Page 63 - JSOM Winter 2019

explosive injury and 22% from gunshot wounds. In this way, on hemorrhage control. In the near term, the medical specialty
the ANASOC data are more similar to data published by Kat- contractor, a former 18D Special Forces medic sergeant, has
zenell et al. on Israel Defense Forces, which demonstrated already implemented daily tourniquet drills as a part of the
2
63% of fatalities from gunshot wounds. The prehospital death Commando Medic Course instruction. These efforts will help
rate found in the ANASOC data is considerably higher than create an immediate emphasis on bleeding control among the
the 87% rate reported by Eastridge et al. for US fatalities, sug- Afghan course instructors.
gesting opportunity for improvement in either medical evacu-
ation or medical training in addressing potentially survivable Conclusion
death. However, improvements in Afghan medical evacuation
are constrained by logistical and geographical obstacles, se- The analyzed data have significant limitations in quality and
verely handicapping Afghanistan’s nascent trauma system. scope, but they provided the fundamental background that
There then becomes little opportunity to save these soldiers confirmed what many CJSOTF-A personnel suspected: in the
without far-forward surgical support or increasing medical case of ANASOC soldiers, hemorrhage control is the most im-
competency across ANASOC. portant intervention for preventing combat death. Possessing
the analyzed data allowed people with different agendas to
To optimize the ANASOC medical curriculum, the most im- come together and agree on the necessary changes within the
portant question then becomes what medical tasks can we em- School of Excellence curriculum. This process emphasizes the
phasize at the School of Excellence to address the prevalence of proper application and fundamental value of evidence-based
fatal gunshot wounds? It is difficult to match gunshot wounds medicine within Special Operations Forces. Although the US
to an exact physiologic cause of death and an appropriate med- and NATO system provides an acceptable starting point for
ical intervention, but some research suggests that a large pro- medical instruction under the umbrella of foreign internal de-
portion are due to hemorrhagic shock that could be prevented fense, the ultimate goal should be a program tailored to re-
by bleeding control. One study from Nigeria assessing fatalities gional and geographic intricacies.
from penetrating weapons determined that hemorrhagic shock
was the cause of death in 90% of the 254 cases. This conclu- This brief data analysis was possible because of the work of
3
sion corresponds to other combat research suggesting hemor- earlier soldiers who spent years building a casualty-reporting
rhage as the leading cause of potentially survivable death. If mechanism. In discussions with the Combined Security Tran-
1
the ANASOC patient cohort mirrors these studies, a majority sition Command-Afghanistan Preventive Medicine Advisor,
of deaths are a result of inadequate bleeding control. similar reporting mechanisms are now being institutionalized
across Afghan security forces, but ANASOC is currently a
Tactical Combat Casualty Care (TCCC) fundamentals focus- leader on casualty reporting. Not only does this serve as a tes-
ing on bleeding control are key components of the ANASOC tament to Special Operations medical personnel who worked
Commando Qualification Course, but the data suggest that tirelessly to build the right kind of system, but it also demon-
there is sufficient combat mortality to warrant increased fo- strates the value of establishing reporting as an early line of
cus on these basic skills. Additional training on tourniquet ap- effort within a nascent military medical system. Ultimately, the
plication in the qualification course would be ideal; however, goal for casualty reporting in any combat environment should
the high operational demand for commandos in Afghanistan be a system similar to the US Department of Defense Trauma
limits the amount of training time available for the average Registry, which provides a powerful database to drive positive
soldier. Alternatively, the School of Excellence could affect change in combat medicine.
change in the medical curriculum through adjustments in the
advanced Commando Medic Course. A robust emphasis on Author Contributions
hemorrhage control complemented by an effort to mentor JF conceived the study concept, JF and MH devised the study
medics to become instructors of tourniquet use within their design, JF collected and analyzed the data, and JF and MH
units could have reverberating effects on decreasing ANASOC wrote and approved the final manuscript.
combat deaths.
Disclosures
The authors, ANASOC Medical Section advisors, and School There was no funding. The authors have indicated they have
of Excellence instructors collaborated to change the curricu- no financial relationships relevant to this article to disclose.
lum through a medical education working group. After dis-
cussing the data, the working group agreed on the need for an Disclaimer
increased emphasis on bleeding control. The CJSOTF-A Sur- The views presented in this article are those of the authors
geon identified sections of instruction within the medic course and do not necessarily represent the views of Department of
to condense. By deemphasizing medical instruction that was Defense or its components.
not beneficial to addressing combat deaths, the CJSOTF-A
Surgeon created an available week within the schedule to References
dedicate towards TCCC hemorrhage control material. These 1. Eastridge B, et al. Death on the battlefield: implications for the fu-
planned adjustments will not remove any previously approved ture of combat casualty care. J Trauma Acute Care Surg. 2012;73:
topics but will better allocate classroom time based on the S431–S437.
casualty data. The recommended changes are proceeding for- 2. Katzenell U, Ash N, Tapia AL, et al. Analysis of the causes of
death of casualties in field military setting. Mil Med. 2012;177(9):
ward in the formal approval process which requires concur- 1065–1068.
rence from the School of Excellence Education Director before 3. Seleye-Fubara D, Etebu EN. Pathology of cause of death from pen-
submission to the Armed Forces Academy of Medical Sciences. etrating weapons in the Niger Delta region of Nigeria: an autopsy
This formal approval process, which will span months, will study of 254 cases. Niger Postgrad Med J. 2010;19(2):107–110.
create permanent changes that ensure the longevity of focus

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