Attrition: Extreme Emergency Medicine

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October 1, 2017: U.S. SOCOM (Special Operations Command) is gradually getting access to freeze dried plasma (FDP) for use by their combat medics. Plasma is used to replace clotting and other essential blood components in emergencies. It is not whole blood but is taken from whole blood and must be kept refrigerated. FDP is not yet legally available in the United States so SOCOM has been using French FDP, which the French military has been producing and using since 1994. After 2001 SOCOM became aware of allied special operations troops using it and in 2010 sought to get it for American troops. No American firm produced FDP because earlier (late 1940s) efforts were abandoned because of seemingly insoluble contamination problems.

The French military solved those contamination problems and produced it for use by French troops operating in distant parts of the world. By 2010 SOCOM was still trying to find an American supplier of FDP. The problem was that in the United States the FDA (Food and Drugs Administration) needed an American firm to produce FDP that they could put through their testing and approval process. There were problems with finding an American firm that would and could do it and then going through the FDA approval process. It was estimated that this would take until 2020 to complete. In 2016 SOCOM asked for permission to use the French FDP, which had been used without problems since it was introduced and saved at least 10 lives of severely wounded soldiers who needed plasma in a battlefield situation. Frozen plasma has long been available but this requires refrigeration and takes 45 minutes to defrost. FPD can be carried into combat and can be reconstituted (add water) in six minutes. SOCOM put together a team of medical and FDA experts in 2016 and in less than a month had obtained permission to use the French FDP until an American FDA approved product was available. Only SOCOM could use the French product but SOCOM operations are just about the only ones where FDP would be needed. The FDP has a shelf life of two years and is stored in plastic bags which combat medics carry with them into operations where it might be need.

The French FDP is called FLYP (French Lyophilized Plasma) and it was produced by the French military because there was yet much of a commercial market for it except from disaster relief teams in the early stages of handling people injured by some natural disaster that wrecked transportation and infrastructure. The French Army looked into the problems that had halted FDP research in the 1950s and found ways to deal with that and produce a safe FDP. FLYP got little attention outside France and remained something the French military had produced for them in small quantites and used only by their battlefield medics in remote areas.

FDP is unusual because so many similar emergency medicine technologies have been developed and shared by civilian and military medics. That is part of a trend that has been going since the 1990s as the military has received a lot of new medical technology that has made death on the battlefield much less common. Combat deaths were three times more common during Vietnam and World War II for a number of reasons, but a big one was all the new medical tools doctors and medics now have. But as much as combat deaths have been reduced in the last decade there are still some types of wounds for which there is no battlefield treatment, meaning the victim will die before more extensive treatment can be obtained. Chief among these crises are abdominal wounds where the abdominal aorta is opened. When that happens the victim bleeds to death in minutes. But by 2013 there was a solution in the form of a belt that is placed on the abdomen and activated. A bladder inflates which puts sufficient pressure on the abdominal aorta to stop the bleeding or reduce it enough to make it possible to get the casualty to a surgeon. This was just the latest of a number of innovations that have enabled combat medics to prevent massive bleeding from killing the injured. But that created more demand for something like FDP, especially in situations where there was no supply of refrigerated plasma handy (like the local hospital emergency room, or even ambulances equipped with a small refrigerator. Plasma was the last resort once you had halted massive blood loss but you had to replace some of the lost plasma (if whole blood was not available) to keep the patient alive until an operating room could be reached.

Dealing with massive blood loss has always been a seemingly unsolvable problem. While tourniquets have been around for thousands of years, these devices only work on limbs. Preventing death from most other rapid blood loss situations was achieved after 2001 with the development and widespread use of powders and granules that could quickly stop the bleeding. First (in 2003) came special bandages like the Chitosan Hemostatic Dressing (more commonly called HemCon). This was basically a freeze dried substance that caused rapid clotting of blood and was incorporated into what otherwise looked like a typical battlefield bandage. This bandage greatly reduced bleeding, which had become the most common cause of death among wounded American troops. This device was a major breakthrough in bandage technology. Over 95 percent of the time, the HemCon bandages stopped bleeding, especially in areas where a tourniquet could not be applied. This did not work when the abdominal aorta was involved. HemCon was followed by WoundStat powder to deal with some of the bleeding that HemCon could not handle. While medics, and troops, prefer the bandage type device, there are situations where WoundStat (a fine granular substance) is a better solution (especially in the hands of a medic). Only the medics got packets (usually two) of Woundstat powder. That's because this is only needed for deep wounds and has a theoretical risk of causing fatal clots if it gets into the bloodstream.

WoundStat was but one of many new medical tools for battlefield medicine that greatly increased the effectiveness of the immediate (within minutes or seconds after getting hit) medical care for troops. This effort consisted of three programs. First, there was the development of new medical tools and treatments that troops could be quickly and safely be taught to use. This included stuff like HemCon. Then came the equipping of medics (about one for every 30 or so combat troops) with more powerful tools (like FDP), so that troops were less likely to bleed to death or suffocate from certain types of wounds that are not fatal if treated quickly enough.

Finally, there was the Combat Lifesaver program, which more than tripled the number of "medics" by putting selected soldiers through a 40 hour CLS (Combat Lifesaver) course in the most common medical procedures soldiers can perform to deal with the most dangerous types of wounds usually encountered. These CLS trained soldiers are not medics, of course, but they do make available in combat crucial medical treatments. Thus they are sort of "medics lite," which is close enough if you are badly wounded and in need of some prompt medical treatment.

During the last two centuries major wars have tended to produce significant improvements in medical care. This is what has happened since September 11, 2001 but in a much accelerated fashion. For example, since 2001, over two million American troops went off to war and about two percent of them were killed or wounded. Only 12 percent of the 57,000 combat zone injuries were fatal, the lowest percentage in military history. This was largely due to major improvements in dealing with rapid blood loss (as when a major artery is severed) and the increased speed with which complex medical care could be delivered to wounded troops. New medical technologies also made it possible to detect injuries (like brain trauma) that, in the past, was very difficult to detect and treat.

The Combat Lifesaver course teaches the troops how to do things like insert breathing tubes and other emergency surgical procedures to restore breathing. The CLS troops have skills most likely to be needed in lifesaving situations when a medic is not available. The additional emergency medical training, and new emergency first aid gear (the "CLS bag"), has saved hundreds of lives and reduced the severity of even more wounds. Enough troops have taken CLS training so that there is one for every 10-15 combat troops and one for every 20 or so support troops on convoy or security duty.

These new developments were also popular with civilian emergency medical services, and many of the experienced combat medics coming out of the military went to work as EMTs (Emergency Medical Technicians), thus increasing the quality of care for civilian accident victims. This was similar to what happened to the EMT field after the Vietnam War, when ambulance crews rapidly evolved from simply transporting accident victims, after a little first aid, to EMTs who could administer procedures that previously only doctors could handle. This followed the experience in World War II, where war demands led to development of mass production of the newly created antibiotics and that led to a revolution in surgery techniques.

Then there was brain trauma, something that, until quite recently, was not even recognized as a “wound” or “injury.” These injuries can be inflicted by a severe bump on the head or being close to an explosion. Because of better diagnostic tools and techniques, many other combat zone injuries could now be measured as well. These included over a quarter million cases of traumatic brain injury (more commonly called concussion) and over a hundred thousand cases of PTSD (Post Traumatic Stress Disorder) that were discovered among combat veterans since 2001. In the past these conditions were not considered “wounds” in the same sense as something that made the victim bleed. This was despite the fact that many soldiers were put out of action temporarily because of concussion and PTSD.

Physical injuries to the brain can now be detected using more precise instruments like MRI and can often be treated. In the last decade it has become clear that there are several sources of PTSD (post-traumatic stress disorder) and concussions from explosions were more of a factor than previously thought. Many troops, because of exposure to roadside bombs and battlefield explosions in general, developed minor concussions that, like sports injuries, could turn into long term medical problems. Often these concussions were accompanied by some PTSD. Examining medical histories of World War II, Korea, and Vietnam War vets showed a pattern of later medical problems among many concussion victims. The same pattern has been found among athletes and accident victims who suffered concussions. Roadside bombs are only one of several sources of concussions. Military medicine experts believed that roadside bombs were by far the biggest source of these concussions and the resulting brain injuries.

 


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