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Previously published data on CWMP across all types of mil- using pain assessments. As for the wound prophylaxis, we did
itary units largely comprises survey studies. 26,27 Saur et al. not have wound infection rates and are unable to compare
reported 96% of 26 Role 1’s in Afghanistan surveyed from outcomes related to the antimicrobial. Last, as a retrospective
December 2013 to January 2014 did not supply their service analysis we were unable to control for potential unmeasured
members with CWMP. Kotwal et al. revealed that CWMP confounders and biases. In addition, the trauma registry data
27
31
distribution was limited to Special Operations Forces and is subject to human errors in data entry, retrieval, and—perhaps
conventional Marine units after interviewing all echelons of most importantly—failure of inclusion. Previous studies have
intratheater medical units in November 2012. Neither study demonstrated that US military prehospital documentation rates
26
provided an explanation for the limited supply of CWMP. It are poor, which limits data quality in the registry. 32,33
is unclear why conventional military forces did not routinely
issue CWMP; however, previous reports cite inadequate pre- Conclusion
deployment TCCC training and theater logistical supply issues
as impediments to TCCC adherence. 4,19,26,27 Subjects receiving the CWMP were less severely injured com-
pared to those who did not receive this intervention. The
Two studies limited to these same special operations unit re- CWMP had very infrequent use among those casualties with
ported CWMP utilization for wound prophylaxis. These re- injury patterns meeting indications specified in the TCCC
5,6
ports found 19%–21% of its subjects received the antibiotic guidelines for use of this intervention.
from the CWMP in the prehospital setting. We found only <1%
of our subjects received CWMP agents, with 6 of 84 subjects Acknowledgments
included by way of moxifloxacin documentation only. Our We would like to thank the Joint Trauma System Data Analy-
significantly lower rate of CWMP utilization may be partially sis Branch for their efforts with data acquisition.
explained by the aforementioned differences in its distribution
to special operations and conventional military forces. 26,27 The Conflicts
previously cited studies used a smaller population from the 75th We have no conflicts to report.
Ranger Regiment, which has had uniquely high TCCC adher-
ence compared to the rest of the US Army. Our dataset was Funding
5
much larger, included causalities from conventional US military We received no funding for this study.
forces, and included service members from all branches of the
US military. Taken together, these data suggest that the supply Disclaimer
limitations of CWMP during the study period likely explain in Opinions or assertions contained herein are the private views
large part our findings of infrequent use of this intervention. of the authors and are not to be construed as official or as
reflecting the views of the Department of the Air Force, the
While it will be important to address this supply issue mov- Department of the Army, Department of the Navy, or the De-
ing forward, combatant commands should consider prefer- partment of Defense.
entially issuing CWMP to prehospital healthcare providers
(e.g., medics) as opposed to every individual service member. Ethics
There are several reasons for this recommendation. First, our The USAISR regulatory office reviewed protocol H-16-005
data suggest that use of CWMP by nonmedical personnel may and determined it was exempt from IRB oversight. We ob-
be minimal. Second, pharmaceutical expiration, degradation tained only deidentified data.
in field conditions, and limited availability due to logistical
constraints may complicate mass distribution and mainte- Author Contributions
nance. 4,6,19,26–28 Focusing on adequate supply and training for SGS is the principal investigator and was involves in all aspect
healthcare personnel will be likely to maximize their use, so of this study and accepts overall responsibility. JFN, YMA,
helping to prevent making perfect the enemy of the good. Last, and JKM performed data interpretation, manuscript develop-
there is a significant cost associated with universal issue of ment, and manuscript revisions. MDA performed protocol de-
these packs. CWMP currently cost $11.45 each, and over 2 velopment, data interpretation, manuscript development, and
million US military Servicemembers deployed to Iraq and Af- manuscript revisions.
ghanistan by 2010. 29,30 Issuing every deploying service member
a CWMP during this time period would therefore potentially References
have cost tens of millions of dollars. 1. Belmont PJ, et al. Combat wounds in Iraq and Afghanistan from
2005 to 2009. J Trauma Acute Care Surg. 2012;73(1):3–12.
This study has several important limitations. First, our data are 2. Holbrook TL, et al. Morphine use after combat injury in Iraq and
limited to combat casualties admitted to military treatment fa- post-traumatic stress disorder. N Engl J Med. 2010;362(2):110–117.
cilities with surgical capabilities; therefore, patients discharged 3. Gerhardt RT, et al. The effect of systemic antibiotic prophylaxis
from or retained by Role 1 or traditional Role 2 treatment fa- and wound irrigation on penetrating combat wounds in a return-
to-duty population. Prehosp Emerg Care. 2009;13(4):500–504.
cilities were not available for our analysis. Hence, our results 4. Butler FK, et al. A triple-option analgesia plan for Tactical Combat
are subject to selection bias. Second, the available data did not Casualty Care: TCCC guidelines change 13-04. J Spec Oper Med.
permit us to evaluate who administered the CWMP. Conse- 2014;14(1):13–25.
quently, we were unable to report the number of self, buddy, or 5. Kotwal RS, et al. Eliminating preventable death on the battlefield.
medical provider administrations among special operations and Arch Surg. 2011;146(12):1350–1358.
conventional military personnel. Third, pain scores before and 6. Murray CK, et al. Efficacy of point-of-injury combat antimicrobi-
als. J Trauma. 2011;71(2 Suppl 2):S307–S313.
after analgesic administration were not available for our anal- 7. Schauer SG, et al. Multicenter, prospective study of prehospital
ysis. Therefore, we were not able to assess appropriate admin- administration of analgesia in the U.S. Combat theater of Afghan-
istration of CWMP analgesic agents and any perceived benefit istan. Prehosp Emerg Care. 2017;21(6):744–749.

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