Jeffrey Howard, PhDAssistant ProfessorDepartment of Kinesiology, Health and NutritionUniversity of Texas at San AntonioSan Antonio, TX 78249

Combat Deaths Decreased as Military Improved Trauma Care in Afghanistan and Iraq Interview with:

Jeffrey Howard, PhDAssistant ProfessorDepartment of Kinesiology, Health and NutritionUniversity of Texas at San AntonioSan Antonio, TX 78249

Dr. Howard

Jeffrey Howard, PhD
Assistant Professor
Department of Kinesiology, Health and Nutrition
University of Texas at San Antonio
San Antonio, TX 78249 What is the background for this study?

Response:  There is a saying that “the only winner in war is medicine”, which is the first sentence in the article.  The point of that quote is that many medical advances over the last 500 years or more have been learned or propagated as a result of war.

With that as the backdrop, the purpose of our study was to provide a more comprehensive assessment of the trauma system than previous work.  We accomplished this by compiling the most complete data to-date on the conflicts, using data from both Afghanistan and Iraq, and analyzing multiple interventions/policy changes simultaneously rather than in isolation.  Previous work had focused primarily on single interventions and within more narrow timeframes.  We wanted to expand the scope to include multiple interventions and encompass the entirety of the conflicts through the end of 2017. What are the main findings?

Response:  The main findings were that :

(1) Mortality was cut in half from the beginning of the conflicts to the latter periods, roughly 2011-forward,

(2) Three specific intervention/policy changes (increased use of tourniquets, increased use of blood transfusion, and more rapid prehospital transport times, especially in Afghanistan) were responsible for about 44% of the reduction in mortality,

(3) Simulations suggest that without these changes in intervention/policy that approximately 3600 more deaths would have occurred between 2001 and 2017. What should readers take away from your report?

Response: One of the main goals of this work was to ensure that the lessons learned through what has now been 17 years of war are not lost.  At some point there will be another war, and we need to make sure that we don’t have to go through the pain of relearning these lessons.  In fact, many of the lessons from the current war had actually been learned long ago in previous wars. What recommendations do you have for future research as a result of this work?

Response: The famous quote from Shakespeare’s The Tempest, “What is past is prologue”, is a fitting metaphor for this study.  We need to look toward future research questions about how to continue to reduce mortality with a solid understanding of what has been learned before.

In order to move beyond our current level of understanding we need to improve data collection processes regarding the application of interventions and documentation of physiological measures, especially as it relates to documentation of prehospital interventions performed on casualties who do not survive medical evacuation to a medical facility.  This is an important issue not only for military trauma researchers, but also for civilian trauma researchers as well. Is there anything else you would like to add?

Response: Perhaps the most important thing that trauma researchers can do to move forward from here is to focus on system enhancements that continue to reduce the time to needed treatment, whether that be reducing prehospital transport times, or delivering more treatment capabilities, especially hemorrhage control and blood replacement, closer to the point of injury. 

 No disclosures.


Howard JT, Kotwal RS, Turner CA, et al. Use of Combat Casualty Care Data to Assess the US Military Trauma System During the Afghanistan and Iraq Conflicts, 2001-2017. JAMA Surg. Published online March 27, 2019. doi:10.1001/jamasurg.2019.0151

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Last Updated on March 27, 2019 by Marie Benz MD FAAD