Battlefield medicine and the urgency to save Soldiers
April 26, 2011
By Paul Boyce
Gold and platinum aren't rare elements on today's front lines. Army doctors, nurses and medics are measuring the speeds of battlefield care in a "golden hour" and a few "platinum minutes" daily in Iraq and Afghanistan.
Controlling bleeding in those vital minutes after a Soldier is wounded and rapid evacuation from the point of injury now makes deadly injuries survivable.
"War requires agility and adaptability, and so does the medical response to war," said Col. Bruce McVeigh, commander of the 1st Medical Brigade at Fort Hood, Texas, and recent commander of 28th Combat Support Hospital in Iraq. "We used to talk about getting care to a patient in the 'golden hour,' the first hour after injury. Now we are focused on the 'platinum 10 minutes,' when the combat medic provides immediate lifesaving care."
Frontline casualties could have transfusions in as little as 10-25 minutes. With blood loss still the number one cause of death on battlefields, military medical experts say that speed gives wounded Soldiers' lives a golden-hour reprieve.
New medical evacuation policies are expediting Soldiers to treatment facilities faster and in better medical condition, reinforcing our commitment to the best and most timely care, said McVeigh, who was in Iraq from October 2009 to May 2010, and ran the Army's combat medic training program from 2003 to 2005.
McVeigh credits new tourniquets, rapid evacuation and highly trained medics as part of a larger series of changes to military medicine he witnessed in Iraq. "The combat medic on the battlefield has made a huge difference in our life-saving capability at that point of injury because of the realistic and intensified training through the Army Medical Department," McVeigh said.
The Army "brought in Ranger doctors, Special Forces physician assistants and others at the height of the war to assimilate rapidly vital after-action reports from divisions and brigade combat teams...to make the combat medic training program such a huge success for our Army and our Soldiers in need," McVeigh said. "We should credit the current Army surgeon general for his vision in training the combat medic as a key battlefield multiplier."
"Another factor (is) today's commanders at corps, division and brigade combat team levels who made medical training and preparedness a key cornerstone of their readiness to go to war," McVeigh said. "They made this a huge part of their training as they (prepare to) deploy."
One change in treatment on the battlefield is bringing back the tourniquet, said Army Surgeon General Lt. Gen. Eric B. Schoomaker. "It's not conventional practice, but it's saving lives," he said. Tourniquets for medics used to be discouraged for fear of accidentally leaving one on too long in the heat of battle or during transport.
"The Army Medical Department Center and School gathers lessons learned from the battlefield and incorporates them into training so that our medics can be as prepared as possible for what they may face in combat," Schoomaker said. "This training-along with new technology such as bandages that promote lifesaving blood clotting, airway devices and a longer needle for decompression of chest injuries-has saved many lives."
The Army employs five levels of medical care to treat injured or sick military personnel, extending from the forward edge of the battle to the continental United States, with each level providing progressively more intensive treatment.
Since 2001, Army medical leaders reengineered combat trauma care, stressing rapid turnaround, new doctrinal solutions, and new materials and medical devices.
"After making the first major change in 40 years to the field medical kit, the Improved First Aid Kit, we have modified the contents of the kit at least three times since May 2005, based upon ongoing effectiveness reviews and head-to-head comparisons with competing devices or protocols," Schoomaker said.
"Survivability on the battlefield has never been better," said Forces Command Surgeon Col. Brian Lein, who credited four main factors. "First and most important is the competence, quality, training and equipment of our front-line medics. These heroes on the battlefield have been taught how to give care while in contact and how to stabilize these war wounds far forward. Without these medics, wounded warriors would never survive to get off the battlefield.
"Second, continuous improvements in doctrine and procedures for evacuating off the battlefield-putting critical care nurses in the back of helicopters, providing hypothermia prevention kits, and overflying levels of care to get to the best location to care for wounded-have been instrumental in saving the lives of our Soldiers," Lein added. "Bringing trauma specialists in anesthesia, surgery, orthopedics, neurosurgery and others far forward on the battlefield, as well as linking those far forward through telemedicine back to specialists at military hospitals throughout the world, have led to the best hospital survivability rate in any armed conflict."
Lein recognized rapid efforts to stop bleeding wounds as the third factor. "The concept of 'damage control surgery,' to stabilize contamination and stop bleeding-new 10 years ago-is now credited with saving many Soldiers' lives. (It) is being practiced at all military hospitals and has been copied in many civilian trauma programs throughout the United States.
"Rapid evacuation from battlefield hospitals to Landstuhl Regional Medical Center (Germany) by the U.S. Air Force, in combination with the implementation of the critical care air transport team, now means we evacuate the sickest off the battlefield the quickest and get the wounded into the hands of specialized care within 24-48 hours after combat injuries," Lein said.
Fourth, Lein said, "The phenomenal improvement in rehabilitation and complex injury care at Walter Reed Army Medical Center, Bethesda Naval Hospital and Brooke Army Medical Center revolutionized how quickly we are able to get the wounded healed and back into the arms of their Family and often, back to their unit."
A joint, interagency database tracks this rapid-response effort, creating the equivalent of a trauma network available to a major metropolitan area or geographic region in the U.S. The Army's network, however, is spread across three continents, and is 8,000 miles end-to-end. The Joint Theater Trauma System is staffed and led by members of the Army, Navy, Marine Corps and Air Force.
Despite remote locations in Afghanistan, military doctors, nurses and medics are updating a specialized patient database, the Joint Theater Trauma Registry, minute-by-minute, to minimize evacuation times regardless of weather conditions or terrain.
The Government Accountability Office agreed with many of these successful changes in a February 2010 report: "Conducting counterinsurgency operations in often uncertain, dangerous environments such as Iraq and Afghanistan, Army theater commanders have reconfigured the composition of field hospitals and forward surgical teams by breaking them down into smaller, stand-alone units to better position them to give the severely wounded or injured-such as the casualties of blast-type injuries-the advanced emergency medical care needed to save lives."
By maintaining a presence in these areas, these critical life-saving medical units are better able to achieve their goal of providing advanced emergency medical care within 60 minutes of injury to increase survival rates, the GAO report said.
The partnership among the medical and line leadership of Operations New Dawn and Enduring Freedom-Central Command, Army Forces Command, U.S. Army Reserve Command, National Guard Bureau, Army Medical Department Center and School, Medical Research and Materiel Command, Army G-3/5/7, and others-has resulted in a dynamic reconfiguration of the medical formations and tactics, techniques, and procedures required to support the deployed Army, joint and coalition force.
"Army medicine has never missed movement, and we continue to achieve the highest survivability rate in the history of warfare," Schoomaker said.
At the end of July 2010, more than 10,000 military medical personnel were deployed to Iraq and Afghanistan-70 percent of whom were Soldiers.
There is a long history of learning from the battlefield. Anesthetics were first used during the Crimean War. World War I saw the creation of the first blood bank and the beginnings of plastic surgery. The introduction of penicillin and antibiotics in World War II meant only 10 percent died of disease, and during the Korean War, the military stood up the Mobile Army Surgical Hospitals of "M*A*S*H" fame.
Today's Army Medical Command provides "agile and adaptive medical teams ready to execute relevant, responsive health services in any operational environment and in combination with any partnered team" as part of its vision: "America's premier medical team saving lives, fostering healthy and resilient people, and inspiring trust."
Paul Boyce works for U.S. Army Forces Command Public Affairs.