On 23 March 2003, Hospitalman Apprentice Luis E. Fonseca Jr. was traveling with an amphibious assault vehicle (AAV) platoon from Charlie Company, 1st Battalion, 2d Marine Regiment, whose mission was to secure the northern bridge at Al Nasiriyah, Iraq.
Fonseca was in the last AAV in the column when Charlie Company came under attack from mortar, rocket-propelled grenade (RPG), and small-arms fire. He and the company gunnery sergeant leaped out and raced to another AAV that hud been hit and was burning. They arrived to find four or five casualties in the back of the vehicle. Fonseca began removing and treating the wounded Marines while under constant small-arms, machine-gun, and RPG fire. He established a casualty collection point and directed the movement of the wounded to another AAV. Two of the most seriously injured Marines had partial foot amputations caused by the RPG blast. Fonseca applied tourniquets and administered morphine to each of them, marking the tourniquet times on their foreheads.
After the second AAV was disabled by yet another RPG, Fonseca evacuated the Marines and reestablished another casualty collection point on the west side of the road in the swamp. Soon another vehicle was brought forward to load the casualties and carry them toward friendly lines. During the short southbound trip, Fonseca continued to give medical aid, using supplies from the vehicle first-aid kit until he could hand the wounded over to a corpsman from another battalion. He then rode the AAV back through the ambush site to the north side of the bridge, where he continued to provide aid, administering morphine and applying tourniquets to Marines pinned down there until a medevac helicopter was able to land an hour later. Fonseca. credited for saving at least five lives that day, was awarded the Navy Cross.
Readiness
Obviously, military medicine's principal function is the care of the sick and wounded, as was so dramatically illustrated by Hospitalman Fonseca's heroism. Navy medicine, however, also must provide line commanders with a force mentally and physically fit for duty. Here as well Hospitalman Fonseca can serve as a model.
In this era of ratings mergers, shrinking crew sizes, and lighter, more rapidly mobile forces, the role of each individual sailor and Marine is increasingly critical to success. Members of the naval force (including many reserves) must be screened for physical conditions that could affect their readiness to deploy.
Medical readiness, however, is more than just the absence of illness. It encompasses a range of health requirements that include up-to-date dental, physical, and preventive health assessments; required vaccinations-especially against diseases such as anthrax, smallpox, or Japanese equine encephalitis that may be important in specific locations-eyeglasses and prescription gas mask lens inserts for those who require vision correction; and serum specimens for detection of conditions such as a sickle-cell trait (which could put susceptible individuals at risk in certain environments) and for DNA sampling (which can be used for identification).
Navy dentists have for several years been able to classify and report dental readiness using an automated database. More recently, the medical readiness reporting system has evolved as a powerful tool for tracking medical readiness at individual, unit, and service levels. Originally developed in the Navy Reserve and previously known as the reserve automated medical information system, the new reporting method is a secure Web-based system that allows commanders to review and report a unit's medical status in much the same way as they now report unit readiness. It has been adopted by the entire Marine Corps in addition to the Navy Reserve force; active-duty Navy units report medical readiness using other systems.
At a time when the Armed Forces can ill afford to lose qualified volunteers, preventable orthopedic injuries result in lost training time and attrition at recruit and officer training sites. Before 2002. about 1.100 Marines per year (women at twice the rate of men) were discharged because of musculo-skeletal injuries. Since then, the Marine Corps has implemented a sports medicine injury-prevention program at entry-level training locations such as Marine Corps recruit depots, schools of infantry, Officer Candidate School, and the Basic School. Based on research into human performance in both civilian and military settings, the program relies on a combined strategy of prevention and early, aggressive treatment of orthopedic injuries using certified athletic trainers working under the supervision of Navy sports medicine specialists. Boot camp attrition for conditions such as stress fractures and other overuse-type injuries declined by 13% to 24% during the program's first full year, while discharges from the School of Infantry because of musculo-skeletal injuries decreased by nearly half. Continued studies are under way to help us understand how to train more effectively and how to enhance physical performance.
Preventing Casualties
In every conflict in our history sailors and Marines experience significant illness and injury from preventable causes. Warfighters are exposed to a plethora of health threats including hot, cold, or wet environments; infectious diseases; hazardous chemicals; potential chemical and biological weapons or radiation; and the effects of fatigue, stress, and lack of sanitation. Indeed, these disease and non-battle injuries usually account for substantially more hospitalization and loss of manpower than combat wounds. From the commander's standpoint, it is far better to prevent casualties from illness and injury than to have to expend limited resources taking care of them.
Basic preventive measures, however, are sometimes difficult to implement in the field. For example, malaria can be effectively prevented by covering exposed skin, using insect repellants liberally, sleeping under mosquito netting to avoid exposure to biting insects at night, and taking prophylactic medications. But long sleeves and pants are uncomfortable in hot, humid environments, insect repellant must be reapplied frequently when one is perspiring heavily, and mosquito netting designed for use with folding canvas cots is useless when Marines sleep directly on the ground. Since 2004 the Marine Corps has fielded new, self-supporting individual bed netting systems and combat utility uniforms impregnated with insect repellant to reduce the threat of insect-borne diseases, including malaria and leishmaniasis-the disease also known as the "Baghdad Boil"-transmitted by biting sand flies in Iraq. The services hope the combination of these technological improvements and better training will increase protection against preventable infectious diseases.
While many strategies have been developed over the years to mitigate the impact of non-battle casualties on the battlefield, the recent development of the forward deployable preventive medicine unit shows great promise. These highly capable and mobile teams of epidemiologists, environmental-health officers, entomologists, laboratory personnel, and support staff are equipped with sophisticated detection and diagnostic equipment. Using tools such as handheld tests developed in military and civilian laboratories to rapidly identify anthrax and other biologicalwarfare agents, the units employ real-time, easy-to-use, field-capable diagnostic capabilities unimagined just a few years ago.
By now, the American public is familiar with the Interceptor body-armor system that represents a major advance in preventing combat casualties caused by gunshot wounds and shrapnel fragments. Fatal chest and abdominal wounds have decreased dramatically since small-arms protective insert plates were added to Kevlar flak vests. As our enemy in Iraq changes tactics to exploit vulnerable areas such as the neck, armpits, and groin, we have deployed improved body-armor systems that provide extended coverage for these areas. Since the arms and legs are now more susceptible than the torso to penetrating injury, prototype extremity protection systems have been fielded. Ongoing materials research will lead to even lighter, cooler, and more effective protection systems.
We have also made great strides in protecting combat troops from the devastating effects of head and neck injuries, which now make up a larger proportion of combat wounds than ever before. The Marine Corps' new helmet is 15% lighter than older models while providing more skull coverage, better ballistic protection, and greater comfort. During the early phases of Operation Iraqi Freedom doctors began seeing devastating cases of blindness from small fragments penetrating the eyes of Marines injured by improvised explosive devices. The Corps rapidly fielded thousands of pairs of ballistic goggles and glasses. Ballistic eye protection is now a standard part of individual protective gear, as are highly effective ballistic earplugs that protect the sensitive inner ear against injury from the impulse noise of an explosion while allowing the wearer to hear radio transmissions and spoken conversation normally.
Heightened concern over health problems related to deployment came in the wake of Operation Desert Storm (1991) when some veterans began to complain of vague constellations of symptoms and illnesses. The Department of Defense responded by establishing programs for pre- and post-deployment health assessment. Sailors and Marines who deploy away from their home duty station complete questionnaires before departing to detect health concerns that might be affected by deployment; within 30 days of returning they complete similar questionnaires to determine whether any new, possibly deployment-related medical problems have developed. The Navy and Marine Corps are implementing the latest program that requires troops to complete a third survey three to six months after returning from a deployment. The aim of this post-deployment health reassessment effort is to detect problems that might have delayed onset-especially mental health problems-and arrange prompt evaluation and treatment when indicated.
In fact, mental health concerns have taken center stage during Operation Enduring Freedom (Afghanistan) and Operation Iraqi Freedom, and health-care providers working closely with line colleagues are helping members of all services deal with the effects of combat and operational stress. Stress reactions are normal responses for healthy individuals being exposed to the combat environment. If not recognized and handled appropriately, however, such reactions can result in more long-lasting symptoms or even the debilitating illness known as post-traumatic stress disorder. In 2003. the Marine Corps began the operational stress-control and readiness program that integrates psychiatrists, psychologists, chaplains, and specially trained staff non-commissioned officers into line infantry units. This program has revealed that reducing the barriers between mental health experts and Marines helps not only prevent psychological problems in the deployed environment but also enables rapid identification of issues early on so they can be dealt with before they become more serious.
Taken together, all of these preventive measures have yielded gratifying results during Operation Iraqi Freedom, where U.S. service members have suffered from the lowest non-battle casualty rates in our history.
Treating Casualties
Effective casualty management on the battlefield requires a continuum of care. Traditional doctrine of levels of care-Level 1 corpsman/medic and battalion aid stations, Level 2 surgical companies, fleet hospitals, etc.-are giving way to new concepts based on medical-care capabilities along the continuum. Thus emerging doctrine refers to first-responder care, resuscitative care, and essential care in theater, with rapid evacuation out of theater to facilities capable of definitive care. En route care must be provided during transport between each of these stages. This remains a formidable logistical challenge, requiring careful planning, communication, and coordination.
In addition, modern concepts of expeditionary maneuver warfare have created the need for lighter, faster, more mobile medical elements in the field. Navy medicine's deployed capabilities have evolved from large Vietnam-era fixed field hospitals to smaller, modular expeditionary medical facilities (see "Saving Lives Up Front: Forward Resuscitative Surgery," pages 28-32). This transformation in large part stems from amazing technological advances: ventilators, anesthesia machines, and diagnostic imaging, all cornerstones of emergency surgery, are now so much smaller and lighter than before, that it is possible for a forward resuscitative surgical team to transport everything it needs in two Humvees with trailers or perhaps in the future a single MV-22.
Although trauma surgeons and emergency medical system designers often refer to the "golden hour" following injury, in combat the interventions made in the first few minutes may determine life or death. In recognition of this fact, Navy medicine has put great emphasis on training and equipping first responders. Traditional first-aid teaching in corpsman-training programs has been replaced by the tactical combat casualty care course. This emphasizes new approaches to casualty care, including the importance of returning fire when necessary and early tourniquet use to obtain control of hemorrhage. Selected Marines are learning the same principles in the combat lifesaver course that trains them to serve as first responders when a corpsman is not immediately available
Early in 2003 the Marine Corps overhauled the contents of the individual first-aid kit issued to Marines based on input from medical experts and technological advances in emergency medical care. Uncontrolled bleeding is the leading cause of preventable death on the battlefield, so the revamped first aid kit contains a new generation of tourniquets that an injured combatant can apply with one hand. The kits also contain a revolutionary hemostatic powder called QuikClot; effective against bleeding that cannot be stemmed by traditional means. (The U.S. Army issues a hemostatic gauze dressing to every soldier.)
According to unpublished field reports received at headquarters, U.S. Marine Corps, QuikClot has proved its worth on the battlefield. During the second battle of FaIlujah in November 2004, Hospital Corpsman First Class Eugene Johnson, assigned to 1st Battalion, 3d Marines, treated casualties including a Marine who had sustained blast injuries of the right leg and a gunshot wound of his right arm, with arterial bleeding that wasn't adequately controlled using either direct pressure or a tourniquet. Corpsman Johnson took a packet of QuikClot from his individual first-aid kit and applied it to the entrance wound on the Marine's arm. In a later written report of the incident, he wrote that QuikClot was "easy to use, fast-acting, and simply 'it works.'"
After he stopped the hemorrhage, Corpsman Johnson moved the casualty to the battalion aid station. Lieutenant Christopher Fuller, U.S. Navy, the medical officer in charge, recalled that QuikClot was used on six wounded Marines during the Battle of Fallujah, including four cases where it had been used by corpsmen in the field to stop bleeding so that no further treatment was needed at battalion level. The casualty that Corpsman Johnson had treated was rapidly evacuated to Bravo Surgical Company and survived with all four limbs intact. (See "Mighty Life-Saving Packages," page 24.)
The corpsman's medical bag has been redesigned to become more modular and integrated with the modern individual assault pack. Corpsmen riding in convoys in Iraq treat multiple casualties caused by improvised explosive devices using an expanded vehicle life-saving kit that contains larger quantities of tourniquets, bandages, and bleeding-control agents.
As casualties move along the continuum of care, clinical information describing their injuries and intervening treatment must be passed from doctors at each stage to the next one. Electronic systems are replacing easily lost paper triage tags and handwritten medical reports: the Armed Forces Health Longitudinal Technology Application is DoD's new global, electronic health record system. When fully deployed in 2007, it will allow secure access to data reflecting any sailor or Marine's health conditions, prescriptions, and diagnostic tests from anywhere in the world. The deployable version is the core of the theater medical information program (TMIP) that is already being tested on the battlefields of Iraq. Elements of the II Marine Expeditionary Force have been using a prototype system called "TMIP-Lite" since the fall of 2005-the first ever electronic medical record in theater.
The Marine Corps Warfighting Laboratory has taken the lead in developing the tactical medical casualty system that uses passive radio frequency identification technology to provide near real-time patient identification and tracking from the point of injury to sources of in-theater care. Two Web-based systems, the joint patient tracking application and the transportation command's regulating and command and control evacuation system (TRAC^sup 2^ES), track patient movement once a casualty reaches a theater hospital and while on medical evacuation aircraft en route out of theater, respectively.
We are gaining a better understanding of battlefield injuries by collecting detailed information on battle and non-battle injuries and fatalities in Afghanistan and Iraq in an electronic database. The Navy-Marine Corps Combat Trauma Registry is part of the joint theater trauma system but goes further than the Army's database in that it contains information collected from far-forward medical facilities and non-battle statistics as well as battle injury data.
Advances in military medicine come from research, analysis, and adjustment to the modern conditions of war, and the use of new technologies and procedures that are not yet widespread in medical practice. We have progressed, but we must continue to innovate to provide the most effective health-service support.
Captain Cox is the director of Medical Programs at Headquarters, U.S. Marine Corps and is the Navy Surgeon General's leader for Marine Corps medicine. He is board-certified in emergency medicine, preventive medicine, and health-care management. Captain Sharp is the chair of the Department of Military and Emergency Medicine at the Uniformed Services University of the Health Sciences, Bethesda, Maryland. He is board-certified in preventive medicine.