Issue 14 / 28 April 2014

AS Australia marks the 99th Anzac Day and 100 years since the start of World War I, we also mark the end of our troop commitment to Afghanistan — the end of the longest period of sustained military operations in our history.

Warfare represents the ultimate breakdown of human relations — the controlled and deliberate application of violence, with the inevitable and tragic casualties.

Yet out of the tragedy of war also comes innovation in many fields, particularly in trauma management. Much of this can be applied in the civilian setting — particularly in Australia, where long distances and climatic extremes complicate trauma care.

While the brutality of human conflict has not changed much in the past century, the lethality of it certainly has.

The case fatality rate after wounding has halved — from 20% in World War II, to less than 10% in Iraq and Afghanistan combined. There are many reasons for this. Certainly, changed practices and improved personal protection in the form of body armour have played a big role in ensuring the survival of many who would previously have died on the battlefield.

This is not the complete picture though. Improved trauma practices and systems to enable quality, albeit basic, trauma care at the point of injury, with rapid evacuation of the wounded to be treated by the right specialists has also meant better survival.

There are three groups of battlefield casualty — those who will live regardless of what we do; those who will die regardless of what we do; and those whose survival depends on what we do. Recognising how to maximise survival in this last group is the key.

This understanding of the preventable causes of battlefield death has been the focus of innovation in combat trauma management in the past decade.

Perhaps not surprisingly, exsanguination from extremity haemorrhage, airway obstruction from maxillofacial trauma and tension pneumothorax are the big three of preventable battlefield death.

In civilian practice, blast and penetrating injury may be rare, at least in Australia, but the big three from the battlefield are also the main causes of death in road trauma or major industrial accidents.

In Iraq and Afghanistan it became commonplace for all troops to carry tourniquets for extremity haemorrhage and for medics to carry novel haemostatic agents to augment pressure and elevation to control bleeding. In the case of tourniquets, this was perhaps a lesson rediscovered rather than learned for the first time, but nonetheless important.

Early use of blood products and rapid evacuation to forward surgical teams, capable of damage control surgery and resuscitation became standard practice. So too did the early initiation of antibiotic prophylaxis, often given to casualties by medics at the point of injury.

Many civilian trauma units and prehospital retrieval services have absorbed and adapted these lessons from combat to improve outcomes in Australian trauma patients, particularly the early use of blood products. Many retrieval services now have the capacity to take blood products to the scene of an accident to minimise the delay if transfusion is needed.

Trauma care has come a long way since the stretcher-bearers and dressing stations of WWI, but the lessons learned and advances made, particularly in the past decade, have not happened in isolation.

This short article cannot mention all the innovations or acknowledge all the years of hard-won knowledge by the many people across the world that have contributed to improving battlefield trauma care.

Nobel laureate Owen Chamberlain said it best: “Each generation of scientists stands upon the shoulders of those who have gone before them.”

And to those who will not return, lest we forget.


Dr Simon Hendel is an anaesthetist and a medical officer in the Australian Army Reserve. He served in Afghanistan in 2010.

The opinions expressed in this article are the author’s alone and do not necessarily represent the opinion of the Australian Defence Force.

3 thoughts on “Simon Hendel: Lessons from war

  1. Anonymous says:

    Strange that you would attribute the ‘standing on shoulders’ metaphor to Chamberlain. It’s been around since at least the 12th century, though it was Newton in the 17th who popularized it.

  2. Robert Hall says:

    While I agree that warfare has led to significant improvements in trauma care, I think we need to think very carefully about the price we pay for such advances in knowledge.  Warfare is such a major tragedy that we should always try to find peaceful ways of solving social problems.  I recognize that some of these are very nearly intractable, but peaceful resolution of conflict is to be preferred to resolution by war.

    I think we should also take this opportunity to recognize the very important role the medical profession has taken in the promotion of peace.  This requires a continual effort, and is hard work, mostly behind the scenes.  We should recognize and celebrate on occasions such as ANZAC Day events like the award of the Nobel Peace Prize to the International Physicians for the Prevention of Nuclear War in 1985.  Thoughtful military personnel, at least since the time of Sherman, have preferred peace to war, and as health care practitioners we should make every effort to ensure the peaceful resolution of conflict.


  3. Dr R G Bain says:

    Dr Hendel thank you for highlighting this significant aspect of medical practice in our country. One other aspect in this context deserving an additional mention is that of operational stress injury. A somewhat less pejorative term for the commoner PTSD/Anxiety diagnoses. The former being a much more acceptable affliction to the working soldier who will often ignore and not seek trearment when given a mental health label. 

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