Archive for the ‘Military Trauma’ Category

USAISR Receives FDA Approval for Compensatory Reserve Indicator

Monday, February 6th, 2017

Collaborating with other scientists and engineers, the U.S. Army Institute of Surgical Research developed an algorithm that measures the body’s ability to compensate for blood loss, or the compensatory reserve. The compensatory reserve index (CRI) can predict when a patient is about to go into hemorrhagic shock. The device, which takes readings from a standard pulse oximeter, received FDA clearance in December 2016.

USAISR researchers believe that combat medics attending to battlefield wounded, as well as civilian EMTs, can employ the device to save lives, as it can continuously monitor patients and provide a guide for fluid resuscitation and other interventions.

Read the full story.

En Route Care and Training for Immediate Responders Explored in November JOT Supplement Covering 2015 MHSRS Proceedings

Thursday, November 10th, 2016

Supplement 1 of the Journal of Trauma, Volume 81, No.5, carries multiple papers emanating from the 2015 Military Health System Research Symposium. Below are synopses of several. To read the entire supplement, click here.

Machine learning and new vital signs monitoring in civilian en route care: A systematic review of the literature and future implications for the military  

Researchers Nehmiah Liu and Jose Salinas, PhD, reviewed the existing literature related to machine learning (ML) algorithms (MLA) and new vital signs monitoring (NVSM) in civilian en route care in order to determine their potential to fill combat medicine capability gaps. Recent machine learning technologies include those that monitor novel vital signs such as heart rate variability (HRV) and heart rate complexity (HRC). In addition, the photopletysmograph wave form and data quality indices offer potential ways to evaluate the need for lifesaving interventions during en route care.

There continues to be limited means of monitoring and recording data in-flight–such as vital signs, waveforms or interventions made by in-flight personnel—and an imperative to leverage such data to improve care and reduce mortality. Thus, the researchers are optimistic that new innovations could be of benefit in combat scenarios, but caution that further validation is warranted before widespread use. “Almost all studies required further validation in prospective and/or randomized controlled trials,” they determined.


Combat MEDEVAC: A comparison of care by provider type for en route trauma care in theater and 30-day patient outcomes

A 2009 change in military combat medicine policy led to the integration of Air Force Pararescuemen with paramedic training into MEDEVAC missions in a bid to decrease mortality. Paramedic level training was thus incorporated into the initial flight medic training of DUSTOFF medics in 2012, and a new program course at Fort Sam Houston provided additional paramedic and critical care training to promote all skill competencies at the EMT–intermediate/paramedic level as well as CCFP certification.

Vikhyat Bebarta, MD, and other researchers at Fort Sam Houston sought to analyze the resulting reallocation of resources in order to determine whether the intended benefit had been attained. In this study, the researchers identified and described medical providers and their specific roles on MEDEVAC missions, and identified associations between provider type, procedures performed, medications administered, survival, and 30-day outcomes.

In a review of more than 1,200 records of US casualties between 2011 and 2014, they determined that 76% of MEDEVAC personnel were medics, 21% paramedics, and 4% were advanced-level providers (ADVs) including nurses, physicians, and physician assistants. Providers with higher-level training were more likely to perform more advanced procedures during en route care; however, there was no significant association between provider type and in-theater or 30-day mortality rates. “More evidence is needed to determine the appropriate level of MEDEVAC personnel training and skill maintenance necessary to minimize combat mortality,” the researchers concluded.

Liu and Salinas argue for research that advances these technologies for en route care. “Importantly, these innovations could not only enhance trauma casualty care for our nation’s war fighters in a complex global environment but also close gaps–specifically, monitoring and the early detection and treatment of various injuries,” say the researchers.


Improving national preparedness for mass casualty events: A seamless system of evidence-based care

Researchers Alexander Eastman, MD, William Fabbri, MD, Kathryn Brinsfield, MD, and Lenworth Jacobs, MD, argue in a special report that the U.S. lacks “a unified, coordinated national system to respond to intentional mass casualty attacks….”

The researchers note that our national preparedness goal is thwarted by segmented, compartmentalized, or simply unobtainable investigative, clinical, and medical examiner data following mass casualty events. The distributed nature of the ownership of various segments of the civilian health care system is to blame, they say, and the consequence is that “conjecture, bias, and anecdote inform the civilian section of our national response rather than scientific evidence.”

The Hartford Consensus, they contend, is one attempt to evaluate evidence-based approaches to the problem. The authors review recommendations from successive Hartford Consensus meetings and conclude that immediate responders to mass casualty events, employing bleeding control techniques, hold the key to national resilience. Immediate responders, as defined, include law enforcement officers, bystanders, and even victims.

“Our military colleagues have demonstrated that a robust data collection system, organized scientific study of the problem, and system-wide implementation of evidence-based solutions can significantly improve survival from intentional traumatic injury,” Eastman et al. conclude. “Our duty now is to build the foundations of an analogous civilian system in order to begin to answer the remaining questions and to truly improve our national preparedness.”

NIH For Trauma Necessary to Support Civilian Acute Care Needs

Thursday, October 20th, 2016

In an article published in The New England Journal of Medicine, Todd Rasmussen, MD (DoD Combat Casualty Research Program) and Arthur Kellerman, MD (Uniformed Services University of the Health Sciences) propose the establishment of an NIH institute dedicated to trauma and emergency care research.

DoD funding represents more than 80 percent of the federal government’s annual investment in trauma care research, the authors point out. “Although this arrangement ensures the military relevance of federal research on trauma care, it provides little support for civilian priorities and leaves the field overly dependent on DoD funding.”

Rasmussen and Kellerman reference the June 2016 report from the National Academies of Science, Engineering and Medicine, which calls for a National Trauma Action Plan that integrates civilian and military trauma care capabilities. Establishing an NIH for trauma, they contend, will help to “drive the number of preventable deaths after injury down to zero.”

Read the article.

New ACS Curriculum to Prepare Surgeons for War and Disaster Environments

Monday, April 25th, 2016

Most military surgeons are based at facilities where trauma care is not routinely provided, and there is no standard surgical preparation for military surgeons being deployed, finds the Military Health System Strategic Partnership American College of Surgeons (MHSSPACS).

To address this gap, MHSSPACS is creating a course that will prepare surgeons before they are deployed to war zones or areas affected by disasters. M. Margaret (Peggy) Knudson, MD, FACS–MHSSPACS Medical Director, professor of surgery at the University of California, San Francisco (UCSF), and trauma surgeon at San Francisco General Hospital and Trauma Center–is the lead author of an article outlining the partnership’s work. The article appears online on the Journal of the American College of Surgeons website ahead of print.

Dr. Knudson , who also serves on the National Trauma Institute Board of Directors, said this May a group of previously deployed military surgeons will compile a list of the skills and knowledge they believe are necessary to serve as the blueprint for developing test questions for a compiled curriculum.

Read More.

Defense Health and Research Programs Support Troop Readiness, Leaders Testify

Tuesday, March 22nd, 2016

Today, leaders of Department of Defense health programs testified at a hearing held by the House Defense Appropriations Subcommittee. Speaking on behalf of their programs were Vice Admiral Raquel Bono, Director of the Defense Health Agency; Lt Gen. Nadja West, Surgeon General of the U.S. Army; Vice Admiral Clinton Faison, III, Surgeon General of the U.S. Navy; and Lt Gen. Mark Ediger, Surgeon General of the U.S. Air Force.

In his opening statement, Subcommittee Chairman Rodney Frelinghuysen praised remarkable improvements in combat injury survivability and recognized the importance of DoD research and development of innovative treatments and devices within the Congressionally Directed Medical Research Program. Investments in the program have made it possible for gravely wounded troops to survive and thrive, he noted.

Each DoD leader focused attention on the programs and facilities within his or her jurisdiction and gave examples of taxpayer spending that returns enormous benefits to our service men and women and their families. The trauma resources at Bagram Air Base in Afghanistan; research consortia in orthopedic trauma, spinal cord injury, TBI and regenerative medicine; and the trauma system that includes highly trained medical personnel, battlefield units, evacuation systems and rehabilitation facilities were all touted as investments in the readiness of the U.S. fighting force that cannot be overvalued.

In responding to a question from Ranking Member Peter Visclosky regarding whether there were any gaps that were cause for concern, Lt Gen. Ediger made that point that the care provided to U.S. combat troops is more complex than ever before, and deployable medical teams must be ready to deliver that complex care at any given moment. Maintaining their skills and training, he said, is key to maintaining the readiness of the troops.

View the entire hearing.


NTI Studies Gain $1 Million in Funding from the Joint Warfighter Medical Research Program

Wednesday, October 28th, 2015

Funding from the Joint Warfighter Medical Research Program will support the continuation of two studies initially funded by the National Trauma Institute. Deemed to have significance for pre-hospital treatment of the war wounded, the studies by Jay Doucet, MD, University of California at San Diego, and Henry Cryer, MD, University of California at Los Angeles, were selected on the strength of their preliminary results.

Dr. Doucet’s study, Detection and Management of Non-Compressible Hemorrhage Using Vena Cava Ultrasound, postulates that ultrasonic assessment of the inferior vena cava (IVC) can detect and aid management of non-compressible hemorrhage in major trauma victims. As indicated in small clinical studies, observation of the diameter of IVC in both expiration and inspiration, as well as its collapsibility, can be a sensitive indicator of blood volume loss and hemorrhagic shock. Doucet’s study specifically aims to determine how accurate ultrasound assessment of the IVC is, compared to vital signs, as well as the measure’s ability to detect preclinical shock states.

This technique may predict those patients who will require transfusions, surgery or angiographic embolization. Additionally, the study will provide an opportunity to demonstrate the ability of handheld ultrasound devices to detect and monitor hemorrhagic shock in initial trauma care and in the ICU in both civilian and military trauma environments.

The investigation being led by Dr. Cryer, Transfusion Using Stored Fresh Whole Blood (FWB), will determine the appropriate shelf life of FWB by measuring changes in levels of coagulation factors and global clotting potential of banked units over time. Dr. Cryer’s earlier results demonstrated that filtered blood has a filtration lesion resulting in a coagulopathic product and some decrease in clotting capability over 35 days. Platelet transfusion may correct the filtration lesion seen, but further studies are needed to determine the exact timing and ratio of platelet transfusion required.

The follow-on effort will prospectively determine the effectiveness of trauma resuscitation using FWB compared to component therapy and its effects on markers of coagulation, fibrinolysis, inflammation and global hemostatic potential, as well as hospital outcomes including development of coagulopathy, infection, venous thromboembolism, multiple organ failure, total transfusion requirements, and mortality.

The Joint Warfighter Medical Research Program is a program of the Department of Defense Peer Reviewed Medical Research Program (PRMRP). Funding for this program is directed by Congress to “augment and accelerate high priority Department of Defense and Service medical requirements and to continue prior year initiatives that are close to achieving their objectives and yielding a benefit to military medicine.”

Cutting Transport Time and Enhancing Pre-Hospital Care Saved Hundreds

Monday, October 5th, 2015

Sept 30, 2015 JAMA articleIn the September 30, 2015 online edition of JAMA Surgery, Russ S. Kotwal, MD, et al. review the effect of a 2009 policy change on the morbidity and mortality of combat casualties in the wars in Iraq and Afghanistan. Then Secretary of Defense, Robert Gates, issued a mandate to reduce transport time from battlefield to hospital care to 60 minutes—the so called “golden hour.”

According to the researchers, transport time was reduced by 52% to a mean of 73 minutes, and the study “…showed a significant survival benefit after the mandate, specifically as a result of a reduction in KIA [killed in action] mortality.” This decrease persisted despite an increase in the severity of injuries being treated as method of injury shifted from gunshots to explosions as the wars progressed.

Despite acknowledged limitations of the study, the authors note, “the data show that…shorter transport times and enhancements to treatment capability…improved outcomes and potentially saved 359 lives.”

In his invited commentary on the study, “The Power of Advanced Capability and Informed Policy,” Col Todd E. Rasmussen, MD, Director of the US Combat Casualty Care Research Program, notes that reduction in the KIA percentage following the policy change provides evidence of an enhanced capability during the golden hour after injury that includes enhanced point of injury care and en route platforms, in addition to the reduction in transport time.

Rasmussen cautions against a “mission-complete” reaction, however, suggesting that future casualty care scenarios may be more complex and that military and civilian planners should “learn from the whole of the effort…and develop better ways to build trauma care capability and inform policy for future, more complex casualty scenarios.”

Read the article and commentary


Too Many U.S. Troops Lost Lives When Survival Was Possible

Tuesday, September 23rd, 2014

A Sept. 19 Wall Street Journal article illuminates a study published last year in which military trauma researchers found that 24% of the American servicemen and women killed in action over the past 10 years died from potentially survivable wounds–nearly 1,000 troops.

The study, conducted by the U.S. Army Institute of Surgical Research, found that battlefield aid techniques used by some elite units had not found their way into common usage across the rest of the military–techniques such as the use of tanexamic acid as an anti-bleeding agent, junctional tourniquets to stem hemorrhage that occurs close to the trunk, and ketamine as an alternative pain killer that does not depress blood pressure.

While best practices have made it to the battlefield in some cases, the latest gear, drugs and techniques are still inconsistently utilized. Military trauma surgeons interviewed for the story, including Brian Eastridge, an Army Colonel and member of the National Trauma Institute’s Board of Directors, say that bureaucratic issues, the lack of trauma specialists in the field, and a lack of focus on pre-hospital care have all contributed to the problem.

With the return of American forces to the Mideast, some fear that frontline care will be even less adequate, as the expected scattered conflicts will involve smaller units without the extensive evacuation and hospital networks that were in place in Iraq and Afghanistan.

Read the full story:  WSJ 140919 Preventable Deaths.

Military Trauma Research Saved Lives in Civilian Bombing in Boston

Wednesday, April 24th, 2013

Two articles published recently highlight the transfer of military trauma research to civilian trauma response teams. The use of the tourniquet in Boston undoubtedly saved lives. View the two articles which include interviews with Dr. Don Jenkins, NTI’s Board Chairman, by clicking the links below. ”The Return of the Tourniquet: What we learned from war led to lives saved in Boston” ”How Bombs in Iraq Saved Lives in Boston”

Army Times Publicizes WVSM

Tuesday, December 6th, 2011

In its December 5, 2011 edition, the Army Times included a story about the Wireless Vital Signs Monitor (WVSM), a lightweight and portable device that monitors trauma patients and predicts the need for life-saving intervention. NTI oversaw development and managed the funding for the WVSM, which is undergoing clinical trials at Memorial Hermann Hospital in Houston. The publication reports that the WVSM could be available to medics in the field in as soon as 18 months.

For more information on the Wireless Vital Signs Monitor, read NTI’s press release from earlier this year.