casualty care from point of injury to surgery. US Army Med Dep J. April-June 2011:87-91.

AUTHOR

MSG Eldred is Noncommissioned Offi cer-in-Charge, 

Center for Pre-Hospital Medicine, AMEDD Center & 

School Health Readiness Center of Excellence, Joint 

Base San Antonio-Fort Sam Houston, Texas.

DOCTRINE AND TRAINING PROGRAMS
April – September 2016 199

As of February 28, 2014, 1,308,626 US Soldiers had 

deployed in support of Operations Enduring and Iraqi 

Freedom. Of them, 808,969 were Active, 336,043 were 

National Guard, and 163,614 were Army Reserve. Many 

of them, 383,492 Active, 107,906 Guard and 52,097 Reserve component Soldiers, deployed more than once. 

Department of Defense casualties from October 2001 

through March 2014 include 5,332 killed in action, 

1,453 nonhostile deaths, and 51,932 wounded in action 

(Figure 1).1

 The Army has sustained 3,877 killed in action, 1,044 nonhostile deaths, and 36,421 wounded in 

action (WIA) (Figure 2).1

 Approximately 33% of Army 

WIA required evacuation out of theater. Of the Soldiers 

wounded, 44% remained on active duty or inactive reserve and 17% WIA were medically separated. During a 

confl ict that saw dramatic increases in the severity of injuries, equally dramatic improvements in casualty care 

from the point of injury through rehabilitation greatly 

improved survival (Figure 3). Our nation owes a tremendous debt to the service members who sacrifi ced so 

much during the current confl ict, including the medical 

personnel who stood shoulder to shoulder with them on 

the battlefi eld and the families who supported them back 

home. While we continue to care for those who currently serve in Iraq and Afghanistan, we must also begin 

preparations to care for the casualties of future confl icts.

The US Army Operating Concept, Win in a Complex 

World 2

 describes the future environment as unknown, 

unknowable, and constantly changing. The technological advantage the US military has enjoyed over its adversaries since 1945 is diminishing. War remains a fundamentally human endeavor and the Army is preparing 

Soldiers to succeed by maintaining its edge in the human dimension of combat power. The US Army Human 

Dimension Strategy focuses on the cognitive, physical, 

and social components of professionals and teams.3

 Its 

lines of effort—agile, adaptive leaders; realistic training; and institutional agility—are incorporated into 

Army Medicine’s ready medical force model (Figures 

4 and 5). Army Medicine is applying the human dimension strategy to prepare Army Medical Department 

(AMEDD) personnel for the increasing complexity and 

uncertainty ahead. Army Medicine must be prepared 

for the full spectrum of military operations from major 

combat through humanitarian missions. It will play a 

major role in shaping the security environment and developing the capabilities of partners and allies. Combat 

medics in the future may control truncal hemorrhage 

while under fi re, and laboratory technicians may provide rapid confi rmation testing for Ebola in West Africa.

Like armed confl ict, healthcare is a complex, risk-fi lled 

human endeavor. Military healthcare is even riskier, 

more emotionally charged, and fi lled with uncertainty. 

Army Medicine requires leaders who can thrive and 

grow in this environment. These leaders build the teams 

who provide care on the battlefi eld, in the operating 

rooms, intensive care units, wards, and clinics. They 

provide the purpose, direction, and motivation necessary for safe and effective care. The Squad Overmatch 

Study applies the human dimension concept while training the infantry squad as a team. It builds on existing 

warrior skills training and incorporates team building, 

situational awareness, resilience and performance enhancement, and tactical combat casualty care. It also 

provides a framework for squads to conduct after action reviews and take ownership for improving their 

team performance (Figures 6 and 7). This model applies 

equally well to building the AMEDD teams who care 

for warfi ghters and their families.

We do not know when or where we will fi ght in the future. We may be called upon to deploy in days, or a few 

hours. Our adversaries will continually adapt and present us with new and more diffi cult challenges. We may 

operate in remote locations, under austere conditions, 

with long lines of communication. We may fi nd ourselves in ungoverned megacities or face technologically 

advanced near-peer competitors. Communications may 

Army Medical Department at War:

 Healthcare in a Complex World

COL Clinton K. Murray, MC, USA

 MG Stephen L. Jones, MC, USA

CONCLUSION
200 http://www.cs.amedd.army.mil/amedd_journal.aspx

Figure 2. Casualty types for Department of Defense overall and US Army specifi cally.

Figure 1. Reported deaths and wounded in action by military service, and mechanism of nonhostile deaths (source: Carino1).

CONCLUSION
April – September 2016 201

THE ARMY MEDICAL DEPARTMENT JOURNAL

Figure 3. Cumulative rolling monthly averages of killed in action, died of wounds, and case fatality rate during operations in 

Afghanistan, November 2003-March 2013.

Figure 4. A ready medical force model to provide the capability to assist the Army in preventing confl ict, shaping the 

security environment, and winning wars.

Critical wartime capabilities are built through training, education, and 

experience in the institutional, operational, and self-development domains.
202 http://www.cs.amedd.army.mil/amedd_journal.aspx

be degraded, casualty evacuation delayed, and medical 

personnel may provide prolonged fi eld care. We face 

many of these challenges around the world today. In Africa, evacuation distances are measured in thousands of 

miles. In Afghanistan, the Golden-Hour Offset Surgical 

Treatment-Mission provides casualties with lifesaving 

damage control resuscitation/surgery near the point of 

injury. The concept of prolonged fi eld care may begin 

on the front lines, but it has implications for every subsequent level of evacuation and treatment. It applies not 

only to trauma but also to disease and nonbattle injuries. 

Prolonged care of a patient with a pulmonary embolism 

or cerebral malaria in the fi eld will require skills not traditionally taught in our schools or military treatment facilities. New approaches to education and training, new 

organizational structures, equipment, and greater reach 

back capability will required for successful management of complex patients who are awaiting evacuation.

Within the lectures and papers presented in this edition of 

the AMEDD Journal are key lessons learned for each of 

the components of the DOTMLPF-P* domain. The discussion at the end of the symposium raised further issues 

to consider as we look to the future of Army Medicine. 

The questions presented below range from the tactical to 

the strategic level and apply across all AMEDD Corps:

1. How do we effectively capture the lessons of a confl ict, apply them in real time to provide advances in 

care, and document them for those who follow us?

2. How do we identify and apply the enduring lessons 

of the current confl ict while preparing for the new 

challenges of the next?

3. What is the best format to distribute lessons learned 

more broadly, rapidly, and effectively? What is 

the appropriate use of handbooks, clinical practice 

guidelines, doctrine, and policy changes?

4. How do we ensure the National Guard and Reserves 

are incorporated into readiness and lessons learned 

programs?

5. How do we best transition from a counterinsurgency 

campaign and prepare for the full range of military 

operations where ground and air evacuation may 

be more diffi cult, communications degraded, and 

Reported by the Credential/Privileging/Certifying MTF Commander then Excel sheet/MODS/DTMS

AMEDDC&S HRCoE,

DMRTI, USUHS,

USAFSAM, WRAIR

ATTC, TCMC, MSTC,

Flight Paramedic

Point of Injury, Role 1, 2, 3

patient movement,

CoE(ie, JBLM, JBSA Ft Bragg)

Need seasoned, senior, 

deployed experienced

teacher and clinicianTalent manage 21-30 year

COLS

Institutional

Self-development

CPGs

Realistic

Simulation

Volume

Complex

Diverse

Acute

Education Training Experience

Individual

Unit (FRST, CSH,

ASMC, etc)

AssessAssess

Team

•Within our 

MTFs,rebuild, 

recapture, 

recruit (eg, GS)

•Refer to regional 

MTF

•Outside our MTFs 

(team based vs 

individual base)

•VA/civilian MOUs/

MOAs

•Outside our 

MTFs-ODE

Trauma and DNBI

0% 100%

Trauma and DNBI

0% 100%

Trauma and DNBI

0% 100%

AOC, Mission, Clinical, and Regional Essential Medical Knowledge, Skills, and Behavior

Figure 5. The capability requirements for Army Medicine are dependent upon an individual’s AOC/MOS in combination with the mission requirements that align under regionally determined parameters. Individual, team, and units will acquire key education, training, 

and experience to provide the appropriate knowledge, skills, and behaviors to provide the appropriate trauma and disease nonbattle 

injury care.

CONCLUSION
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THE ARMY MEDICAL DEPARTMENT JOURNAL

Figure 6. Overview of the Squad Overmatch Study assessing Tactical Combat Casualty Care and the areas 

that infl uence the squad’s capability.

Figure 7. The 5 primary life-saving domains required for successful squad performance.
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operations may be conducted in megacities or a 

CBRN* environment?

6. How do we develop the critical thinking skills required for healthcare in a complex world?

7. How do we retain the expertise gained across all 

AOC/MOS and Roles of Care in the current confl ict?

8. How do we provide the education, training, and 

experience necessary for casualty care within our 

schools, MTFs, and in the civilian community?

9. How can we best use our senior NCOs to provide 

education, training, and experience in garrison?

10. How do we best develop and implement the concept 

of multidisciplinary teams providing casualty care 

from the front lines through rehabilitation, without 

an artifi cial distinction between care in theater and 

care at home?

11. How do we transition from an AMEDD focused on 

AOCs/MOSs* to one focused on required capabilities? How do we capture the transition in our monitoring and reporting systems?

12. How do we ensure modularity and scalability across 

the full spectrum of operations?

13. Given the lack of SIPR* access for most in Army 

Medicine, especially in the Army Reserve and 

Guard, how do we improve communication within 

NIPR* and/or SIPR channels?

14. Does the current PROFIS* model adequately address 

requirements of the sustainable readiness model?

The Strategic Landscape that Infl uences the Future of Army Medicine Including Concept of Operations and Readiness.

Joint Medical Concept

Required Capabilities

Army Warfighting Challenges ATP 4-02-55 Army Health 

System Support Planning 

Medical Functions

Medical Warfighting 

Functions

Joint medical planning Develop situational understanding. Medical mission command Medical mission command

Joint theater directed coordination, 

synchronization, and medical situational awareness

Shape the security environment. Medical treatment Prehospital care

Monitor patient outcomes, 

assess clinical effects, and 

adapt operations.

Provide security force assistance. Medical evacuation Primary care 

Joint force development framework 

for health services

Adapt the institutional Army. Hospitalization Evacuation and enroute 

care

Medical mitigation of the 

environment 

Counter weapons of mass destruction. Dental services Hospital care

Joint credentialing and privileging Conduct homeland operations. Preventive medicine services Rehabilitation and 

definitive care 

Medical treatment facilities Conduct space and cyber 

electromagnetic operations and 

maintain communication.

Combat and operational 

stress control

Force health protection 

Patient evacuation Enhance training. Veterinary services Medical sustainment

Patient management Improve solider, leader and team 

performance.

Medical logistics Medical engagement 

Joint medical leader development Develop agile and adaptive leaders. Medical laboratory services Medical information

Medical intelligence Conduct airground reconnaissance. Research and innovation

Joint and service medical education 

and training 

Conduct entry operations.

Joint medical research and 

development 

Conduct wide area security.

Medical logistics Ensure interoperability and operate 

in a joint, interorganizational, and 

multinational environment.

Health services contracts and 

resource programming

Conduct combined arms maneuver

Global health services network Set the theater, sustain operations 

and maintain freedom of movement.

Integrate fires.

Deliver fires.

Exercise mission command.

Develop capable formations.

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THE ARMY MEDICAL DEPARTMENT JOURNAL

15. How can the Army Medical Command collaborate 

more closely with operational and special operational forces?

16. How do we modify our business processing and 

monitoring systems to measure the education, training, and experience components of readiness?

17. How do we use Role 1, 2, and 3 outcome data to 

validate the effectiveness of predeployment training 

programs including Tactical Combat Management 

Course, Army Trauma Training Course, and Joint 

Forces Trauma Management Course?

18. How should we select, train, and evaluate personnel for operational assignments? How do we best 

develop their knowledge, skills, and behaviors prior 

to their assignment?

19. How should we optimize the electronic health record to facilitate treatment and support quality improvement programs?

20. How do we use CCQAS,* credentialing, and privileging to document and manage training, education, 

and experience readiness requirements across both 

the Army Medical Command and operational units?

CONCLUSIONS

As we emerge from the mountains and deserts of Afghanistan and Iraq, we must prepare for a future that 

is unknown, unknowable, and constantly changing. We 

can study the lessons of the hybrid war being conducted 

in eastern Ukraine, the confl icts in Syria and Africa, and 

terrorism in Europe. At the same time, we must maintain situational understanding of the entire world since 

any region be our next battlefi eld. Army Medicine will 

face these challenges and, as in the past, it will adapt 

and overcome them. It will face them as a team that includes all Components and Army Civilians. It will draw 

guidance from the Army Operating Concept and Joint 

Concept for Health Support. As shown in the Table, the 

Figure 8. The full support that Army Medicine provides the Warfi ghter from point of injury to rehabilitative care.
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Army Warfi ghting Challenges, Joint Essential Medical 

Capabilities and Medical Warfi ghting Functions will 

serve as the framework for analysis of new concepts.4-6

It will address the entire continuum of casualty care 

from the point of injury through evacuation, defi nitive 

care, rehabilitation, and reintegration (Figure 8).

REFERENCES

1. Carino MJ. Army Casualty: Summary Statistics 

Overview–Update [presentation]. Falls Church, 

VA: Offi ce of the Army Surgeon General; March 

27, 2014.

2. The U.S. Army Operating Concept, Win in a Complex World 2020-2040: TRADOC Pamphlet 525-3-1. 

Fort Monroe, VA: US Army Training and Doctrine 

Command; October 31, 2014. Available at: http://

www.tradoc.army.mil/tpubs/pams/TP525-3-1.pdf. 

Accessed December 15, 2015.

3. The Army Human Dimension Strategy 2015. Washington, DC: US Department of the Army; 2015. 

Available at: http://usacac.army.mil/sites/de

fault/fi les/publications/20150524_Human_Di

mension_Strategy_vr_Signature_WM_1.pdf.

Accessed December 15, 2015.

4. Joint Concept for Health Services. Washington, 

DC: Joint Staff, US Dept of Defense; August 31, 

2015:2. Available at: http://dtic.mil/doctrine/con

cepts/joint_concepts/joint_concept_health_servic

es.pdf. Accessed December 15, 2015.

5. Force 2025 and Beyond. Unifi ed Land Operations. Win in a Complex World. Fort Monroe, 

VA: US Army Training and Doctrine Command; 

October 2014. Available at: http://www.arcic.

army.mil/app_Documents/tradoc_ausa_

force2025andbeyond-unifiedlandoperationswininacomplexworld_07oct2014.pdf. Accessed 

December 15, 2015.

6. Army Techniques Publication 4-02.55: Army Health 

System Support Planning. Washington, DC: US 

Department of the Army; September 2015. Available at: http://armypubs.army.mil/doctrine/

DR_pubs/dr_a/pdf/atp4_02x55.pdf. Accessed 

December 15, 2015.

AUTHORS

COL Murray is Deputy Chief of the US Army Medical 

Corps and Medical Corps Specifi c Branch Proponent Offi cer, AMEDD Center & School, Joint Base San AntonioFort Sam Houston, Texas.

MG Jones is the Commanding General, AMEDD Center 

& School, US Army Health Readiness Center of Excellence, Joint Base San Antonio-Fort Sam Houston, Texas.

*DOTMLPF_P indicates Doctrine, Organization, Training, Material, Leadership, Personnel, and Facilities.

CBRN indicates chemical, biological, radiological, nuclear.

AOC/MOS indicates area of concentration/military occupational specialty.

SIPR indicates secure internet protocol router.

NIPR indicates nonsecure internet protocol router.

PROFIS indicates the Professional Filler System which predesignates qualifi ed Active Army AMEDD personnel to fi ll positions in early 

deploying and forward deployed Army medical units upon mobilization for execution of an operations plan or a contingency operation, 

or for the conduct of mission-essential training.

CCQAS indicates Centralized Credentials Quality Assurance System, an internet-based, worldwide credentialing, privileging, risk management, and adverse actions database for the Defense Health Agency.

CONCLUSION
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THE ARMY MEDICAL DEPARTMENT JOURNAL
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Submission of Manuscripts to the Army Medical Department Journal

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