Fighting for survival

The heightened exposure to trauma has enhanced the understanding of its care, and in particular the speed with which serious injuries are addressed. Statistics drawn from Afghanistan and Iraq show that most battlefield deaths occur within the first 10 minutes of wounding, Medical planners now structure care around an ethos where every second counts towards the chances of survival — revising the “golden hour” rule for effective emergency treatment to the “platinum 10 minutes”. The International Red Cross is working to promote such thinking around the world — in March it held a seminar in Benghazi, a rebel stronghold in the conflict with Colonel Muammar Gaddafi.

Much greater emphasis is now placed on care before the operating theatre, underlined by another important amendment. What used to be described as the “A-B-C” protocol when first attending to someone who has suffered severe injury — meaning airways, breathing and circulation — has had an extra “C” stuck in front of it: catastrophic haemorrhaging. Such revisions helped to save the lives of 75 soldiers who were expected to die from their injuries between 2006 and 2008, and take the unexpected survival rate in Helmand to 25 per cent. In the NHS it is 6 per cent.

In a military setting there is, naturally, a fast, primed system of emergency care (evolved from the Korean and Vietnam wars, which introduced helicopters to transfer people to a mobile army surgical hospital unit, or MASH, and which in turn prompted greater use of helicopters for civilian trauma care). But the statistical gap is still stark, and officials are hoping to learn from it. According to Sir Keith Porter, the UK’s only professor of clinical traumatology, approaches to blood loss derived from battlefield medicine have “altered the care paradigm”. Sir Keith, who has been at the forefront of developing world-class treatment for injured servicemen and women over the past decade, highlights two examples: the reinvention of the tourniquet and the use of a drug called tranexamic acid (TXA).

TXA, an antifibrinolytic agent, works by blocking a natural body response that kicks in after serious injury, to break down blood clots. Although the survival mechanism helps prevent strokes and potentially fatal clots in the lungs, it can lead to heavy blood loss. Until recently, the drug was used mainly to treat women with heavy periods, haemophiliacs and patients undergoing non-emergency surgery. But following Crash2, a study conducted by the London School of Hygiene and Tropical Medicine and funded in part by the Department of Health, it is now a vital treatment strategy on the Afghan front line. It is also becoming a mainstream medicine in domestic healthcare.

Crash2 showed that giving TXA to victims of accidents and violence reduced their overall risk of death by 10 per cent and the chance of dying due to bleeding by 15 per cent. Globally, there are about four million deaths a year from serious injuries — more than half die in hospital, 600,000 as a result of bleeding from their wounds. Routine use of TXA could save up to 100,000 lives a year, doctors suggest, at a cost of just £6 per patient.

Meanwhile in the Royal London Hospital, in Whitechapel, the simple brilliance of the tourniquet is being given renewed attention, following lessons drawn from Afghanistan. Methods of tourniquet application used by soldiers to staunch the bleeding of severely injured comrades have made their way to London’s Helicopter Emergency Medical Service. They might be used in cases such as people who have lost a leg or received a stab or gunshot wound to a major blood vessel. According to Nigel Tai, an RLH consultant in trauma and vascular surgery and a military surgeon, such techniques have saved the lives of people who would probably previously have died.

The RLH has also become the first hospital in Britain to make training in “damage control surgery” mandatory, introducing it in late 2009. This takes a notion somewhat counterintuitive to much of modern medicine — of doing less major operative work and concentrating on fundamental procedures to stop bleeding and avoid infection, done as soon as possible. This might include sewing up a knife wound to the heart, controlling bleeding from a gunshot hole in the lung, or other basic procedures required for a victim to pull through.

According to Sir Keith Porter, delaying major surgery until after the “acute phase” of injury is now the norm. Typically, patients’ wounds are left open, to fight infection, rather than being operated on and closed immediately. “Basically, damage control surgery can be summarised as doing the least you can do to save the patient’s life,” he says. “We have moved away from lengthy initial operations to doing the bare minimum and then going back later.”

The importance of infection control has gained a grisly added relevance in current conflicts. The homemade bombs, known as improvised explosive devices (IEDs), that have caused so many horrific and complex injuries in Afghanistan are often packed with shrapnel such as steel nuts and nails, which increase the likelihood of secondary infection. Bacteria in the soil, like the drug-resistant Acinetobacter baumannii, and other impurities can be driven far into the wound by the blast wind and shrapnel.

The deep cleaning of wounds is critical, and has spawned devices such as the Versajet, which propels a high-pressure jet of sterile water. It is proving a more effective means of carrying out debridement (the removal of dead, damaged or infected tissue) than conventional use of scalpels. Special silver-based dressings, with anti-microbial properties, are also being used, as well as a technique called topical negative pressure, a suction mechanism for larger wounds that are less easily treated with traditional dressings.

Such innovations reflect a part of battlefield medicine that, historically, has been the most critical in terms of saving lives. In the Crimean War, 16,000 men died as a result of infection and sickness — six times as many as were killed in combat. Three centuries earlier, Ambroise Paré, surgeon to a succession of French kings, had wrestled with similar problems. On running out of the boiling elderberry oil that was used on wounds, which were then cauterised to reduce infection, Paré opted for a solution of egg yolk, oil of roses and turpentine — a method used by the Romans a thousand years earlier. When he returned the next morning, the soldiers treated with boiling oil were in agony; those who received his substitute had recovered, courtesy of the antiseptic properties of turpentine. Paré also developed the ligature of arteries during amputation (a necessity to tackle gangrene), and documented the pain suffered by soldiers linked to missing limbs, which he proposed was linked to the brain, rather than the impact site of the trauma.

With advances in body armour significantly reducing fatal injuries to the head and torso, limb injuries and related rehabilitation are now the focus of much research. Paré’s thesis for the pain associated with phantom limb syndrome, an issue for the IED victims of Afghanistan, still holds. Craig Murray, a neuroscientist at the University of Lancaster, has examined how experiences of physical pain embed themselves in the brain. His work is now focused on how a person’s brain might be persuaded, with the use of virtual reality simulations, of the presence of a missing limb, to block or reduce the sensations of pain.

The healing of the trauma war wreaks on the human mind has been far less explored than other areas of battlefield medicine. As is the case for any sufferer of mental health problems in modern society, the help for those scarred emotionally by war is less accessible than other what is available for other illnesses. But rates of post-traumatic stress disorder linked to current conflicts are relatively low, helped by improved awareness within the military, such as Trauma Risk Management (TRiM) programmes to ensure that every unit has soldiers with the skills needed to identify who might be at risk after traumatic incidents. Such initiatives are beginning to address the historic neglect of mental health — epitomised by the asylum wards of the First World War — and the stigma that has so hampered those affected from seeking counselling or medication. But modern medicine is still struggling to unpick the extraordinarily complex amalgam of messages and memories that combine to create perception and that can be so short-circuited by traumatic experience.

Some fields of healthcare have always been energised by the impact of war. The ability to save people with injuries that would once have meant certain death has driven forward physiotherapy, in the same way that orthopaedics advanced after 1918. Likewise maxillofacial surgery, to repair the face and jaw, is building on its foundation as a speciality in the First World War, under Harold Gillies. Then, trench warfare meant that heads were exposed and severe facial injuries were common, prompting the development of external fixation, involving holding fractured bones in place using an external rod screwed into bones around the fracture. This evolved into internal fixation, using small titanium plates, for most facial fractures. But the conflicts in Iraq and Afghanistan — and the complex facial injuries caused by high-energy explosives involving shrapnel — have seen the return of external fixation, albeit with a new generation of more malleable titanium frames.

Other areas of reconstructive surgery are requiring groundbreaking feats of scientific imagination. There is the case of Neil McCallion, a private from the Argyll and Sutherland Highlanders who in 2006 had has hand shattered and shredded in the blast of a suicide bomb. Four of five metacarpal bones were missing, leaving the hand looking like a scooped-out crab shell. Surgeons drew up a plan adapted from a technique that had been used in Japan for a foot injury. They used bone from Private McCallion’s ribs and tendons from his legs and skin was regrown by attaching the hand to his lower abdomen. After a 17-hour operation and several further procedures, Private McCallion can pick up a pint. He recently passed his driving test.

Many such medical challenges and triumphs have come with a decade of continuous combat for British troops, and the lessons are working their way into domestic healthcare. In January, a £20 million Government initiative was launched, led by Sir Keith Porter, to ensure that the advances in emergency medicine on the battlefields of Helmand are translated to the accident and emergency wards of the NHS.

The Ministry of Defence and the Department of Health are contributing to the National Institute of Health Research centre, based at the Queen Elizabeth Hospital in Birmingham. It aims to consolidate and share advances in trauma medicine between military and civilian emergency services, and ensure that breakthroughs do not befall the same fate as Paré’s discoveries in infection control, which did not become commonplace for many years. As Vice-Admiral Philip Raffaelli, the Surgeon General, observed: “The centre is providing a national repository where we can retain these lessons for the future.”

Such are the lessons that Hippocrates observed, and that have been drawn from conflicts ever since. Nothing can outweigh the carnage and waste of war but the legacy of those who fight, suffer appalling injury and die must be medical advances that can improve their odds of survival and, in turn, the health of their compatriots at home.