Bloody miracles
Thanks to advances in battlefield medicine, lives that would have been lost five years ago are now being saved. Steve Smethurst discovers how excellent military trauma care is halting the haemorrhage of blood and lives
Back in March, a report landed on the desk of the surgeon general. Lieutenant General Louis Lillywhite, the man responsible for the healthcare delivered to the Royal Navy, Army and RAF, had asked the Healthcare Commission to investigate “the good and the bad” of the services that he is held accountable for.
He soon discovered that the report had found things that were not exactly ideal (cleanliness in certain buildings, for example). However, one thing was clear: the quality of emergency care provided to casualties of war is very good.
The report’s author, Commission Chairman Sir Ian Kennedy, spelled it out: “There is absolutely no question that personnel injured in battle have a better chance
of survival than ever before. That is entirely due to efficient and innovative care, delivered under exceptionally difficult circumstances.” He added that the NHS’s urgent and emergency services “could learn a lot” from how the defence service plans care, trains staff and constantly seeks to learn and improve trauma services.
The man who is largely responsible for standards in battlefield trauma care is Colonel Tim Hodgetts, from the Royal Centre for Defence Medicine in Birmingham. He says that it is not just about having the latest gadgets. It’s about service personnel having the correct training and ensuring that the appropriate processes are in place. Crucially, too, it’s about getting medical help to the seriously injured as quickly as possible. His job also involves investigating emerging injury patterns or clinical problems and then “very quickly getting on top of them”.
One major advance is treatment at the point of wounding. Research has shown that the most likely cause of avoidable death on the battlefield is from loss of blood, particularly from injuries to limbs. To control this haemorrhage of blood and lives, every soldier now carries an elastic field dressing so they can compress their wound.
“We equip troops with a tourniquet that is simple, robust and that they can apply themselves. Even if you’re under fire, you can get the tourniquet on to your injured limb with one hand and apply in just a few seconds,” says Tim. However, it is only effective with compressible haemorrhages – essentially to injured limbs – as a haemorrhage to a chest or stomach cannot be compressed in this way. For these injuries, surgery remains the only answer.
Tim adds that an improvised tourniquet – using a bit of cloth and a stick – takes too long. “It takes four and a half minutes on average to control bleeding effectively from a limb using an improvised tourniquet, whereas it just takes a matter of seconds to use one of the commercial ones.”
Immediate treatment
The analogy that military medics like to use is that if you are in a car crash on the M6, you have to wait for professional help. What the armed forces are doing is introducing the ability to do something at the point of wounding so that treatment can start immediately after the incident.
Every soldier is taught and tested annually on battlefield casualty drills, and before being deployed they are taught and tested again, undergoing a series of simple drills that are listed on the aide memoir that every soldier carries.
Another life-saving advance is that one in every four combat soldiers is now a trained Army Team Medic (ATM). It’s something that has come into force since April 2006. ATMs carry a small pouch of additional equipment, which includes HemCon bandages (see panel overleaf) and a suction device, so if there is blood or vomit in an airway, they can suck it out. Also, if someone has a chest wound from which air is escaping, then there is a sticky dressing with a flutter valve that can be applied. In addition, they have extra field dressings, extra morphine and scissors. Most of their equipment is focused towards controlling bleeding as it is what costs so many lives.
In Afghanistan, once someone is injured, a radio message is sent to activate the medical emergency response team. Rather than a traditional ambulance, this will be a helicopter, as virtually all patients are moved by air if they are seriously injured. On board will be a senior doctor, usually a consultant in anaesthetics or in emergency medicine. There will also be an experienced emergency nurse and a paramedic.
“We also usually take a fourth person,” says Tim, “who could be a paramedic or junior doctor in training, so that we are preparing people for future operations under supervision. But it is a very senior team with what is effectively an emergency department at their disposal. They will have the facility to use anaesthetics and to intubate, for example.”
The helicopter also carries blood products in a cold box so that a start can be made on replenishing lost supplies. Blood is separated into its different components by the National Blood Service and the medical team will give red cells and plasma in a one-to-one ratio to replicate whole blood while in flight. They will then give platelets according to the patient’s needs back at the field hospital.
One complication is that platelets – the body’s clotting agent – have a shelf-life of just five days. That the National Blood Service and the RAF are able to get supplies of these from the UK to Camp Bastion with some shelf-life remaining is a ‘logistical wonder’, says Tim. However, if supplies do run short there is a process called apheresis, which uses screened donors from the Bastion hospital who hook themselves up to a machine for 90 minutes. They have their blood taken, the platelets removed from it and then the red cells and plasma given back.
“It doesn’t stop them getting on with their ordinary job and we estimate that you can safely have platelets taken from you every two weeks, if you wanted to donate them that frequently,” says Tim.
“We do it this way because platelets don’t usually need to be given immediately. It’s the blood and the plasma that needs to get in to you first. In Afghanistan, the laboratory is next to the emergency department and they are permanently poised to help us with the critical patients. Everybody is tuned in to the transfusion protocol.”
One of the ways this is achieved is through regular three-day exercises, which last both day and night, with simulated casualties coming through constantly. They test the hospital to its extremes and ensure that everybody gets into the habit of the transfusion protocol.
Pioneering war surgery
The fact that the Healthcare Commission report suggested that the NHS could learn lessons from the way the military handles care doesn’t come as a shock to Tim. He explains that the principles used in war surgery are often a step ahead of civilian care. He cites the treatment of people injured during the Asian tsunami of 2004 as an example.
“I was part of the Tsunami Commission that looked at what happened in hospitals in Thailand during the aftermath. Only at one of them did they follow the principles of war surgery and nobody died from infections at that hospital. Most of the others just gave the wounds a clean, stitched them up and then, within 24 or 48 hours, they had patients with septicaemia.
“Our policy is to use something called VAC therapy, which pulls the wound edges together, without completely closing them and sucks out the exudate. It’s been very effective, because if you just stitch them up immediately after cleaning them they will get infected. If you have got a ballistic wound, for example, it’s usually highly contaminated with soil.
“So, you cut away any dead tissue and muscle and give it a good clean. Then you pack it with gauze or put VAC on it, and leave it open. If, after two or three days the flesh is still nice and pink, then you stitch it up. If there are any bits that need the cutting and cleaning process repeating, then you do it again and look a couple of days after that.”
Another factor that sets apart military medicine from civilian is that at Camp Bastion there is consultant-based resuscitation. That means that every seriously injured soldier will be attended by consultants in emergency medicine, anaesthetics, surgery and orthopaedics, not to mention a team of experienced nurses, 24 hours a day.
What’s more, they will be waiting for that patient at the bedside before the patient arrives so they will get the highest possible standard of care. “It’s something that simply can’t be replicated in the NHS,” says Tim, “and it’s effective because seniority saves lives.”
There is also a thorough review process. Every Thursday for the past two years a conference call has taken place. Military and civilian clinicians will gather around a speaker phone in Birmingham and talk to those involved in treating injured service personnel at the hospitals in Bastion, Kandahar and Basra, not to mention Headley Court and RAF Brize Norton.
The purpose of the call is to give feedback on the patients that have been treated, to talk through any clinical issues and to ask why certain decisions were made. The call is also an opportunity to see if any practices, policies or equipment need to be changed.
“If we find anything, then we will aggressively try to change it within the week,” says Tim. He adds that the surgeon general sees detailed minutes of all the meetings. A little-known feature of the review process is that a member of the trauma team attends all military post-mortems. One reason is to check that everything that could have been done clinically was done. The other reason is to protect other troops.
“We look at helmets, body armour, what vehicle they were in and where they were sitting…” says Tim. “The other element is that an enormous amount of effort is made at point of wounding to try to resuscitate even the most devastatingly injured patient. A lot of my time is taken up with feeding back to the guys on the ground, to medics who are worried whether they did the right thing. In practically every instance, all the skills and drills were done effectively, it’s just that the injuries were too severe.
“It’s important to tell them this because if they do the same skills and drills on somebody less severely injured, then that person is going to survive. Unfortunately, it’s an inevitable part of conflict that, sometimes, whatever medical intervention we do, it’s not going to be enough. The injuries are just too severe.”
One other vital role that Tim and his team perform is to see if there is anything that could be done for the future in terms of changing protective systems. “We are very vigilant in looking out for any new emerging injury patterns and to immediately report them,” he says. When asked if he is confident that things he identifies are acted upon, he answers ‘yes’ with no hesitation. “We are constantly scanning the horizon. We look at all the medical literature and generate a good deal ourselves. We’re looking for the absolute best things out there. If we can find something that does the job a little bit better, then we go for it.”
As LtCol John Etherington, a consultant at Headley Court, the Defence Services Medical Rehabilitation Unit, testifies: “The reality is that we’re seeing people who would have died four or five years ago. There are people staying alive who – according to all statistical reasoning
– shouldn’t have done. It’s fair to say that many of our patients would have been dead five years ago, yet they are making remarkable recoveries.”
