Survival

Medical innovations, improved treatment facilities and experienced corpsmen are curtailing battlefield fatalities

By MATT HILBURN, Associate Editor

The 7.62mm round ripped through the Marine’s torso, damaging most of his internal organs before exiting on the left side where, ironically, it was stopped by a ceramic plate in his protective vest.

Marine Chief Warrant Officer 2nd Class Jason Forgash at first believed the vest had stopped the round altogether. But he got up and “reached down with my hand and it was covered with blood,” he said.

Being shot “was like being kicked in the stomach by a 300-pound man without having a chance to brace.”

A sniper had fired with precise accuracy, placing the slug between the right ceramic insert plate and the front plate of his Kevlar vest.

A corpsman attended to him briefly to stem the bleeding, and Forgash soon was in the back of a Humvee speeding to a forward operating base near Ramadi, Iraq. On the verge of passing out, he struggled to stay alert and keep pressure on the entry and exit wounds.

“When I got there, I remember the medical personnel coming in to take me out, and I just let go and passed out,” he said. “I don’t remember anything until I was here at Bethesda [ National Naval Medical Center, Md.] for a day or so.”

Forgash, 37, a reservist and police officer in La Habra, Calif., had deployed to Afghanistan and was on his second Iraq deployment when he was shot on July 22. He had “let go” at a Forward Resuscitative Surgery Suite, where he received enough care to stabilize him for transport by helicopter to Balad where a higher level of medical care was available. From there, he was taken briefly to the Landstuhl, Germany, regional medical center for more treatment.

Within three days of the incident, Forgash was at Bethesda.

“I was amazed at the level of care [at the forward operating base],” he said. “They would get mortared all the time, but they’re able to do full-blown surgery. The doctors were saying they didn’t have that kind of capability at the beginning of the war.”

Like Forgash, thousands of U.S. troops serving in Iraq and Afghanistan are surviving grievous wounds at a rate nearly double that of their World War II and Vietnam counterparts. It is a trend that seems likely to continue given the improved treatment Marines and soldiers receive on the spot and at each medical way station as they are sped to higher levels of care.

Researchers in the Navy and the Defense Advanced Research Projects Agency (DARPA) say that ongoing innovations in medical technology foretell of continuing reductions in battlefield fatality rates.

In Iraq, for example, the deployment of Forward Resuscitative Surgery Suites, which bring basic surgical capability much further forward than ever before, has contributed enormously to increased survivability rates, experts said. Conceptualized in the late 1990s and first used in Operation Iraqi Freedom, the surgery suites are staffed by doctors and nurses who specialize in procedures to foster the stability of patients.

At roughly the same level of care, wounded Marines are sometimes taken to a Shock Trauma Platoon, which is basically a standalone emergency room where patients are stabilized before being moved onto higher-level facilities.

For the future, researchers are experimenting with fully telerobotic “trauma pods,” the use of ultrasound to stop or slow internal bleeding and even doses of estrogen to increase the odds that combatants will survive after a massive blood loss.

One of the most important changes in recent years has been one of the most basic, according to Dr. Mike Given, program officer for Casualty Care and Management at the Office of Naval Research. In 2002, the Marine Corps made the first major upgrade to the contents of the Infantryman’s First Aid Kit since World War II, substantially increasing the ability of the individual Marine to perform first aid, Given said.

“There’s not always a corpsman around,” he said. “A lot of times a Marine has to treat himself or his buddy right next to him.”

The first aid kits now contain Quick Clot, a substance used to stop or lessen bleeding, as well as better dressings and tourniquets.

Given said the Office of Naval Research is unable to collect data about the effectiveness of the improved first aid kits simply because “corpsman are too busy to collect data,” but he did say that after better body armor, increased corpsman training is the No. 1 reason more troops are surviving. Seventy percent of Given’s program is aimed at increasing the capability of the first responders, he said.

“A lot of these people are on multiple rotations right now, so they’re very experienced, and that has a great effect,” Given said.

Once the corpsman has done his work, the next challenge is transporting the wounded soldier to the next level of medical care. This has been done with significant success in Iraq, but experts caution that future conflicts may not present a similar environment where “scoop-and-go” tactics are facilitated by having so many medical personnel forward deployed, said Dr. Stephen T. Ahlers, director of the Combat Casualty Care Directorate at the Naval Medical Research Center.

One current tool for transporting the injured is called the Life Support for Trauma and Transport (LSTAT), which is basically a portable intensive care unit capable of ventilating a patient with onboard oxygen, infusing fluids and drugs, providing suction, defibrillating, analyzing blood chemistry and other physiological monitoring.

However, some say the current LSTAT is too heavy and expensive to be practical for battlefield use. The Marine Corps, for example, brings the same capabilities of the LSTAT to the battlefield in separate pieces allowing, officials said, greater mobility and agility.

“The LSTAT is very good, but it’s 200 pounds, so you’re not going to get to the LSTAT before you’re evacuated pretty far from the battlefield,” said Dr. Brett P. Giroir, a deputy director at the Defense Sciences Office at DARPA.

The Forward Resuscitative Surgery Suite brings a diverse set of resources to forward areas. It consists of a transportable operating table, basic surgical equipment and a staff of eight, including two surgeons, critical care nurses, operating room technicians and an independent duty corpsman. The suite is fully transportable and, according to officials at the Office of Naval Research, one can support an infantry regiment.

The idea, said Joe Dacorta, of the Office of Naval Research, is to “keep you alive and fix what’s trying to kill you and get you back to somewhere you can get fixed up.”

He said that one major procedure done by a surgery suite is temporarily splicing broken blood vessels to keep the blood flowing long enough for the patient to move to a higher echelon of medical care.

“During the maneuver phase of Operation Iraqi Freedom, every Marine that arrived at the surgical facility survived,” Dacorta said.

The Marine Corps initially deployed with 16 surgery suites, and due to their overwhelming success, another eight have been fielded, he said. Once stabilized in a surgery suite, a patient typically is sent to a Combat Army Support Hospital or similar facility and, if necessary, moved on to medical facilities in Germany or the United States.

While recently deployed technology has led to increased survivability, there are many other developing technologies that may enable even more wounded soldiers to live.

A corpsman of the future might be equipped with morphine substitutes; improved Quick Clot; freeze-dried blood platelets; injectable fibrinogens, large proteins that aid in the development of blood clots; a lighter LSTAT; telerobotic surgery pods and more.

Given cautioned that the advent of new technologies requires a delicate balancing act between the desire to equip corpsman with the latest advances while taking into account the increased training new products would demand.

DARPA researchers are working to reduce the weight of the 200-pound LSTAT to 40 pounds.

“I’ve done lots of transports,” said Giroir, and to obtain those capabilities while transporting a patient, “you have machines all over the place. This would all be integrated in a stretcher where everything you need is right there, which is really magnificent for transport from the battlefield.”

Giroir estimated the smaller LSTAT would be fielded in about 18 months.

Even the forward surgery suite could be replaced at some point in the future by a fully robotic “trauma pod” under development at DARPA. It could be autonomous or placed in the back of a Stryker combat vehicle, said Giroir.

“It would have the complete surgical and diagnostic capability of Walter Reed ( Army Medical Center). Everything would be telerobotic, not just the surgeon, but also the nurses, the assistants,” he said.

A surgeon and, if necessary, more people, would be controlling all the machines on site, but they could feasibly be anywhere in the world and work through the robotic devices.

“The goal of this program is to get everybody out of that place” so care would be provided completely by telerobotics, Giroir said, adding that a robotic trauma pod is less than 10 years away from becoming a reality.

Massive bleeding is still a major killer of wounded troops, so a lot of attention is being given to clotting agents and other remedies. Quick Clot is the most widely used such product in the Marine Corps, but experts say a disadvantage of the substance is that it generates heat — potentially enough to cause burning and definitely enough to cause pain — when mixed with blood. Researchers are trying to devise new agents that will have the same effect as Quick Clot without the heat generation.

Internal bleeding still presents a challenge to medical experts, especially front-line caregivers who might not be able to perform surgery on the spot. DARPA is developing something called Deep Bleeder Acoustic Coagulation that would fuse the ability of ultrasound to locate internal bleeding and, at a very high frequency, cauterize the bleed.

DARPA also is working on the long-term storage of blood products. Platelets in particular are crucial to the development of blood clots, but they currently have to be constantly refrigerated and even so will last only five days. Through freeze-drying, DARPA hopes to extend the shelf life of platelets to years at room temperature. When needed, medical specialists would simply add water, revitalizing the platelets with 85-90 percent of their clotting ability.

The Naval Medical Research Center and the Office of Naval Research are also investigating the efficacy of freeze-dried platelets.

Another promising blood-loss survivability regimen being assessed by DARPA is administering doses of estrogen, the female hormone. Female rats, according to Giroir, survive bleeding much better than their male counterparts.

“It turns out that the female advantage is very highly linked to the estrogen,” he said.

In experiments, male rats with lethal hemorrhages die within two hours. But 75 percent of those given a single dose of estrogen survive after three hours.

In addition, DARPA researchers have found that rats in a low oxygen environment, such as from massive bleeding, can be kept in a state of suspended animation with small doses of hydrogen sulfide, normally a poisonous gas.

Researchers at the Naval Medical Research Center are also investigating something called hemoglobin-based oxygen carrier, which would increase the oxygen-carrying capacity to someone who endured substantial bleeding.

Obviously when a soldier is critically wounded, pain control is very important, but morphine and other narcotics have numerous side effects such as cognitive dysfunction, impairment of breathing and increased bleeding. Giroir said DARPA’s goal is to develop pain medications that are as effective as morphine but without the side effects.

Put simply, researchers have found the chemical in the body that transmits the pain message to the spinal cord and up to the brain and have found a way to block that message. Giroir said the agent is currently being tested on humans and that one dose can last an entire month.

The weapon of choice of the insurgency in Iraq has been the improvised explosive device, and while better body armor has resulted in an increased survival rate, many troops are losing arms and legs in such attacks.

Dr. Douglas Tadaki, head of the Regenerative Medicine Department at the Naval Medical Research Center, said research is being done to better preserve lost limbs by attaching a small pump to the severed limb that would mimic the heart’s ability to keep fluids circulating until the patient can be transported to a higher-level medical facility.

While many of these potential technologies sound incredibly promising, researchers are quick to point out that there will always be more to do.

“I think as long as you have somebody that’s dying you can do a little bit better,” said Dr. Richard M. McCarron, head of the Trauma & Resuscitative Medicine Department at the Naval Medical Research Center.

“No matter how much work we’re doing,” the nation’s adversaries are working full time to devise more lethal weapons, he said.

Forgash, who is married and plans to start a family next year, is expected to make a full recovery, though he is still hospitalized and facing, he hopes, one last surgery.

“I feel very fortunate that this didn’t happen to me in ’03 when I first came here,” Forgash said. “If I had to get shot at least it happened in ’06 when they had the technology to take care of it.”