How much of an effect have modern technologies in body armor had on combat casualty care as well as long-term care?
The use of body armor during the recent conflicts is a very significant contributor to the high survival rate of injured warfighters, including those who suffer from mild traumatic brain injury (mTBI). Despite an increase in the severity of injuries suffered by our service members in Iraq and Afghanistan, because of modern body armor’s ability to protect against penetrating wounds, we’ve seen a sharp decrease in the fatality rate. In addition, the modern combat helmet helps protect against penetrating injuries and provides some protection against impact. Adding to this protection, sensors have been included in the helmet and body armor to act as additional indicators for exposure to potentially concussive events and risk for TBI. These sensors can assist medical personnel in the assessment and analysis of concussive events allowing for diagnostic support and better treatment in the critical early period after the event.
What are some of the key technologies, such as hemostatic agents, that have affected military medicine?
The injuries sustained by warfighters today are often severe, destructive, and complex, and can affect the service member for the rest of their lives. For example, a blast injury from an IED [improvised explosive device] can lead to multiple injuries, including burns, amputations, nerve damage, and TBI.
Preparing for the unknown is always the biggest challenge. We live in a volatile, uncertain, chaotic, and ambiguous environment. It’s easy to prepare for the injuries and illnesses from the last war, but we rarely fight the same war twice.
Some of the latest technologies influencing military medicine come from lessons learned in past wars with, of course, an eye on the future of combat operations. We have been working on several exciting new technologies.
Of particular note is the development of junctional tourniquets, which are focal pressure tourniquet devices used to stop blood flow by compressing blood vessels at – or proximal to – a junctional injury. We’re talking about injuries such as pelvic fractures and high leg injuries; injuries that are commonly caused by improvised explosive device blasts, and that can result in massive hemorrhage if not addressed immediately. The SAM® junctional tourniquet was cleared for use by the U.S. Food and Drug Administration in 2013 for groin area use. It was also later cleared for use in the armpit area and for pelvic binding as well. The Combat Ready Clamp (CRoC®) is another type of junctional tourniquet, which differs from the others in that it has a vise-like compression disk that creates direct bilateral pressure in any chosen spot. Ultimately, this helps stop blood flow and thereby stops massive bleeding that might otherwise claim a life. What’s particularly exciting about the CRoC is it can be assembled and applied in less than a minute.
In the realm of hemostatic dressings, a variety of hemostatic agents have been incorporated into gauze and bandage products to aid in hemorrhage management. These products include the HemCon® Bandage and QuikClot Combat Gauze®. The use of products such as these is important, given that hemorrhage accounts for 50 percent of all combat fatalities. In conjunction with direct pressure, hemostatic dressings have proven invaluable for treating severe hemorrhage in soldiers injured during operations in Iraq and Afghanistan.
The next technology is the resuscitative endovascular balloon occlusion of the aorta – or REBOA – which is a technique that stops severe bleeding in trauma patients by deploying a flexible, balloon-tipped catheter up through the femoral artery and into the aorta before it is ultimately inflated. This method stops blood flow beyond the balloon, but also to the lower part of the body. As such, REBOA use is only temporary, and is used as a bridge to get the severely injured patient to more definitive care. To be clear, the REBOA is not yet available for general-use situations, but rather only in certain special operations settings.
An Army lab reconnaissance team for Joint Forces Command-United Assistance, comprising members of the Centers for Disease Control and Prevention, U.S. soldiers, and members of the Armed Forces of Liberia, walk down the flight line at the Roberts International Airport, Monrovia, Liberia, Dec. 4, 2014, on their way to survey and assess potential sites for a new Army medical laboratory in Greenville, Sinoe County, Liberia. Carefully developed and rigorously implemented Force Health Protection guidelines that help ensure troop readiness translated into a very small number of service members presenting with malaria symptoms during Operation United Assistance. U.S. Army photo by Spc. Caitlyn Byrne, 27th Public Affairs Detachment
Another example is the Miniature Field Deployable System for Rapid TBI Assessment, and it serves as a portable electro-encephalography [EEG] device. It quantifies and analyzes the brain’s electrical activity patterns unique to traumatic brain injuries. This in turn aids in the early, rapid, effective, and objective assessment of TBI severity and also helps determine the need for possible medical imaging. One such device, the Ahead® 100, which received clearance from the Food and Drug Administration in November 2014, is a headband-shaped device that measures a patient’s EEG signals, or brain electrical activity. The results are then interpreted by a clinician for diagnosis.
How has Force Health Protection (FHP) changed medical care during your career?
Focus on Force Health Protection has always been essential in preventing illness and injuries that jeopardize missions. With the recent emphasis that the secretary of defense and the chief of staff of the Army have placed on troop readiness, FHP has taken on greater importance. As a result, we’re seeing our armed forces in a higher state of medical readiness and suffering from fewer illnesses that compromise our service members’ ability to complete their missions. Take malaria prevention, as an example. In 2003, 225 Marines deployed to Liberia. Within a month, about 20 percent of the Marines were evacuated due to malaria. Contrast this with Operation United Assistance in 2014-2015. Over 2,500 service members deployed to West Africa in support of the U.S. response to the Ebola outbreak, and yet only five service members presented with malaria symptoms. Carefully developed FHP guidelines and rigorous oversight of their implementation resulted in a nearly complete prevention of malarial infection, which in turn resulted in greater mission effectiveness.
How much has jointness come into play over the years within military medicine?
The Army is more active, mobile, and geographically dispersed than we have been in the past, and more likely to work in joint operations or partnerships with other governmental agencies and nations. We’ve found that working in joint environments at the tactical and operational level helps to advance collaboration, leading to innovative medical research and development to improve military community health and save lives on and off the battlefield.
Most of our graduate medical education programs and advanced practice nursing programs are open to all services and it’s very common to work with medical personnel from our sister services. The Base Realignment and Closure (BRAC) initiative in 2005 directed that all enlisted medical training for the Army, Navy, and Air Force be conducted at Fort Sam Houston, Texas. While there are some unique requirements for each service on their warfighting platforms, the basic medical knowledge and skills are very similar and we continue to work toward collaboration in our training environment.
Soldiers display the various uniforms of Army nurses from World War II through the modern era during the Army Nurse Corps 115th anniversary celebration at William Beaumont Army Medical Center, El Paso, Texas, Feb. 2, 2016. On Feb. 2, 1901, Congress established the Army Nurse Corps as a professional element of nursing professionals within U.S. Army Medicine with the Army Reorganization Act of 1901. While technology has advanced and medical knowledge has increased in the 115 years since the Army Nurse Corps was established, “The need for care and compassion has not changed,” Holcomb noted. U.S. Army photo by Marcy Sanchez
One of the best examples of jointness, from my perspective, was my experience as the commander of Landstuhl Regional Medical Center (LRMC) in 2012. While it is an Army command, we had large numbers of Air Force and Navy staff members, and even some Marines. Everyone worked together and focused on the mission of taking care of casualties flown in from Iraq and Afghanistan as well as the military beneficiaries in Europe. When you walked into a ward, with everyone in scrubs, you could not tell who was in which service, except by the color of their T-shirt, and it didn’t matter to patients. We continue to work toward that same sense of team and camaraderie in several of our other large medical facilities where we have multiple services providing patient care.
What do you see as the greatest future challenges for protecting and ensuring the health and welfare of soldiers?
Preparing for the unknown is always the biggest challenge. We live in a volatile, uncertain, chaotic, and ambiguous environment. It’s easy to prepare for the injuries and illnesses from the last war, but we rarely fight the same war twice. There are many diseases we had not expected, Ebola and Zika for example, and some we haven’t yet discovered. Each corner of the world has something different that we may or may not know about or for which we do not have protective measures in place. There are weapon technologies that continue to evolve, so we have to understand the effects on the human body and brain of those technologies. Some of the most exciting things about the Medical Research and Materiel Command are the scientific research efforts being done to develop vaccines, laboratory testing procedures, and other physical protective measures in anticipation of the unknowns. We also have to continue to refine existing measures to meet the changing technologies and environments in which our service members fight and serve.
This interview first appeared in Veterans Affairs & Military Medicine Outlook magazine.