While wars are being fought thousands of miles overseas, few realize that lessons being learned on the battlefield are being applied every day in violent areas of America’s inner cities, after mass shootings and terror attacks, and in the average community hospital. As the severity of injuries in the wars in Afghanistan and Iraq increased, so did our ability to treat these injuries. In fact, over just an eight-year period between 2005 and 2013, the fatality rate among those same patients decreased by close to 50 percent.
These gains were translated from the battlefield to the streets of America. Trauma centers in the United States applied lessons learned in Afghanistan and Iraq when tragedy struck on April 15, 2013 at the Boston Marathon. Although three individuals lost their lives, over 260 injured spectators and participants survived the twin explosions in downtown Boston. Not one person who reached a hospital that day succumbed to their injuries.
According to the American Association for the Surgery of Trauma, within the United States trauma-related injuries are the leading cause of death for individuals under the age of forty-five and the fourth leading cause of death overall. As the University of Chicago prepares to open its own trauma center on the South Side of Chicago in the coming months, its team of trauma surgeons is applying the lessons learned treating injured service members overseas in order to improve trauma care domestically.
From the Battlefield
When a US service member is severely injured on the battlefield, it triggers a cascade of actions and techniques that have been practiced and fine-tuned over time. Immediately, those on the battlefield with an injured soldier seek to control the bleeding, one of the most crucial aspects in trauma care. It is estimated that nearly 50 percent of soldiers who die on the battlefield do so due to exsanguination (blood loss). Hence, immense strides have been taken to equip front line units with equipment and tools that aid in stopping bleeding after serious injuries. Dr. David Hampton, a trauma surgeon at the University of Chicago Medicine and Commander in the US Naval Reserve, cited the distribution of individual first aid kits (IFAKs) to every enlisted service member as a critical step in rapidly providing care to the injured. These include tourniquets and hemostatic dressings that can be soaked in medication that catalyzes coagulation (blood clotting). Additionally, special operations units have begun deploying with freeze-dried plasma, the liquid phase of whole blood responsible for carrying clotting factors and immunomodulators. A medic simply needs to add water before injecting the plasma into a bleeding soldier.
Rather than the ABCDE (Airway, Breathing, Circulation, Disability, Exposure) acronym associated with the priority levels in many aspects of medical care where ensuring the integrity of a patient’s airway is the preliminary concern, military trauma follows a very different acronym, according to Hampton.
“In the military it’s not so much ABCDE as it is what we call MARCH,” he said. “The M is massive hemorrhage, so the reason why they put that forward is because of the tourniquets so that is something that they can treat quickly and anyone can do it. Airway and respirations are not everyone’s cup of tea, but if you exsanguinate in the field, game over.”
After attempting to stop any bleeding, an immediate attempt is made to evacuate the injured soldier with MEDEVAC or CASEVAC. MEDEVAC encompasses what is frequently seen in television shows and movies. A dedicated helicopter or ground vehicle equipped with medical equipment, likely painted with a red cross, travels to and evacuates a patient, with little to no weapons systems. CASEVAC is a non-dedicated transport vehicle that is used in one of two situations: a patient requires immediate evacuation and cannot wait for MEDEVAC, and/or the patient needs to be evacuated out of an active situation in which the possibility of the evacuation team needing to fight its way in or out of the area is high.
Once soldiers have been evacuated, they can be brought to several different levels of care facilities. In situations like the Persian Gulf War, in which American troops advanced quickly throughout the country, twenty-person Forward Surgical Teams (FSTs) led by a trauma surgeon, an orthopedist, and an anesthesiologist, were established as major medical facilities could not keep up with geographic advancements. FSTs have now become commonplace in warzones. These teams seek to stabilize patients immediately for transport to facilities with a wider array of capabilities, according to Dr. Kenneth Wilson, who is also a trauma surgeon at University of Chicago Medicine and a colonel in the United States Army who recently completed an active duty tour in Afghanistan.
“The transfer times are key,” said Hampton, “so in the military they push the FST as far forward as possible and then the ancillary services go even further. My job was to make sure they get from the 1a [battlefield] back to the Level II [FST]”
Additionally, the United States operates Combat Support Hospitals (CSH) in theatre, which maintain capabilities to provide more intensive care.
“It makes sense if you’re in Baghdad and got injured that you went to the CSH in Baghdad and it was better than if you were out in the field, so now they just pick up the hospital [FST]. I’ve seen a hospital taken down and picked up and moved” Wilson said.
Once patients have been stabilized and treated at a CSH, they can be moved by aircraft to a Level IV regional medical center, which exists outside the combat zone as a fully functioning, stand-alone hospital. At these facilities, “definitive” multidisciplinary trauma treatment can be provided. Lastly there are Level V facilities (Walter Reed National Military Medical Center, San Diego Naval Medical Center, etc.), major stateside military medical facilities which provide long-term and complex care such as reconstructive surgery, just as any major American academic medical center could.
As components of this treatment cascade can be distant when fighting in locations such as the Middle East or Africa, transport is critical. The US Air Force maintains C-17s that are comparable to flying Intensive Care Units that allow evacuation of critically injured soldiers from anywhere in the world. According to the Smithsonian’s Air and Space Magazine, significantly injured service members could wait as long as forty-five days to return to the United States during the Vietnam War with a survival rate of 75 percent, with an improvement in speed but not survival rate by Operation Desert Storm in 1991. However, drastic improvements continued with the Air Force ensuring state-side evacuations within three days. When it comes to survival rate, “If you make it to a field hospital in theater with a heartbeat,” says Justin Brockhoff, an officer with the Tanker Airlift Control Center at Scott Air Force Base in Illinois, “you have a 98 percent chance of living.” In a situation in which rapid evacuation is not possible, or a humanitarian disaster occurs where trauma services are required in-country, the US Navy maintains two hospital ships, the USNS Comfort and USNS Mercy, that each contain hundreds of beds and that are staffed by military personnel from major Naval medical centers.
As important as it is to get an injured service member to major medical centers outside the combat zone, the most important concept in the entire military trauma care process is the golden hour.
“The golden hour is that period of time where what you do or don’t do to a patient determines whether they do very well or very poorly” Hampton said.
If critically injured patients receive treatment rapidly after injury, their survival chances increase dramatically. This is why, according to Wilson, evacuation and ensuring that “hospitals are closer to the point of injury instead of flying directly into Kuwait or Baghdad” are critically important in military trauma care. The chief priority is the rapid stabilization and transport of critically injured soldiers to the appropriate medical facilities.
To the Streets of America
The concept of the golden hour is not unique to military trauma care. In fact, the term was first coined by Dr. R. Adams Cowley at the University of Maryland Medical Center. His research and focus on the time from injury to treatment have largely underpinned the creation of the network of EMS and trauma centers throughout the United States. After the Boston Marathon bombing, many individuals involved in the medical response said in a special journal report (It Takes a Team: The 2013 Boston Marathon: Preparing and Recovering from a Mass Casualty Event) that it was “dumb luck” that the attack happened within close proximity to six Level I trauma centers. To receive Level I accreditation, a center has to maintain 24-hour coverage by general surgeons, and quick to immediate availability of a range of medical specialties from orthopedics and neurosurgery to radiology. Level I trauma centers must be able to provide care for any type of trauma-related injury and conduct trauma-based research to be certified by the American College of Surgeons.
For several decades, a different situation has played out on the South Side of Chicago, an area that has seen extraordinarily high levels of violent crime in recent years. Since 1991 and the closure of Michael Reese Hospital, critically injured South Side residents could have to travel up to ten miles by ambulance to reach a Level I trauma center. On November 25, 2017 a University of Chicago Police Department security alert reported that a shooting had occured at 5401 S. Cottage Grove, where a single victim was shot multiple times. Rather than being transported three blocks to the University of Chicago Medical Center, the victim was taken by ambulance to Stroger Hospital, nine miles away.
Although the University of Chicago maintained a dedicated pediatric Level I trauma center on its Hyde Park campus, it lacked an adult Level I accreditation and could not accept the most critically injured adults.
Starting in May of 2018, South Side victims will no longer need to travel such great distances in an emergency. The University of Chicago will be opening its own adult trauma center within its new emergency room, which will likely result in an uptick in penetrating trauma survival rates as well as those from motor vehicle accidents, falls, and work-related injuries. A study published in 2015 showed that the treatment of severe injuries at a Level I trauma center rather than a standard emergency room resulted in a 25-percent reduction in mortality. With a trauma center closer by, “The issue just becomes, can your physiologic reserve hang on to get you from where you are on the South Side to the nearest facility. Because that’s literally the golden hour,” Hampton said.
With the trauma center in its final preparations for opening in May, operating procedures and supplies are being determined and the military inspiration is not far away for many. For example, Wilson credited his military experience for influencing his care of vascular injuries. At an FST, Wilson explained, medics often place a shunt in an injured extremity to provide blood flow to the remaining portion of the limb and stabilize the patient for transport to a better-equipped facility.
He hopes that “in the civilian world, instead of taking these patients through big long repairs in the middle of the night, [you should] put a shunt in, send them upstairs, and when you’re not tired, when the patient has been resuscitated, when all the inflammatory intermediaries have subsided, then you go back. I’d like to see that happen, because I personally use it that way, because of the military experience. At a busy trauma center like the University of Chicago may one day be, that gunshot wound to the leg may be followed by another gunshot wound. I can’t spend ten hours vascularizing something.”
Additionally, Hampton explained that transexamic acid, a medication used by some special forces medics to help control bleeding, will be tested at the University of Chicago trauma center when a massive transfusion is needed for a patient. Additionally recent research regarding transfusion protocols and the correct ratio between plasma, platelets, and red blood cells will be evaluated. Wilson also cited the importance of research pertaining to transfusion ratios as a very important contribution of military medicine to domestic care. Unlike in the military, when plasma storage is an issue on the battlefield, domestic transfusions can be parsed out and refined.
During wartime, unlike peacetime where bench-level research advances such as new hemostatic dressings are much more common, surgeons are forced to be very creative in a resource-deprived environment. Discussing the benefits of his experience as a military surgeon, Hampton said that “from the perspective of building confidence with your own skill set, most definitely, suddenly you realize you can do a lot with less, and I think that’s what being at an FST really pushes forward. I think the big thing is being overtly resourceful. Once you realize that you don’t need to get the extra CT scan and that the physical exam that you learn as a first-year [medical student] actually goes a long way, then those kinds of small adjunct really separates and builds your confidence.”
One example of this necessary mechanical ingenuity and its impact on modern medicine traces back to the Korean War and general/vascular surgeons being deployed with little assistance. To control the bleeding of one patient while operating on another, the physician devised the idea of placing a small balloon within the aorta to stop hemorrhaging from the thoracic cavity, abdomen, or pelvis. Although it was unsuccessful at the time, this idea led to the creation of a procedure known as REBOA, Resuscitative Endovascular Balloon Occlusion of the Aorta, which entails placing a balloon through a catheter in the femoral artery and inflating the balloon in the abdominal aorta. According to Hampton, REBOA has become common in the treatment of abdominal aortic aneurysms. Hampton also cited a procedure known as a left lateral thoracotomy, which makes use of the same REBOA technique when a surgeon has difficulty placing a clamp on the aortic arch. This emerged into more common use as cardiothoracic surgeons became familiar with the technique in literature and its use in wartime, and then applied it in a domestic setting.
But in the end, Wilson and Hampton both cited the simplest tool as the most important contribution that military trauma care has had on its civilian equivalent: tourniquets.
Their importance was evident on June 14, 2017, when the Congressional Baseball Practice was attacked by a gunman who critically injured House Majority Whip Steve Scalise. Scalise credits fellow congressman Brad Wenstrup for saving his life that day. Wenstrup, a US Army podiatric surgeon who served a tour at a Combat Support Hospital in Iraq, immediately applied a tourniquet to Scalise’s injury, likely providing the time necessary to facilitate transfer to a nearby hospital.
As innovations in military trauma care trickle back to their domestic equivalents, the same cannot be said for its practitioners. In fact, the reverse phenomenon frequently occurs: many military trauma surgeons first train in high-volume civilian trauma centers and then deploy to a military environment. This is mainly due to the case volume sustainment in civilian trauma centers, where complex injuries are routinely seen. Conversely, military trauma centers frequently do not maintain a large enough patient base to allow surgeons to maintain advanced skills and techniques. To ensure the foremost training for its surgeons, the Department of Defense evaluated civilian trauma centers across the nation as locations for skills sustainment centers. At these civilian centers, located at some of the highest-volume facilities in the country such as Cowley Shock Trauma Center in Baltimore and USC/LA County Medical Center, military physicians enhance their skills, share lessons learned from the battlefield, and train military medics prior to deployments.
Unfortunately, in this day and age it’s not enough to be skilled in new surgical procedures and maintain cutting-edge technology. When a mass casualty event occurs, a lack of communication can significantly hamper the efforts of a trauma center. Hampton, a member of the University of Chicago’s mass casualty planning committee, is working to develop a procedure in case such a horrific event occurs. He stressed communication as a vital component and looked to the military integration of various services for inspiration. “When a marine gets injured and they bring them back to the FST which is where the Navy is, the Navy takes care of them, then the Marine pilot brings them back to the CSH and then the Air Force takes over and flies him overseas to Bethesda and then finally you’re at a tri-service facility,” he said. “That kind of dynamic communication, but across all service lines, you can clearly see how well it works getting someone from the battlefield to the United States in twenty-four or forty-eight hours.”
A similar situation, albeit on a smaller scale, exists within a trauma center he explained. Everyone has to know the mass casualty protocol within their department in order to facilitate smooth transitions “from the casualty collection point to the emergency room, to the operating room and onward to the ICUs. The big thing when they say, University of Chicago, you’re the nearest player, the most severely injured patients are going to come to you first, that’s when you have to know where our priorities lie.” For example, elective surgeries would likely be canceled as the operating rooms are cleared and patients in the emergency department would be moved to clear beds for incoming victims.
“Make sure the location you’re going to be triaging people by level is ready to go and that people are in the right spot, and as long as you can get that mobilized quickly, you’ll do very well” said Hampton.
With the University of Chicago trauma center opening, trauma care will be reaching the South Side and advancements from overseas military trauma care will be hitting the streets of Chicago. Hampton is confident that the reduced timing and distance to care will make a positive impact on residents. “If the betting man were betting, he’d be putting money on the University of Chicago.”
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