Introduction.

Abstract

As we transition from a high-volume combat casualty flow era to a low-volume era, we must not forget the lessons learned during the wars in Iraq and Afghanistan. Furthermore, as the world around us seems to be erupting in an unpredictable state of chaos with both intentional violence and natural disasters, we must ensure that these advances in combat extremity trauma care are translated into the civilian medical community so that all may benefit. Over the previous 15 years, we have seen incredible progress, accentuated by the highest US military casualty survival rate ever seen. This was due to improvements in the care of combat-injured service members made at every step along the medical evacuation chain, from prehospital care to the creation of a robust and rapid medical evacuation system. But it took some time to get there. In fact, some data suggest that our success was the result of the growing amount of clinical experience we, as military medical providers, gained treating combat injured patients.1 Put more bluntly, we got better over time as we treated more patients. After all, we were managing a spectrum of injuries that most have never seen before, and we were seeing them at an extremely high volume. The type and constellation of wounds seen earlier in the conflicts were starkly different than those seen in the latter portions of the conflict. In addition, the injury patterns evolved with changes in tactical operations, particularly as troops transitioned from mounted to dismounted maneuvers. Many of the more recent injury patterns were characterized by multiple extremity injuries and amputations usually secondary to improvised explosive devices. What is important to recognize is that as the injury patterns and severity evolved, so too did our management of them. One of the great advances made was the implementation of the battlefield tourniquet. During the early years of the conflicts, there were reports suggesting that up to one-third of combat fatalities were the result of compressible extremity hemorrhage.2,3 This problem was identified, the solution created, and policy changed to make the battlefield tourniquet a standard issue. It not only has resulted in saving limbs but also has saved lives.4 More importantly, its success in the prehospital treatment of extremity hemorrhage has led to rapid implementation into the civilian emergency medical system. Although we are all thankful to have entered a low-volume combat casualty flow state, we do not want this progress to be lost. In fact, we want it to be shared so that all may benefit.