By Donna Miles
American Forces Press Service
WASHINGTON, Nov. 18, 2013 – Traveling around the combat theater over the past four months, Army Lt. Col. (Dr.) James Geracci was on a quest.
Like his contemporaries in military medicine, Geracci, a family physician and operational medicine specialist, is thrilled about advances over the past 12 years of conflict that have elevated casualty care to a whole new level.
Every soldier, Marine, airman and sailor on the ground is now trained as a medical first responder in basic lifesaving skills. Medical evacuation response times have dropped dramatically, and the system now moves casualties through progressive levels of care faster than ever imagined possible. Advanced lifesaving techniques are applied throughout the continuum of trauma care, reducing blood loss, controlling brain swelling, salvaging limbs and saving lives.
But the military trauma community sees its glass as half empty rather than half full. Instead of celebrating the advances that enable 98 percent of U.S. combat casualties that reach an advanced treatment facility to survive, they’re focused on improving the odds for those who don’t.
So as Geracci recently traveled around the combat theater, he went directly to the front-line commanders and combat medics he and his fellow medical professionals believe hold the key. All were familiar with new reporting and documentation procedures that require them to document the care they provide at the point of injury and as casualties are evacuated to advanced-level care.
But what Geracci quickly realized hadn’t trickled down through the chain of command was the “So what?” So he and his team took that message directly to more than 1,400 medics assigned to small combat outposts and forward operating bases across Afghanistan, as well as to their nonmedical commanders and noncommissioned officers.
“We looked them in the eye and said, ‘This is why this is important,'” Geracci said. “We tried to explain that although this is an enterprise-level initiative, it has to start at the ground level. And as we talked to them, it was amazing. A light bulb suddenly went on.”
Air Force Col. (Dr.) Mark Mavity, the U.S. Central Command surgeon, calls that recognition one of the most significant new developments in casualty care for troops in Afghanistan.
The Department of Defense Trauma Registry, established in 2005 as the Joint Theater Trauma Registry, offers detailed information about every trauma patient treated at an advanced theater facility. It tracks patients from the moment of arrival at the closest field hospital or other facility, through each movement to more advanced levels of care, and ultimately through rehabilitation.
The registry also includes autopsy results from every casualty who died.
Eight years since its introduction, the registry has become the world’s largest combat casualty care databank. By studying it, medical professionals have been able to verify which treatments were the most successful and which weren’t, and to flag areas where new or different procedures or technologies might improve survival rates and patient outcomes.
“This gave us an opportunity to step back and understand the population of patients that have moved through the continuum of care and to try to derive information about the care they received and the outcomes associated with that care,” said Air Force Col. (Dr.) Jeffrey Bailey, the Joint Trauma System director. “By being able to analyze and evaluate our practices, we have found points where we can make improvements that provide a survival advantage or some other advantage to our casualties.”
Lessons learned through the registry have resulted in “best evidence-based best practices,” he said, propelling many of the advances in caring for casualties and preventing them in the first place.
The formal documentation of injury patterns, for example, led to improvements in personal protective equipment ranging from protective ballistic undergarments to ancillary plating that protects the groin, shoulders and neck.
The registry also provided statistical evidence of the importance of immediate intervention during the so-called “golden hour.” That led then-Defense Secretary Robert M. Gates to institute a policy in 2009 reducing the timetable for medical evacuation to 60 minutes.
Data provided by the registry also validated the use of tourniquets and led to new approaches to transfusions, resuscitation procedures and hemorrhage control.
But trauma surgeons recognized a glaring weakness in the registry. Because it was based on care delivered at treatment facilities, it omitted critical information about the care provided before the patient ever got there. That “prehospital environment” was where most combat deaths occurred. “So that is where we saw the greatest opportunity to make improvements,” Bailey said.
“Some people call helicopter evacuation the ‘golden hour,’ but others have described what happens on the ground as the ‘platinum 10 minutes,'” he said. “It became clear that we needed to understand what was going on on the ground during those platinum 10 minutes before the helicopter showed up.”
That led to the stand-up of the Pre-Hospital Trauma Registry initiative earlier this year.
Army Col. (Dr.) Russ Kotwal, a family and aerospace medicine specialist assigned to the Joint Trauma System at Fort Sam Houston, Texas, was a pioneer in championing this concept. Working for more than a decade with the special operations community, much of it with the 75th Ranger Regiment, he formulated a precursor to the militarywide prehospital registry in the late 1990s.
“I saw a huge gap,” he said, lacking any documentation of patient care at the initial point of injury and on evacuation platforms.
But getting those who provided that initial care to take time out to annotate exactly what they were doing was no easy task, he acknowledged. “A lot of people find it more exciting to provide the care than to actually document the care,” Kotwal said. “Some don’t understand the big picture and how crucial it is to capture what you are doing for historical purposes, but also for performance improvement.”
So Kotwal made it his personal mission to change that. “I convinced the line command that if everybody has the potential to be a casualty on the battlefield, especially in a line unit, everybody has the potential to also be a first responder,” he said. “And if you don’t capture that information about what you are doing, that data, it is hard to effect performance improvement in that realm.”
Knowing that the success of his effort would depend on the first responders, Kotwal made the documentation process as simple and straightforward as possible. He and his senior medics changed an outdated field medical card that was standard at the time to one that focused solely on tactical combat casualty care.
Every 75th Ranger Regiment member was issued a card as part of their basic equipment, and required to keep it in a standardized location on their uniform. That way, first responders knew exactly where to look for the card if they had to report the care they provided a comrade.
“They filled it out as they provided care if they could,” Kotwal said. Sometimes they were overwhelmed with providing care or the evacuation process was so quick that they couldn’t immediately get to it, he said. “But they did it at the first opportunity,” he added.
As a double-check to ensure the reporting wasn’t overlooked, Kotwal also got the requirement integrated into the after-action review process. “This is something line guys do very well. Every time they come off a mission, they go directly into an AAR and do reports based on the mission so they can assess it and make improvements,” he said.
“The medical community didn’t do it at that level,” Kotwal said. “So we instituted a [medical] AAR that had to be done within 72 hours after a mission.”
Through this process, the 75th Ranger Regiment developed a rudimentary pre-hospital trauma registry, refined it over time and expanded across the special operations community, Kotwal reported.
Kotwal later joined the Joint Trauma System team to expand this concept to conventional forces.
Geracci, a former division surgeon in Afghanistan, said he, too, was “excited about the advancements taking place in facilities-based care,” many attributable to the Joint Trauma System and its trauma registry.
“But I was also frustrated that we hadn’t been able to apply the same degree of rigor in the prehospital environment,” he said. “I saw this as a blind spot in the JTS process. So my goal was to help [the military medical community] go after that blind spot.”
Geracci said he “jumped” at the chance to be one of the Centcom Joint Theater Trauma System’s first pre-hospital directors in the combat theater to address the gap.
“We’re building on the work already proven for about a decade on the special operations side and taking those exact same principles and importing them into the [combat] theater,” he said.
Just months after the Pre-Hospital Trauma Registry was introduced, Geracci said, he’s already seeing its rewards. We have already seen tangible benefits from putting that in place,” he said. “This is proving to be an incredibly valuable tool.”
He credited combat medics and their commanders on the ground who are putting that tool to work as they complete casualty-care cards and AARs.
“They are the reason we have seen success in such a short period of time,” Geracci said. “They understand that this information, and the data they produce, provides better care not only for their comrades, but for anyone who passes through the different levels in the continuum of care.”
(Follow Donna Miles on Twitter: @MilesAFPS)
- The Injury Burden of Recent Combat Operations: Mortality, Morbidity, and Return to Service of U.K. Naval Service Personnel Following Combat Trauma (hispanicbusiness.com)
- Battlefield Surgeons Add Data to Trauma Kit (enterprisetech.com)
- Centcom Strives to Preserve, Share Combat Trauma Lessons (defense.gov)