Damage control surgery and casualty evacuation: techniques for surgeons, lessons for military medical planners

Damage Control Surgery (DCS) is a three-phase team-based approach to maximal injury penetrating abdominal trauma. In Phase I, the hypothermic, coagulopathic, acidotic, hypotensive casualty undergoes a proactively planned one-hour time limited laparotomy by an appropriately trained surgical trauma team. In phase II physiological stabilization takes place in the Intensive Care Unit. In phase III--definitive repair occurs. DCS is extremely resource intensive but will save lives on the battlefield. A military DCS patient will perioperatively require fourteen units of blood and seven units of fresh frozen plasma--half the blood stock of a light-scaled FST. Two DCS patients will in one day, exhaust this FSTs oxygen supply. We know that hypothermic patients with an iliac vascular injury (initial core temp < 34 degrees C) suffer four-fold increases in their mortality, yet we cannot heat our tents above 20 degrees C during a mild British winter. Our primary casualty retrieval is excessively slow. A simple casevac request has to go to too much 'middle-management' before a flight decision is made. In Vietnam, wounded soldiers arrived in hospital within twenty-five minutes of injury. In Iraq in 2005, that figure is over one hundred and ten minutes. We use support or anti-tank helicopters that are re-roled on an adhoc basis for the critical care and transport of our sickest patients. We still do not have a dedicated all-weather military helicopter evacuation fleet despite significant evidence that intensive care unit level military evacuation is safe and eminently achievable in both in the primary and secondary care setting. Should we not be asking why?