«FINAL REPORT 30 January 2013 U.S. Central Command Pre-Hospital Trauma Care Assessment Team Russ S. Kotwal, MD MPH COL, MC, USA Director of Trauma ...»
2. As all on the battlefield have the potential to be a casualty and a first responder, explore information technology (IT) solutions for pre-hospital documentation that are first responder centric, not medic centric, and integrated into tactical communications in a manner that surpasses proven TCCC card method
CENTCOM Commander and Surgeon:
1. Continue support for the Joint Theater Trauma System (JTTS) Deployed Director position in CJOA-A.
2. Create and support the position of JTTS Pre-Hospital Care Director in CJOA-A to be filled by a physician with experience in POI pre-hospital combat trauma care
3. Minimize use of platelet-inhibiting drugs (e.g. aspirin, Motrin, other COX-1 NSAIDs, SSRIs) in individuals who leave secure areas for combat missions in CJOA-A
4. Expand TCCC-endorsed trauma guidelines, training, and use of 1) tranexamic acid (TXA);
and 2) ketamine to all pre-hospital medical providers in CJOA-A (e.g. USSOCOM model)
G. Concluding Remarks:
Pre-hospital combat death can be prevented by combatant and medical leaders at multiple
1. Primary prevention – prevent injury incident through TTPs and evidence-based findings from tactical and medical After Action Reviews (AARs)
2. Secondary prevention – mitigate injury extent through tactical contingency planning and Personal Protective Equipment (PPE)
3. Tertiary prevention – optimize injury care through properly executed TCCC, optimized tactical casualty response (POI and Evacuation), and forward damage control resuscitation Medically, the key to trauma care delivery is the time to a required (injury dictated) capability (successfully performed). However, ultimately, the solution to trauma care delivery, and subsequent reduction of preventable combat death, is both tactical and medical, and therefore must have the attention and support of combatant commanders.
A. BACKGROUND During the Vietnam conflict, many U.S. casualties died because they failed to receive prehospital trauma care interventions as simple as placing a tourniquet on a bleeding extremity. A paper from the Vietnam era noted that: “...little if any improvement has been made in this (prehospital) phase of treatment of combat wounds in the past 100 years.” This statement continued to be true until the development of Tactical Combat Casualty Care (TCCC) in 1996.
TCCC is a set of pre-hospital trauma care guidelines customized for use on the battlefield.
[Maughon JS. An inquiry into the nature of wounds resulting in killed in action in Vietnam. Military Medicine 1970; 135:8-13; Butler FK, Hagmann J, Butler EG. Tactical combat casualty care in special operations. Military Medicine 1996; 161(suppl):1-15] One example of the lifesaving potential of TCCC guidelines is renewed focus on pre-hospital tourniquet use. Until recently military medics were taught that a tourniquet should be used only as a last resort to control extremity hemorrhage, yet a study of 2600 combat fatalities incurred during the Vietnam conflict and a study of 982 combat fatalities incurred during the early years of conflict in Afghanistan and Iraq noted death from extremity hemorrhage was relatively unchanged at 7.4% and 7.8% respectively. After the global implementation of the tourniquet recommendations from the TCCC guidelines, a recent comprehensive study of 4596 U.S.
combat fatalities from 2001 to 2011 noted that only 2.6% of total combat fatalities resulted from extremity hemorrhage. This dramatic decrease in deaths from extremity hemorrhage resulted from ubiquitous fielding of modern tourniquets and aggressive training of all potential first responders on tourniquet application. [Maughon JS. An inquiry into the nature of wounds resulting in killed in action in Vietnam. Military Medicine 1970; 135:8-13; Kelly JF, Ritenhour AE, McLaughlin DF, et al. Injury severity and causes of death from Operation Iraqi Freedom and Operation Enduring Freedom: 2003-2004 versus 2006. Journal of Trauma 2008; 64:S21-S27; Eastridge BJ, Mabry RL, Seguin PG, et al. Death on the battlefield (2001-2011): implications for the future of combat casualty care. Journal of Trauma 2012; 73(6) Suppl 5: 431-7] Currently, if you are a U.S. or Coalition casualty on the battlefield of Afghanistan and you arrive alive to a Role 3 Medical Treatment Facility (MTF), your chance of survival is greater than 98%.
Although the overall case fatality rate in the ongoing conflict is lower in comparison to previous conflicts, significant challenges still remain. The comprehensive study of 4596 U.S. combat fatalities incurred in Afghanistan and Iraq from 2001 to 2011 mentioned above also found that 87% (4016/4596) of deaths occurred prior to reaching a MTF. This percentage remains relatively unchanged from the 88% noted from the Vietnam conflict. Additionally, of the pre-MTF fatalities, a panel of military medical experts determined that 24% (976/4016), or 1 in 4 of these deaths, were potentially preventable. Surgically correctable torso hemorrhage, junctional hemorrhage, airway compromise, and tension pneumothorax remain as significant challenges and causes of preventable death in the pre-hospital battlefield environment. [Eastridge BJ, Mabry RL, Seguin PG, et al. Death on the battlefield (2001-2011): implications for the future of combat casualty care. Journal of Trauma 2012; 73(6) Suppl 5: 431-7; Bellamy RF. The causes of death in conventional land warfare: implications for combat casualty care research. Military Medicine 1984; 149(2):55-62]
A recent study of combat casualties from the 75th Ranger Regiment, U.S. Army Special Operations Command, between 2001 and 2010 documented that 0% of their pre-MTF fatalities and 3% of their total fatalities were potentially preventable. This is largely attributable to the Ranger Casualty Response System, a Tactical Combat Casualty Care (TCCC) based program that is aggressively taught to all unit personnel. This casualty response system is a commanddirected program that was in place prior to the onset of hostilities in Afghanistan in 2001. It has been continuously updated throughout the current conflict as guided by a unit-based trauma registry and by the expert recommendations from the Committee on TCCC. The unprecedented low incidence of preventable deaths achieved by the Ranger Casualty Response System is a model for improving pre-hospital trauma care and saving lives on the battlefield. [Kotwal RS, Montgomery HR, Kotwal BM, et al. Eliminating preventable death on the battlefield.
Archives of Surgery 2011; 146(12): 1350-8] The Ranger system provides an example of how command ownership, comprehensive TCCC training at all levels, casualty data collection, and process improvement using Joint Trauma System principles can save lives when implemented. This system offers key insights into how future improvements in battlefield trauma care and casualty survival can be made throughout the DoD. The 1993 Battle of Mogadishu provided invaluable lessons learned and led to dramatic changes in Ranger pre-hospital trauma care that have subsequently saved many Ranger lives on the battlefield. The current conflict has also provided invaluable lessons which can save lives now and on future battlefields if these techniques are uniformly implemented, well-trained, and well-executed by U.S. military forces.
B. MISSION Assess pre-hospital trauma care within the Combined Joint Operations Area - Afghanistan (CJOA-A) and provide recommendations to reduce preventable combat death among U.S., Coalition, and Afghan forces to the lowest incidence achievable.
C. INTENT To discuss and observe pre-hospital trauma care tactics, techniques, and procedures conducted in the combat environment, and as obtained directly from deployed pre-hospital providers, medical leaders, and combatant leaders from various US military services as well as Coalition partners.
The overall goal of this assessment is to provide recommendations that will reduce preventable combat death among US, Coalition, and Afghan forces to the lowest incidence achievable.
Three primary areas of focus include: 1) identify best practices that can be cross-leveled among the force, 2) identify actionable areas of performance improvement that will optimize prehospital trauma care timing, delivery, and casualty survivability, and 3) identify potential gaps in pre-hospital trauma care, data and performance improvement, tactical evacuation, personnel, training, equipment, medications, research, and technology that merit priority for advancement of pre-hospital trauma care delivery.
1. Command Slide Brief to CENTCOM by 1 DEC 2012; update and synch by 30 JAN 2013
2. Executive Summary to CENTCOM by 20 DEC 2012; update and synch by 30 JAN 2013
3. Final Report to CENTCOM by 20 JAN 2013; update and synch by 30 JAN 2013 E. TEAM
Theater Traveling Team:
COL Russ S. Kotwal, MC, USA – Director, Trauma Care Delivery, Joint Trauma System CAPT Frank K. Butler, MC, USN (Ret) – Chairman, Committee on Tactical Combat Casualty Care COL Erin P. Edgar, MC, USA – Command Surgeon, U.S. Central Command Col Stacy A. Shackelford, MC, USAF – Outgoing Deployed Director, Joint Theater Trauma System, U.S. Central Command CAPT Donald R. Bennett, MC, USN – Incoming Deployed Director, Joint Theater Trauma System, U.S. Central Command
Col Jeffrey A. Bailey, MC, USAF – Director, Joint Trauma System Ms Mary A. Spott – Deputy Director, Joint Trauma System COL Kirby Gross, MC, USA – Director, Performance Improvement, Joint Trauma System LTC Kimberlie A. Biever, AN, USA – Director, Enroute Critical Care, Joint Trauma System LTC Robert L. Mabry, MC, USA – Director, Military EMS and Pre-Hospital Medicine Fellowship MSG Dominique J. Greydanus, 18D, NREMT-P, USA (Ret) – Joint Trauma System
5-6 Nov: Bagram Airfield: Role III (USAF, USA), Role II (USA) 6-7 Nov: Salerno FOB: Role II (USA, USAF), Role I (USA), TACEVAC (USA) 7-10 Nov: Bagram Airfield: Role I (USA), TACEVAC (USA) 8-9 Nov: JTTS Theater-Wide Trauma Conference ( 130 medical providers from AFG, DEU, FRA, NOR, UK, USA, USAF, USMC, USN) 10-11 Nov: Kandahar Airfield: Role III (USN), Role I (USA) 11 Nov: Tarin Kowt: Role II (USN), Role I (USN, AUS) 12-14 Nov: Bastion: Role III (UK, USA), Role I (UK, USA, USMC, USN), TACEVAC (UK, USAF) 14-17 Nov: Bagram Airfield: TACEVAC (USAF), JTTS, JC2RT
G. DETAILED ITINERARY2-3 NOV 2012: Transportation: Air travel from Washington Dulles through Dubai to Doha via Boeing 777, Flight # 976, with follow-on ground travel from Doha Airport to Camp As-Saliyah.
4 NOV 2012: Awaiting transportation.
5 NOV 2012: Transportation: Ground travel from Camp As-Saliyah to Al-Udeid AB, with followon air travel from Al Udeid AB to BAF via USAF C130, Flight # F9346A, Tail # 741660, 0800
1245hrs. Meetings at BAF: 1) JTTS, 2) US Role II (USA medical leader and provider), 3) 30th Medical Brigade (USA medical leaders and providers), 4) US Role III (USAF and USA medical leaders and providers).
6 NOV 2012: Transportation: Air travel from BAF to SAL, Dash 8-100, Tail # N638AR, 1005hrs. Meetings at SAL: 1) US Role II (USA and USAF medical leaders and providers), 2) US Role I – Combatant Unit 1 (USA medical leaders and pre-hospital providers), 3) US Role I (USA MEDEVAC providers), 4) US Role I – Combatant Unit 2 (USA combatant leaders and medical leaders, and USA and USAF pre-hospital providers) 7 NOV 2012: Transportation: Air travel from SAL to BAF, Dash 8-100, Tail # N638AR, 1021hrs. Meetings at BAF: 1) US Role I – Combatant Unit (USA medical leaders), 2) US Role I – Combatant Unit HQ (USA medical leaders and pre-hospital providers), 3) US Role I (USA MEDEVAC leaders and pre-hospital providers).
8 NOV 2012: Conference at BAF: Day 1 of the Trauma Conference: “Bridging the gap between in and out of hospital care,” hosted by JTTS at BAF Chapel, attendance and presentations from Role I-III (US, Coalition, and Afghan Partners). Meeting at BAF: US Role I (USA and USAF medics from multiple combatant units).
9 NOV 2012: Conference at BAF: Day 2 of the Trauma Conference: “Bridging the gap between in and out of hospital care,” hosted by JTTS at BAF Chapel, attendance and presentations from Role I-III (U.S., Coalition, and Afghan Partners). Meeting at BAF: US Role I (USA and USAF medics from multiple combatant units).
10 NOV 2012: Transportation: Air travel from BAF to KAF, Dash 8-100, Tail # N635AR, 0745hrs. Meetings at KAF: 1) US Role III (USN medical leaders and providers), 2) US Role I – Combatant Unit HQ (USA medical leaders and pre-hospital providers), 3) US Role I – Combatant Unit (USA combatant leaders, medical leaders, pre-hospital providers and combatants at multiple levels).
11 NOV 2012: Transportation: Air travel from KAF to Tarin Kowt, CH47F, Tail # 05-08010, 0833-0946hrs. Meetings at Tarin Kowt: 1) US Role I – Combatant Unit (USN combatant leaders, medical leaders, and pre-hospital providers), 2) US Role II (USN medical leaders and providers), 3) Australian Role I (medical leaders and pre-hospital providers). Transportation: Air travel from Tarin Kowt to KAF, C130, Tail # 686, 2021-2044hrs.
12 NOV 2012: Transportation: Air travel from KAF to Bastion, C130, Tail # B583, Danish RAF, 0926-1012hrs. Meetings at Bastion: 1) UK Role III (UK and US medical leaders and providers),
2) JTTS, 3) UK Role I (medical leaders, pre-hospital providers), 4) US Role I – Combatant Unit (USA line leaders).
13-14 NOV 2012: Meetings at Bastion: 1) UK Role III (UK and US medical leaders and providers), 2) UK Role I (RAF MERT medical leaders, providers, and force protection combatants), 3) US Role I (USAF CSAR and CASEVAC leaders and providers), 4) US Role I (USN and USMC medical leaders and pre-hospital providers). Transportation: Air travel from Bastion to BAF, KC130J, Tail # QB7985, 2314-0022hrs.
14 NOV 2012: Meetings at BAF: 1) US Role I (USAF CSAR and CASEVAC leaders and providers).
15-16 NOV 2012: Meetings at BAF: Discussed six PI projects, 5 pre-hospital and 1 hospital.
17 NOV 2012: Transportation: Air travel from BAF to Al-Udeid AB via USAF C130, Tail # 660, 0010-0502hrs, with follow-on ground travel from Al-Udeid AB to Camp As-Saliyah to Al-Udeid AB.