Based on data from Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF), two of the most recent American military operations, ten to fifteen percent of preventable battlefield deaths were due to airway obstruction or respiratory failure. Airway obstruction due to trauma is the second largest cause of potentially survivable (PS) mortality in the military. Additionally, recent military engagements (OEF and OIF) saw a significantly higher percentage of maxillofacial injuries when compared to historical wars such as World War II and the Korean War. The increased use of improvised explosives has led to an increase in blast injuries, which often distort the anatomy of the primary airway. However, developments in protective equipment have allowed more of these maxillofacial injuries to be survivable. Therefore, airway management has become increasingly important in modern military medicine; in fact, “airway management is arguably the single most important skill taught to and possessed by emergency care providers”

The dire situation in which an airway is completely obstructed is known as a “Can’t Ventilate, Can’t Intubate” situation (CVCI) and necessitates a surgical cricothyrotomy (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4173486/). CVCI occurs at twice the incidence in the military, yet military medics have a failure rate 3-5 times higher than their civilian counterparts (http://www.ncbi.nlm.nih.gov/pubmed/22427045). Therefore a more reliable cricothyrotomy method is desirable to the U.S. military because it could significantly reduce casualties in future U.S. military engagements.

In Fundamentals of Combat Casualty Care (http://www.cs.amedd.army.mil/borden/book/ccc/uclachp3.pdf), the military defines the three phases of military medical care. The first phase is known as Care Under Fire which is mainly centered around establishing military superiority. The very title of this phase vividly defines the difference between civilian and military medicine; a combat medic “may become the target of hostile fire and may have to return fire” while treating the patient (http://www.cs.amedd.army.mil/borden/book/ccc/uclachp3.pdf). During this initial phase casualties are moved to safer locations and the only medical care that is performed is the application of tourniquets to life-threatening extremity wounds. No airway care is performed during this phase. It is only in the second phase, Tactical Field Care, where airway intervention is first attempted. This delay in the procedure serves to further limit the already narrow window within which successful airway intervention can be performed.

Further complicating matters, on average, there is one combat medic for each platoon in the military. This one individual can be responsible for up to 30-40 fellow soldiers. US military combat medics (68Ws) are trained at the emergency medical technician (EMT)–basic level. They are also trained to perform the traditional cricothyrotomy surgery. Their training consists of 2 hours of classroom instruction followed by 5 hours of airway laboratory training, with at least 12 to 15 practice procedures repeated on a manikin (http://www.ncbi.nlm.nih.gov/pubmed/24094476). There is often no further training. Delay in the surgery, an incorrect placement of the inserted tube outside of the airway, and a puncture through the trachea all the way to the esophagus are the most common problems that can lead to fatal complications.

Further training may improve the problem with hesitance, but new technology and techniques are necessary to improve outcomes and to prevent these complications. The current standard of care practiced by combat medics is the original surgical procedure using only a scalpel and a tube without any device to aid in guiding tube placement. Unfortunately, this combination of minimal training, poor environmental conditions, and inadequate equipment leads to a very high failure rate: one military study conducted between September 2007 and July 2009 found the combined failure rate for combat medics in Iraq and Afghanistan practicing the surgical procedure was 33%, and the failure rate for physicians and physicians assistants was 15% (http://www.ncbi.nlm.nih.gov/pubmed/22427045).