battlefield medicine battlefield medicine battlefield medicine, also called field surgery and later combat casualty care, is the treatment of wounded combatants and non-combatants in or near an area of combat. civilian medicine has been greatly advanced by procedures that were first developed to treat the wounds inflicted during combat. with the advent of advanced procedures and medical technology, even polytrauma can be survivable in modern wars. battlefield medicine is a category of military medicine. an illustration of the wound man, showing a variety of wounds from the feldbuch der wundarznei (field manual for the treatment of wounds) by hans von gersdorff, (1517); illustration by hans wechtlin. look up meatball surgery in wiktionary, the free dictionary. chronology of battlefield medical advances a wounded knight is carried on a medieval stretcher. during alexander the great’s military campaigns in the fourth century bc, tourniquets were used to stanch the bleeding of wounded soldiers. romans used them to control bleeding, especially during amputations. these tourniquets were narrow straps made of bronze, using leather only for comfort. an early stretcher, likely made of wicker over a frame, appears in a manuscript from c.1380. simple stretchers were common with militaries right through the middle of the 20th century. during the battle of shrewsbury in 1403, prince henry had an arrow removed from his face using a specially designed surgical instrument. ambulances or dedicated vehicles for the purpose of carrying injured persons were first used by spanish soldiers during the siege of málaga (1487). french military surgeon ambroise paré (1510–90) pioneered modern battlefield wound treatment. his two main contributions to battlefield medicine are the use of dressing to treat wounds and the use of ligature to stop bleeding during amputation. the practice of triage, pioneered by dominique jean larrey during the napoleonic wars (1803–1815). he also pioneered the use of ambulances in the midst of combat ('ambulances volantes', or flying ambulances). prior to this, military ambulances had waited for combat to cease before collecting the wounded by which time many casualties would have succumbed to their injuries. russian surgeon nikolay ivanovich pirogov was one of the first surgeons to use ether as an anaesthetic in 1847, as well as the very first surgeon to use anaesthesia in a field operation during the crimean war. american civil war surgeon jonathan letterman (1824–72) originated modern methods of medical organization within armies. the relief society for wounded soldiers, forerunner of the international committee of the red cross (icrc) was founded in 1863 in geneva. the icrc advocated for the establishment of national aid societies for battlefield medical relief, and stood behind the first geneva convention of 1864 which provided neutrality for medics, ambulances, and hospitals. in the late 19th century, the influence of notable medical practitioners like friedrich von esmarch and members of the venerable order of saint john pushing for every adult man and woman to be taught the basics of first aid eventually led to institutionalised first-aid courses amongst the military and standard first-aid kits for every soldier. advances in surgery - especially amputation - during the napoleonic wars and first world war on the battlefield of the somme. medical advances also provided kinder methods for treatment of battlefield injuries, such as antiseptic ointments, which replaced boiling oil for cauterizing amputations. during the spanish civil war there were two major advances. the first one was the invention of a practical method for transporting blood. developed in barcelona by duran i jordà, the technique mixed the blood of the donors with the same blood type and then, using grífols glass tubes and a refrigerator truck, transported the blood to the frontline. a few weeks later norman bethune developed a similar service. the second advance was the invention of the mobile operating room by the catalan moisès broggi, who worked for the international brigades. a us army soldier, wounded by a japanese sniper, undergoes surgery during the bougainville campaign in world war ii. the establishment of fully equipped and mobile field hospitals such as the mobile army surgical hospital was first practiced by the united states in world war ii. it was succeeded in 2006 by the combat support hospital. the use of helicopters as ambulances, or medevacs, was first practiced in burma in 1944. the first medevac under fire was done in manila in 1945 where over 70 troops were extracted in five helicopters, one and two at a time. the extension of emergency medicine to pre-hospital settings through the use of emergency medical technicians. the use of remote physiological monitoring devices on soldiers to show vital signs and biomechanical data to the medic and medevac crew before and during trauma. this allows medicine and treatment to be administered as soon as possible in the field and during extraction. similar telemetry units are used in crewed spaceflight, where a flight surgeon at the command center can monitor vital signs. this can help to see issues before larger problems occur, such as elevated carbon dioxide levels, or a rise in body temperature indicating a possible infection. history of tactical combat casualty care (tccc) in 1989, the commander of the naval special warfare command (navspecwarcom) established a research program to conduct studies on medical and physiologic issues. the research concluded that extremity hemorrhage was a leading cause of preventable death in the battlefield. at that time, proper care and treatment was not provided immediately which often resulted in death. this insight prompted a systematic reevaluation of all aspects of battlefield trauma care that was conducted from 1993 to 1996 as a joint effort by special operations medical personnel and the uniformed services university of the health sciences. through this 3-year research, the first version of the tccc guidelines were created to train soldiers to provide effective intervention on the battlefield. the tccc aims to combine good medicine with good small-unit tactics. one very important aspect that the tccc outlined was the use of tourniquets, initially there was a belief that the use of tourniquets led to the preventable loss of an extremity due to ischemia but after careful literature search the committee arrived at the conclusion that there was not enough information out there to confirm this claim. the tccc therefore outline the appropriate usage of tourniquets to provide effective first aid on the battlefield. after the tccc article was published in 1996, the program undertook 4 parallel efforts during the next 5-year period. these efforts are as follows: presenting tccc concepts to senior department of defense (dod) line and medical leaders and advocating for their use. identifying and developing responses to representative types of tccc casualty scenarios. initiating tccc’s first strategic partnership with civilian trauma organizations—the prehospital trauma life support (phtls) committee, the national association of emergency medical technicians (naemt), and the american college of surgeons committee on trauma (acs-cot). expanding tccc training beyond medical personnel to include seal and 75th ranger regiment combat leaders and nonmedical unit members. current applications of battlefield medicine over the past decade combat medicine has improved drastically. everything has been given a complete overhaul from the training to the gear. in 2011, all enlisted military medical training for the u.s. navy, air force, and army were located under one command, the medical education and training campus (metc). after attending a basic medical course there (which is similar to a civilian emt course), the students go on to advanced training in tactical combat casualty care. tactical combat casualty care (tccc) main article: tactical combat casualty care tactical combat casualty care is becoming the standard of care for the tactical management of combat casualties within the department of defense and is the sole standard of care endorsed by both the american college of surgeons and the national association of emt's for casualty management in tactical environments. tactical combat casualty care is built around three definitive phases of casualty care: care under fire: care rendered at the scene of the injury while both the medic and the casualty are under hostile fire. available medical equipment is limited to that carried by each operator and the medic. this stage focuses on a quick assessment, and placing a tourniquet on any major bleed. tactical field care: rendered once the casualty is no longer under hostile fire. medical equipment is still limited to that carried into the field by mission personnel. time prior to evacuation may range from a few minutes to many hours. care here may include advanced airway treatment, iv therapy, etc. the treatment rendered varies depending on the skill level of the provider as well as the supplies available. this is when a corpsman/medic will make a triage and evacuation decision. tactical evacuation care (tacevac): rendered while the casualty is evacuated to a higher echelon of care. any additional personnel and medical equipment pre-staged in these assets will be available during this phase. since "90% of combat deaths occur on the battlefield before the casualty ever reaches a medical treatment facility" (col. ron bellamy) tccc focuses training on major hemorrhaging and airway complications such as a tension-pneumothorax. this has driven the casualty fatality rate down to less than 9%. interventions used listed below are interventions that a tccc provider may be expected to perform depending on the phase of tccc they are at and their level of training. this list is not comprehensive and may be subject to change with future revisions in tccc guidelines. hemorrhage control interventions include the use of extremity tourniquets, junctional tourniquets, trauma dressings, wound packing with compressed gauze and hemostatic dressings, and direct pressure. newer devices approved for use by the cotccc for hemorrhage control include the itclamp and xstat. pharmacological options also include tranexamic acid, and hemostatic agents such as zeolite and chitosan. in managing a casualty’s airway, a tccc provider may position the casualty in the recovery position or utilize airway adjuncts such as nasopharyngeal airways, oropharyngeal airways, and supraglottic airways. they may also utilize the jaw thrust and head-tilt/ chin-lift maneuver to open a casualty's airway. advanced tccc providers may also perform endotracheal intubation and cricothyroidotomy. respiratory management largely revolves around the use of chest seals, vented and unvented, and needle decompressions to manage tension pneumothoraxes. in circulation management a tccc provider may obtain intravenous/ intraosseous access for the administration of fluids such as normal saline, lactated ringer’s solution, whole blood, and colloids and plasma substitutes for fluid resuscitation. this also provides a route for the administration of other drugs in accordance with the provider’s scope of practice. head injuries would indicate for cervical spine immobilization to the best of the provider’s abilities if deemed appropriate in a given setting, or the use of devices such as a cervical collar. as trauma-induced hypothermia is a leading cause of battlefield deaths, a provider may also perform hypothermia prevention can be accomplished through the use of a hypothermia prevention and management kit or emergency blanket, the placement of a casualty on an insulated surface, and the removal of wet clothing from a casualty’s body. care under fire care under fire is care provided at the point of injury immediately upon wounding while the casualty and care provider remain under effective hostile fire. the casualty should be encouraged to provide self-aid and continue remain engaged in the firefight if possible. if unable to do so, the casualty should be encouraged to move behind cover or "play dead". due to the high risk of injury to the care-provider and limited resources at this phase, care provided to the casualty should be limited to controlling life-threatening hemorrhage with tourniquets and preventing airway obstruction by placing casualty in the recovery position. the primary focus during care under fire should be winning the firefight to prevent further casualties and further wounding of existing casualties. tactical field care tactical field care phase begins when the casualty and care-provider are no longer under imminent threat of injury by hostile actions. though the level of danger is lessened, care-providers should exercise caution and maintain good situational awareness as the tactical situation may be fluid and subject to change. the tactical field care phase enables the provision of more comprehensive care according to care providers' levels of training, tactical considerations, and available resources. major tasks that are to be completed in the tactical field care phase include the rapid trauma survey, the triage of all casualties, and the