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TUESDAY, NOVEMBER 2, 2010


New and old techniques help keep troops alive


casualties from E1 A different analysis compared


battlefield injuries that occurred between 2003 and 2006. Those in the later year were more severe on average than those in 2003, but mortality wasn’t significantly greater. For the subset of “blast injuries” — the most common cause of trauma — wounds in 2006 were more extensive, severe and likely to take a soldier perma- nently out of service than those of 2003. But they weren’t more like- ly to be fatal. The conclusion: Medical treat-


ment has gotten better over the nine-year course of the wars. Almost none of the improve-


ment is the consequence of new drugs or new devices. Most of it, ironically, involves old technolo- gy and old practices that fell out of favor in the past 50 to 100 years and have been rediscovered and improved. And nearly all of them involve


blood.


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AfterMogadishu The modern focus on battle-


field hemorrhage came out of the disastrous military operation in Somalia in 1993 chronicled in the book and movie “Black Hawk Down.” Over a 15-hour period, about


170 U.S. soldiers were involved in a battle in the narrow streets of Mogadishu where they’d gone to capture a Somali warlord. Heli- copters crashed, soldiers were trapped and fired on by civilians, and rescuers got lost. More than 100 troops were wounded, 14 died on the battlefield, and four died later at hospitals. Several years after the event,


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military physicians analyzed ev- ery serious injury and death that occurred. They wanted to learn whether any could have been prevented, or if any of the care had unwittingly led to more casu- alties. The analysis showed that bleeding was a huge problem, leading to most of the deaths. Several people bled to death from wounds in places where direct pressure wasn’t possible, such as the chest or neck. One person, however, was saved by an impro-


6


on washingtonpost.com More from the front


See more of David Brown’s stories about treating


wounded soldiers at www.washingtonpost.com/health.


vised tourniquet on his thigh. “The emphasis on hemorrhage


control certainly stemmed from that episode,” said John B. Hol- comb, one of three surgeons who treated the wounded. “There was a lot of introspection. Frankly, I think the military was ready for a change.” The new treatment strategies


weren’t all hatched out of the Mogadishu experience. Many were already in development. But Somalia accelerated the process. The single most important


change was the endorsement of tourniquets, ancient devices that for the second half of the 20th century were considered too dan- gerous to use because extended use can cause tissue damage. The new ones optimize the force dis- tributed across the strap and can be tightened and locked with one hand. Every soldier carries one, and medics carry a half-dozen. Tourniquets are especially use-


ful in wars where blast injuries, not gunshot wounds, predomi- nate. Many makeshift bombs damage both legs or blow them entirely off.Apersonwhosefemo- ral arteries, the main arteries of the thigh, are both severed will die in about seven minutes. To- day, many soldiers with such wounds arrive at the hospital with tourniquets on each leg and all bleeding stopped. Their usefulness is so obvious


that some soldiers here go on foot patrol with them loosely placed on each limb, ready to be tight- ened. Designers of the next-gen- erationcombat dress are trying to determine whether the devices can be built into the clothing, possibly with gas canisters that can be triggered to inflate them. Military analysts estimate tourniquets have saved the lives of at least 1,000 U.S. soldiers, and possibly as many as 2,000, in the current wars. Of course, many soldiers suffer


wounds in places — such as the neck, chest, abdomen and groin — where tourniquets can’t be used. An analysis of “potentially survivable” wounds in soldiers who died after reaching the hos- pital showed that 80 percent suc- cumbed to hemorrhage, and 70 percent of the time it was from one of those “non-tourni- quetable” sites. A new generation of bandage,


called Combat Gauze, may help solve that problem. The fabric is impregnated with kaolin, a pow- dered clay that stimulates blood clotting. It has proved more effec- tive than clot-forming powders and granules, which often blew away or were washed out by bleeding. Despite these devices, most


soldiers with major trauma lose life-threatening amounts of blood. How medics respond to that condition is the second big innovation in hemorrhage care. The innovation? Do less than


you can and let the body run the show.


Simple assessments Medics are now taught not to


worry if a person’s blood pressure is as low as 85/40 (normal is 120/80) as long as the patient is alert. People in shock — severe low blood pressure, which causes mental confusion or uncon- sciousness — get up to a liter of intravenous fluids. Others get a catheter that is cappedandcan be used later if needed to push fluids into a vein. Gone is the routine hanging of a bottle of fluid, part of the classic visual tableau of bat- tlefield care. The preference for keeping the


blood pressure low in trauma victims — both because they can tolerate it and because raising it can dislodge clots and make mat- ters worse—was well understood inWorldWar I andWorldWar II, according toHolcomb. But by the time of Vietnam, “it seems as if that concept was lost,” he said. In the adoption of an even


older practice—oneHippocrates would endorse—medics are told to evaluate a patient’s status only by looking at him, talking to him


casualties continued on E5


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