It seems like just about every
day the team of Canadian physicians serving in Afghanistan
finds a new way to use cutting edge medical advances
to save the lives of their often grievously injured
patients. From blood-clotting powders to on-the-spot
whole blood transfusions, war medicine advances are
bound to trickle down to civilian medicine.
STORIED
PAST
Technology has been helping to save lives in battle
for centuries. The two World Wars introduced concepts
like 'triage' and created the field of plastic surgery
as well as the widespread use of antibiotics and post-war
proliferation of blood banks. And then Korea brought
MASH units and helicopter evacuation to the fore, which
was further developed in Vietnam along with limb-saving
surgical techniques.
Writing about the lethality of
war wounds from the American Revolution to today, a
2004 article in the NEJM shows that over the
past 230 years, battle wound mortality has dropped from
42% to around 10%, despite increases in firepower. This
drop has only been made possible by the emergence of
medicine's new technologies and techniques.
BRAVE
NEW MEDICINE
Major Sandra West, a senior military physician from
Ottawa who took charge of the Kandahar air field (KAF)
hospital from August 2007 until late February 2008,
witnessed frontline medical advances in action pretty
much every day. And things are done pretty differently
from civilian hospitals back home.
For instance, soldiers in the field
are each given a Velcro tourniquet that can be applied
single-handedly. "Civilian medicine took out tourniquets,
but now we've realized they work in some situations.
They don't have as bad an effect on limbs as once thought.
If it's possible the limb may be lost anyway we should
use them," she says.
Soldiers are also given QuikClot,
a powder made of porous minerals called zeolites that
is poured directly into the wound to staunch bleeding,
as well as hemostatic bandages that contain chitin molecules
from shrimp shells that become super adhesive when they
contact blood. This pair of tools stops the bleeding
and seals the wound, boosting the quality of care immediately
available to soldiers under fire.
Some military docs expect that
these will soon find their way into civilian medicine,
to help hemophiliacs, for instance, or patients on anticoagulant
drugs. The US military is also developing a dried blood
product that can be rehydrated with a quick squirt of
saline solution for a blood supply with a longer shelf
life.
Physicians used to using blood
products back home have discovered the joys of whole
blood at KAF, says Maj West. "When you have someone
who is coagulopathic, whole blood can turn that person
around." With a rapid blood transfuser, doctors deliver
the blood from a healthy soldier directly into the injured
patient.
TRAINING
DAY
There are also advances that play a more latent role.
In Montreal and Vancouver, during intensive two-week
trauma training courses, every physician shipping off
for Afghanistan experiences the simulacrum of war. Small
rooms kitted out to look like the KAF trauma bay simulate
audio and light effects, like the sound of enemy fire
and thunder and lighting, while teams of physicians
attempt to manage an ever increasing number of casualty
simulators.
Commander Ross Brown, medical director
of trauma care at the Vancouver General, runs the Vancouver
course. He says that five years ago the training was
less focused on team dynamics and more on the skill
of each individual. "Combining team training and simulation
reduces our chances of medical errors," he says.
In parallel, the training staff
that have recently returned from tours in Afghanistan
brief the physicians heading out about the medical challenges
they were pitted against and the techniques they used
to overcome them.
A
VIEW TO THE FUTURE
A recent article in the Annals of Emergency Medicine
suggests lessons like new triage skills are being brought
back from Afghanistan and Iraq to improve the efficiency
of emergency departments across North America. With
their bigger budgets, the US military is leading the
pack in this, with such devices as a focused ultrasound
that heats and coagulates blood in an internal wound
in the pipeline.
However, the big payoffs for civilian
medicine might not arrive for a while. The Joint Theater
Trauma Registry, created by America's Department of
Defence, has been collecting data since 2005 about wounds
and medical care provided in the field. But only when
these wars end will the potential to substantially modernize
trauma care be realized.
Captain Ray Wiss
examines the ultrasound of an injured Afghan
soldier
Photo credit: Courtesy
of Capt Ray Wiss |
A soldier's life
saved
Complaining of hip pain, the
otherwise well Afghanistan National Army (ANA)
soldier sitting in front of Captain Ray Wiss looked
to be an easy case. He'd been riding in the back
of one of the ANA's unarmoured pickup trucks,
chasing Taliban fighters, when it suddenly rolled
over.
"His BP and pulse were entirely
normal," says Capt Wiss, an emergency specialist
from Sudbury who finished his tour in Afghanistan
in February. "The soldier had no abrasions or
contusions and his abdomen was soft, with only
minimal tenderness in his lower left. His pelvis
was stable, he had no neurological findings and
all limbs had full range of motion." Everything
checked out.
Just to be safe, he decided
to observe the soldier for an hour or two, give
him some painkillers and send him home. And, just
as a matter of form, Capt Wiss, a pioneer in the
use of ultrasound in emergency rooms back home,
did a quick a scan with the portable ultrasound
he'd been loaned for his three-month tour.
Snooping around the soldier's
abdomen, he was startled when he saw it: around
the liver, internal bleeding.
The ANA fighter was going into
shock by the time he reached the Kandahar airbase
hospital, after being airlifted from Capt Wiss's
clinic on the front-lines near Pakistan's border.
In the OR, lacerations to his liver and spleen
were repaired, and a small hole in his bowel was
oversewn. The portable ultrasound saved his life.
One has to wonder why the military
hasn't yet endorsed the technology for medics
to use on the front lines.
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