Resuscitation Is Better for Combat Casualty Outcomes

Abstract

The study by Langan et al1 reviews the association between damage control resuscitation (DCR) and combat casualty outcomes over a 10-year period (2002-2011). Damage control resuscitation is a resuscitation guidelinewrittenanddistributed in the Iraq war combat theater in 2005, and as Langan et al1 demonstrate in their study of 57 179 soldiers admitted to combat hospitals, improved hospital outcomes are associatedwith thebroadadoptionof this transfusionapproach. Whilemany changes occurred during this decade ofwar, perhaps themost significantwashowresuscitationevolved.Crystalloiduseplummeted,andabalancedapproachtobloodproducts transfusionbecamethenorm.Langanetal1 state that“DCR isoneof themost importantmedical breakthroughsofour current conflicts.” Asastrong testament to thepowerof theJointTraumaSystem, it is important to note that research teams were deployed; protocols approved; data collected, entered into a database, and analyzed; guidelines promulgated; articles published; and changesmade, all while thewarwas ongoing. Literallyhundredsof civilians,USmilitarypersonnel, and collationpartnersworked tirelessly to accomplishment this feat. Currently,more than80 000casualtiesare recorded in theJoint TraumaRegistry.Plannersof futureconflicts (nextmonth,next year, or thenextdecade)must learn fromthis effort and implement the lessons learned.2 Clearlypublishedbutunfortunately largelyoverlookedby the military leadership is the finding that a large percentage of both prehospital and hospital combat deaths are potentially preventable.3,4 In addition, there are less-than-optimal outcomes (not resulting in death) that routinely occur. Both of these findingsdeserve tobegivenequal attention and to receive an immediate response. Data on these potentially preventable adverse outcomes should be compiled on a weekly basis by the Joint Trauma System. They then need to be reviewedby theUS Secretary of Defense, and each adverse outcome should serve as an immediate catalyst for focused research efforts and rapid system change. Similar preventable outcomes on the operational side of the military (eg, negligent discharge, losing aweapon, and leadership deficiencies) routinely incur an immediate command reaction. Preventable adverse outcomes on the medical side deserve a similar immediate command response. Today, some of the service’s medical commanders are drifting away from a focus on combat casualty care. Let’s not repeat what Col DeBakey so clearly articulated hashappenedafter everywar.5 SecretaryofDefenseRobertM. Gates described in his book6 the concepts of rapid review and positive action—theessenceof ahigh-functioning traumasystem. The War on Terrorism will not be over for a long time. Commandattention at all levels on combat casualty caremust remain a laser focus or our casualties will not have the best possible outcome.