Citation
U.S. Army Medical Department journal

Material Information

Title:
U.S. Army Medical Department journal
Alternate title:
United States Army Medical Department journal
Alternate Title:
AMEDD journal
Running title:
Army Medical Department journal
Abbreviated Title:
U.S. Army Med. Dep. j.
Creator:
United States -- Army Medical Department (1968- )
Place of Publication:
Fort Sam Houston, TX
Publisher:
U.S. Army Medical Department
Publication Date:
Frequency:
Quarterly[<Oct.-Dec. 2001->]
Bimonthly[ FORMER Sept.-Oct. 1994-]
quarterly
regular
Language:
English
Physical Description:
volumes : illustrations ; 28 cm

Subjects

Subjects / Keywords:
Medicine, Military -- Periodicals -- United States ( lcsh )
Military Medicine ( mesh )
Medicine ( mesh )
Medicine, Military ( fast )
United States ( mesh )
United States ( fast )
United States
Genre:
Electronic journals.
Periodicals.
Periodicals. ( fast )
Fulltext.
Government Publications, Federal.
Internet Resources.
serial ( sobekcm )
federal government publication ( marcgt )
periodical ( marcgt )
Electronic journals ( lcsh )
Periodicals ( mesh )
Periodicals ( fast )
Fulltext
Government Publications, Federal
Periodicals
Internet Resources

Notes

Dates or Sequential Designation:
Sept.-Oct. 1994-
General Note:
Title from cover.

Record Information

Source Institution:
University of Florida
Holding Location:
University of Florida
Rights Management:
This item is a work of the U.S. federal government and not subject to copyright pursuant to 17 U.S.C. §105.
Resource Identifier:
32785416 ( OCLC )
98642403 ( LCCN )
1524-0436 ( ISSN )
ocm32785416
Classification:
RC970 .U53 ( lcc )
616.9/8023/05 ( ddc )
W1 JO96 ( nlm )

Related Items

Preceded by:
Journal of the US Army Medical Department.

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Digital Military Collection

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TraumaticWoundCareOnandOfftheBattlefieldJanuaryMarch2007 Perspective1MGRussellJ.CzerwAggressiveProactiveCombatDamageControlSurgery3LTCLorneH.Blackbourne,MC,USA,etalTheBloodAugmentationTeam7LTCLorneH.Blackbourne,MC,USA,etalOptimizingTransportofPostoperativeDamageControlPatients11intheCombatZoneLTCLorneH.Blackbourne,MC,USA,etalManagementofTraumaticWarWoundsUsing17Vacuum-AssistedClosureDressingsinanAustereEnvironmentLTCM.ShaunMachen,MC,USACausesofDeathinUSSpecialOperations24ForcesintheGlobalWaronTerrorism:2001-2004COLJohnHolcomb,MC,USA,etalTheProcessofCareofBattleCasualties:38OrthopaedicsandRehabilitationatWalterReedArmyMedicalCenterCOLWilliamC.Doukas,MC,USA,etalTheGrowthoftheProfessionofOccupationalTherapy51MAJSharonNewton,AN,USAAlsointhisIssueMedicalCareintheSustainmentBrigade59MAJBonnieHartstein,MC,USAEvidence-BasedMedicine:TheWaytoCostEffective,QualityMedicalCare63COLHermanJ.Barthel,MC,USA

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MGGaleS.Pollock ActingTheSurgeonGeneral Commander,USArmyMedicalCommandMGRussellJ.CzerwCommandingGeneral USArmyMedicalDepartmentCenterandSchool JanuaryMarch2007 TheArmyMedicalDepartmentCenter&School PB8-07-1/2/3 0635504 PETERJ.SCHOOMAKER General,UnitedStatesArmy ChiefofStaff DISTRIBUTION:Special AdministrativeAssistanttothe SecretaryoftheArmy ByOrderoftheSecretaryoftheArmy: Official: JOYCEE.MORROW Onlineissuesofthe AMEDDJournal areavailableathttps://secure-akm.amedd.army.mil/dasqaDocuments.aspx?type=1 AProfessionalPublication oftheAMEDDCommunity The ArmyMedicalDepartmentJournal [ISSN1524-0436]ispublishedquarterlyfor TheSurgeonGeneralbytheUSArmyMedicalDepartmentCenter&School,ATTN: MCCS-DT,2423FSH-HoodST,FortSamHouston,TX78234-5078. CORRESPONDENCE: Manuscripts,photographs,officialunitrequeststoreceive copies,andunitaddresschangesordeletionsshouldbesenttothe Journal atthe aboveaddress.Telephone:(210)221-6301,DSN471-6301 DISCLAIMER: The Journal presentsclinicalandnonclinicalprofessionalinformation toexpandknowledgeofdomestic&internationalmilitarymedicalissuesand technologicaladvances;promotecollaborativepartnershipsamongServices, components,Corps,andspecialties;conveyclinicalandhealthservicesupport information;andprovideapeer-reviewed,highquality,printmediumtoencourage dialogueconcerninghealthcareinitiatives. Viewsexpressedarethoseoftheauthor(s)anddonotnecessarilyreflectofficialUS ArmyorUSArmyMedicalDepartmentpositions,nordoesthecontentchangeor supersedeinformationinotherArmyPublications.The Journal reservestherighttoedit allmaterialsubmittedforpublication(seeinsidebackcover). CONTENT: Contentofthispublicationisnotcopyrightprotected.Materialmaybe reprintedifcreditisgiventotheauthor(s). OFFICIALDISTRIBUTION: ThispublicationistargetedtoUSArmyMedical Departmentunitsandorganizations,andothermembersofthemedicalcommunity worldwide.

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JanuaryMarch20071ThefocusofthisissueoftheAMEDDJournalisanareaofmedicinethatisinfacttheverybasisfortheexistenceofmilitarymedicine,managementoftraumainjuriesincurredincombat.Indeed,themedicalcareofUSmilitarypersonnelinjuredonthebattlefieldhasneverbeenbetter,intermsofbothsurvivalandrecovery.However,asrapidlyasourmedicalcapabilitiesimproveinsophisticationandeffectiveness,sotoodothecapabilitiesofourenemiesincreaseinsophisticationandlethality.Wemust,therefore,alwaysbeseekingbetterwaystoaddresstheinjuriessufferedbyourSoldiersastheygointoharmsway.ThisissueoftheAMEDDJournaldoesexactlythatwithapresentationofrealworldexperiencesofourmedicalprofessionalsfromthebattlefieldsoftoday,andrelevant,practicalrecommendationsastohowwecandoabetterjobforourSoldiersonbattlefieldsofthefuture.LTCLorneBlackbourneandhiscoauthorsopenwithaseriesof3well-researched,detailedarticlesaddressingvariouswaystoimprovesurvivabilityoftraumacasualtiesfromtheirearliestdamagecontrolsurgeries.Inthefirstarticle,theemphasisisnotonthesurgeryitself,buton2otherpotentiallylethalconditionsattendanttothetrauma,coagulopathyandhypothermia.Thearticlepacksatremendousamountofextremelyimportantinformationintoafewpages,andincludeslogical,practicalrecommendationsforbothcurrentoperationsandfutureplanners.Nextisadirectlyrelatedarticle,expandingontheavailabilityanduseofbloodproductsindamagecontrolsurgerytoaddressthecoagulopathyandrelatedacidosisandhypothermiaoftrauma.Thisisanotherclear,concisepresentationinwhichtheyproposethecreationofbloodaugmentationteamstoprovidebloodtransfusion,processing,andstoragecapabilitiesonthebattlefield,especiallyattheleveloftheForwardSurgicalTeam.LTCBlackbourneandhisteamwrapupthediscussionsofsurvivabilityofbattlefieldtraumawithanexpandedexaminationofthechallengesinherentintheevacuationofinjuredSoldierstocombatsupporthospitals.Thearticleisathoroughanalysisofallofthepotentiallydeadlyhazardsassociatedwiththehelicoptertransportofthosewhohaveundergonedamagecontrolsurgery.Again,aconcise,thoroughlyreferenced,andcompletediscussionofanaspectoftraumacarewhichisoftenunderappreciatedastoitscomplexityandimportanceintheultimatesurvivabilityofourSoldiers.LTCShaunMachenrelateshisexperienceinthedevelopmentofaprotocolfortheuseofvacuum-assistedclosuresinthetreatmentoftraumaticwoundsatthecombatsupporthospital.Hisdetaileddiscussionofthehugelysuccessfuladaptationofthistechnologyintotheaustereenvironmentofcombatmedicineisanotherexampleoftheskills,resourcefulness,and,aboveall,dedicationofthemedicalprofessionalsintodaysArmy.TheresultsofLTCMachenseffortsspeakforthemselves.Theinformationinhisarticleshouldbeofgreatinteresttoallofyouwhoworkwithtraumaticwoundinjuries,especiallyinthecombatenvironment.COLJohnHolcombandhisteamofspecialistsundertookthevitallyimportanttaskofanalyzingthecausesofdeathforUSmilitarypersonnelinthecurrenttheatersofcombatoperations.Theirarticleisameticulousstudy,notonlyoftheinjuriesandPerspectiveMajorGeneralRussellJ.Czerw

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2ArmyMedicalDepartmentJournal treatments,butalsotheenvironments,situations,andsequenceofeventssurroundingtheinjurieswhichwereultimatelyfatal.COLHolcombetalpresentstatisticaldataandcasestudiestosupporttheirdetaileddiscussionofboththeconsiderablesuccessesandpossibleshortcomingsinthecareofthesetraumavictims.Thisisasoberingyetencouraginglookatthosesituationswhenallofthebestofourtrainingandtechnologymaynotbeenough.Itisamustreadforallofus.ThemajorityofthewoundedwhoareevacuatedtomedicalfacilitiesintheUnitedStatesarrivewithextremityandotherorthopaedicinjurieswhichrequiretreatmentandrehabilitationastheSoldierrecovers.COLWilliamDoukashasassembledacollectionofarticleswrittenbytheprofessionalsatWalterReedArmyMedicalCenterdescribingthestructureandprocessesthathaveevolvedastheinfluxofwoundedincreasedconcurrentwiththetempoofcombatoperations.Eachspecialtyinthechainoforthopaediccareorthopaedicsurgery,physicaltherapy,physicalmedicineandrehabilitation,andoccupationaltherapyhavecontributed,describingtheirrespectiveresponsibilities,procedures,adaptations,conclusions,andrecommendationsforimprovementsinthecareofourmostseriouslyinjuredSoldiers.IntheGlobalWaronTerrorism,theroleoftheoccupationaltherapistisbecominganincreasinglyprominentpartoftherecoveryregimenforthosewhohavesufferedtraumaticcombatinjuries.However,fewpeopleprobablyknowthattheneedforwhatisnowknownasoccupationaltherapywasfirstrecognizedinthe18thcentury.MAJSharonNewtonsarticleisaninterestingandinformativedescriptionoftheevolutionofoccupationaltherapyasatreatmentdisciplinewhichhasbecomeintegraltomilitarymedicine.Herwellresearched,chronologicalpresentationillustrateshowinterestinuseofthetherapistshassurgedandwanedinconjunctionwithmedical,societal,andpoliticaltrends.Sheshowshowthedisciplinehasenduredanumberofincarnationsbeforeitfinallyemergedasarecognized,sophisticatedfield,practicedbytrained,skilledprofessionalswhoarekeymembersoftodaystreatmentteamforourwoundedWarriors.MAJBonnieHartsteincontributesanarticlewhichpresentsanotheraspectofcurrentmedicalsupportinthetheaterofcombatoperations.AsBrigadeSurgeonofthe15thSustainmentBrigadeatCampTaji,Iraq,shehasexperiencedthechallengesofmanagingmedicalsupportforSoldiersinoneofthenewmodularArmyorganizationsasittransformsfromapeacetime,headquarterselementtoalarge,integrated,multifunctionalentitydeployedintothetheaterofoperations.Inherarticle,MAJHartsteindescribesthecomplexitiesandtradeoffsinvolvedinplanningandprovidingforthehealthcareofsustainmentbrigadeSoldiersdeployedintothedynamic,nonlinearbattlefieldenvironmentoftoday.Shespotlightsanareaofmajorconcernwhichmustbepromptlyaddressedatthetoplevelsofplanningformedicalsupportforournew,modularArmy.Thefinalarticleinthisissueisaverytimelyandrelevantdiscussionofanevolutionaryapproachtoprovidingbothaccessibleandaffordablequalitymedicalcarethroughoutthemedicalprofession.COLHermanBarthelpresentsanin-depthlookatthehistoryandbasisfortheapplicationofevidence-basedmedicine(EBM)inthedeliveryofhealthcare.Itseemsonlylogicalthatinthiseraofvirtuallyinstantaccesstocurrentinformation,medicalcareshouldbebasedonscientificevidenceusedtosupportthepractitionersjudgmentandspecificcaseknowledge.However,suchanapproachisnotuniversallyapplied.Indeed,muchhealthcaredeliveryisstillbasedontraditionanduncontrolledclinicalexperience.COLBarthelpresentsasoberingdescriptionoftheimplicationsoftheskyrocketingcostsofhealthcare,notonlyonthepersonalhealthofourcitizens,butalsotheimpactonournationalsecurity.HeprovidesexamplesofthesuccessofaninstitutionalizedapproachoftheapplicationofEBMtohealthcaredelivery,andpresentsrecommendationsforstepstohelpmakeEBMastandardforournationalhealthcarepolicy.Perspective

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JanuaryMarch20073AggressiveProactiveCombatDamageControlSurgeryLTCLorneH.Blackbourne,MC,USACPTNeilMcMullin,MC,USACOLBrianEastridge,MC,USACOLToneyBaskin,MC,USACOLJohnHolcomb,MC,USAProactive:[pro-+reactive]:actinginanticipationoffutureproblems,needs,orchanges1 INTRODUCTIONDamagecontrolsurgeryistheprocessofpreventing,inaproactivefashion,theoverwhelmingcatastrophicphysiologiceffectsofseverehemorrhage.Whilethedamagecontroltrilogyof(1)abbreviatedsurgicaloperation,(2)postoperativeintensivecareunitresuscitation,and(3)definitiveoperationisdescribedasthemajortenetsofdamagecontrol,therearemanyextremelyimportantcontributingeffortsthatarecriticaltothesuccessoftheprocess.2Incivilianpractice,theorderofthisdamagecontroltrilogyiswellestablished.However,themilitaryparadigmofcombatdamagecontroloftencreatesavariablecontinuumforthemajortenetsofthistrilogywithamorevariabletimespan.Whilethecurrentcombatdamagecontrolsurgerystressesearlysurgicaloperation,therearecurrentlynouniversalproactivehypothermiaorcoagulopathypreventionstrategiesforforwardsurgicallevelIIfacilities.Aggressivedamagecontrolsurgeryisusedtoproactivelydefeatthelethaltriad.Thistriumvirateofhypothermia,acidosis,andcoagulopathyallfeedoneachotherinafeedbackcycle,andonceinfullfruitionisuniversallyfatal.Ouronlytangibletargetsofthislethaltriadarehypothermiaandcoagulopathy.Amoreinclusiveproactiveapproachtocombatdamagecontrolsurgerywouldmandatethatwedevelopmeasurestocountercoagulopathyandhypothermiaearlierontheresuscitativetimeline.PROACTVECOAGULOPATHYPREVENTIONANDTREATMENTCoagulopathyisnotmerelyanumberoralaboratoryvalue.Coagulopathycanbeobviousclinicallytothesurgeonandanesthesiapersonnel.Coagulopathicbleedingcaneasilybeseenasprofusebleedingfromanyrawanatomicsurfaceandfrommultiplefragmentationwounds.Coagulopathicbleedingisalsoamarkerandariskfactorfordeathinthesedamagecontrolpatients.3Replacingthepatientsbloodwhichcontainsclottingfactors,fibrinogen,andplateletswithonlypackedredbloodcells(PRBCs)whichdonotcontainanyclottingfactors,fibrinogen,orplateletscanactuallyworsenthecoagulopathyduetosimpledilution.4Amajordifferencebetweenciviliandamagecontrolandfar-forwardcombatdamagecontrolsurgeryistheuseofbloodproducts.Themajorityofciviliandamagecontrolpatientswhoreceive10unitsofPRBCsalsoreceivefreshfrozenplasma(clottingfactors)andplatelets.5Incomparison,militarycombatdamagecontrolpatientsusuallyreceiveonlyPRBCs.Hirshbergetalstatethattooptimallytreatandpreventcoagulopathyindamagecontrolpatients,theclottingfactorsandplateletsneedtobetransfusedproactivelybeforetheonsetofadocumentedcoagulopathy.6OptionsfortreatingacoagulopathyincluderecombinantfactorVIIa,freshfrozenplasma(FFP),platelets,andwholeblood.Freshwholeblood(<8hoursold)containsclottingfactors,fibrinogen,andplatelets.Duetoalimiteddonorpool,limitedpersonnel,andvariableexpertise,drawingwholebloodcanbeaverychallengingactivitytothefullengagedlevelIIsurgicalfacility.Freshfrozenplasmamustbekeptinafrozenstate(untilthawedfortransfusion)andinsignificantquantitiesduetoalackofatrulyuniversaldonorbloodtype(ie,mustbeabloodtypespecifictransfusion).LackoffreezercapabilitiesatlevelIIfacilitiescurrentlymakeFFPanonviableoption.Plateletsmustbestorednearroomtemperatureandhaveastoragelife,afterprocessing,

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4ArmyMedicalDepartmentJournalAggressiveProactiveCombatDamageControlSurgeryofapproximately5days,makingtheirappearanceinthecombatzoneunfeasible.FactorVIIacanbestoredinarefrigeratorwiththePRBCsandhasgreatpotentialinfar-forwardcombatdamagecontrol.Ifwearetomaximizecombatdamagecontrol,weneedtofindstrategiesthatwilleffectthelethaltriadearlyinaproactive,aggressiveapproach.PlayingcatchupatalevelIIIsurgicalfacilityplacesthosecombatwoundedinaseriouspredicamentwithmortalityandmorbidity.PROACTIVEHYPOTHERMIAPREVENTIONANDTREATMENTTheotherareaofthelethaltriadthatwecandirectlyimpactishypothermia.Hypothermiaisextremelydetrimentaltodamagecontrol,especiallythecombatwoundeddamagecontrolpatient,asthehypothermiamakesthecoagulopathyofthelethaltriadworse.Hypothermiaalsoinhibitsplateletactivation.7Thus,hypothermiainhibitsthe2procoagulantprocessesuponwhichcurrentlevelIIsurgicalfacilitiescannotmakeanimpactinmostcases.Inciviliandamagecontrolpatients,hypothermiahasbeendocumentedtobeariskfactorfordeath.8-12Improvedhypothermiapreventioninciviliandamagecontrolpatientsisthoughttobeafactorinoverallbetteroutcomeindamagecontrolpatientsinrecentyears.13Furthermore,preventinghypothermiahasbeendocumentedtodecreasetheoverallbloodandintravenous(IV)fluidrequirementsofdamagecontrolpatients.BloodandIVfluidareagreatconcerntothehighlymobile,logisticallychallengedlevelIIsurgicalfacilities.14Aproactive,aggressiveapproachtohypothermiapreventionandtreatmentearlyduringthecourseofcombatdamagecontrolsurgerywillhelpdecreasetheoverallbloodtransfusions,IVfluidusage,andoverallmortalityofcombatwounded.PROACTIVECAREDURINGROTARY-WINGTRANSPORTFROMLEVELIITOLEVELIIIOneareauniquetocombatdamagecontrolsurgeryistherotary-wingevacuationofpostoperativepatientstoalevelIIIfacilitytoundergocompletionoftheintensivecareunitresuscitationphaseofdamagecontrol.Agreatperilexistsduringthisevacuation.Hypothermiacanbeprofoundifmeasuresarenotundertakentoensurethermoregulation.Currently,mostpostoperativepatientsaretransferredwithwoolblanketsandpossiblyanoutershellconsistingofamodifiedbodybag.Convectivewarmingsystems(eg,BairHugger,ArizantHealthcareInc,10393West70thStreet,EdenPrairie,MN55344)havebeendocumentedtooptimizepreservationofbodywarmthinintrahospitaltransfers.15FUTURESOLUTIONSBloodAugmentationUnitsThefirststepinmaximizingthetreatmentofcoagulopathyincombatdamagecontrolpatientsistobringpersonnelwithexpertiseintothelevelIIsurgicalfacilities.Asinglebloodbankexpert(oradditionaltrainingofforwardsurgicalteampersonnelatamedicalcenterintheUnitedStates)couldprovideimmediateexpertiseindrawingandcrossmatchingfreshwholeblood(includingrapidHIVandhepatitisscreening).ThisindividualcouldalsoensuretheadequatestorageofPRBCsandfactorVIIa.Thesecondstep(theoptimalsituation)wouldbethecreationofaplatformforrefrigeratorsandfreezers.ThiscapabilitywouldallowforthestorageofadditionalPRBCsandfortheadventofbloodproductsatlevelIIfacilities.ThesebloodproductscouldincludeFFPandcryoprecipitate.AddingthecapabilitytotransfuseadequatePRBCs,factorVIIa,freshwholeblood,FFP,andcryoprecipitatewouldenablethelevelIIsurgicalfacilitiestoprovidetreatmentofdamagecontrolcoagulopathyatthelevelofacivilianlevelItraumacenter.UniversalHypothermiaPreventionandTreatmentMeasuresTheuseofconvectivewarmingsystemsandIVfluidwarmerscanmakethemostimmediateimpactonthermoregulationincombatdamagecontrolpatientsatlevelIIsurgicalfacilities.Convectivewarmingsystems(eg,BairHugger)havebeendemonstratedtohelpmaximizebodycoretemperaturepreservationintraumapatientsandinpatientsundergoinganoperation.16-19Thesesystemscanbeutilizedtowarmpatientsinpreoperativeholding,intheoperatingroom,andpostoperatively.

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JanuaryMarch20075BloodandIVfluidwarmersprovidetheabilitytomaximizeandwarminfusionvolumes.Fluidwarmershavebeendocumentedtohelpmaintainbodytemperatureinsurgicalandtraumapatients.20Theuseofarapidinfusionwarmingdevicehasbeendocumentedtodecreasetheoverallbloodandfluidrequirementsintheseverelywoundedtraumapatient,againamajorbenefitforourlogisticallychallengedfar-forwardsurgicalplatforms.21TheBelmontFMS-2000(BelmontInstrumentCorp,780BostonRoad,Billerica,MA01821)hasbeenshowntohavemaximalfluidheatingcapability.22Together,convectivewarmingsystemsandIVblood/fluidwarmersofferoptimalcorebodypreservation.23ThesemodalitiesshouldbeuniversallyavailabletoalllevelIIsurgicalfacilities.UniversalRotary-WingTransportCapabilitiesTheproactive,earlyuseofthermallayersinconjunctionwithaconvectivewarmingsystemwillhelpensurepreservationofbodytemperatureinrotary-wingtransportofpostoperativepatients.Testingandapprovalofthesedevicesforuseinhelicopterswouldbethefirststep.Makingtheavailabilityanduseoftheseactivewarmingdevicesuniversalinallrotary-wingedmedicalevacuationaircraftwithinallserviceswouldbeamajorstepinminimizingbodyheatlossduringtransport.CONCLUSIONPerhapsthemostimportantareafordecreasingthedied-of-woundsratesinourcombatwoundedwhoreachafacilitywithsurgicalcapabilitylieswithimprovingcombatdamagecontrolsurgery.24The2areasthatprovidethegreatestimprovementpotentialincludethetreatmentandpreventionofhypothermiaandcoagulopathy.AlleffortsmustbemadetoimproveuniversalmeasurestoimprovetheseareasinlevelIIsurgicalfacilities.Ourproactiveeffortswillberewardedwithadecreasedmortalityinourcombatwounded.REFERENCES 1.Merriam-WebstersCollegiateDictionary.11thed.Springfield,MA:Merriam-Webster,Inc;2003.2.ShapiroM,JenkinsD,SchwabCW,etal.Damagecontrol:collectivereview.JTrauma.2000;49:969-978.3.AokiN,WallMJ,DemsarJ,etal.Predictivemodelforsurvivalattheconclusionofadamagecontrollaparotomy.AmJSurg.2000;180(6):540-544.4.MurrayDJ,PennellBJ,WeinsteinSL,OlsonJD.Packedredcellsinacutebloodloss:dilutionalcoagulopathyasacauseofsurgicalbleeding.AnesthAnalg.1995;80(2):336-342.5.ComoJJ,DuttonRP,ScaleaTM,EdelmanBB,HessJR.Bloodtransfusionratesinthecareofacutetrauma.Transfusion.2004;44(6):809-813.6.HirshbergA,DugasM,BanezEI,ScottBG,WallMJJr,MattoxKL.Minimizingdilutionalcoagulopathyinexsanguinatinghemorrhage:acomputersimulation.JTrauma.2003;54(3):454-463.7.ZhangJN,WoodJ,BergeronAL,etal.Effectsoflowtemperatureonshear-inducedplateletaggregationandactivation.JTrauma.2004;57(2):216-223.8.AsensioJA,McDuffieL,PetroneP,etal.Reliablevariablesintheexsanguinatedpatientwhichindicatedamagecontrolandpredictoutcome.AmJSurg.2001;182(6):743-751.9.TyburskiJG,WilsonRF,DenteC,SteffesC,CarlinAM.Factorsaffectingmortalityratesinpatientswithabdominalvascularinjuries.JTrauma.2001;50(6):1020-1026.10.CushmanJG,FelicianoDV,RenzBM,etal.Iliacvesselinjury:operativephysiologyrelatedtooutcome.JTrauma.1997;42(6):1033-1040.11.HoytDB,BulgerEM,KnudsonMM,etal.Deathintheoperatingroom:ananalysisofamulticenterexperience.JTrauma.1994;37(3):426-432.12.KrishnaG,SleighJW,RahmanH.Physiologicalpredictorsofdeathinexsanguinatingtraumapatientsundergoingconventionaltraumasurgery.AustNZJSurg.1998;68(12):826-829.13.JohnsonJW,GraciasVH,SchwabCW,etal.Evolutionindamagecontrolforexsanguinatingpenetratingabdominalinjury.JTrauma.2001;51(2):261-269.14.BernabeiAF,LevisonMA,BenderJS.Theeffectsofhypothermiaandinjuryseverityonbloodlossduringtraumalaparotomy.JTrauma.1992;33(6):835-839.15.ScheckT,KoberA,BertalanffyP,etal.Activewarmingofcriticallyilltraumapatientsduringintrahospitaltransfer:aprospective,randomizedtrial.WienKlinWochenschr.2004;116(3):94-97.16.PatelN,SmithCE,KnapkeD,PinchakAC,HagenJF.Heatconservationvsconvectivewarminginadultsundergoingelectivesurgery.CanJAnaesth.1997;44(6):669-673.

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6ArmyMedicalDepartmentJournal17.KoberA,ScheckT,FulesdiB,etal.Effectivenessofresistiveheatingcomparedwithpassivewarmingintreatinghypothermiaassociatedwithminortrauma:arandomizedtrial.MayoClinProc.2001;76(4):369-375.18.PatelN,SmithCE,KnapkeD,PinchakAC,HagenJF.Heatconservationvsconvectivewarminginadultsundergoingelectivesurgery.CanJAnaesth.1997;44(6):669-673.19.BormsSF,EngelenSL,HimpeDG,SuyMR,TheunissenWJ.BairHuggerforced-airwarmingmaintainsnormothermiamoreeffectivelythanthermo-liteinsulation.JClinAnesth.1994;6(4):303-307.20.SmithCE,GerdesE,SwedaS,etal.Warmingintravenousfluidsreducesperioperativehypothermiainwomenundergoingambulatorygynecologicalsurgery.AnesthAnalg.1998;87(1):37-41.21.DunhamCM,BelzbergH,LylesR.Therapidinfusionsystem:asuperiormethodfortheresuscitationofhypovolemictraumapatients.Resuscitation.1991;21(2-3):207-227.22.DubickMA,BrooksDE,MacaitisJM,BiceTG,MoreauAR,HolcombJB.Evaluationofcommerciallyavailablefluid-warmingdevicesforuseinforwardsurgicalandcombatareas.MilMed.2005;170(1):76-82.23.SmithCE,DesaiR,GloriosoV,CooperA,PinchakAC,HagenKF.Preventinghypothermia:convectiveandintravenousfluidwarmingversusconvectivewarmingalone.JClinAnesth.1998;10(5):380-385.24.BlackbourneLH,HolcombJB.CanweprovidelevelIIIdamagecontrolproceduresatalevelIIfacility?.ArmyMedDeptJ.2005;AprJun:62-65.AUTHORS LTCBlackbourneistheTrauma,Burn,andSurgicalCriticalCareSurgeonattheInstituteofSurgicalResearch,BrookeArmyMedicalCenter,FortSamHouston,Texas.CPTMcMullinisathirdyearGeneralSurgeryResidentattheBrookeArmyMedicalCenter,FortSamHouston,Texas.COLEastridgeisChiefofTraumaService,BrookeArmyMedicalCenter,FortSamHouston,Texas.COLBaskinisAssistantChief,TraumaandCriticalCare,TraumaDivision,USArmyInstituteofSurgicalResearch,andtheAssistantProgramDirector,SurgicalCriticalCareFellowship,attheBrookeArmyMedicalCenter,FortSamHouston,Texas.COLHolcombisCommander,InstituteofSurgicalResearch,BrookeArmyMedicalCenter,FortSamHouston,Texas,andTraumaConsultanttoTheArmySurgeonGeneral.AggressiveProactiveCombatDamageControlSurgery 2006SpurgeonNeelWritingCompetitionWinnerMichaelHinton,ExecutiveVice-PresidentoftheArmyMedicalDepartmentMuseumFoundation,hasannouncedthatCOLStephenC.CraigoftheUniformedServicesUniversityoftheHealthSciences(USUHS)inBethesda,MD,hasbeenselectedasthewinnerofthe2006SpurgeonNeelWritingCompetition.COLCraig,aprofessorattheUSUHS,istheArmyMedicalDepartmentConsultantinMedicalCorpsHistory.ThearticlebyCOLCraig,titledTheEvolutionofPublicHealthEducationintheUSArmy,1893-1966,appearedintheApril-June2006issueoftheAMEDDJournal.ThearticletracesthebeginningofpreventivemedicinegraduateeducationintheUSArmy,anditsevolutionthroughtheyearsintowhatistodaytheoldestpostgraduatemedicaleducationprograminthemilitary.AstheNeelWritingAwardwinner,COLCraigwillreceivea$500monetaryprizeandacommemorativemedallion.EachyeartheArmyMedicalDepartmentMuseumFoundationpresentstheSpurgeonNeelWritingAwardtotheauthoroftheAMEDDJournalarticlewhichbestexemplifiesthehistory,legacy,andtraditionsoftheArmyMedicalDepartment.

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JanuaryMarch20077INTRODUCTIONAstherateforthosekilledinactionhasdecreased,thediedofwoundsratehasunderstandablyincreased.Improvingthemortalityrateofpatientsundergoingdamagecontrolsurgicalproceduresisthelargestsingleareawithinwhichwecandecreasemortalityofinjuredmilitarypersonnelinthenearfuture.Ourgoalshouldbetoraisethecapabilitiesoffar-forwardsurgicalfacilities(levelIIb)tothoseofcivilianlevelItraumacentersinthemanagementofdamagecontrolpatients.OnreviewofcapabilitiesofcivilianlevelItraumacentersandmilitarylevelIIIfacilities,onesignificantareathatcouldbeimprovedisbloodproductavailability.1Currently,theUSArmyForwardSurgicalTeam(FST)istheArmyslevelIIbfacility.Duetothenecessityofhighmobilityassociatedwithclinicalausterity,FSTsonlycarrypackedredbloodcells(PRBCs).Duetologisticconsiderations,FSTsdonotcarryanyotherbloodcomponentslikefreshfrozenplasma(FFP),cryoprecipitate(cryo),orplatelets(PLTs).2Whilethefuturemayseeintroductionoffreeze-driedcomponents(platelets/plasma)thataremoreeasilystockpiledandstored,atthemomentthemilitarymedicalsystemsshouldbeabletoprovidesomecombinationofstandardcomponenttherapyandasystemoftakingthebloodbanktoalllevelsofthebattlefieldwheresurgeryisexpectedtooccur.WHYISBLOODAVAILABILITYIMPORTANT?Onaverage,thecivilianandcombatdamagecontrolpatientreceivesbetween8and12unitsofPRBCs.3,4Inciviliantraumapatientsthereisasevereinjurysubsetofdamagecontrolpatientswhoreceiveover20unitsofPRBCsandciviliantraumacentersarereportingimprovedsurvivalinpatientsreceivingmorethan50PRBCsinthefirst24hours.5,6Comparingthesenumberswiththe20to50unitsofPRBCscarriedbymostofourdeployedFSTsleadsonetoconcludethatentirebloodsupplycanbeexhaustedin2hourswith1or2damagecontrolpatients(eg,alldamagecontrollaparotomiesshouldbelessthan90minutesinduration,andFSTshave2operatingroomtables).7InamasscasualtysituationtheFST,bynecessity,willhavetogointoaminimalacceptableresuscitationmode,essentiallytriagingbloodsupplies.8,9Bydefault,thesedamagecontrolpatientswillbeunder-resuscitated.Inadequateresuscitationofadamagecontrolpatientcanleadtoworseningofthepatientsacidosis.Acidosisandtheoftenconcomitanthypothermiaworsenthecoagulopathyseenindamagecontrolpatients.10Thecoagulopathyleadstomorebleedingwhichcausesmoreacidosisandtheviciouscycleofthelethaltriadacidosis,hypothermia,andcoagulopathycontinues,eventuallyculminatinginexsanguination.WHYAREBLOODPRODUCTSIMPORTANT?Coagulopathyandacidosisarebothpredictivefactorsfordeathafterdamagecontrolsurgery.11Packedredbloodcellsdonotcontainclottingfactorsorplatelets.Clottingfactors,cryoprecipitate,andplateletsarefrequentlynecessaryfordamagecontroloperationsbutrequirespecialstorageconsiderations.Plateletsarestoredatroomtemperatureandhaveanaverage5-daystoragelifeafterprocessing.12Clottingfactors(FFP/Cryo)arestoredat-30oCandthawedbeforetransfusion.Inthesettingofadamagecontrolprocedureormassiveresuscitation(definedas10ormoreunitsofbloodin24hours),transfusingonlyPRBCswillnotonlyfailtocontrolcoagulopathyorrestoreplatelets(thrombocytopenia),butalsocanworsenthecoagulopathyandthrombocytopeniathroughdilutionofexistingclottingfactorsandplateletsinthepatientssystem.13-15TheBloodAugmentationTeamLTCLorneH.Blackbourne,MC,USAMAJJeremyPerkins,MC,USACPTNeilMcMullin,MC,USACOLBrianEastridge,MC,USACOLJohnB.Holcomb,MC,USA

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8ArmyMedicalDepartmentJournalOver90%ofciviliandamagecontrolpatientsreceiving10ormoreunitsofPRBCsalsoreceiveFFP,andthemajorityreceiveplatelettransfusions.16TheeffectsofFFPandplateletsaremaximizedifgivenearlyduringadamagecontrolsurgerytostopthecoagulopathicprocessbeforeitfeedsintothelethaltriad.17Thisconcepthasbeendescribedashemostaticresuscitation.ThecurrentbloodreplacementstrategyofFSTsisespeciallyproblematicinaseveredamagecontrolpatientby(a)inadequateresuscitationandtheeffectofdefaultacidosisoncoagulopathy,and(b)dilutionofclottingfactorsandplateletsbythetransfusionofPRBCsandcrystalloidalone.TwocurrentoptionsforFSTstocontrolcoagulopathyinvolvetheuseofintravenousFactorVIIaandfreshwholeblood.18FactorVIIaisnotuniversallyavailabletotheFSTs.Thereisnouniversaldonorforwholebloodbecausethisproductcontainsbothplasmaandredcells.WholebloodmustbeABOcompatibleandtransfusingwholebloodwiththewrongbloodtypecanresultinafatalreaction.19,20WhilemostlevelIIbsiteshaveperformedfreshwholebloodtransfusions,itisextremelychallengingtodraw,checkforinfectiousagents,andcross-matchwholebloodduringadamagecontroloperation.TheabilitytodrawfreshwholebloodisevenmoredifficultduringmasscasualtysituationswiththelimitedpersonnelofanFST.WhilethisischallengingevenforanestablishedFSTwithgoodlogisticalsupply,itwouldbeevenmoredifficultduringthemaneuverphaseofcombatwhenlinesofcommunicationarelesswellestablished.HOWCANWEGETBLOODANDBLOODPRODUCTSTOTHEFORWARDSURGICALTEAMS?TooptimizecombatdamagecontrolandtoprovidethecapabilityatlevelIIbsitestocorrecttheabnormalphysiologyofthesecriticalpatients,itisnecessarytorethinksomeofthesupportissues.InordertobringlevelIIbfacilitiesuptothecapabilitiesofacivilianlevelItraumacenter,FSTsmusthaveincreasedabilitytotransfuseFactorVIIa,FFP,cryo,andplatelets.IncreasedrefrigerationspacewillallowincreasedPRBCsstorage,thawedplasmastorage,andsafestorageoffactorVIIa.TheprovisionoffreezercapabilityandspacewillallowstorageofFFPandCryoprecipitate.Expertpersonneltrainedinthescienceofwholebloodacquisitionandcross-matchingwillallowthesafetransfusionofwholebloodforplateletreplacement.TransfusionofFFPandwholeblood,inadditiontoFactorVIIaearlyduringthedamagecontroloperationwillhelpproactivelycorrectthecoagulopathyoftheseverelyinjuredtraumapatient,andwillpotentiallydecreasethePRBCrequirementduetodecreasedcoagulopathicbleeding.Freshfrozenplasmahasashelfstoragelifeofapproximatelyoneyear.Oncethawed,theunitofFFPcanbekeptasthawedplasmafor5daysinarefrigerator.Overa5-dayperiodoftime,FactorVIIlevelsdecreaseto72%ofbaseline,FactorXdecreasestoonly80%ofbaseline,andthereisminimaldecreaseinfibrinogenlevels.21Thawedplasmaoffersseveralbenefitsovercrystalloidsolutionsinthetreatmentofhemorrhagingpatients.Firstandforemost,plasmawillreplacedepletedcoagulationfactors.Second,plasmaprovidesvolumeandexertsacolloideffect.DuringWorldWarIIandKorea,plasmawastheprehospitalresuscitationfluidemployedbythecombatmedic.22Third,plasmahasamorephysiologicelectrolyteprofilethancrystalloid.PlasmahasapHof7.2to7.4,comparedtothepHofnormalsaline(4.5to6.5),orRingerslactatesolution(6to7.0).Plasmaalsocontributessmallamountsofpotassium,glucose,lactate,andcalcium.ThecapabilitytostoreFFPandthawedplasmaatforwardlevelsofcarewillenhancetheabilityofthephysiciantoaggressivelytreatpatientswithcoagulopathyoftrauma.BLOODAUGMENTATIONTEAMBydesigntheFSTshavelimitedbloodandbloodproductoptions.Oneoptionforprovidingincreasedbloodavailabilityandbloodproductswouldbethecreationofahighlymobilemodularteamwithequipmentandexpertiseinbloodtransfusion.SuchateamcouldbenamedaBloodAugmentationTeam(BAT).PersonnelWeneedtolooknofurtherthanthebloodbanksatanyofoursurgicalfacilitiesintheUnitedStatestofindpersonneltrainedinthehandlingandstorageofbloodandbloodproducts.ThesepersonnelarealsoexpertsTheBloodAugmentationTeam

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JanuaryMarch20079indrawingblood,bloodcross-matching,andrapidtestingofwholebloodfortransfusion-transmittedinfections(HIVandHepatitis).OneortwopersonnelcouldfulfillallthebloodtransfusionneedsofanFST.Themedicallaboratoryspecialist(militaryoccupationalspecialty68K)performsbloodbankingproceduresandelementaryandadvancedexaminationsofbiologicalandenvironmentalspecimenstoaidinthediagnosis,treatment,andpreventionofdiseaseandothermedicaldisorders,accordingtoastructureofdefinedskilllevels:SkillLevel1.Performselementaryclinicallaboratoryandbloodbankingprocedures.SkillLevel2.Performselementarybloodbankingandclinicallaboratoryproceduresinhematology,immunohematology,biochemistry,serology,bacteriology,parasitology,andurinalysis.SkillLevel3.Performsadvancedproceduresinallphasesofbloodbankingandclinicallaboratorytestingincludingvirology,mycology,toxicology,andhistologyorsupervisessmallmedicallaboratory.SkillLevel4.Supervisesmediumsizemedicallaboratory.SkillLevel5.Superviseslargemedicallaboratoryactivities.MobilePlatformThefirstrequirementoftheBATwillbemobilitywhichmatchesthatoftheFSTs.Thiscouldbemetwithanarmoredwheeledvehicle(initiallyanarmoredHMMWV*).Thevehiclemusthaverefrigeration,freezers,andalloftheequipmentneededforfieldexpedientbloodcross-matchingandrapidtestingofwholeblood.Thesecomponentswouldrequirethecapabilitytogenerateelectricityforperiodsoftravelbetweensourcesofelectricity.ThenextrefinementwouldbethecapabilitytotransferthesecomponentsontoanyhelicopterorfixedwingaircraftthatmightbetransportingtheFST.CapabilitiesTheBATwouldhavethecapabilityofincreasedPRBCavailability.Itwouldalsohavethecapabilitytocross-matchandprovideFFP,Cryoprecipitate,platelets,andrFVIIa.WhiletheFSTpersonnelarefullyengagedduringamasscasualtysituation,theunitwouldhandlethedrawingandcross-matching/testingofwholebloodifneeded.Thebottomline:theBATcouldenhancethecapabilityoftheFSTtoperformcombatdamagecontrolsurgerytothelevelofacivilianlevelItraumacenterandtopotentiallyhelpdecreasethemortalityrateofthesepatients.IMMEDIATEFUTUREWhileitwilltaketimetocreateandtoaccumulatethecorrectequipmentfortheBloodAugmentationTeam,intheshorttermwecanenhancetheabilityofFSTstocorrectthecoagulopathyseenindamagecontrolpatientsbyaddingthawedplasmaandrFVIIatotheinventoriesofallfarforwardsurgicalplatforms.23-26TheadditiontotheFSTofasinglebloodbankSoldierwillallowsafestorageofallbloodandthesafedrawingandcross-matchingofwholeblood(thisconceptwasvalidatedinOperationEnduringFreedomin2002).CONCLUSIONTheBloodAugmentationTeamwillbringbankingexpertiseandmaterialtothebattlefield.Asmoreshelfstablebloodproductreplacementscomeintothearmentariumofthecombatphysicians,nurses,andmedics,theBloodAugmentationTeamwillhavetoevolve,providingadynamicplatformforrapidfieldingoftheseadvances.REFERENCES 1.BlackbourneLH,HolcombJB.CanweprovidelevelIIIdamagecontrolproceduresatalevelIIfacility?ArmyMedDeptJ.AprilJune2005:62-65.2.FieldManual8-10-25:EmploymentofForwardSurgicalTeams.Washington,DC:USDeptoftheArmy;30September1997.3.JohnsonJW,GraciasVH,SchwabCW,etal.Evolutionindamagecontrolforexsanguinatingpenetratingabdominalinjury.JTrauma.2001;51:261-271.4.SebestaJ,BeekleyA,etal.Damagecontrolsurgeryatthe31stcombatsupporthospital.Abstractpresentedat:27thAnnualGaryWrattenSurgicalConference,April25-27;ElPaso,TX:posterpresentationAAST2005. *Highmobilitymultipurposewheeledvehicle

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10ArmyMedicalDepartmentJournal5.VelmahosGC,ChanL,ChanM,etal.Istherealimittomassivebloodtransfusionafterseveretrauma?ArchSurg.1998;133(9):947-952.6.CinatME,WallaceWC,NastanskiF,etal.Improvedsurvivalfollowingmassivetransfusioninpatientswhohaveundergonetrauma.ArchSurg.1999;134(9):964-968.7.HirshbergA,ShefferN,BarneaO.Computersimulationofhypothermiaduring"damagecontrol"laparotomy.WorldJSurg.1999;23(9):960-965.8.HolcombJB,HellingTS,HirshbergA.Military,civilian,andruralapplicationofthedamagecontrolphilosophy.MilMed.2001;166(6):490-493.9.HirshbergA,HolcombJB,MattoxKL.Hospitaltraumacareinmultiple-casualtyincidents:acriticalview.AnnEmergMed.2001;37(6):647-652.10.MartiniW,PusateriA,UscilwiczJ,DelgadoA,HolcombJ.Independentcontributionsofhypothermiaandacidosistocoagulopathyinswine.JTrauma.2005;58:1002-1010.11.Perez-PujolS,ArasO,LozanoM,etal.Storedplateletscontainresidualamountsoftissuefactor:evidencefromstudiesonplateletconcentratesstoredforprolongedperiods.Transfusion.2005;45(4):572-579.12.CloonanCC.Treatingtraumaticbleedinginacombatsetting.MilMed.2004;169(12suppl):8-10,4.13.FriesD,KrismerA,KlinglerA,etal.Effectoffibrinogenonreversalofdilutionalcoagulopathy:aporcinemodel.BrJAnaesth.2005;95(2):172-177.14.MurrayDJ,PennellBJ,WeinsteinSL,OlsonJD.Packedredcellsinacutebloodloss:dilutionalcoagulopathyasacauseofsurgicalbleeding.AnesthAnalg.1995;80(2):336-342.15.ComoJJ,DuttonRP,ScaleaTM,EdelmanBB,HessJR.Bloodtransfusionratesinthecareofacutetrauma.Transfusion.2004;44(6):809-813.16.HirshbergA,DugasM,BanezEI,ScottBG,WallMJJr,MattoxKL.Minimizingdilutionalcoagulopathyinexsanguinatinghemorrhage:acomputersimulation.JTrauma.2003;54(3):454-463.17.AokiN,WallMJ,DemsarJ,etal.Predictivemodelforsurvivalattheconclusionofadamagecontrollaparotomy.AmJSurg.2000;180(6):540-545.18.HolcombJB,HootsK,MooreFA.TreatmentofanacquiredcoagulopathywithrecombinantactivatedfactorVIIinadamage-controlpatient.MilMed.2005;170(4):287-290.19.McManigalS,SimsKL.IntravascularhemolysissecondarytoABOincompatibleplateletproducts.Anunderrecognizedtransfusionreaction.AmJClinPath.1999;111(Feb):202-206.20.LundbergWB,McGinnissMH.Hemolytictransfusionreactionduetoanti-A.Transfusion.1975;15(1):1-9.21.OShaughnessyDF,AtterburyC,BoltonMaggsP,etal.Guidelinesfortheuseoffresh-frozenplasma,cryprecipitateandcryosupernatant.BrJHaematol.2004;126(Jul):11-28.22.KendrickDB.BloodPrograminWorldWarII.Washington,DC:USDeptoftheArmy,OfficeoftheSurgeonGeneral;1964.23.LynnM,JeroukhimovI,KleinY,MartinowitzU.Updatesinthemanagementofseverecoagulopathyintraumapatients.IntensiveCareMed.2002;28(suppl2):s241-s247.24.MartinowitzU,MichaelsonM.TheIsraeliMultidisciplinaryrFVIIaTaskForce.GuidelinesfortheuseofrecombinantactivatedfactorVII(rFVIIa)inuncontrolledbleeding:areportbytheIsraeliMultidisciplinaryrFVIIaTaskForce.JThrombHaemostasis.2005;3(4):640-648.25.HaanJ,ScaleaT.AJehovah'sWitnesswithcomplexabdominaltraumaandcoagulopathy:useoffactorVIIandareviewoftheliterature.AmSurg.2005;71(5):414-415.26.MartinowitzU,ZaarurM,YaronBL,BlumenfeldA,MartonovitsG.Treatingtraumaticbleedinginacombatsetting:possibleroleofrecombinantactivatedfactorVII.MilMed.2004;169(12suppl):16-18,4.AUTHORS LTCBlackbourneistheTrauma,Burn,andSurgicalCriticalCareSurgeonattheInstituteofSurgicalResearch,BrookeArmyMedicalCenter,FortSamHouston,Texas.MAJPerkinsisaHematologist-OncologistattheWalterReedArmyMedicalCenter,Washington,DC.CPTMcMullinisathirdyearGeneralSurgeryResidentattheBrookeArmyMedicalCenter,FortSamHouston,Texas.COLEastridgeisChiefofTraumaService,BrookeArmyMedicalCenter,FortSamHouston,Texas.COLHolcombisCommander,InstituteofSurgicalResearch,BrookeArmyMedicalCenter,FortSamHouston,Texas,andTraumaConsultanttoTheArmySurgeonGeneral.TheBloodAugmentationTeam

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JanuaryMarch200711 OptimizingTransportofPostoperativeDamageControlPatientsintheCombatZoneLTCLorneH.Blackbourne,MC,USALTCKurtGrathwohl,MC,USACOLBrianEastridge,MC,USACOLDavidL.MacDonald,MS,USACOLJohnB.Holcomb,MC,USAINTRODUCTIONOneareaofpotentialimprovementinmortalityinthecombatzoneisthepatientundergoingdamagecontrolatalevelIIb(eg,ForwardSurgicalTeam)orlevelIIIsurgicalfacility.1Onemajordifferencebetweendamagecontrolsurgeryintheciviliantraumacentersandmilitarycombatdamagecontrolsurgeryistheairevacuationaftertheabbreviatedoperationofthedamagecontroltrilogyatmilitarysurgicalfacilities.AnothermajordifferenceisthatcombatdamagecontrolpatientsatlevelIIareoftennotoptimallyresuscitatedduetolimitedbloodsupplyandlackofstoredbloodproducts(eg,freshfrozenplasmaandplatelets).2,3Thelethaltriadofhypothermia,acidosis,andcoagulopathyrepresentthegreatestchallengetopostoperativecombatdamagecontrolpatientsundergoingrotary-wingairevacuation.4Currently,veryfewinterventionsarepossibleduringhelicoptertransportofthesecriticallyinjuredpatientsduetowidevariationsinpersonnel,personneltraining,helicoptersetup,andinflightconditions.DeLorenzostatedin1997thatImprovedcombatcasualtycareandbattlefieldsurvivalmaybepossiblebyincreasingboththenumberandtrainingofthemedicalattendantsonArmyaircraft.5ThecombatsurgeonoftenhopesthatthepatientwillarrivealiveatthelevelIIIfacilitywithoutirreversiblephysiologicperturbationstoundergocompletionoftheresuscitationphaseofdamagecontrol.Optimizationofthesecriticallyillpatientsduringtransportisanimportantstrategytoincreasesurvivalonthebattlefield,replacinghopewithcapability.CURRENTCOMBATAIREVACUATIONSCurrently,militarydoctrinedictatesseveralvariable,nonstandardplatformsforintratheaterairevacuationofseverelyinjuredpostoperativedamagecontrolpatients(travelingfromlevelIItolevelIIIorlevelIIItolevelIII),mostcommonlyUH-60Blackhawk,CH-47Chinook,orCH-46SeaStallionhelicopters.Medicalcrewmembersintheaircraftlikewisevaryintrainingandexperience,typicallyanArmy68WMedicorNavyCorpsman(usuallyEMTB).6LargerMarineCorpsaircraftmightalsoincludeflightnurses.Personneltraining,experience,andcapabilitiesvarywidely,notonlybetweenunits,butalsoamongstservices.MonitoringwiththePROPAQ(WelchAllyn,Inc,8500SWCreeksidePlace,Beaverton,OR97008)equipmentisnoninvasivebutissignificantlylimitedbyaircraftconfigurationsandcombatlogistics.Thermoregulationiscurrentlymaximizedbyusinganumberofcommercialandimprovisedmethods,suchasplacingthepatientinamodifiedbodybagwith2woolblankets,andareflectiveblanket.CURRENTCIVILIANTRANSPORTOFCRITICALPOSTOPERATIVEPATIENTSTransportofcriticallyillpatientsafterdamagecontrolsurgeryinalevel1traumacenterusuallyinvolvesintrahospitaltransport,includingmovementtoaradiologysuite(eg,computedtomographyorinterventional).Ataminimum,transporttypicallyinvolvesescortbyacriticalcarenurseandrespiratorytherapist.Ifthepatientisgoingtotheoperatingroom,acertifiedregisterednurseanesthetist(CRNA)and/orananesthesiologistwillalsoaccompanythepatient.

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12ArmyMedicalDepartmentJournalCivilianhelicopterairambulancecrewstransportingcriticallyinjuredpatientsusuallyincludeacombinationofatleast2heathcareproviders,usuallyincludingaparamedic(EMT-P)teamedwitharegisterednurse,respiratorytherapist,anotherparamedic,oraphysician.DEFININGOPTIMALCONDITIONSFORROTARY-WINGTRANSPORTOFPOSTOPERATIVEDAMAGECONTROLPATIENTSWhendefiningtheoptimalpersonnelandequipmentfortransportingpostoperativepatients,thefirststepistodefinethepotentialcomplicationsandrisksthatcouldariseinflight,placingthetransportedpatientatriskforinjuryordeath.RISKSTOPOSTOPERATIVEPATIENTSDURINGAIREVACUATIONThefollowingarepotentialrisks,somecatastrophic,totheseverelyinjuredandventilatordependentpostoperativedamagecontrolpatientduringhelicopterairevacuation:SevereHypothermia.Hypothermia(especiallycorebodytemperature<34C)isamarkerandpredictorofdeathafterdamagecontrollaparotomyandisassociatedwithincreasedbleeding,bloodtransfusion,andintravenousfluidrequirements.7-12TheimportanceofpreventionandameliorationofhypothermiaenroutetoalevelIIIfacilitycannotbeoverstressed.Currently,temperatureisnotmonitoredinflightduringpatienttransport.Exsanguination.Patientswithavascularshuntinplaceoraguillotineamputationcanhavecatastrophicresumptionofarterialhemorrhagewithamisplacedshuntorblowoutofarterialclotandligature.Continuedcoagulopathictruncalbleedinginthepostoperativedamagecontrolpatientisthenormandnottheexception,especiallyifthepatienthasnotreceivedanycoagulationfactors,factorVIIa,orwholeblood.13LackofAdequateMonitoringDuringFlight.Thepostoperativedamagecontrolpatientrequiresminute-to-minutemonitoringofheartrate,oxygensaturations,andbloodpressure.Leadplacementmalfunction,inadequatebatteryrecharge,andmonitormechanicalfailurecanallresultininadequateorcompletelackofinflightpatientmonitoring.Inadequateviewofthemonitorbyaccompanyingmedicalpersonnelresultsininadequatemonitoring.LossofAirwayorEndotrachealTube.Lossofthepatientsairwayordislodgementofanendotrachealtubeisalwaysapossibility,especiallywithpatientmovementandtheerratichelicoptermovementoftennecessaryinacombatzone.AirwaymanagementandtherateofsuccessfulintubationareclearlydocumentedtobedirectlyrelatedtotheamountoftrainingobtainedattheEMTlevel.6,14,15LossofIntravenousAccess.Lossofcentralorperipheralintravenousaccessduringairevacuationcouldbelifethreateningtoapatientrequiringinflightfluid/bloodreplacementorfrombloodlossfromdisconnectedIVtubing.VentilatorMalfunction.Ventilators,likeallmachines,arepronetomalfunction,especiallythoseexposedtodustandtemperatureextremes.Inadequatebatterychargelevelcan,ofcourse,alsocauseaventilatortoceaseoperating.SymptomaticPneumothorax.LevelIIfacilitiesdonothavethecapabilitytoperformroutinepostoperativechestx-rays.Aclinicallysignificantpneumothoraxcanbedelayeduntilthepatientisairborne(especiallywithgasexpansionataltitudeinafixed-wingaircraft).Thisconditioncanbeextremelyconfusingtodiagnoseandtreat,especiallyifthepatienthasmultiplepotentialsourcesofhypoxiaand/orhypotension.InadequateSedation/Analgesia.Intravenoussedationandanalgesia,acontinuousprocess,includesobservationandtimelyadministrationofsedative/painmedicationswhich,ifnotadequate,canresultinpatientself-extubationandremovaloflife-sustaininglines,tubes,etc.Thiscanbealethalcomplicationduringflight.Inadequatesedationandrecallcouldcontributetoposttraumaticstressdisorderintraumapatients.16InadequateOxygenSupply.TherearereportsofventilatedpatientsarrivingatalevelIIIfacilitywithouthavingreceivedoxygensupplementationduetoinadequateoxygensupplyontherotary-wingaircraft.InadequateoxygensupplycanbeofgreatOptimizingTransportofPostoperativeDamageControlPatientsintheCombatZone

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JanuaryMarch200713significancetotheoxygendependent,severelyinjured,ventilatedpostoperativedamagecontrolpatient.OPTIMALCRITICALCAREANDCONTINGENCYPLANSFORINFLIGHTCOMPLICATIONSSevereHypothermia.Multiplelayers,asrepresentedbythebodybag/woolblanket/reflectiveblanketcombination,havebeendocumentedasaneffectivemeanstopreservebodyheat.17Theadditionofaconvectiveheatingdevicehasbeendocumentedasprovidingoptimalbodyheatpreservationintransportedandperioperativepatients.18-21Optimalthermoregulationofpatientstransportedinahelicoptermaybeobtainedwiththetesting(forhelicoptersafety)andapprovaloftheuseofaconvectivewarmingsystem(eg,BairHugger,ArizantHealthcareInc,10393West70thStreet,EdenPrairie,MN55344)withintheinsulatinglayers,orthecombinationofmultiplelayers,skullcap,anduseofachemicalheatgeneratingdevice(HypothermiaPreventionandManagementKitNSN#6515-01-532-8056).Exsanguination.Themajorityofpatientswhoarepostoperativefromadamagecontrolsurgeryarepackedandhavebeen(bylogisticnecessity)minimallyresuscitatedwithPRBCsandcrystalloidonly,andwillhavesomedegreeofcoagulopathicbleeding.3,13Overtime,thecumulativeeffectofthisbloodlossmaybeprofoundhypotensionandfurtherexacerbationofcoagulopathichemorrhage.TheabilitytoinfusefurtherPRBCsduringflightwillpotentiallyextendthedurationuntilirreversibleexsanguination.22Allmedicalpersonnelaccompanyingpatientswithextremitytemporaryintravascularshuntsinplaceorpostoperativeafteranamputationmustbetrainedintherapidapplicationoftourniquetsand,ofcourse,mustalsohaveimmediateaccesstoatourniquet.Optimally,patientswithatruncal(orproximalextremityvascularshuntnotamenabletotourniquetplacementproximally)temporaryintravascularshuntinplaceshouldbeaccompaniedbyasurgeonwithimmediateaccesstoavascularclamp.LackofAdequateMonitoringDuringFlight.Postoperativedamagecontrolpatientsneedcontinuousmonitoring.Lossofthismonitoringcouldbecatastrophicwhileairborne.Personnelmustbetrainedtocorrectanysmallmalfunctionsandredundancyshouldbebuiltintoinflightcapability(includingredundantelectricalsupply).Continuousbloodpressuremonitoringcanonlybeobtainedbyintra-arterialmonitoringandshouldbeincorporatedintothecareofalltransportedpostoperativedamagecontrolpatientsinthenearfuture,withredundancyprovidedbynoninvasivebloodpressurecuffmonitoring.LossofAirwayorEndotrachealTube.Personneltransportingintubatedpostoperativedamagecontrolpatientsmustbehighlytrainedinairwaymanagement.23Skillsshouldincludeexcellentbagmaskventilation,inflightreintubation,andcricothyroidotomy(surgicalairway).LossIntravenousAccess.Lossofintravenousaccessinthehypovolemicandhypotensivepostoperativepatientorthepatientwithfluidandvasopressordependencecouldbecatastrophic.Obtainingcommoninflightvenousaccessisextremelydifficult.Oneexcellentoptionforobtaininginflightvenousaccessisintraosseoussternalvenousaccess.Theseskillsandequipmentshouldbeavailabletoallpersonneltransportingthesepostoperativepatients.24,25VentilatorMalfunction.Ventilatormalfunctionduringflightcouldbecatastrophic.Personnelmonitoringthesepatientsmustbeabletodiagnoseventilatormalfunction(andhavearedundantelectricalsource),beabletotroubleshootthemachineand,asadefault,beabletohand-bagthepatient.Hand-baggingapatientcorrectly,especiallyonewithaheadinjury,canbeverydifficult.26TheadditionofendtidalCO2monitoringmayoptimizeventilatorandhand-baggingofpostoperativepatientsandshouldbeconsideredforthearmentariumofinflightmedicalaircrewpersonnelassoonaspossible.27SymptomaticPneumothorax.Diagnosingatensionpneumothoraxinapostoperativedamagecontrolpatientduringflightinahelicoptercanbeextremelydifficult.Lowsaturationsandahighpeakairwaypressureontheventilatormaybetheonlycluesavailableasinflightauscultationisnearlyimpossible.Medicalpersonnelaccompanyingthesepatientsshouldbetrainedinthediagnosisandtreatmentoftensionpneumothorax,includingneedledecompressionandchesttubeplacement.28InadequateSedation.Accompanyingmedicalpersonnelmustbetrainedinthesignsofinadequatesedationandadministrationofsedativemedications.

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14ArmyMedicalDepartmentJournalAdequatesupplyofsedativemedicationsmustbepartofapreflightmedicalchecklist.InadequateAnalgesia.Accompanyingpersonnelmustbetrainedinthesignsofinadequatepaincontrol,thecontinuousmonitoringforsignsofpain,andtimelyadministrationofintravenouspainmedications.Anadequatesupplyofsedativemedicationsmustbepartofapreflightmedicalchecklist.InadequateOxygenSupply.Adequateoxygenandanextravolumeofoxygenasaredundancyshouldbepartofeverypreflightmedicalchecklist.FUTUREOPTIMALTRANSPORTIntheperfectscenario,thepostoperativecombatdamagecontrolpatientwouldbetransportedbetweensurgicalfacilitiesinarotary-wingedaircraftwithcapabilitiesapproachingthatoftheUSAFCombatCasualtyAirTransportTeam,whichhasdemonstratedefficacyinthesafeout-of-theatertransportationofcriticallyinjuredmilitarypersonnelbyfixed-wingaircraft.29OPTIMALROTARY-WINGAIRCRAFTThepatientwouldbetransportedonanelevatedplatformwith360access.Thehelicoptercabinwouldbeshutandauxiliaryheaterswouldheatthecabin(currently,mosthelicoptersareflownwiththedoorsopentoallowfordoorgunnersecurity).Aconvectiveheatingsystem,wallsuction,andoxygenwouldbeavailablefromtheaircraft.Thehelicopterwouldbearmoredwithnewweight-limitedmaterial.ManyofthesecapabilitieswillbefoundintheHH-60L/M(newBlackhawkmedicalvariant).Untilanoptimalaircraftdesignatedforevacuationisfielded,itmaybenecessarytoapproachtheoptimalconditionswithadditionalmobilecomponentequipment.OPTIMALPERSONNELDuetoonboardspacelimitations,aCRNA,anesthesiologist,generalsurgeon,oremergencymedicinephysicianwouldberesponsiblefortheendotrachealtube,ventilator,andfluid/blood/vasopressoradministration.Thesepersonnelarethemostexperiencedatairwaymanagementandresuscitation.Ahighlytrainedregisterednurseorateamconsistingofahighlytrainedparamedicorflightmedictrainedspecificallyforinflightcomplications,accompaniedbyarespiratorytechnicianornurse,couldpotentiallyhavesimilarcapabilities.Thesenurses,flightmedics,and/orparamedicswouldneedextensiveairwayskillsandwouldneedsignificanttimeinspecifictrainingatafacilityintheUnitedStates.30Thesepersonnelwouldbeusedinthetransportionofonlycriticalpostoperativedamagecontrolpatients.OPTIMALEQUIPMENTTheoptimalequipmentforhelicopterevacuationwouldincludeaconvectivewarmingsystemforallpostoperativepatients.MonitoringwouldincludecontinuousintraarterialmonitoringandendtidalCO2analysis.StorageofPRBCsandafluidwarmersystemwouldbeavailable.Surgicalequipmentwouldbeavailableforneedledecompression,chesttubeplacement,andcricothyroidotomy.Ventilatorswouldhavethecapabilitytomeasurepeakairwaypressures.Intraosseousaccessequipmentwouldbeavailable.Preflightmedicalchecklistswouldensurebuilt-inmonitoring/batteryredundancyandadequateoxygensupplies,sedationmedications,andblood.CONCLUSIONSCurrentcapabilitiesofhelicoptermedicalcrewmembersandequipmenttransportingcriticallyinjuredpostoperativecombatdamagecontrolpatientsarelimited.Usingtheinexperiencedparamedicalproviderforthesolecareofthepatientdoesnotprovideoptimalcaretothosepatientswhoarethehighestacuitybattlefieldcasualties.REFERENCES 1.BlackbourneLH,HolcombJB.CanweprovidelevelIIIdamagecontrolproceduresatalevelIIfacility?ArmyMedDeptJ.AprilJune2005:62-65.2.FieldManual8-10-25:EmploymentofForwardSurgicalTeams.Washington,DC:USDeptoftheArmy;30September1997.3.HolcombJB,HellingTS,HirshbergA.Military,civilian,andruralapplicationofthedamagecontrolphilosophy.MilMed.2001;166(6):490-493.4.EddyVA,MorrisJAJr,CullinaneDC.Hypothermia,coagulopathy,andacidosis.SurgClinNAm.2000;80(3):845-854.OptimizingTransportofPostoperativeDamageControlPatientsintheCombatZone

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JanuaryMarch2007155.DeLorenzoRA.Militaryandcivilianemergencyaeromedicalservices:commongoalsanddifferentapproaches.AviatSpaceEnvironMed.1997;68(1):56-60.6.GerhardtRT,StewartT,DeLorenzoRA,etal.USArmyairambulanceoperationsinElPaso,Texas.PrehospEmerCare.2000;4:136-143.7.TyburskiJG,WilsonRF,DenteC,SteffesC,CarlinAM.Factorsaffectingmortalityratesinpatientswithabdominalvascularinjuries.JTrauma.2001;50(6):1020-1026.8.CushmanJG,FelicianoDV,RenzBM,etal.Iliacvesselinjury:operativephysiologyrelatedtooutcome.JTrauma.1997;42(6):1033-1040.9.HoytDB,BulgerEM,KnudsonMM,etal.Deathintheoperatingroom:ananalysisofamulticenterexperience.JTrauma.1994;37(3):426-432.10.AsensioJA,McDuffieL,PetroneP,etal.Reliablevariablesintheexsanguinatedpatientwhichindicatedamagecontrolandpredictoutcome.AmJSurg.2001;182(6):743-751.11.WangHE,CallawayCW,PeitzmanAB,TishermanSA.Admissionhypothermiaandoutcomeaftermajortrauma.CritCareMed.2005Jun;33(6):1296-1301.12.ShafiS,ElliottAC,GentilelloL.Ishypothermiasimplyamarkerofshockandinjuryseverityoranindependentriskfactorformortalityintraumapatients?Analysisofalargenationaltraumaregistry.JTrauma.2005;59(5):1081-1085.13.MurrayDJ,PennellBJ,WeinsteinSL,OlsonJD.Packedredcellsinacutebloodloss:dilutionalcoagulopathyasacauseofsurgicalbleeding.AnesthAnalg.1995Feb;80(2):336-342.14.BradleyJS,BillowsGL,OlingerML,BohaS,CordellW,NelsonDR.Prehospitaloralendotrachealintubationbyruralbasicemergencymedicaltechnicians.AnnEmergMed.1998;32:26-32.15.SingR,RotondoM,ZoniesD,et.al.Rapidsequenceinductionforintubationbyanaeromedicaltransportteam:acriticalanalysis.AmJEmergMed.1998;16:598-602.16.ParslowRA,JormAF,ChristensenH.AssociationsofpretraumaattributesandtraumaexposurewithscreeningpositiveforPTSD:analysisofacommunity-basedstudyof2085youngadults.PsycholMed.October2005;28:1-9.17.BrauerA,PerlT,UyanikZ,EnglishMJ,WeylandW,BraunU.Perioperativethermalinsulation:minimalclinicallyimportantdifferences?BrJAnaesth.2004;92(6):836-840.18.PatelN,SmithCE,KnapkeD,PinchakAC,HagenJF.Heatconservationvsconvectivewarminginadultsundergoingelectivesurgery.CanJAnaesth.1997;44(6):669-673.19.BormsSF,EngelenSL,HimpeDG,SuyMR,TheunissenWJ.Bairhuggerforced-airwarmingmaintainsnormothermiamoreeffectivelythanthermo-liteinsulation.JClinAnesth.1994;6(4):303-307.20.ScheckT,KoberA,BertalanffyP,AramL,AndelH,MolnarC,HoeraufK.Activewarmingofcriticallyilltraumapatientsduringintrahospitaltransfer:aprospective,randomizedtrial.WienKlinWochenschr.February16,2004;116(3):94-97.21.KoberA,ScheckT,FulesdiB,etal.Effectivenessofresistiveheatingcomparedwithpassivewarmingintreatinghypothermiaassociatedwithminortrauma:arandomizedtrial.MayoClinProc.2001;76(4):369-375.22.SampsonJB,DavisMR,MuellerDL,KashyapVS,JenkinsDH,KerbyJD.Acomparisonofthehemoglobin-basedoxygencarrierHBOC-201tootherlow-volumeresuscitationfluidsinamodelofcontrolledhemorrhagicshock.JTrauma.2003;55(4):747-754.23.SwansonER,FosnochtDE,BartonED.Airmedicalrapidsequenceintubation:howcanweachievesuccess?AirMedJ.2005;24(1):40-46.24.CalkinsMD,FitzgeraldG,BentleyTB,BurrisD.Intraosseousinfusiondevices:acomparisonforpotentialuseinspecialoperations.JTrauma.2000;48(6):1068-1074.25.DubickMA,KramerGC.Hypertonicsalinedextran(HSD)andintraosseousvascularaccessforthetreatmentofhaemorrhagichypotensioninthefar-forwardcombatarena.AnnAcadMedSingapore.1997;26(1):64-69.26.DavisDP,DunfordJV,PosteJC,etal.Theimpactofhypoxiaandhyperventilationonoutcomeafterparamedicrapidsequenceintubationofseverelyhead-injuredpatients.JTrauma.2004;57(1):1-8.27.DaveyAL,MacnabAJ,GreenG.ChangesinpCO2duringairmedicaltransportofchildrenwithclosedheadinjuries.AirMedJ.2001Jul-Aug;20(4):27-30.28.BartonED,EppersonM,HoytDB,FortlageD,RosenP.Prehospitalneedleaspirationandtubethoracostomyintraumavictims:asix-yearexperiencewithaeromedicalcrews.JEmergMed.1995;13(2):155-163.29.PiercePF,EversKG.Globalpresence:USAFaeromedicalevacuationandcriticalcareairtransport.CritCareNursClinNAm.2003;15(2):221-231.

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16ArmyMedicalDepartmentJournal30.CrommettJW,McCabeD,HolcombJB.Trainingforthetransportofmechanicallyventilatedpatients.RespirCareClinNAm.2002;8(1):105-111.OptimizingTransportofPostoperativeDamageControlPatientsintheCombatZone AUTHORSLTCBlackbourneistheTrauma,Burn,andSurgicalCriticalCareSurgeonattheInstituteofSurgicalResearch,BrookeArmyMedicalCenter,FortSamHouston,Texas.LTCGrathwohlistheAssistantChief,AnesthesiaandOperativeServices,BrookeArmyMedicalCenter,FortSamHouston,Texas.COLEastridgeisChiefofTraumaService,BrookeArmyMedicalCenter,FortSamHouston,Texas.COLMacDonaldistheDirectoroftheMedicalEvacuationProponencyDirectorate,FortRucker,Alabama,andistheAeromedicalEvacuationConsultanttoTheArmySurgeonGeneral.COLHolcombisCommander,USArmyInstituteofSurgicalResearch,BrookeArmyMedicalCenter,FortSamHouston,Texas,andTraumaConsultanttoTheArmySurgeonGeneral.COLBARRYMOOREANDMAJTERESABRININGERJOINTHEAMEDDJOURNALEDITORIALREVIEWBOARDTheAMEDDJournalwelcomesCOLBarryMoore,DC,USAandMAJTeresaBrininger,SP,USAasnewmembersoftheEditorialReviewBoard.COLMooreistheChief,DepartmentofDentalScience,AMEDDCenter&School,FortSamHouston,Texas.MAJBriningerisaResearchOccupationalTherapistattheArmyResearchInstituteofEnvironmentalMedicine,Natick,Massachusetts.COLMoorejoinstheBoardreplacingCOLThomasR.Cole,DC,USA.COLColeisanoriginalmemberoftheBoard,acceptinghispositioninNovember,1999.WethankCOLColeforhisdedicationtothehighstandardsandprofessionalqualityofthispublication,andhisyearsofserviceandsupporttoourmission.MAJBriningerreplacesLTCRachelEvans,SP,USAwhohasacceptedthepositionofDirector,AmputeeResearchProgramattheCenterfortheIntrepid,FortSamHouston,Texas.LTCEvanshasbeenamemberoftheEditorialReviewBoardsince2002.WethankLTCEvansforherdedicationandsupportoftheAMEDDJournalandcongratulateherforherprofoundlyimportantnewassignment.TheEditors

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JanuaryMarch200717INTRODUCTIONAtotalof286surgicalprocedureswereperformedbyasingleorthopaedicsurgeonduringa5-monthperiodatacombatsupporthospital(CSH)inIraq.Thevastmajorityofinjuriestreatedwerecombatrelatedgunshotwoundsandfragmentinjuriesfrommortarsandimprovisedexplosivedevices.Injuriestreatedincludedcontaminatedsofttissueinjuries,openfractures,openjoints,andtraumaticamputations.Over150procedureswereperformedonIraqisoldiers,detainees,andcivilianswhowouldreceivetheirdefinitivecareattheCSH,andwouldremainasinpatientsuntiltheirwoundswerehealedsufficientlyfordischarge.Initially,allextremitywoundsweretreatedwithsurgicalirrigationanddebridement,fracturestabilization,followedbytwicedailywettodrydressingchangesonthewards.Asthewarescalatedandthehospitalcensusincreasedto75patients,twicedailydressingchangesbecamelogisticallydifficult.Thedevelopmentofalternateformsofwoundmanagementwasnecessary.Vacuum-assistedclosure,initiallydevelopedinthe1990sforthemanagementoflarge,chronicallyManagementofTraumaticWarWoundsUsingVacuum-AssistedClosureDressingsinanAustereEnvironmentLTCM.ShaunMachen,MC,USA ABSTRACTObjective:Thestudywasundertakentodevelopaprotocolfortheongoingmanagementoftraumaticwarwoundsintheaustereenvironmentofacombatsupporthospital.Method:Atotalof286surgicalprocedureswereperformedbyasingleorthopaedicsurgeonduringa5-monthperiodatacombatsupporthospitalinIraq.Over150procedureswereperformedonIraqisoldiers,detainees,andcivilianswhowouldreceivetheirdefinitivecareatthecombatsupporthospital,andwhowouldremainasinpatientsuntiltheirwoundswerehealedenoughfordischarge.Initially,allextremitywoundsweretreatedwithsurgicalirrigationanddebridementfollowedbytwicedailydressingchangesonthewards.Asthewardcensusincreasedto75patients,itbecamenecessarytodevelopalternateformsofwoundmanagement.Fieldexpedientvacuum-assistedclosure(VAC)dressingswereinstituted.Thesedressingswerecreatedwithfluffsorprepsponges,suctiontubing,Ioband,andportablesuctionmachines.TheVACdressingswereleftinplacefor3to4daysandthenchanged.Traumatic,contaminated,andinfectedwoundswererapidlydebridedandgranulationtissuewasinduced.Theportablesuctionpumps,however,wereextremelynoisyandfailedwithcontinueduse.MachinesandspongesmanufacturedbyKCIInc.werepurchased.TheVACdressingbecameaninvaluabletoolformanaging,closing,andpreparingwoundsforskingrafting.Over50traumaticwarwoundsweretreatedwiththeVACdressing.Theclinicalcoursesof20ofthesewoundswerecarefullydocumentedwithdigitalphotography.Results:Over50traumaticwarwoundswereeffectivelytreatedwithinitialirrigationanddebridement,followedbyserialapplicationofVACdressings.VACdressingsrapidlydebridedcontaminatedwounds,reducededema,decreasedwoundsize,andinducedgranulationtissue.Woundswerethentreatedbydelayedprimaryclosure,localflapcoverage,orskingrafting.Conclusion:AneffectiveprotocolutilizingVACdressingswasdevelopedfortheexpeditioustreatmentoftraumaticwarinjuriesinanaustereenvironment.

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18ArmyMedicalDepartmentJournalinfectedwounds1hasmorerecentlybeenusedinthetreatmentoftraumaticwounds.2Themodalitycreatesawoundenvironmentofsubatmosphericpressurewhichreducesinterstitialfluids,removesdebris,contractsthewound,enhancesbloodflowtothewound,andpromotestheformationofgranulationtissue.TheVACdressingcanbeappliedintheoperatingroomafterdebridementandconvenientlyleftinplacefor3to4days.Thepurposeofthisstudywastodevelopawoundtreatmentprotocoltoeffectivelymanagealargenumberoftraumaticwarinjuriesinacombatenvironment.AfieldexpedientVACdressingwasinitiallyused,andlaterreplacedbycommercialV.A.C.ATSSystems(KineticConcepts,Inc.,SanAntonio,Texas)whentheybecameavailableinthemilitarysupplysystem.MATERIALSANDMETHODSTheinitialVACdressingsusedattheCSHwerecreatedfromavailablematerialsintheaustereenvironmentofacombatsupporthospital.Followingthoroughirrigation,debridement,andfracturestabilizationusuallywithanexternalfixatorafieldexpedientVACdressingwasapplied.AsshowninFigure1,thedressingwascreatedbyplacingeitherlapspongesoryellowpreparationkitspongesinthebaseofthewound.Theskinedgeswerecleanedanddefattedwithanalcoholwipe.Theendofastandardsuctiontubewasfenestratedwithholescreatedwithascalpelandwasplacedwithinthesponges.AnIobandadhesivedrapewasthenusedtocoverthespongesandwound,andamesenterywasformedaroundthetube.Thetubewasthenconnectedtoaportablebedsidesuctionmachineonlow,intermittentsuction.TheimprovisedVACsystemsworkedrelativelywell,butsomeproblemswereidentified.Inevitably,whentheyellowprepspongeswereusedtherewereareasofthewoundthatwerenotincontactwithasponge.Theseareasdevelopedamucinous,exudativeslimeoverthecourseof3days.Theimprovisedtubeswouldoccasionallybecomepluggedorcollapse,andthewoundswouldnotcontractaswellastheydowithonelarge,uniformspongepullingtheedgestogether.Thebiggestproblemsexperiencedinvolvedtheportablesuctionmachines.Themachineswereverynoisyanddisruptedthesleeppatternsofpatientspackedintotightwards.Woolblanketsandcardboardboxeswereplacedoverthemachinestoreducethenoise,butthiscontributedtooverheatingandthemachineswouldfail.Withhighambienttemperaturesandcontinuoususe,allofthemachineseventuallyfailed.OurabilitytouseVACdressingsbecamelimitedbythenonavailabilityofsuctionmachines.Assoonastheproblemwithsuctionpumpswasidentified,arushorderwasplacedtoKineticConcepts,Inc.for5V.A.C.ATSsystemsaswellasalargesupplyofblackspongesofvarioussizes.TheV.A.C.ATSisasubatmosphericpressuredevicethatusesamedicalgradereticulatedpolyurethaneethersterilefoamdressing,whichcontainsanembeddednoncollapsibleevacuationtube.Theporesizeofthespongeis400mto600m,whichhasbeenshowntomaximizetissueingrowth,3andthetubecontainssideportstoallowcommunicationofitslumentoallthespacesinthefoam.TheV.A.C.ATSpumpitselfhastechnologywhichallowsaccuratepressuresensing,adjustablepressureintensity,intuitivetouchscreens,filtersystemtominimizewoundodor,andquietoperation.Thearrivalofthismedicalequipmentgreatlyenhancedourabilitytoeffectivelytreateventhemostgruesomebattleinjuries.Aprotocolwasdeveloped:Allbattleinjuriesundergoinitialirrigationviapulsatilelavage,debridementofallforeignmaterialanddevitalizedtissue,andexternalfixationoffractures.Anattemptismadetopreservealllargefracturefragments,smallerfragmentswithsofttissueattachments,andtendons.AsterilegauzeManagementofTraumaticWarWoundsUsingVACDressingsinanAustereEnvironment Figure1.Afield-expedientVACdressingcreatedwithalapspongeandIoband.

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JanuaryMarch200719dressingisapplied.Onpost-opdayone,thepatientundergoesadressingchangeontheward,withKetaminesedationifnecessary.Onpost-opdaytwo,thepatientreturnstotheORforrepeatirrigationanddebridement,andplacementofawoundVAC.Thespongeistrimmedandshapedtocontactallwoundsurfacesallowingequaldistributionofthesubatmosphericpressuretoallsurfacesincontactwiththesponge(Figure2).Theskinalongtheedgesofthewoundiscleanedanddefattedwithalcohol,thenoncollapsibletubeisplaced,andthewoundsealedwithanadhesivedrapesuppliedwiththesponge(Figure3).Wearecarefultotrimbacktheedgesoftheadhesivedrape,whilestillmaintainingaseal,topreventabradedorfragmentinjuredskinfrombecomingexudative.Finally,thetubeisconnectedtothepumpandthesuctionadjustedtobetween50mmand125mmHg.Thepumpisturnedonandthedressingistestedtomakesurethatthespongecollapsesintothewound(Figure4).TheVACdressingisleftinplacefor3to4daysandiseitherchangedintheoperatingroomdependingonwhatotherproceduresareneeded,orchangedonthewardunderKetaminesedation.VACdressingsarechangedevery3to4daysuntilthewoundispreparedfordefinitiveclosure.Typicallythewoundcontractsasedemaisremovedandthewoundedgesarepulledtogether.Thewoundbecomesverycleanandfreeofexudativefluids.Vascularityisenhancedandbeefyredgranulationtissueforms(Figure5).Woundsarethenclosedeitherbydelayedprimaryclosure,localrotationalflaps,orsplitthicknessskingrafts,illustratedinFigure6.ThewoundVACwasusedonavarietyofupperextremity,lowerextremity,andeventorsowounds.Allwoundstreatedweresecondarytogunshot,fragmentation,orblast.TheVACwasplacedovermuscle,tendons,fasciotomysites,limbamputations,exposedbone(Figure7)andevenorthopaedichardware.Severalpatientswithinfectedstumps,resultingfromamputationswhichhadbeenperformedelsewhere,weretreatedwiththeVAC(Figure8).TheVACwasplacedonatleast50combatcasualties.ThecourseofwoundVACtherapyon20caseswasthoroughlydocumentedfrominitialwoundtofullyhealedwoundwithdigitalphotographicrecords.CASEILLUSTRATIONA43-yearoldIraqienemyprisonerofwarsustainedafragmentationinjurytohisleftnondominantelbow.Thefragmentationinjuryresultedinatype3Bolecranonfracturewithbonelossandextensivesofttissueinjury(Figure9).Thesofttissueinjuryinvolvedskinlossina10cmby20cmareainvolvingtheentire Figure2.Asterileblackfoamdressingiscuttofitthecontourofthewound. Figure3.TheVACspongeissealedintothewoundwiththeadhesivedrape. Figure4.Suctionisappliedtothespongeandtheadhesivedrapeistrimmedtominimizeskin

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20ArmyMedicalDepartmentJournalManagementofTraumaticWarWoundsUsingVACDressingsinanAustereEnvironment Figure5. Woundappearanceafter3daysofwound VACtreatment. Figure6.Oneweekafterapplicationofskingrafttowound. Figure7.Accumulationofgranulationtissueonexposedboneandhardware. Figure8.AVACspongeisappliedtotheresiduallimbofaninfectedabovethekneeamputation. Figure9. Type3Bolecranonfracturewithextensive softtissueandboneloss. Figure10.WoundVACinplace.

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JanuaryMarch200721posterioraspectofhiselbow.Thewoundwastreatedwithinitialpulsatileirrigationanddebridement.Thepatientwasreturnedtotheoperatingroom2dayslaterforrepeatirrigationanddebridementfollowedbyplacementofawoundVAC(Figure10).WoundVACtreatmentcontinuedfor12dayswithVACchangesevery4days.Onpost-injuryday14,thewoundhadahealthy,cleanappearance(Figure11).ThewoundVACtreatmenthadresultedinthereductionofedema,andtheformationofbeefyred,well-vascularized,granulationtissue.Asplitthicknessskingraftwasharvestedandplacedoverthewound(Figure12).Theskingraftwas100%successful.Thewoundhealedandthepatientwasdischarged.Thepatientreturnedforfollowup2monthsafterinjury.AsshowninFigure13,thewoundwascompletelyhealed.Thepatientwastakentotheoperatingroomandmanipulationunderanesthesiawasperformedtoincreaserangeofmotion.Afunctionalrangeofmotionwasachievedontheoperatingroomtable.RESULTSThewoundVACevolvedintoanextremelyusefulmodalityforthetreatmentofhigh-energycombatwounds.Theperiodoftimeduringwhichthisdevicewasusedwasoneofintensefightingandhighcasualtyrates.ThewoundVACwasappliedrapidly,eitherintheoperatingroomafterirrigationanddebridement,oronthewardwithKetaminesedation.TheVACdressingcouldthenbeleftinplacefor3or4days,greatlydiminishingtheneedforpainful,time-consumingdressingchangesandmultipletripstotheoperatingroom.WithonlyoneorthopaedicsurgeonassignedtotheCSHduringa5-monthperiod,thisdevicegreatlyincreasedproductivityandfreedthesurgeontoattendmorecriticalpatients.WoundVACtreatmentwasusedonover50patients.Digitalphotographywithdatesandtimeswereobtainedtodocumentstagesoftreatmentandhealingin20cases.Fourinfectedabove-kneeamputationstumpsweretreatedandeffectivelyclosedorskingraftedafterVACuse.Threeopenboth-boneforearmfracturessecondarytothroughandthroughgunshotwounds(GSW)wereplated,treatedwithwoundVAC,andskingrafted.FourType3Bopendistaltibia/fibulafracturessecondarytoGSWweretreatedwithexternalfixation,woundVAC,tibialshorteninginonecase,localrotationalflaporskingraft,andfinallybonegrafting(Figure14).Anopensubtrochantericfemurfracture,secondarytoGSW,withthighcompartmentsyndromewastreatedwithfasciotomy,fracturestabilizationwithaRushRod,90/90traction,woundVAC,anddelayedprimaryclosure.Thepatientwasdischargedtocrutchweightbearingafter3weeksoftraction.TwoopenproximalhumerusfracturesandFigure11.Woundappearanceafter12daysofVACtreatment. Figure12.Woundafterplacementofsplitthicknessskingraft. Figure13.Woundarea2monthsafterinjury.

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22ArmyMedicalDepartmentJournaloneopendistalhumerusfracturewerealleffectivelytreatedwithexternalfixationoropenreductioninternalfixationfollowedbywoundVACandskingrafting.AGSWtotheplantarsurfaceofthefoot,2largesofttissueinjuriestothethigh,andoneGSWtothebuttockwerealltreatedwithwoundVACfollowedbyhealingbysecondaryintention,ordelayedprimaryclosureandskingrafting.ProblemsassociatedwiththeearlierdescribedfieldexpedientVACdressingswereessentiallysolvedbytheV.A.C.ATSsystems.Aswedevelopedgreaterexpertiseintheuseofthesystem,welearned,especiallyinthecaseofamputations,tomakesurethatnoareasofdeadspaceexistedwhenthespongeswereplacedoverlargewounds.Wealsolearnedtoleavenoareaofrawwounduncoveredbyspongematerial.Suctionwasapplied,andthedressingwastrialedintheoperatingroom.Ifanareaofwoundwasuncovered,theadhesivedrapewouldbecut,asmallportionofspongewouldbeinsertedovertheexposedwound,andthedressingwouldberesealed.Macerationwouldoccurincaseswheretheadhesivedrapedidnotcompletelysealtotheskinonthebordersofthewound.Topreventthis,weusedalcoholtothoroughlyclean,defat,anddrytheskinpriortoapplicationofadhesivedrape.TheproblemsencounteredwiththeVACdressingwerereallyminimal.Moreoftenthannot,wewereamazedattheclean,healthyappearanceofthewoundswhenthedressingswereremoved.DISCUSSIONTreatmentofcombatrelatedorthopaedicwounds,whichareoftencomplicatedbylargeskinloss,devitalizedtissue,grosscontamination,openfractures,andinfectionsecondarytotreatmentdelay,iscomplicated.Thetreatmentdifficultyiscompoundedwhenthetreatmentmustoccurintheaustereenvironmentofacombattenthospital,inawarzone,withlimitedsupplies,andlargenumbersofpatients.Thispaperdescribesatechniquethatevolvedandaprotocolthatwasestablishedtoefficientlymanagethewoundcareoflargenumbersofcombatcasualties.TheV.A.C.ATSprovedextremelyvaluableinacceleratingthehealingof20documentedtraumaticwounds.Theabilitytoobtaineventualsofttissuecoverageinthewoundsstudiedwasattributedtoanumberofdifferentfactors:a.Becauseofthenegativepressureactingonthesponge,theinterstitialfluidsthataccumulatedinthesewoundswereevacuated.Thesefluidshavebeenfoundtocontaininhibitoryfactorssuchasinflammatorycytokinesandcollagenasesthatsuppresstheformationoffibroblasts,vascularendothelialcells,andkeratinocytesthatareprominentinwoundhealing.3-5b.Theevacuationofthesefluidseliminatestheformationofanysuperficialpurulenceandslimethatoccursinopenwounds.1Thisenhanceswoundhealingbyreducingthepotentialforanaerobiccolonization,anddecreasingbacterialcounts.6c.Studieshavedemonstratedthatanappliedsubatmosphericpressureresultsindecreasedcapillaryafterload.1,6Thisdecreasedafterloadallowsarteriolestodilate,increasingbloodflowtotheareafourfold.Increasedbloodflowproducesaproliferationofgranulationtissue.d.Thenegativepressurecreatedbythevacuumexertsamechanicalforcetothesofttissuesthatmakeuptheperipheryofawound.Unlikesuturesortensiondevices,theVACcanexertauniformforceoneachindividualpointontheedgeofawound,drawingittowardthecenterofthedefectbymechanicallystretchingthecellsviatheapplicationofnegativepressure.6e.Thelaborinvolvedandthepainassociatedwithfrequentwettodrydressingchangesisminimized.ManagementofTraumaticWarWoundsUsingVACDressingsinanAustereEnvironmentFigure14.Type3Btibiafracturesecondarytogunshotwound,treatedwithexternalfixation,woundVAC,tibialshortening,andlocalskinflap.

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JanuaryMarch200723WhileotherpublishedstudieshaveattemptedtoquantifywoundsizereductionwithVACtreatment,orhaveinvestigatedthecostsoftreatmentcomparedwithconventionalwoundcare,thisstudywasmoreobservationalinnature.Ourmeasureofasuccessfuloutcomewasachievingahealed,noninfectedwound,inanaustereenvironment,withlimitedsupplies,andthenonavailabilityofplasticsurgeons.Thisisthefirststudythatdescribestheuseofsubatmosphericdressingtechnologytotreathigh-energyballisticwoundsinacombatenvironment.WehaveshownthatVACsystemscanbesuccessfullyusedtotreatlargenumbersofpatientsinahighlyeffectiveandefficientmanner.ItisrecommendedthatV.A.C.ATSsystemsbecomepartoftheinventoryofallcombatsupporthospitalstaskedwithmanaginglargenumbersofcombatpatientsforextendedperiodsoftime.Subatmosphericpressuredressingsareanexcellentadjunctintheeffectiveandsafetreatmentofhigh-energy,combat,orthopaedicwounds.REFERENCES 1.ArgentaLC,MorykwasMJ.Vacuum-assistedclosure:anewmethodforwoundcontrolandtreatment.Clinicalexperience.AnnPlastSurg.1997;38:563.2.HerscoviciD,SandersRW,ScadutoJM,etal.Vacuum-assistedwoundclosure(VACtherapy)forthemanagementofpatientswithhigh-energysofttissueinjuries.JOrthopTrauma.2003;17:683-688.3.WakeMC,PatrickCW,MikosAG.Poremorphologyeffectsonthefibrovasculartissuegrowthinporouspolymersubstrates.CellTransplant.1994:3:339-343.4.GrinnellF,HoCH,WysockiA.Degradationoffibronectinandvitrocectininchronicwoundfluid.Analysisbycellblotting,immunoblotting,andcelladhesionassays.JInvestDermatol.1992;98:410-416.5.BucaloB,EaglsteinWH,FalangaV.Inhibitionofcellproliferationbychronicwoundfluid.WoundRepRegen.1993;1:181-186.6.MorykwasMJ,ArgentaLC,Shelton-BrownEI,etal.Vacuum-assistedclosure:anewmethodforwoundcontrolandtreatment.Animalstudiesandbasicfoundation.AnnPlastSurg.1997:38:553-561.AUTHOR LTCMachenisChiefofPediatricOrthopaedicsandAssistantChiefofOrthopaedicServicesattheWilliamBeaumontArmyMedicalCenter,FortBliss,Texas.

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24ArmyMedicalDepartmentJournalCausesofDeathinUSSpecialOperationsForcesintheGlobalWaronTerrorism:20012004COLJohnHolcomb,MC,USACAPTJamesCaruso,MC,USNHowardR.ChampionCPTNeilMcMullin,MC,USAMaryLawnick,RNCharlesE.Wade,PhDCOLWarnerFarr,MC,USALCDRLisaPearse,MC,USNMSGSammyRodriguez,USALynneOetjen-GerdesCAPTFrankButler,MC,USN ABSTRACTIntroduction:Effectivecombattraumamanagementstrategiesdependonanunderstandingoftheepidemiologyofdeathonthebattlefield,resultinginevidence-basedequipment,training,andresearchrequirements.Methods:AllSpecialOperationsForces(SOF)fatalities(combatandnoncombat)inOperationIraqiFreedom/OperationEnduringFreedom(OEF/OIF)fromOctober2001untilNovember2004werereviewed.Allavailableautopsyandtreatmentrecordsandphotographswereused.Inmostcases,theimmediatetacticalsituationwasunknown.Thereviewwasperformedbyamultidisciplinarygroupincludingforensicpathologists,anSOFcombatmedic,andtraumasurgeons.Fatalitieswereclassifiedashavingwoundsthatwereeithernonsurvivableorpotentiallysurvivablewithexistingtraining,equipment,andexpertiseonthebattlefield.Astructuredreviewwasperformedevaluatingtheneedfornewequipment,training,orresearchrequirements.ResultswerecomparedtoautopsydatafromVietnamandmodernciviliantraumacenterdata.ThestudywasapprovedbytheInstitutionalReviewBoardsoftheArmedForcesInstituteofPathologyandtheUSArmyInstituteofSurgicalResearch.Results:Duringthestudyperiod,82SOFfatalitieswereidentified.Autopsieswereperformedon77Soldiers.Fivecasualtiesdiedsecondarytoaircraftcrash,theirbodieswerenotrecoveredfromtheocean.Forthepurposesofthisstudytheywereconsiderednonsurvivable.Eighty-fivepercent(n=70)ofthefatalitiessustainedwoundsthatwerenonsurvivable,whiletheremaining15%(n=12)hadwoundsthatwerepotentiallysurvivable.InjurySeverityScore(ISS)washigherinthenonsurvivablegroup(p<0.05).Truncalhemorrhageaccountedfor47%ofdeathswhileextremityhemorrhageaccountedfor33%.Onecasualtywasnotedatautopsytohaveatensionpneumothoraxaswellasmultiplesourcesofinternalhemorrhage,onesufferedanairwaydeath,whileanotherdiedofsepsis56daysafterinjury.Ofthosecasualtiesdeemedtobenonsurvivable,therewere31patientswith40AbbreviatedInjuryScore(AIS)6injuries(p=.0011),and53patientswith104AIS5injuries.Amongthe12deathsdeemedtobepotentiallysurvivable,therewereonly8AIS5injuries.Deathswerelargelycausedbyexplosions(n=35),gunshotwounds(n=23),andaircraftaccidents(n=19).Nonewtrainingorequipmentneedswereidentifiedfor53%ofthepotentiallysurvivabledeathswhileimprovedmethodsoftruncalhemorrhagecontrolneedtobedevelopedfortheremainder.Thereviewpanelconcludedthat85%ofthedeathswouldnothavebeenpreventedatacivilianLevelIfacility.Availablerecords,inmostcases,didnotcontaininformationabouttheuseofbodyarmor,timetodeathafterinjury,ortheongoingtacticalsituation.Conclusions:Themajorityofdeathsonthemodernbattlefieldarenonsurvivable.Currentresultsarenotdifferentfrompreviousconflicts.InVietnam,reportedpotentiallypreventabledeathratesrangefrom5%to35%andciviliandatareportspotentiallypreventabledeathratesrangingfrom12%to22%.Militarymunitionscausemultiplelethalinjuries.Currenttraumatrainingandequipmentissufficienttocarefor53%ofthepotentiallysurvivabledeaths.Improvedmethodsofintravenousorintracavitarynoncompressiblehemostasiscombinedwithrapidsurgeryarerequiredfortheremaining47%ofthedecedents.

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JanuaryMarch200725INTRODUCTIONIdentifyingareasforimprovementinmoderncombattraumamanagementdependsonaclearunderstandingoftheepidemiologyandoutcomeofcombatinjuries.Thus,animportantprerequisitetooptimizethetreatmentofinjuredcombatantsistheabilitytoanalyzecurrentdatasothatnewstrategiesofcare,equipmentrequirements,andafocusedresearchagendacanbechangedtomeetcontemporarygoalsandneeds.Analysesofdeathsfrominjuryhavelongbeenacornerstoneoftraumasystemdevelopmentandareessentialtomeasureimprovementsofciviliansystemsoftraumacare.1,2Equivalentstudieshaveoccurredonseveralmilitarydatasets.3-5PreviousanalysisofUScombatdeathslargelyrestsintheanalysisofVietnamcasualtiesdescribedbytheWoundDataandMunitionsEffectivenessTeam(WDMET)database.Thisanalysisisnow40yearsoldandhasservedtodrivemilitarymedicalresearch,logistics,andmedicaltacticssincethattime.Changesinbodyarmor,improvedmedicalcare,equipment,andtrainingcommontothecurrentwarversusVietnamraisesthequestionoftheapplicabilityoftheWDMETdatatothecurrentexperience.AnadditionalandperhapsmoreimportantconcernabouttheWDMETapplicabilitystemsfromthecurrentmethodsofdeathanalysis,derivedfrom30yearsofexperienceinmaturingtraumasystemsresearch.6Wehypothesized,basedonimprovementsinbodyarmor,medicalcare,equipment,andtraining,andanimprovedunderstandingofappropriatedeathanalysis,thatdifferentpatternsofpotentiallysurvivableinjurieswouldemerge,leadingtonewresearchandinterventions.Thegoalofthisreviewwastoidentifythoseinjuriesthatwerepotentiallysurvivable,wereamenabletocurrentpreventionandtreatmentmodalities,orrequirednewtreatmentandtrainingcapabilities,orresearch.Theresultingdatawascomparedtopreviouslypublisheddatafromcivilianandmilitarytraumaautopsystudies.METHODOLOGYAllrecoveredremainsofUScombatantsaretransportedtoDover,Delaware,wherecompleteidentificationandforensicexaminationisperformedbytheOfficeoftheArmedForcesMedicalExaminer.Theseuniqueresourcesformthebasisforthisreport.InstitutionalReviewBoardapprovalforthestudywasprovidedbytheUSArmyInstituteofSurgicalResearchandtheArmedForcesInstituteofPathology.AllSOFfatalitieswereidentifiedbythepersonnelofficeoftheUSSpecialOperationsCommand.Thisincludedbothcombatandnoncombatfatalitiesandthosekilledinaction,aswellasthosewhodiedofwounds.7TreatmentrecordsandfilesfromtheJointTheaterTraumaRegistryandtheOfficeoftheArmedForcesMedicalExaminerwerecompiledanduniqueidentifiersremovedforthisreview.Thestudyteamincludedforensicpathologists,militaryandciviliantraumasurgeons,atraumanurse,andaSpecialOperationscombatmedic.Historically,themajorityofcombatdeathsarebeyondsalvage.4Ascreeningreviewusingautopsyinformationtoestimatetheseverityofinjuryandsuddennessofdeathwasperformedtoidentifycasesthatmeritedadetailedevaluation.Asinpreviouswars,theseverityandmultietiology,multisysteminjuryincombatissuchthatdetailedreviewwasnotwarrantedinmostcases.PatientswereclassifiedaseithernonsurvivableorpotentiallysurvivableagainstastandardofthedeployedUSlevelIIImedicaltreatmentfacilitiesintheater.TheselevelIIIfacilitiesrepresentthehigheststandardofmedicalcareavailableinthedeployedsetting.Thisstandardwaschosenwithfullunderstandingoftheextremevariabilityofthetactical,geographic,andlogisticalenvironmentofcombatinjury,andthusthelackofabilitytonormalizecareforasingleindividualcasualty.Thecommonlyusedcivilianmorbidityandmortalitycategoryofpreventablewasnotusedasthetacticalsituationwasnotknown,thusmedicaljudgmentsofpreventableintheabsenceoftacticalknowledgeweredeemedunacceptable.AllpatientsforwhomautopsieswereavailablehadbeencodedindependentlyforAbbreviatedInjuryScore(AIS)andInjurySeverityScore(ISS).Astructuredreviewandanalysisofeachcasewascompletedtodeterminewhereopportunitiesforimprovedoutcomeexisted.Areasthatwereaprimeconsiderationinthisquestionnaireinvolvedequipment,training,expedientevacuation,bodyarmor,TacticalCombatCasualtyCare(TCCC)guidelines,8andnewresearchrequirements.Notallofthedatarequiredtocompletelyanswereachquestionwasavailable.Forexample,whetherornotthe

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26ArmyMedicalDepartmentJournalcasualtywaswearingpersonalprotectiveequipment(PPE)orwhetherPPEwouldhavepreventedthewoundfrombeingsustainedwasoftendifficulttoascertain.RESULTSTherewere82SOFfatalitieswith77autopsies;from35explosions(42%),23gunshotwounds(GSW)(28%),19fromaircraftcrashes(23%),4motorvehiclecrashes,and1fall(Table1).ThenumbersdiffersomewhatfromobservationsthroughoutOEF/OIF.ComparedtoconventionalSoldiers,theSOFfatalitieshaveahigherincidenceofdeathsecondarytogunshots(p<0.05)andalowerincidenceofdeathsecondarytoexplosions(p<0.05).The5decedentswithoutanautopsywerethosewhowerenotrecoveredfromahelicoptercrashatsea.Twenty-four(70%)ofthe82caseswereselectedfordetailedreviewbythepanel.Twelveofthe24caseswhichwerereviewedin-depthwereconsideredtobepotentiallysurvivable.Duringthestudyperiod,12(15%)ofthe82SOFdeathsdiedfrompotentiallysurvivableinjuries.The16mechanismsofinjuryinthese12deathsareshowninTable1.Four(33%)ofthepotentiallysurvivablecasualtiesweredied-of-wounds(DOW),oneofwhichdied56daysafterinjuryatalevelVhospital.Theother3werecategorizedashavingDOWastheyweredeclareddeadatacombatsupporthospital.Theremaining8(66%)casualtieswerekilled-in-action.Ofthosecasualtiesdeemedtobenonsurvivable,therewere31patientswith40AIS6injuries(p=0.0011),and53patientswith104AIS5injuries.Amongthe12deathsdeemedtobepotentiallysurvivable,therewereonly8AIS5injuriesand18AIS4injuries(Table2).ThedistributionofISSisshowninFigure1.Eighty-fivepercentofthefatalitieswerenonsurvivable(ISS=58+35)while12(15%)werepotentiallysurvivable(ISS=35+9,p<0.05)andprovidedsomebasisforpotentialchangeinoutcomes.Figure2showsthedistributionofISSbyquartile.Nearlyone-halfofthenonsurvivablecasualtieshadanISSof60to75.UsingFischersexacttest,therewasasignificantlygreaterpercentageofcasualtiesinthepotentiallysurvivablegroupintheISS20to40quartile(p<00.03).Themostcommonetiologicfactorsinthepotentiallysurvivabledeathswerenoncompressiblehemorrhage(n=8)followedbyhemorrhageamenabletoplacementofatourniquet(n=3),hemorrhagenotamenabletoplacementofatourniquetyetcompressible(n=2),airway(n=1),tensionpneumothorax(n=1),andsepsis(n=1)(Figure3).Table3showstheareaswhereincurrentlyavailableinterventionsmayhaveresultedindifferentoutcomesforthe12patients.Thereadershouldrememberthatthetacticalsituationforthesecasualtiesislargelyunknown.MedicalcareunderfireisextremelyCausesofDeathinUSSpecialOperationsForcesintheGlobalWaronTerrorism:20012004Table1.MechanismsofInjuryin82SOFDeaths(%)andAllCombatInjuriesfromOIF/OEF(Nov2004)MechanismOIF/OEFn=3789SOFn=82NS*n=70PSn=12Allexplosions2030(55)35(43)32(46)3(25)IED1201(32)16(20)14(21)2(17)RPG**466(12)2(2)1(1)1(8)OtherExplosions26(1)16(20)16(23)0Rockets/MortarAttack337(9)1(1)1(1)0Aircraftcrash33(1)19(23)19(27)0MotorVehicleCrashWithoutIED579(15)4(5)3(4)1(8)Fall353(9)1(1)01(8)GunshotWounds712(19)23(28)16(23)7(59)Total3707(100)82(100)70(85)12(15) *NonsurvivableImprovisedexplosivedevicePotentiallysurvivable**Rocketpropelledgrenadep<0.05 Table2.AbbreviatedInjuryScore(AIS)Distribution*TotalScoresPSn=12NSn=65AIS640040AIS51128104*n=77as5fatalitiesduetoaircraftcrashwerenotautopsiedPotentiallysurvivableNonsurvivablep=0.001

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JanuaryMarch200727hazardousandsignificantlymodifieswhatcanbedoneforanindividualcasualty.Additionally,theremayexistmultipleareaswhereininterventionsorimprovementsmayhavealteredtheoutcomeforasinglepatient.Prehospitalopportunitiestopotentiallypreventdeathincludedhemorrhagecontrolwithtourniquet(n=3)andpressurewithhemostaticdressings(n=2),adequateairway(n=1),andneedlethoracostomy(n=1).These8casesoffatalitiesfrompotentiallysurvivablewoundsareallcoveredinthecurrentTCCCguidelines.8Moreexpeditiouscasualtyevacuation(CASEVAC)toafacilitycapableofdefinitivesurgicalinterventionmayhaveimprovedpatientoutcomein8casualties.In3casualties,improvedequipmentthatisnowpresentinthefield,theCombatApplicationTourniquet(CAT)(n=1)anduseofahemostaticdressing(n=2),mayhavealteredthefinaloutcomeofthecasualty.Theseitems,thoughnotavailableatthebeginningofthewar,arenowuseduniversally.Table4showsthat25%ofthepotentiallysurvivablecasualtiessustainedinjuriesinlocationsthatareprotectedbythecurrentpersonalprotectiveequipment(PPE).The3Soldierssustainedwoundsinanatomiclocationsthatareprotectedbythecurrentbodyarmorusedintheatre.Thoughitisunknownwhetherornotthearmorwasworn,theassumptionwasmade,basedTable3.Interventionswhichmayhavepossiblyinfluencedoutcomesforpotentiallysurvivablecasualties(n=12).PotentialInterventionPotentialImprovementinOutcomeDecreasedCASEVACtimes11Intravenoushemostasis8UniformApplicationofCurrentTCCCTraining8Equipment3 Figure1.RangesofInjurySeverityScoresfordeathsofSpecialOperationsForcesSoldiersinOperationsEnduringFreedomandIraqiFreedom. 05101520253035202526293033353638414243495054 57 59667375InjurySeverityScore N u m b e r o f C a s u a l t i e s Total PotentiallyPreventable

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28ArmyMedicalDepartmentJournalonthemechanismofinjury,thathadbodyarmorbeenworn,theSoldierwouldhavebeenprotectedfromthisparticularinjury.Ofthe82SOFdeaths,therewasonlyoneSoldierwhosustainedamortalwoundtothechestinanareathatisnotnowcoveredbycurrentPPE.EightofthepotentiallysurvivablecasualtiesmayhavebenefitedfromaninjectablehemostaticagentorfluidsuchasrecombinantfactorVIIa,lyophilizedorfreezedriedplasma,andoxygencarryingproductssuchashemoglobinbasedoxygencarriers.Sixmajorvascularinjurieswereidentified(Table5).Ofthese6namedarteries,3oftheinjurieswereamenabletoplacementofatourniquet.Hemorrhagewasconsideredtohavebeenacontributingfactorin10ofthe12potentiallysurvivablecasualties.CASESTUDIESThefollowingcasestudiesrepresenttheconsensusofthereviewinggroup.Itisimportantagaintoemphasizethatthetacticalsituationinmostcaseswascompletelyunknown.Thesimplestmedicalcareisoftenimpossibleinthemidstofafirefight,whileaccesstoacasualtyisoftenimpossibleintheterrainfrequentlyencounteredintheseepisodes.Assuch,theconclusionspresentedbelowarebasedentirelyontheobjectivemedicalinformationavailablefromtheautopsyandtheJointTheatreTraumaRegistrymedicalrecords.Case1Theindividualwaswoundedbyanimprovisedexplosivedevice(IED).Hesustainedapenetratingshrapnelinjurytotheneckwithlacerationofhisrightcommoncarotidarteryfromwhichheexsanguinated.Thisdeathmighthavebeenpreventedwithsustaineddirectpressureoverthebleedingsiteuntilsurgicalrepairwasaccomplished.However,thismaybeverydifficultornotCausesofDeathinUSSpecialOperationsForcesintheGlobalWaronTerrorism:20012004Table4.PossibleaffectofPersonalProtectiveEquipment(PPE)onthosefatalitiesjudgedtohavesustainedpotentiallysurvivableinjuries(n=12).InjuryinareaofbodycoveredbyPPE?TotalPercentageYes325%No975% 0%10%20%30%40%50%60%70% 0-1920-394059 60-75InjurySeverityScore** Potentiallysurvivable Nonsurvivable Figure2.ComparisonofInjurySeverityScoresofpotentiallysurvivableandnonsurvivablecasualties.*Significancep<0.03Fischer'sExactTest 0123456789NoncompressiblehemorrhageTourniquetablehemorrhageNontourniquetablehemorrhageTensionPTXSepsisAirway NontourniquetableHemorrhage TourniquetableHemorrhage NoncompressibleHemorrhageFigure3.Distributionofthe16potentialcausesofdeathamongthe12potentiallysurvivablecasualties. Sepsis TensionPneumothorax Airway

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JanuaryMarch200729feasibleincertaintacticalsettings.Useofahemostaticdressingmighthaveeliminatedthenecessityforprolongeddirectpressuretoaccomplishhemostasis.Therewasnoevidencethatahemostaticdressinghadbeenplaced.Case2TheindividualsustainedaGSWafterahelicoptercrash.Thebullettraversedtheretroperitoneum,rectum,andpelvis.Nomajorvascularstructureswereinjuredandhelivedforalmost5hoursafterwounding,indicatingarelativelyslowrateofbleeding.Theinjurywasdeterminedtohavebeenreadilyamenabletosurgicalrepairwithnoinjuriestomajorvascularstructures.Whilethereisnospecificcurrentinterventionwhichcouldhavebeenundertakenbythecombatmedicsthatwouldhavestoppedtheintra-abdominalbleeding,clearlyaCASEVACmoreexpeditiousthan5hourswouldlikelyhavesavedhim.Hemightalsohavebenefitedifpackedredbloodcellshadbeenavailableontherescuehelicopter,asrecommendedintheTacticalCombatCasualtyCaresectionofthePrehospitalTraumaLifeSupport(PHTLS)Manual.8(p394)Itisalsonotknowifahypotensiveresuscitationstrategywasemployedafterwounding.Thispatientillustratestheneedforfurtherresearchintoinjectableagentswhichcanaugmentthecoagulationmechanisminresponsetoinjury.OnesuchareaofcurrentresearchistheuseofrecombinantfactorVIIa.Asecondtherapeuticagentcurrentlyunderstudyarehemoglobinbasedoxygencarrierswhichfunctiontotemporarilyrestoreoxygendeliveringcapabilitiesofthecirculatorysysteminthepresenceofcriticalanemia.GiventheprolongedCASEVACtime,theseinterventionscouldpossiblyhavestabilizedthiscasualty,allowinghimtoreachthesurgicalunitfordefinitivetreatment.Case3ThisindividualsustainedaGSWtothelowerjawthatalsoinjuredthetongueandupperairwaystructures.Hewasreportedtohavebeenintubatedinthefield,butnotubewasnotedatautopsy.Theairwaystructuresatthecricothyroidmembraneandbelowwereintact.Itsnotpossibletoknowfromtheavailabledatawhethertheattemptedintubationwasunsuccessful,orwhethertheendotrachealtubemayhavebeenplacedintheesophagusduetothetissuedisruptioncausedbytheGSW.However,therewerenootherpotentiallyfatalinjuriesnotedandtheindividualwasjudgedtohavediedfromanisolatedairwaydeath.Thereare2interventionsthatcouldhavebeenlife-savingforthisindividual:1)properpositioning(thecasualtyshouldsitupandleanforwardifconscious)tokeepbloodoutoftheairway,or2)immediatecricothyroidotomyifthepreviouspositioningmaneuverprovedunsuccessful.BothinterventionsarerecommendedinTCCC.8Case4ThecasualtywaswoundedbyanRPGexplosionandsustainedinjuriestotherightlowerextremityatthemid-thighlevelandtherightforearmatthemid-forearmlevel.Heexsanguinatedfromthedistalsuperficialfemoralartery,despitetheplacementof3field-expedienttourniquets.Thetreatingfirstresponderclearlyhadtherightideaforeffectivetreatment,butlackedanadequatetourniquetandwasunabletoimproviseaneffectiveoneintimetocontrolthehemorrhage.Thereweremultiplecravatandsticktypetourniquetsappliedtothisextremity,yetadequatehemostasiswasnotachieved.ThisfatalitylikelywouldhavebeenpreventedbytheCATtourniquetthatiscurrentlybeingissuedtodeployingunits.9,10ThedeathmightalsohavebeenpreventedbyimprovedTCCCtrainingtoallmembersoftheunit.Themedicinthisunitwaskilledatthestartofthisengagementandcarewasrenderedbyanonmedicaloperator.ProvidingTCCCtrainingtoallunitmembershasbeenreportedtobeoverwhelminglysuccessfulinarecentpaperbyTarpeydescribingimplementationofTable5.MajorVascularInjuriesandCurrentMethodsofControl(n=7)VesselInjuredCompressibleorNoncompressibleMethodofControlSuperficialfemoralarteryCompressibleTourniquetPoplitealartery(2)CompressibleTourniquetCommonfemoralarteryCompressibleDirectpressureCommoncarotidarteryCompressibleDirectpressureCommoniliacarteryNoncompressibleSurgicalrepairMesentericarteryNoncompressibleSurgicalrepair

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30ArmyMedicalDepartmentJournalTCCCtrainingforallunitmembersofdeploying3rdInfantryDivisionunits.11Case5ThecasualtysustainedaGSWtohisupperthighatananatomiclocationjudgedtooproximalforeffectiveuseofatourniquet.Hisexsanguinationcouldhavebeenpreventedbysustaineddirectpressureonthefemoralarteryattheleveloftheinguinalligament.Certainlysustained,directpressurewouldallowtimetoemployotherstrategiesforhemostasis.Strategiesincludetheuseofhemostaticdressings,suchasHemcon(HemConInc,10575SWCascadeAvenue,Suite130,Tigard,Oregon)andemploymentofhypotensiveresuscitationtacticsasoutlinedinTCCC.8Thiscasealsoillustratesanotherexamplewherethedevelopmentofintravenoushemostaticinterventionsmayhavealteredthefinaloutcome.Case6TheindividualsustainedaGSWtoboththetorsoandhisrightpoplitealartery.Thereisnorecordorpathologicevidenceoftourniquetapplication.Thetorsowoundwaslocatedinanareathatwouldhavebeencoveredbybodyarmorhaditbeenworn.Thisfatalitycouldhavebeenpreventedbyacombinationofwearingbodyarmor,usingatourniquet,and,asthiscasualtylikelyexsanguinatedfrombothhisextremityandtorsowounds,theuseofintravenoushemostasismayhaveprovenfruitfulinthispatient.Case7ThecasualtysustainedaGSWtothelowerabdomenfollowingahelicoptercrash.Thegunshottraversedthepatientsmesentericandleftcommoniliacarteries.Heexsanguinatedfromthese2vascularinjuries,butthetimefromwoundingtodeathisunknown.ThisdeathmighthavebeenpreventedbyamorerapidCASEVACandtheprepositioningofbloodproductsontheaircraft.Again,giventheuncertaintimefromdeathtowounding,theuseofaninjectablehemostaticagenttostemongoingbloodlossfromanoncompressiblesourcemayhaveallowedsufficienttimeforevacuation.Case8ThecasualtysustainedaGSWtothemid-backduringanambush.Theinjurywouldhavebeenpreventedbybodyarmorifithadbeenworn.Thewoundsincludedsignificantdamagetotheupperandlowerlobesoftherightlung,butdeathmighthavebeenpreventedbyamoreexpeditiousCASEVAC,asthetimefromwoundingtodeathinthiscasewas10hours.Again,apossibleinterventionthatmayhaveimpactedthiscaseistheuseofrecombinantfactorVIIainconjunctionwithastrategyofhypotensiveresuscitationtoslowtheongoingbleedingduringtheevacuationdelay.Case9Theinjuryoccurredduringafast-ropeinsertionwhichresultedina25-footfalltorockymountainousterrain.Thefallresultedinaclosedheadinjuryandbleedingfrommultiplethoracic,intra-abdominal,andretroperitonealsites.Thebleedingsiteswerefelttohavebeenamenabletosurgicalrepair.Atensionpneumothoraxwasfoundonpostmortemchestx-ray.Whetherornotthisfindingwasapostmortemartifactisunknown.Thereportedtimefrominjurytodeathforthiscasualtywas4.5hours.ThisindividualmighthavebeensavedbymorerapidCASEVAC,oraneedlethoracostomyperformedbyamedicinthefieldfollowedbysurgicalrepairofhisinjuries.However,itcannotbesaidwithcertaintythattheindividualwouldnothavediedfromtheclosedheadinjuryalone.Themedianlethaldoseforafallisapproximately40feet.12Certainly,thiscasualtyhadsufferedmultiplemajorinjuries.However,the4.5hoursindelayfrominjurytodeathindicatesthathisinjurieswerepotentiallysurvivable.Case10ThecasualtysustainedGSWstothechestandabdomen.Thewoundsresultedinbilateralhemothoracies,aperforatedhemidiaphragm,perforatedliver,andaperforatedrightkidney.Itisnotknownwhetherornotthisindividualwaswearingbodyarmor,butthewoundingsiteswerelocationsthatwouldnothavebeencoveredifbodyarmorhadbeenworn.Thetimeintervalfromwoundingtodeathisnotknown.However,theseinjurieswereamenabletosurgicalrepairandthisindividualmighthavebeensavedifhewereaffordedamoreexpeditiousCASEVAC.Additionally,theuseofintravenoushemostatictherapiesmighthavebeenabletoplayaroleinthecareofthispatient.Thiscasualtyandthepreviouscaseprobablyrepresenttheextremelimitofpotentiallysurvivableinjuriesonthebattlefield.CausesofDeathinUSSpecialOperationsForcesintheGlobalWaronTerrorism:20012004

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JanuaryMarch200731Case11ThecasualtywasanoccupantinamilitaryvehiclethatwasimpactedbyanIEDwithasubsequentrollover.Hehadblunttraumaresultinginafractureofthepelvis,retroperitonealhemorrhage,andanopenfractureoftheleftfemurwithalaceratedleftpoplitealartery.Thetimetodeathwaslessthanonehouranditisunknownwhetherornotatourniquetwasappliedabovethesiteoflowerextremitybleeding.Itisalsounknownifthepelvicfracturehadbeenstabilizedinanyfashion.TheuseofasheetoranotherdevicetoreducethevolumeofthepelvisispartofPHTLStraining.8Thisinjurymighthavebeenpreventedbyseatbeltsand/orairbagsandthedeathmighthavebeenpreventedbyuseofatourniquet,pelvicstabilization,anintravascularhemostaticagent,andmorerapidCASEVAC.Case12ThecasualtywaswoundedbyanIEDwithinjuriestotheheadandneck.Hewastransportedtoamedicaltreatmentfacilitywhereheunderwentaprolonged(56-day)hospitalcoursecomplicatedbymenigingoencephalitis,pneumonia,andbrainabscess.ItisnotknownwhetherornotthiscasualtywaswearinghishelmetorreceivedbattlefieldantibioticsasrecommendedbyTCCC.However,theinjurysustainedwasinalocationcoveredbytheissuedhelmet.Thedeathmighthavebeenpreventedbyimprovedtreatmentofmultipleorganfailureandsepsis.DISCUSSIONTheUSSpecialOperationsCommand(USSOCOM)isauniqueforceintheAmericanmilitary.ItwasestablishedbyCongressin1987tocreateaunifiedcommandstructureencompassingallArmy,Navy,MarineCorps,andAirForceSpecialOperationsunits.USSOCOMhasaforceoflessthan51,000activedutyandreservepersonnel,withanextraordinarybroadrangeofmissionswhichincludedirectaction,specialreconnaissance,foreigninternaldefenseandunconventionalwarfare,counterandanti-terroristsoperations,combatsearchandrescue,counter-drug,humanitarianassistance,andsecurityassistance.USSOCOMhasbeendesignatedbytheNationalCommandAuthoritytoleadtheUSGlobalWaronTerrorism.ThemedicalcapabilitiesandneedsofUSSOCOMareuniqueinmanyrespects.SpecialOperationsForcesareoftendeployedinsmallunitsinhostileenvironments.Thus,SOFcombatmedicshavetobeextremelywelltrainedandhavetheabilitytofunctionindependently,frequentlyfordaysorweeksatatime.TrainingofanSOFcombatmedicrequiresupto52weeksofintensivedidacticandfieldwork.ThebaselinemedicalcaredoctrineandprotocolsforTCCCinspecialoperationsaregeneratedthroughtheCommitteeonTacticalCombatCasualtyCare,atri-service,multidisciplinary,military/civiliancommitteeformedin2002bytheNavalOperationalMedicineInstitutetoensurecontemporarystandardsofpractice.TheseguidelinesarepublishedinthePHTLSmanual.8ThecommanderofUSSOCOMhasorderedthateverydeployingunitintheSpecialOperationsCommandbetrainedinthebasicemergencycareofcombatcasualties,utilizingTCCCconcepts.Thissameapproachtocombatcasualtycareisrapidlybecomingthestandardintheconventionalforcesaswell.TacticalFieldCombatCasualtyCareisgenerallybrokendowninto3phases:1.CareUnderFireiscarerenderedbythemediconthebattlefieldwhileundereffectivehostilefirewithanaidbagastheonlyequipment.2.TacticalFieldCareistreatmentprovidedoncethecasualtyandhisunitarenolongerundereffectivehostilefire,withequipmentlimitedtothatcarriedintothefield.3.CombatCasualtyEvacuationCareistreatmentprovidedoncethecasualtyhasbeenpickedupbyaircraft,vehicle,orboat.TheverynatureofUSSOCOMmissionsresultsinthefactthataccesstoandextractionofwoundedcombatantsmaybedifficultanddelayed,thusplacingasignificantburdenonthepointofwoundingcareprovidersinsmallunits.Topreventaninordinateearlydeath,SOFmedicsmustbehighlytrainedandexpertlyequippedandsupported.These82deathsmustbeconsideredinthecontextoftheover600casualtieswhosurvivedtheirinjuries,sustainedbySpecialOperationsForcesduringtheperiodencompassedbythisstudy.Thatthevastmajorityofthecasualtiesfromthese2conflictssurvivedisagreatcredittothecourageand

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32ArmyMedicalDepartmentJournalprofessionalismofthephysicians,nurses,medicalplanners,pilots,aircrew,combatmedics,andteammateswhocaredforourwoundedwarriors.IntheGlobalWaronTerrorism,thereisnodoubtthattheMarineForwardResuscitativeSurgicalSuites,AirForceEmergencyMedicalDeploymentsSystem(EMEDS),ArmyForwardSurgicalTeamandMobileArmySurgicalHospitalunitsprovideexcellentandeffectivesurgicalsupportduringthemaneuverphase.Likewise,theArmyCombatSupportHospitalsandtheUSAFEMEDSlevelIIIfacilities,strategicallylocatedthroughoutIraqandAfghanistan,providestate-of-the-artcombatcasualtycarecapabilitiesforthecurrentlymorestableinsurgencywarfare.Alloftheseindividualsworkunderverydifficultcircumstancesandatgreatrisktothemselvestoprovidelife-savingcare.Asaresultofthistypeofanalysis,wenowcandefinewheretoapplynewapproachesandstrivetomakeevenmoreimprovementsinthedeployedmedicalcaresystem.Nothinginthisreviewismeanttodetractfromtheiraccomplishments.Rather,wemeantolearnwhereimprovementsintraining,equipment,andresearcharerequiredtosaveevenmorelives.Thisanalysisisafocusedefforttolearnlessonsthatwillhelpussavecasualtiesinbattlesyettocome.Afollow-oneffortwillexaminetheSOFcasualtieswhohadwoundsthatwerenotfatal,andexaminethemechanismsofwoundingandtheoutcomesinthatgroup.Thisanalysiswaslimitedbyincompletedatafromtheprehospitalandhospitalsetting.ThetimebetweenwoundingandCASEVAC,andthetimeintervalbetweenwoundingandarrivalatamedicaltreatmentfacility(MTF)ordeathislargelyunknown.AlsolargelyunknownwerethespecificsofcarerenderedonthesceneandduringCASEVAC,aswellaswhetherornotbodyarmorandhelmetwerewornbythecasualty.Furthermore,bodyarmorwasnotusuallyavailableforexaminationinconjunctionwiththeautopsyresults.Recordingthecarerenderedandcommunicationofthisinformationareoftenimpracticalinthetacticalenvironment.Theseareareasforpotentialimprovements.EffortstoimprovethecaptureofdataonthetacticalandprehospitalcareaspectsofSOFcombatcasualtiesareunderway,bothattheUSArmyInstituteofSurgicalResearchandtheUSSpecialOperationsCommand.Consistentwiththefindingsfrompreviousconflicts,485%ofthefatalitieswerenotsurvivable.Afteranalysis,andasevidencedbythedistributionoftheAISandISSscores(Figures1and2),70(85%)ofthefatalitieswerejudgedtohavebeenwoundedsoseverelythatsurvivalwouldhavebeenimpossibleevenwithCivilianLevel1traumacare.Only12(15%)ofthedeathswerecategorizedaspotentiallysurvivable.Acomparisonofthesepatientswithpublishedreports13,14ofciviliantraumacareintheUnitedStatesisatestamenttothetraining,theskills,andthebattlefieldsuccessesoftheSpecialForcescombatmedic.Thesepapersreportthat8%to22%ofprehospitaldeathsarepreventable,orpotentiallypreventable.Thepotentiallysurvivablerateof15%documentedinthefatalitiesexaminedbythisstudyfallsintothisrange.Moreover,thecasualtiesreviewedinthisstudyweremoreseverelyinjuredthatthosereportedinthecivilianliterature.ThereportedmeanISSofthepotentiallypreventablepatientsinonestudy14was25,whileourpopulationofpotentiallysurvivabledeathshadameanISSof35.TheoverallmeanISSofthereported88civiliandeathswas51.6andourmilitarypopulationwas56.ItisatributetotheSpecialOperationsmedictohavearateofpotentiallysurvivabledeathssimilartothelowendofthatreportedinthecivilianliterature,giventheseverityofinjuriestreatedcombinedwithanaustereandhazardousenvironment.Thecomparisonofthemanagementofciviliantraumapatientsandthefieldmanagementofcombatcasualtiesischallenging,asthereisnoeasywaytoknowthetacticalsituationinwhichthecombatmedicisrequiredtooperate,noristhereacivilianequivalenttothemechanismsofinjuryexperienced.Therearefewcivilianequivalentsbywhichcomparisonscanbemade.TheuseoftheISSasapredictivetoolforoutcomesinthecombattraumahassignificantlimitations.TheISSisobtainedbysummingthesquarevalueofthethreehighestAISscoresinupto3separatebodyregions.Forexample,aSoldierwoundedbyanIEDhasanAIS5foranabdominalinjury,AIS4forachestinjuryandanAIS3foranextremityinjury.HisISSwouldthenbe50,representingasevereinjury.ThelimitationhereisthattheISSdoesnotaccountformultipleinjuriestothesamebodyregion,nordoestheISSconsiderbilateralinjuries.Inourexample,thissameSoldiermayhavemorethanoneAIS5injuryinhisabdomen,oraconcomitantAIS4injuryinadditiontomultipleAIS4injuriesinhischest,orbilateralAIS4extremityCausesofDeathinUSSpecialOperationsForcesintheGlobalWaronTerrorism:20012004

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JanuaryMarch200733injuries.TheconventionalISSscoringsystemdoesnotaccountforthesehighlysignificantinjuries.Injuriessustainedasaresultofcombatmechanisms,ie,highvelocityGSWsfrommilitaryordnanceandexplosions,tendtohavemultipleinjurieswithinthesamebodyregion.Inourpopulationofpotentiallysurvivabledeaths,therewasonepatientwith2AIS5scoresforhischest,onlyonewascountedinthecalculationofhisISS.FourotherpatientswithAIS5injurieshadconcomitantAIS4injuriesinthesamebodyregion.CombatcasualtiestendtohavemultiplesevereinjuriesthatremainunaccountedforbytheconventionalISSscoringsystem.Anewinjuryseverityscoringmechanism,takingintoaccountthedifferencesbetweencombatandcivilianinjuries,isunderdevelopment.Astudyof210combatfatalitiesfromVietnampublishedin2002reportscaseswhichwereindependentlyreviewedby4traumasurgeonsandassessedtobeeitherdefinitelypreventable,possiblypreventable,notsalvageable,orcannotdetermine.3Thestudywasdoneusingmedicalrecords,therewasnotacticalinformationavailable,andnoautopsieswereperformed.Thedeterminationofpreventableornonpreventablewasmadeagainstthecurrentstandardofcare,notthestandardofcarerenderedduringtheVietnamWar.Averagesof5.4%(range1.0%to11%)ofthe210casesweredeterminedtobedefinitelypreventableand34.9%(range26.2%to41.9%)possiblypreventable.Thoughthepercentageoffatalitieswithpotentiallysurvivablewoundsinourstudywassimilar,theresultsaredifficulttocomparetothisstudyasthemethodologywasmarkedlydifferent.ThepaperbyBloodetalusedhospitalmedicalrecords,andonlyconsideredpatientswhowereDOWandnotkilled-in-action.3Thereforeitwasnotanevaluationofcarerenderedonthebattlefield,butratherofcarerenderedathigherechelonsofcare.Thetopicofimprovedpersonalprotectiveequipmenthasgarneredasignificantamountofattentionduringthisconflict.AnalysisofthesedatasuggeststhatPPEissavinglives.OnlyoneSoldierof82sustainedapotentiallysurvivableinjurytothethoraxthatmayhavebeenpreventedbyimprovedPPEcoverage.Therewere3potentiallysurvivabledeathswhoseinjuriesmighthavebeenpreventedhadPPEbeenworn.TwosustainedGSWstothethoraxandthethirdsufferedafragmentationinjurytothehead.TheAISdatapresentedsuggeststhatmanyofthesecasualtiessustainedmultiplesevereinjuriesinmultipleanatomicregionsthatanybodyarmoracceptableforuseinthetacticalenvironmentcouldnothaveprevented.InadequateanatomiccoverageofthecurrentlyfieldedSOFbodyarmorwasnotdocumentedinthisstudy.Inaddition,nocasesweredocumentedwherebodyarmorfailedtostopthehighvelocitymunitionscommonlyencounteredincurrentmilitaryoperations,bearinginmindthepreviouslynotedlackofreliableinformationaboutwhetherornotbodyarmorwaswornbythecasualties.TherewasasignificantdifferenceinthemechanismofinjurybywhichtheSOFdeathsoccurredcomparedtoconventionalforces.TheSOFSoldiersweremorelikelytodiefromgunshotwoundsthanfromanexplosivemechanism,28%versus19%respectively(p<0.05),usingalogitcasecontroloddsratio,95%confidenceintervalof1.42to4.03.Incontrast,theconventionalSoldierwasmorelikelytodieastheresultofanexplosion,55%versus43%respectively(p<0.05).Historically,intheVietnamconflict,51%to52%ofalldeathsatanMTFweretheresultofgunshotwounds,followedbyexplosionsat44%to48%.3,4Therearemultiplelevelsatwhichimprovementsinmanagementstrategiescantheoreticallyimproveoutcomes:TCCCtrainingfornonmedicalcombatants;medicaltrainingandequipmentAirevacuationandcloseairsupportresourcesOperationalmedicalplanningLocationofreceivingMTFsImprovementsinsurgicaltechniquesandtechnologyImprovementsinpostoperativecareNewmedicalinterventionsstemmingfromevidence-basedresearchNonewtrainingrequirementswereidentified.TCCCtrainingwasapplicabletothenonsurgicaldeathswhilestandardsurgicaltechniquesandequipmentapplytotheremainder.Mandatorypredeploymenttraumatraininganduniformapplicationoftheseprinciplesarerequired.TheanalysisofthepotentiallysurvivabledeathsservestoemphasizemanypointsincurrentSOFTCCCtraining:

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34ArmyMedicalDepartmentJournalTheneedtouseatourniquetforextremitywoundswithlife-threateningbleedingtogaininitialcontrolofhemorrhageTheneedtousesustaineddirectpressurewhenconfrontedwithsevereexternalbleedingatananatomiclocationwhereatourniquetcannotbeappliedTheneedtousepropercasualtypositioningandcricothyroidotomyinsteadofintubationformaxillofacialtraumaassociatedwithairwaytraumaTheneedtodecompressatensionpneumothoraxwitha5-inchneedleTheverysmallnumberoffataloutcomesassociatedwiththeseissuessuggeststhat,inmostcases,thesetypesofinjuriesweretreatedappropriatelybySOFcombatmedics.Onepossiblereasonfortheseevents(exceptforthefailedintubation)isthattheremaynothavebeenamedictoprovidetreatment.Inmostcases,itisnotstatedinanyavailablerecordwhetherthewoundswereinitiallytreatedbyacombatmedicoranonmedicalSOFoperator.Insomeinstances,theremaynotbeamediconthemissionatthetimecasualtiesoccur.Atothertimes,asoccurredinoneofthedeathsdescribedabove,theunitmedicmaybekilledorincapacitatedandunabletoprovidecareforotherwoundedunitmembers.TheTCCCTransitionInitiativecurrentlybeingconductedbyUSSOCOMisdesignedtoprovideallSOFoperators(medicalandnonmedical)indeployingunitswiththebasicmedicalskills.15,16Threecaseswereidentifiedwherethecasualtyhadhemorrhagedfromasitethatwasamenabletoplacementofatourniquet.Twoofthesethreehadnotourniquetplacedandonewasatourniquetfailure.These3isolatedextremitydeathshavebeenaddressedbyamajorDepartmentofDefenseinitiativetofieldthenewCATtourniquet.10,17ThisdevicewastestedbyUSSOCOMoperatorsandtraumasurgeonsandfoundtobesuperiorinfunctionandfeasibilitytothetraditionalcravatandstick.Usingthetraditionalcravatandstickmethod,whileeffective,istimeconsuming,difficulttosecureinplaceandrequirespriorplanningtoassureavailabilityofastick.AllofthepotentiallysurvivablefatalitiesmighthavebenefitedfrommoreexpeditiousCASEVACtoanMTF,withthepossibleexceptionofCase12.However,unlesstheexacttimefromwoundingtodeathisknownforaspecificcasualty(whichitrarelywasinthiscaseseries),itisdifficulttosaywhatimpacttheactualCASEVACtimeactuallyhad.AttemptstominimizeCASEVACtimearelimitedbyaircraftresourceconstraintsinoperationalplanning,groundfirepreventingCASEVACaircraftfromlanding,andlackofreadilyavailableMTFsinfar-forwardSOFoperations.TheabilityofreducedCASEVACtimetopreventfatalitiesisclearlydemonstratedbythe2potentiallysurvivablecasualtieswholivedatleast5to10hoursbeforeevacuationwasaccomplished.WiththedispersednatureofSOFoperations,itisunlikelythatsurgicalfacilitiesandCASEVACcapabilitywilleverbeabletoprovidetherapidevacuationcapabilityrequiredtosavethesecasualties.Interventionsplacedintothehandsofmedicswillberequired,thustheemphasisonintravenoushemostasisforthenoncompressiblebleedingsites,whichcontributedtodeathin7ofthe12potentiallysurvivabledeaths.CurrentoperationsinIraqareheavilyfocusedonurbanvehicle-basedmissionswherebytheevacuationtimefrompointofwoundingtonearbyMTFsmaybe30minutesorless,averyfastevacuationtimeformilitarycasualties.Incontrast,Afghanistanoperationsareusuallyconductedinremoteareasfarfrommedicalassets.CASEVACsinOEFarestillusuallyaccomplishedbyrotary-wingaircraftandmayhaveverysignificantdelaysduetobothdifficultflyingconditionsintheruggedmountainousterrainoftheHinduKushandtheremotenessofoperationsfromsurgicallycapableMTFs.Greatdifficultymaybeencounteredinevacuatingcasualtiesfromhigh-threatenvironments.Hostilerocket-propelledgrenadefirehasdownedUShelicoptersengagedinCASEVACoperationsinthepast.Suppressionofhostilefireisacriticalelementinsituationswhereintensegroundfirefromhostileforcescouldimpedeorpreventrotary-wingCASEVAC.ExpeditiousevacuationmightbemorereadilyavailableiftherewereanimprovedcloseairsupportcapabilityfordaytimeSOFCASEVACmissions.TechnologytohardenrotarywingplatformsagainstRPGfirewouldalsobeuseful.OperationalplanningthatensuresavailabilityofCASEVACaircraftistonoavailiftheaircraftcannotsafelypickupthecasualty.CausesofDeathinUSSpecialOperationsForcesintheGlobalWaronTerrorism:20012004

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JanuaryMarch200735Anotherfactorthatimpactstimetosurgicalcareistheproximityofthenearestsurgicalfacility.SinceSOFunitsoftenoperateinareasremotefromforwardsupportbases,CASEVACtimecanbeshortenedbyprepositioningaForwardSurgicalTeam(FST)withSOFunitswhentheywillbeconductingremoteoperationsthatcanbeexpectedtogeneratesignificantnumbersofcasualties.SOFunitsoperatingunderthesecircumstancesmusthaverapidaccesstoFSTs.IfthedeploymentofforcesissuchthatconventionalFSTscannotrespondintimetomeettheoperationaltempo,thenimprovedaccessisavailablebyrequestingoneoftheFSTsnowattachedtotheAirForceSpecialOperationsCommand.Whilethissurgicalsupportislogical,theverycasualtiesthatwillrequiretimesensitiveresuscitativesurgicalsupportareextremelydifficultforanFSTtoadequatelymanage,becauseofthepowerandequipmentrequirementsforrewarminghypothermic,hypotensive,andacidoticpatients,andthelargeamountofbloodandbloodproductstheyrequire.Furtherconfusingthemedicalplanningisthepervasiveconceptofthegoldenhourwhichhasverylittlesupportingdata.Mostauthoritiessuggestthat90to120minutesismorelikelyanevidenced-basedplanningfactor.18,19Thedesireforalightweight,mobilesurgicalteamthatisabletooptimallysupportthederangedphysiologyofthemostcriticallyinjuredcasualtiesisaconundrumyettobecompletelyresolved.Themedicalresearchrequirementisdrivenbythe8casualtiesthatdiedfromnoncompressiblehemorrhage.Thesedeathsmandateafocusoninjectablehemostasisatalllevelsofcare,especiallybymedics.CurrentlytheparadigmofDamageControlResuscitationholdsthemostimmediatepromiseinthisarea.20ThisconceptinvolvestheutilizationofprohemostaticfluidsinconjunctionwithpharmacologicadjunctssuchasrecombinantfactorVIIaandhypotensiveresuscitationtopalliatethehemorrhagingcasualtyuntilarrivalatafacilitywheredefinitivecarecanbeprovided.AlthoughhumanefficacywhenusingrFVIIaaloneintheprehospitalenvironmentisabsent,rFVIIaappearstobeapromisinghemostaticadjunct.Fortunately,safetyandefficacyintraumapatientshasrecentlybeenestablished,andtheprospectofprehospitalnoncompressiblehemostasisistantalizing.21,22Effortsareunderwaytostudythisapplication.PerhapscombiningrFVIIawithotherclottingfactorconcentrateswillprovideboththesubstrateandthethrombinburstrequiredtoaccelerateclotting.23-25Itispossiblethat,byaccelerating/strengtheningtheendogenousclot,bloodlosswilldecrease;thecasualtywillbestabilizedallowingarrivalatthesurgicalfacilityinanimprovedphysiologiccondition,wheresurgicalinterventionmayimproveoutcomes.DamagecontrolresuscitationmayallowtheSOFcasualtytotoleratethelongerCASEVACtimeswehaveseeninthispopulation.AsecondpotentialintravenousinterventionthatiscurrentlyinongoingphaseIIItrialsintheUnitedStatesistheevaluationoftheprehospitaladministrationofhemoglobin-basedoxygencarriers(HBOC).ThisHBOCreplacestheoxygencarryingcapacityofshedbloodallowingfordeliveryofoxygentovitalorgansduringcriticalanemia.26Ifcurrenttrialssupportthisindication,thisinterventionwouldallowaSOFmedictomaintainoxygendeliverywhileawaitingevacuation.Atleast7ofthe12patientsmayhavebenefitedfrommorerapidCASEVACtimessomelivedupwardsof10hoursafterinjury.Itisduringthistimethatdamagecontrolresuscitationcanbeemployed,especiallyinafar-forwardenvironmentwhereCASEVACisnotalwaysreadilyavailable.Additionally,thisstrategycouldpotentiallydecreasetheamountofbloodlossinacasualtyregardlessoftheCASEVACtime.TheapplicationofdamagecontrolresuscitationisparticularlysalienttotheSOFcasualty,wherethetacticalsituationmayprohibitexpeditiousCASEVAC.DamagecontrolresuscitationwouldallowtheSOFmedictotemporarilystabilizeahemorrhagingpatientwhileCASEVACisenroute.Historyisrepletewithnumerousexamplesthatgobackathousandyearsinwhichcombatcasualtycareprovidersuseeverymeansavailabletoprovideemergencycaretocombatcasualties,andeffectivelymatchavailableresourceswiththeneedsofthoseinjured.Historyalsodocumentsthatimprovementincombatcasualtycarestemsfromtheunfortunaterepetitiveexperienceofthewarinjured.Thefindingsprovidedbythisstudythatwillenablethemilitarytocontinuetoimprovebattlefieldtraumacareare:1.Eighty-fivepercentofSOFfatalitiesintheGWOTresultedfrominjuriesthatwerejudgedtobenonsurvivable.

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36ArmyMedicalDepartmentJournal2.ConsistentapplicationofthecurrentlytaughtTCCCguidelinesmighthaveimprovedoutcomesfor8ofthe12fatalitieswithpotentiallysurvivableinjuries.3.FasterCASEVACtimesmighthaveimprovedoutcomesfor11ofthe12fatalitieswithpotentiallysurvivableinjuries.4.ThemostimportantbiomedicalresearchrequirementidentifiedinthestudyisDamageControlResuscitationwhichincorporatestheuseofprohemostaticadjuncts,suchasrecombinantfactorVIIa,lyophilizedplasma,andthawedplasmawithhypotensiveresuscitationandHBOCs.Atpresent,thisrepresentsthemostpromisingmodalitytoimproveoutcomesinthe8fatalitieswithnoncompressiblehemorrhage.5.Whenworn,currentlyfieldedbodyarmorprovidedadequateanatomiccoveragefortheinjuriesdiscoveredinthisstudy.6.Nocaseswherebodyarmorfailedtostophighvelocitymunitionsweredocumentedinthisstudy.7.ImprovedsuppressionofhostilegroundfireiscriticaltoassuringCASEVACavailabilityinsometacticalsituations.8.Improvedmethodstocapturerecordsofwoundssustainedandcarerenderedonthebattlefieldwillgreatlyimprovefutureeffortstoupdatebattlefieldguidelines.REFERENCES 1.CalesRH,TrunkeyDD.Preventabletraumadeaths.Areviewoftraumacaresystemsdevelopment.JAMA.1985;254(8):1059-1063.2.DuboisRW,BrookRH.Preventabledeaths:who,howoften,andwhy?AnnInternMed1988;109(7):582-589.3.BloodCG,PuyanaJC,PitlykPJ,etal.Anassessmentofthepotentialforreducingfuturecombatdeathsthroughmedicaltechnologiesandtraining.JTrauma2002;53(6):1160-1165.4.BellamyRF,ManingasPA,VayerJS.Epidemiologyoftrauma:militaryexperience.AnnEmergMed1986;15(12):1384-1388.5.CareyME.AnalysisofwoundsincurredbyUSArmySeventhCorpspersonneltreatedinCorpshospitalsduringOperationDesertStorm,February20toMarch10,1991.JTrauma1996;40(suppl3):S165-S169.6.HoytDB,CoimbraR,PotenzaB,etal.Atwelve-yearanalysisofdiseaseandprovidercomplicationsonanorganizedlevelItraumaservice:asgoodasitgets?JTrauma2003;54(1):26-37.7.HolcombJB,StansburryLG,ChampionHR,WadeCE,BellamyRF.Understandingcombatcasualtycarestatistics.JTrauma.2006;60:397-401.8.NationalAssociationofEmergencyMedicalTechnicians.PHTLSBasicandAdvancedPrehospitalTraumaLifeSupport.5thed.St.Louis,MO:Mosby;2003.9.WaltersTJ,MabryRL.Issuesrelatedtotheuseoftourniquetsonthebattlefield.MilMed.2005;170(9):770-775.10.WaltersTJ,WenkeJC,KauvarDS,McManusJG,HolcombJB,BaerDG.Effectivenessofself-appliedtourniquetsinhumanvolunteers.PrehospEmergCare.2005;9(4):416-422.11.TarpeyMJ.TacticalcombatcasualtycareinOperationIraqiFreedom.ArmyMedDeptJ.2005;AprJun:38-41.12.GrandeCM,SteneJK.TraumaAnesthesia.Baltimore,MD:Williams&Wilkins;1991.13.EspositoTJ,SanddalTL,ReynoldsSA,SanddalND.Effectofavoluntarytraumasystemonpreventabledeathandinappropriatecareinaruralstate.JTrauma.2003;54(4):663-669.14.MaioRF,BurneyRE,GregorMA,BaranskiMG.AstudyofpreventabletraumamortalityinruralMichigan.JTrauma.1996;41(1):83-90.15.ButlerFK,HolcombJB.Thetacticalcombatcasualtycaretransitioninitiative.ArmyMedDeptJ.2005;AprJun:33-37.16.ButlerFKJr.TacticalmedicinetrainingforSEALmissioncommanders.MilMed.2001;166(7):625-631.17.WenkeJC,WaltersTJ,GreydanusDJ,PusateriAE,ConvertinoVA.PhysiologicalevaluationoftheUSArmyone-handedtourniquet.MilMed.2005;170(9):776-781.18.LernerEB,MoscatiRM.Thegoldenhour:scientificfactormedical"urbanlegend"?AcadEmergMed.2001;8(7):758-760.19.OsterwalderJJ.Canthe"goldenhourofshock"safelybeextendedinbluntpolytraumapatients?ProspectivecohortstudyatalevelIhospitalineasternSwitzerland.PrehospitalDisasterMed.2002;17(2):75-80.CausesofDeathinUSSpecialOperationsForcesintheGlobalWaronTerrorism:20012004

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JanuaryMarch20073720.McMullinNR,HolcombJB,SondeenJ.Hemostaticresuscitation.In:VincentJL,ed.2006YearbookofIntensiveCareandEmergencyMedicine.NewYork,NY:Springer;2006:265-278.21.BoffardKD,RiouB,WarrenB,etal.RecombinantfactorVIIaasadjunctivetherapyforbleedingcontrolinseverelyinjuredtraumapatients:twoparallelrandomized,placebo-controlled,double-blindclinicaltrials.JTrauma.2005;59(1):8-15.22.LynnM,JerokhimovI,JewelewiczD,etal.EarlyuseofrecombinantfactorVIIaimprovesmeanarterialpressureandmaypotentiallydecreasemortalityinexperimentalhemorrhagicshock:apilotstudy.JTrauma.2002;52(4):703-707.23.HednerU.DosingwithrecombinantfactorVIIabasedoncurrentevidence.SeminHematol.2004;41(Suppl1):35-39.24.HednerU,ErhardtsenE.PotentialroleofrecombinantfactorVIIaasahemostaticagent.ClinAdvHematolOncol.2003;1(2):112-119.25.WolbergAS,AllenGA,MonroeDM,HednerU,RobertsHR,HoffmanM.HighdosefactorVIIaimprovesclotstructureandstabilityinamodelofhaemophiliaB.BrJHaematol.2005;131(5):645-655.26.MooreEE,JohnsonJL,ChengAM,MasunoT,BanerjeeA.Insightsfromstudiesofbloodsubstitutesintrauma.Shock.2005;24(3):197-205.AUTHORS COLHolcombisCommander,USArmyInstituteofSurgicalResearch,BrookeArmyMedicalCenter,FortSamHouston,Texas,andTraumaConsultanttotheArmySurgeonGeneral.CAPTCarusoistheRegionalArmedForcesMedicalExaminerandPacificDirectorforClinicalSupportServicesattheUSNavalHospital,CampLester,Okinawa,Japan.Whenthisarticlewaswritten,hewasChiefDeputyMedicalExaminer,OfficeoftheArmedForcesMedicalExaminer,Rockville,Maryland.CPTMcMullinisathirdyearGeneralSurgeryResidentattheBrookeArmyMedicalCenter,FortSamHouston,Texas.DrWadeistheSeniorScientistattheUSArmyInstituteofSurgicalResearch,FortSamHouston,Texas.LCDRPearseisChief,MortalitySurveillanceDivision,ArmedForcesMedicalExaminerSystem,Rockville,Maryland.MsOetjen-GerdesisSeniorEpidemiologist,ArmedForcesMedicalExaminerSystem,Rockville,Maryland.Atthetimethisarticlewaswritten,MrChampionwaswiththeUniformedServicesUniversityfortheHealthSciences,Bethesda,Maryland.MsLawnickisaNurseResearcherintheOfficeoftheArmedForcesMedicalExaminer,Rockville,Maryland.COLFarristheCommandSurgeon,Headquarters,USSpecialOperationsCommand,MacDillAirForceBase,Florida.MSGRodriguezistheSeniorEnlistedMedicalAdvisortotheDeputyChiefofStaff,Surgeon,USArmySpecialOperationsCommand,FortBragg,NorthCarolina.Atthetimethisarticlewaswritten,CAPTButlerwastheCommandSurgeon,Headquarters,USSpecialOperationsCommand,MacDillAirForceBase,Florida.

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38ArmyMedicalDepartmentJournalBEFORECASUALTYARRIVALTheOrthopaedicSurgeryServiceisinvolvedwithspecificbattlecasualtiesviaelectronicmailandongoingcommunicationwithcareprovidersatoverseasregionalmedicalfacilities.TheinitialcommunicationisparamountinmanagingresourcesandoperatingroomscheduleswithintheOrthopaedicSurgeryService.Theinformationinthefaceofthecontinuousinfluxofpatientsrequiringmultiplesurgicalprocedures,extensiverehabilitation,manywithcomplexsocialsituationsallowsorthopaedicsurgeonstodirectthemanagementofnumerouspatientsaswellasthecensusonthewardsandoutpatientfacilities.Thisincludesthedecreaseofelectiveorthopaedicsurgeryproceduresandclinicsizes,aswellasthediversionoforthopaedicpatientswhoarenotTRICAREPrimesubscribers.TransferofthebulkofbattlecasualtiestothecontinentalUnitedStates(CONUS)iscompletedbytheUSAFAirEvacuationSystem(AEROVAC).Thesystemroutinelyprovidesamanifestofcasualtieswiththedefinitiveinboundmanifest,whichisoftenfinalizedafterAEROVACdeparture.ThismanifestandestimatedtimeofarrivalwascommunicatedtotheAEROVACofficeatWRAMC,andwasthensubsequentlymadeavailabletoavarietyofstaff,includingtheorthopaedicsurgicalresidenton-call.ItwasaresponsibilityoftheorthopaedicresidenttocheckwiththeAEROVACofficedailytoacquireTheProcessofCareofBattleCasualties:OrthopaedicsandRehabilitationattheWalterReedArmyMedicalCenterCOLWilliamC.Doukas,MC,USA INTRODUCTIONWalterReedArmyMedicalCenter(WRAMC),anechelonVfacility,hasbeenaprimaryhubintheUnitedStatesforthereceptionofArmybattlecasualtiesfromOperationsEnduringFreedom(OEF)andIraqiFreedom(OIF).ThecareofSoldiersfrominjurytofinaldispositionhasbeenajointserviceandspecialtyeffort.ThisarticleiscomprisedoffoursectionsdetailingexperiencesfromtheOrthopaedicSurgery,PhysicalTherapy,PhysicalMedicineandRehabilitation,andOccupationalTherapyServices.Together,thesectionsdepicttheprocessofcarethatwasdevelopedtoaffectthetimelyandeffectivemanagementofthesecasualties,withemphasisonapredetermined,multidisciplinaryapproachtopatientsandrecommendationstofacilitatethisprocessatWRAMCandothermedicalcenters.Inthetimesincethearticlewaswritten,thestructureoftheprocesshasbeenmodifiedandintegratedintothecareofacontinuousflowoflargenumbersofSoldierswithcontaminated,multiextremityinjuriesthatfrequentlyrequiremultiplesurgicalproceduresandcomplexmedicalmanagement,followedbyextensiverehabilitationandstrongsocialsupport.PART1THEORTHOPAEDICSURGERYSERVICECPTMatthewA.Javernick,MC,USACOLWilliamC.Doukas,MC,USA ThisarticleisreprintedfromMilitaryMedicine:InternationalJournalofAMSUS(2006;171(3):200-210)withpermissionofthepublisher.

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JanuaryMarch200739flightmanifests.Theresidentthenusedprioremailinformationandthemanifesttoestimatethenumberandacuityofpatientswhowouldrequiretriageuponarrival.Thereviewprocessalsoallowedtheresidenttoanticipatethenumberofadmissions,theneedforconsultationwithothermedical/surgicalspecialties,andplanforpotentiallyurgentsurgicalcases.TheinformationwasconveyedtotheChargeNursewhofurthercoordinatedwithotherhealthcareprovidersandadministratorsfortheanticipatedarrivals.The ArrivalofCasualtiesattheWalterReedArmyMedicalCenter Triage GeneralSurgery Inpatient ReturnedtoDuty ExpeditedSurgery Outpatient Rehabilitationand/orUnit Orthopaedics OrthopaedicsMorningReport OperatingRoom SerialDebridementand/orDefinitiveSurgicalCare RecoveryandRehabilitation Disposition:MobilizationSiteHomeDutyStation TemporaryDisabilityRetiredList MedicalEvaluationBoard ConvalescentLeave ReturnedtoDuty TemporaryLodging CasualtycareprocessattheWalterReedArmyMedicalCenter

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40ArmyMedicalDepartmentJournalmajorityofpatientsarrivedduringoff-hours,usuallyinthemiddleofthenight.Itwas,therefore,imperativetopreplantoensureappropriatepersonnel,equipment,andbedspacewereavailable.Itwasalsotheresponsibilityoftheorthopaedicresident,withtheassistanceofthePatientAdministrationDivision,toensurethatthedemographicsofarrivingorthopaediccasualtieshadbeenappropriatelyenteredintotheWRAMCcomputersystem.Thisallowedcasualtiestobeformallyadmittedtothehospitalandorderstobewrittenimmediatelyupontheirarrival,toincludepharmaceuticals(primarilyanalgesics),radiology,laboratory,nutritionalservices(diet),etc.TRIAGETheon-callorthopaedicsurgeryresidentwasnotifiedwhentheAEROVACmissionarrived.WRAMCnursingpersonnelescortedallpatientsinneedofevaluationtotheorthopaediccastandtreatmentroom.Thiswasestablishedasthecenterfortriagebecauseofitslargeopensizethatcouldaccommodatebothhighvolumesofpatientsaswellastherequirednumberofhealthcareproviders.Theorthopaediccastroomisequippedwithmultiplebedswithanattachedradiologysuite.Usingtheinformationreceivedpriortotheirarrival,themostseriouslyinjuredpatientswereescortedtothecastroomforevaluationfirst,andthenthosewithlesssevereinjurieswereplacedinotherexamroomsthroughouttheadjacentorthopaedicclinic.However,allpatientsenteredthroughthecastroomfortriage,whichallowedanorthopaedicsurgeonorgeneralsurgeontoinitiallyexamineandevaluatethepatientpriortotransport,andfacilitateplacementinalessacuteclinicexamroom.Amilitarymedicaltechnicianornursewasassignedtoeachpatientandescortedhimorherthroughtheentiretriageprocess,whilealsoinitiatingappropriatepaperwork.Patientswerethanevaluatedinaroutinetriagefashion,includingprimaryandsecondarysurveys,withattemptstoevaluatethemostseriouslyinjuredfirst.Thespecialtyoftheassignedprimarytriageresidentwasbasedontheinjurycomplexasdeterminedbythemanifestandlistedinjuries,witheitherageneralsurgeryresidentoranorthopaedicsurgeryresidentinthelead.Theremainderofthetriageteamconsistedofananesthesiologyresident,pharmacist,radiologytechnician,chargenurse,criticalcarenurse,aswellasnursesaidesandtechnicians.Pendingprimaryandsecondarysurvey,includingradiographicimagingandwoundassessment(withtheassistanceoftheAnesthesiaService),patientdispositionsweredetermined.ThiswasfacilitatedbycommunicationbetweenmembersoftheOrthopaedicSurgeryService,GeneralSurgeryService,andtheAnesthesiaService.Patientsrequiringsurgeryweretakendirectlytotheoperatingroomforirrigation,debridement,woundexplorationand,lessfrequently,definitivetreatment.Ifpatientswerenottakentotheoperatingroom,theywereeitherdirectlyadmittedtothehospitalorreferredtooneofWRAMCsoutpatientfacilitieswithinstructionstoreturnforappropriateoutpatientmanagementanddefinitivedisposition.INPATIENTSTheOrthopaedicSurgeryServiceadmittedallpatientsthatneededfurtherextremityreconstruction,woundmanagement,and/orrehabilitation.TheGeneralSurgeryServiceadmittedallpatientswithchest,abdominal,oruncomplicatedextremitywounds.ThetwoServicesworkedtogethertomanagethevolumeofcasualtieswithfrequentconsultstoeachotheraswellasotherspecialtiesthroughoutthehospital,ofteninvolvingtheVascularSurgery,Neurosurgery,PlasticSurgery,andPhysicalMedicineServices.AstandardsetofphysicianorderswasestablishedbytheOrthopaedicServicetomaintaincontinuityandqualityofcareoftheorthopaedicinpatient.Thisincludeddeepvenousthrombosisandtwicedailygastrointestinalprophylaxisofunfractionatedheparinandranitidine,continuationofallpreviouslyprescribedantibiotics(pendingspeciesidentification),andaggressivepainmanagement.Allcasualtiesreceiveddietordersthatincludednutritionalshakes,aprotocolbasedonearlylabvaluesdemonstratingthatthemajorityofcasualtiesweremalnourishedintheirhealingstages.TheorthopaedicresidentwasalsoresponsibleforidentificationofthosearrivingpatientswhoneededmalarialprophylaxisandinitiationofappropriatetreatmentThefollowingmorning,allpatientswerepresentedbytheorthopaedicon-callresidentatthedailyMorningReport,whichroutinelyconsistsofareviewofallpreoperativeandimmediatepostoperativepatients,aswellasallpatientsevaluatedon-call.Allattendingorthopaedicsurgeonsandin-houseorthopaedicresidentsattendthismeeting.Thebattlecasualtieswerepresentedintheusualfashion,whichstimulatedOrthopaedicsandRehabilitationattheWalterReedArmyMedicalCenter

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JanuaryMarch200741furtherdiscussionamongattendees,andapreliminarycareplanwasestablished.Theuseofdigitalphotographyobtainedattimeoftriagebytheorthopedicresidentwasimportantinaccuratelypresentingthecomplex,contaminatedwoundssustainedbymanyofthepatients.Informationonincomingcasualtieswasalsosharedatthisforumandtentativeplansweremadeaccordingly.Thechiefresidentwouldthenreviewandupdateposted2-weekfuturesofallbattlecasualtiesneedingoperativetreatment.Thiswasimperativetoeffectivelymanageallresourcesandensurethatpatientsneedingserialirrigationsanddebridementswereadequatelymanaged.Thisalsoallowedtheresidentteamstocompleteandsubmittheappropriateoperativerequestslipsandpurchaseordersaheadoftime,aswellascontactingequipmentrepresentativesandcoordinatingwithconsultingservicesinordertopreparethebattlecasualtyforsurgery.FollowingMorningReport,thejuniororthopaedicresidentorinternwouldsubmit9routineconsults(audiology,dischargeplanning,nutritioncare,occupationaltherapy,pastoral,psychiatry,physicalmedicineandrehabilitation,physicaltherapy,andsocialwork)throughoutthehospitaloneveryOIF/OEFpatient.Forallopenwounds,theInfectiousDiseaseServicewasconsultedandroutineoperativetissueculturesobtained.Itwastheresponsibilityoftheorthopaedicresidenttocoordinateallconsultsandensurethattheorthopaedicteamhadaddressedtherecommendations.Theorthopaedicmanagementofinpatientswasbasedonroutinetraumamanagement,yetthetypeoftraumadifferedfromtheroutinecivilianblunttrauma.Theaveragebattlecasualtyconsistedofablastinjuryinvolvingmultipleextremities,withmultiplesofttissueandbonyinjuries.Thewoundswereoftencontaminated,requiringserialirrigationanddebridementandaggressivewoundmanagementwithdelayedprimaryclosureratherthanskin,free,orlocalflapsandgrafts.Theorthopaedictreatmentsconsistedofamputations,revisionamputations,flaps,alargenumberofwoundvacuum-assistedclosuredevices,antibiotic-impregnatedpolymethylmethacrylatebeads,andavarietyoffracturestabilizationproceduresforlimbsalvage.Theorthopaedicresidentmadeacontinuingeffortinthedispositionofpatientstoothermedicaltreatmentfacilities(MTFs).ThedispositionofpatientstoothermilitaryMTFswasdifficultbecauseoftheextensivenumberofcasualtiesexperiencedinthefaceoftheongoingwar,whichlimitedthenumberofCONUSAEROVACflights.ThedispositionofActiveArmySoldierswasroutinependingtravelarrangementstotheirhomedutystation.ThedispositionoftheArmyNationalGuardorArmyReserveSoldierswaschallengingduetotheadministrativecomplexityintroducedbecausethehomeofrecordusuallydifferedfromthemobilizationsite,andtheassociatedlackofsurroundingmilitarymedicalfacilitiesinagivenregion.EveryeffortwasmadetoreturntheSoldiertotheirmobilizationsite,assumingappropriatefollow-upandtherapycouldbeobtained.Medicalevaluationboards,ifrequired,werecompletedattimeofdischargeorattimeofoptimalfunctionalimprovement.THEOUTPATIENTCASUALTYAnorthopaedicnursecasemanagerexpeditedthemanagementofoutpatientbattleandnonbattlecasualties.Thisnursecasemanagercoordinatedallappointmentsandexpeditedsurgicalschedulingwithanattempttoscheduleoperativewithina2-weektimeframe.Allpatientsthatweretriagedtoanoutpatientsettingweregivenfollow-updateswithappropriateattendingphysicians.Ifapatientwasseenattriageandnoorthopaedicissueswereidentified,heorshewasthenreferredtotheappropriateServiceformedicalcare.Outpatientsurgicalcasesreceivedpriorityoverallelectivecasesnotoriginatinginoneofthecombattheatersinanattempttoreducethelargevolumeofoutpatients.CONCLUSIONSTheevolutionoftheprocessofcareofbattlecasualtiesisanongoingprocess.Itisimperativetoinitiallyestablishandimplementahospital-wideplanaddressinglogisticsandprocessofcare.Themostimportantissue,however,remainsopen,ongoingbidirectionalcommunicationbetweenthetransferringandreceivingfacilities,aswellasbetweendepartments,services,andproviders.WerecommendthatappropriatelegalpersonnelwithintheinstitutionestablishaworkingprotocolthatallowstransferofpatientinformationwhileremainingcompliantwithcurrentHealthInsurancePortabilityandAccountabilityActregulations.Wealsosuggestaunificationofthedigitalradiographicsystemsand/orestablishmentofcommunicationlinksbetweenoverseassystemstoeliminateduplicationofeffort.Thiswillbecost-effective,saferforthepatient,and

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42ArmyMedicalDepartmentJournalultimatelyimproveefficiency.Finally,wesuggestimplementingaplanthatautomaticallyincorporatesalloftheroutineconsultsthatarerequiredinthecareofthebattlecasualty.Themyriadofadministrativetasks(eg,dischargeplanning,HIVtesting,TBtesting,malariaprophylaxis,familytravel,etc)cannotberelegatedasaresponsibilityoftheprimarysurgicalteaminthefaceoflargenumbersofbattlefieldpolytraumapatientsthatarearrivingfromcombatoperations.ThedispositionofSoldiersfromthereceivinginstitutiontotheirhomeunitsorregionsisstillnotseamless.WRAMCcontinuestorefinethisprotocol.AUTHORS CPTJavernickisassignedtotheDepartmentofOrthopaedicsandRehabilitationattheWalterReedArmyMedicalCenter,Washington,DC.COLDoukasisChairman,DepartmentofOrthopaedicsandRehabilitationattheWalterReedArmyMedicalCenter,Washington,DC.OrthopaedicsandRehabilitationattheWalterReedArmyMedicalCenter PART2PHYSICALTHERAPYCOLBarbaraA.Springer,SP,USACOLWilliamC.Doukas,MC,USAAspartofapatient-centeredteam,physicaltherapists,physicaltherapyassistants,andphysicaltherapytechniciansarededicatedtoprovidingthebestpossiblecaretowoundedSoldiers,Sailors,Marines,andAirmenreturningfromOperationsEnduringFreedom(OEF)andIraqiFreedom(OIF)fortreatmentandrehabilitation.Therapistsworkcloselywithotherhealthcareproviderssuchasorthopaedists,neurologists,physiatrists,occupationaltherapists,speech/languagetherapists,prosthetists,socialworkers,nursingstaff,andpsychologiststoreturntheSoldierstothehighestpossiblelevelofactivity.OEF/OIFpatientsarereferredtoinpatientoroutpatientphysicaltherapyprimarilyfromphysiatristsandorthopaedists.Duringthefirstmonthofcombatoperations,thephysicaltherapiston-callwaspresentatthetriagecenterwithorthopaedic,general,andvascularsurgeonstoidentifypatientswithphysicaltherapyneeds,assistwithdressingchanges,andcommunicatedirectlywiththesurgeonsaboutweight-bearingstatus,restrictions,andprecautions.Thisallowedthoroughconsultations,enhancedcommunication,andinpatientphysicaltherapystaffplanning.However,duetothenumberandfrequencyofpatientsfromoverseasandthehoursofarrival,itwasdecidedthaton-callphysicianswouldtriageandmakerecommendationsandreferralswithin24hours.INPATIENTPHYSICALTHERAPYInpatientconsultsaretypicallyreceivedwithin24hoursofadmissionorwhenthepatientisstableenoughtoreceivephysicaltherapy.PhysicaltherapistsprovideevaluationsandtreatmentsfortheseOEF/OIFpatientsonanyofthewards,toincludetheintensivecareunits.Mostinjuriesincurredbythesepatientsarecausedbylandmines,improvisedexplosivedevices,rocketpropelledgrenades,gunshotwounds,andmotorvehicleaccidents.Examplesofcommonconditionsevaluatedandtreatedbythephysicaltherapystaffincludemultipletrauma,softtissueinjuries,burns,skingraftsandflaps,fractures,amputations,traumaticbraininjuries,hemiplegia,spinalcordinjury,andvestibulardysfunction.Unfortunately,manypatientsdonotsustainonlyasingleinjuredlimb,butrathersuffermultipleinjuriesandconditions.Forexample,challengingpatientsincludethosewhoundergodoubleortripleamputations,areblinded,andsuffertraumaticbraininjury.Physicaltherapytreatmentsincludebedmobility,transfers,gaittraining,donanddoffingofprosthesis,matexercises,residuallimbdesensitization,strengthening,stretchingandrangeofmotion,conditioning,aquatictherapy,balancetraining,neurorehabilitation,andpatientandfamilyeducation.Inpatientsaretreatedtwicedailywhereappropriateonweekdaysandonceadayonweekends.Thereisapoolofcontractweekendphysicaltherapists,andphysicaltherapyassistantsandtechnicians.TwoofeacharescheduledtoworkeverySaturdayandSunday.Ifthereisaneedformorethan4staffmembersontheweekends,themilitaryon-callphysicaltherapistand/ortechnicianwillassist.Inordertoprovidecontinuityofcareforouramputeesthroughouttheentireweek,rotatingscheduleswerecreatedforourfull-timeamputeetherapists.

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JanuaryMarch200743Inpatientphysicaltherapistsworkcloselywithsocialworkersandnursecasemanagerstocoordinatefurthercare,toincludeevaluatingrehabilitationandequipmentneeds.OccasionallyanOEF/OIFpatientmustgotoaspecializedVeteranAffairsrehabilitationhospitalforseveretraumaticbrainorspinalcordinjuryrehabilitation.Othertimestheyaredischargedandstayinthelocalguesthouseawaitingfurthersurgeryand/orwoundchecks.Inpatientphysicaltherapistsalsohelpcoordinateoutpatientphysicaltherapy,whetheritisatWalterReedArmyMedicalCenter(WRAMC),atthepatientsmobilizationsite,orhome.Sometimespatientsgohomeonconvalescentleave,thenreturnforfurtherwork-upand/orrehabilitation.OUTPATIENTPHYSICALTHERAPYOutpatientphysicaltherapyisprovidedwithin72hours(typicallyless)ofreceivingaconsultfromhealthcareproviders,suchasphysiatristsororthopaedists.ThreemorningseachweekarededicatedtoOEF/OIFpatients,aswellasanyotherActiveArmypatients.Afterthepatientsareevaluated,physicaltherapistsdeterminetheirrehabilitationneedsandmayreferthemtootherspecialtyclinicssuchasneurologyororthopaedics.AdetailedtreatmentplanforphysicaltherapytreatmentatWRAMCiswrittenforpatientswhoarestayingforanyotherhealthreasons,orpatientsarereferredtoothermilitaryorcivilianphysicaltherapyclinics,dependingontheirstatus.ThereisadedicatednursecasemanagerfortheOEF/OIFpatientstohelpcoordinatetheirmedicalneedsattheirmobilizationsites,orathomeshouldtheygoonconvalescentleave.PROBLEMS,SOLUTIONS,LESSONSLEARNEDThenumberofmultipletraumas,blastinjuries,gunshotwounds,amputations,andburnsincurredbyOEF/OIFpatientsarenumerous.Theirrequirementsarenotthetypicalanklepainorlowbackstrainpatientswewouldnormallyevaluateandtreatinoutpatientphysicaltherapy.OEF/OIFpatientshaveamuchhigheracuityandrequiremanymoreresources,ie,increasedstaffandtime.Physicaltherapyofdoubleandtripleamputees,orblindamputeeswithmultiplelimbsinvolvedisnotuncommon,andmanyinjuredpatientshavetraumaticbraininjuryand/oropenwoundsandfractures.Thepatientprofileshavecausedamajorshiftinfocus.TheincreaseinOEF/OIFpatientsmadeitnecessaryforthePhysicalTherapyServicetogotoaprime-onlystatus,whichreducedouroutpatientvisitsbyapproximately45%.Thisresultedindecrementsinphysicaltherapyspecialtyservicessuchasvestibularrehabilitation,totaljointevaluationandtreatments,andchronicobstructivepulmonarydiseaseexerciseclasses.Solution:ArmyReservespecialistsshouldbecalledupearlyanddedicatedtoservices,suchasphysicaltherapy,tohelpeasetheburdenontheregularstaffduringthistimeofincreasedcasualties.WRAMCprovidedfundingtohire3additionalcontractphysicaltherapistsandasinglephysicaltherapistassistanttocontinueprovidingqualitycareforall.Theamputeesectionstaffwasincreasedfrom1to3physicaltherapists,inadditiontotheexistingsinglephysicaltherapistassistant.Anothersolutionwastosendpatientsover65yearsold,suchasmanyofthediabeticamputees,tocivilianfacilitieswheretheycouldusetheirMedicarebenefits.Additionally,civiliansecuritypersonnelwerehiredfortheWRAMCgates,freeingSoldierstoconcentrateontheprovisionofpatientcare.Therewasagreaterneedforspaceinboththe3rdand 5thfloorclinicsatWRAMCduetothegreaterneedforpatientequipment,suchasinpatientbeds,gerichairs,wheelchairs,andprosthetics.Additionally,spacewasneededtoprovidesafefunctionaltraining,especiallyforouryoungtraumaticamputeepopulation.Functionaltrainingincludesbalancetraining,functionaldrills,hopping,running,climbing,andambulatingonuneventerrain.Thesepatientscouldbeprogressedtohighlevelsoffunction,toincludeathleticcompetitionandmilitaryduties.However,adequatespacewouldallowbetterrehabilitationservices.Solution:Atemporarysolutionistoworkwithsomeofthepatientsoutside(whentheweathercooperates)oratthephysicalfitnesscenterontheWRAMCcampus.Along-termsolutionistobuildadedicatedclinicspaceforouramputeepopulation.In2002,Congressprovidedfundingtoestablishanamputeecareprogramfortheseyoung,healthy,highlyfunctionalActiveArmySoldierswhosustaintraumaticamputations.Dedicatedclinicspacethatcanbesharedbyalltheteammembersinvolvedinamputeecareisplannedforconstruction.

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44ArmyMedicalDepartmentJournalTherehasbeensomedifficultytrackingOEF/OIFoutpatients.Noparticularcaseworkerwasaccountableforpatientswhostayatthelocalguesthouse.Therewasnoonetocontactiftheydidnotappearforscheduledphysicaltherapytreatments.ThereshouldbecurrentandspecificguidanceonthemanagementofOEF/OIFpatients,includingthelengthofstay,locationoffurtherevaluationsand/orsurgeries,follow-onoutpatientphysicaltherapy,andeligibilityissues.Solution:AnursecasemanagerhasbeencoordinatingcarefortheOEF/OIFpatientsandsheisavailableforanswerstothesequestions.Additionally,anursecasemanagerwashiredspecificallyfortheamputeepatientmanagement.WebelievethatthemediaandvisitingVIPshavea positiveeffectonthecasualties.Itisveryimportanttothepatients.However,itisoccasionallyexcessiveandmayinterferewithgettingpatientstothephysicaltherapyclinicfortreatment.Solution:WeshouldcertainlyallowVIPsandthemediatovisit,buttheremustbeclosecoordinationwiththepublicaffairsofficeandourservice.AnothersuggestionistolimitVIPvisitstoeveningvisitinghours(oratleastafter1500).Somemilitarypatientsarebeingbroughtbackfrom Iraqbecauseofpreexistingconditions(suchashammertoes,chronicknee,orchronicbackpain).Ourresourcesareusedtoevaluateandtreatthesepatients.Solution:Healthcareprofessionalsatmedicalevaluationsitesshouldcloselyscreenthosewhoarebeingcalledtoactivedutytoensuretheymeetthephysicalrequirementsandcanperformtheirdutiesbeforetheyaredeployed.AUTHORS COLSpringerisChief,PhysicalTherapyServiceattheWalterReedArmyMedicalCenter,Washington,DC,andisthePhysicalTherapyConsultantfortheNorthAtlanticRegionalMedicalCommand.COLDoukasisChairman,DepartmentofOrthopaedicsandRehabilitationattheWalterReedArmyMedicalCenter,Washington,DC.OrthopaedicsandRehabilitationattheWalterReedArmyMedicalCenter PART3PHYSICALMEDICINEANDREHABILITATIONLTCPaulF.Pasquina,MC,USACOLJeffereyGambel,MC,USALTCLeslieS.Foster,MC,USAMAJAnnKim,MC,USACOLWilliamC.Doukas,MC,USAINTRODUCTIONThePhysicalMedicineandRehabilitationService(PM&R)playsacriticalroleintheassessment,management,anddispositionoftheinjuredcombatant.ThisrolewaswelldemonstratedduringOperationsEnduringFreedom(OEF)andIraqiFreedom(OIF).PlacementofthePM&RServicewithinthesamedepartmentasorthopaedics,physicaltherapy,andoccupationaltherapygreatlyenhancesthecommunicationandflexibilitytoprovideoptimalmedicalandrehabilitativecareforthoseinjuredcombatantswithmusculoskeletalinjuries.INPATIENTCONSULTSAllcombatcasualtieswhoareadmittedtoWalterReedArmyMedicalCenter(WRAMC)receiveseveralautomaticreferrals,includinganevaluationfromthePM&RService.PM&Rconsultationtotheprimaryadmittingservicehelpsfocuseachpatientsrehabilitationplanattheearliestpossiblemoment.PM&Rconsultationsalsohelptoidentifyothercomorbiditiessuchasperipheralneuropathies,fractures,andmildtraumaticbraininjuriesthatmightnothaveyetbeenidentifiedduringtheinitialacutephaseofinpatienttreatment.Inadditiontoproviding

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JanuaryMarch200745comprehensiverehabilitativecareplans,itiscustomaryforPM&Rconsultationstoproviderecommendationsforpainmanagement,bowelandbladdermanagement,strategiesforavoidingcomplicationsofimmobilitysuchasdeepvenousthrombosis,skinbreakdown,orcontractureformation.Also,PM&Rconsultationsdevelopthecoordinationplanswithsocialworkservicesandalliedhealthprofessionalstoensureappropriatedisposition,whichoftenincludestransitiontoaninpatientrehabilitationservice.TheprimarygoalofthePM&Rconsultationistoestablishtheframeworkfortheholisticmanagementofthepatientandtoensurethatallstrategiesforrestoringoptimalfunctionarebeingconsidered.INPATIENTPM&RSERVICES(INPATIENTREHABILITATION)WhiletheaveragedailycensusoftheWRAMCinpatientrehabilitationunitiscustomarilybetween8to12beds,thenumberofinpatientPM&Rbedscanbeincreasedgivencommandapproval,spaceavailability,andappropriatestaffing.Duringwartime,priorityforadmissionsisappropriatelygiventoinjuredactivedutyservicememberswhorequireinpatientrehabilitation.Guidelinesforadmissionaresimilartothosecriteriausedbycivilianinpatientrehabilitationunitsandinclude:1.Thepatienthasaconditionthatisamenabletoinpatientrehabilitationinterventions.2.Thepatientismotivatedandisabletoparticipateinaminimumof3hoursoftherapy(physical,occupational,speech,psychological,orrecreational)perday.3.Thepatienthasthecapacitytolearnandshowcarryoverfromdaytodayinordertomeetidentifiedfunctionalgoals.TheinpatientrehabilitationunitatWRAMChasspecialchallengeswhencaringforcombatcasualties.Injuredservicememberswhoneedinpatientrehabilitationoftenpresentwithcomplexinjuriesandmultiplecomorbidities,whichrequirecreativesolutionstoprogressinrehabilitation.Forexample,arighttranstibialamputationmaybereadyforprostheticstrainingandambulation,howevernon-weight-bearingfracturesonthecontralaterallimbmayprohibitthisfromoccurring.Otherexamplesillustratingthecomplexchallengesinjuredcombatantposefortherehabilitationspecialistsincludeblinddoubleamputees,spinalcordinjurieswithconcomitantperipheralnerveinjuries,ormultitraumavictimsalsosufferingfrompost-traumaticstressdisorder.Becauseofthespecializedfacilityrequirementandneedforprotractedrehabilitationinthetreatmentofhighspinalcordinjuryorseverelyimpairedheadinjurypatients,theWRAMCinpatientrehabilitationunitwillgenerallyinitiateimmediatetransferofthesepatientstoamorespecializedfacilityclosesttothepatientshomeofrecord.TheInpatientRehabilitationUnitiscollocatedwiththeinpatientOrthopaedicService.GiventhelargenumberofSoldierswithextremityinjuries,suchcollocationfacilitatesthetransfersofpatientswithinthehospital,whileimprovingcommunicationbetweenphysicians,nurses,therapists,andotherhealthcareprofessionals.Theinpatientrehabilitationunithasmanydedicatedandcaringmilitaryandciviliannursestrainedinmedical-surgicalnursing,however,cross-traininginrehabilitationisalsorequired.Therefore,anongoingeducationalprocessmustexisttoensurethehighestlevelofcare.Criticaltothefunctioningoftheinpatientrehabilitationunitistheactiveparticipationofamultidisciplinaryteam.Thecorpsmembersofthisteaminclude:PM&R,physicalandoccupationaltherapy,socialwork,nursing,andpsychiatry.HavingtherehabilitationunitlocatedwithintheechelonVfacilityensuresthehighestqualityofcareforthesecomplexpatients.First,itensurescontinuityofcareasthesepatientsaretransferredtotherehabilitationunitfrommultipledifferentmedicalspecialties(orthopaedics,vascularsurgery,generalsurgery,neurosurgery,internalmedicine,etc).Second,ifduringtherehabilitationphaseofrecoveryapatientdevelopsamedicalorsurgicalcomplication,immediatemultispecialtyevaluationandcomanagementisavailable.ItisthePM&Rspecialistsresponsibilitytoserveastheinpatientsprimarycarephysician,facilitatingcommunicationbetweenspecialties,providingattentiontodetailinmonitoringdailyprogress,andensuringtheexecutionoftheoptimaltreatmentplan.TheinpatientrehabilitationteammusthaveacloseworkingrelationshipwiththeDepartmentofVeterans

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46ArmyMedicalDepartmentJournalAffairs(VA)inordertoexpeditethetransferofpatientstothesefacilitieswhenwarranted.Inaddition,thePM&Rspecialistmusthaveanextensiveworkingknowledgeofthemilitarydisabilitysystem,toincludetraininginwritingmedicalevaluationboards,counselingpatientsonthephysicalevaluationboardprocess,andwritingphysicalprofiles.Mostpatientsadmittedtotheinpatientrehabilitationunitrequirecomplexdispositiondecisionsandextensiveadministrativeprocessing.ItisthePM&Rspecialistthatmustensureallnecessaryrequirementsarecompletedtoensurethatoptimallong-termcareisprovidedtothepatient,whetherthepatientisreturnedtodutyortransitionedtoaVAfacility.CARINGFORTHEAMPUTEEExperiencegainedduringOEFandOIFhasfurtherhighlightedthespecialandcomplexneedsofcombatamputees.Thesepatientspresentuniquechallengesbecauseofthenatureoftheirwoundsaswellastheextentoftheircomorbidities.Complexdecisionsastotheneedandoptimallengthofresiduallimbrevisions,woundmanagement,painmanagement,timingforprostheticfittingandweightbearing,typesoftherapy,appropriateprostheticcomponents,etc,requireamultidisciplinaryteamapproach.Tohelpfacilitatethisapproachandachieveoptimalcareforthesepatients,itisbesttocreateanindependentamputeeservice.AtWRAMCthisservicefallswithintheDepartmentofOrthopedicsandRehabilitation,withPM&Rservingasthesupervisingattendingphysician.TheamputeeserviceisdesignedtobesimilartotheInpatientRehabilitationService,withtheadditionoforthopaedistsandcertifiedprosthetists.TheprocessofechelonVcareofthecombatamputeeinpresentedinthefigure.ELECTRODIAGNOSTICEVALUATIONSThePM&RSpecialistisalsoskilledinperformingelectrodiagnostictestingtoincludenerveconductionstudies(NCS)andneedleelectromyography(EMG).Itiscommonforcombatcasualtiestosustainmultipleextremitywoundsthereforejeopardizingtheperipheralnervoussystem.Acompleteandaccurateassessmentoftheperipheralnervoussystemisneededtomakebettermedical,surgical,andrehabilitativedecisions.Itisoftendifficulttomakeaccurateclinicalassessmentsoftheperipheralnervoussystemincombatcasualties,giventheextensivenatureofthewounds,particularlythoseresultingfromblastinjuries.Inthesesituations,electrodiagnostictestingcanbeveryhelpful.Determinationsofcentralratherthanperipheralnervelesion,androotratherthanplexusinjuryarepossiblebyaskilledelectrodiagnostician.Finally,resultsfromelectrodiagnostictestingprovideinputondevelopingprognosis.Performingelectrodiagnosticexamsonthecombatcasualtyisoftenchallenging,consideringtheextentofsofttissueinjurythathasoccurred.Inaddition,thepresenceofswellingand/oranexternalfixationdevicefurtherincreasesthedifficultyinperformingtheseproceduresandinterpretingtheirresults.ItisthereforeimperativeforthePM&Rspecialisttohaveexperienceamongthistypeofpatientpopulation.AMBULATORYCASUALTIESWhilemuchattentionispaidtothemultitraumavictim,agreaternumberofSoldiersreturnfromtheaterwithnon-life-threateningmedicalproblems.Asignificantamountoftheseproblemsinvolvethemusculoskeletalsystem,especiallytheneck,back,shoulder,andknee.Themajorityoftheseinjuriescanbeattributedtoacutemacro-traumaorrepetitivemicro-trauma.Asignificantportionofthesepatients,however,presentwiththeexacerbationofapreexistentconditionthatwasaggravatedbytheextraordinaryphysiological,psychological,andsocialdemandsandstressofcombat.Soldierswhoareunabletocontinuewiththeircombatmissionbecauseofanon-life-threateninginjuryareevacuatedtotheUnitedStatesinanonemergentstatus.Theseverityofinjurieswilldictatetheirtriagestatus.PatientswithlesssevereinjuriesmaynotarrivetoanechelonVfacilitylikeWRAMCforseveralweeksorevenmonths.OftenthesepatientshavealreadyspentmanydaysintransitbeforearrivingattheechelonVfacility.Itiscounterproductivetopursueanextensivemedicalevaluationofthesepatientsupontheirarrivalinthemiddleofthenight.Itismuchmoreeffectiveandefficienttoallowtheseambulatorypatientstogetagoodnightssleep,shower,andamealpriortotheirevaluation.ItisthereforeimperativetoidentifyahousingfacilityinreasonableproximitytotheechelonVfacilitythatishandicapaccessible.Inaddition,priorarrangementsmustbemadetohaveclothing,shoes,OrthopaedicsandRehabilitationattheWalterReedArmyMedicalCenter

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JanuaryMarch200747 ArrivalatWalterReedArmyMedicalCenter Triage:Orthopaedics,Surgery,Medicine TemporaryLodging PM&R*ClinicNextmorningappointmentAddressmedicalandrehabilitationneedsInitiateconsults MedicineGeneralSurgeryIntensiveCareUnits(surgical,medical)OrthopaedicsNeurosurgery PM&R*AmputeeService PM&R*ConsultWithin24hoursEnsurephysicaltherapy,occupationaltherapy,psychiatry,painand/orsocialworkcasemanagementinitiatedCoordinatetransfertoAmputeeServicewhenappropriate(goalunder72hours) AmputeeInpatientService(PM&R*)ComprehensivecareMultidisciplinarymeetingsMedicalEvaluationBoarddecisionsTrackwithcasemanagement inpatient ReturntoDuty VeteransAffairsSystem TricareNetwork PM&R*AmputeeClinicEveryWednesdaymorningtomonitor:MedicalproblemsProstheticfittingTherapyDisposition(medicalorphysicalevaluationboards,returntoduty) outpatient SoldierdesiresPM&R*follow-up(3,6,9,12months)orassessmentforReturntoDuty VeteransAffairsSystemorTricareforlifelongmanagement ProcessflowforamputeecareattheWalterReedArmyMedicalCenter*PhysicalMedicineandRehabilitationService

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48ArmyMedicalDepartmentJournalOrthopaedicsandRehabilitationattheWalterReedArmyMedicalCenter PART4OCCUPATIONALTHERAPYCOLWilliamJ.HowardIII,SP,USACOLWilliamC.Doukas,MC,USAOccupationaltherapyspecialistsarepartofthelargerteamresponsibleforassistingOperationsIraqiFreedom(OIF)andEnduringFreedom(OEF)Soldiers,Sailors,Airmen,Marines,CoastGuardsmen,andtheirfamiliesinrehabilitationforreturntothehighestleveloffunctionpossible.Specifically,occupationaltherapyaddressesdeficitsinactivitiesofdailyliving,upperextremitymotorperformanceandmealsfortheseindividualsuponarrivalastheytypicallyarrivewithonlytheclothestheyhadwhentheywereremovedfromthebattlefield.AmbulatorypatientswithmusculoskeletalproblemsareinstructedtoreporttothePM&Rclinicthemorningfollowingtheirarrival,whereacompleteevaluationmaybeperformedtoincludeobtainingappropriatefurtherstudies(radiographic,laboratory,electrodiagnostic)aswellasarrangingreferralstoothermedicalspecialtiesorhealthcareprofessionals.Prearrangementsmustbemadewithorthopaedics,physicaltherapy,occupationaltherapy,psychology/psychiatryandsocialworktoensureeasypatientflow,astheseserviceswillbemostoftenneeded.Inaddition,theevaluatingPM&RspecialistmusthaveagoodunderstandingoftheairevacuationsystemandtherequirementsofthePatientAdministrationDivision,whichisresponsibletotrackpatients,issuetheirmilitaryorders,andmaketransportationarrangementsforreturntotheirhomedutystationormobilizationsite.TheprocessfordispositiondecisionsonSoldiersintodaysmodernarmyisextremelycomplex.NotonlydotheseSoldierspresentwithdifferentmedicalproblems,butmostalsohaveuniquesocialsituations.ThisespeciallyholdstruefortheNationalGuardandactivatedArmyReserveSoldiers,whosefamilymaybeinonestate,theirunitinanother,andthedemobilizationsiteinevenathird.ItisgenerallybesttomoveeachSoldiertohis/herdemobilizationsiteasquicklyaspossible,providedappropriatemedicalandtherapyfacilitiesareaccessibleandarearrangedpriortotheSoldiersdeparturefromtheechelonVfacility.ItisalsogenerallybestforthePM&RSpecialisttoensureacompleteandcomprehensivediagnosticworkupiscompletedandanappropriatetreatmentplanisestablishedpriortoallowingaSoldiertoleavetheechelonVfacility.ConflictsariseastheseinjuredSoldiersrequestconvalescentleavetovisittheirlovedones.Toaddressthisissue,itishelpfultohaveanestablishedpolicytoensureSoldiersaretreatedfairly,butatthesametimeensuresaccountabilityandtrackingofSoldierswhomayotherwisebelosttomedicalfollow-up,orwhomaycompromisetheirmedicalrecoveryiftheyarenotcompliantwiththeestablishedtreatmentprogram.Ingeneral,echelonVhospitalconvalescentleaveshouldnotbegrantedtotheseSoldiersunlesstheymustreturnforfollow-upatthatfacility.Inthissituation,thehospitalcommandmaygrantupto30daysasindicatedbythetypeofinjury.AllotherSoldiersshouldbereturnedtotheirdemobilizationsiteordutystation,wheretheirrearunitmaygrantunitconvalescentleavebasedontheneedsoftheunitaswellastheavailabilityofmedicalcareattheirleavelocation.AUTHORS LTCPasquinaisChief,PhysicalMedicineandRehabilitation,andMedicalDirector,AmputeeProgramattheWalterReedArmyMedicalCenter,Washington,DC.LTC(P)GambelisChiefoftheAmputeeClinicattheWalterReedArmyMedicalCenter,Washington,DC.LTCFosterisAssistantChiefofPhysicalMedicineandRehabilitation(PM&R)ServiceandChiefoftheOutpatientClinicinPM&RattheWalterReedArmyMedicalCenter,Washington,DC.Whenthisarticlewaswritten,MAJKimwasDirector,InpatientAmputeeRehabilitationServiceattheWalterReedArmyMedicalCenter,Washington,DC.COLDoukasisChairman,DepartmentofOrthopaedicsandRehabilitationattheWalterReedArmyMedicalCenter,Washington,DC.

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JanuaryMarch200749deficitssecondarytoinjuryordiseaseandoccupational,orroleperformancedeficitsduetomental/behavioralhealthconditions.Occupationaltherapistsandcertifiedoccupationaltherapyassistantsworkwithahostofotherprofessionalsincluding,butnotlimitedto,physicaltherapists,physiatrists,orthopedicandgeneralsurgeons,neurosurgeons,psychiatrists,socialworkers,nursecasemanagers,prosthetists,orthotists,andnursestoprovidethehighestqualityofcarethroughoutthetreatmentcontinuum.INPATIENTOCCUPATIONALTHERAPYOccupationaltherapyreceivesconsultsonOIFandOEFpatientsfromsurgicalservices,primarilyorthopaedics,andgeneralsurgery.Theseconsultsusuallyarereceivedwithin24hoursofthepatientbeingadmittedtoWalterReedArmyMedicalCenter.ThereisusuallyawarningoranticipatorynotificationfromtheChief,DepartmentofOrthopedicsandRehabilitation,onpatients,particularlyamputees,comingthroughtheairevacuationsystemwhichprovidessomeabilitytoprojectworkloadinamputeecare.Onceconsultsarereceived,patientsareevaluatedwithin24hours.Theteamresponsibleforamputeecareseespatientswithupperandlowerlimbamputations.Thisteamconsistsof2occupationaltherapistsand2certifiedoccupationaltherapyassistants.Theteamisaugmentedasneededwithadditionalstaffdependingontheworkload.Theinpatientorthopedicandrehabilitationsectionsseepatientswithothertraumaticinjurieswithoutamputations.EvaluationandtreatmentsforphysicallyinjuredpatientsaredonebothonthewardsandintheOccupationalTherapyClinic.Patientsevacuatedfromthetheatersofoperationswithmental/behavioralhealthconditionsarealsoseenonthewardinaninpatientstatus,andintheOccupationalTherapyClinicasoutpatients.Patientswhosustainamputationsasaresultoftheirinjuriesrequirespecializedcare.Thisspecializedcareinvolveswoundmanagement,preprosthetictrainingandprosthetictraining(basicandadvanced).Factorsinvolvingresiduallimbcareintermsofstrengthening,regainingrangeofmotion,andactivitiesofdailylivingoccurwithineachphase.Typically,amputeeinpatientsareinphaseIpreprostheticcareandtraining.ThosepatientsfromOIFandOEFwhosustainedsignificanttraumanotresultinginamputationsareseenfortheremediationoftheirdeficitsusingstandardoccupationaltherapymethodsandprotocols.Initialevaluationandtreatmentisfocusedonassistingpatientsinreachingindependenceinactivitiesofdailyliving,aswellastheremediationofwhatevermusculoskeletalsystemhasbeenaffected.OccupationaltherapyispartofthemultidisciplinaryteamwhichseesthoseOIFandOEFpatientswhoareundergoingtreatmentformentaland/orbehavioralhealthconditions.Patientsrequiringinpatientcareareseeninamilieumodeloftreatment.OutpatientOIFandOEFpatientsareseenaspartofthePartialHospitalizationProgram(PHP).Thisisaspecializedoutpatientprogram,whichispartofthePsychiatryDepartmentsContinuityServices.AlifeskillgroupfromOccupationalTherapyServicesisapartofthePHP.OUTPATIENTOCCUPATIONALTHERAPYMostpatientsfromOIFandOEFwhoareseenforoutpatientcarehavebeeninpatientsandareseenwithin48hoursofdischargefromthehospital.ApatientwhoisevacuatedtoWalterReedArmyMedicalCenterasanoutpatientandwhoisinneedofOccupationalTherapyisseenwithin72hoursorless(usually),onceareferralhasbeenreceived.Theevaluationandtreatmentprocessissimilartothatofinpatients.LESSONSLEARNEDTheinitialoccupationaltherapyproceduresforcareofOIFandOEFpatientshadseveralinefficiencies.Theamputeepatientswereevaluatedandtreatedbymultiplestaffmembers,aprocesswhichlackedconsistencyandwassomewhatinefficient.Solution:AdedicatedOccupationalTherapyAmputeeSectionwascreatedinlateAugust2003.Thiscentralizedthecaretoagroupoftherapistswhoprovideconsistentevaluationandtreatmenttoallamputees.Thisteamconsistedof2occupationaltherapistsand2certifiedoccupationaltherapyassistants.Therewasonemilitarytherapistandonemilitaryoccupationaltherapyassistantwhowillrotatewithothermilitarystaff,allowingcrosstrainingofalloccupationaltherapystaffovertime.Thisteam-basedprocessallowedbettersynergywiththelarger

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50ArmyMedicalDepartmentJournalAmputeeCareCenterworkingcloselywithprosthetists,physicaltherapists,andthephysicianstaff.Aprotocol/treatmentpathwaywasdevelopedtoprovideanobjective,reproduciblemethodforamputeecarewithallupperextremityandlowerextremityprosthetics,frompreprosthetictrainingtodischarge.ClosecoordinationwiththecontractpersonnelfromtheProstheticsLaboratoryhasresultedinasolidteamapproachintheupperextremityprostheticsfittingandtrainingofSoldiers,andintheeducationoftheirfamilymembers.Experiencewiththegroupsofpatientsfromthe AfghanistanTheaterinthefallof2001through2002madeitclearthatthetypeofrehabilitationthesepatientsrequiredmustincludeamorecomprehensiveeffortintheareaofactivitiesofdailyliving.Solution:InJune2003,renovationswerecompletedforpartoftheOccupationalTherapyClinictoaccommodateanapartment-typeareaforactivityofdailylivingtherapy.Thisareaisheavilyused,providingtheOIFandOEFpatientsaplacetopracticeskillsnecessarytoreturntoindependentfunctioning.Theapartmentallowspatientstobecomeindependentinpersonalhygiene,transfers,cooking,householdcleaning,andcomputeruse.CONCLUSIONThecareofSoldiersfromOIFandOEFisahighhonor.Thenatureofbattlefieldinjuriesrequiresmorecomplexandtime-intensiveevaluationsandtreatments.ItalsorequiresastrongmultidisciplinaryteamofdedicatedprofessionalstoaddressallaspectsoftheSoldierwhowasinjuredinthedefenseofourcountry.TheamountofeffortnecessaryfromthenumerousprofessionalsinvolvedintherehabilitationoftheseSoldierscannotbemeasuredintimeormoney.Thetruemeasurementisseeninthededicationandcaringofatrulyworldclassmilitarymedicalteam,fromthebattlefieldtothemedicalcenter,withtransitionbacktoactiveduty,ortotheVeteransAffairssystemtoassistwithmainstreamingintotheworkforceasproductivemembersofsociety.AUTHORS COLHowardisChief,OccupationalTherapyClinicandAssistantChief,PhysicalMedicineandRehabilitationServiceattheTriplerArmyMedicalCenter,Honolulu,HI.COLDoukasisChairman,DepartmentofOrthopaedicsandRehabilitationattheWalterReedArmyMedicalCenter,Washington,DC. TheWalterReedArmyMedicalCenter,Washington,DC.OrthopaedicsandRehabilitationattheWalterReedArmyMedicalCenter

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JanuaryMarch200751TherootsoftheprofessionofoccupationaltherapycannotbeseparatedfromtheArmy,forthehistoryoftheprofessionisintertwinedwiththehistoryofmilitaryhealthcare.Occupationaltherapyisthetherapeuticuseofpurposefulandmeaningfuloccupationstoevaluateandrestorefunctionandindependence.Inherentinthisdefinitionistheimportanceofoccupationandpurposefulactivity.Itissignificanttonotethattheseactivitiesarenotmerelyselectedatrandom.Rather,theoccupationaltherapypractitionerselectsthoseactivitiesthatarebestsuitedtothepatient/Soldierscurrentleveloffunctioninordertoensuresuccessfulcompletion.Thisbeliefisthebasisonwhichtheprofessionwasfounded.Althoughthebenefitsoftheuseofactivityhavebeenacknowledgedovertheyears,theselessonstendtobeforgottenuntilatimeofcrisis.Sotooisthecasewiththedevelopmentofoccupationaltherapy.Asthispaperillustrates,thenumbersofoccupationaltherapistsdeclineduringtimesofpeace.Thenawarnecessitatesanincrease,andtrainingprogramsaredevelopedinanattempttofilltheranks.AGEOFENLIGHTENMENT1780STO1880SThelate18thcenturyheraldedtheAgeofEnlightenmentandMoralTreatment.Duringthisperiod,DrPhilippePinelusedactivitiestotakethepatientsthoughtsawayfromtheiremotionalproblemsanddeveloptheirabilities.1Pinelwasaphilosopher,scholar,naturalscientist,andphysicianwhosawthebenefitofusingactivitiesinthetreatmentofthementallyill.Thiswasadrasticchangefromtheacceptedpracticeofplacingpeoplewithmentalillnessinchains.Itwasfeltthatpeopleneededapredictableroutinetoallowthemtofunctionoptimally.Inanefforttohelpthemmanagetheirenvironment,physicalexercise,andworkwasbelievedessentialandanecessarypartofeveryinstitutionsprogram.1Additionally,inareportsignedbyDrHenryM.Hurd,theuseofoccupationwasfoundtobeasuccessfulsubstitutefortheuseofrestraints.2Bytheendofthe1880s,MoralTreatmentwasdiminishinginfavorofalesscostlyformofcustodialcare.3Priortoitsendthough,aphilosophyemergedthatwasbasedonCivilWarexperiences.Thisphilosophyheldthatthebestmeansofpreventingnostalgia[battlefatigue]wastoprovideoccupationforthemindandbody....4ThisphilosophyalsostatedthatSoldiersplacedinhospitalsneartheirhomesaremorelikelytodevelopnostalgiathanthosewhoremainneartheirunitsfortreatment.4Itisimportanttonotethattheseideaswillberepeatedinthe20thcenturywiththedevelopmentofcombatstresscontrolunits,andwillbediscussedlater.Asthisillustrates,evenwiththeendofMoralTreatmenttherewerestillthosewhoheldfirmtotheirbeliefinthebenefitofoccupation. TheGrowthoftheProfessionofOccupationalTherapyMAJSharonNewton,AN,USAABSTRACTOccupationaltherapyisafrequentlyunknownandmisunderstoodprofession.However,occupationaltherapypractitionershavearichhistoryintheUSArmy,fromtheinceptionoftheprofessiontocurrentchallenges.ThearticleisachronicleofhistoricalhighlightsofoccupationaltherapywhichdiscusseshowthishistoryisharmoniouswiththatofoccupationaltherapyintheUSArmy.Inresearchingthistopic,severalconceptsemerged:(1)occupationaltherapygrewfromabeliefthatpeopleneedoccupation,oractivity,toremainhealthy;(2)peoplelearnthebestthroughpurposefulactivity;(3)thenumberofoccupationaltherapistsintheUSArmydecreasesduringpeacetime,butintimeofwarthebenefitofthisprofessionisrecognizedanditsnumbersincrease;(4)althoughmodelsofhealthcarechange,theprimaryfocusofoccupationaltherapyremainsconstant;and(5)thereisadirectcorrelationbetweenthephilosophyofoccupationaltherapyandthephilosophyoftreatingSoldierswithcombatstressreactions,ago-to-warmissionofArmyoccupationaltherapypractitioners.Assuch,themanagementoftheseSoldiersisenhancedbytheuniqueskillsofferedbythisprofession.

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52ArmyMedicalDepartmentJournalTheperiodfrom1890to1910becameknownastheArtsandCraftsMovement.AgreatinfluenceearlyinthisperiodwastheHullHouseLaborMuseum.5Thegeneralideaofthistimewasthatoccupationshouldbeusedasameansofeducationtosubstituteforcustodialcareofthementallyill.5Tosupportthistreatment,acourseforplayandoccupationwasestablishedfornurses.2JustastheeraofMoralTreatmentended,sodidtheArtsandCraftsMovement.By1910,thenumberofmedicalschoolswasincreasingandthefocusofpatienttreatmentturnedtoamorescientificstudy.5Occupationaltherapywasnotyetaprofessionperse,butthefoundationhadbeenset.JustastheCoastalRedwoodcangrowfromtherootsofotherredwoods,occupationaltherapygrewfromtherootsofotherprofessions.THEWARTOENDALLWARSManyofthefoundersofwhatwastobeknownasoccupationaltherapystillbelievedthatactivityworked.5Forexample,anursenamedSusanTracypublishedapaperinwhichapremiumwasplacedontheadoptionoftheoccupationtotheconditionandnaturaltastesofthepatient.2Thiswastosetanotherpieceofoccupationaltherapysfoundation,thatofadoptingtheactivitytotheneedsandabilitiesofthepatient.WhentheUnitedStatesenteredWorldWarI(WWI)in1917,thisconceptofre-educatingpeoplewiththeskillsneededtoenablethemtobecomeeffectivemembersofsocietywaslaudedasthebestmeansoftreatment.6Infact,theCivilServiceCommissionrecognizedoccupationaltherapyastheprofessionthatcouldprovidethisservice,andadmittedoccupationaltherapiststoserveasReconstructionAidesintheArmyMedicalDepartment.7Theeffortsofthesefirstoccupationaltherapistsweretorestoreacutepsychiatriccasualtiesandpatientswithimpairedmotorfunctionbyteachingcrafts.Thesepioneersinthefieldwerecallednondescriptasfewpeopleknewwhattheydid,6whichcontinuestobeproblematictoday!Apparentlytheirbenefitwasfelt,though,as24civilianReconstructionAidesweredeployedtoFranceinsupportofthewareffort.7Thisfirstreconditioningprogramemphasizedthatactivityshouldbeprescribedearly,aswithourcurrentdoctrineofcombatstresscontrol.6In1918,theArmySurgeonGeneralexpandedtheemergencytrainingprogramstosevencivilianinstitutionsinanefforttofilltheneedforReconstructionAides.7Inadditiontoworkingwithneuropyschiatricpatients,theprofessionsoontobeknownasoccupationaltherapytreatedpeoplewithamputations,blindness,headandnerveinjuries,osteomyelitits,andtuberculosis.6Theideaofprovidingactivityappropriatetotheneedsofthepatientswasstillvital.In1919,ArmyMAJBirdT.Baldwindescribedtheuseofactivityanalysis,whichwashowtheappropriatenessofanactivitywasdetermined.Thisstrongsupporteroftheprofessionstatedthatthepurposeofoccupationaltherapyistohelpeachpatientfindhimselfandfunctionagainasacompletemanphysically,socially,educationally,andeconomically.8Therootsofoccupationaltherapybegantoestablishthemselvesandthefoundationofanewprofessionwasset.BytheendofWWI,thenumberofoccupationaltherapyReconstructionAidesservingwasanastounding455,butby1919mostoccupationaltherapistsemployedbytheArmyweredischarged.7THEWORLDATPEACEAPROFESSIONGROWSInanefforttotreattheveteransofWWI,theemphasiswasonvocationalrehabilitation,withtheFederalBoardofVocationalRehabilitationprovidingoccupationaltherapyservices.7However,by1920thetherapeuticuseofworkwaspartofphysicalrehabilitationinsteadofvocationalrehabilitation,whichresultedinoccupationaltherapistsbeingcut-offfromworkrelatedprograms.5EventhoughthenumberofoccupationaltherapistsservingwiththeArmydiminished,theprofessiondidnotdieitsrootsspreadandthetrunkthatwastobecomeoccupationaltherapybegantogrow.Amajorsteptowardthisgrowthoccurredin1922whenDrAdolphMeyerwrotewhatwastobecomethephilosophyoftheprofession.2Threemainideasservedasthebasisofthisphilosophy.Onewasthatpeopleneedabalanceofwork,rest,play,andsleepinordertofunctionwithnormallives.9Whenthisbalanceisdisrupted,beitthroughdisease,injury,orcombat,dysfunctionresults.Thesecondideawasthatofthemind-bodyconnection.2DrMeyersupportedthelesspopularbeliefthatthemindandthebodycouldnotbeseparated,thatoneaffectedtheotherinrelationtoTheGrowthoftheProfessionofOccupationalTherapy

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JanuaryMarch200753illness.Thethirdideawasthatpeoplelearnbestbydoingthings,orthroughoccupation.9Thisdescribedthebeneficialuseofappropriateactivitythathadbeeninherentinthetreatmentofpeoplesincethelate18thcentury.Theprofessionsawotherchangesaswellasthisrollercoasterofeventsthunderedonward.ThetermReconstructionAideswaschangedin1926tophysiotherapyandoccupationaltherapy.6Onlyafewyearslater,duringthel930s,amodelbasedontheorthopedicneedsofthepatientbegantoevolve.5Occupationaltherapistswerethenalsoworkingwithmusclestrengtheningandmaintainingjointrangeofmotion.AstheDepressionendedandthenationwasrecovering,changeswereexperiencedinoccupationaltherapyaswell.In1933,thetrainingcourseatWalterReedArmyMedicalCenterwasabolishedsecondarytoalackoffunds,andoccupationaltherapyprogramsandpersonnelinallpermanentArmyhospitalswerereducedtoaminimum.9WORLDWARIIOnceagainhistoryrepeatsitself.Thenationfounditselfatwarandtheprofessionofoccupationaltherapyfounditsnumbershaddwindledtoalmostnothing.WhentheJapaneseattackedPearlHarboronDecember7,1941,therewereonly9occupationaltherapypractitionersaffiliatedwiththeArmy,andonly3ofthosewerequalifiedregisteredtherapists.9Itcomesasnosurprisethatthebigconcernatthistimewastherecruitmentofqualifiedtherapistsandtheestablishmentofaccreditedtrainingprogramstomeetthisneed.10Althoughthenumberofpersonnelwassmall,thebenefitsoftheprofessionweregreat.TocontinueouranalogywiththeCoastalRedwood,therootshadspreadandestablishedthemselves,andthetrunkbegantoshootupward.TheperiodduringWorldWarII(WWII)foundseveralsupportersofoccupationaltherapy.Amongthemwasaphysician,MAJWalterBarton.Hestronglybelievedthatwork,rest,andplayactivitiesrepresentedtheessentialtriadfortherestorationofhealth,andrecommendedoccupationaltherapydepartmentsestablishprogressiveactivityprograms.10Occupationaltherapy,henoted,shouldbeappliedatallpointsoftreatmentfromforwardtheechelonaidstationtothelastpointofevacuationinthepsychiatricsectionofanamedgeneralhospital.11Theimportanceofmeaningfulactivityandconstructiveworkwascontinuallystressedasamethodoftreatingtherestlessnessgeneratedfrominactivity.Peoplewanttofeeluseful.ItwasfrequentlyobservedthatSoldiershadanintuitiveneedforoccupation,andbecamewillingtoperformworkiftheyvieweditatleastindirectlysupportiveofthewareffort.10AnothersupporterwasLTCAlanChallman(MedicalCorps)andtheconsultanttoneuropsychiatryinthesouthwestPacificarea.In1942,hewaschargedtoreviewtheorganizationofpsychiatricservicesandcreateanapproachthatcouldreverseanalarmingtrend:theSurgeonGeneralsofficedeterminedthatpsychiatriccasualtiesconstitutednearly40%ofthemedicaldischargesbeingprocessedbytheArmy-asituationviewedasintolerableandunnecessary.10LTCChallmanfoundthatSoldierswithmentaldisabilitiescouldbebettertreatedandmoreappropriatelydiagnosed,withmoreofthemrestoredtoduty,iftheyweregivenspecializedhelpthatincludedoccupationaltherapy.Thiswasbasedonhisfindingthatpatientswhohadbeengivenupforlostbythewardofficermadecompleterecoverieswhenprovidedpurposefulactivitysuitedtotheirabilities[italicsadded].10Eventhislevelofsupportwasnotenoughtocounteractthelownumberofqualifiedoccupationaltherapists,anditwasdeterminedearlyinthewarthattheywouldnotbemilitarypersonnel.ThismeantthatalloccupationaltherapyactivitieswouldbeconfinedtotheZoneoftheInterior,whichinrealityhinderedtherecruitmentofadequatepersonnel.9LikesomanyAmericans,occupationaltherapistswantedtoservetheircountry.Infact,theactualneedforoccupationaltherapistsdidnotmeettheperceivedneed.Inresponsetothislackofqualifiedoccupationaltherapists,aWarEmergencyCoursebeganinJuly1944bytheOccupationalTherapybranchoftheSurgeonGeneralsOfficeinconjunctionwiththeAmericanOccupationalTherapyAssociationandWarManpowerCommission.6Thiswasanaccelerated12-monthprogram,withmorehoursdevotedtothesciences,clinicalconditions,andthetheoryofoccupationaltherapythantoartsandcrafts.Theneedforastrongknowledgebaseinpsychiatricconditionswasrecognized,but,duetotheshorttrainingperiod,itwasmadeaprerequisitetoattend.Intheinterim,

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54ArmyMedicalDepartmentJournaloccupationaltherapistssupervisedRedCrossvolunteersinthecraftprogramsotheprovisionofthisvitalactivitytotheSoldierswasnotlost.5However,by1945alltreatmentwastobeofafunctionalnature,notmerelydiversional.Craftswerenolongerconfinedtothebed,butbroughttotheclinics.6Thismeantthatalltreatment,eventheuseofcrafts,neededtobedevelopedand/orsupervisedbyaskilledoccupationaltherapist.Thiscreatedanevengreaterstrainonthesmallnumberofoccupationaltherapists.DuetotheWarEmergencyCourse,thenumberofoccupationaltherapistscontinuedtorise,andthetypesofprogramsprovidedexpandedinnumber.TheTableillustratessomeoftheareasoftreatmentandthetypeoftreatmentprovidedbyoccupationaltherapiststowardtheendofWWII.Althoughavarietyofconditionswerebeingtreated,thebasicpremiseofusingpurposefulactivitygradedtotheindividualscurrentleveloffunctionremainedthesame.Additionally,theareasoftreatmentweredividedinto4mainprograms:91.FunctionalPrograms:Theseprovidededucationandtraininginself-care,andaddressedgeneralbodyweakness,jointrangeofmotion,anddecreasedrespiratorytolerance.2.NeuropsychiatricPrograms:Personsintheseprogramswerenotonlypsychiatricpatients,butalsothosewithpsychoneurosissecondarytothestressofwar.Manyoftheideasintheseprogramswouldbeseenagaininthedoctrineforthemanagementofcombatstressreactions,12suchastheneedforimmediatetreatmentbeingessential.Thepurposeoftheseprogramswasmultifaceted:(1)toguidementalattitudesintohealthychannels,(2)promotethedesiretogetwell,(3)restoreself-confidenceandasenseofsecurity,(4)provideencouragementoftheSoldierimproving,(5)establishandmaintaingoodworkhabits,and(6)affordanopportunityforsocialization.OnecanrecognizeintheseideassimilaritiestotheArmyscurrentdoctrineonthemanagementofSoldierswithbattlefatiguerest,replenishmentofphysiologicalneeds,reassuranceofnormalcyandreturntoduty,andrestorationofconfidence.123.IndustrialTherapyPrograms:Theseprogramswereprovidedasthepatientprogressed.Theyappliedtomedical,surgical,andneuropsychiatricpatients,addressingthephysicalaswellasthepsychologicalneeds.Thepurposewasnotonlytoincreasegeneralmuscletoneandjointrangeofmotion,butalsotocombattheeffectsofaprolongedhospitalization.Inthisprogram,patientswereabletoimprovetheirtolerancetowork,establishgoodworkhabits,andstimulatementalalertness.4.DiversionalPrograms:Thepurposeoftheseprogramswastodivertthepatientfromthinkingofhimself.However,thebenefitsdidnotstopthere.Theystimulatedthepatientsinterestandprovidedconstructiveuseofleisuretime.Byprovidinganopportunityforself-expression,theSoldiersmoralewassustained.Inaddition,thepatientsworkhabitsweremaintainedandhisgeneralphysicalfitnesswouldimprove.TheGrowthoftheProfessionofOccupationalTherapy TypesofOccupationalTherapyTreatmentin1945DiagnosisTreatmentHeadinjuryCognitiveretraining,languagetrainingOrthopedicExercisethroughpurposefulactivityPlasticsurgeryFunctionaltherapy,diversiontherapyGeneralmedical(polio,cardiac,etc)Gradedactivitiestocreateasenseofindependence.Hobbydevelopment,muscletonemaintenance,functionaluseofupperextremity,restorationofself-confidenceNewlyblinded,deafOrientation,activitiestocreateasenseofindependenceandself-confidenceinperformanceofself-care,etcSpinalcordinjury,paralysisAdaptationtoallowperformanceofdailyactivitiesindependently,improvestrengthinfunctionalmusclesAmputeeAddressedthepsychologicalaspect,functionaluseofprosthesisandremainingupperextremityTropicaldiseaseMainlyactivitiestocounterboredom,apathy,anxiety

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JanuaryMarch200755ABRIEFPEACEGREATPROGRESSInthe5yearsbetweenwarstherewere2majoraccomplishmentsfortheprofession.Becauseofthediversityofprogramsofferedbyoccupationaltherapy,andtherecognitionofthebenefitsoftheservicesprovided,occupationaltherapistsfinallybecameapartoftheArmy.In1947,occupationaltherapistswerecommissionedasofficersintheUSArmywiththeestablishmentoftheWomensMedicalSpecialistCorps,whichalsoincludedphysicaltherapistsanddietitians.6Then,in1949,postgraduateprogramsforoccupationaltherapistswerereinstatedformilitarypersonnel.7Thisisthefirsttimeatrainingprogramforoccupationaltherapywasinstitutedbeforetheneedbecamegreat.Asfarasthemilitarywasconcerned,occupationaltherapyhadbecomeanentityuntoitself,liketheCoastalRedwoodthatgrewintoamaturetree.Nevertheless,theyearsofpeacewereshort-livedastheUSbecameinvolvedwiththeKoreanWar.THEFORGOTTENWARANDBEYONDTheperiodof19501953sawadrasticslowingofthegrowthanddevelopmentofoccupationaltherapyintheUSArmy.Thenumberwasdownfromthe899therapistsseenattheendofWWII,toaround90womenservingin1953.6Onechangeseen,however,wastheresurgenceofthedominanceofthepsychiatricmodel.5AfterthetrucetohalttheKoreanWarwassigned,occupationaltherapistscontinuedtoworkprimarilyingeneralhospitals.By1954,theywereworkinginadditionalareasoftreatmentsuchaswithburnpatientsandthoseinvolvedinsubstanceabuse.13Occupationaltherapistsalsoreturnedtobeingalargepartofworkrelatedprograms.5Thebiggestchangeseenduringthisperiodwasin1955,whenmenwerefirstallowedtoserveasoccupationaltherapists.OfcoursethisforcedachangeinthenamefromtheWomensMedicalSpecialistCorpstotheArmyMedicalSpecialistCorps.7ATURBULENTDECADEThe1960swereatimeofturbulenceandchange,notonlyfortheAmericansocietyingeneralbutfortheprofessionofoccupationaltherapyaswell.Itisnosurprisethat,withthereemergenceofthepsychiatricmodelduringthelastdecade,humanismreturned.Theeffectthishadoncivilianoccupationaltherapistswasdrastic,forthewaytheytreatedtheirpatientshadtochangeasmorepeopleweredeinstitutionalized.5Onceagain,Armyoccupationaltherapistssawachangeintheirnumbers.OccupationaltherapyauthorizationsdecreasedinordertomakeslotsavailableforotherArmyofficers.Thenumberofoccupationaltherapistsdroppedtoamere64in1960.6Thefirsthalfofthe1960ssawabuildupofUSmilitaryadvisorsinVietnam.14Thetrainingofoccupationaltherapistswitnessedasimilarbuildupwiththestartofastudentoccupationaltherapyprogramin1962.7Thedecadeendedwiththequestioningofmanyestablishedbeliefs.Theideaofhumanismwasbeingchallengedonceagainin1970.Itwasfelttobeunscientificandimmeasurable,5andamedicalmodelwasenvisionedasareplacement.Asaresult,theroleofArmyoccupationaltherapydevelopedamedicalfocusaswell.Inthemid1970saskillidentifierwasestablishedwhich,withadditionaltraining,allowedoccupationaltherapiststoserveasphysicianextendersinthetreatmentofupperextremityinjuries.13Butevenwiththisemphasisonthemedicalmodel,thevalueofoccupationandactivitywasstillrecognized.ALifeSkillsprogramwhichaddressedtheneedsofSoldierswithpsychiatricandstressdisorderswasdevelopedbyoccupationaltherapypractitionersattheEisenhowerArmyMedicalCenter,FortGordon,Georgia,in1974.TheuseofoccupationasamethodtoimprovetheperformanceoftheseSoldierswasparamount.15POST-VIETNAMIntheyearafterthefallofSaigon,theArmyStudentOccupationalTherapyprogramalsoendedduetotheneedtoreallocateactivedutyslots.7Theoccupationaltherapistsusedthistimetotheiradvantageanddevelopedaphilosophyfortheirprofessionin1980.ThisphilosophywasmuchthesameastheonewrittenbyDrAdolphMeyerin1922,forthefoundationhadnotchangedovertheyears.Itemphasizedtheimportanceofthemind-bodyconnectioninthediseaseprocess,andhowoccupationaltherapyaddressesallaspectsofanindividual.Roleperformancewasdiscussedfromtheperspectiveofmaintainingabalanceofwork,rest,play,andsleep.Skillacquisitionwasbelievedtooccurthroughpurposefulactivityandrepetitionofrelevanttasks.16Occupationaltherapistsbelievedthen,aswedotoday,thatthecapacitytoresumeroleperformancemaybeachievedeventhoughsymptomsremain,namelythroughadaptation.10

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56ArmyMedicalDepartmentJournalAninterestinworkprogramsreturnedonceagain.InsteadofmerelyprovidingworkactivitiesforSoldiers,thisconcepthadmaturedtowhereworkhardeningprogramsandjobevaluationswereperformedaswell.5OccupationaltherapistscouldevaluatetheskillsnecessaryforaSoldiertoperformajob,adaptthetreatmenttomatchtheSoldierscurrentleveloffunction,andpreparethatSoldiertoreturntoduty.Theyear1980alsosawanincreasedawarenessofphysicalfitnessintheArmy.Occupationaltherapistsjoinedinthateffortastheybecameactiveinprogramssuchasstressmanagementandweightcontrol.13Someinterestingconceptsreemergedin1984,whentheArmyMedicalDepartmentidentifiedcombatstresscontrolasaseparatefunctionalmissionarea.TheseconceptswereformallypresentedinFieldManual8-5112underthepremisethattheSoldiershouldbetreatedintheproximityofhisunit,immediately,withtheexpectationofhisreturntoduty,andutilizingsimplemethodsofmanagement.Thiswasaccomplishedusingwhatatthattimewerethreemainprinciples:reconstitution,reorientation,andreintegration.Soldierswithcombatstressreactionssevereenoughtoaffectjobperformancewouldperformduty-relatedactivitiesinworkassignments.TheoccupationaltherapypractitionersuniqueroleinthemanagementoftheseSoldiersistoprecipitateadaptiveandeffectiveoccupationalperformancebyengagingthemintherapeuticoccupation[occupationaltherapy]whichsupportstheirmilitaryidentity,reinforcesingrainedadaptiveoccupationalskills,enhancestheirsenseofcompetency,supportstheirsocializedmilitaryvalues,andmaintainstheirphysicalconditioning.17Thisallowedthemtoviewthemselvesascontributingtothemission,whichinturnwouldhastentheirrecoveryandreturntoduty.Inotherwords,theSoldierswouldbeperformingoccupationaltherapy!WatsonandThome18recognizedthissimilaritybetweenArmydoctrineandoccupationaltherapyphilosophy,andproposedaprogramcalledProjectABLE.Thiswasatask-directedbehaviorprogramdesignedtoimprovetheSoldiersjobperformance.Areviseddoctrineofcombatstresscontrolwaspublishedin1994,andsomeoftheprincipleswereupdatedandchangedfromthepreviousedition.12Themethodsofthemanagementofcasualtieswasexpandedandclarified,buttheprimaryconceptsremainedthesame.However,beforetheArmycouldofficiallyinitiatethesemanagementprinciples,DesertShield/DesertStormerupted.Duringthisperiod,activedutyoccupationaltherapypractitionersweredeployedtothePersianGulfandmanyReservistswerecalledtoactivedutytofillstatesideassignments.7LTCMaryLaedtkewasoneoftheoccupationaltherapypractitionersdeployedtothePersianGulf.Whileassignedtothe528thMedicalDetachment(Psychiatric),sheutilizedtheprinciplesofcombatstresscontrolinworkingwithSoldiers.Shereportedthattheuseofworkandotheroccupations[whichwerecarefullyselectedtomeettheSoldierscurrentability]toreturnthecombat-stressedSoldiertodutyprovedtobeanintegralpartoftherestorationprocess.7Sinceoccupationaltherapyistheonlyhealthcaredisciplinetoapproachinterventioninthismanner,LTCLaedtkewasabletodemonstratethebenefitsofoccupationaltherapyinanactivetheaterofoperations.THEWARONTERRORISMTheeventsofSeptember11,2001changedthelivesofcountlesspeople.ThoseinvolvedintheprofessionofoccupationaltherapyintheUSmilitarywerenoexception.Inhisarticle,19ArmyoccupationaltherapistCPTRogerBannonrelateshisexperiencesasamemberofaSpecialMedicalAugmentationResponseTeamforstressmanagement.InthedaysthatfollowedtheattackatthePentagon,CPTBannonutilizedhistrainingandexperienceincombatstresscontrolandcriticalincidentstressmanagementtohelpthevictimsbegintheirrecovery.OperationEnduringFreedomprovidedopportunitiesforoccupationaltherapypractitionerstofurtherdemonstratetheuniqueskillsoftheirprofession.Asamemberofthe528thMedicalDetachment(CombatStressControl)fromFortBragg,NorthCarolina,ArmyCPTRobertMontzservedonateamthatprovidedmentalhealthandpreventiveservicesinUzbekistan,Afghanistan,andPakistan.CPTMontzassistedinprovidingbriefingssuchasstressmanagement,handlinghumanremains,andredeployment.Healsoregularlyvisitedandwalkedthroughthesupportedunitsareas,wherehewasabletoobservetheSoldiersatworkandassesshowtheSoldierswerefunctioning.20TheGrowthoftheProfessionofOccupationalTherapy

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JanuaryMarch200757Anotheruniqueopportunityforoccupationaltherapyemergedthatyearasthe85thMedicalDetachment(CombatStressControl)atFortHood,Texas,beganpreparationstodeployaPreventionTeamtoGuantanamoBay,Cuba,tosupporttheJointTaskForce.Theteamwasledby2occupationaltherapyprofessionals,theauthor,anoccupationaltherapist,andoccupationaltherapyassistant,SSGTRBHoward.ThiswasthefirsttimeanactualcombatstresscontrolpreventionprogramforservicememberswasdevelopedandimplementedonthissmallNavalinstallation.Inadditiontothetypicalworkperformedbycombatstresscontrolteams,theseoccupationaltherapypractitionerswereabletobringtheuniqueperspectiveofoccupationaltherapytothemission.Forexample,whileconductingtheusualwalk-aboutsperformedinconjunctionwithpreventivecombatstresscontrol,Iwouldworkwiththeservicememberstodeterminethestressors,mental,physical,andemotional,thatwerepresentintheperformanceoftheirjob.Educationandactivitiesmeaningfultotheservicememberswereusedtoaddressthevariousstressorsthatarose.Thiswouldsometimesentailstructuringtheenvironmentand/orthejobtoensuresuccessfulcompletionofthetask,and,inoneinstance,ergonomicrecommendationsweremadetomakethejobsaferandmoreefficient.Asthisarticleiswritten,manyoccupationaltherapypractitionersareservinginKuwaitandIraqinsupportofOperationIraqiFreedom.Inadditiontocombatstresscontrolteams,occupationaltherapistsareworkinginfieldhospitalsandonamedicalbrigadestaff,activedutyandreservecomponents.ContinuityofcareisensuredastheservicemembersevacuatedfromtheaterreceiveoccupationaltherapyatmedicaltreatmentfacilitiesinGermanyandtheUnitedStates.Theseoccupationaltherapypractitionersareprovidingvitalservicesinthetreatmentofupperextremityandspinalcordinjuries,amputations,andpsychiatry.TODAYANDINTOTHEFUTUREOccupationaltherapytodaycontinuestoevolvetomeettheneedsofchangingtimes.The79occupationaltherapistscurrentlyonactivedutyareservingincombatstresscontrolunits,medicalcenters,medicalactivities,asProfessionalOfficerFillers(PROFIS),andonstressmanagementSpecialMedicalAugmentationResponseTeams.Inadditiontothedeploymentsdiscussedabove,occupationaltherapistshavebeendeployedtosupportmissionstoareassuchasBosnia-Herzegovina,Cuba,Peru,Russia,Columbia,Honduras,ElSalvador,SriLanka,andtoSouthAmericafollowingHurricaneMitch.TodaysoccupationaltherapistsareworkingwithSoldiers,familymembers,andretireeswithavarietyofproblemsorthopedic,neurological,psychological,andstress.Occupationaltherapistshavecommandedmedicalunits,fromcompanyleveltoamedicalfacility.Theprofessionsabilitytoaddressamyriadofdiseasesandinjurieshascontributedtothiswiderangeofpositions.Ashistoryvacillatedbetweentheuseofmedicalandhumanisticmodels,sotoodidtheprofessionofoccupationaltherapy.Thisvacillationcontinuestodayasdisciplinesinthehealthcarefielddebatethebestwaytotreatpatients.Eventhoughtheroleofoccupationaltherapyhaschangedovertheyears,theprofessioneventuallyreturnstoitsrootsofoccupationandtheuseofpurposefulactivity,thebeliefintheimportanceoftreatingtheentireperson,andthebeliefinthebenefitofmaintainingabalanceofrest,work,play,andsleep.Thispremiseallowsoccupationaltherapiststoplaytheroleofmediatorbetweenthesciences[medicalmodel]andthehumanities[humanisticmodel],andbetweenthehightechnologyofdiagnosisandtreatmentandtheartofhumancaring.21REFERENCES 1.BingRK.Occupationaltherapyrevisited:Aparaphrasicjourney.AmJOccupTher.1981;35:499-518.2.MeyerA.Thephilosophyofoccupationaltherapy.AmJOccupTher.1977;31:639-642.3.LidzT.AdolfMeyerandthedevelopmentofAmericanpsychiatry.AmJPsychiatry.1966;123:320-336.4.HammondWA.ATreatiseonInsanityinitsMedicalRelations.London:HKLouis;1883.5.ReedKL.Toolsofpractice:heritageorbaggage.AmJOccupTher.1986;40:597-605.6.AndersonRS,ed.ArmyMedicalSpecialistCorps.Washington,DC:USDeptoftheArmy;1986.7.EllsworthPD,SinnottMW,LaedtkeME,McPheeSD.UtilizationofoccupationaltherapyincombatstresscontrolduringthePersianGulfWar.MilMed.1993;158:381-385.

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58ArmyMedicalDepartmentJournal8.Wish-BaratzS.BirdT.Baldwin:aholisticscientistinoccupationaltherapy'shistory.AmJOccupTher.1989;43:257-260.9.KahmannWC,WestW.OccupationaltherapyintheUnitedStatesArmyHospitals,WorldWarll.In:WillardHS,SpackmanCS,eds.PrinciplesofOccupationalTherapy.Philadelphia,PA:JBLippincottCompany;1947:329-375.10.EllsworthPD.ArmyPsychiatricoccupationaltherapy:fromthepastandintothefuture.In:EllsworthPD,GibsonD,eds.PsychiatricOccupationalTherapyintheArmy.NewYork:HaworthPress;1983:1-6.11.BartonWE.OccupationalTherapy.In:SolomonHC,YakovlevPI,eds.ManualofMilitaryNeuropsychiatry.Philadelphia,PA:WBSaunders;1945:604-610.12.FieldManual8-51:CombatStressControlinaTheaterofOperations:Tactics,Techniques,andProcedures.Washington,DC:USDeptoftheArmy;1994.13.StrandEB.OccupationaltherapyandtheArmy-arichtraditionofservice.OccupTherWeek.1997;Nov6.14.SolheimB.TimelineoftheVietnamWar[CitrusCollegeofSocialScienceswebsite].Availableat:http://mil.citrus.cc.ca.us/cat2courses/HIST155/BigtimelineVWar.htm.AccessedNovember30,2003.15.ThomesLJ,BajemaSL.Thelifeskillsdevelopmentprogram:ahistory,overviewandupdate.In:EllsworthPD,GibsonD,eds.PsychiatricOccupationalTherapyintheArmy.NewYork:TheHaworthPress;1983:35-48.16.SundstromC.Insearchoferudition:theevolutionofaphilosophicalbaseforoccupationaltherapypracticeintheArmy.In:EllsworthPD,GibsonD,eds.PsychiatricOccupationalTherapyintheArmy.NewYork:TheHaworthPress;1983:7-13.17.GerardiSM.TheManagementofbattle-fatiguedsoldiers:anoccupationaltherapymodel.MilMed.1996;161(8):483-488.18.WatsonNM,ThomesLJ.ProjectABLE:AmodelformanagementofstressintheArmysoldier.In:EllsworthPD,GibsonD,eds.PsychiatricOccupationalTherapyintheArmy.NewYork:TheHaworthPress;1983;55-61.19.BannonR.Asoldier'sstory.ADVANCEforOccupTherPractitioners.Novl2,2001.20.Montz,R.After-actionreportforOperationEnduringFreedom[March4,2003].Availableat:https://ke2.army.mil/synergy/main.AccessedNovember15,2003.21.HasselkusBR.DearAnnLanders....AmJOccupTher.2001;55:247-248.AUTHOR Whenthisarticlewaswritten,MAJNewtonwasanOccupationalTherapist,85thMedicalDetachment(CombatStressControl)atFortHood,Texas. TheGrowthoftheProfessionofOccupationalTherapy

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JanuaryMarch200759INTRODUCTIONMilitarylogisticsdoctrineconceivedtosupporttraditionalconflictwithaclearlydefinedfrontandrearhasrecentlyevolvedtosustainthefightagainstanenemywithoutdefinedrealestate.Thenonlinearbattlefielddemandsquicklymobileandself-sufficientunits.Modularity(thedeploymentofunitsassmallerstandalonepieces)emerged,resultinginashufflingofsupportandmedicalassets.Combatunits,renamedbrigadecombatteams(BCT),assumedcontrolovertheirownlogisticalandmedicalresources,decentralizingownershipoutoftheformerdivisionsupportbrigade(DISCOM).ThisinternalcontrolenablestheBCTstomoveeasilyassingleself-sustainingunits.TheDISCOM,oncethecommandandcontrolcenterofallthedivisionslogisticalandmedicalsupport,assumedanewroleandnewnamethesustainmentbrigade.Steppinguptoacorpsorareasupportrole,whilemaintainingsomeresponsibilitytocollocateddivisionalelements,thesustainmentbrigadeassumescommand,controlandresponsibilityforlogisticalsupporttomeetadditionalneedsofthedivisionandforallcollocatedunitswhicharewithoutorganicsupportelements.Inkeepingwiththeconceptofmodularity,asustainmentbrigadeownswhateverpiecesareneededtoprovidesupportinagivenarea.Uniqueinthisabilitytogainandloseassetswhilemovinginandoutofawarzone,thesustainmentbrigadeisusuallyaheadquarterselementwithafewhundredSoldierswhilenotdeployed.Asitmovesintoatheater,newunits,identifiedbytheheadquarterselementduringpredeploymentplanningandsitevisits,comeundertheumbrellaofthesustainmentbrigadecommand.Asitredeployshome,theseunits,manymobilizedNationalGuardandArmyReserve,areshedanddeactivated.Planningiscentraltotheprocessofsustainmentbrigadedeploymentasitisthemechanismbywhichthecorrectlogisticalresourcesareestablishedinanarea.SUSTAINMENTBRIGADEMEDICALSUPPORTThesustainmentbrigadeconceptcreatesspecificchallengesformedicalsupport.Thesustainmentbrigadesmedicalelementconsistsofaplanningsectionandasmallmedicalplatoon.Themedicaloversightandplanningsectionisheadedbyaphysician,thebrigadesurgeon,whoisusuallyaseniorcaptainormajorandisresidencytrainedinoneofseveralkeyspecialties.Withinthesurgeonssection,showninFigure1,thereare2cells,medicalplansandoperationsandmedicallogisticsandsustainment,eachwithastaffofseniornoncommissionedofficersandmedicalservicecorpsofficers.Thesustainmentbrigadesmedicalplatoon,showninFigure2,consistsofaheadquarterselement,atreatmentsquad,andanambulancesquad.WithinthisstructurearethemedicalprovidersandmedicstosupportlevelI,oremergencycareandsickcallservicestopersonnelwithintheMedicalCareintheSustainmentBrigadeMAJBonnieHartstein,MC,USA MedicalLogisticsOfficers1Major,1CaptainMedicalLogisticsNCOs*1StaffSergeant,1SergeantMedicalPlanners1Major,1CaptainMedicalOperationsNCO*1MasterSergeantSeniorHealthCareNCO*1MasterSergeantPatientAdministrationNCO*1Sergeant SUSTAINMENTBRIGADESURGEONSECTION BrigadeSurgeon MedicalPlansandOperationsCellOverseeandcoordinateforcehealthprotectionforallsustainmentbrigadepersonnel. MedicalLogisticsandSustainmentCellCoordinatetheorderinganddistributionofClassVIII(medicalsupply)inthesustainmentbrigade.Figure1.TheorganizationoftheSustainmentBrigadeSurgeonSection.*NoncommissionedOfficer

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60ArmyMedicalDepartmentJournalsustainmentbrigadeheadquarterssection,apopulationofabout400people.Whenthesustainmentbrigadedeploysandassumescommandandcontrolofseveralbattalions,dependingonitsareasupportmission,itgrowsseveralthousandsinstrength.Thereislittlethesustainmentbrigadecannotdoforitself,exceptprovideadequatemedicalcaretoallitsdeployedunitswithoutadditionalhelp.Thisisbecausemostunitsthatdeployunderthesustainmentbrigadeinwardonotcomewiththeirownmedicalassets.Amongthesustainmentbrigaderesources,medicalsupportisnearlyabsent(exceptforthesmallmedicalplatoon).Medicalservicesfortheadditionalsustainmentbrigadeunitsmustbecoordinatedbythesustainmentbrigadesurgeonsplanningsection.Thecommandandcontrolofcorpslevelhealthservicesupportistheresponsibilityofthemedicalsupportcommand,aseparateunitwithitsowncommandelement.Asthesustainmentbrigadepreparesfordeployment,additionalmedicalassetscanbearrangedthroughthemedicalsupportcommand,dependinguponthenumberofadditionalSoldiersjoiningtheunitandtheneedsoftheunitsintheareasupported.Asubordinateunitofthemedicalsupportcommand,themultifunctionalmedicalbrigade(MMB),providesareamedicalsupportmuchinthesamewaythesustainmentbrigadetakesresponsibilityforlogistics.Ittooisamodularstyleunitwiththevarietyofmedicalassetstailoredtomeettheareasmedicalneeds.Accurateandwell-coordinatedplanningwithboththemedicalsupportcommandandMMBiscriticaltoensureadequatemedicalsupportforsustainmentbrigadeSoldiers.Inthecaseofmedicalplanning,thefocusofthesustainmentbrigadesurgeonsectionisturnedinwardtowardcaringforthoseSoldiers.Thereinliesthecriticalissueconcerningmedicalsupportinsustainmentbrigades.Whereasthesustainmentbrigadeprovidesadditionalarealogisticalsupport,itisthemedicalsupportcommandthatcoordinatesandprovidestheareamedicalsupport.Thesustainmentbrigadeandmedicalsupportcommandmayinteractinanydifferentnumberofways,dependingonthelayoutofthetheater.Piecesofthemedicalsupportcommandmaybeallocatedtothesustainmentbrigade,thesustainmentbrigademayuseassetsofthemedicalsupportcommandthathappentobecollocated,orthemedicalsupportcommandmightbeunderoperationalcontrolofthesustainmentbrigade.Intheory,thesustainmentbrigadeandmedicalsupportcommandare2separatesupportunitsoperatingasinterdependententities,thesustainmentbrigadeprovidingnecessarynonmedicalsuppliesandservicestothemedicalsupportcommandwhichprovidestheadditionalmedicalcareabsentinthesustainmentbrigade.However,coordinatedplanningbetween2separatecommandsiscomplexand,inadynamictheater,medicalsupportcommandassetsmaynotbegeographicallyavailabletosupportsustainmentbrigadeSoldiers.Inareversalofthesupportconcept,thesustainmentbrigademaycometorelyonthelocalBCTtocareforitsSoldierssincetheBCTdeployswithrobustmedicalassets.ThemedicalelementoftheBCTlooksmuchlikeitspredecessorintheformerforwardsupportbattalion/mainsupportbattalion,withamedicalcompanyinthesupportbattalionandamedicalplatoon(Figure3)ineachcombatbattalion.Bydesign,theBCThasmedics,physicians,andphysicianassistantsimbeddedinthestructureofitsbattalions.ThemedicalcompanyprovideslevelIIcare,bydefinition,higher-levelcarewithx-ray,laboratory,MedicalCareintheSustainmentBrigade SUSTAINMENTBRIGADEMEDICALPLATOON Headquarters TreatmentSquad1Physician1PhysicianAssistant2MedicalSergeants4MedicsFigure2.TheSustainmentBrigadeMedicalPlatoonisorganized,staffed,andequippedtoprovidelevelI,oremergencycareandsickcallservicesonlytopersonnelwithinthesustainmentbrigadeheadquarterssection,apopulationofabout400people.Asstructured,itcannotprovideadequateservicestotheadditionalunitsthatareassignedtothebrigadewhenitisdeployed. AmbulanceSquad AmbulanceTeam2Medics AmbulanceTeam2Medics

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JanuaryMarch200761dental,mentalhealth,pharmacy,andpatientholdcapabilities.However,asystemwherebyasustainmentbrigadereliesonaBCTforlevelIand/orlevelIImedicalcarecanpresentaproblemastheBCTisnotdesignedtobeanareaasset.Slicesmayneedtomovetosupportthefight,takingwiththemsome(ormost)medicalassets.ItisasituationthatcanadverselyaffectthosesustainmentbrigadeSoldierswhorelyontheBCTsmedicalresourceswhencombatmissionsdictaterelocationofthosesameassets.Intheplanningphasesbeforedeployment,sustainmentbrigademedicalplannersmustdecidehowmuchhealthservicesupportisrequiredfortheirtroops.Thissupportmustbereliableandresponsivetothemedicalneedsofthesustainmentbrigade,thepopulationofwhichmayincludenewlyactivatedArmyReserveandNationalGuardSoldiersrepresentingadifferentmedicaldemographicthanactivedutytroops.Lackingclear-cutguidelinestodictateprovider-to-patientratios,planningcanbedifficult.OnemodeltouseisthemedicalpersonnelstructureoftheBCTwhere,generallyspeaking,provider(physicianorphysicianassistant)topatientratiosinadeployedsettingareestimatedat1/400to1/600Soldiers.Combatcasualtyestimatesaredifferentinafightingbrigadeascomparedtothesupportbrigade,butsimilaritiesexistforlevelIsickcallservices.HEREANDNOWThefirstsustainmentbrigadeswerecreatedinIraqinamaturetheater,transformingfromtheDISCOM.Medicalsupportwaswellestablishedinmostareasasunitssettledontobuiltupforwardoperatingbases(FOBs)withmedicalclinicsorhospitals.Inthefuture,assustainmentbrigadesfaceestablishingnewtheatersfromthegroundup,theonuswillrestheavilyonthemedicalsupportcommandandsustainmentbrigademedicalplanningsectionstoensureadequatemedicalservicesforsustainmentbrigadepersonnelmovingintotheater.Asearlysetupofthetheatersupportstructureisacentralmissionofthesustainmentbrigade,futureleadersmustplancarefullyformedicalsupportoftheearlyforwardlogisticalteams.Otherwise,levelIandIImedicalcareforsustainmentbrigadeSoldiers,especiallyinthephasesbeforethedeploymentofBCTs,willbeabsent.InIraq,themedicalsupportcommand(knownastheMedicalTaskForce)operatesindependentlyfromthesustainmentbrigadeswithaseparatecommandstructure.HealthcareforsustainmentbrigadeSoldiersineachregionevolveddifferentlybasedonsurroundingresources.The82ndsustainmentbrigadeinSouthernIraq(FOBTalill)obtainslevelIandIIcarefromaneighboringBCT,the45thSustainmentBrigadeinNorthernIraq(FOBQwest)provideslevelIandIIareamedicalsupportforpersonnelontheirFOB,withtheaugmentationoflaboratoryandx-raytechniciansandonemedicalproviderprovidedbythemedicalsupportcommand.The15thSustainmentBrigadeinCentralIraq(FOBTaji)operatesalevelImedicalclinicprovidingcarefor2battalionsofthesustainmentbrigadeusingonlytheorganicassetsoftheheadquartersmedicalplatoonwhilerelyingonlevelIIassetsofthelocalBCTs.Threeadditional Figure3.EachinfantrybattalioninabrigadecombatteamhasamedicalplatoontoprovidelevelIcare(sickcall,emergency,acutetraumacare)tothebattalionSoldiers.Eachambulanceteamhaseither2or3medics,dependingonthetransportvehicles.Thecombatmedicsectionprovidesonecombatmedicperinfantryplatoonthroughoutthebattalion. EvacuationSection INFANTRYBATTALIONMEDICALPLATOON Headquarters TreatmentSquad1Physician1PhysicianAssistant2MedicalSergeants4Medics CombatMedicSection AmbulanceSquad AmbulanceTeam AmbulanceTeam AmbulanceSquad AmbulanceTeam AmbulanceTeam AmbulanceSquad AmbulanceTeam AmbulanceTeam

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62ArmyMedicalDepartmentJournalbattalionsofthe15thSustainmentBrigadeoperatingoutofdifferentFOBsandreceivemedicalcareatcollocatedBCTsorfromtheareasupportmedicalcompany,anelementofthemedicalsupportcommand.ThereareuniquechallengesfacingthesustainmentbrigadesinIraq.The45thSustainmentBrigadesmedicalplatoon,whileaugmentedbythemedicalsupportcommand,hasasignificantlyleanerstaffingthanaBCTmedicalcompanyslevelIIfacility.Comparingonlymedicalproviders,inthisinstance,aBCTwithasimilarmissionintheaterwouldhaveanadditionalphysicianandphysicianassistanttocareforthesamepatientpopulation.The15thSustainmentBrigadehashalfabrigadeofSoldierslocatedthroughoutIraqwithoutimbeddedorganicmedicalpersonnel.Trackingillnesstrends,evaluatingenvironmentalandhealththreats,andprovidingthefullspectrumofhealthoversighttotheseunits,allofwhicharetheresponsibilityofthesurgeonsection,aredifficultwithoutonsitemedicalassetswithinthebrigadeandbattalioncommandstructure.CONCLUSIONANDRECOMMENDATIONSFORTHEFUTUREOutliningtheroleofthesustainmentbrigadeinareamedicalsupportandthedefinitionofassetstocareforsustainmentbrigadeSoldiersarestillworksinprogress.WhilethenewsustainmentbrigademaysharemanyofthelogisticsandsupplyresponsibilitiesoftheformerDISCOM,itshedallbutaskeletonofmedicalassetsduringtransformation.ThesustainmentbrigadesrelianceonoutsideelementstoprovideitsSoldiersandcustomersmedicalsupportissomewhatcounterintuitive.Modularityofmedicalassetsmustevolvetocoordinatewiththesustainmentbrigadeandeffectivelyfillinthegaps.Acentralconceptofcombathealthsupportisthemaintenanceofanoperationalforceinadeployedsetting.Forapopulationaslargeasthatofthesustainmentbrigadeintheater,suchresponsibilityshouldbeassumedbymedicalprovidersandsupportpersonnelinternaltothebrigade.LevelIImedicalcapabilitiesshouldbeundertheoperationalcommandandcontrolofthebrigadecommanderandsurgeonsectionwhenthesustainmentbrigademovesintotheater.MedicalcareforthethousandsofSoldiersinthesustainmentbrigadecannotbeadequatelyprovidedbyunitsthatdonothaveadirectinterestinhealthcaretrendsofthesustainmentbrigade.AdditionalslicesofmedicalcareprovidedbythemedicalsupportcommandshouldbeattachedtothesustainmentbrigadeonaratiothatmodelstheBCTmedicalorganization.REFERENCES 1.FieldManual4-93.2TheSustainmentBrigade.Washington,DC:USDeptoftheArmy.Indraft.2.FieldManual4-02.4MedicalPlatoonLeadersHandbookTactics,TechniquesandProcedures.Washington,DC:USDeptoftheArmy;18December2003.3.FieldManual4-02.21:DivisionandBrigadeSurgeons'Handbook(Digitized);Tactics,Techniques,andProcedures.Washington,DC:USDeptoftheArmy;28August2000.4.FieldManual3-21.21TheStrykerBrigadeCombatTeamInfantryBattalion.Washington,DC:USDeptoftheArmy;8April2003.AUTHOR MAJHartsteinistheBrigadeSurgeonofthe15thSustainmentBrigadeatCampTaji,Iraq. MedicalCareintheSustainmentBrigade

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JanuaryMarch200763Evidence-BasedMedicine:TheWaytoCost-Effective,QualityMedicalCareCOLHermanJ.Barthel,MC,USATheDeclarationofIndependencehighlightsthekeyenduringprinciplesforallAmericansLife,Liberty,andthePursuitofHappiness.TheseenduringprinciplessetthefoundationforthebasicrightsandexpectationsofallUScitizens.Americanswantanddeserveahealthcaresystemthatensuresqualitymedicalcarethatisbothaccessibleandaffordable.Whattheynowhaveisadisorganizedandunsustainablesystemwithincreasinglyseriousproblemsofaccess,cost,andquality.In2005,theUnitedStatesspent$1.9trillion(16%ofthegrossdomesticproduct(GDP))onmedicalcare,anditisexpectedtospend$4.0trillion(20%oftheGDP)in2015.1CanAmericansaffordthisrisingcost?Alreadyanestimated45millionpeople(15%ofthepopulation)areuninsuredintheUnitedStates.Gettingcontrolofthehealthcaresystemiscrucialtonationalsecurity,especiallyintodaysenvironmentofvolatility,uncertainty,complexity,andambiguity.PresidentBushstatedinhis2006StateoftheUnionAddress,KeepingAmericacompetitiverequiresaffordablehealthcareforallAmericans,wemustconfronttherisingcostofcare2TheUShealthcaresystemistransitioningintoevidence-basedmedicine(EBM),inwhichgoodevidenceisusedtostimulateeffectiveperformancebyprovidersandorganizations.ThispaperfocusesontheutilizationofEBMasastrategytoensurehigh-quality,cost-effectivemedicalcareinanefforttoreversethemomentumofeverrisingcosts.BACKGROUNDTheUShealthcaresystemhasbeenproclaimedasthebestintheworld.Theadvancementsintechnology,pharmaceuticals,procedures,andintegrationoftheindustryhaveledtheworld.However,hasallofthisguaranteedthebestcareintheworld?TheUnitedStateshasbyfartheworldsmostexpensivehealthcaresystem,basedonhealthexpenditurespercapitaandontotalexpendituresasapercentageofGDP.AccordingtodatafromtheOrganizationforEconomicCooperationandDevelopment(OECD),percapitahealthspendingwasabout2timestheOECDmedian,andhealthspendingasapercentageofGDPwastwicethemedianforthe29memberOECDcountries.3In2000,theWorldHealthOrganization(WHO)releasedareportwhichstatedthatagoodhealthsystemisbasedongoodhealth,fairnessinfinancing,andresponsiveness.Inspiteofthemassivespendingonhealthcare,theUSdoesnotranknumberoneoverallintheworld.Withregardstogoodhealth,theUSinfantmortalityrateof7.0deaths/1,000livebirthswashigherthanthemeanrateof6.1forOECDcountries,andtheUSdisability-adjustedlifeexpectancyranks24thofthe29members.4TheUSrankedthelowestoftheOECDcountrieswithregardtofairnessinfinancing,ameasurementofthedegreeinwhichfinancialcontributionstothehealthsystemaredistributedequitablyacrossthepopulation.AccordingtotheWHO,theUnitedStatesandSouthAfricaaretheonly2countriesinthedevelopedworldthatdonotprovidehealthcareforallcitizens.5Incontrast,theUShealthsystemrankednumberoneoftheOECDcountriesinresponsiveness,theextenttowhichcaregiversareresponsivetopatientexpectations.AsevidencedbytheWHOgoodhealthsystemreport,Americanpatientsdofeelthattheircaregiversareresponsivetotheirexpectations.Lammstatedthat,Thedoctor-patientrelationshipisthemostimportantperspectiveinhealthcare.Itisahealingperspective,concentratingonthepatient,focusingmodernskillsina2,000year-oldtraditionthatmakesthedoctoradvocateafiduciary,healer,andconfidantforthepatient.6Thephysicianisthekeytohelpingresolvetheever-increasingcostofhealthcareintheUS.Patientstrusttheirphysicians,andphysiciansdeterminewhattherapiesandinterventionsarenecessaryfortheirpatients.Physicianshavebeentrainedtooffertheirpatientsthebestmedicinehastooffer,nomatterthecost.Eventhoughtheyear2000

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64ArmyMedicalDepartmentJournalEvidence-BasedMedicine:TheWaytoCostEffective,QualityMedicalCareUSstandardformedicalcareisgoodandispracticedbymostoftheworldatalowercost,theUSstandardformedicalcareintheyear2006isbetterandmoreexpensive.Thecostofnewtherapies,medications,andproceduresarealwaysmoreexpensivewhentheyarefirstintroduced,duetotheaddedresearchanddevelopmentcost,butisitthatmuchbetterforoutcomes?Physiciansarecaughtbetweenbeingpatientadvocatesinprovidingthebestqualitymedicalcare,andbeingcost-effectiveforthepayers(government,employers,taxpayers,individuals,andinsuranceandmanagedcarecompanies).WHATISEVIDENCE-BASEDMEDICINE?Atoolavailabletophysicianstoprovidehighqualityandcost-effectivemedicalcareisEBM.PhilosophicaloriginsofEBMextendtomid-19thcenturyParis.Itwasgivenitsbrandnamein1992byamedicalgroupatCanadasMcMasterUniversitywhichtaughtmedicalstudentsthenewparadigm.7EBMisdefinedastheconscientious,explicit,andjudicioususeofcurrentbestevidenceinmakingdecisionsaboutthecareofindividualpatients.8Thisconceptgivesnewvigortothelong-establishedprinciplethathealthcareshouldbebasedonsolidscientificevidence,ratherthanontraditionanduncontrolledclinicalexperience.Thephysicianmustbalanceresearchevidencewiththeirknowledge,judgment,andexperiencetotheuniquelydifferentindividualneedsoftheirpatients.Withoutcurrentbestevidence,practicerisksbecomerapidlyoutofdateandcanadverselyaffectthepatient.ThepursuitofEBMisatthecenterforimprovementofhealthcareintheUnitedStates.Qualitymeasurementsystemsusescience-basedindicatorstoevaluateproperprocessesofpatientcare.Forexample,theORYXmeasurementrequirementsoftheJointCommissiononAccreditationofHealthCareOrganizations,theHealthEmployerDataandInformationSets(measuresoftheNationalCommitteeonQualityAssurance),andtheQualityImprovementOrganizationsfortheCentersforMedicareandMedicaidServicesallusescience-basedindicators.9MedicaljournalsandcontinuedmedicaleducationconferencesutilizeEBMthroughastrength-of-recommendation(SORT)process.TheSORTgivesgradesfortheeffectivenessandqualityofevidencetosupporttherecommendationfortreatmentortherapy.10Thevolumeofscientificresearchandmedicaljournalsisoverwhelming.Itwasrecentlyestimatedthatphysicianswouldneed627.5hoursjusttoreadthe7,287journalarticlesthatarepublishedeachmonth.11However,thereareseveralweb-basedEBMtoolsavailableforphysicianstoquicklyfindthelatestrecommendations.12AlthoughEBMgivesphysicianssolidscientificevidenceonwhichtobasetheirclinicaldecisions,itisnotcook-bookmedicine.Evenso,EBMdoesreducethevariationofthemedicalcaredeliveredtopatientsacrossthecountry.PhysiciansfearthattheartofmedicinewillbelostwiththescienceofmedicineprovidedbyEBM.Physiciansstillmustlistentotheneedsandvaluesoftheirpatients.Boththeartandscienceofmedicinecanbebalancedtoachievesuccessfuloutcomesthatprovidecost-effective,qualityhealthcare.EFFECTIVEEBMSTRATEGIESTOLOWERHEALTHCARECOSTThediversehealthcareindustryoffersplentyofopportunitiestolowerthecostofmedicine.EBMoffers3cost-effectivestrategiestolowertheoverallcostofhealthcare:Lesscostlyoriscost-savingwithanequalorbetteroutcome,orMoreeffectiveandmorecostly,withtheaddedbenefitworththeaddedcost,orLesseffectiveandlesscostly,withtheaddedbenefitofthealternativenotworththeaddedcost.13Thefollowingparagraphsdescribe5keyexamplesofhowEBMcanprovidecost-effectivehealthcarewithareductioninoverallcost.SoutheastRegionalMedicalCommand(SERMC)ProfitandLossReimbursementModelSERMChasledtheArmyMedicalDepartment(AMEDD)withaninnovativeProfitandLossReimbursementModelthatrewardsproductivityandoutcomesbasedonEBMwithfinancialincentives.Resultshaveshownimprovementinclinicalprocessesandoutcomesthroughaccuratecarerendered,enhancedworkloadrecorded,andcaredocumentedintheelectronicmedicalrecord(EMR).ThegoalsestablishedbyEBMformammograms,papsmears,diabeticHbA1Candretinalexams,andasthmawithcontrollermedicationshaveledtoimprovedcost-

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JanuaryMarch200765effectivecontinuityofcareandpopulationhealth.Inaddition,SERMChospitalsaregivenfinancialincentivesupto$6millionbasedonoutcomesandperformanceproductivity.ThissuccessfulmodelwillbeincorporatedthroughouttheAMEDDinFY07.DiseaseManagementProgramsTheuseofEBMwithoutpatientdiseasemanagementprogramshasbeenextensiveandhasledtocost-effectivehealthcare.Smoking,obesity,anddiabetesaccountforover1milliondeathsannuallyintheUnitedStates,andover$270billionindirectandindirectmedicalcosts.14PhysicianadvocatesleadingmultidisciplinaryteamshaveimplementedeffectiveEBMprogramstargetingobesity,asthma,diabetes,hypertension,chronicpain,andhighcholesterol.Resultshaveshownreductionsinhospitaladmissionsandcostsavings,andhavedocumentedadecreaseintheprogressionoftherespectivediseases.LeapfrogGroupTheLeapfrogGroup*identified3initialpatientsafetypractices(leaps)accompaniedbyEBMtobenefitpatientsandtoprovidecost-effectivehealthcareinthemedicalarena.15These3safetypracticesareEMRphysicianordering,intensivistphysicianstaffing(IPS)ofintensivecareunits,andEBMhospitalreferrals.TheresultsofEMRuseshowedareductioninmedicalerrors,adversedrugeffects,lengthofstays(LOS),morbidity,mortality,andmorecost-effectiveutilizationofmedication.IfEMRwerefullyimplemented,hospitalswouldsaveanestimated$1.5billionannually.Inaddition,IPSinitiativeswouldresultinanannualsavingsofover54,000liveswithanadditionalcostsavingsofnearly$16.5billion.ThesesavingswereachievedthroughadecreaseinLOS,productivitybenefitsthroughEBM,andlowererrorrates.Finally,EBMhospitalreferralswouldsavenearly$10billionannually.AllthreeofthesemeasuresincorporateEBMandleadtocost-effectiveandhighqualitymedicalcarewithgreatoutcomes.100KLivesCampaignThe100KLivesCampaigninvolvesover3,000hospitalswiththegoaltoavoidthenearly100,000annualdeathsfrommedicalinjuriesand2millionhospitalacquiredinfections.16Ithasbeenverysuccessfulinreducingdeathsandmorbidity.Thecampaignfocuseson6EBMchangestoavoidhospitaldeaths:rapidresponseteams,acutemyocardialinfarctioncare,preventadversedrugevents,preventcentrallineinfections,preventsurgicalsiteinfections,andpreventventilator-associatedpneumonia.Additionally,thesefullyimplementedinitiativeswillleadtoadecreaseinthe1%ofUSGDPthatisspentonICUmedicalcare.17CombinationofEBMwithEMRThecombinationofEMRandEBMhasshownpromisingresults.Hiebstatedthatthebenefitofthiscombinationleadstoimprovedreporting,cost-effectivecare,reducedmedicalerrors,improvedpatientsatisfaction,andcompetitiveadvantage.18Thisfusionhasledtophysiciansdevelopingcasemanagementprotocols,decisionsupportsets,providerordersets,andworkflowsthatprovidequalitymedicalcare.Inaddition,thehighadministrativecostofhealthcare(26%)hasbeenreduced.TheRandCorporationhasshownthatanimplementationgoalofhavingEMRin90%ofhospitalsanddoctorsofficeswillrequireanannualcostof$8billionfor15years.19Furthermore,thecombinationwithEBMwillleadtoannualefficiencysavingsofmorethan$77billionafteranaccumulatedbenefitof$500billionin15years.IMPLICATIONSOFEBMANDRISINGHEALTHCARECOSTSONNATIONALSECURITYTheUnitedStatesspreadsitsinfluence,prosperity,anddemocracythroughouttheworldthroughits4instrumentsofnationalpowerdiplomacy,information,military,andeconomy(DIME).ThemilitaryandeconomiccomponentsoftheDIMEarethe2mostimportantinstrumentstoensureboththenationalsecurityandvitalinterestsoftheUnitedStates.Moreover,these2instrumentsarethemostvulnerabletoahealthcaresystemthatisabsorbingabiggerpercentageoftheGDPandfederalbudget.Currently,thegovernmentpaysthebillfor60%oftheoverallhealthcarecostintheUS.1Inthenext10years,twomajorfactorswillaffecttheDIMEandthecostofhealthcare,theagingbabyboomerpopulation,andtherisingcostoftheDepartmentofDefense(DoD)healthcare.Thesefactorswillhaveanenormousimpactonournationalsecurity.First,theagingbabyboomerpopulationof77millionwillleadMedicareandMedicaidgrowthfrom25%ofallhealthcarespendingin1965to49%in2014.1This *Availableat:http://www.leapfroggroup.org/homeAvailableat:http://www.ihi.org/IHI/Programs/Campaign

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66ArmyMedicalDepartmentJournalEvidence-BasedMedicine:TheWaytoCostEffective,QualityMedicalCarewillimposeastoundingcostsforalltaxpayersandthefederalgovernment.Inordertopaythebill,thegovernmentwillhavetodrawfromotherareasofthebudgeteducation,infrastructure,anddefense.HealthcareasapercentageofGDPin1960was6%,aswasdefenseandeducation.6In2005,healthcaregrewto16%oftheGDPwhileeducationremainedat6%andDoDdroppedto4%.CanAmericanscontinuetoabsorbthisriseincost?Willtheywanttocontinuetopayforitintheyearstocome?Timeandprioritieswilltell.Finally,theimpactofthecostofhealthcareonDoDsbudgetishuge.DoDsTRICAREcostwas$19billionin2001,grewto$37billionin2006,andisexpectedtotop$64billionin2015.20Inaddition,healthcarerepresented4.5%ofDoDsbudgetin1990andisprojectedtoincreasetoover12%in2015.ThiswillhaveanimpactonotherDoDprograms,eg,personnel,procurement,weaponsystems,operations,andmaintenance.ThenationandDoDmustmaketoughdecisionsinordertoensurethatthestrengthoftheinstrumentsofnationalpowerarepreserved.EBMprovidesaneffectivewaytocurbtherisingcostofhealthcare,andDoDhascontinuedtoleadthewayinitsimplementationwithEMR,asevidencedbytheSERMCProfitandLossModel.POLICYRECOMMENDATIONSInordertoensurethenationalsecurityoftheUnitedStatesandtopreserveitsvitalinterestandenduringprinciples,5keypolicyrecommendationsareoffered.1.DevelopandAssureAccesstoEBMThispolicyiscrucialtocreatenationwidestandardsofhealthcarebasedonEBMwithclearscientificevidence.Thiswillensureareductioninthevarianceofhealthcareandprovideacommoncost-effectiveprocess.Inaddition,createacentralwebportalthatisdevelopedbytherespectiveprofessionalmedicalsocietiesanddirectedbythegovernment.Practicalclinicaltrialsestablishedbyprioritiesfromthegovernmentwillleadtoimprovementsofcost-effectivemedicalcare,qualityoflife,safety,andinthedeliveryofhealthcareservices.2.CombineEBMwithEMRThemultipleresultsfromtheSERMCProfitandLossModel,diseasemanagementprograms,LeapfrogGroup,andthe100KLivesCampaignstronglysupportthisrecommendation.Thisisaforcemultiplierthatprovidessafe,effective,qualityhealthcarewiththeadditionofsignificanthealthcarecostsavings.Thispolicywillensurethatmultidisciplinaryteamsandphysicianchampionscreateordersets,managementtools,andoutcomemeasurementswhichwillleadtoanoverallreductionofmedicalerrors.TheinvestmentbytheUSgovernmentandthehealthcareindustrywilldefinitelypayoff.3.EnsureanAdequateNumberofPrimaryCareGatekeepersTheseprovidersaretheportalforentryofpatientsintothehealthcaresystem.IncombinationwithEBM,availablegatekeepershavebeenshowntobethemostcost-effectivesourceofmedicalcare.PatientsarereferredtospecialistsbasedonEBMcriteria.ThissystemworksverywellforKaiserPermanenteandcountrieswithuniversalhealthcare.TheOECDstudieshavedemonstratedthatotherwesterncountrieshavebetteroutcomeswithalowerpercapitaspendingonhealthcare.ThissystemmustbetiedintoensuringmedicalcareforeveryoneintheUnitedStates,notjustcoveringeverythingmedicinehastooffer.Furthermore,theprimarycareprovidersmustemphasizeandmonitorEBMpreventivemedicinepracticesinthepopulation.Thiswillresultincumulativecostsavingswithahealthierpopulation.4.AlignIncentivesandRewardsforImprovementIncentivesarekeytocontinuedsuccessandimplementationofEBMintoeverydaypractice.Outcomeandutilizationmeasurementsmustbealignedwithdocumentedresults.Thiswillleadtoalimitationofproceduresthatareineffectiveormarginallyeffectivewithresultingcostsavings.Also,thiscanbeextendedtothepatientpopulationbyrewardinggoodhealthpractices(idealbodyweight,nosmoking,aerobicconditioning,etc)Inaddition,rewardingproviders,hospitals,andhealthcareorganizationsforbuildingsystemimprovements(EBM,EMR,etc)arekeysforsuccess.5.UsetheGovernmenttoFacilitateandCollaboratethePursuitoftheOther4PoliciesThegovernmenthasthepowerofthepayor,inthatitpays60%ofthehealthcarecostsinthe

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JanuaryMarch200767UnitedStates.Accordingly,itcandirectchangeinthesystemwithfinancialincentivesandprocesses.Thegovernmentcansubsidizeresearchanddevelopmentofthesystemsanddisseminationoftheinformation,andestablishpracticestandardsandprioritieswithanimplementationtimeline.Also,itcaninstitutetaxpolicychangesthatmakehealthcaremoreaffordablebyshapingandsupportingthemarket.Thiscanbeachievedthroughinsurancesubsidies,expansionofthehealthsavingsandflexiblesavingsaccounts,decreasingadministrativebureaucracy,andincreasingpatientcostsharing.Thegovernmentmustpromotetheeducationofhealthcareconsumersonpreventive,self-care,andcost-effectivehealthcare.Finally,itmustpromotethesynergyofpublicandprivatesectorsandbuilduponthegainsandfoundationofEBM.Incorporationofall5oftherecommendedpolicieswillensuresuccessforthepatient,thehealthcareindustry,andthegovernment.CONCLUSIONAsthestrategyofEBMbecomesmoreincorporatedineverydaypractice,thebettertheoutcomesareforpatientsandthelowerthehealthcarecostsareforthenation.Inaddition,EBMhasconsistentlyshownimprovementsinpatientsafety,qualityoflife,andinthedeliveranceofcost-effectivehealthcare.TheseimprovementsareessentialtomaintainingthenationalsecurityandtoprotectingthevitalinterestsoftheUnitedStatesthroughtheDIMEinstrumentsofnationalpower.Consequently,implementationofthe5policyrecommendationsforEBMwillensurethattheenduringprinciplesoftheUnitedStatesLife,Liberty,andthePursuitofHappinessarepreservedforallAmericans.REFERENCES 1.PlunkettResearch.HealthcareIndustryTrends.Availableat:http://www.plunkettresearch.com/industries/healthcare/healthcaretrends.AccessedMarch1,2006.2.StateOfTheUnionAddressByThePresident.Washington,DC:TheWhiteHouse;January31,2006.Availableat:http://www.whitehouse.gov/stateoftheunion/2006/index.html.AccessedFebruary1,2006.3.OrganisationforEconomicCooperationandDevelopment.OECDHealthData2000:AComparativeAnalysisofTwenty-nineCountries.AvailablefromOECD,2,rueAndrPascal,F-75775ParisCedex16,France.telephone331.45.24.82.00.Website:http://www.oecd.orghome/0,2605,en_2649_201185_1_1_1_1_1,00.html.4.JensonJ.HealthcareSpending:ContextandPolicy.Washington,DC:CongressionalResearchService;March31,2006.OrderCodeRL32545.Availableat:http://pennyhill.com/index.php?lastcat=75&catname=Defense+Economics&viewdoc=RL32545.5.WorldHealthOrganization.TheWorldHealthReport2000-HealthSystems:ImprovingPerformance.Availableat:http://www.who.int/whr/2000/en/.6.LammRD.TheBraveNewWorldOfHealthCare.Golden,Co:FulcrumPublishing;2003.7.Grahame-SmithD.Evidencebasedmedicine:Socraticdissent.BrMedJ.1995;310:1126-1127.8.SackettDL,RosenbergWM,GrayJA,HaynesRB,RichardsonWS.Evidence-basedmedicine:whatitisandwhatitisnt.BrMedJ.1996;312:71-72.9.NolanT,BerwickDM.All-or-nonemeasurementraisesthebaronperformance.JAMA.2006;295(10):1168-1170.10.EbellMH,SiwekJ,WeissBD,etal.Strengthofrecommendationtaxonomy(SORT):Apatient-centeredapproachtogradingevidenceinthemedicalliterature.AmFamPhysician.2004;69:549-557.11.UpshurRE.Lookingforrulesinaworldofexceptions:reflectionsonevidence-basedpractice.PerspectBiolMed.2005;48(4):477-489.12.Glickman-SimonR.BringingEvidence-BasedMedicinetothePointofCare.2005.Availableat:http://www.medscape.com/viewprogram/4216_pnt.AccessedMarch13,2006.13.FriedlandDJ.Evidenced-BasedMedicine:AFrameworkforClinicalPractice.NewYork,NY:LangeMedicalBooks/McGraw-Hill;1998.14.USDeptofHealthandHumanServices.DiseasePreventionandHealthPromotionProgramsatHHS.Washington,DC:April30,2002.Availableat:http://www.hhs.gov/news/press/2002pres/prevent.html.AccessedFebruary21,2006.15.ConradDA,GardnerM.UpdatedEconomicImplicationsoftheLeapfrogGroupPatientSafetyStandards:FinalReporttotheLeapfrogGroup.WashingtonDC:TheLeapfrogGroup;2005.

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68ArmyMedicalDepartmentJournalEvidence-BasedMedicine:TheWaytoCostEffective,QualityMedicalCare16.InstituteforHealthcareImprovement.100kLivesCampaign.Availableat:http://www.ihi.org/IHI/Programs/Campaign/Campaign.htm?TabId=1.AccessedMarch13,2006.17.PronovostPJ,JenekesMW,DormanD,etal.Organizationalcharacteristicsofintensivecareunitsrelatedtooutcomesofabdominalaorticsurgery.JAMA.1999;281(14):1310-1317.18.HiebB.Gartnerontechnology:healthplanscanfacilitateevidence-basedmedicine.ManagHealthcExec.2005;15(9);51.19.RandCorporation.Healthinformationtechnology:canHITlowercostsandimprovequality?.SantaMonica,CA:RandCorporation;2005.Availableat:http://www.rand.org/pubs/research_briefs/RB9136/index1.html.AccessedSeptember7,2006.20.BestRA.IncreasesinTricareFees:BackgroundandOptionsforCongress.Washington,DC:CongressionalResearchService;March16,2006.OrderCodeRS22402.Availableat:http://pennyhill.com/index.php?lastcat=75&catname=Defense+Economics&viewdoc=RS22402.AUTHOR COLBarthelistheChief,MedicalCorpsBranch,ArmyHumanResourcesCommand,Alexandria,Virginia.

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SUBMISSION OF MANUSCRIPTS TO THE ARMY MEDICAL DEPARTMENT JOURNAL The United States Army Medical Department Journal is published quarterly to expand knowledge of domestic and international military medical issues and technological advances; promote collaborative partnerships among the Services, components, Corps, and specialties; convey clinical and health service support information; and provide a professional, high quality, peer reviewe d print medium to encourage dialogue concerni ng health care issues and initiatives. REVIEW POLICY All manuscripts will be reviewed by the AMEDD Journal s Editorial Review Board and, if re quired, forwarded to the appropriate subject matter expert for further review and assessment. IDENTIFICATION OF POTENTIAL CONFLICTS OF INTEREST 1. Related to individual authors commitments: Each author is responsible for the full disclosure of all financial and personal relationships that might bias the work or information presented in the manuscript. To prevent ambiguity, authors must state explicitly whether potential conflicts do or do not exist. Auth ors should do so in the manuscript on a conflict-of-interest notification section on the title page, pr oviding additional detail, if necessary, in a cover letter that accompanies the manuscript. 2. Assistance: Authors should identify Individuals who provide writing or other assistance and disclose the funding source for this assistance, if any. 3. Investigators: Potential conflicts must be disclosed to study participants. Authors must clearly state whether they have done so in the manuscript. 4. Related to project support: Authors should describe the role of the study sponso r, if any, in study design; collection, analysis, and interpretation of data; writing the repo rt; and the decision to submit the report for publication. If the supporting source had no such involvement, the authors should so state. 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Articles should be submitted in digi tal format, preferably an MS Word docume nt, either as an email attachment (with illustrations, etc), or by mail on CD or floppy disk accomp anied by one printed copy of the manuscript. Ideally, a manuscript should be no longer than 24 double-spaced pages. However, exce ptions will always be considered on a case-by-case basis. In general, 4 double-spaced MS Word pages produc e a single page of 2 column text in the AMEDD Journal production format. 2. The American Medical Association Manual of Style governs formatting in the preparation of text and references. All articles should conform to those guidelines as cl osely as possible. Abbreviati ons/acronyms should be limited as much as possible. Inclusion of a list of article acronyms an d abbreviations can be very helpful in the review process and is strongly encouraged. 3. A complete list of refere nces cited in the article must be provided with the manuscript. The following is a synopsis of the American Medical Associ ation reference format: Reference citations of published articles must include the auth ors surnames and initials, arti cle title, publication title, year of publication, volume, and page numbers. Reference citations of books must includ e the authors surnames and initials, b ook title, volume and/or edition if appropriate, place of publ ication, publisher, year of copyright, and specific page numbers if cited. Reference citations for presentations, unp ublished papers, conferences, symposia, etc, must include as much identifying information as possible (l ocation, dates, presente rs, sponsors, titles). 4. Either color or black and white photographs may be submitted with the manuscript. Color produces the best print reproduction quality, but please avoid excessive use of multiple colors and shading. Digital graph ic formats (JPG, GIF, BMP) and MS Word photo files are preferred. Prints of phot ographs are acceptable. 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