Page 145 - Journal of Special Operations Medicine - Winter 2015

Strategies to Enhance Survival in Active Shooter
and Intentional Mass Casualty Events

The Hartford Consensus

A Major Step Forward in Translating
Battlefield Trauma Care Advances to the Civilian Sector

Frank K. Butler, MD

TC (P) Bob Mabry, a former Special Forces 18D have seen lifesaving advances in battlefield trauma care
Lmedic, now an emergency medicine physician; a past pioneered by the Joint Trauma System (JTS) and the
president of the Special Operations Medical Associa- Committee on Tactical Combat Casualty Care (TCCC)
tion; and a well-recognized thought leader in caring for dramatically increase survival in US military casualties
our nation’s wounded, often poses this question: “Who and those of our coalition partner-nations. This is espe-
owns battlefield trauma care?” His point is that divided cially true when all members of combat units—not just
responsibilities and distributed authorities in the mili- medics—are trained in TCCC. 4,7–9
tary structure complicate the implementation of new
battlefield trauma care training and equipment. That Advances in military trauma care have historically ben-
factor, combined with the complexities of delivering and efitted the civilian sector as well. LTC (P) Mabry’s ques-
documenting care during an ongoing combat engage- tion, however, can equally well be posed for the civilian
ment, the aversion of many organizations to making sector: “Who owns prehospital trauma care on the
errors of commission (in contrast to making errors of streets of America?” There are many thousands of au-
omission), and the lack of high-quality evidence in pre- tonomous law enforcement, fire, and emergency medi-
hospital trauma care, makes it difficult to effect innova- cal services (EMS) organizations throughout the United
tions in this area. Despite these challenges, a sharp States that establish standards for prehospital trauma
1–3
focus on this aspect of combat casualty care is mandated care in their systems. So organizational complexities—
by the fact that approximately 90% of those who die of and the other limiting factors noted previously (with the
wounds sustained on the battlefield do so before ever exception of the combat setting)—also serve to slow ad-
reaching definitive medical care. vances in prehospital trauma care in the civilian setting.
4
Certainly advances in expediting the transport of casual- As a result, 10 years after the TCCC-recommended use
ties from the point of injury to definitive care—primar- of tourniquets and hemostatic dressings became wide-
ily through helicopter evacuation—have dramatically spread in the military, Haider et al. reported that these
10
improved casualty survival. The lifesaving effect of a two proven lifesaving interventions on the battlefields of
Secretary of Defense–mandated 60-minute maximum Iraq and Afghanistan had gained very limited acceptance
evacuation time in Afghanistan was recently documented in civilian trauma centers. In contrast, other advances in
by Kotwal et al. 5 trauma care, such as the damage control resuscitation
strategy now incorporated into the JTS Clinical Practice
With respect to the actual care provided by combat Guidelines, have been widely adopted in civilian trauma
medics on the battlefield, however, Maughon noted in centers. One additional factor contributing to delays in
his 1970 report that little had changed in the past 100 translating prehospital trauma care advances between
years. Similarly, little had changed in the interval be- the military and civilian sectors at present has been the
6
tween the time that his report was published and the imposition of restrictive policies on military physicians
start of the US participation in the conflict in Afghani- and combat casualty care researchers attending medical
stan in 2001–31 years later. The war years, however, and scientific conferences. 11

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