Treating and then returning military personnel to duty — which has always been a primary mission of any military medical corps — maintains force strength. Moreover, knowing that they will be cared for and have a high chance of survival if injured boosts service members’ morale and will to fight. In a 2017 survey of West Point cadets conducted via the Modern War Institute, over 80 percent of respondents expressed confidence in the military’s ability to care for injured soldiers. This confidence also enables recruitment and maintenance of a robust all-volunteer force.
In the wars in Iraq and Afghanistan, the U.S. military medicine achieved the highest rate of survival from battlefield injuries in history. The wounded-to-killed ratio has more than doubled, from 4:1 during last century’s world wars, to 10:1 today. Substantial credit for this achievement goes to a tireless focus on getting wounded warfighters lifesaving care within 60 minutes of injury — a timespan that is referred to as the “golden hour.”
The military’s ability to deliver golden hour care was developed in the recent low-level counter-insurgencies and counter-terrorism wars of the early 21st century. With the shift away from global unipolarity, however, the United States may be more likely to fight conventional wars against peer or near-peer adversaries in the future. This shift requires the military to reassess existing approaches and innovate new ones for extending golden hour care in a different kind of war. Specifically, the military needs to recognize the new challenges to rapid evacuation and shift focus to bringing enhanced treatment capability to the patient on the battlefield, in order to accommodate the geographical and logistical constraints of future wars.
At the onset of the wars in Afghanistan and Iraq, the U.S. military did not have a joint service (i.e., Army, Navy, and Air Force) integrated trauma system that would allow it to get the wounded to the right facility for the right treatment within the golden hour. To make matters worse, the military also lacked the capability to collect and analyze data to determine how well it was doing. As a result, in the early days of the wars, military health professionals were unable to identify which changes needed to be made to improve a casualty’s odds of survival.
Between 2003 and 2005, the Army, Navy, and Air Force worked together to implement a “Joint Trauma System” and a clinical database known as the “Joint Theater Trauma Registry.” Using real-world data from the Joint Trauma System, military health experts were able to pinpoint the main causes of deathwithin the golden hour (e.g. uncontrolled bleeding, loss of airway, pneumothorax) and target them with adjustments in training, improved theater evacuation policies, and research to develop new products, such as one-handed tourniquets. Soon, the military was using data collection and analytics to inform policy and improve care.
Redefining the Golden Hour
To overcome these challenges, the U.S. military will have to extend the golden hour, focusing less on quickly evacuating the injured and more on bringing life-saving capabilities directly to the patient. This means focusing on prolonged field care, advanced resuscitative care, and long-distance en-route care. Redefining the golden hour in this way will require that the military adapt its medical technologies, training, and expectations.
A variety of developing technologies will improve resuscitative care at the front lines. New tools may allow medics working near the point of injury to autonomously establish entry inside the large arteries and veins of the torso. Linked to small catheters that can work inside the vessels, these tools could allow medics to stop bleeding, restore blood volume, and control the circulatory system. New endovascular devices (that is, devices operating inside vessels) could also be coupled with automated drug and fluid delivery tools to provide pain control, anesthesia, and organ support. While this network of technologies is complex, all the elements exist in some form today. The remaining challenges are to miniaturize and integrate them, make them battery-powered, and test them in the lab and in field conditions.
Wearable biosensors and advanced vital signs monitors, which could serve the dual purpose of remotely locating and triaging injured troops, are also on the horizon. Collecting and analyzing large amounts of real-time patient data (a.k.a. predictive analytics) from these monitors could help inform and build automated devices such as ventilators, organ support machines, and infusion pumps. Decision support and automated devices would expand the medic or corpsman’s ability to provide golden hour care to a greater number of injured at any one time.
In situations where MEDEVAC and other life-saving measures are not available, telemedicine will also expand the capability of point-of-injury providers to perform some types of surgeries such as wound debridement, extremity fasciotomy, or amputation. Subsequent prolonged field care delivered by medics and corpsmen could then include treatment of large wounds, intra-abdominal injuries, and mangled extremities — injuries managed inside of a hospital operating room today. Although the science is less advanced in these areas, the military is investing in research on antimicrobial dressing systems and self-expanding foams able to be injected into the abdomen to stabilize bleeding and contamination until definitive surgery can occur.
Managing traumatic brain injury during the new golden hour will be challenging. In addition to more comprehensive study of new and wearable blast gauge technologies and improved protection measures to avoid blast exposure, research is focusing on devices to diagnose concussive traumatic brain injury and limit severe brain injury. Brain-wave and eye-tracking devices and rapid blood tests may soon be available to diagnose concussions on the battlefield. Innovations such as small devices that use light sources and software algorithms to look inside the skull to diagnose bleeding and then drill a hole to evacuate blood and relieve pressure could help treat more severe forms of traumatic brain injury.
Unmanned technology could also enable a new golden hour paradigm. Drones or unmanned ground vehicles could preposition — or deliver in real time — supplies for different tactical situations, a strategy already employed for humanitarian aid in Africa. Additionally, the military is researching whether and how unmanned MEDEVAC might augment patient evacuation. By creating teams of combat developers, medics, scientists and engineers to work on these initiatives, the military is trying to make sure that new technologies are not merely “cool,” but that they are actually necessary and will be effective in the golden hour of future wars.