Statistics show that most battlefield deaths occur within the first 10 minutes of wounding. To survive injury in combat every second counts.
Medical planners in the military now refer to the time immediately after injury as the “platinum 10 minutes”, rather than the “golden hour” that used to be talked about.
To reduce the number of fatalities during these critical first few minutes, emergency medicine can now be provided deep inside enemy territory.
All soldiers on operation have basic first aid training. At least one in four soldiers is an army team medic. They have advanced first aid training and carry additional medical equipment including products to stem excessive bleeding.
If the injury is serious, a Medical Emergency Response Team (MERT) is sent urgently. This is a Chinook helicopter carrying highly specialist medical personnel, consisting of a consultant, an emergency nurse and two paramedics.
In Afghanistan, the MERT is equipped to deliver life-saving care onboard the helicopter on the way to the field hospital.
"In effect, we are taking the resuscitation room to the injured," says Lieutenant Colonel Rob Russell, head of the academic department of military emergency medicine at the Royal Centre for Defence Medicine (RCDM) in Birmingham.
Casualties are taken to Camp Bastion field hospital, which has an intensive care facility with CT and X-ray imaging equipment.
Based on two years of figures, the average time between injury on the battlefield and arrival in a hospital bed is under 50 minutes.
More British troops are surviving battlefield injuries than ever.
Between April 2006 and July 2008 there were 75 unexpected survivors out of nearly 300 trauma cases in British field hospitals. These were casualties who suffered injuries so severe that they were not expected to survive.
“That’s a substantial number of people surviving who should have died from their injuries,” says Lt Col Rob Russell. “All our statistics tell us they should be dead.
“These casualties include penetrating brain injuries and multiple injuries to limbs which require amputation, causing life-threatening blood loss at the scene.
“We’ve had people with serious trauma, such as gunshot wounds to the chest, who have had a cardiac arrest as a result of their injuries and have made a full recovery.”
While advances in emergency medicine have made a difference, improvements to hardware, such as body armour and helmets, have also been significant.
Emergency medicine was introduced as a speciality in the armed forces in Kosovo in 1999. Lt Col Russell has been at the forefront of developments in emergency medicine since 2003, when he served in Iraq.
Having completed four tours of Iraq, two of Afghanistan, and been deployed in Northern Ireland and Bosnia, his research is supported by extensive experience.
His work involves the analysis of every stage of a serviceman or woman’s treatment, from the point of wounding to rehabilitation, to see where improvements can be made.
Research into combat fatalities shows that most deaths occur within the first hour. Rapid treatment after an injury can greatly improve chances of survival. Improvements in medical care mean that this "golden hour" has been narrowed down further.
“The most important part of that hour is the first 10 minutes. We call them the ‘platinum 10 minutes’,” says Lt Col Russell. “We've tightened up our processes, concentrating on how we can save a life during that time.”
“If you survive long enough to enter the military medical chain then the chance of survival is good.
“We’ve made sure an individual soldier or army medic can stop external bleeding in the first few minutes after injury, particularly from the limbs.”
The standard practice for checking vital signs, ABC (airway, breathing, circulation), has been updated to CABC, with the first C standing for catastrophic haemorrhage.
Army team medics are equipped with the latest blood-stemming agents, such as the Celox gauze.
Celox gauze, which contains a substance derived from crushed shellfish, becomes sticky on contact with blood, helping clots develop and rapidly stopping even severe bleeding.
“The bandage can be applied by the soldier himself as soon as the wound occurs,” says Lt Col Russell.
“Their buddy can give them additional first aid, and so can the army team medic. Within seconds a soldier can receive life-saving care that you would not get as a civilian.”
Army doctors have intraosseous needles, which are special syringes that deliver drugs or vital fluids into the bone when access to a vein is impossible due to severe injury.
These have proved invaluable on MERT helicopters. The MERT system, which has been likened to taking accident and emergency (A&E) into the battle zone, is consistently praised for its novel approach and achievements.
“We are bringing the emergency department forward on to the helicopter,” says Lt Col Russell. “Soldiers who would have died are now surviving because of more advanced first aid and better emergency and pre-hospital critical care.
“But all the parts of the process, including treatment at University Hospitals Birmingham and rehabilitation at Headley Court, have made great advances in caring for the wounded.”
Lt Col Russell describes the military’s approach to healthcare as “horizon scanning” or always looking ahead for new medical products, treatment techniques and best practice.
Research is underway into controlling internal bleeding which, with current techniques, can only be contained through surgery in a hospital.
New ways of giving pain relief on the battlefield, including inhalers and nose sprays, are also being considered.
“Substantial advances in medicine have been made during wartime,” says Lt Col Russell. “We’re doing the same now in trauma care.”
He says one of the biggest advances in British military healthcare in the past few years has been its ability to keep its practices up to date.
Every week there is a clinical-case phone conference between the UK and the field hospitals in Afghanistan. Those taking part discuss the treatment of individual patients in the theatre of operations and, where necessary, make suggestions for improvement.
“The weekly meetings can bring about immediate changes and most problems are solved within one week,” says Lt Col Russell.
Expertise gained in the field of emergency medicine, surgery and intensive care is shared with the NHS to improve civilian care.
“The process is patient-focused and gives clinicians the ability to change the system,” says Lt Col Russell.