Two wars have (unfortunately) contributed to better trauma care. (AFP/Getty Images)
TAKING UP ARMS: The “Like,” named after the “Star Wars” character, can hold a lightbulb without breaking it. (Getty Images)
FIT TO BE TIED: Because of the large number of limb injuries, one-handed tourniquets were introduced to war zones. (AP)
IT HAS CLOT: HemCon’s bandage stops bleeding faster and then is absorbed into the skin — because it’s derived of shrimp. (Getty Images)
American soldiers have lost lives and limbs in Iraq and Afghanistan, but they have given life — through warzone medical advances — to countless others.
New technologies have led to fewer of our soldiers dying from their combat injuries than in any previous war Americans have fought — fewer than 10%, compared to 30% in World War II and 24% in the first Gulf War. And those breakthroughs are moving from battlefield to bedside with remarkable speed.
Previous wars gave us penicillin, blood transfusions and even the notion of modern hospitals. Our recent entanglements have seen, among other things, an improvement in prosthetics, better treatment for traumatic brain injury and more efficient wound care.
Civilians wheeled into trauma centers with gunshot wounds or severe injuries from car accidents owe a debt of thanks to soldiers whose traumas sped up medical innovation, military doctors said.
War is associated with medical breakthroughs for the simple reason that it gives us “a lot of people to try things out on,” said Dale C. Smith, senior vice president and professor of medical history at the Uniformed Services University of Health Sciences in Bethesda, Md. “If you had to depend on the NFL to give you a traumatic brain injury, they’re only going to give you one or two cases every Sunday. Iraq gives you 100 a month.”
Col. Geoffrey Ling, a neurosurgeon who has done six tours in Afghanistan and Iraq combined, said the contributions made to medicine on the battlefield do more than help soldiers in the field and Americans back home.
“That’s the beauty of America: These [advances] are paid for by American taxpayers because we want to benefit our young men and women, but it doesn’t just stay here. It goes all over the world,” Ling said. “It’s another contribution that America is going to make for the entire world.”
Building a better bandage
Whether the weapons were spears and swords or IEDs, soldiers have always succumbed to severe bleeding during battles. To keep our troops alive, the military has funded the development of several novel bandages and products that quickly stanch the flow of blood.
One of the bandages, made from a derivative of shrimp shells, can seal a pumping wound and then get absorbed into the body without attracting bacteria and viruses. HemCon, an Portland-based company that created the bandages, received FDA approval this summer to sell their GuardaCareXR bandages to hospitals throughout the country.
The bandages work by getting incredibly sticky when wet with blood and sealing up the pumping wound. Because it’s biodegradable, the body literally “eats it up,” Ling said. (It is also edible, but company officials don’t recommend serving it for dinner.)
Prosthetic limbs that move
Among the most noted advances, the wars in Afghanistan and Iraq have lead to dramatic improvements in prosthetic limbs. Amputation has occurred twice as often in Iraq as in any conflict of the past century, and according to a 2008 Department of Defense report, more than 1,200 American soldiers had lost limbs, primarily to improvised explosive devices.
Improvements in prosthetics are a direct response to this increase in amputations, but it will have implications for civilians who lose limbs to cancer, vascular disease and diabetes, Ling said.
Some of the most promising prosthetics include Ossur’s Power Knee, a battery-powered prosthetic with embedded sensors that predict and react to movement, and Otto Bock’s C-Leg, a microprocessor-controlled knee joint.
The Power Knee uses artificial intelligence to give users an almost unconscious control over bending, walking, climbing and speeding up and slowing down. The C-Leg has microsensors in the knee and shin that monitor and detect terrain changes up to 50 times a second, allowing the wearer to speed up, slow down and climb stairs with far more freedom of movement than prosthetic legs have ever provided before.
Prior to the wars, artificial legs were one step above peg legs. Lacking any form of computer power or artificial intelligence, amputees were not able to “catch” themselves when they stumbled and keep themselves from falling. While the new designs are not perfect, they represent a major improvement in returning a kind of normal control over balance and gait.
For soldiers who have lost arms, the military is funding research into two prosthetics, a foot-switch controlled arm that is affectionately being called “Luke,” for Luke Skywalker and another arm controlled by the patient’s own nervous system that provides sensations as subtle as temperature recognition. Both are in clinical trials, and it is hoped they will take the place of the hook-and-cable models created during World War II that are still in use by most amputees
“Necessity is the mother of invention,” Ling said. “In peacetime, the military does not have the money to spend as it does during war. When the war breaks out you’re able to spend money on research and development. If you have the cash, the best and the brightest will come.”
Diagnosing the brain
An estimated 175,00 veterans of Iraq and Afghanistan have sustained traumatic brain injury (TBI), with the majority going untreated. Of those, 6,000 troops survived with brain injuries caused by severe penetrating trauma.
Mild or severe TBI can have long-lasting effects on a person’s health, ranging from headaches and mood swings to abnormal speech and behavioral problems. Because it is so easy to miss or ignore the symptoms, the military has standardized an evaluation to help catch cases of TBI and provide occupational therapy and other treatment to soldiers who need it.
Like the standardized approach first responders use in cases of heart attacks, the TBI protocol is meant to ensure the same level of care everywhere someone may get injured, whether it’s the battlefield or the football field.
In fact, the NFL will likely adopt military’s protocol this year, said Ling, who is on a medical committee for the football league.
“Once a soldier is diagnosed, you go to a concussion restoration center,” Ling said. “That’s what we need in the US. I believe that this will be the future.”
Now, if a kid on a soccer field gets knocked down from a blow to the head, the coach might tell the child to “walk it off.” Ideally, Ling said, that player would be evaluated for TBI using the military’s guidelines and, if need be, sent to the hospital for a CT scan. There, doctors would focus on maintaining proper brain oxygen levels and controlling intracranial pressure.
Making artificial blood
Human blood can be stored for up to six weeks, after which it starts to pose a great risk of infection and organ failure to anyone receiving a transfusion. But battlefields are obviously not neighborhood blood drives. So the military is currently funding research into “culture blood,” the creation of red blood cells from discarded human umbilical cords.
The small number of blood cells are turned into large quantities of blood through a process called “blood pharming,” which uses genetically engineered plants or animals to mimic the functions of bone marrow, which produce blood in the body. The hope is that result would be a fresh supply of universal-donor blood — with no donor required.
Blood pharming is still being developed but could be available for military use within the next few years. With blood banks in this country chronically running low on supply, blood pharming could save countless lives stateside as well.
Return of the tourniquet
For years, tourniquets had been taboo in the medical community because improper use led to severe nerve and limb damage. But because of the high number of IED injuries troops are enduring, the military is changing the way it looks at tourniquets.
In fact, in New York and other cities, firefighters now carry the kind of one-handed tourniquets used by troops in Afghanistan and Iraq.
“If you teach them how to put it on and take it off, it can save a tremendous amount of lives,” said former Navy surgeon Dr. Peter Rhee, who recently retired after 25 years of duty, including several tours in Afghanistan and Iraq.
Improving ER
procedures
As a student at Uniformed Services University in 1998, Rhee wrote a paper challenging the common use of IV fluids, known as crystalloids, in treating severely bleeding trauma patients. No one paid attention.
“These crystalloids don’t resemble anything in our body,” he said. “It’s like adding Kool-Aid to your gas tank.”
He wrote 40 papers, suggesting that the solutions used to save patients would eventually cause multiple organ failure, lung trauma and other complications that often killed them. Instead, he said, trauma doctors should consider keeping patients’ blood pressure low and giving them plasma and blood products through their IVs.
Again, crickets.
But after Sept. 11, 2001, Rhee was on a committee tasked with creating medical guidelines for the military. He suddenly had the forum to challenge a long-held philosophy and push for military research into this new method.
The results on the battlefield have started to convince doctors stateside to make the switch, including Level 1 Trauma Centers like Johns Hopkins.
“This dramatically improves survival and outcome,” Ling said.
Rhee expects more hospitals to follow suit.
“One hundred years ago, if you were dying from shock, they would bleed you,” he said. Someday, pumping crystalloids into trauma patients may seem as naive.
Faster-thinking doctors
The war is also helping enhance care here by training doctors under fire — literally.
On Jan. 6, 2006, former Navy surgeon Rhee was on hand when more than 200 people — mostly Iraqi civilians training to become police — were injured by a suicide bomber just outside the US military compound in Ramadi. The pressure-cooker situation, the unimaginable volume of patients and the bare-bones resources combined to create what Rhee understatedly called “an unusual situation.”
Fast-forward almost two years to the day. When Arizona Rep. Gabrielle Giffords and 10 other people were wheeled into the University Medical Center in Tucson with gunshot wounds, chief of trauma Rhee was there.
The Tucson shooting “was like going from living in the woods to a palace,” he said. “I had all the resources I needed.”
In those early days of Giffords’ treatment, Rhee spoke optimistically and confidently. Abandoning the qualifiers and couched language normally associated with medical predictions, Rhee told the world Giffords would survive.
He was right. Rhee credits his military training with his confidence and his ability to maintain calm during chaos.
Reflecting on the experience a year later, Rhee sounded ever the military man, saying, “It was a privilege to take care of those people who were injured on that day.”