An important lesson from treating dismounted IED injuries, Galhotra says, has been immediate prevention of severe blood loss, a point echoed in a study last year in The Journal of Bone & Joint Surgery. British researchers reviewed lessons learned from injuries in Iraq and Afghanistan and noted that the most common cause of death was bleeding out. They described a 2005 protocol change in treating battlefield trauma that prioritized the control of catastrophic hemorrhage over “airway, breathing and circulation,” which had previously taken priority.
“This immediate phase of care used to be relatively neglected as medics and bystanders focused on calling for help and transportation,” Rasmussen says. “However, the military has shown that a certain percentage of patients who have the potential to survive will die if not tended to immediately.” That rapid response includes sitting conscious patients up so they can maintain open airways and breathing, using small needles to release the pressurize around a collapsed lung, use of topical agents and dressings to stop bleeding and, especially, widespread use of tourniquets to step excessive bleeding, such as the Combat Application Tourniquet developed during the wars.
Both the British study and a 2012 study from researchers at Walter Reed National Military Medical Center noted the “universal acceptance and use of tourniquets” as crucial to reducing mortality. According to U.S. army combat medic Caleb Causey, all soldiers are issued tourniquets at deployment, but many U.S. cities’ emergency services are still behind the times in tourniquet use. “First responders and anybody in public safety, whether law enforcement, fire department, or EMS, should have medical direction to use tourniquets and have tourniquets readily available,” says Causey, who now operates Lone Star Medics in Arlington, Texas. “In civilians we’re not usually seeing the same injuries we’re seeing in Iraq and Afghanistan, but bleeding is bleeding, and you’ll lose the whole patient if they bleed out.”
A 2008 study in the Journal of Emergency Medical Services discussed the effective use of tourniquets at Boston Medical Center and in the unofficial guidelines of Boston EMS, although it’s unclear how many first responders had tourniquets on hand during the marathon. Regardless, stopping the bleeding is just the first step in the acute treatment phase.
The next step, Galhotra and other trauma experts note, is rapid amputation and ongoing, thorough cleaning of the wound, including removal of dead, damaged or infected tissue, which is essential to preventing infection, a hallmark of IED injuries because the bombs are often literally dirty. The bomb-makers, he says, will “put anything they can find into the device, such as rusted old bolts, to contaminate the contents of the bomb, and whatever goes off of that gets embedded into tissue, causing long-term risk of infections.” The IEDs in Boston were “six-liter pressure cookers, filled with nails and small ball bearings, like buckshot,” the Boston Globe reported–exactly the kind of dirty bomb ingredients that can lead to additional or higher amputations if an infection spreads. Galhotra says it wasn’t unusual for a soldier to make it all the way back to the U.S. with a below-knee amputation, only to have more amputated because of an infection.
But equally important to these surgical interventions is not overdoing it, once the initial immediate amputations have occurred, at the cost of the patient’s well-being, Rasmussen says. That is where new protocols in damage control surgery have come in. “Damage-control surgery refers to doing just enough to stop hemorrhage, control contamination and reduce fractures with the anticipation of coming back to do further operations when the patient is more stable," Rasmussen says. "If you have a patient under an anesthetic for too long, it can be detrimental, and we realized we were pursuing perfection during 16 to 18 hours of operation at the expense of the patient's overall physiology and well-being." Now, patients receive "abbreviated operating" that allows for better improvement in their overall physiology, with ongoing resuscitation and subsequent operations over several days and weeks. Resuscitation involves replacing the appropriate amounts and types of fluids patients require when they have lost a lot of blood and are in shock. Rasmussen noted another study in JAMA Surgery last year outlining military research into certain medications and ratios of blood components that have benefited civilian trauma care.