Page 75 - Journal of Special Operations Medicine - Winter 2016

Pretrauma Interventions in Force Health Protection

Introducing the “Left of Bang” Paradigm

Neil M. Eisenstein, BMBCh, MA (Oxon); David N. Naumann, MA, MB BChir;
Douglas M. Bowley, MBBS; Mark J. Midwinter, MD

Introduction
The delivery of timely and effective emergency trauma avenues for LOB-IT to promote further discussion
care for battlefield casualties is paramount in the busi- among the military medical community.
ness of saving lives during armed conflict. The tradi-
tional paradigm for medical care of the war wounded Historical Context
has been a sequence of events on a linear timeline from
first responder care at point of injury, moving toward Preventive practices in nontrauma medical fields have
evacuation, onward to medical care, and eventual treat- been used in the deployment of military forces. Force
ment and rehabilitation in the patient’s home nation. health protection is now considered an essential compo-
With few deviations, this schedule has been in practice nent of battlefield medicine. Field Marshal Rommel’s
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since Napoleonic times. This conventional timescale campaign in North Africa during the Second World War
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can be visualized on an axis moving from left to right, was severely hampered by widespread disease among
often starting from the injury—the “bang.” The military his troops and generals, including his own staff. Indeed,
metaphor “left of bang” has been coined to describe the he was evacuated with hepatitis during the campaign.
events preceding this point. but has not previously Meanwhile, General Slim, the Allied Commander at
2,3
been applied to the medical setting. the time, was facing an enormous malaria problem that
required prophylactic treatment to maintain a fighting
Historically, the “golden hour” and “platinum 10 min- force. Closer to the present day, those involved in the
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utes” concepts have been applied to postinjury military first Gulf Conflict were given pyridostigmine bromide as
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and civilian trauma care. More recently, this framework a prophylaxis against the effects of nerve agent attack,
has evolved into the Tactical Combat Casualty Care and malaria prophylaxis continues to be paramount
(TCCC) continuum. TCCC is a more nuanced approach for troops deployed to endemic regions (e.g., the recent
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that takes into account additional factors including the deployment to Sierra Leone). More recent advances in
level of hostile threat and evacuation timelines. The ap- ballistic protection (individual and collective), as well
plication of this model of trauma care in recent conflicts as vehicle design, have been instrumental in improving
has led to such a progressive improvement of care for survival of trauma casualties.
the combat casualty as to be unrecognizable from previ-
ous times. 6 It is in the context of medical force protection that we
can now start to explore the LOB paradigm: can some
In our search for further improvement in trauma out- interventions mitigate the effects of injury and prevent
comes, we ask the following question: is it now time to death from trauma before it happens?
explore the concept of trauma care “left of the bang”?
Such a movement of attention to a point before battle- Exploring the Paradigm
field injury would be in keeping with other fields of pre- To explore which innovations and technologies might
ventive medicine. be used, it is worthwhile discussing what makes an ideal
intervention in this context. First, interventions need to
For this perspective article, left of bang innovations in cause no harm, a lesson learned from the controversial
trauma (LOB-IT) are defined as any medical, pharma- legacy of Gulf war prophylaxis. 9,10 They must also pro-
cologic, or surgical intervention that is delivered before vide clinical benefit to the potential casualty if they are
trauma and may act to reduce morbidity and mortal- injured, without hindering the postinjury resuscitation.
ity after injury. This review aims to explore potential A favorable cost-benefit analysis may also be relevant

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