Iraq and Afghanistan Wars: Lessons in Emergency Medicine

An Expert Interview With Lt. Col. Vikhyat S. Bebarta, MD

Laird Harrison

October 19, 2011

October 19, 2011 (San Francisco, California) — Editor's note: Every war has led to discoveries in the care of trauma patients, and the combat in Afghanistan and Iraq is no exception.

A presentation on lessons learned from these conflicts was featured here at the American College of Emergency Physicians (ACEP) 2011 Scientific Assembly, held October 15 to 18. Medscape Medical News interviewed presenter Lt. Col Vikhyat S. Bebarta, MD, chief of medical toxicology at the San Antonio Medical Center, Texas, and interim director of the US Air Force Enroute Care Research Center, who commanded emergency departments in Iraq and Afghanistan.

Medscape: Has trauma care improved during the current wars?

Dr. Bebarta: There is no doubt about it. Mortality is the lowest in the history of war. Armor and vehicles have a lot to do with it, but it also has to do with the clinical care we are providing. We have changed the way combat medicine is delivered.

Medscape: What innovations could affect civilian emergency medicine?

Dr. Bebarta: The way we transfuse patients, the liberal use of tourniquets, the joint theater system, the critical care air transport team (CCATT), the use of ultrasound and intraosseous needles, the treatment of blast injury, and the use of hemostatic dressings are some of the most significant developments.

Medscape: Let's take those one by one. What's new about transfusion?

Dr. Bebarta: In World War II, we transfused whole blood and it worked well. However, it was not an efficient use of blood products. Then we learned how to separate blood into its components of red cells, plasma, and platelets to be used for bleeding, cancer, and other illnesses. For many years, we transfused only red cells to bleeding patients. However, around 2003, we realized that patients may do better if they are transfused with more than just the oxygen-carrying components, [and added] the plasma component in a 1:1 ratio. This combination, infused early, reduces bleeding and increases survival.

Medscape: Haven't tourniquets been around for centuries?

Dr. Bebarta: Yes they have. They were used a lot in World War II. Then in the 1950s and 1960s, it was decided they may be harmful. They had blast-related injured limbs that they put tourniquets on and they lost the limbs anyway. But after Vietnam, researchers looked back and asked: "Why did people die?" Two of the biggest causes were extremity hemorrhage and collapsed lung. Then came Somalia with Black Hawk Down, and several soldiers died of extremity hemorrhage. So once Operation Iraqi Freedom and Operation Enduring Freedom were launched, there was a big push to get tourniquets out. Now in Iraq and Afghanistan, every person carries a tourniquet in their first aid kit. One study reported that if a tourniquet was placed before hemorrhagic shock, 96% survived, but if the tourniquet was placed after hemorrhagic shock, 4% survived. There is slightly greater nerve injury and probably no difference in limb salvage, but survival is greater.

Medscape: What is the joint theater trauma system?

Dr. Bebarta: It's the principle of getting the right patient to the right place at the right time, level I vs level II or level III surgical facilities. We had 2 or 3 primary trauma centers in Afghanistan and 2 or 3 in Iraq. Doctors are in communication by phone and email. And we have a primary air hub in each country that receives and reevaluates every patient who is flown out of the country.

Medscape: What difference have the CCATTs made?

Dr. Bebarta: This may be the biggest contribution of the war. Each team is made up of 3 people: a critical care physician (it could be an emergency physician, a pulmonary intensive care unit [ICU] physician, a surgeon or another physician with critical care experience), a critical care nurse, and a respiratory technician. The patients get the same level of critical care as they are transported that they would get in the trauma ICU. In contrast to the Vietnam War, we don't have to wait days to take them off the ventilator or until they are stabilized to transport them. New technology has helped. Ventilators are small, and we have other portable technology specific for flight. But the most important thing is the philosophy of transporting the patient out of theater quickly with a high level of care, and training clinicians to do this.

Medscape: What about ultrasound?

Dr. Bebarta: Ultrasound is being used early in the resuscitation and far forward in the field to detect internal bleeding or collapsed lungs, among other injuries.

Medscape: Are intraosseous needles being used more as well?

Dr. Bebarta: Yes, they are simple and easy to place. These were also used in World War II, but in the 1950s and 1960s, they were supplanted by plastic venous catheters. However, placing an intravenous catheter can be difficult and requires advanced skills. Intraosseous needles are very easy to use; almost anybody can do it. Medics can do it, even in a dark helicopter. You can transfuse blood, fluids, or medications through them urgently and set up an IV later. They are already being used by paramedics in the prehospital setting. Currently, we use intraosseous catheters in the hospital (both in combat and in our hospitals in the United States) if we cannot obtain IV access quickly in a critically ill patient. We can insert an intraosseous needle, then place a central venous catheter later.

Medscape: What have you learned about blast injuries?

Dr. Bebarta: We have always been taught that eardrum perforation is a predictor of blast lung injury. We found that eardrum perforation is not a good predictor of blast-related lung injury, but it is a good sign of traumatic brain injury. We reported those data in the New England Journal of Medicine (2007;357:830-831) and the Journal of Trauma (2009;67:210-211), and summarized them in a review article in the Lancet (2009;374:405-415).

Medscape: What's the story on hemostatic dressings?

Dr. Bebarta: There are parts of the body, such as the groin, axilla, and neck, where you can't use a tourniquet to control bleeding, also called junctional bleeding. In these places, you can use a hemostatic dressing. Hemostatic dressings are gauze embedded with chemicals that make blood clot, thus reducing hemorrhage. Their use has spilled over into civilian medicine. You can find them at outdoor sports stores and on camping Web sites. We have learned a lot from these wars that is already being used by civilians. Many of these lessons are learned through the sacrifice of the lives and limbs of young marines, soldiers, airman, and sailors. Their service is notable.

Dr. Bebarta has disclosed no relevant financial relationships. The comments expressed in this article do not reflect the opinion or official policy of the Department of the Air Force, Department of the Army, Department of Defense, or the United States Government.

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