Surgery In the Dirt

In Iraq in 2007 five hundred pounds of explosives detonated beneath Combat Medic Greg Dotson’s Bradley Fighting Vehicle. His unit soldiers, trained by Greg, pulled him and his medic bag from the wreck and began work. While a furious firefight was going on around them, they applied tourniquets high on his shredded legs, slid a breathing tube down his nose and throat and got a field dressing secured tightly around the shrapnel wounds in his abdomen. They tried to start an IV, but his veins were flat. Splints were taped to his legs and they strapped his 6”6” frame to a stretcher and a Blackhawk medevac helicopter picked him up. Minutes later he was on the operating room table at the closest U.S. air base.

This “scoop and run” protocol is standard stuff for military medics in a war zone.  It ensures that the patient reaches necessary medical treatment in the “golden hour”.   In the last few years this point of injury care has been widely used in our military actions in Iraq and Afghanistan.  Clear the breathing passage, stop the bleeding, package the patient on a litter, wrap them in a Mylar blanket, strap them in, and wave the medevac helicopter to fly the wounded to a nearby combat surgical hospital.  Advanced care is left to the surgical team and ICU nurses there. The severely wounded are airlifted to Germany or the United States.

These protocols have increased the survival rate of Americans fallen in combat to 91 percent. In Vietnam, the survival rate was 75 percent.  This has been possible because Iraq and Afghanistan lacked air forces and means to and kill aircraft giving America control of the airspace in these countries. But future wars with enemies such as Russia, China, or North Korea will not be the same.  Long range precision weapons will put the medevac helicopter at severe risk. Coupled with the fact that injuries have increased in severity, the current protocol for treatment and transport will be woefully inadequate.

Young Army medics get 16 weeks of basic training in first-aid skills and they practice algorithmic medicine using a simple set of steps in a decision ladder they memorize. What is to come is far beyond their current training and experience. The new term for what will be required is “prolonged field care”, It is entirely different and vastly more complicated.  Essentially, it moves the emergency room and ICU’s into the field and into the dirt. Basic combat medics have to learn 70 separate skills. The prolonged field care medics must learn as many as 480 skills. Basic medics work with 5 drugs. Prolonged field care medics have to study the uses of dozens of drugs and their interactions. Patients could be in their care for days instead of just one hour.

Military medic training has intensified and is applied in field training exercises. They are made as realistic as possible through simulation. Scenarios are planned and executed, evaluated, and changes implemented for what did not work or went wrong.  Each Advanced medic is assisted in the field with the help of a basic medic.   There are major issues on how to move the medical equipment around and what the medics can carry. A portable ultrasound machine is utilized to diagnose and evaluate the patient’s condition.  These machines are invaluable in the field, but subject to the environment (they do not like to be wet or banged around).  Getting supplies to the medics is a large problem to overcome. Currently, if a medic has 4 bags of saline, he can hang one to a patient because the medevac helicopter is going to restock him when it comes in an hour. In the new reality, one patient could require all 4 bags of saline over several days before transport is arranged to remove them from the field.  What happens to the next patient that requires a saline drip?

The new weapons that cause mass casualties generally induce some type of burns. Burn care in the field is extremely difficult and requires massive amounts of administered fluids over several days. Included in the burn care in the field is the regular administrations of silver sulfadiazine salve to help prevent infection. Each burn patient will need, every day, two 400-gram tubs of this salve, each the size of a coffee can. Multiple victims could empty the supply even if a supply truck was available.

And where will the medic get a blood supply for patients who have had a severe blood loss?  The army is working on a freeze-dried version of plasma to provide volume and support stock. Research with drugs that can change the body’s metabolism and the slow the need for more blood are in development.  The list of solutions in prototype or already in the field goes on: a device that finds blood vessels after they have flattened out from loss of blood, a balloon stent device that can be threaded from the groin into the abdomen to fix a tear in a blood vessel,  a device that goes on a finger that can predict hemorrhagic shock and a mechanical leg brace that enables a patient to get up and walk instead of having to be carried.

One scenario for blood supply is to go back to what was used in previous wars where the soldiers were the blood banks. If all the soldiers were typed for their blood type and type O negative universal donors carried that designation, then blood donation (patient to patient) in the field would be a possibility.

And where would this medical treatment take place?  Literally, surgery in the dirt with remnants of war littering the ground around them.  It makes all old warfare seem like child’s play. The military is saying that there will be significant casualties in this kind of war.

The Advanced Medic must be able to train others in his outfit to assist him and/or take care of him if he is the one that is injured.  The Army is working hard to ensure crucial care for wounded soldiers on the battlefield of tomorrow, but the medics must bring their courage to rush headlong into deadly peril with limited backup to save their wounded comrades.

If you are interested further, read the December 2019 Issue of Texas Monthly magazine article Surgery in the Dirt.



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