Note: This is part two of a two-part series. Read part one here. In part one of this series, SOFREP discussed the myriad challenges involved in improving the U.S. military’s practice of battlefield trauma care.  Unfortunately, bureaucratic delays and roadblocks to advancement are nothing new in the U.S. military, and no one should expect that making advances in combat trauma care should be any different.

At the start of the war in Afghanistan, for example, the U.S. military was using the same pain relief drug for wounded soldiers on the battlefield that was used by military doctors under Generals Sherman, Grant, and Lee in the Civil War. Let that soak in for a minute. Granted, morphine is a good drug, but when it is given intramuscularly, as it most often is, it works very slowly, and when it does start working, it can drop blood pressure and suppress breathing. Neither of those are good things for a combat casualty.

Today, there are far better medications with which to relieve pain, as well as other significant advances to improve the treatment of America’s combat wounded. The next step is making them permanent and prescribed throughout the entire U.S. military. An important lesson learned over the last 14 years of war is that in combat casualty care, the actions of combat commanders are critical to the rapid and uniform use of those advances.

The progress made

In combat operations, unit surgeons advise, but it is combat commanders who command. In fact, the most critical advances in casualty care during recent years of combat were made by senior combat leaders in special operations—imposing TCCC as the standard of care for SOF—and by Secretary of Defense Robert Gates, who mandated that casualties in Afghanistan be evacuated within 60 minutes of being wounded.

The question of just how to fully implement the advances made in combat medicine—particularly in the last 14 years in Afghanistan and Iraq—as well as how to ensure that those advances are preserved for future conflicts, was the subject of a paper published in the summer of 2015 in the “Journal of Trauma and Acute Care Surgery.”

The paper, entitled “Implementing and Preserving the Advances in Combat Casualty Care from Iraq and Afghanistan throughout the U.S. Military,” opens with a statement that almost perfectly captures just where U.S. military medicine was before 9/11/2001, and where it is today:

The U.S. military had not effectively sustained many of the lessons learned from past conflicts and went to war in Afghanistan without wide availability of tourniquets, without modern battlefield analgesics, without prehospital plasma, and without trauma care guidelines designed specifically for use on the battlefield. Hemostatic dressings had not yet been developed and fielded. There was no military deployed trauma system, no Department of Defense trauma registry (DoDTR), no weekly worldwide trauma teleconferences to review treatments and outcomes for all casualties occurring in the preceding week, and no Committee on Tactical Combat Casualty Care (CoTCCC).

The progress made has been nothing short of remarkable. Over the past 14 years, military medicine has made advances in essentially all aspects of trauma care, from controlling external bleeding, to relieving the pain of combat wounds, to using better methods for treating shock resulting from blood loss. Military medical personnel record all aspects of a casualty’s care. Evacuations from the battlefield, back to advanced medical facilities at Landstuhl, Germany, and the United States, are executed faster than ever before. In other words, U.S. military medicine has come a long way in caring for combat casualties.

While the “Implementing and Preserving…” paper heralds these advances, it also sounds a cautionary note, and makes some specific recommendations about the next steps senior military leaders need to take to preserve those advances.

What the experts say

Before digging into the specific recommendations made in the paper, one should first note three important caveats. First, it is worth taking note of the paper’s three authors. One, Dave Smith, is a retired two-star Navy admiral who worked with the SEALs as a diving medical officer early in his career, and who later served as the surgeon for the chairman of the Joint Chiefs of Staff. Smith also served as the senior U.S. medical officer in Afghanistan.

The second author, former Surgeon General of the United States Richard Carmona, was an Army Special Forces medic who was wounded in Vietnam, and who then went on to become a trauma surgeon. He was later appointed by President George W. Bush as surgeon general.

Finally, retired Navy Captain Frank Butler was an officer in the Navy SEALs, and later became a surgeon. He worked for the SEAL community for 14 years as the head of their biomedical research program, and later served as a task force surgeon in Afghanistan in 2003. His last active-duty assignment was command surgeon at the U.S. Special Operations Command.

The three authors, in other words, are the consummate “insiders” in military combat medicine. They know what they are talking about. All three have been working to improve medical care for U.S. combat forces for much of their professional careers. What they are not are outside agitators throwing rocks at the Pentagon and military leadership, nor are they approaching this with “special interests,” advancing some program or weapons system to make themselves millions of dollars.

The second concept the paper sheds light on, and acknowledges, is the remarkable improvements made by the U.S. military in overcoming the myriad challenges to improving and sustaining combat casualty care. While some in the military have taken the recommendations as implied criticism of senior military leadership, in reality, the paper reads more as counsel to America’s senior Department of Defense leaders.

The end goal of the paper—its central theme and recommended courses of action—focus on preserving the advances made by military medicine in caring for U.S. casualties. The authors appear to be doing exactly what military medical personnel should be doing: advising the combat commanders, who have the authority and the responsibility to implement the recommended actions.

Read Next: Combat Medicine: Senior Military Commanders Need to Do More to Save American Lives (Pt. 1)

Finally, the 2015 paper was written on the backside of 14 years of war, upon which the authors were able to reflect and base their study. That long period of war is accompanied by countless experiences, lessons learned, and after-action reports, as well as by the accumulated knowledge and expertise gained. This breadth of accumulated knowledge, in fact, is unprecedented for military medicine. The U.S. military has had a prolonged period of war to get combat casualty care right, and for the most part, it appears to have done so. Published medical reports have, in fact, concluded that U.S. troops are receiving the best combat casualty care that they have ever had. Again, the challenge now is to make sure that it stays that way.

What must be done

With all of the above as preamble, we come to brass tacks. What exactly are the most critical things that the U.S. military medical community has learned over the last 14 years? The paper’s authors make eight specific recommendations, none of which appear to be extraordinarily expensive or complex, but all of which require command will and executive action by line combat commanders. Only in that way can the gains made in battlefield medicine—through hard work, blood, and treasure—be secured.

First, the paper recommends that commanders at every level mandate Tactical Combat Casualty Care (TCCC) as the standard of battlefield trauma care. This would entail all medical providers being trained to the most current standards and maintaining sufficient proficiency to both use it and to train others to use it.

TCCC, as the pre-hospital element of the military’s Joint Trauma System (JTS), is essentially the military’s EMS system during combat operations. Given that almost nine out of 10 combat fatalities occur before the casualty ever makes it to a military hospital, it is important that military medical personnel get this facet of combat casualty care right. Only then will they maximize the number of lives saved.

The 75^th Ranger Regiment’s highly effective use of TCCC has made it clear that every single American combatant needs to be able to perform essential life-saving TCCC on the battlefield. A casualty can easily bleed out while waiting for a medic to arrive. Everyone is a medical provider, to some extent, just as everyone is a shooter when in combat.

Secondly, the paper recommends that combatant commanders adopt the JTS Clinical Practice Guidelines (CPGs) as the standard of care for deployed military hospitals and evacuation platforms under their command. Basically, this means that wherever a wounded U.S. serviceman receives hospital care in a deployed environment, he or she should be assured the same high level of care that the JTS helped the U.S. Central Command to achieve in Iraq and Afghanistan.

Commanders in all of the military’s geographic combatant commands should ensure that surgeons operating in facilities designated to receive casualties in his or her area of command are trained and prepared to use the JTS CPGs prior to the need arising. No American casualty should ever receive substandard care just because a combatant commander has failed to mandate that the JTS CPGs be used within that command. To date, only Central Command, acting on the advice of its command surgeon, has taken this important step.

Third, the JTS should be made a permanent fixture within the Military Health System, and should be the military’s lead organization for trauma care. According to the authors, this will ensure that there is a lasting repository of trauma expertise within the U.S. military, so that when America goes to war, expert advice on trauma care is immediately available to military leaders. All of the armed services, and the geographic combatant commanders, must be able to interact directly and effectively with the JTS in order to optimize trauma care within their commands.

The authors’ fourth recommendation is to preserve and enhance the Department of Defense Trauma Registry (DoDTR). This was established over the course of the past 14 years, with the goal of providing visibility on all U.S. casualties. The DoDTR facilitates continuous learning with respect to the care provided, and over the last decade, it has become the largest combat trauma registry in history.

The authors stress that this should be preserved and enhanced, with all U.S. combat casualties from all combatant commands being entered into the registry. These types of trauma registries facilitate the retrospective study of the care received, as well as the outcomes for the casualties (whether they fully recovered and what complications they may have sustained).

The DoDTR promotes continuous improvements in trauma care and strengthens the evidence base for future decisions about casualty management. At the start of the recent period of conflict, the U.S. military had no centralized, comprehensive registry of those injured in combat. In 2016, lack of such a trauma registry is unacceptable for the world’s most advanced military.

Fifth, the paper’s authors stress that the U.S. military must employ continuous learning when it comes to its casualty care. Each combat death should be analyzed by the JTS and military pathologists to ascertain whether or not the death might have been prevented by better medical care or by more rapid evacuation to a medical treatment facility.

The need for such a process would seem to the layman, such as this author, to be stunningly obvious. And yet, such a process was not in place at the start of the recent wars. Going forward, every death that is identified as being potentially preventable should trigger a determination of what needs to be done better the next time.

Sixth, the authors also take aim at the delays and inefficiencies faced in putting the latest innovations in combat casualty care into the hands of the corpsmen, medics, PJs, physician assistants, and physicians who can then use them to save lives. They note that, although the U.S. military has a robust military medical research program and routinely interacts with civilian medical experts to look for ways to improve combat casualty care, there is currently no system in place to rapidly field newly developed combat casualty care equipment and techniques once they have been recommended for use by the JTS. It is impossible to save a life with a piece of gear that you do not have.

The services would be well served by a program that takes newly recommended combat casualty care equipment and provides it to deploying units along with the required training to use it. The system would then, ideally, capture feedback about the performance of the new equipment, thus facilitating the cycle of innovation, feedback, reevaluation, and improvement within the military trauma care system.

The authors’ seventh recommendation focuses on the U.S. military’s large investment in combat casualty care research. The authors stress that this investment should be focused on reducing preventable combat fatalities. In addition, the authors note that the Food and Drug Administration’s (FDA) drug-labelling methodology does not lend itself well to maximizing the availability of newly recommended medications in battlefield trauma care.

Once medications are approved for any uses, physicians can and often do routinely use those medications for other disorders, assuming there is clinical evidence to support it. So-called “off-label” use is much more difficult in the military, which is detrimental to the optimal care of combat casualties. One way to address this problem would be a collaborative DOD and FDA military drug-use panel to overcome the regulatory impediment to optimizing use of battlefield medicines.

Finally, the paper recommends that training in TCCC and the JTS CPGs be ongoing for those who will be caring for America’s casualties, especially during peacetime. Trauma surgery skills languish in peacetime unless surgeons and nurses work in a civilian trauma center, where there is no shortage of gunshot wounds from criminal violence. Such outside-the-box thinking and practice is required if military medical personnel are to stay sharp in trauma care after the guns of war go silent.

How to make it happen

Returning to Lieutenant Colonel Mabry’s point mentioned in part one of this series, regarding who “owns” battlefield medicine, it is obvious that combat commanders have the major role to play. As anyone familiar with the military’s chain of command structure understands, actions taken by military leaders apply only to those units within the decision-makers’ chain of command. Thus, for the above recommendations to benefit the entire U.S. military, the directive must come from the very top level of the Pentagon’s leadership.

As the old Ranger saying goes, “Lessons learned are not really lessons learned unless you actually learn them.”  With that in mind, six months after the 2015 “Preserving and Implementing…” paper was published, it is worth noting that the Pentagon leadership has done very little to act on the recommendations in the paper.

Two of the most important advances in combat casualty care were the direct result of actions taken by line combat commanders—the adoption of TCCC directed by special operations commanders Rear Admiral (SEAL) Tom Richards, General Stanley McChrystal, Admiral (SEAL) Eric Olsen, and General Doug Brown; and former Secretary of Defense Robert Gates’ “Golden Hour” mandate in 2009. Those actions were responsible for saving many American lives.

Now, Defense Secretary Ash Carter has the opportunity to progress military medicine even further forward, by making the advances in combat casualty care a permanent part of the U.S. military. Only by directing that all of the recommendations outlined above be enacted can Mr. Carter ensure the continued availability of the high level of combat casualty care that has been achieved. It will require a directive from the Secretary of Defense to ensure that this level of care is available for all of America’s future war wounded.

Pentagon leaders, and the country as a whole, owe that to the men and women who go into harm’s way in the service of the United States.