THE FUTURE OF COMBAT MEDICINE
Above All of the Technological Innovations and Improved Treatment
Techniques, People are Still the Key to Better Battlefield Health Care.
by Kelly Fodel, MMT Correspondent
Combat medics are angels on the battlefield. They are the responders who, possibly without the aid of intricate equipment or emergency rooms, ensure the survival of injured soldiers. Thanks to the continuing evolution and improvement of medical research and development, combat medicine treatments and technologies are evolving as well, resulting in improved care for our troops. Military Medical Technology spoke with some of the leaders in military medicine and R&D, to learn more about the advancements we will see in the coming months.
TRAINING
Mandatory pre-deployment trauma training is not standard practice for Army medical combat staff. According to Colonel John Holcomb, commander of the U.S. Army Institute of Surgical Research, the military medic needs realistic training that employs the devices and products the medical staff will actually be using in the field. Holcomb is coordinating mandatory training efforts in that regard.
“Training is critically important. We must have realistic training that is based upon the problems the medics, doctors, nurses, all the medical providers [encounter] at all levels of care,” saidHolcomb.
POTENTIAL NEW PAINKILLERS
The Army is getting ready to start a Phase III clinical trial on the use of nasal ketamine as an analgesic. Ketamine is normally used as an anesthesia, but it is unique in that it does not interfere with breathing or require respiratory assistance for the patient. It is being considered for use as a battlefield painkiller because it could be a safer alternative to morphine, which can cause respiratory distress.
“We are working with a company that has put [ketamine] in a nasal spray,” said Colonel Bob Vandre, director of the U.S. Army Combat Casualty Care Research Program. “A few squirts of this stuff in the nose, and it gets rid of pain. The nice thing about squirting it into the nose is that it gets into the bloodstream quickly. If you give a shot, it takes about a half hour to get into the bloodstream, but in the nose, the mucous membranes absorb [the medicine and pain relief occurs] in about five minutes.”
Vandre continued, “We are hoping that it can replace morphine, because when you give a patient morphine, it knocks them out. When they are out cold, they can’t defend themselves with a rifle and keep shooting. What we’ve seen so far is that you can take the ketamine and keep fighting.”
The Army is currently testing the effect of ketamine on a soldier’s clarity and accuracy. These tests, occurring at Walter Reed Army Medical Center, are measuring if a soldier is safe to stay on the battlefield after taking the drug, in terms of shooting accuracy and distinguishing fellow soldiers from the enemy.
The ketamine clinical trial is expected to begin in late 2008, concluding in 2009. Nasal ketamine could begin use on the battlefield in about 18 months. Vandre said it could potentially be given to the soldier to carry himself, rather than be administered by a combat medic. However, there is an abuse potential with the drug, so Vandre said the Army may decide not to issue a nasal spray of the drug to each soldier.
While the Army pursues ketamine research, the Navy is currently looking at some glycopeptide compounds as potential analgesics. Captain Kenneth Cole is director of M5B3 Future Plans and Strategies in the Navy Bureau of Medicine and Surgery. He notes the abuse potential as a negative aspect to ketamine.
“The glycopeptides are not necessarily as potent as the ketamine, but they have far fewer side effects,” said Cole. “It’s a complementary effort [within the military], and whichever one breaks though first will get used. If both break through, it gives the health care provider additional options.” Cole said the use of ketamine as a painkiller is probably further along the track. The advanced clinical trials of glycopeptide will likely not occur until later in 2009.
FREEZE DRIED PLASMA
Plasma is the liquid part of the blood that contains the clotting factors. Blood clotting factors are proteins that work with the platelets to help stop bleeding. Without clotting factors, bleeding would not stop after an injury. If a patient is bleeding profusely, he or she can use up (or lose) the clotting factors in the plasma, which is potentially deadly. Vandre said that data shows that there is a very strong correlation between the extent of injury and the potential to clot incorrectly. He said 80 percent of the most severely injured soldiers are not clotting right. Research has also shown that those who do not clot correctly have twice the death rate of those who do clot correctly. Though the statistics might seem like common sense, solving this issue has been a challenge on the battlefield.
In the field, the combat medics only have a limited supply of plasma, which can only be kept at field hospitals. Thawed plasma is kept on hand for immediate use, but it only has a shelf life of about two weeks. If the staff runs out of blood for transfusions, it is not as if they can just call over to a nearby hospital for more. Their options are to wait for a shipment of blood from the U.S., or take blood from a “walking blood bank;” also known as a nearby soldier. That, of course, is a risky process.
“There is no test to [immediately] tell if the guy [you are taking blood from] has hepatitis or HIV. It is taking it from one guy and giving it to the other, but if you do not do it, the guy will die,” said Vandre.
All members of the military are checked for HIV, but a small percentage could hypothetically still be HIV positive. Other blood-borne illnesses, such as hepatitis, are not subject to routine testing. “Plasma is like blood, you can’t just give any plasma to anyone else,” Vandre said. “In plasma, the type you can give universally is AB positive. That is the scarcest blood type there is.”
Keeping the freeze-dried AB plasma on hand allows medical staff to have immediate access to plasma. Once reconstituted, it is able to be used in the field during the first golden hour after injury, and stop bleeding before the soldier even gets to the hospital, ultimately saving more lives.
Freeze-dried plasma is currently in the clinical trial phase. “If the research is successful, this shows great potential,” said Holcomb.
The Army Medical Department is also working on freeze-dried platelets in conjunction with the Navy.
WOUND CARE
Troops entering the theater now are starting to receive the new QuikClot combat gauze. QuikClot, manufactured by Z-Medica Corporation, is being used as the firstline hemostatic treatment for injuries that cannot be helped by tourniquet placement. The gauze stops arterial and venous bleeding in seconds, and can be shaped to most any wound and reach bleeding vessels in penetrating wounds. Clinical trials were held earlier this year, and the product is just starting to be used in combat.
WoundStat is another new product, manufactured by TraumaCure, which just received FDA approval in August of 2007. It is a granular mix that comes in a pouch and is applied to stop bleeding. This can be lifesaving, as it stops the soldier from bleeding out before transfer to a field hospital can be arranged. Most notably, it avoids the problem of heat generation, which had plagued other products designed for the same purpose.
“The newer material has superior clotting function and it doesn’t get hot. You don’t have burning associated with the heat,” Cole said. No burning means that the medic can apply the product without burning his or her hands, and the site of the wound will not sustain tissue damage as a result of heat.
Holcomb also mentioned the HemCon bandage, manufactured by HemCon Medical Technologies, which becomes very sticky when it contacts blood. It seals the wound by attracting red blood cells, which create a seal over the wound and stop bleeding, as well as keeping germs out of the wound.
MEDICAL DEVICES
Holcomb said that over the next 12 to 24 months, we will see better monitoring devices in field hospital triage units. He also said the devices used to monitor soldiers during transportation to field hospitals will be upgraded.
CHALLENGES
According to Holcomb, the “biggest challenge is funding for prospective randomized studies to prove the benefit [of new technologies or techniques].” That is why he has supported the development of trauma registries, which track the care of wounded soldiers. The registries are designed to identify the best products and practices, and hopefully improve patient care.
COOPERATION AMONG THE SERVICES
The Army, Navy and Air Force are all working together to create complimentary technologies. As Cole puts it, “Research dollars are slim, so if it is redundant, well if we don’t do something about it, Congress will. We will have stuff that is complementarily redundant. We have the same target, but we are taking different approach in the hopes that one of the products makes it through the regulatory process.”
The R&D community within the military is small. The big players all know each other, and a number of their laboratories are joined. There is a good deal of synchronicity between the services in that aspect, as they share ideas and innovations, and develop a joint perspective on how to move forward.
“We are looking at all possible ways to give the best quality of care as fast as we can,” said Cole. •
For more information, contact MMT Editor Jeff McKaughan or search our online archives for related stories.
TRAINING
Mandatory pre-deployment trauma training is not standard practice for Army medical combat staff. According to Colonel John Holcomb, commander of the U.S. Army Institute of Surgical Research, the military medic needs realistic training that employs the devices and products the medical staff will actually be using in the field. Holcomb is coordinating mandatory training efforts in that regard.
“Training is critically important. We must have realistic training that is based upon the problems the medics, doctors, nurses, all the medical providers [encounter] at all levels of care,” saidHolcomb.
POTENTIAL NEW PAINKILLERS
The Army is getting ready to start a Phase III clinical trial on the use of nasal ketamine as an analgesic. Ketamine is normally used as an anesthesia, but it is unique in that it does not interfere with breathing or require respiratory assistance for the patient. It is being considered for use as a battlefield painkiller because it could be a safer alternative to morphine, which can cause respiratory distress.
“We are working with a company that has put [ketamine] in a nasal spray,” said Colonel Bob Vandre, director of the U.S. Army Combat Casualty Care Research Program. “A few squirts of this stuff in the nose, and it gets rid of pain. The nice thing about squirting it into the nose is that it gets into the bloodstream quickly. If you give a shot, it takes about a half hour to get into the bloodstream, but in the nose, the mucous membranes absorb [the medicine and pain relief occurs] in about five minutes.”
Vandre continued, “We are hoping that it can replace morphine, because when you give a patient morphine, it knocks them out. When they are out cold, they can’t defend themselves with a rifle and keep shooting. What we’ve seen so far is that you can take the ketamine and keep fighting.”
The Army is currently testing the effect of ketamine on a soldier’s clarity and accuracy. These tests, occurring at Walter Reed Army Medical Center, are measuring if a soldier is safe to stay on the battlefield after taking the drug, in terms of shooting accuracy and distinguishing fellow soldiers from the enemy.
The ketamine clinical trial is expected to begin in late 2008, concluding in 2009. Nasal ketamine could begin use on the battlefield in about 18 months. Vandre said it could potentially be given to the soldier to carry himself, rather than be administered by a combat medic. However, there is an abuse potential with the drug, so Vandre said the Army may decide not to issue a nasal spray of the drug to each soldier.
While the Army pursues ketamine research, the Navy is currently looking at some glycopeptide compounds as potential analgesics. Captain Kenneth Cole is director of M5B3 Future Plans and Strategies in the Navy Bureau of Medicine and Surgery. He notes the abuse potential as a negative aspect to ketamine.
“The glycopeptides are not necessarily as potent as the ketamine, but they have far fewer side effects,” said Cole. “It’s a complementary effort [within the military], and whichever one breaks though first will get used. If both break through, it gives the health care provider additional options.” Cole said the use of ketamine as a painkiller is probably further along the track. The advanced clinical trials of glycopeptide will likely not occur until later in 2009.
FREEZE DRIED PLASMA
Plasma is the liquid part of the blood that contains the clotting factors. Blood clotting factors are proteins that work with the platelets to help stop bleeding. Without clotting factors, bleeding would not stop after an injury. If a patient is bleeding profusely, he or she can use up (or lose) the clotting factors in the plasma, which is potentially deadly. Vandre said that data shows that there is a very strong correlation between the extent of injury and the potential to clot incorrectly. He said 80 percent of the most severely injured soldiers are not clotting right. Research has also shown that those who do not clot correctly have twice the death rate of those who do clot correctly. Though the statistics might seem like common sense, solving this issue has been a challenge on the battlefield.
In the field, the combat medics only have a limited supply of plasma, which can only be kept at field hospitals. Thawed plasma is kept on hand for immediate use, but it only has a shelf life of about two weeks. If the staff runs out of blood for transfusions, it is not as if they can just call over to a nearby hospital for more. Their options are to wait for a shipment of blood from the U.S., or take blood from a “walking blood bank;” also known as a nearby soldier. That, of course, is a risky process.
“There is no test to [immediately] tell if the guy [you are taking blood from] has hepatitis or HIV. It is taking it from one guy and giving it to the other, but if you do not do it, the guy will die,” said Vandre.
All members of the military are checked for HIV, but a small percentage could hypothetically still be HIV positive. Other blood-borne illnesses, such as hepatitis, are not subject to routine testing. “Plasma is like blood, you can’t just give any plasma to anyone else,” Vandre said. “In plasma, the type you can give universally is AB positive. That is the scarcest blood type there is.”
Keeping the freeze-dried AB plasma on hand allows medical staff to have immediate access to plasma. Once reconstituted, it is able to be used in the field during the first golden hour after injury, and stop bleeding before the soldier even gets to the hospital, ultimately saving more lives.
Freeze-dried plasma is currently in the clinical trial phase. “If the research is successful, this shows great potential,” said Holcomb.
The Army Medical Department is also working on freeze-dried platelets in conjunction with the Navy.
WOUND CARE
Troops entering the theater now are starting to receive the new QuikClot combat gauze. QuikClot, manufactured by Z-Medica Corporation, is being used as the firstline hemostatic treatment for injuries that cannot be helped by tourniquet placement. The gauze stops arterial and venous bleeding in seconds, and can be shaped to most any wound and reach bleeding vessels in penetrating wounds. Clinical trials were held earlier this year, and the product is just starting to be used in combat.
WoundStat is another new product, manufactured by TraumaCure, which just received FDA approval in August of 2007. It is a granular mix that comes in a pouch and is applied to stop bleeding. This can be lifesaving, as it stops the soldier from bleeding out before transfer to a field hospital can be arranged. Most notably, it avoids the problem of heat generation, which had plagued other products designed for the same purpose.
“The newer material has superior clotting function and it doesn’t get hot. You don’t have burning associated with the heat,” Cole said. No burning means that the medic can apply the product without burning his or her hands, and the site of the wound will not sustain tissue damage as a result of heat.
Holcomb also mentioned the HemCon bandage, manufactured by HemCon Medical Technologies, which becomes very sticky when it contacts blood. It seals the wound by attracting red blood cells, which create a seal over the wound and stop bleeding, as well as keeping germs out of the wound.
MEDICAL DEVICES
Holcomb said that over the next 12 to 24 months, we will see better monitoring devices in field hospital triage units. He also said the devices used to monitor soldiers during transportation to field hospitals will be upgraded.
CHALLENGES
According to Holcomb, the “biggest challenge is funding for prospective randomized studies to prove the benefit [of new technologies or techniques].” That is why he has supported the development of trauma registries, which track the care of wounded soldiers. The registries are designed to identify the best products and practices, and hopefully improve patient care.
COOPERATION AMONG THE SERVICES
The Army, Navy and Air Force are all working together to create complimentary technologies. As Cole puts it, “Research dollars are slim, so if it is redundant, well if we don’t do something about it, Congress will. We will have stuff that is complementarily redundant. We have the same target, but we are taking different approach in the hopes that one of the products makes it through the regulatory process.”
The R&D community within the military is small. The big players all know each other, and a number of their laboratories are joined. There is a good deal of synchronicity between the services in that aspect, as they share ideas and innovations, and develop a joint perspective on how to move forward.
“We are looking at all possible ways to give the best quality of care as fast as we can,” said Cole. •
For more information, contact MMT Editor Jeff McKaughan or search our online archives for related stories.