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and other criteria to diagnose ARDS. Both efforts demonstrate analysis, and process improvement. SOF medical personnel will
the challenges of poor combat causality documentation and need to continue to adapt and evolve practices to be ready to
the inability to extract data from silo entities of patient care. treat ARDS and other critical care–type medical problems as
We attempted to expand upon this research question. The lim- treatment time domains will likely increase.
itations of our study once again highlight the paramount im-
portance of better clinical documentation for combat casualty Conclusion
tracking and quality improvement purposes.
Higher mortality in trauma ARDS patients was associated
Interestingly, for comparison purposes, Schmitt et al. did a with high ISS, explosive MOI, spine injury, low initial GCS
similar retrospective study of French war casualties who had score, high mean base deficit, high INR, high Paco , low pH,
2
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developed ARDS. This study consisted of 57 ARDS patients low temperature, complications in the first 24 hours, and low
of 141 total patients who had been evacuated out of a war platelet count. Our study demonstrated a need for better and
zone. They found a 30-day mortality of 14%. Interestingly, more comprehensive battlefield data capture and collection.
this study was able to compare the ARDS patients with other And current events show that the golden hour will likely evap-
evacuation patients who did not develop ARDS. They were orate in future conflicts due to A2/AD. As we do more PCC–,
able to further classify the ARDS patients by severity and management of critical care pathologies like ARDS will be-
determine number of patients who received protective ven- come increasingly prevalent and likely become a fundamen-
tilation, paralysis, prone position, and inhaled nitric oxide. tal component of evolving combat casualty care. Critical care
20
Interestingly, there was no analysis between ARDS survivors treatment will continue to be an increasing core part of the
versus nonsurvivors. SOF medical personnel toolkit and skillset on the changing
modern battlefield.
Without surprise, our findings of increased overall mortality
with complications in the first 24 hours, increased ISS, high Author Contributions
INR, low pH, high Paco , low temperature, and high mean JN, MM, PM, JG, KH, VS, and LJ contributed to the inter-
2
base deficit reflect the high severity of traumatic injury in the pretation of data. JN, JA, and VS did data acquisition and
nonsurvivors. Simply put, military ARDS patients who died data analysis. ST and VS helped design this study. All au-
were sicker. It is hard to know whether the trauma itself or thors reviewed and contributed to writing and revision of the
the ARDS had a greater impact on mortality. However, these manuscript
findings seem to parallel the findings of civilian trauma ARDS
population. What is also potentially concerning is that these Disclaimer
casualties were from the Global War on Terrorism (GWOT) in The views expressed herein are those of the authors and do not
which the US military had unthreatened air superiority and the reflect the official policy or position of the US Air Force, the
potential to practice the golden hour with medical evacuation US Army Medical Department, the US Army Office of the Sur-
platforms and far-forward placement of DCR/DCS teams. geon General, the Department of the Army, the Department of
Defense, or the US Government.
Current events foreshadow that future conflicts will likely be
large-scale combat operations (LSCO) or multidomain oper- Disclosure
ations (MDO). These could be against peer/near-peer com- The authors have no conflict of interest to declare.
petitors or pacing threats who will likely practice antiaccess
and area denial (A2/AD) operations. Both MDO and A2/AD Presentation
operations likely mean orders of magnitude greater battlefield Portions of this work were presented at the Society of Ameri-
casualties and combat casualty care occurring over longer time can Gastrointestinal and Endoscopic Surgeons (SAGES) 2019
domains than what was previously practiced during GWOT. It Annual Meeting Surgical Symposium on 3 April 2019 in Hous-
is these broad time domains in which medical critical care is- ton, TX and at the American College of Surgeons Committee
sues such as ARDS manifest because of insidious volume over- on Trauma as the Air Force Regional Trauma Paper Competi-
load, resuscitation, and prolonged multiorgan dysfunction, tion Winner in October 2019.
sepsis, and shock.
Funding
In fact, even during GWOT, the principles and techniques of None.
PCC emerged as the golden hour could evaporate in remote
and resource-limited prehospital settings. This sort of role is References
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where SOF medics thrive and could help bridge the gap. Even 1. Morris MJ. Acute respiratory distress syndrome in combat casual-
during GWOT, in a review of 54 PCC–cases, the median pre- ties: military medicine and advances in mechanical ventilation. Mil
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hospital time was about 120 hours. Future MDO will likely Med. 2006;171(11):1039–1044.
have even longer casualty prehospital times and times to trans- 2. Ashbaugh DG, Bigelow DB, Petty TL, Levine BE. Acute respiratory
distress in adults. Lancet. 1967;2(7511):319–323.
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23
that, SOF personnel are working to improve PCC– processes. distress syndrome. J Clin Invest. 2012;122(8):2731–2740.
And SOF medics are changing training to meet these chang- 4. Calfee CS, Eisner MD, Ware LB, et al. Trauma-associated lung in-
ing expectations/requirements and do more critical care and jury differs clinically and biologically from acute lung injury due to
critical transport over longer periods of time on the changing other clinical disorders. Crit Care Med. 2007;35(10):2243–2250.
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6. Bein T, Zonies D, Philipp A, et al. Transportable extracorporeal
Our study shows that future LSCO and MDO will require lung support for rescue of severe respiratory failure in combat ca-
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