Combat casualty care and lessons learned from the last 100 years of war

Combat Casualty Care and Lessons Learned from the Last 100 Years of War Author’s Accepted Manuscript Combat Casualty Care and Lessons Learned from the Last 100 Years of War Matthew Bradley, Matthew Ne[.]

Author’s Accepted Manuscript Combat Casualty Care and Lessons Learned from the Last 100 Years of War Matthew Bradley, Matthew Nealiegh, John Oh, Philip Rothberg, Eric Elster, Norman Rich www.elsevier.com/locate/cpsurg PII: DOI: Reference: S0011-3840(16)30157-5 http://dx.doi.org/10.1067/j.cpsurg.2017.02.004 YMSG552 To appear in: Current Problems in Surgery Cite this article as: Matthew Bradley, Matthew Nealiegh, John Oh, Philip Rothberg, Eric Elster and Norman Rich, Combat Casualty Care and Lessons Learned from the Last 100 Years of War, Current Problems in Surgery, http://dx.doi.org/10.1067/j.cpsurg.2017.02.004 This is a PDF file of an unedited manuscript that has been accepted for publication As a service to our customers we are providing this early version of the manuscript The manuscript will undergo copyediting, typesetting, and review of the resulting galley proof before it is published in its final citable form Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain COMBAT CASUALTY CARE AND LESSONS LEARNED FROM THE LAST 100 YEARS OF WAR Matthew Bradley, M.D 1, 2, Matthew Nealiegh, M.D 1, John Oh, M.D 1, Philip Rothberg, M.D , Eric Elster M.D 1, 2, Norman Rich M.D 1 Department of Surgery, Uniformed Services University -Walter Reed National Military Medical Center, 8901 Wisconsin Ave., Bethesda, MD 20889 Naval Medical Research Center, 503 Robert Grant Ave., Silver Spring, MD 20910 Corresponding Author: Matthew J Bradley, MD LCDR MC USN Trauma/Critical Care Surgeon Assistant Professor of Surgery Walter Reed National Military Medical Center/Uniformed Services University E-mail: matthew.j.bradley22.mil@mail.mil Author email addresses in order: matthew.j.bradley22.mil@mail.mil, matthew.d.nealeigh.mil@mail.mil, john.s.oh.mil@mail.mil, philrothberg@gmail.com, eric.elster@usuhs.edu, norman.rich@usuhs.edu Conflict of Interest Statement: The authors declare no conflicts of interest Disclosure: The authors are military service members (or employees of the U.S Government) The opinions or assertions contained herein are the private ones of the author/speaker and are not to be construed as official or reflecting the views of the Department of Defense, the Uniformed Services University of the Health Sciences or any other agency of the U.S Government No funding was received for this work The views expressed in this article are those of the author and not necessarily reflect the official policy or position of the Department of the Navy, Department of Defense, nor the U.S Government This work was prepared as part of their official duties Title 17, USC, §105 provides that ―copyright protection under this title is not available for any work of the United States Government.‖ Title 17, USC, §101 defines a U.S Government work as a work prepared by military service member or employee of the U.S Government as part of that person‘s official duties The study protocol was approved by the Walter Reed National Military Medical Center and the Naval Medical Research Center Institutional Review Boards in compliance with all applicable Federal regulations governing the protection of human subjects COMBAT CASUALTY CARE AND LESSONS LEARNED FROM THE LAST 100 YEARS OF WAR KEY WORDS: military history, combat casualty care, military surgery I INTRODUCTION From our earliest records of Western societies sending their citizens into harm‘s way, those societies have usually made some provision for their citizens‘ care However, the organization of medical professionals in various times and places makes meaningful comparison difficult and probably not productive The names are the eponym legends: Paré and ligature, Larrey and forward surgical care, Letterman and medically controlled evacuation, Esmarch and first aid However, we have chosen N Pirogoff‘s observation that ―war is an epidemic of trauma‖ to shape this discussion For the last 15 years the U.S military has been at war in Asia and has witnessed and treated a variety of injuries, most notably from improvised explosive devices (IEDs), which have produced injury patterns never seen before in prior combat operations The military medical community has learned a great deal from the care of these casualties while witnessing unprecedented survival rates As we strive to evaluate and apply this latest epidemic experience we believe the involvement of the U.S military in various 20th century wars may provide some guidance and warnings We have chosen to focus on the 20th century for both military and medical reasons First, war had become an extension of the modern industrial society, fought by huge armies, mobilizing the entire resources of the nation state Operationally, combined arms warfare is the norm; logistics is the crucial staff activity; and the 19th century humanitarian revolutions had assured social leaders would watch the care of the soldier, sailor, airman, and Marine Medically, preventive medicine based in germ theory had begun to make cities safer and this technology was used to help reduce disease and non-battle injury in deployed forces Even more important, the various medical professional traditions had coalesced into a common, scientifically educated general practitioner (GP), and out of that community there was emerging a new surgeon, medically qualified, scientifically educated and hospital trained Every Western army at the beginning of the 20th century used its social power to credential this new GP as the general medical officer (GMO) and this new surgeon as its hospital-based trauma manager Arguably, the most significant progress in the care of the combat casualty may have occurred within the last century with contributions from several nations What follows is a detailed description of the progress in the care of battlefield casualties and lessons learned from modern conflicts with U.S involvement II WORLD WAR I As the whole of Europe fell into the clutches of World War I, the U.S was coming of age Medicine grew out of the 19th century with widespread acceleration of learning, sharing, and scientific interest The Nobel Prize Committee awarded its inaugural prize in 1901[1], and would soon honor Alexis Carrel‘s revolutionary vascular work in 1912; he was the first surgeon, and, at the time, the youngest Nobel Laureate in history Soon thereafter Carrel joined the French military, making strides in wound management[2] The burgeoning Mayo Clinic transformed into a public institution in 1915, barely three years after Drs Will and Charlie Mayo accepted reserve commissions as first lieutenants in the U.S Army Medical Corps[3] Acute medical conditions still carried grave danger—C L Gibson‘s paper in a 1900 volume of Annals of Surgery noted nearly 50% mortality from acute intestinal obstruction [4] With notable exceptions, however, (Major Walter Reed‘s work on mosquito vectors and yellow fever, for example,) medicine on the front lines of conflict still slogged along at the pace of the U.S Civil War During the Spanish-American War, 10 times more soldiers died from illness in unsanitary conditions in domestic base camps than died close to the front lines[5] ―Necessity is the mother of invention,‖ however, and the storms of war in Europe would soon water the fertile minds of military medicine around the world WOUNDS AND WOUND CARE Turn-of-the-century wound care ranged widely, encompassing techniques old and new The practice of Hippocrates‘ wound suppuration still lingered centuries later Surgical legends such as Baron Guillaume Dupuytren and Baron Dominique Jean Larrey promoted surgical wound debridement in earlier centuries, but the practice largely disappeared after the decline of Napoleonic France, flowing in and out of favor through the early 20th century[6] The new wave of physicians at the dawn of the 20th century espoused technological advances as the panacea for all ailments, wounds included Sir Joseph Lister‘s proposal in 1867 that chemical antibiosis in the hospital could kill the bacteria causing wound infections stands as a milestone discovery in the annals of human medicine Translation of his techniques into forward military practice came quickly when antiseptic occlusion dressings in soldiers‘ aid kits appeared in the Spanish-American War[7]; antiseptic coverage of wounds was taught as basic care to the European armies at the outset of The Great War Lister himself, however, avoided ―old-fashioned‖ debridement of tissue, favoring his carbolic acid tonics alone for the best treatment of soft-tissue infection, though Sir Alexander Fleming thought the long-term gangrenous damage he saw at General Hospital Number 13 in 1915 outweighed the early benefit of Lister‘s caustic antiseptics[8] The optimal, balanced approach to Listerian implementation combined with Larrey‘s debridement would eventually be promoted by Army Colonel Antoine Depage as what we would think of now as combined therapy—sharp debridement of dead tissue with medicinal cleansing of the remaining microscopic contamination.[6] Fleming‘s discovery of penicillin had not yet opened the floodgates for systemic antibiotics, so local delivery in the Listerian paradigm served as the primary medical antibiosis of the time Topical carbolic acid only treated the surface of the wound, and with lower efficacy than desired Alexis Carrel, only three years removed from receiving his Nobel Prize, collaborated with English chemist Henry Dakin to advance local decontamination They perfected targeted delivery of Dakin‘s solution (0.5% sodium hypochlorite and dichlormaine T) to damaged tissues through perforated rubber tubing implanted or tunneled through the wounded service member‘s body[2, 7] Infusions every two hours reportedly cleansed myriad wounds, allowing better surgical debridement or closure with a purified field[9] Tubes and chemicals provided the best antiseptic therapy for salvaging wounds—and lives—in World War I, and was adopted in civilian practice until systemic delivery of antibiotics was developed later in the century[10] Depage, also by then the director of the Belgian Red Cross, presented illustrative data to the American Surgical Association‘s 1919 meeting based on his hospitals‘ treatments in the later stages of the war The decrease in amputations was astounding, especially after the addition of arthrotomies with Carrel-Dakin‘s irrigation, followed by immediate closure when the wound included a major joint capsule.[11] Even centuries before the bacteriological model of infection, military surgeons knew that infected or gangrenous wounds killed patients Unfortunately for the injured soldier or sailor, this often meant amputating the offending limb While Lister, Carrel, Fleming, and others worked to manage the infection, surgical contemporaries devised better interventions for source control The prevailing thought for projectile-wound infections, almost since the debut of powder-fired weapons, was that of poisoning by gunpowder or poison-laden projectiles themselves New observations by military physicians in far-flung global wars advanced the corporate knowledge of wounds through the tragedy of soldiers injured in those conflicts One U.S surgeon, Navy Commander A M Fauntleroy, wrote about this prolifically, as a result of his assignment as a forward medical observer in Europe before the U.S entered the war Fauntleroy presented a paper at the 1916 American Surgical Association meeting proposing contaminated clothing as an infectious source, and that wounds reflected the environment in which they were incurred His experience treating the injured from the Boer Wars on the dry veldts of South Africa noted quick recoveries for soldiers with open but minimally contaminated wounds When open wounds met the muck of trench warfare throughout Western Europe, results differed The wet fields of France and Germany, heavy with manure fertilizer, held different threats than the veldts.[12] Even warfare itself changed the microbial profiles of wounds Trench warfare‘s stagnation meant injured men could sometimes lay for days in the contaminated No Man‘s Land between trenches Fleming worked tirelessly at the Institut Marie Depage in the years prior to his revolutionizing discovery of penicillin His studies of wounded soldiers‘ clothing yielded numerous bacteria, most of them terribly virulent, including C perfringens and C tetani.[6] As Thomas Helling notes in his treatise on Depage, ―[t]he dead were sometimes left indefinitely to rot before the trenches and often became part of the terrain as artillery pulverized them into the dirt and mud, adding to the microbial morass.‖[6] Dirt is the soldier‘s constant companion, and the wounds of ongoing wars continue to vex modern medicine Similar work regarding invasive fungal infections from blast injuries is ongoing at America‘s leading military medical center, and carries direct relevance to the conflicts of today[13] The new projectiles of higher-powered rifles and fragments of thousand-pound shells could lodge deep into the muscles of battle-hardened soldiers Prevailing practices in earlier conflicts taught surgeons only to explore the wound in search of the offending missile if easily accessible or if arterial bleeding ensued With the realization of Roentgen‘s X-ray technology, new devices and techniques arrived for accurate localization and removal of foreign objects Joseph Flint, professor of surgery at Yale, served in several hospitals in France His staff variously used a vibrating magnet and the ring compass (and developed modifications that allowed it to be molded and hinged, useful on any location on the body), finally settling on their modification of the Sutton Localizer A piano wire, eventually modified to a more robust wire with a harpoon-style tip, was inserted under fluoroscopic guidance through a blunt obturator until contacting the bullet The obturator allowed manipulation under the fluoro screen without sharp dissection or perforation concerns This effectively established wire/needle localization as a technique for preoperatively defining a deep-tissue target for surgeons[14] Flint credited these targeted removals for low rates of sepsis in his hospitals BURNS Late 1800s burn care had changed little in the centuries prior that is in all but the most avant-garde surgeons Balms, oils, tinctures of all sorts and sources—many had been in use since medieval days The technologically advanced treatments essentially replaced solutions of steeped plants or animal products with picric or boric acid solutions A Minnesota surgeon, Haldor Sneve, presented a paper that was decades ahead of its time when he suggested salt solution clysis for resuscitation and even xenografts of chicken skin to replace lost tissue [15] Fauntleroy turned tragedy into progress with his analysis of burn treatments Late in the War, a coal ship explosion severely burned 32 men who presented within hours to Fauntleroy‘s hospital His team essentially instituted a randomized, controlled crossover trial by starting half the victims with ―noninterference,‖ meaning without debridement, and the rest with standard removal of damaged tissue All patients received the World War I version of treatments we recognize today—external heat, fluid resuscitation (done by Fauntleroy with rectal clysis using dextrose 4% with normal saline), dressing changes, and pain control Interestingly, Fauntleroy concluded that burns healed best without debridement Other aspects sound strikingly similar to the Clinical Practice Guidelines and leading research published by today‘s U.S Army Institute of Surgical Research Burn Center, a world leader in burn care and research at the San Antonio Military Medical Center: early fluid resuscitation prevents burn shock, burn sepsis sets in quickly, and extensive body surface area burns poorly.[16] Fauntleroy‘s paper stands as one of the first in a distinguished, ongoing line of military burn research LABORATORY MEDICINE Entering World War I, laboratory medicine meant completing one‘s own tests with the office microscope or chemical kit, or contracting out to a local private chemist Few hospitals offered laboratory services inhouse Residents or researchers provided the service for hospitals lucky enough to have the funding required Private chemists were in short supply on the battlefields of Europe, however, so the Army provided lab services with speed and quality unexpected to deployed physicians Pathologist Army Colonel Joseph Siler, M.D., managed a network of laboratories headquartered at the Central Medical Laboratory in Dijon, France Notably, Siler exercised significant autonomy directing his labs, particularly because of confusion surrounding his chain of command For many months early in the War, laboratory services ostensibly fell under the Division of Sanitation, managed by the Army‘s supply corps Physicians employed the labs with such gusto that efficiency became key Army Colonel Louis Wilson served as Siler‘s assistant director of the Allied Expeditionary Force‘s laboratories He served while on leave from his civilian role as director of laboratories at the Mayo Clinic Wilson instituted a report detailing which ordered tests turned positive to determine appropriate utilization This may be the first documented use of a ―Physician Report Card‖ for practice adjustment.[17] Army labs offered wide-ranging tests, including the first forward-deployed pathogen testing Typhoid and syphilis, specifically, ran rampant through troop encampments; testing and treating these infections effectively increased combat readiness of the force So accustomed were physicians to the support of Siler and Wilson‘s labs that returning physicians soon demanded their home hospitals develop similar programs.[3] National societies soon joined the movement The American College of Surgeons required in-house labs as part of their post-war accreditation package.[17] Pathologists within range of the front also meant routine autopsies on deceased soldiers Many young surgeons learned trauma care through the pathologist‘s knife, turning those tragedies to successes when treating future wounds These autopsies also enhanced development of protective gear used by Allied troops, with real-time feedback available for commanders.[17] BLOOD BANK One of the military‘s greatest medical legacies from World War I is the blood bank Leading surgery and hematology experts from around the world entered the Allied countries‘ services with an impassioned focus on saving lives through transfusion Almroth Wright described citration for the storage of blood in 1897 Physicians at Harvard/Massachusetts General Hospital stood on his shoulders in support of the war in Europe Dr Oswald H ―Robby‖ Robertson widely advocated for typed blood to be available for transfusion at hospitals near the battlefront, citrated in a modification of Wright‘s method Tremendous support came in the person of Harvey Cushing and Base Hospital 5, (known throughout the theater as ―Cushing‘s Hospital‖) especially after Cushing and other Harvard staff visited Carrel and staff working under Depage With input from Carrel, Robertson and Cushing‘s staffs developed improved apparatus for administering the blood in a deployed setting British physicians immediately embraced the practice, inviting Robertson to travel and teach.[7] Hundreds of physicians and nurses received training from Robertson‘s crew, spreading this lifesaving capability throughout the European fronts As Hedley-Whyte notes in his review of transfusions and war, ―[b]y 1918 each base-hospital and casualty clearing station hospital was transfusing about 50 to 100 pints of blood to an average of 50 wounded each day on the Western Front.‖[18] Robertson‘s impassioned drive to care for the troops yielded another world first—the blood bank ―Robby‖ could often be found treating patients near or on the front battle lines—even once barely escaping German capture when his unit was overrun During 1917‘s Battle of Cambrai, in far-northern France, Robertson fashioned an ice chest from ammunition cases to personally transport 22 units of blood to a clearing station within range of the fight The blood survived the trip, treating Canadian shock casualties, and the blood bank was born.[19] Refrigerated banks became the rule throughout the Western Front.[20] SHOCK Army General J.M.T Finney, a future American College of Surgeons (ACS) president, served as the Chief Surgical Consultant to the American Expeditionary Force for much of The Great War In an act of visionary leadership, he established a Central Laboratory for focused, translational research on topics immediately applicable to battlefield medicine Finney chose another future ACS president, Army Major George Crile, to head the Central Laboratory Crile established early fame in the 1890s for his research in shock and surgical physiology, performed the first human-to-human blood transfusion in 1906, and would go on to found the Cleveland Clinic after being promoted to brigadier general in the inter-war years Walter Cannon, Harvard‘s eminent physiologist, researched and published prolifically from the FinneyCrile Laboratory Cannon realized the detrimental effects of hypothermia on patients in shock, and was among the first to advocate active, artificial rewarming of trauma patients.[21] Cannon also proposed that shock resulted from blood and plasma loss, and was not purely a condition of nerves He supported the use of intravenous fluids for treatment; earlier in the century, rectal clysis or subcutaneous (―under the breast‖[22]) was the quickest parenteral entry Edward Archibald and W S McLean, two Canadian medical officers serving in Europe, followed Cannon‘s lead They observed excellent resuscitation results with saline, even proposing an idea decades ahead of its time—―hypertonic salt solution at twice decinormal strength‖ for volume expansion Their conclusions that the response to saline is important, but fleeting, also led to proposals of adding colloid to resuscitations Further, they even noted some mechanism for blood being ―sucked away‖ from the circulation during shock, perhaps foreshadowing the widened intracellular junction model of today.[22] MEDICAL EVACUATION Long before World War I, surgeons realized the basic fact that casualty survival increased as injury-tosurgeon time decreased Larrey‘s ―flying ambulance‖ model had not been fully espoused by military planners, so most medical care comprised first aid by line medics, with advanced care waiting until after the battle subsided This led to high mortality rates for intra-abdominal injuries, even leading some surgeons to avoid abdominal operations.[12] In Russia, Dr Viera Gedroitz (a Russian princess and surgeon) refused to operate on abdominal injuries older than three hours To access more soldiers inside that critical window, Gedroitz outfitted a railcar as a mobile operating suite, moving treatment toward the fight.[7] Another Russian pioneer instituted a continent-wide trauma treatment and evacuation system that became the basis for major wars of the next 100 years Vladimir Oppel‘s system was based on his emphatic belief—―[t]he wounded patient needs to undergo the right operation at the right time and in the right place.‖ As a surgeon on his first assignment early in the war, he lamented inefficiencies in medical care, where injured soldiers only received cursory treatment on the line; others, less injured, might evacuate more easily and arrive at collecting stations, using resources meant for their comrades dying in the field Dismal results followed—the Russian army was losing a war of attrition, returning only 40% to 60% of its casualties to duty, while on the western fronts, nearly 80% returned to fight Oppel proposed an integrated trauma treatment and evacuation system recognizable to today‘s military surgeons, with the first decisions of care being made immediately in a maximum of six hours In Echelon 1, wound debridement cleaned the wound and provided lifesaving treatment; Echelon allowed major operative treatment with definitive procedures; Echelon began rehabilitation, serial procedures, and other longterm treatments.[23] Adaptations on Oppel‘s plan form the basis of today‘s Joint Trauma System, itself a modification of the World War II structure.[23] The Royal College of Surgeons so appreciated his accomplishments that they accepted Oppel as an honorary fellow In the Allied forces, the Belgian surgeon Depage pushed care toward the line, setting up postes avances des hopitaux du front (advance posts of the front hospitals) Depage was already revered as one of the leading surgeons of northern Europe in 1912 when as a colonel in the Belgian army, he and Marie—his wife, anatomy illustrator, and research partner—traveled to the Balkans to set up hospitals for Belgian soldiers Only months after delivering his 1914 presidential address, “Les enseignements de la chirurgie de la guerre” (―Instructions in the surgery of war‖) at the New York meeting of the Societe Internationale de Chirurgie, he and Marie separately escaped the German invasion of Belgium, soon reuniting to found an ambulance (military hospital) at the personal request of Belgium‘s Queen Elisabeth.[6] From his main Ambulance de l'Ocean at La Panne, on the North Sea coast of Belgium, Depage deployed his first postes avances in the paradigm of Gedroitz, but on motorcars instead of rail Depage focused most of his forward care on abdomen and chest casualties, or massive hemorrhage Patients stable for duty could return from there, gaining back time previously lost to long round-trip transport; those requiring further care traveled back to an ambulance He reported that placing these mobile stations within km of the active battlefront reduced abdominal wound mortality from 65% to 45% Fauntleroy, the multi-war veteran renowned for burn care, supported this structure, noting when ―the patient could receive prompt attention, the results from operative treatment had been most encouraging‖ when compared with the expectant policies of prior conflicts.[12] When Marie died in the sinking of the Lusitania, he renamed Ambulance de l’Ocean the Institut Marie Depage in her honor She was returning to his side from a lecturing and recruiting tour in the U.S when she perished in the event that changed public opinion about U.S involvement in the War.[6] It was out of Ambulance de l’Ocean that Fleming and Carrel produced so much military medical literature BIRTH OF PLASTIC SURGERY Plastic surgery blossomed in World War I Sir Harold Gillies, an otolaryngologist by training, so impressed his seniors with skill and vision for the treatment of facial wounds that they chose him to open one of the first plastic surgery units in the world Widely regarded as the ―father of plastic surgery,‖ Gillies treated nearly 11,000 patients in the United Kingdom‘s military service over two World Wars.[24] His impassioned care of ―our boys‖ changed the lives of his patients Sir Harold developed numerous facial reconstructive techniques, perhaps the most famous being the ―tubed pedicle‖ graft.[25] Here he succeeded in maintaining robust blood flow to facial grafts with notably lower infection rates than prior techniques He also championed the psychological impact of plastics, encouraging peer support and multiple follow-up visits to boost patient morale Among those he trained would be his cousin and burn plastics pioneer, Sir Archibald McIndoe, whose newfound skills would bloom in World War II.[26] VASCULAR SURGERY Carrel led the world in vascular surgery techniques at the turn of the century His triangulation-and-fill suture technique enabled consistently successful end-to-end arterial repair for the first time in history Surgeons throughout the U.S and Europe began implementing this technique, but military applications came slowly; ligation or amputation remained standard practice throughout World War I Dr Bertram Bernheim quotes poor transport times and high infection rates that prevented widespread use of arterial repair techniques Most vascular repair work involved ligating pseudoaneurysms that had formed over injured vessels in the weeks after injury, when collateral circulation had already developed to help salvage the injured limb.[27] SURGICAL SPECIALTY CARE ―[T]he one agent of successful surgery, whether war surgery or civil surgery, is the good surgeon.‖[28] Crile‘s classic proverb arrived at the 1919 meeting of the American College of Surgeons Crile, along with several other pillars of American surgery, integrated civilian medicine into military structure and advanced the surgical care of our casualties.[29] American Surgical Association President Robert G LeConte encouraged military training for physicians, especially surgeons, knowing that surgeons in uniform encounter patients and environments not seen in civilian practice ―The duties of the military surgeon are vastly different from those of a civil practitioner, and no one in civil life can take the place of a trained medical officer.‖[5] Even simple topics like hygiene contained inherent differences During the Spanish-American War, for example, 3,681 mortalities were attributed to disease—2,649 of which were in stateside encampments Only 293 men died from battle wounds The risk of death was 10 times higher for those living at ―home‖ than fighting on the front line To permanently remedy that civilian-military medical chasm, Will Mayo formally proposed a standing military medical school in 1919, just after the end of World War I.[3] As the war brewed in Europe, Cushing, the Mayo brothers, and other medical giants prepared for America‘s contribution Will and Charlie Mayo began formal service for their country when they accepted commissions as Army first lieutenants in 1912 at ages 51 and 46, respectively Will Mayo chaired a committee of national medical leaders (Charlie Mayo also joined the board) who advised President Woodrow Wilson beginning in 1916 The Mayo brothers and committee began to assemble plans for mobilizing American medical expertise for war Much help was needed, as the U.S Army Medical Corps consisted of only 443 medical officers prior to World War I Politically, Charlie Mayo championed the Owens-Drier bill, allowing medical officers to be promoted as high as major general to provide parity in operational planning Prior to this time, regular Army physicians could only promote to colonel, and reservists (including Cushing, Crile, et al.,) could only attain the rank of major The Mayo ... governing the protection of human subjects COMBAT CASUALTY CARE AND LESSONS LEARNED FROM THE LAST 100 YEARS OF WAR KEY WORDS: military history, combat casualty care, military surgery I INTRODUCTION From. . .COMBAT CASUALTY CARE AND LESSONS LEARNED FROM THE LAST 100 YEARS OF WAR Matthew Bradley, M.D 1, 2, Matthew Nealiegh, M.D 1, John Oh, M.D 1, Philip... the front lines[5] ―Necessity is the mother of invention,‖ however, and the storms of war in Europe would soon water the fertile minds of military medicine around the world WOUNDS AND WOUND CARE