DISMOUNTED COMPLEX BLAST INJURY 

REPORT OF THE ARMY DISMOUNTED COMPLEX 

BLAST INJURY TASK FORCE 

Prepared by the Dismounted Complex Blast Injury Task Force 

For The Army Surgeon General 

Fort Sam Houston, TX 

18 June 2011 

i 

EXECUTIVE SUMMARY

“Dismounted Complex Blast Injury” 

(DCBI) is an explosion-induced battle injury (BI) sustained by a warfighter on foot 

patrol that produces a specific pattern of 

wounds. In particular, it involves traumatic 

amputation of at least one leg, a minimum 

of severe injury to another extremity, and 

pelvic, abdominal, or urogenital wounding. 

The incidence of dismounted complex blast 

injuries has increased during the last 15 

months of combat in the Afghanistan Theater of Operations (ATO). The number of 

Service Members with triple limb amputation has nearly doubled this past year from 

the sum of all those seen over the last eight 

years of combat. The number of genital 

injuries increased significantly from previous OIF rates. 

The US Army Surgeon General (SG) appointed a task force to study the causation, 

prevention, protection, treatment, and longterm care options of this BI pattern. The 

Task Force was comprised of clinical and 

operational medical experts from the Departments of Defense (DoD) and Veterans 

Affairs (VA) and solicited input from subject matter experts in both Federal and civilian sectors. 

This report will look at current candidates 

for “best practice” designation for prevention, mitigation, or treatment of dismounted 

complex blast injuries. It will address opportunities for intervention from the POI to 

long-term rehabilitation. The Task Force 

will address a systematic approach to this 

problem set from a medical perspective, 

using the Doctrine, Organization, Training, 

Materiel, Leadership, Personnel, Facilities 

and Contracting (DOTMLPF-C) approach, 

followed by specific recommendations for 

the way forward. 

This Task Force first undertook to describe 

what constitutes a complex injury. After 

nearly a decade of war in two theaters, 

marked by severe burns, traumatic brain injury, and extremity injuries, what makes 

this pattern different? Both line and medical communities have noted the combination of high thigh amputations with genital 

injury associated with dismounted patrolling. In a significant subpopulation, the 

casualties sustained double and triple limb 

amputations. 

The severity of these injuries presents new 

challenges to the medical and military 

communities to prevent, protect, mitigate 

and treat. This Task Force has an obligation to assess whether we are effectively 

managing the immediate-, near-, and longterm healthcare needs required by these 

Wounded Warriors, as well as those expected by his/her Family and loved ones. 

Battle injuries (BIs) were at an all-time 

high in the Iraq Theater of Operations 

(ITO) during the troop surge and associated 

fighting in 2007. In 2008, the ATO 

monthly BIs exceeded that seen in the ITO, 

and the associated trend lines have continued to diverge. 

The ATO BI severity scores have increased 

steadily since 2006. The number of extremity injuries, to include major amputations—the major focus of this Task Force—

has exceeded that seen within the ITO at 

any point. 

These trends reflect the tactical requirement 

for dismounted battle in the face of groundemplaced improvised explosive devices 

(IEDs) and land mines. 

Among those with lower extremity injuries 

we are seeing a significant proportion with 

associated genitourinary (GU) injuries—

both internal and external—along with other pelvic, intra-abdominal, and spinal injuries. TBI co-morbidity adds yet another 

layer of complexity to some patients with 

DCBI. It is beyond the scope of this Task 
ii 

Force to identify associated post-traumatic 

stress, although an increase is plausible. 

The dismounted Warrior is at greater risk 

for severe injuries from IEDs, and the injury severity from the ATO since 2006 confirms this. The died of wounds (DOW) rate 

has been constant and we have seen a corresponding drop in the case fatality rate 

(CFR) and killed in action (KIA) rates over 

the eight years preceding 2010. (Definitions on Page 7). 

Altogether, this suggests our warfighters at 

the point of injury (POI)—Marines, 

Corpsmen, Soldiers and Medics, alike—are 

better able to keep Warriors alive in spite 

of increasingly severe wounds. Current 

personal protective equipment (PPE) has 

mitigated head, eye and torso injuries drastically. Well-designed and heavily protected vehicles provide the mounted Warrior superior protection against roadside 

explosive devices. Extensive burn injuries 

among mounted Warriors, more common 

early in the wars, have nearly disappeared. 

Extremities, therefore, are at greatest risk 

for complex blast injuries, especially 

among dismounted Warriors. To appreciate 

the burden of these injuries, for every major amputation (i.e., from the wrist or ankle 

and higher), we have encountered approximately four additional casualties with severe extremity injuries. For every seven of 

these individuals with mangled limbs and 

who undergo limb salvage efforts, one will 

ultimately undergo a late amputation (i.e., 

between 90 days and as late as five years 

following the initial injury). 

Evidence from the US Army Institute of 

Surgical Research (ISR) suggests that these 

severely injured casualties survive due to 

the immediate application of extremity 

tourniquets by first responders. 

The concept of Tactical Combat Casualty 

Care (TCCC) which emphasizes primary 

hemorrhage control in the tactical setting 

effectively replaced the resuscitation mantra of “A-B-C” for “Airway-BreathingCirculation.” Lives are saved when massive hemorrhage is controlled promptly. 

Once a Wounded Warrior can get to a 

surgeon, his/her chances of survival increase significantly. DoD made significant 

advances in the field of resuscitation and 

trauma surgery in the current operations, 

many of which have been adopted by civilian medicine. 

Of note, the advances were made with great 

attention to scientific rigor, so outcome 

measures could be tied to specific interventions. The Surgeons General of the Army, 

Navy, and Air Force have resourced the 

analysis of battlefield healthcare in order to 

allow documentation and measurement of 

our interventions throughout the wars. 

Current evidence-based best practices include the development and implementation 

of a formal military trauma system; aggressive tourniquet use; early use of fresh 

whole blood and blood products; hypothermia prevention and management; damage 

control resuscitation and surgery; rapid 

strategic evacuation (STRATEVAC); comprehensive and multidisciplinary approaches to pain management, and rehabilitation. 

Further refinement and implementation are 

required in: aggressive pain management at 

the POI; advanced-level medical staff 

aboard rotary wing (RW) evacuation platforms; consistent control of core body temperature; use of blood products—including 

plasma—within one hour of severe hemorrhage, oftentimes at the POI when delivered 

by RW assets; placement of a urologist at a 

Role III facility to address GU injuries; 

greater spiritual involvement in the healing 

process for both the Wounded Warrior and 

his/her loved ones once in CONUS; and 

widespread recognition within the Service 

Medical Departments and medical treatment 

facility (MTF) leadership of the extensive 

personnel, equipment, and operating room 

resources essential for definitive care of 

these severely injured Warriors. 
iii 

With advances in rehabilitation, prosthetic 

care, robotics and assistive technology, 

most of our Warriors with major limb loss 

envision a future for themselves that can be 

full and rewarding. The Warrior with highlevel lower extremity major limb loss will 

have greater rehabilitative challenges related to both the extremity and GU injuries 

spanning the physical, emotional, social, 

Family, and spiritual domains. 

Organizational alignment between agencies 

tasked to protect our Warriors in combat 

will be required. The medical community 

needs a proactive multi-disciplinary surveillance system that can generate the 

proper notifications and actions in response 

to early trends. Line unit liaison officers 

(LNOs) within the medical community will 

ease information and intelligence sharing, 

where appropriate to help facilitate improvements in Warrior tactics, techniques 

and procedures (TTPs) and PPE. 

Finally, the Task Force applauds the aggressive medical advances made on behalf 

of the Warriors in harm’s way. The 

envelope has been pushed, but within the 

constraints of medical science. 

This latter point is important. Without 

scientific rigor, we are collecting anecdotes, Warriors are left with marked variability in their care, and questions from the 

American public as to the benefits provided 

would certainly arise. 

The most important takeaway from this report is that our Warriors and their Families 

can trust our military medical community to 

provide absolutely everything possible to 

help them overcome any injury through a 

whole-person approach to healing. Our 

goal is to address the cognitive, emotional, 

spiritual, and physical aspects to our 

wounded Warriors’ sense of personhood, as 

well as on their social and environmental 

accessibility. 

The Task Force wishes to thank The Surgeon General and Commanding General of the 

US Army Medical Command, LTG (Dr.) 

Eric Schoomaker, the Vice Chief of Staff of 

the Army, GEN Peter Chiarelli, and the 

Commandant of the US Marine Corps, Gen. 

James Amos, for their personal guidance 

that assisted me and my team through this 

process. These officers and senior leaders 

like them possess not only the vision, but 

the deep-seated compassion for our Warriors. I am also grateful for the valuable 

comments and recommendations for this 

report from our Sister Services’ medical 

leadership, namely, Maj Gen Thomas Travis, the Air Force Deputy Surgeon General, 

and RDML Michael Anderson, the Medical 

Officer to the Marine Corps. I certainly 

appreciate that everyone is doing all within 

their power to keep our Warriors from being injured, but if they are injured, we want 

to ensure we expend every effort to help 

each and every one reach their maximum 

potential. 

This report expresses the views of the 

author and the DCBI Task Force, alone. It 

does not necessarily reflect the views of the 

Army’s Office of The Surgeon General, the 

United States Army Medical Command, the 

United States Army, Navy Medicine, the 

United States Navy, the United States 

Marine Corps, Air Force Medicine, the 

United States Air Force, or the Defense 

Department.

Joseph Caravalho, Jr., M.D. 

Brigadier General, US Army 

Chair, DCBI Task Force 

18 June 2011
iv 

CONTENTS 

Executive Summary .................................................................................................... i

Contents .................................................................................................................... iv

Overview .................................................................................................................... 1

Defining the Problem ................................................................................................. 3

Historical Army Perspective .......................................................................................................... 3

Background .................................................................................................................................. 4

Analysis ...................................................................................................................... 7

Burden of Injury............................................................................................................................ 7

Definitions................................................................................................................................ 7

Preventable Deaths ...................................................................................................................... 8

Incidence of Battle Injuries ........................................................................................................... 9

Improving Survivability............................................................................................................... 12

Massive Transfusion ................................................................................................................... 13

Primary Mechanisms of Amputation ........................................................................................... 13

Associated Genitourinary Injuries ............................................................................................... 16

Associated Traumatic Brain Injury .............................................................................................. 16

Current Practice ....................................................................................................... 18

Pre‐Hospital Care........................................................................................................................ 18

Best Practices in Pre‐Hospital Care ......................................................................................... 18

Challenges and Issues in Pre‐Hospital Care ............................................................................. 19

Rotary Wing Evacuation .............................................................................................................. 21

Best Practices in Rotary Wing Evacuation ............................................................................... 22

Challenges and Issues within Rotary Wing Evacuation ............................................................ 22

Role II/III:  Acute Resuscitation................................................................................................... 24

Best Practices in Acute Resuscitation...................................................................................... 24

Challenges and Issues within Acute Resuscitation ................................................................... 25

Role IV/V:  Definitive Care and Rehabilitation ............................................................................ 27

Best Practices in Definitive Care and Rehabilitation................................................................ 27
v 

Challenges and Issues within Definitive Care and Rehabilitation ............................................. 32

Whole‐Person Approach to Healing............................................................................................. 36

Protection .............................................................................................................................. 36

Urologic Considerations, Issues and Interventions .................................................................. 37

Neurological Considerations, Issues and Interventions ........................................................... 38

Psychological Considerations, Issues and Interventions .......................................................... 39

Rehabilitation Considerations, Issues and Interventions......................................................... 40

Pain Management Considerations, Issues and Interventions ................................................... 42

Spiritual Considerations, Issues and Interventions.................................................................. 43

Recommendations .................................................................................................... 44

General ...................................................................................................................................... 44

DOTMLPFC Domains.................................................................................................................... 44

Doctrine ................................................................................................................................. 44

Organization........................................................................................................................... 45

Training .................................................................................................................................. 45

Materiel ................................................................................................................................. 46

Leadership.............................................................................................................................. 46

Personnel ............................................................................................................................... 47

Facilities................................................................................................................................. 47

Contracting............................................................................................................................. 47

Conclusion ................................................................................................................ 48

Appendix A ............................................................................................................. A-1

Charter .....................................................................................................................................A-1

Information Paper to VCSA .......................................................................................................A-4

Appendix B ............................................................................................................. B-1

Key References (Alphabetical Order):........................................................................................B-1

Appendix C ............................................................................................................. C-1

Definitions................................................................................................................................C-1

Appendix D ............................................................................................................. D-1

CoTCCC Research Priorities (November 2011) ............................................................................D-1
vi 

Appendix E ............................................................................................................. E-1

Action Plan ............................................................................................................................... E-1

Casualty Evacuation.............................................................................................................. E-1

Joint Theater Trauma System................................................................................................ E-1

Injury Severity Scores ........................................................................................................... E-2

Pre‐Deployment Training ...................................................................................................... E-2

Medical Organization and Configuration ............................................................................... E-3

Medical Equipment............................................................................................................... E-3

Medical Documentation........................................................................................................ E-3

Clinical Research .................................................................................................................. E-4

Pain Management................................................................................................................. E-4

Spiritual Care........................................................................................................................ E-4

Behavioral Health ................................................................................................................. E-4

Appendix F ............................................................................................................. F-1

JTTS Clinical Practice Guideline:  Management of High Bilateral Amputations .......................... F-1

Appendix G ............................................................................................................ G-1

DCBI Task Force Membership ....................................................................................................G-1

Appendix H ............................................................................................................ H-1

DCBI Task Force Contributors....................................................................................................H-1

Appendix I ............................................................................................................... I-1

Glossary of Acronyms ................................................................................................................ I-1
1 

OVERVIEW 

In 2009-2010, the Joint Theater Trauma 

System (JTTS) identified the reversing BI 

trend between the two combat theaters. In 

2010, BIs from the Iraq Theater of Operations (ITO) declined to near-zero, with a 

corresponding rise in BIs from the ATO. 

Though still only a very small percentage 

of troops on the ground, and fewer than that 

seen during the ITO surge in 2007, the 

ATO experienced a significant relative rise 

in overall BI. Among these casualties, 

some were due to ground-emplaced IED 

blasts on dismounted patrols. Through the 

summer and fall of 2010, peaking in October, the JTTS identified a new trend of devastating injuries characterized primarily 

by high lower extremity amputations, pelvic and genital injuries, and spine injuries. 

While absolute numbers are low, the rates 

of these injuries in the last half of 2010 

demonstrated a continuous rise. 

With this apparent injury pattern change, 

The Army SG appointed a task force to further define and analyze the problem, with a 

charter to characterize the phenomenon, 

identify the cause, and recommend the 

medical way forward. 

Injury from IEDs and land mines has been a 

realistic threat for these Warriors, and they 

took every measure they could to eliminate 

these risks. Units developed tactics, techniques and procedures (TTPs) to mitigate 

IED exposure, but the explosions could not 

be eliminated completely. Utilization of 

the current generation of mine-resistant armor-protected (MRAP) vehicles was constrained by terrain. The surge in the ATO 

addressed the need to hold terrain once 

cleared. In support of this need, newer, 

more mobile MRAP vehicles—the MATV 

(MRAP–All Terrain Vehicle)—adapted for 

the Afghanistan terrain are being introduced into the ATO to decrease the need 

for dismounted patrols. The Stryker program is introducing a new double-V hull 

that should improve defeat of IEDs. Organizations such as Joint IED Defeat Organization (JIEDDO) are researching ways to 

eliminate the threat of IEDs in both theaters 

of operation. Dismounted patrols required 

TTP changes to minimize IED exposure. 

Traumatic battlefield amputations were not 

uncommon, but Warriors knew of the prosthetic care and rehabilitation advances at 

facilities such as the Military Advanced 

Training Center in Washington, DC, the 

Center for the Intrepid (CFI) at Fort Sam 

Houston, TX, and the Comprehensive Combat Casualty Care Center (C5) at Balboa 

Naval Medical Center in San Diego, CA. 

However, the increased rate of double and 

triple amputees, coupled with pelvic and 

genital injuries, represented a new level of 

injury to overcome. Devastating injuries of 

the kind just described took their toll on 

unit morale. To some, the resultant burden 

on their Family and loved ones seemed too 

much to accept, and, anecdotally, some actually developed “do not resuscitate” pacts 

with their battle buddies in the event of this 

type of injury. 

The Army SG took the step of creating a 

dedicated task force to address the 

following questions: Is there an actual or 

perceived increased incidence of these 

complex injury patterns? If actual, does it 

reflect an increase in the number of 

casualties generated? Alternatively, are a 

greater number of IED blast victims 

surviving these horrific wounds? 

Regardless of causation, can we improve 

medical and surgical management of these 

victims throughout their spectrum of care—

from the POI to long-term rehabilitation 

and reintegration into the force or society? 

What is the way forward to prevent, protect, or mitigate ground-emplaced IED 

blasts to dismounted patrols? Are we doing 

everything possible to manage, treat, and 

care for the whole Warrior and his/her 
2 

Family through the recovery, rehabilitation 

and long-term care following these devastating injuries? Are we addressing the 

physical, cognitive, emotional and spiritual 

domains fully? 

Are there statutes, Departmental policies or 

regulations, directives or guidance that can 

better address unforeseen challenges to this 

population of Warriors? Finally, are our 

Warriors aware of the significant medical 

advances that may allow even these types 

of severe injuries to return to duty as a Service Member, or contribute as a fully integrated member of society? How can we 

demonstrate these capabilities to every 

Warrior and his/her Family before deployment? Following a brief overview, the first 

of four sections will characterize the injury 

we refer to as “dismounted complex blast 

injury.” The second provides data and 

analysis. The third section presents current 

practices, highlighting the successes and 

challenges within the phases of evacuation 

and treatment. Also addressed is the 

“whole person” approach, focusing on multimodal pain management, urologic reconstruction, rehabilitation, neurological, psychological, and spiritual aspects of healing. 

The fourth section of recommendations lists 

each under the appropriate domain, using 

the Doctrine, Organization, Training, Materiel, Leadership, Personnel, Facilities and 

Contracting (DOTMLPF-C) approach. 

Following the conclusion, there are a number of appendices to support this report, 

including an action plan to facilitate tracking of recommendations approved for action. 

Figure 1. Definitive reconstruction requires extensive resources: three surgical teams; multiple operating room 

events, and prolonged rehabilitation.
3 

DEFINING THE PROBLEM 

HISTORICAL ARMY 

PERSPECTIVE 

As military battlefield technologies change 

and increase in complexity, so do the injuries they produce and the medical interventions employed to counter their impact. 

The observational and reasoning skills of 

Ambroise Paré, a surgeon serving with the 

French Army near Turin in 1537, led him to 

conclude that gunshot wounds were not 

poisoned by gunpowder and, therefore, 

boiling oil need not be part of therapy. He 

also observed how these unburned tissues 

healed more readily and were more amenable to surgical sewing to stem blood loss, a 

technique he pioneered on the battlefield. 

Low velocity munitions, which tended to 

mutilate the human body upon impact, provided military surgeons with ample opportunity for amputation. Whether to perform 

a primary amputation immediately after injury or wait until the patient had recovered 

from the initial shock of trauma (secondary 

amputation) was a point of contention for 

French, German, and British military 

surgeons through the 18th century. 

The wars of the French Revolution and early Napoleonic Era convinced Dominique 

Jean Larrey, Surgeon to Napoleon’s Imperial Guard, that primary amputation was 

imperative in the unsalvageable limb. Larrey also invented and employed the Flying 

Ambulance on the battlefield to bring the 

wounded and surgeons together more rapidly. By the time of our Civil War, ether and 

chloroform anesthesia and an efficient 

tourniquet had improved the surgical art 

somewhat. Surgeon General Hammond 

recognized the value of collecting and 

studying wartime injuries and diseases to 

improve future outcomes. He founded the 

Army Medical Museum to study war injuries and directed the publication of the 

Medical and Surgical History of the War of 

the Rebellion. Hammond also assigned Major Jonathan Letterman as Medical Director 

to a medically-disorganized Army of the 

Potomac in summer 1862. Over the next 

six months, Letterman brought reorganization and efficiency to battlefield surgical 

care, tactical and strategic evacuation, distribution of supplies, and standards of practice which were instituted Army-wide by 

1864. 

By the late 1890s, higher velocity munitions combined with bacteriology, safer 

anesthetic control, the x-ray machine, and 

the advent of the modern combat medic to 

change the production and treatment of BIs. 

Surgeon General George Sternberg, founder 

of the Army Post-Graduate Medical School, 

where current standard of care was taught, 

told his medical officers this represented 

greater battlefield survival, and that the 

days of dying from surgical intervention 

were over. The modern era of battlefield 

care had arrived. 

In WWI, British and US Army medical officers made inroads into the mysteries of 

shock, hypotension, volume replacement, 

and demonstrated that whole blood could be 

administered in forward areas. Surgical 

principles of wound excision, debridement 

and amputations emerged as life saving 

measures. Medical officers of the French 

Army recognized and treated battle-induced 

psychiatric injuries. Twenty years later, 

British and US medical officers would relearn these lessons of WWI in North Africa 

and Italy and adapt more advanced technologies to the battlefield environment. Captain Fred Hansen established forward 

treatment of what was soon called battle 

fatigue, returning 70% of those casualties 

to General Patton’s Army fighting at El 

Guettar. Captain Lyman Brewer and his 

surgical team with the 2nd Auxiliary Surgical Group designed an intermittent positive 
4 

pressure breathing apparatus, thereby allowing chest wounds to be explored in the 

field. By the summer of 1944, enclosed 

ether anesthesia systems were developed, 

fluid resuscitation solved, and American 

ingenuity brought penicillin to the battlefield. In the Technical Bulletins issued by 

the Office of the Army Surgeon General 

(OTSG), consultants previewed current data 

which led to real-time improvements in 

military medicine. 

In Korea and Vietnam, the US Army Medical Department pioneered helicopter evacuation and in the mid-1950s funded what 

would become one of the most famous aircraft in the world, the UH-1 Iroquois helicopter, as a battlefield ambulance. These 

aircraft allowed injuries to be addressed 

more rapidly by military surgeons like Major Carl Hughes, who developed forward 

repair of arterial injuries in Korea, and 

Captain Norman Rich who did the same for 

venous injury in Vietnam. 

Today in Southwestern and Western Asia, 

advances in trauma management continue. 

Under the auspices of the US Army Institute of Surgical Research (USAISR) and the 

US Army Medical Research and Materiel 

Command (MRMC), hemorrhage control 

has become the primary treatment focus 

following injury. Use of blood products, 

maintaining normal body core temperature, 

and implementation of “damage-control resuscitation and surgery” have been the 

mainstays in improving BI survival rates 

beyond that seen in any prior war. Similarly, these conflicts have been marked with 

widespread use of external fracture fixation, delayed management of mangled limb 

injuries and low amputation rates that were 

comparable to Vietnam, but with more severe injuries. 

Over the last several years, the US Army 

made tremendous advances in battlefield 

pain control with the use of multimodal 

opioid adjuncts and alternatives, new medication delivery systems, and comprehensive 

pain protocols. As a direct result, more 

complete pain relief is provided sooner after injury than was previously possible. 

The Army Regional Anesthesia and Pain 

Management Initiative, started in 2000, led 

to advances such as the first continuous peripheral nerve block used early in Operation Iraqi Freedom (OIF) and the implementation of pain pumps for use on medical 

evacuations on Air Force military aircraft. 

The SG chartered the Army Pain Management Task Force in August 2009 to make 

recommendations for a comprehensive pain 

management strategy. The resulting program is holistic, multidisciplinary, and multimodal in its approach, utilizing state of 

the art techniques and technologies. 

With the SG’s oversight, Army Medicine 

has also made significant advances in the 

field of prosthetics and robotics, extremity 

injury rehabilitation and limb salvage techniques, and regenerative medicine. 

Army medicine and the Army Medical Department have a long and rich heritage of 

real-time battlefield investigation and intervention to reduce BIs. The current wars 

are no different—new problem sets are 

identified against which significant gains 

are being made on the medical front. 

BACKGROUND 

In 2010, BIs in the ATO exceeded those in 

the ITO. The primary injury in the ATO 

often resulted from enemy contact with 

ground-emplaced IEDs and land mines. 

The injury of interest, DCBI, has increased 

significantly. A significant number of 

these injuries, but not all, were sustained by 

Warriors on dismounted patrols. 

Because the observed injuries were occurring more frequently than previously seen, 

the Army SG appointed a task force to characterize the injury and determine how to 

better manage these Warriors and Families 

from POI through physical, emotional, in-
5 

tellectual and spiritual recovery and rehabilitation. 

The Joint Theater Trauma System was established in 2004 under US Central Command to effect trauma care performance 

improvement on the battlefield to provide a 

near-real time registry of combat-related 

casualties. In addition to deploying a trauma surgeon to lead this effort downrange, 

the JTTS maintains a team of nurses and 

other healthcare providers to collect hundreds of data points on each casualty evacuated from the battlefield. These efforts 

have proven invaluable not only in adjusting efforts among medics and providers 

on the battlefield, but also in improving 

medical and surgical techniques to optimize 

outcomes amongst our casualties. 

Since its inception in 2006, the Blast Injury 

Research Program has made significant improvements in the way warfighters are protected from blast-related injuries, and in the 

way injured warfighters are treated and rehabilitated. Among many noteworthy contributions was the establishment of the 

Joint Trauma Analysis and Prevention of 

Injury in Combat (JTAPIC) Program. 

JTAPIC links the DoD medical, intelligence, operational, and materiel development communities with a common mission 

to collect, integrate, and analyze injury and 

operational data. Its goal is to improve the 

understanding of threat vulnerabilities and 

to enable the development of improved 

TTPs and materiel solutions to prevent or 

mitigate traumatic injuries. 

To accomplish this, JTAPIC partners with 

the Army National Ground Intelligence 

Center; Office of the Armed Forces Medical Examiner (OAFME); Project Manager 

Protection and Individual Equipment; Army 

Research Laboratory; Army Aeromedical 

Research Laboratory; USAISR; Army Infantry Center, Naval Health Research Center; and the Marine Corps Systems Command. 

Among casualties evacuated from POI to 

higher levels of care in 2009, there were 86 

Warriors with major limb loss, of whom 23 

had multiple amputations. By comparison, 

in 2010 there were 187 Warriors with major 

limb loss, with 72 casualties losing multiple 

limbs. 

OAFME evaluated 111 Warriors who died 

in 2010 as a result of blast injuries. Of 

these, 68 had multiple amputations, 13 had 

sustained total body fragmentations, and 

106 also had severe body injuries. This 

analysis demonstrated that death occurred 

among the Warriors with the more severe 

injuries, and nearly every case involved 

severe associated head or body injury. 

During this same period there was a corresponding increase in the number of evacuated Warriors requiring massive transfusions (i.e., greater than 10 units of blood) 

from 91 to 165. By way of comparison, the 

2007 surge in Iraq—the highest casualtyproducing year in OIF—produced 216 amputees, of whom 60 had multiple limb amputations. 

The ATO’s most dramatic changes in 2010 

were the increased numbers of bilateral 

thigh amputations, triple and quadruple 

amputations, and associated genital injuries. 

The JTTS casualty data for the ATO shows 

274 fatalities (KIA +DOW) and 2,108 

WIAs in 2009. These numbers increased to 

332 fatalities and 5095 WIAs in 2010. Additionally, the JTTS noted a large spike in 

multi-limb loss Warriors in the latter part 

of 2010. Associated with this was a large 

increase in the percentage of US casualties 

arriving at Landstuhl Regional Medical 

Center (LRMC) with amputations from October to December 2010. 

IED explosions on dismounted patrols 

caused the large majority of these injuries, 

with traumatic amputation of at least one, 

and often both, lower extremities. It wasn’t 

uncommon for these amputations to have 

accompanying GU injuries, penetrating 
6 

pelvic and abdominal trauma, and an upper 

extremity amputation or severe injury. 

Relative to a baseline incidence of 4.7%, 

the GU injury incidence among US casualties at LRMC was 19% in October 2010, 

10% in November 2010, and 13% in December 2010. When those who sustained 

major lower limb amputations were 

matched with those who also sustained genital injuries, the correlation approached 

90%. 

Post-traumatic stress (PTS) and TBI still 

play a significant role and add complexity 

and challenges to the rehabilitation and 

reintegration of these Warriors. 

To better study this apparent change in injury pattern more effectively, we propose 

using the name “Dismounted Complex 

Blast Injury.” The definition of this injury 

is: An injury caused by an explosion, occurring to a Service Member while dismounted in a combat theater that results in 

amputation of at least one lower extremity 

at the knee or above, with either amputation 

or severe injury to the opposite lower limb, 

combined with pelvic, abdominal, or urogenital injury. This definition is intended 

only to clarify what injuries should be included in this report. It is not meant to define a subset of injuries for policy-making 

decisions.

 
7 

ANALYSIS 

BURDEN OF INJURY 

DEFINITIONS 

As a primer for the discussion of data on 

the topic of DCBI, it is necessary to understand key military injury terminology. 

The Defense Manpower Data Center 

(DMDC) provides periodic updates for the 

number of Army WIA and either KIA or 

Died of Wounds Received in Action 

(DWRIA). The DMDC is the officially 

sanctioned source for DoD statistics related 

to Combat Operations. 

The DMDC validated the mutually exclusive nature among the variables used in the 

Survivability Calculation Methodology, 

i.e., Warriors are only counted in either 

KIA number, DWRIA number, or WIA 

number. 

WOUNDED IN ACTION 

A critical term used to define combatinjured casualties is the number of wounded 

in action (WIA) and is the sum of three 

subgroups. 

Admitted to MTF: These are BIs evacuated 

successfully to a Role II or III echelon of 

care. They are held for up to 72 hours or 

evacuated further toward more definitive 

and longer-stay facilities. 

Returned to Duty (RTD): These are BIs 

whose injuries are mild enough to allow for 

a successful return to his/her unit within 72 

hours, without need for further evacuation. 

Died of Wounds (DOW), or DOW Received 

in Action (DWRIA): These are BIs who 

die from their wounds after having been 

successfully evacuated to the attention of a 

surgeon at a Role II/III echelon of care. 

Conventionally, the subgroup of surviving 

WIAs who return to duty within 72 hours—

the RTD—is excluded from denominators 

when proportional statistics are presented. 

This is significant because this group traditionally represents the majority of all 

wounded in action. The number and classification of combat wounded and dead is 

used traditionally to render insights into the 

lethality of the battle, the effectiveness of 

the systems of care and evacuation, and allows the investigator to focus attention on 

required areas of research. The following 

definitions standardize the numbers to allow a reasonable retrospective comparison 

among armed US conflicts.

CASE FATALITY RATE (CFR) 

CFR refers to the combat deaths (i.e., KIA 

and DOW) as a percentage of total number 

of serious BIs (i.e., not counting those injured who are able to be returned to duty). 

CFR = (KIA + DOW) (100) (KIA + WIA - RTD) 

This summary statistic provides a measure 

of the battlefield’s composite lethality for 

our BIs. Of note, the denominator for CFR 

includes the RTDs that are excluded in the 

denominator of DOW and killed in action 

(KIA) rates. However, this statistic has 

been used both with and without the RTD 

population, creating a major source of confusion when comparing data sets. Insufficient detail is provided by a CFR for detailed medical planning, since its assessment is not based on the population at risk. 

In this case, the CFR simply describes the 

mortality rate among Warriors who are actually wounded. 

Survivability = (1- CFR) x 100 
8 

The metric of survivability is merely the 

converse of CFR and can also be described 

mathematically as a percentage. 

PERCENT KILLED IN ACTION (KIA) 

KIA refers to the number of combat deaths 

that occur before reaching a military treatment facility (MTF, namely, a Role II or III 

echelon of care), and then expressed as a 

percent of the WIA minus the RTDs. 

%KIA= (Deaths before MTF) (100) [KIA + (WIA - RTD)] 

This figure provides some measure of: 1) 

the lethality of weapons (>80% of KIAs die 

instantly from non-survivable injuries; 2) 

the effectiveness of pre-hospital care and 3) 

the efficiency of evacuation from the POI 

to higher echelons of care. 

PERCENT DIED OF WOUNDS (DOW) 

DOW is the number of all combat deaths 

that occur after the casualty reaches an 

MTF, or Role II/III echelon of care. It is 

expressed as a percentage of total wounded 

minus the RTDs. 

%DOW= (Deaths after MTF) (100) (WIA - RTD) 

This figure provides a measure of the effectiveness of the MTF care and perhaps also 

of the appropriateness of field triage, initial 

care, optimal evacuation routes and application of a coordinated trauma systems approach in mature combat settings. Deaths 

that occur at any time after evacuation to an 

MTF are included in this category. 

It is important to note the above two figures, %KIA and %DOW, have different denominators. The latter does not include 

deaths before reaching a medical treatment 

facility or those who are dead on arrival at 

an MTF. This focuses %DOW as a measure 

of MTF care. However, both denominators 

use the same definition of a battle injury—

those injured severely enough that they will 

not return to duty within at least 72 hours. 

For practical purposes, these Warriors are 

generally evacuated out of theater. 

The main difference between %KIA and 

%DOW is that the number of KIAs is excluded from DOW calculations. With that, 

it becomes clear the %KIA and %DOW 

cannot be summed to obtain the CFR. 

PREVENTABLE DEATHS 

The JTTS conducts a weekly worldwide 

teleconference to review recent casualty 

data and injury outcomes. This has proven 

extremely beneficial in providing frontline 

medical personnel near-real time feedback 

on their care of the battle injured casualties. 

Concerning DCBI, the JTTS teleconference 

audience can readily identify early trends to 

optimize care from Role II and higher locations. It has been limited, however, in its 

ability to garner information from Warriors 

who do not survive before reaching a Role 

II. These cases are not routinely reviewed 

in the weekly trauma teleconferences. 

Avoidance of preventable death is an important outcome measure in battlefield 

trauma care. Every friendly death in combat is a tragedy; every preventable friendly 

death is a call to action. Understanding the 

incidence of potentially preventable combat 

deaths requires autopsy data review from 

OAFME. 

A review of OAFME records for the past 12 

months revealed 111 dismounted Service 

Members killed by explosion with at least 

one major lower extremity amputation. Fifty of 111 (45%) were Soldiers, 55 of 111 

(49.5%) were Marines; 2 were Sailors, and 

4 were Airmen. Nearly half of these BIs 

had bilateral lower extremity amputations 

(38 of 81 casualties with more than one 

amputation). Additionally, 22 of 81 (27%) 

had three-extremity amputations, and 8 of 

81 (10%) had segments of all four extremi-
9 

ties amputated. 

 A preventable 

death analysis has not been accomplished 

on this particular casualty subgroup to date, 

however, published reports in 2007 and 

2008 indicate a potentially preventable 

death rate among US military fatalities in 

Iraq and Afghanistan to range between 15% 

and 50% in the DOW category, largely 

from hemorrhage. This area is extremely 

important and requires coordination between JTTS and OAFME. 

The incidence of preventable deaths among 

419 battle casualties sustained by one Army 

Ranger unit that trained all of its warfighters in TCCC since prior to the start of the 

war is 3%. Within this unit, the incidence 

of preventable deaths from failure to carry 

out required interventions in the prehospital phase of care was zero. 

INCIDENCE OF BATTLE 

INJURIES 

Based on OIF composite casualty data, the 

casualty rates for %KIA, %DOW and CFR 

are 17%, 6.5%, and 11%, respectively, with 

a corresponding survivability rate of 89%. 

(See Figure 2). 

These rates have remained relatively stable 

through the past three years. However, it is 

important to note the graph reflects cumulative rates over the course of many years, 

which tends to normalize day-to-day 

changes. This will tend to blunt or conceal 

any short-term trends. This report will 

compare the past 24 months in the ATO to 

identify any recent trends. 

The JTTS implemented a military variation 

to the civilian trauma scoring system because our battle injuries are not seen within 

the civilian community. The resultant Military Injury Severity Score (mISS) takes into 

account markers of significant trauma relevant to the battlefield scenario. The ISR is 

studying the trauma severity scoring system 

Figure 2. OIF Cumulative rolling monthly averages of % Killed in Action, % Died of Wounds, % 

Case Fatality Rate, and Military Injury Severity Score. Joint Theater Trauma Registry. 

(b) (7)(F)
10 

to optimize the predictive value for military 

operations. 

Note the decreasing injury severity associated with the measured drawdown and 

advent of Operation New Dawn (OND) in 

the ITO. This suggests a decreased operational tempo, and less exposure to direct or 

indirect enemy contact compared to the 

2007 troop surge. 

The OEF composite casualty data shows 

corresponding %KIA, %DOW, and CFR of 

15%, 5%, 12%, with a survivability rate of 

88%. With respect to that seen in 

OIF/OND, this data demonstrates steady 

trends in three of the four measures, starting in 2006. (See Figure 3). 

First, the injury severity has steadily increased. Secondly, both %KIA and CFR 

have decreased over this same period, with 

a more dramatic drop over the last twelve 

months. Of the four measures, %DOW has 

remained relatively stable during the past 

five years. 

Again, the reader should bear in mind these 

data reflect cumulative rates over the 

course of many years. As such, small dayto-day changes become normalized over 

time. 

The most striking takeaway from this graph 

is that KIA rates and CFR, when compared 

to the total Warriors exposed to risk, are 

declining at the same time injury severity is 

increasing. 

The increased severity of injuries can reflect any number of events, either alone, or 

in combination, including, but not limited 

to, increased weapon lethality, TTP of either side, or an improved capability among 

Soldiers and Marines, Corpsmen and Medics, front line medical personnel, and evacuation assets to provide excellent prehospital care and efficient evacuation to 

sites that can provide acute resuscitation 

and damage control surgery. 

The DoD is fully engaged in helping USCENTCOM and ATO troops eliminate or 

Figure 3. OEF Cumulative rolling monthly averages of % Killed in Action, % Died of Wounds, 

% Case Fatality Rate, and Military Injury Severity Score. Joint Theater Trauma Registry. 
11 

mitigate enemy 

threats across the 

battlefield. This 

Task Force believes 

a leading cause for 

these improved survival rates is due to 

a better trained and 

equipped warfighter 

force. Indeed, these 

findings portend a 

dynamic commitment to improving 

Warrior protection 

and combat casualty 

care. 

Looking now at 

non-cumulative 

monthly casualty 

trends, the 

OIF/OND BIs have 

steadily decreased 

since 2008, following the troop surge and 

its intense fighting in 2007. (See Figure 4). 

With the sustained movement towards transitioning military responsibilities to the 

Government of Iraq 

(GoI), it appears this 

downward trend will 

continue unabated. 

To the contrary, casualty numbers have 

steadily increased in 

the ATO, consistent 

with the increased 

number of troops at 

risk and the associated increased operational tempo. 

(See Figures 4 and 

5). Throughout OEF, 

casualty numbers declined each winter. 

Despite this predictable variability, the 

casualty trends have 

steadily increased. 

Although we described a decreasing KIA 

rate on the previous slide, the actual numbers of KIAs and WIAs have both increased 

slightly this past year. Importantly, the 

Figure 4. OCO monthly casualty data from OCT 01 to DEC 10. 

Figure 5. OEF Yearly Total Casualty Data (2003-2010). 
12 

KIA rate remained static during the period 

of increased troops at risk with the surge. 

IMPROVING 

SURVIVABILITY 

Survival in battle is contingent upon a 

number of factors in addition to medical 

care, including equipment, 

training, maneuver techniques, tactics, and adaptability to the enemy threat. 

Attributable improvements 

in survival have come from 

lessons learned as a result 

of previous conflicts in 

American history. (See 

Figures 6 and 7). 

Survival in World War II 

was improved by the novel 

utilization of blood transfusion and improvements in 

ground evacuation. With 

Korea and Vietnam, the advent of RW evacuation to 

expedite moving the combat 

casualty from POI to a medical facility markedly improved survival outcomes. 

The current contingency operations have 

demonstrated unprecedented survival compared to previous conflicts in US military 

history. 

Key components in the 

contemporary improvement in battlefield survival are improved PPE and materiel, improvements in field provider training with the tenets of Tactical Combat Casualty Care (TCCC) and the implementation 

and evolution of a formal trauma system to 

effect performance improvement along the 

entire continuum of combat casualty care. 

These effects are emphasized by the progressive improvements in survival shown in 

Figure 7. 

Figure 7. Six-month OEF Survivability trends (JAN 2008 – DEC 2010).

DMDC, 03JAN11. 

Figure 6. US military survival from battle injuries have increased with each major conflict since World War II. 

(b) (6)
13 

MASSIVE TRANSFUSION 

As a surrogate marker for injury severity 

and complexity, the number of massive 

transfusions has increased relative to the 

OEF casualty rates. (See Figures 8 and 9). 

Massive transfusion of blood is a marker of 

severe bleeding and hemorrhagic shock. 

The survival of combat casualties requiring 

massive transfusion has increased from 

62% (before mid-2006) to greater than 80% 

(after mid-2006). The most significant 

component of this survival improvement is 

the change in resuscitation strategy focused 

upon 

balanced 

transfusion of 

blood, 

plasma, 

and 

platelets, 

which 

approximates 

fresh 

whole 

blood. 

Other 

factors 

in the outcome improvement likely include 

improved training for Combat Medics and 

Corpsmen, tourniquet utilization, rapid casualty evacuation, and damage control surgery. 

PRIMARY MECHANISMS 

OF AMPUTATION 

Different phases of the current conflict 

have produced discrete injury patterns requiring adaptation for mitigation. Historically, the overwhelming number of US milFigure 9. Recent monthly massive transfusions. Left axis represents # units of blood. 

(JAN09 – DEC10) 

Figure 8. Monthly OEF massive transfusions. Left axis represents # units of blood. (DEC01 – DEC10)
14 

itary casualties was caused by explosions. 

The hallmark of the injury pattern in the 

contemporary context is the dismounted 

Warrior injured by a landmine or other improvised ground-based explosive (Table 1). 

The dismounted posture places the warfighter at risk for more significant orthopedic and soft tissue 

injury, including 

amputation, GU, 

pelvic and abdominal injury, as a 

result of the blast 

and energy and multiple projectile 

force. 

The rate of major 

amputations has 

changed throughout 

the course of combat operations in the 

ATO. (See Figure 

10). This rate of 

amputation in the 

context of personnel 

at risk suggests an 

increasing demand 

on the continuum of the healthcare 

throughout the echelons of care, from the 

battlefield to long-term rehabilitation centers. 

The graph shows the relative increase in 

OEF amputations over time, something lost 

when considering a single month or a single 

Figure 10. Major amputations for OIF/OND and OEF per 10,000 deployed 

troops (OCT05–DEC10. 

Table 1. Major and minor limb amputations from OIF/ OND and OEF. 

(b) (7)(F)

(b) (7)(F)
15 

year in isolation. Even though the numbers 

are less than that seen in the ITO during its 

peak casualty-producing months, it remains 

impressive by its relative increase. On the 

other hand, the absolute number of major 

amputations is a better reflection of the 

demand placed on the healthcare system 

throughout. 

Figure 11. Service affiliation of surviving amputees 

from JAN 2010 through MAR 2011. 100% of these 

individuals were men. Naval Health Research Center. 

These particular casualties not only require 

aggressive resuscitative and surgical support on the battlefield, but also encounter 

significant definitive and rehabilitative 

challenges as a result of their injuries. Advances in pre-hospital care, evacuation, and 

acute care are saving casualties with injuries that likely would not have survived in 

the past. 

However, the significant explosive energyproducing event in the current scenario is 

associated with substantial destructive 

force, often leading to multiple amputations, the numbers of which have increased 

in OEF since mid-2010. 

Navy Medicine studied 194 amputees in the 

ATO from January 1, 2010, through March 

31, 2011. (See Figure 11). The first thing 

to note is that the USMC sustained the majority of these injuries. Among the BI amputees, there was a 50:50 distribution between the Army and USMC. Because of 

the smaller USMC footprint, the amputation 

rate among Marines was much higher than 

that of the Army: 1:206 USMC BOG vs. 

1:641 Army BOG. Furthermore, of the 78 

cases that met the DCBI definition, 68% 

(n=53) of the multiple-limb amputees were 

Marines (1 DCBI:377 USMC BOG). Additionally, the two Navy BIs were affiliated 

with USMC operations. Army Soldier BIs 

represented 29% (n=23) of the remaining 

DCBI cases during this 15-month period (1 

DCBI:2565 Soldier BOG). (See Figure 12). 

Figure 12. Service affiliation of surviving DCBI 

casualties from JAN 2010 through MAR 2011. Naval Health Research Center. 

For the 15 month time period studied, 12% 

(n=23) of the 194 amputees were mounted 

and 88% (n=171) were dismounted. 

 The average 

rate of DCBI per 1000 BIs was 6.69 for the 

Army and 28.45 for the Marines. 

(b) 

(7)

(F)
16 

Figure 13. Rate of GU injury among all admissions from OIF/OEF from 2005 to 2010.

Historical average is 2-5%. Source JTTR.

ASSOCIATED 

GENITOURINARY 

INJURIES 

Also associated with the ground-based explosive injury is an increase in the number 

and severity of GU injuries, particularly 

injury to the external genitalia (See Figure 

13 and 14). As with amputations, the number of GU injuries has increased as a function of increased combat casualty number. 

BI amputations 

have a significant association 

of perineal and 

GU injuries 

(Figure 15). The 

significance of 

the current pattern of GU injury is the potential impact on 

physical, 

reproductive, 

and behavioral 

health of these 

casualties. It is 

imperative, 

therefore, management of this 

complex pattern 

of GU injury 

requires attention paid towards surgical 

reconstruction 

and psychological health. 

ASSOCIATED 

TRAUMATIC BRAIN 

INJURY 

Finally, available data suggests fewer cases 

of comorbid TBI among major amputation 

casualties from OEF compared to 

OIF/OND. Because this chart does not distinguish mounted from dismounted settings 

at the time of injury, the rate difference 

Figure 14. Total number of GU injuries among all admissions from OIF/OEF from 2005 to 

2010. Source JTTR. 
17 

may simply reflect the greater number of 

dismounted cases in the ATO. (See Table 

2). In turn, this may reflect the open space 

effects of explosive devices and vehicular 

crashes among dismounted troops. 

Regardless, there remains a significant subpopulation of traumatic amputation casualties with some degree of TBI secondary to 

the inciting event. As will be discussed 

later, these comorbid injuries significantly 

increasingly challenge the patient’s rehabilitation and recovery plan. In a wholeperson approach to healing, these issues 

must be addressed comprehensively by the 

healthcare team and Family alike in support 

of the patient. 

Figure 15. OCT09–DEC10 major amputations for OIF/OND and OEF with trends for associated GU injuries circled. 

(b) (7)(F)

(b) (7)(F)
18 

CURRENT PRACTICE 

PRE-HOSPITAL CARE 

The primary goal of pre-hospital care is to 

initiate actions that keep the casualty alive 

to reach a Role II/III medical treatment facility (MTF) with the capability to perform 

trauma resuscitation and surgical intervention if necessary. Pre-hospital’s secondary 

goal is to optimize the battle casualty’s potential for the best possible functional recovery and long-term good quality of life. 

This is best accomplished by mitigating 

risk factors for onset of the “lethal triad” of 

coagulopathy, hypothermia, and hypovolemia (i.e., the inability of the blood to 

clot, low body temperature, and low 

blood volume). 

BEST PRACTICES IN PREHOSPITAL CARE 

TOURNIQUETS 

Exsanguination—lethal blood loss—from 

extremity wounds was the leading cause of 

preventable death among US military casualties in the Vietnam conflict. Published 

reports on causes of death in that conflict 

documented a 7.4% rate of preventable 

death from failure to use tourniquets. 

As a result, TCCC began calling for the aggressive use of tourniquets for the initial 

control of life-threatening extremity hemorrhage five years before the onset of 

OEF. Tourniquet use is one of many areas 

in which TCCC recommends somewhat different pre-hospital trauma management 

strategies than those currently taught in civilian trauma courses. 

A review of combat fatalities in OIF and 

OEF through 2006 reported a 7.8% death 

rate from extremity hemorrhage (77 deaths 

associated with lack of tourniquet use 

among 982 fatality cohort). Of note, this 

rate mirrored that seen in the Vietnam War. 

Contrast this experience with that of the 

75th Ranger Regiment. The Rangers are 

one of only three US infantry units to have 

implemented TCCC throughout its force 

before the war, and the only group to have 

documented their experience. As such, 

they reported a 0% preventable death rate 

from extremity hemorrhage among 419 

Ranger casualties throughout the entire 

decade of conflict in both OIF/OND and 

OEF. 

When tourniquets are used in the pre-hospital setting, they have been shown to be 

remarkably effective at decreasing preventable deaths due to extremity hemorrhage 

without a corresponding threat to the 

treated limb. In addition, in a case series of 

232 casualties with tourniquets placed in 

the field on 309 extremities, there were no 

limbs lost to ischemia (i.e., inadequate 

blood flow to tissues). 

TCCC has gained increasing acceptance 

among US conventional forces since 2005. 

The Task Force expects future data will 

show improvement in preventable deaths. 

PREVENTION OF POST-TRAUMATIC 

COAGULOPATHY 

Coagulopathy, the inability for blood to 

clot normally, is common in combat casualties requiring transfusion (38%) upon arrival at the emergency department, and is associated with a six-fold increase in mortality. Additionally, coagulopathy increases 

mortality among trauma patients with severe TBI. 

Acute traumatic coagulopathy, regardless 

of the underlying injury severity, resuscitative transfusion regimen, or other physiological markers for hemorrhage, was associated with early death in major trauma patients, with an odds ratio of 8.7 (i.e., the 
19 

patient is 8.7 times more likely to suffer 

early death than a patient without coagulopathy). 

The hypovolemia associated with extremity 

trauma impairs the body’s ability to maintain adequate temperatures. The resultant 

hypothermia—even at normal or hot ambient temperatures—results in coagulopathy, which, in turn, leads to further bleeding. 

The best practices seen in this area are twofold: 1) TCCC course emphasis on eliminating the routine use of anti-platelet 

agents, namely aspirin- and nonsteroidal 

anti-inflammatory agents; and 2) relatively 

common post-traumatic use of specific 

warming blankets to maintain core body 

temperatures throughout the pre-hospital 

phase of care. 

CHALLENGES AND ISSUES IN 

PRE-HOSPITAL CARE 

CONTROL OF JUNCTIONAL 

BLEEDING 

DCBI casualties are often noted to have 

life-threatening bleeding in the groin or 

very proximal lower extremity regions, 

where a tourniquet cannot be applied effectively. Although hemostatic gauze has 

been reported to work well in some cases, a 

backup means of hemorrhage control is 

needed. 

The ISR evaluated a Food and Drug Administration (FDA)-approved clamping device 

to address difficult-to-control junctional 

bleeding in the groin or axilla, with promising early results. Further development and 

evaluation of this technology is underway. 

Of note, at least two Special Operations 

Force (SOF) units have deployed this device into theater, although early data from 

Armed Forces Institute of Pathology (AFIP) 

is not yet available. 

BATTLEFIELD ANALGESIA 

Prompt relief of severe pain resulting from 

combat trauma has been shown to decrease 

the incidence of post-traumatic stress disorder in combat casualties. 

The time from administration to onset of 

analgesia for intramuscular (IM) morphine 

can be as much as 30 minutes. In an attempt to gain rapid control of the pain, IM 

morphine’s delayed response places the casualty at risk for inadvertent overdosing. 

For this reason, TCCC recommends that 

morphine and OTFC be administered intravenously for battlefield analgesia. 

Oral transmucosal fentanyl (OTFC) was 

found to achieve rapid and effective battlefield analgesia. In addition to its rapid onset of pain control, OTFC had the advantage of obviating the need to obtain venous 

access in the battlefield. In 2003 TCCC 

added OTFC to the list of analgesia options. Unpublished data demonstrated 109 

successive safe battlefield administrations 

of OTFC by Ranger Medics. 

There is an FDA “black-box” warning for 

the administration of OTFC. However, 

there are multiple published reports in the 

civilian setting that document OTFC’s safety with non-breakthrough cancer pain. The 

Committee on TCCC (CoTCCC) reviewed 

OTFC’s adverse events reported to the 

FDA, which reflected problems in unmonitored clinical settings. 

The TCCC recommends the one-time use of 

OTFC under the immediate supervision of a 

skilled combat medic. (CoTCCC Meeting 

Minutes, November 2010). Despite its 

event-free track record for prompt and effective battlefield analgesia, currently only 

SOF medics are equipped to provide pain 

relief with OTFC or intravenous (IV) morphine. This is an extremely important area 

to improve overall point of injury pain 

management through widespread adoption 

of CoTCCC recommendations. Additional 

medic training would further improve this 
20 

valuable adjunct and safety in its application. 

HYPOTHERMIA 

Hypothermia-induced coagulopathy is a 

well-described compilation of decreased 

platelet function, slowing of coagulation 

cascade enzyme activity, and alterations of 

the fibrinolytic system. Of note, post-traumatic hypovolemic shock impairs one’s 

ability to generate heat to maintain normal 

body temperature. This predisposes largevolume hemorrhagic casualties to a vicious 

cycle of hypothermia that leads to a coagulopathy and worsening hemorrhage. 

Preliminary data from an ongoing ISR 

study on battlefield trauma care noted that 

83 of 192 casualties had only a wool blanket for hypothermia prevention. Its studies 

also show that wool blankets are ineffective 

at preventing heat loss. 

TCCC has long recommended specific and 

aggressive strategies (the Hypothermia Prevention and Management Kit) to combat 

hypothermia in combat casualties. Reporting this through Unit Status Reports (USR) 

will improve the opportunities for its use 

with combat casualties.

FLUID RESUSCITATION 

There is no evidence from human trials that 

aggressive pre-hospital administration of 

crystalloid fluids improves survival among 

trauma patients. On the contrary, there is 

some evidence it decreases survival. 

Large-volume crystalloid fluid resuscitation 

is not used in TCCC. Of note, even civilian 

trauma centers stopped advocating largevolume crystalloid resuscitations. 

The use of hypotensive colloid fluid resuscitation was reported in a large, nonrandomized study at Ryder Trauma Center 

in Miami that showed a trend towards improved survival, without impairing coagulation status. Hypotensive resuscitation with 

Hextend® was approved by the CoTCCC in 

2003. Both the limited use of IV access 

recommended in the 1996 TCCC paper and 

the hypotensive resuscitation strategy are 

now being reflected in some civilian trauma 

organizations. 

Despite the above, the ongoing ISR’s prehospital trauma interventions study found 

crystalloids used for fluid resuscitation in 

87% of casualties who received prehospital fluids. There is as yet no requirement for unit-level reporting of fluids used 

in resuscitations, despite TCCC recommendations. 

TCCC TRAINING 

TCCC is now used by all Services in the 

US military and by many coalition partners 

as the standard for training medics to manage combat trauma on the battlefield. It is 

taught to new Soldiers by the Army Training and Doctrine Command (TRADOC) as 

part of its Combat Lifesaver training program. On the other hand, US military physicians and nurses do not routinely receive 

formal TCCC training. This disparity between medics and medical officers can lead 

to incongruous approaches to the DCBI casualty regarding hemorrhage control or resuscitation regimen. 

TCCC is also not taught routinely to combat leaders or to all deploying warfighters 

during their pre-deployment preparation for 

combat operations. This eliminates the 

possibility of these individuals being taught 

TCCC’s latest developments and lessons 

learned. 

Pre-deployment provider training requirements should be the same for providers assigned to either Army or Marine Role II 

facilities. Familiarization with CENTCOM 

CPGs and TCCC principles should be a predeployment training prerequisite. 
21 

FREEZE-DRIED PLASMA 

Data indicates a significant advantage to 

administering packed red blood cells 

(PRBCs) and plasma in a 1:1 delivery ratio. 

Within the MTF, plasma is stored as fresh 

frozen plasma (FFP), and then thawed prior 

to administration. To administer blood 

products in the pre-hospital phase, one 

needs a means to get plasma into the battlefield reliably. 

As such, freeze-dried, or lyophilized, plasma has gained interest recently. Although 

available overseas, these products, lack 

FDA approval presently. 

Gaining this approval or accelerated fielding through the FDA process has become a 

top priority among the military science 

community. In fact, it was identified as a 

top priority research area in pre-hospital 

fluid resuscitation by the ISR-MRMC sponsored fluid resuscitation conference held in 

Dallas in January 2010. 

PRE-HOSPITAL DOCUMENTATION 

Pre-hospital care is key to mitigating worsening morbidity following an explosion 

injury. Systematic improvement requires a 

means to document care rendered at the 

POI 

Only 14% of casualties have pre-hospital 

care documented upon arrival at a Role 

II/III facility. The lack of consistent prehospital documentation of care continues to 

be a requirement gap across the Services. 

Unit-based pre-hospital trauma registries 

(PHTRs) have proven beneficial for the 

healthcare team at successively higher 

echelons of care. Unfortunately, use of 

such registries, such as that seen in standard NATO documentation forms, has not 

been embraced across the force. Implementation of its use is being developed currently. At a minimum, documenting the datetime group of tourniquet placement on the 

card and on the patient is the most important information for decision making at the 

next level of care. Medications and intravenous fluids are next most important. 

ROTARY WING 

EVACUATION 

Almost every casualty is evacuated to 

Role II or III care via RW platforms. This 

has been through combat RW, which is 

called casualty evacuation (CASEVAC), or 

by dedicated, medically equipped RW MEDEVAC platforms. This has been due to 

theater-wide air superiority and the relatively high risk of ground evacuations due 

to roadside bombs. It is important to note 

Marine Corps doctrine differs from the other Services in that evacuation platforms are 

designated, not dedicated. Additionally, 

CASEVAC from the POI to Role II/III 

echelons of care is not restricted to RW 

platforms. In this regard, Marine RW CASEVAC involves lifts of opportunity. 

The Marine Corps employs an En Route 

Care System (ERCS) that provides essential 

follow-on support for the Forward Resuscitative Surgical System (FRSS). The 

ERCS has the mission of transporting stabilized post-operative patients from Role II 

sites to the next echelon of care. As such, 

it is capable of providing two hours of inflight medical care for two critical, stabilized, patients. The ERC team consists of 

one critical care nurse and one 8404 ERC 

Corpsman

supported by Army and Air Force RW platforms. 

ROTARY WING PLATFORMS AND 

ORGANIZATION 

In both theaters of operation we have been 

able to evacuate BIs from the POI to a 

surgeon within one-hour of request. This 

has proven more difficult in the ATO due to 

its rugged terrain, high altitudes, and long 

(b) (3) [10 USC 130(b)]
22 

distances between Role II/IIIs and the operating force engaged with the enemy. 

The cost has been high on these lowdensity, highly specialized air ambulance 

units. To meet the one-hour evacuation 

standard within both theaters of operation, 

mission requirements have produced significant wear on both airframes and personnel, 

with only slight relief from the drawdown 

of troops in OND. 

Accelerated implementation of the Army’s 

decisions to increase MEDEVAC units’ 

complement of organic aircraft from 12 to 

15, along with the growth of nine additional 

MEDEVAC companies within the force 

structure, will provide much greater flexibility in the operational employment of 

these strategically vital assets. 

BEST PRACTICES IN ROTARY 

WING EVACUATION 

In 2007, a RW evacuation database was implemented to track timelines for each phase 

of every RW MEDEVAC mission. This 

allowed senior leaders and commanders to 

understand and control performance at each 

step to maintain or enhance evacuation 

times and standards. 

Although well-postured for shorter evacuation missions, Army aircraft are not the 

best suited for the longer distances in place 

in the ATO. The Army should consider 

other airframes with better speed, range and 

lift. 

CHALLENGES AND ISSUES 

WITHIN ROTARY WING 

EVACUATION 

The DCBI patients routinely overfly Role II 

sites in their evacuation to Role III echelons of care. This occurs because: 1) The 

Role II site may not have the requisite resource capability to handle these very severely wounded casualties; 2) the Role II 

facility is not located between the casualty 

pickup location and the next higher echelon 

of care; 3) the casualty is directed to a Role 

III echelon by the MRO; and/or 4) the aircrew determines the patient’s condition 

warrants overflight to a Role III echelon of 

care. 

Although survivability has increased and 

KIA/DOW rates remain fairly constant, we 

do not know the rates of KIAs with the 

DCBI pattern in relationship to Role II locations. The questions that merit further 

study include: 

Are those patients with a DCBI occurring 

closer to Role II dying prior to receiving 

definitive care? 

If RW evacuations of DCBI patients routinely bypass Role II echelons of care, does 

it result in a higher mortality? 

Greater speeds and payloads substantially 

enhance aerial medical evacuation operations by facilitating timely evacuation to 

the appropriate Role of care, over greater 

distances, and with more efficient use of 

forces. 

With greater ranges, vertical lift aircraft 

could operate from more secure locations, 

with less logistical support lines, less of a 

footprint on the ground, and provide evacuation to better care facilities for injured 

Warriors. 

Platforms with cabin space sufficient to allow medical providers to stand, with appropriate equipment and interior lighting, 

could facilitate limited en-route emergency 

surgical procedures. 

However, it has been shown that delay of 

transport to definitive care has resulted in 

an increased mortality. This begs the question of whether mid-level providers should 

staff these platforms, similar to that done 

by the United Kingdom (UK) and its Medical Emergency Response Team (MERT) 

system utilizing physicians, not medics, or 

physician assistants. The ISR is working to 
23 

obtain the UK MERT data for review. In 

the meantime, the US Army is using critical 

care nurses for the transport of complex 

patients between Role II and Role III facilities, and is completing a study to increase 

the flight medic skill set to that of a paramedic. Other Services may address this 

gap utilizing different manning options. 

Ultimately a Joint solution should be explored, maximizing all of the different Service strengths. 

The issue of patient regulation and when to 

overfly Role II needs further evaluation. 

Clinical decision-making needs to be part 

of the process, whether at the time of pickup and/or as part of the Patient Evacuation 

Coordination Cell (PECC). 

ON-BOARD TACTICAL 

EVACUATION CAPABILITY 

Medical expertise aboard evacuation platforms is not presently standardized in the 

ATO. The level of medical expertise on 

board ranges from Basic Emergency Medical Technician (EMT-B) flight medics to 

paramedics and critical care nurses, while 

others, namely the UK, utilize MERTs 

staffed with highly trained trauma providers. 

Currently in Regional Command-Southwest 

[RC(SW)], the UK MERT is used preferentially to evacuate the most severely 

wounded casualties. The MERT is the only 

unit that has a physician-led RW medical 

team onboard. As such, it routinely administers pre-hospital blood products (four 

units of packed red blood cells and four 

units of fresh frozen plasma), provides advanced airway interventions, and treats 

with vasopressor agents, tranexamic acid, 

and IV analgesia with ketamine or fentanyl. 

The UK’s approach is promising in that it 

brings resuscitative concepts far forward, 

potentially extending the reach of RW 

evacuation hubs. Air Force Special Operations Command (AFSOC) deploys Special 

Operations Surgical Teams (SOST) and 

Critical Care Evacuation Teams (SOCCET) 

that operate in a fashion similar to the UK’s 

MERTs. 

USSOCOM has long had a surgical capability on evacuation platforms. 

Army flight medics do not generally receive advanced trauma training beyond 

what their 68W ground combat medic counterparts receive. As they are trained currently, US flight medics lack the complete 

skill set to manage all patient categories 

through the full spectrum of military operations. The Task Force believes the new 

Army flight medics should have the capability to provide enroute specialized advanced trauma management at or near the 

point of injury. 

Unpublished data demonstrates an increased 48-hour survival rate among casualties transported by critical care flight 

paramedics (CCFP) relative to those monitored by EMT-B flight medics (92.1% vs. 

84.9% survival). The AMEDDCS CG approved a recommendation recently to train 

all 68W Flight Medics to qualify as Critical 

Care Flight Paramedic Certified (CCEMTP/FP-C). Having paramedic-certified flight 

medics will bring the Army in line with the 

US civilian medical standard. 

Based on their experience, the Navy contends transport of stabilizing casualties 

from Roles II to III facilities must be performed by at least a critical care nurse with 

flight training (i.e., ERC RN) who is capable of monitoring hemodynamic parameters, administering vasoactive medications 

and blood products, and performing immediate life-saving interventions. For unstable casualties, the Navy further contends a 

physician should lead the critical transport 

team. 
24 

ROLE II/III: ACUTE 

RESUSCITATION 

Acute resuscitation involves the prehospital phase and the hospital phase of 

combat care. The focus of this section is 

initial definitive surgical care provided on 

arrival to the combat treatment facility. 

Mitigating the severe ischemia and irreversible shock cascade these patients face requires skills and resources not available 

from a Medic/Corpsman at the POI, or routinely available on Army or Air Force RW 

aircraft. 

BEST PRACTICES IN ACUTE 

RESUSCITATION 

STAFFING 

There is significant variability in personnel 

composition and capability of the Services’ 

forward surgical units. The various Role II 

sites share a common core mission, however, which is to control non-compressible 

hemorrhage and mitigate the effects of the 

lethal triad of acidosis, coagulopathy and 

hypothermia. 

Data from I MEF’s experience in RC(SW) 

during 2010 support placing a forward resuscitative team (FRT) in close proximity 

to areas of active engagement. Physician 

judgment, clinical decision making, and 

resuscitative skills proved beneficial to 

both the patients’ short- and long-term clinical outcome.

The FRTs provided enroute resuscitative 

care, and consisted of an emergency medicine physician and nurse, physician assistant (PA), and three-to-six Corpsman. Typically they were attached to an isolated 

(geographical or tactical) battalion aid station (BAS) or to the UK MERT transport 

crew. 

FACILITIES 

Combat medical facilities include the US 

Military Role II and the Role III echelons 

of care. The Army Role II echelon is the 

forward surgical team (FST). The FST is a 

24-person unit which includes three general 

surgeons, one orthopedic surgeon and two 

anesthesia providers. The ability to hold 

critically injured patients after surgery at 

the FST is limited to 12-to-24 hours due to 

manpower and supplies. 

The Marines’ Role II is filled by the shock 

trauma platoon (STP) and the forward resuscitative surgical system (FRSS). The 

eight-person team includes two general 

surgeons and an anesthesiologist. 

The FRSS can manage five patients simultaneously (two pre-operative, one intraoperative, and two post-operative). It can 

provide for a maximum of 18 surgical patients over 48 hours before relief and resupply. 

Doctrinal USMC Role II facilities (FRSS) 

are similar in capability to an Army splitFST (two surgeons; one anesthesiologist; 

one OR table). Alternatively, an Army FST 

(four surgeons; two anesthetists; two OR 

tables) is similar in capability to a surgical 

shock trauma platoon (SSTP = 2 FRSS and 

an STP). The Marines deployed SSTPs 

successfully during OIF. 

In the ATO, the Marines reorganized their 

Role II facilities. With a minimum of 20 

personnel, these enhanced units included 

two general surgeons, an orthopedic surgeon, and an anesthesiologist, emergency 

medicine physician, PA, emergency medicine nurse, CRNA and two critical care 

nurses. 

The Role III echelon of care is the combat 

support hospital (CSH). The CSH consist 

of over 200+ personnel supporting multiple 

general/trauma surgeons, orthopedic surgeons, as well as vascular surgery, thoracic 

surgery, neurosurgery, gynecologic surgery 

and intensive care providers. Urologic 
25 

surgeons are not presently a requirement at 

the CSH, but are frequently assigned as an 

alternative to the general surgeon. These 

specialty-trained surgeons can make a direct impact on salvage at the time of initial 

resuscitative surgery. 

The CSH has an extended holding capability with a fully staffed intensive care unit. 

Both the FST and the CSH may be split in 

different locations as needed. Presently, 

FSTs and CSHs are strategically placed to 

provide initial surgical care to all US Warriors within one hour of injury. All US patients with DCBIs are transferred to 

Landstuhl Regional Medical Center via 

Critical Care Aeromedical Transport 

(CCAT) Teams. Transport is generally 

within 12-24 hours of initial surgical treatment. 

Despite the ATO’s steady increase in injury 

severity over the past four years, the percentage of KIAs relative to significant BIs 

has declined slightly over the same period, 

and the percentage of DOWs for the same 

population has remained steady. However, 

this Task Force is focused on a specific injury pattern that significantly increased in 

occurrence over the last six months. Put 

together, we see a long-term increase in 

survivability among BIs in the ATO, with a 

peak of 91.6% in 2010. Of note, the DOW 

rate is equivalent among the FST, split-FST 

and the CSH. 

CLINICAL PRACTICE GUIDELINES 

Over the course of OIF, OEF and OND, the 

JTTS has developed and refined many advances in acute resuscitation and care of the 

trauma patient to include massive transfusion protocols, traumatic amputation protocols, theater transfer protocols, pain protocols, TBI protocols and many others. The 

advances in combat care have set new standards in civilian trauma centers for transfusion practices. These Clinical Practice 

Guidelines (CPGs) are the backbone of the 

standards of practice in combat trauma 

care. The CPGs are taught to Army surgeons currently in graduate medical education 

programs and to deploying staff surgeons 

during their preparatory training. However, 

there is no standardized mandatory predeployment trauma training for all medical 

providers. The CPGs are also available on 

the ISR website: 

www.usaisr.amedd.army.mil/cpgs.html 

Upon arrival at the CSH, the DCBI patient 

receives rapid care by a multidisciplinary 

group of surgeons and support providers. 

Massive transfusion protocols are instituted 

using 1:1:1 PRBC:plasma:platelets ratios. 

Tourniquets are confirmed or applied to 

injured extremities and standard guidelines 

of trauma care are followed. Patients are 

rapidly transferred to the operating rooms 

and multiple surgeons address the various 

injuries simultaneously. 

CHALLENGES AND ISSUES 

WITHIN ACUTE 

RESUSCITATION 

ROLE III STAFFING 

Minimum staffing requirements for a Role 

III hospital site should include general/trauma surgeons with vascular surgical 

capability, orthopedic surgeons, critical 

care physician and appropriate intensive 

care unit (ICU) and support staff, to include 

an Acute Pain Service (APS) with a medical officer trained in pain management. 

Presently, urologists are assigned only as 

alternatives in general surgeon slots. Their 

presence in the ATO would provide a specialist focused on salvage or repair procedures in the setting of GU injuries. 

It is not clear if a surgeon’s combat experience is a factor in survival among DCBI 

patients, but it would appear not to be so. 

As opposed to the medical officers at the 

POI, surgeons have been exposed to trauma 
26 

management during their respective residencies. 

That stated, staff providers not currently 

assigned to high-volume, trauma-heavy 

MTFs, such as Brooke or Walter Reed 

Army Medical Centers, should undergo predeployment trauma refresher training. 

These training programs are currently 

available in Miami, Fort Sam Houston, and 

other sites. 

ROLE II STAFFING 

Role II [Army Forward Surgical Team 

(FST)] is much smaller in size and capability than its Role III counterpart. As an example, FSTs do not have platelets or cryoprecipitate, and the pool for whole blood is 

typically more limited. 

Generally speaking, FSTs are being split 

throughout the ATO. These smaller Role 

IIs have one general surgeon and one orthopedic surgeon, or two general surgeons 

and no orthopedic surgeon. This also 

means they only have one anesthesia provider. 

In general, most split-FSTs hold 30-to-50 

units of PRBCs and similar amounts of 

FFP. A split-FST could stabilize a DCBI 

patient and then send the casualty to the 

next echelon of care. Many FSTs have taken care of local national patients with this 

injury pattern and have maintained high 

survival rates. However, given the limited 

resources of the split FST, should they have 

multiple patients, they would be quickly 

overwhelmed. 

Within the ATO Roles II are routinely 

overflown when evacuating DCBI patients. 

This is more a reflection of the MTF’s capabilities than on the specific training of its 

assigned personnel. Published data based 

on survival reports indicate the FST and the 

split-FST have the similar survival rates, 

stratified for ISS, as the CSH. However, 

this data must be interpreted carefully—

most of these patients are currently evacuated directly to Role III facilities. 

Therefore, if bypassing an FST to reach a 

Role III site will add more than 30 minutes 

to the evacuation for a single patient, the 

current recommendation would be an initial 

stop at the FST for stabilization, and then 

continue transport. KIA data must be studied to determine any relationship between 

DCBI KIA and proximity to Role II care. 

The Role II echelon of care remains valuable to the warfighter. Mobility is its greatest advantage and Role IIs should be moved 

throughout the battlefield to best support 

likely high intensity operations. 

The Navy’s experience is that combat trauma experience is critical to the clinical decision-making that occurs at its Role II facilities. 

They see provider rotations between the 

Marines’ Role II and III sites as integral to 

their skill development and maintenance. 

Finally, placement and utilization of Role II 

assets must be done on the basis of at least 

a regional trauma system plan. 

PAIN MANAGEMENT 

The JTTS does not track pain control 

through the Role II and III facilities. There 

is a CPG addressing pain management and 

the implementation of the Joint Regional 

Anesthesia and Analgesia Tracking System 

(JRAATS) just released that will now allow 

the Theater Medical Data Store (TMDS) a 

tool to collect data on how well pain is 

treated at the Roles II/III. An Acute Pain 

Service in Level III facilities would not only treat pain effectively, but it would also 

heighten the awareness of commanders to 

make treating (and tracking) pain control a 

parameter of success for the DCBI patient. 
27 

ROLE IV/V: DEFINITIVE 

CARE AND 

REHABILITATION 

Over the decade, DoD and VA established 

definitive care programs, and developed 

and refined many advances in medical, surgical, psychological, and rehabilitative care 

for Warriors who sustain severe combat injuries, particularly those with complex limb 

trauma and amputation. Most of these lessons learned and advanced techniques are 

described in the Textbooks of Military 

Medicine’ Care of the Combat Amputee, 

published by the Borden Institute in 2009. 

Additionally, several joint DoD and VA 

CPGs have been developed to promote 

standardized optimal care for combat casualties with TBI, spinal cord injury (SCI), 

hearing and/or vision loss, polytrauma, and 

limb loss. 

BEST PRACTICES IN 

DEFINITIVE CARE AND 

REHABILITATION 

SURGICAL PRACTICES 

The basic tenets of war surgery apply to all 

combat wounds. These include: 1) Aggressive and frequent debridement of all contaminated wounds; 2) preserving as much viable tissue as possible; and 3) leaving the 

wound open until ready for definitive closure. The timing of definitive closure is 

often based on the surgeon’s direct observation of the wound. Recent research suggests that laboratory analysis of wound effluent may offer a more scientific method 

to making this decision. 

Despite the advances in prosthetic technology, when patients present with severe bilateral lower limb injury, it is still preferable 

to attempt salvage by whatever means 

available (circular frames, free tissue transfer, etc.) if the casualty will physiologically 

tolerate the procedure. If function of the 

lower limb is not satisfactory after reconstruction and rehabilitative efforts, an elective amputation may be considered. 

For the lower limb amputee with severe upper extremity injury, all efforts should be 

made to preserve as much function of the 

upper limb. In these circumstances, stability and optimum upper limb function become even more important because the upper limb will be required for transfers and 

wheelchair use. Therefore deliberate or 

permissive fusion of the wrist, elbow or 

shoulder may be preferred to an unstable or 

painful limb that is more mobile. 

Providing adequate soft tissue coverage for 

individuals with multiple limb loss and extensive soft tissue wounds can be extremely 

challenging because of the lack of adequate 

donor sites. Furthermore, great care must 

be taken to not disturb remaining limb or 

trunk function by harvesting nerve, bone, or 

soft tissue. The use of vacuum dressings 

helps to improve wound healing and skin 

graft acceptance. 

With multi-limb amputations, it is better to 

have different surgical teams simultaneously working on their respective limb, rather 

than performing sequential surgeries. This 

approach reduces operative and anesthesia 

time, enhances surgical communication, 

and helps to reduce longer lapses of deep 

venous thrombosus (DVT) prophylaxis and 

nutritional support. 

CENTERS OF EXCELLENCE 

To provide care optimally for Service 

Members who sustain DCBI, specialized 

centers are needed that have both the experience and subspecialists necessary to provide comprehensive medical, surgical, behavioral health and rehabilitative care. It is 

well recognized that advanced skills are 

developed through a combination of education and experience. 
28 

By seeing a high volume of patients at a 

few selective facilities, the medical system 

will maintain and build expertise. In addition, having a large concentration of individuals with similar combat injury patterns 

creates a better therapeutic milieu for recovery. Not only is the patient able to 

share experiences and help motivate each 

other, but his/her Family is able to build 

relationships with other Families who are 

going through the same process. 

Other advantages of focusing care of these 

individuals at select treatment facilities, 

include: access to advanced equipment and 

technology; ability to build and refine specialized treatment and support services; optimization of patient and Family education; 

and the ability to form partnerships with 

outside organizations, such as the VA, industry manufacturers, academic institutions, leaders in science and technology, 

and civilian and governmental support 

groups, including Veteran Service Organizations. 

Data reported to the Limb Loss Panel of the 

Defense Health Board indicate rehabilitating Warriors do better when working together with other Wounded Warriors. Dr. 

Messinger documented clear emotional and 

physical healing benefits when peers and 

peer Families interact. He also demonstrated rehabilitation from traumatic injury has 

to move along multiple dimensions, taking 

into account both the physical body and the 

social world the patients have inhabited and 

will inhabit. This supports the strong interdisciplinary team processes currently in 

place. 

AGGRESSIVE AND 

COMPREHENSIVE PAIN 

MANAGEMENT 

Optimal pain control should be the goal in 

treating all DCBI Warriors. This should 

occur at all echelons of care. During the 

definitive care period, the use of multiple 

peripheral nerve blocks is often helpful in 

managing multiple limb trauma and/or amputation. Intravenous use of opioids and/or 

NMDA receptor agonists, such as ketamine 

can also be effective, but should be managed by a physician with pain experience. 

The use of multimodal medications, including membrane stabilizers, antidepressants, 

and topical preparations, may be effective 

in treating neuropathic and phantom limb 

pain. This approach along with access to 

Complementary and Alternative Medicine 

(CAM) interventions, such as acupuncture 

and meditation can be very helpful at improving pain and reducing the need for excessive opioids. Although no studies have 

reported on the incidence of persistent 

phantom limb pain among multiple limb 

amputees, anecdotal reports do not suggest 

a significant increase in this patient population. It is more likely that one, rather than 

all, limbs will be problematic, and also 

more likely the affected limb will be an upper extremity. 

As in all patients, the use of opioids should 

be monitored closely. It is imperative to 

teach people to adjust to some level of 

chronic pain. There are significant sideeffects to many current treatments for pain. 

Sports, recreation, meditation, and other 

activities may help. Young patients will 

often develop an early tolerance to opioids, 

which can be treated best with opioid rotation, adjuvant medications and modalities. 

Furthermore, all members of the treatment 

team must be sensitive to the fact that opioids with or without alcohol may often be 

used to self-treat conditions such as depression, anxiety and sleep disturbances. Pain 

and Behavioral Health Specialists should be 

readily available for this patient population. 

In addition, provide the Warrior access to 

CAM. 

HOLISTIC CARE 

The focus of care must be directed to the 

individual patient and his/her Family rather 

than a specific limb, surgical wound, or 
29 

medical issue. Additionally, community 

leaders, employers and municipal planners, 

as well as DoD leadership, must enhance, 

educate, and manage expectations, as these 

individuals reintegrate into functioning and 

productive members. This requires comprehensive interdisciplinary care with frequent meetings to facilitate communication 

and creative thinking to help overcome significant obstacles to care. 

FAMILY PARTICIPATION 

Providing Families and non-medical attendants (NMA) opportunities to participate in 

the care of the DCBI patient represents a 

significant advancement in the approach to 

healthcare. This fosters Family support, 

patient motivation for recovery, and the 

promotion of independence. Family members are often the first to note morale 

changes and risky behavior. They need 

training, and will benefit from healthcare, 

particularly behavioral health training, during their displacement. For casualties with 

severe injuries requiring extensive assistance for independent activities, the military should have the ability to provide 

NMA orders to more than one person. 

EARLY REHABILITATION 

Rehabilitation has been viewed traditionally along the continuum of care after all 

acute medical and surgical issues are 

treated. In addition, many individuals believe that “rehabilitation” is the role of the 

Veterans Health Administration (VHA), 

rather than the DoD. This has been demonstrated to be outdated. In fact, improved 

function results ultimately from earlier rehabilitation implementation. 

It has been proven that early rehabilitation 

throughout the acute medical and surgical 

period is essential for success. By preventing secondary complications that are often 

associated with immobility such as muscle 

atrophy, decreased cardiovascular and pulmonary reserve, joint contractures, venous 

clot formation, etc., better short- and longterm outcomes may be achieved. Furthermore, building independence in activities of 

daily living, such as grooming, bathing, 

toileting, and feeding helps build confidence, motivation, and independent mobility, and it reduces depression and anxiety. 

REHABILITATION LESSONS 

LEARNED 

In the field of rehabilitative medicine, best 

practices and lessons learned include the 

following: 

Optimal TBI and SCI care are best achieved 

in partnership with specialized VA facilities. Currently, traumatic amputee care is 

most highly developed within the DoD. 

Rehabilitation plans should be goaldirected in a step-wise fashion to set challenging goals appropriate for each stage of 

recovery. 

Early introduction to wheelchairs and 

wheelchair skill training can help multilimb amputees begin the reintegration 

process sooner. These Warriors require 

proper wheelchair selection, fit, and training. 

Multi-limb amputees require specialized 

therapy treatment protocols, to include a 

patient-focused, higher therapist-patient 

ratio. 

Highly skilled and experienced prosthetists 

are necessary to fabricate and fit advanced 

technology prostheses. 

Socket comfort and suspension for individuals with hemi-pelvectomy, hip disarticulation, and high transfemoral amputation is 

very challenging. Novel solutions to this 

have been developed within the DoD by 

partnering with industry. 

Upper limb prosthetics remain inadequate 

for transhumeral and shoulder amputees. 

Continued effort needs to be made on the 

Defense Advanced Research Products 

Agency (DARPA) project. 
30 

Return to vocation is influenced by multiple factors, requiring the need for access 

to highly skilled Vocational Rehabilitation 

specialists. 

The use of Assistive Technology (AT) is 

often needed to improve functional independence. Partnering between the DoD and 

VA has increased injured Service Members’ 

access to AT specialists 

ADAPTIVE SPORTS 

Programs that encourage, promote, and 

support a return to sports and recreational 

activities often have a profound positive 

effect on individuals recovering from 

DCBI. These programs enhance confidence, community integration, and motivation, as well as skill development and perception of self. 

GOAL SETTING PROGRAMS 

The Army Center for Enhanced Performance (ACEP) originated at the United 

States Military Academy (USMA) as a systematic educational and developmental 

process to enhance adaptive thinking, mental agility, and self-regulation skills essential to the pursuit of overall personal 

strength, professional excellence, and the 

Warrior Ethos. 

Grounded in cutting edge performance psychology and academic strategies, the ACEP 

utilizes realistic and engaging virtual environments to reinforce its principles. The 

mental skills training develops the Warriors 

and their Families’ full potential of personal strength, professional excellence, and the 

Warrior Ethos. 

The ACEP has migrated across Army installations, including WRAMC for use with 

its Wounded Warriors. 

Within ACEP, the Comprehensive Soldier 

Fitness-Performance and Resilience Enhancement Program (CSF-PREP) provides a 

systematic way to build mental and emotional strength using scientifically tested, 

evaluated, and validated education methods 

from the fields of sport and performance 

psychology. The CSF-PREP goal setting 

training for WRAMC’s Wounded Warriors 

and their Families includes a comprehensive goal setting plan. The Wounded Warriors’ personal outcome goals are broken 

down progressively into priority goals, 

plans of action and attitude statements for 

goal accomplishment. This increases focus, 

purpose, motivation, direction, selfconfidence, persistence and creative strategies to increase the chances of success. 

The physical plan provides the Warrior 

with a guide that can be monitored and applied for continued success. 

Examples of outcome goals for Wounded 

Warriors in the WRAMC CSF-PREP: 

"I am in the World Class Athlete 

Program." 

"I return to duty focused on all of 

the things that I can do." 

"I am an ultimate Warrior who is an 

excellent father, husband and 

Soldier." 

"I complete an Olympic distance triathlon." 

"I become a cadre member in the 

Warrior Transition Command." 

"I successfully transition into a productive career in the Department 

of Homeland Security." 

"I graduate from college in the Class 

of 2012." 

Examples of outcome goal priorities: 

"I attend all of my appointments and 

give 100%." 

"I research materials provided by 

my medical providers." 

"I make use of the educational opportunities provided to me as a 

WT." 
31 

"I go to the park with my daughter 

three times each week." 

"My wife and I have a date night 

one time each week." 

"I work out four times per week for 

45 minutes." 

"I meet with financial services to 

create a budget." 

"I celebrate my success to keep me 

motivated." 

"I manage my time and study for 

one hour each night, giving myself one night off each week." 

Examples of attitude statements: 

"I am all that I want to be." 

"I go further every day." 

"I have no regrets." 

"If he can, I can." 

"I've still got it." 

"My Family and friends are here for 

me." 

"I'm stronger now than I ever was." 

"Through tragedy comes strength." 

The benefits of goal setting and that of its 

aggressive and relentless pursuit appear to 

be long-lasting in the realm of emotional 

and physical healing.

INTEGRATED CASE MANAGEMENT 

SYSTEM 

Skilled and experienced case managers are 

critical for the care of DCBI Warriors. 

They promote healthcare coordination, 

medical appointments deconfliction, and 

enhanced communication between the 

treatment team and patient. These individuals maintain up-to-date information on 

available support services from numerous 

government and nongovernmental organizations. They also facilitate better communication between the clinical team and the 

Warrior Transition Unit (WTU) staff and/or 

the patient’s unit liaison representative. 

DOD-VA PARTNERSHIP 

To provide optimal short- and long-term 

care for DCBI patients, the DoD and VA 

treatment and support programs must complement each other. VA facilities, primarily those designated as Levels 1 or 2 Polytrauma Centers, are well staffed and 

equipped to provide expert care to severely 

injured Service Members. Many of these 

facilities may also offer geographic advantages to a Service Member’s home or social 

support system. Early dialogue should take 

place between the DoD and VA facilities 

for each patient to establish the most effective comprehensive care plan maximizing 

available expert services. 

Continuity of care between the DoD and 

VA is greatly enhanced by establishing 

team video teleconferencing prior to transferring care from one facility to another. 

Enhanced communication also allows for 

the sharing of best practices, development 

of clinical practice guidelines (CPGs), and 

clarifying patient and Family expectations. 

The VA has recently established a number 

of Transition Rehabilitation Programs to 

help better support individuals with disabilities return to their communities and vocation. Additionally, community-based support organizations provide assistance. 

PROXIMITY OF OUTPATIENT 

SUPPORT SYSTEMS 

Many DCBI Warriors will require extended 

acute and sub-acute rehabilitation given the 

number of injuries and impairments they 

must overcome. This often involves the 

fitting and training of more than one prosthetic limb; additional challenges with 

achieving comfortable prosthetic socket 

fittings given the often proximal limb amputation and extensive soft tissue scars and 

wounds; the frequent need of ongoing reconstructive surgeries; co management of 
32 

other injuries such as sensory loss (vision, 

hearing), balance difficulties, pain syndromes, and behavioral health problems. 

Access to accessible post housing and 

transportation are critical for this care. 

EDUCATION AND RESEARCH 

PROGRAMS 

Ongoing educational programs, especially 

graduate medical education (GME) programs, are critical to provide optimal definitive care for DCBI Warriors. Militaryunique curricula ensure the house staff develop the skill set needed to treat complex 

injury patterns seen in this patient population. 

In addition, an active research program is 

essential to discover novel interventions to 

improve the quality of life of DCBI Warriors. 

CHALLENGES AND ISSUES 

WITHIN DEFINITIVE CARE 

AND REHABILITATION 

While a unique pattern of injury has been 

observed in Service Members who sustain 

DCBI, previously published reports offer 

some insight to many problems these individuals will face during their recovery and 

rehabilitation. A recent survey conducted 

on Vietnam and OIF/OEF casualties with 

limb loss provides important data that the 

military should consider when developing 

comprehensive definitive care programs. 

Overall supplementary wheelchair use averaged 32% for Vietnam veterans and 53% 

for OIF/OEF veterans. Among OIF/OEF 

members, 83.3% of bilateral lower-limb 

loss and 77% of multiple limb loss (including arm and leg) reported supplementary 

wheelchair use compared to 46% and 56% 

respectively in Vietnam Veterans. 

Approximately 25% of OIF/OEF amputees 

are already reporting arthritis. Vietnam 

veterans report a frequency of 64.4%. 

Reported problems with persistent pain 

(chronic back pain > 36%; phantom pain > 

72%; and residual limb pain > 48%) are excessive. 

Over 50% of individuals with limb loss report frequent skin problems on the residual 

limb (51% Vietnam veterans and 58% of 

OIF/OEF veterans). 

Mental health problems, such as depression, anxiety and PTSD occur commonly 

after military deployment, ranging from 15 

to 17%, as compared to the 9.3% observed 

prior to deployment. Recent evidence suggests this number is much higher for individuals who sustain a combat related amputation. Reports suggest nearly 66% of 

combat amputees have at least one behavioral health diagnosis, much greater than 

the 20-30% rate commonly reported in the 

general traumatic amputee population. In 

addition, the likely higher incidence of depression in combination with PTSD for individuals who sustain DCBI increases their 

risk of a slower recovery, distress, and suicidal behavior. 

Hearing loss is present in 47% of Service 

Members and veterans with traumatic limb 

loss. 

Anecdotal observations note more of a psychological burden for young males who 

sustain severe genital injuries. This needs 

additional investigation and research. 

While the rates of return to vocation and 

meaningful community participation are 

unknown for Service Members who sustain 

DCBI, the overall national statistics for returning to work after a severe disabling injury remain low. 

PROSTHETIC ABANDONMENT 

Among war veterans with multiple-limb 

loss, 68% of Vietnam veterans and 92% of 

OIF/OEF veterans use at least one prosthet-
33 

ic device. With regards to those who sustain bilateral upper limb loss, between 55 to 

60% of Vietnam veterans and 40 to 45% of 

the OIF/OEF veterans do not use prostheses 

at all. This data suggests a relatively high 

dissatisfaction with upper limb prostheses 

in both groups, as well as a higher rejection 

rate for the Vietnam group. 

In fact, 30% of Vietnam amputee group and 

22% of the OIF/OEF group reported total 

prosthesis abandonment. This difference 

was even more significant for individuals 

with multiple limb amputation. Over 29% 

of Vietnam veterans with multiple limb loss 

abandoned the use of any prosthetic support. 

The most frequent reason for prosthetic abandonment among the OIF/OEF group was 

that their residual limb was too short 

(30%), whereas the Vietnam group reported 

that the prosthesis was “too much fuss” 

(57%). 

Interestingly, in both the Vietnam and 

OIF/OEF group, those who were more likely to abandon the use of their prosthesis 

had undergone a hip disarticulation amputation, illustrating the additional challenges 

posed with using a prosthetic device at a 

higher amputation level. It was shown previously the energy cost of ambulation is 

much higher in an individual with an above 

knee amputation (AKA) than a below knee 

amputation (BKA). This increase in energy 

demand is even more pronounced for individuals with a hip disarticulation or bilateral above knee amputations, patterns of injury commonly seen in the DCBI population. 

It is not surprising that Vietnam veterans, 

particularly those with a high-level or bilateral lower extremity loss, report a greater 

rate of prosthetic abandonment than 

OIF/OEF veterans. As veterans age, they 

typically experience a generalized decrease 

in overall strength and endurance, making it 

more difficult for them to use a prosthesis. 

Aging also makes it more difficult for them 

to continue to compensate for other comorbid battle injuries, such as fracture, soft 

tissue loss, TBI and post-traumatic stress 

disorder (PTSD). 

Additionally, it is likely long-term secondary complications of limb loss, such as 

arthritis, pain, diabetes and cardiovascular 

disease also contribute to prosthetic abandonment over time. The Task Force feels 

confident newer prosthetic technology, advances in medical, surgical and rehabilitative care, and a greater emphasis on fitness 

and a healthy lifestyle will help mitigate 

this abandonment rate in the future. 

QUALITY OF LIFE 

Upper limb prosthetics continue to be inadequate for those with transhumeral and 

shoulder amputations. Advances in upper 

limb prosthetic technology is on the horizon, although, more effort must be made to 

translate this technology to the clinic. 

Of particular interest to the DCBI Task 

Force, survey results indicate individuals 

with multiple limb amputation report a better overall quality of life (QOL) than those 

with single limb amputation. This effect 

was observed among both Vietnam and 

OIF/OEF veterans. In the Vietnam group, 

among participants with unilateral lowerlimb loss, 26.4% reported a better QOL, 

44.9% reported a good QOL, and 28.7% 

reported a worse QOL. In the Vietnam vet 

group with multiple limb loss, 47.2% reported a better QOL. 

In the OIF/OEF group with unilateral lower-limb loss, 50.3% reported a better QOL, 

38.0% reported a good QOL, and 11.7% 

reported a worse QOL. Among multiple 

limb loss amputees, over 50% of responders 

reported an overall better QOL. 

The authors of this study speculate that individuals who sustain multiple limb loss 

from war often experience more injuries 

and as a result are grateful to be alive and 

have a more dramatic change in life priorities. For example, in one survey of people 
34 

with limb loss, participants with bilateral 

limb loss more frequently reported they 

considered something good had happened 

to their life (character building, more appreciation for life, developing coping abilities) because of the amputations. The Vietnam vets could show a stronger effect because the vets have had nearly 38 years to 

develop coping mechanisms. In contrast, 

OIF/OEF veterans had only had an average 

of 3 years to adjust to their injuries. 

HIP DISARTICULATION AND HEMIPELVECTOMY 

Very proximal lower limb amputations occur at a higher rate for DCBI casualties. 

Hemi-pelvectomy had been traditionally 

rarely seen in the trauma patient, because 

most patients with injuries at this level did 

not survive. Now, with of the advances in 

combat casualty care and expeditious use of 

tourniquets, many of these Warriors are 

now surviving on the battlefield. Definitive 

closure of this level of injury requires specialty trained surgeons. These cases are 

often associated with higher wound complication rates, such as pressure ulcer formation, cardiopulmonary dysfunction, limb 

contractures, and generalized deconditioning. 

HAND TRANSPLANTATION 

Individuals with bilateral upper limb loss, 

severe unilateral upper limb loss and visual 

deficits, bilateral lower extremity limb loss 

requiring prostheses or transfer independence may benefit from hand transplant 

surgery. Currently within the United 

States, several medical centers have ongoing research protocols to perform this procedure. Post-transplant rehabilitation is 

critical for success. The Army SG chartered a specialty advisory board to ensure 

patients and their Families receive adequate 

screening and education about this procedure. Notably among these risks is the 

post-transplant requirement for lifelong 

immunosuppressive therapy. Navy Medicine’s Executive Research Advisory Board 

(ERAB) and Emerging Therapeutics Validation Panel (ETVP) advises Navy/Marine 

Corps leadership on cutting edge medical 

treatments and technologies in response to 

requests for information (RFI) from patients, patient care providers, and Service 

Line and Staff leadership. 

TRAUMATIC BRAIN INJURY 

Unpublished data obtained from the Department of Orthopedics & Rehabilitation 

at Walter Reed suggest the co-existence of 

traumatic brain injury (TBI) is essentially 

the same for single limb loss (40%) compared with multiple limb loss (41%). 

Because of the high rate of TBI in combat 

casualties, including those with DCBI, 

access to TBI rehabilitation services are 

needed during the acute, subacute, and 

chronic care of this patient population. 

Highly skilled neuropsychologists, case 

managers, behavioral health specialists, rehabilitation counselors, speech language 

pathologists, occupational and physical therapists, as well as TBI physicians, are 

needed to co-manage these patients. Typical co-existing symptoms include: headache, cognitive impairment, balance difficulty, and behavioral changes. Novel 

treatment strategies include supervised selfpaced computer learning activities, and 

cognitive behavioral therapy principles applied to more traditional physical and occupational therapy. 

AGGRESSIVE INFECTION 

SURVEILLANCE 

Although definitive data does not exist, 

military providers report that DCBI wounds 

are particularly susceptible to infection, 

and that the risk of infection (especially 

fungal infection) is even greater when multiple limbs are involved. Therefore this 

patient population will likely require a 

more prolonged antibiotic use and a higher 
35 

risk of wound failure, necessitating additional trips to the operating room. 

Given this increased infection risk, aggressive institutional infection control policies 

must be established and enforced to help 

reduce the added risk of nosocomial infections. Institutions providing definitive care 

to this patient population should have 

skilled and experienced Infection Disease 

Specialists and Infection Control experts. 

PREVENTION AND TREATMENT OF 

SECONDARY COMPLICATIONS 

While the risk of venous thrombus formation—DVT and its complication, pulmonary 

thromboembolism (PTE)—are higher in the 

combat amputee population (30%), data is 

currently not available on the incidence of 

DVT or PTE for individuals with DCBI. 

Special consideration should be made as to 

the timing of DVT prophylaxis in the setting of multiple surgical interventions. 

GENITOURINARY (GU) 

RECONSTRUCTION 

GU interventions must be performed in 

multiple stages. If extensive soft tissue is 

lost, finding adequate tissue to cover these 

wounds or perform reconstruction is more 

challenging. Individuals with DCBI and 

genital injury will often require a protracted inpatient/outpatient stay. It is best 

if these injuries are managed by the same 

surgical team over time rather than transferring care elsewhere. 

Because of this, provisions must be made to 

have adequate staffing, housing, administrative, and medical support at Role V facilities to provide protracted care for these 

individuals. Currently, there are a limited 

number of providers (civilian and military) 

who perform phallic reconstruction surgery—thus indicating the need to train 

more military urologists and plastic surgeons in these techniques. 

GENITAL LOSS AND HORMONAL 

CONCERNS 

While GU injuries present complex surgical 

and behavioral health challenges, other 

medical issues must be addressed. Low testosterone levels have been reported after 

trauma, serum testosterone levels are significantly reduced. Therefore testicular 

loss will only complicate further hormone 

deprivation. 

The role of hormone replacement to promote soft tissue and nervous tissue healing 

has not yet been determined. It is also unknown when the optimal timing for replacement should begin. Given the longterm needs of hormonal replacement and 

monitoring, systems should be established 

to provide life-long care by medical specialists in this area. Related problems of 

infertility also require needed attention. 

All Service Members who sustain DCBI 

(with or without genital injuries) should 

have access to fertility expert consultation 

as needed. 

THE ROLE OF THE PRESS 

By increasing public awareness of the sacrifices and challenges Service Members 

and their Families confront, there appears 

to be a better acceptance to disability, improved access to community participation, 

and decreased negative stigma to body disfigurement and the scars of war. 

IMPACT TO CARE TEAM WITH 

LONG TERM MANAGEMENT OF 

PATIENTS WITH THIS INJURY 

Individuals caring for these patients—the 

physicians, nurses and medics—expend a 

great deal of personal resources to maintain 

a positive attitude throughout their provider-patient relationship with these wounded 

Warriors. Provider resiliency is a key 

component for the well-being of the team. 

This important aspect cannot be overlooked. 
36 

WHOLE-PERSON 

APPROACH TO HEALING 

PROTECTION 

Project Manager Soldier Protection and Individual Equipment (PM-SPIE) is leading a 

consortium of organizations in researching 

ballistic undergarments. The objectives are 

to define the threat, characterize capabilities and limitations of commercially available products, and recommend a path forward (development through production and 

fielding). The consortium membership includes representatives from the United 

States Army Product Manager Soldier Protective Equipment (PM-SPE), the United 

States Marine Corps (USMC) Program 

Manager for Infantry Combat Equipment 

(PM-ICE), Army Research Laboratory 

(ARL), Navy Research Laboratory (NRL), 

Natick Soldier Research Development & 

Engineering Center (NSRDEC), and the 

Joint Trauma Analysis and Prevention of 

Injury in Combat (JTAPIC) Program. 

 

 

 

 

 

 

 

 

The Joint Trauma Analysis and Prevention 

of Injury in Combat (JTAPIC) partnership 

has conducted an analysis of GU injuries 

for relevant incidents. While it conveys the 

statistics related to GU injuries, it does not 

contain any information regarding the blast 

threat mechanism (e.g., blast effects: penetration, overpressure, blunt trauma) of the 

wounds and whether they could be countered by a low level of protection. 

 

 

(b) (7)(F)

(b) 

(7)

(F)

(b) (7)(F)
37 

 

MEDCOM can provide the consortium specific information on wound data to assist 

with protective garment design. Up to 40% 

of pelvic and groin injuries may be mitigated through additional protection. 

What is of critical importance to the material developer is an understanding of the 

size and quantity (distribution) of fragments causing GU injuries and to what 

depth they are embedded in the tissue. This 

data would allow reverse engineering of 

kinetic threats and provide a basis for requirement and product specification development. A MEDCOM perspective on the 

amount of, and complications from, dust 

and debris in the wound area would provide 

valuable insight on the benefit of a specific 

undergarment as a countermeasure. 

 

 

The ARL is working to produce a means of 

propelling sand at high velocity so that a 

repeatable measure of resistance to penetration can be made of various candidate materials and systems. In addition, they hope 

to correlate this to known threat mines so a 

meaningful description of the threat can be 

defined. 

While the test fixture and methodology are 

nearly complete, the characterization of this 

threat and material screening is expected to 

continue into 3QFY11. ARL is also correlating the probability of injury through 

from modeling and simulation. These models, compared to actual injury data, would 

provide useful tools to understand the area 

of coverage required and would help confirm the threats needed. 

UROLOGIC 

CONSIDERATIONS, ISSUES 

AND INTERVENTIONS 

In the most recent few years of overseas 

contingency operations there has been a 

sharp increase in the number and severity 

of injuries to the external genitalia and 

lower urinary tract primarily in dismounted 

troops. The reasons for this are multifactorial and addressed in other portions of 

this report. 

There are several areas where military 

urology can provide their expertise in providing state of the art care for these complex injuries. 

The first area is in the area of improving 

protection for the external genitalia, groin 

and perineum. 

 Urology is involved with the Natick Soldier Research, Development, and 

Engineering Center to look at innovative 

ways to provide protection for our Warriors. 

Providing individual protection is about 

striking the right balance among many 

competing factors, including level of protection; weight and bulk of materials; mission and environment; hygiene, etc.). Having Warriors and medical experts provide 

input helps achieve that balance, as we 

work to provide improved Warrior protection capabilities with our PM partners. 

After receiving initial resuscitative and 

life-saving treatments at Roles I and II 

echelons, patients often obtain their comprehensive surgical care at level III facilities by general surgeons. Historically, the 

(b) (7)(F)

(b) (7)(F)

(b) (7)(F)
38 

care provided has often relied on the experience and training of the on-site surgeon. 

Previous reports from OIF show that having 

a deployed urologist available in the CSH 

may result in a better rate of testicular salvage. While it would be difficult to determine if the current testicular injuries are 

salvageable, it is likely that having a specialty-trained urologist available in theater 

would be a positive factor in addressing 

these often-complex injuries. Additionally, 

urologists likely have a broader knowledge 

of the future reconstruction strategies anticipated for major penile, scrotal and urethral 

injuries that should be taken into consideration during acute resuscitation. Having a 

urologist available in theater might provide 

additional training for other providers and 

allow for more seamless consultation 

among the medical areas that are initially 

receiving these injuries. 

There are fewer concerns once Warriors 

with complex urological injuries reach 

higher echelons of care that have fellowship-trained urologists. Military urology 

has incorporated complex GU reconstructive techniques among its residency training 

programs. 

The JTTR has been a valuable resource in 

identifying certain injury patterns and demonstrating at-risk populations, but it lacks 

the ability to provide longer term outcome 

data. Army urology is involved in designing research to follow these injuries in a 

longitudinal manner to track long-term urological disabilities (e.g., voiding dysfunction, erectile dysfunction, and infertility) 

and to correlate these complications with 

initial management. It also would be helpful to partner with Behavioral Health to 

study the long-term psychological effects of 

complex genital injuries. 

Opportunities also exist for military urology to partner with civilian organizations 

and institutions to further study and provide 

quality care for wounded Warriors with 

complex GU injuries. The American Urological Association has appointed a special 

task force to study and make recommendations regarding genitourinary trauma. The 

Military will play an important role on this 

project. 

Having urology specialists in the ATO 

makes a difference in providing expert care 

during acute resuscitation. Waxman published his experience in theater, noting an 

excellent testicular salvage rate following 

exploration. To this end, the Army SG directed that the ATO’s Role III have a staff 

urologist assigned at all times. 

NEUROLOGICAL 

CONSIDERATIONS, ISSUES 

AND INTERVENTIONS 

Explosive mechanisms are the leading 

cause of TBI for active duty military personnel in war zones. In the DBCI setting, 

with substantial blast force as the primary 

mechanism of injury, it is especially crucial 

to perform TBI screening, as it can be under-recognized, given the gravity and 

enormity of other life threatening injuries. 

DoD has implemented a brief (fourquestion) TBI screening (BTBIS) tool that 

can be followed by more formal cognitive 

assessments if TBI is suspected clinically. 

Blast force produces multiple mechanisms 

for TBI, including direct structural brain 

injury and secondary injury from hypoxia, 

hypoglycemia, or hypotonic fluid resuscitation of severe polytrauma. In this setting, 

the specific challenges of TBI include, but 

are not limited to, increased seizure risk, 

adverse effects of over-medication, and an 

ongoing barrier to rehabilitation programs 

that require intact attention, memory and 

learning skills for maximum recovery. 
39 

PSYCHOLOGICAL 

CONSIDERATIONS, ISSUES 

AND INTERVENTIONS 

Due to continuing advances in the trauma 

care and management, an increasing number of casualties are surviving severe battlefield trauma. As these Warriors survive 

their severe injuries, they face significant 

challenges in the emotional, cognitive, spiritual and physical aspects of recovery. 

Recent trauma literature suggests a high 

propensity for post-injury depression and 

post-traumatic stress disorder (PTSD) 

among severely injured individuals. These 

studies demonstrate prolonged and profound dysfunction (physical and emotional) 

that is oftentimes underestimated by healthcare providers. 

With this in mind, behavioral health (BH) 

specialists’ goal for these patients is to 

maximize their potential for emotional, 

mental, spiritual and physical recovery. 

BH care focuses on improving the Warrior’s quality of life, increasing his/her 

functional abilities, and addressing residual 

psychological issues or complications. 

Regarding the question of genital 

loss/damage early on the injured might find 

it overwhelming to talk about it. However, 

timing will be important and it might be 

best for a patient with a prolonged hospital 

course, or especially after the patient's transition to an outpatient setting. 

Probing too deeply or "encouraging," the 

patient to talk about it before they are ready 

would be intrusive and potentially undermine the patient's ego defenses which they 

need to continue to function. Making them 

aware that physical intimacy is a topic that 

we can address and treating it in a normalized manner could be productive. Specialized sex instructions with marital or intimacy counseling can be beneficial. 

This issue might be more germane after the 

acute phases of intervention are completed 

and could be initiated upon the transition 

from inpatient to outpatient. Having a 

trained sex therapist within either BH or 

Physical Medicine and Rehabilitation 

(PMR) Services could provide consultation 

to not only the Psychiatry Consultation 

Liaison Service (PCLS), but to other services, as well. 

Specific BH tasks during the definitive care 

and rehabilitative phases of recovery include: 1) Appropriately assessing the injured Warrior’s emotional status and needs; 

2) establishing a comprehensive treatment 

plan to address assessed issues/needs; 3) 

recognizing expected emotional responses 

and complications which require intervention; 4) providing comprehensive psychiatric support to the Warrior and his/her Family through his/her transition from inpatient 

to outpatient status, and then as he/she adjusts to community interactions; 5) providing individual, group and medical management treatment; and 6) facilitating all BH 

needs through the Warrior’s nurse case 

manager. 

The Marines receive behavioral health 

support specifically from Navy Medicine, 

although, they may receive trauma care 

from the other Services. The Marine Corps 

Operational Stress Control and Readiness 

(OSCAR) program embeds behavioral 

health personnel with ground combat 

elements at the regimental level to provide 

primary prevention, early detection, 

intervention, and command consultation. 

These providers are augmented by trained 

primary care providers and religious 

personnel (OSCAR Extenders), and junior 

leaders and Marines (OSCAR Mentors). 

Beyond the POI, OSCAR personnel play a 

minimal role in the injured Marine’s 

medical care, but have a significant task in 

helping to provide psychological first aid to 

both the affected Marines and their unit. 

Any comprehensive BH plan must 

recognize that military BH personnel 

typically have limited experience dealing 

with DCBI Warriors. To handle these 

patients appropriately, the BH specialist 

will need additional specialized training to 
40 

manage the unique challenges these 

Warriors place on the system. It must also 

recognize that multiple amputees are at 

increased risk for BH challenges, and that 

the critical nature to providing a seamless 

provision of care from Active Duty to 

Veteran/Retiree status, which requires 

dedicated case management. 

REHABILITATION 

CONSIDERATIONS, ISSUES 

AND INTERVENTIONS 

CENTER SELECTION 

DCBI casualties should be evaluated by rehabilitation specialists within 72 hours of 

admission to the definitive care hospital. 

Based on the degree of injury, impairment, 

and likely course of recovery, early discussion should be initiated between the rehabilitation specialists, treating team, patient, 

and Family. Issues of critical importance 

to discuss include: 1) The presence of a 

SCI; 2) significant TBI; 3) presence or likelihood of major limb loss; and 4) geographic location of the patient’s support structure. 

Every effort should be focused on getting 

the injured patient to the facility that best 

meets his/her medical, surgical, rehabilitative, psychological, and social needs. 

Therefore it is essential for DoD practitioners to have current understanding of the 

DoD and VA capabilities at each of their 

major medical centers. 

A fundamental principle is that rehabilitation requires both a re-learning of old skills 

as well as the acquisitions of new skills. 

This becomes most difficult for a TBI patient impaired by severe cognitive deficits. 

Therefore, these patients are best treated at 

a facility with expertise in inpatient TBI 

rehabilitation, particularly one of the designated VA polytrauma centers. 

Similarly, it is widely recognized that SCI 

patients are best treated at a center specializing in SCI care and rehabilitation. The 

VA currently has 23 SCI Centers throughout the United States. While many DoD 

providers and facilities offer expertise in 

various components of inpatient TBI and 

SCI care, the designated VA specialty facilities have more experience in providing 

comprehensive interdisciplinary care for 

individuals with these injuries. 

In addition to providing expert care, these 

VA sites also have several advantages over 

other civilian sites, to include expertise in 

initiation and educating patients about the 

VA disability benefits, entrance into vocational rehabilitation programs, access to 

assistive technology (e.g., cognitive aids, 

wheelchairs, orthotics), home modifications, continuity of long-term care, and military liaisons to link the Warrior with his 

home unit. 

The majority of the Amputee Programs 

within the VA system have focused care 

primarily on older patients with acquired 

amputations from disease (e.g., diabetes, 

vascular disease, etc.), which represent a 

different population than multi-limb DCBI 

amputees. In response, the military has developed three Amputee Centers of Excellence (Walter Reed and Brooke Army Medical Centers and Balboa Naval Medical 

Center that provide state-of-the art inpatient and outpatient rehabilitation). 

Coordination of rehabilitative care between 

the DoD and VA systems is significantly 

enhanced by the use of Video Teleconferencing (VTC). On a weekly basis providers within both systems are able to exchange ideas, share learning experiences, 

and better transfer care from one facility to 

another. In addition, having the patient and 

Family attend the VTC allows them to have 

a face-to-face introduction and conversation to the receiving treatment team, which 

helps to alleviate transfer concerns. There 

is currently very little cross-communication 

between the various electronic medical 

records, increasing risk of documentation 
41 

loss between the DoD MTFs and VA system. 

Multi-limb loss creates significant challenges to independence in one’s activities 

of daily living (ADLs) and mobility (e.g., 

sitting, transferring, standing, and walking). Experienced therapists and prosthetists should be embedded with the treatment 

and rehabilitation team to establish realistic 

goals with each patient in a manner that 

promotes success. 

For example, an individual with bilateral 

AKAs should first learn to stand independently on short prostheses, prior to initiating walking or lengthening the prosthesis. 

They also need early and advanced wheelchair skills. Achieving success at each 

stage of recovery with small milestones 

will result in better outcomes than attempting to push rehabilitation too fast. 

To help support this rehabilitation paradigm, the Amputee Care Program at Walter 

Reed has developed rehabilitation treatment 

protocols from consensus opinion among 

experienced providers. These are available 

among the DoD, VA, and civilian medical 

communities. 

ACCESS TO ADVANCED 

TECHNOLOGY 

Over the past decade significant advances 

have been made in prosthetics, orthotics, 

wheelchairs and other ATs. Given the significant challenges to regaining independence for the severely injured Warriors, 

access to these technologies is essential. 

Early introduction to a power or manual 

wheelchair typically results in a dramatic 

improvement in a Warrior’s mood as independent mobility is achieved. 

It is more common to require repeated prosthetic trials through the first year—before 

achieving the basic goals of independence 

with ADLs and ambulation. Experienced 

orthotists, prosthetists, and AT specialists 

are required to optimize the fit and function 

of these technologies. Novel suspension 

systems, upper limb prostheses that support 

crutch ambulation, and motorized wheelchairs with customized user controls and 

power seat functions represent some of the 

common needs of this unique patient population. 

Technological advances have also been 

made in rehabilitation devices. The use of 

simulators (e.g., Fire Arms Training System 

(FATS)), virtual reality environments (e.g., 

Computer Assisted Rehabilitation Environment, or CAREN), and mobility training 

aids (e.g., Solo-Step®) have all helped in 

providing comprehensive rehabilitation for 

DCBI patients. 

SPECIALIZED AND EXPERIENCED 

STAFF 

While much attention has been given to the 

advances in technology, the technology is 

useless without experienced therapists who 

can teach patients how to make the best use 

of that technology. A humanistic quality is 

essential to promote recovery and rehabilitation. 

Setting realistic goals, monitoring and assessing barriers to advancement, and application of therapeutic exercise promote maximum outcomes. A therapeutic and trusting 

relationship between the provider and the 

patient helps to promote motivation, enhances behavioral health, and improves 

compliance with treatment. 

Optimal staffing ratios have yet to be determined for the DCBI patient. The Task 

Force’s consensus is the level of care for an 

individual with multiple limb injuries increases substantially with every severely 

impaired limb. 

One therapist may be able to supervise two 

to three patients with non-complicated 

trauma simultaneously, whereas the DCBI 

patient may require continued direct twoon-one physical therapy. This is also true 

for prosthetists, who must spend a signifi-
42 

cantly greater amount of time to fit and adjust a prosthesis for multi-limb or proximal 

amputations. 

Evidence demonstrates that Service Members with combat injuries, particularly limb 

loss, greatly benefit from peer visitors. 

Peer training programs exist at the DoD 

rehabilitation sites, as peer visitors are 

more effective once trained. 

VOCATIONAL REHABILITATION 

Return to vocation is influenced by multiple factors and is especially challenging 

for DCBI Warriors. Early instruction and 

continual follow up by vocational rehabilitation specialists can greatly improve return 

to work, education, and career development. 

Currently these services are provided by the 

VA but integrated within the DoD treatment 

sites. Providing vocational assessments 

and counseling, as well as coordinating efforts in an interdisciplinary fashion, will 

help alleviate patient and Family concerns 

and facilitate community reintegration. 

EMBEDDED BEHAVIORAL HEALTH 

SPECIALISTS 

Given the significant challenges to rehabilitation and recovery and the high incidence 

of secondary psychological problems 

among DCBI Warriors, Behavioral Health 

experts should be embedded within the 

acute, sub-acute, and chronic care treatment 

teams. At Walter Reed, experience has 

shown the implementation of Preventative 

Psychiatric Consultative Services has 

helped educate patients and Family, normalize alterations in mood, affect, and expectations, quickly identify problems for 

immediate treatment, and help remove the 

stigma associated with behavioral health 

diagnoses and treatment. 

Easy access to behavioral health experts in 

the therapy areas helps identify mood problems as they develop, promote early intervention, and facilitate interdisciplinary 

communication. It is not uncommon for 

DCBI Warriors to manifest psychological 

problems once they have completed their 

early phase of rehabilitation, sometimes 

years later, as they struggle with relationships, sense of self, and difficulties with 

obtaining and sustaining a fulfilling vocation. 

DRIVING REHABILITATION 

Independent driving is essential for individuals to successfully integrate back into 

the community. Driving Rehabilitation 

Specialists provide much needed support to 

ensure proper patient evaluation, training, 

assistive equipment modifications to a car 

or truck. They can also conduct certified 

road testing to meet independent driving 

and motor vehicle insurance requirements. 

PAIN MANAGEMENT 

CONSIDERATIONS, ISSUES 

AND INTERVENTIONS 

There have been significant advances in the 

treatment and tracking of battlefield pain. 

New technology, training, medications, and 

the US Army Pain Task Force’s progressive 

multimodal approach to pain treatment have 

begun to methodically transition pain 

treatment from an opioid-centric treatment 

to a multimodal comprehensive solution. 

SOF Medics are trained currently to perform peripheral nerve blocks at the POI 

with local anesthetics. This is proving to 

be of great benefit, as it: 1) improves the 

speed and quality of pain control; 2) increases the chance that the injured Warrior 

can shoot, move and communicate with the 

tactical unit, if needed; 3) mitigates the 

need for high doses of narcotics later in the 

course of treatment; and 4) decreases the 

likelihood of pain-driven post-traumatic 

stress. 
43 

Pain adjuncts such as IV acetaminophen, 

recently FDA-approved for US use, have 

proven useful in our Wounded Warriors 

during definitive surgery at Level IV facilities. This has a clear potential for battlefield use as a quick-acting pain adjunct. 

Intranasal ketamine, recently shown to have 

neuroprotective properties—and newer 

types of narcotics and methods of administration, such as patient-activated fentanyl 

transdermal systems and sublingual sufentanil tabs—may complement and, in certain 

situations, replace morphine as the drug of 

choice. 

The US Army’s Pain Task Force’s team approach to pain management is crucial in 

optimizing the Wounded Warriors’ immediate, acute, and definitive rehabilitation 

and recovery. Access to the full spectrum 

of pain control is necessary throughout the 

Warrior’s lifetime. 

SPIRITUAL 

CONSIDERATIONS, ISSUES 

AND INTERVENTIONS 

As a standard of care, all patients are assessed spiritually with the Spiritual Attitude Inventory (SAI). This is an evidenced-based instrument designed to assess 

the patient’s spirituality. In general terms, 

it allows the ministry team to follow the 

patient over time. It also nests well with 

the post-hospitalization comprehensive 

transition planning. 

The hospital ministry team works closely 

with behavioral health experts, particularly 

shortly after admission, to collaborate on a 

mutually supportive approach to the 

Wounded Warrior. The hospital chaplain 

community recognizes the unique challenges facing the DCBI Warrior, and more 

frequent spiritual assessments would be the 

norm. 

Anecdotally, we have seen our female 

chaplains excel at connecting with these 

DCBI and other Wounded Warriors. It is 

possible they represent a non-threatening, 

yet compassionate, fellow Warrior who can 

wade directly into the raw issues of perception and reality with these male DCBI patients and take on a similar role with the 

WWs’ spouses and fiancées. This requires 

further study, but it would be prudent to 

ensure the major Role IV sites for definitive care have at least one female chaplain 

on staff. 

 
44 

RECOMMENDATIONS 

GENERAL 

This report’s recurring themes can inform 

our leadership of current best practices and 

additional opportunities to more fully care 

for severely injured Warriors. The particular injuries described have severe, global 

effects on the Warrior, of course, but also 

affect their fellow Warriors, their Families, 

and their healthcare providers. 

The recommendations that follow are based 

on the DOTMLPF-C domain format (namely, Doctrine, Organization, Training, Materiel, Leadership, Personnel, Facilities, and 

Contracting). These recommendations are 

ordered from the most urgent and near-term 

imperatives to lower, but still important, 

priorities. 

While the majority of these recommendations address gaps in Army Operational 

medicine, they may not be supportable by 

all the Services. A multi-Service working 

group needs to formulate Joint solutions for 

the present ATO and future Joint medical 

missions. 

DOTMLPFC DOMAINS 

DOCTRINE 

 1. Initiate a ‘pilot’ solution to the POIto-Role II/III evacuation capability: 

 a. Evacuate urgent polytrauma casualties on RW platforms staffed with paramedics and flight nurses to include minimum of two attendees per critical (alpha) 

casualty. 

 b. Provide PRBCs and plasma on 

POI-to-Role II/III evacuation platforms 

routinely for critical casualties; administer 

at 1:1 ratio during flight. 

 c. Update system based on documented outcomes. 

 2. Overfly Role II echelons of care when 

evacuating an urgent polytrauma patient, if 

Role III site is less than 30 minutes away. 

 3. Mandate CoTCCC hypothermia prevention measures be followed and tracked. 

 4. Provide multimodal treatment and 

tracking of pain starting from the POI 

through stabilization, transport, and definitive treatment phases. 

 5. Elevate coordination of the Patient 

Evacuation Coordination Cells throughout 

the RCs within the ATO to IJC level. 

 6. Facilitate electronic medical information exchange between all echelons of care, 

including the VA and agencies involved 

with prevention, protection, and mitigation 

(beyond treatment). 

 7. Formalize relationship between 

MRMC (JTAPIC, OAFME, and JTTS), US 

Army Public Health Command, intelligence, operational, materiel communities 

and JIEDDO to optimize situational awareness, coordination and surveillance among 

all elements. 

 8. Direct and resource OAFME to conduct comprehensive, multi-disciplinary reviews of all combat deaths, with a focus on 

potentially survivable deaths. Every death 

must be reviewed, with information regarding preventability and cause of death entered into a searchable database within 30 

days of death. 

 9. Offer fertility medical services to any 

Service Member and spouse with combat 

injury-related infertility. 

 10. Enlist command attention to completion of TCCC card, and entering TCCC 

card information into the JTTR and electronic medical record (EMR) for all casualties; make this a USR item. 
45 

 11. Clarify shared responsibility between 

DoD Health Affairs and VA for the shortand long-term medical, surgical and rehabilitative care for Service Members who sustain DCBI. 

 12. Develop a military injury functional 

disability score 

 13. Consider employment of more capable 

MH-47, CV-22, or MH-53 RW evacuation 

platforms; engage in DoD efforts in articulating future vertical lift requirements and 

incorporate requisite MEDEVAC components. 

 14. Study optimal airway management 

and fluid resuscitation for polytrauma casualties. 

ORGANIZATION 

 1. Institutionalize the JTTS, and resource it and the Public Health Command 

to optimize their collective ability to track 

all phases of evacuation through proactive 

surveillance. 

 2. Develop appropriate medical surveillance systems that track severe injury and 

alert leaders when trends vary from historical/acceptable ranges. 

 3. Relook organization of Roles II and 

III echelons of care to best facilitate management of DCBI. 

 4. Enlist command emphasis on capturing pre-hospital casualty data. 

 5. Establish programs to prevent and mitigate DCBI complications, such as arthritis, chronic pain, heart disease, hypertension, obesity, diabetes and behavioral 

health disease. 

 6. Improve coordinating efforts among 

federal agencies to implement effective vocational rehabilitation for DCBI Warriors. 

 7. Establish Assistive Technology programs between MTFs and sister VA centers 

that address DCBI Warrior requirements. 

 8. Direct and resource the JTTS to provide case summaries and focused reviews 

for all DCBI casualties. 

TRAINING 

 1. Increase Air Ambulance medic/nurse 

training to Paramedic level. 

 2. Mandate pre-deployment combat casualty clinical trauma refresher, evidencebased clinical practice guideline review, 

TCCC familiarization and EMR familiarization for all providers and nurses. 

 3. Provide for better training in TCCC 

concepts to all combat leaders and all deploying warfighters and require USR reporting to measure commanders’ use of guidelines. 

 4. Ensure IED and C-IED training remain embedded in collective training. 

 5. Provide additional specialized training to military rehabilitation providers who 

care for DCBI patients. Incorporate cognitive behavioral therapy, rehabilitation 

counseling, psycho-social sensitivity, regenerative medicine exposure, and the basics 

of assistive technology. 

 6. Ensure a more robust pre-deployment 

trauma experience for POI-to-Role II/III 

evacuation providers assigned to air evacuation units. 

 7. Provide additional specialized training for BH specialists caring for DCBI patients. Focus on coping and thriving with 

multiple limb loss, sensory loss, and genitalia injury; incorporate Family counseling 

and support skills. 

 8. Develop optimized training modalities 

for sustainment training on pre-hospital 

surgical airways. 

 9. Ensure adequate number of urologists 

and plastic surgeons are trained and skilled 

in genitalia reconstruction. 
46 

 10. Assess validity and relevance of the 

Army Trauma Training Center as the FST’s 

pre-deployment culminating training event. 

MATERIEL 

 1. Facilitate accelerated fielding of an 

FDA-approved freeze-dried plasma product 

for use by US Medics. 

 2. Pending an FDA-approved freezedried plasma product becoming available 

for fielding, pursue steps needed to field 

the French or the German freeze-dried 

plasma products for resuscitation of DCBI 

casualties in shock until blood and plasma 

can be used on evacuation. 

 3. Conduct studies to assess the safety 

and efficacy of FDA-approved truncal tourniquet systems to control non-compressible 

pelvic-area bleeding. 

 4. Conduct expedited studies on the value of plasma as the sole resuscitation fluid 

for pre-hospital resuscitation of shock. 

 5. Assess the risk-benefit ratio for the 

early use of tranexamic acid for casualties 

with non-compressible bleeding. 

 6. Conduct studies to compare the safety 

and efficacy of current and future hemostatic agents. 

 7. Conduct studies to compare the safety 

and efficacy of current and future commercially available tourniquets. 

 8. Ensure all TCCC-recommended 

equipment is provided in the Army individual first aid kits (IFAKs) and combat medical sets; make this reportable in the USR. 

 9. Emphasize high-priority research for 

clinical validation studies and comparative 

effectiveness of surgical methods, rehabilitation paradigms, regenerative medicine 

applications, including large peripheral and 

spinal nerve function for individuals with 

DCBI. 

 10. Acquire DoD funding and oversight 

for prosthesis and mobility device development for DCBI Warriors, particularly 

those with mangled limbs undergoing limb 

salvage, multiple limb loss, and very proximal upper and lower limb loss. 

 11. Continue aggressive research in tissue 

regeneration. 

 12. Establish systems to expedite specialized DCBI-related healthcare equipment 

and supply acquisition. 

 13. Continue to improve upon prosthetic, 

robotic and regenerative options to include 

user interfaces, cognitive Assistive Technology, and smart home technology. 

 14. Continue to improve dismounted IED 

detection devices. 

 15. Assess current and future patient 

movement items for enroute RW care. 

 16. Develop optimized electronic physiological monitors to better manage prehospital fluid resuscitation. 

 17. Compare current and future PPE to 

protect against GU and perineal injuries. 

 18. Equip US Combat Medics to achieve 

more effective narcotic analgesia using IV 

morphine or OTFC during Tactical Field 

Care. 

 19. Improve prosthetic socket interfaces 

to prevent commonly occurring acute and 

chronic skin problems. 

 20. Assess helmet-mounted sensors to 

measure blast exposure to the head. 

LEADERSHIP 

 1. Develop venues by which predeployment command teams can visit extremity injury centers of excellence, and 

WWs can visit units preparing to deploy. 

 2. Establish JIEDDO and JTAPIC LNOs 

to weekly JTTS teleconferences. 
47 

 5. Place priority of effort on Combat Casualty Care within Role V MTFs; require 

tracking of “first starts” in the operating 

rooms. 

 4. Clarify responsibility of the clinical 

oversight of flight medic protocols within 

the ATO. Raise onboard medical care standards to that of civilians. 

 5. Synchronize injury data gathering and 

presentation. 

 6. Tri-Service strategic communication 

about the definitive care and long-term 

needs and expectations of DCBI Warriors 

should be incorporated into the leadership 

training of officers and non-commissioned 

officers at all levels. 

 7. Keep senior leadership apprised of 

trends on severely wounded Warriors’ 

treatment and long-term functional recovery. 

 8. Conduct research on the impact genitalia injury has on psychological health, 

quality of life and short- and long-term outcomes. 

 9. Direct future research to address longterm complications, such as post-traumatic 

arthritis and overuse injuries to intact 

limbs. 

 10. Provide recurring updates to all active 

duty trauma surgeons outlining the DCBI 

pattern and specific CPGs related to their 

care. 

 11. Improve surgical interventions to help 

restore peripheral and central nerve function after traumatic injury. 

 12. Implement existing CPG to manage 

pain. 

 13. Establish a Pre-Hospital Consultant to 

the Army SG. 

PERSONNEL 

 1. Deploy urologist to Role III MTF with 

every rotation 

 2. Relook manning and staffing of air 

ambulance companies, Area Support Medical Companies, Forward Surgical Teams 

 3. Staff definitive care facilities with 

adequate personnel to support multiple operating room teams on multiple returns for 

surgery, specifically to include first starts 

in the operating room and dedicated surgical teams, nursing teams, rooms and equipment. 

 4. Establish appropriate staffing ratios to 

care for DCBI patients at all echelons of 

care to maintain flexibility to adjust to increased casualty flow, humanitarian missions, and individual deployments. This 

not only optimizes DCBI patient care, but it 

helps maintain long-term provider resiliency. 

FACILITIES 

 1. Competing interests within MTFs 

must be clarified, with existing trauma facilities taking on the main effort in definitive reconstruction and return to function. 

 2. Update Medical Simulation Training 

Centers and Combined Training Centers to 

include the ATO’s most current lessons 

learned. 

CONTRACTING 

 1. Ensure appropriate resourcing for 

DCBI Warriors’ long-term rehabilitative 

care within both DoD and VA healthcare 

systems. 

 2. Develop improved and more flexible 

healthcare support contracts to acquire specialized providers to meet the DCBI patients’ dynamic clinical requirements. 

 3. Have urologic specialty panel review 

all GU injuries. 
48 

CONCLUSION 

DCBI is a devastating injury. Tactical imperatives drive the need for dismounted patrols. Many organizations and agencies are 

working to eliminate the current threat of 

ground-emplaced IEDs and land mines. 

Advances in tactical combat casualty care 

and technical expertise of everyone in the 

chain of survival has decreased what were 

certainly fatal injuries just a few years ago. 

Our focus is to minimize morbidity associated with the initial explosive injury, and 

to present the patient in an optimal physiological state for long-term rehabilitation 

and functional recovery. Also important 

for this injury pattern, as with many others, 

is the medical community’s concerted effort at healing the whole person—

physically, cognitively, emotionally, psychologically and spiritually. Included within this healing arc are the Warriors’ Families and loved ones and those providing 

care. 

Many of the issues and gaps addressed in 

this paper cross Service, Interagency and 

DoD/Civilian lines, thus comprehensive 

solutions should be determined by diverse 

stakeholder working groups. 

Finally, it is reassuring to note we have yet 

to recognize an injury pattern or volume of 

cases that has overwhelmed our medical 

capabilities or led to increased fatalities. 

Nonetheless, we continue to reevaluate 

clinical practices and outcomes and refine 

diagnosis and treatment with evidence in 

order to maintain the highest survivability 

and functionality possible. 
A-1 

APPENDIX A 

CHARTER 
A-2 
A-3 

(b) (6) (b) (6) (b) (6) (b) (6) (b) (6) (b) (6) (b) (6) (b) (6) (b) (6) (b) (6) (b) (6) (b) (6) (b) (6) (b) (6) (b) (6) (b) (6) (b) (6) (b) (6) (b) (6) (b) (6) (b) (6) (b) (6) (b) (6) (b) (6) (b) (6) (b) (6) (b) (6) (b) (6) (b) (6) (b) (6)
(b) (6)

(b) (6)

(b) (6)
B-1 

APPENDIX B 

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Butler FK, Giebner SD, McSwain N, et al, eds. Pre-hospital trauma life support manual; 

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B-3 

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B-4 

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B-6 

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C-1 

APPENDIX C 

DEFINITIONS 

Dismounted Complex Blast Injury: IED-or land mine-related blast injury to a dismounted 

Warrior that includes at least one lower extremity amputation and also includes severe injuries 

to other limbs, GU system, pelvis, and/or abdomen. This description is based more on the inclusion of several severe injuries compounding complexity, and not intended to be exclusive of 

injuries of similar severity, sustained from other mechanisms. 

Polytrauma: Two or more injuries sustained in the same incident that affect multiple body 

parts or organ systems and result in physical, cognitive, psychological, or psychosocial impairments and functional disabilities. TBI frequently occurs as part of the polytrauma spectrum 

in combination with other disabling conditions, such as amputations, burns, pain, fractures, 

auditory and visual impairments, post-traumatic stress disorder (PTSD), and other mental 

health conditions. When present, injury to the brain is often the impairment that dictates the 

course of rehabilitation due to the nature of the cognitive, emotional, and behavioral deficits 

related to TBI. 

Major Limb Amputation: Any loss at or above the ankle or wrist. 
D-1 

APPENDIX D 

COTCCC RESEARCH PRIORITIES (NOVEMBER 2011) 

Follow-Up Tranexamic Acid Studies: As a follow-on effort to the CRASH-2 study, trials 

should be performed to determine the benefits and risks of using tranexamic acid for the subset 

of trauma patients who have non-compressible hemorrhage. 

German Freeze-Dried Plasma Experience: Documentation of the German experience with this 

agent in both the pre-hospital and hospital settings would help to define the potential benefits 

that might be obtained by the use of this agent in the pre-hospital setting by US Forces. 

Prospective Study Using FDA-Approved Plasma Alone for Pre-hospital Resuscitation Fluid in 

Patients with Non-Compressible Hemorrhage: This study would provide a basis for judging the 

benefit to be gained from fielding a freeze-dried plasma product when one becomes available 

in the US. 

MERT Team Experience with 1:1 PRBC: Plasma Experience: With British MERT teams routinely giving PRBCs and plasma in a 1:1 ratio during POINT OF INJURY TO ROLE 2/3 MTF 

EVACUATION, the outcomes from their experience should be studied and compared to outcomes using Hextend® alone during evacuation. 

Improved Battlefield Analgesia – Ketamine: Additional case series detailing the benefits and 

risks of using ketamine for pre-hospital analgesia in trauma patients are needed. 

Pre-Hospital Care Documentation and Databasing: Research and transition efforts are needed 

to aid in the capture of battlefield trauma care rendered and the transfer of this information to 

both unit-based pre-hospital trauma registries. 

Truncal Tourniquet: A prototype truncal tourniquet designed to assist in controlling external 

junctional hemorrhage in the tactical environment has recently been approved by the FDA. 

Studies documenting the efficacy of this device in eliminating distal pulses on extremities as 

well as the ability of users to apply it effectively are needed. 

Use and Outcomes Data for Individual Elements of TCCC: Studies such as those performed on 

tourniquet use are essential to assessing recommended TCCC interventions and identifying 

areas for improvement. 

Monitor-Driven Pre-hospital Fluid Resuscitation: Pre-hospital fluid resuscitation has the potential to do harm as well as good and the data to support specific fluid resuscitation protocols 

needs to be stronger. 

Comparison Testing of Celox Gauze, Combat Gauze, and ChitoGauze: It would be useful to 

compare newerhemostatic agents to Combat Gauze in the consensus bleeding model developed 

at ISR to gain an understanding of their relative efficacy. 

Comparison Testing of New Tourniquets: Although there have been good reports from both 

pre-hospital and in-hospital use of the CAT, SOFT-T, and EMT tourniquets, it would be useful 

to compare the new tourniquets to these currently-fielded devices. 

Surgical Airway Training Methods: Surgical airways have been shown to be the most technically difficult pre-hospital trauma skill to train and sustain. Comparison studies of different 

training modalities used to teach this skill are needed. 
D-2 

Clinicopathological Review of Every US Fatality in Iraq and Afghanistan:Using a multidisciplinary team approach, OAFME autopsy records from the current conflicts should be reviewed 

to determine the causes of death and which deaths were potentially preventable. 

Optimal Management of Traumatic Brain Injury in TCCC: Studies that better define optimal 

airway and fluid resuscitation management for casualties who often have polytrauma in addition to their TBI offer the potential to enhance both survival and the clinical outcomes in survivors. 

The Impact of point of injury to Role 2/3 MTF Evacuation Provider Level and Skill Sets on 

Survival: There are at least three models of evacuation platform staffing in use in the CENTCOM area of operations at present: Determination of the optimal model for point of injury to 

Role 2/3 MTF Evacuation platform staffing requires an analysis of the outcomes obtained to 

date using these different options. 

Hypothermia Prevention Equipment Comparative Studies: New and improved technologies to 

prevent hypothermia are being developed and there should be an ongoing program to evaluate 

these technologies as they evolve. 

Combat Medic/Corpsman/PJ Equipment Evaluations: Equipment after-action evaluations would 

allow for quantitative evaluations and specific comments about the merits of currently fielded 

combat medical equipment. 

Focused Analysis of JTTR Data Regarding Specific TCCC Interventions: Analysis of the information contained in the trauma system trauma registry may yield valuable insights about the 

success or deficiencies of the current TCCC Guidelines. 

Enhanced Pelvic Protection in Personal Protective Equipment: Deployed forces currently sustain injuries to the pelvic, GU, and perineal areas from dismounted IED explosions. Research 

is needed to identify options to protect this region while minimizing additional weight and discomfort to the warfighter.
E-1 

APPENDIX E 

ACTION PLAN 

This report’s recurring themes provide the military with opportunities to more fully care for 

the severely injured Warriors discussed herein. Not only are these casualties injured on many 

fronts, but so too are their fellow Warriors, Families, and healthcare providers. 

There are four focus areas of strategic importance for all battle injuries: 1) Comprehensive 

pain management at the POI; 2) complex behavioral health challenges facing DCBI Warriors 

and their Families, especially when there are concomitant GU injuries; 3) the incorporation of 

a rehabilitation mindset and philosophy throughout the spectrum of care; and 4) spiritual considerations for long-term care and rehabilitation for Warriors, Families, and units. 

The recommendations that follow are based on the DOTMLPFC domains (namely, Doctrine, 

Organization, Training, Materiel, Leadership, Personnel, Facilities, and Contracting). The main 

body of this report contains detailed and more specific recommendations, ranked in the Task 

Force’s collective order of priority. This action plan addresses the major operational goals for 

improved care of the Warrior with severe complex blast injuries. 

CASUALTY EVACUATION 

There is wide training level variability among evacuation staff. The UK’s MERT employs a 

physician to accompany the most severely injured casualties, whereas US evacuation providers 

are typically flight medics trained to the EMT-B level. Nurse Corps Officers augment Air 

Ambulance companies currently to assist in transporting severely wounded casualties. 

(D,T,M,P) 

Recommendation: Define minimum standards of certification for air evacuation providers as 

EMT-P for evacuation of critically injured Warriors. AMEDDCS should ensure the current 

RW evacuation equipment sets meet current and future challenges. Finally, the Medical and 

Aviation communities should consider a trial of small numbers of MERT-like specialized RW 

platforms with surgical capability. 

JOINT THEATER TRAUMA SYSTEM 

The Army SG implemented the JTTS to document trauma presentations, interventions and outcomes through a centralized database. Over the years, its registry, the JTTR has become one 

of the nation’s largest trauma registries, with 10 years of longitudinal data from Echelons I to 

V care. This organization, similar to its predecessor from Vietnam, the Wound Data & Munitions Effectiveness Team (WDMET), plays an absolutely critical role in establishing long-term 

commitment to military trauma care and research. The overarching and large scope nature of 

JTTR requires augmentation through modules with enhanced specificity for more detailed 

tracking of data and trends with injuries. Specifically, the Military Orthopaedic Trauma Registry is required to identify and track these complex injury patterns. (D,O,L,P,F) 
E-2 

Recommendation: Develop and codify the JTTS as a Joint Service Requirement for continuous 

long-term funding, staffing, and facility support with additional development or support for 

region specific modules. 

INJURY SEVERITY SCORES 

Current military doctrine pulls definitions, grading scores, and disease criteria from civilian 

trauma literature. The use of Injury Severity Scores allows comparisons to current medical 

literature and outcomes data. The use of standardized definitions also allows better correlation 

with existing literature. However, the definitions and scores do not take into account functional and long-term challenges that specific battlefield injuries face. Military-specific definitions 

are needed to facilitate thorough research and comparison of long-term outcomes. (D,T,P) 

Recommendation: The USAISR should develop military-specific trauma scoring criteria for 

DoD that address the complexities of battlefield injuries. 

PRE-DEPLOYMENT TRAINING 

Six levels of trained personnel provide battlefield medical care. Since 2007, every Army Recruit received initial medical training, which provides them adequate tools to render “Buddy 

Aid,” when needed. Non-medical Soldiers who receive additional training are identified as a 

Combat Lifesaver (CLS). Current doctrine places one CLS per squad/vehicle/formation. 

However, most deploying units exceed this requirement, often training everyone in the unit to 

the CLS-level. 

Combat medics (68W Military Occupational Skill, or MOS) undergo extensive initial entry 

training, including EMT-B, Pre-Hospital Tactical Lifesaver, etc. Additionally, medics typically receive training in TCCC prior to deployment. Currently, there is no advanced training for 

68Ws assigned to ground or air ambulance units. 

Battalion physicians and physician assistants are prevalent on the battlefield in combat formations. However, the level of medical care in functional and multifunctional formations can be 

quite variable from unit to unit, depending on the type of unit and level of individual provider 

training. Specialists at the Role II/III echelons possess have undergone more extensive graduate medical education, in general, but not necessarily so in the fields of emergency medicine or 

trauma surgery. This can lead to wide variability in the field. 

The Army SG mandated that all FSTs conduct pre-deployment training at the Army Trauma 

Training Center (ATTC), a civilian trauma center in Miami, FL. This training event helps to 

build teams that will later deploy, but its benefit appears directed primarily to the non-surgical 

members. The main reason is this training does not replicate the severity of trauma currently 

seen in the ATO. Additionally, this civilian setting lacks training venues on other warfighting 

functions, with which the deploying staff must be facile. (T,M,L,P) 

Recommendation: AMEDDCS and CALL should collaborate to develop programs of instruction based on specific theaters of operation, echelons of care, and anticipated skill requirements. This must include specialty specific individual and team skills. Requirement for each 

surgeon prior to first deployment to spend an additional week of training at LRMC, where they 

will encounter the types of casualties he/she will likely see during deployment. Ensure predeploying officer, NCO and spouse leadership visit the Warrior with major limb loss and ex-
E-3 

tremity injury centers of excellence. As a corollary, ensure volunteer WWs visit units before 

deployment. 

MEDICAL ORGANIZATION AND CONFIGURATION 

Current doctrine calls for echelons of care, with progressively robust capabilities with each 

successive level. Wounded, Ill, and Injured warfighters are to sequentially traverse these care 

echelons. This report highlights areas for improvement, from the POI through definitive care, 

to better address current and future requirements. There has not been a comprehensive joint 

analysis of battlefield care since before OEF. Multiple compartmental looks at specific areas 

and echelons of care have been undertaken by individual Services. However no systematic 

comprehensive review of the entire theater healthcare system has been performed in the past 

ten years. (D,O,P,F) 

Recommendation: ASD(HA) should establish a tri-Service team to reexamine and validate or 

remodel joint medical combat casualty care doctrine throughout every level of care. 

MEDICAL EQUIPMENT 

Continuous research and development are needed for equipment such as truncal or junctional 

tourniquets, upper and lower extremity prostheses, and robotics. The field of regenerative 

medicine also holds great promise for these injured Warriors. (D,T,M,P,F,C) 

Recommendation: Develop a tri-Service research forum to discuss and develop new DCBI 

strategies, with DoD and FDA commitment to test, approve and rapidly field potentially lifesaving equipment or validate best practices and technology rapidly. 

MEDICAL DOCUMENTATION 

Care on the battlefield is complex, and requires timely input of critical medical information to 

make expedient decisions on prioritization and delivery of finite resources on the battlefield. 

Documentation has significantly improved during OIF and OEF with the fielding of Medical 

Communications for Combat Casualty Care, the development of The Joint Theater Trauma Registry, the use of AHLTA-T, Theater Medical Data Store, and many other systems. However, 

the current system is often stove-piped, paper-based and difficult to manage. This impacts our 

ability to address pre-hospital care, the most fertile area for targeted improvement. 

(T,M,L,P,F,C) 

Recommendation: Rapidly develop user-friendly, reliable, digital system to capture POI prehospital care from the POI. Consolidate documentation systems into one electronic health 

record that fully captures healthcare delivery across the enterprise of care, from the battlefield 

to the VA. 
E-4 

CLINICAL RESEARCH 

Battlefield care has improved significantly over the recent years due to research-driven advances. New and ongoing research must continue to allow for optimal care of the wounded. 

(D,O,T,L,P,F,C) 

Recommendation: Form inter-Service and inter-agency relationships to facilitate aggressive, 

innovative and relevant translational and outcomes-based clinical research. 

PAIN MANAGEMENT 

Throughout this report, from POI through definitive care, each section discussed the significant 

opportunities to improve upon pain management from the POI forward. The current battlefield 

focus is almost exclusively based on opioid pain control. A Comprehensive Pain Management 

Care Strategy has been developed that will mitigate most of the shortfalls in training and pain 

management. (D,O,T,M,L,P,F,C) 

Recommendation: Fully support the Comprehensive Pain Management Strategy. Ensure rapid 

fielding of all appropriate resources. Prioritize training on the next deploying units and those 

involved in immediate care to these Warriors and Families. 

SPIRITUAL CARE 

DCBI casualties with concomitant GU injuries require special spiritual considerations not 

made with other wounded Warriors—including those with major amputations. The ability to 

be intimate in a way that involves the genitalia is a significant identifier of self. At a minimum, more frequent spiritual assessments would be indicated for these types of casualties. 

(D,O,L) 

Recommendations: Couple with civilian organizations and VA to rapidly gain expertise in this 

area. Develop an Ethics Panel with civilian and military leaders to discuss and gain options on 

DCBI-related issues. Additionally, a strategic communication effort must be rapidly initiated 

to emphasize quality of life, continued self-efficacy and significance/ value for the injured 

Warrior living with these injuries, to be managed at Unit, Service, and Public levels. 

BEHAVIORAL HEALTH 

The behavioral health needs of these Warriors and their Families are not fully understood. 

These severe injuries, coupled with the possible loss of reproductive organs or function, will 

pose long-term challenges for everyone involved. Behavioral Health providers are often poorly equipped to cope with the challenges these patients face. (T,L,P) 

Recommendation: Consider utilizing the National Intrepid Center of Excellence (NICoE) or 

similar behavioral health resource as a referral and training site for this subset of Warriors. 

Train providers specifically on the care of these Warriors and Families. Develop virtual and 

other remote access processes to allow these Warriors and Families to receive care while home 

and in long term rehabilitation. Lifelong monitoring of these Warriors and Families will be 

critical to long-term outcome management. 
F-1 

APPENDIX F 

JOINT THEATER TRAUMA SYSTEM CLINICAL 

PRACTICE GUIDELINE: MANAGEMENT OF HIGH 

BILATERAL AMPUTATIONS 

Original Release/Approval: Note: This CPG requires an annual review 

Reviewed: Approved: 

Supersedes: Initial management of high bilateral lower extremity amputations with associated pelvic/perineal injuries

 Minor Changes (or) Changes are substantial and require a thorough reading of this CPG (or)

 Significant Changes POC: 

1. Goal. To review indications for and the procedures associated with the initial management 

of bilateral lower extremity amputations with associated pelvic/perineal injuries. 

2. Background. Bilateral lower extremity amputations with associated pelvic/perineal injuries 

represent one of the most challenging cohorts of surgical patients from management of the initial injury through final reconstruction. These injuries are associated with an increased incidence of morbidity and mortality. Survival is initially dependent upon hemorrhage control and 

massive resuscitation protocols. Later risks for mortality include sepsis and multisystem organ 

dysfunction. These injuries can broadly be divided into two categories; those with a perineal/pelvic floor injury and those without. There are few counterparts in civilian trauma. An 

organized aggressive continuum of surgical care by general surgeons and orthopaedists is critical to optimize outcomes. 

3. Evaluation and Treatment. 

a. Initial Resuscitation. These patients typically arrive in extremis shortly after injury. 

Tourniquets are often in place on all injured extremities. Due to profound shock and associated upper extremity amputations, IV access may not be obtained in the field. Rapid placement of IO (intra-osseous) lines is sometimes a useful adjunct to begin resuscitation prior to 

venous access. This injury pattern mandates immediate activation of massive transfusion protocols, the preferential use of fresh blood (< 21 days old), minimal use of crystalloid products, 

and early consideration for the use of fresh whole blood (FWB), if blood resources are limited. 

(Refer to Damage Control Resuscitation CPG). 

b. Role of Resuscitative Thoracotomy. Occasionally these patients arrive with CPR in 

progress. When signs of life are present, consideration of resuscitative thoracotomy should be 

given according to established clinical practice guidelines. Outcome data from OIF suggest a 

reasonable survival rate in properly selected patients. Another alternative described with exsanguination in civilian extremity injuries is the use of a brief period of CPR with concomitant 

massive blood product resuscitation before resorting to a resuscitative thoracotomy. 

(b) (6)
F-2 

c. Triage considerations. These patients consume massive amounts of blood products and 

utilize multiple surgical assets to include operative teams, equipment and operative hours. In 

the multiple casualty scenario, consideration of a balance between resources and surgical assets 

should be considered prior to proceeding with resuscitative thoracotomy. 

d. Preoperative studies. Useful preoperative studies may include CXR, AP Pelvis, FAST, 

and DPL. Expeditious CT of the head may be considered in patients displaying lateralizing 

signs consistent with severe TBI requiring operative intervention, but should not degrade resuscitation or delay surgical hemorrhage control. 

4. Operative Approach. 

a. Prioritization and surgical teams. The initial operative goal is hemorrhage control and 

control of contamination. Due to the nature of these injuries, this is best achieved using a team 

of general surgeons and orthopaedists working concurrently on the patient (if available). For 

example, two surgeons can achieve proximal control and address intra-abdominal injuries 

while a second team focuses on the amputations. A third team can be utilized to address upper 

extremity injuries, if present. This approach maximizes efficiency and limits prolonged physiologic insult to a severely injured patient. Prior to operation, the most critical procedures (i.e., 

proximal hemorrhage control, control of contamination, completion amputations, bladder repair and potential colonic diversion) should be listed, keeping in mind reasonable parameters 

to terminate surgery. 

b. Proximal vascular control. The level of proximal vascular control is dictated by several 

clinical variables: previous resuscitative thoracotomy, associated pelvic disruption, level of 

tourniquet placement and level of amputation(s). Typically vascular control should be 

achieved at the most distal level possible, including control via a retroperitoneal approach or in 

the groin. A strategy of walking the clamps down in patients with massive pelvic injuries is 

prudent. This involves laparotomy, infra-renal aortic control, and movement of control distal 

to the internal and external iliacs. In the case of pelvic floor injuries with open pelvic wounds 

and active posterior bleeding, temporary control of the internal iliacs is prudent. This can be 

achieved with vascular clamps, vessel loops, Rommel tourniquets, or vascular clips. The benefit of achieving hemorrhage control must be balanced against the risk of ischemic tissue at the 

site of injury and subsequent infection and diminished wound healing. An attempt to reperfuse 

the internal iliacs should be made at the index or subsequent procedure. 

c. Role of proximal diversion. In patients with an obvious need to divert the fecal stream 

due to pelvic disruption or an open pelvic fracture, stapled interruption of the sigmoid colon at 

the pelvic brim should be performed early to facilitate pelvic exposure and vascular control. 

d. Orthopedic considerations. It is common for these patients to present with traumatic bilateral lower extremity amputations at various levels from transtibial amputation’s to very high 

transfemoral amputation’s, often with extremely complex soft tissue blast wounds up to and 

including the perineal and gluteal region. Associated traumatic amputation of the nondominant upper extremity is also common. The most challenging cases involve open pelvic 

ring and peri-acetabular fractures and dislocations. Initial orthopaedic resuscitative involvement entails assuring that extremity hemorrhage control is sufficient with tourniquets. Often 

after the onset of the massive transfusion protocol, patients can bleed through in-place field 

tourniquets. In this case, they require placement of additional field tourniquets or pneumatic 

ones (if available) to control bleeding until optimized in the operating theater. Quick examination of the pelvic ring should be performed to address stability. Pelvic fractures can be stabilized with the use of clamped sheets or commercial pelvic binders centered over the trochanters. 
F-3 

Index operative procedures should be prioritized with surgical team leader. Hemorrhage 

control of traumatic amputated limbs and peri-pelvic sources is the priority. Pelvic and perineal packing is helpful for tiny vessel hemorrhage control and cases with continued coagulopathic oozing. In the multilevel amputee, limb length is inversely proportional to later energy 

expenditure. Revision amputations should occur at the most distal viable level with double 

ligation of all named vessels in an open, length-preserving fashion. Atypicalotational flaps are 

greatly preferred over guillotine-style or open circular amputations. Care should be given to 

salvaging healthy tissue for flap coverage, even if it is an atypical anterior rotational flap in 

the face of destroyed posterior tissue. When necessary, pelvic ring stabilization with external 

fixation is preferable to binders due to proximity of wounds and serial debridements that will 

be required. ASIS or AIIS pins are both appropriate, with the latter offering the greatest reduction control but which demands fluoroscopy and surgeon experience. Consideration should 

be given for later orthopaedic pelvic incisions so as to appropriately divert the location of colonic and urinary streams. External fixation of long bone fractures should be accomplished 

during the index procedure when possible. Smaller bone and joint fractures can be addressed if 

the patient remains stable, otherwise they are cared for after the initial resuscitation. 

e. Soft tissue debridement. Adequate initial surgical debridement is critically important. 

These blast wounds are typically complex and extensive. They may be grossly contaminated 

with dirt, fragment debris, clothing and foliage. Wounds should be incised with well-planned 

incisions to extend the zone of injury to healthy tissue. Systematic debridement of nonviable 

skin, subcutaneous tissue, fascia, muscle, periosteum and bone is critical to reduce the bioburden and later risk of sepsis. With subsequent debridements, these blast wounds tend to 

evolve; if tissue is questionable and not contaminated it should be maintained and addressed at 

later surgical interventions. However, since the timing of the next operation (at the next echelon of care) is unpredictable, avoid leaving marginally viable tissue behind, as many of these 

complex wounds will develop progressive necrosis. When present, pelvic/perineal and pelvic 

wounds need to be similarly addressed. 

f. Associated vascular injuries. This injury pattern appears to be associated with iliac 

vein injury. When possible these injuries should be shunted or repaired rather than ligated. 

Unless easily repairable, arterial injuries in these critically injured patients should be managed 

initially with shunting followed by formal repair at subsequent operation. Care should be taken to avoid exclusion of the profunda femoris during shunting or repair, in order to perfuse the 

soft tissue and muscle. 

g. Associated GU injuries. Injuries to the ureters, urethra, bladder, scrotum, penis, and 

prostate are common. These should be addressed if feasible with a focus on hemorrhage control, urinary control or diversion, and preservation of tissue for later reconstruction. See urologic trauma management CPG for specific recommendations. 

h. Consideration of prone positioning. In most patients, the posterior soft tissue injuries 

can be addressed with elevation of the amputated stumps, or with the patient in a lateral position after the supine portion of the case has been completed. However certain injury patterns 

have a large posterior element. In these cases it is sometimes necessary to prone the patient 

during the index procedure for either hemorrhage control or debridement of deep blast wounds 

in the gluteal and low back region. This decision should not be made lightly and can often be 

deferred to secondary procedures. When undertaken, the use of a Jackson table can facilitate a 

safe transition to the prone position. Unstable pelvic ring injuries should be stabilized prior to 

placing a patient prone, as this position can exacerbate pelvic volume widening and hemorrhage. 
F-4 

i. Temporary abdominal closure. Liberal use of temporary abdominal closure with delayed stoma maturation is advised. 

j. Wound dressings. Traumatic wounds should not be definitively closed until multiple 

adequate debridements have been performed. By nature, the extensive soft tissue destruction 

and degree of contamination in these wounds make them infected until proven otherwise and a 

continuum of surgical debridements is necessary to prepare wounds for closure or coverage. If 

necessary and in the face of clean viable tissue, incisions made to extend the zone of wounds to 

healthy levels can be loosely approximated to prevent massive skin retraction. The preferred 

initial wound dressings include wet-to-dry, Dakin’s soaked gauze, antibiotic bead pouches or 

wound vacs. 

5. Perioperative management. 

a. Need for Radiologic Imaging. These injuries are associated with a significant transfer 

of energy to the casualty resulting in high risk for associated injuries of a blunt and penetrating 

nature. Once the patient is physiologically stabilized, complete imaging, including “Pan Scan” 

CT and plain film examination, should be obtained to evaluate for occult injury. 

b. Need for repeated debridements. It is important to appreciate the phenomenon of 

wound evolution and the expectation that the soft tissue will evolve with respect to extent and 

tissue viability over the course of several days. In the acute phase (<72 hours from injury) 

wounds should be frequently inspected in the operation room (every 24 hours). In the later, 

sub-acute phase (3-7 days from injury) wounds may require less frequent treatment based on 

the presence of viable tissue and absence of ongoing contamination. Multiple debridements are 

routinely required and the massively injured, physiologically deranged patient should not undergo excessive surgical procedures during the initial operation other than those required to 

control hemorrhage and gross contamination. See the Initial management of War Wounds CPG 

for further guidance. 

c. Role of systemic and topical antibiotics. Initial antibiotic selection should avoid empiric broad spectrum coverage but rather focus on narrow spectrum antibiotics (such as first generation cephalosporins) and the liberal use of topical delivery with Dakin’s soaked gauze or 

antibiotic beads. See Guidelines to Prevent Infection in Combat-Related Injuries CPG for specific recommendations. 

d. Role of VTE prophylaxis. These patients are at very high risk of developing proximal 

deep vein thrombosis (DVT) and associated pulmonary embolus (PE). The presence of lower 

extremity amputation does NOT reduce this risk. In fact, patients with lower extremity amputations may actually be at higher risk for development of DVT and PE than those with similar 

injury severity without lower extremity amputation. It is recommended that these patients be 

started on appropriate DVT/PE prophlylaxis as soon as coagulopathy is reversed. If contraindications to prophylactic anticoagulation persist, prophylactic IVC filter placement should be 

strongly considered. See Prevention of Deep Venous Thrombosis CPG for further recommendations. 

e. Transfer of care. The down-range surgeon should make every effort to coordinate 

dressing changes and necessary repeat debridements in anticipation of required patient transport up-range. Given the propensity for wounds to evolve in their acute phase, the down-range 

surgeon must maintain a low threshold to perform additional debridement prior to evacuating 

the casualty if the patient would otherwise undergo an unacceptable interval between debridements. Given the unpredictable nature of the air evacuation system and to optimize timing of 
F-5 

subsequent serial debridements, the patient should remain NPO for flight so that they are prepared for the next operation. 

6. Responsibilities. It is the trauma team leader’s responsibility to ensure compliance with 

CPG adherence. 

7. References. 

a. Edens JW, Beekley AC, et al. Longterm outcomes after combat casualty emergency department thoracotomy. J Am Coll Surg. 2009 Aug;209(2):188-97. 

b. Dorlac WC, DeBakey ME, Holcomb JB, et al. Mortality from isolated civilian penetrating extremity injury. J Trauma. 2005 Jul;59(1):217-22. 

c. Wisner DH, Victor NS, Holcroft JW. Priorities in the management of multiple trauma: 

intracranial versus intra-abdominal injury. J Trauma. 1993 Aug;35(2):271-6; discussion 276-8. 

d. Dubose J, Inaba K, et al. Bilateral Internal Iliac Artery Ligation as a Damage Control 

Approach in Massive Retroperitoneal Bleeding After Pelvic Fracture. J Trauma. 2010 May 20. 

[Epub ahead of print]. 

e. Urologic Trauma Management CPG. 

f. Labler L, Trentz O. The use of vacuum assisted closure (VAC) in soft tissue injuries after high energy pelvic trauma. Langenbecks Arch Surg. 2007 Sep;392(5):601-9. 

g. Initial Management of War Wounds CPG. 

h. Guidelines to prevent Infection in Combat-Related Injuries CPG. 

i. Prevention VTE CPG. 

Approved by CENTCOM JTTS Director, JTS Director and Deputy Director and CENTCOM 

SG
G-1 

APPENDIX G 

DCBI TASK FORCE MEMBERSHIP 

BG (Dr.) Joseph Caravalho, Jr. Chairman, DCBI TF 

COL (P) (Dr.) US Army Forces Command Representative 

COL (Dr.) Chief of Staff, DCBI TF/Orthopedic Consultant 

COL (Dr.) JTAPIC Representative 

COL Critical Care Nursing Representative 

COL (Dr.) US Army Institute of Surgical Research Representative 

COL (Dr.) US Special Operations Command Representative 

COL (Dr.) Joint Theater Trauma Registry/System / Trauma 

Consultant 

COL Air Ambulance Representative 

COL (Dr.) Neurology Representative 

COL (Dr.) US Army Medical Command Health Policy & Services 

Representative 

COL (Dr.) Psychiatry Representative 

COL (Dr.) Neurosurgical Representative 

COL (Dr.) Physiatry Representative 

COL (Dr.) Urology Representative 

COL US Army Medical Command Rehabilitation & 

Reintegration Representative 

COL (Dr.) Rehabilitation and Amputee Representative 

COL (Dr.) Warrior Transition Command Representative 

LTC(P) (Dr.) Orthopedic Trauma Representative 

LTC (Dr.) General Surgery Representative 

LTC US Army Medical Command Operations Representative 

(b) (6) (b) (6) (b) (6) (b) (6) (b) (6) (b) (6) (b) (6) (b) (6) (b) (6) (b) (6) (b) (6) (b) (6) (b) (6) (b) (6) (b) (6) (b) (6) (b) (6) (b) (6) (b) (6) (b) (6)
G-2 

LTC (Dr.) Trauma Surgery Representative 

Lt Col (Dr.) Pain Representative 

LTC (Dr.) US Army Institute of Surgical Research Orthopedic 

Trauma Representative 

LTC (Dr.) OASD (Health Affairs) Representative 

CAPT (Ret.) (Dr.) TCCC Representative 

COL (Ret) (Dr.) US Army Medical Command PA&E Representative 

Dr. US Army Public Health Command Representative 

Dr. Veterans Affairs Representative 

CPT Task Force Executive Officer 

Ms. Army Medical Department Center and School 

Representative 

(b) (6) (b) (6) (b) (6) (b) (6) (b) (6) (b) (6) (b) (6) (b) (6) (b) (6) (b) (6)
H-1 

APPENDIX H 

DCBI TASK FORCE CONTRIBUTORS 

GEN (Ret.) Frederick M. Franks, Jr. General, United States Army (Retired) 

Chairman, Defense Health Board’s Amputee Care 

Program Panel 

LTG Michael D. Barbero Director, Joint IED Defeat Organization 

Maj Gen (Dr.) Thomas W. Travis Deputy Surgeon General 

Office of the Surgeon General 

Headquarters, U.S. Air Force 

Mr. (SES) Mitchell Howell Deputy Director, Joint IED Defeat Organization 

RDML (Dr.) Michael H. Anderson Medical Officer of the Marine Corps (TMO) 

CH (COL) Command Chaplain,

COL (Dr.) (Ret.) Medical Historian

COL (Dr.) (Ret.) Vice Chair and Professor of Surgery 

Chief, Division of Acute Care Surgery 

Director, Center for Translational Injury 

Research

COL (Ret) Chief, Amputee Patient Care Service 

Integrated Department of Orthopaedics and 

Rehabilitation 

LTC Program Manager, Soldier Protective Equipment 

(b) (6) (b) (6) (b) (6)

(b) (6)

(b) (6)

(b) (6)

(b) (6)

(b) (6)

(b) (6)
H-2 

 Ph.D. Distinguished Professor and FISA Foundation - 

Mr. Deputy Manager, ACEP 

 Ph.D. Chief, Psychiatry Consultation Liaison Service 

(b) (6)(b) (6) (b) (6)

(b) (6)

(b) (6)

(b) (6)
I-1 

APPENDIX I 

GLOSSARY OF ACRONYMS 

ADL Activity of daily living 

AFSOC Air Force Special Operations Command 

AKA Above knee amputation 

AMEDDCS US Army Medical Department Center and School 

ARL US Army Research Laboratory 

AT Assistive technology 

ATO Afghanistan Theater of Operations 

ATTC Army Trauma Training Center 

BAMC Brooke Army Medical Center 

BAS Battalion aid station 

BI Battle injury 

BKA Below knee amputation 

BOG Boots on ground 

BTBIS Brief traumatic brain injury screen 

CAM Complementary and alternative medicine 

CAREN Computer-assisted rehabilitation environment 

CASEVAC Casualty evacuation (to Role II or III facility in other than medical 

platform) 

CCAT Critical care aeromedical transport 

CCCCC Comprehensive Combat Casualty Care Center (C5) at Balboa Naval 

Medical Center 

CCFP Critical care flight paramedic 

CFI Center for the Intrepid 

CFR Case fatality rate 

CG Commanding General 

CLS Combat lifesaver 
I-2 

CoTCCC Committee on Tactical Combat Casualty Care 

COTS Commercial-off-the-shelf 

CPG Clinical practice guideline 

CRNA Certified registered nurse anesthetist 

CSH Combat support hospital 

CTC Combat training center 

DARPA Defense Advanced Research & Projects Agency 

DCBI Dismounted complex blast injury 

DMDC Defense Manpower Data Center 

DNBI Disease and non-battle injury 

DoD Department of Defense 

DoDD Department of Defense Directive 

DOTMLPFC Doctrine, Organization, Training, Materiel, Leadership, Personnel, 

Facilities, and Contracting 

DOW Died of wounds 

DWRIA Died of wounds received in action 

ERC En route care 

ERCS En route care system 

EMR Electronic medical record 

EMT-B Basic emergency medical technician 

EOD Explosive ordnance disposal 

ERAB Navy Medicine’s Executive Research Advisory Board 

ETVB Navy Medicine’s Emerging Therapeutics Validation Panel 

FATS Firearms training system 

FDA Food and Drug Agency 

FORSCOM US Army Forces Command 

FRSS US Navy forward resuscitation and surgical squad 

FRT US Navy forward resuscitation team 

FST US Army Forward Surgical Team 
I-3 

FW Fixed wing 

GME Graduate medical education 

GU Genitourinary 

HP&S Office of The Surgeon General, Health Policy and Services 

ICU Intensive care unit 

IFAK Individual first aid kit 

IOTV Improved outer tactical vest 

IM Intramuscular 

IO Intraosseus 

ISR US Army Institute of Surgical Research 

ITO Iraq theater of operations 

IV Intravenous 

JIEDDO Joint Improvised Explosive Device Defeat Office 

JTAPIC Joint Trauma Analysis for the Prevention of Injuries in Combat 

JTTR Joint theater trauma registry 

JTTS Joint theater trauma system 

KIA Killed in action 

LRMC Landstuhl Regional Medical Center 

MEDCOM US Army Medical Command 

MEDEVAC Medical evacuation using dedicated medical rotary wing transport 

MATV MRAP all-terrain vehicle 

MERT Medical emergency response team 

MRAP Mine-resistant ambush-protected 

MRMC US Army Medical Research and Materiel Command 

MRO Medical regulating officer 

MTF Medical treatment facility 

MTV Marine tactical vest 

NHRC Naval Health Research Center 

NICoE National Intrepid Center of Excellence 
I-4 

NMA Non-medical attendant 

NRL US Navy Research Laboratory 

NSRDEC Natick Soldier Research Development & Engineering Center 

OEF Operation Enduring Freedom 

OIF Operation Iraqi Freedom 

OND Operation New Dawn 

OSCAR USMC’s operational stress control and readiness program 

PA&E Program analysis and evaluation 

PECC Patient Evacuation Coordination Cell 

POI Point of injury 

PHTR Pre-hospital trauma registry 

PM-SPE Product manager for Soldier protective equipment 

PM-SPIE Project manager for Soldier protection and individual equipment 

PM-ICE Program manager for infantry combat equipment 

PPE Personal protective equipment 

PTS Post-traumatic stress 

PTSD Post-traumatic stress disorder 

QOL Quality of life 

RC(SW) Regional Command-Southwest 

RN Registered nurse 

RW Rotary wing 

SAI Spiritual attitude inventory 

SOCCET Air Force special operations critical care evacuation team 

SOF Special operations force 

SOST Special operations surgical team 

SSTP US Navy surgical shock trauma platoon (2 FRSSs + STP) 

STP US Navy shock trauma platoon 

STRATEVAC Strategic evacuation (across theaters of operation) 

TCCC (TC3) Tactical combat casualty care 
I-5 

TMDS Theater medical data store 

TSG The Army Surgeon General 

UK United Kingdom 

USAARL US Army Aeromedical Research Laboratory 

USAISR US Army Institute of Surgical Research 

USAMEDCOM US Army Medical Command 

USAPHC US Army Public Health Command 

USMA US Military Academy 

USMC US Marine Corps 

USR Unit status report 

USSOCOM US Special Operations Command 

UUNS Urgent universal needs statement 

VA Department of Veterans Affairs 

VHS Veterans health services 

VTC Video teleconference 

WDMET Wound data & munitions effectiveness team 

WIA Wounded in action 

WIIW Wounded, ill and injured Warrior 

WRAMC Walter Reed Army Medical Center 

WT Warrior-in-transition 

WTC Warrior Transition Command 

WTU Warrior transition unit 

WW Wounded Warrior