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MILITARY
MEDICINE
Injury as a modern-day epidemic
By Brian Eastridge, MD
Death from injury was described as the neglected
epidemic of modern medicine by the Institutes of
Medicine in 1966. Despite dramatic advances in
acute trauma care over the last several decades, in-
cluding resuscitation of massive hemorrhage, dam-
age-control surgery and technological advances in critical care, the
health burden of injury on our society remains substantial. From a
public health perspective, injury remains the leading cause of death
in individuals up to the age of 45 and is responsible for a domestic
cost of more than $406 billion in medical care and lost productivity
each year. The majority of injury mortality occurs in the field with-
out access to hospital care or prior to hospital admission.
Within the past 15 years of war, a tremendous amount of evi-
dence has been amassed validating improvements in combat casualty
care once a casualty has reached a military medical treatment facility
(MTF). It was noted by military surgeons that a discrete “blind spot”
in the data was evidenced by the fact that no studies comprehen-
sively evaluated the outcomes of combat casualties who succumbed
to their injuries before reaching an MTF. As a result, a multidisci-
plinary military review group was formed that produced the most
comprehensive analysis of pre-hospital injury death to date. This re-
view of all battlefield deaths from 2001-2011 demonstrated that 87
percent of battlefield mortality occurred in the field before the ca-
sualty reached an MTF. Of the pre-hospital battlefield deaths, 24
percent were deemed potentially survivable under optimal medical
circumstances as qualified by the analysis.
Assuming similar potential survivability of injury in the civilian
injury environment, the number of annual trauma deaths in the
United States being approximately 40 times per year the number of
deaths in the 2001-2011 military analysis. Put in perspective, the
public health implications are staggering. In 2014, the number of
potentially survivable injuries in the United States was estimated to
be 147,790, according to the 2016 National Academies of Science,
18 San Antonio Medicine • August 2017
Engineering and Medicine report titled “A National Trauma Care
System: Integrating Military and Civilian Trauma Systems to
Achieve Zero Preventable Deaths After Injury.”
In combat, tactical and logistical issues may cause protracted time
periods from point-of-wounding to resuscitative surgery. As a result,
military and civilian trauma thought-leaders have begun to investi-
gate the concept of Remote Damage Control Resuscitation
(RDCR), whereby Damage Control Resuscitation (DCR) principles
are projected forward into the combat casualty care setting. This re-
search effort is the Remote Trauma Outcomes Research Network
and is a combined effort of UT Health San Antonio, the San Anto-
nio Military Medical Center and the Southwest Texas Regional Ad-
visory Council serving Texas Trauma Service Area P.
The first goal of the research was to develop a linked field and
clinical test-bed for the study of the interplay of out-of-hospital care,
new diagnostic and therapeutic agents, and medical direction that
could provide a civilian research model for clinical testing of RDCR
protocols and outcomes. Although RDCR is only in preliminary
stages of development, a critical component of evaluation and even-
tual fielding will be clinical trials of diagnostics, therapeutic agents
and outcome. In addition, the impact of time-distance sequencing
on the development of the “Lethal Triad” during evacuation to sur-
gical care will be more comprehensively analyzed. With the damage
control resuscitation and surgery principles already established at
Role II/III, similar to civilian trauma centers, the exploration of out-
of-hospital treatment and transport and the use of RDCR interven-
tions may contribute to greater casualty survival.
Civilian regional trauma systems possess many salient character-
istics analogous to those encountered in the military operational en-
vironment. Improving our understanding of pre-hospital injury care
and outcomes is a vital component of trauma system maturation
and optimization and stands to benefit the composite military-civil-
ian trauma care system.