Combat casualty care research for the multidomain battlefield

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The 2017 Military Health System Research Symposium (MHSRS) supplement marks a decade of the Journal of Trauma and Acute Care Surgery hosting publications resulting from the military's premier medical research meeting. Among the manuscripts in this 10th consecutive military supplement are projects presented at the 2016 MHSRS. Since its origins as Advanced Technology Applications for Combat Casualty Care or ATACCC, a primary aim of the symposium has been to accelerate research and innovation through information sharing among the military and civilian academic and entrepreneurial communities. The MHSRS and the efforts featured in this publication embody the military-civilian partnership, which has now been formalized through a strategic partnership between the Military Health System and the American College of Surgeons (October 2014), publication of a National Academy of Medicine report (June 2016), and language in the 2017 National Defense Authorization Act.1–4
Today, the military is at crossroads where potentially more sophisticated, near-peer adversaries pose a challenge to past successes in casualty care, a projection that requires development of newer life-saving and resuscitative capabilities for military medicine.5 Planners have challenged medical research to innovate for the mid-term and far-term to continue to build a casualty care capability able to sustain the force in more complex and logistically constrained battles with fewer resources, and potentially without direct support for long periods of time.5–7 These scenarios, many of which are encountered by military medics today, are referred to as tactical combat casualty care-extended and prolonged field care (PFC).
As stated in the United States Army-Marine Corps white paper entitled The Multi-Domain Battlefield, “A decade and a half of counterinsurgency campaigns––against an asymmetrical terrorist threat––coupled with the drawdown and repositioning of forward deployed forces to [the Continental U.S.], and the continued stagnation of close fight capabilities has eroded the ability of the U.S. military to confront a peer adversary.”5 The document assesses the implications of losing air superiority and its effect on forces accustomed to unfettered air access, including evacuation of the injured.5 A similar assessment was echoed in parts of the 2017 congressional testimony of the surgeon general of the Air Force.8 While the Army-Marine Corps document focuses on the broad challenges of combat, it projects a future where sustaining the sub-10% case fatality rate achieved in the recent wars would be threatened by the absence of rapid aeromedical evacuation to robust medical facilities, the lack of numbers of specialty trained medical staff at or near the site of injury, inability to reliably communicate with a health care system, and the potential for mass casualties. The document suggests that “forces will require enhanced prolonged care capability at the point of injury to increase survivability because of potential higher casualty numbers against peer threats and possible delays in medical evacuation due to force disruption.”5
The Combat Casualty Care Research Program anticipated this charge, as it documented a need for sustained investment in trauma and injury care in its No Drift and Ahead of the Curve papers in 2014 and 2015.6,9 These publications articulated the need for innovation to address future challenges and were followed by a $50-million program announcement in 2016 that will support and direct research aimed at enhancing the military's PFC capability.10,11 With this new urgency and a collaborative stance with the civilian sector, the military's research program is planning to meet the challenges associated with the multidomain battlefield, including the potential absence of customary MEDEVAC and echelons of care. The cover of this issue shows a resuscitation room of opportunity in which life-saving interventions occurred near the point of injury in today's operational environment.
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