When it comes to our military, Americans expect the best. We expect the best weapons, the best-trained soldiers, the latest and best equipment, and we fully expect to be the best fighting force in the world. And when our men and women in uniform are wounded in combat, we definitely expect them to receive the best medical care possible. When they do not, we expect heads to roll. What happened when housing for wounded servicemen at Walter Reed was found to be substandard in 2007? The hospital commander and the Army surgeon general were both quickly relieved of command.
The battlefield is a bit different. We expect the medical care received there to also be the best, sure, but who is it that defines what constitutes the best combat medical care? And just who is responsible for making sure that the medical care our fighting men and women receive meets that high standard? Military medical personnel command military hospitals, but U.S. troops are not wounded in military hospitals. They are wounded on the battlefield, and combat commanders own the battlefield. So who should be held responsible for making sure that our fighting men and women receive the best care? Medical personnel or combat commanders?
The birth of modern combat casualty care
In October 1993, a mostly special operations-led force of U.S. military units fought a fierce battle against Somali fighters in the Battle of Mogadishu, famously depicted in the book and movie “Black Hawk Down.” The relentless street-to-street fighting resulted in the deaths of 18 U.S. servicemen. An Army special missions unit medic during that battle, Specialist First Class Bob Mabry, was one of the combat rescue team members who fast-roped down to the first helicopter crash site and provided care under fire to the wounded for 15 hours.
Later, Second Lieutenant Bob Mabry, by then a medical student at the Uniformed Services University of the Health Sciences (USUHS), would write a paper that described the casualties sustained in Mogadishu and the shortfalls in casualty care that he observed during the action. Later still, fully 21 years after the Battle of Mogadishu, Lieutenant Colonel Bob Mabry, now an Army emergency medicine physician and a leading thinker in combat medicine, would author another paper titled “Challenges to Improving Combat Casualty Survivability on the Battlefield” that would highlight some of the reasons behind the shortfalls in pre-hospital trauma care.
Mabry observed, “Responsibility for battlefield care delivery is distributed to the point where seemingly no one ‘owns’ it. Unity of command is not established, and thus no single senior military medical leader, directorate, division, or command is solely focused on battlefield care, the quintessential mission of military medicine.” Furthermore, when “best-practice” medical care guidelines are developed for battlefield injuries, who is responsible for implementing them?
During roughly the same timeframe as the Battle of Mogadishu, but initially unrelated to that action since details regarding those casualties were not made public until later, a three-year research effort in battlefield trauma care was being conducted by the Naval Special Warfare Command, the parent command of the Navy’s SEAL teams, in partnership with USUHS, and later, with the U.S. Special Operations Command (SOCOM). That project—for the first time—brought evidence-based medicine to the study of battlefield trauma care, and resulted in the 1996 publication in Military Medicine of one of the seminal papers in the history of U.S. military medicine, “Tactical Combat Casualty Care in Special Operations.”
This 1996 tactical combat casualty care (TCCC) paper took what at the time was a unique approach, in that it took into account the unique aspects of casualty treatment in the tactical environment, and recognized the need to make battlefield trauma care consistent with good small-unit tactics. TCCC broke battlefield trauma care into three phases: care under fire, tactical field care, and casualty evacuation care, with prescribed care for each phase.
For example, TCCC emphasized that, first and foremost, one should maintain tactical awareness and return fire as needed during a gunfight, to prevent both the casualty and the medic from being killed by hostile fire, and to help prevent more unit members from being wounded or killed.
TCCC also recommended tourniquets for life-threatening extremity bleeding, despite tourniquets being universally disparaged by civilian pre-hospital trauma experts at the time. Extremity bleeding was the leading cause of preventable death on the battlefield in Vietnam, and tourniquets are generally harmless when applied for short periods of time, so TCCC made a strong push for tourniquet use when a casualty is in danger of bleeding to death from an arm or a leg wound. This initial observation about tourniquets led to a complete, evidence-based re-evaluation of all aspects of prehospital trauma care. TCCC revamped battlefield pain relief and fluid resuscitation recommendations and also recommended against tactically unsound and medically futile CPR on the battlefield.
TCCC was thus a revolutionary approach to battlefield medicine. It was relatively quickly adopted within some special operations forces (SOF) units after publication of the 1996 paper, first by the Navy’s elite SEAL teams in 1997, then by the 75th Ranger Regiment, the Army special missions units, and Air Force’s pararescuemen.
All of those units had TCCC programs in place by the start of the war in Afghanistan in 2001. After early reports of TCCC success, the rest of the military began to follow suit, and to use this approach in caring for its casualties. The increase in lives saved would prove to be dramatic. Military experts have estimated that over 1,000 lives were saved by tourniquet use alone. A fundamental observation about this shift in battlefield trauma care is that it was the commanders of the units who were the early adopters of TCCC—not military physicians. The commanders directed that TCCC be used in their units. In combat units, doctors advise but commanders decide.
Meanwhile, improvements also occurred with respect to the medical care provided within deployed medical treatment facilities (MTFs), the military’s field hospitals. The Joint Trauma System (JTS) was established within the U.S. military to address all aspects of combat casualty care, including hospital care of battlefield casualties, following their evacuation from the point of injury.
As experience was gained, trauma surgeons from all of the military services helped the JTS to craft clinical practice guidelines (CPGs) to help capture battlefield trauma care “lessons learned,” and to make best-practice recommendations for surgeons and nurses in theater hospitals and evacuation aircraft. The JTS’s clinical practice guidelines were codified and were for the hospital setting what TCCC was for the battlefield—best-practice medical guidelines specially crafted for combat trauma. These CPGs represented 14 years of collective wisdom and the experience of our nation’s best combat trauma surgeons, emergency medicine physicians, and critical care nurses.
The Department of Defense’s Trauma Registry was also created by the JTS so that the care provided to each casualty could be documented, and later studied, to see if there were improvements that could have been made to the care provided.
It took a combat leader—the commander of U.S. Central Command, acting on the advice of his surgeon—however, to direct the implementation of all these advances.
With all of the above measures in place, the survival rate of U.S. casualties in the country’s most recent 15 years of war has been the highest ever seen. Units like the 75th Ranger Regiment and the Army special missions units that had used TCCC from the start of the conflicts succeeded in almost completely eliminating potentially preventable fatalities, an unprecedented accomplishment in combat casualty care. TCCC’s emphasis on tourniquet use dropped the fatality rate due to bleeding out from extremity wounds from eight out of every 100 combat fatalities in 2006 to one out of 100 fatalities by 2011.
This was a remarkable level of success, no doubt, but it was all dependent upon the successful interaction between the combat commanders and well-informed unit surgeons advising them.
Executing the plan
The changes that were made in combat casualty care may now seem straightforward and obvious, but in fact, they were anything but. Developing and implementing those changes in combat casualty care for use in the conflicts in Afghanistan and Iraq was a slow and painstaking process that required the concerted effort of both military physicians and combat commanders. The work is not yet done, either. As the old SOF saying goes, ‘It doesn’t matter how good your plan is if you don’t execute it well.”
Even now, neither the clinical practice guidelines, nor TCCC, nor the Trauma Registry, nor even a fully functioning JTS are fully established in the Department of Defense. Two surveys of pre-hospital trauma care in Afghanistan in 2012 and 2013 found TCCC being used unevenly and inconsistently throughout U.S. forces in the battle space. Furthermore, the JTS CPGs have not been adopted by any U.S. combatant commander other than CENTCOM. Finally, the Pentagon cannot decide who “owns” the JTS, and the continued existence of DoD’s Trauma Registry is far from assured.
So how is it that the U.S. military could be in danger of losing all of these advances in trauma care?
This speaks to how the U.S. military is fundamentally run. As former Secretary of Defense Robert Gates pointed out in his book, “Duty,”
“Symbolically, there was no one of high rank in Defense whose specific job it was to ensure that the commanders and troops in the field had what they needed…the very size and structure of the Department assured ponderousness, if not paralysis, because so many different organizations had to be involved in even the smallest decisions. The idea of speed and agility to support current combat operations was totally foreign to the building.”
In terms of organizational dynamics, medicine has the same problems that all other programs in the military have. In addition, as Lieutenant Colonel Mabry emphasized, “ownership” of combat casualty care is more complex than other aspects of military operations because of the overlap between line and medical leaders.
Locking in the military’s advances in combat casualty care made over the last 14 years will require acceptance of new concepts by the DoD, and extensive cooperation between the various services and commands within the U.S. military—neither of which is easily achievable. Each branch of the armed services has a somewhat different perspective and somewhat different interests than the other services, and they all jealously guard their autonomy. Decisions made in the Marine Corps about medical care—or anything else—do not necessarily reflect decisions made by the Army. Orders issued by the CENTCOM commander have no weight whatsoever in other geographic combatant commands.
So how are all of these competing viewpoints and interests to be reconciled so that advances in trauma care can be made permanent? What are the steps that need to be taken for this to happen? And who has the authority to take them? One thing is certain: It will take more than military doctors to make this happen.
To be continued in part 2.