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 viii | Out Of the CruCible: hOw the uS Military tranSfOrMed COMbat CaSualty Care in iraq and afghaniStan 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