Wounds of war bring home new ways of healing

Dr. Edward V. Craig

Throughout history, the experiences of doctors in wartime have led to dramatic advances in civilian medical care.

Hippocrates, best known for the oath every graduating medical student takes, recognized this in 400 B.C. when he wrote that war was a surgeon’s best training ground. Each war has exposed physicians to injuries not seen previously, and the Iraq War — with its signature roadside bombs (in this war’s lingo “improvised explosive devices”) — is no exception.

The treatment of the injured soldier has always centered on three things: minimizing the time between injury and treatment, stopping blood loss and avoiding infection.

In the Napoleonic Wars, soldiers were rapidly transported to medical facilities from the battlefield via convoys of horse-drawn wagons in the earliest version of a “trauma center.”

World War I introduced the concept of “triage,” prioritizing the care of the wounded by severity — now standard practice in emergency rooms. This war also created the field of plastic surgery. With soldiers tucked in the trenches, their legs and torso protected, their faces and heads were exposed to the most devastating injuries. Treating these acute injuries and the need for reconstruction spawned a series of post-war hospitals tending to facial disfigurement.

The legacy of World War II was the widespread use of antibiotics, which slashed the incidence of serious infection. At the same time, the use of blood replacement to treat hemorrhage became common practice and led to the post-war proliferation of blood banks.

Korea brought the MASH units and helicopter evacuation, forever changing the approach to trauma care from bandaging and administering pain medication from on-site in first aid kits to stabilizing the patient for immediate evacuation to a location where he could receive more intensive, life-saving treatment.

This approach, which spared countless lives, was applied to an even greater extent in Vietnam. And as the military doctors returned home, sophisticated trauma centers, fed by helicopter transport systems, became widespread. Vietnam also brought the modern concept of mobile blood banks, and surgical repair of blood vessels became a limb-saving technique that would eventually lead to microsurgical repair of the smallest arteries and veins.

Lessons from Iraq
Now, five years into the Iraq War, with more than 30,000 service members wounded in Iraq and Afghanistan, we’re starting to see how this war's unique medical challenges have fueled progress here at home.

On the one hand, advances in body armor and head protection have permitted many of our troops in Iraq and Afghanistan to survive trauma that they wouldn’t have previously; but at the same time, their skulls are being rattled and their minimally protected extremities are taking the brunt of this battle.

As many as 20 percent of U.S. combat troops in Iraq or Afghanistan leave with signs of mild traumatic brain injury, or concussion. As a result, much is being learned about the lingering health effects of brain injury, including a link to post-traumatic stress disorder and depression.

On the battlefield, controlling bleeding is still a major focus of treatment. Tourniquets haven't been widely used on civilians outside of hospitals because of complications if not used correctly. But self-applied tourniquets tested in Iraq have been found 100 percent effective in stopping bleeding from arteries. So now stateside emergency responders are using them in on-the-scene emergency care.

A second major means of staunching bleeding is the use of bandages no war has seen before. These “hemostatic dressings” are impregnated with substances that not only stop the bleeding, but also seal and protect the wound. While used in Iraq for often catastrophic wounds, this same blood-stopping technology may offer hemophiliacs or people on anticoagulant drugs freedom from the fear of routine cuts and scrapes.

A rapid blood transfuser, which injects blood quickly rather than the traditional slow-drip system, has also come directly from the Iraq experience.

Game-changing advances in prosthetics
Unfortunately, the injuries in Iraq involve more than blood loss, they also involve loss of limbs. Since the Civil War, the military has been the innovator in the care of the amputee.

Because of their youth and excellent physical condition, injured service members can begin rehabilitation training almost immediately. By the time their prostheses are fitted, soldiers are ready for the extra work their body must do. This experience has taught civilian doctors the value of immediate conditioning.

This war’s more than 500 amputees have also driven forward prosthetic research, including advances in materials such as anatomic socket designs and silicone gel liners.

The real game-changer in this field is the “biohybrid” concept that treats the patient’s tissue and the prosthesis as one continuous arm or leg. This exciting area of research is centered on the human-prosthetic interface and involves methods of trying to get tissue to grow directly into the prosthesis, giving it a better seal and laying the groundwork for direct nerve control of the artificial limb.

Already developed is an ankle-foot prosthesis, which reproduces muscle-like activity and mimics a more normal walking pattern.

But the most lasting medical legacy of the Iraq War is likely to be a rather low-tech advance: quick and clear communication of medical information. Today’s soldiers carry personal identification cards with extensive patient information, enabling emergency caregivers to quickly gather health history, minimize errors and maximize integration of medical care. Such successes are likely to have a profound impact on attempts to make medical information portable.

With each war, we are unfortunately left with new ways of killing. But the other side of the story is that each war also produces new ways of healing.

Dr. Edward V. Craig is Attending Surgeon at the Hospital for Special Surgery in New York City and Professor of Clinical Orthopedic Surgery at Cornell Medical School.

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