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The United States has achieved unprecedented survival rates, as high as 98%, for casualties arriving alive at the combat hospital. Our military medical personnel are rightly proud of this achievement. Commanders and Servicemembers are confident that if wounded and moved to a Role II or III medical facility, their care will be the best in the world. Combat casualty care, however, begins at the point of injury and continues through evacuation to those facilities. With up to 25% of deaths on the battlefield being potentially preventable, the prehospital environment is the next frontier for making significant further improvements in battlefield trauma care. Strict adherence to the evidence-based Tactical Combat Casualty Care (TCCC) Guidelines has been proven to reduce morbidity and mortality on the battlefield. However, full implementation across the entire force and commitment from both line and medical leadership continue to face ongoing challenges. This report on prehospital trauma in the Combined Joint Operations Area?Afghanistan (CJOA-A) is a follow-on to the one previously conducted in November 2012 and published in January 2013. Both assessments were conducted by the US Central Command (USCENTCOM) Joint Theater Trauma System (JTTS). Observations for this report were collected from December 2013 to January 2014 and were obtained directly from deployed prehospital providers, medical leaders, and combatant leaders. Significant progress has been made between these two reports with the establishment of a Prehospital Care Division within the JTTS, development of a prehospital trauma registry and weekly prehospital trauma conferences, and CJOA-A theater guidance and enforcement of prehospital documentation. Specific prehospital trauma-care achievements include expansion of transfusion capabilities forward to the point of injury, junctional tourniquets, and universal approval of tranexamic acid., (2015.)

A panel convened to develop an evidence-based set of guidelines for the recognition and treatment of eye injuries and illnesses that may occur in the wilderness. These guidelines are meant to serve as a tool to help wilderness providers accurately identify and subsequently treat or evacuate for a variety of ophthalmologic complaints. Recommendations are graded on the basis of the quality of their supporting evidence and the balance between risks and benefits according to criteria developed by the American College of Chest Physicians. This is an updated version of the original guidelines published in Wilderness & Environmental Medicine 2012;23(4):325-336., (Copyright © 2014 Wilderness Medical Society. Published by Elsevier Inc. All rights reserved.)

The vast majority of combat casualties who die from their injuries do so prior to reaching a medical treatment facility. Although most of these deaths result from nonsurvivable injuries, efforts to mitigate combat deaths can still be directed toward primary prevention through modification of techniques, tactics, and procedures and secondary prevention through improvement and use of personal protective equipment. For deaths that result from potentially survivable injuries, mitigation efforts should be directed toward primary and secondary prevention as well as tertiary prevention through medical care with an emphasis toward prehospital care as dictated by the fact that the preponderance of casualties die in the prehospital environment. Since the majority of casualties with potentially survivable injuries died from hemorrhage, priority must be placed on interventions, procedures, and training that mitigate death from truncal, junctional, and extremity exsanguination. In response to this need, multiple novel and effective junctional tourniquets have recently been developed., (2013.)

A panel convened to develop an evidence-based set of guidelines for the recognition and treatment of eye injuries and illnesses that may occur in the wilderness. These guidelines are meant to serve as a tool to help wilderness providers accurately identify and subsequently treat or evacuate for a variety of ophthalmologic complaints. Recommendations are graded based on the quality of their supporting evidence and the balance between risks and benefits according to criteria developed by the American College of Chest Physicians., (Copyright © 2012. Published by Elsevier Inc.)

Pressure-related vision loss has been reported during ascent to altitude. We report the case of an otherwise healthy diver who suffered painless, sudden-onset binocular vision loss at depth, followed by complete recovery immediately upon surfacing. We examine the dive and briefly discuss the differential diagnosis of transient vision loss in the setting of ambient pressure changes. We conclude that the diver likely suffered from sphenoid sinus barotrauma, possibly in association with dehiscence of the bony canals of the optic nerves as they travel in close proximity to the walls of the sphenoid sinus.

Objective: To evaluate battlefield survival in a novel command-directed casualty response system that comprehensively integrates Tactical Combat Casualty Care guidelines and a prehospital trauma registry., Design: Analysis of battle injury data collected during combat deployments., Setting: Afghanistan and Iraq from October 1, 2001, through March 31, 2010., Patients: Casualties from the 75th Ranger Regiment, US Army Special Operations Command., Main Outcome Measures: Casualties were scrutinized for preventable adverse outcomes and opportunities to improve care. Comparisons were made with Department of Defense casualty data for the military as a whole., Results: A total of 419 battle injury casualties were incurred during 7 years of continuous combat in Iraq and 8.5 years in Afghanistan. Despite higher casualty severity indicated by return-to-duty rates, the regiment's rates of 10.7% killed in action and 1.7% who died of wounds were lower than the Department of Defense rates of 16.4% and 5.8%, respectively, for the larger US military population (P = .04 and P = .02, respectively). Of 32 fatalities incurred by the regiment, none died of wounds from infection, none were potentially survivable through additional prehospital medical intervention, and 1 was potentially survivable in the hospital setting. Substantial prehospital care was provided by nonmedical personnel., Conclusions: A command-directed casualty response system that trains all personnel in Tactical Combat Casualty Care and receives continuous feedback from prehospital trauma registry data facilitated Tactical Combat Casualty Care performance improvements centered on clinical outcomes that resulted in unprecedented reduction of killed-in-action deaths, casualties who died of wounds, and preventable combat death. This data-driven approach is the model for improving prehospital trauma care and casualty outcomes on the battlefield and has considerable implications for civilian trauma systems.