Lessons From the Battlefield

      On today's modern battlefield, medical care has made remarkable strides in saving the lives of the wounded. Soldiers and Marines who would have perished in yesterday's wars are returning home in spite of devastating injuries. Our troops are equipped to stabilize their own injuries and those of their buddies, even in the absence of medical personnel. Medics and corpsmen are armed with advances in technology as they emerge, and our experience helps set new standards of trauma care.

   Front-loading definitive medical care at the point of injury makes obvious sense. The patient's own well-oxygenated blood, circulating in a system of relatively intact blood vessels, is the gold standard of perfusion. Does it make sense to lie still on the battlefield, bleeding and yelling "Medic!" when the means exist for the injured to stop his own bleeding? Does it make sense for the casualty with a patched-up circulatory system to arrive at the hospital without an airway, suffering from irreversible hypoxic brain injury?

A VS. B, EXCEPT AFTER C

   Of the many advances in battlefield medicine, some of the most beneficial are also the simplest. Consider the tourniquet. Once we apply it, we no longer consider an extremity lost. We have learned that as long as the tourniquet is removed in the next few hours, the limb will likely make a full recovery. Along with this change in thinking, the military has also adopted newer tourniquets, manufactured with a sturdy nylon strap and an attached windlass instead of a stick. Today, every soldier is issued this one-handed tourniquet to apply to their own injured limbs, stopping the loss of blood before significant hemorrhage occurs. These are much quicker and simpler to apply than yesterday's homemade strip of cloth and a stick foraged from the woods.

   But what about the simultaneous presentation of airway compromise and significant hemorrhage? Does it make sense to apply a tourniquet before opening an airway? Does A always have to come before B and C? Like any question worth pondering, the answer is usually, "It depends." Logic says without air in it, the circulating blood won't do any good. True ... but without blood to carry it, the inhaled oxygen won't do any good either. It takes both.

   In the case of significant penetrating extremity trauma, especially in the prehospital setting, where blood transfusions are not readily available, the patient really needs to keep their own blood on board. If we consider bleeding control only in the context of our traditional civilian approach (direct pressure, elevation, pressure point, almost never a tourniquet), it might indeed take so long that the patient suffocates from lack of a definitive airway. Fortunately, penetrating trauma with significant hemorrhage is uncommon in the civilian trauma patient, and when it occurs, our approach is often defined by the simultaneous efforts of more than one EMT. In this arrangement, one rescuer might well be spared to do nothing but provide direct pressure, elevation and squeeze a pressure point, while others tend to the airway.

   In the case of the military medic, however, we are often presented with multiple casualties, many of whom may simultaneously suffer from severe penetrating extremity trauma with uncontrolled hemorrhage and airway compromise. Our battlefield triage differs as well: We must return the most troops to the fight as quickly as possible in order to prevent the loss of additional lives. It is sometimes necessary to treat and return the lesser-injured to the fight first so that they may defend us while we attend to the more serious casualties. There are even times when the combat medic may save the most lives by taking up his own weapons and jumping into the fight personally. This is a vastly different proposition from the civilian EMT staging at a safe distance while law enforcement makes the scene safe.

   In this setting, rapid application of the tourniquet makes good sense. We know the newer tourniquets are quick to apply, and every soldier carries one. We also know that even with a compromised airway, patients can survive a brief hypoxic event. Certainly most can survive for the time it takes to apply the tourniquet.

   In deciding whether to address airway or bleeding first, consider the significance of the injuries. While penetrating trauma to an artery may require the rapid application of a tourniquet, one is often not needed in the case of a slower venous bleed. If there are numerous critical patients awaiting your attention, however, the tourniquet may be the quickest way to stabilize the patient with the venous bleed, permitting you to move on to the next case and ultimately save the most life.

CONTROLLING THE B

   After a 20-year career in EMS, during which I went on to become a registered nurse and worked part-time in an emergency department, I was deployed to Ramadi, Iraq, as a combat medic with the Vermont National Guard. Aside from my weapons, I found my three most useful tools were tourniquets, the new trauma dressings with built-in elastic bandages, and my laryngoscope.

   The new one-handed tourniquets are designed to be used by the casualty, and every soldier has one. When I was in Iraq, however, we did not have these in sufficient quantity to use them frequently on other people. Instead, we used simple ratchet straps cut down to size. These are inexpensive and available at any neighborhood hardware store. While they require two hands to apply, they are effective at controlling bleeding and cheap enough to be disposable.

   My next favorite innovation was the "Israeli" dressing, consisting of a thick gauze pad sewn into an elastic bandage. Developed and manufactured in Israel, it is remarkably effective, simple to apply and inexpensive to manufacture. The thick gauze is held tight to the injury by the attached bandage. The more significant the hemorrhage, the tighter the bandage is applied.

   There were other tools at our disposal. The simple tampon does a phenomenal job of stopping the bleeding in a bullet hole or stab wound. The Asherman Chest Seal comes with a flutter valve and is used for sucking chest wounds, with or without a 14-gauge IV needle to decompress a pneumothorax. In addition to the traditional IV catheters and tubing, the military medic carries a spring-loaded device called a FAST1 to initiate intraosseous infusions in the upper part of the adult sternum when venous access is impossible.

   The fluids we carried were also different. Subscribing to the logic of controlled hypotension, we no longer ran large volumes of Ringer's lactate wide open in every case of trauma. I carried equal quantities of normal saline and Ringer's lactate, knowing the NS was compatible with blood products to be used later and more useful in managing heat casualties. Farther from the hospitals, medics might use hetastarch, a hypertonic starch-based solution designed to draw interstitial fluid into the circulatory system and keep it there longer, thus providing more effective fluid volume replacement per liter of IV fluid administered. This is especially useful when medics must carry supplies over long distances in rucksacks. Water is heavy.

   Then there was QuikClot, a powder that undergoes an exothermic reaction in the presence of blood, effectively cauterizing wounds it's poured into. We also carried HemCon bandages, which are fabricated from chitosan and designed to stop bleeding by adhering to wounds. Both of these tools were expensive, in short supply and we were concerned about potential complications such as burns and foreign-body emboli in the bloodstream.¹ While we carried these tools for hemorrhage that couldn't be controlled through other means, I never used either of them.

MANAGING THE A

   While control of major bleeding was an obvious necessity, it was also imperative to provide definitive and reliable airways. In the civilian sector, we might have enough medical personnel to spare a rescuer who does nothing but attend to the airway, but in combat this is not always the case. The combat medic often has to give the patient their best chance of survival and move on to the next casualty. Just as in the civilian sector, there are a variety of tools to accomplish that task.

   I carried a tightly packed difficult-airway kit and collapsible BVM in my aid bag. The airway kit contained a laryngoscope and endotracheal tubes in a variety of sizes, as well as a surgical airway kit and Combitube. When the situation did not allow me to stay with the airway-compromised patient and monitor their condition, at least they would have the best possible chance of survival. Often another soldier or even a bystander could be pressed into service to periodically squeeze the BVM attached to the ET tube, but expecting such a lay person to effectively ventilate the patient with a mask while somehow protecting the airway from aspiration is not realistic. Even with no one available to provide ventilation, the ET tube still had its place in facilitating spontaneous respirations without danger of aspiration.

   Traditional thought would hold that in combat, the patient who requires intubation should be considered expectant, and based on the tactical environment, we may not be able to devote the time needed to save him. This is no hard and fast rule, however. More than once I found myself one-on-one with a critical patient, pinned down in combat where rapid evacuation was not an option. Intubating a trauma patient in these conditions, without suction or medication, is no easy feat, but it can be done. With blood in the airway, the vocal cords become difficult to distinguish. Becoming very familiar with the anatomy of the airway, so you know where to look, helps immensely. A steady hand applying firm cricoid pressure can also make the difference.

   In the case of the fluid-filled airway, begin by rolling the patient on their side and clearing out everything you can. Get as much fluid out of the way as possible, then roll the patient onto their back. Have someone else apply cricoid pressure with one hand and compress the chest with the other while you observe the airway. With the stylus forming the ET tube into the shape of a hockey stick, aim for the bubbles that escape when the chest is pushed down. Most of the time it works. If all else fails, there is still the surgical option, although I only had to do that once.

WHAT THE DATA SAYS

   While it is self-evident that allowing a patient to bleed longer will have a negative effect on their outcome, there seems to be disagreement on the efficacy of prehospital endotracheal intubation of the trauma patient. Rather than rely on anecdotes or obvious truths, let's examine the research.

   There are multiple studies seeming to indicate that prehospital ETI of the trauma patient is associated with a higher mortality. The numbers don't lie, but they can be interpreted in a variety of ways.

   A 2005 Journal of Trauma study, for example, found a higher mortality rate among intubated patients in a trauma registry.² The study did not, however, examine independent variables. What percentage of the surviving patients were not intubated because their injuries did not warrant it? Of intubated patients who survived, would their outcomes have been better with less effective ventilation? Would other means (e.g., BVM) have been adequate to ventilate them, or were they intubated because no other available option was sufficient and they would have died otherwise?

   Similarly, a study of traumatic head injury patients conducted from 1995-97 showed an 82% mortality rate among trauma patients with GCS scores less than 8 who were intubated in the prehospital setting, vs. 43% among patients with the same GCS scores who were not intubated.³ This study also did not consider other factors, so it's not possible to say with certainty that the nonintubated patients fared better simply because of the absence of a definitive airway. Perhaps they fared better because their injuries were less severe or some other means of oxygenation (like BVM) was effective.

   Finally, a study from 1999-2002 compared survival rates of patients with penetrating vs. blunt head trauma, and those who were intubated vs. those managed with BVMs.⁴ Not surprisingly, the intubated patients suffered higher mortality rates (95.8% of those with penetrating trauma, 78.4% of those with blunt) than the patients managed with BVMs (53.5%).

   So, does it make sense to avoid pre-hospital intubation? The results of a 2000 Journal of Emergency Medicine study seem to argue in favor of prehospital rapid-sequence intubation of trauma patients.⁵ This study examined trauma patients who underwent RSI in the field vs. RSI in the hospital, and found that prehospital RSI trauma patients had a mortality rate of 14%, vs. 22% among those who received this procedure at the hospital.

   An interesting aside to this study: These patients were all given medications prior to intubation, indicating the presence of a presumably experienced prehospital provider. The study did not examine those patients intubated without the benefit of premedication. This data set would tend to exclude patients treated by less-skilled or less-experienced prehospital practitioners.

   With the advent of the laryngeal mask airway, the Combitube and the King airway, it would be interesting to study the outcomes of trauma patients treated prehospitally with these devices by nonparamedics against those managed by those same intermediate-level practitioners using BVMs. I suspect the patients managed with some form of adjunctive device would enjoy better tissue perfusion and have better outcomes.

   Another open question is the effect on these patients of hyperventilation, with the associated decreased cerebral perfusion due to vasoconstriction. In the earlier studies, this phenomenon was less well known, and prehospital protocols tended to include hyperventilation before intubation, rather than the more appropriate preoxygenation referred to in later protocols.

CONCLUSION

   Front-loading medical care at the point of injury has made a big difference for our troops. Prompt bleeding control, definitive control of the airway and controlled hypotension via the judicious use of specialized IV fluid has helped troops survive who otherwise might not have. Minimizing the hypoxic insults brought on by hypoperfusion also greatly enhances the quality of life for those who survive.

New Technologies for Old Injuries?

   There is much debate about whether the use of our wounded warriors as unwitting test subjects is ethical. Perhaps, some say, the military should slow down its process of implementing new techniques. On one side is the argument that our wounded warriors are entitled to the best care available, and that advances in trauma care should be implemented as quickly as possible. On the other is the argument that our military men and women are entitled to the same level of protection from questionable practices as civilians. This argument, however, fails to consider that a certain percentage of our troops are critically injured in remote locations, far from definitive trauma care, and that even among those injured closer to surgical facilities, the combat that caused their injuries often prevents a timely evacuation to definitive care.

   I believe the answer is somewhere in the middle. Clearly, the lethality of modern weapons and the sheer numbers of casualties they inflict mandate that we make every effort to provide the best care possible. In evaluating data from the clinical use of new techniques on the critically wounded, we must bear in mind that this is a population with an already high mortality rate. Just because the majority of intubated patients in cardiac arrest die does not always mean that intubating them contributes to their demise.

   The same is true of patients treated with factor VII in the absence of surgical capability. Although this population will exhibit a higher-than-normal incidence of clot formations (including cerebral vascular accidents, pulmonary emboli and deep-vein thrombosis), if we consider that many would not be alive to suffer these events without factor VII, it makes sense to consider using it in some settings, especially where significant internal bleeding occurs and surgery is unavailable.

Case Study in Survival: Staff Sgt. Jose Pequeño

   It was around 2 in the afternoon in Ramadi, and the sun was beating down. I was part of a roving patrol just north of our forward operating base when we heard a massive explosion. Looking west, we observed a huge column of white smoke rising near the local police station and our nearby observation post. We raced in that direction, while over the radio we heard the voice of Staff Sgt. Jose Pequeño calling in a report. Suddenly, his transmission stopped.

   We passed by the police station and observed heavy damage to its front. A truck bomb had detonated, destroying part of the building. We went to the north end of the highway overpass atop which SSG Pequeño and his crew were positioned. From the highway below, we could see Jose was lying on the ground, not moving.

   Sgt Sorrento and his crew from OP1 arrived in their humvee just ahead of us, went up on the bridge and retrieved the only man left standing, Spec. Richard Ghent of the New Hampshire National Guard. Ghent told them Pequeño and the driver, Spec. Chris Merchant, were dead. They grabbed Ghent and headed back down in our direction, taking heavy fire.

   Our lieutenant had them stop near us so I could treat the casualty. We parked our Humvees next to one another to shelter us from the enemies' bullets, and I treated Ghent for his injuries. While I did, he told me what happened. He was the gunner, and right after the explosion, a three-man team snuck up on them from the other direction, tossing a grenade that struck him in the chest, then fell down into the vehicle. He yelled "Grenade!" and jumped out the gunner's hatch just as it detonated inside. Facing the three insurgents armed only with his pistol, he attacked. Pistol blazing, he ran right at them, hitting at least one and probably two and shocking the third into running away. They scrambled over the guardrail and down the embankment to their car, Ghent firing at them the whole time. As they reached their car, one of them turned and opened fire with an AK-47, hitting Ghent once.

   My sworn statement describing the event reads in part:

   I applied an Israeli bandage to Ghent's back and told him to climb into my vehicle… The lieutenant ordered me to drive, and he and SSG Pratt ran toward the disabled vehicle. We were receiving incoming small arms fire, and I heard impacts all around us. (They) raced ahead of the Humvee I was driving. I drove as fast as Pratt could run, shielding him at least from the incoming fire from our west. Until we reached the disabled Humvee atop the bridge, there were no U.S. forces firing, but we were receiving fire.

   Upon arrival I positioned our Humvee to the east of the disabled vehicle, creating a box around SSG Pequeño. Lt. Golden told me the fire was coming from the northwest. SSG Pratt climbed into the gunner's hatch of the disabled vehicle and provided suppressive fire, engaging as targets became available. Lt. Golden went to the rear of the disabled vehicle and laid down continuous fire on the enemy position, across a field directly to our northwest.

   As I opened the driver's door, I was met by a barrage of enemy bullets impacting my Humvee all around me. I slammed the door, took my weapon off safe, and threw the door open while I laid down a blanket of suppressive fire in the direction from which I took fire. I exited my Humvee, then went around the rear of the vehicle. I observed muzzle flashes to our northwest. I fired approximately 1½-2 magazines at the enemy position while our other elements moved into position. When our crew began firing, I went to assess SSG Pequeño.

   He was slumped on the ground with his feet still in the vehicle. I dragged him out, opened his airway, removed his IBA (individual body armor) and opened his shirt to assess for wounds. I could see his left arm was bloody, and there was approximately a 1" wound on the rear left side of his head. The patient was breathing spontaneously at a rate of approximately 14 per minute. He was unable to maintain his airway in the open position, and there was bloody fluid present in his oropharynx. When I released the head-tilt chin-lift maneuver, the patient had snoring respirations, with difficulty breathing. I did a quick sweep of the patient, determined the bleeding from his left arm was not immediately life-threatening, and began preparing for an endotracheal intubation.

   At some point while I was assessing the patient, Sgt. James Morrisette (another medic) arrived. He cut away the patient's clothing and controlled the bleeding in his left arm. As I was attempting to intubate, Sgt. Cole and Specs. Hardy and Brooks arrived. With Cole providing cricoid pressure, I was able to intubate the patient on my second attempt. We confirmed tube placement by observing equal bilateral chest rise, tube condensation and by Cole's report of the tactile sensation of the tube passing beneath his fingers. Due to the machine guns firing on both sides of me, I was unable to auscultate lung sounds. We loaded Pequeño onto a folding litter, and I called for suppressive fire. The guns began firing, and we carried Pequeño through an open area, while receiving enemy fire, to the rear gate of the 113, and loaded him in.

   At one point on the bridge, I prayed the prayer for the dying. Jose, however, refused to die.

   Half a world away, his mother heard about his injuries. Once he arrived at Walter Reed Army Medical Center, she and his sister stayed with him 24 hours a day. She refused to give up hope, and three years later he was finally discharged from the hospital. He now lives with his mother and sister in their Tampa home. They continue to care for him, with strong support from the nearby VA hospital and a huge network of friends and supporters.

   So why did my friend Jose survive, when more than 95% of patients with his types of injuries do not? First, I attribute his survival to the hand of God. There is no way Jose should have survived an injury that destroyed 40% of his brain. Second, the hemorrhage from the compound fracture of his left humerus was venous, not arterial. He was able to survive the first moments after the injury without exsanguinating. Although his airway was subsequently compromised by the presence of fluid, it was not enough to suffocate him. His spontaneous respirations were labored, snoring and slowly decreasing in rate when I reached him.

   Third, Jose was a beneficiary of the best neurosurgical and rehabilitative care in the world. He has since survived multiple surgeries and many subsequent brushes with death. His neurosurgeon reports that until Jose, no one had ever survived an injury this severe. Jose's neurosurgeon and I agree that had he not been intubated when he was, he would not have survived.

References

1. Z-Medica, that company that manufactures QuikClot, says the burn concern mentioned about the product refers to an early version that has since been improved and is now in use. The company's new QuikClot Combat Gauze was just voted a "Top 10 New Invention" by the U.S. Army.

2. Davis DP, et al. The effect of paramedic rapid sequence intubation on outcome in patients with severe traumatic head injury. J Trauma 54(3): 444-53, Mar 2003.

3. Murray JA, et al. Prehospital intubation in patients with severe head injury. J Trauma 49(6): 1,065-70, Dec 2000.

4. Stockinger ZT, McSwain NE, Jr. Prehospital endotracheal intubation for trauma does not improve survival over bag-valve-mask ventilation. J Trauma 56(3): 531-6, Mar 2004.

5. Sloane C, et al. Rapid sequence intubation in the field versus hospital in trauma patients. J Emerg Med 19(3): 259-64, 2000.

Thomas A. Middleton is the assistant fire marshal and public information officer for the Burlington (VT) Fire Department, and has been a long-time firefighter and EMT. He served as a combat medic in Iraq as part of Task Force Saber from June 2005-June 2006 and is a member of the Vermont Army National Guard.