Battlefield medicine


Battlefield medicine, also known as field surgery and later combat casualty care, is the treatment of wounded combatants and non-combatants in or near an area of combat. Civilian medicine has been greatly advanced by procedures that were first developed to treat the wounds inflicted during combat. With the advent of advanced procedures and medical technology, even polytrauma can be survivable in modern wars. Battlefield medicine is a category of military medicine.

History

Antiquity

  • During Alexander the Great's military campaigns in the 4th century BC, tourniquets were used to stanch the bleeding of wounded soldiers. Romans used them to control bleeding, especially during amputations. These tourniquets were narrow straps made of bronze, using leather only for comfort.
  • According to bamboo slips from the Han dynasty, external injury from combat and infighting comprised the plurality of injuries and illnesses from soldiers on the front line. These injuries were followed in numbers by exogenous febrile diseases and diseases of abdominal pain, namely disorders of the digestive and respiratory systems. Medical treatment was poor and comprised such treatments as acupuncture, applications of plaster, and drugs, the latter being the most common.
  • During the 1st century BC, the Roman army used spider webs and honey-soaked bandages as field dressings. Wounds were packed with webs before being wrapped in honey-soaked bandages; the webs served as a natural fungicide while the honey staved off bacterial infection. Amulets were provided to wounded combatants and field doctors distributed those associated with particular gods based whichever god was most appropriate to the circumstances. This appears to have been effective for the combatant's mental health.

    Middle Ages

  • During the Middle Ages, most soldiers were killed on the battlefield by a fatal loss of blood.
  • An early stretcher, likely made of wicker over a frame, appears in a manuscript from. Simple stretchers were common with militaries right through the middle of the 20th century.
  • After being wounded during the Battle of Shrewsbury in 1403, Prince Henry had an arrow removed from his face by John Bradmore using a specially designed surgical instrument.
  • Ambulances were first used by Spanish soldiers during the Siege of Málaga in 1487, a part of the Reconquista campaigns to seize control of southern Spain. Authorized by Isabella I of Castile, the ambulances were largely ineffective, though they were perceived as critical to Spanish morale.

    Early modern period

  • French military surgeon Ambroise Paré pioneered modern battlefield wound treatment. His two main contributions to battlefield medicine are the use of dressing to treat wounds and the use of ligature to stop bleeding during amputation.
  • The practice of triage was pioneered by Dominique Jean Larrey, Napoleon Bonaparte's surgeon-in-chief of the Imperial Guard during the Napoleonic Wars. He also pioneered the use of ambulances in the midst of combat, called ambulances volantes. Prior to this, military ambulances had waited for combat to cease before collecting the wounded by which time many casualties had succumbed to their injuries.
  • Russian surgeon Nikolay Pirogov was one of the first surgeons to use ether as an anaesthetic in 1847, as well as the very first surgeon to use anaesthesia in a field operation during the Crimean War.
  • During the American Civil War, Jonathan Letterman modernized medical organization on the battlefield for the Union. Following his appointment as the Medical Director of the Army of the Potomac, Letterman founded an ambulance corps staffed with permanent and trained attendants which was later compounded in efficacy by the organization of hospital echelons and tent hospitals in the war's eastern theater. His contributions led to his being recognized as the "father of battlefield medicine".
  • The Relief Society for Wounded Soldiers, forerunner of the International Committee of the Red Cross was founded in 1863 in Geneva. The ICRC advocated for the establishment of national aid societies for battlefield medical relief, and stood behind the First Geneva Convention of 1864 which provided neutrality for medics, ambulances, and hospitals.
  • In the late 19th century, the influence of notable medical practitioners like Friedrich von Esmarch and members of the Venerable Order of Saint John pushing for every adult man and woman to be taught the basics of first aid eventually led to institutionalized first-aid courses amongst the military and standard first-aid kits for every soldier.

    20th and 21st centuries

  • Advances in surgery – especially amputation – during the Napoleonic Wars and First World War during the Battle of the Somme.
  • Medical advances also provided kinder methods for treatment of battlefield injuries, such as antiseptic ointments, which replaced boiling oil for cauterizing amputations.
  • Advances in understanding of Germ Theory and Asepsis as well as the introduction of High Explosive Artillery and Machine Gun filled Trench Warfare lead to conditions primed for better battlefield wound care. One such advance was the Carrel-Dakin Technique. This was developed by many but namely involved Alexis Carrel. This involved initial cleaning/Debridement of the wound, followed by irrigation with Dakin's Solution. This cleaned the wound of dead tissue and pathogen contaminated soil, as well as aided in drainage of Pus etc.
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  • During the Spanish Civil War there were two major advances. The first one was the invention of a practical method for transporting blood. Developed in Barcelona by Duran i Jordà, the technique mixed the blood of the donors with the same blood type and then, using Grifols glass tubes and a refrigerator truck, transported the blood to the front line. A few weeks later Norman Bethune developed a similar service. The second advance was the invention of the mobile operating room by the Catalan Moisès Broggi, who worked for the International Brigades.
  • The establishment of fully equipped and mobile field hospitals such as the Mobile Army Surgical Hospital was first practiced by the United States in World War II. It was succeeded in 2006 by the Combat Support Hospital.
  • The use of helicopters as ambulances, or aeromedical evacuation, was first practiced in Burma in 1944. The first MEDEVAC under fire was done in Manila in 1945 where over seventy troops were extracted in five helicopters, one and two casualties at a time.
  • The extension of emergency medicine to pre-hospital settings through the use of emergency medical technicians.
  • The use of remote physiological monitoring devices on soldiers to show vital signs and biomechanical data to the medic and MEDEVAC crew before and during trauma. This allows medicine and treatment to be administered as soon as possible in the field and during extraction. Similar telemetry units are used in crewed spaceflight, where a flight surgeon at the Command Center can monitor vital signs. This can help to see issues before larger problems occur, such as elevated carbon dioxide levels, or a rise in body temperature indicating a possible infection.

    History of Tactical Combat Casualty Care (TCCC)

In 1989, the Commander of the Naval Special Warfare Command established a research program to conduct studies on medical and physiologic issues. The research concluded that extremity hemorrhage was a leading cause of preventable death in the battlefield. At that time, proper care and treatment was not provided immediately which often resulted in death. This insight prompted a systematic reevaluation of all aspects of battlefield trauma care that was conducted from 1993 to 1996 as a joint effort by special operations medical personnel and the Uniformed Services University of the Health Sciences. Through this 3-year research, the first version of the TCCC guidelines were created to train soldiers to provide effective intervention on the battlefield. The TCCC aims to combine good medicine with good small-unit tactics. One very important aspect that the TCCC outlined was the use of tourniquets, initially there was a belief that the use of tourniquets led to the preventable loss of an extremity due to ischemia but after careful literature search the committee arrived at the conclusion that there was not enough information out there to confirm this claim. The TCCC therefore outline the appropriate usage of tourniquets to provide effective first aid on the battlefield.
After the TCCC article was published in 1996, the program undertook 4 parallel efforts during the next 5-year period. These efforts are as follows:
  1. Presenting TCCC concepts to senior Department of Defense line and medical leaders and advocating for their use.
  2. Identifying and developing responses to representative types of TCCC casualty scenarios.
  3. Initiating TCCC's first strategic partnership with civilian trauma organizations—the Prehospital Trauma Life Support Committee, the National Association of Emergency Medical Technicians, and the American College of Surgeons Committee on Trauma.
  4. Expanding TCCC training beyond medical personnel to include SEAL and 75th Ranger Regiment combat leaders and nonmedical unit members.

    Modern applications

Over the past decade combat medicine has improved drastically. Everything has been given a complete overhaul from the training to the gear. In 2011, all enlisted military medical training for the U.S. Navy, Air Force, and Army were located under one command, the Medical Education and Training Campus. After attending a basic medical course there, the students go on to advanced training in Tactical Combat Casualty Care.

Tactical combat casualty care (TCCC)

Tactical combat casualty care is becoming the standard of care for the tactical management of combat casualties within the Department of Defense and is the sole standard of care endorsed by both the American College of Surgeons and the National Association of EMT's for casualty management in tactical environments.
Tactical combat casualty care is built around three definitive phases of casualty care:
  1. Care Under Fire: Care rendered at the scene of the injury while both the medic and the casualty are under hostile fire. Available medical equipment is limited to that carried by each operator and the medic. This stage focuses on a quick assessment, and placing a tourniquet on any major bleed.
  2. Tactical Field Care: Rendered once the casualty is no longer under hostile fire. Medical equipment is still limited to that carried into the field by mission personnel. Time prior to evacuation may range from a few minutes to many hours. Care here may include advanced airway treatment, IV therapy, etc. The treatment rendered varies depending on the skill level of the provider as well as the supplies available. This is when a corpsman/medic will make a triage and evacuation decision.
  3. Tactical Evacuation Care : Rendered while the casualty is evacuated to a higher echelon of care. Any additional personnel and medical equipment pre-staged in these assets will be available during this phase.
Since "90% of combat deaths occur on the battlefield before the casualty ever reaches a medical treatment facility" TCCC focuses training on major hemorrhaging and airway complications such as a tension-pneumothorax. This has driven the casualty fatality rate down to less than 9%.