Battlefield trauma care then and now: a decade of Tactical Combat Casualty Care.

M1 reported in 1970 that 193 of a cohort of 2,600 casualties that were killed in action in Vietnam died of isolated extremity hemorrhage. The percentage of fatalities that resulted from exsanguination from extremity wounds was 7.9%; this was the leading cause of preventable death among US military casualties in the Vietnam War. Maughon commented at the time that little progress had been made in battlefield trauma care in the last 100 years. A sobering postscript to Maughon’s observations in 1970 is found in the preventable death analyses done by Holcomb et al. and Kelly et al. in the current conflicts. Holcomb et al. found a 15% incidence of potentially preventable fatalities in his article that reviewed all Special Operations deaths in Iraq and Afghanistan from the initiation of hostilities until November 2004. He found that 25% (3 of 12) fatalities with potentially survivable injuries might have been saved by the simple application of a tourniquet. The larger causes of death analysis by Kelly et al. studied 982 fatalities from the first 5 years of the conflicts in Afghanistan and Iraq. He documented that 77 of 232 potentially preventable deaths from the Armed Forces Medical Examiner records resulted from failure to use a tourniquet; exsanguination from isolated extremity wounds thus caused 7.8% of the combat-related deaths reported in the article of Kelly et al.. The failure to make progress in addressing the leading cause of preventable deaths on the battlefield in the 30 years between the Vietnam and Afghanistan wars, despite the ready availability of the requisite technology, dramatically underscores Maughon’s point about the lack of progress in battlefield trauma care. The decade of conflict in Iraq and Afghanistan has, however, seen sweeping changes in the prehospital care of combat casualties. This section reviews the concepts of battlefield trauma care at the start of the war, how changes to this care have been implemented, the current state of battlefield trauma care, and the available metrics of success.