A 25-year-old soldier was on dismounted foot patrol when an improvised explosive device detonated, showering only him with metallic fragments. He sustained multiple penetrating wounds to his lower extremities resulting in pulsatile, bright red bleeding from a large wound to his left thigh with underlying bony deformity. While most of his squad mates secured the site, others tended to him according to Tactical Combat Casualty Care guidelines. Direct pressure was immediately placed upon the wound until a tourniquet could be placed to control the bleeding. He was loaded onto a standard HumVee and transported to a predetermined helicopter landing zone. A HH-60M Black Hawk manned by Army Combat Flight Medics (Callsign: DUSTOFF) was launched to transport him to a Role II military medical facility for initial resuscitative trauma care.

The casualty arrived to the Role II facility 67 min after injury. He was evaluated by an Army Forward Surgical Team (FST) and underwent external fixation of his left open femur fracture and vascular shunting of his lacerated left superficial femoral artery. The FST also performed left four-compartment calf fasciotomies. He was resuscitated primarily with packed red blood cells and plasma. Postoperatively, he remained intubated and was transported by an Air Force Tactical Critical Care Evacuation Team member on a HH-60 M to the regional Role III facility, an Air Force Theater Hospital.

At the Role III facility, the casualty underwent definitive, reversed saphenous vein interposition graft reconstruction of his left superficial femoral artery and repeat washout and debridement of his left thigh wound. He was extubated without complication. Less than 48 h post-injury, the casualty was evacuated from the combat zone on a C-17 Globemaster attended to by an Air Force Critical Care Air Transport Team for a 6-h, 3200-mile intercontinental flight to the regional Role IV evacuation hub.

The effective movement of casualties through increasingly capable levels of care is a hallmark of the modern combat casualty care system (Fig. 38.1). In contemporary military operations, surgical capabilities are ideally positioned as far forward as possible to provide resuscitations and urgent lifesaving hemorrhage control. Minimal patient-holding capacity necessitates “patient throughput” to recover capability for subsequent casualty care (Fig. 38.2). While surgeons are generally not deployed as en route care providers, surgical judgment in the planning for and execution of patient transfers is paramount for patient safety and mission success. Transport is an extremely dangerous process for a casualty, and a heroic surgical save can be quickly negated by a simple, unanticipated problem arising during transport. The three distinct categories of patient movement occurring in the operational environment are presented in the preceding vignette with each offering opportunities for surgical input.

CASEVAC : Evacuation of Casualties from the Point of Injury to the Deployed Medical System by Nonmedical Personnel

Initial care of a wounded soldier following a traumatic event will be performed by other soldiers immediately available at the point of injury and not necessarily dedicated medical personnel. Prehospital care in a hostile, tactical environment is guided by the recommendations of the multidisciplinary Committee on Tactical Combat Casualty Care (TCCC ) to accomplish the objectives of (1) treating the casualty, (2) avoiding further harm to the casualty and caregivers, and (3) preserving combat mission integrity. Contemporary Combat Medic (MOS: 68 W) and Combat Lifesaver training emphasizes TCCC concepts. The three phases of TCCC are (1) care under fire, (2) tactical field care, and (3) tactical evacuation care.

The tactical evacuation phase of care occurs when the casualty is moved from the potentially hostile, austere point of injury toward a more secure location for staging and subsequent care. The mode and timing of evacuation will vary widely, occurring either when the main force exfiltrates from the objective or as a separate component of the operation. Pre-mission planning is essential to identify available vehicles, destinations, and routes of travel within the area of operations for casualty evacuation. Ideally, medical equipment and/or personnel can be pre-positioned to support the operation: dressing supplies, junctional tourniquets, supplemental oxygen sources (oxygen generator or concentrator preferred over compressed gas cylinders as less explosive hazard), and hypothermia prevention measures. If possible, a Combat Medic or Combat Lifesaver should accompany all casualties. Combat Medics are trained to provide emergency medical interventions, whereas Combat Lifesavers are soldiers trained to provide enhanced first aid. CASEVAC degrades military mission capability by diverting resources from the fighting force, but it may be the only option when the hostile threat level is high or dedicated medical assets are not otherwise available.

TCCC saves lives. In 1998, the 75th Ranger Regiment under the command of COL Stanley McChrystal focused on four training priorities termed the “Big Four”: (1) marksmanship, (2) physical training, (3) small unit tactics, and (4) medical training. TCCC training was incorporated into programs of instruction, training exercises, and contingency planning for all Rangers. An analysis of Ranger casualties sustained from 2001 to 2010 in combat action supporting Operations Enduring Freedom in Afghanistan and Operation Iraqi Freedom was published by Kotwal et al. in 2011. Substantial prehospital care was provided by nonmedical personnel. Despite sustaining more severe injuries, the Rangers’ killed in action and died of wound rates were lower than the overall US military’s rates (10.7 vs 16.4%, p = 0.04 and 1.7 vs 5.8%, p = 0.02). Of the 32 total fatalities, none were judged to have been potentially survivable through additional prehospital medical intervention.

TCCC is not Advanced Trauma Life Support (ATLS ) exported to a prehospital setting, and there is some conflicting instruction between the two philosophies, particularly in the combat setting. In a review of combat-related US military deaths occurring between 2001 and 2011, Eastridge et al. retrospectively identified that 23% of deaths were potentially survivable under ideal conditions. They found that 90% of deaths occurred prior to arrival at a medical treatment facility and that 92% of deaths resulted from hemorrhage. Thus, hemorrhage control is paramount in TCCC and is the first priority, even ahead of airway and breathing management. Because cervical spine injuries are rare and cervical collars are often unavailable in the combat setting, cervical spine immobilization is de-emphasized in TCCC. It is not the purpose of this chapter to detail all TCCC concepts. Open-access educational materials are available for download at the National Association of Emergency Medical Technicians’ website for all three phases of TCCC, and surgeons receiving patients from a TCCC environment must educate themselves on these concepts. Real-world, prehospital care is not routinely practiced within the in-garrison military medical system so for most military personnel, training alone acts as a surrogate for true, hands-on clinical experience. Surgeons should proactively seek to provide TCCC-appropriate education as well as timely, constructive feedback whenever possible to prehospital personnel, both medical and nonmedical. These efforts are always highly appreciated.

DUSTOFF – “Dedicated Unhesitating Support To Our Fighting Forces.”

MEDEVAC : Evacuation of Casualties by Medical Personnel on Dedicated Evacuation Platforms

If dedicated medical evacuation platforms (ground and/or air) are available, casualties should be evacuated on these vehicles to ensure they receive proper en route medical care both from the point of injury and during inter-facility movement. Military MEDEVAC platforms and crew are categorized as non-combatants and identified as such by visible display of a Red Cross. For this reason, MEDEVAC assets may not be able to retrieve casualties in a high hostile threat environment. Due to distances and hazards of ground travel in Iraq and Afghanistan, the majority of both battlefield and inter-facility MEDEVAC transfers were executed by US Army Combat Flight Medics (MOS: 68WF) flying in versions of the UH-60 Black Hawk helicopter (Fig. 38.3). The HH-60 M is the MEDEVAC -specific version of the UH-60 Black Hawk helicopter. The HH-60 M offers six patient litter positions, cabin climate control, oxygen generation capability, as well as other built-in medical support systems. In other operational theaters, both military and nonmilitary MEDEVAC platforms may be utilized depending on availability. It is critical that surgeons know the MEDEVAC plan supporting their operational location prior to their first casualty to include the response times and the potential limitations of the vehicles and the medical attendants. The following discussion primarily focuses on inter-facility MEDEVAC by military rotary wing aircraft.