The New Salvation Army

The soldier was in awful shape, with abdominal wounds, injuries to his thighs and face, and a hand carved up by shrapnel. At death’s proverbial doorstep following a mortar attack in Iraq last year, he was stabilized, then hustled from the field to a nearby combat support hospital. There doctors performed a laparotomy with diverting colostomy and amputated one leg at the thigh.

With a plastic bag covering the incision in his abdomen, the young airman was then flown on to the U.S.’s Landstuhl Regional Medical Center in Germany. Surgeons there decided he would need more than 30 days’ recovery and sent him home. After several more weeks stateside and multiple operations at Walter Reed Army Medical Center, the soldier emerged, missing both legs, his right hand and part of his face…but alive.

That’s a fairly remarkable outcome. In wars past, a soldier injured this severely would likely not have lived to tell about it. But in America’s most recent conflicts, in Afghanistan and Iraq, soldiers like this are surviving at a pace that outstrips any previous military engagement. In fact, combat-casualty survival rates are up even from the first Gulf War, barely 10 years ago. Then, around three-quarters of all American soldiers injured in fighting survived. Now, in Operations Iraqi Freedom and Enduring Freedom, it’s around 90%.

To what can such a jump be attributed? Certainly, our opponents’ guns and bombs aren’t getting any less lethal. So what has changed? For one thing, how U.S. forces handle casualties.

“Little recognized is how fundamentally important the medical system is—and not just the enemy’s weaponry—in determining whether or not someone dies,” wrote Atul Gawande, MD, an assistant professor in the Department of Health Policy and Management at Harvard, in an examination of the survival-rate increase appearing in the New England Journal of Medicine last December.

While cautioning that data is fragmentary and definitive pronouncements should not yet be made, Gawande—whose article chronicled the salvation of the soldier described above—concluded that “a suggestive picture has emerged [that] depicts a military medical system that has made fundamental—and apparently effective—changes in the strategies and systems of battle care, even since the Persian Gulf War.”

The inquiring mind might naturally want to know what those changes are and, more to the point, if the new concepts and tactics of the military might be applicable to the practice of EMS on the streets of America.

Speed Saves

In recent years, the focus of battlefield medical care has evolved. Trauma interventions have become much more rapid. Technology has improved too, but perhaps the greatest difference is one of approach: Reshaping the way in which emergency medical care is delivered to combat casualties has resulted in a leaner, more efficient system that provides faster interventions and stabilization at and near the front lines and a quicker, smoother transition to sources of definitive care.

“The idea is basically earlier intervention—earlier surgery to stop bleeding and correct things that can be corrected,” says Lt. Col. John McManus, MD, a combat casualty care research physician at the U.S. Army Institute of Surgical Research at Ft. Sam Houston in San Antonio, TX. “The earlier we can get somebody to definitive care or perform a lifesaving intervention, the more likely they will survive. It just makes sense. That’s what trauma care in the civilian world does.”

This emphasis on rapidity permeates the entire spectrum of combat casualty care. As one barometer, the average time needed to get the severely injured from the front lines all the way back to U.S. hospitals is now around four days. Three decades ago in Vietnam, it took 45 days.

Even more vital to survival, though, is what’s done closer to the point of injury. Wounded soldiers who die typically do so before getting to surgical care. In Vietnam, just 2.6% of those who made it to surgical field hospitals died. Now, while definitive care still can’t be routinely given on the battlefield, more stabilization is the norm.

“Used to be, the medic would basically just patch somebody up and throw them in an ambulance,” says McManus. “Now they start IVs, they apply tourniquets to stop hemorrhage. The training we’re doing for the medics and the forward people is a lot more than we used to do. We’re focusing on the things that increase mortality.”

Beyond the front, an array of surgical capabilities, like those that aided the soldier at the beginning, are quickly and proximately available as well, and transport to them is more direct.

“It’s just like the trauma systems over here (in the U.S.): It’s not one guy who’s really, really good and is saving all the lives; it’s all the parts and pieces together,” says Col. John Holcomb, MD, commander of the Institute of Surgical Research and a trauma consultant to the Army’s surgeon general. “You want to have that continuum, where everybody’s on the same sheet of music, using the same guidelines and protocols, working and communicating together—that’s what saves lives.”

The Battlefield and Beyond

Medical care of combat casualties is delivered through a tiered system of increasingly definitive assets. The first level, at the front, is the combat medics and fellow soldiers trained to augment them.

The Army is utilizing a new type of combat medic in its current conflicts. Known by the military designation 91 Whiskey, or 91W, it blends the roles of traditional combat medics (formerly known as 91 Bravos) and combat LPNs (previously 91 Charlies). Created in 2001, the 91W has a scope of practice that falls roughly between the EMT-I and EMT-P levels familiar to civilian EMS providers, with an emphasis on immediate care of battlefield phenomena like trauma and hemorrhage, fluids and resuscitation, and triaging patients to the appropriate next level of care.

“With the implementation of the 91-Whiskey, we’ve had a distinct increase in the level of advanced care provided at the point of injury,” says Capt. Phillip Carlisle, who trains medics for the National Guard and Army Reserve at Camp Shelby, MS. “They’re proficient now at things like IV therapy, needle chest decompression, advanced airways. A big part of the transition from the old medic to the new medic is the Prehospital Trauma Life Support course, so they get extensive training in rapid survey, airways and life-threatening injuries, including controlling bleeding. And they have an increased ability to sustain casualties on longer evacuation legs.”

These frontline providers are backed by regular soldiers who now receive some of the education and equipment previously reserved for the medics. So-called “combat lifesavers” are soldiers—infantrymen, clerks, mechanics, etc.—who receive extra training in lifesaving skills; in the Army’s deployable units, one out of every 10–15 members is schooled this way. They are essentially first responders-plus who bolster the smaller number of actual combat medics.

“It’s a three-day course,” explains Carlisle, “that gives them proficiency with IVs, the use of oropharyngeals and some other basic medical skills.”

When a solider needs more help than the 91Ws can provide, the next level of care is the forward surgical team, or FST. Situated just beyond the action for the Army (other branches of the service have rough equivalents), FSTs consist of 20 healthcare providers: three general surgeons, an orthopedic surgeon, two nurse anesthetists, three nurses, plus medics and other support personnel. Moving directly behind troops, FSTs can set up working field hospitals with four ventilator-equipped beds and two operating tables in about an hour. They carry basic surgical supplies, including sterile instruments, anesthesia equipment, medicines, catheters and other essentials. The teams also carry portable monitors, small ultrasound machines, transport ventilators, oxygen concentrators, packed red blood cells and a half-dozen roll-up stretchers with litter stands. FSTs can handle up to 30 wounded soldiers.

Badly injured soldiers may move from FSTs to the next level, combat support hospitals (CSHs). CSHs are 248-bed hospitals with six operating tables, some specialty surgery services and lab and radiology capabilities. Soldiers are intended to be in CSHs for a maximum of three days; those needing longer stays or higher levels of care are sent to institutions like Landstuhl and comparable facilities in Spain and Kuwait. Those needing more than 30 days of treatment are, like the soldier at the outset, returned to the U.S., to places like Walter Reed or the Brooke Army Medical Center, colocated at Ft. Sam Houston.

In the past, the military employed formal levels called echelons of care. The new system has changed some terminology, but the concepts, for the most part, remain intact.

Obviously, much depends on the most-forward medical providers. They perform initial assessments and stabilizations of injured soldiers and decide what needs to be done and where they need to go. In addition to their increased medical capabilities, they also have more latitude now to make decisions and bypass certain levels of care if they feel it’s warranted.

“Because there really isn’t a front line in Iraq, if somebody’s substantially injured and we think they’re going to require surgery, we take them right to a hospital, instead of trying to go through the echelons of care,” explains McManus. “We’re trying to expand the medics’ capability to make triage decisions. If an IED [improvised explosive device] explodes and there are two casualties we know need surgery, we may fly them right to the CSH. That’s what they do in your town: If somebody’s a trauma victim, they don’t take them to the hospital first and have the ED doc look at them and go, ‘Yeah, they need to go to a trauma center. Let’s stabilize them and send them on.’ If we think they need to be in a trauma center, we try to get them right to the trauma center first.”

If this all sounds familiar to civilian EMTs, it should.

“The concept of moving patients to the right place at the right time, in the midst of a battle, really springs from civilian trauma systems’ maturation over the last 30–40 years,” says Holcomb. “People talk about the urban battlefield. We’re just applying it on the real battlefield.”

In fact, a large part of the current approach overlaps with the Prehospital Trauma Life Support curriculum many EMS providers know well.

“The idea of tactical combat casualty care—that chapter in PHTLS—is really starting to make a difference, I think, in its emphasis on how to do the things you have to do on a battlefield to save lives,” says Holcomb. “Your ability to carry equipment is limited, and with the [limited] number of medics and other medical assets, there really are only three or four things you can do. So you have to be able to do them well and have good equipment to do them, which is kind of based on tactical combat casualty care.”

A military version of the current 5th edition of PHTLS is available; the forthcoming 6th edition, due in fall 2006, will be extensively rewritten with a comprehensive picture of military prehospital care. Military-specific courses may also be developed.

Technologies and Techniques

Advances in technology and tools have also contributed to American soldiers surviving their combat injuries.

For instance, one thing that increases mortality, as any EMT-B knows, is uncontrolled hemorrhage. Recognizing that, the Army has endorsed certain techniques for hemorrhage control.

“One of the things we’ve done research on is improving tourniquet use,” says McManus. “For EMS agencies in the civilian world, tourniquet use is a last resort, or even discouraged. With the new Army policy, the first thing you do if someone’s been shot and is bleeding is apply the tourniquet. You don’t try other measures first. When people are getting shot at, there’s not time to apply dressings and all that stuff.”

“With all the IEDs we’re seeing, we have a lot of damaged limbs—think about everything that’s not covered by the armor they wear,” says Carlisle. “The tourniquets have been very successful for us.”

What the Army is using, though, aren’t your father’s tourniquets. In March, the service announced the ordering of 172,000 new easy-to-use plastic-and-nylon tourniquets from Simpsonville, SC-based North American Rescue Products. These can be applied with one hand and cinched tight using an attached plastic bar. They can be left on for 3–4 hours, the Army says, and still allow the limb to be saved.

A related advance has been the HemCon (for hemorrhage control) bandage. A chitosan-based product made by HemCon, Inc., of Portland, OR, the bandage can stop severe external hemorrhage following trauma. Other hemostatics like QuikClot and recombinant factor VIIa are in use by the Army and other branches of the military.

Another combat killer is hypothermia. Even in the desert environment of Iraq, when you’re bleeding, your body loses its ability to control temperature.

“It sounds funny, but even though it’s 140 degrees outside, your casualty may be cold and dying,” says McManus. “You have vasoconstriction, and you get cold. And we know that mortality goes up the colder you are. So we’ve really pushed forward with different ways to warm troops. We used to have these old green blankets we threw on people. We found out they didn’t really keep people as warm as we thought, so now we’re pushing forward a new type of blanket and new warming devices as well.”

A big area of emphasis for the Army is developing tools to help triage decision-making. To that end, it is working on informatics tools such as sensors that can be worn by soldiers and automatically transmit things like vital-sign information to medical personnel.

“We’re basically trying to figure out some kind of monitoring system,” says McManus. “Vital signs are important, obviously, but there are other things we need to know too. How do I know if someone’s dehydrated? How do I know if they’re going to require an IV? How do I know if this person’s going to go into shock in 10 minutes if I don’t do something? So we’re looking at something to wear that can provide early detection for triage decisions.”

Other major pushes include intraosseous infusion devices and ultrasonography to detect internal bleeding.

As with EMS, it’s hard to do controlled long-term studies of products or practices in the midst of a war. For that reason, a lot of what’s currently being embraced isn’t yet backed by reams of evidence. That’s not to say the Army is throwing untested solutions onto the battlefield, just that the threshold for demonstrating full, safe effectiveness isn’t necessarily as high as it might be in peacetime or in the civilian world. An army fighting a war doesn’t have the luxuries of time and control groups.

“With products we think work, we’ll put them out there,” says McManus. “The problem with that is that often, we don’t have studies done. There aren’t any landmark studies on, for instance, the HemCon dressing. There are studies that show it’s safe and can be used, but there’s no landmark study that concluded, ‘This is definitely what you need to use.’ We basically studied it, knew it worked and put it out there. That’s obviously controversial, but what are you going to do in war? Are you going to say, ‘Half the people can only get this bandage, and the other half can’t get it’? If we feel we have a product that’s safe, FDA-approved and saves lives, we’re pushing it forward.”

What to Take

Before considering what parts of the Army’s approach might benefit America’s civilian EMS systems, it’s prudent to note some differences between the theater of war and the relatively peaceful environs of the homeland.

These start with the types of injuries likely to be seen. In war—at least this one—providers are dealing with large amounts of penetrating trauma and a high number of blast injuries (which can combine blunt and penetrating trauma with burn injuries, as well as a range of shrapnel that can include nails, bolts, dirt, clothing and even bone fragments from suicide attackers). Kevlar vests have reduced injuries to torsos, but as Carlisle noted, there’s been a corresponding jump in mangled extremities.

Trauma-care criteria used in the civilian world aren’t reliable in wartime. Soldiers’ limb injuries are often so bad (and often in conjunction with other injuries) that they can’t be saved by standard trauma procedures. Blood loss, ischemia and sepsis are all threats, as are later complications like pulmonary embolism and deep-vein thrombosis. Infection with the Gram-negative coccobacillus Acinetobacter baumanii has been a problem in Iraq, though it wasn’t in Afghanistan. It’s not known why.

“The injuries we’re seeing are almost beyond comprehension,” says Holcomb. “People are just really, really mangled: head injuries, chest injuries, multiple-extremity injuries requiring big teams of people working on them. And not just one a week or one a night, but many, many, many like that. We’ve looked at a number of the injuries and scored them with ISS, but the ISS doesn’t take into account the multiple body areas affected and severity of these injuries on the battlefield. My guess is, we’re going to have to come up with a new scoring system to take all that into account.”

Obviously, any care model developed for civilian use won’t translate directly to a wartime environment, and one developed for war can’t be directly applied to the civilian setting. But despite such differences, it may be enlightening for civilian EMSers to examine some of what the Army has done. What does the Army think is responsible for that survival-rate jump?

“Applying tactical combat casualty care concepts on the battlefield has been important,” says Holcomb. “The emphasis on hemorrhage control, with tourniquets and different hemostatic agents, is making a difference. The widespread use of fresh whole blood, of recombinant factor VIIa. The wide utilization of our surgical assets is making a difference. Body armor is saving lives, with a decrease in chest injuries. Rapid evacuation is continuing to save lives. There’s a lot of new things going on out there.”

This isn’t to say EMS should automatically rush out and re-embrace tourniquets or start outfitting crews with ultrasound. But the broader lessons of delivering care to trauma victims seem clear enough.

Then it’s a matter of deploying personnel and resources to facilitate it.

“One thing, obviously, is moving technology far forward, which we’re already seeing in civilian EMS,” says McManus. “We’re moving a lot of the technology closer to the point of injury.”

Then there are scope-of-practice issues. Based on the Army’s experience, perhaps our civilian EMTs and medics can handle a bit more responsibility.

“Folks need to be looking at the success our 91 Whiskey has had,” says Carlisle, who has also chaired the National Association of EMTs’ Military Division. “The reports from the theater are extremely positive. And look at our combat lifesavers—we’re basically taking a mechanic, and in three days we have him pushing fluids.”

“We’re kind of leading the way in training as far as increased scope of practice,” says McManus. “Paramedics already can do a lot, but we’re allowing them to do even more. In the civilian world, they’re actually redoing the curriculum and scope of practice right now. They’re undertaking a change for the paramedics. We’ve done the same thing. Our medics are now better trained and allowed more treatment and diagnosis ability.”

Conclusion

Many factors are contributing to the increase in combat casualty survival rates seen by the U.S. in its recent conflicts. Technologies new (like state-of-the-art hemostatic agents) and old (such as tourniquets) appear to contribute to the improvement, as does the system by which injury care is provided—fast stabilization by better-trained, better-equipped and better-supplemented combat medics; the forward deployment of basic surgical assets like FSTs; and fast evacuation to more definitive assets like CSHs. Though the environments in which civilian EMS agencies operate and the kinds of injuries they see don’t normally resemble those of actual war, these are important points civilian EMS can draw upon to help improve its operations and service to its constituents.

“A lot of the research and products and results from this war can be applied to civilian trauma,” says McManus. “And a lot already are.”

References

1. Gawande A. Casualties of war—military care for the wounded from Iraq and Afghanistan. NEJM 351(24): 2471–75, Dec. 9, 2004.