It's no secret that the sooner a wounded soldier gets treatment, the greater his chance of survival. That's why the Army began using MASH (Mobile Army Surgical Hospital) units and tasking helicopters with carrying wounded quickly to medical sites. Olive-drab choppers have given way to bright-yellow Life Flights that regularly pick up people hurt in accidents and ferry them quickly to hospital ERs. This technology transfer was a natural.

Medical planners in the U.S. military continue working on shortening its response time with the most effective material and medical devices imaginable. Many of those developments will make their way into civilian applications. A few of these first-response methods include ways to stop nasty wounds from bleeding, storing blood in less than ideal conditions, and advanced prosthetic devices. Looking a little into the future, armored robotic vehicles could pick wounded soldiers off the battlefield under fire and perform remote surgery.

A few attack plans

The Combat Casualty Care Research Program (CCCRP) at Ft. Detrick, Md., (usaccc.org) conducts much of the military medical research. The program's mission is to reduce mortality and morbidity from battlefield injuries through new life-saving strategies, surgical techniques, and biological and mechanical products. The organization's investigations include blood clotting agents, resuscitation fluids, brain injury biomarkers, and databases to track outcomes. It's even rethinking what aid should be first.

“For instance, one recent idea is that medics must consider the tactical situation before treating patients,” says CCCRP director Col. Robert Vandre. “Sometimes it's better to shoot first and treat later.” Another idea promotes hypotensive resuscitation (letting blood pressure fall to minimize blood loss) for bleeding patients during delayed evacuations. “This is contrary to the civilian practice of giving large volumes of resuscitation fluid early on. The thinking now is that medics should not give actively bleeding soldiers fluids until they lose consciousness. That's because IV fluids increase blood pressure which increases bleeding. Obviously, this is something to avoid. Research on animals shows Hextend, a plasma volume expander, to be the best fluid for hypotensive resuscitation.”

CCCRP together with Israeli doctors are promoting the first use of recombinant activated Factor VII, a blood product, for treating severe surgical bleeding. “Activated Factor VII stops bleeding when clotting mechanisms are not working properly. It was initially licensed for use on hemophiliacs. Factor VII is being used in major trauma centers worldwide and has been used on over 400 wounded patients in Iraq,” says Vandre. The drug's maker, NovoNordisk, is pursuing clinical trials to earn the drug FDA certification for trauma. Vandre anticipates giving medics access to it.

“I can also see Factor VII on civilian ambulances and used routinely on seriously injured trauma patients. It has the potential to save about 10% of those who now die. The same could happen with our advanced resuscitation fluid, assuming the price is not too high,” he says.

CCCRP is also looking for a better resuscitation fluid. Civilian trauma calls for normal saline or lactated ringers as an initial IV. “There is little effort looking for replacements, partly because transportation times to civilian hospitals are usually short and a particular resuscitation fluid makes little difference. Inexpensive fluids have little profit potential. But conditions are reversed in the military. Evacuation times can be long so the resuscitation fluid becomes more important,” he says.

Surgeons would likely say that whole blood is the best resuscitation fluid. But it is impossible to collect, ship, store, and send it forward to the battlefield. “We are hoping to use freeze-dried products as substitutes for whole blood that can be used on battlefields. We are also looking at additives that reduce inflammation and can put in resuscitation fluids to lessen the incidence of shock. This substitute for whole blood will probably end up being fairly expensive and therefore unlikely to find widespread use in the civilian community unless it is highly effective,” he says.

Another Dept. of Defense (DOD) R&D area ahead of civilian efforts is in treating penetrating head injuries. Most civilian head injuries are blunt trauma, usually from auto accidents. Head injuries in the military are more often from objects that penetrate the skull. “We are investigating ways to detect the severity of brain injuries using biomarkers. These are proteins elicited in the blood after the brain experiences trauma. We have found about 50 proteins that are apparently related a level of brain injury. Research now is to find the best of the 50 that indicate a severity level. We are also working with the pharmaceutical industry to see if drugs developed for strokes and other neurological disorders can help patients with head injuries,” says Vandre.

If the traumatic brain-injury test kits live up to their potential, Vandre sees them changing standard practice. The kits would let doctors quickly determine the extent of brain trauma and whether it was getting better or worse. This would tell physicians sooner whether interventions have been effective and let them change strategy if they have not.

Even an IT mainstay, the database, is being called to active duty. For instance, Special Forces and other services are collaborating on a Joint Theater Trauma Registry. It's a database for tracking causes and results of wounds to soldiers in Iraq and Afghanistan. “The database will let us give better care to soldiers by tying outcomes to treatments. Even though it's new, it has shown that one way to reduce deaths is to stop internal bleeding. Hence, we are doing more research in using hemorrhage control, resuscitation, and blood products together as a team.”

Through all of this, training cannot be ignored. There are over 100,000 armed forces medics on active and reserve status. All have to be trained when they come on duty and need regular refresher courses to keep their skills honed. Information comes from texts and computer simulations, but experience must be hands-on. For example, many DOD medics are expected to be able to insert chest tubes between ribs and into the space next to lungs to drain fluid. This is a surgical procedure they are authorized to do only in combat.

So how do you practice that? “With an advanced patient simulator. It's under development. These mannequins let medics practice lifesaving procedures such as inserting chest tubes and cricothyroidotomies - putting a tube through the skin of the neck into the windpipe when the airway is obstructed - before they have to do them for real on the battlefield,” says Vandre.

Advanced prosthesis

Rehabilitation is also in Army crosshairs. With roadside bombs harming GIs, DARPA (Defense advanced research projects agency) recently awarded Johns Hopkins University Applied Physics Laboratory (APL), Laurel, Md., (jhuapl.edu) a $30.4 million contract to start the first phase of Revolutionizing Prosthetics 2009, a four year program to develop a next-generation mechanical arm that mimics a real arm as much as possible.

APL team leader Stuart Harshbarger says there have been significant improvements in upper extremity prosthetics in recent years. “The state-of-the-art myoelectric arm, for example, lets users control hand and arm movements with three degrees of freedom by flexing a muscle or through mechanical movement. But patients generally have control of only one motion at a time,” he says.

Research will focus on advanced neural-control strategies that will let users operate the arm in a near-biological manner. They also aim to develop new power, actuation, and control technologies, as well as advanced sensors. “The resulting prosthetic will improve quality of life for a range of daily living and job functions, including the dexterous manipulation of objects,” adds Harshbarger. “The greatest challenges are long-term neural control that lets a person move the limb as naturally as they would their native limb and that provides sensory perception of limb position for interaction with their environment.”

“We have a hand picked team with experience in prosthetics and with many promising developments,” says Harshbarger. “Given the complexity of the challenge, we are casting a broad net to make sure truly innovative approaches are not overlooked. In addition, a series of iterative developments and demonstrations will help weed out technologies that may not be ready within the four-year program.”

First, stop the bleeding

In past conflicts, a tourniquet was the best way to stop wounds from bleeding. Sometimes, it is. But it also chokes off blood flow to an extremity. The military has found several ways to halt bleeding that don't involve tourniquets. Most use an absorbing material that draws liquid from blood, thereby concentrating platelets and speeding clot formation. Developers say their materials start clotting in as little as 30 sec. to one minute, compared to as much as 30 min required by traditional hemostats. Because of their ease of use, troops can self-apply or buddy-apply the bandage until a medic arrives. A drawback is that nonabsorbed beads in several products must be later cleaned from a wound.

One material that does not require removal from the wound site uses a potato-starch-based material called microporous polysaccharide hemospheres. “The main ingredient in Traumadex is a particle or bead with a controlled pore size. It acts like a sponge to dehydrate blood and accelerate natural clotting,” says Chief Scientist James Drake at Medafor, Minneapolis, (medafor.com). “It's applied in one step without mixing. It gels rapidly without irritating tissue, creating a protected environment for hemostasis and healing. The initial gel forms almost instantaneously,” says Drake. Once that happens, regular clotting mechanisms quickly take over. “We've concentrated clotting factors on the surface so you get a strong stable clot in about two minutes after application. The starchy beads begin breaking down in hours, and depending on where it's applied, the body absorbs them in 24 to 48 hours,” says Drake.

The company says Traumadex is biocompatible so there is no risk of disease transmission. It contains no human or animal proteins so it's hypoallergenic. And it's effective even in profuse bleeding. The base materials have shelf lives measured in years. It can be packaged as a spray, or the powder can be contained and applied with a variety of devices such as syringes, surgical applicators, nasal applicators, and absorbable dressings.

Drake says research is looking into the details of how the process works. “We are not certain what bead size is best. There may also be better applicators. It's a powder now and new formulations would be useful. Since particles dissolve at the wound site, it leaves a porous network in the clot that we might take advantage of by adding wound-healing drugs, peptides, antibiotics, and improving the base formula.”

QuikClot, from Z-Medica Corp., Wallingford, Conn., (quikclot.com), works similarly but uses zeolites to absorb blood liquid. The microporous crystalline solids have well-defined structures and are applied by a syringe into a wound or pressing a treated bandage over the wound. “The material uses several different phenomena to stop bleeding,” says company president Raymond Huey. “Zeolites, the main ingredient, absorb water from blood and concentrate clotting factors and platelets. Electron microscopes show that platelets are activated at the surface of the zeolite crystals. Lipids also bind to the zeolite to enhance clotting. Proprietary compositions in the zeolite also encourage clotting.” Huey says several units of the material could be applied to a large wound.

A drawback is that temperature where the zeolite is applied rises to the point where it could cause second-degree burns. “But that seems infrequent and is a lesser evil than bleeding to death,” adds Huey. Developments are underway to eliminate the heat issue, let the material kill more microbes, and package it for surgical applications. Huey says all branches of the military use QuikClot and the company credits it with saving 155 lives in Iraq and Afghanistan.

Storing blood at room temperature

Handling freeze-dried blood often requires two bags and that's an opportunity for contamination. So the Army wants to freeze-dry blood and reconstitute it when needed in one bag.

Medical design firm Foster-Miller Inc., Waltham, Mass., (fostermiller.com) developed a blood collection bag for the Army. The goal is to collect, lyophilize (freeze dry), store, and reconstitute blood products. Using only one bag reduces contamination when transferring blood to another container. The bag is made of breathable polymers that improve water-vapor transmission during freeze drying. After removing water vapor, an access port permanently seals and the bag can be stored at ambient conditions.

Trauma pods on the battlefield

Quickly stabilizing wounded soldiers is so important that the Army has awarded a $12-million contract to SRI International, Menlo Park, Calif., (sri.com) to develop an armored first-aid vehicle that would pull hurt soldiers off the battlefield and attend to them, potentially minutes after they were wounded. This robotic medical-treatment system would not require medical personnel on front lines, yet it would receive, assess, and stabilize wounded soldiers in the critical minutes following injury prior to evacuation and during transport.

The first phase of the two-year program is to develop a way to perform totally unmanned surgical procedures within a fixed facility. In combat, a doctor will conduct all surgical procedures from remote locations using surgical manipulators. Its actions would be transmitted to the surgery site. When fully developed, the Trauma Pod can be carried by a medical ground or air vehicle.