“God gave you ears, eyes, and hands; use them on the patient in that order.”

William Kelsey Fry

One of the common attributes of great trauma surgeons is that they seem (to us mere mortals) to have the ability to magically sort out who needs emergent intervention without all of that “new-fangled technology” that has replaced the physical examination and clinical judgment. I had the great opportunity to train under one such legendary figure and quickly realized that the strongest predictor that the patient needed to go emergently to the operating room was when he pulled his cloth scrub cap out of his back pocket and put it on. We all learned to watch closely for this tell-tale sign and how incredibly accurate it was for predicting life-threatening injuries just by simple observation and examination. However, with close observation I came to realize that he was able to do this in large part by applying a basic set of rules and principles governed by common sense and a deep understanding of trauma mechanisms and anatomy. Although no chapter or guidelines can hope to replicate that level of judgment built on decades of experience and hard-learned lessons, you can easily adopt the principles and algorithms outlined here to manage the most challenging group of patients you will ever encounter – combat trauma patients.

The sharp decline in penetrating trauma volume and the increase in nonoperative management of most injuries have inadvertently created a widespread disease pathology among surgeons and surgical trainees – catatonia. I define this as “the inability to make definitive management decisions without the use of detailed computed tomography imaging, coupled with a fear of the “exploratory” operation.” If there is one overriding principle to guide you in managing combat trauma , it is to abandon or adjust the civilian trauma algorithms that you have learned. Combat trauma is in many ways the polar opposite of civilian trauma – penetrating mechanisms predominate, severe and multi-compartment injury is more common, and the majority will require some form of operative intervention. It is very different than being at a Level 1 trauma center in the USA, where the majority of trauma is blunt mechanism and you have all of the “bells and whistles” available to you. The goal of this chapter is to help you make the early and critical decision of “what next?” after the initial trauma evaluation and learn to be comfortable “pulling the trigger” to go to the operating room even in uncertain situations. I have yet to have a case where I regretted going right to the OR, but I have certainly had and seen many cases involving regret (and avoidable morbidity or mortality) about going to the CT scanner instead of the OR. In the stable patient, these approaches may save you time and resources; in the unstable or bleeding patient, these approaches may save his or her life.