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Opinion

VIEWPOINT Implications of Combat Casualty Care for Mass Casualty Events

Eric A. Elster, MD Norman M. Rich

Department of Surgery,

Uniformed Services

University of the Health

Sciences, Bethesda,

Maryland, and Naval

Medical Research

Center, Silver Spring,

Maryland.

Frank K: Butler, MD

United States Army

Institute of Surgical

Research, Joint Base

San Antonio, Ft Sam

Houston, Texas.

Todd E. Rasmussen, MD

Norman M. Rich

Department of Surgery,

Uniformed Services

University of the Health

Sciences, Bethesda,

Maryland, and United

States Army Institute of

Surgical Research, Joint

Base San Antonio, Ft

Sam Houston, Texas.

Corresponding Author: Eric A. Elster,

MD, Department of

Surgery, Uniformed

Services University of

the Health Sciences,

4301 Jones Bridge Rd,

Bethesda, MD 20814

(eric.elster@usuhs.edu).

Violence from explosives and firearms results in mass casualty events in which the injured have multiple pen- etrating and soft tissue injuries. Events such as those in Boston, Massachusetts; Newtown, Connecticut; and Au- rora, Colorado, as well as those in other locations, such as Europe and the Middle East, demonstrate that civil- ian trauma may at times resemble that seen in a com- bat setting. As the civilian sector prepares for and re- sponds to these casualty scenarios, research and trauma practices that have emerged from the wars in Afghani- stan and Iraq provide a valuable foundation for respond- ing to civilian mass casualty events. Several lessons learned by the US military were implemented duringthe response to the bombings in Boston in April of this year.

Military research has found thatapproximately 25% of persons who die as a result of explosive or gunshot wounds have potentially survivable wounds.' These in- dividuals have injuries that are not immediately or nec- essarily lethal and have a chance to survive if appropri- ate care is rendered in a timely fashion. The military has learned that implementation of evidence-based, clini- cal practice guidelines can reduce potentially prevent- able death.^ Certain aspects of these lessons also apply to multiple casualty scenarios in civilian settings.

The care of wounded military service personnel is based on an integrated trauma system and involves timely point-of-injury intervention, coordinated pa- tient transport, whole blood or blood component- based resuscitation, and initial operatingfocused on con- trol of hemorrhage and optimizing patient physiology. Referred to as damage control surgery, this approach in- volves abbreviated techniques instead of longer defini- tive operations. The principles of combat casualty care should be considered in 3 phases: point of injury, dur- ing transport to the hospital, and hospital-based treat- ment. The wars have highlighted the importance of a trauma system to coordinate these phases and im- prove survival. In implementing this strategy, the mili- tary developed the Joint Trauma System, which is de- signed to provide wounded troops an optimal chance for survival and recovery.

Care at the Point of Injury The majority of wartime deaths occur in the out-of- hospital setting. The point of injury component of care is termed tacticalcombatcasualtycare. During the past de- cade, this phase has been transformed to introduce and integrate elements of medical care with military tactics. Combat units are now trained in tactical combat casualty care, a strategy that has reduced preventable death.^'^ Kotwal et aP reported that the 75th Ranger Regiment's implementation of a system based on tactical combat ca- sualty care was associated with a historically low 3% inci-

dence of preventable death. Moreover, none ofthe regi- ment's 32 fatalities died of preventable causes duringthe out-of-hospital phase of care. The critical elements ofthe protocol include early control of hemorrhage using tour- niquets for extremity bleeding and hemostatic dressings for bleeding not amenable to tourniquets.

Care During Transport Evacuation is the next step in the continuum. Findings from military research have shown improved survival as- sociated with the use of more advanced en route care capability. Mabry et al'* demonstrated a 66% reduction in mortality among patients evacuated by critical care flight paramedic teams (16 deaths among 202 pa- tients) compared with casualties transpoited by basic emergency medical technicians (71 deaths among 469 patients). The survival benefit was attributed to higher levels of trainingand experience amongflight paramed- ics. Morrison et al^ extended these observations in a study of injured military personnel evacuated by the United Kingdom's physician-led platform (aircraft or air- frame used to transport patients) referred to as the medi- cal emergency response team-extended (M£RT-£).\nth\s report, there was a 33% reduction in mortality in the most severely injured who underwent evacuation with MERT-E (47 deaths among 385 patients) compared with those evacuated with conventional platforms (36 deaths among 198 patients). Many ofthe advanced evacua- tion platforms include the capacity to administer blood and blood components and to provide other lifesaving interventions priorto reachingthe hospital. The person- nel on these advanced platforms may be acute care nurse practitioners, flight nurses, critical care flight paramed- ics, or critical care trained physicians.

Hospital-Based Care The receiving trauma center provides the third phase of care. The US military's hospital-based experience with multiple casualty scenarios following single explosive events was documented in the 2009 Balad Air Base (in northern Iraq) report,® which described strategies used to mitigate morbidity and mortality in 50 injured pa- tients following 3 consecutive explosive events and quantified estimates of casualty surge capacity. Man- agement ofthe most severely injured patients with com- plex penetrating wounds included strategies of dam- age control resuscitation; treatment of hemorrhagic shock with whole blood or balanced ratios of blood com- ponents such as plasma, platelets, and cryoprecipitate instead of crystalloid solutions; and damage control sur- gery. These approaches to combat casualty care are out- lined in the Joint Trauma System clinical practice guidelines.^

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Opinion Viewpoint

Damage control resuscitation is based on results of military re- search showing a survival benefit associated with administration of equal ratios of plasma, packed red blood cells, platelets, and more re- cently tranexamicacid.^-^ Damage control surgery involves perform- ing only necessary amounts of operating to control bleeding, de- bride nonviable tissue, stabilize fractures, and restore extremity perfusion. Application of damage control surgery means that more definitive operations are delayed until initial resuscitation has been completed. The Balad report also documented the value of parallel operating, which involves having more than 1 surgical team simulta- neously tendingtoa patient to reduce anesthesia and operative time.® For example, a patient with extremity injuries as well as and head and neck injuries may have 2 teams composed of general and orthopedic surgeons operating on these different anatomic locations at the same time. Although this strategy does not apply to all cases, it can be used for patients with multiple extremity fractures or penetratingand soft tissue injuries to several different anatomic locations.

The military has also demonstrated the effectiveness of oper- ating on multiple patients simultaneously in a single operating room.^ During the surgical surges in Balad, Iraq, more than three-fourths of initial operations (involving a total of 50 patients) were performed in rooms with more than 1 patient without adverse outcomes and an overall 8% mortality. Practices like these demonstrate how space, personnel, operating room tables and supplies, and anesthesia equip- ment can be used effectively to perform lifesaving operations at a pace greater than that of routine conditions.

The Balad report projected that three-quarters of patients in- jured enough to require admission to the hospital would need an op- eration and that nearly 4 procedures would be required per opera- tion to manage penetrating injuries.® Findings from the US military demonstrated that 110 procedures were performed during 40 op- erations on 38 patients in the first 24 hours. The report also showed that a balanced, blood component-based resuscitation was achiev- able in the setting of a multiple-casualty event. The report esti- mated that an average of just more than 3 units of packed red blood

cells, plasma, and platelets would be required per hospitalized ca- sualty. The report also characterized intensive care unit and venti- lator requirements, demonstrating that 1 nurse and 1 ventilator would be anticipated for every 2 admitted casualties. The Balad report con- firmed that many patients injured during explosive events re- quired multiple operative interventions (191 procedures were per- formed during 75 operations, translating to 3.8 procedures per patient) in the days after the initial or index procedure (ie, a second- ary wave of operating).®

Lessons From Wartime Trauma Care These lessons from the wars in Afghanistan and Iraq are a product of the nation's investment in military trauma care and combat casualty care research. However, few military clinical practice guidelinesare the result of standard, randomized clinical trials. Instead, these lessonsare the result of a process of focused empiricism, or by "identifying what works and what does not, refining it over time and embracing a cul- ture of continuous process improvement."'" This pragmatic ap- proach adopted for military combat casualty care has allowed for rapid adoption of lifesaving strategies through practical methods. In this con- text, the evidence base supporting the milita ry'sdinical practice guide- lines is driven by the results of basic science, translational large ani- mal research, and retrospective cohort analyses. Despite the lack of randomized trials, the net outcome of the military's approach and other improvements in trauma care is the lowest case fatally rate for US ser- vice personnel recorded in the history of war.

As the United States and other nations continue to prepare for casualty scenarios from explosives or mass shooting events involv- ing civilians, lessons from wartime trauma careand resuscitation may be helpful in planning responses. The trauma practices that have re- sulted from more than a decade of combat casualty care and re- search are transferable to the civilian world. Continuing to trans- late these lessons from war should provide a foundation to help reduce mortality and morbidity among civilians injured in future mass casualty events.

ARTICLE INFORMATION

Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.

Disclaimer: The views expressed in this article are those of the authors and do not reflect the official policy of the US Departments of the Army, Navy, or Defense: the Federal Bureau of Investigation: the US Department of Justice, or the US government.

Copyright Protection: Our team comprises military service members and employees of the US government. This work was prepared as part of our official duties. Title 17 US Code 105 provides that "Copyright protection under this title is not available for any work of the US government." Title 17 US Code 101 defines US governmental work as work prepared by a military service member or employee of the US government as part ofthat person's official duties.

Additional Contributions: We thank David S. Wade, MD, chief medical officer for the Federal Bureau of Investigation, for his for support and insightful guidance on this article, for which he was not compensated beyond his normal salary.

REFERENCES

1. Eastridge BJ, Mabry RL, Seguin P, et al. Death on the battlefield (2001-2011): implications for the future of combat casualty care (correction published in J Trauma Acute Care Surg. 2O13:74(2):7O6]. J Trauma Acute Care Surg. 2O12:73(6)(suppl 5):S431-S437

2. Butler FK Jr, Blackbourne LH. Battlefield trauma care then and now: a decade of tactical combat casualty care. J Trauma Acute Care Surg. 2O12:73(6)(suppl 5):S39S-S402.

3. Kotwal RS, Montgomery HR, Kotwal BM, etal. Eliminating preventable death on the battlefield. Arch Surg. 2Oll:146(12):135O-1358.

4. Mabry RL, Apodaca AA, Penrod J. Orman JA, Gerhardt RT, Dorlac WC. Impact of critical care-trained flight paramedics on casualty survival during helicopter evacuation in the current war in Afghanistan. J Trauma Acute Care Surg. 2O12:73(2)(suppl 1):S32-S37

5. Morrison JJ, Oh J, DuBose JJ, et al. En-route care capability from point of injury impacts mortality after severe wartime injury. Ann Surg. 2013:257(2): 330-334.

6. Propper BW, Rasmussen TE, Davidson S, et al. Surgical response to multiple casualty following single explosive events. Ann Surg. 2009:250(2): 311-315.

7. US Army Institute of Surgical Care website. http://viiww.usaisr.amedd.army.mil. Accessed May 29,2013.

8. 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(4): 805-813.

9. Morrison JJ, Dubose JJ, Rasmussen TE, Midwinter MJ. Military Application of Tranexamic Acid in Trauma Emergency Resuscitation (MATTERS) study. Arch Surg. 2012:147(2):113-119.

ID. Timbie JW, Ringel JS, Fox DS, et al. Allocation of scarce resources during mass casualty events: evidence report 207. Rockville, MD: Agency for Healthcare Research and Quality: June 2012. AHRQ publication 12-EOO6-EF. http://effectivehealthcare .ahrq.gov/index.cfm/search-for-guides-reviews -and-reports/Ppageaction^displayproduct &productid=llS2. Accessed May 29,2013.

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Mass-Casualty Incident Management: Non-Clinical Issues Whether it is during a crisis or normal operations, controlling access to facility is a key part of any security plan. This control can become much more difficult to manage and monitor in a crisis situation if the control mechanisms are not established for certain conditions. To properly plan for crowd control in a crisis, the facility must first establish what population is being controlled; what boundaries of the control are to be exerted; and what goals are necessary to maintain control in any situation.

Security in general and hospital security in particular can require much planning and control than it is required with other types of facilities. Unlike commercial and corporate properties, hospitals become a focal point and gathering area in an emergency. While other facilities must plan for evacuation and escape, hospitals' preparedness works in the opposite: they must plan for additional work and additional people.

The need to governmental support in Mass Casualty Incident Management at all levels is clear and compelling. The government has the responsibility to efficiently divide available resources, and support the various programs that will benefit the system of disaster mitigation the most. Areas of government financial support include pre-disaster appeals, concurrent funding requests, and post-disaster appeals.

Communication is one the most important factors during all phases phases of a disaster. Regardless of the emergency operation plans, if the commanders cannot communicate to those in the field, communication is of no value. Integral to that communication is the use of standardized language to clearly and unambiguously relay information and instruction to those on the front lines. Communication is also important in the pre-planning and recovery phases of a disaster. External communication through social media is imperative to ensuring the correct message is being delivered. We learned much through the different guidance changes in COVID-19. Communication begins with all agencies using the same information. Dispelling false information took on a whole new area of crisis communication.

The need for social services in the management of a Mass Casualties is profound. However, the deficiencies in the system are staggering. After a disaster, the local population in particular suffers from the aftermath of the damage to the infrastructure, whether it be a tangible or a virtual infrastructure. It is proposed that the Network Model approach to community Social Services planning is a far more viable and effective method of post-disaster management than the present system.

Creation of a community-oriented disaster plan is a cornerstone of a successful disaster management program. With the support and awareness of the community, the health care providers' task is made more manageable and the stress of the community can be minimized by the knowledge of the situation and potential obstacles.