Attrition: Curbing The Quick Killers

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October 25, 2019: The U.S. Army recently had some paratroopers carry freeze-dried plasma (FDP) kits in their rucksacks during a parachute jump. This was to verify for the FDA that the FDP kits can survive an airdrop. That was really no problem because FDP does not require refrigeration and, like an MRE (freeze-dried Meals, Ready to Eat), contains no liquid. It comes in a plastic bag ready to be mixed with an accompanying bag of sterile water. Both are packaged in a hard plastic container built to handle rough treatment in a combat zone. The FDP kits carried by these paratroopers were the new American-made FDP. Since 2012 SOCOM (Special Operations Command) troops have been using French FDP kits, which have been used by the French military since 1994. SOCOM medics have used the French FDP over twenty times since 2016 and that saved the lives of several American soldiers. The American FDP is expected to get final FDA (Food and Drugs Administration) approval by 2020.

U.S. SOCOM has often been the first to use new emergency medicine developments. Once the special operations medics confirm that these new items work well in a combat zone, the army and navy medics adopt them. FDP was something of a special case and it took two years (2016-17) for SOCOM to deal with the U.S.government medical bureaucracy (FDA) and get permission for French FDP to be used by SOCOM combat medics.

FDP is a big deal because 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 (the 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 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 but the FDA agreed in 2018 speed up the testing process for an American producer of FDP.

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 French 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 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. FDP has a shelf life of two years and is stored in containers similar to the ones the American FPD uses. SOCOM and French combat medics carry with them into operations where it might be needed, and there have never been problems with the French FDP packaging.

FDP was unusual because so many similar emergency medicine technologies have been developed and shared by civilian and military medics rather than, in the case of FDP, something that was mainly of use for the military. Despite that, FDP was still part of a trend that had 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. The proportion of combat deaths to injuries was 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. Though the proportion of combat deaths was already greatly reduced by 2010, there were still some types of wounds for which there was no battlefield treatment, meaning the victim would 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. 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 in a field hospital. 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 long 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. This was more commonly called HemCon and 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 by then become the most common cause of death among wounded American troops. HemCon 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 bleedings 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 immediate (within minutes or seconds after getting hit) medical care for troops. This effort consisted of three programs. First was the development of new medical tools and treatments that troops could be quickly and safely be taught to use, such as 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 were a growing number of ways to deal with PTSD (Post Traumatic Stress Disorder). While largely the result of being exposed to a lot of combat, it was, by the late 1990s, realized that head trauma, usually from being too close to a lot of explosions, played a part as well. Work on PTSD continues, especially now that more methods have been developed, including medicines, to treat it. As an immediate problem, medics were taught the signs that indicated a soldier might have PTSD and if left alone might become a danger to himself or his fellow soldiers. That is because PTSD often shows up in troops who don’t realize they have it and continue trying to do their job. PTSD can be more quickly and effectively treated if it is detected early.

 


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