Military medical revolution (2012)

The development and advancement of trauma care has shown stepwise improvements for centuries owing to the interrelationship of civilian and military medical systems. With respect to trauma systems, the sophisticated civilian trauma system in the United States was born directly out of the successes and lessons learned from the Vietnam War. The American College of Surgeons (ACS) took the lead in advocacy for US trauma systems and, in 1972, published Early Care of the Injured Patient1 followed in 1976 by the first iteration of the Optimal Resources for Care of the Injured Patient.2 These documents outlined resources and practices to optimally care for injured patients across the continuum of care within the civilian spectrum. Numerous subsequent studies and analyses demonstrated that inclusive trauma centers and trauma assistance systems improve trauma outcomes. The development of combat casualty care capabilities during the current contingency operations has been a revolutionary story of successful adaptation and evolution, which has driven substantive improvements in the care of the battlefield casualty. This revolution was initiated in 2004 with the inception of a formal military trauma system, the Joint Trauma System (JTS). The purpose of the JTS was to develop a novel systematic and integrated approach to organize and coordinate combat casualty care. The basic principles of the trauma system were founded on four simple tenets: right patient, right place, right time, right care with the guiding vision that every soldier, sailor, airman, and marine injured in the battlefield will have the optimal chances of survival and functional recovery.3 In 2005, the JTS was originated within the US Army Institute of Surgical Research (USAISR) to support the overarching architecture of the entire continuum of combat casualty care from point of injury through rehabilitation. To support the development of this new military trauma system, a Joint Theater Trauma Registry (JTTR) was developed concurrently and became functional in early 2005. The JTTR captured injury demographics, anatomic and physiologic parameters, and trauma care and outcomes across the continuum of combat casualty care. This registry data provided vital information used to effect improvements in clinical care, drive medically related doctrine and policy, and support the creation of new knowledge through research. The revolutions in military medical affairs (RMMA) relative to the military trauma system are shown in Table 1.TABLE 1: RMMAs, 2001 to 2011 Overseas Contingency Operations in Afghanistan and IraqJoint Trauma System Clinical Performance Improvement Battlefield injury care clinical performance improvements were driven by two major pathways: evidence-based practice guidelines and telemedicine. The goal of clinical practice guidelines (CPGs) is to serve as a resource for military providers to reduce practice variation. The value of battlefield medicine CPGs has been demonstrated in numerous series. Representative impact of CPGs has been manifested in several analyses to include burn resuscitation-associated abdominal compartment syndrome mortality in which mortality decreased from 36% to 18% after introduction of the CPG. Similarly, hypothermia on presentation decreased from 7% to 1% after introduction of the CPG. Perhaps, most notably, mortality in those receiving massive transfusions has been dramatically reduced from 32% to 20% after introduction of the damage-control resuscitation (DCR) paradigm and its associated CPG.4,5 As technology and communication access improved, a performance improvement tool using telemedicine conferencing was developed. This conferencing capability allowed providers across the continuum of care to discuss active patients as they were evacuated. The value of this program was twofold: it allowed providers at receiving facilities to understand the management subtleties and rationale for patients at previous facilities and gave providers valuable opportunities for feedback and loop closure of performance improvement issues through near–real-time interaction. Medical Decision Making Medical decision making in the battlefield is most useful when supported by strong data. Using the JTTR data, the trauma system published a monthly theater trauma surveillance report. This tool, along with other products of the JTS, provided valuable information to military leadership for use in injury prevention, resource allocation, and management and supporting advanced capabilities in the battlefield. Development of New Knowledge Although not specifically developed as a research tool, combat casualty care data from the JTTR have been used extensively through the formal institutional review board process to augment the knowledge base of injury care cited by more than 200 peer-reviewed articles in the scientific literature. JTS initiatives have revolutionized field trauma care as demonstrated by improved survival and functional outcomes after battlefield injury. The JTS has set the standard for trauma care on the modern battlefield using contemporary systems-based methodologies and will continue to foster advances in military medicine. Committee on Tactical Combat Casualty Care In the mid-1990s, medics, corpsman, and pararescuemen in the US military were taught to manage trauma in the battlefield using training curricula that were based on the approach used in civilian trauma courses. These courses emphasized civilian principles of care such as the “ABC approach,” starting two large-bore intravenous lines on every significantly injured patient, large-volume crystalloid fluid resuscitation for casualties in shock, and an avoidance of tourniquet use for fear of causing ischemic damage to extremities.6 Reports of preventable deaths in combat casualties in previous conflicts7,8 highlighted the opportunity to reduce preventable death in combat casualties through a focus on improved battlefield trauma care. In the mid-1990s, a medical research effort funded by the US Special Operations Command (USSOCOM) and performed in partnership with the Uniformed Services University of the Health Sciences conducted a comprehensive review of battlefield trauma care as practiced in the US military, with particular focus on first-responder care. The final product was a new concept called tactical combat casualty care (TCCC); TCCC is essentially a set of battlefield trauma care guidelines that have been customized for use by combat medics in the battlefield.6 The core principles of TCCC are to avoid preventable deaths and to combine good medicine with good tactics. Many of the concepts noted in the 1996 Military Medicine TCCC article were not new but rather were built on observations and recommendations of earlier authors;7–11 these recommendations had, however, never been woven into a comprehensive set of battlefield trauma care strategies such as TCCC. Lacking this structure, they were transitioned into combat trauma care courses in the military only sporadically, if at all. Of note, many elements of prehospital trauma care that were widely accepted as gospel were found to be not well supported by the available evidence. Not surprisingly, preventable death analyses from early in the Iraq and Afghanistan conflicts found that a significant incidence of potentially preventable death was still present in US combat fatalities.12,13 TCCC proposed many fundamental changes to trauma care for the combat environment. The Committee on Tactical Combat Casualty Care To provide a methodology for updating TCCC as new evidence in battlefield trauma care becomes available, USSOCOM sponsored the establishment of the Committee on Tactical Combat Casualty Care (CoTCCC) in 2001. The CoTCCC was located first at the Naval Operational Medicine Institute and later moved to the Defense Health Board (DHB). The CoTCCC is a triservice and civilian group that includes trauma surgeons, emergency medicine physicians, combatant unit physicians, and combat medical personnel. Meetings are held quarterly, and recommendations for changes to the TCCC Guidelines are made as needed. TCCC publishes its recommendations online and in the Prehospital Trauma Life Support Manual, which is endorsed by the ACS Committee on Trauma (ACSCOT) and the National Association of Emergency Medical Technicians. The TCCC guidelines are the only comprehensive set of trauma guidelines customized for use in the battlefield that has won this dual endorsement. In this recent decade of conflict, the CoTCCC has learned how to gather and analyze new information relating to battlefield trauma care and to translate that information into action.14,15 TCCC in 2012 With the leadership of the CoTCCC, the TCCC guidelines have incorporated the lessons learned from the current conflicts and new trauma literature and now include features such as the following: phased care designed to combine good medicine with good tactics; aggressive tourniquet use to control life-threatening extremity hemorrhage; Combat Gauze to control external, nonextremity hemorrhage; the Combat Ready Clamp for junctional hemorrhage; tranexamic acid for noncompressible hemorrhage; aggressive use of surgical airways in casualties with airway trauma; prompt needle decompression of suspected tension pneumothorax; modified spinal precautions for casualties with penetrating trauma; limited use of intravenous access for combat casualties; hypotensive resuscitation with Hextend for casualties in shock; intraosseous infusion techniques when vascular access is needed but difficult to obtain; better battlefield analgesia with intravenously administered morphine and oral transmucosal fentanyl citrate; an emphasis on the prevention of coagulopathy in combat casualties; battlefield antibiotics to avoid preventable deaths from wound infections, especially in situations where evacuation is delayed; scenario-based combat trauma training; and an increased use of plasma early on in trauma resuscitations (Dickey et al. DHB memo dated June 14, 2011, and DHB memo dated September 23, 2011).16–24 TCCC training has been recommended by the DHB for all deploying combatant personnel and for the medical providers who support them (DHB memo, TCCC training). TCCC—Saving Lives in the Battlefield TCCC has been noted in multiple published reports to have been successful in saving lives in the battlefield.25–32 After a decade of war, TCCC has emerged as the standard of care for managing trauma in the battlefield. It is used throughout the US military17 and by coalition partner nations33 (also SP Amor letter dated February 22, 2011). TCCC represents a revolutionary change in the training of combat medics in all three services. Prehospital Trauma Registry The considerable potential for prehospital care to increase the salvage of combat casualties through those listed as killed in action is not a novel concept.8 Likewise, it has been known that civilian trauma victims have the potential to benefit in similar fashion.34 Although TCCC offered a paradigm shift in prehospital trauma care, with the potential to substantially increase combat casualty survivability, validation of TCCC protocols and procedures ultimately requires data collection and analysis. Collection of prehospital data in the battlefield has proven to be a challenge.35 Although documentation of prehospital care can be beneficial to individual patients, this tenet alone has failed to consistently motivate prehospital personnel to document care. The Field Medical Card (DD Form 1380) is another barrier because it is not TCCC-based and is medic centric instead of casualty centric. In 1999, the 75th Ranger Regiment developed a Ranger Casualty Card to document prehospital trauma care that was consistent with TCCC guidelines. In addition, because all personnel have the potential to become a casualty or to be a prehospital first responder, all personnel carried this casualty card. The use of this casualty card quickly spread throughout the USSOCOM and multiple other combatant units in both Afghanistan and Iraq. This card was modified slightly and adopted as the official TCCC Casualty Card in 2009 by the US Army. With the start of the conflict in Afghanistan in 2001, the 75th Ranger Regiment initiated a rudimentary prehospital database from data captured through after-action reports and a Ranger Casualty Card collection program, which has been expanded into a Web-based Prehospital Trauma Registry (PHTR) software tool to capture Ranger Casualty Card data. This registry includes basic statistical analysis and instant data graphing functions, providing combatant unit commanders and prehospital medical personnel with near–real-time trends and reports for lessons learned, quality assurance, and rapid implementation of protocols and initiatives designed to immediately reduce morbidity and mortality in the battlefield.20,36–40 Thus, this registry afforded combatant unit personnel with the ability to quickly and autonomously make evidence-based decisions based on objective data. The immediate feedback provided by the PHTR helped to motivate and propagate data collection at the combatant unit level. The PHTR developed by the 75th Ranger Regiment is a novel effort within the US military. Not only does a PHTR keep combatant unit leaders engaged and informed on the health and welfare of their personnel, but it also augments leaders’ decision-making processes. The PHTR prompts performance improvements in prehospital casualty care, generates novel treatment strategies, and further refines personnel, training, and equipment initiatives. A detailed PHTR validates force protection requirements and directs procurement in a cost-effective manner. Commanders and medical providers gain invaluable knowledge on tactics, techniques, and procedures that result in lives saved in the battlefield. Combatant unit commanders with appropriately trained prehospital personnel do have the potential to eliminate preventable death in the battlefield.40 A PHTR can validate and refine the training of prehospital personnel to accommodate this goal. ACS Trauma Center Verification Landstuhl Regional Medical Center (LRMC) is a permanent US military installation and is the largest American military hospital outside the United States. It is staffed by military personnel from the three services as well as US and host-nation civilians. Since 2003, LRMC has provided care to nearly all ill and injured casualties evacuated out of the combat theaters of Iraq and Afghanistan. In 2006, a process began at LRMC to meet ACS Level II criteria and obtain Level II verification to demonstrate that the resources, staffing, educational programs, and expertise available at LRMC were comparable with a civilian trauma centers in the United States.41 The ACS Level II review team found no criterion deficiencies, few weaknesses, and a multitude of trauma care strengths, which led to verification. The committee recommended that LRMC submit a future application to seek Level I verification because of the outstanding care that it delivered and the trauma performance improvement systems it had in place. During the next 3 years, the LRMC trauma staff continued to receive casualties from the war and to improve their clinical outcomes. They expanded their trauma research program and postgraduate residency training positions. In 2010, LRMC leaders, with the concurrence of the Surgeon General of the US Army, submitted an application for Level I verification with a site inspection in May 2011. The ACSCOT review team reported no criterion deficiencies. In July 2011, LRMC was verified as one of 142 US hospitals with ACS Level I Trauma Center designation. LRMC remains the only verified center outside the United States. The approval solidified additional resources and staff to efficiently and expertly manage the of injured military personnel who at LRMC Surgeon The Surgeon is a change for military trauma care. 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