Page 79 - JSOM Fall 2024

that autogenous grafts were more commonly used than syn- importance of timing and the Golden Hour in arterial repair
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thetic alternatives in the definitive repair of vascular trauma. remains a relevant concept in modern combat operations.
Despite its diminished popularity compared with autogenous As the U.S. military shifts its focus from the GWOT to the
grafts, synthetic grafts can provide an important limb salvage realities of LSCOs, the military healthcare system must pro-
strategy, especially when available soft tissue and autogenous actively address the challenges of this dynamic environment.
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conduits are reduced by multiple injuries. With the many The expectation of the Golden Hour, with short evacuation
advancements made in synthetic graft composition since the times, consistent air superiority, and the ability to transport to
1950s, the decision between synthetic and autogenous grafts hardstand, level II/III military treatment facilities is unrealistic
is becoming increasingly dependent on surgeon preference, for the military’s future challenges. Innovative, inter-service
based on the localization of injury and patient condition. 8,9 medical solutions are required to position U.S. Forces to face
large-scale conflict.
Dr. Hughes described how arterial homografts did not remain
viable beyond providing a “collagenous framework,” while Preparations for LSCOs are evident in the Navy’s latest class
“the autogenous vein graft maintains a degree of cellular vi- of expeditionary medical ships, including the recently chris-
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ability.” His statements were supported by the significant tened USNS Cody (EPF-14) and the newly authorized USNS
incidence of amputation associated with homologous artery Bethesda (EMS-1). These new ships may enhance the integra-
grafts—a 33.3% reported amputation rate out of 48 patients tion of afloat medical capabilities with land-based forward
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treated with these grafts. The ready availability of homografts units, including field hospitals and SOF teams, as part of Joint
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was likely their only notable benefit. Currently, the use of Force Operations. Future conflicts will likely present medical
homo grafts has mostly been abandoned due to their suscep- teams with nonlinear patient care challenges, requiring patient
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tibility to aneurysm and atheromatous degradation. Recent transport to make frequent stops on non-traditional platforms
attempts using treated homografts, such as cryopreserved arte- before receiving treatment. These fast medical ships can bridge
rial homografts to reduce contamination and improve efficacy, the gap between medical support and the POI in an unprece-
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have demonstrated the need for further study. Interestingly, dented manner. Most importantly, they have the potential to
these treated homografts have shown some benefit in infected alleviate logistical challenges tied to transporting and stabiliz-
fields as a temporizing maneuver for prosthetic grafting; how- ing multiple casualties from littoral zones of operation, while
ever, they do not appear to be effective substitutes for syn- also bringing life-saving equipment and medical teams closer
thetic or autogenous grafts in and of themselves. 10,12 Among to the fight.
the many advances made in vascular surgery, it appears that
Dr. Hughes’ views on various procedures from the Korean War Growing logistical capabilities are beneficial, but they remain
remain consistent with current opinions on vascular repair. constrained by medics’ abilities to address casualties quickly
and effectively. Medics must move at the speed of the warf-
Importance of Balancing Efficacy and Urgency ighter and be prepared for prolonged field/casualty care. This
in Vascular Treatment Amid Operational Reality involves more than just attending a school or course; it re-
Ligation as a method of treatment was less successful for limb quires active involvement in hospital critical care units to learn
salvage than direct anastomosis or grafting techniques. The leg- not only the necessary skills but also the equipment require-
acy of Dr. Hughes and fellow surgeons in Korea is a significant ments for caring for combat casualties away from hardstand
advancement of limb salvage provided by vascular reconstruc- hospitals. One major skill—and logistical constraint—is the
tion rather than ligation. 4,13 In today’s combat environment, transfusion and resuscitation of the combat-wounded. Med-
ligation remains an effective strategy in constrained combat ics need to ensure they are confident and capable of provid-
settings or where soft tissue, bony, and neurologic compromise ing resuscitation as close to the POI as possible to improve
of the distal limb preclude reasonable attempts to salvage. The patient outcomes. Adequate medical capability demands not
decision to ligate is based on the projected treatment efficacy. only possessing the necessary skills, but also the initiative to
In combat operations, available manpower, proximity to the apply them.
POI, and triage decisions are often the deciding factors. As
mentioned by Dr. Hughes, “ligation of major vessels will be Medics and their command teams need to engage with their
indicated in the presence of mass casualties requiring other Army-supporting field hospital (FH) units to ensure that re-
urgent surgery. While blood vessel repair was performed quite suscitative and surgical care remains as close as possible to
successfully in Korea, the situation was favorable to the extent the injured casualty. In addition to these large FHs, profi-
that the main line of resistance was fairly stable, there was cient, rapidly mobile surgical teams, such as those in the
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good air coverage and fairly rapid evacuation.” Despite the Army’s 528th or Air Force Special Operations Surgical Teams
immense benefit of vascular surgery, the fog of war remains (SOSTs), will need to be utilized to bring surgery and greater
a deciding factor in how a patient is treated. Every military resuscitation capability even closer to the POI. Strategically
element involved in patient transport, from the frontline medic positioned Navy forces can provide shore-to-ship medical
to the supporting ship or aircraft, should remember that action platforms during larger scale operations as well as sea-based
during the first few minutes of a casualty response will decide tactical insertions and extractions, allowing for more rapid
subsequent care in the hours to follow. decompression of ground-based surgical teams and increasing
capability across the Force. The U.S. Military’s recent focus on
LSCOs will provide unique opportunities to plan inter-service
Where Do We Go From Here?
coordination of medical readiness. Ultimately, medics—partic-
The LWF series serves to remind the Special Operations Forces ularly those in SOF—need to own this planning component,
(SOF) community, and all members of our medical corps team acting as the liaison between the medical community and their
that history is an ever-present teacher of battlefield lessons for command teams, to ensure the best care for their wounded
future conflicts. Drawing on the insights of Dr. Hughes, the soldiers.

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