An Amtrak train struck a dump truck on June 27, 2022, derailing and scattering its aluminum-colored cars into the lush green terrain, killing four people and injuring nearly 150 more. Multiple EMS agencies worked together, including the crews from 28 ambulances, 19 fire trucks, and 17 helicopters. These first responders quickly began triaging, prioritizing those with life-threatening injuries and transporting them to hospitals near the small town of Mendon, Missouri. Medics applied tourniquets to mangled limbs, placed tranexamic acid (TXA) coated hemostatic dressings, and gained access with intraosseous (IO) devices when venous access was difficult. Next, medics worked to clear the hot zone. More stable patients were transported to a nearby school that was converted into a casualty collection point. Empty for the summer, the school provided relief from the heat and a safe place for further assessment and treatment of patients. Meanwhile, as the most critical patients arrived by helicopter at the nearest trauma center, where the emergency department team transfused blood in a 1:1:1 ratio of platelets to plasma to packed red blood cells (pRBC).

How did these lifesaving interventions arrive in a small town in Missouri? They were best practices adapted from military medicine by the civilian sector. Although military and civilian health care systems usually operate separately in the United States, the crossover of academia and research has proven valuable to both systems. Emergency physicians (EPs) are particularly valuable in the military for their expertise in trauma but also for their breadth of knowledge ranging from infectious diseases to environmental exposures and even psychiatric conditions.¹ In the civilian sector, emergency medicine has benefited from the military’s advances in mass casualty response, trauma care,

Dr. Fontenette

resuscitation, and pain control. Roderick Fontenette, MD, FACEP, a retired Lieutenant Colonel from the air force, has seen the growing collaboration between the civilian and military sectors occur during his career. “It’s a beneficial relationship for both sides—working in civilian hospitals, we keep up our clinical skills while stateside and in return, we bring with us new and proven critical care techniques from the battlefield.” Joshua Stilley, MD, FACEP, Chief of Division of EMS at the University of Missouri as well as the medical director for Chariton County Ambulance, whose district this crash occurred in adds, “Other than those invaluable techniques, one of the best things we’ve learned in prehospital medicine from the military is the staged approach to triage—extracting patients from the low-resources setting of the disaster and moving them to casualty collection points where we can better assess their needs.”

Mass Casualty Response

Mass casualty incidents (MCIs), where the number of patients exceeds hospital resources and capacity, in the military commonly range from in the military active battle to roadside bombs or terrorist attacks. In the civilian sector, active shooter and terrorist attacks easily come to mind, but natural disasters such as wildfires or hurricanes, major motor vehicle collisions, and even a derailed Amtrak train can instantly strain a hospital system, especially if occurring in a small town whose population is less than the number of passengers affected by the crash. “Command structure is key in MCI events like the Amtrak crash,” Dr. Stilley says. “That’s something we learned from the military—directing resources where they’re needed, evacuating the scene, and managing the collaboration of multiple EMS systems and hospitals.”

Dr. Stilley

Lessons learned from military medicine have helped civilian communities develop response plans, including anticipatory guidance for second-wave victims, and refine training programs.¹ When health care systems are overwhelmed in disasters, they may also have to resort to damage control resuscitation (attempts to achieve quick hemostasis until definitive care can be given) and damage control surgery (saving definitive surgery for later while controlling bleeding quickly to prevent fatal metabolic derangements from prolonged surgeries, or to care for large volumes of patients).^2-4 Dr. Fontenette says that another damage control strategy he is starting to see utilized in civilian medicine is Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA). “Military EPs paved the way for civilian EPs to place REBOAs,” Dr. Fontenette says. While there was initially hesitancy about EPs placing REBOAs in the civilian setting, the military model was based on the idea that when there were multiple casualties an EP could place a REBOA while the surgeon was in the midst of surgery.⁵ The data on ideal patient population and efficacy of REBOA use in the civilian setting is still being defined.⁶

Trauma Care and Resuscitation

In the battlefield, hemorrhage control is a life-saving intervention, but the usefulness of tourniquets, hemostatic dressing, and TXA have also been realized by civilian health care workers dealing with trauma.¹ While tourniquets have proven beneficial in the military setting, civilian prehospital care has been slow to adopt this change.^7-10 However, many communities are realizing the benefits of this hemorrhage prevention technique which saves limbs and lives with few complications if used appropriately, and are incorporating it into their bystander intervention education, such as through the Stop the Bleed program, and their prehospital care.^7-10 “The Stop the Bleed program, which teaches the public about pressure and tourniquet use, is one of the most valuable things we integrated from the military,” Dr. Stilley says. “It’s simple first aid, but giving that knowledge to everyone, like the military did in its training, saves countless lives.”

Hemostatic dressings also first came to prominence in battlefield settings, but have since become widely adopted in the civilian sector. Hemostatic dressings made of primarily of minerals or polysaccharides (such as QuikClot or HemCon) act as either factor concentrators, procoagulants, or muco-adhesives, and help stem hemorrhage in the field by (used by EMS), in austere environments, or in the emergency department until definitive management can be obtained.^7,10,11 These types of materials have also been used successfully incorporated for hemorrhagic control of common emergency medicine complaints such as epistaxis, post-surgical bleeding, and lacerations.⁷ Additionally, after its success in the military at decreasing mortality in patients with combat injuries, TXA has been similarly adapted to civilian use for everything from trauma to epistaxis to post-partum hemorrhage, with various degrees of success that

are still not fully studied.^12-14

In severe trauma, hemorrhage control is only the first step; access must be obtained and resuscitation initiated. Given the difficulty of securing intravenous (IV) access in the field, battlefield medicine has been relying on intraosseous access for decades, a method often preferred to venous cutdown.^7,10,15 This method, useful for drawing some labs and more importantly for giving fluids, blood products, and medication, has translated successfully to the care of civilian trauma and even medical patients when timely resuscitation is needed.^7,10,15

Knowledge from military medicine revolutionized civilian trauma resuscitation—the previous paradigm of crystalloids or colloids was abandoned for a 1:3 ratio of plasma to pRBC, the newest evidence points to a 1:1:1 ratio of platelets to plasma to pRBC.^1,7,10,16,17 “At the Amtrak MCI, our helicopter crews carried blood products and were able to transfuse on scene,” Dr. Stilley says, “which makes a difference when the nearest trauma center is almost an hour away.” Presently, military medicine is examining fresh whole blood transfusions, which have the benefit of being readily available from other soldiers (i.e., “walking blood banks”) and which have few additives and dilutional components, making whole blood transfusion ideal for patients with immediate threats to life or limb in austere settings or with metabolic derangements or coagulopathy.¹⁶ However, fresh whole blood likely has limited use in the civilian setting due to blood donor logistics and risk of blood-borne infections.¹⁶ “Whole blood is in many ways the ideal resuscitation fluid,” Dr. Fontenette notes, and he hopes that low titer group O whole blood, which is unseparated blood with low IgM and IgG anti-A and anti-B antibodies, may prove more translatable to civilian medicine.^18,19

Moving Forward

Military medicine and civilian medicine are more intertwined than most people realize, especially during the golden hour of prehospital and emergency medicine. Although research provides the evidence to uphold new ideas, “Integration of military medicine into civilian medicine really happens in the clinical setting,” Dr. Fontenette says. “Between deployments, military physicians keep up their medical skills by working in civilian hospitals, and they bring their modes of practice with them.” Austere environments like the battlefront foster some of the most innovative ideas, and with the collaboration of EPs on both sides, the military’s openness to new initiatives and academia’s rigor in research can translate these lessons to civilian medicine.

Dr. Sophia Gorgens

Dr. Görgens is part of the Zucker Emergency Medicine Residency at North Shore University Hospital and Long Island Jewish Medical Center. Her work has been  published in the Journal of the American Medical Association and Annals of Emergency Medicine, and she is the newest guest resident editor for the AMA Journal of Ethics.

References

1. Muck AE, Givens M, Bebarta VS, Mason PE, Goolsby C. Emergency Physicians at War. West J Emerg Med. 2018;19(3):542-547.
2. Chang R, Eastridge BJ, Holcomb JB. Remote Damage Control Resuscitation in Austere Environments. Wilderness Environ Med. 2017;28(2S):S124-S134.
3. Beldowicz BC. The Evolution of Damage Control in Concept and Practice. Clin Colon Rectal Surg. 2018;31(1):30-35.
4. Holcomb JB, Helling TS, Hirshberg A. Military, civilian, and rural application of the damage control philosophy. Mil Med. 2001;166(6):490-493.
5. Bulger EM, Perina DG, Qasim Z, et al. Clinical use of resuscitative endovascular balloon occlusion of the aorta (REBOA) in civilian trauma systems in the USA, 2019: a joint statement from the American College of Surgeons Committee on Trauma, the American College of Emergency Physicians, the National Association of Emergency Medical Services Physicians and the National Association of Emergency Medical Technicians. Trauma Surg Acute Care Open. 2019;4(1):e000376. Published 2019 Sep 20.
6. Castellini, G., Gianola, S., Biffi, A. et al. Resuscitative endovascular balloon occlusion of the aorta (REBOA) in patients with major trauma and uncontrolled haemorrhagic shock: a systematic review with metaanalysis. World J Emerg Surg. 16, 41 (2021).
7. Givens M, Muck AE, Goolsby C. Battlefield to bedside: Translating wartime innovations to civilian Emergency Medicine. Am J Emerg Med. 2017;35(11):1746-1749.
8. El Sayed MJ, Tamim H, Mailhac A, Mann NC. Trends and Predictors of Limb Tourniquet Use by Civilian Emergency Medical Services in the United States. Prehosp Emerg Care. 2017;21(1):54-62.
9. BenÍtez CY, Ottolino P, Pereira BM, et al. Tourniquet use for civilian extremity hemorrhage: systematic review of the literature. Rev Col Bras Cir. 2021;48:e20202783. Published 2021 Jan 13.
10. Haider AH, Piper LC, Zogg CK, et al. Military-to-civilian translation of battlefield innovations in operative trauma care. Surgery. 2015;158(6):1686-1695.
11. Chiara O, Cimbanassi S, Bellanova G, et al. A systematic review on the use of topical hemostats in trauma and emergency surgery. BMC Surg. 2018;18(1):68. Published 2018 Aug 29.
12. Morrison JJ, Dubose JJ, Rasmussen TE, Midwinter MJ. Military Application of Tranexamic Acid in Trauma Emergency Resuscitation (MATTERs) Study. Arch Surg. 2012;147(2):113-119.
13. CRASH-2 trial collaborators, Shakur H, Roberts I, et al. Effects of tranexamic acid on death, vascular occlusive events, and blood transfusion in trauma patients with significant haemorrhage (CRASH-2): a randomised, placebo-controlled trial. Lancet. 2010;376(9734):23-32.
14. Zahed R, Mousavi Jazayeri MH, Naderi A, Naderpour Z, Saeedi M. Topical Tranexamic Acid Compared With Anterior Nasal Packing for Treatment of Epistaxis in Patients Taking Antiplatelet Drugs: Randomized Controlled Trial. Acad Emerg Med. 2018;25(3):261-266.
15. Tyler JA, Perkins Z, De‘Ath HD. Intraosseous access in the resuscitation of trauma patients: a literature review. Eur J Trauma Emerg Surg. 2021;47(1):47-55.
16. Chandler MH, Roberts M, Sawyer M, Myers G. The US military experience with fresh whole blood during the conflicts in Iraq and Afghanistan. Semin Cardiothorac Vasc Anesth. 2012;16(3):153-159.
17. Holcomb JB, Wade CE, Michalek JE, et al. Increased plasma and platelet to red blood cell ratios improves outcome in 466 massively transfused civilian trauma patients [published correction appears in Ann Surg. 2011 Feb;253(2):392]. Ann Surg. 2008;248(3):447-458.
18. Strandenes G, Berséus O, Cap AP, et al. Low titer group O whole blood in emergency situations. Shock. 2014;41 Suppl 1:70-75.
19. Kemp Bohan PM, McCarthy PM, Wall ME, et al. Safety and efficacy of low-titer O whole blood resuscitation in a civilian level I trauma center. J Trauma Acute Care Surg. 2021;91(2S Suppl 2):S162-S168.