Out Of The Crucible: How The US Military Transformed Combat Casualty Care In Iraq And Afghanistan

2017·189.5 MB·English

by  US Army Medical Department Center and School. Borden Institute

Out of the Crucible

HOW THE US MILITARY TRANSFORMED COMBAT CASUALTY CARE IN
IRAQ AND AFGHANISTAN

Out of the Crucible

HOW THE US MILITARY TRANSFORMED COMBAT CASUALTY CARE IN
IRAQ AND AFGHANISTAN
senior editors
Arthur L. Kellermann, MD, MPH
Professor of Military and Emergency Medicine and Dean, F. Edward Hébert School of Medicine
Uniformed Services University of the Health Sciences
Eric Elster, MD
Captain, MC, US Navy
Professor and Chair, USU-Walter Reed Department of Surgery, F. Edward Hébert School of Medicine
Uniformed Services University of the Health Sciences
associate editors
Charles Babington
Principal, WaVe Communications
Racine Harris, MPH
Program Manager, Defense Health Horizons
Henry M. Jackson Foundation for the Advancement of Military Medicine
BORDEN INSTITUTE
US ARMY MEDICAL DEPARTMENT CENTER AND SCHOOL
HEALTH READINESS CENTER OF EXCELLENCE
Fort Sam Houston, Texas
JOHN H. GARR, MD, MSE, FACEP, Colonel, MC, US Army | Director & Editor-in-Chief, Borden Institute
JOAN REDDING | Senior Production Editor
VIVIAN MASON | Volume Editor
CHRISTINE GAMBOA, MS, MBA | Creative Director & Production Manager, Fineline Graphics LLC

The views expressed are those of the authors and do not necessarily represent those of the US Army, the US Department of Defense, or the United States Government. Use of
trade or brand names in this publication does not imply endorsement by the Department of Defense. Partial support for this book was provided by Defense Health Horizons, a
policy analysis unit at the Uniformed Services University of the Health Sciences.
CERTAIN PARTS OF THIS PUBLICATION PERTAIN TO COPYRIGHT RESTRICTIONS. ALL RIGHTS RESERVED. NO COPYRIGHTED PARTS OF THIS PUBLICATION MAY BE REPRODUCED OR TRANSMITTED IN ANY
FORM OR BY ANY MEANS, ELECTRONIC OR MECHANICAL (INCLUDING PHOTOCOPY, RECORDING, OR ANY INFORMATION STORAGE AND RETRIEVAL SYSTEM), WITHOUT PERMISSION IN WRITING FROM
THE PUBLISHER OR COPYRIGHT OWNER.
Published by the OFFICE OF THE SURGEON GENERAL
Borden Institute
US Army Medical Department Center and School
Health Readiness Center of Excellence
Fort Sam Houston, Texas
2017

Library of Congress Cataloging-in-Publication Data
Names: Kellermann, Arthur, editor. | Elster, Eric, editor. | Babington, Charles, editor. | Harris, Racine, editor. | Borden Institute (U.S.), issuing body.
Title: Out of the crucible : how the US military transformed combat casualty care in Iraq and Afghanistan / senior editors, Arthur L. Kellermann,
Eric Elster ; associate editors, Charles Babington, Racine Harris.
Other titles: Out of the crucible (Kellermann)
Description: Fort Sam Houston, Texas : Borden Institute, 2017. | Includes bibliographical references.
Identifiers: LCCN 2017032811
Subjects: | MESH: Emergency Medical Services | Military Medicine | War-Related Injuries—therapy | War-Related Injuries—rehabilitation | Iraq War, 2003-2011 | Afghan Campaign 2001-
Classification: LCC RC971 | NLM WB 116 | DDC 616.9/8023—dc23 LC record available at https://lccn.loc.gov/2017032811
PRINTED IN THE UNITED STATES OF AMERICA
24, 23, 22, 21, 20, 19, 18, 17 5 4 3 2 1
[Title Page image] US Army Soldiers carry a critically wounded American Soldier on a stretcher to an awaiting MEDEVAC helicopter from Charlie Co., Sixth Battalion, 101st Airborne
Combat Aviation Brigade, Task Force Shadow, June 24, 2010, near Kandahar, Afghanistan. Photo by Justin Sullivan/Getty Images. Reproduced with permission from: Getty Images.
contents
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
| v
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
vi | Out Of the CruCible: hOw the uS Military tranSfOrMed COMbat CaSualty Care in iraq and afghaniStan
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
COntentS | vii
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
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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
COntentS | ix
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
x | Out Of the CruCible: hOw the uS Military tranSfOrMed COMbat CaSualty Care in iraq and afghaniStan