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many PAs who commissioned through the Interservice Physi- codes between 800-959.9, near-drowning/drowning with as-
cian Assistant Program (IPAP) often have prior military and sociated injury (ICD-9 994.1) or inhalational injury (ICD-9
medical experience as enlisted service members, frequently as 987.9), and trauma occurring within 72 hours from presenta-
medics. In the US Army, physicians assigned through MAP to tion to a facility with surgical capabilities.
deploying conventional units are usually hospital or clinic-based
physicians with variability in the type and volume of post- Data Analysis
graduate training. In other services, units may have a GMO. The dataset was screened for all casualty encounters that doc-
These physicians generally have just graduated from medical umented the type of medical provider. These encounters were
school or completed an internship. While the MO may have a categorized as either MO or medic. Encounters without type
greater foundation of knowledge and experience than medics, of medical provider were excluded. If an encounter listed both
they sometimes lack training or real-world experience in per- MO and medic, the encounter was categorized as an MO en-
forming Tactical Combat Casualty Care (TCCC) in the pre- counter. We proceeded under the assumption that the care ren-
hospital environment at or near the POI. Appropriate delivery dered was documented appropriately.
of TCCC is credited with decreasing mortality in the prehos-
pital combat setting. Thus, this study evaluated prehospital Analyses were performed using Microsoft Excel (Microsoft;
4,5
battlefield trauma care provided by MOs and compared this www.microsoft.com) and JMP Statistical Discovery from Sta-
care to that provided by medics. We analyzed interventions and tistical Analysis System (SAS; www.jmp.com). Continuous
outcomes to include survival to discharge based on the type of variables were reported using means and standard deviations,
medical personnel involved in the chain of care. ordinal variables through medians and interquartile ranges
(IQRs), and nominal variables through numbers and percent-
ages. Descriptive and inferential statistics were used, with sig-
Methods
nificance for inferential tests set at P < .05.
Data Acquisition
Protocol H-19-018 was submitted to the US Army Institute Results
of Surgical Research regulatory office who determined this
study to be exempt from institutional review board oversight. A total of 826 casualty encounters met study inclusion cri-
Data sharing agreement 19-2186 was submitted and executed teria. These encounters were mostly due to battle injuries
with the Defense Health Agency (DHA) prior to submitting a (88.3%, 729/826), occurred primarily in Afghanistan (98.8%,
request for data to the Joint Trauma System (JTS). Deidenti- 816/826), and in the period from June 2003 through May
fied data on all casualties captured by the Prehospital Trauma 2019. There were 418 encounters categorized as MO (57 with
Registry (PHTR) from June 2003 to May 2019 were obtained MO, 361 with MO and medic), and 408 encounters catego-
from the JTS, along with outcomes data for PHTR casual- rized as medic. Casualties cared for by an MO tended to be
ties linkable to the Department of Defense Trauma Registry members of the host-nation military (66.3%, 277/418), while
(DoDTR). Due to new DHA requirements regarding deiden- the majority of those treated by medics were members of the US
tified data, only an age range, and not a specific age, were military (68.1%, 278/408). Within the MO category, 13.6%
provided for each casualty. of the total number of patients were SOF affiliated ( Table 1).
Casualties within the MO group more often sustained injuries
Prehospital Trauma Registry (PHTR) from a firearm (45.2%, 189/418), whereas most patients cared
The JTS PHTR is a data collection and analytic tool designed for by a medic had an explosive mechanism of injury (MOI)
to provide near real-time feedback to commanders. As previ- (52.4%, 214/408). The composite median and IQR injury se-
ously described, the primary purpose of this tool is to improve verity score (ISS) was higher in the medic cohort (9, 3.5–17)
casualty visibility, augment command decision-making pro- than for the MO cohort (5, 2–9.5) (P = .006). Also, higher
cesses, and direct procurement of medical resources. Addition- rates of extremity injuries occurred among those in the medic
6
ally, this tool seeks to reduce morbidity and mortality through group (28.8% vs. 13.7%; P = .009). Of the 36.1% (298/826)
performance improvement in the areas of primary prevention of PHTR encounters linked to the DoDTR for outcomes,
(tactics, techniques, and procedures), secondary prevention there was no statistically significant difference in survival to
(personal protective equipment), and tertiary prevention (casu- discharge between the MO and medic groups (98.6% [72/73]
alty response system and TCCC). The US Central Command vs. 95.6% [215/225]; P = .226) (Table 2).
7
JTS Prehospital Directorate collected TCCC cards and TCCC
after-action reports (AARs) and transferred information from With respect to life-saving interventions (LSIs), most propor-
these documentation tools into the PHTR. The origin of the tional differences favored casualties in the MO group: pelvic
PHTR has been previously described in the literature. 8,9 binder placement (2.6% vs. 0.4%; P = .021), endotracheal in-
tubation (ETI) (11.7% vs. 0.4%; P < .001), tube thoracostomy
Department of Defense Trauma Registry (DoDTR) (6.4% vs. 1.2%; P < .001), intraosseous access (10.2% vs.
The DoDTR, formerly known as the Joint Theater Trauma 5.8%; P = .020), and hypothermia kits (41.3% vs. 14.7%;
Registry, is the DoD’s data repository for trauma-related in- P < .001) (Table 3). For hemorrhage control, there were no dif-
juries. 10–16 The DoDTR includes documentation regarding ferences between MOs and medics with respect to providing
demographics, injury-producing incidents, diagnoses, treat- a hemostatic agent, limb tourniquet, or junctional tourniquet.
ments, and outcomes following injuries. The registry includes However, medics did apply more pressure dressings (38.2%
data on US and non-US military casualties, as well as US and vs. 28.2%; P = .002). Medics administered blood products
non-US civilian casualties and their treatment from the POI to more often than MOs (2.7% vs. 0.7%; P = .031), while dif-
final disposition. The DoDTR is primarily comprised of pa- ferences in all other medications favored those treated by an
tients admitted to a hospital with an injury diagnosis using the MO ( Table 4). Every vital sign demonstrated a higher rate of
International Classification of Diseases, 9th Edition (ICD-9) documentation among MOs than medics (Table 5).

54 | JSOM Volume 20, Edition 4 / Winter 2020