The symbiosis of combat casualty care and civilian trauma care: 1914-2007.

During the past century, wartime surgical experience and military medical research, principally that conducted in the U.S. Army Medical Corps and the U.S. Navy Bureau of Medicine during both war and peace, have combined to improve combat casualty care. Many of those advances have had direct application to civilian trauma care. Conversely, advances in technology and patient care in the civilian surgical community, often based on the results of clinical and/or laboratory research, have been readily adopted by the military to improve the care of casualties. The symbiosis between combat casualty care and civilian trauma care has accelerated surgical progress not only in the care of injured patients but other patients as well. The velocity of that progress over the past century has been increased by the ever greater availability of specialty-trained board-certified surgeons whose experience enabled them to overcome military medical dogma and even ignore directives and Circular Letters, mandating specific care for limb and abdominal injuries, issued by the Surgeon General of the U.S. Army in 1943. Improvements resulting from planned research, which was conducted in the theater of operations for the first time during World War I, were largely initiated and directed by volunteer or drafted surgeons and other physicians with strong academic background and extensive research experience. Traffic in the other direction has brought the benefits of surgical techniques and skills gained in wartime surgery to the victims of urban violence and provided experience-based support for the development of trauma systems and centers. There are four areas in which remarkable progress in the past 93 years has improved the outcomes of patients injured in each successive conflict from WWI to the current conflicts in Afghanistan (OEF) and Iraq (OIF). Those areas include wound care, control and correction of blood loss, prevention and treatment of organ failure, and organization and delivery of surgical care. In addition to research activities initiated by individual investigators during each conflict in the 20 century, designated units conducted research in the theater of operations (Table 1). In World War I, General J.M.T. Finney, the Chief Surgical Consultant for the AEF and longtime associate of William Stewart Halsted, established a central laboratory and organized an Experimental Surgery Department within that laboratory under the direction of Major Walter B. Cannon of homeostasis fame. The tradition of in-theater integrated clinical/laboratory research was continued in World War II when Colonel Edward B. Churchill, Surgical Consultant of the North African-Mediterranean Theater of Operations and later the Chief of Surgery at the Massachusetts General Hospital, organized the Board for the Study of the Severely Wounded, in the Korean conflict by the Army Medical Service Graduate School Surgical Research Team organized by Colonel William S. Stone, and in the Vietnam conflict by the Trauma Study Section of the U.S. Army Medical Research Team in Vietnam, a unit of the Walter Reed Army Institute of Research. There have been no designated research units in the theater of operations during any of the conflicts since Vietnam. A tentative step to correct that deficiency and the associated loss of research opportunities has been recently made with the assignment of research personnel from the Institute of Surgical Research to medical treatment facilities within Iraq. Additionally, since 1947 integrated clinical/laboratory research has been continuously conducted at the U.S. Army Institute of Surgical Research, the results of which have revolutionized burn care with unprecedented reduction in mortality and improvement in the outcomes of burned soldiers. Those advances have been transferred to civilian trauma care in the form of current methods of wound care, physiologically-based fluid resuscitation regimens, organspecific surgical critical care, and the development of regional hierarchical systems of care delivered in trauma and burn centers.