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July 6, 2016 by Kyle Remick, MD

Combat Casualty Care Research for Continuing Conflict

Although not directly related to civilian global health, our national efforts in saving the lives of our American Heroes fighting in remote and austere locations around the globe should not go unrecognized by our global surgical community.  In much the same way we as military trauma surgeons attempt to translate lessons to civilian trauma care especially to ensure preparedness for mass casualty events, we must also understand and realize the mutual contribution of US Military surgeons to global surgery.  Despite what is presented by our national leadership and by the media, there are still US Military service members serving in dangerous places overseas.  I don’t just mean the usual training exercises which are occurring regularly in Africa, Europe, Asia, and South America.  I mean specifically in Afghanistan and Iraq.

I was deployed when the “official end” of hostilities occurred in Afghanistan in December 2014.  In reality, the decision was not “everyone is coming home now.”  It was more of a numbers game.  By January 1, 2015, the US had to reduce troop numbers with “boots on ground” in Afghanistan to less than 10,000…but of course still continue the same mission.  Currently, there are still thousands of US service members in danger there, and there are still deployed forward surgical teams (FST) and two combat support hospitals (CSH) on the ground in Afghanistan.  In case you don’t understand, this means that there are still Army, Navy, and Air Force physicians and surgeons who leave their families for 3-12 months at a time to support our continued “effort”…whatever you want to call the “effort”.

Example of US Army deployed, austere damage control surgery
Example of US Army deployed, austere damage control surgery

Official hostilities ended in Iraq in 2012, but there are still hundreds of US personnel there also.  Again, there is at least one FST in Iraq, and most recently a small CSH was added as well.  I know this because my Army reserve colleague, Dr. (LTC) John Chovanes, who normally works at Cooper University Hospital in Camden, NJ, is currently deployed with this FST, which is located at an undisclosed location outside of Fallujah.  Fallujah you will recall was the extremely hard fought city won by the US Marines after much blood and sweat in roughly 2009.  After we left, ISIS rapidly took it back, nullifying the sacrifice of our brave American Heroes.  Regardless of political leanings, this was a horrible outcome.  And I said, we are currently right back there now, and in fact just retook the city a few days prior to my writing of this (end June 2016).

We also have recently increased our medical footprint in Iraq this summer by adding a small CSH back outside of Baghdad.  My active duty US Army colleague Dr. (COL) John Oh is currently deployed there as its trauma director.  I anxiously await an update from him as I am currently his named replacement.

I am an active duty US Army trauma surgeon serving as the Military Deputy Director for the Combat Casualty Care Research Program at Ft Detrick, Maryland.  This program plans, programs, budgets, and guides the execution of the Department of Defense (DOD) trauma research equity.  The DOD’s research funding for trauma care in fact represents nearly all of our national research investment in injury care.  Put another way, we as a Nation do NOT have a research investment to improve trauma care for our Nation’s citizens despite the fact that injury is the leading cause of death among ages 1-44, arguably the most productive portion of one’s life.  This is shameful and this fact was pointed out by the recently released National Academy of Medicine report (partially funded by the DOD) titled “A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths.”

The DOD Joint Trauma System (JTS) has conducted a worldwide patient care teleconference for over 10 years now.  The purpose of this call is to have all those who have cared for a service member on the phone, from point of injury pre-hospital care, to medical evacuation, to initial damage control surgery and first in-hospital care, to medical evacuation from the combat zone to Germany and finally to a military medical center in the US.  All are on this call discussing each significantly injured patient to ensure optimal care and to provide immediate feedback for improvement.  One area of feedback is to the Combat Casualty Care Research Program.

At the CCCRP, we are directly responsive to the needs of our warfighters.  We take issues in trauma care from the battlefield called “gaps” and translate these into hypothesis-driven research.  Based on this, we provide funding for gap-driven research that will provide the material or knowledge product that will improve combat casualty care.

Yesterday was the latest JTS teleconference.  The case discussed on the worldwide conference was that of a  28 year old US service member who sustained multiple gunshot wounds in combat.  Although there are not a large volume of US casualties, thankfully, this case demonstrates no fewer than 8 advances in CCC – each having been delivered by military’s learning health system in trauma care, trauma research, trauma training over the past decade.  These were all brought to bear in saving this guy’s life.

From my experience, this patient had a lethal injury pattern which was managed fairly routinely in today’s deployed trauma system (the Joint Theater Trauma System or JTTS).  I personally recall service members from my prior deployments in 2001-2, 2008-9, and 2014 who may not have survived this same injury pattern because that patient arrived under resuscitated and became increasingly coagulopathic and bled to death in the OR.

This patient received pre-hospital tourniquets, ketamine, chest seals, TXA, dried plasma, whole blood and was warmed with a hypothermia kit en-route.  He received robust balanced, component based-resuscitation and was the beneficiary of damage control surgery which included use of combat gauze, bladder injury drainage, and delayed abdominal closure (damage control surgery).  The CCCRP investment has underpinned every one of those advances, which in aggregate are the reason this guy is now at Walter Reed National Military Medical Center in Bethesda, MD recovering less than 2 weeks after his injury.

If I have the opportunity to blog again, I can discuss the unrecognized humanitarian contribution by US Military surgeons over the last two conflicts and the synergy that can be gained in developing trauma systems in LMICs.  For now, sitting comfortably at my desk at home, I would like to applaud our colleagues currently deployed caring for US personnel, Afghan soldiers and citizens, Iraqi soldiers and citizens, and countless others around the world.

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Kyle Remick, MD

Dr. (LTC) Kyle N. Remick is an active duty US Army trauma surgeon with 28 months of combat deployment. His other interests include global injury care, trauma systems, and injury care for the epidemic of inner city violence crime. He is Assistant Professor of Surgery at the Uniformed Services University – Walter Reed Department of Surgery, Bethesda, MD, and his current military assignment is Military Deputy Director for the Combat Casualty Care Research Program, Ft Detrick, MD.

Latest posts by Kyle Remick, MD (see all)

  • Combat Casualty Care Research for Continuing Conflict - July 6, 2016

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