Battlefield care: Treating a unique population
In 2010, the Surgeon General of the Canadian Forces Health Services (CFHS) articulated a health research strategy to focus and coordinate Canadian military research efforts. In his report, the Surgeon General stated that the purpose of our military health research efforts is to “better shield and sustain Canada’s fighting forces through health innovation.”
Although civilian scientists can conduct some military health research – many lessons learned in the civilian setting can also be applied to the military environment – some research questions are unique to the military environment and are best understood and answered by scientists in uniform. The creation of the Canadian Institute for Military and Veteran Health Research (CIMVHR) has provided the necessary bridge in connecting the research of civilian and military institutes across Canada.
The quintessential “unique” military environment that is the focus of military health care research is the battlefield. On the battlefield, health care has to be provided in low light conditions, under adverse weather conditions, and in conditions where health care providers are facing mortal threats such as incoming hostile fire. There is no comparable setting in civilian health care. Developing novel techniques for caring for injured soldiers on the battlefield is a major focus of military health research efforts.
The vast majority of soldiers injured from combat die on the battlefield, prior to reaching a medical facility. Tactical combat casualty care (TCCC) is a military paradigm of pre-hospital trauma care that allows combat medical technicians to deal with treatable causes of death on the battlefield, while taking into account the harsh environmental and tactical realities of the battlefield. TCCC was first developed by U.S. navy researchers for their Special Operations community.
The CFHS adopted TCCC in the late 1990s, and has since developed an extremely robust and well-regarded training program, termed Tacmed, for its combat medical technicians. CFHS researchers have significantly improved many of the original TCCC protocols and interventions, which have been adopted worldwide.
Once casualties reach a surgical facility, the leading cause of early in-hospital death from trauma is massive bleeding. Much of this bleeding is not controllable by surgery – patients succumb to coagulopathy, which is a condition where the blood no longer clots properly as a result of the original injury and ongoing resuscitation.
Trauma remains an under-funded area of research by civilian granting agencies, as priorities tend to be focused on cancer and cardiovascular health, which accounts for the majority of deaths in the civilian setting. The military population, however, consists primarily of young, healthy males, and trauma remains a leading cause of death in this group. Therefore, trauma research remains a priority for CFHS.
Our researchers have been studying the basic mechanisms contributing to the development of coagulopathy. Also, combat surgical experience from our Role 3 Multinational Medical Unit in Afghanistan and other combat support hospitals suggests that a novel method for transfusing blood products is required to treat this coagulopathy – a method termed “damage control resuscitation.” CFHS researchers have conducted the world’s first randomized controlled trial on the efficacy of damage control resuscitation, which is now being widely adopted by trauma centres across North America and Europe.
Trauma is not only the leading cause of death in young adults in Canada, but is also the leading cause of disability in Canadians. The Canadian Forces Health Services has made the rehabilitation of its wounded veterans an institutional priority, both as a focus of research and clinical care. As such, the CFHS has recently purchased a computer assisted rehabilitation environment (CAREN) system, and has used this to help a tertiary care civilian hospital in Canada to develop its rehabilitation virtual reality laboratory. The CAREN system will facilitate the rehabilitation of Canada’s wounded veterans, and will hopefully result in future advancements in rehabilitation of trauma patients in the civilian context as well.
Abraham Lincoln was once quoted as saying, “there is no greater responsibility than the care of our wounded soldiers, and that it takes all of us to make this happen.” So long as we continue to send our soldiers out in harm’s way, Canadians will continue to have a duty to care for them, and to seek health innovations that will return more of them home alive, sound of body and mind. Members of the Canadian Forces Health Services take this responsibility seriously. We will continue to deploy with our soldiers onto the battlefield to treat them. And, while at home, in collaboration with the CIMVHR, we will continue to develop new ways to better sustain and shield them.
LCol Homer Tien is with the Canadian Forces Health Services.