EDITORIAL URRENT C OPINION
Military contributions to modern trauma care Michael C. Reade
As over 12 years of continuous conflict fought by the armed forces of the developed world appear to draw to a close, medical journals and conferences have become venues for reflections on the benefit modern combat has brought to trauma care. Those of us who have looked into the eyes of a dying 2-yearold girl senselessly wounded by an insurgent rocket, or tried to find something meaningful to say to a soldier waking in the ICU to find himself a bilateral amputee, are perhaps less enthusiastic about the benefits of war – recognizing that many have paid a very high price for any technical and organizational advances. Nonetheless, privileged and humbled to have worked in an environment that at times brings out the best and the worst of humanity, many of us feel an obligation to ensure that the ‘lessons learnt’ in modern conflict are lost neither to inevitable future battlefields, nor to the civilian trauma systems to which many of us return. This issue of Current Opinion in Critical Care brings together contributions from military or military-affiliated trauma surgeons, intensivists, emergency physicians, and anaesthesiologists from the ‘ABCA’ (America, Britain, Canada, and Australia) nations engaged in the two major conflicts of the early 21st century. The outstanding article from Bailey et al. from the US Army Institute of Surgical Research and the Royal Centre for Defence Medicine sets the scene well. The case fatality rate from modern combat wounds has fallen from above 16% to around 9% in the last 7 years – now the lowest figure in reliably recorded history [1]. Bailey et al. comprehensively describe how this remarkable achievement eventuated through the evolution of the US-led Joint Trauma System, informed by continuous quality feedback, a detailed and ever more comprehensive trauma registry, and with support from basic and clinical research programmes. Lessons for the delivery of civilian trauma care, especially for populations remote from major trauma centers, are clear. Other contributions in this volume describe more clinically focussed lessons from (or potentially relevant to) combat trauma: the utility of point-ofcare viscoelastic clotting measurement in the management of both the acute coagulopathy of trauma and the procoagulant state that frequently ensues; developments in operative trauma surgical techniques in the last 10 years; and the US
Department of Defense-affiliated research programme seeking methods to improve outcome in patients with traumatic cardiac arrest. Authors from Calgary and Sydney describe the logical evolution of trauma infrastructure given the increasing importance of interventional radiology and nonoperative aspects of trauma care: combining operative surgery and interventional radiology in the same room, facilitating a simultaneous approach to the diagnosis and multidisciplinary management of the most severely injured trauma patients. Although not part of the armed forces, both hospitals have substantial military links, with military staff members and longstanding military training programmes. The ‘RAPTOR’ suite described has clear applications to both military and civilian trauma. The advances in trauma care described in this volume, at least in part stimulated by modern conflict, form only the latest chapter in a story that is as old as war itself. Innovations such as ligatures rather than hot oil cauterization for bleeding [2], debridement to prevent gangrene [3], vascular repair as an alternative to amputation [4], widespread adoption of the Thomas splint for femur fractures [5], and Fleming’s wartime bacteriological understanding of infection in war wounds [6] followed by the discovery and subsequent isolation and mass production of penicillin [7], form an incomplete list of innovations relevant to trauma care with origins in war. However, despite the intuitive attractions of new medical devices or therapies, the quantitatively most important advance in battlefield trauma medicine was the development of a system for treating trauma patients. Prior to the Napoleonic wars, until the battle was finished wounded soldiers were generally left where they fell. Baron Dominique Jean Larrey introduced ‘ambulances volantes’ (‘flying ambulances’) that brought the wounded to the surgeon – necessitating a method of selecting those Joint Health Command, Australian Defence Force and Burns, Trauma and Critical Care Research Centre, University of Queensland, Australia Correspondence to Lieutenant Colonel Michael C. Reade, Level 9, Health Sciences Building, Royal Brisbane & Women’s Hospital, Herston, QLD 4029, Australia. Tel: +61 7 3365 5114; e-mail: [email protected] and [email protected] Curr Opin Crit Care 2013, 19:567–568 DOI:10.1097/MCC.0000000000000029
1070-5295 ß 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
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Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Trauma
who warranted immediate attention (‘triage’) [8]. The Crimean and American Civil Wars saw the introduction of professional nursing, turning nurses from doctors’ assistants into independent clinicians and patient advocates. Although the second AngloBoer War saw the first field hospitals, only by the First World War was an integrated trauma system introduced, comprising a series of echelons capable of increasingly complex medical and surgical care. Helicopters reduced the transit time to surgical care from around 12–15 h in the Second World War to less than 2 h in the Vietnam War [9]. In Vietnam, rudimentary resuscitation in flight was first possible; currently, almost the full resources of an emergency department can be brought to a patient on the battlefield. Baily et al. elegantly describe how this echelon system continues to evolve in response to demand and technology. Trauma systems require information to drive improvements – a concept just as relevant in the modern Joint Trauma System as it was when Florence Nightingale published her statistical analysis of the causes of mortality in the Crimean War [10]. Technology, however, has facilitated almost immediate feedback, generating improvements in both individual and system performance. The modern weekly teleconferences linking prehospital and hospital personnel in Afghanistan with staging and definitive care hospitals in the United States and United Kingdom, in which individual patients are discussed [11,12], are excellent templates for civilian trauma systems. The work described in this issue of the journal is the ‘tip of the iceberg’ of modern combat casualty care research. Most of the medical advances stemming from 21st century wars are directly relevant to critical care [13]. Some of this has been a relearning of lessons forgotten – such as the utility of arterial tourniquets [14] or of avoiding crystalloid dilution of clotting factors with the simultaneous replacement of plasma and red cells [15]. Other elements of modern combat casualty research have built substantially on earlier lessons. Plastic surgery, developed by Sir Harold Gillies in the First World War and his pupil, Sir Archibald McIndoe, famous for facial reconstructions in burnt fighter pilots in the Battle of Britain [16], has evolved to provide complex reconstructive surgery [17,18], increasingly functional prosthetic limbs [19], and the hope that stem cell research will facilitate regrowth of biological tissue. McIndoe’s ‘Guinea Pig Club’ of patients who supported one another during prolonged hospital stays [20] is the forerunner of the modern military approach to rehabilitating physically and psychologically wounded servicemen in the company of their peers [21]. Research in both mild and severe traumatic brain injury has been spurred by 568
www.co-criticalcare.com
the prevalence of blast wounds in modern combat, and while effective diagnostics and therapeutics might not be routine practice by the time this conflict ends, research currently underway holds much promise for the future [22]. The best way to ensure improvements in trauma care derived from battlefield lessons are not forgotten is to translate as many as possible into routine civilian practice. Therefore, I hope everyone involved in the care of critically ill trauma patients finds something of use in this volume. Acknowledgements None. Conflicts of interest M.C.R. is a serving officer in the Australian Defence Force. No financial or academic conflict of interest is reported.
REFERENCES 1. Gawande A. Casualties of war: military care for the wounded from Iraq and Afghanistan. N Engl J Med 2004; 351:2471–2475. 2. Price BA. The influence of military surgeons in the development of vascular surgery. J R Army Med Corps 1999; 145:148–152. 3. Guthrie HC, Clasper JC. Historical origins and current concepts of wound debridement. J R Army Med Corps 2011; 157:130–132. 4. Seeley SF, Hughes CW, Jahnke EJJ Jr, et al. Direct anastomosis versus ligation and excision in traumatic arteriovenous fistulas and aneurysms; experience with 150 consecutive Korean wounds. Surg Forum 1953; 152–154. 5. Robinson PM, O’Meara MJ. The Thomas splint: its origins and use in trauma. J Bone Joint Surg Br 2009; 91:540–544. 6. Fleming A. On the bacteriology of septic war wounds. Lancet 1915; 186:638–643. 7. Ligon BL. Penicillin: its discovery and early development. Semin Pediatr Infect Dis 2004; 15:52–57. 8. Blair JS. Jean Dominique, First Baron Larrey. J R Army Med Corps 2005; 151:207–208. 9. Manring MM, Hawk A, Calhoun JH, Andersen RC. Treatment of war wounds: a historical review. Clin Orthop Relat Res 2009; 467:2168–2191. 10. Nightingale F, Mundinger MO. Florence Nightingale: measuring hospital care outcomes. Excerpts from the books Notes on matters affecting the health, efficiency, and hospital administration of the British Army founded chiefly on the experience of the late war and Notes on hospitals. Oakbrook Terrace, IL, USA: Joint Commission on Accreditation of Healthcare Organizations; 1999. 11. Lam DM, Fecura SE Jr. The trauma continuum-of-care quality forum integration committee system-wide video teleconference. Mil Med 2007; 172:611–615. 12. Smith J, Hodgetts T, Mahoney P, et al. Trauma governance in the UK defence medical services. J R Army Med Corps 2007; 153:239–242. 13. Orman JA, Eastridge BJ, Baer DG, et al. The impact of 10 years of war on combat casualty care research: a citation analysis. J Trauma Acute Care Surg 2012; 73:S403–S408. 14. Kragh JF Jr, O’Neill ML, Walters TJ, et al. Minor morbidity with emergency tourniquet use to stop bleeding in severe limb trauma: research, history, and reconciling advocates and abolitionists. Mil Med 2011; 176:817–823. 15. Borgman MA, Spinella PC, Perkins JG, et al. The ratio of blood products transfused affects mortality in patients receiving massive transfusions at a combat support hospital. J Trauma 2007; 63:805–813. 16. Ellis H. Two pioneers of plastic surgery: Sir Harold Delf Gillies and Sir Archibald McIndoe. Br J Hosp Med (Lond) 2010; 71:698. 17. Tucker DI, Zachar MR, Chan RK, Hale RG. Characterization and management of mandibular fractures: lessons learned from Iraq and Afghanistan. Atlas Oral Maxillofac Surg Clin North Am 2013; 21:61–68. 18. Dean W. The Armed Forces Institute of Regenerative Medicine: a collaborative approach to Department of Defense-relevant research. Regen Med 2011; 6:71–74. 19. Zlotolow DA, Kozin SH. Advances in upper extremity prosthetics. Hand Clin 2012; 28:587–593. 20. Andrew DR. The Guinea Pig Club. Aviat Space Environ Med 1994; 65:428– 433. 21. Dharm-Datta S, Etherington J, Mistlin A, et al. The outcome of British combat amputees in relation to military service. Injury 2011; 42:1362–1367. 22. Ling GS, Ecklund JM. Traumatic brain injury in modern war. Curr Opin Anaesthesiol 2011; 24:124–130.
Volume 19 Number 6 December 2013
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Military contributions to modern trauma care Michael C. Reade
As over 12 years of continuous conflict fought by the armed forces of the developed world appear to draw to a close, medical journals and conferences have become venues for reflections on the benefit modern combat has brought to trauma care. Those of us who have looked into the eyes of a dying 2-yearold girl senselessly wounded by an insurgent rocket, or tried to find something meaningful to say to a soldier waking in the ICU to find himself a bilateral amputee, are perhaps less enthusiastic about the benefits of war – recognizing that many have paid a very high price for any technical and organizational advances. Nonetheless, privileged and humbled to have worked in an environment that at times brings out the best and the worst of humanity, many of us feel an obligation to ensure that the ‘lessons learnt’ in modern conflict are lost neither to inevitable future battlefields, nor to the civilian trauma systems to which many of us return. This issue of Current Opinion in Critical Care brings together contributions from military or military-affiliated trauma surgeons, intensivists, emergency physicians, and anaesthesiologists from the ‘ABCA’ (America, Britain, Canada, and Australia) nations engaged in the two major conflicts of the early 21st century. The outstanding article from Bailey et al. from the US Army Institute of Surgical Research and the Royal Centre for Defence Medicine sets the scene well. The case fatality rate from modern combat wounds has fallen from above 16% to around 9% in the last 7 years – now the lowest figure in reliably recorded history [1]. Bailey et al. comprehensively describe how this remarkable achievement eventuated through the evolution of the US-led Joint Trauma System, informed by continuous quality feedback, a detailed and ever more comprehensive trauma registry, and with support from basic and clinical research programmes. Lessons for the delivery of civilian trauma care, especially for populations remote from major trauma centers, are clear. Other contributions in this volume describe more clinically focussed lessons from (or potentially relevant to) combat trauma: the utility of point-ofcare viscoelastic clotting measurement in the management of both the acute coagulopathy of trauma and the procoagulant state that frequently ensues; developments in operative trauma surgical techniques in the last 10 years; and the US
Department of Defense-affiliated research programme seeking methods to improve outcome in patients with traumatic cardiac arrest. Authors from Calgary and Sydney describe the logical evolution of trauma infrastructure given the increasing importance of interventional radiology and nonoperative aspects of trauma care: combining operative surgery and interventional radiology in the same room, facilitating a simultaneous approach to the diagnosis and multidisciplinary management of the most severely injured trauma patients. Although not part of the armed forces, both hospitals have substantial military links, with military staff members and longstanding military training programmes. The ‘RAPTOR’ suite described has clear applications to both military and civilian trauma. The advances in trauma care described in this volume, at least in part stimulated by modern conflict, form only the latest chapter in a story that is as old as war itself. Innovations such as ligatures rather than hot oil cauterization for bleeding [2], debridement to prevent gangrene [3], vascular repair as an alternative to amputation [4], widespread adoption of the Thomas splint for femur fractures [5], and Fleming’s wartime bacteriological understanding of infection in war wounds [6] followed by the discovery and subsequent isolation and mass production of penicillin [7], form an incomplete list of innovations relevant to trauma care with origins in war. However, despite the intuitive attractions of new medical devices or therapies, the quantitatively most important advance in battlefield trauma medicine was the development of a system for treating trauma patients. Prior to the Napoleonic wars, until the battle was finished wounded soldiers were generally left where they fell. Baron Dominique Jean Larrey introduced ‘ambulances volantes’ (‘flying ambulances’) that brought the wounded to the surgeon – necessitating a method of selecting those Joint Health Command, Australian Defence Force and Burns, Trauma and Critical Care Research Centre, University of Queensland, Australia Correspondence to Lieutenant Colonel Michael C. Reade, Level 9, Health Sciences Building, Royal Brisbane & Women’s Hospital, Herston, QLD 4029, Australia. Tel: +61 7 3365 5114; e-mail: [email protected] and [email protected] Curr Opin Crit Care 2013, 19:567–568 DOI:10.1097/MCC.0000000000000029
1070-5295 ß 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
www.co-criticalcare.com
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Trauma
who warranted immediate attention (‘triage’) [8]. The Crimean and American Civil Wars saw the introduction of professional nursing, turning nurses from doctors’ assistants into independent clinicians and patient advocates. Although the second AngloBoer War saw the first field hospitals, only by the First World War was an integrated trauma system introduced, comprising a series of echelons capable of increasingly complex medical and surgical care. Helicopters reduced the transit time to surgical care from around 12–15 h in the Second World War to less than 2 h in the Vietnam War [9]. In Vietnam, rudimentary resuscitation in flight was first possible; currently, almost the full resources of an emergency department can be brought to a patient on the battlefield. Baily et al. elegantly describe how this echelon system continues to evolve in response to demand and technology. Trauma systems require information to drive improvements – a concept just as relevant in the modern Joint Trauma System as it was when Florence Nightingale published her statistical analysis of the causes of mortality in the Crimean War [10]. Technology, however, has facilitated almost immediate feedback, generating improvements in both individual and system performance. The modern weekly teleconferences linking prehospital and hospital personnel in Afghanistan with staging and definitive care hospitals in the United States and United Kingdom, in which individual patients are discussed [11,12], are excellent templates for civilian trauma systems. The work described in this issue of the journal is the ‘tip of the iceberg’ of modern combat casualty care research. Most of the medical advances stemming from 21st century wars are directly relevant to critical care [13]. Some of this has been a relearning of lessons forgotten – such as the utility of arterial tourniquets [14] or of avoiding crystalloid dilution of clotting factors with the simultaneous replacement of plasma and red cells [15]. Other elements of modern combat casualty research have built substantially on earlier lessons. Plastic surgery, developed by Sir Harold Gillies in the First World War and his pupil, Sir Archibald McIndoe, famous for facial reconstructions in burnt fighter pilots in the Battle of Britain [16], has evolved to provide complex reconstructive surgery [17,18], increasingly functional prosthetic limbs [19], and the hope that stem cell research will facilitate regrowth of biological tissue. McIndoe’s ‘Guinea Pig Club’ of patients who supported one another during prolonged hospital stays [20] is the forerunner of the modern military approach to rehabilitating physically and psychologically wounded servicemen in the company of their peers [21]. Research in both mild and severe traumatic brain injury has been spurred by 568
www.co-criticalcare.com
the prevalence of blast wounds in modern combat, and while effective diagnostics and therapeutics might not be routine practice by the time this conflict ends, research currently underway holds much promise for the future [22]. The best way to ensure improvements in trauma care derived from battlefield lessons are not forgotten is to translate as many as possible into routine civilian practice. Therefore, I hope everyone involved in the care of critically ill trauma patients finds something of use in this volume. Acknowledgements None. Conflicts of interest M.C.R. is a serving officer in the Australian Defence Force. No financial or academic conflict of interest is reported.
REFERENCES 1. Gawande A. Casualties of war: military care for the wounded from Iraq and Afghanistan. N Engl J Med 2004; 351:2471–2475. 2. Price BA. The influence of military surgeons in the development of vascular surgery. J R Army Med Corps 1999; 145:148–152. 3. Guthrie HC, Clasper JC. Historical origins and current concepts of wound debridement. J R Army Med Corps 2011; 157:130–132. 4. Seeley SF, Hughes CW, Jahnke EJJ Jr, et al. Direct anastomosis versus ligation and excision in traumatic arteriovenous fistulas and aneurysms; experience with 150 consecutive Korean wounds. Surg Forum 1953; 152–154. 5. Robinson PM, O’Meara MJ. The Thomas splint: its origins and use in trauma. J Bone Joint Surg Br 2009; 91:540–544. 6. Fleming A. On the bacteriology of septic war wounds. Lancet 1915; 186:638–643. 7. Ligon BL. Penicillin: its discovery and early development. Semin Pediatr Infect Dis 2004; 15:52–57. 8. Blair JS. Jean Dominique, First Baron Larrey. J R Army Med Corps 2005; 151:207–208. 9. Manring MM, Hawk A, Calhoun JH, Andersen RC. Treatment of war wounds: a historical review. Clin Orthop Relat Res 2009; 467:2168–2191. 10. Nightingale F, Mundinger MO. Florence Nightingale: measuring hospital care outcomes. Excerpts from the books Notes on matters affecting the health, efficiency, and hospital administration of the British Army founded chiefly on the experience of the late war and Notes on hospitals. Oakbrook Terrace, IL, USA: Joint Commission on Accreditation of Healthcare Organizations; 1999. 11. Lam DM, Fecura SE Jr. The trauma continuum-of-care quality forum integration committee system-wide video teleconference. Mil Med 2007; 172:611–615. 12. Smith J, Hodgetts T, Mahoney P, et al. Trauma governance in the UK defence medical services. J R Army Med Corps 2007; 153:239–242. 13. Orman JA, Eastridge BJ, Baer DG, et al. The impact of 10 years of war on combat casualty care research: a citation analysis. J Trauma Acute Care Surg 2012; 73:S403–S408. 14. Kragh JF Jr, O’Neill ML, Walters TJ, et al. Minor morbidity with emergency tourniquet use to stop bleeding in severe limb trauma: research, history, and reconciling advocates and abolitionists. Mil Med 2011; 176:817–823. 15. Borgman MA, Spinella PC, Perkins JG, et al. The ratio of blood products transfused affects mortality in patients receiving massive transfusions at a combat support hospital. J Trauma 2007; 63:805–813. 16. Ellis H. Two pioneers of plastic surgery: Sir Harold Delf Gillies and Sir Archibald McIndoe. Br J Hosp Med (Lond) 2010; 71:698. 17. Tucker DI, Zachar MR, Chan RK, Hale RG. Characterization and management of mandibular fractures: lessons learned from Iraq and Afghanistan. Atlas Oral Maxillofac Surg Clin North Am 2013; 21:61–68. 18. Dean W. The Armed Forces Institute of Regenerative Medicine: a collaborative approach to Department of Defense-relevant research. Regen Med 2011; 6:71–74. 19. Zlotolow DA, Kozin SH. Advances in upper extremity prosthetics. Hand Clin 2012; 28:587–593. 20. Andrew DR. The Guinea Pig Club. Aviat Space Environ Med 1994; 65:428– 433. 21. Dharm-Datta S, Etherington J, Mistlin A, et al. The outcome of British combat amputees in relation to military service. Injury 2011; 42:1362–1367. 22. Ling GS, Ecklund JM. Traumatic brain injury in modern war. Curr Opin Anaesthesiol 2011; 24:124–130.
Volume 19 Number 6 December 2013
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
