A second step will be to ensure that all members of combat casualty care teams are proficient in the skills needed in the expeditionary environment. The Defense Health Agency’s Clinical Readiness Program, which divides JTS clinical practice guidelines into expeditionary domains, provides training, practice, and assessment of the knowledge and skills necessary for each.

The third driver toward keeping combat casualties at their lowest possible level, Elster said, will be continued investment in a requirements-driven research program: “The ‘requirement,’” said Elster, “is whatever the military identifies as a need to take care of patients in the expeditionary environment, whether it’s a new tourniquet or an advanced resuscitative strategy. We need to make sure we continue robust investments, because if we don’t do it, no one else will.”

Several of the requirements that surfaced during the Iraq and Afghanistan wars were met with innovations from military clinicians and researchers, including the requirement for safe and faster-acting anticoagulants and hemostatic dressings; for tourniquets able to stop bleeding with compression at the armpit or groin; for a device that forward surgical teams could use to stop aortal bleeding; and for standardized high-level care during helicopter evacuations.

At Fort Detrick, the CCCRP and other elements of the USAMRMC help lead the effort to meet further requirements – and anticipate future needs. In an email interview, Davis said these requirements generally involve time (the ability to do things faster, automating them where possible) and distance (the ability to push lifesaving capabilities as far forward into the expeditionary environment as possible). For example, Davis said, automated vascular access – the use of miniaturized robotics, equipped with ultrasound and artificial intelligence, to deliver resuscitative fluids into an injured warfighter’s bloodstream – is likely only one to three years away from being used on the battlefield. These same scanning technologies could be used for non-invasive hemorrhage detection in cases where warfighters aren’t overtly bleeding or visibly symptomatic.

Several of the requirements that surfaced during the Iraq and Afghanistan wars were met with innovations from military clinicians and researchers.

One of the most potent lifesaving technologies being investigated at the CCCRP, said Davis, is the extracorporeal life support (ECLS) tool for combat trauma – essentially a bypass system for severely injured warfighters that can do the work of the heart, lungs, liver, and kidneys for hours or days in forward locations. Working versions of the ECLS tool exist today, Davis said, but “the current generation of ECLS systems will need to be improved upon, then miniaturized and ruggedized for the future battlefield.”

The coalescence of automation, robotics, data integration, and artificial intelligence, Davis said, “could allow for the care of multiple casualties at once, allowing for more casualties to be treated at a faster rate.” The CCCRP and other USAMRMC laboratories, such as the Medical Simulation and Information Systems Research Program and the Telemedicine & Advanced Technology Research Center, are investing in autonomous medical interventions to integrate into future battlefield systems. Among the most promising solutions are autonomous unmanned vehicles for delivering lifesaving supplies and technologies. With the ability to move faster and farther than current rotary-wing aircraft, and without the potential cost of further human casualties, these platforms, Davis said, “could bring blood, sterile water, and other medical supplies faster and farther into the battlespace than current technology allows.”

The coalescence of automation, robotics, data integration, and artificial intelligence, Davis said, “could allow for the care of multiple casualties at once, allowing for more casualties to be treated at a faster rate.”

While point-of-injury care remains a top concern for the CCCRP, said Davis, the military medical establishment is looking at ways to integrate medical evacuation or casualty evacuation capabilities into vertical-lift platforms – which may be manned or unmanned, but may still be equipped with some degree of robotic or automated lifesaving technology. “Imagine a future scenario,” said Davis, “where military-grade drones – with their ability to carry substantial weight and deliver medical supplies – can also carry up to six casualties on the return flight without the need for piloted flight.”

 

Combat Medicine in the Future Battlespace

A new term appeared last year in the updated Army Field Manual: Multi-Domain Battle. It’s a term military scholars and policymakers use to describe what they imagine warfare will be like for American combatants in the future – and what it’s already beginning to look like in places like eastern Ukraine and the Middle East. This type of conflict, combining traditional forms of kinetic military warfare with psychological, cyber, and economic attacks, is increasingly practiced by peer- or near-peer adversaries looking to challenge American military dominance in all domains: land, sea, air, space, and cyberspace.