The farther backward you can look, the farther forward you are likely to see

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“The farther backward you can look, the farther forward you are likely to see.” ― Winston Churchill (1874-1965)

Like most Americans, I was shocked and horrified at the Boston Marathon bombings that ripped through the event on Monday, April 15, 2013, at 1450 (2:50 p.m.). It was difficult to process the images of explosions and injuries coming out of Boston that I personally associate with distant lands and conflicts. I recognize that, for many countries, this senseless violence is, sadly, all too routine. We are a country that prides itself on the nonviolent expression of political views and the use of peaceful demonstration to effect political change. While, as a society, we have not always been successful in the nonviolent expression of political views, we are rarely exposed as a nation to the random, cowardly and senseless attacks that were perpetrated on the Boston Marathon. The political value of attacking that historic event escapes me.

While digesting these horrific events as they played out on the nightly news and the local newspaper, I was intrigued by some of the descriptions of the care given to many of the wounded directly after the bombings and subsequently in Boston hospitals. I believe the country was inspired by the bravery fellow Americans, many in uniform, demonstrated in the immediate aftermath and carnage of the bombings. News reports noted the prompt application of mtourniquets to numerous patients with missing or mangled limbs. Boston-area physicians were quoted as saying that the rapid use of this age-old device likely saved many lives.1 Interestingly, such rapid use of the tourniquet to stop bleeding, before direct pressure, elevation or pressure points was not the standard only a decade ago.

What changed? Specifically, America’s military medical experience in Iraq and Afghanistan has demonstrated and confirmed the lifesaving properties of a properly-placed tourniquet following severe limb trauma. Fortunately, for many victims, our hard-fought wartime1 medical experience has influenced and changed civilian practice for the better.

Other news stories noted that Boston physicians, many with military medical experience, first stabilized patients with quick initial operations and then performed more definitive procedures at a later time, after patients had somewhat recovered. This is standard surgical practice for managing the poly trauma seen in combat-wounded. Additionally, those who tragically lost limbs in this horrific event will benefit greatly from the tremendous advances in prosthetic development that have emerged from the federal medicine experience.

As I was thinking about how our wartime medical experience had influenced the medical response in Boston, I was reminded of the biological theory of quantum evolution and punctuated equilibria concerning species evolution. Basically, the theory holds that some extraordinary environmental stress can result in periods of rapid evolutionary change, followed by periods of relative evolutionary stability. In the evolution of the medical arts, I believe war has been, historically and most recently, an extraordinary stress on medical practice that leads to quantum leaps forward in medical knowledge and innovation. Notwithstanding the appalling waste and stain on the human race that war represents, its inimitable impact on medicine is undeniable.

I have shared in this column before my concerns that 12 years of medical improvement, forged in the fighting in Iraq and Afghanistan, will be squandered and lost to posterity. The harsh realities of shrinking federal medicine budgets and the Draconian economics of “sequestration” are diverting attention away from continued development and inculcation of medical war lessons learned. It is a fact that military attendance at national medical meetings is rapidly in decline due to travel restrictions. These meetings are essential for exchange of new ideas that will become the American medical standards used in the next war. Many war-related health programs that 2 serve as repositories for military medical advances in the federal government are in jeopardy of funding elimination due to harsh sequestration economics.

I would suggest that the response observed in Boston is a prime example of why we should strive in federal medicine to reconnect with civilian medicine at national meetings. We need to educate our leadership on the value these medical exchanges have for both federal and civilian medical systems. Additionally, we need to redouble our efforts to preserve the finest aspects of our wartime federal medicine system as we deal with the reality of shrinking budgets and a contracting military. The harshest irony of our nation’s longest conflicts would be the loss of the last 12 years of medical history through haphazard program elimination under the excusing banner of sequestration.

I would contend that during this longest of American conflicts we have also experienced one of the longest periods of military medical improvement. I believe our “less than 10% died of wounds” rate is testimony to that improvement. Consider how much farther we will advance in the next conflict if we have the fiscal courage now to look back and preserve the finest trauma system the world has ever seen.

1Tourniquets play key role after Boston bombings. The Associated Press. April 24, 2013

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