The first formally trained ambulance service owes its existence to military operations. The first formal emergency medical service is traced back to the middle ages during the crusades of the 11th century. The Knights of Saint John received instruction in first-aid treatment from both Arab and Greek doctors. These Knights of Saint John then acted as the first formally trained prehospital medical personnel, treating soldiers on both sides of the war on the battlefield and bringing in the wounded to nearby tents for further medical treatment.1 The military again played a significant role in the development of prehospital care in 1487 during the Siege of Malaga, in Spain. This was the first recorded use of an ambulance—a horse drawn cart with a trained attendant.2 In the 1700s, Napoleon Bonaparte appointed Baron Dominique-Jean Larrey to develop the first systematic collection of wounded on the battlefield. In 1797, Larrey created “ambulance volantes” or light with carriages with trained personnel to collect, transport, and treat injured.3 Larrey developed all of the precepts of emergency medical care that are used today by all modern EMS systems: rapid access to the patient by trained personnel, field treatment and stabilization, and rapid transportation back to the medical facility while providing medical care en route.4
Describe the factors that make military EMS unique.
Describe provider types and skill sets.
Describe basic principles of care under fire.
Describe essential equipment for care under fire.
Describe basic principles of patient extraction, forward treatment, and treatment destinations.
Describe the roles of EMS physicians in military EMS.
Discuss the approach to care of noncombatants and enemy combatants.
Describe the interoperability issues in military-civilian EMS deployment for domestic disasters.
MILITARY AND THE HISTORY OF EMS
At the beginning of the 1860s, the United States created the first field ambulance and attendant. The first recorded use of a field ambulance and attendant was during the Civil War. During the US Civil War, both sides attempted to emulate the medical practices of the Napoleonic wars. During the Battle of Bull Run, the ambulance service was being coordinated by the Quartermaster Corps. It was then transferred to Surgeon General Jonathan Letterman, MD, to organize, and he reinstated all of Larrey’s concepts greatly increasing the survival rate of the wounded. In 1862, due to the unexpected size of casualty lists during the battle of Manassas where it took 1 week to remove the wounded from the battlefield, Dr Jonathan Letterman, Head of Medical Services of the Army of the Potomac, revamped the Army Medical Corps. His contribution included staffing and training men to operate horse teams and wagons to pick up wounded soldiers from the field and to bring them back to field dressing stations for initial treatment. This was our Nation’s first Ambulance Corps. Dr Letterman also developed the three-tiered evacuation system.5–7 Dr Jonathan Letterman is known today as the Father of Modern Battlefield Medicine.
ROLES OF CARE
The fundamental characteristic of the modern army health services (AHS) is the distribution of medical resources and capabilities to facilities at various echelons of command, diverse locations, and progressive capabilities, which are referred to as roles of care. As a general rule, no role is bypassed except for medical urgency, efficiency, or expediency. The rationale for this organization principle is to ensure the stabilization/survivability of the casualty through advanced trauma management and far forward resuscitative surgery prior to movement between military treatment facilities (MTFs). This strategy is tactical in nature and only addresses Roles of Care I and II.8,9
Role I is the first level of medical care a soldier receives and is also referred to as unit-level medical care. This role of care includes immediate lifesaving measures, disease and nonbattle injury (DNBI) prevention, combat and operational stress control preventive measures, patient location and acquisition, medical evacuation (MEDEVAC) from supported units (point of injury or wounding), company aid posts, or casualty collection points to supporting MTFs; treatment is provided by designated combat medics’ treatment squads/teams. The major emphasis at this level of care is for the patient to return to duty or to stabilize him/her and allow for his/her evacuation to the next role of care. The measures at Role I include maintaining the airway, stopping bleeding, preventing shock, protecting wounds, immobilizing fractures, and other emergency measures as indicated.8,9
Nonmedical personnel performing first-aid procedures assist the combat medic in his/her duties. Each individual soldier is trained to be proficient in a variety of specific first-aid procedures including aid for chemical casualties with particular emphasis on lifesaving tasks. This training enables the common soldier to apply immediate first aid to alleviate potential life-threatening situations. Self and buddy aid is repeatedly identified as absolutely essential for ensuring casualty survival. If the casualty is to survive, lifesaving actions such as the application of a tourniquet often cannot be delayed until the arrival of a medic. The person most likely to provide immediate aid is not the medic but another soldier. Combat leaders understand modern battlefield trauma care concepts and realize that tactical treatment strategies may vary somewhat from trauma care in the civilian sector. All army combatants on the battlefield are trained, equipped, and completely ready to save lives by performing such basic measures such as stopping the bleeding and opening the airway. Greater awareness of the importance of tactical combat casualty care (TCCC) on the part of unit commanders is now being reported as a major factor in avoiding these preventable deaths.8–11
The combat lifesaver (CLS) is a nonmedical soldier selected by the unit commander for additional training beyond basic first-aid procedures. In accordance with (IAW) AR 350-1, each squad, crew, or equivalent-sized deployable unit has at least one member trained and certified as a combat lifesaver. Combat lifesavers must be recertified every 12 months at unit level. The primary duty of this individual does not change. Functioning as a combat lifesaver is a secondary mission undertaken when the tactical situation permits. CLS training is provided by medical personnel assigned, attached, or in a medical platoon of a maneuver unit. The senior 68W combat medic designated by the commander manages the training program. The Army Medical Department Center and School (AMEDDC&S) proponent for CLS utilized TCCC principles as the foundation of for the CLS course. The CLS course is focused on training soldiers in those skills that save lives in combat: bleeding control, treatment of chest injuries, airway management and the tactical context of care, safe patient extraction, and movement techniques that avoid additional injuries.10
The 68W combat medic is the first individual in the medical chain that makes medically substantiated decisions based on military occupational specialty (MOS)–specific training. Combat casualty care is the primary mission of the 68W. The enhanced technical proficiency and medical competency of the 68W combat medic save lives on the battlefield. The current combat medic training program incorporates TCCC principles. TCCC principles have continued to be the primary focus of the combat medic training program. More than 60% of the curriculum is dedicated toward battlefield medicine. The combat medic is uniquely skilled and capable of providing advanced combat casualty care. The 68W MOS critical tasks consist of the treatment skills required to address the three leading causes of battlefield death. These casualty care skills are related to combat trauma assessment, bleeding control, advanced airway management, and needle decompression.10,12
68W Advanced Initial Training (AIT) is located at the AMEDDC&S, Fort Sam Houston, Texas. This course is the basic course to teach 68W combat medics critical medical treatment skills and tasks. It is a 16-week course with 17 iterations annually, consisting of 450 students per class for a total of 7600 students each year. The course consists of 7 weeks of Emergency Medical Technician-Basic course, 1 week of limited primary care, 5 weeks of Tactical Medicine, and 3 weeks of Combined Situational and Field Training Exercises. The primary changes to the 68W Program of Instruction from 2001 to 2009 were the incorporation of National Registry Emergency Medical Technician-Basic (NREMT-B) and TCCC. Significant focus has been on Tactical Medicine and battlefield lifesaving care.13
Role I begins from point of wounding/injury and ends at the level of the Battalion Aid Station (BAS). At the BAS, a physician, physician assistant, and nurse practitioner are trained and equipped to provide advanced trauma management to the combat casualty. Combat medics support these health care providers. The BAS also conducts routine sick call when the tactical situation permits. Based on input from recent operational experience with 68W combat medics function at the BAS, the army identified the need and resulted in focused additional training of 68Ws on basic principles and techniques of sick call, medication administration, and wound care. 68W combat medics also gained additional training on orthopedics, respiratory illnesses, ear-nose-throat (ENT) disease, and abdominal illness and injuries.10
Role II medical treatment is provided by the combat medic, physician or physicians’ assistant at the level of the brigade support medical company, the area support medical company, or the forward surgical team (FST) associated with one of the medical companies. At this role, care is rendered and evaluation is made to determine evacuation priority. The Role II MTF has the capability to provide packed red blood cells, limited x-ray, laboratory, dental support, combat and operational stress control, and preventive medicine. The Role II MTF provides a greater capability to resuscitate trauma patients than is available at Role I. Role II assets are located in the following locations:
Medical company (brigade support battalion), assigned to modular brigades which include the heavy brigade combat team (BCT), infantry BCT, the Stryker BCT, and the medical troop in the armored cavalry regiment.
Medical company (area support) which is an echelons above brigade asset and provides direct support to the modular division and supports echelons above brigade units.
Preventive medicine and combat and operational stress control assets are also located in the brigade support medical support company and area support medical company.
Patients who can return to duty (RTD) within 72 hours (1-3 days) or within theater evacuation guidelines are held for treatment. Patients, who are nontransportable due to their medical condition, may require resuscitative surgical care from a forward surgical team collocated with a medical company/troop. A detailed discussion of the FST composition and capabilities is contained in Army Field Manual 4-02.25, employment of forward surgical teams, tactics, techniques, and procedures. The goal is to reach surgical care within 1 hour of injury. FSTs provide immediate, life-sustaining resuscitation and surgery until the patient can reach a higher-level facility for definitive treatment and longer-term care. Doctrinally, FSTs consist of 20 personnel, including at least three general surgeons, an orthopedic surgeon with supporting nursing personnel consisting of nurse anesthetists, critical care, operative, and emergency nurses, and their health care support personnel. FST personnel are capable of rapid assembly and takedown of the operation. The unit comprises two operating tables and a blood supply. The FST logistically supports up to 30 operations over 72 hours before needing resupply. Forward surgical teams offer a highly effective combination of proximity and capability for patients who cannot be evacuated rapidly to a combat support hospital. Role II provides MEDEVAC from Role I MTFs and also provides Role I medical treatment on an area support basis for units without organic Role I resources.
At Role III, the patient is treated in a medical treatment facility staffed and equipped to provide care to all categories of patients, to include resuscitation, initial wound surgery, and postoperative treatment. This role of care expands the support provided at Role II. Patients who are unable to tolerate and survive movement over long distances receive surgical care in a hospital as close to the supported unit as the tactical situation permits. This role includes provisions for the following:
Evacuating patients from supported units
Providing care for all categories of patients in an MTF with the proper staff and equipment
Providing support on an area basis to units without organic medical assets
Role IV medical care is found in continental US (CONUS)–based hospitals and other safe havens. Mobilization requires expansion of military hospital capacities and the inclusion of Department of Veterans Affairs (VA) and civilian hospital beds in the National Disaster Medical System (NDMS) to meet the increased demands created by the evacuation of patients from the area of operations. The support-base hospitals represent the most definitive medical care available within the AHS.