11-Medical Support to Military Operations on the Future Battlefield

<img src="/media/202408//1724832298.762274.jpeg" />Surgery and Associate Chair for Operations at USU.Chairman of the School of Medicineat USU.Captain TravisM.Polk,USN,is Director of the DODSpecial AmphibiousReconnaissance Corpsmenassignedto November Company,30Raider Battalion,providetacticalcombat casualtycare training to Soldiers of 3 Battalion,102n⁰Cavalry Regiment,duringroutine deployment toSomalia,August24,2019(U.S.Navy/Patrick W.MullenⅢI)The“Survival Chain”Medical Support to Military Operations on the Future BattlefieldBy Jennifer M.Gurney,Jeremy C.Pamplin,Mason H.Remondelli,StacySean P.Conley,Benjamin K.Pótter,Travis M.Polk,Eric A.EIster,and KýleA.Shackelford,Jay N.RemickB.Baker,Colonel Jennifer M.Gurney,USA,is Director ofthe Department of Defense(DOD)Joint TraumaSystem.Colonel Jeremy C.Pamplin,USA,is Director of the Telemedicine and AdvancedTechnology ResearchCenter Headquarters.Second LieutenantMason H.Remondelli,USA,is anMD Candidate at the Unifomed Services University(USU).Colonel Stacy A.Shackelford,USAF,isthe Trauma Medical Directorat the Defense Health Agency.Colonel Jay B.Baker,USA,is Directorof the DOD Joint Trauma Center,Combatant Command Trauma Systems Branch.Captain Sean P.Conley,USN,is an Assistant Professor at USU.Colonel BenjaminK.Potter,USA,is Professor andJPC-6 Combat Casualty Care Research Program.Captain EricA.Elster,USN(Ret.),is Professorand Dean inthe Schoolof Medicine at USU.Colonel Kyle N.Remick,USA(Ret.),is Professor ofn The Kill Chain:DefendingAmerica in the Future ofHigh-TechWarfare,author Christian Brosedescribes a concept in which thespeed that a combat force is effectiveat“closing the kill chain”will deter-mine whether it wins or loses.!Broseproposes a redesign of our militarycombat infrastructure to“understand,94 Features/The &quot;Survival Chain&quot; JFQ 112,1st Quarter 2024decide, and act” faster than the enemy to employ the required force (forexample, lethal versus nonlethal) toachieve operational overmatch. Follow- ing his lead, we propose the concept of a “survival chain” as the medicalequivalent that could provide combat casualty care support to the “killchain” to gain and maintain medical overmatch on future battlefields .The Department of Defense JointTrauma System (JTS) was created to pro- vide optimal care to the wounded on abattlefield. The current National Defense Strategy anticipates future threats oflarge-scale combat operations (LSCO) against peer adversaries that may limitoverall freedom of maneuver for medical evacuation, increase survivability risk of medical units, and limit timeliness and robustness of critical medical logistics. Thus, the JTS must continue to evolve and embrace the concept of MedicalPerformance Optimization (MPO) to adapt to this new operational reality.MPO captures the intent of the JTS as a “continuously learning health sys-tem” to evolve the speed at which it can cycle through near-real-time data capture, analysis, and adaptation of knowledgeand material solutions to optimize battle- field trauma care. Like the “understand, decide, and act” of the kill chain, JTSMPO will be the survival chain thatrelies on rapidly closing the JTS MPO cycle via “observe, orient, decide [orunderstand],and act” (the JTS OODA loop).2 Therefore, the purpose of this article is to inform military leadership about the risks to optimal combat ca- sualty care in potential future LSCOsand to provide a focused discussion of potential solutions to gain and maintain medical overmatch in the survival chain on the 21st-century battlefields.Reframing CurrentChallengesCasualty care on the battlefield is based on the JTS performance improvement cycle (MPO) overlaid on the NorthAtlantic Treaty Organization’s Roles of Care guidelines.3 The JTS mission includes overall clinical care optimiza- tion of the battlefield trauma systemby providing clinical data collectionand analysis, “loop closure” feedbackto medical commands, identification of gaps in knowledge and skills for further research, best practice clinical guide-lines,quality improvement, and inform- ing education/training.4 The JTS MPO process must continuously and rapidly optimize battlefield trauma care—that is, continuously enhance the survivalchain to gain and maintain medical overmatch to address the volume of casualties expected for an LSCO.The crux of the current challenge is that the past two decades of war in the Middle East have resulted in the focus on a conflict in which there are robust medical resources, fixed Role 3 combat support (Role 3facilities are equivalent to multidisciplinary general hospitals), field hospitals in relatively safeguarded locations, as well as a hierarchical trauma system in which casualties move along a continuum of care with increasing capa- bility at each level of care (figure 2).The JTSperformed well in the recent conflicts, but the reality of future land or maritime LSCOs drives the challenges we now face to prepare the system to deliver the excellent care expected from ourServicemembers and our nation. Dataintegration and technology are integralto MPO for our system to observe (col- lect real-time, relevant data), orient (orunderstand via rapid data analysis), decide (increase speed and accuracy of deci-sions),and act (treat casualties) to meet the expectation of leaders to decreaseforce attrition from injury and maximize its lethality. As Brose notes, “The prob- lems facing the U.S. military are nowtaking on a fundamentally different and greater sense of urgency, and it goes be- yond emerging technologies.”5The goal of the JTS in preparing for LSCOs is a more effective survival chain not only to provide new technologies that improve the deployed medical systembut also to continue to evolve the cur- rent system by enhancing real-time data acquisition forMPO. As Brose describes for increasing lethality, solutions thatimprove survival and force regeneration may involve novel medical innovations, new mechanisms by which to deliveralready proven medical interventions, and modernization of trauma medical systems involving nontraditional architectures that are not platform-centric.6 Therefore, in this article, we focus on the three most urgent challenges to providing a survival chain in support of future military operations:• point-of-injury care• casualty evacuation care• surgical care.Challenge 1: oint-of-Injury CareInitial casualty care at the classic Role1 (Role 1 care includes medical treat-ment, initial trauma care, and forward resuscitation) will face many challenges that are typical of a force-on-force bat- tlespace.7 We know from data developed during the war on terror that mostpreventable deaths (88 percent) occur in the field, that is, the time betweenthe point of injury to the first treatment facility (Role 2).8 Therefore, the chal-lenges during this phase of trauma care will be essential to illuminate gaps ineducation, training, and research to gain overmatch in LSCOs.Main Risks and Potential Mitigating Measures During Point-of-InjuryCasualty Care.• Death from massive bleeding• Increase Tactical Combat Casualty Care training for nonmedical per- sonnel to control hemorrhaging and free up line medics to care for the more seriously wounded• Train and equip combat medics for blood transfusion, walkingblood banks, and additionalhemorrhage control techniques and simultaneously develop novel technological solutions for bleed- ing control and delivering blood9• Develop novel antishock drugs, blood products or alternatives,and advanced clotting technology to mitigate combat deaths from hemorrhage.10• Large casualty volume• Ensure more sophisticated training for combat medics on knowledge<img src="/media/202408//1724832298.839097.jpeg" />Soldiers assigned to Army Reserveparticipate in TacticalCasualty Combat Carecourse atJoint Base McGuire-Dix-Lakehurst,New Jersey,September 10,2023(U.S.AirForce/Matt Porter)<img src="/media/202408//1724832298.9525309.png" />and skills in triage (the sorting of casualties by the severity of injury) involving an intentional transi-tion from optimal care for eachindividual casualty to “the greatest good for the greatest number”in mass casualty incidents (when the number of casualties outstrips resources available)11• Develop simpler and more func-tional models for triage that mayinvolve swift identification ofthose who are ambulatory or dead first,then stable or unstable, andincreasing knowledge of resources readily available to the triage team12• Develop best practices in the care of the injured in mass casualtyincidents to clear the battlefield of hundreds (or thousands) of casu- alties and simultaneously provide care and maximize the force.• Lack of resources• Integrate remote-piloted aircraft or other technology for medical logistics support in denied and hostile environments• Develop clinical decision-support tools for personnel working with limited medical resources• Develop real-time monitoring and decision support tools for medical assessments and interventions.Challenge 2: CasualtyEvacuation CareThe next phase of care conventionally involves the movement of casualtiesfrom the immediate area of activeconflict to one that can render moreadvanced trauma care and damagecontrol resuscitation. However, during a large-scale force-on-force fight with adversaries that possess comparablelong-range fire technology and air-power, challenges might arise thatcould diminish this potentially lifesav- ing evacuation capability. As a result,this phase of care, still classically con- sidered Role 1 care, will include Pro- longed Casualty Care (PCC) through eventual medical evacuation whenavailable.13 In this phase, medics will be faced with caring for casualties beyonddoctrinal timelines with large volumes of casualties and resource constraints— in other words, more complex care with less resources.Main Risks and Potential Mitigating Measures to Casualty Evacuation and Prolonged Casualty Care.• Denied operating environment• Increase knowledge and skillsrequired by combat medics toperform PCC to extend typical hold and evacuation times until a more advanced resuscitation and surgical care capability can arrive or be reached14• Develop the means to employtelehealth and decision support in austere environments to augment medical care further forward• Improve clinical data capturethrough real-time, automateddocumentation for ongoing care and for MPO.• Risk of air maneuver/groundmovement• Develop automated medical care technology for aerial and ground vehicles and include environmen- tal surveys for railways as a poten- tial means for medical evacuation of large numbers of casualties• Employ remote-piloted aircraft for medical resupply to include blood products that could be delivered on demand to forward locations• Evolve Patient Evacuation Coordi- nation Cells that include real-time, intelligent tasking that accountsfor both clinical and operational factors in optimal timing and des- tination for patient movements.• Lack of communication/command and control• Develop counter-electronic/counter–cyber warfare technolo- gies to protect and ensure clinical and operational medical com-munications are available and not compromised• Consider a battlefield medical command and control element, linked with the JTS, with real-time situational awareness of the battlefield and, with oversightto best match patient evacuation timing, clinical care required,as well as the right destination medical capability for the best outcomes• Develop a method of automated, real-time tracking of casualtiesacross the battlespace.Challenge 3: Surgical CareAlthough most combat casualties who succumb to their injuries do so at Role 1 before they arrive at a surgical capa- bility, the concept of Role 2 and Role 3 care remains critical to the remain-der of survivable injuries.15 Withoutdamage control and definitive surgery, a casualty may initially survive but then die of bleeding or long-term traumacomplications, such as infection andorgan failure. For example, a casualty with a bleeding liver may receive theappropriate initial treatment to prolong life until reaching a facility capableof surgery, but that injury could only be more definitively controlled by asurgeon opening the abdomen andmanually controlling the ongoingbleeding. Due to this situation, survival will be compromised without timelysurgical intervention. However, on the potential peer contingency battlefield, Role 2 facilities and advanced surgical teams will face challenges.Risks and Potential Mitigating Measures for Initial Lifesaving Surgical Care.• Operational training/interoperability• Re-emphasize organizing, train- ing, and equipping small surgi- cal teams that could optimally perform as both a surgical team and as an operational element16• Optimize surgical teams thathave access to work together in high-volume trauma centers andconduct specific training to attain the clinical and operational capa- bility required• Conduct research and dataanalysis to better understand what capability is required and howto best employ surgical teams in future operations• Improve the ability of surgical teams to capture data in future operations to be used for MPO.• Maintaining casualty care expertise• Increase opportunities for deploy- ing medical personnel to workindividually and as teams in mili- tary Medical Treatment Facilities or in military-civilian partnerships• Continue to leverage the JointKnowledge, Skills, and AbilitiesProgram Management Officeas the means to measure clinical specialty-specific medical readiness and provide clinical deployment readiness assessments• Research and develop technology that could augment clinical care through telementoring, telerobot- ics, augmented reality, or otheremerging solutions.• Risk of far-forward-deployment• Consider surgical teams with doc- trine akin to a quick reaction force with the capability to move on the battlefield alongside operational elements to mass for casualty care at decisive points and thendis-perse when complete to minimize the risk of exposure• Establish international partnerships in geostrategic locations that could then be leveraged as a regionaltrauma capability while minimizing our military footprint17• Research and develop telesurgery capability forfar-forward surgical locations to limit risk to surgeons and medical teams.Conclusion: Closingthe Survival Chain toSupport the Kill ChainThe JTS has proved its effectivenessat decreasing death on the battlefieldsince its inception in 2005,and thusthe organization was codified into doc- trine in 2016. While the JTS provided tremendous advances over the past 20 years in combat, the next conflict might last for less than 2 years but have 10times as many combat casualties as thelast two decades. The JTS must con- tinue to evolve through its MPO cycle to meet these anticipated challenges, most urgently for point-of-injury care, care during casualty evacuation, and surgical care as discussed.We must actively seek to maintain our ability to optimize survival on the battle- field by decreasing warfighter attritionand thus producing the operational effect of maintaining combat strength. This is the mission of the Joint Trauma System. With the support of military leadership, the JTS could continue to evolve to sup- port this critical role. TheMPO concept is the cycle of near-real-time data collec- tion and analysis, novel knowledge and/ or material solutions, and rapid integra- tion into battlefield trauma care (the JTS OODA) that would enable the JTS toadapt and react quickly when needed. By leveraging the existing processes of MPO and enhancing its speed of loop closure, the JTSwould provide the survival chain that could gain and maintain medicalovermatch on future battlefields regard- less of the challenges presented. JFQNotes1 Christian Brose, The Kill Chain: Defend- ing America in the Future of High-Tech Warfare(New York: Hachette Books, 2020).2 Ibid.3 Allied Joint Publication (AJP) 4.10(A), Allied Joint Medical Support Doctrine (Brus-sels: North Atlantic Treaty Organization, May 30, 2011), https://shape.nato.int/resources/ site6362/medica-secure/publications/ajp-4.10(a).pdf.4 Jeffrey Bailey et al., eds., The JointTrauma System: Development, ConceptualFramework, and Optimal Elements (Fort Sam Houston, TX: U.S. Army Institute of Surgical Research, January 2012), https://jts.health. mil/assets/docs/publications/Joint_Trauma_ System_final_clean2.pdf.5 Brose, The Kill Chain.6 Ibid.7 AJP 4.10(A).8 Brian J. Eastridge et al., “Death on the Battlefield (2001–2011): Implications for the Future of Combat Casualty Care,” Journal of Trauma and Acute Care Surgery 73, no. 6 (December 2012), S431–S437, https://doi. org/10.1097/TA.0b013e3182755dcc.9 Andrew D. Fisher et al., “Low TiterGroup O Whole Blood Resuscitation: Military Experience from the Point of Injury,” Journalof Trauma and Acute Care Surgery 89, no. 4 (October 2020), 834–841, https://doi. org/10.1097/TA.0000000000002863.10 Jonathan J. Morrison, Joseph J. Dubose, and Todd E. Rasmussen, “Military Applica-tion of Tranexamic Acid in Trauma Emergency Resuscitation (MAT-TERs) Study,” Archives of Surgery 147, no. 2 (February 2012), 113–119, https://jamanetwork.com/journals/jamasur- gery/article-abstract/1107351; I. Roberts et al., “The CRASH-2 Trial: A Randomised Con- trolled Trial and Economic Evaluation of the Effects of Tranexamic Acid on Death, Vascular Occlusive Events and Transfusion Require-ment in Bleeding Trauma Patients,” Clinical Governance: An International Journal 18, no. 3 (July 2013), https://doi.org/10.1108/cgij.2013.24818caa.005.11 Stacy A. Shackelford et al., “Evidence- Based Principles of Time, Triage and Treat- ment: Refining the Initial Medical Response to Massive Casualty Incidents,” Journal ofTrauma and Acute Care Surgery 93, no. 2S Suppl 1 (August 2022), S160–164, https:// doi.org/10.1097/ta.0000000000003699.12 Ibid.13 “Prolonged Casualty Care Guidelines:Joint Trauma System,” JTSHealth.mil, Decem- ber 21, 2021, https://jts.health.mil/assets/docs/cpgs/Prolonged_Casualty_Care_Guide- lines_21_Dec_2021_ID91.pdf.14 Nedas Jasinskas, Regan Lyon, and Jay Baker, “Unconventional Warfare Medicine Is the Ultimate Prolonged Field Care,” Medical Journal (Fort Sam Houston, TX), no. Per 22- 04-05-06 (April–June 2022), 27–31.15 AJP 4.10(A).16 Jay B. Baker et al., “Austere Resuscita-tive and Surgical Care in Support of ForwardMilitary Operations—Joint Trauma SystemPosition Paper,” Military Medicine 186, no.1–2 (January–February 2021), 12–17, https:// doi.org/10.1093/milmed/usaa358.17 Regan F. Lyon, “When the ‘GoldenHour’ Is Dead: Preparing Indigenous Guer-rilla Medical Networks for UnconventionalConflicts” (Master’s thesis, Naval Postgraduate School, December 2021), https://calhoun.nps. edu/handle/10945/68685.