title: En-route care capability from point of injury impacts mortality after severe wartime injury.
abstract: OBJECTIVE
  The objective of this study is to characterize modern point-of-injury (POI) en-route care platforms and to compare mortality among casualties evacuated with conventional military retrieval (CMR) methods to those evacuated with an advanced medical retrieval (AMR) capability.
  
  
  BACKGROUND
  Following a decade of war in Afghanistan, the impact of en-route care capabilities from the POI on mortality is unknown.
  
  
  METHODS
  Casualties evacuated from POI to one level III facility in Afghanistan (July 2008-March 2012) were identified from UK and US trauma registries. Groups comprised those evacuated by a medically qualified provider-led, AMR and those by a medic-led CMR capability. Outcomes were compared per incremental Injury Severity Score (ISS) bins.
  
  
  RESULTS
  Most casualties (n = 1054; 61.2%) were in the low-ISS (1-15) bracket in which there was no difference in en-route care time or mortality between AMR and CMR. Casualties in the mid-ISS bracket (16-50) (n = 583; 33.4%) experienced the same median en-route care time (minutes) on AMR and CMR platforms [78 (58) vs 75 (93); P = 0.542] although those on AMR had shorter time to operation [110 (95) vs 117 (126); P < 0.001]. In this mid-ISS bracket, mortality was lower in the AMR than in the CMR group (12.2% vs 18.2%; P = 0.035). In the high-ISS category (51-75) (n = 75; 4.6%), time to operation was lower in the AMR than the CMR group (66 ± 77 vs 113 ± 122; P = 0.013) but there was no difference in mortality.
  
  
  CONCLUSIONS
  This study characterizes en-route care capabilities from POI in modern combat. Conventional platforms are effective in most casualties with low injury severity. However, a definable injury severity exists for which evacuation with an AMR capability is associated with improved survival.
authors.affiliation: United States Army Institute of Surgical Research, Fort Sam Houston, TX 78234, USA.
authors.forename: Jonathan J
authors.initials: JJ
authors.lastname: Morrison
authors.forename: John
authors.initials: J
authors.lastname: Oh
authors.forename: Joseph J
authors.initials: JJ
authors.lastname: DuBose
authors.forename: David J
authors.initials: DJ
authors.lastname: O'Reilly
authors.forename: Robert J
authors.initials: RJ
authors.lastname: Russell
authors.forename: Lorne H
authors.initials: LH
authors.lastname: Blackbourne
authors.forename: Mark J
authors.initials: MJ
authors.lastname: Midwinter
authors.forename: Todd E
authors.initials: TE
authors.lastname: Rasmussen
mesh_terms: D000328:Adult; D055826:Afghan Campaign 2001-; D001930:Brain Injuries / Q000401:mortality / Q000628:therapy; D005260:Female; D017052:Hospital Mortality; D006801:Humans; D015601:Injury Severity Score; D008297:Male; D008887:Military Medicine / Q000379:methods*; D008889:Military Personnel; D010360:Patient Transfer / Q000379:methods*; D013898:Thoracic Injuries / Q000401:mortality / Q000628:therapy; D006113:United Kingdom; D014481:United States; D014947:Wounds and Injuries / Q000401:mortality* / Q000628:therapy*; D055815:Young Adult