Where do we go from here?

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The figure on the cover of this supplement of the Journal of Trauma and Acute Care Surgery depicts the return on investment in military trauma care and combat casualty care research. The figure illustrates a decrease in the case fatality rate (CFR) for US service personnel in Afghanistan between 2005 and 2013. The reduction in this “bottom line” metric is unprecedented and has occurred during a sustained period during which the injury severity of US troops has notably increased. As a measure of battlefield lethality, CFR is calculated by dividing combat deaths (killed in action plus died of wounds) by all of those wounded or killed in action. CFR refers to the percentage of those injured in combat who die. For historical context, the CFR in World War II and Vietnam was 19% and 16%, respectively.1 The reasons behind this improvement in survival are multifactorial. However, there is little doubt that this trend is in large part caused by the more systematic and rapid application of evidence-based trauma care to injured service personnel.2
With the striking observations from this figure in mind and in this the terminal stages of the longest war in US history, the question must be asked, “where do we go from here?” More specifically, where do we propose the CFR start for the next military conflict? As noted in the legend for this figure, the nation did not start this period of war with a military trauma system, and we did not start with a significant programmed investment in combat casualty care research. Through unrelenting will and commitment and the sacrifices of a generation, we now have both. The data illustrated on the cover of this supplement should provide impetus to sustain both, even during challenging fiscal times.
The pages of this supplement are filled with examples of military-specific trauma review and original research coming from the nation’s combat casualty care research investment and the military trauma system. These scientific undertakings are all aimed at sustaining and improving combat casualty care and survival (i.e., driving down the CFR). This supplement begins with a foreword led by the military surgeon and former editor of the Journal of Trauma, Dr. Basil A. Pruitt, acknowledging the military giants on whose shoulders we stand. A special report by Dr. Elon Glassberg and colleagues from the Israeli Defense Force follows describing the potential for dried plasma as a resuscitation adjunct. Expert review articles from US military members on four “hot topics” in combat casualty care are provided along with editorial perspectives from leading civilian surgeons, Drs. Kenneth Mattox and Lena Napolitano. Findings from original basic and clinical research are reported in the series of articles that follow and are grouped in the categories of prehospital and hospital-based care as well as clinical outcomes.
Convening of the Military Health System Research Symposium and accomplishing this peer-reviewed publication provide the foundation of military-specific scientific exchange essential to the advancement of combat casualty care. A sustained commitment to these undertakings is one way by which to positively answer the question “where do we go from here?” These endeavors assure that military trauma research is accomplished in an open and vetted fashion and that both military and civilian trauma communities garner the lessons learned from war. Sustained commitment to combat casualty care research funding in the coming years will also allow for translation of the foundation of knowledge developed during the past decade.
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