An HH-60M from the10th Combat Aviation Brigade makes its approach at Forward Operating Base Fenty in Logar province, Afghanistan, in 2013. Higher rates of in-hospital deaths are likely the result of improved care by battalion medics and corpsmen and rapid evacuations that ensured the seriously injured quickly reached a combat hospital. (Army)
New procedures to treat massive blood loss from combat injuries are saving lives, according to a new study in JAMA Surgery.
The study’s authors said there is a “general belief” that the procedures, known as damage control resuscitation or DCR, represents “one of the most important medical breakthroughs of our current conflicts.”
While the battlefield mortality rates for U.S. troops in Iraq and Afghanistan have been low by historical standards, in-hospital deaths reached historic highs — likely the result of improved care by battalion medics and corpsmen and rapid evacuations that ensured the seriously injured quickly reached a combat hospital.
But the number of those who died of wounds, 2,565, may have been higher if patients had not been treated with DCR, which was adopted in 2006 as part of tactical combat casualty care, according to researchers at Madigan Army Medical Center in Washington state.
That year, military surgeons began using fewer fluids and more blood products like fresh frozen plasma to replenish blood loss. And while there were more in-hospital deaths after the military embraced DCR, the deaths stemmed largely from head injuries rather than hemorrhage, indicating the treatment improved the survivability of those most likely to be saved — troops who were bleeding to death, wrote Dr. Nicholas Langan and others.
The researchers said they did the study to determine how military physicians could save more troops that reach emergency rooms.
“Given ... that 51 percent of in-hospital deaths were due to wounds that were labeled as potentially survivable, it would seem prudent to shift more focus on those patients who died of wounds after” arriving at a hospital, Langan wrote.
“There appears to be a significant potential for salvage in up to 50 percent of patients who die of wounds at a military treatment facility,” he noted.
The researchers reviewed the Joint Trauma Registry records of 57,179 troops admitted with injuries to a forward combat hospital from 2002 to 2011. Of those, 2,565, or 4.5 percent, died, most with serious injures. Eighty percent of those deaths occurred within 24 hours of arrival at the facility.
In reviewing the records, researchers found that military doctors broadly embraced DCR methods in 2006, even though the methods have not been tested in randomized controlled trials.
While the authors did not note how many lives were saved by DCR methods or may have been saved if DCR had been developed earlier, Col. John Holcomb, one of the Army’s top trauma surgeons and one of a handful of physicians who drove the military’s acceptance of tactical combat casualty care, said the study shows the Pentagon’s efforts to chronicle and document every combat casualty in the Joint Trauma Registry could improve outcomes in future wars.
In commentary also printed in JAMA Surgery on Wednesday, Holcomb urged colleagues to remain vigilant in preserving the medical lessons learned from the battlefields of Iraq and Afghanistan.
“Today, some of the services’ medical commanders are drifting away from a focus on combat casualty care,” he said. “Let’s not repeat what [some] so clearly have articulated has happened after every war. Command attention at all levels on combat casualty care must remain a laser focus or our casualties will not have the best possible outcome.”