Wartime medicine is an incredibly challenging setting for those who practice it. Not only are the injuries frequently serious, but the tools at hand are often more limited than in a traditional hospital. Over time, that has meant that medical personnel have had to innovate. These innovations, in turn, often serve to refine medical practices beyond the military.
During the last decade of the War on Terror (Operations Enduring and Iraqi Freedom), several important medical and surgical innovations created for these conflicts have found their way into everyday civilian trauma, emergency, and critical care practice. These range from the creation of new bandages, devices, and transfusion protocols to control life-threatening hemorrhage, to new operative and surgical care models which improve a trauma victim’s chance of survival. The University of Michigan not only uses these innovations today, but continues to play a significant role in developing these and other technologies that will be used to save lives on the battlefield and at home.
Two critical differences and challenges face the wounded warrior in battle compared to the injured civilian at home. The first is the severity and type of injury incurred. Injuries produced by high velocity munitions and explosions can result in multiple amputations and traumatic brain injuries that are not commonly experienced off the battlefield.
The second is the fact that there is no “Golden Hour” on the battlefield. The Golden Hour concept developed and practiced by the civilian trauma community holds that trauma victims have the best chance of survival if they begin receiving their care at a definitive trauma center within one hour of their injury. However, in battle, rapid care and transport to a definitive surgical facility cannot be guaranteed for many reasons, from terrain, to weather, to active combat conditions. In the Special Operations community, definitive care could be several days away. These unique circumstances make it imperative that sophisticated life-saving care is made available to the injured within an hour, despite the location of the victim.
While advances in combat casualty care and training have helped significantly reduce current battlefield mortality and morbidity, many opportunities remain. The challenge is the inability to predict with certainty, the landscape of future conflicts, which could range from moving from the desert and mountainous environments of Iraq and Afghanistan to the tropics of South America or Asia, or advancing small tactical operations at a growing number of locations to conducting combat operations in mega-cities. This unpredictability will require a new generation of adaptive tools and devices that can be deployed in the battlefield, which is why MCIRCC developed its Combat Casualty Care Program.
The Combat Casualty Care Program brings together world-class scientists, clinicians, and engineers from the University of Michigan, and pairs them with industry partners and entrepreneurs to develop and deploy cutting-edge solutions that elevate the care, outcomes, and quality of life of critically injured warriors.
Hemorrhage is the leading cause of preventable death for both battlefield and civilian trauma. Due to increased use of IEDs on the battlefield, many victims sustain multiple injuries, causing catastrophic bleeding. Of particular challenge is controlling hemorrhage in areas of the body that are difficult to compress such as the abdomen, chest, neck, axilla, and groin.
MCIRCC researchers have played a significant role in developing and testing hemostatic strategies that have been deployed in the battlefield as well as those that are envisioned to become next generation products.
The scope and severity of battlefield injuries, as well as the rapid movement of casualties by ground and air in austere environments pose significant challenges for monitoring patients.
The use of traditional vital signs such as blood pressure, heart rate, respiratory rate, and temperature have very limited value in helping health care providers determine the severity of injury and guiding therapy. An additional challenge is aggregating health care data (physiologic, laboratory, etc.) and optimally using it to improve diagnostic and therapeutic accuracy or to monitor the patient’s physiological status.
Our teams of clinicians, physiologists, engineers, and data scientists are creating the next generation of deep physiological vital signs and monitors, as well as big data clinical decision support algorithms that will allow for precision diagnoses and care for the severely wounded.
Resuscitation is a complex process of providing the body with certain essential elements, such as oxygen and fluids, to prevent cardiovascular collapse and organ failure. It is also usually necessary during and after surgery, to optimize organ function and survival. Most severely wounded warriors require resuscitation in order to survive long enough to reach definitive surgical care, however the ability to provide resuscitation to multiple severely wounded individuals on the battlefield poses overwhelming logistical challenges.
Our researchers have been instrumental in testing new resuscitation strategies and are developing low volume (weight) resuscitation and other modalities, which enhance tissue survival and healing, reduce bleeding, prevent infection, and reduce pain.
Despite having definitive surgical repair and resuscitation of initial combat injuries, casualties on the battlefield continue to occur for a number of reasons. From associated injuries that cannot be surgically repaired (e.g. severe lung damage), to developing states of overwhelming inflammation as a consequence of resuscitation, or from injuries such as burns, survival is only possible by supporting vital organ function until tissues heal and inflammation resides.
Our researchers are developing innovative technologies that support vital organs such as the respiratory, cardiovascular, and renal systems. Several of these technologies incorporate advanced control approaches, which attempt to develop closed-loop systems. These systems take multiple physiologic inputs, and use them to provide precision acute life support to the individual.
As a signature injury of the war over the last decade, severe traumatic brain injury (TBI) represents one of the most challenging injuries to treat. Little progress has been made in the treatment of TBI over the last 30 years, whether at home or on the battlefield. While there are many reasons for this, ranging from the lack of monitoring capabilities to the innate inability of the brain to repair itself like other organs, the challenges of caring for TBI patients are only compounded by the austere conditions of the battlefield.
Our researchers are re-examining how severe TBI is diagnosed, monitored, and treated by leveraging new models, therapeutics, devices, and diagnostics in parallel, rather than using the prevalent “silver-bullet” approach.
Many seriously wounded warriors require weeks to months of intensive care to immobilize their bodies. This type of immobilization can result in long-term muscle loss and weakness, and may even cause immune system dysregulation, making victims more prone to future infection. Prolonged immobilization can also result in complications such as deep venous thrombosis, pulmonary embolisms, bedsores, and pneumonia.
While early mobilization has been demonstrated to counteract many of these complications, such an approach is not scalable and cannot be carried out in the most severely injured, especially as they rapidly move across echelons of care.
Our researchers are developing new approaches to automated and precision rehabilitation, and other countermeasures that will leave patients stronger, and reduce complications from prolonged immobilization.