An updated combat application tourniquet from 2016 (Photo by: U.S. Army).
Rule No. 1
These developments and advances in military medicine should not diminish the terrors of being on what Smith calls "the pointy end" of battle.
Suffering a traumatic brain injury or losing a limb are no small matters, no matter how sophisticated the subsequent treatment or prosthetic replacement limb may be. But in many cases, these developments mean not just survivability, but a "return to function," as Cancio put it, or even a "return to ambulation" despite losing one or even both legs. And that return to function could even mean staying on active duty. Gone are the days when losing a leg in battle meant an automatic medical discharge.
"At either end of this long sequence of events and different echelons of care is an individual who is wounded and a combat medic who is taking care of that individual," Cancio said. "That individual at the end of that process is returning to his family and community. So those people are really the most important factors in this whole process – the people, not the technology. And really, none of the technology that we talked about is meaningful or helpful unless we put it in the hands of medics who are properly trained."
Said Smith, "We have pioneered in the military pushing people to the limit of their training. In World War II, we didn't have enough doctors to put on airplanes to evacuate patients, and so we taught nurses to take blood pressures."
Now, he said, there are physician assistants, techs, advance practice nurses, people who do psychosocial work - the works. "You've got all levels of practice from psychiatrists on down to technicians who forward deploy to deal with acute combat reaction in theater. (The USU) even has a campus in San Antonio to get the medics and corpsmen trained up to give them college credit to jump-start their associate degrees, because we see them needing those degrees to move to the limits of practice and certification. So, the military is still in this business of extending the scope of practice of people in order to provide more robust, systematic care, wherever you are."
For example, “the Joint Trauma Registry has been a huge factor in educating people and keeping one group from not knowing what the previous group did – they are now getting better at that. All of this has contributed to improved survivability.” That includes intra-service communications, Smith said. “You’ve got more people at the table, they’re talking more frequently, both in the line and in medicine.”
At that, he paused, remembering a line from a fictional doctor -, the beloved Col. Henry Blake from the first few seasons of the TV show "MASH." Blake was consoling the usually irreverent main character, Army Capt. Benjamin "Hawkeye" Pierce, who was upset after one of his patients died.
Blake stated: "Look, all I know is ... there are certain rules about a war. And rule No. 1 is young men die. And rule No. 2 is ... doctors can't change rule No. 1."
"We can't change rule No. 1," said Smith. "But we can amend it, and we have been amending it, really, for the past 70 years, but phenomenally in the last generation."
Continuing this summer
(July): Advances in prosthetic limbs and quality of life after traumatic injury. (August): How 3-D printing is re-writing what's possible in post-traumatic care.