Operations in Iraq and Afghanistan have changed military medicine. Now, the uniformed medics’ knowledge is more and more often used in the civilian environment.

On August 22, 2019, a violent storm in the Tatra mountains left four killed and 150 injured. Jan Krzysztof, the head of Tatra Volunteer Search and Rescue (TOPR), which was the first to begin the rescue operation, said that never before had there been a tragedy comparable to what had happened on Giewont. He told the journalists that “the situation could be compared to a terrorist attack. The victims were a big group of random people, including children. Broken legs, wounds, burns.” It was possible to bring the situation under control thanks to the effort of TOPR, and cooperation with other services: Mountain Volunteer Search and Rescue (GOPR), Medical Air Rescue (LPR), the fire service and the police.

Andrzej Górka, TOPR’s paramedic, was one of the first people who reached the injured people on this ill-fated day. “At first, I thought we were flying to burns in adults and cardiac arrest in a child. When we approached the top of Giewont, we saw many, many people who needed immediate help,” he recalls. “It was a mass accident, unprecedented in TOPR’s history. First, we started resuscitating two children, but we quickly switched to operating according to the mass casualty incident scenario, so we had to assess the state of all the injured. It wasn’t easy, as we were operating in steep, wet and slippery terrain, with occasional atmospheric discharges,” he adds.

Andrzej Górka has worked as a paramedic for ten years. He practices not only in TOPR, but also in the district hospital in Zakopane. He has additionally completed tactical medicine trainings. “For me, there is just one type of medicine. I don’t want to divide it into military and civilian, because soldiers’ physiology is the same as civilians’. In my everyday work on the medical rescue team, I usually deal with problems related to internal medicine or chronic diseases, and less often traumatic patients. That’s why I don’t use the knowledge obtained at TCCC [Tactical Combat Casualty Care] trainings in my everyday work, but I know that it can be useful, for example, in mountain rescue,” explains the paramedic. Górka admits that during rescue operations paramedics apply solutions used in the army. “I have already used a tactical tourniquet or hemostatic dressings preventing blood loss several times in my work,” he adds. He also says that TOPR rescuers operate in medical vests modeled on military ones, since the most important thing is to always have basic equipment with you.

Apart from TOPR full-time workers and other services, also tourists joined the August rescue operation. Robert Szulc from Łódź (who had finished a tactical medicine training) volunteered to help at the hospital in Zakopane where the injured people were brought from the mountains. A private of the Territorial Defense Forces (he did not want to reveal his name) took care of the injured at the Hala Kondratowa mountain hut. He selected those most severely injured and sent them down to the valley. Later, he went up towards the top to help more victims.

Military doctors and paramedics recognize elements of tactical medicine in the Giewont rescue operation. “TOPR had patients with mechanical injuries, burns, cases of neurological deficits – loss of hearing or sight, and hypothermia in the last phase of the operation. We dealt with similar problems during missions – sometimes we had to help multiple heavily wounded people at the same time, in order to dress the wounds as quickly as possible and evacuate them to a safe place,” describes a Special Forces medic.

Mission... into the Future

Elements of tactical medicine are more and more often used in civilian rescue work. It is worth noting that tactical medicine would have never reached such a high level if it had not been for the operations in Iraq and Afghanistan. “This is a rule that applies to all armed conflicts. Medicine »thrives« in wartime,” emphasizes Capt Anita Podlasin, a paramedic and an instructor of the Military Medical Training Center (Wojskowe Centrum Kształcenia Medycznego, WCKMed.). “My way of thinking about medical support in the army has changed. A stretcher-bearer has been replaced by a professional paramedic,” says JWO (Ret) Łukasz Sikora, a former soldier of the Military Commando Unit, a paramedic.

The direction of changes in tactical medicine around the world was set over 20 years ago by the USA, where in 1996 Capt Frank Butler published a set of tactically appropriate battlefield trauma care guidelines (Tactical Combat Casualty Care - TCCC) for combat medics in the Military Medicine scientific journal. He wrote, i.a., about how to take care of combat casualties. He assumed that TCCC should be based on preventing reversible causes of deaths on the battlefield: hemorrhage, airway obstruction and tension pneumothorax. The guidelines were quickly applied in the US Army, and later became standard procedure in all of NATO. A Committee on TCCC was also established to give recommendations on medical care of combat casualties. “Guidelines collected by Butler have been implemented in many following armed conflicts. The last 20 years are definitely a time of medics,” emphasizes Capt Podlasin, the author of courses for lifesavers organized at the WCKMed.. “As a result of missions, we have advanced medical equipment, such as individual medical packages, tourniquets, and medics trained according to TCCC. They finally stopped learning about immobilizing fractures or resuscitation, and instead started to prevent deaths,” says the lifesaver, adding: “Soldiers are now very aware of how important it is to help yourself or your wounded fellow on the battlefield. They understand that they are the ones who have to go out of their way in order for the medics to be able to meet their patients before they die.”

Lt Col Adam Machowicz, PhD, of the anesthesiology and intensive care ward of the Cardiac Surgery Clinic at the Military Institute of Medicine, also admits that when specialists – surgeons, orthopedists, anesthesiologists, and other medical personnel – began service in Afghanistan, military health care underwent significant changes. “People who perfected their skills on the mission in Afghanistan were those with big professional potential, enormous passion and extensive knowledge. After this group of enthusiasts returned to Poland, they began to slowly change the reality of military medicine,” says the anesthesiologist.

The people who went to Afghanistan included, i.a., Lt Col (Ret) Prof. Waldemar Machała, MD, PhD, head of the Anesthesiology and Intensive Care Clinic at the Central Clinical Hospital of the Medical University of Łódź, and during the mission an anesthesiologist at the field hospital in Ghazni; and surgeon Lt Robert Brzozowski, PhD, today the head of the General Surgery Clinic at the 5th Military Clinical Hospital and Polyclinic in Cracow.

In 2010, Robert Brzozowski created the Battlefield Medicine Institute at the Military Institute of Medicine (Zakład Medycyny Pola Walki WIM). He worked with people who, just like him, had war experience, and wanted to popularize the rules of tactical medicine in the military and civilian environment. In Afghanistan, Prof. Machała prepared videos from surgeries. He documented treatment of every patient to later have easy access to information on bullet wounds of the stomach, chest, limbs, or find examples of using a tourniquet or hemostatic dressings. This, he claims, serves science and significantly improves the quality of casualty care. “Americans have something we can envy – the trauma registry system, where they describe every medical activity undertaken on a wounded or sick person. They include it in statistics, carefully describe the state of the injured and their therapy. Therefore, it is easier for them to assess which treatment methods are effective,” convinces Prof. Machała. Experiences of doctors who serve on missions are supposed to help all medics, also those unrelated to the army, and therefore they are described in specialist publications. “Missions have left their mark on medicine. Today, people who have been on missions publish, are invited to various conferences, workshops and scientific symposia. Civilian and military medics want to listen to us, which is reflected in the number of people attending such lectures,” points out Prof. Machała. He says that another benefit is that people who have taken part in military operations now run hospital wards and clinics, so they have an actual, real impact on transferring tactical medicine procedures and techniques to the civilian environment. “We now have equipment in the Central Clinical Hospital of the Medical University of Łódź which I have used on mission. We also adopt identical techniques, as tactical medicine also works well in the civilian environment. All the practices and work organization at my clinic have been transferred from the field hospital in Ghazni,” says the professor.

Medicine Is not a Secret

Over time, various centers in Poland started to trust tactical medicine: trauma centers, hospital emergency rooms. “I am optimistic about the transfer of knowledge between military and civilian medics. All change starts in the head. You can have the best equipment, and still use it wrong. Now doctors have faith in tactical procedures. They know how to manage their casualty care team. I can also see a tremendous change as regards, for example, paramedics, who willingly participate in lectures, workshops, and invest their money in equipment tested on missions,” says Prof. Machała.

TCCC guidelines were first introduced in the civilian environment by Medical Air Rescue, which started using, i.a., quick blood transfusion devices, hemostatics, tourniquets and an ultrasound scanner. They applied military methods of dressing gunshot wounds and procedures for multi-organ injuries or hypothermia. Doctors emphasize that owing to procedures worked out on the battlefield, we can save many people today. “Missions have shown that it’s not enough to train doctors. We need to start with lifesavers, who are directly responsible for helping the injured person at the scene and on their way to hospital. They are the ones who have to dress the patient’s wounds appropriately so that I can help when he or she arrives at the hospital,” admits Dr. Machowicz. The anesthesiologist was the successor of Dr. Brzozowski and managed the Battlefield Medicine and Medical Simulation Department at the Military Institute of Medicine. Machowicz recalls a recent accident, in which a young motorcyclist lost a leg, and which is a perfect example of how important medical help is on the scene: “There were a lot of onlookers, but only one person knew what to do. He ran up to the injured man, took off his belt and tightened it firmly above the point where the leg had been cut off. He probably saved the injured man’s life, because he would have bled out before the arrival of an ambulance.

Capt Anita Podlasin points out that recommendations to act according to the tactical medicine assumptions are already given by civilian organizations and medical societies. “Examples of such organizations are ITLS [International Trauma Life Support], devoted to preventing death and disability caused by trauma, and the European Resuscitation Council [ERC]. They say a tourniquet should be applied in the event of a hemorrhage, and decompression performed in the case of a traumatic cardiac arrest. This is a success that can be attributed to missions,” argues Capt Anita Podlasin, adding: “I am glad that publications in high-ranking medical journals on applying tactical medicine are beginning to reach the civilian world.”

Medics unanimously admit that the fields which gained most from military operations are surgery, orthopedics, and other areas related to surgery, such as anesthesiology and medical rescue. “I work on a medical rescue team and at the hospital emergency room, and I look at my patients through the prism of experience I gained on the mission. I’m certain that if all paramedics in Poland were trained according to the TCCC guidelines, we would be able to save more lives,” emphasizes Tomasz Sanak, a lifesaver and a trainer, participant of several missions in Afghanistan.

We are still far from perfection. In many places, paramedics lack good equipment and do not take part in courses that would raise their qualifications. Directors do not invest in personnel, because usually they do not have money to do that. “Lifesavers are tired, overworked, have small salaries. However, I go by the rule of the creator of International Trauma Life Support. Our patients have no choice, they are brought to us because of symptoms and injuries. We, on the other hand, consciously decided to pursue this career path, and we should constantly learn and acquire knowledge, or... resign,” says Tomasz Sanak.

Help on Time

Tactical medicine knowledge can be useful to civilian medical services in three main areas: pre-hospital activities, mass casualty incidents, and organizing work at hospital emergency rooms or trauma centers. JWO (Ret) Łukasz Sikora also points to the fact that medical services might also have to deal with terrorist attack victims. “We have already had attacks of the so-called active shooters or stabbers who wounded random people. In such situations, victims have similar wounds to soldiers on missions. In order to help them, you need more than average medical skills. You need specialist TCCC training,” says Sikora, adding: “I am sure that we must invest in education and appropriate equipment for rescue teams.” He points to the USA as a state where professionals, and also people without special education, can attend trainings on stopping hemorrhages. “In Poland, we teach people resuscitation, but not how to stop massive bleeding, which will kill the victim in several minutes,” says the former commando. Americans, on the other hand, equip their people with both knowledge and necessary materials. “At airports, train and bus stations, shopping centers, there is equipment for resuscitation, but also a »trauma« package, including tourniquets, hemostatic dressings, bandages, gloves,” enumerates the rescuer.

Tomasz Sanak is of a similar opinion: “You can find fire blankets at schools, but not sets for stopping hemorrhages or resuscitation, while children in such places are much more likely to suffer trauma than be victims of a fire. In May, there was a situation in Brześć Kujawski, where a boy carrying a gun entered a primary school, shooting a girl and a janitor.”

Terrorist-related threats are also an important issue for Przemysław Guła, PhD, a doctor at the field hospital in Ghazni, a TOPR worker, and a participant of the rescue operation on Giewont. “Terrorism is a phenomenon that confronts civilian medical services with battlefield medicine,” he writes in the book entitled Medyczne Skutki Terroryzmu (Medical Consequences of Terrorism). In the publication, he explains that the level of preparation to react to terrorist attacks in a given country depends on its experiences. He gives Israel as an example of a state where years of terror forced the creation of a system which can be applied in mass casualty incidents. Professional rescue structures function similarly in Great Britain and France. “It is much harder to talk about the level of risk in states which have never experienced such tragic events,” points out the author. Guła has analyzed military experiences that can be useful in the work of medical services during terrorist attacks. He thinks that TCCC rules would prove useful in pre-hospital care on site, where properly securing the injured and quick evacuation are crucial.

Guła also recommends introducing adjustments in hospitals, setting the field hospital in Ghazni as a model – organizing posts in the preoperative and operating rooms, adjusting the configuration of medical equipment, and even the way of coordinating the work of specialists. On top of that, he points to some rules taken from TCCC: classifying casualties (searching first for the most severely wounded, but with a chance of surviving), the rescue procedure that prioritizes stopping hemorrhages over establishing a patent airway, checking breathing and blood circulation. Guła also suggests using tactical tourniquets, hemostatic dressings to stop hemorrhages, implementing fluid therapy and pain treatment. He points to the advantages of the walking blood bank and full blood transfusion in the event of mass casualty incidents (these activities in the hospital phase).

One of the people who agrees with Guła is Prof. Machała. He thinks that trauma or wounds sustained in terrorist attacks are similar to war injuries. The comparison refers to injuries caused by weapons or explosions. They are considered reversible causes of death. “We are talking about hemorrhage, airway obstruction and tension pneumothorax. It is nothing else than a direct reference to rules applied in tactical medicine,” explains the professor.

Equal Chances

A soldier wounded in Afghanistan has a bigger chance of survival than a citizen of Poland who has been in a car accident. This is the opinion expressed on medical forums, but is it right? Physicians and paramedics agree: yes. “Obviously, you have to consider many factors, such as the scene of event, but it is very important how his colleagues react,” says “Sly,” a paramedic of the Military Commando Unit, a participant of the prestigious NATO Special Operations Combat Medic course. “In Afghanistan, we had worked-out procedures, a great team, and everyone knew what their task was. Before the patient was sent to the operating table, he was properly secured by medics or his fellows from the platoon. Before he reached base, all of the personnel were already on their feet. In Poland, it’s not so obvious. You have to wait for an ambulance for several minutes, and then... well, not every hospital is organized as well as the one in Ghazni,” says the commando.