One of the most important aspects of DCS is the abbreviated surgery followed by a period of physiological restoration in an intensive care unit setting before further surgical intervention. : Eastridge BJ, Mabry RL, Seguin P, et al. In parallel, advancements in medical care for casualties have progressed, although often in fits and starts. Despite such advancements, human biology has not changed over millennia of warfighting, and early deaths from combat continue to be most likely due to brain injury and massive hemorrhage, many of which will still be un-survivable even with optimal postinjury care. : Morrison JJ, Oh J, DuBose JJ, et al. Ireland News. Balancing maintenance of a robust combat support care capability with sharing skills and resources with a population in acute need is challenging. Our editors will review what youve submitted and determine whether to revise the article. (Though the use of tourniquets was previously considered undesirable, today the military regards them as lifesaving tools for severe limb wounds.) Role 3 (R3, also known as Combat Support Hospital or Field Hospital) is usually further back from the point of wounding, but has more capacity to treat casualties and has extra facilities, personnel, and resources in addition to all the R2 capabilities.3 Early accurate triage of patients is paramount in order to determine which patients can be safely evacuated to more established facilities (i.e., to a R3 facility) and which would be better served by DCS closer to the point of injury (i.e., R2 facility). Role 2 (R2, also known as a Forward Surgical Team) is typically the first point at which surgical teams are present and delivers advanced resuscitation, blood products, and DCS. Allied joint doctrine for medical support, Medical evacuation and triage of combat casualties in Helmand province, Afghanistan: October 2010April 2011, The impact of sleep deprivation in military surgical teams: a systematic review, The effect of a Golden Hour policy on the morbidity and mortality of combat casualties, Reexamination of a battlefield trauma Golden Hour policy, Time is the enemy: mortality in trauma patients with hemorrhage from torso injury occurs long before the Golden Hour, Death on the battlefield (2001-2011): implications for the future of combat casualty care, Killed in action (KIA): an analysis of military personnel who died of their injuries before reaching a definitive medical treatment facility in Afghanistan (2004-2014), Published Online First: 2 June 2020. Within every military unit there are personnel specially trained to provide medical assistance to the wounded in order to stabilize their condition until they can be treated by a physician. However, overemphasis on timelines may be somewhat one-dimensional and is at risk of neglecting other important considerations. Dubost and colleagues compared two concurrent activities from urban guerrilla and large desert-based arenas (in Mali and Central African Republic), with differing patterns of injury and treatments,21 emphasizing that there cannot be a one-size-fits-all design of surgical facilitiessomething that presents a challenge to military doctrine. In-depth analysis of the medical care provided over periods of prolonged conflict has identified areas for quality improvement. The CSH is modular in design and can be configured in sizes from 44 to 248 beds as needed. Role 2 (R2, also known as a Forward Surgical Team) is typically . Civil War Battlefield Surgery. Peer-to-peer (or near-peer) warfare is very different to asymmetric warfare, and each requires understanding of the threats and geographical space without oversimplification. Effective enemy forces in peer-to-peer conflict are likely to limit surgical capability because of constraint of freedom of movement. Similarly, the teams were designed to be divided into two teams with equal complements of providers. The deployment of mobile surgical teams as a means of bringing definitive surgical care to the seriously wounded in the forward areas was introduced in World War 2. During the American Civil War, The Father of Battlefield Medicine, Dr. Jonathan Letterman (1824 1972) originated the system of organizing military medical supplies, procedures, and personnel that is still in use today. With the advent of advanced procedures and medical technology, even polytrauma can be survivable in . Such considerations are integral (not supplementary) to the mission of any military deployment. News of anesthesia's successful application in battlefield surgery profoundly influenced its increasing acceptance in civilian settings . Jeannie Huh, MD, FAAOS, LTC, is an attending orthopaedic surgeon at Womack Army Medical Center at Fort Bragg in North Carolina. Civilian medicine has been greatly advanced by procedures that were first developed to treat the wounds inflicted during combat. It is faster and better protected than previous military ambulances, and it can carry up to six patients while its crew of three medics provides medical care. It is established by well-conducted studies in the modern era that noncompressible torso hemorrhage and head injury are the mechanisms by which most combat patients die early.1012 All health support services (rather than just surgical services) must prioritize early lifesaving intervention for patients who have survival potential. : Mazuchowski EL, Kotwal RS, Janak JC, et al. The History of Silver in Military Medicine, Military Medics on US Navy Hospital Ships, Shell Shock / Combat Stress Reaction (CSR) / Post-Traumatic Stress Disorder (PTSD), US Army Nurse Corps (NC) / US Navy Nurse Corps. There may be a single combat casualty near to a R2 forward surgical facility who requires urgent surgery but not DCSin other words, they could safely be evacuated to a R3 facility with more resources and capacity, effectively bypassing the R2 facility. Patients who may benefit from rapid early surgical intervention are those with brain injury,15 penetrating trauma16 (especially when hypotensive17), and torso trauma and hypotension.18 The rapid triage and transfer of such patients to a R2 facility for DCS may improve survival, and therefore, medical and nonmedical personnel at the FLOT must be able to determine who these patients are. Allied joint doctrine for medical support, Medical evacuation and triage of combat casualties in Helmand province, Afghanistan: October 2010April 2011, The impact of sleep deprivation in military surgical teams: a systematic review, The effect of a Golden Hour policy on the morbidity and mortality of combat casualties, Reexamination of a battlefield trauma Golden Hour policy, Time is the enemy: mortality in trauma patients with hemorrhage from torso injury occurs long before the Golden Hour, Death on the battlefield (2001-2011): implications for the future of combat casualty care, Killed in action (KIA): an analysis of military personnel who died of their injuries before reaching a definitive medical treatment facility in Afghanistan (2004-2014), Published Online First: 2 June 2020. A R3 facility is the best resourced military treatment facility that critically injured casualties can access on the battlefield. surgery notes another benefit from ancient rome comes from their experience in fighting wars and dealing with combat casualties. It is important to also determine during a conflict who is eligible for surgical treatment, since this directly affects the resource requirements and locations of surgical facilities. Your email address will not be published. However, it should be noted that direct comparisons do not take into account the important factors of distance and timings from injury to surgery. Finding the optimal geospatial location and timelines for surgical facilities must be done within the larger operational framework if it is to be credible, achievable, and sustainable. This requires a deep understanding of the surgical care concept. Here we discuss the key considerations of battlefield surgery with reference to the operational patient care pathway. Fig. In order to function with high efficiency in high-stress situations, teams must acquaint themselves with their equipment and personnel. Here we discuss the key considerations of battlefield surgery with reference to the operational patient care pathway. Abbreviation: DCS, damage control surgery. Battlefield surgical care has evolved from its famous portrayal in the 1970s war comedy-drama television series M*A*S*H, which brought Army medicine to family rooms of everyday Americans. "American Academy of Orthopaedic Surgeons" and its associated seal and "American Association of Orthopaedic Surgeons" and its logo are all registered U.S. trademarks and may not be used without written permission. Given that the effectiveness of surgical care deteriorates with fatigue and activity,6 commanders may wish to take this into consideration when designing deployed roles and patterns. We argue that injured service persons should be treated in the highest level of care they can feasibly be evacuated to, within the context of a sustainable, enduring battle plan. As the R2s main distinction is maneuverability, great care must be taken to maintain this advantage. For permissions, please e-mail: journals.permissions@oup.com. Oxford University Press is a department of the University of Oxford. It is assembled from metal shelters and climate-controlled tents, complete with water and electricity. Author Information. : Howard JT, Kotwal RS, Santos-Lazada AR, Martin MJ, Stockinger ZT: Alarhayem AQ, Myers JG, Dent D, et al. However, it is plausible in the modern era that adherence may be complicated by nonstate or third-party insurgency actors that may compound the conflict. Combat casualty care. Be it a large-magnitude earthquake or a catastrophic manmade disaster, orthopaedic surgeons serve an important role, but a role that must be accepted within the larger focus of life preservation. Some brilliant ideas are the result of some of that fast thinking. Surgeons to the Front Surgeons to the Front: Twentieth-Century Warfare and the Metamorphosis of Battlefield Surgery Thomas S. Helling and W. Sanders Marble This is a reprint of Chapter 10 from. It would be unethical and unwise to divert a patient away from a higher standard of care if they could benefit from it, or indeed unnecessarily occupy a valuable far-forward facility so that time-critical lifesaving interventions are denied to others. Public Accounts Committee. As soon as the situation permits, the wounded are taken from the scene of the battle to their units closest treatment facility, which serves as a collection point for casualties and is maintained as close to the battlefield as possible. The FST comprises 20 persons, including 4 surgeons, and it typically has 2 operating tables and 10 litters set up in self-inflating shelters. In the aftermath of World War I, nurse Bess Crawford is caught in a deadly feud between two families in this thirteenth book in the beloved mystery series from New York Times bestselling author Charles Todd. Given that the effectiveness of surgical care deteriorates with fatigue and activity,6 commanders may wish to take this into consideration when designing deployed roles and patterns. If the R2 facility is ready and able to perform the surgery and then evacuate the casualty, should they do so or should they allow the onward evacuation? Therefore, the dynamic relationships between the R2 and R3 facilities should be under constant surveillance by commanders in order to shape the medical plan in such scenarios. : McCoy CE, Menchine M, Sampson S, Anderson C, Kahn C: Remick KN, Schwab CW, Smith BP, Monshizadeh A, Kim PK, Reilly PM: Marsden M, Carden R, Navaratne L, et al. Terrain, environment, and climate must be taken into account when deciding the location and nature of surgical facilities. Thus, developments in military medicine have focused on treatment to quickly stop bleeding and on the provision of immediate medical care. Local intelligence is also paramount for the safety of front-line medical assets, especially if this may change over time. Illustration of battlefield wounds from a 1517 Field Manual for the Treatment of Wounds. : Webster S, Barnard EBG, Smith JE, Marsden MER, Wright C: Kotwal RS, Montgomery HR, Kotwal BM, et al. The specific 1-hour constraint that dichotomizes care into Golden Hour or outside the Golden Hour is an oversimplification. However, such a model of casualty evacuation would not necessarily be tenable if air evacuation assets were scarcer or there was an enduring threat from enemy air assets or man-portable air-defense systems. This is especially important during high-tempo operations or multiple casualty scenarios. They examine, diagnose, and treat the initial phase of battlefield disease and injury. Fallon, William F. Jr., MD, FACS. Many people have construed the Civil War surgeon to be a heartless individual or someone who was somehow incompetent and that was the reason . These considerations are summarized in a 5Ws manner. An additional innovation was the use of plaster of Paris as a support for broken bones . Earlier surgery may improve survival for those who are most severely injured, with the highest chance of death. Combat casualty care. Surgical Lessons Learned on the Battlefield. Save my name, email, and website in this browser for the next time I comment. Instead, the trend has been to create multiple small, mobile surgical teams and locate them at forward-deployed locations. As the R2s main distinction is maneuverability, great care must be taken to maintain this advantage. The type of warfare is likely to have an important influence on the nature and requirements of surgical facilities. We argue that it is not good enough to simply push surgical assets forward closer to the point of injury without also considering all other factors that might optimize the care for our troops. For example, military hospitals have CT scanners and ultrasound machines with Internet links to medical specialists to allow military doctors to consult with the specialists about detailed diagnosis and treatment. MASH unitswhich had 60 beds, required 50 large trucks to move, and took 24 hours to set upwere deemed too cumbersome to keep up with fast-moving armoured and airmobile forces, and they were supplanted by the smaller Forward Surgical Team (FST). With many soldiers surviving the loss of an arm or a leg, there is also the challenge of developing better prosthetics. 1995-2023 by the American Academy of Orthopaedic Surgeons. Choice of evacuation modality further impacts the nature of prehospital interventions that can be delivered (i.e., in the back of a helicopter or land-based transport). Instead, we propose that commanders should consider who their patients will be (including potential enemy and host nationals), what facilities are available, which of these should be utilized for which patients, as well as the details of evacuation timelines that take into account the type of warfare and enemy, and modes of transport. A distinctly American invention, anesthetics first saw widespread use about 15 years before the Civil War. The teams were intended to provide lifesaving and/or sustaining surgical care to injured service members at risk of succumbing to their injuries during evacuation and transportation. The Napoleonic Wars and World War I (1914 1918) produced advances in surgery, with notable advances in surgical amputations. In 2004, military doctors began using an experimental blood-clotting drug called recombinant activated factor VII to treat severe bleeding, despite some medical evidence that linked it to deadly blood clots. They reported that the case fatality rate and Killed in Action rate decreased after the mandate, but there was no proportional increase in Died of Wounds rate.7 Their interpretation of these data was that the Golden Hour policy improved survival.8 Such findings would suggest that if a combat casualty cannot reach a R3 facility within a short (i.e., hour) time frame, then surgery at a R2 facility that is nearer the point of injury is justified. Role 3 (R3, also known as Combat Support Hospital or Field Hospital) is usually further back from the point of wounding, but has more capacity to treat casualties and has extra facilities, personnel, and resources in addition to all the R2 capabilities.3 Early accurate triage of patients is paramount in order to determine which patients can be safely evacuated to more established facilities (i.e., to a R3 facility) and which would be better served by DCS closer to the point of injury (i.e., R2 facility). 2). This is determined by an eligibility matrix (Medical Rules of Eligibility) and an appreciation of the mission requirement, with adherence to the legal and ethical requirements of good practice. Patients without such injuries may be more suitable for a longer transfer to R3 if the situation allows. It is apparent that there is likely to be a role for more mobile and agile facilities, as well as more established tented facilities, and some facilities in hard-standing buildings.