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对未来战场上的军事行动的医疗支援
 USU外科手术副主席。 美国联邦立州立大学医学院主席。船长的船长。美国海军的波尔克是国防部主任 特种两栖侦察部队隶属于11月连，30突袭营，为102n⁰Cavalry团3营的士兵提供战斗临时护理训练，August24,2019（U.S.Navy/Patrick W. MullenⅢI） **“生存链”** 对未来战场上的军事行动的医疗支援 **作者：詹妮弗M.格尼，杰里米C.潘普林，梅森H.雷蒙德利，史黛西** **肖恩P.康利，本杰明K。波特，特拉维斯·M.波尔克，埃里克·A.伊斯特，和凯尔** **A. 沙克尔福德，Jay N. Remick** **B. 贝克** 詹妮弗·m·格尼上校，美国，是美国国防部（DOD）联合创伤部主任 体系杰里米·c·潘普林上校，美国，是远程医疗和高级部门的主任 技术研究中心总部。第二中尉，美国，是一个 美国联合服务大学（USU）的医学博士候选人。美国空军的史黛西·a·沙克尔福德上校是这样的 美国国防卫生局的创伤医疗局局长。美国杰伊·贝克上校，现任主任 美国国防部联合创伤中心，战斗指挥创伤系统分部。肖恩上尉。 康利是US大学的助理教授。本杰明克上校。美国波特教授和 JPC-6战斗伤亡护理研究项目。埃里卡船长。埃尔斯特（注册）是教授吗 以及USU医学学校的院长。美国Kyle N. Remick上校（Ret.），他是哈佛大学的教授吗 *n杀戮链：防御* *高科技未来的美国* *战争，作家克里斯蒂安·布罗斯* 描述了一个概念，其中 战斗部队有效的速度 在“关闭杀戮链”将阻止 我的决定是赢是输。！布罗斯 建议重新设计我们的军队 战斗基础设施，以“理解， **94个特征/“生存链”**JFQ 112,2024年第一季度 决定和行动“比敌人更快地使用所需的力量” 例如，致命的和非致命的) *实现操作过度匹配。按照他的领导，我们提出了一个“生存链”的概念作为医疗* 相当于为“杀死”提供战斗伤亡护理支持 “在未来战场上获得和保持医疗优势。 美国国防部的联合部队 创伤系统（JTS）的创建是为了为伤员提供最佳的护理 战场。当前的国防战略预测了未来的威胁 针对可能有限制的同伴对手的大规模作战行动（LSCO） 医疗后送的整体机动自由度，增加了医疗单位的生存能力风险，并限制了关键医疗后勤的及时性和稳健性。因此，JTS必须继续发展，并接受医学的概念 性能优化（MPO），以适应这种新的操作现实。 MPO抓住了JTS作为一个“持续学习健康系统”的意图 通过近实时的数据捕获、分析和知识适应来发展其循环的速度 以及优化战场创伤护理的材料解决方案，如杀戮链的“理解、决定和行动”，JTS. MPO将是一个生存链 依赖于快速关闭JTS MPO循环，通过“观察，定位，决定[或” 理解]，并采取行动”（JTS OODA循环）。2因此，本文的目的是告知军事领导在未来潜在的后勤保障中最佳作战护理的风险 并提供一个集中的讨论潜在的解决方案，以获得和维持医疗过剩的生存链在21st世纪战场。 **重新框架电流** **挑战** 战场上的伤亡护理是基于在北部覆盖的JTS性能改进周期（MPO） 大西洋公约组织的护理作用指南。3JTS的任务包括战场创伤系统的整体临床护理优化 通过提供临床数据收集 和分析，“循环闭合”反馈 对医疗命令，识别知识和技能方面的差距，以供进一步研究，最佳实践临床指南- 线路，质量改进，并告知教育/培训。4JTS MPO过程必须不断和快速地优化战场创伤护理，即不断提高生存率 获得和维持医疗过剩，以解决LSCO的伤亡人数。 当前挑战的关键在于，过去二十年的战争在中东导致了关注冲突有健壮的医疗资源，固定角色3战斗支持（角色3设施相当于多学科综合医院），野战医院在相对保障的位置，以及分层创伤系统伤亡沿着连续的护理增加在每个级别的护理（图2）。 JTS在最近的冲突中表现良好，但未来陆地或海上后勤中心的现实推动了我们现在面临的挑战，以准备系统提供我们预期的优质护理 军人和我们的国家。数据 集成和技术是不可分割的 到MPO为我们的系统观察（收集实时、相关数据），定向(或 通过快速的数据分析来理解)，决定(提高决策的速度和准确性 采取措施)，并采取行动（治疗伤亡人数），以满足领导人减少的期望 正如布罗斯指出的那样，“美国面临的问题。. 军队现在是 它有一种根本不同的、更强烈的紧迫感，超越了新兴技术。”5 JTS为LSCOs做准备的目标是一个更有效的生存链，不仅是提供新的技术，改进已部署的医疗系统 并通过增强MPO的实时数据采集，继续发展租金系统。正如布罗斯所描述的那样，解决方案 提高生存率和力量再生可能涉及新的医疗创新，新的交付机制 已经被证实的医疗干预措施，以及涉及非以平台为中心的非传统架构的创伤医疗系统的现代化。6因此，在本文中，我们将关注提供生存链的三个最紧迫的挑战： **•**伤害点护理 **•**伤亡人员疏散护理 **•**外科护理。 **挑战1：int-** **伤害护理** 最初的伤亡护理在经典的角色 1(角色1的护理包括医疗治疗- 治疗、初始创伤护理和向前复苏)将面临许多挑战，这是典型的强力蝙蝠空间。7我们从反恐战争期间发展起来的数据中知道，大多数 可预防的死亡（88%）发生在现场，即两者之间的时间 第一个治疗机构的损伤点（角色2）。8因此，cal- 在创伤护理的这一阶段的延长将是阐明差距 教育、培训和研究。 ***受伤点期间的主要风险和潜在的缓解措施*** ***伤亡护理。*** **•**大出血死亡 增加对非医疗每医护人员的战术战斗伤亡护理培训，以控制大出血和释放在线医疗人员来护理更严重的伤员 训练和装备战斗医务人员进行输血，行走 血库和其他 出血控制技术，同时开发新的技术控制出血和输送血液的解决方案9 开发新型的抗休克药物、血液制品或替代品， 先进的凝血技术可以减少因出血造成的死亡。10 **•**大规模伤亡人数 确保对战斗医务人员进行更复杂的知识培训 被分配到陆军预备役的士兵 参与战术人员伤亡战斗护理 在麦圭尔-迪克斯-莱克赫斯特联合基地开设的课程， 新泽西州，9月，10,2023(U.S.Air 力/马特波特）  以及分类（根据受伤的严重程度分类伤亡）的技能 从对每个人的最佳护理开始 个人伤亡“最大利益最大” 在大规模伤亡事件中（当伤亡人数超过可用资源时）11 开发出更简单和更有趣的东西 可能的分类模型 涉及快速识别 那些先走动或死亡，然后稳定或不稳定，和 增加对分诊小组容易获得的资源的知识12 制定大规模伤亡中伤者护理的最佳做法 清除战场上数百（或数千）伤亡的事件，同时提供护理和最大限度地增加兵力。 **•**缺乏资源 集成远程驾驶飞机或其他技术，以便在被拒绝和敌对的环境中提供医疗后勤支持 为医疗资源有限的工作人员开发临床决策支持工具 为医疗评估和干预措施开发实时监测和决策支持工具。 **挑战2：伤亡** **疏散护理** 下一阶段的护理通常涉及伤亡人员的转移 从邻近的活动区域开始 将冲突转移到一个可以呈现更多内容的人身上 高级创伤护理和损伤 控制复苏。然而，在一个大规模的武力战斗与对手拥有类似的 远程火灾技术和空中- 权力，挑战可能会出现 可能会降低这种可能挽救生命的疏散能力。因此， 这一阶段的护理，仍然是经典的角色1护理，将包括延长伤亡护理（PCC）通过最终的医疗后送 可用的13在这个阶段，医护人员将面临照顾伤员的问题 有大量伤亡和资源限制的教义时间线——换句话说，更复杂的护理和更少的资源。 ***伤亡疏散和延长伤亡护理的主要风险和潜在的减轻措施。*** **•**拒绝操作环境 提高知识和技能 战斗医务人员要求 实施PCC以延长典型的等待和疏散时间，直到达到或达到更先进的复苏和手术护理能力14 开发可供使用的手段 在严峻环境下的远程保健和决策支持，以进一步加强医疗保健 改善临床数据捕获能力 通过实时、自动化 持续护理和MPO的文件。 **•**空中机动/地面风险 运动 开发空中和地面车辆的自动化医疗保健技术，并将铁路环境调查作为大量伤亡人员医疗后送的潜在手段 使用遥控飞机进行医疗补给，包括可按需运送到前方地点的血液产品 进化的病人疏散协调细胞，包括实时、智能任务的帐户 为临床和操作因素在最佳的时间和目的地的病人运动。 **•**缺乏沟通/指挥和控制 沙痂发展反电子/ 反网络战技术系统，以保护和确保临床和作战医疗网络 发音是可用的，而且不妥协 考虑一个战场医疗指挥和控制元素，与JTS相连，与真实的- 战场的时间态势感知，并有监督 为了最匹配病人的疏散时间，需要临床护理， 以及正确的目的地医疗能力，以获得最佳的结果 开发一种自动、实时跟踪伤亡人员的方法 穿越战场空间。 **挑战3：外科护理** 虽然大多数受伤的战斗伤员在到达手术能力之前就在角色1，但角色2和角色3护理的概念仍然是至关重要的 可存活的伤害。15没有 损伤控制和最终的手术，伤员最初可能存活下来，但随后死于出血或长期创伤 并发症，如感染和 器官衰竭例如，一个肝脏出血的伤员可能会接受 适当的初始治疗，以延长生命，直到达到一个有能力的设施 但是，这种损伤只能由a 外科医生打开腹部和 手动控制正在进行的 流血由于这种情况，生存将会不及时地受到损害 外科手术然而，在潜在的同伴应急战场上，角色2设施和高级外科团队将面临挑战。 ***初始救生手术护理的风险和潜在的减轻措施。*** **•**操作培训/互操作性 再次强调组织、训练和装备小型外科团队，使其能够作为外科团队和作战元素的最佳表现16 优化外科手术团队 能否在大型创伤中心一起工作 进行特定的培训，以达到所需的临床和操作能力 进行研究和数据 分析以更好地理解需要什么能力以及如何进行 为了在未来的手术中最好地雇用手术团队 提高手术团队在未来用于MPO的手术中获取数据的能力。 **•**保持急救护理的专业知识 增加部署医务人员去工作的机会 在军事医疗设施或军民伙伴关系中 继续利用联合投资 知识、技能和能力 项目管理办公室 作为衡量临床专业特定的医疗准备情况和提供临床部署准备情况评估的手段 研究和开发技术，通过远程技术、远程机器人、增强现实或其他来增强临床护理 新兴的解决方案。 **•**远前部署的风险 考虑使用类似于快速反应部队的外科团队，他们有能力在战场上与作战人员一起移动，以便在决定性的地点进行伤亡护理 完成时考虑，以减少暴露风险 在地缘战略地点建立国际伙伴关系，然后可以作为一个区域加以利用 创伤能力，同时最小化我们的军事足迹17 研究和开发针对远期手术部位的远程手术能力，以限制对外科医生和医疗团队的风险。 **结论：结束** **生存链** **支持杀戮链** JTS已经证明了其有效性 在战场上减少死亡人数 自2005年成立以来，因此 该组织于2016年被编入委员会。虽然JTS在过去20年的战斗中取得了巨大的进展，但下一场冲突可能持续不到2年，但仍有10年 战斗伤亡人数是 过去二十年。JTS必须在其MPO周期中不断发展，以应对这些预期的挑战，最迫切的是伤害点护理、伤员疏散期间的护理以及所讨论的手术护理。 我们必须通过减少作战人员的消耗来保持我们在战场上优化生存的能力 从而产生维持作战力量的作战效果，这是联合创伤系统的任务。. 在军事领导层的支持下，JTS可以继续发展，以支持这一关键角色。MPO的概念是一个近实时的数据收集和分析、新的知识和/或材料解决方案，以及快速集成到战场创伤护理（JTS OODA）的循环，这将使JTS能够 . 在需要时快速适应和反应通过利用MPO的现有过程并提高其环路闭合速度，JTS将提供能够获得和维持医疗的生存链 无论它所面临的挑战如何，在未来战场上的超越. **记下** 1*克里斯蒂安·布罗斯，《杀戮链：在高科技战争的未来保卫美国》* （纽约：阿歇特图书出版社，2020年）。 2同上。 3*联合联合出版物（AJP）4.10(A)，联合联合医疗支持原则(Brus-* sels：北大西洋公约组织，2011年5月30日)，https://shape.nato.int/resources/网站6362/医疗机构-安全/出版物/ajp- 4.10(a).pdf. 4杰弗里·贝利等人，编辑版。，联合的 *创伤系统：发展、概念化* 框架和最优元素（山姆·休斯顿堡，德克萨斯州：美国陆军外科研究所，2012年1月），https://jts.health。管理/资产/文档/出版物/Joint\_Trauma\_System\_final\_clean2。pdf. 5布罗斯，杀戮链。 6同上。 7AJP 4.10(A). 8“战场上的死亡（2001-2011）：对战斗伤亡护理未来的影响”，《创伤与急性护理外科杂志》第73期，第73期。6（2012年12月），S431-S437，https://doi。org/10.1097/TA.0b013e3182755dcc. 9Andrew D. Fisher等人，“低滴度” O组全血复苏：从受伤的角度开始的军事经验，”杂志 *创伤和急性护理手术89例，不适用。*4（2020年10月），834-841，https://doi。org/10.1097/TA.0000000000002863. 10乔纳森·莫里森，约瑟夫·杜博斯和托德·拉斯穆森，《军事应用》 . 2氨甲环酸在创伤紧急复苏中的作用（MAT-TERs）研究，“手术档案147，无（2012年2月），第113-119页，https://jamanetwork.com/journals/jamasur-页/文章摘要/1107351；罗伯茨等人，“碰撞2试验：氨甲环酸对死亡、血管闭塞事件和输血要求影响的随机对照试验和经济评估” 《出血创伤患者》，“临床治理：国际杂志第18期。3日（2013年7月），https://doi.org/10.1108/ cgijcaa.2013.24818.005. 11. “基于证据的时间、分诊和治疗原则：细化对大规模伤亡事件的初始医疗反应”，美国杂志 创伤和急性护理手术93,2S补充1（2022年8月），S160-164，https:// doi。org/10.1097/ta.0000000000003699. 12同上。 13“长期伤亡护理指南”： “联合创伤系统”，JTSHealth.mil，2021年12月21日，https://jts.health.mil/assets/ docs/cpgs/Prolonged\_Casualty\_Care\_Guidelines\_21\_Dec\_2021\_ID91.pdf. 14“非常规战争医学是最终的长期野外护理”，医学杂志（山姆休斯顿堡，德克萨斯州），第2204-05-06（2022年4月-6月），27-31。. 15AJP 4.10(A). 16. Jay BBaker等人，“自闭症复苏- 积极和外科护理，以支持向前 军事行动-联合创伤系统 *立场文件，《军事医学186》，no。* 1-2（2021年1月-2月），12-17日，https:// doi.org/10.1093/milmed/usaa358。 17里昂，《当黄金》 时间已经死了：准备土著人 瑞拉的非常规医疗网络 “冲突”（硕士论文，海军研究生院，2021年12月），https://calhoun.nps。edu/handle/10945/68685.  Surgery and Associate Chair for Operations at USU. Chairman of the School of Medicineat USU.Captain TravisM.Polk,USN,is Director of the DOD Special 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 Battlefield **By Jennifer M.Gurney,Jeremy C.Pamplin,Mason H.Remondelli,Stacy** **Sean P.Conley,Benjamin K.Pótter,Travis M.Polk,Eric A.EIster,and Kýle** **A.Shackelford,Jay N.Remick** **B.Baker,** Colonel Jennifer M.Gurney,USA,is Director ofthe Department of Defense(DOD)Joint Trauma System.Colonel Jeremy C.Pamplin,USA,is Director of the Telemedicine and Advanced Technology ResearchCenter Headquarters.Second LieutenantMason H.Remondelli,USA,is an MD Candidate at the Unifomed Services University(USU).Colonel Stacy A.Shackelford,USAF,is the Trauma Medical Directorat the Defense Health Agency.Colonel Jay B.Baker,USA,is Director of 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 and JPC-6 Combat Casualty Care Research Program.Captain EricA.Elster,USN(Ret.),is Professor and Dean inthe Schoolof Medicine at USU.Colonel Kyle N.Remick,USA(Ret.),is Professor of *n The Kill Chain:Defending* *America in the Future ofHigh-Tech* *Warfare,author Christian Brose* describes a concept in which the speed that a combat force is effective at“closing the kill chain”will deter- mine whether it wins or loses.!Brose proposes a redesign of our military combat infrastructure to“understand, **94 Features/**The "Survival Chain" JFQ 112,1st Quarter 2024 decide, and act” faster than the enemy to employ the required force (for example, lethal versus nonlethal) to achieve *operational overmatch*. Follow- ing his lead, we propose the concept of a “survival chain” as the medical equivalent that could provide combat casualty care support to the “kill chain” to gain and maintain *medical overmatch* on future battlefields . The Department of Defense Joint Trauma System (JTS) was created to pro- vide optimal care to the wounded on a battlefield. The current National Defense Strategy anticipates future threats of large-scale combat operations (LSCO) against peer adversaries that may limit overall 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 Medical Performance 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 knowledge and material solutions to optimize battle- field trauma care. Like the “understand, decide, and act” of the kill chain, JTS MPO will be the survival chain that relies on rapidly closing the JTS MPO cycle via “observe, orient, decide [or understand],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 LSCOs and to provide a focused discussion of potential solutions to gain and maintain medical overmatch in the survival chain on the 21st-century battlefields. **Reframing Current** **Challenges** Casualty care on the battlefield is based on the JTS performance improvement cycle (MPO) overlaid on the North Atlantic Treaty Organization’s Roles of Care guidelines.3 The JTS mission includes overall clinical care optimiza- tion of the battlefield trauma system by providing clinical data collection and analysis, “loop closure” feedback to 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 survival chain 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 our Servicemembers and our nation. Data integration and technology are integral to MPO for our system to observe (col- lect real-time, relevant data), orient (or understand via rapid data analysis), decide (increase speed and accuracy of deci- sions),and act (treat casualties) to meet the expectation of leaders to decrease force attrition from injury and maximize its lethality. As Brose notes, “The prob- lems facing the U.S. military are now taking on a fundamentally different and greater sense of urgency, and it goes be- yond emerging technologies.”5 The 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 system but also to continue to evolve the cur- rent system by enhancing real-time data acquisition forMPO. As Brose describes for increasing lethality, solutions that improve survival and force regeneration may involve novel medical innovations, new mechanisms by which to deliver already 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 Care** Initial casualty care at the classic Role 1 (*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 most preventable deaths (88 percent) occur in the *field*, that is, the time between the 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 in education, training, and research to gain overmatch in LSCOs. ***Main Risks and Potential Mitigating Measures During Point-of-Injury*** ***Casualty 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, walking blood banks, and additional hemorrhage 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 Soldiers assigned to Army Reserve participate in TacticalCasualty Combat Care course atJoint Base McGuire-Dix-Lakehurst, New Jersey,September 10,2023(U.S.Air Force/Matt Porter)  and skills in triage (the sorting of casualties by the severity of injury) involving an intentional transi- tion from optimal care for each individual 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 may involve swift identification of those who are ambulatory or dead first,then stable or unstable, and increasing knowledge of resources readily available to the triage team12 • Develop best practices in the care of the injured in mass casualty incidents 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: Casualty** **Evacuation Care** The next phase of care conventionally involves the movement of casualties from the immediate area of active conflict to one that can render more advanced trauma care and damage control resuscitation. However, during a large-scale force-on-force fight with adversaries that possess comparable long-range fire technology and air- power, challenges might arise that could 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 when available.13 In this phase, medics will be faced with caring for casualties beyond doctrinal 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 skills required by combat medics to perform 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 employ telehealth and decision support in austere environments to augment medical care further forward • Improve clinical data capture through real-time, automated documentation for ongoing care and for MPO. **•** Risk of air maneuver/ground movement • 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 accounts for 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 oversight to 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 casualties across the battlespace. **Challenge 3: Surgical Care** Although 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 Without damage control and definitive surgery, a casualty may initially survive but then die of bleeding or long-term trauma complications, such as infection and organ failure. For example, a casualty with a bleeding liver may receive the appropriate initial treatment to prolong life until reaching a facility capable of surgery, but that injury could only be more definitively controlled by a surgeon opening the abdomen and manually controlling the ongoing bleeding. Due to this situation, survival will be compromised without timely surgical 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 that have access to work together in high-volume trauma centers and conduct specific training to attain the clinical and operational capa- bility required • Conduct research and data analysis to better understand what capability is required and how to 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 work individually and as teams in mili- tary Medical Treatment Facilities or in military-civilian partnerships • Continue to leverage the Joint Knowledge, Skills, and Abilities Program Management Office as 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 other emerging 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 regional trauma capability while minimizing our military footprint17 • Research and develop telesurgery capability forfar-forward surgical locations to limit risk to surgeons and medical teams. **Conclusion: Closing** **the Survival Chain to** **Support the Kill Chain** The JTS has proved its effectiveness at decreasing death on the battlefield since its inception in 2005,and thus the 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 10 times as many combat casualties as the last 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 attrition and 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 to adapt 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 medical overmatch on future battlefields regard- less of the challenges presented. **JFQ** **Notes** 1 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 Joint* *Trauma System: Development, Conceptual* *Framework, 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 Titer Group O Whole Blood Resuscitation: Military Experience from the Point of Injury,” *Journal* *of 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 of* *Trauma 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 Forward Military Operations—Joint Trauma System Position 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 ‘Golden Hour’ Is Dead: Preparing Indigenous Guer- rilla Medical Networks for Unconventional Conflicts” (Master’s thesis, Naval Postgraduate School, December 2021), https://calhoun.nps. edu/handle/10945/68685.
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2024年12月5日 17:04
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