A matter of life and death on the battlefield

Uncontrolled bleeding can kill a soldier in minutes, so new techniques and drugs are vital to save lives

A matter of life and death on the battlefield


There's a memorable scene in the film Black Hawk Down after US Ranger Corporal Jamie Smith is shot in the upper thigh. The wound extends too high for a tourniquet to work; direct pressure is inadequate and his severed femoral artery cannot be clamped. He messily bleeds to death in front of his helpless comrades. It has happened: Black Hawk Down is based on real events in Somalia 13 years ago.

Colonel Tim Hodgetts offers Smith's death as an example of where military first aid failed to stop catastrophic haemorrhage. Hodgetts has served in hotspots around the world including Belfast, Kosovo, Iraq and Afghanistan. As an adviser for emergency medicine covering all three armed services - and honorary professor of emergency medicine at Birmingham university - Hodgetts knows battlefield injuries at first hand. Smith's death saw the US military turning to researchers and industry for new solutions. "If you look back through history, many advances have been made in medicine through conflict," says Hodgetts.

Bearing the brunt

Although body armour means soldiers are now better protected, it has altered injury patterns. Limbs now bear the brunt and the most common cause of potentially avoidable battlefield death is external haemorrhage. "Catastrophic external haemorrhage from the limbs is a real priority," says Hodgetts.

American figures show that almost 50% of combat fatalities before evacuation in Iraq and Afghanistan are attributed to uncontrolled bleeding; two minutes may be all it takes.

"If you're next to somebody who has had their leg blown off by a landmine, then the first thing we do is rapidly apply a tourniquet - called the combat application tourniquet," says Hodgetts.

The tourniquet - which can be applied with one hand - has been given to soldiers in operational areas since April 2005 along with a new emergency bandage. They also have ready what Corporal Smith's comrades did not.

"The difference today is that we have provided products that are designed particularly to control massive haemorrhage in those areas of the body that are too proximal [close to the torso] for a tourniquet and where pressure through a dressing alone is not adequate. These injuries are in the junctional areas of the groin and axilla [armpit]," says Hodgetts.

Those parts of the body are most at risk because the arteries come closest to the skin. The new products, used in Iraq and Afghanistan, are topical haemostatic (to stop bleeding) agents for application directly to the wound.

The British army has given the HemCon bandage to its team medics, who comprise one in four combat soldiers. It controls bleeding by becoming extremely sticky when in contact with blood and promoting clot formation. HemCon has saved more than 100 lives in the US military.

Another life-saving technology - QuikClot - is also used by British medics further back in the evacuation chain between the point of wounding and hospital. It's an inert, grainy mineral that is poured directly into the wound and acts like a molecular sieve. It sucks up water molecules from the blood, leaving platelets and clotting factors behind to promote rapid natural clotting, and so prevents severe blood loss.

"HemCon and QuikClot have been used, but a lot more extensively by the Americans," says Hodgetts. "The feedback we get from the frontline troops is that they have great faith in the products."

But not everything is so professionally rewarding. Hodgetts takes issue with a front page story in the Guardian (Veterans' groups criticise "guinea pig" decision, September 16) which said the MoD had decided that soldiers in Iraq and Afghanistan could be treated with a blood-clotting drug without controlled trials.

That drug is NovoSeven (Recombinant Factor VIIa or rFVIIa), made by Nodo Norvisk, the Danish pharmaceuticals company. It has only been licensed for use with haemophilia patients and it works on the complex process of blood clotting.

Hodgetts says: "The inference was that we use this drug widely, we use it indiscriminately and we are experimenting on soldiers." But, he says, "We are extremely cautious about its use and have rigid guidelines. It is only used by consultants and is only used at hospital level."

NovoSeven has been used twice on UK soldiers in Iraq and Afghanistan after consultants had exhausted all other methods of treatment. The two soldiers were bleeding from severe pelvic injuries.

Says Hodgetts: "It was used when everything else was failing and the clinician thought that the patients were going to die. Both of the patients survived."

The civilian world

Tim Coats understands serious injuries in the civilian world. As professor of emergency medicine at Leicester University, he has a research interest in bleeding. Half his time is spent at Leicester Royal Infirmary where he treats badly injured patients.

While gunshot wounds are rare in NHS hospitals, road traffic accidents resulting in blunt trauma are not. Coats says blood may leak internally from many small vessels or ooze from damaged organ surfaces. This calls for a different approach.

"That's where the haemostatic agents come in," says Coats. Although he has not used it, he knows about NovoSeven which strengthens and accelerates this process. There is some feeling, he says, that the military is a little more enthusiastic about the drug than the current medical evidence supports.

It is not licensed for use in trauma cases - but that's not a prohibition. "NovoSeven is occasionally used as a drug of last resort in the NHS. Most of the largest UK hospitals might have used it for trauma once or twice. It is certainly not in common use," says Coats. Another much cheaper drug, tranexamic acid, is undergoing a large international clinical trial in trauma patients. Routinely used in heart surgery, it's believed that tranexamic acid may be of benefit in trauma by stopping the body breaking down a new clot.

The military remains eager for new medical technology, and Hodgetts says: "We are constantly scanning the horizons. Every year we will re-evaluate what our strategy is for haemorrhage and, if something has changed significantly and there is good evidence, then we will change our strategy," he says.

Nanotechnology may be one possibility for the future. In experiments with animals, Massachusetts Institute of Technology and Hong Kong University researchers have shown that bleeding can be stopped in seconds - far faster than present methods. A liquid made from peptides (protein fragments) is applied to open wounds. The peptides self-assemble into a nanoscale protective barrier gel. This seals the wound, stops the bleeding in less than 15 seconds and eventually breaks down into molecules that cells can use for tissue repair.

Haemorrhage is still a battlefield reality. But technology is making it less lethal.
