• Intercontinental casualty transportation. 21st century combat medicine saw the transformation of fixed-wing transport aircraft into airborne intensive care units. Wounded patients being flown to upper-echelon medical facilities in Germany or stateside were accompanied by critical care air transport teams (CCATTs), which include a critical care-trained physician, a critical care-trained nurse, and a respiratory therapist.
The Iraq/Afghanistan survival rate is remarkable not only in that it was an improvement over previous conflicts, but also because it improved on itself through the duration of the war, despite the fact that the severity of injuries increased overall among U.S. warfighters. In the first decade of Operation Enduring Freedom and Operation Iraqi Freedom, the combat injury case fatality rate decreased from 18 percent to 5 percent.
The Iraq/Afghanistan survival rate is remarkable not only in that it was an improvement over previous conflicts, but also because it improved on itself through the duration of the war, despite the fact that the severity of injuries increased overall among U.S. warfighters.
This improvement points to advances in logistics as much as in medicine, said Elster, who last year published Out of the Crucible: How the U.S. Military Transformed Combat Casualty Care in Iraq and Afghanistan, a book he co-edited with Arthur Kellermann, M.D., M.P.H., dean of USU’s School of Medicine. The Joint Trauma System (JTS), pioneered by Holcomb beginning in 2003, established lines of communication and a tri-service trauma care system that, by design, continues to be refined today. More than any medical innovation, Elster said, the most important contributor to historic combat survival rates “has been the establishment of a Joint Trauma System as a learning health care system. The thing that ties all the advances together and provides the opportunity or ability to disseminate those advances, and then to measure their effectiveness, is the Joint Trauma System.”
Combat medic soldiers with the 230th Brigade Support Battalion conduct lifelike combat casualty care training with soldiers injured on the battlefield. Soldiers trained on medical techniques and medical intervention at a training area near Fort Bliss, Texas, during the 30th Armored Brigade’s eXportable Combat Training Capability (XCTC) exercise, Aug. 6-21, 2018. U.S. Army National Guard photo by Sgt. Odaliska Almonte; North Carolina National Guard Public Affairs
Closing the Gaps
In June 2016, the lessons learned in forming and operating the JTS were the focus of a report issued by the National Academies of Science, Engineering and Medicine titled “A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths After Injury.” The report articulated a vision for “a national trauma care system driven by the clear and bold aim of zero preventable deaths after injury and minimal trauma-related disability to benefit those the nation sends into harm’s way in combat as well as every American.”
Elster sees three major steps that need to be taken in order to move combat medicine closer to zero preventable deaths – and those steps are currently underway. First, the JTS must be embedded throughout the entire military medical system. Established and developed post-9/11, the JTS, Elster said, evolved into a theater-based system, particular to circumstances presented by Iraq and Afghanistan, but “has been maturing over the last several years to become an enterprise-level solution.” Originally administered by the Army’s Institute of Surgical Research, the JTS was recently established in the Defense Health Agency’s Combat Support Agency, where it serves as the reference body for all trauma care in the military health system, sets standards for trauma care, coordinates the translation of research, and incorporates lessons learned from trauma education and training partnerships into clinical practice.
Established and developed post-9/11, the JTS, Elster said, evolved into a theater-based system, particular to circumstances presented by Iraq and Afghanistan, but “has been maturing over the last several years to become an enterprise-level solution.”
At this scale, the success of military medicine won’t depend on where the next war is fought. “You need the ability to practice this focused empiricism,” Elster said, “which is taking the best data you have, developing practice guidelines, disseminating those guidelines, measuring their effectiveness, and measuring outcomes.”