Sunday, August 22, 2010

‘War is the only proper school for surgeons’

BALAD, Iraq — Army Dr. Colin Meghoo stared at the dry-erase board at Baghdad’s Ibn Sina Hospital. In black marker were the names of the injured, and the procedures chosen to try to save their lives — many of which he had never seen performed.
It was September 2005, and Meghoo, now a lieutenant colonel, had just completed his surgical residency. Trained in repairing the car crash injuries and the occasional gunshot wound that trickled into his Texas emergency room, he now was confronted with the devastating and hugely varied wounds of modern warfare: legs and arms mangled by explosions, arteries severed by bullets, vital organs peppered with shrapnel.
“It was a bit overwhelming,” he recalled, “but then you think to yourself, ‘Wow, this doesn’t even exist in busy civilian hospitals. You need to be in a war zone to see this.’ ”
The ancient Greek physician Hippocrates said that “war is the only proper school for surgeons,” and the war in Iraq has been just that, but with an important development: Lessons were learned and shared immediately.
In the past, doctors had to wait until the gunfire stopped before examining what lessons had emerged.
There are dozens of volumes just about World War II, published long after the war, said Air Force Dr. (Lt. Col.) Raymond Fang, trauma director Landstuhl Regional Medical Center in Germany.
But in Iraq, improvising surgeons and up-to-the minute observational research have resulted in techniques that helped troops survive at a greater rate than in any previous war. Some are high-tech and novel; others were rediscovered; and a few are reinterpretations of old protocols. Moreover, these lessons were documented and shared as the war raged.
Military surgeons have been able to rewrite the book on trauma before U.S. troops have even left the country. “War Surgery in Afghanistan and Iraq: A Series of Cases, 2003-2007” was published by the U.S. Army in 2008, detailing 83 cases from 53 battlefield
Now the lessons and techniques tested in Iraq are being honed in Afghanistan, and new ones are being explored.
“It’s not about the next war anymore,” Meghoo said, who recently completed his second tour at Forward Operating Base Sharana near the Afghanistan-Pakistan border.
The advances are needed now.

Stopping the blood
Wars have always birthed medical advancements.
During the Civil War, physicians found new ways to amputate limbs and began using rags soaked in chloroform to anesthetize patients. The typhoid vaccine was developed during World War I, when an Army officer also established the first blood depot. World War II brought the mass use of penicillin, and the Korean War, helicopter evacuation.
One of the legacies of Iraq is a new emphasis on stopping blood loss. Better body armor and helmets protected troops’ vital organs, but high-velocity bullets, rocket-propelled grenades and roadside bombs inflicted the exposed limbs with massive, bleeding wounds.
To stanch the bleeding, doctors turned to one of the oldest and simplest tools in battlefield medicine: the tourniquet. Tourniquets had been maligned and shunned since World War II because of fears that they caused gangrene and limb loss. They do, when used for long periods — but faster evacuation and hospitalization combined with tourniquets saved hundreds of lives in Iraq. A 2008 review of records at the 31st Combat Support Hospital in Baghdad showed that four in seven deaths could have been prevented had a tourniquet been used before the patient arrived.
“This is a simple mechanical thing done since the time of the Egyptians,” Fang said, “and now it’s returning.”
Soldiers in the field are issued one combat application tourniquet, or CAT; some carry more than half a dozen. Slipped around a limb, the tourniquet’s nylon strap is cinched, and the plastic bar on top is twisted, crimping the artery below. The lever is cranked with one hand, so servicemembers can secure their own tourniquets even when badly injured.
Sgt. Chris Bickford, a combat medic who has deployed to Iraq twice, said he trains all his soldiers to clamp on a tourniquet in less than 12 seconds.
“Before we could only use pressure dressings, and there was the chance you may lose the life,” he said. “Now the way the tourniquets are built, allowing them to be placed high on the limb — that saves lives.”
At the start of the Iraq war, innovative clotting agents such as QuikClot were also poured into open wounds. QuikClot, a loose substance made of synthetic absorbents that looks like dry clay, draws water from blood, helping it coagulate. But surgeons often had to pick out the sticky granules, and in some cases QuikClot burned tissue, or even the eyes of the patient on a windy day.
QuikClot’s manufacturer, Z-Medica Corp., soon replaced the loose product with a bag filled with the clotting agent, then, finally, combat gauze treated with it. Medics in the field now push the gauze into wound cavities. The gauze is “easier to carry and much more comfortable for the patient,” Bickford said.
Now the military is looking for alternatives to these synthetic materials, Fang said. One possibility is dried plasma, the liquid part of blood that has proteins and clotting factors. The dried plasma would be revived in a saline solution and then given to wounded troops intravenously or injected into the bone marrow. The latter technique keeps medics from having to search for a vein, a difficult task when soldiers are covered in thick packs and bleeding, said Col. Dallas Hack, director of the Combat Casualty Care Research Program.
“The bone marrow is a fairly large area,”” Hack said, “and you can do it by feel.”
Clinical trials of two forms of dried plasma, one freeze-dried and the other spray-dried, are under way, and it could be in the hands of medics within three to five years, Hack said.
Fang said long-held conventions about blood transfusions also changed. Doctors once pumped saline into hemorrhaging patients to restore hydration, and then added red blood cells and extra platelets. Now surgeons try to “emulate whole blood,” Fang said, forgoing saline and pumping in equal amounts of platelets, cells and plasma.
Before the war, surgeons had regarded the freshness of donor blood as unimportant — as long as it was used within a two-month window. But downrange doctors discovered that fresher red blood cells carry more oxygen, which keeps vital organs working better and provides more oxygen to the brain, helping prevent comas.
“There is a push downrange to use blood that is 14 days old or younger,” Fang said.
At forward operating bases in Iraq, loudspeakers often called for blood donors during periods of heavy fighting. Troops lined up at combat hospitals to donate as the wounded were carried in.
It’s a procedure that has continued in Afghanistan, Meghoo said, even at small outposts.
“You’d put the call out,” he said, “and people would just descend.”
Surgeons like Meghoo also practiced closer to the battlefield than in previous wars, often in the dusty tents of forward operating bases. There, teams lacked many resources of typical trauma hospitals, including imaging equipment such as CAT scanners and fluoroscopes. But they performed minimal yet crucial operations to stabilize a patient, often within the critical “golden hour” after injury, said Dr. (Col.) David P. Blake, director of trauma at the Balad hospital. After the initial lifesaving surgery, patients were taken to Balad, where they were warmed up and given fluids, allowing them to recover enough for the next surgery.
“You control what is immediately going to kill them,” Blake said, “and then you come back another day to address the details.”
Roadside bombs mangled limbs, leaving many soldiers amputees. To prevent this, surgeons improvised with shunts, tiny plastic tubes placed into damaged blood vessels. The combat surgeons found the shunts, which had been used occasionally by vascular surgeons, indispensable to keep blood flowing to troops’ injured limbs, hands or feet until the damaged vessels could be repaired.
Meghoo, for example, had a patient in Afghanistan who was shot in the leg by a high-velocity bullet. The patient’s femoral artery had been severed, and worse, the bullet had burned the edges of the artery, causing it to contract.
“That’s a huge hole,” he said, showing a picture of the gaping wound. “And I can’t sew the [artery] back together because the ends don’t reach anymore.”
To control the flow of blood, Meghoo placed two shunts into the patient’s leg, one in the artery and the other in the vein, and sent him on to another hospital for further care.
In previous wars, Meghoo said, he likely would have bled to death or lost a limb.

Battlefield advances

Devices developed at civilian hospitals were also brought to the battlefield, where doctors found new uses for them.
Before 2004, doctors opened and cleared wounds of blood-soaked gauze and other debris twice daily, a treatment that was painful for patients, but needed to keep their wounds clean. The frequent changing of dressings was common practice for centuries, Fang said, until surgeons at Balad experimented with a vacuum that sucks away the excess fluid, allowing a wound to be sealed for nearly three days.
With negative pressure wound therapy, the wound cavity is covered with a clear plastic bandage with a suction tube attached, then vacuum-sealed. Designed for chronic wounds, the suction helps troops’ tissues heal faster “because all that wound soup is not staying around,” said Lt. Col. Joe Sniezek, director of the Seventh Joint Combat Casualty Research Team.
Better still, patients on long evacuation flights no longer need to have their bloody dressings removed and cleaned in transit.
“It remains to be seen whether the outcome is better,” said Fang, “but it definitely makes it more comfortable for the patients.”
Several high-tech devices were tested for the first time on troops, including an infrared camera that helps doctors detect compartment syndrome, a crimping of the blood vessels in the leg or arm. Deep wounds cause muscle inside the limb to swell, potentially leading to gangrene. The only way to relieve the pressure, or even diagnose compartment syndrome, is to flay the leg or arm muscles open.
The surgery works, said Sniezek, but it’s a “morbid procedure, making an incision all the way down the limb.”
The infrared device, however, allows doctors to detect any difference between the temperatures of the body’s core and the limbs, an indicator that blood is not flowing correctly. If the temperatures are within normal range, surgeons can potentially avoid an unnecessary opening of the limb.
“This is a nice example of how new technologies are being integrated here on the battlefield,” said Sniezek, “and the study is now moving to Afghanistan.”
A cardiothoracic surgeon at Landstuhl was the first to save a patient with the Novalung — a simple-looking slender box with a complex membrane inside that acts as a temporary lung. It connects to blood vessels in the groin, allowing blood to flow from one leg into the box, where it passes through a filter that leaches off the carbon dioxide and infuses the cells with oxygen, mimicking the trade-off that takes place naturally in the lungs. The refreshed blood then returns to body through the other leg.
Unlike a heart-lung machine, the Novalung doesn’t require a mechanical pump because it “works off the body’s own blood pressure,” Fang said.
Approved by European regulators but not yet by the U.S. Food and Drug Administration, the Novalung has been used successfully on about a dozen troops transported to Landstuhl, Fang said. But each time they use it, doctors must submit to the FDA that it is being used to save a life.
“Every time there is a war we learn a lot, because we have to,” said Fang. “And what you learn over years of time is condensed.”
Meghoo recalled using the many lessons that he learned in Iraq during his recent deployment to FOB Sharana, where he was one of two surgeons working in a shed.
“It could be a very lonely feeling,” he said of being away from the safety net of a large hospital with many specialists. “You can’t pass things off to anyone else, and these people have big problems, and you are the only one who can fix them.”
On one occasion an Afghan woman had her right shoulder severed in a mortar attack. Blood gushed from the wound, making it impossible for Meghoo to reach the artery.
“It’s the equivalent of a fire hydrant,” he said. “You can’t go through the water to find the hole. You have to know where the shut-off valve is.”
Meghoo removed part of the woman’s collarbone, and then stemmed the flow of blood by temporarily cinching the artery.
“I remember that case,” he said, “because it was a skill I didn’t have until after I deployed to Iraq.”
The techniques discovered by military surgeons are trickling down to civilian hospitals as well, said Dr. James Dennis, a visiting vascular surgeon at Landstuhl who choked up while talking about the troops with catastrophic injuries whom he had treated in the intensive care unit.
“You can’t help but be moved by what these young people are going through,” said Dennis, whose 25-year-old son Trevor is in the Marines.
Dennis practices at a hospital in Jacksonville, Fla., that recently adopted the military’s protocol when giving blood transfusions to patients with massive injuries.
“They used to learn from us,” Dennis said of military surgeons. “Now we learn from them.”

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