Writing this chapter forced me to think in more depth than I had
before about the enormous array of clinical research that is
conducted in the Department of Defense. That research covers a broad
spectrum of issues, some of which are particular to the military, but much
of which are relevant to the civilian world. The other thing that struck me
is the talented group of people conducting research across the military.
One instructive message from the chapter is the need to be adaptive
in how a research agenda is shaped to address truly critical problems.
One particular example is the joint theater trauma registry. When I
was learning surgery, the idea that you would use a tourniquet to stop
hemorrhage in an extremity was considered an absolute anathema
because of earlier experience leading to limb loss. But in studying
experiences around injuries caused by improvised explosive devices,
researchers found that stopping hemorrhage by use of a tourniquet was
an absolutely essential part of immediate care. Another example is in the
way that laboratory values for resuscitating trauma patients using old
models of saline solution and whole blood proved to be out of date, at least
in dealing with patients who manifested massive hemorrhage.
Neither the tourniquet nor the change in the resuscitation paradigm was
subjected to a prospective, double-blind, randomized controlled trial. In
field medicine, there simply isn’t time for that. But there was a constant,
iterative process with feedback that does provide solid and convincing
evidence about the appropriate way to proceed. That tells me that clinical
investigators need to think of approaches to research questions that go
beyond what we were always taught as a gold standard—the prospective,
randomized, controlled trial. I think adaptive approaches to urgent
clinical problems are essential.
Further, our chapter suggests that leaders have to be willing to consider
research approaches that go beyond the traditional ones, and to think
creatively and innovatively—always being cognizant, of course, of both
ethical and legal requirements.
Finally, I hope that this chapter will help readers who are in civilian
institutions to understand that there is a very vibrant and responsible
clinical research community in the military, and that it welcomes
partnerships with civilian institutions and researchers.
Charles L. Rice, MD
Uniformed Services University
of the Health Sciences