Introduction: Field Medicine in the Forward and Tactical Environment

There are many unique aspects of providing medical care in the combat environment. The vast majority of the considerations covered also apply to providing care for the neurologically injured. This chapter will review some of the major issues related to providing combat care with emphasis on neurological injury and illness. While a majority of the chapter will focus on the difficulties inherent in this environment, the final portion will discuss some advantages.

As the following chapters will outline, the majority of available recommendations are extrapolated from civilian data. In some instances, it will be obvious that the best civilian data have direct application to military scenarios. In others, it will be equally obvious that the best available civilian recommendation is impractical at best, and potentially threatening to life or mission accomplishment at worst. We have attempted to discriminate between the two as often as possible, based on the available military-specific literature and personal experience. Ultimately, it will be the decision of the individual medic and/or the unit chain of command as to whether a particular diagnostic or therapeutic maneuver can be implemented. The general direction we have taken with our recommendations is that the best-known community standard should be implemented whenever possible.

The recommendations in the following chapters are based on the best available data, and the authors maintained a patient-driven focus during development. In other words, each recommendation was created based upon the best care possible for the patient, in spite of the fact that tactical limitations may prevent this level of care from actually being available to all patients at all times. It should also be noted that guidelines such as these are quite different than protocols developed by medical facilities or military units. Protocols should be generated locally to give very specific directions as to how individual providers are to act in a variety of situations. Guidelines such as these are intended to serve as a starting point for the development of facility-specific protocols.

Patient-driven guidelines can and, we feel, should also drive educational and technological development. Once the "best possible" care is defined, it is incumbent upon trainers and developers to make that care available as far forward as possible. For instance, if it is proven that monitoring tissue oxygenation saves lives, it becomes important to provide combat medics with a practical means of doing so.

Factors that create limitations in the level of medical care available in the combat environment include the overall tactical scenario, physiologic parameters associated with combat, and logistics. Our ability to develop standards for optimal management is, as will be seen in the following chapters, limited by a lack of scientific data. The majority of the recommendations provided are extrapolated from civilian data. While many of these recommendations will be both practical and applicable, the ability of the individual medic to provide this care may be limited.

There are numerous tactical considerations that can impact medical care. Noise and light discipline will restrict a complete history and physical examination. Individual unit mobility and the availability of casualty evacuation assets can delay movement of a seriously wounded casualty to the next level of care. Rapid movement of a tactical unit may prevent casualty assessment or implementation of a care plan. The inability to secure an area under heavy fire can hamper care plans or prevent resupply. Chemical, biological, or nuclear contamination may have a significant impact on the neurologic system. Additionally, presence of these agents precludes effective examination and limits care due to the donning of chemical protective gear by both patient and provider.

While the medic is clearly responsible for providing medical care, it is important to remember that the overall tactical scenario is dictated by the chain of command. Communication between medics and the chain of command will improve both casualty care and accomplishment of the mission. The chain of command must be kept informed of the needs of the patients, including evacuation priorities, resupply requirements, and movement restrictions, to name only a few. The medic must also be kept informed of the battlefield limitations influencing all of the above. It cannot be overemphasized how important this type of communication becomes in a hostile environment, nor how important it is to develop these lines of communication and relationships prior to entering a combat zone. Training exercises should be realistic and should include medical care scenarios within the tactical plan.

Multiple issues within the combat environment affect human physiology. Regardless of whether the battle is taking place in a hot or cold environment, dehydration is common. The ability of the body to compensate for fluid loss associated with wounding may be compromised if the casualty is severely dehydrated before injury. The stress of combat leads to increased anxiety and an increase in circulating catecholamines. This can be protective, but also may result in changes in mental status that make neurologic assessment more difficult. The psychological effects of heavy combat may also result in acute stress reactions, creating a casualty who is disoriented, incoherent, or mute. Exposure to high velocity blast can result in a transient loss of consciousness, deafness, or visual dysfunction secondary to globe deformation, retinal injury, or traumatic iridoplegia. It is important to remember that interpretation of the scoring on the Glasgow Coma Scale may be influenced by some of these issues in the hyperacute setting. Triage decisions should take this into account. The Glasgow Coma Scale is extremely important for assessment and continued monitoring of neurologic status, but it is important to keep in mind that its usefulness as a prognostic indicator is limited.

Logistical support varies greatly depending on the location of the medical provider. The independent duty corpsman aboard ship may have hundreds or thousands of pounds of supplies and equipment at his or her disposal, whereas the medic with a small unit traveling on an independent reconnaissance patrol for several weeks will only have what can be carried, or in the best of circumstances, resupplied as needed. Any type of resupply may also be a challenge. In the absence of ground or aerial resupply, several casualties may rapidly deplete available bandages, fluids, and medications. Tactical considerations such as speed of unit movement, intensity of enemy engagement, weather, terrain, and visibility all may work together to create an impossible situation for resupply.

All of these individual components affect the practicality of providing high-level care to a neurologically wounded servicemember. In this type of environment, where decisions must be made about casualty movement on the battlefield, casualty evacuation, distribution of limited resources, and many other parameters, experience matters. Years of medical training and experience, even outside a combat environment, can give the medic the knowledge to be able to adapt to multiple patient scenarios in varying environments while providing the best possible care.

Although there are many limitations, it should not be assumed that all aspects of neurologic trauma care in the combat environment are negative. First and foremost, the dedication of all medics to saving casualties is extraordinarily high. While there is clearly much heroism seen in the provision of trauma care in the civilian setting, an overriding principle taught to providers is to avoid becoming a casualty. In the military, the mandate to leave no one behind creates a level of confidence in the warrior and a level of fearlessness in the medic that has not been routinely duplicated in the civilian setting. From a physiologic standpoint, there are few populations where the medical providers can uniformly expect an extremely high level of physical fitness, psychological preparedness, and compliance with therapeutic recommendations. Finally, the long and glorious history of battlefield medics has created a situation where the level of cooperation from the chain of command and from fellow service members is unique. This advantage allows the medic to leverage the resources of the entire unit when practical to assist in the care of the wounded.

We have no doubt that the medics of the future will continue to serve in the time-honored tradition of the medics of the past. It is our hope that this course will highlight current recommendations with regard to the care of the neurologically injured patient. We wish safety and success to each and every one of you.