How Did We Get
Where We Are
in
Combat Casualty Care
Paul K. Carlton Jr., MD, FACS.
LtGen, USAF, MC, Ret.
Professor of Surgery,
Texas A&M HSC, Ret.
29 May 2015
Begin with the end in
mind
FINISH
Combat Casualty Statistics
From Stansbury, Holcomb, Champion, Bellamy, 2005
Best
survival
we have
ever had
in the
history of
war!
25
20
15
WWII
Vietnam
OIF/OEF
10
5
0
%KIA
%DOW
WIA = Wounded in Action (WIA =RTD+ Evacuated+ DOW)
RTD = Returned to Duty in 72 hrs
Evacuated = Not RTD in 72 hrs
DOW = Died of Wounds
KIA = Killed in Action
CFR = Case Fatality Rate
%CFR
• %KIA = KIA / KIA + (WIA - RTD)
• %DOW = DOW / WIA – RTD
• %CFR = KIA +DOW / KIA + WIA
Press On
Nothing in the World can take the place of persistence.
Talent will not; nothing is more common than
An Aviators
perspective!
unsuccessful
men with talent.
Genius will not; unrewarded genius is almost a proverb.
Education will not; the world is full of educated derelicts.
Persistence and determination alone are
omnipotent!
Calvin Coolidge 1929
Historical Review
of Casualty Care
1.Antiquity
2.Napoleon's Surgeon
3.Civil War and anesthesia.
4.Boer War.
5.WWI
6.WWII
7.Korea
8.Vietnam
9.Current Activity
Combat Casualty Care
1. No one would resist trying to
improve the survival of our
war wounded!
2. Everyone is trying to do that!
3. WRONG!
4. Any change upsets the status
quo, so will be resisted
tremendously!
Why is Change So Hard
Positives =
Neutral =
Negatives=
Positives:
Interest - excitement
Pleasure - joy
Two
One
Six
Startle
Negatives:
Anger
Fear
Shame
Because our brains
are hard wired to
resist change!
Distress
Disgust
Dis-smell
Source: Silvan Thompkins
How did we get where we
are today in combat
casualty care?
Historical Review
of Casualty Care
1.Antiquity
2.Napoleon's Surgeon
3.Civil War and anesthesia.
4.Boer War.
5.WWI
6.WWII
7.Korea
8.Vietnam
9.Current Activity
Historical Review
of Casualty Care
1.This topic is basically the history of medicine as we
know it today!
2.Medicine had no scientific basis until Pasteur made
his observations on cowpox and smallpox in 1796!
3.Modern, scientific medicine follows the development
of necessity during wartime activities!
4.Medical facilities did not really develop in this
country until after WW2, when soldiers saw their
value.
Wounding
Contrary to what we have all witnessed on countless TV and Movie
shows, no one dies right away when struck with a projectile!
They die or stop fighting when the brain no longer receives oxygen
or the brain is dis-associated from the body!
This can be very quickly, if the head is blown off, or take days to
weeks, depending on where the projectile hits the body.
This is a very difficult concept to get across to our law enforcement
community, just because someone has a lethal wound does not
mean they stop resisting!
It is very important to you as warfighters if you have to protect your
colleagues!
Historical Review
of Casualty Care
1.Antiquity
2.Napoleon's Surgeon
3.Civil War and anesthesia.
4.Boer War.
5.WWI
6.WWII
7.Korea
8.Vietnam
9.Current Activity
Antiquity
1. Wounding was by low velocity missiles of many typesswords, spears, arrows, primitive rifles and bullets.
2. Medical care was typical of the times- poultices, bleedings,
amputations.
3. No formal medical school, just an apprenticeship.
4. Mortality rates ran in the 60% or greater realm.
5. Questions from ancient India, who showed cross arm flaps
to reconstruct noses in drawings from 500 BC.
Historical Review
of Casualty Care
1.Antiquity
2.Napoleon's Surgeon
3.Civil War and anesthesia.
4.Boer War.
5.WWI
6.WWII
7.Korea
8.Vietnam
9.Current Activity
Casualty Care -Prior to Larrey
•Casualties lay in the field
•If won – care given
•If lost – executed or left to die on the battlefield
and looted as spoils of war
Dominique-Jean Larrey
•1786 – Completed medical studies
•1792 – War breaks out
•1797 – designed first “flying ambulances” for
evacuation
- “flying ambulances” were horse drawn wagons to collect
and carry wounded from battlefield to hospital
- consisted of transport, medical supplies and support
personnel
•1815- spared by the Duke of Wellington because he
took care of all casualties at Battle of Waterloo
Napoleon's Surgeon
“Flying Ambulance”
Hence the name of the first modular team
was “Flying Ambulance Surgical Trauma
Team” 1984- USAFE
Same concept
Napoleon's Surgeon
1. Wounding was by low velocity missiles of many types,
swords, spears, arrows, primitive rifles and bullets.
2. Medical care was typical of the times- poultices, bleedings,
amputations.
3. Mortality rates ran in the 60% or greater realm.
4. For the first time, the casualty did not lay in the field to wait
to see who won, they were moved to receive medical care.
5. This practice saved Larrey’s life after the Battle of Waterloocustom was to execute entire General Staff.
Historical Review
of Casualty Care
1.Antiquity
2.Napoleon's Surgeon
3.Civil War and anesthesia.
4.Boer War.
5.WWI
6.WWII
7.Korea
8.Vietnam
9.Current Activity
Civil War and anesthesia.
The discovery of ether in 1846 was a landmark in the surgical
field, now you could operate painlessly!
First abdominal surgery in the USA was in 1846, an ovarian
tumor was removed and the patient survived.
The first survivor of a pelvic gunshot would was Col Joshua
Chamberlain, of Gettysburg fame.
He was from the 20th Maine and held the left flank of the
Union lines at that battle.
At the Battle of the Wilderness in 1864 he was shot in the
pelvis and categorized as expectant.
No one had ever survived such a wound.
Civil War and anesthesia.
The discovery of ether in 1846 was a landmark in the surgical field, now you could operate
painlessly!
First abdominal surgery in the USA was in 1846, an ovarian tumor was removed and the patient
survived.
The first survivor of a pelvic gunshot would was Col Joshua Chamberlain, of Gettysburg fame.
He was from the 20th Maine and held the left flank of the Union lines at that battle.
At the Battle of the Wilderness in 1864 he was shot in the pelvis and categorized as expectant.
No one had ever survived such a wound.
His brother pleaded his case and he underwent an operation
to suture his bladder injury under ether anesthesia.
The bladder always ruptured when it filled after suturing.
His bladder was decompressed with a rigid catheter and
he survived to go on and be a University President and
Governor of Maine.
Civil War and anesthesia.
The discovery of ether in 1846 was a landmark in the surgical field, now you could operate
painlessly!
The first survivor of a pelvic gunshot would was Col Joshua Chamberlain, of Gettysburg fame.
He was from the 20th Maine and held the left flank of the Union lines at that battle.
At the Battle of the Wilderness in 1864 he was shot in the pelvis and categorized as expectant.
No one had ever survived such a wound.
His surgeon was willing to think
differently than conventional wisdom
His brother pleaded his case and he underwent an operation
dictated!
to suture his bladder injury under ether anesthesia.
War
leads
to ruptured
many innovations
in suturing.
medical
The
bladder
always
when it filled after
His
bladder
with a rigid catheter and
care,
aswas
it isdecompressed
doing now!
he survived to go on and be a University President and
Governor of Maine.
“In times of change the learners will inherit the
world…
while the learned will find themselves
beautifully equipped to deal with a world that
no longer exists”
Eric Hoffer
Civil War and anesthesia.
1. Wounding was still by low velocity missiles of many types,
swords, spears, arrows, primitive rifles and bullets.
2. Grape shot by cannon began to move into high velocity
wounding.
3. Medical care was typical of the times- poultices, bleedings,
amputations, but anesthesia, when available, made it less
painful!
4. Mortality rates came down to around 50% using hot
cautery for amputations.
Historical Review
of Casualty Care
1.Antiquity
2.Napoleon's Surgeon
3.Civil War and anesthesia.
4.Boer War.
5.WWI
6.WWII
7.Korea
8.Vietnam
9.Current Activity
Boer War
1. South Africa between Dutch and British armies and
their surrogates.
2. First high velocity wounds prompted the Dutch to
charge the British with using “exploding bullets!”
3. The high velocity bullets imparted their energy into
the tissue and created a large exit wound with a small
entry wound.
4. Mortality rates remained at the 50% level despite this
high velocity wound due to better medical care.
Historical Review
of Casualty Care
1.Antiquity
2.Napoleon's Surgeon
3.Civil War and anesthesia.
4.Boer War.
5.WWI
6.WWII
7.Korea
8.Vietnam
9.Current Activity
World War One
1. High velocity wounds were the norm.
2. Artillery caused a large number of wounds.
3. Horror of trench warfare created a large number of gas
gangrene cases.
4. Wounding to medical care was measured in hours.
5. Chemical warfare created a new type of casualty.
6. Mortality rates remained in the 50% range because
medical care was more sophisticated despite more
horrific wounding.
World War One
We sent the major medical facilities to war!
Mayo Clinic, Harvard, Hopkins, Cincinnati, Yale,
etc. all went to war as an integral team of
University people!
Historical Review
of Casualty Care
1.Antiquity
2.Napoleon's Surgeon
3.Civil War and anesthesia.
4.Boer War.
5.WWI
6.WWII
7.Korea
8.Vietnam
9.Current Activity
World War Two
We sent the major medical facilities to war!
Mayo Clinic, Harvard, Hopkins, Cincinnati, Yale,
etc. all went to war as an integral team of
University people!
They brought modern medical and surgical
techniques to the war for the first time!
This time they had antibiotics and more
sophisticated surgical care.
World War Two
1.
2.
3.
4.
Modern surgical technique were used.
Antibiotics were available.
Medical planning was integral.
Wounding to medical care was now 6-12
hours.
5. Vascular repairs became available instead
of ligation.
6. Mortality rates came down to around 30%
despite high velocity wounding!
Historical Review
of Casualty Care
1.Antiquity
2.Napoleon's Surgeon
3.Civil War and anesthesia.
4.Boer War.
5.WWI
6.WWII
7.Korea
8.Vietnam
9.Current Activity
Korea
1. Rotary wing evacuation lowered time to
surgery from wounding to hours.
2. Antibiotics.
3. Forward Surgical hospitals.
4. Evacuation was rapid.
5. Mass casualty management.
6. Mortality rate came down to around 25%.
Historical Review
of Casualty Care
1.Antiquity
2.Napoleon's Surgeon
3.Civil War and anesthesia.
4.Boer War.
5.WWI
6.WWII
7.Korea
8.Vietnam
9.Current Activity
Vietnam
1.
2.
3.
4.
5.
6.
Rotary wing evacuation.
Antibiotics.
Good surgical techniques.
Echelons of care.
Mortality remained high at 24%.
Breakdown the mortality though showed us
that we only had a 2.8% in hospital mortality
rate in country, if the casualty got to us alive.
17% KIA group were those who never saw a
physician before dying.
Historical Review
of Casualty Care
1.Antiquity
2.Napoleon's Surgeon
3.Civil War and anesthesia.
4.Boer War.
5.WWI
6.WWII
7.Korea
8.Vietnam
9.Current Activity
Current Activity
What changed in medical care from 1970-2000:
1. Modern Ventilator care.
2. Golden Hour in Trauma.
3. Platinum 10 minutes in trauma care.
4. Salvage surgery.
5. Transportation platforms.
6. Level One Trauma Centers.
7. Organized system of trauma care.
8. Designated Trauma Surgeon.
Current Activity
What changed in medical care from 1970-2000:
1. Modern Ventilator care.
2. Golden Hour in Trauma.
3. Platinum 10 minutes in trauma care.
4. Salvage surgery.
5. Transportation platforms.
6. Level One Trauma Centers.
7. Organized system of trauma care.
8. Designated Trauma Surgeon.
We applied all of these activities
to our military teams in the
combat zone!
Military Medicine
Measure of Merit for Military Medicine
Soldiers, sailors, airmen and marines at work doing
their jobs- protected against environmental
hazards and if injured, receiving the very best
possible care!
1. Public Health
2. Casualty Management
Public Health
Best job we have ever done in the
history of war
Major improvement over GW I in
water, food, sanitation, etc…
Prior to WW 2, we always lost more
to public health than to combat!
Casualty Management in
Global War on Terrorism
2001-2015
“Unprecedented” Survival Rates
• Soldier survival rates in Iraq highest in U.S. war history
– 1/9 soldiers injured died from wounds
– Wounds critical as past wars
• Several advances
– Improved body armor technology (kevlar helmets and vests)
– On-site treatment by mobile surgical units
• “The average time from battlefield to arrival in the United States
is now less than four days. In Vietnam, it was 45 days.”
-- Dr. Atul Gawande
Navy Times, Jan 05
Addressed All Areas as Joint
Team 2004
Led to highest survival in history of war –
WWII Vietnam/GWI
OIF
70%
90%
76%
Result of “Heretical” Thinking
NEJM 9 Dec 04
What does 90% Mean?
11,000+ Injured in Iraq
GW2
90%
9,900
Vietnam/GW1
76%
1,540
8,360
Extra alive because of new thinking!
Source: New England Journal of Medicine 9 Dec 2004
What does 90% Mean?
11,000+
Injured
in Iraqupdated
Number
is now
to
GW2
9,900because
over 6,00090%
extra alive
we were willing
to 8,360
think
Vietnam/GW1
76%
differently! 1,540
Extra alive because of new thinking!
Source: New England Journal of Medicine 9 Dec 2004
“In times of change the learners will inherit
the world…
while the learned will find themselves
beautifully equipped to deal with a world
that no longer exists”
Eric Hoffer
Nomenclature is Important
KIA= Killed in Action, means died before saw a
physician.
DOW= Died of Wounds, means died after saw a
physician.
CFR= Case Fatality Rate, means of the total injured,
how many die.
Combat Casualty Statistics
From Stansbury, Holcomb, Champion, Bellamy, 2005
25
Best we
have ever
done!
20
15
WWII
Vietnam
OIF/OEF
10
5
0
%KIA
%DOW
%CFR
WIA = Wounded in Action (WIA =RTD+ Evacuated+ DOW)
RTD = Returned to Duty in 72 hrs
• %KIA = KIA / KIA + (WIA - RTD)
Evacuated = Not RTD in 72 hrs
• %DOW = DOW / WIA – RTD
DOW = Died of Wounds
KIA = Killed in Action
• %CFR = KIA +DOW / KIA + WIA
CFR = Case Fatality Rate
Nomenclature is Important
Hospital died of wounds rate was 2.8% in Vietnam.
Our current hospital died of wounds rate is 1% at a
Level III facility.
This is only a 1.8% improvement!
The big advances were on out of hospital care and
prevention- 5%!
That is where we focused!
Improvement
Most of the improvement is out of the KIA group.
Our DOW rates actually went up!
We made a conscious decision to go after the KIA
group from Vietnam by putting medical care much
closer to the battle field, knowing that our DOW rate
would actually go up!
Our postulate was that it would improve the overall
survival rates, the Combined Case Fatality Rate.
Combat Casualty Statistics
From Stansbury, Holcomb, Champion, Bellamy, 2005
25
Best we
have ever
done!
20
15
WWII
Vietnam
OIF/OEF
10
5
0
%KIA
%DOW
%CFR
WIA = Wounded in Action (WIA =RTD+ Evacuated+ DOW)
RTD = Returned to Duty in 72 hrs
• %KIA = KIA / KIA + (WIA - RTD)
Evacuated = Not RTD in 72 hrs
• %DOW = DOW / WIA – RTD
DOW = Died of Wounds
KIA = Killed in Action
• %CFR = KIA +DOW / KIA + WIA
CFR = Case Fatality Rate
Major Variables
•Better body armor that protects vital area
•Stabilization of injury with far forward
surgery
•Critical care in the air
•Family support - No One “gives up!”
Apples to Apples Comparison
Data from ISR--Case Fatality Rates
8.8% IF/EF
16.5% VN/GWI
22.8% WWII
Stansbury, Holcomb, Champion, Bellamy
July 2005
This segment will focus on how we
got where we are today and look to
the future
1983- After Action report from Marine
Barracks Bombing
Examined how we dealt with injured globally:
Vietnam
•Comprehensive care in country
•Close by referral to Japan or Philipines
•45 days to reach USA
1983- After Action report from Marine
Barracks Bombing
Examined how we dealt with injured globally:
Vietnam
•Comprehensive care in country
•Close by referral to Japan or Philipines
•45 days to reach USA
This was a young team- Dan Locker, Win Mabry, Craig Hinman,
Dave Welling, Geoff Wiedeman, PK Carlton, John Lockett, and
many others- mostly LtCols in rank.
We were laughed at for our audacity for thinking we could
change a big system like the Air Force!
1983- After Action report from Marine
Barracks Bombing
Examined how we dealt with injured globally:
Vietnam
•Comprehensive care in country
•Close by referral to Japan or Philipines
•45 days to reach USA
This was a young team- Dan Locker, Win Mabry, Craig Hinman, Dave Welling, Geoff Wiedeman, PK
Carlton, John Lockett, and many others- mostly LtCols in rank.
We were laughed at for our audacity for thinking we could change a big system like the Air Force!
Our response was to say it was “our Air Force” and we had an
obligation to make it better!
1983- After Action
report from Grenada
•Grenada invasion
•LtGen Jim Peake, Ret. did much the same thing after
Grenada 1983
•Parallel development that intertwined repeatedly USAFUSA-USN-USMC
•I know the Air Force side so will relate that, understand
other services participated in this improvement as well!
1983- After Action report from Marine
Barracks Bombing
Is that correct?
1983- After Action report from Marine
Barracks Bombing
Is that correct?
Is there a better way?
1983- After Action report from Marine
Barracks Bombing
Is that correct?
Is there a better way?
Is that what you want for your son or
daughter?
1983- After Action report from Marine
Barracks Bombing
Is that correct?
Is there a better way?
Is that what you want for your son or daughter?
Could you look a grieving parent or
spouse in the eye and say “no one could
have done better!”
Post Injury Phases of Illness 1983
Salvageable Mortality From:
Blood
Loss
Infection
Respiratory Failure
Injury
Days
Rehabilitation
Recovery
Weeks
Months
Post Injury Phases of Illness 1983
Salvageable Mortality From:
Salvage Surgery in 1st
hour
Blood
Loss
Secondary Surgery
Definitive Care
Infection
Respiratory Failure
Rehabilitation
Recovery
Injury
Days
Critical Care in
the Air
Months
Weeks
Critical Care in
the Air
Truisms!
Right is right,
even if everyone is against it, and
wrong is wrong,
even if everyone is for it.”
William Penn,
British statesman and philosopher
This thinking and planning paid
dividends in 1st hour of
deployment in October 2001
Recent Support of War Effort:
Operation Enduring Freedom--Oct 2001
Injury Scenario: Military and Civilian Care Comparison
Elapsed Time Post
Injury
1
2
3
4
Care Received
Emergency Surgery
25 min
Damage Control
Military
Setting
MFST personnel
6* hours
Emergency Surgery CCATT enroute
Further
Stabilization
/surgical team at
AmSurg Center
24* hours
CCATT enroute
/surgical team in
Military Hospital
Setting
48*+ hours
Definitive Surgical
Care
Definitive Surgical
Care
Military Medical Center
Civilian
Setting
Level 1
Trauma Center
Level 1
Trauma Center
Level 1
Trauma Center
Level 1
Trauma Center/
Tertiary Hospital
*Times and locations are estimated
This has now become the norm according
to surgeons at Landstuhl, Germany.
Team work has never been better!
Warren Dorlac 5 August 2005
Advantage
•Smaller footprints in theater
•Address needs as a threat become apparent
•“Meet Golden Hour”
•Home quickly with full resources
•Family present!
Lacking to Achieve Vision - 1983
•Critical care in the air
•Modular teams
•Team training
•Joint cooperation
•Trauma Surgeon
Mired in 60’s
MIND SET ISSUE!
“In times of change the learners will inherit the
world…
while the learned will find themselves
beautifully equipped to deal with a world that
no longer exists”
Eric Hoffer
Lacking to Achieve Vision - 1983
•Critical care in the air
•Modular teams
•Team training
•Joint cooperation
•Trauma Surgeon
Mired in 60’s
MIND SET ISSUE!
Critical Care in the Air
CCATT
“Their Story”
Heretical Thinking!
Critical Care in the Air
CCATT
Continuous En Route Care
Historical Route From Injury to Definitive Care
STRATEGIC EVAC
- Evac Policy 15 Days
TACTICAL EVAC
- Evac Policy 7 Days
Definitive Care
“Level 4”
CASUALTY EVAC
- Evac Policy 1 Day
In Theater
Hospital
“Level 3”
Field Hospital
“Level 2”
Battalion Aid Station
“Level 1”
Out of “ME” and into
“WE” JOINT TEAM
Continuous En Route Care
Current Route from Injury to Definitive Care
CASEVAC
1 Hour
TACTICAL EVAC
24 Hours
BAS
Level 1
STRATEGIC EVAC
48-72 Hours
Forward Surgical teams
Level 2
Combat Support Hospital, EMEDS,
Fleet Hospital
Level 3
Surgical Capability
Definitive Care
Level 4
CCATT History
•Conceptualized 1983- rejected by AE- “Like trying to catheterize
a running race horse! Sit down, shut up, and never bring this
up again!” AF SG
•Specifics in 1988
•1988 – 1999 developed concept, equipment, training
•2001-2015 proven effective
•2009-15 implemented for NDMS in USA.
Against Heavy Opposition
Evolution of Critical Care in the Air
• Aeromedical Evacuation (AE) system
• Stable casualties only - GW1 and prior- “They might die
on our airplanes!”
• Critically ill patients could be transferred but the team had
to be assembled ad hoc
• Mogadishu, Somalia 1993
• Concept of Critical Care Air Transport Team developed and
tested
• Lt Gen Paul K. Carlton (ret.), MD, FACS
• Col Christopher Farmer (ret.), MD, FACP
• Col Jay Johannigman MD, FACS
• Col Bill Beninati (ret), MD, FACP
• BGen Rick Hersack (ret.), MD, AFMC/SG
Critical Care Air Transport Team (CCATT)
• Teams provide critical care expertise to manage
patients in transit
• Augment normal AE crew
• Personnel
• Active Duty
• Guard and Reserve
• Goal of 210 teams
• 12-15 teams in theater
• 4 special operations teams
Critical Care Air Transport Team (CCATT)
• Teams are multidisciplinary
• Physician
• Nurse
• Respiratory Therapist
• CCATT Course
• 2 weeks
• 3 ventilated patients
• 6 patients maximum
AE AIRFRAMES
Opportune-- not dedicated
Maximizes flexibility
Critical Care in the Air
We have now moved over 12,000
patients on ventilators in this current
conflict!
Over 100,000 total patients!
3 deaths enroute!
CCATT
Lacking to Achieve Vision - 1983
•Critical care in the air
•Modular teams
•Team training
•Joint cooperation
•Trauma Surgeon
Mired in 60’s
MIND SET ISSUE!
Expeditionary Packages
• Prevention and Aerospace Medicine (PAM) Team
• Designed to prevent disease and non-battle injuries
• Mobile Field Surgical Team (MFST)
• Rapidly deployable, easily transportable, small surgical team
• Small Portable Expeditionary Aeromedical Rapid Response Team
(SPEARR)
• Deployable within two hours
• Flexible, broad scope of care
• Critical Care Air Transport Team (CCATT)
• For rapid aeromedical evacuation (AE) worldwide
• Expeditionary Medical Support (EMEDS)
• New version of traditional Air Transportable Clinic / Hospital
• Biological Augmentation Team (BAT)
• Field identification of pathogens of operational concern
Modular Units of Capability:
Providing What’s needed, When
needed
• The Crisis Defines
the Response
• Optimizes Resources
• Maximizes Options
for Commanders
Staging Aug
+20 Bed
Expanded Beds
+10 and +25
SPEAR
Staging/Crews
Comm
Surgical TEAMS
CRITICAL CARE
PAM Teams
Modular Units of Capability:
Providing What’s needed, When
needed
• The was
Crisis Defines
This
simply force packaging, as the
the Response
• Optimizes Resources
Air
Force
line
does
so
well!
• Maximizes Options
Staging Aug
+20 Bed
for Commanders
Expanded Beds
+10 and +25
SPEAR
Staging/Crews
Comm
Surgical TEAMS
CRITICAL CARE
PAM Teams
Prevention and Aerospace
Medicine Team (PAM)
• Designed to prevent disease
and non-battle injuries
• Missions/Tasks
• Health threat/risk assessment
• Health hazard surveillance, control, and mitigation of effects
• Primary/emergency care, flight medicine
• Population at risk; 2-10,000
• 9 personnel in 3 modules
• Module 1 (Advon) - Aerospace medicine
physician,
public health officer
• Module 2 - Bioenvironmental engineer (BEE),
independent duty medical technician
• Module 3- 2 public health technicians, 2 BEE technicians,
aerospace physiologist
Critical Care Air Transport Team (CCATT)
• For Aeromedical Evacuation Patients
• Capability: Provides in-flight critical care
transport of 3 ICU patients; with 2nd
critical care nurse, 5 stabilized patients
• Personnel: 3 - 1 Physician, 1 Nurse,
•
1 Respiratory Tech
• Equipment: Light weight, compact,
advanced and sophisticated patient
management equipment and supplies
• Operating Conditions: Work with 5 member AE
crews to care for stabilized casualties; for
tactical and strategic evacuation
Mobile Field Surgical Team (MFST)
Rapidly deployable, easily transportable, small surgical team
Provide lifesaving trauma care within one hour of injury
Personnel: 1-General Surgeon, 1-Orthopedic Surgeon,
1-Emergency Physician, 1-Anesthesiologist, 1-OR Nurse/Tech
Equipment: Manportable 300 lbs of medical equipment and supplies
in 5 backpacks, 60lb generator, 1 folding litter
Capability: Care for up to 20 patients in 48 hrs; perform up to 10 life
or limb saving/stabilization procedures
Operating conditions: Intended for specialized surgery
tasks as stand alone for short periods or as medical
augmentation unit; transportable by any means; uses
shelter of opportunity; no patient holding capability
Similar Thinking
Service
Name
Number
Time
USA
FFST
50
1943
USAF
FAST
20
1984
USA
FST
24
1985
USAF
MFST
5
1994
USN
FSRT
8
2000
All interchangeable as needed
Lacking to Achieve Vision - 1983
•Critical care in the air
•Modular teams
•Team training
•Joint cooperation
•Trauma Surgeon
Mired in 60’s
MIND SET ISSUE!
Team Training
Until 1999 our medical readiness focus was on the small tactical
hospital to deploy with their fighter wings.
The problem was that our small hospitals never took care of
people who were sick, trauma patients!
In 1999 we moved into our new world of Expeditionary Medical
Support, EMEDS, which was focused on the Medical Centers as
the primary responders.
This lowered the training requirements but did not
eliminate them!
1998
Push hard to establish
“Ft. Ben Taub” in Houston
Did in 1999 with joint team of 13
1 Army CC, 3 Navy enlisted, 9 AF
2000 - 2015
Training Spread
•USAF
Center for Sustainment Training and Readiness Skills
(CSTARS)
1. Baltimore Shock Trauma
2. Cincinnati for CCATT
3. St. Louis for National Guard and reserves
•USA – Miami
•USN - LA
Lacking to Achieve Vision - 1983
•Critical care in the air
•Modular teams
•Team training
•Joint cooperation
•Trauma Surgeon
Mired in 60’s
MIND SET ISSUE!
Lacking to Achieve Vision - 1983
Standards Established
RSVP
Readiness
Skills
Verification
Program
RSVP-Dance Card
•What are requirements to go to war?
•Consultants answered those program
questions.
•RSVP criteria established for each deployable
person
For Example
General surgery
-50 open laps every 2 years
-50 ventilated patient days
-etc…
If not met then go to CSTARS for 4 week update
prior to deployment
Certified for deployment!
For Example
CCATT Nurses
• 50 ventilator patient days
• Readiness training
• Etc…
If not met then go to CSTARS for 2 week update
prior to deployment
Certified for Deployment
Result
•Military teams better prepared for conflicts that started after
11 September 2001
•Patients more challenging in war, but principles are real and
applicable
•Learning never stopped–
1. First year in Balad, Iraq, we had an 80% wound infection
rate, dropped to less than 1% with use of wound vac.
2. Compartment syndromes rose, we countered with
aggressive decompressive surgery and changing timing
for AE.
History is Important
1995- on call one night at Wilford Hall we were
discussing how to speed up our ability to put blood
vessels back together over a difficult case.
One item that came up was how to shorten the time
to put blood vessels back together again once
damaged from trauma.
A bright young resident, Todd Rasmussen, and his
staff, David Dawson, brought up the idea of using a
shunt to bypass the vessel until you had time to
repair it.
History is Important
They asked me to buy them 10 pigs to prove the
point that an extremity could survive for 24 hours
without damage using such a shunt.
I did and they proved the point, published the
paper, and we added the shunt to our surgical
back packs.
Fast forward to Feb 2010: Todd Rasmussen is now
at the Bagram Hospital in Afghanistan on call. He
has just received a young Marine woman who
stepped on an IED on patrol.
History is Important
Her right leg was blown off below the knee.
Her left groin took shrapnel and divided both artery
and vein to her leg.
Her battle buddy got two tourniquets on for her.
She was resuscitated at a forward surgical station,
using two shunts for the dual vascular injury, and
shipped to him in about four hours.
He reconstructed the artery and vein after
removing the shunt- saving her remaining leg.
He then took this picture, telling me that it was the
best investment I had ever made, buying those 10
pigs, for the war wounded!
22 Year Old Marine
22 Year Old Marine
Dr Rasmussen has now done
over 1300 such cases in the
current conflicts!
Combat Casualty Statistics
From Stansbury, Holcomb, Champion, Bellamy, 2005
25
Best
we
have
ever
done!
20
15
WWII
Vietnam
OIF/OEF
10
5
0
%KIA
%DOW
WIA = Wounded in Action (WIA =RTD+ Evacuated+ DOW)
RTD = Returned to Duty in 72 hrs
Evacuated = Not RTD in 72 hrs
DOW = Died of Wounds
KIA = Killed in Action
CFR = Case Fatality Rate
%CFR
• %KIA = KIA / KIA + (WIA - RTD)
• %DOW = DOW / WIA – RTD
• %CFR = KIA +DOW / KIA + WIA
Lacking to Achieve Vision - 1983
•Critical care in the air
•Modular teams
•Team training
•Joint cooperation
•Trauma Surgeon
Mired in 60’s
MIND SET ISSUE!
Joint Cooperation
•Casualty does not care who takes care of them –
Army, Navy, Air Force, Marine Corp
•They care that they get taken care of
•Has required many years to get into “WE” mindset
of Jointness!
Team
Military
US Army
US Air Force
US Navy
US Marine Corp
All now closely integrated team members
Focus Areas
Historical Route From Injury to Definitive Care
STRATEGIC EVAC
TACTICAL
EVAC
CASUALTY EVAC
- Evac Policy 15 Days
- Evac Policy 7 Days
- Evac Policy 1 Day
Definitive Care
“Level 4”
In Theater
Hospital
“Level 3”
Field Hospital
“Level 2”
Battalion Aid
Station
“Level 1”
Out of “ME” and into
“WE” JOINT TEAM
Lacking to Achieve Vision - 1983
•Critical care in the air
•Modular teams
•Team training
•Joint cooperation
•Trauma Surgeon
Mired in 60’s
MIND SET ISSUE!
Trauma Surgeon
It had become clear that we needed a constantly
prepared cadre of surgeons who had dedicated
themselves to the care of the traumatically wounded
in our military to really optimize our surgical care in
the military.
The Vietnam cadre had departed and we seemed to
have a significant gap of skills between what we
trained for peacetime healthcare and what we
needed for wartime surgery.
As we worked on these concepts in the military the
private sector had come to the same conclusion and
were developing the whole concept of a “trauma
surgeon”.
Trauma Surgeon
This “trauma surgeon” would be taught in a fellowship
program, post general surgery or orthopedic surgery
residencies, the intricacies of ICU care, management of the
trauma patient, mass casualties, system thinking for trauma
care, and how to integrate all of the pieces of the puzzle into a
cohesive team!
Our military invested in several of these training programs
with our best residents. The results have been remarkable!
People like Ty Putnam, Don Jenkins, Jay Johanigman, David
Kissinger, Warren Dorlac, Ken Kaylor, Mark Richardson, Jeff
Bailey, etc. carried this focus on wartime medicine to the
best outcomes in the history of war!
Trauma Surgeon
The current wartime strategy is the
first ever designed by and for
surgeons using modern techniques!
The results speak for themselves!
Give Me Examples!
1.Index case #1- first Nova Lung use.
2.Index case #2- first survivor of a
traumatic pneumonectomy in
wartime.
3.Index case #3- first survivor using
ECMO in wartime.
Give Me Examples!
1.Index case #1- first Nova
Lung use.
2.Index case #2- first survivor of a
traumatic pneumonectomy in
wartime.
3.Index case #3- first survivor using
ECMO in wartime.
Index Case #1
1. 21 year old male, blown up in IED
explosion in Iraq, 2006.
2. Severe lung injury resulting in an
inability to oxygenate him on the
ventilator, despite all the tricks known.
3. Dying quickly from this injury!
Index Case #1
4. Call to Landstuhl Trauma Team- is there nothing we
can do?
5. Landstuhl launched the new NovaLung Team to
Baghdad, hooked the man up to the Nova Lung, flew
him back to Germany, took him to a German hospital on
the Nova Lung, where he spent two weeks on this
device.
EVOLUTIONARY ADVANCES:
NOVALUNG
Index Case #1
21 year old male, blown up in IED explosion in Iraq, 2006.
Severe lung injury resulting in an inability to oxygenate him on the ventilator, despite all the tricks
known.
Dying quickly from this injury!
Call to Landstuhl Trauma Team- is there nothing we can do?
Landstuhl launched the new NovaLung Team to Baghdad, hooked the man up to the NovaLung,
flew him back to Germany, took him to a German hospital on the NovaLung, where he spent two
weeks on this device.
He graduated to a conventional ventilator, was sent back to
Landstuhl, and is now home with his family- stone cold normal
in his physiology!
The Army tried to Court Martial the AF physician who gave this
man a chance at life!
Give Me Examples!
1.Index case #1- first Nova Lung use.
2.Index case #2- first survivor of a
traumatic pneumonectomy in
wartime.
3.Index case #3- first survivor using
ECMO in wartime.
Index Case #2
1. 19 yo Male, shot at close range with AK-47.
2. Bullet entered his right side, went through the
hilum of the right lung, and left him in shock!
3. This is the type of person who coughed blood
up once or twice and died in any previous
conflict!
4. Brought to a forward operating location where
he was addressed surgically in minutes.
5. When the surgeon saw the extent of his injury
he knew he was in trouble.
6. He had to remove the entire right lung, a
traumatic pneumonectomy.
Index Case #2
7. There had never been a survivor of this in war!
8. The surgeon called the Trauma Czar and asked for
help!
9. The Trauma Czar mobilized the Nova Lung team
from Germany, met them in Bagram, flew to the
forward operating location, hooked the man up to the
Nova Lung, and transported him back to Germany.
EVOLUTIONARY ADVANCES:
NOVALUNG
Index Case #2
1.
2.
3.
4.
5.
6.
7.
8.
9.
19 yo Male, shot at close range with AK-47.
Bullet entered his right side, went through the hilum of the right lung, and left him in shock!
This is the type of person who coughed blood up once or twice and died in any previous conflict!
Brought to a forward operating location where he was addressed surgically.
When the surgeon saw the extent of his injury he knew he was in trouble.
He had to remove the entire right lung, a traumatic pneumonectory.
There had never been a survivor of this in war!
He called the Trauma Czar and asked for help!
The Trauma Czar mobilized the NovaLung team from Germany, met them in Bagram, flew to the
forward operating location, hooked the man up to the NovaLung, and transported him back to
Germany.
10.This gentleman spent several weeks on the Nova
Lung and then went home.
11.He is doing well at home now with no
complications.
Give Me Examples!
1.Index case #1- first NovaLung use.
2.Index case #2- first survivor of a
traumatic pneumonectomy in
wartime.
3.Index case #3- first survivor
using ECMO, a heart lung
machine, in wartime.
Index Case #3
1. 19 yo Male, shot at close range with AK-47.
2. Bullet entered his right side, went through the
hilum of the right lung, proceeded across the
mediasteinum, took off the top of his left lung, and
left him in shock!
3. This is the type of person who had no chance for
survival in any previous conflict!
Index Case #3
4. His buddies got him to a Far Forward Surgical team in
Afghanistan very quickly.
5. The surgeon addressed him surgically, had to
remove his right lung and a portion of his left lung.
6. The surgeon called the “Trauma Czar” as he
started, asking for help!
7. The “Trauma Czar” was well experienced, had taken
care of the first survivor of a traumatic
pneumonectomy in history and knew what would
happen to the patient- his right heart would fail
within 24 hours.
Index Case #3
8. The “Trauma Czar” called for the ECMO team to
come from Germany to pick this young man up, giving
them a very short window to arrive.
9. They arrived at the 16 hour mark, traveled with the
Trauma Czar to the forward location, and hooked up
the patient to the heart lung machine at the 20 hour
mark as he was entering florid right heart failure.
EVOLUTIONARY ADVANCES:
EXTRACORPOREAL MEMBRANE OXYGENATION
We had to work this one for our people on
Okinawa in the NICU from 1985 to present!
This was certified for AE use on 1
Oct 2010. It was used on this
patient for the first time two weeks
later.
Index Case #3
10. They then flew this young man back to
Germany, kept him on the machine for two
weeks to allow his heart to accommodate his new
circulation, and he is home now with his family!
11. He has a normal life expectancy!
Index Case #3
10. They then flew this young man back to
Germany, kept him on the machine for two
weeks to allow his heart to accommodate
his new circulation, and he is home now
with his family!
11. He has a normal life expectancy!
That is what we mean by
“nothing is too good for
those in uniform!”
“In times of change the learners will inherit the
world…
while the learned will find themselves
beautifully equipped to deal with a world that
no longer exists”
Eric Hoffer
A Little Humor
Don’t accept your dog’s admiration as
conclusive evidence that you are
wonderful!
How to Dissent
Begin with the end in
mind
FINISH
Combat Casualty Statistics
From Stansbury, Holcomb, Champion, Bellamy, 2005
Best
survival
we have
ever had
in the
history of
war!
25
20
15
WWII
Vietnam
OIF/OEF
10
5
0
%KIA
%DOW
WIA = Wounded in Action (WIA =RTD+ Evacuated+ DOW)
RTD = Returned to Duty in 72 hrs
Evacuated = Not RTD in 72 hrs
DOW = Died of Wounds
KIA = Killed in Action
CFR = Case Fatality Rate
%CFR
• %KIA = KIA / KIA + (WIA - RTD)
• %DOW = DOW / WIA – RTD
• %CFR = KIA +DOW / KIA + WIA
Press On
Nothing in the World can take the place of persistence.
Talent will not; nothing is more common than
An Aviators
perspective!
unsuccessful
men with talent.
Genius will not; unrewarded genius is almost a proverb.
Education will not; the world is full of educated derelicts.
Persistence and determination alone are
omnipotent!
Calvin Coolidge 1929
Historical Review
of Casualty Care
1.Antiquity
2.Napoleon's Surgeon
3.Civil War and anesthesia.
4.Boer War.
5.WWI
6.WWII
7.Korea
8.Vietnam
9.Current Activity
Questions?
Medical Initiatives
in Current Wars
Medical Initiatives Updated 22March12
Sum total:
NavyArmyAir ForceShared A/AF/NCOALITION-
0.
2.
25.
10.
2.
FOR THE NEXT CONFLICT, CAN WE AFFORD TO LOSE THE AIR
FORCE CONTRIBUTION?
CLEARLY, THE ANSWER IS NO!