Throughout 21st century combat in Afghanistan and Iraq, American military medicine achieved an unprecedented survival rate. By 2016, more than 90 percent of U.S. warfighters wounded in battle had made it home alive, compared to about 75 percent for each of the wars in Korea, Vietnam, and the Persian Gulf. The highest survival rate in the history of warfare was achieved in spite of the increasing severity of battle injuries inflicted by the weapon of choice for counterinsurgents: improvised explosive devices (IEDs) planted in the ground or delivered by vehicles or suicidal attackers. Up to two-thirds of American service members killed or wounded in Iraq and Afghanistan were victims of IEDs.

Military experts have documented the litany of improvements in trauma care, from points of injury to stateside hospitals, that contributed to this improvement. Last year, in the journal Current Problems in Surgery, six military physicians – including Eric Elster, M.D., chair of the Department of Surgery at the Uniformed Services University of Health Sciences (USU) and a captain in the Medical Corps of the U.S. Navy – documented these advances in an article, “Combat Casualty Care and Lessons Learned from the Past 100 Years of War.” The innovations mentioned by the authors included improvements in:

• Point-of-injury care. In Iraq and Afghanistan, the revised Tactical Combat Casualty Care guidelines, developed in 1996, were conveyed via training not only to medics and corpsmen, but to all warfighters. The effective use of extremity tourniquets and hemostatic agents, some of them newly developed, helped slow rates of hemorrhage, which studies revealed to be the cause of 90 percent of preventable battlefield deaths.

• Care during prehospital transport. Blood transfusions and hypothermia prevention measures helped to sustain wounded warfighters, and toward the end of the war in Afghanistan, critical care flight paramedics from Army National Guard units were providing a high level of care during helicopter transports to in-theater medical facilities.

In 2009, Secretary of Defense Robert Gates issued a mandate based on the “golden hour” standard of care that had been developed for civilian trauma systems, requiring prehospital transports of critically injured casualties in 60 minutes or less. According to Michael Davis, M.D., director of the U.S. Army Medical Research and Materiel Command (USAMRMC) Combat Casualty Care Research Program (CCCRP) at Fort Detrick, Maryland, and a colonel in the U.S. Air Force Medical Corps, the golden hour mandate “is likely the greatest thematic breakthrough relative to our medical successes in the most recent overseas conflicts.” According to a 2015 report in the Journal of American Medicine, the mandate saved a total of 359 lives.

In 2009, Secretary of Defense Robert Gates issued a mandate based on the “golden hour” standard of care that had been developed for civilian trauma systems, requiring prehospital transports of critically injured casualties in 60 minutes or less.

• Surgical care in theater. The use of “damage control” resuscitative and surgical measures focused on stabilizing patients for transport to definitive care. Previous resuscitation protocols, developed before advancements in the storing and transport of blood products, had involved generous intravenous infusion of crystalloid solutions, such as normal saline or Ringer’s lactate solution. “They would get 2 liters of that salt-based solution regardless of how sick they were,” Elster said, “and then if that didn’t work, they would get two units of packed red blood cells.”

Pumping high volumes of fluid into patients, however, increased the incidence of several adverse complications, including acute respiratory failure, and in 2006, the military medical community transitioned to the “hypotensive resuscitation” strategy developed by Col. John Holcomb, an Army trauma surgeon, which involves a balanced infusion of platelets, plasma, and packed red blood cells. While whole blood transfusions remain the ideal method of resuscitation, it’s not always possible on the battlefield, and Holcomb’s ratio-driven method improved survival and decreased the incidence of acute respiratory failure among severely injured patients.