During the last decade, the US Military Health System—while caring simultaneously for combatants fighting two wars and for millions of service members, dependents, and military retirees at home—completely transformed its approach to combat casualty care. From the point of injury on the battlefield to rehabilitation and reintegration of wounded warriors into their communities, military innovators rapidly devised, implemented, refined, and spread new techniques and technologies throughout the force. They were able to succeed because the Military Health System was willing to learn from its failures and build on its successes. Through a mix of observation and the systematic collection and analysis of data (most notably, creation of the Joint Trauma System), military medicine continually improved. Primarily written by the military providers responsible for innovations in each field, this 44-chapter book documents each of these advances and provides stories of individual service members who benefited from them.
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active military, veteran hospitial and care givers, civilian medical providers, and first responders
Contributors. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xiii
Foreword | ARTHUR L. KELLERMANN, MD, MPH, and ERIC ELSTER, MD. . . . . . . . . . . . . . . . . . . . . . . . xxiii
Section One: Foundations
Chapter 1: A Soldier’s Story . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
GENERAL DANIEL B. ALLYN, VICE CHIEF OF STAFF, US ARMY
Chapter 2: A Heritage of Innovation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
DALE C. SMITH, PHD
Learning from “Black Hawk Down” BY MAJOR GENERAL BRIAN C. LEIN
Chapter 3: Educating Military Health Leaders. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
COLONEL (RETIRED) CRAIG LLEWELLYN, MD, MPH; CAPTAIN (RETIRED) JERRI CURTIS, MD; and
COLONEL (RETIRED) BRIAN V. REAMY, MD
Bushmaster’s Legacy BY COLONEL KELLY A. MURRAY, MD
Chapter 4: Combat Casualty Care Research. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
DAVID G. BAER, PHD; ANDREW CAP, MD, PHD; and COLONEL TODD E. RASMUSSEN, MD
Chapter 5: Futurist Thinking: Military Health Services System 2020. . . . . . . . . . . . . . . . . . . . . . . . 41
MAJOR GENERAL (RETIRED) PATRICK SCULLEY, DDS, and REAR ADMIRAL (RETIRED) WILLIAM R. ROWLEY, MD
Section Two: Innovations
Chapter 6: The Health Challenges of Operation Enduring Freedom and Operation Iraqi Freedom. . . . . 53
MAJOR GENERAL STEPHEN L. JONES, MD, and COLONEL CLINTON K. MURRAY, MD
Chapter 7: Force Health Protection: Preventing Deployment-Related Diseases and Nonbattle Injuries. . . 61
CAPTAIN MARK S. RIDDLE, MD, DRPH; CAPTAIN (RETIRED) JOHN W. SANDERS, MD; and
COLONEL (RETIRED) BONNIE SMOAK, MD, PHD
Chapter 8: The Joint Trauma System. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73
COLONEL JEFFEREY BAILEY, MD; COLONEL (RETIRED) DONALD JENKINS, MD; and SUSAN WEST, BSN
The Military’s “Learning Healthcare System” BY DONALD M. BERWICK, MD
Chapter 9: Devising Countermeasures: The Joint Trauma Analysis for Prevention of
Injury in Combat Program. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83
COLONEL COLIN M. GREENE, MD, MPH
Chapter 10: Battlefield Tourniquets. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93
JOHN F. KRAGH JR, MD, and COLONEL (RETIRED) JOHN B. HOLCOMB, MD
Getting the Right Equipment Into Theater BY CAPTAIN JEFFREY W. TIMBY, MD
Chapter 11: Tactical Combat Casualty Care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103
CAPTAIN (RETIRED) FRANK K. BUTLER, MD, and COLONEL ROBERT MABRY, MD
Chapter 12: Topical Hemostatic Agents. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111
PATRICK GEORGOFF, MD; CAPTAIN (RETIRED) PETER RHEE, MD; and HASSAN ALAM, MD
Chapter 13: MEDEVAC Lessons from the Iraq and Afghan Wars. . . . . . . . . . . . . . . . . . . . . . . . . . 119
COLONEL ROBERT MABRY, MD
Preventing In-Flight Hypothermia on MEDEVAC Helicopters BY REAR ADMIRAL BRUCE L. GILLINGHAM, MD
Chapter 14: The Forward Surgical Team. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 131
COLONEL (RETIRED) STEPHEN P. HETZ, MD
Chapter 15: Damage Control Surgery. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 141
MICHAEL F. ROTONDO, MD; C. WILLIAM SCHWAB, MD; and COLONEL BRIAN J. EASTRIDGE, MD
One Team, One Fight BY BRIGADIER GENERAL (RETIRED) KORY CORNUM, MD, AND
BRIGADIER GENERAL (RETIRED) RHONDA CORNUM, MD
Chapter 16: Balanced Resuscitation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 153
COLONEL JEREMY W. CANNON, MD; CAPTAIN (RETIRED) PETER M. RHEE, MD, MPH; and
COLONEL MARTIN A. SCHREIBER, MD
Chapter 17: Tranexamic Acid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 161
COLONEL MATTHEW J. MARTIN, MD, and COLONEL TODD E. RASMUSSEN, MD
Chapter 18: Battlefield Pain Control: 19th Century Medicine Meets a 21st Century Conflict. . . . . . . . . 167
COLONEL (RETIRED) CHESTER C. BUCKENMAIER III, MD, and LIEUTENANT (RETIRED) GUY F. DISNEY,
BRITISH ARMY, THE LIGHT DRAGOONS
Ketamine for Battlefield Pain Relief BY MAJOR ANDREW D. FISHER, PA-C
Chapter 19: Decompressive Craniectomy and Control of Vasospasm. . . . . . . . . . . . . . . . . . . . . . . . 177
SECOND LIEUTENANT M. BENJAMIN LARKIN, PHARMD; LIEUTENANT BRIAN CURRY, MD;
COLONEL (RETIRED) ROCCO ARMONDA, MD; and COMMANDER RANDY BELL, MD
Chapter 20: Advancing Burn Care During Combat. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 185
COLONEL (RETIRED) LEOPOLDO C. CANCIO, MD
Chapter 21: Combat Ocular Trauma. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 197
LIEUTENANT COLONEL MARCUS H. COLYER, MD, and COMMANDER KEVIN JACKSON, OD, MPH
Chapter 22: Controlling Pain With “Soldier-Friendly” Regional Anesthesia. . . . . . . . . . . . . . . . . . . . 203
COLONEL (RETIRED) CHESTER C. BUCKENMAIER III, MD, and SERGEANT (RETIRED) BRIAN WILHELM
Chapter 23: Helicopter Evacuation With En Route Critical Care Nurses. . . . . . . . . . . . . . . . . . . . . . 211
COLONEL MARLA J. DE JONG, PHD; COLONEL JAMES J. GERACI, MD; and
LIEUTENANT COLONEL KIMBERLIE BIEVER, AN
Tactical Critical Care Evacuation From the Point of Injury BY MAJOR GENERAL BART O. IDDINS, MD
Chapter 24: Telehealth in the Central Command Region . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 223
COLONEL DANIEL KRAL, MSMOT, and COLONEL (RETIRED) RON POROPATICH, MD
A Pediatrician Goes to War BY COLONEL (RETIRED) MARTIN G. OTOLINI, MD
Chapter 25: Critical Care Air Transport Teams . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 235
COLONEL (RETIRED) JAY JOHANNIGMAN, MD, and LIEUTENANT GENERAL (RETIRED) PAUL K. CARLTON JR, MD
A Different Paradigm BY LIEUTENANT GENERAL (RETIRED) THOMAS W. TRAVIS, MD
Chapter 26: Limb Salvage and Reconstruction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 245
LIEUTENANT COLONEL BENJAMIN K. POTTER, MD, and COLONEL (RETIRED) ROMNEY C. ANDERSEN, MD
Chapter 27: Preventing and Treating Infectious Complications in Wounded Warriors. . . . . . . . . . . . . 251
COLONEL CLINTON K. MURRAY, MD; DANIEL R. ROBLES; and DAVID R. TRIBBLE, MD, DRPH
Chapter 28: Advances in Combat Amputee Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 257
COLONEL (RETIRED) PAUL F. PASQUINA, MD, and LIEUTENANT COLONEL BENJAMIN K. POTTER, MD
A Message from Boston BY JESSICA KENSKY, RN, AND PATRICK DOWNES, PSYD
Chapter 29: Rehabilitation of Blast Casualties With Traumatic Brain Injury . . . . . . . . . . . . . . . . . . . 271
COLONEL (RETIRED) PAUL F. PASQUINA, MD; LOUIS M. FRENCH, PSYD; and RORY A. COOPER, PHD
Americans Helping Wounded Warriors BY ARNOLD FISHER
Chapter 30: Recognition and Management of Posttraumatic Stress Disorder and
Combat-Related Stress Reactions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 285
CAPTAIN JAMES C. WEST, MD; LIEUTENANT COLONEL GARY H. WYNN, MD; and COLONEL DAVID M. BENEDEK, MD
Chapter 31: Warrior Care and Transition: Patient-Centered Care for
Wounded, Ill, and Injured Warriors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 295
LIEUTENANT GENERAL (RETIRED) ERIC B. SCHOOMAKER, MD, PHD
A Former Wounded Warrior’s Personal Journey BY COLONEL (RETIRED) GREGORY D. GADSON, MSIS, MPM
Chapter 32: Assessing Suicide Risk and Resilience in Service Members:
The Army STARRS Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 307
COLONEL (RETIRED) ROBERT J. URSANO, MD; PAUL E. HURWITZ, MPH; ROBERT K. GIFFORD, PHD; and
MURRAY B. STEIN, MD, MPH
Chapter 33: Family and Community Support. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 317
COLONEL (RETIRED) STEPHEN J. COZZA, MD; PAULA RAUCH, MD; and MARY KELLER, EDD
Section Three: Challenges
Chapter 34: Anticipating the Challenges of Potential Battlefields. . . . . . . . . . . . . . . . . . . . . . . . . . 329
MAJOR GENERAL (RETIRED) STEPHEN L. JONES, MD; REAR ADMIRAL BRUCE L. GILLINGHAM, MD; AND
BRIGADIER GENERAL SEAN L. MURPHY, MD
Chapter 35: Prehospital Casualty Care: The Next Frontier. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 339
COLONEL ROBERT L. MABRY, MD, AND COLONEL (RETIRED) RUSS KOTWAL, MD, MPH
Chapter 36: Pushing Past the Limits: Strategies to Advance Resuscitation and Recovery. . . . . . . . . . . . 349
COLONEL MATTHEW J. MARTIN, MD; HASSAN ALAM, MD; AND JEREMY PERKINS, MD
Chapter 37: Endovascular Control of Bleeding. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 359
LIEUTENANT COLONEL JOSEPH J. DUBOSE, MD, AND COLONEL TODD E. RASMUSSEN, MD
Chapter 38: Optimizing Surgical Outcomes With Biomarker-Based Decision-Making. . . . . . . . . . . . . 365
CAPTAIN ERIC ELSTER, MD, AND ARNAUD BELARD, MBA
Chapter 39: Neuroscience . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 375
ALICIA T. CROWDER, PHD; COLONEL JAMIE GRIMES, MD; AND REGINA C. ARMSTRONG, PHD
Targeting Traumatic Brain Injury BY RICHARD W. THOMAS, MD, DDS
Chapter 40: Applying Regenerative Medicine to Battlefield Injuries. . . . . . . . . . . . . . . . . . . . . . . . 389
ANTHONY ATALA, MD; COMMANDER JONATHAN FORSBERG, MD, PHD; and KAREN RICHARDSON
Chapter 41: In-Theater Research: Optimizing the Combat Environment to Continue to
Advance the State of the Science. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 395
CAPTAIN LISA OSBORNE, PHD; M. MARGARET KNUDSON, MD; and COLONEL (RETIRED) JOHN B. HOLCOMB, MD
Chapter 42: Human Performance Optimization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 401
PATRICIA A. DEUSTER, PHD, MPH, and COLONEL (RETIRED) FRANCIS G. O’CONNOR, MD, MPH
Chapter 43: Beyond the Battlefield: Civilian–Military Trauma Collaboration. . . . . . . . . . . . . . . . . . . 411
JOHN H. ARMSTRONG, MD; M. MARGARET KNUDSON, MD; AND DAVID B. HOYT, MD
Ensuring the Future of Military Trauma Care BY VICE ADMIRAL RAQUEL BONO, MD
Chapter 44: Homecoming. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 425
LIEUTENANT GENERAL (RETIRED) THOMAS W. TRAVIS, MD, MPH
Afterword | JONATHAN WOODSON, MD, and CHARLES L. RICE, MD. . . . . . . . . . . . . . . . . . . . . . . . . . 429
Abbreviations and Acronyms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 435
Index
"What a phenomenal book...thank you for capturing the enormous contributions of military medicine to life-saving, comprehensive health and safety of America's fighting men and women. The authors have done an extraordinary job and the pictures are without peer! It brought back many deeply personal memories and reflections on the many heroes these wars spawned among our Warriors and the Military Medics (writ large) who cared for them. You and Eric Elster have done a great service to these heroes. Required reading for every concerned citizen, elected representative and military leader...and for every member of the Military Health System. These lessons cannot be permitted to shrink into obscurity." --LTG Eric Schoomaker, 42nd Army Surgeon General (Ret)
