Page 55 - JSOM Winter 2025

“Ruck-Truck-House-Plane” Plan Application for the Management of
Combat-Related Wound Infections and Prevention of Multidrug-Resistant
Organism Spread in Prolonged Field Care Scenarios

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Pierre Pasquier, MD *; Philippe Laitselart, MD, MSc ; Mathieu David, MD ;
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Griet Vermeulen, MD ; Tristan Alie, MD, MSc ; Florent Josse, MD ; Sean Keenan, MD 7
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ABSTRACT
Wound infections represent an increasing risk in combat have proposed a system of mission or evacuation stages to
trauma, especially in prolonged casualty care conditions char- simplify and standardize the language, using the Ruck-Truck-
acterized by evacuation delays and resource scarcity. This risk House-Plane framework, rather than echelons of patient care.
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is compounded by multidrug-resistant organisms, which are This article describes a Ruck-Truck-House-Plane approach
difficult to detect and treat in austere settings. This article designed to improve combat-related, wound-infection preven-
introduces a “Ruck-Truck-House-Plane” model for infection tion and control spread of multidrug-resistant organisms.
control and wound management in prolonged casualty care
(Role 1) and prolonged care (beyond Role 1) environments. Ruck-Truck-House-Plane
This original approach includes practical procedures and de-
cision-making from point of injury to tertiary care transfer. Mohr et al. explained a Ruck-Truck-House-Plane conceptual
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It emphasizes early decontamination, phased surgical care, re- framework as follows:
mote microbial diagnostics, and antimicrobial stewardship to
reduce morbidity and mortality in modern warfare. • Ruck: the gear carried to the furthest point on a mission,
generally carried by medical personnel dismounted.
Keywords: combat-related wound infection; prolonged casualty • Truck: whatever additional equipment will be carried in
care; prolonged care; military trauma; multidrug-resistant mission-specific transportation, whether that be a truck,
organisms boat, all-terrain vehicle, kayak, light over-snow vehicle, etc.
• House: gear available to the medic, but which can only be
feasibly maintained at a team house, firebase, or other mis-
sion support site. It represents the highest level of care the
Introduction
operational element has that is organic to it.
Combat-related wound infections are a major concern in • Plane: planning stage included to allow the medical pro-
combat trauma care, particularly in prolonged casualty care viders to consider how they will move patients on aircraft,
environments, where long delays before evacuation, limited whether medical evacuation (MEDEVAC) aircraft (those
access to surgical support, and environmental contamination designated and equipped to move casualties as a primary
all contribute to high infection rates. These challenges are mission) or casualty evacuation (CASEVAC) (preplanned
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exacerbated by the resurgence of large scale-combat opera- nonmedical mission support aircraft, opportunity or “slick”)
tions (LSCOs), as illustrated by the war in Ukraine, in which aircraft.”
the development of Anti-Access/Area Denial threats increases
the time from injury to definitive care. Also, these delays are Inherent to this framework of operational phases or settings,
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associated with higher risk of infection and the emergence of is the understanding that, in many cases, the care team may
multidrug-resistant organisms (MDROs). To overcome the have limited resources available and are responsible for the ca-
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challenges in prolonged casualty care and prolonged care en- sualty’s treatment over time and movement through these en-
vironments, including delayed evacuation, some researchers vironments. Ongoing care may need to be provided by a small
*Correspondence to pierre.pasquier@intradef.gouv.fr
1 Prof. Pierre Pasquier is affiliated with the French Military Medical Academy (Écoles militaires de Santé, Lyon, France; École du Val-de-Grâce,
Paris, France) French Special Operations Forces Medical Command, Villacoublay, France. Prof. Pierre Pasquier and Dr Philippe Laitselart are
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affiliated with the Department of Anesthesiology and Intensive Care, Percy Military Teaching Hospital, Clamart, France. Dr. Mathieu David
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is affiliated with the Allied Special Operations Forces Command, Mons, Belgium. Dr Griet Vermeulen is affiliated with Belgian Defence, BEL
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SOST, Brussels, Belgium. Dr. Tristan Alie is affiliated with Hôpital Montfort, Department of Anesthesiology and Pain Medicine, University of
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Ottawa, Ottawa, ON, Canada, and 1 Canadian Field Hospital, Canadian Forces Base – Petawawa, ON, Canada. Dr. Florent Josse is affiliated
with the Department of Anesthesiology, Intensive Care, Emergency Medicine and Pain Medicine, and the German Special Operations Surgical
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Team, Military Hospital Ulm, Ulm, Germany. Dr. Sean Keenan is affiliated with the Department of Military and Emergency Medicine, Uniformed
Services University, Bethesda, MD, the University of Colorado Anschutz Medical Campus School of Medicine, Aurora, CO, and the Joint Trauma
System, Defense Health Agency, San Antonio, TX.
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