Afghan war offers medical lessons put to use back home
Doctor Louis-Philippe Palerme, right, from Gatineau, Qu�bec, is getting assistance from a Danish doctor, Captain Sacha Soelbeck, during a surgery at the Role 3 Multinational Medical Unit in Afghanistan. (Sgt. Paz Quill� / Department of National Defence)
Published Tuesday, July 5, 2011 7:19AM EDT
Last Updated Saturday, May 19, 2012 5:12AM EDT
When "improvised explosive devices" became the Taliban's weapon of choice in Afghanistan, not only did our military commanders have to adjust their strategy, so did military doctors.
Trauma surgeons and medics in the field made changes that have allowed soldiers to survive injuries that, even 10 years ago, would have been fatal. And now, some of those medical developments are being put to use in civilian hospitals back home in Canada.
The Taliban deliberately stepped up its use of IEDs around 2007, scattering ever-more sophisticated bombs that were anything but "improvised" all over areas where NATO troops were stationed. The bombs turned out to be tragically effective.
Of the 158 Canadian soldiers who have died in Afghanistan, 97 were victims of IED explosions – and most of them have been killed since 2006. Suddenly, medics and surgeons at Canada's Role 3 hospital at the Kandahar Airfield were dealing not just with gunshot wounds, but with devastating blast injuries, such as amputated limbs and serious abdominal wounds.
As surgeons and medics were forced to refine their approaches, they revived the use of a simple medical device that had fallen out of favour for years: the tourniquet.
The return of the tourniquet
When asked to name one medical advancement that has had the most impact in this war, trauma surgeon Dr. Homer Tien replies: "The biggest difference was by far the tourniquet, in my opinion."
Tien ought to know. Not only is he the medical director of the trauma centre at Sunnybrook Health Sciences Centre in Toronto, he's a military surgeon who has done four tours of medical service in Afghanistan and plans to return for another two-month stint in September.
He says IED injuries present unique challenges to doctors and medics. Body armour and Kevlar helmets might protect soldiers from many kinds of wounds, but they're effectiveness is limited when a soldier steps on an IED. All too often, the blasts shear off feet or legs. And that's where the tourniquet comes in.
Tourniquets are nothing new, invented as they were hundreds of years ago. But for many years, doctors simply abandoned them, Tien says.
"Tourniquets were once completely out of style, absolutely," he says.
One of the arguments against their use was that when tourniquets are tightened around a damaged limb, they cause tissue below to die. So doctors and hospitals discouraged their use. But Tien says battlefield surgery is very different from surgery in a city, where many of the decisions on such things are often made.
"Battlefield injuries are usually not puncture wounds, like the gunshot wounds and stabbings you'd see in a city," he says.
The wait for medical help is also not nearly as long in the city as it might be for a soldier injured in a hard-to-reach outpost in Afghanistan. And in the case of a limb amputation from an IED, the biggest worry is that the soldier will bleed to death while he waits for medical help.
So in recent years, there's been a revival of tourniquets.
"They made a comeback for Canadians around 2004-2005. And by the time we got to Kandahar [in 2006], it was part of the kit we gave to medics," Tien says.
Today's tourniquets are not what they once were. Now, they look like short belts made of nylon webbing that can be wrapped around a limb and tightened off with one hand. Every soldier is issued one and instructed on how to use them as part of their pre-deployment training. Soldiers report that some comrades even strap their tourniquets on each leg every morning before setting out on a patrol, just in case.
Tien calls tourniquets "a 90 per cent solution to the bleeding issues that come up in the field." But in cases where a tourniquet won't help, such as an abdominal wound or shoulder injury, other new and effective tools called "hemostatic agents" are being put to use.
Hemostatic agents limit blood loss
One of them is called QuikClot. It was originally a powder that every soldier carried in their packs. The powder was made of a mineral called zeolite that was poured directly on wounds to stop bleeding. While it was effective in stopping bleeding, it created a great deal of heat and often caused chemical burns that made repairing the wound more difficult. So it was discontinued.
QuikClot's manufacturer then switched approaches and created a gauze containing kaolin, a mineral found in clay. Kaolin activates a key clotting factor in the blood, allowing blood under the gauze to clot and block off broken vessels.
The gauze is now part of the kit carried by Canadian medics, as are HemCon bandages, a kind of bandage that works much the same way as QuikClot.
HemCon bandages actually made from crushed shrimp and crab shells. The shells contain chitin, which attracts the blood's platelets and red blood cells and causes them to form a gel-like clot that seals a bleeding vessel.
The bandages and gauze offer medics one more tool to minimize blood loss when a tourniquet won't work. They're also being tested for use in civilian hospital settings and among first responders, such as paramedics. The manufacturers of both products are marketing their products to consumers as well, though it seems just through their websites for now.
More intense training for soldiers, medics
Training on how to use hemostatic agents is just one component of a new type of first aid training that all soldiers now undergo, called "tactical combat casualty care." Tien says TCCC is another development that is having a big impact on saving lives in the field, by ensuring that more injured soldier and civilians make it to the hospital quickly.
The Canadian military adopted TCCC after the devastating "friendly fire" incident in 2002, in which four Canadian soldiers died. All Canadian combat soldiers now undergo two weeks of TCCC training that focuses on teaching them how to suppress enemy action first, so that they can quickly evacuate injured comrades.
Once they can tend to the wounded, the soldiers put to use their training on how to stop bleeding quickly, when to use tourniquets and when not to, and how to quickly treat collapsed lungs.
Tien says another key advancement he's witnessed in the field in Afghanistan is the better training of medics, who are a critical link in treating injured soldiers and civilians.
"I was in Yugoslavia in the mid-90s and the way we train our medics is just completely different. They're so much better prepared now," he says.
Medics are now trained to deal with multiple traumas, even while still under fire, tending to multiple patients at once if needed. They, too, focus on quickly stopping bleeding and stabilizing the injured to prepare them for evacuations.
While these small changes to first aid approaches may seem modest, they can make a big difference, since 90 per cent of soldier deaths occur in the field and the most common reason for trauma deaths in war is massive blood loss.