TCS Daily


Good Unintended Consequences

By Sydney Smith - April 4, 2003 12:00 AM

War, what's it good for? Plenty. Some say this war will save lives by liberating Iraqis from a repressive, brutal, regime. But Iraqi lives won't be the only ones saved by the war. For war, as horrible as it is, has time and again been the crucible for new medical advancements.

Each innovation in killing has to be met by an innovation in healing if an army is to survive. Sometimes those innovations are the result of happenstance; sometimes they're well thought out and planned. But, at least since the 16th century when French military surgeon Ambroise Pare accidentally discovered that the in vogue treatment of pouring boiling oil on gunshot wounds was worse than leaving them alone (he only made the discovery because he ran out of oil), military doctors have been at the forefront of some of our most important medical advances.

The use of anesthesia, although known for years, wasn't widely adopted until Civil War surgeons used it to perform surgery on thousands of casualties. Before that, doctors were too wary of its potential side effects to make much use of it. After 5,000 soldiers died of yellow fever in the brief Spanish-American War, the Army devoted its energies to discovering its cause, and two years later made the definitive connection between the disease and mosquitoes. By the next year, mosquito control measures had reduced yellow fever mortality in Havana to fewer than twenty people. Many of the plastic surgery techniques used today were developed by doctors in World War I, many of them improvised on the spot, while repairing the shattered faces of the men in the trenches. Penicillin, although discovered in 1928, wasn't produced in a form or quantity to be useful until World War II provided the impetus for both its use and mass production. Helicopters were used to transport wounded for the first time in the Korean conflict, and now hospitals stateside routinely use them to transport trauma victims from the site of an accident. In fact, our system of trauma centers and triage is modeled on the military's system for treating casualties.

And even though this war is only a couple of weeks old, it's already contributing to new medical advances, as well as reshaping our thinking about trauma care. Two thirds of modern combat deaths occur in the first ten minutes after injury, usually from blood loss. In Iraq, this is being addressed with innovative medical treatments that can be delivered within minutes, sometimes seconds, and often by the wounded man himself. Some are
simple, like the pressure dressing described by one marine as "just an elastic wrap bandage, a feminine pad, a Velcro strip and a shower hook," or the tourniquet that can be applied with one hand. Others are more technologically innovative, such as the clotting powder made of zeolite crystals, a highly absorbent, naturally occurring mineral that's used in the chemical-processing industry. Poured into a bleeding wound, it absorbs the liquid portion of blood and acts as a framework for the blood's clotting factors and cells. Or the bandage made of layers of chitosan gel, a derivative of chitin, the protein that makes up lobster, shrimp, and insect shells. The protein easily forms a positively charged viscous layer that attracts negatively charged red blood cells to it, thus promoting clotting. Sold for some time as a dietary supplement for weight loss, it was research funded by the Army that spurred its application to trauma care. Now, chitosan bandages are being used on the front lines to save lives.

But the war is spurring other advances, as well, and perhaps the greatest of these is the re-evaluation of the delivery of trauma care. In the past, the wounded were stabilized with first-aid and transported far to the rear to field hospitals for life-saving surgery. But now, recognizing the importance of early intervention, the surgical teams are being brought to the wounded. Thanks to improved technology, equipment that once had to be transported on trucks (EKG machines, ultrasounds, blood analyzers) can all be carried on a laptop in a backpack. Special operations medics can carry enough equipment on their back to start intravenous lines, secure compromised airways, and do minor surgery in the field.

And then, there's the "Forward Resuscitative Surgical System," a two tent, climate-controlled highly mobile operating room that can be set up and taken down in less than an hour. Staffed by two surgeons, an anesthesiologist, a critical-care nurse, as well as a couple of technicians and medics, and equipped with everything needed to perform surgery under anesthesia, it allows stabilization of internal wounds until the wounded can be safely transferred to hospitals further from the action, where more complicated surgery can be performed.

Given our history of adapting military medical innovations to the civilian world, it's only a matter of time before hemostatic bandages, and on-site surgical interventions become a routine part of our trauma care at home. Think of the lives that will be saved. And all thanks to the armed forces.
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