Current Navy and Marine Corps medical evacuation plans have five levels of care, from basic (1) to advanced (5). Unfortunately, while a wounded Marine or sailor is being transported from one level to the next, there can be a temporary degradation in care. Given the dynamic nature of the transportation environment—whether in Afghanistan today or the western Pacific tomorrow—this hazard to patient safety is unacceptable. One investigation revealed that as many as 30 percent of patients transported in a combat environment experienced clinical deterioration during flight.1
The conflicts of the past two decades have driven home the need to revise evacuation and resuscitation procedures for critically injured troops. We hear a lot about the “golden hour” of trauma—a century-old concept based on World War I French military records showing that wounded soldiers suffered 10 percent mortality if they reached medical care in one hour and 75 percent if their journey took ten hours. But this is not 1917.2 Medical care back then cannot compare with medical care now. While some data suggests advantages to the “golden hour,” other data points to its being woefully inadequate as a modern standard for trauma care.3
Many commanders believe troops will fight harder if they know top-tier trauma care is immediately available. Sadly, those same commanders do not realize the safety net has gaping holes, including the degradation of care in transit and being treated by trauma surgeons who come from military treatment facilities that see very little trauma.4 When deployed in the field or at sea with level-two facilities, military trauma surgeons perform on average only one surgical procedure per month—not nearly enough to maintain their skills, let alone improve them. Nevertheless, since 2009 it has been mandated that all troops be within one hour of surgical care. This often means transporting casualties to a level-two facility, typically a tent with minimal resources.
While determining a specific time limit for critical care is difficult, there is no doubt that the sooner a severely wounded patient receives care, the better. But if the golden hour is less relevant—or even irrelevant—and surgeons at level-two facilities are out of practice, why transport critically wounded combatants there? Would it not be better to bring the trauma bay to the wounded and provide resuscitation en route to higher levels of surgical care?
The Navy Lags Other Services and Nations
Life-saving tactical combat casualty care interventions are one of the great military medicine success stories of the past two decades.5 Prompt prehospital intervention is the most important element in wounded combatant survival. The Navy and Marine Corps, however, are behind their Army and Air Force colleagues in providing critical care in far-forward environments. The Air Force has innovative physician-led critical care air transport teams that turn aircraft into “flying intensive care units.”6 The Air Force Special Operations Command uses the special operations surgical team to support special operations force (SOF) elements, and Air Force national registry paramedic-qualified pararescue jumpers are used to augment various units throughout the Department of Defense (DoD).
The Army has a variety of specialized teams to augment SOF elements, and it has instituted national registry paramedic-level training for flight medics. While a wide variety of medical assets exists across the joint force, the Navy and Marine Corps have no plan for critical care transportation at the Army and Air Force level. Indeed, the Marine Corps uses Air Force pararescue jumpers as de facto flight medics.7 Although some Navy corpsmen and nurses are trained at the Joint Enroute Care Course prior to deploying, this does not compare to other more advanced prehospital care courses, such as the UK Royal Air Force Medical Emergency Response Team Qualification Course or the London Prehospital Care Course.
A robust transportation care system can initiate advanced resuscitation prior to delivering the wounded to a definitive care facility. U.S. international partners already have embraced a system of advanced forward resuscitative care. The physician-led UK Royal Air Force Medical Emergency Response Team has demonstrated improved survival rates with more seriously wounded combatants.8 Civilian systems also have demonstrated a survival advantage when patients are treated on scene by teams that include critical-care doctors. In the United States, the benefit of physician-staffed prehospital teams was demonstrated more than 30 years ago.9 In Australia, physician-staffed helicopters have an improved functional outcome in patients with head injuries.10 And while with this model doctors must perform more procedures at the scene, that has not significantly increased on-scene time. In fact, as recently as 2011 a U.S. military analysis of critical-care transportation advocated for the use of “critical-care teams . . . and direct triage to the highest echelon of care.”11
Critical-Care Doctor/Paramedic Teams
The evidence associates emergency anesthesia with improved survival in certain severely injured patients.12 A variety of critical-care procedures and human factors play a role in the success of battlefield physician-based prehospital critical care.13 The presence of both a critical-care doctor and paramedic confers benefits. The doctor brings diagnostic expertise to the field and “speaks the language” of the trauma center, while the paramedic brings prehospital experience and speaks the language of the field corpsman.
Sydney Helicopter Emergency Medical Service in Australia uses a paramedic/doctor team to bring the trauma bay to the patient. Working in a helicopter, this team places breathing tubes, treats collapsed lungs, administers blood, and makes advanced trauma assessments using ultrasound. When I was a prehospital and retrieval medicine doctor there, my colleagues and I were able to initiate a damage-control resuscitation en route to the trauma center. Using different diagnostic analytics, we determined if patients were so severely injured that they needed to proceed directly from the helicopter pad to the operating room. A recent study of more than 1,000 trauma patients taken directly to the operating room from the field revealed that with patients meeting certain inclusion criteria, mortality was significantly lower than predicted (5 percent versus 10 percent).14
The Navy Needs a Resuscitation Transportation Team
A resuscitation transportation team (RTT) brings together critical-care doctors and national registry paramedics. Resident physicians at military medical centers specializing in critical care, anesthesiology, and emergency medicine can be trained in the Fundamentals of Critical Care Support course currently taught at military medical facilities across the DoD. In addition, an immersive simulation experience covering topics in transportation medicine can familiarize students with resuscitation concepts in a virtual or augmented reality environment. The result will be residency-trained medical officers familiar with current critical-care concepts who have passed a challenging assessment in resuscitation transportation.
Paramedics are instrumental to RTT success and must be trained to the national registry level, the civilian standard. Currently, that is true of only a few Navy corpsmen. To work effectively as a team, both doctor and paramedic must be at the top of their respective fields. National registry paramedic-level training for all Navy RTT paramedics would be consistent with similar programs among international partners.
This approach will provide operational commanders with residency-trained medical officers and national registry paramedic-qualified corpsmen who will work with standardized medical equipment and employ treatment protocols based on best practices. Clinical practice guidelines drawn by the Institute for Surgical Research from the lessons of trauma care in recent conflicts will benchmark RTT quality assurance. They are available online.
It is better for an injured civilian to be transported to a trauma center than to be treated at a community hospital. Similarly, it is better for a wounded Marine to receive critical care resuscitation en route directly to the combat trauma center than to stop first for intermediate-level care. Medical evacuation must respect the physiologic continuum of care from point of injury to definitive therapy. This recognizes the important contribution of prehospital care and the critical-care innovations that now can bring the trauma bay to the patient. The RTT concept offers a solution for prolonged transport times that may be required in a peer-level conflict or in distributed SOF operations far from conventional military trauma center-based care.
RTTs can be dispersed throughout the fleet to maximize availability by sea, air, and land to operational commanders. Thanks to standardized treatment plans, critical-care doctors and national registry paramedics will work from a familiar template. This approach will leverage existing Sea Service assets in future conflicts to mitigate the risk to wounded Marines and sailors.
1. Ryan Lehman, John Oh, Sherry Killius, Mark Cornell, Elizabeth Furay, and Matthew Martin, “Interhospital Patient Transport by Rotary Wing Aircraft in a Combat Environment: Risks, Adverse Events, and Process Improvement,” The Journal of Trauma: Injury, Infection, and Critical Care 66, no. 4 (April 2009): S4–6.
2. Santy P. Shock, “Traumatique dans les Blessures de Guerre, Analysis D’observations,” Bull Med Soc Chir 1918, 44.
3. E. Brooke Lerner and Ronald M. Moscati, “The Golden Hour: Scientific Fact or Medical ‘Urban Legend’?” American Emergency Medicine 8, no. 7 (July 2001): 758–60; Russ S. Kotwal, Jeffrey T. Howard, and Jean A. Orman, “The Effect of the Golden Hour Policy on the Morbidity and Mortality of Combat Casualties,” Journal of American Medical Association Surgery 151, no.1 (January 2016): 15–24.
4. Mary J. Edwards, Christopher E. White, Kyle N. Remick, Kurt D. Edwards, and Kirby R. Gross, “Army General Surgery’s Crisis of Conscience,” Journal of American College Surgeons 226, no. 6 (June 2018): 1190–94.
5. CAPT Frank K. Butler Jr., USN; LtCol John Haymann, USA; ENS E. George Butler, USN, “Tactical Combat Casualty Care in Special Operations,” Military Medicine 161, Supplement 3 (1996): 3–16.
6. Jay A. Johannigman, Maintaining the Continuum of En Route Care (Cincinnati, OH: Division of Trauma and Surgical Critical Care, Department of Surgery, University Hospital, 2008), 36: S377–82.
7. Shawn Snow, “This Is Why the Corps Is Partnering with Elite Air Force Pararescue Jumpers in Africa and Europe,” Marine Corps Times, 21 February 2019.
8. Amy Apodaca, Chris M. Olson Jr., Jeffrey Bailey, Frank Butler, Brian J. Eastridge, and Eric Kuncir, “Performance Improvement Evaluation of Forward Aeromedical Evacuation Platforms in Operation Enduring Freedom: A Brief History, Lessons Learned from the Global War on Terror, and the Way Forward for U.S. Policy,” Journal of Trauma and Acute Care Surgery 75, no. 2 (August 2013): S157–63; S130–36.
9. William G. Baxt and Peggy Moody, “The Impact of a Physician as Part of the Aeromedical Prehospital Team in Patients with Blunt Trauma,” Journal of American Medical Association 257, no. 23 (19 June 1987): 3246–50.
10. Alan Garner, Jennell Crooks, Anna Lee, and Rod Bishop, “Efficacy of Prehospital Critical Care Teams for Severe Blunt Head Injury in the Australian Setting,” Injury 32, no. 6 (July 2001): 455–60.
11. Jonathan E. Clarke and Peter R. Davis, “Medical Evacuation and Triage of Combat Casualties in Helmand Province, Afghanistan: October 2010–April 2011,” Military Medicine 177, no. 11 (November 2012): 1261–66.
12. LtCol Peter R. Davis, USA; Alisa C. Rickards; and J. E. Ollerton, “Determining the Composition and Benefit of the Pre-Hospital Medical Response Team in the Conflict Setting,” Journal of the Royal Army Medical Corps 153, no. 4 (December 2007): 269–73.
13. Anthony Kehoe, A. Jones, Stuart L. Marcus, G. Nordmann, C. Pope, Paul Reavely, and Cheryl F. Smith, “Current Controversies in Military Pre-Hospital Critical Care,” Journal of the Royal Army Medical Corps 157, no. 3 (September 2011): S305–9.
14. Matthew Martin, Seth Izenber, Frederick Cole, Sue Bergstrom, and William Long, “A Decade of Experience with a Selective Policy for Direct to Operating Room Trauma Resuscitations,” The American Journal of Surgery 204, no. 2 (August 2012): 187–92.