Quora Query: How Recent Wars Have Changed Trauma Care

Gentle Reader – I was asked to answer this on Quora (www.Quora.com) and thought it might prove of interest.  Comments are, as always, requested.



How will the recent wars in Iraq and Afghanistan change trauma care – is the ATLS algorithm undergoing changes ?

How does war change trauma care ?

Disclaimer – My Opinion of War:
All war is evil.  Even wars fought for the best reasons, with the best intentions.

People die, screaming, crying for their mothers.  The look and smell of intestines hanging out of an abdomen that has been blown open has nothing to recommend it.  The smell of blood and fecal material mixed together is one of the worst smells in the world, topped only by the sickly-sweet smell of decaying flesh.

All war is evil. Even wars fought for the best reasons, with the best intentions.

How does war change trauma care ?
Medical care has been improved – in civilian as well as military hospitals – as a consequence of each of the wars of the 20th century.  For example, the first recorded air evacuation occurred in 1915 during World War I, and now there are flying ICUs  – Critical Care Air Support Teams – that can take a wounded soldier from a field hospital in Afghanistan to Germany or the UK.  While this may seem like a straightforward issue, it is quite complex (see Turner, et al, Journal of the Royal Army Medical Corps, 2009;155:171) and is a remarkable advance.

Fluid resuscitation in response to severe wounds is another improvement.  Damage control resuscitation, consisting of permissive hypotension, use of blood / blood products instead of crystalloid for volume replacement, and component therapy to correct coagulopathy has shown lower mortality than standard resuscitation maneuvers (30% versus 41% to 74%, see Murray, Military Medicine, 2011;176:674).

The table, below, is from Doctor Murray’s article.

The Joint Theater Trauma System and Joint Theater Trauma Registry – which mirrors the civilian trauma system – was developed and is “mined” to determine best practices in the care of war wounded patients.  As of 2011, there were 23 evidence-based guidelines / best practices developed from analysis of this registry that are in use for the war wounded.

Some of the advances noted in the field have made their way to the civilian health system and have improved trauma care as well as non-trauma critical care medicine.

As in the past, the dichotomy of war – in which lives are violently lost – leading to improvements in medicine – in which lives are aggressively saved, is a remarkable and unsettling one.

About AJ Layon

AJ Layon was, for 28 years, at the University of Florida College of Medicine, in the Division of Critical Care Medicine, in Gainesville, FL. For the approximately 10 years until September 2011, he was Professor and Chief of Critical Care Medicine at UF; In September of 2011 he became System Director and Co-Chairman of Critical Care Medicine in PA; this ended in 2017. He served as a Physician in the Surgical Group with Médecins sans Frontières (MSF, Doctors without Borders) through 2018 and is presently an intensivist in Florida, struggling through the SARS-CoV-2 crisis. While his interests are primarily related to health care, health care reform, and ethical issues, as a citizen of our United States and our world, he will occasionally opine on issues of our "time and destiny". Follow on Twitter @ajlayon
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