Vietnamese patient in the back of a helicopter receiving inflight care from a medic. Photo Credit: CW2 Michael J. Novosel Collection U.S. Army Heritage and Education Center
Much of the U.S. Army Medical Department’s job on the battlefield can be boiled down to two imperatives: protect soldiers from disease and mend their wounds. For the second, the Medical Department has employed a system of tiered medical capability beginning with combat medics and ending at inpatient hospitals in the United States. Success was measured by mortality in hospital: those who died after arrival at a battlefield hospital were counted as “died of wounds.” Those who died before reaching a hospital were counted as “killed in action.”
From the Korean War onward, “died of wound” rates remained both relatively low and constant. “Killed in action” rates were much more dependent on the tactical environment. Evacuating a casualty might take several hours during the Korean War. The use of the UH-1 “Huey” air ambulance in Vietnam reduced most evacuation times to under an hour and introduced an on-board flight medic who could monitor and provide limited treatment to the casualties en route. Shorter evacuation times decreased the number of people dying before they could reach a hospital. Additionally, researchers collected data from the Vietnam Vascular Registry and the Wound Data and Munitions Effectiveness Team (WDMET) database, which provided valuable information enabling evidence-based improvements in pre-hospital care and trauma surgery.
The Army Medical Department continues to capture lessons learned on the battlefield and use them to improve pre-hospital care… Many of those lessons are transferable to civilian medical practice…
In the 1970s and 1980s, advances in emergency medicine were adopted and adapted by the Army for use on the battlefield. Advanced trauma life support training for health care professionals was initiated, enlisted medical personnel benefitted from an expanded training program, and combat lifesaver training for non-medical soldiers was established in combat units. An experimental unit, the Forward Surgical Team, which provided far forward resuscitative surgery, was developed at Fort Bragg. By the early 1990s, it was accepted and in widespread use. Despite the improvements the Army had made since Vietnam, Operation Desert Storm highlighted areas where trauma patient treatment could be improved.
Beginning in 1992, a Naval Special Warfare research program examined ways to improve battlefield trauma care, including reassessing some practices considered axiomatic. Vietnam casualty data showed the majority of battlefield deaths occurred before a casualty reached a hospital and the primary cause of preventable deaths was exsanguination from an extremity wound. At that time, medical personnel were taught that tourniquets were a treatment of last resort and emplacing a tourniquet was tantamount to designating a limb for amputation. Evidence based on the use of tourniquets during orthopedic surgery indicated tourniquets could be used safely, leading to a reexamination of much of what was being taught to determine its evidentiary basis. It also became clear to the investigators that it was necessary to integrate the practice of pre-hospital medicine with the tactical requirements of operating on the battlefield. 1
In 1996, the research team published new guidelines for pre-hospital care on the battlefield and identified three areas which dictated what procedures could be performed: care under fire, tactical field care, and casualty evacuation care. In addition to recommending tourniquet use to control life-threatening hemorrhage, the guidelines also recommended changes to fluid replacement, pain control, pharmaceutical guidelines, and requirements for spinal immobilization and cardiopulmonary resuscitation for specific wounds and injuries. Finally, they recommended training programs designed to prompt critical thinking about implementing the guidelines using scenarios to confront first responders with the variety of environments, tactical conditions, and casualties they were likely to encounter. These guidelines established the foundation for Tactical Combat Casualty Care.1,2
The Army Medical Department placed greater emphasis on developing the skills of its front-line combat medics during the late 1990s, creating a new military occupational specialty (68W) and requiring emergency medical technician certification for all soldiers holding the military occupational specialty. With the advent of the wars in Afghanistan and Iraq, the U.S. Army Institute of Surgical Research, in partnership with the U.S. Air Force and U.S. Navy, established the Joint Theater Trauma Registry (JTTR) to collect and analyze data on battlefield injury. Data from the JTTR confirmed early WDMET data leading to new research in controlling hemorrhage, resulting in the fielding of hemostatic bandages and tourniquets to soldiers in the field and instruction in their use. Tension pneumothorax and airway compromise were identified as the next two leading causes of preventable deaths, resulting in additional training for medics.2
The Army Medical Department continues to capture lessons learned on the battlefield and use them to improve pre-hospital care, increasing soldiers’ chances of surviving to reach definitive care. Many of those lessons are transferable to civilian medical practice, and Army health care professionals retiring from the military also take those lessons with them when they take up practice in a civilian health care facility.
Disclaimer: The opinions and views expressed in this article are those of the author. They are not, nor should they be implied as being endorsed by the United States Army Medical Department, United States Army, Department of Defense, or the federal government.
References
- Butler FK Jr. Tactical Combat Casualty Care: beginnings. Wilderness Environ Med. 2017;28(2S):S12-S17.
- Gerhardt RT, Mabry RL, De Lorenzo RA, et al. Chapter 3: fundamentals of combat casualty care. In: Combat Casualty Care: Lessons Learned from OEF and OIF. Frederick, MD: Office of The Surgeon General, Borden Institute; 2011:85-120.
Mr. Barger is an historian in the Army Medical Department Center of History and Heritage.
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