Impact and Limitations of Advances in War Surgery, 1975 to Present

Abbreviations

CSH

Combat Support Hospital

DCR

Damage Control Resuscitation

DCS

Damage Control Surgery

FST

Forward Surgical Team

IHL

International Humanitarian Law

JTS

Joint Trauma System

JTTR

Joint Theater Trauma Registry

LMICs

Low‐ and Middle‐Income Countries

LRCS

Low‐Resource Conflict Settings

LSCO

Large Scale Combat Operations

MTOS

Major Trauma Outcome Study

OEF

Operation Enduring Freedom

OIF

Operation Iraqi Freedom

TCCC

Tactical Combat Casualty Care

1. Introduction

The past 50 years have been dominated by non‐state armed conflict, with significantly fewer major interstate wars involving conventional militaries [1]. Asymmetric and hybrid warfare involving insurgency‐counterinsurgency dynamics, guerrilla warfare, and intrastate conflict are increasingly common. Significant attention has been given to conflict dynamics such as large‐scale combat operations (LSCO) and irregular warfare, which may pose different tactical casualty care challenges than those typically encountered by high‐resource militaries in recent wars. Advances in weaponry pose new threats, including the widespread use of drones and high‐order explosives such as thermobaric weapons [2]. In addition, respect for international humanitarian law (IHL) has eroded, contributing to increased attacks on humanitarian workers in conflict [3].

From a clinical perspective, the practice of war surgery is highly dependent on the tactical circumstances: urban versus rural conflict, guerrilla or conventional warfare, etc. The feasibility of casualty care delivery depends partly on how military, civilian, and humanitarian medical actors are coordinated within a given context [4]. Most significant is the distinction between high‐ or low‐resource health systems, as resource availability defines logistical capabilities and the staffing of trained surgical personnel. Warring parties either have the logistical means—industrialization, wealth, administrative capacities—to influence the tactical situation through advanced care of the wounded, or they do not.

Among high‐resource militaries with sufficient resources, numerous lessons of the post‐WWII period have been refined, including air evacuation of the wounded and deployment of forward surgical teams. These advances are contingent on logistical capacity and therefore remain largely inaccessible in low‐resource conflict settings (LRCS). Acknowledging this reality, we present and contextualize the following five advances: (i) standardized data collection and trauma registries; (ii) improvements in transport and rapid evacuation; (iii) prehospital hemorrhage control; (iv) damage control resuscitation and damage control surgery; (v) ketamine and locoregional anesthesia.

These key concepts of modern conflict surgery were largely developed during the US‐led wars in Iraq and Afghanistan: Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF). Of the advances presented in this perspective, only the use of ketamine and whole blood have been widely implemented in LRCS. The challenge of adapting and implementing modern advances in conflict surgery to low‐resource settings is a complex, systems‐level problem. As incremental progress is made, surgical teams working in LRCS must continue to adhere to the basic principles of war surgery [5, 6], which remain fundamentally unchanged.

2. Logistical Developments

Much progress in casualty care over the past 50 years has been a function of logistical capabilities. The following strategies have been successfully implemented predominantly, but not exclusively, by high‐resource armed forces:

2.1. Trauma Registries and Standardized Data Collection

Standardized trauma registries are a fundamental part of casualty care and are critical to: (i) analyze causes of preventable death [7], (ii) benchmark the impact of interventions introduced to address these causes of preventable death [8], and (iii) conduct quality improvement and monitoring of specific casualty care interventions [9]. The first trauma registries were civilian, designed to document the epidemiology of traumatic injuries [10].

During OIF and OEF, US and coalition service members faced lower case fatality rates among wounded service members than in any previous conflict [11]. This unprecedented survivability can be credited in part to the Joint Trauma System (JTS) implementing a continuous performance improvement cycle using the Joint Theater Trauma Registry, now the Department of Defense Trauma Registry. Other high‐income military trauma registries, including the Israel Defense Forces Prehospital Trauma Registry, which is integrated into the Israeli National Trauma Registry, have produced similar results [12]. While successful, these registries require continued monitoring and context‐specific adaptation.

Trauma registries continue to be implemented in low‐ and middle‐income countries (LMICs) globally, including those affected by conflict, with many examples available in recent literature [13]. However, numerous constraints to robust data collection, including limited information management systems as well as inadequate workforce, financing, and infrastructure, lead to gaps that hinder these registries' ability to reliably support evidence‐based advances in casualty care in LRCS [14]. Wider adoption of a standardized casualty data registry holds potential to improve casualty care in low‐resource settings [11]. An open‐access casualty data toolkit encompassing the full continuum of casualty care has been presented for this purpose and can be adapted to suit the needs of surgical teams in a range of LRCS (Supporting Information S1) [14].

2.2. The Golden Hour: Advances in Casualty Transport and Rapid Evacuation

The operational context of the Vietnam War resulted in a paradigm shift in casualty care through a model of predominantly aeromedical casualty evacuation that informed later multi‐level trauma systems [15]. The concept of a “Golden Hour,” which linked rapid hemorrhage control and evacuation to marked increases in survivability, became a core tenet of casualty care [9, 16]. Logistics of rapid evacuation to surgical care, including en‐route medical capabilities, were further developed during 21st century US‐led military interventions in the Middle East and informed the modern echelon of care structure used by high‐resource militaries [11, 17].

The US military's modern trauma system is a continuum of care divided into four roles: Role 1, Tactical Combat Casualty Care (TCCC), where frontline personnel perform basic emergency point‐of‐injury care; Role 2, Forward Surgical Teams (FSTs) capable of performing damage control resuscitation (DCR), which includes damage control surgery (DCS); Role 3, Combat Support Hospitals (CSHs), which provide the highest level of in‐theater care and stabilize casualties before evacuation out‐of‐theater; and Role 4, well‐resourced definitive and rehabilitative care facilities [18].

Although the US military reduced combat mortality to the lowest levels in modern history during OIF and OEF, data indicate that further reductions in preventable death will require increased emphasis on prehospital care and forward surgical capabilities [19, 20]. In future conflict, air superiority may not be achievable, especially in near peer conflicts, LSCO, irregular or unconventional warfare, and other austere settings. Current casualty evacuation practiced by the Ukrainian Armed Forces relies almost completely on overland extraction and frequently entails prolonged prehospital care [21].

Neither rapid transport times resembling a “golden hour” nor analogous tiered trauma systems with echelons of care have been successfully implemented at scale in LRCS, where resource constraints and remote terrain make these strategies infeasible [22]. In many LRCS, the war‐wounded are mostly treated in civilian hospitals, with limited to nonexistent prehospital care. One systems‐level response to this operational reality would be increased uptake of a condensed, trauma‐focused version of the World Health Organization's Community First Aid Responder training, integrating certified lay responders into the prehospital emergency care system to improve point‐of‐injury care by nonmedical personnel [23]. The establishment of trauma stabilization points in select settings may potentially move care closer to the point of injury in LRCS [11]. Given that accelerating transport times is unlikely, at least in the short term, alternative strategies to improve prehospital casualty care in such environments are needed. The security of such prehospital personnel, particularly when relying on layperson response, presents a significant challenge in conflict settings.

3. Clinical Developments

Throughout history, trauma care advances have been exchanged bilaterally between civilian and military systems [24]. Wartime medical necessity forces innovations that are later adapted to civilian trauma systems, while, likewise, advances made in the civilian peacetime environment are translated to a military context. The following clinical advances continue to be developed through civilian‐military collaboration.

3.1. Prehospital Hemorrhage Control

Catastrophic hemorrhage is the most common cause of preventable death on the battlefield [25], and early hemorrhage control has the potential to significantly improve survivability [26]. The effectiveness of hemorrhage control is determined not only by injury pattern, but by evacuation timeline, product availability, and application quality [27]. Initial management of external hemorrhage relies on hemostatic agents and mechanical interventions including extremity tourniquets (TQ), junctional TQs, and pelvic binders [28].

TQs were widely used during OEF/OIF and subsequently in civilian practice. In high‐resource settings, they have been shown to reduce mortality from hemorrhage as well as to be safe with few complications [29]. These outcomes were observed within systems supported by trained application and rapid evacuation and conversion [27]. Junctional TQs and external aortic compression devices require specific training and structured continuation of care and may therefore be difficult to deploy reliably in austere environments [30].

Coordinated efforts to address gaps in training and produce context‐appropriate hemorrhage control guidelines are needed to retain the survival advantage of TQ use without amplifying harm during periods of prolonged field care or delayed presentation [29]. These efforts should prioritize context‐adapted training that emphasizes appropriate indications for TQ placement, principles of reassessment and conversion, and non‐TQ hemorrhage control modalities, supported by device and hemostatic product selection aligned with local constraints and evacuation timelines [29, 31].

The application of hemorrhage control guidelines derived from high‐income countries without context‐specific adaptation to LRCS has been associated with harm in austere settings where prolonged prehospital times remain the norm. Significant morbidity and mortality associated with improvised, improper, or contraindicated TQ application has been observed in the Sahel [29], Sri Lanka [32], Israel [33], and Ukraine [34], in keeping with the history of the “tourniquet pendulum” between benefit and harm [35]. Hemostatic products may facilitate earlier TQ conversion where feasible [27], potentially mitigating tissue loss due to ischemia.

3.2. Damage Control Resuscitation and Damage Control Surgery

War casualties presenting with multidimensional injuries and severe shock require a damage control approach. DCR is a framework for mitigating the “lethal triad” of acidosis, hypothermia, and coagulopathy via rapid hemorrhage control, hypotensive resuscitation, and restoration of intravascular volume through the early use of blood and the limited use of crystalloids [36, 37]. DCR includes autotransfusion and whole blood transfusion, longstanding practices in LMICs, as well as components such as freeze‐dried plasma and tranexamic acid [38]. DCS is applied within DCR.

DCS refers to minimizing operative time through rapid hemorrhage and contamination control, focusing on immediate lifesaving measures so that the casualty may then be warmed and resuscitated until hemodynamic stability is restored. DCS prioritizes restoration of physiology over anatomical reconstruction, with definitive reconstruction delayed until the patient has metabolically recovered from hemorrhagic shock [39]. In high‐resource trauma systems, DCS has been associated with improved outcomes for severely injured patients [40]. While DCS is lifesaving in appropriate contexts, overuse is associated with increased morbidity and mortality among trauma victims [41].

Although DCS can be effectively performed in low‐intensity, austere, and guerrilla contexts, its application in LRCS depends on logistical capacity and is often delivered without the downstream support required for staged physiological recovery [5, 42, 43, 44, 45]. DCS requires the capability to stage surgical care close to the front lines, trained personnel, and adequate blood supply, which pose challenges to implementing damage control principles in LRCS. It is a resource‐intensive and highly individualized mode of treatment that may be unavailable when casualty volume exceeds staging capacity.

3.3. Ketamine and Locoregional Anesthesia

Of the advances presented, ketamine is the most applicable in LRCS and is widely used in the management of traumatic injury across high‐ and low‐resource settings in peace and wartime. Ketamine is often the only available agent capable of providing reliable anesthesia in austere environments and can be administered with basic equipment. Ketamine is safe and effective in these environments [46]: it requires minimal training to administer [47], requires no electricity or compressed gas, and is shelf‐stable and low‐cost [48]. Accordingly, it is widely used as the anesthetic of choice for surgical interventions in LMICs.

Ketamine may be administered intramuscularly when intravenous access is unavailable, intravenously as a bolus, or titrated by infusion to maintain anesthesia [5]. It may also be combined with regional anesthesia or nerve blocks to support patient comfort while preserving spontaneous respiratory control [5, 49]. When emergency care systems collapse, ketamine preserves the capacity to deliver anesthesia for surgical interventions.

Widespread US military adoption of ketamine did not occur until OEF, where prehospital casualty data analysis prompted a focus shift toward improving TCCC guidelines and prehospital care, despite its earlier use as a surgical anesthetic during the Vietnam War [25, 50]. Since its re‐adoption by the US military, contemporary guidelines [51] advocate the use of ketamine in a wide range of settings. Unfortunately, recreational abuse has led to multiple attempts at scheduling ketamine as an internationally controlled substance [52]. Ketamine must remain available to clinicians providing surgical care in LMICs. If access is restricted through international scheduling, the impact on surgical care within LMIC health systems may be disastrous.

4. Conclusion

Most reports of modern trauma care emphasize advances made within high‐resource militaries in the 21st century. Without diminishing the impact of these achievements in their context, few are currently applicable in LRCS where a significant burden of conflict‐related injury occurs, and where the fundamentals of war surgery have remained largely unchanged. In addition to resource limitations, the erosion of respect for IHL and the Geneva Conventions constrains access and safe operation for medical personnel in LRCS, directly threatening the provision of surgical care. Where access is not protected, the continuity of surgical care becomes untenable.

While considerations surrounding high‐resource militaries should not detract from the intrinsic imperative to improve casualty care in low‐resource settings, in future conflicts where air superiority and intact supply chains cannot be achieved, high‐resource militaries may experience conditions that resemble LRCS more closely. Improving outcomes for local casualties in LRCS requires increased focus on alternative strategies applicable to environments with extreme resource constraints where advances contingent on logistical capabilities cannot be achieved. Increased attention should be given to scalable and context‐appropriate hemorrhage control, prolonged field care, whole blood use close to the point of injury, and context‐appropriate DCS where feasible, prioritizing co‐design of alternative care strategies with local surgical personnel.

Author Contributions

Mick Chivers: conceptualization, writing – original draft, writing – review and editing, project administration. Christos Giannou: conceptualization, writing – review and editing. Amila Ratnayake: conceptualization, writing – review and editing. Hannah B. Wild: conceptualization, supervision, writing – review and editing, project administration.

Conflicts of Interest

The authors declare no conflicts of interest.

Supporting information

Supporting Information S1

Data Availability Statement

Data sharing not applicable to this article as no datasets were generated or analyzed during the current study.