thumb|upright=1.22|[[Combat medics attend to Irish casualties following the opening attack of the Battle of Passchendaele, 1917]]

Battlefield medicine, also known as field surgery and later combat casualty care, is the treatment of wounded combatants and non-combatants in or near an area of combat. Civilian medicine has been greatly advanced by procedures that were first developed to treat the wounds inflicted during combat. With the advent of advanced procedures and medical technology, even polytrauma can be survivable in modern wars. Battlefield medicine is a category of military medicine.

History

Antiquity

During the 4th century BC, Alexander the Great (July 356 BC – June 323 BC) ran a lengthy military campaign, creating one the largest empires in history. During his military campaigns, tourniquets were used to slow the bleeding of wounded soldiers. Romans used them to control bleeding, especially during amputations. These tourniquets were narrow straps made of bronze, using leather only for comfort. In the 1st century BC, the Roman army used spider webs and honey-soaked bandages as field dressings. Wounds were packed with webs before being wrapped in honey-soaked bandages. The webs served as a natural fungicide while the honey staved off bacterial infection. Field healers provided wounded soldiers with amulets associated with their circumstances. This appears to have been effective for the combatant's mental health.

In 3rd century China, bamboo slips from the Han dynasty (202 BC – 9 AD) list injuries sustained by soldiers on the front line and from infighting. Illnesses related to the digestive and respiratory systems were also included. Medical treatment was limited and comprised such treatments as acupuncture, applications of plaster, and drugs, the latter being the most common. The practice of cranioplasty, or skull repair surgery, may have originated in pre-Incan Peru. Skulls with evidence of cranioplasty have been found more commonly in military burial grounds than residential ones, and primarily in male skeletons, suggesting the practice was mainly performed as a result of traumatic battle-related injury. Various materials were used to graft skull injuries, including non-natural and organic materials, such as gold and silver plates, shells and coconut.

Middle Ages

thumb|left|A wounded knight is carried on a medieval stretcher.The Middle Ages saw further developments in battlefield medicine. The Crusades allowed for significant development of trauma surgery and military medicine. In 1112, the first king of the Crusaders ordered a hospital to be built. This hospital was shown to have military medicine uses after 750 patients were admitted in a 24-hour period after a battle in November of 1177. This hospital utilized medicinal traditions from Schola Medica Salernitana, a prominent medieval medical school located in Salerno, such as examining the urine. The practices at the hospital were also influenced by Byzantine and Islamic methods. Despite these hospital systems and the recent invention of the tourniquet, most soldier fatalities on the battlefield were due to a fatal loss of blood. In order to return deceased crusaders' bodies home, practices like boiling the body to remove the bones, dissecting out important organs like the heart, and packing the body with salt were all common practices. This practice of dismemberment for transport occurred across Europe until a decree banning it was issued in 1299 by Pope Boniface III. However, it continued illegally after. Notably, crusaders performing such preservations learned a significantly better anatomical knowledge of the human body. As more soldiers were brought into the Crusades, more medical interventions for fatal blood loss were introduced. For example, texts from Islamic Spain describe an early cauterization method to stop arterial bleeding. This method involves using a hot olive cautery, a metal rod with an olive-shaped tip, to burn the artery shut. Performance of this procedure would be complicated by blood filling the site and making both the vessel and instruments slippery. Another notable innovation with a modern counterpart is an early stretcher, likely made from wicker over a frame. This stretcher appears in a manuscript from . Simple stretchers were commonly used in militaries through the middle of the 20th century. Ambulances as well were first used by Spanish soldiers during the Siege of Málaga in 1487, a part of the campaigns to seize control of southern Spain. Authorized by Isabella I of Castile, the ambulances were largely ineffective, though they were perceived as critical to Spanish morale.

Battlefield medicine also appears in classical medieval texts such as Wolfram von Eschenbach's (1160/80 – <abbr>c.</abbr> 1220) Parzival, first published in 1210. Wolfram von Eschenbach was a German knight, poet and composer, regarded as one of the greatest German writers in national history. A scene in the book describes a wounded soldier with internal bleeding in his chest. The book explains that the soldier was thrown from his mount after being struck by a lance that pierced his shield. After, a procedure similar to a modern-day thoracostomy, inserting a tube into the chest to release blood or fluid, is described. A similar procedure done for an accumulation of pus in the chest was described as early as 460 BC, by Hippocrates, (460 BC – 370 BC) an influential medical figure from Kos. Galen (129 – 216 AD), another influential medical figure, describes the procedure roughly 500 years later again for pus and not blood.

Early modern period

right|thumb|An illustration of the [[Wound Man, showing a variety of wounds from the ('Field Manual for the Treatment of Wounds') written by Hans von Gersdorff in 1517 and illustrated by Hans Wechtlin.]]The early modern period brought several large changes to the conduction of warfare, which in turn brought major developments to medicine. For one, political changes like the formation of nation-states meant that armies were now national institutions, and military medicine became an established professional field. Political conflict between emerging nation-states meant more organized warfare and larger conquests, both in duration and number of soldiers, thus requiring more surgeons and physicians to accompany. Social and cultural trends also impacted medicine and medical advancements. At the beginning of the 16<sup>th</sup> century, it was generally not socially accepted to alter the human body away from its natural form, even if that meant danger, or even death. Amputation was only accepted in cases of necrosis. Over the course of the 16<sup>th</sup> and 17<sup>th</sup> centuries, this convention gradually faded, allowing for more and more alterations to the body for the sake of health, including a gradual accepting of amputation as a lifesaving practice. Organized armies brought army surgeons along on their conquests; these surgeons were more specialized and more highly respected than civilian barber-surgeons, and they were trained to the same battle standards as soldiers, but better paid. Surgeons' social status grew significantly during this time, as the practical skills and handiness with tools was far more useful than a physician's knowledge of internal ailments in situations of dire injury. Further, guns enabled soldiers to become more accurate shots in shorter training times, leading to an increase in head injuries as soldiers aimed to cause maximal damage to their enemies' forces

With amputations becoming more common, prosthetic limb development also become more common. Notably, only among members of society with considerable wealth. An early modern German knight, Götz von Berlichingen (1480–1562), wrote a series of memoirs describing the aftermath of the loss of his right hand in 1504 when a piece of his own sword, shattered by a culverin (small handgun) wedged itself into his wrist, effectively severing it. At the same time in Europe, Italian Catholic anatomist Gabriele Falloppio (1522–1562) was also gaining experience with cranioplasty. He stated that a bone replacement is possible only if the dura mater (a thick protective membrane surrounding the brain) is not affected by the injury. if it is, the entire injured bone should be replaced with a gold plate. During the American Civil War, Jonathan Letterman modernized medical organization on the battlefield for the Union. Following his appointment as the Medical Director of the Army of the Potomac, Letterman founded an ambulance corps staffed with permanent and trained attendants which was later compounded in efficacy by the organization of hospital echelons and tent hospitals in the war's eastern theater. His contributions led to his being recognized as the "father of battlefield medicine".

During this time, the Relief Society for Wounded Soldiers, forerunner of the International Committee of the Red Cross (ICRC) was founded in 1863 in Geneva. The ICRC advocated for the establishment of national aid societies for battlefield medical relief, and stood behind the First Geneva Convention of 1864 which provided neutrality for medics, ambulances, and hospitals. In the late 19th century, the influence of notable medical practitioners like Friedrich von Esmarch and members of the Venerable Order of Saint John pushing for every adult man and woman to be taught the basics of first aid eventually led to institutionalized first-aid courses amongst the military and standard first-aid kits for every soldier.

20th and 21st centuries

left|thumb|An American soldier, wounded by a Japanese sniper, undergoes surgery during the [[Bougainville campaign in World War II.]]

  • Advances in surgery – especially amputation – during the Napoleonic Wars and First World War during the Battle of the Somme.
  • Medical advances also provided kinder methods for treatment of battlefield injuries, such as antiseptic ointments, which replaced boiling oil for cauterizing amputations.
  • Advances in understanding of Germ Theory and Asepsis as well as the introduction of High Explosive Artillery and Machine Gun filled Trench Warfare lead to conditions primed for better battlefield wound care. One such advance was the Carrel-Dakin Technique . This was developed by many but namely involved Alexis Carrel. This involved initial cleaning/Debridement of the wound, followed by irrigation with Dakin's Solution (Essentially dilute Aqueous Sodium Hypochlorite a solution developed by Henry Dakin ). This cleaned the wound of dead tissue and pathogen contaminated soil, as well as aided in drainage of Pus etc.
  • "During the Battle of Champagne in 1915, 80% of the wounded were infected with gas gangrene bacteria. A year later, when surgeons applied the Carrel-Dakin technique during the Battle of the Somme, that number was 20%"
  • During the Spanish Civil War there were two major advances. The first one was the invention of a practical method for transporting blood. Developed in Barcelona by Duran i Jordà, the technique mixed the blood of the donors with the same blood type and then, using Grifols glass tubes and a refrigerator truck, transported the blood to the front line. A few weeks later Norman Bethune developed a similar service. The second advance was the invention of the mobile operating room by the Catalan Moisès Broggi, who worked for the International Brigades.
  • The establishment of fully equipped and mobile field hospitals such as the Mobile Army Surgical Hospital (MASH) was first practiced by the United States in World War II. It was succeeded in 2006 by the Combat Support Hospital.
  • The use of helicopters as ambulances, or aeromedical evacuation, was first practiced in Burma in 1944. The first MEDEVAC under fire was done in Manila in 1945 where over seventy troops were extracted in five helicopters, one and two casualties at a time.
  • The extension of emergency medicine to pre-hospital settings through the use of emergency medical technicians.
  • The use of remote physiological monitoring devices on soldiers to show vital signs and biomechanical data to the medic and MEDEVAC crew before and during trauma. This allows medicine and treatment to be administered as soon as possible in the field and during extraction. Similar telemetry units are used in crewed spaceflight, where a flight surgeon at the Command Center can monitor vital signs. This can help to see issues before larger problems occur, such as elevated carbon dioxide levels, or a rise in body temperature indicating a possible infection.

History of Tactical Combat Casualty Care (TCCC)

In 1989, the Commander of the Naval Special Warfare Command (NAVSPECWARCOM) established a research program to conduct studies on medical and physiologic issues. The research concluded that extremity hemorrhage was a leading cause of preventable death in the battlefield.

Tactical combat casualty care (TCCC)

Tactical combat casualty care is becoming the standard of care for the tactical management of combat casualties within the Department of Defense and is the sole standard of care endorsed by both the American College of Surgeons and the National Association of EMT's for casualty management in tactical environments.

Tactical combat casualty care is built around three definitive phases of casualty care:

  1. Care Under Fire: Care rendered at the scene of the injury while both the medic and the casualty are under hostile fire. Available medical equipment is limited to that carried by each operator and the medic. This stage focuses on a quick assessment, and placing a tourniquet on any major bleed.
  2. Tactical Field Care: Rendered once the casualty is no longer under hostile fire. Medical equipment is still limited to that carried into the field by mission personnel. Time prior to evacuation may range from a few minutes to many hours. Care here may include advanced airway treatment, IV therapy, etc. The treatment rendered varies depending on the skill level of the provider as well as the supplies available. This is when a corpsman/medic will make a triage and evacuation decision.
  3. Tactical Evacuation Care (TACEVAC): Rendered while the casualty is evacuated to a higher echelon of care. Any additional personnel and medical equipment pre-staged in these assets will be available during this phase.

Since "90% of combat deaths occur on the battlefield before the casualty ever reaches a medical treatment facility" (Col. Ron Bellamy) TCCC focuses training on major hemorrhaging and airway complications such as a tension-pneumothorax. This has driven the casualty fatality rate down to less than 9%. Newer devices approved for use by the CoTCCC for hemorrhage control include the iTClamp and XStat. Pharmacological options also include tranexamic acid, and hemostatic agents such as zeolite and chitosan. They may also utilize the jaw thrust and head-tilt/ chin-lift maneuver to open a casualty's airway. This also provides a route for the administration of other drugs in accordance with the provider's scope of practice.

As trauma-induced hypothermia is a leading cause of battlefield deaths, a provider may also perform hypothermia prevention can be accomplished through the use of a Hypothermia Prevention and Management Kit or emergency blanket, the placement of a casualty on an insulated surface, and the removal of wet clothing from a casualty's body.

Care under fire

Care under fire is care provided at the point of injury immediately upon wounding while the casualty and care provider remain under effective hostile fire. The casualty should be encouraged to provide self-aid and remain engaged in the firefight if possible. If unable to do so, the casualty should be encouraged to move behind cover or "play dead". The primary focus during care under fire should be winning the firefight to prevent further casualties and further wounding of existing casualties. Requests for evacuation of casualties and pertinent information are typically communicated through 9-Line MEDEVAC and MIST reports.

Tactical evaluation is an umbrella term that encompasses both medical evacuation (MEDEVAC) and casualty evacuation (CASEVAC). Medical evacuation platforms are typically not engaged in combat except in self-defence and defence of patients. MEDEVAC takes place using special dedicated medical assets marked with a red cross. Casualty evacuation is through non-medical platforms and may include a Quick-Reaction force aided by air support. The priority is to continue the combat mission, gain fire superiority, and then treat casualties. The acronyms MARCH and PAWS help personnel remember crucial treatment steps while under duress.

MARCH

The MARCH acronym is used by personnel to remember the proper order of treatment for casualties.

Massive hemorrhage. The most potentially survivable cause of death is hemorrhage from extremity bleeds, however more than 90% of 4596 combat mortalities post September 11, 2001 died of hemorrhage associated injuries. Of the 4,596 casualties, 87% died in the pre-medical treatment facility, prior to receiving surgical care. A four-year retrospective analysis showed that out of 91 soldiers who were treated with tourniquets, 78% of tourniquets were applied effectively. The study concluded that tourniquets are effective, but must be used appropriately.