Traumatic Wound Care

On and Off the Battlefield

January – March 2007

Perspective 1

MG Russell J. Czerw

Aggressive Proactive Combat Damage Control Surgery 3

LTC Lorne H. Blackbourne, MC, USA, et al

The Blood Augmentation Team 7

LTC Lorne H. Blackbourne, MC, USA, et al

Optimizing Transport of Postoperative Damage Control Patients 11

in the Combat Zone

LTC Lorne H. Blackbourne, MC, USA, et al

Management of Traumatic War Wounds Using 17

Vacuum-Assisted Closure Dressings in an Austere Environment

LTC M. Shaun Machen, MC, USA

Causes of Death in US Special Operations 24

Forces in the Global War on Terrorism: 2001-2004

COL John Holcomb, MC, USA, et al

The Process of Care of Battle Casualties: 38

Orthopaedics and Rehabilitation at Walter Reed Army Medical Center

COL William C. Doukas, MC, USA, et al

The Growth of the Profession of Occupational Therapy 51

MAJ Sharon Newton, AN, USA

Also in this Issue

Medical Care in the Sustainment Brigade 59

MAJ Bonnie Hartstein, MC, USA

Evidence-Based Medicine: The Way to Cost Effective, Quality Medical Care 63

COL Herman J. Barthel, MC, USA
MG Gale S. Pollock

Acting The Surgeon General

Commander, US Army Medical Command

MG Russell J. Czerw

Commanding General

US Army Medical Department Center and School

January – March 2007 The Army Medical Department Center & School PB 8-07-1/2/3

0635504

PETER J. SCHOOMAKER

General, United States Army

Chief of Staff

DISTRIBUTION: Special

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Secretary of the Army

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JOYCE E. MORROW

Online issues of the AMEDD Journal are available at https://secure-akm.amedd.army.mil/dasqaDocuments.aspx?type=1

A Professional Publication

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

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January – March 2007 1

The focus of this issue of the AMEDD Journal is an

area of medicine that is in fact the very basis for the

existence of military medicine, management of trauma

injuries incurred in combat. Indeed, the medical care

of US military personnel injured on the battlefield has

never been better, in terms of both survival and

recovery. However, as rapidly as our medical

capabilities improve in sophistication and

effectiveness, so too do the capabilities of our enemies

increase in sophistication and lethality. We must,

therefore, always be seeking better ways to address the

injuries suffered by our Soldiers as they go into harm’s

way. This issue of the AMEDD Journal does exactly

that with a presentation of real world experiences of

our medical professionals from the battlefields of

today, and relevant, practical recommendations as to

how we can do a better job for our Soldiers on

battlefields of the future.

LTC Lorne Blackbourne and his coauthors open with a

series of 3 well-researched, detailed articles addressing

various ways to improve survivability of trauma

casualties from their earliest damage control surgeries.

In the first article, the emphasis is not on the surgery

itself, but on 2 other potentially lethal conditions

attendant to the trauma, coagulopathy and

hypothermia. The article packs a tremendous amount

of extremely important information into a few pages,

and includes logical, practical recommendations for

both current operations and future planners. Next is a

directly related article, expanding on the availability

and use of blood products in damage control surgery to

address the coagulopathy and related acidosis and

hypothermia of trauma. This is another clear, concise

presentation in which they propose the creation of

blood augmentation teams to provide blood

transfusion, processing, and storage capabilities on the

battlefield, especially at the level of the Forward

Surgical Team. LTC Blackbourne and his team wrap

up the discussions of survivability of battlefield trauma

with an expanded examination of the challenges

inherent in the evacuation of injured Soldiers to

combat support hospitals. The article is a thorough

analysis of all of the potentially deadly hazards

associated with the helicopter transport of those who

have undergone damage control surgery. Again, a

concise, thoroughly referenced, and complete

discussion of an aspect of trauma care which is often

underappreciated as to its complexity and importance

in the ultimate survivability of our Soldiers.

LTC Shaun Machen relates his experience in the

development of a protocol for the use of vacuumassisted closures in the treatment of traumatic wounds

at the combat support hospital. His detailed discussion

of the hugely successful adaptation of this technology

into the austere environment of combat medicine is

another example of the skills, resourcefulness, and,

above all, dedication of the medical professionals in

today’s Army. The results of LTC Machen’s efforts

speak for themselves. The information in his article

should be of great interest to all of you who work with

traumatic wound injuries, especially in the combat

environment.

COL John Holcomb and his team of specialists

undertook the vitally important task of analyzing the

causes of death for US military personnel in the

current theaters of combat operations. Their article is a

meticulous study, not only of the injuries and

Perspective

Major General Russell J. Czerw
2 Army Medical Department Journal

treatments, but also the environments, situations, and

sequence of events surrounding the injuries which

were ultimately fatal. COL Holcomb et al present

statistical data and case studies to support their

detailed discussion of both the considerable successes

and possible shortcomings in the care of these trauma

victims. This is a sobering yet encouraging look at

those situations when all of the best of our training and

technology may not be enough. It is a must read for all

of us.

The majority of the wounded who are evacuated to

medical facilities in the United States arrive with

extremity and other orthopaedic injuries which require

treatment and rehabilitation as the Soldier recovers.

COL William Doukas has assembled a collection of

articles written by the professionals at Walter Reed

Army Medical Center describing the structure and

processes that have evolved as the influx of wounded

increased concurrent with the tempo of combat

operations. Each specialty in the chain of orthopaedic

care—orthopaedic surgery, physical therapy, physical

medicine and rehabilitation, and occupational

therapy—have contributed, describing their respective

responsibilities, procedures, adaptations, conclusions,

and recommendations for improvements in the care of

our most seriously injured Soldiers.

In the Global War on Terrorism, the role of the

occupational therapist is becoming an increasingly

prominent part of the recovery regimen for those who

have suffered traumatic combat injuries. However, few

people probably know that the need for what is now

known as occupational therapy was first recognized in

the 18th century. MAJ Sharon Newton’s article is an

interesting and informative description of the evolution

of occupational therapy as a treatment discipline which

has become integral to military medicine. Her well

researched, chronological presentation illustrates how

interest in use of the therapists has surged and waned

in conjunction with medical, societal, and political

trends. She shows how the discipline has endured a

number of incarnations before it finally emerged as a

recognized, sophisticated field, practiced by trained,

skilled professionals who are key members of today’s

treatment team for our wounded Warriors.

MAJ Bonnie Hartstein contributes an article which

presents another aspect of current medical support in

the theater of combat operations. As Brigade Surgeon

of the 15th Sustainment Brigade at Camp Taji, Iraq,

she has experienced the challenges of managing

medical support for Soldiers in one of the new

modular Army organizations as it transforms from a

peacetime, headquarters element to a large, integrated,

multifunctional entity deployed into the theater of

operations. In her article, MAJ Hartstein describes the

complexities and tradeoffs involved in planning and

providing for the healthcare of sustainment brigade

Soldiers deployed into the dynamic, nonlinear

battlefield environment of today. She spotlights an

area of major concern which must be promptly

addressed at the top levels of planning for medical

support for our new, modular Army.

The final article in this issue is a very timely and

relevant discussion of an evolutionary approach to

providing both accessible and affordable quality

medical care throughout the medical profession. COL

Herman Barthel presents an in-depth look at the

history and basis for the application of evidence-based

medicine (EBM) in the delivery of health care. It

seems only logical that in this era of virtually instant

access to current information, medical care should be

based on scientific evidence used to support the

practitioner’s judgment and specific case knowledge.

However, such an approach is not universally applied.

Indeed, much health care delivery is still based on

tradition and uncontrolled clinical experience. COL

Barthel presents a sobering description of the

implications of the skyrocketing costs of health care,

not only on the personal health of our citizens, but also

the impact on our national security. He provides

examples of the success of an institutionalized

approach of the application of EBM to healthcare

delivery, and presents recommendations for steps to

help make EBM a standard for our national healthcare

policy.

Perspective
January – March 2007 3

Aggressive Proactive Combat Damage

Control Surgery

LTC Lorne H. Blackbourne, MC, USA

CPT Neil McMullin, MC, USA

COL Brian Eastridge, MC, USA

COL Toney Baskin, MC, USA

COL John Holcomb, MC, USA

Proactive: [pro- + reactive]: acting in anticipation of future problems, needs, or changes1

INTRODUCTION

Damage control surgery is the process of preventing,

in a proactive fashion, the overwhelming catastrophic

physiologic effects of severe hemorrhage. While the

damage control “trilogy” of (1) abbreviated surgical

operation, (2) postoperative intensive care unit

resuscitation, and (3) definitive operation is described

as the major tenets of damage control, there are many

extremely important contributing efforts that are

critical to the success of the process.2In civilian

practice, the order of this damage control trilogy is

well established. However, the military paradigm of

combat damage control often creates a variable

continuum for the major tenets of this trilogy with a

more variable time span.

While the current combat damage control surgery

stresses early surgical operation, there are currently no

universal proactive hypothermia or coagulopathy

prevention strategies for forward surgical level II

facilities. Aggressive damage control surgery is used

to proactively defeat the “lethal triad.” This triumvirate

of hypothermia, acidosis, and coagulopathy all feed on

each other in a feedback cycle, and once in full fruition

is universally fatal. Our only tangible targets of this

lethal triad are hypothermia and coagulopathy. A more

inclusive proactive approach to combat damage

control surgery would mandate that we develop

measures to counter coagulopathy and hypothermia

earlier on the resuscitative time line.

PROACTVE COAGULOPATHY PREVENTION AND

TREATMENT

Coagulopathy is not merely a number or a laboratory

value. Coagulopathy can be obvious clinically to the

surgeon and anesthesia personnel. Coagulopathic

bleeding can easily be seen as profuse bleeding from

any raw anatomic surface and from multiple

fragmentation wounds. Coagulopathic bleeding is also

a marker and a risk factor for death in these damage

control patients.3 Replacing the patient’s blood which

contains clotting factors, fibrinogen, and platelets with

only packed red blood cells (PRBCs) which do not

contain any clotting factors, fibrinogen, or platelets

can actually worsen the coagulopathy due to simple

dilution.4 A major difference between civilian damage

control and far-forward combat damage control

surgery is the use of blood products. The majority of

civilian damage control patients who receive 10 units

of PRBCs also receive fresh frozen plasma (clotting

factors) and platelets.5In comparison, military combat

damage control patients usually receive only PRBCs.

Hirshberg et al state that to optimally treat and prevent

coagulopathy in damage control patients, the clotting

factors and platelets need to be transfused proactively

before the onset of a documented coagulopathy.6

Options for treating a coagulopathy include

recombinant factor VIIa, fresh frozen plasma (FFP),

platelets, and whole blood. Fresh whole blood (<8

hours old) contains clotting factors, fibrinogen, and

platelets. Due to a limited donor pool, limited

personnel, and variable expertise, drawing whole

blood can be a very challenging activity to the full

engaged level II surgical facility. Fresh frozen plasma

must be kept in a frozen state (until thawed for

transfusion) and in significant quantities due to a lack

of a truly universal donor blood type (ie, must be a

blood type specific transfusion). Lack of freezer

capabilities at level II facilities currently make FFP a

nonviable option. Platelets must be stored near room

temperature and have a storage life, after processing,
4 Army Medical Department Journal

Aggressive Proactive Combat Damage Control Surgery

of approximately 5 days, making their appearance in

the combat zone unfeasible. Factor VIIa can be stored

in a refrigerator with the PRBCs and has great

potential in far-forward combat damage control.

If we are to maximize combat damage control, we

need to find strategies that will effect the lethal triad

early in a proactive, aggressive approach. “Playing

catch up” at a level III surgical facility places those

combat wounded in a serious predicament with

mortality and morbidity.

PROACTIVE HYPOTHERMIA PREVENTION AND

TREATMENT

The other area of the lethal triad that we can directly

impact is hypothermia. Hypothermia is extremely

detrimental to damage control, especially the combat

wounded damage control patient, as the hypothermia

makes the coagulopathy of the lethal triad worse.

Hypothermia also inhibits platelet activation.7 Thus,

hypothermia inhibits the 2 procoagulant processes

upon which current level II surgical facilities cannot

make an impact in most cases.

In civilian damage control patients, hypothermia has

been documented to be a risk factor for death.8-12

Improved hypothermia prevention in civilian damage

control patients is thought to be a factor in overall

better outcome in damage control patients in recent

years.13 Furthermore, preventing hypothermia has been

documented to decrease the overall blood and

intravenous (IV) fluid requirements of damage control

patients. Blood and IV fluid are a great concern to the

highly mobile, logistically challenged level II surgical

facilities.14

A proactive, aggressive approach to hypothermia

prevention and treatment early during the course of

combat damage control surgery will help decrease the

overall blood transfusions, IV fluid usage, and overall

mortality of combat wounded.

PROACTIVE CARE DURING ROTARY-WING

TRANSPORT FROM LEVEL II TO LEVEL III

One area unique to combat damage control surgery is

the rotary-wing evacuation of postoperative patients to

a level III facility to undergo completion of the

intensive care unit resuscitation phase of damage

control. A great peril exists during this evacuation.

Hypothermia can be profound if measures are not

undertaken to ensure thermoregulation. Currently,

most postoperative patients are transferred with wool

blankets and possibly an outer shell consisting of a

modified body bag. Convective warming systems (eg,

Bair Hugger®, Arizant Healthcare Inc, 10393 West

70th Street, Eden Prairie, MN 55344) have been

documented to optimize preservation of body warmth

in intrahospital transfers.15

FUTURE SOLUTIONS

Blood Augmentation Units

The first step in maximizing the treatment of

coagulopathy in combat damage control patients is to

bring personnel with expertise into the level II surgical

facilities. A single blood bank expert (or additional

training of forward surgical team personnel at a

medical center in the United States) could provide

immediate expertise in drawing and cross matching

fresh whole blood (including rapid HIV and hepatitis

screening). This individual could also ensure the

adequate storage of PRBCs and factor VIIa.

The second step (the optimal situation) would be the

creation of a platform for refrigerators and freezers.

This capability would allow for the storage of

additional PRBCs and for the advent of blood products

at level II facilities. These blood products could

include FFP and cryoprecipitate.

Adding the capability to transfuse adequate PRBCs,

factor VIIa, fresh whole blood, FFP, and

cryoprecipitate would enable the level II surgical

facilities to provide treatment of damage control

coagulopathy at the level of a civilian level I trauma

center.

Universal Hypothermia Prevention and Treatment

Measures

The use of convective warming systems and IV fluid

warmers can make the most immediate impact on

thermoregulation in combat damage control patients at

level II surgical facilities.

Convective warming systems (eg, Bair Hugger) have

been demonstrated to help maximize body core

temperature preservation in trauma patients and in

patients undergoing an operation.16-19 These systems

can be utilized to warm patients in preoperative

holding, in the operating room, and postoperatively.
January – March 2007 5

Blood and IV fluid warmers provide the ability to

maximize and warm infusion volumes. Fluid warmers

have been documented to help maintain body

temperature in surgical and trauma patients.20 The use

of a rapid infusion warming device has been

documented to decrease the overall blood and fluid

requirements in the severely wounded trauma patient,

again a major benefit for our logistically challenged

far-forward surgical platforms.21 The Belmont FMS2000® (Belmont Instrument Corp, 780 Boston Road,

Billerica, MA 01821) has been shown to have

maximal fluid heating capability.22

Together, convective warming systems and IV blood/

fluid warmers offer optimal core body preservation.23

These modalities should be universally available to all

level II surgical facilities.

Universal Rotary-Wing Transport Capabilities

The proactive, early use of thermal layers in

conjunction with a convective warming system will

help ensure preservation of body temperature in

rotary-wing transport of postoperative patients. Testing

and approval of these devices for use in helicopters

would be the first step. Making the availability and use

of these active warming devices universal in all rotarywinged medical evacuation aircraft within all services

would be a major step in minimizing body heat loss

during transport.

CONCLUSION

Perhaps the most important area for decreasing the

died-of-wounds rates in our combat wounded who

reach a facility with surgical capability lies with

improving combat damage control surgery.24 The 2

areas that provide the greatest improvement potential

include the treatment and prevention of hypothermia

and coagulopathy. All efforts must be made to

improve universal measures to improve these areas in

level II surgical facilities. Our proactive efforts will be

rewarded with a decreased mortality in our combat

wounded.

REFERENCES

1. Merriam-Webster’s Collegiate Dictionary. 11th ed.

Springfield, MA: Merriam-Webster, Inc; 2003.

2. Shapiro M, Jenkins D, Schwab CW, et al. Damage

control: collective review. J Trauma. 2000;49:969-978.

3. Aoki N, Wall MJ, Demsar J, et al. Predictive model for

survival at the conclusion of a damage control

laparotomy. Am J Surg. 2000;180(6):540-544.

4. Murray DJ, Pennell BJ, Weinstein SL, Olson JD.

Packed red cells in acute blood loss: dilutional

coagulopathy as a cause of surgical bleeding. Anesth

Analg. 1995;80(2):336-342.

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

JR. Blood transfusion rates in the care of acute trauma.

Transfusion. 2004;44(6):809-813.

6. Hirshberg A, Dugas M, Banez EI, Scott BG, Wall MJ

Jr, Mattox KL. Minimizing dilutional coagulopathy in

exsanguinating hemorrhage: a computer simulation. J

Trauma. 2003;54(3):454-463.

7. Zhang JN, Wood J, Bergeron AL, et al. Effects of low

temperature on shear-induced platelet aggregation and

activation. J Trauma. 2004;57(2):216-223.

8. Asensio JA, McDuffie L, Petrone P, et al. Reliable

variables in the exsanguinated patient which indicate

damage control and predict outcome. Am J Surg.

2001;182(6):743-751.

9. Tyburski JG, Wilson RF, Dente C, Steffes C, Carlin

AM. Factors affecting mortality rates in patients with

abdominal vascular injuries. J Trauma. 2001;50

(6):1020-1026.

10. Cushman JG, Feliciano DV, Renz BM, et al. Iliac

vessel injury: operative physiology related to outcome.

J Trauma. 1997;42(6):1033-1040.

11. Hoyt DB, Bulger EM, Knudson MM, et al. Death in the

operating room: an analysis of a multicenter experience.

J Trauma. 1994;37(3):426-432.

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

predictors of death in exsanguinating trauma patients

undergoing conventional trauma surgery. Aust NZ J

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

13. Johnson JW, Gracias VH, Schwab CW, et al. Evolution

in damage control for exsanguinating penetrating

abdominal injury. J Trauma. 2001;51(2):261-269.

14. Bernabei AF, Levison MA, Bender JS. The effects of

hypothermia and injury severity on blood loss during

trauma laparotomy. J Trauma. 1992;33(6):835-839.

15. Scheck T, Kober A, Bertalanffy P, et al. Active

warming of critically ill trauma patients during

intrahospital transfer: a prospective, randomized trial.

Wien Klin Wochenschr. 2004;116(3):94-97.

16. Patel N, Smith CE, Knapke D, Pinchak AC, Hagen JF.

Heat conservation vs convective warming in adults

undergoing elective surgery. Can J Anaesth. 1997;44

(6):669-673.
6 Army Medical Department Journal

17. Kober A, Scheck T, Fulesdi B, et al. Effectiveness of

resistive heating compared with passive warming in

treating hypothermia associated with minor trauma: a

randomized trial. Mayo Clin Proc. 2001;76(4):369-375.

18. Patel N, Smith CE, Knapke D, Pinchak AC, Hagen JF.

Heat conservation vs convective warming in adults

undergoing elective surgery. Can J Anaesth. 1997;44

(6):669-673.

19. Borms SF, Engelen SL, Himpe DG, Suy MR,

Theunissen WJ. Bair Hugger forced-air warming

maintains normothermia more effectively than thermolite insulation. J Clin Anesth. 1994;6(4):303-307.

20. Smith CE, Gerdes E, Sweda S, et al. Warming

intravenous fluids reduces perioperative hypothermia in

women undergoing ambulatory gynecological surgery.

Anesth Analg. 1998;87(1):37-41.

21. Dunham CM, Belzberg H, Lyles R. The rapid infusion

system: a superior method for the resuscitation of

hypovolemic trauma patients. Resuscitation. 1991;21(2-

3):207-227.

22. Dubick MA, Brooks DE, Macaitis JM, Bice TG,

Moreau AR, Holcomb JB. Evaluation of commercially

available fluid-warming devices for use in forward

surgical and combat areas. Mil Med. 2005;170(1):76-

82.

23. Smith CE, Desai R, Glorioso V, Cooper A, Pinchak

AC, Hagen KF. Preventing hypothermia: convective

and intravenous fluid warming versus convective

warming alone. J Clin Anesth. 1998;10(5):380-385.

24. Blackbourne LH, Holcomb JB. Can we provide level III

damage control procedures at a level II facility?. Army

Med Dept J. 2005; Apr–Jun:62-65.

AUTHORS

LTC Blackbourne is the Trauma, Burn, and Surgical Critical

Care Surgeon at the Institute of Surgical Research, Brooke

Army Medical Center, Fort Sam Houston, Texas.

CPT McMullin is a third year General Surgery Resident at

the Brooke Army Medical Center, Fort Sam Houston,

Texas.

COL Eastridge is Chief of Trauma Service, Brooke Army

Medical Center, Fort Sam Houston, Texas.

COL Baskin is Assistant Chief, Trauma and Critical Care,

Trauma Division, US Army Institute of Surgical Research,

and the Assistant Program Director, Surgical Critical Care

Fellowship, at the Brooke Army Medical Center, Fort Sam

Houston, Texas.

COL Holcomb is Commander, Institute of Surgical

Research, Brooke Army Medical Center, Fort Sam Houston,

Texas, and Trauma Consultant to The Army Surgeon

General.

Aggressive Proactive Combat Damage Control Surgery

2006 Spurgeon Neel Writing Competition Winner

Michael Hinton, Executive Vice-President of the Army Medical Department Museum Foundation, has

announced that COL Stephen C. Craig of the Uniformed Services University of the Health Sciences (USUHS)

in Bethesda, MD, has been selected as the winner of the 2006 Spurgeon Neel Writing Competition. COL

Craig, a professor at the USUHS, is the Army Medical Department Consultant in Medical Corps History.

The article by COL Craig, titled “The Evolution of Public Health Education in the US Army, 1893-1966,”

appeared in the April-June 2006 issue of the AMEDD Journal. The article traces the beginning of preventive

medicine graduate education in the US Army, and its evolution through the years into what is today the oldest

postgraduate medical education program in the military. As the Neel Writing Award winner, COL Craig will

receive a $500 monetary prize and a commemorative medallion.

Each year the Army Medical Department Museum Foundation presents the Spurgeon Neel Writing Award to

the author of the AMEDD Journal article which best exemplifies the history, legacy, and traditions of the

Army Medical Department.
January – March 2007 7

INTRODUCTION

As the rate for those killed in action has decreased, the

“died of wounds” rate has understandably increased.

Improving the mortality rate of patients undergoing

damage control surgical procedures is the largest

single area within which we can decrease mortality of

injured military personnel in the near future. Our goal

should be to raise the capabilities of far-forward

surgical facilities (level IIb) to those of civilian level I

trauma centers in the management of damage control

patients.

On review of capabilities of civilian level I trauma

centers and military level III facilities, one significant

area that could be improved is blood product

availability.1 Currently, the US Army Forward

Surgical Team (FST) is the Army’s level IIb facility.

Due to the necessity of high mobility associated with

clinical austerity, FSTs only carry packed red blood

cells (PRBCs). Due to logistic considerations, FSTs do

not carry any other blood components like fresh frozen

plasma (FFP), cryoprecipitate (cryo), or platelets

(PLTs).2 While the future may see introduction of

freeze-dried components (platelets/plasma) that are

more easily stockpiled and stored, at the moment the

military medical systems should be able to provide

some combination of standard component therapy and

a system of taking the blood bank to all levels of the

battlefield where surgery is expected to occur.

WHY IS BLOOD AVAILABILITY IMPORTANT?

On average, the civilian and combat damage control

patient receives between 8 and 12 units of PRBCs.3,4

In civilian trauma patients there is a severe injury

subset of damage control patients who receive over 20

units of PRBCs and civilian trauma centers are

reporting improved survival in patients receiving more

than 50 PRBCs in the first 24 hours.5,6 Comparing

these numbers with the 20 to 50 units of PRBCs

carried by most of our deployed FSTs leads one to

conclude that entire blood supply can be exhausted in

2 hours with 1 or 2 damage control patients (eg, all

damage control laparotomies should be less than 90

minutes in duration, and FSTs have 2 operating room

tables).7

In a mass casualty situation the FST, by necessity, will

have to go into a “minimal acceptable resuscitation”

mode, essentially “triaging” blood supplies.8,9 By

default, these damage control patients will be underresuscitated. Inadequate resuscitation of a damage

control patient can lead to worsening of the patient’s

acidosis. Acidosis and the often concomitant

hypothermia worsen the coagulopathy seen in damage

control patients.10 The coagulopathy leads to more

bleeding which causes more acidosis and the vicious

cycle of the “lethal triad”—acidosis, hypothermia, and

coagulopathy—continues, eventually culminating in

exsanguination.

WHY ARE BLOOD PRODUCTS IMPORTANT?

Coagulopathy and acidosis are both predictive factors

for death after damage control surgery.11 Packed red

blood cells do not contain clotting factors or platelets.

Clotting factors, cryoprecipitate, and platelets are

frequently necessary for damage control operations but

require special storage considerations. Platelets are

stored at room temperature and have an average 5-day

storage life after processing.12 Clotting factors (FFP/

Cryo) are stored at -30oC and thawed before

transfusion. In the setting of a damage control

procedure or massive resuscitation (defined as 10 or

more units of blood in 24 hours), transfusing only

PRBCs will not only fail to control coagulopathy or

restore platelets (thrombocytopenia), but also can

worsen the coagulopathy and thrombocytopenia

through dilution of existing clotting factors and

platelets in the patient’s system.13-15

The Blood Augmentation Team

LTC Lorne H. Blackbourne, MC, USA

MAJ Jeremy Perkins, MC, USA

CPT Neil McMullin, MC, USA

COL Brian Eastridge, MC, USA

COL John B. Holcomb, MC, USA
8 Army Medical Department Journal

Over 90% of civilian damage control patients

receiving 10 or more units of PRBCs also receive FFP,

and the majority receive platelet transfusions.16 The

effects of FFP and platelets are maximized if given

early during a damage control surgery to stop the

coagulopathic process before it feeds into the lethal

triad.17 This concept has been described as hemostatic

resuscitation.

The current blood replacement strategy of FSTs is

especially problematic in a severe damage control

patient by (a) inadequate resuscitation and the effect of

default acidosis on coagulopathy, and (b) dilution of

clotting factors and platelets by the transfusion of

PRBCs and crystalloid alone. Two current options for

FSTs to control coagulopathy involve the use of

intravenous Factor VIIa and fresh whole blood.18

Factor VIIa is not universally available to the FSTs.

There is no universal donor for whole blood because

this product contains both plasma and red cells. Whole

blood must be ABO compatible and transfusing whole

blood with the wrong blood type can result in a fatal

reaction.

19,20

While most level IIb sites have performed fresh whole

blood transfusions, it is extremely challenging to draw,

check for infectious agents, and cross-match whole

blood during a damage control operation. The ability

to draw fresh whole blood is even more difficult

during mass casualty situations with the limited

personnel of an FST. While this is challenging even

for an established FST with good logistical supply, it

would be even more difficult during the maneuver

phase of combat when lines of communication are less

well established.

HOW CAN WE GET BLOOD AND BLOOD

PRODUCTS TO THE FORWARD SURGICAL

TEAMS?

To optimize combat damage control and to provide the

capability at level IIb sites to correct the abnormal

physiology of these critical patients, it is necessary to

rethink some of the support issues. In order to bring

level IIb facilities up to the capabilities of a civilian

level I trauma center, FSTs must have increased ability

to transfuse Factor VIIa, FFP, cryo, and platelets.

Increased refrigeration space will allow increased

PRBCs storage, thawed plasma storage, and safe

storage of factor VIIa. The provision of freezer

capability and space will allow storage of FFP and

Cryoprecipitate. Expert personnel trained in the

science of whole blood acquisition and cross-matching

will allow the safe transfusion of whole blood for

platelet replacement.

Transfusion of FFP and whole blood, in addition to

Factor VIIa early during the damage control operation

will help proactively correct the coagulopathy of the

severely injured trauma patient, and will potentially

decrease the PRBC requirement due to decreased

coagulopathic bleeding.

Fresh frozen plasma has a shelf storage life of

approximately one year. Once thawed, the unit of FFP

can be kept as thawed plasma for 5 days in a

refrigerator. Over a 5-day period of time, Factor VII

levels decrease to 72% of baseline, Factor X decreases

to only 80% of baseline, and there is minimal decrease

in fibrinogen levels.21 Thawed plasma offers several

benefits over crystalloid solutions in the treatment of

hemorrhaging patients. First and foremost, plasma will

replace depleted coagulation factors. Second, plasma

provides volume and exerts a colloid effect. During

World War II and Korea, plasma was the prehospital

resuscitation fluid employed by the combat medic.22

Third, plasma has a more physiologic electrolyte

profile than crystalloid. Plasma has a pH of 7.2 to 7.4,

compared to the pH of normal saline (4.5 to 6.5), or

Ringer’s lactate solution (6 to 7.0). Plasma also

contributes small amounts of potassium, glucose,

lactate, and calcium. The capability to store FFP and

thawed plasma at forward levels of care will enhance

the ability of the physician to aggressively treat

patients with coagulopathy of trauma.

BLOOD AUGMENTATION TEAM

By design the FSTs have limited blood and blood

product options. One option for providing increased

blood availability and blood products would be the

creation of a highly mobile modular team with

equipment and expertise in blood transfusion. Such a

team could be named a “Blood Augmentation

Team” (BAT).

Personnel

We need to look no further than the blood banks at any

of our surgical facilities in the United States to find

personnel trained in the handling and storage of blood

and blood products. These personnel are also experts

The Blood Augmentation Team
January – March 2007 9

in drawing blood, blood cross-matching, and rapid

testing of whole blood for transfusion-transmitted

infections (HIV and Hepatitis). One or two personnel

could fulfill all the blood transfusion needs of an FST.

The medical laboratory specialist (military

occupational specialty 68K) performs blood banking

procedures and elementary and advanced examinations

of biological and environmental specimens to aid in

the diagnosis, treatment, and prevention of disease and

other medical disorders, according to a structure of

defined skill levels:

 Skill Level 1. Performs elementary clinical

laboratory and blood banking procedures.

 Skill Level 2. Performs elementary blood

banking and clinical laboratory procedures in

hematology, immunohematology, biochemistry,

serology, bacteriology, parasitology, and

urinalysis.

 Skill Level 3. Performs advanced procedures in

all phases of blood banking and clinical

laboratory testing including virology, mycology,

toxicology, and histology or supervises small

medical laboratory.

 Skill Level 4. Supervises medium size medical

laboratory.

 Skill Level 5. Supervises large medical

laboratory activities.

Mobile Platform

The first requirement of the BAT will be mobility

which matches that of the FSTs. This could be met

with an armored wheeled vehicle (initially an armored

HMMWV*). The vehicle must have refrigeration,

freezers, and all of the equipment needed for field

expedient blood cross-matching and rapid testing of

whole blood. These components would require the

capability to generate electricity for periods of travel

between sources of electricity. The next refinement

would be the capability to transfer these components

onto any helicopter or fixed wing aircraft that might be

transporting the FST.

Capabilities

The BAT would have the capability of increased

PRBC availability. It would also have the capability to

cross-match and provide FFP, Cryoprecipitate,

platelets, and rFVIIa. While the FST personnel are

fully engaged during a mass casualty situation, the unit

would handle the drawing and cross-matching/testing

of whole blood if needed.

The bottom line: the BAT could enhance the capability

of the FST to perform combat damage control surgery

to the level of a civilian level I trauma center and to

potentially help decrease the mortality rate of these

patients.

IMMEDIATE FUTURE

While it will take time to create and to accumulate the

correct equipment for the Blood Augmentation Team,

in the short term we can enhance the ability of FSTs to

correct the coagulopathy seen in damage control

patients by adding thawed plasma and rFVIIa to the

inventories of all far forward surgical platforms.23-26

The addition to the FST of a single blood bank Soldier

will allow safe storage of all blood and the safe

drawing and cross-matching of whole blood (this

concept was validated in Operation Enduring Freedom

in 2002).

CONCLUSION

The Blood Augmentation Team will bring banking

expertise and material to the battlefield. As more

“shelf stable” blood product replacements come into

the armentarium of the combat physicians, nurses, and

medics, the Blood Augmentation Team will have to

evolve, providing a dynamic platform for rapid

fielding of these advances.

REFERENCES

1. Blackbourne LH, Holcomb JB. Can we provide level

III damage control procedures at a level II facility?

Army Med Dept J. April–June 2005:62-65.

2. Field Manual 8-10-25: Employment of Forward

Surgical Teams. Washington, DC: US Dept of the

Army; 30 September 1997.

3. Johnson JW, Gracias VH, Schwab CW, et al.

Evolution in damage control for exsanguinating

penetrating abdominal injury. J Trauma.

2001;51:261-271.

4. Sebesta J, Beekley A, et al. Damage control surgery

at the 31st combat support hospital. Abstract

presented at: 27th Annual Gary Wratten Surgical

Conference, April 25-27; El Paso, TX: poster

*High mobility multipurpose wheeled vehicle presentation AAST 2005.
10 Army Medical Department Journal

5. Velmahos GC, Chan L, Chan M, et al. Is there a limit to

massive blood transfusion after severe trauma? Arch

Surg. 1998;133(9):947-952.

6. Cinat ME, Wallace WC, Nastanski F, et al. Improved

survival following massive transfusion in patients who

have undergone trauma. Arch Surg. 1999;134(9):964-

968.

7. Hirshberg A, Sheffer N, Barnea O. Computer

simulation of hypothermia during "damage control"

laparotomy. World J Surg. 1999;23(9):960-965.

8. Holcomb JB, Helling TS, Hirshberg A. Military,

civilian, and rural application of the damage control

philosophy. Mil Med. 2001;166(6):490-493.

9. Hirshberg A, Holcomb JB, Mattox KL. Hospital trauma

care in multiple-casualty incidents: a critical view. Ann

Emerg Med. 2001;37(6):647-652.

10. Martini W, Pusateri A, Uscilwicz J, Delgado A,

Holcomb J. Independent contributions of hypothermia

and acidosis to coagulopathy in swine. J Trauma.

2005;58:1002-1010.

11. Perez-Pujol S, Aras O, Lozano M, et al. Stored platelets

contain residual amounts of tissue factor: evidence from

studies on platelet concentrates stored for prolonged

periods. Transfusion. 2005;45(4):572-579.

12. Cloonan CC. Treating traumatic bleeding in a combat

setting. Mil Med. 2004;169(12 suppl):8-10,4.

13. Fries D, Krismer A, Klingler A, et al. Effect of

fibrinogen on reversal of dilutional coagulopathy: a

porcine model. Br J Anaesth. 2005;95(2):172-177.

14. Murray DJ, Pennell BJ, Weinstein SL, Olson JD.

Packed red cells in acute blood loss: dilutional

coagulopathy as a cause of surgical bleeding. Anesth

Analg. 1995;80(2):336-342.

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

JR. Blood transfusion rates in the care of acute trauma.

Transfusion. 2004;44(6):809-813.

16. Hirshberg A, Dugas M, Banez EI, Scott BG, Wall MJ

Jr, Mattox KL. Minimizing dilutional coagulopathy in

exsanguinating hemorrhage: a computer simulation. J

Trauma. 2003;54(3):454-463.

17. Aoki N, Wall MJ, Demsar J, et al. Predictive model for

survival at the conclusion of a damage control

laparotomy. Am J Surg. 2000;180(6):540-545.

18. Holcomb JB, Hoots K, Moore FA. Treatment of an

acquired coagulopathy with recombinant activated

factor VII in a damage-control patient. Mil Med.

2005;170(4):287-290.

19. McManigal S, Sims KL. Intravascular hemolysis

secondary to ABO incompatible platelet products. An

underrecognized transfusion reaction. Am J Clin Path.

1999;111(Feb):202-206.

20. Lundberg WB, McGinniss MH. Hemolytic

transfusion reaction due to anti-A. Transfusion.

1975;15(1):1-9.

21. O’Shaughnessy DF, Atterbury C, Bolton Maggs P, et

al. Guidelines for the use of fresh-frozen plasma,

cryprecipitate and cryosupernatant. Br J Haematol.

2004;126(Jul):11-28.

22. Kendrick DB. Blood Program in World War II.

Washington, DC: US Dept of the Army, Office of the

Surgeon General; 1964.

23. Lynn M, Jeroukhimov I, Klein Y, Martinowitz U.

Updates in the management of severe coagulopathy

in trauma patients. Intensive Care Med. 2002;28

(suppl 2):s241-s247.

24. Martinowitz U, Michaelson M. The Israeli

Multidisciplinary rFVIIa Task Force. Guidelines for

the use of recombinant activated factor VII (rFVIIa)

in uncontrolled bleeding: a report by the Israeli

Multidisciplinary rFVIIa Task Force. J Thromb

Haemostasis. 2005;3(4):640-648.

25. Haan J, Scalea T. A Jehovah's Witness with complex

abdominal trauma and coagulopathy: use of factor

VII and a review of the literature. Am Surg. 2005;71

(5):414-415.

26. Martinowitz U, Zaarur M, Yaron BL, Blumenfeld A,

Martonovits G. Treating traumatic bleeding in a

combat setting: possible role of recombinant

activated factor VII. Mil Med. 2004;169(12

suppl):16-18,4.

AUTHORS

LTC Blackbourne is the Trauma, Burn, and Surgical Critical

Care Surgeon at the Institute of Surgical Research, Brooke

Army Medical Center, Fort Sam Houston, Texas.

MAJ Perkins is a Hematologist-Oncologist at the Walter

Reed Army Medical Center, Washington, DC.

CPT McMullin is a third year General Surgery Resident at

the Brooke Army Medical Center, Fort Sam Houston,

Texas.

COL Eastridge is Chief of Trauma Service, Brooke Army

Medical Center, Fort Sam Houston, Texas.

COL Holcomb is Commander, Institute of Surgical

Research, Brooke Army Medical Center, Fort Sam Houston,

Texas, and Trauma Consultant to The Army Surgeon

General.

The Blood Augmentation Team
January – March 2007 11

Optimizing Transport of

Postoperative Damage Control

Patients in the Combat Zone

LTC Lorne H. Blackbourne, MC, USA

LTC Kurt Grathwohl, MC, USA

COL Brian Eastridge, MC, USA

COL David L. MacDonald, MS, USA

COL John B. Holcomb, MC, USA

INTRODUCTION

One area of potential improvement in mortality in the

combat zone is the patient undergoing damage control

at a level IIb (eg, Forward Surgical Team) or level III

surgical facility.1 One major difference between

damage control surgery in the civilian trauma centers

and military combat damage control surgery is the air

evacuation after the “abbreviated” operation of the

damage control trilogy at military surgical facilities.

Another major difference is that combat damage

control patients at level II are often not optimally

resuscitated due to limited blood supply and lack of

stored blood products (eg, fresh frozen plasma and

platelets).2,3 The lethal triad of hypothermia, acidosis,

and coagulopathy represent the greatest challenge to

postoperative combat damage control patients

undergoing rotary-wing air evacuation.4 Currently,

very few interventions are possible during helicopter

transport of these critically injured patients due to wide

variations in personnel, personnel training, helicopter

setup, and inflight conditions. De Lorenzo stated in

1997 that “Improved combat casualty care and

battlefield survival may be possible by increasing both

the number and training of the medical attendants on

Army aircraft.”5

The combat surgeon often hopes that the patient will

arrive alive at the level III facility without irreversible

physiologic perturbations to undergo completion of the

resuscitation phase of damage control. Optimization of

these critically ill patients during transport is an

important strategy to increase survival on the

battlefield, replacing hope with capability.

CURRENT COMBAT AIR EVACUATIONS

Currently, military doctrine dictates several variable,

nonstandard platforms for intratheater air evacuation

of severely injured postoperative damage control

patients (traveling from level II to level III or level III

to level III), most commonly UH-60 Blackhawk, CH47 Chinook, or CH-46 Sea Stallion helicopters.

Medical crewmembers in the aircraft likewise vary in

training and experience, typically an Army 68W

Medic or Navy Corpsman (usually EMT–B).6 Larger

Marine Corps aircraft might also include flight nurses.

Personnel training, experience, and capabilities vary

widely, not only between units, but also amongst

services. Monitoring with the PROPAQ®(Welch

Allyn, Inc, 8500 SW Creekside Place, Beaverton, OR

97008) equipment is noninvasive but is significantly

limited by aircraft configurations and combat logistics.

Thermoregulation is currently maximized by using a

number of commercial and improvised methods, such

as placing the patient in a modified body bag with 2

wool blankets, and a reflective blanket.

CURRENT CIVILIAN TRANSPORT OF CRITICAL

POSTOPERATIVE PATIENTS

Transport of critically ill patients after damage control

surgery in a level 1 trauma center usually involves

intrahospital transport, including movement to a

radiology suite (eg, computed tomography or

interventional). At a minimum, transport typically

involves escort by a critical care nurse and respiratory

therapist. If the patient is going to the operating room,

a certified registered nurse anesthetist (CRNA) and/or

an anesthesiologist will also accompany the patient.
12 Army Medical Department Journal

Civilian helicopter air ambulance crews transporting

critically injured patients usually include a

combination of at least 2 heath care providers, usually

including a paramedic (EMT-P) teamed with a

registered nurse, respiratory therapist, another

paramedic, or a physician.

DEFINING OPTIMAL CONDITIONS FOR ROTARYWING TRANSPORT OF POSTOPERATIVE

DAMAGE CONTROL PATIENTS

When defining the optimal personnel and equipment

for transporting postoperative patients, the first step is

to define the potential complications and risks that

could arise in flight, placing the transported patient at

risk for injury or death.

RISKS TO POSTOPERATIVE PATIENTS DURING

AIR EVACUATION

The following are potential risks, some catastrophic, to

the severely injured and ventilator dependent

postoperative damage control patient during helicopter

air evacuation:

Severe Hypothermia. Hypothermia (especially core

body temperature <34°C) is a marker and predictor of

death after damage control laparotomy and is

associated with increased bleeding, blood transfusion,

and intravenous fluid requirements.7-12 The importance

of prevention and amelioration of hypothermia en

route to a level III facility cannot be overstressed.

Currently, temperature is not monitored inflight during

patient transport.

Exsanguination. Patients with a vascular shunt in

place or a guillotine amputation can have catastrophic

resumption of arterial hemorrhage with a misplaced

shunt or blowout of arterial clot and ligature.

Continued coagulopathic truncal bleeding in the

postoperative damage control patient is the norm and

not the exception, especially if the patient has not

received any coagulation factors, factor VIIa, or whole

blood.13

Lack of Adequate Monitoring During Flight. The

postoperative damage control patient requires minuteto-minute monitoring of heart rate, oxygen saturations,

and blood pressure. Lead placement malfunction,

inadequate battery recharge, and monitor mechanical

failure can all result in inadequate or complete lack of

inflight patient monitoring. Inadequate view of the

monitor by accompanying medical personnel results in

inadequate monitoring.

Loss of Airway or Endotracheal Tube. Loss of the

patient’s airway or dislodgement of an endotracheal

tube is always a possibility, especially with patient

movement and the erratic helicopter movement often

necessary in a combat zone. Airway management and

the rate of successful intubation are clearly

documented to be directly related to the amount of

training obtained at the EMT level.6,14,15

Loss of Intravenous Access. Loss of central or

peripheral intravenous access during air evacuation

could be life threatening to a patient requiring inflight

fluid/blood replacement or from blood loss from

disconnected IV tubing.

Ventilator Malfunction. Ventilators, like all machines,

are prone to malfunction, especially those exposed to

dust and temperature extremes. Inadequate battery

charge level can, of course, also cause a ventilator to

cease operating.

Symptomatic Pneumothorax. Level II facilities do

not have the capability to perform routine

postoperative chest x-rays. A clinically significant

pneumothorax can be delayed until the patient is

airborne (especially with gas expansion at altitude in a

fixed-wing aircraft). This condition can be extremely

confusing to diagnose and treat, especially if the

patient has multiple potential sources of hypoxia and/

or hypotension.

Inadequate Sedation/Analgesia. Intravenous

sedation and analgesia, a continuous process, includes

observation and timely administration of sedative/pain

medications which, if not adequate, can result in

patient self-extubation and removal of life-sustaining

lines, tubes, etc. This can be a lethal complication

during flight. Inadequate sedation and recall could

contribute to posttraumatic stress disorder in trauma

patients.16

Inadequate Oxygen Supply. There are reports of

ventilated patients arriving at a level III facility

without having received oxygen supplementation due

to inadequate oxygen supply on the rotary-wing

aircraft. Inadequate oxygen supply can be of great

Optimizing Transport of Postoperative Damage Control Patients in the Combat Zone
January – March 2007 13

significance to the oxygen dependent, severely injured,

ventilated postoperative damage control patient.

OPTIMAL CRITICAL CARE AND CONTINGENCY

PLANS FOR INFLIGHT COMPLICATIONS

Severe Hypothermia. Multiple layers, as represented

by the body bag/wool blanket/reflective blanket

combination, have been documented as an effective

means to preserve body heat.17 The addition of a

convective heating device has been documented as

providing optimal body heat preservation in

transported and perioperative patients.18-21 Optimal

thermoregulation of patients transported in a helicopter

may be obtained with the testing (for helicopter safety)

and approval of the use of a convective warming

system (eg, Bair Hugger®, Arizant Healthcare Inc,

10393 West 70th Street, Eden Prairie, MN 55344)

within the insulating layers, or the combination of

multiple layers, skull cap, and use of a chemical heat

generating device (Hypothermia Prevention and

Management Kit NSN# 6515-01-532-8056).

Exsanguination. The majority of patients who are

postoperative from a damage control surgery are

packed and have been (by logistic necessity)

minimally resuscitated with PRBCs and crystalloid

only, and will have some degree of coagulopathic

bleeding.3,13 Over time, the cumulative effect of this

blood loss may be profound hypotension and further

exacerbation of coagulopathic hemorrhage. The ability

to infuse further PRBCs during flight will potentially

extend the duration until irreversible exsanguination.22

All medical personnel accompanying patients with

extremity temporary intravascular shunts in place or

postoperative after an amputation must be trained in

the rapid application of tourniquets and, of course,

must also have immediate access to a tourniquet.

Optimally, patients with a truncal (or proximal

extremity vascular shunt not amenable to tourniquet

placement proximally) temporary intravascular shunt

in place should be accompanied by a surgeon with

immediate access to a vascular clamp.

Lack of Adequate Monitoring During Flight.

Postoperative damage control patients need continuous

monitoring. Loss of this monitoring could be

catastrophic while airborne. Personnel must be trained

to correct any small malfunctions and redundancy

should be built into inflight capability (including

redundant electrical supply). Continuous blood

pressure monitoring can only be obtained by intraarterial monitoring and should be incorporated into the

care of all transported postoperative damage control

patients in the near future, with redundancy provided

by noninvasive blood pressure cuff monitoring.

Loss of Airway or Endotracheal Tube. Personnel

transporting intubated postoperative damage control

patients must be highly trained in airway

management.23 Skills should include excellent bag

mask ventilation, inflight reintubation, and

cricothyroidotomy (surgical airway).

Loss Intravenous Access. Loss of intravenous

access in the hypovolemic and hypotensive

postoperative patient or the patient with fluid and

vasopressor dependence could be catastrophic.

Obtaining common inflight venous access is extremely

difficult. One excellent option for obtaining inflight

venous access is intraosseous sternal venous access.

These skills and equipment should be available to all

personnel transporting these postoperative patients.24,25

Ventilator Malfunction. Ventilator malfunction during

flight could be catastrophic. Personnel monitoring

these patients must be able to diagnose ventilator

malfunction (and have a redundant electrical source),

be able to troubleshoot the machine and, as a default,

be able to hand-bag the patient. Hand-bagging a

patient correctly, especially one with a head injury, can

be very difficult.26 The addition of end tidal CO2

monitoring may optimize ventilator and hand-bagging

of postoperative patients and should be considered for

the armentarium of inflight medical aircrew personnel

as soon as possible.27

Symptomatic Pneumothorax. Diagnosing a tension

pneumothorax in a postoperative damage control

patient during flight in a helicopter can be extremely

difficult. Low saturations and a high peak airway

pressure on the ventilator may be the only clues

available as inflight auscultation is nearly impossible.

Medical personnel accompanying these patients should

be trained in the diagnosis and treatment of tension

pneumothorax, including needle decompression and

chest tube placement.28

Inadequate Sedation. Accompanying medical

personnel must be trained in the signs of inadequate

sedation and administration of sedative medications.
14 Army Medical Department Journal

Adequate supply of sedative medications must be part

of a preflight medical checklist.

Inadequate Analgesia. Accompanying personnel

must be trained in the signs of inadequate pain control,

the continuous monitoring for signs of pain, and timely

administration of intravenous pain medications. An

adequate supply of sedative medications must be part

of a preflight medical checklist.

Inadequate Oxygen Supply. Adequate oxygen and an

extra volume of oxygen as a redundancy should be

part of every preflight medical checklist.

FUTURE OPTIMAL TRANSPORT

In the perfect scenario, the postoperative combat

damage control patient would be transported between

surgical facilities in a rotary-winged aircraft with

capabilities approaching that of the USAF Combat

Casualty Air Transport Team, which has demonstrated

efficacy in the safe out-of-theater transportation of

critically injured military personnel by fixed-wing

aircraft.29

OPTIMAL ROTARY-WING AIRCRAFT

The patient would be transported on an elevated

platform with 360° access. The helicopter cabin would

be shut and auxiliary heaters would heat the cabin

(currently, most helicopters are flown with the doors

open to allow for door gunner security). A convective

heating system, wall suction, and oxygen would be

available from the aircraft. The helicopter would be

armored with new weight-limited material. Many of

these capabilities will be found in the HH-60L/M (new

Blackhawk medical variant). Until an optimal aircraft

designated for evacuation is fielded, it may be

necessary to approach the optimal conditions with

additional mobile component equipment.

OPTIMAL PERSONNEL

Due to onboard space limitations, a CRNA,

anesthesiologist, general surgeon, or emergency

medicine physician would be responsible for the

endotracheal tube, ventilator, and fluid/blood/

vasopressor administration. These personnel are the

most experienced at airway management and

resuscitation. A highly trained registered nurse or a

team consisting of a highly trained paramedic or flight

medic trained specifically for inflight complications,

accompanied by a respiratory technician or nurse,

could potentially have similar capabilities. These

nurses, flight medics, and/or paramedics would need

extensive airway skills and would need significant

time in specific training at a facility in the United

States.30 These personnel would be used in the

transportion of only critical postoperative damage

control patients.

OPTIMAL EQUIPMENT

The optimal equipment for helicopter evacuation

would include a convective warming system for all

postoperative patients. Monitoring would include

continuous intraarterial monitoring and end tidal CO2

analysis. Storage of PRBCs and a fluid warmer system

would be available. Surgical equipment would be

available for needle decompression, chest tube

placement, and cricothyroidotomy. Ventilators would

have the capability to measure peak airway pressures.

Intraosseous access equipment would be available.

Preflight medical checklists would ensure built-in

monitoring/battery redundancy and adequate oxygen

supplies, sedation medications, and blood.

CONCLUSIONS

Current capabilities of helicopter medical

crewmembers and equipment transporting critically

injured postoperative combat damage control patients

are limited. Using the inexperienced paramedical

provider for the sole care of the patient does not

provide optimal care to those patients who are the

highest acuity battlefield casualties.

REFERENCES

1. Blackbourne LH, Holcomb JB. Can we provide level

III damage control procedures at a level II facility?

Army Med Dept J. April–June 2005:62-65.

2. Field Manual 8-10-25: Employment of Forward

Surgical Teams. Washington, DC: US Dept of the

Army; 30 September 1997.

3. Holcomb JB, Helling TS, Hirshberg A. Military,

civilian, and rural application of the damage control

philosophy. Mil Med. 2001;166(6):490-493.

4. Eddy VA, Morris JA Jr, Cullinane DC. Hypothermia,

coagulopathy, and acidosis. Surg Clin N Am. 2000;80

(3):845-854.

Optimizing Transport of Postoperative Damage Control Patients in the Combat Zone
January – March 2007 15

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6. Gerhardt RT, Stewart T, De Lorenzo RA, et al. US

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8. Cushman JG, Feliciano DV, Renz BM, et al. Iliac

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10. Asensio JA, McDuffie L, Petrone P, et al. Reliable

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damage control and predict outcome. Am J Surg.

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11. Wang HE, Callaway CW, Peitzman AB, Tisherman SA.

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a marker of shock and injury severity or an independent

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(5):1081-1085.

13. Murray DJ, Pennell BJ, Weinstein SL, Olson JD.

Packed red cells in acute blood loss: dilutional

coagulopathy as a cause of surgical bleeding. Anesth

Analg. 1995 Feb;80(2):336-342.

14. Bradley JS, Billows GL, Olinger ML, Boha S, Cordell

W, Nelson DR. Prehospital oral endotracheal intubation

by rural basic emergency medical technicians. Ann

Emerg Med. 1998;32:26-32.

15. Sing R, Rotondo M, Zonies D, et. al. Rapid sequence

induction for intubation by an aeromedical transport

team: a critical analysis. Am J Emerg Med.

1998;16:598-602.

16. Parslow RA, Jorm AF, Christensen H. Associations of

pretrauma attributes and trauma exposure with

screening positive for PTSD: analysis of a communitybased study of 2085 young adults. Psychol Med.

October 2005;28:1-9.

17. Brauer A, Perl T, Uyanik Z, English MJ, Weyland W,

Braun U. Perioperative thermal insulation: minimal

clinically important differences? Br J Anaesth. 2004;92

(6):836-840.

18. Patel N, Smith CE, Knapke D, Pinchak AC, Hagen JF.

Heat conservation vs convective warming in adults

undergoing elective surgery. Can J Anaesth. 1997;44

(6):669-673.

19. Borms SF, Engelen SL, Himpe DG, Suy MR,

Theunissen WJ. Bair hugger forced-air warming

maintains normothermia more effectively than thermolite insulation. J Clin Anesth. 1994;6(4):303-307.

20. Scheck T, Kober A, Bertalanffy P, Aram L, Andel H,

Molnar C, Hoerauf K. Active warming of critically ill

trauma patients during intrahospital transfer: a

prospective, randomized trial. Wien Klin Wochenschr.

February 16, 2004;116(3):94-97.

21. Kober A, Scheck T, Fulesdi B, et al. Effectiveness of

resistive heating compared with passive warming in

treating hypothermia associated with minor trauma: a

randomized trial. Mayo Clin Proc. 2001;76(4):369-375.

22. Sampson JB, Davis MR, Mueller DL, Kashyap VS,

Jenkins DH, Kerby JD. A comparison of the

hemoglobin-based oxygen carrier HBOC-201 to other

low-volume resuscitation fluids in a model of controlled

hemorrhagic shock. J Trauma. 2003;55(4):747-754.

23. Swanson ER, Fosnocht DE, Barton ED. Air medical

rapid sequence intubation: how can we achieve

success? Air Med J. 2005;24(1):40-46.

24. Calkins MD, Fitzgerald G, Bentley TB, Burris D.

Intraosseous infusion devices: a comparison for

potential use in special operations. J Trauma. 2000;48

(6):1068-1074.

25. Dubick MA, Kramer GC. Hypertonic saline dextran

(HSD) and intraosseous vascular access for the

treatment of haemorrhagic hypotension in the farforward combat arena. Ann Acad Med Singapore.

1997;26(1):64-69.

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

hypoxia and hyperventilation on outcome after

paramedic rapid sequence intubation of severely headinjured patients. J Trauma. 2004;57(1):1-8.

27. Davey AL, Macnab AJ, Green G. Changes in pCO2

during air medical transport of children with closed

head injuries. Air Med J. 2001 Jul-Aug;20(4):27-30.

28. Barton ED, Epperson M, Hoyt DB, Fortlage D,

Rosen P. Prehospital needle aspiration and tube

thoracostomy in trauma victims: a six-year

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1995;13(2):155-163.

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16 Army Medical Department Journal

30. Crommett JW, McCabe D, Holcomb JB. Training for the transport of mechanically ventilated patients. Respir Care

Clin N Am. 2002;8(1):105-111.

Optimizing Transport of Postoperative Damage Control Patients in the Combat Zone

AUTHORS

LTC Blackbourne is the Trauma, Burn, and Surgical Critical Care Surgeon at the Institute of Surgical Research, Brooke

Army Medical Center, Fort Sam Houston, Texas.

LTC Grathwohl is the Assistant Chief, Anesthesia and Operative Services, Brooke Army Medical Center, Fort Sam

Houston, Texas.

COL Eastridge is Chief of Trauma Service, Brooke Army Medical Center, Fort Sam Houston, Texas.

COL MacDonald is the Director of the Medical Evacuation Proponency Directorate, Fort Rucker, Alabama, and is the

Aeromedical Evacuation Consultant to The Army Surgeon General.

COL Holcomb is Commander, US Army Institute of Surgical Research, Brooke Army Medical Center, Fort Sam

Houston, Texas, and Trauma Consultant to The Army Surgeon General.

COL BARRY MOORE AND MAJ TERESA BRININGER

JOIN THE AMEDD JOURNAL EDITORIAL REVIEW BOARD

The AMEDD Journal welcomes COL Barry Moore, DC, USA and MAJ

Teresa Brininger, SP, USA as new members of the Editorial Review Board.

COL Moore is the Chief, Department of Dental Science, AMEDD Center &

School, Fort Sam Houston, Texas. MAJ Brininger is a Research

Occupational Therapist at the Army Research Institute of Environmental

Medicine, Natick, Massachusetts.

COL Moore joins the Board replacing

COL Thomas R. Cole, DC, USA. COL

Cole is an original member of the Board,

accepting his position in November, 1999.

We thank COL Cole for his dedication to

the high standards and professional

quality of this publication, and his years

of service and support to our mission.

MAJ Brininger replaces LTC Rachel Evans, SP, USA who has accepted the

position of Director, Amputee Research Program at the Center for the

Intrepid, Fort Sam Houston, Texas. LTC Evans has been a member of the

Editorial Review Board since 2002. We thank LTC Evans for her dedication

and support of the AMEDD Journal and congratulate her for her profoundly

important new assignment.

The Editors
January – March 2007 17

INTRODUCTION

A total of 286 surgical procedures were performed by

a single orthopaedic surgeon during a 5-month period

at a combat support hospital (CSH) in Iraq. The vast

majority of injuries treated were combat related—

gunshot wounds and fragment injuries from mortars

and improvised explosive devices. Injuries treated

included contaminated soft tissue injuries, open

fractures, open joints, and traumatic amputations.

Over 150 procedures were performed on Iraqi soldiers,

detainees, and civilians who would receive their

definitive care at the CSH, and would remain as

inpatients until their wounds were healed sufficiently

for discharge. Initially, all extremity wounds were

treated with surgical irrigation and debridement,

fracture stabilization, followed by twice daily wet to

dry dressing changes on the wards. As the war

escalated and the hospital census increased to 75

patients, twice daily dressing changes became

logistically difficult. The development of alternate

forms of wound management was necessary.

Vacuum-assisted closure, initially developed in the

1990s for the management of large, chronically

Management of Traumatic War Wounds

Using Vacuum-Assisted Closure

Dressings in an Austere Environment

LTC M. Shaun Machen, MC, USA

ABSTRACT

Objective: The study was undertaken to develop a protocol for the ongoing management of traumatic war

wounds in the austere environment of a combat support hospital.

Method: A total of 286 surgical procedures were performed by a single orthopaedic surgeon during a 5-month

period at a combat support hospital in Iraq. Over 150 procedures were performed on Iraqi soldiers, detainees,

and civilians who would receive their definitive care at the combat support hospital, and who would remain as

inpatients until their wounds were healed enough for discharge. Initially, all extremity wounds were treated with

surgical irrigation and debridement followed by twice daily dressing changes on the wards. As the ward census

increased to 75 patients, it became necessary to develop alternate forms of wound management. Field expedient

vacuum-assisted closure (VAC) dressings were instituted. These dressings were created with fluffs or prep

sponges, suction tubing, IobandTM, and portable suction machines. The VAC dressings were left in place for 3 to

4 days and then changed. Traumatic, contaminated, and infected wounds were rapidly debrided and granulation

tissue was induced. The portable suction pumps, however, were extremely noisy and failed with continued use.

Machines and sponges manufactured by KCI Inc. were purchased. The VAC dressing became an invaluable tool

for managing, closing, and preparing wounds for skin grafting. Over 50 traumatic war wounds were treated with

the VAC dressing. The clinical courses of 20 of these wounds were carefully documented with digital

photography.

Results: Over 50 traumatic war wounds were effectively treated with initial irrigation and debridement,

followed by serial application of VAC dressings. VAC dressings rapidly debrided contaminated wounds,

reduced edema, decreased wound size, and induced granulation tissue. Wounds were then treated by delayed

primary closure, local flap coverage, or skin grafting.

Conclusion: An effective protocol utilizing VAC dressings was developed for the expeditious treatment of

traumatic war injuries in an austere environment.
18 Army Medical Department Journal

infected wounds1has more recently been used in the

treatment of traumatic wounds.2 The modality creates

a wound environment of subatmospheric pressure

which reduces interstitial fluids, removes debris,

contracts the wound, enhances blood flow to the

wound, and promotes the formation of granulation

tissue. The VAC dressing can be applied in the

operating room after debridement and conveniently

left in place for 3 to 4 days.

The purpose of this study was to develop a wound

treatment protocol to effectively manage a large

number of traumatic war injuries in a combat

environment. A “field expedient” VAC dressing was

initially used, and later replaced by commercial

V.A.C.® ATS®Systems (Kinetic Concepts, Inc., San

Antonio, Texas) when they became available in the

military supply system.

MATERIALS AND METHODS

The initial VAC dressings used at the CSH were

created from available materials in the austere

environment of a combat support hospital. Following

thorough irrigation, debridement, and fracture

stabilization—usually with an external fixator—a field

expedient VAC dressing was applied. As shown in

Figure 1, the dressing was created by placing either lap

sponges or yellow preparation kit sponges in the base

of the wound. The skin edges were cleaned and

defatted with an alcohol wipe. The end of a standard

suction tube was fenestrated with holes created with a

scalpel and was placed within the sponges. An

IobandTM adhesive drape was then used to cover the

sponges and wound, and a “mesentery” was formed

around the tube. The tube was then connected to a

portable bedside suction machine on low, intermittent

suction.

The improvised VAC systems worked relatively well,

but some problems were identified. Inevitably, when

the yellow prep sponges were used there were areas of

the wound that were not in contact with a sponge.

These areas developed a mucinous, exudative slime

over the course of 3 days. The improvised tubes would

occasionally become plugged or collapse, and the

wounds would not contract as well as they do with one

large, uniform sponge pulling the edges together. The

biggest problems experienced involved the portable

suction machines. The machines were very noisy and

disrupted the sleep patterns of patients packed into

tight wards. Wool blankets and cardboard boxes were

placed over the machines to reduce the noise, but this

contributed to overheating and the machines would

fail. With high ambient temperatures and continuous

use, all of the machines eventually failed. Our ability

to use VAC dressings became limited by the

nonavailability of suction machines.

As soon as the problem with suction pumps was

identified, a rush order was placed to Kinetic

Concepts, Inc. for 5 V.A.C. ATS systems as well as a

large supply of black sponges of various sizes. The

V.A.C. ATS is a subatmospheric pressure device that

uses a medical grade reticulated polyurethane ether

sterile foam dressing, which contains an embedded

noncollapsible evacuation tube. The pore size of the

sponge is 400 μm to 600 μm, which has been shown to

maximize tissue ingrowth,3and the tube contains side

ports to allow communication of its lumen to all the

spaces in the foam. The V.A.C. ATS pump itself has

technology which allows accurate pressure sensing,

adjustable pressure intensity, intuitive touch screens,

filter system to minimize wound odor, and quiet

operation. The arrival of this medical equipment

greatly enhanced our ability to effectively treat even

the most gruesome battle injuries.

A protocol was developed: All battle injuries undergo

initial irrigation via pulsatile lavage, debridement of all

foreign material and devitalized tissue, and external

fixation of fractures. An attempt is made to preserve

all large fracture fragments, smaller fragments with

soft tissue attachments, and tendons. A sterile gauze

Management of Traumatic War Wounds Using VAC Dressings in an Austere Environment

Figure 1. A field-expedient VAC dressing created

with a lap sponge and Ioband.
January – March 2007 19

dressing is applied. On post-op day one, the patient

undergoes a dressing change on the ward, with

Ketamine sedation if necessary. On post-op day two,

the patient returns to the OR for repeat irrigation and

debridement, and placement of a wound VAC. The

sponge is trimmed and shaped to contact all wound

surfaces allowing equal distribution of the

subatmospheric pressure to all surfaces in contact with

the sponge (Figure 2). The skin along the edges of the

wound is cleaned and defatted with alcohol, the

noncollapsible tube is placed, and the wound sealed

with an adhesive drape supplied with the sponge

(Figure 3). We are careful to trim back the edges of the

adhesive drape, while still maintaining a seal, to

prevent abraded or fragment injured skin from

becoming exudative. Finally, the tube is connected to

the pump and the suction adjusted to between 50 mm

and 125 mm Hg. The pump is turned on and the

dressing is tested to make sure that the sponge

collapses into the wound (Figure 4).

The VAC dressing is left in place for 3 to 4 days and is

either changed in the operating room depending on

what other procedures are needed, or changed on the

ward under Ketamine sedation. VAC dressings are

changed every 3 to 4 days until the wound is prepared

for definitive closure. Typically the wound contracts as

edema is removed and the wound edges are pulled

together. The wound becomes very clean and free of

exudative fluids. Vascularity is enhanced and beefy

red granulation tissue forms (Figure 5). Wounds are

then closed either by delayed primary closure, local

rotational flaps, or split thickness skin grafts,

illustrated in Figure 6.

The wound VAC was used on a variety of upper

extremity, lower extremity, and even torso wounds.

All wounds treated were secondary to gunshot,

fragmentation, or blast. The VAC was placed over

muscle, tendons, fasciotomy sites, limb amputations,

exposed bone (Figure 7) and even orthopaedic

hardware. Several patients with infected stumps,

resulting from amputations which had been performed

elsewhere, were treated with the VAC (Figure 8). The

VAC was placed on at least 50 combat casualties. The

course of wound VAC therapy on 20 cases was

thoroughly documented from initial wound to fully

healed wound with digital photographic records.

CASE ILLUSTRATION

A 43-year old Iraqi enemy prisoner of war sustained a

fragmentation injury to his left nondominant elbow.

The fragmentation injury resulted in a type 3B

olecranon fracture with bone loss and extensive soft

tissue injury (Figure 9). The soft tissue injury involved

skin loss in a 10 cm by 20 cm area involving the entire

Figure 2. A sterile black foam dressing is cut to fit

the contour of the wound.

Figure 3. The VAC sponge is sealed into the

wound with the adhesive drape.

Figure 4. Suction is applied to the sponge and the

adhesive drape is trimmed to minimize skin
20 Army Medical Department Journal

Management of Traumatic War Wounds Using VAC Dressings in an Austere Environment

Figure 5. Wound appearance after 3 days of wound

VAC treatment.

Figure 6. One week after application of skin graft to

wound.

Figure 7. Accumulation of granulation tissue on

exposed bone and hardware. Figure 8. A VAC sponge is applied to the residual

limb of an infected above the knee amputation.

Figure 9. Type 3B olecranon fracture with extensive

soft tissue and bone loss. Figure 10. Wound VAC in place.
January – March 2007 21

posterior aspect of his elbow. The wound was treated

with initial pulsatile irrigation and debridement. The

patient was returned to the operating room 2 days later

for repeat irrigation and debridement followed by

placement of a wound VAC (Figure 10). Wound VAC

treatment continued for 12 days with VAC changes

every 4 days. On post-injury day 14, the wound had a

healthy, clean appearance (Figure 11). The wound

VAC treatment had resulted in the reduction of edema,

and the formation of beefy red, well-vascularized,

granulation tissue. A split thickness skin graft was

harvested and placed over the wound (Figure 12). The

skin graft was 100% successful. The wound healed

and the patient was discharged. The patient returned

for followup 2 months after injury. As shown in Figure

13, the wound was completely healed. The patient was

taken to the operating room and manipulation under

anesthesia was performed to increase range of motion.

A functional range of motion was achieved on the

operating room table.

RESULTS

The wound VAC evolved into an extremely useful

modality for the treatment of high-energy combat

wounds. The period of time during which this device

was used was one of intense fighting and high casualty

rates. The wound VAC was applied rapidly, either in

the operating room after irrigation and debridement, or

on the ward with Ketamine sedation. The VAC

dressing could then be left in place for 3 or 4 days,

greatly diminishing the need for painful, timeconsuming dressing changes and multiple trips to the

operating room. With only one orthopaedic surgeon

assigned to the CSH during a 5-month period, this

device greatly increased productivity and freed the

surgeon to attend more critical patients.

Wound VAC treatment was used on over 50 patients.

Digital photography with dates and times were

obtained to document stages of treatment and healing

in 20 cases. Four infected above-knee amputation

stumps were treated and effectively closed or skin

grafted after VAC use. Three open both-bone forearm

fractures secondary to through and through gunshot

wounds (GSW) were plated, treated with wound VAC,

and skin grafted. Four Type 3B open distal tibia/fibula

fractures secondary to GSW were treated with external

fixation, wound VAC, tibial shortening in one case,

local rotational flap or skin graft, and finally bone

grafting (Figure 14). An open subtrochanteric femur

fracture, secondary to GSW, with thigh compartment

syndrome was treated with fasciotomy, fracture

stabilization with a Rush Rod, 90/90 traction, wound

VAC, and delayed primary closure. The patient was

discharged to crutch weight bearing after 3 weeks of

traction. Two open proximal humerus fractures and

Figure 11. Wound appearance after 12 days of

VAC treatment.

Figure 12. Wound after placement of split thickness

skin graft.

Figure 13. Wound area 2 months after injury.
22 Army Medical Department Journal

one open distal humerus fracture were all effectively

treated with external fixation or open reduction

internal fixation followed by wound VAC and skin

grafting. A GSW to the plantar surface of the foot, 2

large soft tissue injuries to the thigh, and one GSW to

the buttock were all treated with wound VAC followed

by healing by secondary intention, or delayed primary

closure and skin grafting.

Problems associated with the earlier described field

expedient VAC dressings were essentially solved by

the V.A.C. ATS systems. As we developed greater

expertise in the use of the system, we learned,

especially in the case of amputations, to make sure that

no areas of dead space existed when the sponges were

placed over large wounds. We also learned to leave no

area of raw wound uncovered by sponge material.

Suction was applied, and the dressing was trialed in

the operating room. If an area of wound was

uncovered, the adhesive drape would be cut, a small

portion of sponge would be inserted over the exposed

wound, and the dressing would be resealed.

Maceration would occur in cases where the adhesive

drape did not completely seal to the skin on the

borders of the wound. To prevent this, we used alcohol

to thoroughly clean, defat, and dry the skin prior to

application of adhesive drape. The problems

encountered with the VAC dressing were really

minimal. More often than not, we were amazed at the

clean, healthy appearance of the wounds when the

dressings were removed.

DISCUSSION

Treatment of combat related orthopaedic wounds,

which are often complicated by large skin loss,

devitalized tissue, gross contamination, open fractures,

and infection secondary to treatment delay, is

complicated. The treatment difficulty is compounded

when the treatment must occur in the austere

environment of a combat “tent” hospital, in a war

zone, with limited supplies, and large numbers of

patients. This paper describes a technique that evolved

and a protocol that was established to efficiently

manage the wound care of large numbers of combat

casualties. The V.A.C. ATS proved extremely valuable

in accelerating the healing of 20 documented traumatic

wounds.

The ability to obtain eventual soft tissue coverage in

the wounds studied was attributed to a number of

different factors:

a. Because of the negative pressure acting on the

sponge, the interstitial fluids that accumulated

in these wounds were evacuated. These fluids

have been found to contain inhibitory factors

such as inflammatory cytokines and

collagenases that suppress the formation of

fibroblasts, vascular endothelial cells, and

keratinocytes that are prominent in wound

healing.3-5

b. The evacuation of these fluids eliminates the

formation of any superficial purulence and

slime that occurs in open wounds.1 This

enhances wound healing by reducing the

potential for anaerobic colonization, and

decreasing bacterial counts.6

c. Studies have demonstrated that an applied

subatmospheric pressure results in decreased

capillary afterload.1,6 This decreased afterload

allows arterioles to dilate, increasing blood flow

to the area fourfold. Increased blood flow

produces a proliferation of granulation tissue.

d. The negative pressure created by the vacuum

exerts a mechanical force to the soft tissues that

make up the periphery of a wound. Unlike

sutures or tension devices, the VAC can exert a

uniform force on each individual point on the

edge of a wound, drawing it toward the center

of the defect by mechanically stretching the

cells via the application of negative pressure.6

e. The labor involved and the pain associated with

frequent wet to dry dressing changes is

minimized.

Management of Traumatic War Wounds Using VAC Dressings in an Austere Environment

Figure 14. Type 3B tibia fracture secondary to

gunshot wound, treated with external fixation,

wound VAC, tibial shortening, and local skin flap.
January – March 2007 23

While other published studies have attempted to

quantify wound size reduction with VAC treatment, or

have investigated the costs of treatment compared with

conventional wound care, this study was more

observational in nature. Our measure of a successful

outcome was achieving a healed, noninfected wound,

in an austere environment, with limited supplies, and

the nonavailability of plastic surgeons. This is the first

study that describes the use of subatmospheric

dressing technology to treat high-energy ballistic

wounds in a combat environment. We have shown that

VAC systems can be successfully used to treat large

numbers of patients in a highly effective and efficient

manner. It is recommended that V.A.C. ATS systems

become part of the inventory of all combat support

hospitals tasked with managing large numbers of

combat patients for extended periods of time.

Subatmospheric pressure dressings are an excellent

adjunct in the effective and safe treatment of highenergy, combat, orthopaedic wounds.

REFERENCES

1. Argenta LC, Morykwas MJ. Vacuum-assisted closure: a

new method for wound control and treatment. Clinical

experience. Ann Plast Surg. 1997;38:563.

2. Herscovici D, Sanders RW, Scaduto JM, et al. Vacuumassisted wound closure (VAC therapy) for the

management of patients with high-energy soft tissue

injuries. J Orthop Trauma. 2003;17:683-688.

3. Wake MC, Patrick CW, Mikos AG. Pore morphology

effects on the fibrovascular tissue growth in porous

polymer substrates. Cell Transplant. 1994:3:339-343.

4. Grinnell F, Ho CH, Wysocki A. Degradation of

fibronectin and vitrocectin in chronic wound fluid.

Analysis by cell blotting, immunoblotting, and cell

adhesion assays. J Invest Dermatol. 1992;98:410-416.

5. Bucalo B, Eaglstein WH, Falanga V. Inhibition of cell

proliferation by chronic wound fluid. Wound Rep

Regen. 1993;1:181-186.

6. Morykwas MJ, Argenta LC, Shelton-Brown EI, et al.

Vacuum-assisted closure: a new method for wound

control and treatment. Animal studies and basic

foundation. Ann Plast Surg. 1997:38:553-561.

AUTHOR

LTC Machen is Chief of Pediatric Orthopaedics and

Assistant Chief of Orthopaedic Services at the William

Beaumont Army Medical Center, Fort Bliss, Texas.
24 Army Medical Department Journal

Causes of Death in US Special

Operations Forces in the Global

War on Terrorism: 2001–2004

COL John Holcomb, MC, USA

CAPT James Caruso, MC, USN Howard R. Champion

CPT Neil McMullin, MC, USA Mary Lawnick, RN

Charles E. Wade, PhD COL Warner Farr, MC, USA

LCDR Lisa Pearse, MC, USN MSG Sammy Rodriguez, USA

Lynne Oetjen-Gerdes CAPT Frank Butler, MC, USN

ABSTRACT

Introduction: Effective combat trauma management strategies depend on an understanding of the

epidemiology of death on the battlefield, resulting in evidence-based equipment, training, and research

requirements.

Methods: All Special Operations Forces (SOF) fatalities (combat and noncombat) in Operation Iraqi

Freedom/Operation Enduring Freedom (OEF/OIF) from October 2001 until November 2004 were reviewed.

All available autopsy and treatment records and photographs were used. In most cases, the immediate tactical

situation was unknown. The review was performed by a multidisciplinary group including forensic

pathologists, an SOF combat medic, and trauma surgeons. Fatalities were classified as having wounds that

were either nonsurvivable or potentially survivable with existing training, equipment, and expertise on the

battlefield. A structured review was performed evaluating the need for new equipment, training, or research

requirements. Results were compared to autopsy data from Vietnam and modern civilian trauma center data.

The study was approved by the Institutional Review Boards of the Armed Forces Institute of Pathology and

the US Army Institute of Surgical Research.

Results: During the study period, 82 SOF fatalities were identified. Autopsies were performed on 77

Soldiers. Five casualties died secondary to aircraft crash, their bodies were not recovered from the ocean. For

the purposes of this study they were considered nonsurvivable. Eighty-five percent (n=70) of the fatalities

sustained wounds that were nonsurvivable, while the remaining 15% (n=12) had wounds that were potentially

survivable. Injury Severity Score (ISS) was higher in the nonsurvivable group (p<0.05). Truncal hemorrhage

accounted for 47% of deaths while extremity hemorrhage accounted for 33%. One casualty was noted at

autopsy to have a tension pneumothorax as well as multiple sources of internal hemorrhage, one suffered an

airway death, while another died of sepsis 56 days after injury. Of those casualties deemed to be

nonsurvivable, there were 31 patients with 40 Abbreviated Injury Score (AIS) 6 injuries (p=.0011), and 53

patients with 104 AIS 5 injuries. Among the 12 deaths deemed to be potentially survivable, there were only 8

AIS 5 injuries. Deaths were largely caused by explosions (n=35), gunshot wounds (n=23), and aircraft

accidents (n=19). No new training or equipment needs were identified for 53% of the potentially survivable

deaths while improved methods of truncal hemorrhage control need to be developed for the remainder. The

review panel concluded that 85% of the deaths would not have been prevented at a civilian Level I facility.

Available records, in most cases, did not contain information about the use of body armor, time to death after

injury, or the ongoing tactical situation.

Conclusions: The majority of deaths on the modern battlefield are nonsurvivable. Current results are not

different from previous conflicts. In Vietnam, reported potentially preventable death rates range from 5% to

35% and civilian data reports potentially preventable death rates ranging from 12% to 22%. Military

munitions cause multiple lethal injuries. Current trauma training and equipment is sufficient to care for 53%

of the potentially survivable deaths. Improved methods of intravenous or intracavitary noncompressible

hemostasis combined with rapid surgery are required for the remaining 47% of the decedents.
January – March 2007 25

INTRODUCTION

Identifying areas for improvement in modern combat

trauma management depends on a clear understanding

of the epidemiology and outcome of combat injuries.

Thus, an important prerequisite to optimize the

treatment of injured combatants is the ability to

analyze current data so that new strategies of care,

equipment requirements, and a focused research

agenda can be changed to meet contemporary goals

and needs. Analyses of deaths from injury have long

been a cornerstone of trauma system development and

are essential to measure improvements of civilian

systems of trauma care.1,2 Equivalent studies have

occurred on several military data sets.3-5

Previous analysis of US combat deaths largely rests in

the analysis of Vietnam casualties described by the

Wound Data and Munitions Effectiveness Team

(WDMET) database. This analysis is now 40 years old

and has served to drive military medical research,

logistics, and medical tactics since that time. Changes

in body armor, improved medical care, equipment, and

training common to the current war versus Vietnam

raises the question of the applicability of the WDMET

data to the current experience. An additional and

perhaps more important concern about the WDMET

applicability stems from the current methods of death

analysis, derived from 30 years of experience in

maturing trauma systems research.6

We hypothesized, based on improvements in body

armor, medical care, equipment, and training, and an

improved understanding of appropriate death analysis,

that different patterns of potentially survivable injuries

would emerge, leading to new research and

interventions. The goal of this review was to identify

those injuries that were potentially survivable, were

amenable to current prevention and treatment

modalities, or required new treatment and training

capabilities, or research. The resulting data was

compared to previously published data from civilian

and military trauma autopsy studies.

METHODOLOGY

All recovered remains of US combatants are

transported to Dover, Delaware, where complete

identification and forensic examination is performed

by the Office of the Armed Forces Medical Examiner.

These unique resources form the basis for this report.

Institutional Review Board approval for the study was

provided by the US Army Institute of Surgical

Research and the Armed Forces Institute of Pathology.

All SOF fatalities were identified by the personnel

office of the US Special Operations Command. This

included both combat and noncombat fatalities and

those killed in action, as well as those who died of

wounds.7 Treatment records and files from the Joint

Theater Trauma Registry and the Office of the Armed

Forces Medical Examiner were compiled and unique

identifiers removed for this review. The study team

included forensic pathologists, military and civilian

trauma surgeons, a trauma nurse, and a Special

Operations combat medic.

Historically, the majority of combat deaths are beyond

salvage.4 A screening review using autopsy

information to estimate the severity of injury and

suddenness of death was performed to identify cases

that merited a detailed evaluation. As in previous wars,

the severity and multietiology, multisystem injury in

combat is such that detailed review was not warranted

in most cases.

Patients were classified as either nonsurvivable or

potentially survivable against a standard of the

deployed US level III medical treatment facilities in

theater. These level III facilities represent the highest

standard of medical care available in the deployed

setting. This standard was chosen with full

understanding of the extreme variability of the tactical,

geographic, and logistical environment of combat

injury, and thus the lack of ability to normalize care

for a single individual casualty. The commonly used

civilian morbidity and mortality category of

preventable was not used as the tactical situation was

not known, thus medical judgments of preventable in

the absence of tactical knowledge were deemed

unacceptable. All patients for whom autopsies were

available had been coded independently for

Abbreviated Injury Score (AIS) and Injury Severity

Score (ISS). A structured review and analysis of each

case was completed to determine where opportunities

for improved outcome existed. Areas that were a prime

consideration in this questionnaire involved

equipment, training, expedient evacuation, body

armor, Tactical Combat Casualty Care (TCCC)

guidelines,8and new research requirements. Not all of

the data required to completely answer each question

was available. For example, whether or not the
26 Army Medical Department Journal

casualty was wearing personal protective equipment

(PPE) or whether PPE would have prevented the

wound from being sustained was often difficult to

ascertain.

RESULTS

There were 82 SOF fatalities with 77 autopsies; from

35 explosions (42%), 23 gunshot wounds (GSW)

(28%), 19 from aircraft crashes (23%), 4 motor vehicle

crashes, and 1 fall (Table 1). The numbers differ

somewhat from observations throughout OEF/OIF.

Compared to conventional Soldiers, the SOF fatalities

have a higher incidence of death secondary to gunshots

(p<0.05) and a lower incidence of death secondary to

explosions (p<0.05). The 5 decedents without an

autopsy were those who were not recovered from a

helicopter crash at sea.

Twenty-four (70%) of the 82 cases were selected for

detailed review by the panel. Twelve of the 24 cases

which were reviewed in-depth were considered to be

potentially survivable. During the study period, 12

(15%) of the 82 SOF deaths died from potentially

survivable injuries. The 16 mechanisms of injury in

these 12 deaths are shown in Table 1. Four (33%) of

the potentially survivable casualties were died-ofwounds (DOW), one of which died 56 days after

injury at a level V hospital. The other 3 were

categorized as having DOW as they were declared

dead at a combat support hospital. The remaining 8

(66%) casualties were killed-in-action.

Of those casualties

deemed to be

n o n s u r vi va b l e ,

there were 31

patients with 40

AIS 6 injuries

(p=0.0011), and

53 patients with

104 AIS 5 injuries.

Among the 12

deaths deemed to

be potentially

survivable, there

were only 8 AIS 5

injuries and 18

AIS 4 injuries (Table 2). The distribution of ISS is

shown in Figure 1. Eighty-five percent of the fatalities

were nonsurvivable (ISS=58+35) while 12 (15%) were

potentially survivable (ISS=35+9, p<0.05) and

provided some basis for potential change in outcomes.

Figure 2 shows the distribution of ISS by quartile.

Nearly one-half of the nonsurvivable casualties had an

ISS of 60 to 75. Using Fischer’s exact

test, there was a significantly greater

percentage of casualties in the potentially

survivable group in the ISS 20 to 40

quartile (p<00.03).

The most common etiologic factors in

the potentially survivable deaths were

noncompressible hemorrhage (n=8)

followed by hemorrhage amenable to

placement of a tourniquet (n=3),

hemorrhage not amenable to placement

of a tourniquet yet compressible (n=2),

airway (n=1), tension pneumothorax

(n=1), and sepsis (n=1) (Figure 3).

Table 3 shows the areas wherein

currently available interventions may

have resulted in different outcomes for

the 12 patients. The reader should

remember that the tactical situation for

these casualties is largely unknown.

Medical care under fire is extremely

Causes of Death in US Special Operations Forces in the Global War on Terrorism: 2001–2004

Table 1. Mechanisms of Injury in 82 SOF Deaths (%) and All

Combat Injuries from OIF/OEF (Nov 2004)

Mechanism OIF/OEF

n=3789

SOF

n=82

NS*

n=70

PS†

n=12

All explosions 2030 (55) 35‡(43) 32 (46) 3 (25)

IED§

1201 (32) 16 (20) 14 (21) 2 (17)

RPG** 466 (12) 2 (2) 1 (1) 1(8)

Other Explosions 26 (1) 16 (20) 16 (23) 0

Rockets/Mortar

Attack 337 (9) 1 (1) 1 (1) 0

Aircraft crash 33 (1) 19 (23) 19 (27) 0

Motor Vehicle Crash

Without IED 579 (15) 4 (5) 3 (4) 1 (8)

Fall 353 (9) 1 (1) 0 1 (8)

Gunshot Wounds 712 (19) 23‡(28) 16 (23) 7(59)

Total 3707 (100) 82 (100) 70 (85) 12 (15)

*Nonsurvivable §Improvised explosive device

†Potentially survivable **Rocket propelled grenade

‡

p<0.05

Table 2. Abbreviated Injury

Score (AIS) Distribution*

Total

Scores

PS†

n=12

NS‡

n=65

AIS 6 40 0 40§

AIS 5 112 8 104

*n=77 as 5 fatalities due to aircraft

crash were not autopsied

†Potentially survivable

‡Nonsurvivable

§

p=0.001
January – March 2007 27

hazardous and significantly modifies what can be done

for an individual casualty. Additionally, there may

exist multiple areas wherein interventions or

improvements may have altered the outcome for a

single patient. Prehospital opportunities to potentially

prevent death included hemorrhage control with

tourniquet (n=3) and pressure with hemostatic

dressings (n=2), adequate airway (n=1), and needle

thoracostomy (n=1). These 8 cases of fatalities from

potentially survivable wounds are all covered in the

current TCCC guidelines.8 More expeditious casualty

evacuation (CASEVAC) to a facility capable of

definitive surgical intervention may have improved

patient outcome in 8 casualties. In 3 casualties,

improved equipment that is now present in the field,

the Combat Application Tourniquet (CAT) (n=1) and

use of a hemostatic dressing (n=2), may have altered

the final outcome of the casualty. These items, though

not available at the beginning of the war, are now used

universally.

Table 4 shows that 25% of the potentially survivable

casualties sustained injuries in locations that are

protected by the current personal protective equipment

(PPE). The 3 Soldiers sustained wounds in anatomic

locations that are protected by the current body armor

used in theatre. Though it is unknown whether or not

the armor was worn, the assumption was made, based

Table 3. Interventions which may

have possibly influenced outcomes

for potentially survivable casualties

(n=12).

Potential Intervention

Potential

Improvement

in Outcome

Decreased CASEVAC

times

11

Intravenous hemostasis 8

Uniform Application of

Current TCCC Training 8

Equipment 3

Figure 1. Ranges of Injury Severity Scores for deaths of Special Operations Forces Soldiers in

Operations Enduring Freedom and Iraqi Freedom.

0

5

10

15

20

25

30

35

20 25 26 29 30 33 35 36 38 41 42 43 49 50 54 57 59 66 73 75

Injury Severity Score

Number of Casualties

Total

Potentially Preventable
28 Army Medical Department Journal

on the mechanism of injury, that had body armor been

worn, the Soldier would have been protected from this

particular injury. Of the 82 SOF deaths, there was only

one Soldier who sustained a mortal wound to the chest

in an area that is not now covered by current PPE.

Eight of the potentially survivable casualties may have

benefited from an injectable hemostatic agent or fluid

such as recombinant factor VIIa, lyophilized or

freeze dried plasma, and oxygen carrying products

such as hemoglobin based oxygen carriers. Six

major vascular injuries were identified (Table 5).

Of these 6 named arteries, 3 of the injuries were

amenable to placement of a tourniquet.

Hemorrhage was considered to have been a

contributing factor in 10 of the 12 potentially

survivable casualties.

CASE STUDIES

The following case studies represent the consensus of

the reviewing group. It is important again to

emphasize that the tactical situation in most cases was

completely unknown. The simplest medical care is

often impossible in the midst of a firefight, while

access to a casualty is often impossible in the terrain

frequently encountered in these episodes. As such, the

conclusions presented below are based entirely on the

objective medical information

available from the autopsy and

the Joint Theatre Trauma

Registry medical records.

Case 1

The individual was wounded by

an improvised explosive device

(IED). He sustained a

penetrating shrapnel injury to

the neck with laceration of his

right common carotid artery

from which he exsanguinated.

This death might have been

prevented with sustained direct

pressure over the bleeding site

until surgical repair was

accomplished. However, this

may be very difficult or not

Causes of Death in US Special Operations Forces in the Global War on Terrorism: 2001–2004

Table 4. Possible affect of Personal

Protective Equipment (PPE) on those

fatalities judged to have sustained

potentially survivable injuries (n=12).

Injury in area of body

covered by PPE? Total Percentage

Yes 3 25%

No 9 75%

0%

10%

20%

30%

40%

50%

60%

70%

0-19 20-39 40-59 60-75

Injury Severity Score

*

*

Potentially survivable Nonsurvivable

Figure 2. Comparison of Injury Severity Scores of

potentially survivable and nonsurvivable casualties.

*Significance p<0.03 Fischer's Exact Test

0 1 2 3 4 5 6 7 8 9

Noncompressible

hemorrhage

Tourniquetable

hemorrhage

Nontourniquetable

hemorrhage

Tension PTX

Sepsis

Airw ay

Nontourniquetable

Hemorrhage

Tourniquetable

Hemorrhage

Noncompressible

Hemorrhage

Figure 3. Distribution of the 16 potential causes of death among the 12

potentially survivable casualties.

Sepsis

Tension

Pneumothorax

Airway
January – March 2007 29

feasible in certain tactical settings. Use of a hemostatic

dressing might have eliminated the necessity for

prolonged direct pressure to accomplish hemostasis.

There was no evidence that a hemostatic dressing had

been placed.

Case 2

The individual sustained a GSW after a helicopter

crash. The bullet traversed the retroperitoneum,

rectum, and pelvis. No major vascular structures were

injured and he lived for almost 5 hours after wounding,

indicating a relatively slow rate of bleeding. The injury

was determined to have been readily amenable to

surgical repair with no injuries to major vascular

structures. While there is no specific current

intervention which could have been undertaken by the

combat medics that would have stopped the intraabdominal bleeding, clearly a CASEVAC more

expeditious than 5 hours would likely have saved him.

He might also have benefited if packed red blood cells

had been available on the rescue helicopter, as

recommended in the Tactical Combat Casualty Care

section of the Prehospital Trauma Life Support

(PHTLS) Manual.8(p394) It is also not know if a

hypotensive resuscitation strategy was employed after

wounding. This patient illustrates the need for further

research into injectable agents which can augment the

coagulation mechanism in response to injury. One

such area of current research is the use of recombinant

factor VIIa. A second therapeutic agent currently

under study are hemoglobin based oxygen carriers

which function to temporarily restore oxygen

delivering capabilities of the circulatory system in the

presence of critical anemia. Given the prolonged

CASEVAC time, these interventions could possibly

have stabilized this casualty, allowing him to reach the

surgical unit for definitive treatment.

Case 3

This individual sustained a GSW to the lower jaw that

also injured the tongue and upper airway structures.

He was reported to have been intubated in the field,

but no tube was noted at autopsy. The airway

structures at the cricothyroid membrane and below

were intact. It’s not possible to know from the

available data whether the attempted intubation was

unsuccessful, or whether the endotracheal tube may

have been placed in the esophagus due to the tissue

disruption caused by the GSW. However, there were

no other potentially fatal injuries noted and the

individual was judged to have died from an isolated

airway death. There are 2 interventions that could have

been life-saving for this individual: 1) proper

positioning (the casualty should sit up and lean

forward if conscious) to keep blood out of the airway,

or 2) immediate cricothyroidotomy if the previous

positioning maneuver proved unsuccessful. Both

interventions are recommended in TCCC.8

Case 4

The casualty was wounded by an RPG explosion and

sustained injuries to the right lower extremity at the

mid-thigh level and the right forearm at the midforearm level. He exsanguinated from the distal

superficial femoral artery, despite the placement of 3

field-expedient tourniquets. The treating first

responder clearly had the right idea for effective

treatment, but lacked an adequate tourniquet and was

unable to improvise an effective one in time to control

the hemorrhage. There were multiple “cravat and

stick” type tourniquets applied to this extremity, yet

adequate hemostasis was not achieved. This fatality

likely would have been prevented by the CAT

tourniquet that is currently being issued to deploying

units.9,10 The death might also have been prevented by

improved TCCC training to all members of the unit.

The medic in this unit was killed at the start of this

engagement and care was rendered by a nonmedical

operator. Providing TCCC training to all unit members

has been reported to be overwhelmingly successful in

a recent paper by Tarpey describing implementation of

Table 5. Major Vascular Injuries and Current

Methods of Control (n=7)

Vessel Injured

Compressible or

Noncompressible

Method of

Control

Superficial femoral

artery

Compressible Tourniquet

Popliteal artery (2) Compressible Tourniquet

Common femoral

artery

Compressible Direct

pressure

Common carotid

artery

Compressible Direct

pressure

Common iliac

artery

Noncompressible Surgical

repair

Mesenteric artery Noncompressible Surgical

repair
30 Army Medical Department Journal

TCCC training for all unit members of deploying 3rd

Infantry Division units.11

Case 5

The casualty sustained a GSW to his upper thigh at an

anatomic location judged too proximal for effective

use of a tourniquet. His exsanguination could have

been prevented by sustained direct pressure on the

femoral artery at the level of the inguinal ligament.

Certainly sustained, direct pressure would allow time

to employ other strategies for hemostasis. Strategies

include the use of hemostatic dressings, such as

Hemcon® (HemCon Inc, 10575 SW Cascade Avenue,

Suite 130, Tigard, Oregon) and employment of

hypotensive resuscitation tactics as outlined in TCCC.8

This case also illustrates another example where the

development of intravenous hemostatic interventions

may have altered the final outcome.

Case 6

The individual sustained a GSW to both the torso and

his right popliteal artery. There is no record or

pathologic evidence of tourniquet application. The

torso wound was located in an area that would have

been covered by body armor had it been worn. This

fatality could have been prevented by a combination of

wearing body armor, using a tourniquet, and, as this

casualty likely exsanguinated from both his extremity

and torso wounds, the use of intravenous hemostasis

may have proven fruitful in this patient.

Case 7

The casualty sustained a GSW to the lower abdomen

following a helicopter crash. The gunshot traversed the

patient’s mesenteric and left common iliac arteries. He

exsanguinated from these 2 vascular injuries, but the

time from wounding to death is unknown. This death

might have been prevented by a more rapid

CASEVAC and the prepositioning of blood products

on the aircraft. Again, given the uncertain time from

death to wounding, the use of an injectable hemostatic

agent to stem ongoing blood loss from a

noncompressible source may have allowed sufficient

time for evacuation.

Case 8

The casualty sustained a GSW to the mid-back during

an ambush. The injury would have been prevented by

body armor if it had been worn. The wounds included

significant damage to the upper and lower lobes of the

right lung, but death might have been prevented by a

more expeditious CASEVAC, as the time from

wounding to death in this case was 10 hours. Again, a

possible intervention that may have impacted this case

is the use of recombinant factor VIIa in conjunction

with a strategy of hypotensive resuscitation to slow the

ongoing bleeding during the evacuation delay.

Case 9

The injury occurred during a fast-rope insertion which

resulted in a 25-foot fall to rocky mountainous terrain.

The fall resulted in a closed head injury and bleeding

from multiple thoracic, intra-abdominal, and

retroperitoneal sites. The bleeding sites were felt to

have been amenable to surgical repair. A tension

pneumothorax was found on postmortem chest x-ray.

Whether or not this finding was a post mortem artifact

is unknown. The reported time from injury to death for

this casualty was 4.5 hours. This individual might have

been saved by more rapid CASEVAC, or a needle

thoracostomy performed by a medic in the field

followed by surgical repair of his injuries. However, it

cannot be said with certainty that the individual would

not have died from the closed head injury alone. The

median lethal dose for a fall is approximately 40 feet.12

Certainly, this casualty had suffered multiple major

injuries. However, the 4.5 hours in delay from injury

to death indicates that his injuries were potentially

survivable.

Case 10

The casualty sustained GSWs to the chest and

abdomen. The wounds resulted in bilateral

hemothoracies, a perforated hemidiaphragm,

perforated liver, and a perforated right kidney. It is not

known whether or not this individual was wearing

body armor, but the wounding sites were locations that

would not have been covered if body armor had been

worn. The time interval from wounding to death is not

known. However, these injuries were amenable to

surgical repair and this individual might have been

saved if he were afforded a more expeditious

CASEVAC. Additionally, the use of intravenous

hemostatic therapies might have been able to play a

role in the care of this patient. This casualty and the

previous case probably represent the extreme limit of

potentially survivable injuries on the battlefield.

Causes of Death in US Special Operations Forces in the Global War on Terrorism: 2001–2004
January – March 2007 31

Case 11

The casualty was an occupant in a military vehicle that

was impacted by an IED with a subsequent rollover.

He had blunt trauma resulting in a fracture of the

pelvis, retroperitoneal hemorrhage, and an open

fracture of the left femur with a lacerated left popliteal

artery. The time to death was less than one hour and it

is unknown whether or not a tourniquet was applied

above the site of lower extremity bleeding. It is also

unknown if the pelvic fracture had been stabilized in

any fashion. The use of a sheet or another device to

reduce the volume of the pelvis is part of PHTLS

training.8 This injury might have been prevented by

seat belts and/or air bags and the death might have

been prevented by use of a tourniquet, pelvic

stabilization, an intravascular hemostatic agent, and

more rapid CASEVAC.

Case 12

The casualty was wounded by an IED with injuries to

the head and neck. He was transported to a medical

treatment facility where he underwent a prolonged

(56-day) hospital course complicated by

menigingoencephalitis, pneumonia, and brain abscess.

It is not known whether or not this casualty was

wearing his helmet or received battlefield antibiotics

as recommended by TCCC. However, the injury

sustained was in a location covered by the issued

helmet. The death might have been prevented by

improved treatment of multiple organ failure and

sepsis.

DISCUSSION

The US Special Operations Command (USSOCOM) is

a unique force in the American military. It was

established by Congress in 1987 to create a unified

command structure encompassing all Army, Navy,

Marine Corps, and Air Force Special Operations units.

USSOCOM has a force of less than 51,000 active duty

and reserve personnel, with an extraordinary broad

range of missions which include direct action, special

reconnaissance, foreign internal defense and

unconventional warfare, counter and anti-terrorists

operations, combat search and rescue, counter-drug,

humanitarian assistance, and security assistance.

USSOCOM has been designated by the National

Command Authority to lead the US Global War on

Terrorism.

The medical capabilities and needs of USSOCOM are

unique in many respects. Special Operations Forces

are often deployed in small units in hostile

environments. Thus, SOF combat medics have to be

extremely well trained and have the ability to function

independently, frequently for days or weeks at a time.

Training of an SOF combat medic requires up to 52

weeks of intensive didactic and field work. The

baseline medical care doctrine and protocols for TCCC

in special operations are generated through the

Committee on Tactical Combat Casualty Care, a triservice, multidisciplinary, military/civilian committee

formed in 2002 by the Naval Operational Medicine

Institute to ensure contemporary standards of practice.

These guidelines are published in the PHTLS manual.8

The commander of USSOCOM has ordered that every

deploying unit in the Special Operations Command be

trained in the basic emergency care of combat

casualties, utilizing TCCC concepts. This same

approach to combat casualty care is rapidly becoming

the standard in the conventional forces as well.

Tactical Field Combat Casualty Care is generally

broken down into 3 phases:

1. Care Under Fire is care rendered by the medic

on the battlefield while under effective hostile

fire with an aid bag as the only equipment.

2. Tactical Field Care is treatment provided once

the casualty and his unit are no longer under

effective hostile fire, with equipment limited to

that carried into the field.

3. Combat Casualty Evacuation Care is treatment

provided once the casualty has been picked up

by aircraft, vehicle, or boat.

The very nature of USSOCOM missions results in the

fact that access to and extraction of wounded

combatants may be difficult and delayed, thus placing

a significant burden on the point of wounding care

providers in small units. To prevent an inordinate early

death, SOF medics must be highly trained and expertly

equipped and supported.

These 82 deaths must be considered in the context of

the over 600 casualties who survived their injuries,

sustained by Special Operations Forces during the

period encompassed by this study. That the vast

majority of the casualties from these 2 conflicts

survived is a great credit to the courage and
32 Army Medical Department Journal

professionalism of the physicians, nurses, medical

planners, pilots, aircrew, combat medics, and

teammates who cared for our wounded warriors. In the

Global War on Terrorism, there is no doubt that the

Marine Forward Resuscitative Surgical Suites, Air

Force Emergency Medical Deployments System

(EMEDS), Army Forward Surgical Team and Mobile

Army Surgical Hospital units provide excellent and

effective surgical support during the maneuver phase.

Likewise, the Army Combat Support Hospitals and the

USAF EMEDS level III facilities, strategically located

throughout Iraq and Afghanistan, provide state-of-theart combat casualty care capabilities for the currently

more stable insurgency warfare. All of these

individuals work under very difficult circumstances

and at great risk to themselves to provide life-saving

care. As a result of this type of analysis, we now can

define where to apply new approaches and strive to

make even more improvements in the deployed

medical care system. Nothing in this review is meant

to detract from their accomplishments. Rather, we

mean to learn where improvements in training,

equipment, and research are required to save even

more lives. This analysis is a focused effort to learn

lessons that will help us save casualties in battles yet to

come. A follow-on effort will examine the SOF

casualties who had wounds that were not fatal, and

examine the mechanisms of wounding and the

outcomes in that group.

This analysis was limited by incomplete data from the

prehospital and hospital setting. The time between

wounding and CASEVAC, and the time interval

between wounding and arrival at a medical treatment

facility (MTF) or death is largely unknown. Also

largely unknown were the specifics of care rendered

on the scene and during CASEVAC, as well as

whether or not body armor and helmet were worn by

the casualty. Furthermore, body armor was not usually

available for examination in conjunction with the

autopsy results. Recording the care rendered and

communication of this information are often

impractical in the tactical environment. These are areas

for potential improvements. Efforts to improve the

capture of data on the tactical and prehospital care

aspects of SOF combat casualties are underway, both

at the US Army Institute of Surgical Research and the

US Special Operations Command.

Consistent with the findings from previous conflicts,4

85% of the fatalities were not survivable. After

analysis, and as evidenced by the distribution of the

AIS and ISS scores (Figures 1 and 2), 70 (85%) of the

fatalities were judged to have been wounded so

severely that survival would have been impossible

even with Civilian Level 1 trauma care. Only 12 (15%)

of the deaths were categorized as potentially

survivable.

A comparison of these patients with published

reports13,14 of civilian trauma care in the United States

is a testament to the training, the skills, and the

battlefield successes of the Special Forces combat

medic. These papers report that 8% to 22% of

prehospital deaths are preventable, or potentially

preventable. The potentially survivable rate of 15%

documented in the fatalities examined by this study

falls into this range. Moreover, the casualties reviewed

in this study were more severely injured that those

reported in the civilian literature. The reported mean

ISS of the potentially preventable patients in one

study14 was 25, while our population of potentially

survivable deaths had a mean ISS of 35. The overall

mean ISS of the reported 88 civilian deaths was 51.6

and our military population was 56. It is a tribute to the

Special Operations medic to have a rate of potentially

survivable deaths similar to the low end of that

reported in the civilian literature, given the severity of

injuries treated combined with an austere and

hazardous environment. The comparison of the

management of civilian trauma patients and the field

management of combat casualties is challenging, as

there is no easy way to know the tactical situation in

which the combat medic is required to operate, nor is

there a civilian equivalent to the mechanisms of injury

experienced. There are few civilian equivalents by

which comparisons can be made.

The use of the ISS as a predictive tool for outcomes in

the combat trauma has significant limitations. The ISS

is obtained by summing the square value of the three

highest AIS scores in up to 3 separate body regions.

For example, a Soldier wounded by an IED has an AIS

5 for an abdominal injury, AIS 4 for a chest injury and

an AIS 3 for an extremity injury. His ISS would then

be 50, representing a severe injury. The limitation here

is that the ISS does not account for multiple injuries to

the same body region, nor does the ISS consider

bilateral injuries. In our example, this same Soldier

may have more than one AIS 5 injury in his abdomen,

or a concomitant AIS 4 injury in addition to multiple

AIS 4 injuries in his chest, or bilateral AIS 4 extremity

Causes of Death in US Special Operations Forces in the Global War on Terrorism: 2001–2004
January – March 2007 33

injuries. The conventional ISS scoring system does not

account for these highly significant injuries. Injuries

sustained as a result of combat mechanisms, ie, high

velocity GSWs from military ordnance and explosions,

tend to have multiple injuries within the same body

region. In our population of potentially survivable

deaths, there was one patient with 2 AIS 5 scores for

his chest, only one was counted in the calculation of

his ISS. Four other patients with AIS 5 injuries had

concomitant AIS 4 injuries in the same body region.

Combat casualties tend to have multiple severe injuries

that remain unaccounted for by the conventional ISS

scoring system. A new injury severity scoring

mechanism, taking into account the differences

between combat and civilian injuries, is under

development.

A study of 210 combat fatalities from Vietnam

published in 2002 reports cases which were

independently reviewed by 4 trauma surgeons and

assessed to be either definitely preventable, possibly

preventable, not salvageable, or cannot determine.3

The study was done using medical records, there was

no tactical information available, and no autopsies

were performed. The determination of preventable or

nonpreventable was made against the current standard

of care, not the standard of care rendered during the

Vietnam War. Averages of 5.4% (range 1.0% to 11%)

of the 210 cases were determined to be definitely

preventable and 34.9% (range 26.2% to 41.9%)

possibly preventable. Though the percentage of

fatalities with potentially survivable wounds in our

study was similar, the results are difficult to compare

to this study as the methodology was markedly

different. The paper by Blood et al used hospital

medical records, and only considered patients who

were DOW and not killed-in-action.3 Therefore it was

not an evaluation of care rendered on the battlefield,

but rather of care rendered at higher echelons of care.

The topic of improved personal protective equipment

has garnered a significant amount of attention during

this conflict. Analysis of these data suggests that PPE

is saving lives. Only one Soldier of 82 sustained a

potentially survivable injury to the thorax that may

have been prevented by improved PPE coverage.

There were 3 potentially survivable deaths whose

injuries might have been prevented had PPE been

worn. Two sustained GSWs to the thorax and the third

suffered a fragmentation injury to the head. The AIS

data presented suggests that many of these casualties

sustained multiple severe injuries in multiple anatomic

regions that any body armor acceptable for use in the

tactical environment could not have prevented.

Inadequate anatomic coverage of the currently fielded

SOF body armor was not documented in this study. In

addition, no cases were documented where body armor

failed to stop the high velocity munitions commonly

encountered in current military operations, bearing in

mind the previously noted lack of reliable information

about whether or not body armor was worn by the

casualties.

There was a significant difference in the mechanism of

injury by which the SOF deaths occurred compared to

conventional forces. The SOF Soldiers were more

likely to die from gunshot wounds than from an

explosive mechanism, 28% versus 19% respectively

(p<0.05), using a logit case control odds ratio, 95%

confidence interval of 1.42 to 4.03. In contrast, the

conventional Soldier was more likely to die as the

result of an explosion, 55% versus 43% respectively

(p<0.05). Historically, in the Vietnam conflict, 51% to

52% of all deaths at an MTF were the result of gunshot

wounds, followed by explosions at 44% to 48%.3,4

There are multiple levels at which improvements in

management strategies can theoretically improve

outcomes:

 TCCC training for nonmedical combatants;

medical training and equipment

 Air evacuation and close air support resources

 Operational medical planning

 Location of receiving MTFs

 Improvements in surgical techniques and

technology

 Improvements in postoperative care

 New medical interventions stemming from

evidence-based research

No new training requirements were identified. TCCC

training was applicable to the nonsurgical deaths while

standard surgical techniques and equipment apply to

the remainder. Mandatory predeployment trauma

training and uniform application of these principles are

required. The analysis of the potentially survivable

deaths serves to emphasize many points in current

SOF TCCC training:
34 Army Medical Department Journal

 The need to use a tourniquet for extremity

wounds with life-threatening bleeding to gain

initial control of hemorrhage

 The need to use sustained direct pressure when

confronted with severe external bleeding at an

anatomic location where a tourniquet cannot be

applied

 The need to use proper casualty positioning and

cricothyroidotomy instead of intubation for

maxillofacial trauma associated with airway

trauma

 The need to decompress a tension pneumothorax

with a 5-inch needle

The very small number of fatal outcomes associated

with these issues suggests that, in most cases, these

types of injuries were treated appropriately by SOF

combat medics. One possible reason for these events

(except for the failed intubation) is that there may not

have been a medic to provide treatment. In most cases,

it is not stated in any available record whether the

wounds were initially treated by a combat medic or a

nonmedical SOF operator. In some instances, there

may not be a medic on the mission at the time

casualties occur. At other times, as occurred in one of

the deaths described above, the unit medic may be

killed or incapacitated and unable to provide care for

other wounded unit members. The TCCC Transition

Initiative currently being conducted by USSOCOM is

designed to provide all SOF operators (medical and

nonmedical) in deploying units with the basic medical

skills.15,16

Three cases were identified where the casualty had

hemorrhaged from a site that was amenable to

placement of a tourniquet. Two of these three had no

tourniquet placed and one was a tourniquet failure.

These 3 isolated extremity deaths have been addressed

by a major Department of Defense initiative to field

the new CAT tourniquet.10,17 This device was tested by

USSOCOM operators and trauma surgeons and found

to be superior in function and feasibility to the

traditional cravat and stick. Using the traditional cravat

and stick method, while effective, is time consuming,

difficult to secure in place and requires prior planning

to assure availability of a stick.

All of the potentially survivable fatalities might have

benefited from more expeditious CASEVAC to an

MTF, with the possible exception of Case 12.

However, unless the exact time from wounding to

death is known for a specific casualty (which it rarely

was in this case series), it is difficult to say what

impact the actual CASEVAC time actually had.

Attempts to minimize CASEVAC time are limited by

aircraft resource constraints in operational planning,

ground fire preventing CASEVAC aircraft from

landing, and lack of readily available MTFs in farforward SOF operations. The ability of reduced

CASEVAC time to prevent fatalities is clearly

demonstrated by the 2 potentially survivable casualties

who lived at least 5 to 10 hours before evacuation was

accomplished. With the dispersed nature of SOF

operations, it is unlikely that surgical facilities and

CASEVAC capability will ever be able to provide the

rapid evacuation capability required to save these

casualties. Interventions placed into the hands of

medics will be required, thus the emphasis on

intravenous hemostasis for the noncompressible

bleeding sites, which contributed to death in 7 of the

12 potentially survivable deaths.

Current operations in Iraq are heavily focused on

urban vehicle-based missions whereby the evacuation

time from point of wounding to nearby MTFs may be

30 minutes or less, a very fast evacuation time for

military casualties. In contrast, Afghanistan operations

are usually conducted in remote areas far from medical

assets. CASEVACs in OEF are still usually

accomplished by rotary-wing aircraft and may have

very significant delays due to both difficult flying

conditions in the rugged mountainous terrain of the

Hindu Kush and the remoteness of operations from

surgically capable MTFs.

Great difficulty may be encountered in evacuating

casualties from high-threat environments. Hostile

rocket-propelled grenade fire has downed US

helicopters engaged in CASEVAC operations in the

past. Suppression of hostile fire is a critical element in

situations where intense ground fire from hostile

forces could impede or prevent rotary-wing

CASEVAC. Expeditious evacuation might be more

readily available if there were an improved close air

support capability for daytime SOF CASEVAC

missions. Technology to harden rotary wing platforms

against RPG fire would also be useful. Operational

planning that ensures availability of CASEVAC

aircraft is to no avail if the aircraft cannot safely pick

up the casualty.

Causes of Death in US Special Operations Forces in the Global War on Terrorism: 2001–2004
January – March 2007 35

Another factor that impacts time to surgical care is the

proximity of the nearest surgical facility. Since SOF

units often operate in areas remote from forward

support bases, CASEVAC time can be shortened by

prepositioning a Forward Surgical Team (FST) with

SOF units when they will be conducting remote

operations that can be expected to generate significant

numbers of casualties. SOF units operating under these

circumstances must have rapid access to FSTs. If the

deployment of forces is such that conventional FSTs

cannot respond in time to meet the operational tempo,

then improved access is available by requesting one of

the FSTs now attached to the Air Force Special

Operations Command. While this surgical support is

logical, the very casualties that will require time

sensitive resuscitative surgical support are extremely

difficult for an FST to adequately manage, because of

the power and equipment requirements for rewarming

hypothermic, hypotensive, and acidotic patients, and

the large amount of blood and blood products they

require. Further confusing the medical planning is the

pervasive concept of the “golden hour” which has very

little supporting data. Most authorities suggest that 90

to 120 minutes is more likely an evidenced-based

planning factor.18,19 The desire for a lightweight,

mobile surgical team that is able to optimally support

the deranged physiology of the most critically injured

casualties is a conundrum yet to be completely

resolved.

The medical research requirement is driven by the 8

casualties that died from noncompressible hemorrhage.

These deaths mandate a focus on injectable hemostasis

at all levels of care, especially by medics. Currently

the paradigm of Damage Control Resuscitation holds

the most immediate promise in this area.20 This

concept involves the utilization of prohemostatic fluids

in conjunction with pharmacologic adjuncts such as

recombinant factor VIIa and hypotensive resuscitation

to palliate the hemorrhaging casualty until arrival at a

facility where definitive care can be provided.

Although human efficacy when using rFVIIa alone in

the prehospital environment is absent, rFVIIa appears

to be a promising hemostatic adjunct. Fortunately,

safety and efficacy in trauma patients has recently

been established, and the prospect of prehospital

noncompressible hemostasis is tantalizing.21,22 Efforts

are underway to study this application. Perhaps

combining rFVIIa with other clotting factor

concentrates will provide both the substrate and the

thrombin burst required to accelerate clotting.23-25 It is

possible that, by accelerating/strengthening the

endogenous clot, blood loss will decrease; the casualty

will be stabilized allowing arrival at the surgical

facility in an improved physiologic condition, where

surgical intervention may improve outcomes. Damage

control resuscitation may allow the SOF casualty to

tolerate the longer CASEVAC times we have seen in

this population.

A second potential intravenous intervention that is

currently in ongoing phase III trials in the United

States is the evaluation of the prehospital

administration of hemoglobin-based oxygen carriers

(HBOC). This HBOC replaces the oxygen carrying

capacity of shed blood allowing for delivery of oxygen

to vital organs during critical anemia.26 If current trials

support this indication, this intervention would allow a

SOF medic to maintain oxygen delivery while

awaiting evacuation.

At least 7 of the 12 patients may have benefited from

more rapid CASEVAC times—some lived upwards of

10 hours after injury. It is during this time that damage

control resuscitation can be employed, especially in a

far-forward environment where CASEVAC is not

always readily available. Additionally, this strategy

could potentially decrease the amount of blood loss in

a casualty regardless of the CASEVAC time. The

application of damage control resuscitation is

particularly salient to the SOF casualty, where the

tactical situation may prohibit expeditious CASEVAC.

Damage control resuscitation would allow the SOF

medic to temporarily stabilize a hemorrhaging patient

while CASEVAC is en route.

History is replete with numerous examples that go

back a thousand years in which combat casualty care

providers use every means available to provide

emergency care to combat casualties, and effectively

match available resources with the needs of those

injured. History also documents that improvement in

combat casualty care stems from the unfortunate

repetitive experience of the war injured. The findings

provided by this study that will enable the military to

continue to improve battlefield trauma care are:

1. Eighty-five percent of SOF fatalities in the

GWOT resulted from injuries that were judged

to be nonsurvivable.
36 Army Medical Department Journal

2. Consistent application of the currently taught

TCCC guidelines might have improved outcomes

for 8 of the 12 fatalities with potentially

survivable injuries.

3. Faster CASEVAC times might have improved

outcomes for 11 of the 12 fatalities with

potentially survivable injuries.

4. The most important biomedical research

requirement identified in the study is Damage

Control Resuscitation which incorporates the use

of prohemostatic adjuncts, such as recombinant

factor VIIa, lyophilized plasma, and thawed

plasma with hypotensive resuscitation and

HBOCs. At present, this represents the most

promising modality to improve outcomes in the 8

fatalities with noncompressible hemorrhage.

5. When worn, currently fielded body armor

provided adequate anatomic coverage for the

injuries discovered in this study.

6. No cases where body armor failed to stop high

velocity munitions were documented in this study.

7. Improved suppression of hostile ground fire is

critical to assuring CASEVAC availability in

some tactical situations.

8. Improved methods to capture records of wounds

sustained and care rendered on the battlefield will

greatly improve future efforts to update battlefield

guidelines.

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CE, Bellamy RF. Understanding combat casualty

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8. National Association of Emergency Medical

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(9):770-775.

10. Walters TJ, Wenke JC, Kauvar DS, McManus JG,

Holcomb JB, Baer DG. Effectiveness of self-applied

tourniquets in human volunteers. Prehosp Emerg

Care. 2005;9(4):416-422.

11. Tarpey MJ. Tactical combat casualty care in

Operation Iraqi Freedom. Army Med Dept J.

2005;Apr–Jun:38-41.

12. Grande CM, Stene JK. Trauma Anesthesia.

Baltimore, MD: Williams & Wilkins; 1991.

13. Esposito TJ, Sanddal TL, Reynolds SA, Sanddal ND.

Effect of a voluntary trauma system on preventable

death and inappropriate care in a rural state. J

Trauma. 2003;54(4):663-669.

14. Maio RF, Burney RE, Gregor MA, Baranski MG. A

study of preventable trauma mortality in rural

Michigan. J Trauma. 1996;41(1):83-90.

15. Butler FK, Holcomb JB. The tactical combat casualty

care transition initiative. Army Med Dept J.

2005;Apr–Jun:33-37.

16. Butler FK Jr. Tactical medicine training for SEAL

mission commanders. Mil Med. 2001;166(7):625-

631.

17. Wenke JC, Walters TJ, Greydanus DJ, Pusateri AE,

Convertino VA. Physiological evaluation of the US

Army one-handed tourniquet. Mil Med. 2005;170

(9):776-781.

18. Lerner EB, Moscati RM. The golden hour: scientific

fact or medical "urban legend"? Acad Emerg Med.

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19. Osterwalder JJ. Can the "golden hour of shock"

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Causes of Death in US Special Operations Forces in the Global War on Terrorism: 2001–2004
January – March 2007 37

20. McMullin NR, Holcomb JB, Sondeen J. Hemostatic

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NY: Springer; 2006:265-278.

21. Boffard KD, Riou B, Warren B, et al. Recombinant

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22. Lynn M, Jerokhimov I, Jewelewicz D, et al. Early use

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on current evidence. Semin Hematol. 2004;41(Suppl

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AUTHORS

COL Holcomb is Commander, US Army Institute of

Surgical Research, Brooke Army Medical Center, Fort

Sam Houston, Texas, and Trauma Consultant to the

Army Surgeon General.

CAPT Caruso is the Regional Armed Forces Medical

Examiner and Pacific Director for Clinical Support

Services at the US Naval Hospital, Camp Lester,

Okinawa, Japan. When this article was written, he was

Chief Deputy Medical Examiner, Office of the Armed

Forces Medical Examiner, Rockville, Maryland.

CPT McMullin is a third year General Surgery Resident

at the Brooke Army Medical Center, Fort Sam Houston,

Texas.

Dr Wade is the Senior Scientist at the US Army Institute

of Surgical Research, Fort Sam Houston, Texas.

LCDR Pearse is Chief, Mortality Surveillance Division,

Armed Forces Medical Examiner System, Rockville,

Maryland.

Ms Oetjen-Gerdes is Senior Epidemiologist, Armed

Forces Medical Examiner System, Rockville, Maryland.

At the time this article was written, Mr Champion was

with the Uniformed Services University for the Health

Sciences, Bethesda, Maryland.

Ms Lawnick is a Nurse Researcher in the Office of the

Armed Forces Medical Examiner, Rockville, Maryland.

COL Farr is the Command Surgeon, Headquarters, US

Special Operations Command, MacDill Air Force Base,

Florida.

MSG Rodriguez is the Senior Enlisted Medical Advisor

to the Deputy Chief of Staff, Surgeon, US Army Special

Operations Command, Fort Bragg, North Carolina.

At the time this article was written, CAPT Butler was

the Command Surgeon, Headquarters, US Special

Operations Command, MacDill Air Force Base, Florida.
38 Army Medical Department Journal

BEFORE CASUALTY ARRIVAL

The Orthopaedic Surgery Service is involved with

specific battle casualties via electronic mail and

ongoing communication with care providers at

overseas regional medical facilities. The initial

communication is paramount in managing resources

and operating room schedules within the Orthopaedic

Surgery Service. The information—in the face of the

continuous influx of patients requiring multiple

surgical procedures, extensive rehabilitation, many

with complex social situations—allows orthopaedic

surgeons to direct the management of numerous

patients as well as the census on the wards and

outpatient facilities. This includes the decrease of

elective orthopaedic surgery procedures and clinic

sizes, as well as the diversion of orthopaedic patients

who are not TRICARE Prime subscribers.

Transfer of the bulk of battle casualties to the

continental United States (CONUS) is completed by

the USAF Air Evacuation System (AEROVAC). The

system routinely provides a manifest of casualties with

the definitive inbound manifest, which is often

finalized after AEROVAC departure. This manifest

and estimated time of arrival was communicated to the

AEROVAC office at WRAMC, and was then

subsequently made available to a variety of staff,

including the orthopaedic surgical resident on-call. It

was a responsibility of the orthopaedic resident to

check with the AEROVAC office daily to acquire

The Process of Care of Battle

Casualties: Orthopaedics and

Rehabilitation at the Walter Reed

Army Medical Center

COL William C. Doukas, MC, USA

INTRODUCTION

Walter Reed Army Medical Center (WRAMC), an echelon V facility, has been a primary hub in the United

States for the reception of Army battle casualties from Operations Enduring Freedom (OEF) and Iraqi Freedom

(OIF). The care of Soldiers from injury to final disposition has been a joint service and specialty effort. This

article is comprised of four sections detailing experiences from the Orthopaedic Surgery, Physical Therapy,

Physical Medicine and Rehabilitation, and Occupational Therapy Services. Together, the sections depict the

process of care that was developed to affect the timely and effective management of these casualties, with

emphasis on a predetermined, multidisciplinary approach to patients and recommendations to facilitate this

process at WRAMC and other medical centers. In the time since the article was written, the structure of the

process has been modified and integrated into the care of a continuous flow of large numbers of Soldiers with

contaminated, multiextremity injuries that frequently require multiple surgical procedures and complex medical

management, followed by extensive rehabilitation and strong social support.

PART 1

THE ORTHOPAEDIC SURGERY SERVICE

CPT Matthew A. Javernick, MC, USA

COL William C. Doukas, MC, USA

This article is reprinted from Military Medicine: International Journal of AMSUS (2006;171(3):200-210) with permission

of the publisher.
January – March 2007 39

flight manifests. The resident then used prior email

information and the manifest to estimate the number

and acuity of patients who would require triage upon

arrival. The review process also allowed the resident to

anticipate the number of admissions, the need for

consultation with other medical/surgical specialties,

and plan for potentially urgent surgical cases. The

information was conveyed to the Charge Nurse who

further coordinated with other health care providers

and administrators for the anticipated arrivals. The

Arrival of Casualties at the

Walter Reed Army Medical Center

Triage General Surgery

Inpatient

Returned

to Duty

Expedited

Surgery

Outpatient

Rehabilitation

and/or Unit

Orthopaedics

Orthopaedics

Morning Report

Operating Room

Serial Debridement

and/or

Definitive Surgical

Care

Recovery and

Rehabilitation

Disposition:

Mobilization Site

Home Duty Station

Temporary Disability

Retired List

Medical

Evaluation Board

Convalescent

Leave

Returned

to Duty

Temporary

Lodging

Casualty care process at the Walter Reed Army Medical Center
40 Army Medical Department Journal

majority of patients arrived during off-hours, usually

in the middle of the night. It was, therefore, imperative

to preplan to ensure appropriate personnel, equipment,

and bed space were available. It was also the

responsibility of the orthopaedic resident, with the

assistance of the Patient Administration Division, to

ensure that the demographics of arriving orthopaedic

casualties had been appropriately entered into the

WRAMC computer system. This allowed casualties to

be formally admitted to the hospital and orders to be

written immediately upon their arrival, to include

pharmaceuticals (primarily analgesics), radiology,

laboratory, nutritional services (diet), etc.

TRIAGE

The on-call orthopaedic surgery resident was notified

when the AEROVAC mission arrived. WRAMC

nursing personnel escorted all patients in need of

evaluation to the orthopaedic cast and treatment room.

This was established as the center for triage because of

its large open size that could accommodate both high

volumes of patients as well as the required number of

health care providers. The orthopaedic cast room is

equipped with multiple beds with an attached

radiology suite. Using the information received prior

to their arrival, the most seriously injured patients

were escorted to the cast room for evaluation first, and

then those with less severe injuries were placed in

other exam rooms throughout the adjacent orthopaedic

clinic. However, all patients entered through the cast

room for triage, which allowed an orthopaedic surgeon

or general surgeon to initially examine and evaluate

the patient prior to transport, and facilitate placement

in a less acute clinic exam room. A military medical

technician or nurse was assigned to each patient and

escorted him or her through the entire triage process,

while also initiating appropriate paperwork. Patients

were than evaluated in a routine triage fashion,

including primary and secondary surveys, with

attempts to evaluate the most seriously injured first.

The specialty of the assigned primary triage resident

was based on the injury complex as determined by the

manifest and listed injuries, with either a general

surgery resident or an orthopaedic surgery resident in

the lead. The remainder of the triage team consisted of

an anesthesiology resident, pharmacist, radiology

technician, charge nurse, critical care nurse, as well as

nurses aides and technicians. Pending primary and

secondary survey, including radiographic imaging and

wound assessment (with the assistance of the

Anesthesia Service), patient dispositions were

determined. This was facilitated by communication

between members of the Orthopaedic Surgery Service,

General Surgery Service, and the Anesthesia Service.

Patients requiring surgery were taken directly to the

operating room for irrigation, debridement, wound

exploration and, less frequently, definitive treatment.

If patients were not taken to the operating room, they

were either directly admitted to the hospital or referred

to one of WRAMC’s outpatient facilities with

instructions to return for appropriate outpatient

management and definitive disposition.

INPATIENTS

The Orthopaedic Surgery Service admitted all patients

that needed further extremity reconstruction, wound

management, and/or rehabilitation. The General

Surgery Service admitted all patients with chest,

abdominal, or uncomplicated extremity wounds. The

two Services worked together to manage the volume of

casualties with frequent consults to each other as well

as other specialties throughout the hospital, often

involving the Vascular Surgery, Neurosurgery, Plastic

Surgery, and Physical Medicine Services. A standard

set of physician orders was established by the

Orthopaedic Service to maintain continuity and quality

of care of the orthopaedic inpatient. This included

deep venous thrombosis and twice daily

gastrointestinal prophylaxis of unfractionated heparin

and ranitidine, continuation of all previously

prescribed antibiotics (pending species identification),

and aggressive pain management. All casualties

received diet orders that included nutritional shakes, a

protocol based on early lab values demonstrating that

the majority of casualties were malnourished in their

healing stages. The orthopaedic resident was also

responsible for identification of those arriving patients

who needed malarial prophylaxis and initiation of

appropriate treatment

The following morning, all patients were presented by

the orthopaedic on-call resident at the daily Morning

Report, which routinely consists of a review of all

preoperative and immediate postoperative patients, as

well as all patients evaluated on-call. All attending

orthopaedic surgeons and in-house orthopaedic

residents attend this meeting. The battle casualties

were presented in the usual fashion, which stimulated

Orthopaedics and Rehabilitation at the Walter Reed Army Medical Center
January – March 2007 41

further discussion among attendees, and a preliminary

care plan was established. The use of digital

photography obtained at time of triage by the

orthopedic resident was important in accurately

presenting the complex, contaminated wounds

sustained by many of the patients. Information on

incoming casualties was also shared at this forum and

tentative plans were made accordingly. The chief

resident would then review and update posted 2-week

futures of all battle casualties needing operative

treatment. This was imperative to effectively manage

all resources and ensure that patients needing serial

irrigations and debridements were adequately

managed. This also allowed the resident teams to

complete and submit the appropriate operative request

slips and purchase orders ahead of time, as well as

contacting equipment representatives and coordinating

with consulting services in order to prepare the battle

casualty for surgery.

Following Morning Report, the junior orthopaedic

resident or intern would submit 9 routine consults

(audiology, discharge planning, nutrition care,

occupational therapy, pastoral, psychiatry, physical

medicine and rehabilitation, physical therapy, and

social work) throughout the hospital on every OIF/

OEF patient. For all open wounds, the Infectious

Disease Service was consulted and routine operative

tissue cultures obtained. It was the responsibility of the

orthopaedic resident to coordinate all consults and

ensure that the orthopaedic team had addressed the

recommendations.

The orthopaedic management of inpatients was based

on routine trauma management, yet the type of trauma

differed from the routine civilian blunt trauma. The

average battle casualty consisted of a blast injury

involving multiple extremities, with multiple soft

tissue and bony injuries. The wounds were often

contaminated, requiring serial irrigation and

debridement and aggressive wound management with

delayed primary closure rather than skin, free, or local

flaps and grafts. The orthopaedic treatments consisted

of amputations, revision amputations, flaps, a large

number of wound vacuum-assisted closure devices,

antibiotic-impregnated polymethylmethacrylate beads,

and a variety of fracture stabilization procedures for

limb salvage.

The orthopaedic resident made a continuing effort in

the disposition of patients to other medical treatment

facilities (MTFs). The disposition of patients to other

military MTFs was difficult because of the extensive

number of casualties experienced in the face of the

ongoing war, which limited the number of CONUS

AEROVAC flights. The disposition of Active Army

Soldiers was routine pending travel arrangements to

their home duty station. The disposition of the Army

National Guard or Army Reserve Soldiers was

challenging due to the administrative complexity

introduced because the home of record usually differed

from the mobilization site, and the associated lack of

surrounding military medical facilities in a given

region. Every effort was made to return the Soldier to

their mobilization site, assuming appropriate follow-up

and therapy could be obtained. Medical evaluation

boards, if required, were completed at time of

discharge or at time of optimal functional

improvement.

THE OUTPATIENT CASUALTY

An orthopaedic nurse case manager expedited the

management of outpatient battle and nonbattle

casualties. This nurse case manager coordinated all

appointments and expedited surgical scheduling with

an attempt to schedule operative within a 2-week time

frame. All patients that were triaged to an outpatient

setting were given follow-up dates with appropriate

attending physicians. If a patient was seen at triage and

no orthopaedic issues were identified, he or she was

then referred to the appropriate Service for medical

care. Outpatient surgical cases received priority over

all elective cases not originating in one of the combat

theaters in an attempt to reduce the large volume of

outpatients.

CONCLUSIONS

The evolution of the process of care of battle casualties

is an ongoing process. It is imperative to initially

establish and implement a hospital-wide plan

addressing logistics and process of care. The most

important issue, however, remains open, ongoing

bidirectional communication between the transferring

and receiving facilities, as well as between

departments, services, and providers. We recommend

that appropriate legal personnel within the institution

establish a working protocol that allows transfer of

patient information while remaining compliant with

current Health Insurance Portability and

Accountability Act regulations. We also suggest a

unification of the digital radiographic systems and/or

establishment of communication links between

overseas systems to eliminate duplication of effort.

This will be cost-effective, safer for the patient, and
42 Army Medical Department Journal

ultimately improve efficiency. Finally, we suggest

implementing a plan that automatically incorporates all

of the routine consults that are required in the care of

the battle casualty. The myriad of administrative tasks

(eg, discharge planning, HIV testing, TB testing,

malaria prophylaxis, family travel, etc) cannot be

relegated as a responsibility of the primary surgical

team in the face of large numbers of battlefield

polytrauma patients that are arriving from combat

operations. The disposition of Soldiers from the

receiving institution to their home units or regions is

still not seamless. WRAMC continues to refine this

protocol.

AUTHORS

CPT Javernick is assigned to the Department of

Orthopaedics and Rehabilitation at the Walter Reed Army

Medical Center, Washington, DC.

COL Doukas is Chairman, Department of Orthopaedics

and Rehabilitation at the Walter Reed Army Medical

Center, Washington, DC.

Orthopaedics and Rehabilitation at the Walter Reed Army Medical Center

PART 2

PHYSICAL THERAPY

COL Barbara A. Springer, SP, USA

COL William C. Doukas, MC, USA

As part of a patient-centered team, physical therapists,

physical therapy assistants, and physical therapy

technicians are dedicated to providing the best possible

care to wounded Soldiers, Sailors, Marines, and

Airmen returning from Operations Enduring Freedom

(OEF) and Iraqi Freedom (OIF) for treatment and

rehabilitation. Therapists work closely with other

health care providers such as orthopaedists,

neurologists, physiatrists, occupational therapists,

speech/language therapists, prosthetists, social

workers, nursing staff, and psychologists to return the

Soldiers to the highest possible level of activity.

OEF/OIF patients are referred to inpatient or

outpatient physical therapy primarily from physiatrists

and orthopaedists. During the first month of combat

operations, the physical therapist on-call was present at

the triage center with orthopaedic, general, and

vascular surgeons to identify patients with physical

therapy needs, assist with dressing changes, and

communicate directly with the surgeons about weightbearing status, restrictions, and precautions. This

allowed thorough consultations, enhanced

communication, and inpatient physical therapy staff

planning. However, due to the number and frequency

of patients from overseas and the hours of arrival, it

was decided that on-call physicians would triage and

make recommendations and referrals within 24 hours.

INPATIENT PHYSICAL THERAPY

Inpatient consults are typically received within 24

hours of admission or when the patient is stable

enough to receive physical therapy. Physical therapists

provide evaluations and treatments for these OEF/OIF

patients on any of the wards, to include the intensive

care units. Most injuries incurred by these patients are

caused by landmines, improvised explosive devices,

rocket propelled grenades, gunshot wounds, and motor

vehicle accidents. Examples of common conditions

evaluated and treated by the physical therapy staff

include multiple trauma, soft tissue injuries, burns,

skin grafts and flaps, fractures, amputations, traumatic

brain injuries, hemiplegia, spinal cord injury, and

vestibular dysfunction. Unfortunately, many patients

do not sustain only a single injured limb, but rather

suffer multiple injuries and conditions. For example,

challenging patients include those who undergo double

or triple amputations, are blinded, and suffer traumatic

brain injury. Physical therapy treatments include bed

mobility, transfers, gait training, don and doffing of

prosthesis, mat exercises, residual limb desensitization,

strengthening, stretching and range of motion,

conditioning, aquatic therapy, balance training, neuro

rehabilitation, and patient and family education.

Inpatients are treated twice daily where appropriate on

weekdays and once a day on weekends. There is a pool

of contract weekend physical therapists, and physical

therapy assistants and technicians. Two of each are

scheduled to work every Saturday and Sunday. If there

is a need for more than 4 staff members on the

weekends, the military on-call physical therapist and/

or technician will assist. In order to provide continuity

of care for our amputees throughout the entire week,

rotating schedules were created for our full-time

amputee therapists.
January – March 2007 43

Inpatient physical therapists work closely with social

workers and nurse case managers to coordinate further

care, to include evaluating rehabilitation and

equipment needs. Occasionally an OEF/OIF patient

must go to a specialized Veteran Affairs rehabilitation

hospital for severe traumatic brain or spinal cord injury

rehabilitation. Other times they are discharged and stay

in the local guesthouse awaiting further surgery and/or

wound checks. Inpatient physical therapists also help

coordinate outpatient physical therapy, whether it is at

Walter Reed Army Medical Center (WRAMC), at the

patients’ mobilization site, or home. Sometimes

patients go home on convalescent leave, then return

for further work-up and/or rehabilitation.

OUTPATIENT PHYSICAL THERAPY

Outpatient physical therapy is provided within 72

hours (typically less) of receiving a consult from

health care providers, such as physiatrists or

orthopaedists. Three mornings each week are

dedicated to OEF/OIF patients, as well as any other

Active Army patients. After the patients are evaluated,

physical therapists determine their rehabilitation needs

and may refer them to other specialty clinics such as

neurology or orthopaedics. A detailed treatment plan

for physical therapy treatment at WRAMC is written

for patients who are staying for any other health

reasons, or patients are referred to other military or

civilian physical therapy clinics, depending on their

status. There is a dedicated nurse case manager for the

OEF/OIF patients to help coordinate their medical

needs at their mobilization sites, or at home should

they go on convalescent leave.

PROBLEMS, SOLUTIONS, LESSONS LEARNED

The number of multiple traumas, blast injuries,

gunshot wounds, amputations, and burns incurred by

OEF/OIF patients are numerous. Their requirements

are not the typical ankle pain or low back strain

patients we would normally evaluate and treat in

outpatient physical therapy. OEF/OIF patients have a

much higher acuity and require many more resources,

ie, increased staff and time. Physical therapy of double

and triple amputees, or blind amputees with multiple

limbs involved is not uncommon, and many injured

patients have traumatic brain injury and/or open

wounds and fractures. The patient profiles have caused

a major shift in focus. The increase in OEF/OIF

patients made it necessary for the Physical Therapy

Service to go to a prime-only status, which reduced

our outpatient visits by approximately 45%. This

resulted in decrements in physical therapy specialty

services such as vestibular rehabilitation, total joint

evaluation and treatments, and chronic obstructive

pulmonary disease exercise classes.

Solution: Army Reserve specialists should be called

up early and dedicated to services, such as physical

therapy, to help ease the burden on the regular staff

during this time of increased casualties. WRAMC

provided funding to hire 3 additional contract physical

therapists and a single physical therapist assistant to

continue providing quality care for all. The amputee

section staff was increased from 1 to 3 physical

therapists, in addition to the existing single physical

therapist assistant. Another solution was to send

patients over 65 years old, such as many of the

diabetic amputees, to civilian facilities where they

could use their Medicare benefits. Additionally,

civilian security personnel were hired for the WRAMC

gates, freeing Soldiers to concentrate on the provision

of patient care.

There was a greater need for space in both the 3rd and

5th floor clinics at WRAMC due to the greater need

for patient equipment, such as inpatient beds, geri

chairs, wheelchairs, and prosthetics. Additionally,

space was needed to provide safe functional training,

especially for our young traumatic amputee

population. Functional training includes balance

training, functional drills, hopping, running, climbing,

and ambulating on uneven terrain. These patients

could be progressed to high levels of function, to

include athletic competition and military duties.

However, adequate space would allow better

rehabilitation services.

Solution: A temporary solution is to work with some

of the patients outside (when the weather cooperates)

or at the physical fitness center on the WRAMC

campus. A long-term solution is to build a dedicated

clinic space for our amputee population. In 2002,

Congress provided funding to establish an amputee

care program for these young, healthy, highly

functional Active Army Soldiers who sustain traumatic

amputations. Dedicated clinic space that can be shared

by all the team members involved in amputee care is

planned for construction.
44 Army Medical Department Journal

There has been some difficulty tracking OEF/OIF

outpatients. No particular caseworker was accountable

for patients who stay at the local guest house. There

was no one to contact if they did not appear for

scheduled physical therapy treatments. There should

be current and specific guidance on the management of

OEF/OIF patients, including the length of stay,

location of further evaluations and/or surgeries,

follow-on outpatient physical therapy, and eligibility

issues.

Solution: A nurse case manager has been coordinating

care for the OEF/OIF patients and she is available for

answers to these questions. Additionally, a nurse case

manager was hired specifically for the amputee patient

management.

We believe that the media and visiting VIPs have a

positive effect on the casualties. It is very important to

the patients. However, it is occasionally excessive and

may interfere with getting patients to the physical

therapy clinic for treatment.

Solution: We should certainly allow VIPs and the

media to visit, but there must be close coordination

with the public affairs office and our service. Another

suggestion is to limit VIP visits to evening visiting

hours (or at least after 1500).

Some military patients are being brought back from

Iraq because of preexisting conditions (such as

hammer toes, chronic knee, or chronic back pain). Our

resources are used to evaluate and treat these patients.

Solution: Health care professionals at medical

evaluation sites should closely screen those who are

being called to active duty to ensure they meet the

physical requirements and can perform their duties

before they are deployed.

AUTHORS

COL Springer is Chief, Physical Therapy Service at the

Walter Reed Army Medical Center, Washington, DC, and is

the Physical Therapy Consultant for the North Atlantic

Regional Medical Command.

COL Doukas is Chairman, Department of Orthopaedics and

Rehabilitation at the Walter Reed Army Medical Center,

Washington, DC.

Orthopaedics and Rehabilitation at the Walter Reed Army Medical Center

PART 3

PHYSICAL MEDICINE AND REHABILITATION

LTC Paul F. Pasquina, MC, USA

COL Jefferey Gambel, MC, USA

LTC Leslie S. Foster, MC, USA

MAJ Ann Kim, MC, USA

COL William C. Doukas, MC, USA

INTRODUCTION

The Physical Medicine and Rehabilitation Service

(PM&R) plays a critical role in the assessment,

management, and disposition of the injured combatant.

This role was well demonstrated during Operations

Enduring Freedom (OEF) and Iraqi Freedom (OIF).

Placement of the PM&R Service within the same

department as orthopaedics, physical therapy, and

occupational therapy greatly enhances the

communication and flexibility to provide optimal

medical and rehabilitative care for those injured

combatants with musculoskeletal injuries.

INPATIENT CONSULTS

All combat casualties who are admitted to Walter Reed

Army Medical Center (WRAMC) receive several

automatic referrals, including an evaluation from the

PM&R Service. PM&R consultation to the primary

admitting service helps focus each patient’s

rehabilitation plan at the earliest possible moment.

PM&R consultations also help to identify other

comorbidities such as peripheral neuropathies,

fractures, and mild traumatic brain injuries that might

not have yet been identified during the initial acute

phase of inpatient treatment. In addition to providing
January – March 2007 45

comprehensive rehabilitative care plans, it is

customary for PM&R consultations to provide

recommendations for pain management, bowel and

bladder management, strategies for avoiding

complications of immobility such as deep venous

thrombosis, skin breakdown, or contracture formation.

Also, PM&R consultations develop the coordination

plans with social work services and allied health

professionals to ensure appropriate disposition, which

often includes transition to an inpatient rehabilitation

service.

The primary goal of the PM&R consultation is to

establish the framework for the holistic management

of the patient and to ensure that all strategies for

restoring optimal function are being considered.

INPATIENT PM&R SERVICES (INPATIENT

REHABILITATION)

While the average daily census of the WRAMC

inpatient rehabilitation unit is customarily between 8

to 12 beds, the number of inpatient PM&R beds can be

increased given command approval, space availability,

and appropriate staffing. During wartime, priority for

admissions is appropriately given to injured active

duty service members who require inpatient

rehabilitation. Guidelines for admission are similar to

those criteria used by civilian inpatient rehabilitation

units and include:

1. The patient has a condition that is amenable to

inpatient rehabilitation interventions.

2. The patient is motivated and is able to

participate in a minimum of 3 hours of therapy

(physical, occupational, speech, psychological,

or recreational) per day.

3. The patient has the capacity to learn and show

carryover from day to day in order to meet

identified functional goals.

The inpatient rehabilitation unit at WRAMC has

special challenges when caring for combat casualties.

Injured service members who need inpatient

rehabilitation often present with complex injuries and

multiple comorbidities, which require creative

solutions to progress in rehabilitation. For example, a

right transtibial amputation may be ready for

prosthetics training and ambulation, however nonweight-bearing fractures on the contralateral limb may

prohibit this from occurring. Other examples

illustrating the complex challenges injured combatant

pose for the rehabilitation specialists include blind

double amputees, spinal cord injuries with

concomitant peripheral nerve injuries, or multitrauma

victims also suffering from post-traumatic stress

disorder. Because of the specialized facility

requirement and need for protracted rehabilitation in

the treatment of high spinal cord injury or severely

impaired head injury patients, the WRAMC inpatient

rehabilitation unit will generally initiate immediate

transfer of these patients to a more specialized facility

closest to the patient’s home of record.

The Inpatient Rehabilitation Unit is collocated with the

inpatient Orthopaedic Service. Given the large number

of Soldiers with extremity injuries, such collocation

facilitates the transfers of patients within the hospital,

while improving communication between physicians,

nurses, therapists, and other healthcare professionals.

The inpatient rehabilitation unit has many dedicated

and caring military and civilian nurses trained in

medical-surgical nursing, however, cross-training in

rehabilitation is also required. Therefore, an ongoing

educational process must exist to ensure the highest

level of care. Critical to the functioning of the inpatient

rehabilitation unit is the active participation of a

multidisciplinary team. The corps members of this

team include: PM&R, physical and occupational

therapy, social work, nursing, and psychiatry.

Having the rehabilitation unit located within the

echelon V facility ensures the highest quality of care

for these complex patients. First, it ensures continuity

of care as these patients are transferred to the

rehabilitation unit from multiple different medical

specialties (orthopaedics, vascular surgery, general

surgery, neurosurgery, internal medicine, etc). Second,

if during the rehabilitation phase of recovery a patient

develops a medical or surgical complication,

immediate multispecialty evaluation and

comanagement is available. It is the PM&R

specialist’s responsibility to serve as the inpatient’s

primary care physician, facilitating communication

between specialties, providing attention to detail in

monitoring daily progress, and ensuring the execution

of the optimal treatment plan.

The inpatient rehabilitation team must have a close

working relationship with the Department of Veteran’s
46 Army Medical Department Journal

Affairs (VA) in order to expedite the transfer of

patients to these facilities when warranted. In addition,

the PM&R specialist must have an extensive working

knowledge of the military disability system, to include

training in writing medical evaluation boards,

counseling patients on the physical evaluation board

process, and writing physical profiles. Most patients

admitted to the inpatient rehabilitation unit require

complex disposition decisions and extensive

administrative processing. It is the PM&R specialist

that must ensure all necessary requirements are

completed to ensure that optimal long-term care is

provided to the patient, whether the patient is returned

to duty or transitioned to a VA facility.

CARING FOR THE AMPUTEE

Experience gained during OEF and OIF has further

highlighted the special and complex needs of combat

amputees. These patients present unique challenges

because of the nature of their wounds as well as the

extent of their comorbidities. Complex decisions as to

the need and optimal length of residual limb revisions,

wound management, pain management, timing for

prosthetic fitting and weight bearing, types of therapy,

appropriate prosthetic components, etc, require a

multidisciplinary team approach. To help facilitate this

approach and achieve optimal care for these patients, it

is best to create an independent amputee service. At

WRAMC this service falls within the Department of

Orthopedics and Rehabilitation, with PM&R serving

as the supervising attending physician. The amputee

service is designed to be similar to the Inpatient

Rehabilitation Service, with the addition of

orthopaedists and certified prosthetists. The process of

echelon V care of the combat amputee in presented in

the figure.

ELECTRODIAGNOSTIC EVALUATIONS

The PM&R Specialist is also skilled in performing

electrodiagnostic testing to include nerve conduction

studies (NCS) and needle electromyography (EMG). It

is common for combat casualties to sustain multiple

extremity wounds therefore jeopardizing the peripheral

nervous system. A complete and accurate assessment

of the peripheral nervous system is needed to make

better medical, surgical, and rehabilitative decisions. It

is often difficult to make accurate clinical assessments

of the peripheral nervous system in combat casualties,

given the extensive nature of the wounds, particularly

those resulting from blast injuries. In these situations,

electrodiagnostic testing can be very helpful.

Determinations of central rather than peripheral nerve

lesion, and root rather than plexus injury are possible

by a skilled electrodiagnostician. Finally, results from

electrodiagnostic testing provide input on developing

prognosis.

Performing electrodiagnostic exams on the combat

casualty is often challenging, considering the extent of

soft tissue injury that has occurred. In addition, the

presence of swelling and/or an external fixation device

further increases the difficulty in performing these

procedures and interpreting their results. It is therefore

imperative for the PM&R specialist to have experience

among this type of patient population.

AMBULATORY CASUALTIES

While much attention is paid to the multitrauma

victim, a greater number of Soldiers return from

theater with non-life-threatening medical problems. A

significant amount of these problems involve the

musculoskeletal system, especially the neck, back,

shoulder, and knee. The majority of these injuries can

be attributed to acute macro-trauma or repetitive

micro-trauma. A significant portion of these patients,

however, present with the exacerbation of a preexistent

condition that was aggravated by the extraordinary

physiological, psychological, and social demands and

stress of combat.

Soldiers who are unable to continue with their combat

mission because of a non-life-threatening injury are

evacuated to the United States in a nonemergent status.

The severity of injuries will dictate their triage status.

Patients with less severe injuries may not arrive to an

echelon V facility like WRAMC for several weeks or

even months. Often these patients have already spent

many days in transit before arriving at the echelon V

facility. It is counterproductive to pursue an extensive

medical evaluation of these patients upon their arrival

in the middle of the night. It is much more effective

and efficient to allow these ambulatory patients to get

a good night’s sleep, shower, and a meal prior to their

evaluation. It is therefore imperative to identify a

housing facility in reasonable proximity to the echelon

V facility that is handicap accessible. In addition, prior

arrangements must be made to have clothing, shoes,

Orthopaedics and Rehabilitation at the Walter Reed Army Medical Center
January – March 2007 47

Arrival at Walter Reed

Army Medical Center

Triage:

Orthopaedics,

Surgery, Medicine

Temporary

Lodging

PM&R* Clinic

Next morning appointment

Address medical and

rehabilitation needs

Initiate consults

Medicine

▪

General Surgery

▪

Intensive Care

Units (surgical,

medical)

▪

Orthopaedics

▪

Neurosurgery

PM&R*

Amputee Service

PM&R* Consult

Within 24 hours

Ensure physical therapy, occupational

therapy, psychiatry, pain and/or social

work case management initiated

Coordinate transfer to Amputee Service

when appropriate (goal–under 72 hours)

Amputee Inpatient Service

(PM&R*)

Comprehensive care

Multidisciplinary meetings

Medical Evaluation Board

decisions

Track with case management

inpatient

Return to Duty

Veterans

Affairs System

Tricare

Network

PM&R* Amputee Clinic

Every Wednesday morning to monitor:

Medical problems

Prosthetic fitting

Therapy

Disposition (medical or physical

evaluation boards, return to

duty)

outpatient

Soldier desires PM&R*

follow-up (3, 6, 9,12 months)

or assessment for Return to

Duty

Veterans Affairs System

or Tricare for lifelong

management

Process flow for amputee care at the Walter Reed Army Medical Center

*Physical Medicine and Rehabilitation Service
48 Army Medical Department Journal

Orthopaedics and Rehabilitation at the Walter Reed Army Medical Center

PART 4

OCCUPATIONAL THERAPY

COL William J. Howard III, SP, USA

COL William C. Doukas, MC, USA

Occupational therapy specialists are part of the larger

team responsible for assisting Operations Iraqi

Freedom (OIF) and Enduring Freedom (OEF)

Soldiers, Sailors, Airmen, Marines, Coast Guardsmen,

and their families in rehabilitation for return to the

highest level of function possible. Specifically,

occupational therapy addresses deficits in activities of

daily living, upper extremity motor performance

and meals for these individuals upon arrival as they

typically arrive with only the clothes they had when

they were removed from the battlefield.

Ambulatory patients with musculoskeletal problems

are instructed to report to the PM&R clinic the

morning following their arrival, where a complete

evaluation may be performed to include obtaining

appropriate further studies (radiographic, laboratory,

electrodiagnostic) as well as arranging referrals to

other medical specialties or health care professionals.

Prearrangements must be made with orthopaedics,

physical therapy, occupational therapy, psychology/

psychiatry and social work to ensure easy patient flow,

as these services will be most often needed. In

addition, the evaluating PM&R specialist must have a

good understanding of the air evacuation system and

the requirements of the Patient Administration

Division, which is responsible to track patients, issue

their military orders, and make transportation

arrangements for return to their home duty station or

mobilization site.

The process for disposition decisions on Soldiers in

today’s modern army is extremely complex. Not only

do these Soldiers present with different medical

problems, but most also have unique social situations.

This especially holds true for the National Guard and

activated Army Reserve Soldiers, whose family may

be in one state, their unit in another, and the

demobilization site in even a third. It is generally best

to move each Soldier to his/her demobilization site as

quickly as possible, provided appropriate medical and

therapy facilities are accessible and are arranged prior

to the Soldier’s departure from the echelon V facility.

It is also generally best for the PM&R Specialist to

ensure a complete and comprehensive diagnostic

workup is completed and an appropriate treatment plan

is established prior to allowing a Soldier to leave the

echelon V facility. Conflicts arise as these injured

Soldiers request convalescent leave to visit their loved

ones. To address this issue, it is helpful to have an

established policy to ensure Soldiers are treated fairly,

but at the same time ensures accountability and

tracking of Soldiers who may otherwise be lost to

medical follow-up, or who may compromise their

medical recovery if they are not compliant with the

established treatment program.

In general, echelon V hospital convalescent leave

should not be granted to these Soldiers unless they

must return for follow-up at that facility. In this

situation, the hospital command may grant up to 30

days as indicated by the type of injury. All other

Soldiers should be returned to their demobilization site

or duty station, where their rear unit may grant unit

convalescent leave based on the needs of the unit as

well as the availability of medical care at their leave

location.

AUTHORS

LTC Pasquina is Chief, Physical Medicine and

Rehabilitation, and Medical Director, Amputee Program at

the Walter Reed Army Medical Center, Washington, DC.

LTC(P) Gambel is Chief of the Amputee Clinic at the

Walter Reed Army Medical Center, Washington, DC.

LTC Foster is Assistant Chief of Physical Medicine and

Rehabilitation (PM&R) Service and Chief of the Outpatient

Clinic in PM&R at the Walter Reed Army Medical Center,

Washington, DC.

When this article was written, MAJ Kim was Director,

Inpatient Amputee Rehabilitation Service at the Walter

Reed Army Medical Center, Washington, DC.

COL Doukas is Chairman, Department of Orthopaedics and

Rehabilitation at the Walter Reed Army Medical Center,

Washington, DC.
January – March 2007 49

deficits secondary to injury or disease and

occupational, or role performance deficits due to

mental/behavioral health conditions. Occupational

therapists and certified occupational therapy assistants

work with a host of other professionals including, but

not limited to, physical therapists, physiatrists,

orthopedic and general surgeons, neurosurgeons,

psychiatrists, social workers, nurse case managers,

prosthetists, orthotists, and nurses to provide the

highest quality of care throughout the treatment

continuum.

INPATIENT OCCUPATIONAL THERAPY

Occupational therapy receives consults on OIF and

OEF patients from surgical services, primarily

orthopaedics, and general surgery. These consults

usually are received within 24 hours of the patient

being admitted to Walter Reed Army Medical Center.

There is usually a warning or anticipatory notification

from the Chief, Department of Orthopedics and

Rehabilitation, on patients, particularly amputees,

coming through the air evacuation system which

provides some ability to project workload in amputee

care.

Once consults are received, patients are evaluated

within 24 hours. The team responsible for amputee

care sees patients with upper and lower limb

amputations. This team consists of 2 occupational

therapists and 2 certified occupational therapy

assistants. The team is augmented as needed with

additional staff depending on the workload. The

inpatient orthopedic and rehabilitation sections see

patients with other traumatic injuries without

amputations. Evaluation and treatments for physically

injured patients are done both on the wards and in the

Occupational Therapy Clinic. Patients evacuated from

the theaters of operations with mental/behavioral

health conditions are also seen on the ward in an

inpatient status, and in the Occupational Therapy

Clinic as outpatients.

Patients who sustain amputations as a result of their

injuries require specialized care. This specialized care

involves wound management, preprosthetic training

and prosthetic training (basic and advanced). Factors

involving residual limb care in terms of strengthening,

regaining range of motion, and activities of daily

living occur within each phase. Typically, amputee

inpatients are in phase I preprosthetic care and

training.

Those patients from OIF and OEF who sustained

significant trauma not resulting in amputations are

seen for the remediation of their deficits using standard

occupational therapy methods and protocols. Initial

evaluation and treatment is focused on assisting

patients in reaching independence in activities of daily

living, as well as the remediation of whatever

musculoskeletal system has been affected.

Occupational therapy is part of the multidisciplinary

team which sees those OIF and OEF patients who are

undergoing treatment for mental and/or behavioral

health conditions. Patients requiring inpatient care are

seen in a milieu model of treatment. Outpatient OIF

and OEF patients are seen as part of the Partial

Hospitalization Program (PHP). This is a specialized

outpatient program, which is part of the Psychiatry

Department’s Continuity Services. A life skill group

from Occupational Therapy Services is a part of the

PHP.

OUTPATIENT OCCUPATIONAL THERAPY

Most patients from OIF and OEF who are seen for

outpatient care have been inpatients and are seen

within 48 hours of discharge from the hospital. A

patient who is evacuated to Walter Reed Army

Medical Center as an outpatient and who is in need of

Occupational Therapy is seen within 72 hours or less

(usually), once a referral has been received. The

evaluation and treatment process is similar to that of

inpatients.

LESSONS LEARNED

The initial occupational therapy procedures for care of

OIF and OEF patients had several inefficiencies. The

amputee patients were evaluated and treated by

multiple staff members, a process which lacked

consistency and was somewhat inefficient.

Solution: A dedicated Occupational Therapy Amputee

Section was created in late August 2003. This

centralized the care to a group of therapists who

provide consistent evaluation and treatment to all

amputees. This team consisted of 2 occupational

therapists and 2 certified occupational therapy

assistants. There was one military therapist and one

military occupational therapy assistant who will rotate

with other military staff, allowing cross training of all

occupational therapy staff over time. This team-based

process allowed better synergy with the larger
50 Army Medical Department Journal

Amputee Care Center working closely with

prosthetists, physical therapists, and the physician

staff. A protocol/treatment pathway was developed to

provide an objective, reproducible method for amputee

care with all upper extremity and lower extremity

prosthetics, from preprosthetic training to discharge.

Close coordination with the contract personnel from

the Prosthetics Laboratory has resulted in a solid team

approach in the upper extremity prosthetics fitting and

training of Soldiers, and in the education of their

family members.

Experience with the groups of patients from the

Afghanistan Theater in the fall of 2001 through 2002

made it clear that the type of rehabilitation these

patients required must include a more comprehensive

effort in the area of activities of daily living.

Solution: In June 2003, renovations were completed

for part of the Occupational Therapy Clinic to

accommodate an apartment-type area for activity of

daily living therapy. This area is heavily used,

providing the OIF and OEF patients a place to practice

skills necessary to return to independent functioning.

The apartment allows patients to become independent

in personal hygiene, transfers, cooking, household

cleaning, and computer use.

CONCLUSION

The care of Soldiers from OIF and OEF is a high

honor. The nature of battlefield injuries requires more

complex and time-intensive evaluations and

treatments. It also requires a strong multidisciplinary

team of dedicated professionals to address all aspects

of the Soldier who was injured in the defense of our

country. The amount of effort necessary from the

numerous professionals involved in the rehabilitation

of these Soldiers cannot be measured in time or

money. The true measurement is seen in the dedication

and caring of a truly world class military medical

team, from the battlefield to the medical center, with

transition back to active duty, or to the Veterans

Affairs system to assist with mainstreaming into the

workforce as productive members of society.

AUTHORS

COL Howard is Chief, Occupational Therapy Clinic and

Assistant Chief, Physical Medicine and Rehabilitation

Service at the Tripler Army Medical Center, Honolulu, HI.

COL Doukas is Chairman, Department of Orthopaedics and

Rehabilitation at the Walter Reed Army Medical Center,

Washington, DC.

The Walter Reed Army Medical Center, Washington, DC.

Orthopaedics and Rehabilitation at the Walter Reed Army Medical Center
January – March 2007 51

The roots of the profession of occupational therapy

cannot be separated from the Army, for the history of

the profession is intertwined with the history of

military health care. Occupational therapy is the

therapeutic use of purposeful and meaningful

occupations to evaluate and restore function and

independence. Inherent in this definition is the

importance of occupation and purposeful activity. It is

significant to note that these activities are not merely

selected at random. Rather, the occupational therapy

practitioner selects those activities that are best suited

to the patient/Soldier’s current level of function in

order to ensure successful completion. This belief is

the basis on which the profession was founded.

Although the benefits of the use of activity have been

acknowledged over the years, these lessons tend to be

forgotten until a time of crisis. So too is the case with

the development of occupational therapy. As this paper

illustrates, the numbers of occupational therapists

decline during times of peace. Then a war necessitates

an increase, and training programs are developed in an

attempt to fill the ranks.

AGE OF ENLIGHTENMENT — 1780S TO 1880S

The late 18th century heralded the “Age of

Enlightenment and Moral Treatment.” During this

period, Dr Philippe Pinel used activities to “take the

patient’s thoughts away from their emotional problems

and develop their abilities.”1Pinel was a philosopher,

scholar, natural scientist, and physician who saw the

benefit of using activities in the treatment of the

mentally ill. This was a drastic change from the

accepted practice of placing people with mental illness

in chains. It was felt that people needed a predictable

routine to allow them to function optimally. In an

effort to help them manage their environment, physical

exercise, and work was believed essential and a

necessary part of every institution’s program.1

Additionally, in a report signed by Dr Henry M. Hurd,

the use of “occupation” was found to be a successful

substitute for the use of restraints.2

By the end of the 1880s, Moral Treatment was

diminishing in favor of a less costly form of custodial

care.3Prior to its end though, a philosophy emerged

that was based on Civil War experiences. This

philosophy held that “the best means of preventing

nostalgia [battle fatigue] was to provide occupation for

the mind and body....”4 This philosophy also stated

that Soldiers placed in hospitals near their homes are

more likely to develop nostalgia than those who

remain near their units for treatment.4It is important to

note that these ideas will be repeated in the 20th

century with the development of combat stress control

units, and will be discussed later. As this illustrates,

even with the end of Moral Treatment there were still

those who held firm to their belief in the benefit of

occupation.

The Growth of the Profession of

Occupational Therapy

MAJ Sharon Newton, AN, USA

ABSTRACT

Occupational therapy is a frequently unknown and misunderstood profession. However, occupational therapy

practitioners have a rich history in the US Army, from the inception of the profession to current challenges.

The article is a chronicle of historical highlights of occupational therapy which discusses how this history is

harmonious with that of occupational therapy in the US Army. In researching this topic, several concepts

emerged: (1) occupational therapy grew from a belief that people need occupation, or activity, to remain

healthy; (2) people learn the best through purposeful activity; (3) the number of occupational therapists in the

US Army decreases during peacetime, but in time of war the benefit of this profession is recognized and its

numbers increase; (4) although models of health care change, the primary focus of occupational therapy

remains constant; and (5) there is a direct correlation between the philosophy of occupational therapy and the

philosophy of treating Soldiers with combat stress reactions, a “go-to-war” mission of Army occupational

therapy practitioners. As such, the management of these Soldiers is enhanced by the unique skills offered by

this profession.
52 Army Medical Department Journal

The period from 1890 to 1910 became known as the

Arts and Crafts Movement. A great influence early in

this period was the Hull House Labor Museum.5 The

general idea of this time was that “occupation should

be used as a means of education to substitute for

custodial care of the mentally ill.”5 To support this

treatment, a course for play and occupation was

established for nurses.2Just as the era of Moral

Treatment ended, so did the Arts and Crafts

Movement. By 1910, the number of medical schools

was increasing and the focus of patient treatment

turned to a more scientific study.5 Occupational

therapy was not yet a profession per se, but the

foundation had been set. Just as the Coastal Redwood

can grow from the roots of other redwoods,

occupational therapy grew from the roots of other

professions.

THE WAR TO END ALL WARS

Many of the founders of what was to be known as

occupational therapy still believed that activity

worked.5For example, a nurse named Susan Tracy

published a paper in which a premium was placed on

the “adoption of the occupation to the condition and

natural tastes of the patient.”2 This was to set another

piece of occupational therapy’s foundation, that of

adopting the activity to the needs and abilities of the

patient. When the United States entered World War I

(WWI) in 1917, this concept of re-educating people

with the skills needed to enable them to become

effective members of society was lauded as the best

means of treatment.6In fact, the Civil Service

Commission recognized occupational therapy as the

profession that could provide this service, and

admitted occupational therapists to serve as

Reconstruction Aides in the Army Medical

Department.7

The efforts of these first occupational therapists were

to restore acute psychiatric casualties and patients with

impaired motor function by teaching crafts. These

pioneers in the field were called “nondescript” as few

people knew what they did,6 which continues to be

problematic today! Apparently their benefit was felt,

though, as 24 civilian Reconstruction Aides were

deployed to France in support of the war effort.7 This

first reconditioning program emphasized that activity

should be prescribed early, as with our current doctrine

of combat stress control.6

In 1918, the Army Surgeon General expanded the

emergency training programs to seven civilian

institutions in an effort to fill the need for

Reconstruction Aides.7In addition to working with

neuropyschiatric patients, the profession soon to be

known as occupational therapy treated people with

amputations, blindness, head and nerve injuries,

osteomyelitits, and tuberculosis.6 The idea of

providing activity appropriate to the needs of the

patients was still vital. In 1919, Army MAJ Bird T.

Baldwin described the use of activity analysis, which

was how the appropriateness of an activity was

determined. This strong supporter of the profession

stated that the purpose of occupational therapy is to

“help each patient find himself and function again as a

complete man physically, socially, educationally, and

economically.”8 The roots of occupational therapy

began to establish themselves and the foundation of a

new profession was set. By the end of WWI, the

number of occupational therapy Reconstruction Aides

serving was an astounding 455, but by 1919 most

occupational therapists employed by the Army were

discharged.7

THE WORLD AT PEACE — A PROFESSION GROWS

In an effort to treat the veterans of WWI, the emphasis

was on vocational rehabilitation, with the Federal

Board of Vocational Rehabilitation providing

occupational therapy services.7 However, by 1920 the

therapeutic use of work was part of physical

rehabilitation instead of vocational rehabilitation,

which resulted in occupational therapists being cut-off

from work related programs.5 Even though the number

of occupational therapists serving with the Army

diminished, the profession did not die—its roots

spread and the trunk that was to become occupational

therapy began to grow.

A major step toward this growth occurred in 1922

when Dr Adolph Meyer wrote what was to become the

philosophy of the profession.2 Three main ideas served

as the basis of this philosophy. One was that people

need a balance of work, rest, play, and sleep in order to

function with normal lives.9 When this balance is

disrupted, be it through disease, injury, or combat,

dysfunction results. The second idea was that of the

mind-body connection.2 Dr Meyer supported the less

popular belief that the mind and the body could not be

separated, that one affected the other in relation to

The Growth of the Profession of Occupational Therapy
January – March 2007 53

illness. The third idea was that people learn best by

doing things, or through occupation.9 This described

the beneficial use of appropriate activity that had been

inherent in the treatment of people since the late 18th

century.

The profession saw other changes as well as this roller

coaster of events thundered onward. The term

“Reconstruction Aides” was changed in 1926 to

“physiotherapy” and “occupational therapy.”6 Only a

few years later, during the l930s, a model based on the

orthopedic needs of the patient began to evolve.5

Occupational therapists were then also working with

muscle strengthening and maintaining joint range of

motion. As the Depression ended and the nation was

recovering, changes were experienced in occupational

therapy as well. In 1933, the training course at Walter

Reed Army Medical Center was abolished secondary

to a lack of funds, and occupational therapy programs

and personnel in all permanent Army hospitals were

reduced to a minimum.9

WORLD WAR II

Once again history repeats itself. The nation found

itself at war and the profession of occupational therapy

found its numbers had dwindled to almost nothing.

When the Japanese attacked Pearl Harbor on

December 7, 1941, there were only 9 occupational

therapy practitioners affiliated with the Army, and

only 3 of those were qualified registered therapists.9It

comes as no surprise that the big concern at this time

was the recruitment of qualified therapists and the

establishment of accredited training programs to meet

this need.10 Although the number of personnel was

small, the benefits of the profession were great. To

continue our analogy with the Coastal Redwood, the

roots had spread and established themselves, and the

trunk began to shoot upward.

The period during World War II (WWII) found several

supporters of occupational therapy. Among them was a

physician, MAJ Walter Barton. He strongly believed

that “work, rest, and play activities represented the

essential triad for the restoration of health,” and

recommended occupational therapy departments

establish progressive activity programs.10

“Occupational therapy,” he noted, “should be applied

at all points of treatment from forward the echelon aid

station to the last point of evacuation in the psychiatric

section of a named general hospital.”11 The importance

of meaningful activity and constructive work was

continually stressed as a method of treating the

restlessness generated from inactivity. People want to

feel useful. It was frequently observed that Soldiers

had an intuitive need for occupation, and became

willing to perform work if they viewed it at least

indirectly supportive of the war effort.10

Another supporter was LTC Alan Challman (Medical

Corps) and the consultant to neuropsychiatry in the

southwest Pacific area. In 1942, he was charged to

review the organization of psychiatric services and

create an approach that could reverse an alarming

trend: the Surgeon General’s office determined that

“psychiatric casualties constituted nearly 40% of the

medical discharges being processed by the Army - a

situation viewed as intolerable and unnecessary.”10

LTC Challman found that Soldiers with mental

disabilities could be better treated and more

appropriately diagnosed, with more of them restored to

duty, if they were given specialized help that included

occupational therapy. This was based on his finding

that “patients who had been given up for lost by the

ward officer made complete recoveries when provided

purposeful activity suited to their abilities [italics

added].”10

Even this level of support was not enough to

counteract the low number of qualified occupational

therapists, and it was determined early in the war that

they would not be military personnel. This meant that

all occupational therapy activities would be confined

to the Zone of the Interior, which in reality hindered

the recruitment of adequate personnel.9 Like so many

Americans, occupational therapists wanted to serve

their country. In fact, the actual need for occupational

therapists did not meet the perceived need. In response

to this lack of qualified occupational therapists, a War

Emergency Course began in July 1944 by the

Occupational Therapy branch of the Surgeon

General’s Office in conjunction with the American

Occupational Therapy Association and War

Manpower Commission.6 This was an accelerated 12-

month program, with more hours devoted to the

sciences, clinical conditions, and the theory of

occupational therapy than to arts and crafts. The need

for a strong knowledge base in psychiatric conditions

was recognized, but, due to the short training period, it

was made a prerequisite to attend. In the interim,
54 Army Medical Department Journal

occupational therapists supervised Red Cross

volunteers in the craft program so the provision

of this vital activity to the Soldiers was not lost.5

However, by 1945 all treatment was to be of a

functional nature, not merely diversional. Crafts

were no longer confined to the bed, but brought

to the clinics.6 This meant that all treatment, even

the use of crafts, needed to be developed and/or

supervised by a skilled occupational therapist.

This created an even greater strain on the small

number of occupational therapists.

Due to the War Emergency Course, the number

of occupational therapists continued to rise, and

the types of programs provided expanded in

number. The Table illustrates some of the areas

of treatment and the type of treatment provided

by occupational therapists toward the end of

WWII. Although a variety of conditions were

being treated, the basic premise of using

purposeful activity graded to the individual’s

current level of function remained the same.

Additionally, the areas of treatment were divided

into 4 main programs:9

1. Functional Programs: These provided

education and training in self-care, and

addressed general body weakness, joint range of

motion, and decreased respiratory tolerance.

2. Neuropsychiatric Programs: Persons in these

programs were not only psychiatric patients, but

also those with “psychoneurosis” secondary to

the stress of war. Many of the ideas in these

programs would be seen again in the doctrine for

the management of combat stress reactions,12

such as the need for immediate treatment being

essential. The purpose of these programs was

multifaceted: (1) to “guide mental attitudes into

healthy channels,” (2) promote the desire to get

well, (3) restore self-confidence and a sense of

security, (4) provide encouragement of the

Soldier improving, (5) establish and maintain

good work habits, and (6) afford an opportunity

for socialization. One can recognize in these

ideas similarities to the Army’s current doctrine

on the management of Soldiers with battle

fatigue—rest, replenishment of physiological

needs, reassurance of normalcy and return to

duty, and restoration of confidence.12

3. Industrial Therapy Programs: These programs

were provided as the patient progressed. They

applied to medical, surgical, and

neuropsychiatric patients, addressing the

physical as well as the psychological needs. The

purpose was not only to increase general muscle

tone and joint range of motion, but also to

combat the effects of a prolonged

hospitalization. In this program, patients were

able to improve their tolerance to work, establish

good work habits, and stimulate mental

alertness.

4. Diversional Programs: The purpose of these

programs was to divert the patient from thinking

of himself. However, the benefits did not stop

there. They stimulated the patient’s interest and

provided constructive use of leisure time. By

providing an opportunity for self-expression, the

Soldier’s morale was sustained. In addition, the

patient’s work habits were maintained and his

general physical fitness would improve.

The Growth of the Profession of Occupational Therapy

Types of Occupational Therapy Treatment in 1945

Diagnosis Treatment

Head injury Cognitive retraining, language training

Orthopedic Exercise through purposeful activity

Plastic surgery Functional therapy, diversion therapy

General medical

(polio, cardiac, etc)

Graded activities to create a sense of

independence. Hobby development,

muscle tone maintenance, functional

use of upper extremity, restoration of

self-confidence

Newly blinded, deaf

Orientation, activities to create a

sense of independence and selfconfidence in performance of selfcare, etc

Spinal cord injury,

paralysis

Adaptation to allow performance of

daily activities independently, improve

strength in functional muscles

Amputee

Addressed the psychological aspect,

functional use of prosthesis and

remaining upper extremity

Tropical disease Mainly activities to counter boredom,

apathy, anxiety
January – March 2007 55

A BRIEF PEACE—GREAT PROGRESS

In the 5 years between wars there were 2 major

accomplishments for the profession. Because of the

diversity of programs offered by occupational therapy,

and the recognition of the benefits of the services

provided, occupational therapists finally became a part

of the Army. In 1947, occupational therapists were

commissioned as officers in the US Army with the

establishment of the Women’s Medical Specialist

Corps, which also included physical therapists and

dietitians.6 Then, in 1949, postgraduate programs for

occupational therapists were reinstated for military

personnel.7 This is the first time a training program for

occupational therapy was instituted before the need

became great. As far as the military was concerned,

occupational therapy had become an entity unto itself,

like the Coastal Redwood that grew into a mature tree.

Nevertheless, the years of peace were short-lived as

the US became involved with the Korean War.

THE “FORGOTTEN WAR” AND BEYOND

The period of 1950–1953 saw a drastic slowing of the

growth and development of occupational therapy in

the US Army. The number was down from the 899

therapists seen at the end of WWII, to around 90

women serving in 1953.6 One change seen, however,

was the resurgence of the dominance of the psychiatric

model.5 After the truce to halt the Korean War was

signed, occupational therapists continued to work

primarily in general hospitals. By 1954, they were

working in additional areas of treatment such as with

burn patients and those involved in substance abuse.13

Occupational therapists also returned to being a large

part of work related programs.5

The biggest change seen during this period was in

1955, when men were first allowed to serve as

occupational therapists. Of course this forced a change

in the name from the Women’s Medical Specialist

Corps to the Army Medical Specialist Corps.7

A TURBULENT DECADE

The 1960s were a time of turbulence and change, not

only for the American society in general but for the

profession of occupational therapy as well. It is no

surprise that, with the reemergence of the psychiatric

model during the last decade, humanism returned. The

effect this had on civilian occupational therapists was

drastic, for the way they treated their patients had to

change as more people were deinstitutionalized.5 Once

again, Army occupational therapists saw a change in

their numbers. Occupational therapy authorizations

decreased in order to make slots available for other

Army officers. The number of occupational therapists

dropped to a mere 64 in 1960.6

The first half of the 1960s saw a buildup of US

military advisors in Vietnam.14 The training of

occupational therapists witnessed a similar buildup

with the start of a student occupational therapy

program in 1962.7 The decade ended with the

questioning of many established beliefs. The idea of

humanism was being challenged once again in 1970. It

was felt to be “unscientific and immeasurable,”5and a

medical model was envisioned as a replacement. As a

result, the role of Army occupational therapy

developed a medical focus as well. In the mid 1970s a

skill identifier was established which, with additional

training, allowed occupational therapists to serve as

physician extenders in the treatment of upper

extremity injuries.13 But even with this emphasis on

the medical model, the value of occupation and

activity was still recognized. A Life Skills program

which addressed the needs of Soldiers with psychiatric

and stress disorders was developed by occupational

therapy practitioners at the Eisenhower Army Medical

Center, Fort Gordon, Georgia, in 1974. The use of

occupation as a method to improve the performance of

these Soldiers was paramount.15

POST-VIETNAM

In the year after the fall of Saigon, the Army Student

Occupational Therapy program also ended due to the

need to reallocate active duty slots.7 The occupational

therapists used this time to their advantage and

developed a philosophy for their profession in 1980.

This philosophy was much the same as the one written

by Dr Adolph Meyer in 1922, for the foundation had

not changed over the years. It emphasized the

importance of the mind-body connection in the disease

process, and how occupational therapy addresses all

aspects of an individual. Role performance was

discussed from the perspective of maintaining a

balance of work, rest, play, and sleep. Skill acquisition

was believed to occur through purposeful activity and

repetition of relevant tasks.16 Occupational therapists

believed then, as we do today, that “the capacity to

resume role performance may be achieved even

though symptoms remain,” namely through

adaptation.10
56 Army Medical Department Journal

An interest in work programs returned once again.

Instead of merely providing work activities for

Soldiers, this concept had matured to where work

hardening programs and job evaluations were

performed as well.5 Occupational therapists could

evaluate the skills necessary for a Soldier to perform a

job, adapt the treatment to match the Soldier’s current

level of function, and prepare that Soldier to return to

duty. The year 1980 also saw an increased awareness

of physical fitness in the Army. Occupational

therapists joined in that effort as they became active in

programs such as stress management and weight

control.13

Some interesting concepts reemerged in 1984, when

the Army Medical Department identified combat stress

control as a separate functional mission area. These

concepts were formally presented in Field Manual 8-

5112 under the premise that the Soldier should be

treated in the proximity of his unit, immediately, with

the expectation of his return to duty, and utilizing

simple methods of management. This was

accomplished using what at that time were three main

principles: reconstitution, reorientation, and

reintegration. Soldiers with combat stress reactions

severe enough to affect job performance would

perform duty-related activities in work assignments.

The occupational therapy practitioner’s unique role in

the management of these Soldiers is to “precipitate

adaptive and effective occupational performance by

engaging them in therapeutic occupation [occupational

therapy] which supports their military identity,

reinforces ingrained adaptive occupational skills,

enhances their sense of competency, supports their

socialized military values, and maintains their physical

conditioning.”17 This allowed them to view themselves

as contributing to the mission, which in turn would

hasten their recovery and return to duty. In other

words, the Soldiers would be performing occupational

therapy! Watson and Thome18 recognized this

similarity between Army doctrine and occupational

therapy philosophy, and proposed a program called

“Project ABLE.” This was a task-directed behavior

program designed to improve the Soldier’s job

performance. A revised doctrine of combat stress

control was published in 1994, and some of the

principles were updated and changed from the

previous edition.12 The methods of the management of

casualties was expanded and clarified, but the primary

concepts remained the same.

However, before the Army could officially initiate

these management principles, Desert Shield/Desert

Storm erupted. During this period, active duty

occupational therapy practitioners were deployed to

the Persian Gulf and many Reservists were called to

active duty to fill stateside assignments.7 LTC Mary

Laedtke was one of the occupational therapy

practitioners deployed to the Persian Gulf. While

assigned to the 528th Medical Detachment

(Psychiatric), she utilized the principles of combat

stress control in working with Soldiers. She reported

that the use of “work and other occupations [which

were carefully selected to meet the Soldier’s current

ability] to return the combat-stressed Soldier to duty

proved to be an integral part of the restoration

process.”7Since occupational therapy is the only

health care discipline to approach intervention in this

manner, LTC Laedtke was able to demonstrate the

benefits of occupational therapy in an active theater of

operations.

THE WAR ON TERRORISM

The events of September 11, 2001 changed the lives of

countless people. Those involved in the profession of

occupational therapy in the US military were no

exception. In his article,19 Army occupational therapist

CPT Roger Bannon relates his experiences as a

member of a Special Medical Augmentation Response

Team for stress management. In the days that followed

the attack at the Pentagon, CPT Bannon utilized his

training and experience in combat stress control and

critical incident stress management to help the victims

begin their recovery.

Operation Enduring Freedom provided opportunities

for occupational therapy practitioners to further

demonstrate the unique skills of their profession. As a

member of the 528th Medical Detachment (Combat

Stress Control) from Fort Bragg, North Carolina,

Army CPT Robert Montz served on a team that

provided mental health and preventive services in

Uzbekistan, Afghanistan, and Pakistan. CPT Montz

assisted in providing briefings such as stress

management, handling human remains, and

redeployment. He also regularly visited and walked

through the supported units’ areas, where he was able

to observe the Soldiers at work and assess how the

Soldiers were functioning.20

The Growth of the Profession of Occupational Therapy
January – March 2007 57

Another unique opportunity for occupational therapy

emerged that year as the 85th Medical Detachment

(Combat Stress Control) at Fort Hood, Texas, began

preparations to deploy a Prevention Team to

Guantanamo Bay, Cuba, to support the Joint Task

Force. The team was led by 2 occupational therapy

professionals, the author, an occupational therapist,

and occupational therapy assistant, SSGT RB Howard.

This was the first time an actual combat stress control

prevention program for service members was

developed and implemented on this small Naval

installation. In addition to the typical work performed

by combat stress control teams, these occupational

therapy practitioners were able to bring the unique

perspective of occupational therapy to the mission. For

example, while conducting the usual “walk-abouts”

performed in conjunction with preventive combat

stress control, I would work with the service members

to determine the stressors, mental, physical, and

emotional, that were present in the performance of

their job. Education and activities meaningful to the

service members were used to address the various

stressors that arose. This would sometimes entail

structuring the environment and/or the job to ensure

successful completion of the task, and, in one instance,

ergonomic recommendations were made to make the

job safer and more efficient.

As this article is written, many occupational therapy

practitioners are serving in Kuwait and Iraq in support

of Operation Iraqi Freedom. In addition to combat

stress control teams, occupational therapists are

working in field hospitals and on a medical brigade

staff, active duty and reserve components. Continuity

of care is ensured as the service members evacuated

from theater receive occupational therapy at medical

treatment facilities in Germany and the United States.

These occupational therapy practitioners are providing

vital services in the treatment of upper extremity and

spinal cord injuries, amputations, and psychiatry.

TODAY AND INTO THE FUTURE

Occupational therapy today continues to evolve to

meet the needs of changing times. The 79 occupational

therapists currently on active duty are serving in

combat stress control units, medical centers, medical

activities, as Professional Officer Fillers (PROFIS),

and on stress management Special Medical

Augmentation Response Teams. In addition to the

deployments discussed above, occupational therapists

have been deployed to support missions to areas such

as Bosnia-Herzegovina, Cuba, Peru, Russia, Columbia,

Honduras, El Salvador, Sri Lanka, and to South

America following Hurricane Mitch. Today’s

occupational therapists are working with Soldiers,

family members, and retirees with a variety of

problems—orthopedic, neurological, psychological,

and stress. Occupational therapists have commanded

medical units, from company level to a medical

facility.

The profession’s ability to address a myriad of

diseases and injuries has contributed to this wide range

of positions. As history vacillated between the use of

medical and humanistic models, so too did the

profession of occupational therapy. This vacillation

continues today as disciplines in the health care field

debate the best way to treat patients. Even though the

role of occupational therapy has changed over the

years, the profession eventually returns to its roots of

occupation and the use of purposeful activity, the

belief in the importance of treating the entire person,

and the belief in the benefit of maintaining a balance

of rest, work, play, and sleep. This premise allows

occupational therapists to “play the role of mediator

between the sciences [medical model] and the

humanities [humanistic model], and between the high

technology of diagnosis and treatment and the art of

human caring.”21

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ke2.army.mil/synergy/main. Accessed November 15,

2003.

21. Hasselkus BR. Dear Ann Landers.... Am J Occup Ther.

2001;55:247-248.

AUTHOR

When this article was written, MAJ Newton was an

Occupational Therapist, 85th Medical Detachment

(Combat Stress Control) at Fort Hood, Texas.

The Growth of the Profession of Occupational Therapy
January – March 2007 59

INTRODUCTION

Military logistics doctrine conceived to support

traditional conflict with a clearly defined front and

rear has recently evolved to sustain the fight

against an enemy without defined real estate. The

nonlinear battlefield demands quickly mobile and

self-sufficient units. Modularity (the deployment

of units as smaller standalone pieces) emerged,

resulting in a shuffling of support and medical

assets. Combat units, renamed brigade combat

teams (BCT), assumed control over their own

logistical and medical resources, decentralizing

ownership out of the former division support

brigade (DISCOM). This internal control enables

the BCTs to move easily as single self-sustaining

units. The DISCOM, once the command and

control center of all the division’s logistical and

medical support, assumed a new role and new

name—the sustainment brigade. Stepping up to a

corps or area support role, while maintaining some

responsibility to collocated divisional elements, the

sustainment brigade assumes command, control

and responsibility for logistical support to meet

additional needs of the division and for all

collocated units which are without organic support

elements.

In keeping with the concept of modularity, a

sustainment brigade owns whatever pieces are needed

to provide support in a given area. Unique in this

ability to gain and lose assets while moving in and out

of a war zone, the sustainment brigade is usually a

headquarters element with a few hundred Soldiers

while not deployed. As it moves into a theater, new

units, identified by the headquarters element during

predeployment planning and site visits, come under the

umbrella of the sustainment brigade command. As it

redeploys home, these units, many mobilized National

Guard and Army Reserve, are shed and deactivated.

Planning is central to the process of sustainment

brigade deployment as it is the mechanism by which

the correct logistical resources are established in an

area.

SUSTAINMENT BRIGADE MEDICAL SUPPORT

The sustainment brigade concept creates specific

challenges for medical support. The sustainment

brigade’s medical element consists of a planning

section and a small medical platoon. The medical

oversight and planning section is headed by a

physician, the brigade surgeon, who is usually a senior

captain or major and is residency trained in one of

several key specialties. Within the surgeon’s section,

shown in Figure 1, there are 2 cells, medical plans and

operations and medical logistics and sustainment, each

with a staff of senior noncommissioned officers and

medical service corps officers. The sustainment

brigade’s medical platoon, shown in Figure 2, consists

of a headquarters element, a treatment squad, and an

ambulance squad. Within this structure are the medical

providers and medics to support level I, or emergency

care and sick call services to personnel within the

Medical Care in the Sustainment

Brigade

MAJ Bonnie Hartstein, MC, USA

Medical Logistics Officers

1 Major, 1 Captain

Medical Logistics NCOs*

1 Staff Sergeant, 1 Sergeant

Medical Planners

1 Major, 1 Captain

Medical Operations NCO*

1 Master Sergeant

Senior Health Care NCO*

1 Master Sergeant

Patient Administration NCO*

1 Sergeant

SUSTAINMENT BRIGADE SURGEON SECTION

Brigade Surgeon

Medical Plans and

Operations Cell

Oversee and coordinate

force health protection for

all sustainment brigade

personnel.

Medical Logistics and

Sustainment Cell

Coordinate the ordering

and distribution of Class

VIII (medical supply) in

the sustainment brigade.

Figure 1. The organization of the Sustainment

Brigade Surgeon Section.

*Noncommissioned Officer
60 Army Medical Department Journal

sustainment brigade headquarters section, a population

of about 400 people. When the sustainment brigade

deploys and assumes command and control of several

battalions, depending on its area support mission, it

grows several thousands in strength.

There is little the sustainment brigade cannot do for

itself, except provide adequate medical care to all its

deployed units without additional help. This is because

most units that deploy under the sustainment brigade

in war do not come with their own medical assets.

Among the sustainment brigade resources, medical

support is nearly absent (except for the small medical

platoon). Medical services for the additional

sustainment brigade units must be coordinated by the

sustainment brigade surgeon’s planning section.

The command and control of corps level health service

support is the responsibility of the medical support

command, a separate unit with its own command

element. As the sustainment brigade prepares for

deployment, additional medical assets can be arranged

through the medical support command, depending

upon the number of additional Soldiers joining the unit

and the needs of the units in the area supported. A

subordinate unit of the medical support command, the

multifunctional medical brigade (MMB), provides area

medical support much in the same way the sustainment

brigade takes responsibility for logistics. It too is a

modular style unit with the variety of medical assets

tailored to meet the area’s medical needs. Accurate

and well-coordinated planning with both the medical

support command and MMB is critical to ensure

adequate medical support for sustainment brigade

Soldiers. In the case of medical planning, the focus of

the sustainment brigade surgeon section is turned

inward toward caring for those Soldiers.

Therein lies the critical issue concerning medical

support in sustainment brigades. Whereas the

sustainment brigade provides additional area logistical

support, it is the medical support command that

coordinates and provides the area medical support. The

sustainment brigade and medical support command

may interact in any different number of ways,

depending on the layout of the theater. Pieces of the

medical support command may be allocated to the

sustainment brigade, the sustainment brigade may use

assets of the medical support command that happen to

be collocated, or the medical support command might

be under operational control of the sustainment

brigade. In theory, the sustainment brigade and

medical support command are 2 separate support units

operating as interdependent entities, the sustainment

brigade providing necessary nonmedical supplies and

services to the medical support command which

provides the additional medical care absent in the

sustainment brigade. However, coordinated planning

between 2 separate commands is complex and, in a

dynamic theater, medical support command assets may

not be geographically available to support sustainment

brigade Soldiers.

In a reversal of the support concept, the sustainment

brigade may come to rely on the local BCT to care for

its Soldiers since the BCT deploys with robust medical

assets. The medical element of the BCT looks much

like its predecessor in the former forward support

battalion/main support battalion, with a medical

company in the support battalion and a medical

platoon (Figure 3) in each combat battalion. By design,

the BCT has medics, physicians, and physician

assistants imbedded in the structure of its battalions.

The medical company provides level II care, by

definition, higher-level care with x-ray, laboratory,

Medical Care in the Sustainment Brigade

SUSTAINMENT BRIGADE

MEDICAL PLATOON

Headquarters

Treatment Squad

1 Physician

1 Physician

Assistant

2 Medical

Sergeants

4 Medics

Figure 2. The Sustainment Brigade

Medical Platoon is organized, staffed,

and equipped to provide level I, or

emergency care and sick call services

only to personnel within the

sustainment brigade headquarters

section, a population of about 400

people. As structured, it cannot

provide adequate services to the

additional units that are assigned to

the brigade when it is deployed.

Ambulance Squad

Ambulance Team

2 Medics

Ambulance Team

2 Medics
January – March 2007 61

dental, mental health, pharmacy, and

patient hold capabilities. However, a

system whereby a sustainment brigade

relies on a BCT for level I and/or level II

medical care can present a problem as the

BCT is not designed to be an area asset.

Slices may need to move to support the

fight, taking with them some (or most)

medical assets. It is a situation that can

adversely affect those sustainment

brigade Soldiers who rely on the BCT’s

medical resources when combat missions

dictate relocation of those same assets.

In the planning phases before

deployment, sustainment brigade medical

planners must decide how much health

service support is required for their

troops. This support must be reliable and

responsive to the medical needs of the

sustainment brigade, the population of

which may include newly activated Army

Reserve and National Guard Soldiers

representing a different medical

demographic than active duty troops.

Lacking clear-cut guidelines to dictate

provider-to-patient ratios, planning can

be difficult. One model to use is the

medical personnel structure of the BCT

where, generally speaking, provider (physician or

physician assistant) to patient ratios in a deployed

setting are estimated at 1/400 to 1/600 Soldiers.

Combat casualty estimates are different in a fighting

brigade as compared to the support brigade, but

similarities exist for level I sick call services.

HERE AND NOW

The first sustainment brigades were created in Iraq in a

mature theater, transforming from the DISCOM.

Medical support was well established in most areas as

units settled onto built up forward operating bases

(FOBs) with medical clinics or hospitals. In the future,

as sustainment brigades face establishing new theaters

from the ground up, the onus will rest heavily on the

medical support command and sustainment brigade

medical planning sections to ensure adequate medical

services for sustainment brigade personnel moving

into theater. As early setup of the theater support

structure is a central mission of the sustainment

brigade, future leaders must plan carefully for medical

support of the early forward logistical teams.

Otherwise, level I and II medical care for sustainment

brigade Soldiers, especially in the phases before the

deployment of BCTs, will be absent.

In Iraq, the medical support command (known as the

Medical Task Force) operates independently from the

sustainment brigades with a separate command

structure. Health care for sustainment brigade Soldiers

in each region evolved differently based on

surrounding resources. The 82nd sustainment brigade

in Southern Iraq (FOB Talill) obtains level I and II

care from a neighboring BCT, the 45th Sustainment

Brigade in Northern Iraq (FOB Qwest) provides level I

and II area medical support for personnel on their

FOB, with the augmentation of laboratory and x-ray

technicians and one medical provider provided by the

medical support command. The 15th Sustainment

Brigade in Central Iraq (FOB Taji) operates a level I

medical clinic providing care for 2 battalions of the

sustainment brigade using only the organic assets of

the headquarters medical platoon while relying on

level II assets of the local BCTs. Three additional

Figure 3. Each infantry battalion in a brigade combat team has

a medical platoon to provide level I care (sick call, emergency,

acute trauma care) to the battalion Soldiers. Each ambulance

team has either 2 or 3 medics, depending on the transport

vehicles. The combat medic section provides one combat

medic per infantry platoon throughout the battalion.

Evacuation

Section

INFANTRY BATTALION MEDICAL PLATOON

Headquarters

Treatment Squad

1 Physician

1 Physician

Assistant

2 Medical

Sergeants

4 Medics

Combat Medic

Section

Ambulance Squad

Ambulance Team

Ambulance Team

Ambulance Squad

Ambulance Team

Ambulance Team

Ambulance Squad

Ambulance Team

Ambulance Team
62 Army Medical Department Journal

battalions of the 15th Sustainment Brigade operating

out of different FOBs and receive medical care at

collocated BCTs or from the area support medical

company, an element of the medical support

command.

There are unique challenges facing the sustainment

brigades in Iraq. The 45th Sustainment Brigade’s

medical platoon, while augmented by the medical

support command, has a significantly leaner staffing

than a BCT medical company’s level II facility.

Comparing only medical providers, in this instance, a

BCT with a similar mission in theater would have an

additional physician and physician assistant to care for

the same patient population. The 15th Sustainment

Brigade has half a brigade of Soldiers located

throughout Iraq without imbedded organic medical

personnel. Tracking illness trends, evaluating

environmental and health threats, and providing the

full spectrum of health oversight to these units, all of

which are the responsibility of the surgeon section, are

difficult without onsite medical assets within the

brigade and battalion command structure.

CONCLUSION AND RECOMMENDATIONS FOR

THE FUTURE

Outlining the role of the sustainment brigade in area

medical support and the definition of assets to care for

sustainment brigade Soldiers are still works in

progress. While the new sustainment brigade may

share many of the logistics and supply responsibilities

of the former DISCOM, it shed all but a skeleton of

medical assets during transformation. The sustainment

brigade’s reliance on outside elements to provide its

Soldiers and customers medical support is somewhat

counterintuitive. Modularity of medical assets must

evolve to coordinate with the sustainment brigade and

effectively fill in the gaps.

A central concept of combat health support is the

maintenance of an operational force in a deployed

setting. For a population as large as that of the

sustainment brigade in theater, such responsibility

should be assumed by medical providers and support

personnel internal to the brigade. Level II medical

capabilities should be under the operational command

and control of the brigade commander and surgeon

section when the sustainment brigade moves into

theater. Medical care for the thousands of Soldiers in

the sustainment brigade cannot be adequately provided

by units that do not have a direct interest in health care

trends of the sustainment brigade. Additional slices of

medical care provided by the medical support

command should be attached to the sustainment

brigade on a ratio that models the BCT medical

organization.

REFERENCES

1. Field Manual 4-93.2 The Sustainment Brigade.

Washington, DC: US Dept of the Army. In draft.

2. Field Manual 4-02.4 Medical Platoon Leader’s

Handbook Tactics, Techniques and Procedures.

Washington, DC: US Dept of the Army; 18

December 2003.

3. Field Manual 4-02.21: Division and Brigade

Surgeons' Handbook (Digitized); Tactics,

Techniques, and Procedures. Washington, DC: US

Dept of the Army; 28 August 2000.

4. Field Manual 3-21.21 The Stryker Brigade Combat

Team Infantry Battalion. Washington, DC: US Dept

of the Army; 8 April 2003.

AUTHOR

MAJ Hartstein is the Brigade Surgeon of the 15th

Sustainment Brigade at Camp Taji, Iraq.

Medical Care in the Sustainment Brigade
January – March 2007 63

Evidence-Based Medicine: The Way to

Cost-Effective, Quality Medical Care

COL Herman J. Barthel, MC, USA

The Declaration of Independence highlights the key

enduring principles for all Americans—Life, Liberty,

and the Pursuit of Happiness. These enduring

principles set the foundation for the basic rights and

expectations of all US citizens. Americans want and

deserve a healthcare system that ensures quality

medical care that is both accessible and affordable.

What they now have is a disorganized and

unsustainable system with increasingly serious

problems of access, cost, and quality. In 2005, the

United States spent $1.9 trillion (16% of the gross

domestic product (GDP)) on medical care, and it is

expected to spend $4.0 trillion (20% of the GDP) in

2015.1 Can Americans afford this rising cost? Already

an estimated 45 million people (15% of the

population) are uninsured in the United States. Getting

control of the healthcare system is crucial to national

security, especially in today’s environment of

volatility, uncertainty, complexity, and ambiguity.

President Bush stated in his 2006 State of the Union

Address, “Keeping America competitive requires

affordable health care...for all Americans, we must

confront the rising cost of care...”2 The US healthcare

system is transitioning into evidence-based medicine

(EBM), in which good evidence is used to stimulate

effective performance by providers and organizations.

This paper focuses on the utilization of EBM as a

strategy to ensure high-quality, cost-effective medical

care in an effort to reverse the momentum of ever

rising costs.

BACKGROUND

The US healthcare system has been proclaimed as the

best in the world. The advancements in technology,

pharmaceuticals, procedures, and integration of the

industry have led the world. However, has all of this

guaranteed the best care in the world? The United

States has by far the world’s most expensive health

care system, based on health expenditures per capita

and on total expenditures as a percentage of GDP.

According to data from the Organization for Economic

Cooperation and Development (OECD), per capita

health spending was about 21⁄2 times the OECD

median, and health spending as a percentage of GDP

was twice the median for the 29 member OECD

countries.3In 2000, the World Health Organization

(WHO) released a report which stated that a good

health system is based on good health, fairness in

financing, and responsiveness. In spite of the massive

spending on health care, the US does not rank number

one overall in the world. With regards to good health,

the US infant mortality rate of 7.0 deaths/1,000 live

births was higher than the mean rate of 6.1 for OECD

countries, and the US disability-adjusted life

expectancy ranks 24th of the 29 members.4 The US

ranked the lowest of the OECD countries with regard

to fairness in financing, a measurement of the degree

in which financial contributions to the health system

are distributed equitably across the population.

According to the WHO, the United States and South

Africa are the only 2 countries in the developed world

that do not provide health care for all citizens.5In

contrast, the US health system ranked number one of

the OECD countries in responsiveness, the extent to

which caregivers are responsive to patient

expectations.

As evidenced by the WHO good health system report,

American patients do feel that their caregivers are

responsive to their expectations. Lamm stated that,

“The doctor-patient relationship is the most important

perspective in health care. It is a healing perspective,

concentrating on the patient, focusing modern skills in

a 2,000 year-old tradition that makes the doctor

advocate a fiduciary, healer, and confidant for the

patient.”6 The physician is the key to helping resolve

the ever-increasing cost of health care in the US.

Patients trust their physicians, and physicians

determine what therapies and interventions are

necessary for their patients. Physicians have been

trained to offer their patients the best medicine has to

offer, no matter the cost. Even though the year 2000
64 Army Medical Department Journal

Evidence-Based Medicine: The Way to Cost Effective, Quality Medical Care

US standard for medical care is good and is practiced

by most of the world at a lower cost, the US standard

for medical care in the year 2006 is better and more

expensive. The cost of new therapies, medications, and

procedures are always more expensive when they are

first introduced, due to the added research and

development cost, but is it that much better for

outcomes? Physicians are caught between being

patient advocates in providing the best quality medical

care, and being cost-effective for the payers

(government, employers, taxpayers, individuals, and

insurance and managed care companies).

WHAT IS EVIDENCE-BASED MEDICINE?

A tool available to physicians to provide high quality

and cost-effective medical care is EBM. Philosophical

origins of EBM extend to mid-19th century Paris. It

was given its brand name in 1992 by a medical group

at Canada’s McMaster University which taught

medical students the new paradigm.7 EBM is defined

as “the conscientious, explicit, and judicious use of

current best evidence in making decisions about the

care of individual patients.”8 This concept gives new

vigor to the long-established principle that health care

should be based on solid scientific evidence, rather

than on tradition and uncontrolled clinical experience.

The physician must balance research evidence with

their knowledge, judgment, and experience to the

uniquely different individual needs of their patients.

Without current best evidence, practice risks become

rapidly out of date and can adversely affect the patient.

The pursuit of EBM is at the center for improvement

of health care in the United States. Quality

measurement systems use science-based indicators to

evaluate proper processes of patient care. For example,

the ORYXTM measurement requirements of the Joint

Commission on Accreditation of Health Care

Organizations, the Health Employer Data and

Information Sets (measures of the National Committee

on Quality Assurance), and the Quality Improvement

Organizations for the Centers for Medicare and

Medicaid Services all use science-based indicators.9

Medical journals and continued medical education

conferences utilize EBM through a strength-ofrecommendation (SORT) process. The SORT gives

grades for the effectiveness and quality of evidence to

support the recommendation for treatment or therapy.10

The volume of scientific research and medical journals

is overwhelming. It was recently estimated that

physicians would need 627.5 hours just to read the

7,287 journal articles that are published each month.11

However, there are several web-based EBM tools

available for physicians to quickly find the latest

recommendations.12

Although EBM gives physicians solid scientific

evidence on which to base their clinical decisions, it is

not “cook-book” medicine. Even so, EBM does reduce

the variation of the medical care delivered to patients

across the country. Physicians fear that the “art of

medicine” will be lost with the “science of medicine”

provided by EBM. Physicians still must listen to the

needs and values of their patients. Both the art and

science of medicine can be balanced to achieve

successful outcomes that provide cost-effective,

quality health care.

EFFECTIVE EBM STRATEGIES TO LOWER

HEALTH CARE COST

The diverse healthcare industry offers plenty of

opportunities to lower the cost of medicine. EBM

offers 3 cost-effective strategies to lower the overall

cost of health care:

 Less costly or is cost-saving with an equal or

better outcome, or

 More effective and more costly, with the added

benefit worth the added cost, or

 Less effective and less costly, with the added

benefit of the alternative not worth the added

cost.13

The following paragraphs describe 5 key examples of

how EBM can provide cost-effective health care with a

reduction in overall cost.

Southeast Regional Medical Command (SERMC)

Profit and Loss Reimbursement Model

SERMC has led the Army Medical Department

(AMEDD) with an innovative Profit and Loss

Reimbursement Model that rewards productivity and

outcomes based on EBM with financial incentives.

Results have shown improvement in clinical processes

and outcomes through accurate care rendered,

enhanced workload recorded, and care documented in

the electronic medical record (EMR). The goals

established by EBM for mammograms, pap smears,

diabetic HbA1C and retinal exams, and asthma with

controller medications have led to improved cost-
January – March 2007 65

effective continuity of care and population health. In

addition, SERMC hospitals are given financial

incentives up to $6 million based on outcomes and

performance productivity. This successful model will

be incorporated throughout the AMEDD in FY07.

Disease Management Programs

The use of EBM with outpatient disease management

programs has been extensive and has led to costeffective health care. Smoking, obesity, and diabetes

account for over 1 million deaths annually in the

United States, and over $270 billion in direct and

indirect medical costs.14 Physician advocates leading

multidisciplinary teams have implemented effective

EBM programs targeting obesity, asthma, diabetes,

hypertension, chronic pain, and high cholesterol.

Results have shown reductions in hospital admissions

and cost savings, and have documented a decrease in

the progression of the respective diseases.

Leapfrog Group

The Leapfrog Group* identified 3 initial patient safety

practices (leaps) accompanied by EBM to benefit

patients and to provide cost-effective health care in the

medical arena.15 These 3 safety practices are EMR

physician ordering, intensivist physician staffing (IPS)

of intensive care units, and EBM hospital referrals.

The results of EMR use showed a reduction in medical

errors, adverse drug effects, length of stays (LOS),

morbidity, mortality, and more cost-effective

utilization of medication. If EMR were fully

implemented, hospitals would save an estimated $1.5

billion annually. In addition, IPS initiatives would

result in an annual savings of over 54,000 lives with an

additional cost savings of nearly $16.5 billion. These

savings were achieved through a decrease in LOS,

productivity benefits through EBM, and lower error

rates. Finally, EBM hospital referrals would save

nearly $10 billion annually. All three of these

measures incorporate EBM and lead to cost-effective

and high quality medical care with great outcomes.

100K Lives Campaign

The 100K Lives Campaign†involves over 3,000

hospitals with the goal to avoid the nearly 100,000

annual deaths from medical injuries and 2 million

hospital acquired infections.16 It has been very

successful in reducing deaths and morbidity. The

campaign focuses on 6 EBM changes to avoid hospital

deaths: rapid response teams, acute myocardial

infarction care, prevent adverse drug events, prevent

central line infections, prevent surgical site infections,

and prevent ventilator-associated pneumonia.

Additionally, these fully implemented initiatives will

lead to a decrease in the 1% of US GDP that is spent

on ICU medical care.17

Combination of EBM with EMR

The combination of EMR and EBM has shown

promising results. Hieb stated that the benefit of this

combination leads to improved reporting, costeffective care, reduced medical errors, improved

patient satisfaction, and competitive advantage.18 This

fusion has led to physicians developing case

management protocols, decision support sets, provider

order sets, and workflows that provide quality medical

care. In addition, the high administrative cost of health

care (26%) has been reduced. The Rand Corporation

has shown that an implementation goal of having EMR

in 90% of hospitals and doctors offices will require an

annual cost of $8 billion for 15 years.19 Furthermore,

the combination with EBM will lead to annual

efficiency savings of more than $77 billion after an

accumulated benefit of $500 billion in 15 years.

IMPLICATIONS OF EBM AND RISING HEALTH

CARE COSTS ON NATIONAL SECURITY

The United States spreads its influence, prosperity, and

democracy throughout the world through its 4

instruments of national power—diplomacy,

information, military, and economy (DIME). The

military and economic components of the DIME are

the 2 most important instruments to ensure both the

national security and vital interests of the United

States. Moreover, these 2 instruments are the most

vulnerable to a healthcare system that is absorbing a

bigger percentage of the GDP and federal budget.

Currently, the government pays the bill for 60% of the

overall healthcare cost in the US.1In the next 10 years,

two major factors will affect the DIME and the cost of

health care, the aging “baby boomer” population, and

the rising cost of the Department of Defense (DoD)

health care. These factors will have an enormous

impact on our national security.

First, the aging baby boomer population of 77 million

will lead Medicare and Medicaid growth from 25% of

all healthcare spending in 1965 to 49% in 2014.1 This

*Available at: http://www.leapfroggroup.org/home

†Available at: http://www.ihi.org/IHI/Programs/Campaign
66 Army Medical Department Journal

Evidence-Based Medicine: The Way to Cost Effective, Quality Medical Care

will impose astounding costs for all taxpayers and the

federal government. In order to pay the bill, the

government will have to draw from other areas of the

budget—education, infrastructure, and defense. Health

care as a percentage of GDP in 1960 was 6%, as was

defense and education.6In 2005, health care grew to

16% of the GDP while education remained at 6% and

DoD dropped to 4%. Can Americans continue to

absorb this rise in cost? Will they want to continue to

pay for it in the years to come? Time and priorities

will tell.

Finally, the impact of the cost of health care on DoD’s

budget is huge. DoD’s TRICARE cost was $19 billion

in 2001, grew to $37 billion in 2006, and is expected

to top $64 billion in 2015.20 In addition, health care

represented 4.5% of DoD’s budget in 1990 and is

projected to increase to over 12% in 2015. This will

have an impact on other DoD programs, eg, personnel,

procurement, weapon systems, operations, and

maintenance. The nation and DoD must make tough

decisions in order to ensure that the strength of the

instruments of national power are preserved. EBM

provides an effective way to curb the rising cost of

health care, and DoD has continued to lead the way in

its implementation with EMR, as evidenced by the

SERMC Profit and Loss Model.

POLICY RECOMMENDATIONS

In order to ensure the national security of the United

States and to preserve its vital interest and enduring

principles, 5 key policy recommendations are offered.

1. Develop and Assure Access to EBM

This policy is crucial to create nationwide

standards of health care based on EBM with clear

scientific evidence. This will ensure a reduction

in the variance of healthcare and provide a

common cost-effective process. In addition,

create a central web portal that is developed by

the respective professional medical societies and

directed by the government. Practical clinical

trials established by priorities from the

government will lead to improvements of costeffective medical care, quality of life, safety, and

in the delivery of healthcare services.

2. Combine EBM with EMR

The multiple results from the SERMC Profit and

Loss Model, disease management programs,

Leapfrog Group, and the 100K Lives Campaign

strongly support this recommendation. This is a

force multiplier that provides safe, effective,

quality health care with the addition of significant

health care cost savings. This policy will ensure

that multidisciplinary teams and physician

champions create order sets, management tools,

and outcome measurements which will lead to an

overall reduction of medical errors. The

investment by the US government and the

healthcare industry will definitely pay off.

3. Ensure an Adequate Number of Primary Care

“Gatekeepers”

These providers are the portal for entry of

patients into the healthcare system. In

combination with EBM, available gatekeepers

have been shown to be the most cost-effective

source of medical care. Patients are referred to

specialists based on EBM criteria. This system

works very well for Kaiser Permanente and

countries with universal health care. The OECD

studies have demonstrated that other western

countries have better outcomes with a lower per

capita spending on health care. This system must

be tied into ensuring medical care for everyone in

the United States, not just covering everything

medicine has to offer. Furthermore, the primary

care providers must emphasize and monitor EBM

preventive medicine practices in the population.

This will result in cumulative cost savings with a

healthier population.

4. Align Incentives and Rewards for Improvement

Incentives are key to continued success and

implementation of EBM into everyday practice.

Outcome and utilization measurements must be

aligned with documented results. This will lead to

a limitation of procedures that are ineffective or

marginally effective with resulting cost savings.

Also, this can be extended to the patient

population by rewarding good health practices

(ideal body weight, no smoking, aerobic

conditioning, etc) In addition, rewarding

providers, hospitals, and healthcare organizations

for building system improvements (EBM, EMR,

etc) are keys for success.

5. Use the Government to Facilitate and

Collaborate the Pursuit of the Other 4 Policies

The government has the “power of the payor,” in

that it pays 60% of the healthcare costs in the
January – March 2007 67

United States. Accordingly, it can direct change

in the system with financial incentives and

processes. The government can subsidize

research and development of the systems and

dissemination of the information, and establish

practice standards and priorities with an

implementation timeline. Also, it can institute tax

policy changes that make health care more

affordable by shaping and supporting the market.

This can be achieved through insurance subsidies,

expansion of the health savings and flexible

savings accounts, decreasing administrative

bureaucracy, and increasing patient cost sharing.

The government must promote the education of

healthcare consumers on preventive, self-care,

and cost-effective health care. Finally, it must

promote the synergy of public and private sectors

and build upon the gains and foundation of EBM.

Incorporation of all 5 of the recommended policies

will ensure success for the patient, the healthcare

industry, and the government.

CONCLUSION

As the strategy of EBM becomes more incorporated in

everyday practice, the better the outcomes are for

patients and the lower the healthcare costs are for the

nation. In addition, EBM has consistently shown

improvements in patient safety, quality of life, and in

the deliverance of cost-effective health care. These

improvements are essential to maintaining the national

security and to protecting the vital interests of the

United States through the DIME instruments of

national power. Consequently, implementation of the 5

policy recommendations for EBM will ensure that the

enduring principles of the United States—Life,

Liberty, and the Pursuit of Happiness—are preserved

for all Americans.

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Evidence-Based Medicine: The Way to Cost Effective, Quality Medical Care

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AUTHOR

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