Battlefield Medicine And Its Implication For Global Trauma Care
According to the Global Burden of Disease, trauma is now responsible for five million deaths each year. High-income countries have made great strides in reducing trauma-related mortality figures but low–middle-income countries have been left behind with high trauma-related fatality rates, primarily in the younger population.
Much of the progress high-income countries have made in managing trauma rests on advances developed in their armed forces. This analysis looks at the recent advances in high-income military trauma systems and the potential transferability of those developments to the civilian health systems particularly in low–middle-income countries. It also evaluates some potential lifesaving trauma management techniques, proven effective in the military, and the barriers preventing these from being implemented in civilian settings.
The link between military and civilian medicine has deep historical roots. In high-income countries each successive conflict that the military engages in affords the opportunity to contribute improvements in trauma care, many of which are translated into civilian healthcare systems. The wars of the last decade in Iraq and Afghanistan have changed the nature of injuries seen on the battlefield leading to further trauma management innovation. Lessons learned in these hostile environments have guided many developments in trauma care in high-income countries resulting in improved casualty outcomes and a lower mortality rate; an objective shared by the civilian and military trauma doctrine.
On the other hand, trauma management is a neglected epidemic in low- and middle-income countries, both in civilian and conflict settings. Trauma is responsible for more global deaths annually than HIV, malaria and tuberculosis combined, but receives a fraction of the attention and funding. Death from accidental or non-accidental injury has fast become the leading cause of death in young people in low–middle-income countries.
One of the greatest challenges to implementing any sort of trauma intervention in a resource-poor setting is the inadequacies in the health system in which it is set. Weak health systems and poor public funding test both the feasibility and the sustainability of trauma care development. With trauma constituting such a significant portion of mortality, and with many simple cost-effective solutions being pioneered in the military setting in high-income countries, this area should be one of the most active research areas for cost-effective health investment and knowledge transfer. In spite of the heterogeneity (fiscal, health systems development, etc.) of low–middle-income countries, there is a commonality of need for cost-effective interventions for dealing with trauma irrespective of the different barriers that each country presents.
The battlefield has been a key area for innovations in trauma care and throughout the great wars of the last two centuries, military and civilian trauma care have evolved synergistically. Physicians in the American Civil War first noted that prompt attention to casualties, debridement of wounds and amputation to prevent systemic infection all had the potential to preserve life. World War I witnessed the institution of casualty evacuation reducing the time from point of wounding to reaching a medical facility, and in World War II the first use of blood transfusion and fluid resuscitation in combat hospitals was instituted; alongside the introduction of antibiotics, these developments were hailed as the turning point for survival rates of those injured on the battlefield.
An intense exposure to such high volumes of trauma victims is cited as one of the main reasons for such huge leaps forwards in care. Coupled with this, the dynamic and reactive environment of conflict fosters an attitude among physicians to strive for better clinical outcomes. The burden of morbidity in conflict is, however, increasing. The reason for this is two-fold; first, due to medical and logistical developments the lives of many more seriously injured soldiers are being saved, even those who have experienced injuries previously deemed ‘unsurvivable’. Second, there has been a shift in tactics used in most low-intensity modern conflicts, with greater emphasis on maiming soldiers rather than killing them, as this has a greater impact on enemy resources (Gawande, 2004).
In low–middle-income countries the rapidly evolving infrastructure and construction sector, as well as more roads, has meant trauma has become a leading cause of death in young people (0–24 years old).9 Given the financial constraints in low–middle-income countries and the inherent costs in improving the health system, trauma care has been neglected in research. In this analysis, we examine the current state of military trauma care in high-income countries and how these developments could have wider cost-effective impact for helping deliver affordable trauma care in low–middle-income setting(s).
Pre-hospital care has dramatically improved survival odds for those injured in combat, particularly use of Medical Emergency Response Teams (helicopter-borne, physician-led teams), to cut down time from battlefield trauma to hospital. One of the primary advantages of having a doctor on board is the possibility of conducting pre-hospital anaesthesia which can improve outcomes in patients with devastating injuries.
Despite the uniquely challenging working environment of a tactical helicopter, Medical Emergency Response Teams deliver some of the most effective pre-hospital care. The lessons from military pre-hospital care have been clear. With (para)medically led teams, fast access and evacuation times all combine to save lives.
However, most advances in pre-hospital care have not been examined for feasibility in low–middle-income settings, e.g. delivery of first aid at the point of trauma. Early use of tourniquets and topical haemostatics has been a major lifesaver on the battlefield, yet consideration of how this could be deployed outside hospital settings in low–middle-income countries has yet to be given.
Likewise, where air evacuation is now common in high-income countries, low–middle-income countries, particularly those with emerging economies, have yet to assess the cost effectiveness of air ambulance service for trauma. In spite of often poor road infrastructure, many low–middle-income countries still have trauma patients being transferred by private cars/vans to hospitals.
The distances, poor infrastructure and high cost–gain ratio of implementing any form of air evacuation remain major barriers to executing any form of fast casualty evacuation programme suggesting that the focus needs to be at the point of trauma to stabilise patients for what are often long journeys to receive definitive trauma care.
Another logistical adaptation that has saved lives is the enhanced battlefield first aid training given to soldiers before and during deployment. At the point of wounding, basic medical care such as haemorrhage control with tourniquets and topical haemostatics such as the HemCon field-dressing can be delivered. All soldiers are taught haemorrhage control techniques. If a non-medic comrade can deliver care from the point of wounding until medical help arrives, this dramatically increases the chance of survival.
Also imbedded in the units on the frontline are combat medical technicians who have enhanced training in trauma care. They are qualified to provide advanced first aid, administer strong analgesics for pain relief and call for helicopter evacuation when necessary. Care is embedded at the point of wounding, and improvements in evacuation capabilities mean timeframe for moving casualties to the next echelon of care is much reduced.
The notion of training individuals in first aid if they work in a situation where casualties are regularly taken is widely applicable in high-income countries. Soldiers are trained in first aid for rapid delivery of care after the point of wounding. Following a similar principle, those working in the public sector and where frequent accidents occur, such as bus drivers, taxi drivers and the police force, could be trained in basic first aid, given equipment to use and given two-way radios in order to alert hospitals of incoming patients in many developing countries.
In middle-income settings where emergency medical services do exist, relatively low-cost interventions could have a substantial impact on improving pre-hospital trauma care such as a wider geographical distribution of ambulance dispatch and further training for ambulance staff which have been shown to be highly effective in Latin America.
