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Raising the Bar: A New Era in Combat Casualty Care for the U.S. Military 8 September 2013 Frank K. Butler, MD, FAAO, FUHM CAPT MC USN (Ret) Joint Trauma System Jeffrey A. Bailey, M.D., FACS Col MC USAF Joint Trauma System

Disclaimer: The opinions or assertions contained herein are the private views of the author and are not to be construed as official or as reflecting the views of the Department of the Army or the Department of Defense.�


As the United States and its coalition partners approach the end of over 12 years of conflict in Afghanistan and Iraq, we should take time to reflect on the advances that have been made on behalf of our combat wounded during these years of war. Battlefield Trauma Care – Then (2001) The events of 911 shattered an interlude of peace and plunged the U.S. military into a war against an enemy that had no credible military, just a willingness to use the tactics of terror to achieve their political and religious objectives. As the war began, the U.S. military was in some respects not optimally prepared to care for those injured in the many battles to follow. Consider that in 2001: - Battlefield trauma care training in the U.S. military was based on courses that did not consider or accommodate for the austerity and lethality of the battlefield. - U.S. combatants did not routinely carry tourniquets and were trained to use tourniquets only a last resort to control life-threatening extremity bleeding. The reason for avoiding tourniquet use, unfounded in retrospect, was fear of causing ischemic damage to injured limbs. - U.S. combatants were not equipped with hemostatic agents. - Establishing a definitive airway for severely injured casualties focused primarily on endotracheal intubation, a technique that has not been shown to improve survival in trauma patients in the prehospital setting, even when used by medical personnel who routinely intubate patients, which most U.S. medics do not. - There was no DoD trauma system to develop and update best-practice trauma care guidelines for our theater medical facilities. - There was no worldwide electronic patient care forum during which to review on a weekly basis the injuries sustained by our casualties, the care rendered, and the eventual outcomes. - There was no mechanism to systematically capture information related to casualty care in a registry format, so that it could be systematically analyzed and used to drive improvements in care. Now, 12 years later, all of the issues noted above have been addressed. The numerous advances in trauma care that have been implemented – along with the torso protection provided by modern body armor - have resulted in the highest casualty survival rate in the history of modern warfare.

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Battlefield Trauma Care - Now Prehospital trauma care in the military has undergone an unprecedented transformation. This is of paramount importance, because if you are a combatant wounded on the battlefield, the most critical phase of your care is the period from the time of injury until the time that you arrive at the surgically capable medical treatment facility (MTF). Almost 90% of our service men and women who die from combat wounds do so before they arrive at an MTF. This highlights the importance of the battlefield trauma care that is provided by our combat medics, corpsmen, and PJs, as well as by the casualties themselves and their fellow combatants. Combat medical personnel in the U.S. military (and those of most of our coalition partners) are now trained to manage combat trauma on the battlefield using the Tactical Combat Casualty Care (TCCC) guidelines. TCCC started as a biomedical research project in the U.S. Special Operations Command (USSOCOM). The existing, largely tradition-based, trauma care practices in place in 1993 were systematically re-evaluated and there was found to be a need to reconsider these principles for use in combat. TCCC was introduced as a new framework on which to build trauma care guidelines customized for the battlefield. The original TCCC paper came out in Military Medicine in 1996 and provided a foundation, but TCCC has been in constant state of evolution during the last 12 years. These trauma care guidelines customized for battlefield use are now reviewed and updated by the Committee on TCCC (CoTCCC) on an ongoing basis. The CoTCCC is comprised of trauma surgeons, emergency medicine physicians, combatant unit physicians, and combat medics, corpsmen, and PJs., This group at present has representation from all of the U.S. armed services and has 100% deployed experience. Although previously part of the Defense Health Board, the CoTCCC now functions as part of the Joint Trauma System, which will be discussed in the paragraphs below. Changes in TCCC are based on direct input from combat medical personnel, an ongoing review of the published medical literature, new research coming from military medical research organizations, and lessons learned from both the U.S. and allied service medical departments. The CoTCCC publishes its recommendations both in the Journal of Special Operations Medicine and in the Prehospital Trauma Life Support Manual. The TCCC Guidelines are the only set of battlefield trauma care best-practice guidelines to have received the triple endorsement of the American College of Surgeons Committee on Trauma, the National Associations of EMTs, and the DoD.

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As the CoTCCC has continued to work to improve battlefield trauma care, it has formed strategic partnerships with other organizations that also seek to improve prehospital trauma care. TCCC began its partnership with the Prehospital Trauma Life Support executive committee in 1998 and continues to work with this internationally recognized group of leaders in prehospital trauma care. PHTLS teaches their courses around the world and has recently established a program to provide TCCC training to law enforcement agencies and the militaries of allied countries when these groups request it. TCCC established a critical partnership with the U.S. Army Institute of Surgical Research (USAISR) in 2004. The USAISR undertook the first preventable death analysis on fatalities from Afghanistan and Iraq, which helped to highlight the critical need for all combatants to be trained in basic TCCC interventions. The USAISR subsequently developed a research effort with a strong focus on battlefield first responder care and published breakthrough reports on items such as tourniquets, hemostatic agents, junctional tourniquets, chest seals and prehospital fluid resuscitation. This ongoing work has since firmly established USAISR as the DoD leader in developing and evaluating battlefield trauma care technology and management strategies. The USAISR also led the very successful USSOCOM-sponsored TCCC Transition Initiative designed to ensure that deploying Special Operations units were equipped with the latest TCCC technologies and that feedback about both the training and the equipment was captured when the units returned from their combat deployment. It was the success of this project that provided the foundation for TCCC to eventually be adopted by conventional forces as well as Special Operations units. CoTCCC meetings before the recent travel restrictions in the DoD were very well attended by medical representatives from combat units, the service Surgeons Generals’ offices, liaisons from coalition partner nations, stakeholders from nonDoD government agencies, and representatives from federal law enforcement agencies. Representatives from combat medical schoolhouses were there to help ensure that they could accurately reflect TCCC changes and the rationale behind them in their training courses. The Defense Medical Material Program Office was present to ensure that TCCC equipment issues, both in procurement and performance, were tracked by and discussed with the group. All of the above participants have played key roles in proposing, refining, and gaining approval for recent changes in the TCCC Guidelines. This robust and inclusive interaction has helped to ensure that TCCC continues to reflect the state of the art in battlefield trauma care. During the time that the travel restrictions have been in place, the CoTCCC has continued to convene the participants noted above in a series of issue-specific teleconferences so that at least some of the combat casualty care issues that would have been discussed at the quarterly meetings are being addressed in these forums. How has TCCC changed the face of combat medicine? One striking example is tourniquet use. Tourniquets - which were in disfavor with the medical establishment at the start of the war – were strongly emphasized by TCCC and

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were re-introduced into use on the battlefield as a result of a strong combined effort of TCCC, USSOCOM, the USAISR, and the U.S. Central Command. Tourniquets have been the signature success in prehospital trauma care in Afghanistan and Iraq. As noted previously, prior to this re-introduction, military medics were taught that a tourniquet should be used only as a last resort for bleeding control in extremity hemorrhage. This approach resulted in a 7.4% rate of preventable death from extremity hemorrhage in 2600 combat fatalities from the Vietnam conflict. Since TCCC was used only by a select few units, mostly within the Special Operations community, in the early years of the wars in Afghanistan and Iraq, this high rate of potentially preventable deaths due to extremity hemorrhage continued at the start of those conflicts. A study of 982 combat fatalities from the early years of these wars found that 7.8% of our combat fatalities had bled to death from arm or leg wounds. Beginning in 2005, however, there was a DoD-wide implementation of the tourniquet recommendations from the TCCC guidelines. A more recent comprehensive study of the 4596 U.S. combat fatalities from 2001 to 2011 found that only 2.6% of these fatalities resulted from extremity hemorrhage. This dramatic decrease in preventable death from extremity hemorrhage from 7.8% to 2.6% of combat fatalities was a direct result of the ubiquitous fielding of modern tourniquets and aggressive training of all potential first responders in the principles of tourniquet application. Tourniquets have been now been estimated by the Army to have saved as many as 2,000 American lives during these two wars. Figures 1-3 depict a homemade tourniquet used at the onset of hostilities, a fatality that died from extremity hemorrhage in the early years of the Afghanistan conflict despite the use of several field-expedient tourniquets, and a modern Combat Application Tourniquet. Another element critical to the success of TCCC has been the emphasis on integrating TCCC into good small-unit tactics. To that end, TCCC is divided into three phases of care to allow the care provided to be appropriate to the flow of actions that occur during a combat engagement. These phases are: Care Under Fire, Tactical Field Care, and Tactical Evacuation Care. Although there have been no studies that have evaluated the results of integrating best-practice tactical considerations with best-practice medical strategies or of minimizing nonessential medical interventions on the battlefield, these two new aspects of battlefield trauma care have undoubtedly saved many lives and contributed to the successful execution of combat missions. Other features of TCCC in 2013 include: - The use of Combat Gauze to control life-threatening hemorrhage from external bleeding at sites that are not amenable to tourniquet use. - The use of nasopharyngeal airways to protect the airway when there is no airway obstruction from direct maxillofacial or neck trauma. - Initial management of the airway in maxillofacial trauma that consists of having the casualty sit up and lean forward if possible, thus allowing blood to simply drain out of the mouth and thus clear the airway.

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- Surgical airways are emphasized for maxillofacial trauma when airway compromise is present and the sit-up-and lean forward position is not feasible or not successful. - Aggressive needle thoracostomy is indicated for suspected tension pneumothorax and is done with 3.25 inch needles rather than the shorter 2 inch needles previously used by the military and still used in much of the civilian sector for this purpose. The McPherson paper from Vietnam noted a 2.9% incidence of potentially preventable deaths due to tension pneumothorax. In contrast, COL Brian Eastridge's paper found that only 11 of 4,596 combat fatalities in Afghanistan and Iraq were due to tension pneumothorax - a 0.2% incidence of preventable deaths from this disorder. This is a reduction of deaths due to tension pneumothorax by over 90%. Some of that is certainly due to the body armor that now protects the chest area in our service members, but the longer needle and aggressive approach to NDC when indicated as recommended by TCCC are also factors in this dramatic success. - A different approach is now used to protect the spinal cord when neck or back injuries are present or suspected. Spinal immobilization is not emphasized for casualties with penetrating trauma only. Spinal immobilization is still recommended for use as tactically feasible when a blunt trauma mechanism of injury is present. - IV access is recommended only when it is required for medications or fluid resuscitation, thus saving time on the battlefield and allowing medics to focus on other aspects of care that are more likely to be lifesaving. - The use of intraosseous techniques when vascular access is needed, but difficult to obtain. - Hypotensive resuscitation with Hextend is performed for casualties in shock when no blood products are available, as outlined in the papers by Dr. John Holcomb and Dr. Howard Champion in 2003. - Faster and more effective battlefield analgesia – initially through the use of IV morphine, and now with Oral Transmucosal Fentanyl Citrate (OTFC) lozenges (as recommended by Army COLs Russ Kotwal and Kevin O’Connor) and ketamine (as recommended by retired Ait Force Lt Col John Gandy). The older analgesic standard of intramuscular morphine works more slowly and has been associated with overdose and cardiorespiratory depression. - Battlefield antibiotics to help reduce morbidity from combat wounds when evacuation is delayed, as is often the case early in conflicts before the tactical evacuation system is well-established. - Tactical scenario-based combat trauma training to emphasize that battlefield trauma care, as provided in a specific tactical situation, must often be tailored to the tactical circumstances of that situation. - The administration of tranexamic acid (TXA) to help prevent death from non-compressible hemorrhage. - Junctional tourniquets to help prevent death from hemorrhage in junctional areas, especially when dismounted IED casualties sustain very high bilateral lower extremity amputations.

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- A user-friendly TCCC casualty card that was designed by medics in the Ranger Regiment and subsequently endorsed by the CoTCCC. This card helps to document care rendered at the point of injury and has been used very successfully by the Ranger Regiment. The TCCC Casualty Card was adopted by the Army several years ago, and an updated version has now been recommended to become a Department of Defense form that would be used by all services to document point of injury care. The U.S. Central Command has directed the use of this card and a TCCC Medical After-Action Report for all casualties in the Afghanistan area of operations. 75th

The above measures as well as the clinical and animal evidence that supports them are outlined in the paper by Butler and Blackbourne published in the Journal of Trauma and Acute Care Surgery in 2012. This material will also be included in the upcoming Eighth Edition (Military) of the PHTLS Manual.

Eliminating Preventable Death on the Battlefield TCCC uses all of the techniques described above to maximize survival. As described in COL Russ Kotwal’s paper “Eliminating Preventable Death on the Battlefield,” the 75th Ranger Regiment, which began training all of its unit members in TCCC prior to the onset of hostilities, has achieved an unprecedented low incidence of potentially preventable battlefield fatalities in Afghanistan and Iraq. The concept of training and equipping all combatants – not just combat medics – to perform the lifesaving interventions recommended by TCCC is a key facet of the Ranger Regiment’s success and was also by the Navy SEALs, the Army Special Missions Unit, and selected other Army units throughout the entire duration of the wars in Afghanistan and Iraq with great success. To quote from COL Brian Eastridge’s landmark study: “There has been a dramatic transition in the concepts and execution of battlefield trauma care during the last decade of war. Beginning with innovations pioneered by the US Special Operations Command and using new combat trauma technologies tested by the US Army Institute of Surgical Research, TCCC has revolutionized how combat medicine is practiced in the battlefield. Use of TCCC concepts progressed sporadically throughout the US military, with widespread concept acceptance occurring in the latter part of the war. The value of TCCC implementation and use was highlighted in a recent study of preventable death on the battlefield in the 75th Ranger Regiment. Investigators demonstrated that the use of an aggressive command-directed casualty response system and TCCC-based Ranger First Responder program was able to reduce the incidence of preventable death to the unprecedented low level of 3% of their total fatalities.” (Eastridge – Death on The Battlefield - J Trauma, 2012)

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The Joint Trauma System The CoTCCC is now part of the DoD’s Joint Trauma System (JTS). The JTS was established in 2005 by the USAISR in collaboration with the US Central Command, the service Surgeons General, and the Assistant Secretary of Defense for Health Affairs. The goal was to create a systems approach to improving trauma care for the coalition’s combat casualties. In 2013, at the direction of the acting Undersecretary of Defense for Personnel and Readiness, the CoTCCC was relocated to the JTS. On 19 June 2013, the JTS was designated to become a DoD Center of Excellence. In this capacity, the JTS will be the lead agency in the DoD for developing best-practice trauma care recommendations. This transformation is currently in progress.

Tactical Evacuation (TACEVAC) Care The Joint Trauma System encompasses all aspect of trauma care within the DoD. After point of injury care has been rendered, casualties are transported from the Point of Injury to a Medical Treatment Facility (MTF). This phase of casualty care is designated as Tactical Evacuation (TACEVAC) Care and affords an opportunity to provide additional medical personnel and equipment to increase the level of care rendered. CASEVAC platforms are typically armed tactical assets that bear no Red Cross markings. These may be aircraft, vehicles, or combatant craft of opportunity. During the drive on Baghdad in Operation Iraqi Freedom (OIF), some casualties were moved to the rear on tanks because evacuation by MEDEVAC aircraft and vehicles was not feasible given the tactical circumstances. The term Medical Evacuation or “MEDEVAC” refers to medically regulated casualty movement using dedicated medical evacuation platforms (ground vehicles or rotary wing aircraft.) These are crewed by medical attendants and may have more medical treatment equipment available than non-medical assets. MEDEVAC platforms are pre-designated assets that bear Red Cross markings and carry no offensive weaponry such as rockets or missiles. MEDEVAC movements may include both clearing casualties from the battlefield and moving casualties between medical treatment facilities in theater. Since casualty movement following Tactical Field Care may be accomplished by either CASEVAC or MEDEVAC, the third phase of care in TCCC is designated “Tactical Evacuation (TACEVAC) Care” to encompass both options. The wars in Afghanistan and Iraq have permanently changed the face of TACEVAC care. The evacuation platforms employed in Afghanistan and Iraq and the improvements in TACEVAC Care seen in these conflicts have been documented in the excellent papers by LTC Bob Mabry, Major Jonathan Morrison, Dr. Amy Apodaca, LT Chris Olson, and others (see “selected reading” below.) One landmark advance in TACEVAC Care during the last 12 years of

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conflict has been the realization that training the flight medics on evacuation platforms to the paramedic level instead of the older standard of EMT-Basic increases casualty survival. Another has been the use of advanced capability platforms such as the Medical Emergency Rescue Team (MERT) used by U.K. forces in Helmand in the latter half of the war in Afghanistan. Capabilities on the MERT include a larger aircraft, a larger, physician-led medical team, advanced airway capability, use of ketamine rather than opioids for analgesia, and aggressive use of prehospital plasma and Packed Red Blood Cells (PRBCs). The MERT has been shown in several studies to improve survival in the subset of casualties that has suffered severe, but not overwhelming, injuries. Casualty survival was also improved by the Secretary of Defense-directed one-hour maximum evacuation time in the Afghanistan theater established by Secretary Robert Gates in 2009. Although the MERT is a MEDEVAC platform rather than a CASEVAC platform, several units that have primary combat missions, such as the 160 th Special Operations Aviation Regiment (SOAR) and the Air Force Air Rescue units, also have highly developed medical capabilities on their aircraft, including paramediclevel flight medics and the ability to give blood products and TXA in the air.

The JTS Weekly Worldwide Trauma Teleconferences The JTS, with the support of the CENTCOM Surgeon, uses various performance improvement initiatives to improve trauma care, including a weekly teleconference to review all severely injured combat casualties from the preceding week. The nature of the injuries sustained, the medical care rendered, the casualty’s present location, and his or her current condition are all discussed in a worldwide teleconference. Participants in this electronic forum include representatives from medical treatments facilities in theater, in Landstuhl, and in the continental U.S. Also included are representatives from the wide array of military medical organizations that have a mission to assist in the care of wounded warriors.

JTTS Trauma Clinical Practice Guidelines (CPGs) The JTS maintains a robust set of clinical practice guidelines to provide evidence-based recommendations for trauma care provided during enroute care and within theater medical treatment facilities. There are 39 of these CPGs at present. They have incorporated the use of the cutting-edge medical technology and treatment strategies that have been found to be successful during the recent conflicts. One example of an advance in trauma care contained in the JTS CPGs is hemostatic resuscitation (so called “Damage Control Resuscitation” or DCR) that calls for early plasma use in conjunction with PRBCs (and platelets when available), so that resuscitation for casualties in shock treats potentially evolving coagulopathy as it restores intravascular volume and oxygen-carrying capacity. Other advances include:

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- Accelerated evacuation back to Landstuhl Regional Medical Center and CONUS-based hospitals using evacuation aircraft with Air Force Critical Care Air Transport Teams on board to provide intensive care in the air - Advanced rehabilitation techniques for neurological injuries and amputations - The use of tranexamic acid to help prevent death from hemorrhage; awareness and early treatment of hypothermia in combat casualties - The aggressive use of fasciotomies in casualties at risk for development of compartment syndrome - Negative-pressure wound therapy to promote better wound healing - Better fluid resuscitation and burn flow sheets for burn patients - The use of extracorporeal membrane oxygenation (ECMO) to increase survival in casualties with severely impaired pulmonary function. All of the above advances are new to the recent conflicts. The CPG and Performance Improvement processes undertaken by the JTS will ensure that these advances are preserved in the system and that there is an ongoing evaluation of all aspects of the trauma care provided in theaters of conflict and identification of opportunities to improve.

The DoD Trauma Registry The JTS also maintains the DoD Trauma Registry (DoDTR) to facilitate improvements in trauma care and to guide future trauma-related research. This unique repository of trauma care information is the indispensable factor in enabling the JTS to understand and improve combat trauma care. It is at this point in time the largest combat trauma registry in history, containing trauma care information on 77,063 casualties as of August 2013. Two hundred and ninety-six research projects have been undertaken based on the trauma information contained in the DoDTR to date. This research has resulted in 80 scientific papers, 104 abstracts, 61 posters, and 47 presentations at medical conferences. The DoDTR has already enabled the trauma care research noted above and many more unpublished performance improvement initiatives and efforts. It has the potential to continue to make major contributions to trauma care in the military if: 1) military medical research funding is provided to allow DoD researchers to analyze the data contained in the DoDTR so that we can continue to learn as many lessons as possible from the recent wars during the peace interval; and 2) we can effect the culture change that is needed in combat units to achieve better documentation of point of injury care. The very large majority of our casualties have no documentation of care prior to TACEVAC. The JTS and USCENTCOM have addressed this deficiency by the recent direction that TCCC After Action Reports be submitted when casualties are sustained on combat missions (after the combat action has been concluded) to create a prehospital trauma registry that will document injuries sustained and what point of injury care was rendered.

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Learning from Our Fatalities The JTS also works with the Armed Forces Medical Examiners System to review and discuss selected combat fatalities so that we can better understand the causes of death in our casualties and take the necessary actions to avoid future potentially preventable deaths. With trauma surgeons and pathologists working in concert, this process allows our fallen warriors to perform one last service to their country – to help prevent loss of life in future wars whenever possible. The JTS – A Worldwide Asset The JTS provides assistance and advice to the Command Surgeon for Combatant Commands engaged in conflicts. In the case of Afghanistan and Iraq, this has been the U.S. Central Command, but similar working relationships with other Combatant Commands can be established should conflicts erupt in their geographic areas of responsibility.

The Way Ahead With the unprecedented casualty survival from the recent conflicts, the realignment of the CoTCCC as part of the JTS, and the designation of the JTS as a DoD Center of Excellence for Trauma, our military is clearly entering a new era during which further improvements in combat casualty care may be expected to continue to occur more quickly than ever before. Dr. A. Brent Eastman – 93rd President of the American College of Surgeons – noted in his 2009 Scudder Oration at the Annual Meeting of the ACS: “The military has developed a superb Joint Theater Trauma System, and this system is a lesson for rural trauma care.” More recently, the past Surgeon for the Chairman of the Joint Chiefs of Staff and the newly designated head of the Defense Health Agency, Air Force Lt Gen Doug Robb, stated at the 2013 Military Health Services Research Symposium that: “The JTS is what right looks like.” Advances in trauma care require resources, experience, vision, focus, expert analysis, and the willingness to accept the appropriate degree of risk in implementing new advances. Despite the successes noted above, the Joint Trauma System is a relatively new organization that must use the interval of peace that our nation will hopefully soon experience to make sure that the trauma care lessons of the past are not lost when our nation fights the wars of the future. New technology and new trauma care research findings will continue to present additional opportunities to improve the care of our nation’s combat wounded. The JTS, with the remarkable DoD-wide and international team that it has developed, will serve our armed forces well by helping to ensure that these new opportunities are quickly translated into lives saved.

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Selected reading: Apodaca A, Olson CM, Bailey JA, Butler F, Eastridge BJ, Kuncir E. Performance Improvement Evaluation of Forward Aeromedical Evacuation Platforms in Operation Enduring Freedom. J Trauma Acute Care Surg. 2013; 75(2) S157-63 Olson C, Bailey J, Mabry R, Rush S, Morrison J, Kuncir E. Forward Aeromedical Evacuation: A Brief History, Lessons Learned from the Global War on Terrorism and the Way Forward for U.S. Policy. J Trauma Acute Care Surg. 2013; 75(2) S130-6 Apodaca A, Morrison J, Spott M, Lira J, Bailey J, Eastridge B, et al. Improvements in the Hemodynamic Stability of Combat Casualties during En-Route Care. Shock. 2013 Apr 30;201878 Blackbourne LH, Baer DG, Eastridge BJ, Butler FK, Wenke JC, Hale RG, Kotwal RS, Brosch LR, Bebarta VS, Knudson MM, Ficke JR, Jenkins D, Holcomb JB: Military medical revolution: Military trauma system. J Trauma Acute Care Surg 2012;73: S388-S394 Butler FK, Blackbourne LH: Battlefield Trauma Care Then and Now: A Decade of Tactical Combat Casualty Care. J Trauma Acute Care Surg 2012;73:S395-S402 Butler FK, Giebner SD, McSwain N, Salomone J, Pons P, eds. Prehospital Trauma Life Support Manual. Seventh Edition – Military Version. November 2010. Butler FK, Hagmann J, Butler EG. Tactical combat casualty care in special operations. Milit Med. 161; Supplement; August 1996. Caravalho J. OTSG Dismounted Complex Blast Injury Task Force; Final Report. 18 June 2011:44–47. Eastridge BJ, Mabry R, Seguin P, Cantrell J, Tops T, Uribe P, Mallett O, Zubko T, Oetjen-Gerdes L, Rasmussen T, Butler FK, Kotwal R, Holcomb J, Wade C, Champion H, Moores L, Blackbourne LH: Pre-hospital Death on the Battlefield: Implications for the Future of Combat Casualty Care. J Trauma Acute Care Surg 2012;73:S431-S437 Eastridge B, Costanzo G, Jenkins D, et al: Impact of joint theater trauma system initiatives on battlefield injury outcomes. Am J Surg 2010;198(6):852-857 Eastridge BJ, Jenkins D, Flaherty S, Schiller H, Holcomb JB: Trauma system development in a theater of war: experiences from Operation Iraqi Freedom and Operation Enduring Freedom. J Trauma 2006;61:1366-1372

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Holcomb JB, McMullen NR, Pearse L, Caruso J, Wade CE, Oetjen-Gerdes L, Champion HR, Lawnick M, Farr W, Rodriguez S, Butler FK. Causes of death in Special Operations Forces in the Global War on Terror. Ann Surg. 2007;245:986– 991. Holcomb JB, Stansbury LG, Champion HR, Wade C, Bellamy RF. Understanding Combat casualty Care Statistics. J Trauma. 2006;60:1–5. Kelly JF, Ritenhour AE, McLaughlin DF, et al. Injury severity and causes of death from Operation Iraqi Freedom and Operation Enduring Freedom: 2003-2004 versus 2006. J Trauma. 2008;64:S21–S27. Kotwal RS, Butler FK, Edgar EP, Shackelford SA, Bennett DR, Bailey JA: Saving Lives on the Battlefield: A Joint Trauma System Review of Pre-Hospital Trauma Care in Combined Joint Operating Area – Afghanistan (CJOA-A). 30 January 2013 Kotwal RS, Montgomery HR, Kotwal BM, Champion HR, Butler FK, Mabry RL, Cain JS, Blackbourne LB, Mechler KK, Holcomb JB. Eliminating preventable death on the battlefield. Arch Surgery. 2011; 146:1350–1358. Kragh JF, Walters TJ, Baer DG, Fox CJ, Wade CE, Salinas J, Holcomb JB. Practical use of emergency tourniquets to stop bleeding in major limb trauma. J Trauma. 2008;64:S38–S50. Kragh JF Jr, Walters TJ, Baer DG, Fox CJ, Wade CE, Salinas J. Holcomb JB: Survival with emergency tourniquet use to stop bleeding in major limb trauma. Ann Surg. 2009;249:1–7. Mabry R, Apodaca A, Penrod J, Orman J, Gerhardt R, Dorlac WC: Impact of critical care trained flight paramedics on casualty survival during helicopter evacuation in the current war in Afghanistan. J Trauma Acute Care Surg 2012;73:S32-S37 Mabry RL, Holcomb JB, Baker AM, Cloonan CC, Uhorchak JM, Perkins DE, Canfield AJ, Hagmann JH: United States Army Rangers in Somalia: an analysis of combat casualties on an urban battlefield. J Trauma 2000;49:515-529 Martin M, Oh J, Currier H, Tai N, Beekley A, Eckert M, Holcomb J: An Analysis of In-Hospital Deaths at a Modern Combat Support Hospital. J Trauma 2009;66:S51-S61 McPherson JJ, Feigin DS, Bellamy RF. Prevalence of tension pneumothorax in fatally wounded combat casualties. J Trauma. 2006;60(3):573–578.

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Morrison JJ, Oh J, Dubose JJ, O’Reilly DJ, Russell RJ, Blackbourne LH, Midwinter MJ, Rasmussen TE: En-Route Care Capability From Point of Injury Impacts Mortality After Severe Wartime Injury. Ann Surg 2013;257:330-334 Tarpey MJ. Tactical combat casualty care in Operation Iraqi Freedom. U.S. Army Medical Dept. J. April-June 2005: 38–41.

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Tccc article for defense standard 130906