Combat casualty care and lessons learned from the last 100 years of war

Combat Casualty Care and Lessons Learned from the Last 100 Years of War Author’s Accepted Manuscript Combat Casualty Care and Lessons Learned from the Last 100 Years of War Matthew Bradley, Matthew Ne[.]

Author’s Accepted Manuscript

Combat Casualty Care and Lessons Learned from

the Last 100 Years of War

Matthew Bradley, Matthew Nealiegh, John Oh,

Philip Rothberg, Eric Elster, Norman Rich

PII: S0011-3840(16)30157-5

DOI: http://dx.doi.org/10.1067/j.cpsurg.2017.02.004

Reference: YMSG552

To appear in: Current Problems in Surgery

Cite this article as: Matthew Bradley, Matthew Nealiegh, John Oh, Philip Rothberg, Eric Elster and Norman Rich, Combat Casualty Care and Lessons Learned from the Last 100 Years of War, Current Problems in Surgery,

http://dx.doi.org/10.1067/j.cpsurg.2017.02.004

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COMBAT CASUALTY CARE AND LESSONS LEARNED FROM THE LAST 100

Department of Surgery, Uniformed Services University -Walter Reed National Military

Medical Center, 8901 Wisconsin Ave., Bethesda, MD 20889

Trauma/Critical Care Surgeon

Assistant Professor of Surgery

Walter Reed National Military Medical Center/Uniformed Services University

E-mail: matthew.j.bradley22.mil@mail.mil

Author email addresses in order: matthew.j.bradley22.mil@mail.mil,

matthew.d.nealeigh.mil@mail.mil, john.s.oh.mil@mail.mil, philrothberg@gmail.com,

eric.elster@usuhs.edu, norman.rich@usuhs.edu

Conflict of Interest Statement: The authors declare no conflicts of interest

Disclosure: The authors are military service members (or employees of the U.S Government)

The opinions or assertions contained herein are the private ones of the author/speaker and are not

to be construed as official or reflecting the views of the Department of Defense, the Uniformed Services University of the Health Sciences or any other agency of the U.S Government

No funding was received for this work

The views expressed in this article are those of the author and do not necessarily reflect the official policy or position of the Department of the Navy, Department of Defense, nor the U.S Government This work was prepared as part of their official duties Title 17, USC, §105

provides that ―copyright protection under this title is not available for any work of the United States Government.‖ Title 17, USC, §101 defines a U.S Government work as a work prepared

by military service member or employee of the U.S Government as part of that person‘s official duties The study protocol was approved by the Walter Reed National Military Medical Center and the Naval Medical Research Center Institutional Review Boards in compliance with all applicable Federal regulations governing the protection of human subjects

COMBAT CASUALTY CARE AND LESSONS LEARNED FROM THE LAST 100

observation that ―war is an epidemic of trauma‖ to shape this discussion For the last 15 years the U.S military has been at war in Asia and has witnessed and treated a variety of injuries, most notably from improvised explosive devices (IEDs), which have produced injury patterns never seen before in prior combat operations The military medical community has learned a great deal from the care of these casualties while witnessing unprecedented survival rates As we strive to evaluate and apply this latest epidemic experience we believe the involvement of the U.S military in various 20th century wars may provide some guidance and warnings

We have chosen to focus on the 20th century for both military and medical reasons First, war had

become an extension of the modern industrial society, fought by huge armies, mobilizing the entire resources of the nation state Operationally, combined arms warfare is the norm; logistics is the crucial staff activity; and the 19th century humanitarian revolutions had assured social leaders would watch the care of the soldier, sailor, airman, and Marine Medically, preventive medicine based in germ theory had begun to make cities safer and this technology was used to help reduce disease and non-battle injury in deployed forces Even more important, the various medical professional traditions had coalesced into a common, scientifically educated general practitioner (GP), and out of that community there was emerging

a new surgeon, medically qualified, scientifically educated and hospital trained Every Western army at the beginning of the 20th century used its social power to credential this new GP as the general medical officer (GMO) and this new surgeon as its hospital-based trauma manager Arguably, the most significant progress in the care of the combat casualty may have occurred within the last century with contributions from several nations What follows is a detailed description of the progress in the care of battlefield casualties and lessons learned from modern conflicts with U.S involvement

II WORLD WAR I

As the whole of Europe fell into the clutches of World War I, the U.S was coming of age Medicine grew out of the 19th century with widespread acceleration of learning, sharing, and scientific interest The Nobel Prize Committee awarded its inaugural prize in 1901[1], and would soon honor Alexis Carrel‘s revolutionary vascular work in 1912; he was the first surgeon, and, at the time, the youngest Nobel Laureate in history Soon thereafter Carrel joined the French military, making strides in wound

management[2] The burgeoning Mayo Clinic transformed into a public institution in 1915, barely three

years after Drs Will and Charlie Mayo accepted reserve commissions as first lieutenants in the U.S Army Medical Corps[3] Acute medical conditions still carried grave danger—C L Gibson‘s paper in a

1900 volume of Annals of Surgery noted nearly 50% mortality from acute intestinal obstruction [4] With

notable exceptions, however, (Major Walter Reed‘s work on mosquito vectors and yellow fever, for example,) medicine on the front lines of conflict still slogged along at the pace of the U.S Civil War During the Spanish-American War, 10 times more soldiers died from illness in unsanitary conditions in domestic base camps than died close to the front lines[5] ―Necessity is the mother of invention,‖

however, and the storms of war in Europe would soon water the fertile minds of military medicine around the world

WOUNDS AND WOUND CARE

Turn-of-the-century wound care ranged widely, encompassing techniques old and new The practice of Hippocrates‘ wound suppuration still lingered centuries later Surgical legends such as Baron Guillaume Dupuytren and Baron Dominique Jean Larrey promoted surgical wound debridement in earlier centuries, but the practice largely disappeared after the decline of Napoleonic France, flowing in and out of favor through the early 20th century[6]

The new wave of physicians at the dawn of the 20th century espoused technological advances as the panacea for all ailments, wounds included Sir Joseph Lister‘s proposal in 1867 that chemical antibiosis in the hospital could kill the bacteria causing wound infections stands as a milestone discovery in the annals

of human medicine Translation of his techniques into forward military practice came quickly when antiseptic occlusion dressings in soldiers‘ aid kits appeared in the Spanish-American War[7]; antiseptic coverage of wounds was taught as basic care to the European armies at the outset of The Great War Lister himself, however, avoided ―old-fashioned‖ debridement of tissue, favoring his carbolic acid tonics alone for the best treatment of soft-tissue infection, though Sir Alexander Fleming thought the long-term gangrenous damage he saw at General Hospital Number 13 in 1915 outweighed the early benefit of Lister‘s caustic antiseptics[8] The optimal, balanced approach to Listerian implementation combined with Larrey‘s debridement would eventually be promoted by Army Colonel Antoine Depage as what we would think of now as combined therapy—sharp debridement of dead tissue with medicinal cleansing of the remaining microscopic contamination.[6]

Fleming‘s discovery of penicillin had not yet opened the floodgates for systemic antibiotics, so local delivery in the Listerian paradigm served as the primary medical antibiosis of the time Topical carbolic acid only treated the surface of the wound, and with lower efficacy than desired Alexis Carrel, only three years removed from receiving his Nobel Prize, collaborated with English chemist Henry Dakin to

advance local decontamination They perfected targeted delivery of Dakin‘s solution (0.5% sodium hypochlorite and dichlormaine T) to damaged tissues through perforated rubber tubing implanted or tunneled through the wounded service member‘s body[2, 7] Infusions every two hours reportedly

cleansed myriad wounds, allowing better surgical debridement or closure with a purified field[9] Tubes and chemicals provided the best antiseptic therapy for salvaging wounds—and lives—in World War I,

and was adopted in civilian practice until systemic delivery of antibiotics was developed later in the century[10] Depage, also by then the director of the Belgian Red Cross, presented illustrative data to the American Surgical Association‘s 1919 meeting based on his hospitals‘ treatments in the later stages of the war The decrease in amputations was astounding, especially after the addition of arthrotomies with Carrel-Dakin‘s irrigation, followed by immediate closure when the wound included a major joint

meeting proposing contaminated clothing as an infectious source, and that wounds reflected the

environment in which they were incurred His experience treating the injured from the Boer Wars on the dry veldts of South Africa noted quick recoveries for soldiers with open but minimally contaminated wounds When open wounds met the muck of trench warfare throughout Western Europe, results differed

The wet fields of France and Germany, heavy with manure fertilizer, held different threats than the

veldts.[12] Even warfare itself changed the microbial profiles of wounds Trench warfare‘s stagnation meant injured men could sometimes lay for days in the contaminated No Man‘s Land between trenches Fleming worked tirelessly at the Institut Marie Depage in the years prior to his revolutionizing discovery

of penicillin His studies of wounded soldiers‘ clothing yielded numerous bacteria, most of them terribly

virulent, including C perfringens and C tetani.[6] As Thomas Helling notes in his treatise on Depage,

―[t]he dead were sometimes left indefinitely to rot before the trenches and often became part of the terrain

as artillery pulverized them into the dirt and mud, adding to the microbial morass.‖[6] Dirt is the soldier‘s constant companion, and the wounds of ongoing wars continue to vex modern medicine Similar work regarding invasive fungal infections from blast injuries is ongoing at America‘s leading military medical center, and carries direct relevance to the conflicts of today[13]

The new projectiles of higher-powered rifles and fragments of thousand-pound shells could lodge deep into the muscles of battle-hardened soldiers Prevailing practices in earlier conflicts taught surgeons only

to explore the wound in search of the offending missile if easily accessible or if arterial bleeding ensued With the realization of Roentgen‘s X-ray technology, new devices and techniques arrived for accurate localization and removal of foreign objects Joseph Flint, professor of surgery at Yale, served in several hospitals in France His staff variously used a vibrating magnet and the ring compass (and developed

modifications that allowed it to be molded and hinged, useful on any location on the body), finally

settling on their modification of the Sutton Localizer A piano wire, eventually modified to a more robust wire with a harpoon-style tip, was inserted under fluoroscopic guidance through a blunt obturator until contacting the bullet The obturator allowed manipulation under the fluoro screen without sharp dissection

or perforation concerns This effectively established wire/needle localization as a technique for

preoperatively defining a deep-tissue target for surgeons[14] Flint credited these targeted removals for low rates of sepsis in his hospitals

BURNS

Late 1800s burn care had changed little in the centuries prior that is in all but the most avant-garde

surgeons Balms, oils, tinctures of all sorts and sources—many had been in use since medieval days The technologically advanced treatments essentially replaced solutions of steeped plants or animal products with picric or boric acid solutions A Minnesota surgeon, Haldor Sneve, presented a paper that was decades ahead of its time when he suggested salt solution clysis for resuscitation and even xenografts of chicken skin to replace lost tissue [15]

Fauntleroy turned tragedy into progress with his analysis of burn treatments Late in the War, a coal ship explosion severely burned 32 men who presented within hours to Fauntleroy‘s hospital His team

essentially instituted a randomized, controlled crossover trial by starting half the victims with interference,‖ meaning without debridement, and the rest with standard removal of damaged tissue All patients received the World War I version of treatments we recognize today—external heat, fluid

―non-resuscitation (done by Fauntleroy with rectal clysis using dextrose 4% with normal saline), dressing changes, and pain control Interestingly, Fauntleroy concluded that burns healed best without

debridement Other aspects sound strikingly similar to the Clinical Practice Guidelines and leading research published by today‘s U.S Army Institute of Surgical Research Burn Center, a world leader in burn care and research at the San Antonio Military Medical Center: early fluid resuscitation prevents burn shock, burn sepsis sets in quickly, and extensive body surface area burns do poorly.[16] Fauntleroy‘s paper stands as one of the first in a distinguished, ongoing line of military burn research

LABORATORY MEDICINE

Entering World War I, laboratory medicine meant completing one‘s own tests with the office microscope

or chemical kit, or contracting out to a local private chemist Few hospitals offered laboratory services house Residents or researchers provided the service for hospitals lucky enough to have the funding required Private chemists were in short supply on the battlefields of Europe, however, so the Army provided lab services with speed and quality unexpected to deployed physicians Pathologist Army Colonel Joseph Siler, M.D., managed a network of laboratories headquartered at the Central Medical Laboratory in Dijon, France Notably, Siler exercised significant autonomy directing his labs, particularly because of confusion surrounding his chain of command For many months early in the War, laboratory services ostensibly fell under the Division of Sanitation, managed by the Army‘s supply corps

in-Physicians employed the labs with such gusto that efficiency became key Army Colonel Louis Wilson served as Siler‘s assistant director of the Allied Expeditionary Force‘s laboratories He served while on leave from his civilian role as director of laboratories at the Mayo Clinic Wilson instituted a report detailing which ordered tests turned positive to determine appropriate utilization This may be the first documented use of a ―Physician Report Card‖ for practice adjustment.[17]

Army labs offered wide-ranging tests, including the first forward-deployed pathogen testing Typhoid and syphilis, specifically, ran rampant through troop encampments; testing and treating these infections effectively increased combat readiness of the force So accustomed were physicians to the support of Siler and Wilson‘s labs that returning physicians soon demanded their home hospitals develop similar

programs.[3] National societies soon joined the movement The American College of Surgeons required in-house labs as part of their post-war accreditation package.[17]

Pathologists within range of the front also meant routine autopsies on deceased soldiers Many young surgeons learned trauma care through the pathologist‘s knife, turning those tragedies to successes when treating future wounds These autopsies also enhanced development of protective gear used by Allied troops, with real-time feedback available for commanders.[17]

BLOOD BANK

One of the military‘s greatest medical legacies from World War I is the blood bank Leading surgery and hematology experts from around the world entered the Allied countries‘ services with an impassioned focus on saving lives through transfusion

Almroth Wright described citration for the storage of blood in 1897 Physicians at Harvard/Massachusetts General Hospital stood on his shoulders in support of the war in Europe Dr Oswald H ―Robby‖

Robertson widely advocated for typed blood to be available for transfusion at hospitals near the

battlefront, citrated in a modification of Wright‘s method Tremendous support came in the person of Harvey Cushing and Base Hospital 5, (known throughout the theater as ―Cushing‘s Hospital‖) especially after Cushing and other Harvard staff visited Carrel and staff working under Depage With input from Carrel, Robertson and Cushing‘s staffs developed improved apparatus for administering the blood in a deployed setting British physicians immediately embraced the practice, inviting Robertson to travel and teach.[7] Hundreds of physicians and nurses received training from Robertson‘s crew, spreading this lifesaving capability throughout the European fronts As Hedley-Whyte notes in his review of

transfusions and war, ―[b]y 1918 each base-hospital and casualty clearing station hospital was transfusing about 50 to 100 pints of blood to an average of 50 wounded each day on the Western Front.‖[18]

Robertson‘s impassioned drive to care for the troops yielded another world first—the blood bank

―Robby‖ could often be found treating patients near or on the front battle lines—even once barely

escaping German capture when his unit was overrun During 1917‘s Battle of Cambrai, in far-northern France, Robertson fashioned an ice chest from ammunition cases to personally transport 22 units of blood

to a clearing station within range of the fight The blood survived the trip, treating Canadian shock

casualties, and the blood bank was born.[19] Refrigerated banks became the rule throughout the Western Front.[20]

SHOCK

Army General J.M.T Finney, a future American College of Surgeons (ACS) president, served as the Chief Surgical Consultant to the American Expeditionary Force for much of The Great War In an act of visionary leadership, he established a Central Laboratory for focused, translational research on topics immediately applicable to battlefield medicine Finney chose another future ACS president, Army Major George Crile, to head the Central Laboratory Crile established early fame in the 1890s for his research in shock and surgical physiology, performed the first human-to-human blood transfusion in 1906, and would

go on to found the Cleveland Clinic after being promoted to brigadier general in the inter-war years

Walter Cannon, Harvard‘s eminent physiologist, researched and published prolifically from the Crile Laboratory Cannon realized the detrimental effects of hypothermia on patients in shock, and was among the first to advocate active, artificial rewarming of trauma patients.[21] Cannon also proposed that shock resulted from blood and plasma loss, and was not purely a condition of nerves He supported the use of intravenous fluids for treatment; earlier in the century, rectal clysis or subcutaneous (―under the breast‖[22]) was the quickest parenteral entry Edward Archibald and W S McLean, two Canadian medical officers serving in Europe, followed Cannon‘s lead They observed excellent resuscitation results with saline, even proposing an idea decades ahead of its time—―hypertonic salt solution at twice

Finney-decinormal strength‖ for volume expansion Their conclusions that the response to saline is important, but fleeting, also led to proposals of adding colloid to resuscitations Further, they even noted some

mechanism for blood being ―sucked away‖ from the circulation during shock, perhaps foreshadowing the widened intracellular junction model of today.[22]

MEDICAL EVACUATION

Long before World War I, surgeons realized the basic fact that casualty survival increased as surgeon time decreased Larrey‘s ―flying ambulance‖ model had not been fully espoused by military planners, so most medical care comprised first aid by line medics, with advanced care waiting until after the battle subsided This led to high mortality rates for intra-abdominal injuries, even leading some surgeons to avoid abdominal operations.[12] In Russia, Dr Viera Gedroitz (a Russian princess and surgeon) refused to operate on abdominal injuries older than three hours To access more soldiers inside that critical window, Gedroitz outfitted a railcar as a mobile operating suite, moving treatment toward the fight.[7]

injury-to-Another Russian pioneer instituted a continent-wide trauma treatment and evacuation system that became the basis for major wars of the next 100 years Vladimir Oppel‘s system was based on his emphatic belief—―[t]he wounded patient needs to undergo the right operation at the right time and in the right place.‖ As a surgeon on his first assignment early in the war, he lamented inefficiencies in medical care, where injured soldiers only received cursory treatment on the line; others, less injured, might evacuate more easily and arrive at collecting stations, using resources meant for their comrades dying in the field Dismal results followed—the Russian army was losing a war of attrition, returning only 40% to 60% of its casualties to duty, while on the western fronts, nearly 80% returned to fight Oppel proposed an integrated trauma treatment and evacuation system recognizable to today‘s military surgeons, with the first decisions of care being made immediately in a maximum of six hours In Echelon 1, wound

debridement cleaned the wound and provided lifesaving treatment; Echelon 2 allowed major operative treatment with definitive procedures; Echelon 3 began rehabilitation, serial procedures, and other long-term treatments.[23] Adaptations on Oppel‘s plan form the basis of today‘s Joint Trauma System, itself a modification of the World War II structure.[23] The Royal College of Surgeons so appreciated his accomplishments that they accepted Oppel as an honorary fellow

In the Allied forces, the Belgian surgeon Depage pushed care toward the line, setting up postes avances

des hopitaux du front (advance posts of the front hospitals) Depage was already revered as one of the

leading surgeons of northern Europe in 1912 when as a colonel in the Belgian army, he and Marie—his wife, anatomy illustrator, and research partner—traveled to the Balkans to set up hospitals for Belgian

soldiers Only months after delivering his 1914 presidential address, “Les enseignements de la chirurgie

de la guerre” (―Instructions in the surgery of war‖) at the New York meeting of the Societe

Internationale de Chirurgie, he and Marie separately escaped the German invasion of Belgium, soon

reuniting to found an ambulance (military hospital) at the personal request of Belgium‘s Queen

Elisabeth.[6] From his main Ambulance de l'Ocean at La Panne, on the North Sea coast of Belgium, Depage deployed his first postes avances in the paradigm of Gedroitz, but on motorcars instead of rail

Depage focused most of his forward care on abdomen and chest casualties, or massive hemorrhage Patients stable for duty could return from there, gaining back time previously lost to long round-trip

transport; those requiring further care traveled back to an ambulance He reported that placing these

mobile stations within 2 km of the active battlefront reduced abdominal wound mortality from 65% to 45% Fauntleroy, the multi-war veteran renowned for burn care, supported this structure, noting when

―the patient could receive prompt attention, the results from operative treatment had been most

encouraging‖ when compared with the expectant policies of prior conflicts.[12] When Marie died in the

sinking of the Lusitania, he renamed Ambulance de l’Ocean the Institut Marie Depage in her honor She

was returning to his side from a lecturing and recruiting tour in the U.S when she perished in the event

that changed public opinion about U.S involvement in the War.[6] It was out of Ambulance de l’Ocean

that Fleming and Carrel produced so much military medical literature

BIRTH OF PLASTIC SURGERY

Plastic surgery blossomed in World War I Sir Harold Gillies, an otolaryngologist by training, so

impressed his seniors with skill and vision for the treatment of facial wounds that they chose him to open one of the first plastic surgery units in the world Widely regarded as the ―father of plastic surgery,‖ Gillies treated nearly 11,000 patients in the United Kingdom‘s military service over two World Wars.[24] His impassioned care of ―our boys‖ changed the lives of his patients Sir Harold developed numerous facial reconstructive techniques, perhaps the most famous being the ―tubed pedicle‖ graft.[25] Here he succeeded in maintaining robust blood flow to facial grafts with notably lower infection rates than prior

techniques He also championed the psychological impact of plastics, encouraging peer support and multiple follow-up visits to boost patient morale Among those he trained would be his cousin and burn plastics pioneer, Sir Archibald McIndoe, whose newfound skills would bloom in World War II.[26]

VASCULAR SURGERY

Carrel led the world in vascular surgery techniques at the turn of the century His triangulation-and-fill suture technique enabled consistently successful end-to-end arterial repair for the first time in history Surgeons throughout the U.S and Europe began implementing this technique, but military applications came slowly; ligation or amputation remained standard practice throughout World War I Dr Bertram Bernheim quotes poor transport times and high infection rates that prevented widespread use of arterial repair techniques Most vascular repair work involved ligating pseudoaneurysms that had formed over injured vessels in the weeks after injury, when collateral circulation had already developed to help salvage the injured limb.[27]

SURGICAL SPECIALTY CARE

―[T]he one agent of successful surgery, whether war surgery or civil surgery, is the good surgeon.‖[28] Crile‘s classic proverb arrived at the 1919 meeting of the American College of Surgeons Crile, along with several other pillars of American surgery, integrated civilian medicine into military structure and advanced the surgical care of our casualties.[29]

American Surgical Association President Robert G LeConte encouraged military training for physicians, especially surgeons, knowing that surgeons in uniform encounter patients and environments not seen in civilian practice ―The duties of the military surgeon are vastly different from those of a civil practitioner, and no one in civil life can take the place of a trained medical officer.‖[5] Even simple topics like hygiene contained inherent differences During the Spanish-American War, for example, 3,681 mortalities were attributed to disease—2,649 of which were in stateside encampments Only 293 men died from battle wounds The risk of death was 10 times higher for those living at ―home‖ than fighting on the front line

To permanently remedy that civilian-military medical chasm, Will Mayo formally proposed a standing military medical school in 1919, just after the end of World War I.[3]

As the war brewed in Europe, Cushing, the Mayo brothers, and other medical giants prepared for

America‘s contribution Will and Charlie Mayo began formal service for their country when they

accepted commissions as Army first lieutenants in 1912 at ages 51 and 46, respectively Will Mayo chaired a committee of national medical leaders (Charlie Mayo also joined the board) who advised President Woodrow Wilson beginning in 1916 The Mayo brothers and committee began to assemble plans for mobilizing American medical expertise for war Much help was needed, as the U.S Army Medical Corps consisted of only 443 medical officers prior to World War I Politically, Charlie Mayo championed the Owens-Drier bill, allowing medical officers to be promoted as high as major general to provide parity in operational planning Prior to this time, regular Army physicians could only promote to colonel, and reservists (including Cushing, Crile, et al.,) could only attain the rank of major The Mayo

brothers eventually rose from 1st lieutenants to brigadier generals

Meanwhile, Cushing led a team of Harvard physicians on a fact-finding and advising trip to Europe The

training and camaraderie this group developed became the de facto first reserve hospital unit Western

Reserve University and University of Pennsylvania soon followed suit as the concept spread.[7] The training paid dividends in battle—Cushing‘s hospital in France treated 499 patients in 27 hours during one particularly fierce battle

III WORLD WAR II

World War II saw major advances in surgery, blood transfusion, rapid patient transportation, and

decreasing mortality from combat injuries The U.S military was thrust in the middle of a war already in progress across continents including Europe, Asia, Africa, and South America While casualty statistics vary widely, the total number of battle wounded exceeded 25,000,000 and battle deaths numbered around 15,000,000.[30] At the time, the medical corps of the Army, Air Force, and Navy did not have enough medical officers ready for the volume of patients they would be receiving Therefore, the Department of Defense (DoD) relied heavily on the direct commissioning of civilian physicians

In his 1949 Presidential Address to the American Surgical Association, Fred W Rankin, who had served

in the U.S Army in both world wars, reviewed his experience as an Army general and director of the surgery division of the U.S Army in World War II.[31] Rankin cited four factors as being most important

in the reduction of mortality and morbidity rates for battle injuries in World War II These included the availability of excellently trained young surgeons who could perform surgery in combat areas; improved methods of resuscitation, including the ready availability of blood and blood plasma; the availability of antibiotics and chemotherapeutic agents used as adjuncts to surgery; and improved means of

transportation, including aircraft, for movement of convalescent patients over long distances, even to the continental U.S.[31] As a result of those improvements in care, the percentage of combat casualties dying

of wounds was reduced to 3.3% from the World War I level of 8.1%.[31] Furthermore, the mortality rates

of patients with life-threatening wounds of the head, chest, and abdomen were reduced to approximately one-third of the rates in World War I.[31]

SURGICAL CONSULTANTS AND AUXILIARY SURGICAL GROUPS (ASG)

During the inter-war period, the U.S Army Medical Department‘s strength after World War I was reduced from a peak of 340,000 to 11,500 officers and enlisted personnel by 1939.[32] To prepare for World War II, the Army Medical Department relied heavily on reserve and National Guard units to supplement the medical corps In addition, the Medical Department shortened the length of the medical officer basic training course from five to three months and expanded the size of training classes Due to the need to rapidly deploy medical personnel, much of the training, including specialized medical training required for the support of combat troops, occurred ―on the job.‖[32] While the efficacy of this new pre-war training regimen was not well documented, one can imagine that personnel experienced in war wounds, complex surgical procedures, and leadership were in high demand

In response, the Office of the Surgeon General created the Professional Consultants Division within the office of the Army Surgeon General.[33] These consultants were academic surgical luminaries who were commissioned into the Army and served full time in their roles in uniform These consultants became full-time medical and surgical advisors to the surgeon general This is in distinct contrast to World War I where the consultants only served part time, or were only called upon when needed while they maintained their civilian duties as their primary roles The responsibilities of the surgical consultants included

promotion of the highest standards of surgery The surgical consultants included Army Brigadier General Fred Rankin, Army Brigadier General Elliott Cutler, Army Colonel Edward Churchill, and Army Colonel Michael DeBakey Through their observations of combat injuries and application of best surgical

techniques within this challenging environment, practice guidelines and best practice solutions were devised that resulted in a 25-% to 50% decrease in case fatality rates from previous wars.[33] In addition, the assignment of appropriately trained young surgical specialists to forward combat areas as

recommended by the consultants was key to the successes of the military medical department in reducing mortality from war wounds

In distinction from the static trench warfare of World War I, the Second World War was far more kinetic with rapidly moving front lines Churchill advocated that the best-trained surgeons needed to be toward the front to perform the most demanding procedures in the most unforgiving environment in the most severely injured patients.[23] The consultants group was tasked to provide a solution to get surgical care

as close to the point of injury as possible In response, the Auxiliary Surgical Groups (ASG) were

proposed by the Surgical Consultants Division to push surgical care forward.[33] This novel concept was endorsed by Rankin, who was head of the surgical consultants group, and General Norman T Kirk, the Army surgeon general at the time

At the beginning of World War II, the field hospitals, which were large, fixed, 400-bed facilities, were the Army‘s primary surgical facility These hospitals had to be placed close to airfields outside of the combat zone in order to evacuate patients out of theater ASGs formed under Army Colonel James Forsee at Lawson General Hospital, Atlanta, were designed as mobile units that could bring surgical specialty care

to the front and fluidly augment surgical care where it was most needed.[7, 33] Originally, four teams were created Each specialty team in the group initially consisted of a chief surgeon, assistant surgeon, anesthesiologist, surgical nurse, and two enlisted technicians.[33] Eventually, specialist teams were also created to augment the ASGs These teams included general, thoracic, neuro, plastic, maxillofacial, and orthopedic surgeons These teams proved extremely valuable as they were surgical assets that could be moved around where needed most.[33] The initial ASG in combat (2nd ASG) deployed with 5th Army in

1943 to the North Africa, Sicily, and Italy campaigns.[21]

As with any novel concept, there was initial resistance to their implementation, primarily from the

administrative side of the Army as the ASGs were not part of the official military inventory In addition, many hospital personnel felt outsiders were supplanting them However, the ASGs were eventually

embraced because of the expertise of the surgeons deployed with them and their outstanding outcomes Most importantly, their ability to pass on skills and best practices learned during combat proved

invaluable The ASGs compiled thorough medical records which were eventually analyzed.[33]

Attachment of these teams was credited with decreasing mortality from penetrating abdominal mortality from a high of 66% in World War I to 24% in World War II.[7]

BLOOD TRANFUSIONS

Between the two world wars, the U.S military gained much needed experience in blood storage,

transportation, and transfusion While blood and plasma transfusions were used in the latter years of World War I, it was during the Spanish Civil War (1936–1939) where the practicability of stored blood transported to severely wounded soldiers was proven During this time, the Barcelona Blood Transfusion Service under General Francisco Franco‘s nationalist movement provided blood stored in citrated

solutions to forward-deployed medical facilities The blood was maintained under refrigeration and transported in insulated containers.[34] These techniques in blood storage and delivery would become a revolution in the resuscitation of victims of hemorrhagic shock

With German aggression and the threat of war looming on the European continent, the British Ministry of Defense in 1938 established a committee in London to devise a solution for blood transfusion support to military hospitals This led to the formation of the Army Blood Transfusion Service and the opening of the Army Blood Supply Depot in 1939, becoming the first military transfusion service in the world.[35] Prior to the U.S involvement in World War II, the British experience with blood transfusion in the North Africa theater was already accumulating It was their experience with transfusion of seriously wounded casualties that showed the ―oxygen carrying capacity [of whole blood] was essential during anesthesia and initial wound surgery.‖[34]

The problems of delivering large volumes of whole blood to the front during World War II were

numerous Obstacles included providing equipment for collection, storage, and delivery Techniques to provide a prolonged shelf life as well as techniques for proper blood group typing were just being

developed Therefore, plasma, and later albumin, although not substitutes for whole blood, were widely used as the preferred resuscitation product Plasma was being used in large quantities during World War

II, primarily due to its ease of procurement, storage, and transportation in comparison to whole blood During the early part of the war, the techniques for freeze-drying plasma were refined, and large volumes

of it were transported to the front lines While the ability to store frozen plasma existed at the time, freeze dried plasma could be preserved and stored for years under extreme heat and cold conditions

Furthermore, it would also be reconstituted with a simple kit and then transfused to the recipient with few adverse reactions.[34]

However, it was recognized by the Red Cross Subcommittee on Blood Substitutes that plasma was only a temporary solution without the availability of whole blood Churchill, the North Africa consultant to the

surgeon general, reported during the North Africa campaigns that whole blood was the resuscitation fluid

of choice, and that it was the only therapeutic fluid for preparing seriously injured casualties for surgery, lowering both mortality and infection rates In addition, he stated that plasma should only be used as a supplement to whole blood, and not a substitute for it The experiences in the North African theater, as well as the subsequent campaigns in Italy, provided ample evidence for the efficacy of whole blood and plasma transfusions in severely wounded casualties prior to the large-scale engagements in the latter part

of the European theater campaigns

ANTIBIOTICS AND SURGICAL CARE

Sulfonamide antibiotics, discovered in Germany prior to the conflict, were first used in World War II They were mass produced in preparation for the war and used by both the British and U.S military Sulfonamides were used in powder, oral, and parenteral forms to treat infected wounds as well as

gonorrhea Initially, there was widespread enthusiasm for sulfa antibiotics, and it was even issued as a powder inside the first aid kits that were given to every American soldier They were instructed to place the powder on open wounds immediately after injury

Sulfonamides were credited with significantly decreasing the incidence of gas gangrene in wounds as compared to World War I, although the principle of early surgical debridement contributed

significantly.[36] Unfortunately, sulfonamides had significant adverse effects, to include agranulocytosis and nausea when taken in oral form By 1943, sulfonamides were phased out as treatment for gonorrhea due to the development of bacterial resistance.[37] Penicillin soon replaced sulfonamides for the

treatment of all infections During the war, it was soon realized that penicillin was active against

gonorrhea, syphilis, streptococcal, and staphylococcal infections with greater potency and less tissue toxicity As a result, penicillin completely replaced sulfonamides for the treatment of infections during World War II.[38] While the use of antibiotics during the war was a vital supplement to surgical care, it was emphasized that it was not a replacement for good surgical technique

Churchill summarized the revolutionary management of major war wounds after his experience in the Mediterranean theater.[23] He proposed the concept of ―phased wound management,‖ involving three surgical stages, similar to what Oppel proposed in Russia during World War I.[23, 39] The initial and reparative phases occurred in-theater, and the third, the reconstructive phase, occurred in the interior zone The initial phase of wound surgery involved procedures designed to save life or limb and prevent or eradicate wound infection This included closure of chest wounds or hollow viscous injuries and thorough debridement of grossly damaged tissue In addition, the prompt setting of fractures was advocated, as the

―exact maintenance of the reduction of fractures by precise methods is precluded by the necessity for evacuation to the rear…‖[23] Surgeries during this phase took place close to the front lines at the ASGs or field hospitals

The reparative surgery phase occurred in the zone of communication, typically in the larger general hospitals Procedures performed during this phase were designed to abbreviate wound healing, restore function, and minimize disability The closure of wounds intentionally left open at the initial surgery typically happened on or after the fourth post-injury day If there remained any hint of infection, it was debrided surgically or with application of moist dressings Wound closure was then re-attempted on subsequent days It was recognized here that quantitative culture of the wounds was not helpful in

determining the timing of wound closure, and that all open wounds would demonstrate varied aerobic and anaerobic flora.[23] Rather, it was the gross appearance of the wound itself that determined whether it was ready for healing by primary intention In addition, the use of topical sulfonamides or penicillin was found to be ineffective, and parenteral penicillin was used only for established infections or complex injuries involving bones, joints, and viscera The recognition of ―secondary anemia‖ from chronic

infections and indolent wound healing occurred during this time, and was corrected with whole blood transfusions Early closure of small bowel fistulae, repair of end colostomies, and the implementation of loop sigmoid colostomies to protect anal and perineal open wounds occurred during this phase as well Reduction and internal fixation of fractures and debridement of infected joint capsules were also

undertaken during this stage.[23]

Of particular note, the active management of retained hemothorax and organizing empyema was

addressed during the reparative phase In contrast to management of thoracic trauma in World War I, thoracic splints were abandoned, and the evacuation of large thoracic clots through thoracotomy and decortication was advocated Churchill described this as ―… one of the significant advances of World War II.‖[23] By removing the clot burden, it was recognized during the Mediterranean campaign that this avoided the subsequent complications of empyema and fibrosis, allowing for early healing and full lung expansion Again, penicillin was an important adjunct to this procedure Once patients were sent to the contiguous U.S (CONUS), correction of deformities (reconstructive phase) were undertaken and

rehabilitation started

VASCULAR TRAUMA

With the use of high-velocity weapons and high-impact explosives, major vascular injuries were also common during World War II Vascular surgery techniques for acutely injured vessels were still in the early stages prior to the beginning of World War II Previous attempts at arterial anastomosis and vein grafts were limited to case reports and small series, primarily for non-acute injuries to the vessels,

consisting primarily of pseudo-aneurysms or arteriovenous fistula Vascular surgery for trauma during World War I was poor, largely attributed to prolonged evacuation times combined with the high

frequency of infections As a result, most arterial sutures were doomed to rupture with secondary

exsanguination.[27]

After World War II, Dr Michael DeBakey co-authored a review of 2,471 cases of arterial injury Nearly all of the arterial injuries were treated by ligation, resulting in an amputation rate of 49% Repair of the artery was attempted in only 81 recorded procedures, the majority consisting of lateral suture repair In

this small subset, the amputation rate was decreased to 35% In addition, the use of vein grafts was also disappointing In 40 cases of vein homolog grafts, the amputation rate was 58%.[40] The official policy was to forego formal arterial repair in favor of ligation primarily due to the poor clinical results DeBakey concluded that arterial ligation ―is of stern necessity, for the basic purpose of controlling hemorrhage

…‖[27, 40] The lack of efficacy in vascular repair may also have been due to prolonged transportation times to the first surgical facility While the time to first surgery improved compared to previous conflicts with ASGs, this time averaged over 10 hours, likely precluding any successful revascularization.[27]

CASUALTY TRANSPORT

Churchill ―emphasized…the importance of minimizing the time lag between initial surgery and early reconstructive procedures…Thereby extending the role of the ‗field trauma center‘ into the rehabilitation phase.‖[15] The term ―golden period‖ was used to describe the importance of the time lag between wounding and initial surgery Just as importantly, Churchill also stressed the importance of minimizing the time between initial and reparative surgery.[23]

World War II provided the Army Air Force with a large-scale experience in aeromedical evacuation of over 1 million patients by the end of World War II The C-47, a large, fixed-wing cargo plane, became the primary method of moving patients in and out of the combat theater These planes were originally

designed to move cargo, and there was initial resistance to utilizing them for patient transportation.[41]

Near the beginning of U.S involvement in the war in 1942, aeromedical evacuation was in its infancy, and the concept of being able to take injured patients to altitude for prolonged flights was unproven In

1943, the first trans-oceanic aeromedical evacuation occurred with five patients from Karachi, India (now Pakistan) to Bolling Field, District of Columbia This flight was heralded as proof of concept that a global aeromedical evacuation system was feasible.[41]

By the time of the Battle of the Bulge from 1944-1945, casualties were flown directly to the U.S as early

as three days after being wounded General Dwight D Eisenhower touted air evacuation as a major medical advancement in World War II saving thousands of lives.[41] In later wars, many of the obstacles

of aeromedical evacuation would be solved, such as standardization of litter and patient carry systems, high-altitude physiology, provision of advanced medical treatments and monitoring in flight, and

probably most importantly, crew rest and rotation

IV KOREAN WAR

The post-World War II period, while largely peaceful for most Americans, was marked by increasing tensions between the U.S and the Soviet Union The predominant foreign policy at the time was focused

on the containment of communism, both at home and abroad The U.S clearly concerned with

communism spreading throughout Europe, formulated the Truman documents and the Marshall Plan, and the Berlin Airlift America‘s foreign policy of containment also extended to Asia and in 1950 the Korean Conflict would be the first major battle the U.S waged against the spread of communism, a mere five years after the end of World War II Publications from the U.S DoD reported 36,574 deaths and 103,284 wounded in action during this three-year conflict.[42] Tragically, though, the Korean Conflict is also known as the ―Forgotten War,‖ overshadowed by the support for and overwhelming victory of World War II However, it should never be forgotten that 1.8 million service members fought in Korea, and major lessons in the practice of surgery were learned there These included advancements in medical evacuation and mobile hospital support, vascular and burn surgery, and dialysis in forward locations

HELICOPTER EVACUATION

The rugged, impassable terrain in Korea led to the edict that ―A man dies in a period of time, not over a distance of miles.‖[43] In order to evacuate casualties efficiently, a helicopter evacuation platform was needed, as ground transportation was near impossible in certain inaccessible locations On Aug 3, 1950, the first official demonstration for helicopter medical evacuation was established by the Eighth Army Surgeon, Army Colonel Chauncey Dovell, and Army Captain Leonard Crosby at Taegu Teachers College

in what is now South Korea.[43, 44] The demonstration was a success and by August 10 this platform was authorized for use to evacuate casualties In addition to the efficiency of transport, the smooth ride of the aircraft compared to a hand-carried litter over rugged terrain or the jostling of a jeep over dirt roads made aeromedical transport the vehicle of choice for injured patients.[43]

In 1951, the 8063rd Mobile Army Surgical Hospital (MASH) was the first unit to use helicopters to evacuate casualties The Bell H-13 was the primary helicopter used for medical evacuation, or

"medevac.‖ Up to two patients were transported on skids placed outside on either side of the helicopter, limiting the treatment each patient could receive during transport In 1952, the Army medevac helicopter units were organized and assigned to the Eighth Army medical command The identification change of the helicopter units to officially being known as MEDEVAC units, mandated by Army Surgeon General Major General George Armstrong in December 1952, meant they were now under medical control.[43]

There were several limitations to work around with helicopter transport Because there were no lights and only basic instrument gauges, most helicopter flights occurred during daylight.[43] Despite these

limitations, many intrepid pilots would risk their own lives to fly at night in order to save the lives of severely injured service members As patients were attached to the outer skids of the aircraft, patients would occasionally freeze, so crews made tubes to divert engine heat to patients In addition, small openings in the aircraft doors were made so that resuscitation fluids, whole blood, and plasma could be stored inside the cockpit This kept the fluid from freezing in the intravenous tubing as the patients were resuscitated in flight.[43, 44] The medevac pilots during the Korean Conflict had no medical training These pilots would take improvisational courses on basic medical knowledge from the medical and surgical units when they could Anecdotally, many pilots were so dedicated to the mission that they would assist in the casualty care in field hospitals and even assisted in the operating rooms between

flights.[43] In 1953, Medical Service Corps officers became the primary pilots for medevac flights These officers were chosen for their expertise in transporting the wounded.[21] However, by then, most of the fighting was over Between Jan 1, 1951 and the end of active hostilities in July 1953, Army helicopter teams evacuated 17,690 patients, with USMC helicopters adding thousands more for a total of nearly 22,000.[43, 44]

MOBILE ARMY SURGICAL HOSPITALS

The first Mobile Army Surgical Hospitals were established on paper on Aug 23, 1945.[44] These units were based upon the ASG concept of World War II in order to move surgery to the patient, rather than moving the patient to surgery.[33, 44] By doctrine, there were 14 physicians, 12 nurses, two medical service corps officers, one warrant officer, and 97 enlisted personnel assigned to the MASH The MASH facility was a 60-bed, truck-borne hospital designed to be taken down to move within six hours and set up again within four hours

By the time hostilities broke out on the Korean peninsula in 1950, there were no active MASH units available, although five existed on paper Furthermore, the Eighth Army had less than half the medical officers it required assigned to it.[44] As a result, the Army relied heavily upon the reserves, as well as a physician draft system, known at the time as the ―Berry Plan.‖ At the onset of conflict, casualty levels were extremely high, and hospital activity was brisk

Monthly admission rates of over 3,000 casualties were routine.[21] The famed 8076th MASH was cited for treating over 15,000 patients in only a nine-month period During this time, the unit also moved between 13 different locations The MASH units performed spectacularly during the Korean War, and were credited with decreasing the case fatality rate for Army troops to 2.5% from 4.5% during World War II.[45]

VASCULAR TRAUMA

During World War II and the first years of the Korean Conflict, all arterial injuries in combat were treated with ligation This was primarily due to the experience from poor outcomes with arterial repairs in World War II.[27] In addition, the proper, atraumatic surgical instruments and techniques for arterial repair did not exist at the time

In 1952, Navy Lieutenant, Junior Grade (Dr.) Frank Spencer went against the current surgical dogma, and against official orders, and began repairing arterial injuries His resolve to initiate a project on arterial repair started while observing a young Marine develop a gangrenous foot from a simple, mid-thigh, superficial femoral artery injury that was treated with ligation.[46] Despite the official rule that all arterial injuries must be treated by ligation, Dr Spencer decided that attempting a repair, and potentially

salvaging an extremity, was better than watching a dying limb He gained experience with vascular surgery as a resident at Johns Hopkins under the tutelage of Dr Alfred Blalock and Dr Helen Taussig, who developed a novel surgery for tetralogy of fallot or blue baby syndrome His first repair and

subsequent repairs requiring interposition grafts involved the use of arterial homografts from casualties that were killed in action Their femoral arteries were harvested and maintained in a tissue bank that he devised which consisted of placing the harvested arteries in a suspension of plasma Degradation of the grafts did not become a problem as they were routinely used within a few days.[46, 47]

Despite Spencer‘s innovation, most combat medical facilities lacked the proper instruments to perform arterial repairs Army Captain John Howard and his team were initially using modified hemostats that the Eighth Army engineers adjusted (creating interdigitating rather than opposed teeth) in an attempt to minimize intimal damage However, the clamps still crushed tissue and caused thrombosis.[48] Potts clamps were only recently developed in the late 1940s and were used for the Blalock-Taussig procedure These fine-toothed, multi-point clamps provided secure traction while minimizing intimal trauma These and other desperately needed instruments weren‘t readily available until they were hand-delivered to MASH (and to other units) by vascular pioneer Army Colonel Carl Hughes.[46, 48]

Through Spencer‘s experience, he learned the rule that ―as long as the calf muscles were soft and the patient could move his toes, arterial repair was feasible because the gastrocnemius muscle was viable and functioning.‖[46, 47] Delayed primary closure was performed after the arterial repairs were initially covered by a viable soft tissue flap in order to avoid infection He also noted that if the vascular exam did not improve in four to six hours, return to the operating room was needed.[47] Using principles of early and complete wound debridement, along with new antibiotics (aureomycin, chloramphenicol, and

terramycin) combined with refined techniques in arterial vascular repair, the incidence of gangrenous wounds, particularly from Clostridial species, was as low as 0.08% in one published series.[49]

SURGICAL RESEARCH TEAMS AND RENAL FAILURE

The Army Medical Service Graduate School Surgical Research Team in Korea organized by Army Colonel William Stone, Commandant of the Army Medical Service Graduate School, identified high output renal failure as well as resuscitation and physiologic responses to injury during its 20-month existence in the Korean Conflict.[50] In particular, the resuscitation of burn patients was closely studied The research team noted that prompt fluid resuscitation reduced the incidence of renal failure in burn injury Prior to the development of resuscitation guidelines for burn injury developed in Korea, the incidence was over 35%

Renal support teams were deployed near the Korean front during the war Army Major Paul Teschan from the Walter Reed Army Institute of Research and his team brought Brigham-Kolff rotating drum dialyzers

to Korea and established the first forward-deployed dialysis unit at the 11th Evacuation Hospital.[51] Teschan and his team documented an incidence of acute renal failure in 0.5% of all combat casualties

with an increase in expected mortality from 5% to over 90% with renal failure Teschan also documented the direct correlation with severity of trauma to degree of renal failure.[51] Teschan and his team

performed prophylactic dialysis for severely injured patients in order to mitigate the adverse effects of renal failure.[52, 53]

V VIETNAM WAR

The Vietnam War spanned 20 years—the longest active conflict in our nation‘s young history During those two decades, military surgeons made continued improvements in the organization, equipment and execution of worldwide trauma care; military scientists and physicians collaborated on a major discovery for burn care; and new vascular surgery techniques saved lives and limbs near the front lines

TRAUMA EVACUATION

Helicopter evacuation came of age in Vietnam Korea‘s one- and two-man evacuations in small-boy helicopters grew to the mighty Huey in Vietnam Officially designated the UH-1 Iroquois, the Huey‘s powerful jet-powered rotors could carry up to nine patients on each mission.[21, 43, 44] Call signed

―DUSTOFF‖ due to the amount of dust and dirt blown from the rotors, each team consisted of a flight crew along with a medic

Evacuations became so efficient that even major arterial trauma could reach the operating table quickly, with most surgeries starting less than an hour after first treatment by a line medic.[54] As a result, this led

to rising mortality statistics at military hospitals—care improved, but sicker patients reached the hospital Critically burned patients, in particular, benefitted from formalizing the rapid transport chain from the battlefield to the U.S The U.S Army Institute of Surgical Research burn flight team ―accomplished 103 intercontinental flights with over 824 critically ill, severely burned patients from the burn holding unit in the U.S Army hospital at Kashine Barracks in Japan to the U.S Army Burn Center in San Antonio with only one in-flight death.‖ [55]

BURN CARE

Since the advent of intravenous fluid delivery, burn care remained essentially stagnant Severely burned

patients surviving the initial shock faced burn sepsis, the overwhelming infection grown in vivo in the wounds themselves Pseudomonas aeruginosa proved particularly deadly, until Army Colonel John

Moncrief and Army Major (later, colonel and president of the American Surgical Association) Basil Pruitt manipulated sulfamylon cream for human topical use Leading the U.S Army Surgical Research Unit (now the U.S Army Institute of Surgical Research) in San Antonio, Moncrief and Pruitt collaborated with Army Colonel Douglas Lindsey at the U.S Army Chemical Laboratory in Edgewood, Maryland, to base mafenide acetate in an absorbable cream (Sulfamylon Burn Cream) This allowed an effective anti-pseudomonal drug to be delivered directly to the burn; deeply damaged tissue loses or thromboses blood vessels, rendering intravenously delivered medications ineffective Lindsey‘s team chose a base easily

broken down by blood enzymes and readily excreted in the urine Burn centers around the world still widely employ sulfamylon today.[55, 56]

VASCULAR TRAUMA

Treatment of vascular injuries continued evolution in Vietnam Viewed purely through the lens of

amputation rates after major vascular injury, the 13% rate from Korea improved to 8% in Vietnam‘s early months, eventually falling below 4% by war‘s end.[21] Hughes, Spencer, Howard and others‘ mentoring fueled improved technical acumen of deployed surgeons Army Captain Sidney Levitsky and Army Colonel Robert Hardaway described one series of 55 consecutive major arterial injuries at the Army 3rd Surgical Hospital, which confirmed Spencer‘s ―viable calf, viable limb‖ rule, noting that amputations were only required after infrapopliteal injuries.[46, 47, 54] Levitsky and others polished Korean War techniques, specifically arterial debridement Practice shifted from the standard 1cm debridement on each side of the damaged vessel, instead only removing enough to see a grossly normal intima layer, thereby preserving valuable vessel length Embolectomy catheters, unavailable to Korean War surgeons, came to widespread use Wound care over vascular repairs evolved as well, with n-butyl monomers of

cyanoacrylate—―vessel glue‖—widely implemented for leak and infection prophylaxis Glue used in prior eras showed notable local tissue toxicity, contributing to, rather than protecting from, wound

complications Arterial grafts banked by Spencer during Korea gave way to saphenous vein grafts,

yielding better viability; routine muscle flap coverage of all grafts added protection Many surgeons implemented standard penicillin coverage (alternatively chloramphenicol or streptomycin) until wound closure for further prophylaxis [54]

One of vascular surgery‘s landmark resources, the Vietnam Vascular Registry, emerged through the impassioned drive of Army Major Norman Rich, a vascular surgeon who later became the first chairman

of the Uniformed Services University of the Health Sciences Department of Surgery Rich meticulously logged detailed notes about his cases, even providing his patients with a registry card for reference and further research at future visits His impeccable documentation of venous repair began a massive swing in standard therapy Previously, surgeons routinely ligated major venous injuries to concentrate on the limb‘s arterial inflow Rich‘s experimental work, matched with registry data, showed drastically

decreased morbidity after vascular injury if major venous wounds underwent repair along with their arterial counterparts Limb edema, for example, dropped from over 50% with venous ligation to 13% with venous repair, clearly illustrating the ―inflow/outflow‖ pillar of vascular surgery The Vietnam Vascular Registry continues to grow even today, adding long-term veteran information to the growing volumes of vascular research, as well as exemplifying the tradition of ―the military takes care of its own.‖ Enrolled veterans ―feel someone still cares,‖ a sentiment not always felt by Vietnam warriors.[27, 57, 58] Walter Reed National Military Medical Center, now the public interface for registry members, continues to receive queries from registry cardholders regarding their care Rich, meanwhile, would rise to the rank of colonel in the Army; among myriad other honors, the Department of Surgery at the Uniformed Services University of the Health Sciences and a surgical fellowship at the Walter Reed National Military Medical Center bear his name

VI MAJOR CONFLICTS OF THE LATE 20TH CENTURY

American interventions in Iraq and Somalia (Operation Desert Storm and Operation Restore Hope) were the major contributors to military surgical research in the late 20th century Though both of these conflicts were short and involved relatively modest deployments of American troops, much was learned that would later be applied in future engagements

OPERATION DESERT STORM AND OPERATION RESTORE HOPE

On Aug 2, 1990, Iraqi forces invaded Kuwait and rapidly routed the Kuwaiti government An

international coalition of armed forces opposing the Iraqi military interventions would be built up over the next six months An aggressive air campaign against Iraqi-held military targets and positions began in early January of 1991.[59] On Feb 24, 1991, a ground combat campaign began Within four days, ground troops had liberated Kuwait and forced Iraq to surrender [60]

A few years later during the Somali Civil War, the U.S led a multinational mission, Operation Restore Hope, initially to secure delivery of humanitarian aid and later to stabilize a nascent democratic Somali state.[61, 62] The results of the mission led to a mass-casualty incident among U.S troops that would lay clear the need for change among casualty care The high-intensity urban warfare seen in this conflict represented a shift from frontline field battles to blurred lines of battle with challenging conditions and rapidly changing tactical situations, which exposed deficiencies in combat casualty care.[63]

A prospective research effort to gather data regarding care of combat casualties during the conflict in Somalia was not supported However, Air Force Lieutenant Colonel Robert Mabry, now a military emergency department physician, was a Special Forces medic and directly participated in the care of

casualties in Somalia Mabry and co-authors later wrote a retrospective review of injuries sustained and

outcomes from that engagement Data was derived from medical, flight, and pathology records, as well as available media and eyewitness reports.[64]

The review identified potential areas of improvement, including body armor design and medical care, training, and education Specifically, the medical initiative focused on the addition of prehospital

prophylaxtic antibiotics, the utility of tourniquets in preventing extremity exsanguination, hypothermia prevention, and the potential benefit of a trauma registry.[64] Assertions in that study were supported by other prominent experts in trauma, emergency medicine, and battlefield tactics

The Special Operations Medical Association held a panel discussion in 1998 to discuss combat casualty care amid urban warfare This discussion became the basis for the paper ―Tactical Management of Urban Warfare Casualties in Special Operations‖[63], which recapitulated many of Mabry et al‘s observations mentioned above Numerous conferences were held after Somalia to absorb lessons from the conflict and plan for future engagements [64-66] The findings of these conferences and lessons learned from

Operations Desert Storm and Restore Hope are discussed in the following sections

Tactical Combat Casualty Care

The events of the ―Battle of Mogadishu‖ were chronicled in the historical nonfiction book ―Black Hawk Down‖ and the subsequent film of the same name In this engagement, many American service members were injured and the ability to care for them was paralyzed by the tactical situation.[67] The joint special operations task force, ―Task Force Ranger,‖ entered downtown Mogadishu on Oct 3, 1993 to capture high-ranking members of General Aidid‘s militia[67] The task force suffered an early casualty in which a

soldier fast-roping from a helicopter fell and suffered a severe traumatic brain injury As a result, three of the 12 Humvees in the ground element of the task force were diverted to transport the casualty to medical care The remainder of the task force came under heavy attack by Somali militiamen, resulting in the downing of two Black Hawk helicopters The inability of U.S forces to control the tactical situation in the setting of mounting casualties hindered delivery of casualty care and critically delayed patient

evacuation.[63, 67]

Two fundamental deficiencies were identified following the Somalia conflict First, the military had no specific combat trauma medical training, so procedures for field care of combat casualties followed Advanced Trauma Life Support guidelines.[68] The guidelines had been designed for the care of civilian trauma patients and therefore did not consider the needs of the concurrent tactical situation Second, during non-combat assignments, medics and corpsmen were often assigned to large military hospitals that saw few, if any, acute trauma patients, limiting their experience to the care of wounded patients.[69, 70] These shortfalls in training and caring for casualties while in a volatile combat situation spurred the Naval Special Warfare Command (NSWC) to revisit how special operations medical providers prepared for combat casualty care.[68] This NSWC inquiry, which involved an extensive literature search and

consensus panel of subject matter experts, laid the foundation for the development of Tactical Combat Casualty Care (TCCC) Overall, the goal of TCCC was to develop a set of guidelines that incorporated the care of combat casualties while managing the tactical requirements of a mission.[68] Initially, TCCC was taught to physicians attached to Navy SEAL units, but it was quickly adopted by the other military branches and taught to combat first responders (Army medics, Navy corpsmen, Air Force

pararescuemen).[68]

TCCC has remained the key training platform and is now a mandatory course for deploying medical personnel TCCC consists of three phases that govern the care that may be given during the corresponding tactical situation.[71] The priority of the first phase of TCCC, Care Under Fire, is directed at attaining fire superiority It is the period of time during enemy contact when the team remains under effective enemy flak and it is expected that all available team members, including the injured casualty (-ies) if possible, return fire Because the focus is on engaging the enemy, the extent of care in this phase includes removing the casualty from potential further injury and controlling life-threatening external hemorrhage through the use of an extremity tourniquet if tactically feasible

The second phase, Tactical Field Care, begins once fire superiority is achieved or the casualty is removed from further immediate danger In this phase, providing airway support and securing a definitive airway are stressed During the TCCC course, students are taught airway adjuncts, how to perform a

cricothyroidotomy, how to assess for and treat a tension pneumothorax using a needle thoracostomy, how

to place intravenous or intraosseous lines, and techniques for preventing hypothermia and splinting orthopedic injuries Appropriate application of various junctional tourniquets is also stressed during this phase of care Finally, medical first responders are taught how to appropriately document patient status and care rendered while awaiting the arrival of an evacuation platform [72] The emphasis on

documentation has been beneficial to treatment in later stages of care as well as contributing to the data available for analysis in the Department of Defense Trauma Registry (DoDTR)

In the third and final phase of TCCC, Tactical Evacuation, the casualty is loaded into an evacuation platform for transport to higher echelons of care Evacuation platforms can be ground or air vehicles with different levels of resources depending on the intent and staffing of the vehicle Tactical vehicles adapted

for casualty evacuation may offer no medical equipment or expertise other than that of the treating medic More advanced medical evacuation platforms may offer advanced monitoring, mechanical ventilation, blood products, and other life-saving equipment The guiding principle of tactical evacuation is ensuring that previous interventions (tourniquets, definitive airways, needle thoracotomies) remain in place and function properly During this phase a provider must remain vigilant for evidence of treatable

Extremity tourniquets were available during the Somalia campaign; however, their carriage and use was

not widely prescribed In his analysis of combat casualties in Somalia, Mabry cites only one example of a tourniquet application in the field after an RPG blast that caused a partial through-knee amputation of a soldier‘s leg.[64] However, tourniquets were more frequently placed for extremity wounds after arrival of casualties at a Role II facility The successful (and in one case, lifesaving) role of tourniquets in this conflict reaffirmed the original TCCC guidelines regarding tourniquet use and spurred renewed interest in their use in subsequent conflicts.[74] Additional experience with extremity tourniquets during the Global War on Terrorism (GWOT) led to unprecedented distribution of manufactured tourniquets to all deployed service members.[75]

One particular death that was potentially survivable during the Somalia Campaign occurred when a soldier suffered a penetrating femoral artery and vein injury Due to the proximal extent of the injury, an extremity tourniquet could not be effectively applied and the patient exsanguinated despite direct pressure and wound packing.[76] This junctional hemorrhage sparked the development of a number of junctional tourniquet devices over the next decade.[77]

Theater Medical Research and Data Collection

The value of data gathering regarding combat injuries was well understood prior to the start of Operation Desert Storm This was a lesson learned from Rich, creator of the Vietnam Vascular Registry To ensure a robust effort of prospectively collected data, a 30-member Casualty Data Assessment Team (CDAT) was originally organized for deployment to Iraq to gather details on combat casualty care The CDAT was a cooperative venture between the Division of Military Trauma Research-Letterman Army Institute of Research and the Army‘s Medical Research and Development Command.[78] Unfortunately, this plan was stymied by the Army Office of the Surgeon General, and instead a four-member team was directed to gather data by reviewing medical records and interviewing patients that had already been evacuated to Germany.[78] The smaller CDAT sent to Germany decried the loss of detailed information on initial injury care and resuscitation and a cross-sectional appraisal of the medical evacuation system that could have been gathered if the entire complement of team members had been sent into the theater.[78]

Though the CDAT admitted it was not possible to gather much crucial data about the conflict, some recommendations were generated from their experience First, it was recommended that a fully

complemented CDAT be formed and instituted prior to the next conflict to ensure complete data

collection and analysis In addition, it was noted that orthopedic injuries made up a significant contingent

of injuries suffered and additional effort should be devoted to research on treatment of these wounds Furthermore, non-medical providers were frequently found to be the initial combat casualty care

providers These fellow soldiers with rudimentary medical training delivered the majority of injury care during the conflict, and their utilization reinforced the need for advanced training Finally, the Personal Armor System, Ground Troops (PASGT) fragmentation vest and helmet system was found to prevent penetrating injury in covered areas Although this system was initially issued to U.S Army troops

point-of-in the 1980s, it had not been widely tested point-of-in a combat environment until Operation Desert Storm It was also suggested that additional armor protecting the neck and shoulders should be developed, which was lacking in the current vest.[79]

The legacy of the medical experience in Operation Desert Storm was to underscore the need for and potential benefits of large-scale data collection on combat injury to guide research and product

development for future conflicts

Impact of Modern Body Armor

During the Vietnam War, the primary form of torso protection for the dismounted soldier was the flak jacket They provided some protection against low-velocity bullets but did not provide protection against high-velocity bullets fired from rifles.[80] The PASGT mentioned above provided greater coverage to the thorax, and initial animal testing suggested improvements in protection from projectiles as compared to the flak jacket.[79]

During Operation Desert Storm, the overwhelming majority of combat injuries suffered by U.S service members were a result of penetrating trauma, specifically that of blast fragmentation.[81] The most common cause of death in this conflict was from junctional extremity hemorrhage rather than penetrating head, thoracic, or abdominal injury This change in distribution of injuries from head and torso to

extremity proved the effectiveness of the coverage of the body armor issued to warfighters during the conflict

Mabry examined the effectiveness of body armor at preventing injury during Operation Gothic Serpent in Somalia His study noted that modern body armor was effective at decreasing penetrating chest and abdominal injuries when compared to previous conflicts.[64] The PASGT helmet likely saved the life of a soldier injured by a bullet to the occiput; unfortunately, 36% of deaths in this conflict were the result of penetrating head wounds to areas not covered by the helmet.[64]

Intercontinental Aeromedical Evacuation and Critical Care Air Transport Teams (CCATT)

Numerous after-action reports decrying deficits in staffing and supply chain were submitted by senior medical officers after Operation Desert Storm Units tasked with running hospitals or evacuating combat casualties were found to lack the appropriate personnel or skills, physical and mental fitness, and training

to complete their missions.[82] Supplies were outdated, unavailable, not mission-appropriate, or in short supply.[82] The report noted that if casualties during the conflict had risen to the level expected,

appropriate care would not have been able to be provided to the wounded.[82] These reports forced the General Accounting Office to investigate the state of medical care provided during the conflict Based on their findings, the office and the Air Force comprehensively reviewed delivery of medical care and developed numerous initiatives to improve readiness prior to the next conflict.[82]

At the time of the conflict in Somalia, aeromedical evacuation platforms provided by the U.S Air Force did not have the native personnel or resources to care for critically ill patients Staff and equipment for grievously wounded patients had to be drawn from host facilities and borrowed for the duration of

transport In Operation Desert Storm, for example, teams capable of providing early resuscitation to burn victims were transferred from the U.S Army Institute of Surgical Research in San Antonio or Landstuhl Regional Medical Center in Germany.[83] This limitation in aeromedical capabilities sparked a renewed interest in adding equipment and physicians capable of caring for critically ill casualties in flight This led

to the development of the Critical Care Air Transport Team (CCATT) program by Air Force Lieutenant General (Dr.) Paul K Carlton, Jr and Air Force Colonel (Dr.) J Christopher Farmer The medical assets intrinsic to each team consisted of a critical care-trained physician, a critical care nurse, and a respiratory therapist with the expected capability of taking care of up to three critically ill ventilator-dependent patients or up to six non-critically ill casualties By 1994, the CCATT program would be fully operational

to sustain high-level care for critically ill patients during intercontinental evacuation However, its

utilization would be limited until the onset of Operation Enduring Freedom in October 2001

New Perspectives in Fluid Resuscitation

Prehospital fluid resuscitation during Operation Desert Storm and Operation Gothic Serpent consisted only of crystalloids, as blood products were not readily available prior to casualty arrival to a combat support hospital However, the value of pure crystalloid resuscitation, especially in large volume, was brought back into question following these conflicts because of deleterious consequences, such as

pulmonary fluid overload, congestive heart failure, prolonged ileus and impaired anastomotic healing, coagulopathy, and bleeding.[84-88] Aggressive crystalloid resuscitation was also found to be a major cause of abdominal compartment syndrome.[89] Data from animal models over the ensuing years

suggested improved mortality with judicious, rather than aggressive, use of crystalloid.[90-92] Likewise, clinical data in a prospective trial of early and aggressive crystalloid resuscitation compared to delayed infusion of crystalloids until operation demonstrated improved survival and earlier hospital discharge in the delayed group.[93] Studies comparing the tonicity of crystalloids (isotonic versus hypertonic) also failed to demonstrate a mortality benefit between tonicities.[94]

Furthermore, carrying a large volume of crystalloid for resuscitation was prohibitive for combat medics and corpsmen, thus alternative fluids, such as various colloids, were considered Although comparisons of colloid versus crystalloid resuscitation failed to show that one had a significant advantage over others, the hetastarch colloids were pursued given their relatively small volume, hemodynamic effects, and ability to

be stored at room temperature.[95] In particular, the hetastarch Hextend (Biotime Inc., Berkeley,

California) was selected as the prehospital fluid of choice given its suitable side effect profile compared with other colloids.[96] With its plasma-expanding potential, Hextend given in smaller volumes by combat medical first responders achieved similar hemodynamic effects as compared to much larger volumes of crystalloids.[65, 97] Despite its side effect profile on coagulopathy and acute kidney injury, Hextend would remain the recommended prehospital option in the absence of blood product availability until the later years of GWOT.[95, 98, 99]

VII OPERATION IRAQI FREEDOM, OPERATION ENDURING FREEDOM, AND THE

GLOBAL WAR ON TERRORISM

One month after the horrific terrorist attack on Sept 11, 2001, Operation Enduring Freedom officially commenced in Afghanistan, initiating what would become the longest war in U.S history On March 19,

2003, the U.S along with coalition allies, primarily from the United Kingdom, initiated war in Iraq, in what would be known as Operation Iraq Freedom Together, these conflicts would fall under the GWOT mission

As GWOT progressed, the majority of combat in Iraq and Afghanistan became unconventional warfare Enemy tactics evolved from conventional small-arms fire and explosives to more extensive use of

improvised explosive devices (IEDs)[100] Injuries, often complex wounds, caused by these blasts accounted for nearly three-quarters of all combat wounds.[101] Even so, survival was the highest

compared with all other U.S conflicts largely due to improvements in first responder care, evacuation times, and resuscitation practices

I ADVANCEMENTS IN POINT-OF-INJURY CARE

a) Tactical Combat Casualty Care Revisited

OEF/OIF marked the first major conflicts in which TCCC was widely instituted throughout the DoD Since initial publication in 1996, the TCCC guidelines have undergone multiple revisions as a process improvement to address the evolution of combat casualty care.[73]

A review of casualty mortality in GWOT found that 90% of potentially survivable battlefield deaths were caused by hemorrhage with the majority the result of truncal hemorrhage, followed by junctional and extremity hemorrhage.[102] In an attempt to improve on potentially survivable deaths, under the TCCC guidelines use of extremity and junctional tourniquets was emphasized as the primary tool for hemostasis

in the field.[103] For hemorrhage that could not be controlled with tourniquets, TCCC guidelines

advocated the use of hemostatic dressings and hemostatic adjuncts such as tranexamic acid.[104-107] These interventions will be further discussed in later sections

Airway compromise was identified as the second most common cause of potentially survivable battlefield death.[100] Thus, aggressive use of cricothyroidotomies by prehospital providers, especially for patients with maxillofacial trauma, was stressed with TCCC providers.[108] Needle decompression was also emphasized as tension pneumothorax had been cited as another cause of potentially survivable battlefield death with current guidelines now recommending all patients with chest trauma and cardiovascular collapse receive a needle decompression.[72]

Fluid resuscitation in the TCCC guidelines changed drastically over the past 10 years Knowledge from previous wars as well as ongoing research combined to significantly change combat resuscitation

strategies Hypotensive resuscitation and ratio-driven resuscitation, or 1:1:1, replaced large-volume crystalloid infusion.[95] In addition, standardized antibiotic prophylaxis regimens to be given in the field for open wounds were instituted Battlefield analgesia, which had previously consisted primarily of