The Power of Advanced Capability and Informed Policy

Incharacterizing theeffectofa2009mandate to reducemedical evacuation times inAfghanistan, in this issueof JAMASurgery, Kotwal and colleages1 demonstrate the effectiveness of combining advanced trauma care capability with informed policy. Unlike any report before it, this study demonstrates that one without the other—capability without policy or policy without capability—results in compromised success. In this case, the principle applies to success of theUS military’s trauma system that endeavors to save lives and improve recovery of personnel injured in defense of the nation. Acompelling finding fromthis report is thedecrease in the case fatality rate (CFR) even before initiation of the 60minute directive. Figure 1 illustrates that the CFR decreased tobelow15%between2001 and2009, a ratepredicted tohave reached 10%by2013.1 Although several factors contributed to this decrease, an enhanced trauma care capability—one improved by knowledge and materiel solutions coming from a robust trauma research program—undoubtedly played a role. The longitudinal CFR analysis provides evidence that as gaps incasualtycarewerebeingnarrowed,anenhancedtraumacare capability developed. Notably, gaps in care that guide military trauma research were reinvigorated in 2008 through timelyGuidance forDevelopment of theForce issued through the same US Secretary of Defense.2,3 Reduction in thepercentage killed in action following the 2009 policy change provides evidence of the effect of an enhanced capability during the “goldenhour” after injury. Although the notion of a golden hour is not new, this study assembled injurymanagement data from theUSDepartment of DefenseTraumaRegistry, autopsydata fromtheArmedForces Medical Examiner, and previously classified data pertaining to evacuation times to provide insight into what can be accomplished during this acute phase of care. Findings of a reduced percentage killed in action also confirmprevious studies suggesting theeffectivenessofpoint-of-injury care and the care provided by enhanced en route platforms.4,5 Lestwe view this report as a pronouncement that themission is complete, it is vital to consider the study’s limitations. Foremost, the incomplete and inaccessible nature of the data needed forwhat shouldbe amore routineprocess is troubling. Althoughthearticledoesnot lament, it is likely that it tookyears for 9 senior military investigators to assemble the data to provide this analysis by which to enlighten policy. Unless we are willing todismissprehospitalmortalityasunsolvable,wemust do better at recording, coordinating, and analyzing data from this phaseof care.Also chastening is the fact that the advances reported in this studywereachieved inoptimal theatersofwar withunfettered air access andpositioningof surgical facilities. Futurecasualty care scenariosmaybe frighteninglymorecomplexandinvolvedelayedresuscitation,prolongedfieldcare,and longer-distance critical care transport.6 Itwouldbewisenot to bemesmerized by trends reported in this study. Instead, military and civilian planners should learn from the whole of the effort—including its limitations—and develop better ways to build traumacare capability and informpolicy for future,more complex casualty scenarios.