Lessons From the Battlefield

      On today's modern battlefield, medical care has made remarkable strides in saving the lives of the wounded. Soldiers and Marines who would have perished in yesterday's wars are returning home in spite of devastating injuries. Our troops are equipped to stabilize their own injuries and those of their buddies, even in the absence of medical personnel. Medics and corpsmen are armed with advances in technology as they emerge, and our experience helps set new standards of trauma care.

   Front-loading definitive medical care at the point of injury makes obvious sense. The patient's own well-oxygenated blood, circulating in a system of relatively intact blood vessels, is the gold standard of perfusion. Does it make sense to lie still on the battlefield, bleeding and yelling "Medic!" when the means exist for the injured to stop his own bleeding? Does it make sense for the casualty with a patched-up circulatory system to arrive at the hospital without an airway, suffering from irreversible hypoxic brain injury?

A VS. B, EXCEPT AFTER C

   Of the many advances in battlefield medicine, some of the most beneficial are also the simplest. Consider the tourniquet. Once we apply it, we no longer consider an extremity lost. We have learned that as long as the tourniquet is removed in the next few hours, the limb will likely make a full recovery. Along with this change in thinking, the military has also adopted newer tourniquets, manufactured with a sturdy nylon strap and an attached windlass instead of a stick. Today, every soldier is issued this one-handed tourniquet to apply to their own injured limbs, stopping the loss of blood before significant hemorrhage occurs. These are much quicker and simpler to apply than yesterday's homemade strip of cloth and a stick foraged from the woods.

   But what about the simultaneous presentation of airway compromise and significant hemorrhage? Does it make sense to apply a tourniquet before opening an airway? Does A always have to come before B and C? Like any question worth pondering, the answer is usually, "It depends." Logic says without air in it, the circulating blood won't do any good. True ... but without blood to carry it, the inhaled oxygen won't do any good either. It takes both.

   In the case of significant penetrating extremity trauma, especially in the prehospital setting, where blood transfusions are not readily available, the patient really needs to keep their own blood on board. If we consider bleeding control only in the context of our traditional civilian approach (direct pressure, elevation, pressure point, almost never a tourniquet), it might indeed take so long that the patient suffocates from lack of a definitive airway. Fortunately, penetrating trauma with significant hemorrhage is uncommon in the civilian trauma patient, and when it occurs, our approach is often defined by the simultaneous efforts of more than one EMT. In this arrangement, one rescuer might well be spared to do nothing but provide direct pressure, elevation and squeeze a pressure point, while others tend to the airway.

   In the case of the military medic, however, we are often presented with multiple casualties, many of whom may simultaneously suffer from severe penetrating extremity trauma with uncontrolled hemorrhage and airway compromise. Our battlefield triage differs as well: We must return the most troops to the fight as quickly as possible in order to prevent the loss of additional lives. It is sometimes necessary to treat and return the lesser-injured to the fight first so that they may defend us while we attend to the more serious casualties. There are even times when the combat medic may save the most lives by taking up his own weapons and jumping into the fight personally. This is a vastly different proposition from the civilian EMT staging at a safe distance while law enforcement makes the scene safe.