When I first started writing this editorial around the middle of January 2012, I was at Manas Air Base, near Bishkek, the capital of Kyrgyzstan. I had arrived there a couple of days earlier from a multiple-leg flight that took me from Baltimore to Germany to Turkey and then to Manas, one of the staging areas for service members transitioning into and out of Afghanistan. I was sitting in the local coffee shop awaiting my connecting flight into Bagram Airfield in Afghanistan, where I would soon serve as the Human Protections Administrator (HPA) on the Joint Combat Casualty Care Research Team (JC2RT). The irony is that when Dr Craik originally approached Dr Aiken and me in the fall of 2011 to gauge our interest in putting together a special issue focused on military rehabilitation, I had absolutely no idea I would even be deployed. I now sit back in the comforts of my home in the United States putting the finishing touches on this editorial, the writing of which spanned my entire 6-month deployment. Needless to say, this special issue now has more personal relevance for me than perhaps it otherwise would have had!
Regardless of your political leanings, war is the closest thing to hell on Earth, especially as it relates to combat casualties. Fortunately, service members at war now have immediate access to new lifesaving drugs, blood products, and techniques for applying tourniquets. Due to these rapid advancements, survival rates among combat casualties are frequently better than those among civilian trauma cases. However, with this dramatic improvement in survival rates from battle-related injuries comes an ever-pressing need to address the rehabilitation needs of our nation's wounded service members—which is in part the rationale behind this special issue. Compared with civilian trauma, the mechanism of injury in combat casualties is typically penetrating trauma, with the majority of cases attributable to explosive fragments from improvised explosive devices (IEDs). Moreover, given the explosive nature of these injuries, service members typically suffer from polytrauma, and many sustain extremely debilitating injuries—limb loss, traumatic brain injury, and posttraumatic stress disorder, among others. The cumulative effects of these injuries have profound implications for our nation's postwar rehabilitation, infrastructure, and research needs. Even when war ends, the health issues arising from it do not. Veterans come forward many years later with service-related illnesses and injuries.
Musayi, Afghanistan, 2006, SFC Darrold Peters. Courtesy of the Army Art Collection, US Army Center of Military History.
Many of the medical innovations that have contributed to the increased survival rates have arisen from the medical research conducted in Iraq and Afghanistan under the purview of the JC2RT. On the one hand, war offers a tremendous real-time laboratory to discover breakthrough innovations in lifesaving interventions because of the high number of unique trauma cases. The potential subject pool is vast because researchers have access to service members with explosive injuries, gunshot and shrapnel wounds, burns, musculoskeletal injuries, and brain trauma. Conditions like this fortunately do not occur under virtually any other circumstance, thus finding medical breakthroughs for combat casualties is difficult in peacetime. The casualty care system during combat also is an ideal research environment because of the ability to link pre-deployment health status with the injury and eventual outcome and the fact that all levels of care, including rehabilitation, occur within the same health care system, providing a single database. In fact, the techniques used in civilian emergency medicine have been transformed in many ways from the knowledge gained on the battlefield.
On the other hand, despite these favorable conditions for combat casualty care research, there also are challenges. War is a highly austere environment that often presents chaotic and stressful circumstances. Data collectors find themselves in the trauma bay and operating rooms collecting blood samples for a research study in patients undergoing a lifesaving intervention; busy clinicians measure tissue perfusion in the back of a helicopter or intracranial pressures during flights out of the combat zone to understand the impact of flight on the patient's physiologic status. Injured service members also are rapidly transported from the point of injury to a number of medical facilities until they reach a facility that can provide definitive care for their injuries, making research data collection particularly difficult. For example, patients rarely remain at a fixed facility for more than 24 hours (sometimes only 4–6 hours) before being evacuated to the next level of care. Multiple coordination efforts with other facilities in the care process are required if serial data collection is required at specific time points. Other challenges include difficulty obtaining research supplies, limited connectivity (eg, Internet, phone, etc), and cultural issues in a multinational health care system (Dutch, German, British, Afghan, etc). Complicating matters, investigators and JC2RT team members frequently rotate in and out of theater, resulting in high personnel turnover rates and, therefore, a lack of continuity for conducting research.
The conduct of medicine in Iraq and Afghanistan has not been without criticism. For example, charges were made in 2009 regarding experimental treatments having been rushed onto the battlefield without adequate safety testing or ethical review, unnecessarily placing service members at risk of harm. There are also legitimate concerns that service members could be coerced into participating in research via their chain of command. Despite the chaos of war, the importance of protecting human subjects in a war zone is just as relevant as it is during peacetime. Therefore, in addition to JC2RT's role in facilitating the conduct of combat casualty care research, it also plays a regulatory role, particularly the HPA position in which I served. My job was largely to ensure that studies were being conducted according to the applicable rules, regulations, and laws and that the rights of human subjects were being protected. Practically speaking, I reviewed protocols to ensure that appropriate human subjects protections were in place, and I performed site visits to conduct study audits. Serving in a regulatory role was an interesting shift for me, as I am an investigator in my “natural habitat,” not a regulator. Being on the other side of the fence made me appreciate the important role that regulators play, so long as these efforts genuinely protect human subjects rather than add unnecessary process that primarily serves to feed the research bureaucracy.
I am deeply thankful for the opportunity to have served, but, more important, I am thankful for the countless men and women who place their lives at risk every day “outside the wire,” some of whom gave the ultimate sacrifice and others whose lives will never be the same as a result of their injuries. It is to these US, Canadian, and other coalition service members around the world that this special issue is dedicated. Our aim in producing this special issue was to provide a global forum for authoritative empirical research, theoretical development and perspectives, clinical cases, and innovations. I hope our readers agree that this aim has been accomplished. Increasing our rehabilitation evidence base will ensure that we provide our military members and veterans with the care and support they need and will help bring rehabilitation innovations to civilian health care for generations to come. Our Wounded Warriors—and the legacy they leave behind—deserve nothing less.
Photo credits: United States Army Medical Department, Office of Medical History website, Government works (17 USC 403).
- © 2013 American Physical Therapy Association
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