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war and trauma- opinions on the medkit?

Andy Brainard trauma-list@trauma.org
Mon, 31 Mar 2003 18:27:17 -0700


New York Times
March 30, 2003
Armed With New Tools, Doctors Head to Battle
By GINA KOLATA



rom redesigned first-aid kits to a radically new kind of surgery on the
front lines, battlefield medicine has changed markedly and, as a result,
doctors in the war in Iraq hope to significantly reduce the death rate =
from
battlefield wounds =97 a rate that has not budged for 150 years.

Since the Civil War, experts in military medicine say, one of five =
wounded
soldiers has died, half from profuse bleeding. Pentagon doctors hope to
change that, and have mobilized an array of innovations.

Some, like putting pressure bandages in first-aid kits, are drugstore =
cheap.
Others, like a new anticlotting drug for internal bleeding, are =
high-tech
expensive, about $7,000 per dose. And some, like sending radically
redesigned surgical teams to operate at the front lines, involve tactics =
and
equipment that simply were not available in the last gulf war. These =
special
surgery units were tested in Afghanistan, where they reduced the
died-of-wounds rate, the death rate for those who survived long enough =
for a
surgeon to operate, to a fraction of a percent. For the past =
half-century,
it has hovered around 2 percent.

Doctors said it was hard to overestimate the difference.

There was little change from Vietnam to the first gulf war in doctors'
instruments, drugs, techniques or tactics. Except for some in the Army,
which put surgeons in the front lines in Desert Storm, wounded soldiers
received first aid from medics but no surgical care until they were
evacuated to a larger hospital.

Now, all the services have small mobile surgical teams scattered =
throughout
the battlefield, where they operate on the most severely wounded as =
close to
the front as possible. They do the minimum operation to stabilize =
patients
for evacuation to a larger hospital. There, they may have another =
operation
to further stabilize them for evacuation to a hospital in Europe.=20

"Never before in modern warfare have we done things so differently," =
said
Lt. Col. Donald Jenkins, a surgeon who is chief of trauma at Wilford =
Hall
Air Force Medical Center in San Antonio.=20

Many of the patients treated have been Iraqis. "By Geneva Convention and
NATO standards, casualties are taken care of in order of priority, based =
on
injury and illness, not based on uniform," Dr. Jenkins said. "That's =
been
the policy back to our own Civil War at least."=20

Col. John Holcomb, a surgeon who directs the Army Institute of Surgical
Research in San Antonio, said some of the innovations came from =
after-action
reviews in which doctors analyzed data on why soldiers died, where they
died, and how.=20

Each branch of the service makes its own decisions about which =
innovations
to adopt. For example, the Marine Corps has added a new product, =
QuikClot,
to every marine's first-aid kit, said Lt. Cmdr. Joe DaCorta, who is in
charge of expeditionary medicine at the Marine Corps Warfighting Lab in
Quantico, Va.

The substance was tested for battlefield use by Dr. Hasan Alam, a trauma
surgeon at the Uniformed Services University of the Health Sciences in
Bethesda, Md. Dr. Alam said he was haunted by troops who bled to death =
in
Somalia before surgeons could help them.

For Dr. Alam, it meant that "your buddy has to stop the bleeding, not =
the
medic, not the surgeon."=20

So he turned to QuikClot, a product made of the mineral zeolite and sold
over the counter by Z-Medica. It looks like cat litter but, sprinkled on =
a
wound, it absorbs water from blood, concentrating the body's own =
clotting
factors and speeding up the formation of a clot.

Z-Medica has supplied 50,000 doses to the military.=20

Dr. Alam and his colleagues tested the substance on 36 Yorkshire swine,
which are close to a person's size. The results have not been published, =
but
Dr. Alam said QuikClot converted wounds that were 100 percent fatal into
wounds that were 100 percent nonfatal =97 clots formed and none of the =
animals
died.

Although the Marine Corps plans to use it, other branches of the =
military
are not yet convinced. The question is whether to use it, and at what =
dose.
One concern is that heat is generated when QuikClot is poured on a =
wound,
and the fear is that it might burn tissue. "We don't have a huge amount =
of
data," Dr. Alam said. "We've done two studies."=20
Also, the troops must be trained in how to use it and surgeons must be
trained about what to expect.=20

Meanwhile, the Army and the Special Operations forces are taking an
additional approach to clotting, Colonel Holcomb said. They will use =
coated
bandages to stop bleeding. One bandage, developed by the Red Cross, used =
two
clotting proteins, fibrin and thrombin, to speed clot formation. The =
other,
made by HemCon of Oregon, uses chitosan, a clot-promoting protein in =
shrimp
shells.=20

Remaining problems include what to do about severe injuries to the =
abdomen
or pelvis, which may cause rapid and uncontrolled internal bleeding, or
bleeding in the brain from a head injury.=20

"What about an intravenous drug that could accelerate the =
hemorrhage-control
process?" Dr. Holcomb asked. The Army, he said, is considering using =
factor
VIIa, a clotting drug recently approved for treating hemophilia. Animal
studies, he said, indicate that it can work, and trauma centers often =
use
it. The Defense Department and the company hope to conduct a clinical =
trial.

Military medical experts said the hope, with all of these new products, =
is
that they will keep the wounded alive until they can see a surgeon.

Surgeons will be using a method pioneered a decade ago in trauma centers =
in
cities reeling from an epidemic of drug-fueled violence.

One of its leading innovators was Dr. C. William Schwab, a trauma =
surgeon at
the University of Pennsylvania, who was troubled by the number of =
patients
treated there who died later.

"We started to see that even though we would get the injury controlled =
and
fixed, even though we put them back together, they would die," Dr. =
Schwab
said. Patients would go into shock, their temperatures would drop, their
blood would become acidic and coagulate, forming fatal clots.

Dr. Schwab decided to try doing the absolute minimum surgically to stop =
the
bleeding, so doctors could turn their attention to stabilizing the =
patients.
Later, he reasoned, surgeons would complete their repair.

Dr. Schwab named the method damage control, a Navy term he recalled from =
the
10 years he spent on an aircraft carrier in Vietnam. When a ship was =
hit, he
recalled, the idea was to patch it up and keep it afloat, doing the =
major
repairs later.=20

He tried it with trauma victims. "We would control bleeding and any
contamination from the GI tract," he said. "Then we would continue to
resuscitate them and bring them back in two or three days and do =
definite
surgery."=20

To assess the method, he compared patients treated with damage control =
with
similar, seriously injured patients who had had traditional surgery. =
With
damage control, 75 percent survived. With traditional surgery, almost =
every
patient died. A decade later, after further refining of the technique, =
90
percent are surviving, Dr. Schwab said.=20

As the approach spread in trauma centers across the country, military
surgeons started showing up at Dr. Schwab's hospital for training.=20

"What I learned from Bill Schwab was absolutely indispensable," said Dr.
Jenkins, who spent two years there. "I took care of people who for sure =
in
my training we would have looked at them and said, `There is no way this
person could survive.' " Yet survive they did.=20

But to bring the technique to the battlefield, the military had to make
major changes. First, it had to put the surgeons with the frontline =
troops,
so they could do damage control surgery immediately.

The new idea was to keep a small surgical team on the front line, using =
a
portable operating room that is set up in an hour for damage control
surgery. From there, patients are stabilized and taken to hospitals for
additional surgery days later.
It required making what once was bulky equipment light and portable, =
said
Dr. Paul K. Carlton Jr., the recently retired surgeon general of the Air
Force who now directs the Integrative Center for Homeland Security at =
Texas
A & M. Today, Dr. Carlton said, surgeons can carry the equipment they =
need
in a backpack.

For example, frontline units are equipped with sonogram machines the =
size of
cassette recorders, and devices the size of a PDA that can do a complete
laboratory analysis on a drop of blood.

Another piece of the plan is to train surgeons and support staff, and =
once
again military doctors turned to urban trauma center. "They have too =
many
patients," Colonel Holcomb said. "We need patients."

In Miami, Dr. Tom Knuth, who directs the Army Trauma Training Center at
Ryder Trauma Center, is training military general surgeons, plastic =
surgeons
and other specialists and technicians and medics.

"They integrate with the civil staff to manage whatever patients come
through the door =97 bad motor vehicle crashes, gunshot wounds," Dr. =
Knuth
said. "And they get to work together as a team." With the war, the =
training
regimen has been compressed from a month to 10 days.

Dr. Carlton said the war in Afghanistan showed what is possible. Of 250
seriously injured patients, only one died. "It was the lowest =
died-of-wounds
rate in the history of war," he said.

One man suffered a catastrophic wound to his rectum, prostate, anus and
bladder. The ghastly injury plunged him into shock immediately, but one =
of
the backpack surgical teams got to him right away and did a damage =
control
surgery. Then, he was put on an airplane equipped as a critical care =
unit
and flown a few thousand miles to another hospital for another surgery =
to
stabilize him. Then he was flown to Germany for reconstructive surgery.

"He's home with his family now," Dr. Carlton said. In any other war, he
added, "he would have been dead."=20

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