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Battlefield Medicine

Proven in combat, blood-clotting agents are finding their way to the kits of first responders.

March 01, 2003  |  by Lois Pilant

Dave Sanders bled to death. Shot twice in the shoulder, the 47-year-old teacher managed to shepherd students from the library at Columbine High School to safety during the 1999 massacre launched by Dylan Klebold and Eric Harris. Shot minutes into the assault, he rushed students into a science classroom where they, in turn, desperately tried to save his life. But when help finally came four hours later, Sanders was dead. Minutes before his death, students took pictures of Sanders’ three children out of his wallet so he could see them one last time.

Experts—-law enforcement, medical, and legal-—still disagree on whether getting to Sanders sooner would have saved his life. Sanders’ family sued and later settled the case against Colorado’s Jefferson County Sheriff’s Department. The JCSD admitted no wrongdoing in the case. However, it did change its policies regarding how it would handle future incidents.

But Sanders didn’t need a policy change or revised operational procedures. What he needed was something to stop the bleeding. His death is illustrative of a fact that medical and military personnel have known for years: 90 percent of people who die in war die before they reach a medical facility. Fifty percent of combat casualties die from bleeding, and most of them die less than 30 minutes after injury.

“Of that, 50 percent to 60 percent die in the first five minutes,” says Lt. Cmdr. Joseph DaCorta, a former Navy field medic who is now a project officer at the U.S. Marine Corps Warfighting Lab in Quantico, Va. “The remaining 30 to 40 percent die from five minutes to 60 minutes. A lot of these are wounds to the extremities, where the vein just lays there and oozes blood. There is not a lot we can do in the belly or with a head wound, but for someone to die of an extremity wound these days is just a tragedy because about half of them could have been controlled. That’s a quarter of the combat deaths that we should be able to do something about.”

The statistics for trauma on the streets of the United States are not much different. If a person can be taken to a Level 1 medical facility or trauma center within minutes of his or her injury, there is a 97 percent chance of survival. It is astonishing that medical science, advanced as it often appears, has yet to address the reasons why people die so quickly before they reach a hospital.

As many medical experts will attest, little is known about prehospital care, which is apparently the redheaded stepchild of medical research. Billions of dollars have been spent on studies and the collection of statistics that detail what happens after patients reach the hospital. Little has been spent on studying what happens before they get there.

One of the results of this neglect of pre-hospital trauma care is that on the streets or on the battlefield, a person has the same chance of bleeding to death today as did a soldier in the Civil War.

Biologics and Devices

Hemostasis, or the ability to stop bleeding, has been called the most significant public health challenge in the 21st century. This is especially true given that motor vehicle injuries cause 1.5 million deaths a year, and that many of these could be prevented if there were a way to staunch a fatal hemorrhage.

Since police officers are routinely the first to arrive on the scene of a car wreck or a gun battle, they need something more effective than a tourniquet or a pressure bandage. And several companies are now competing for that business with hemostats that they claim will stop bleeding in seconds.

Each hemostatic product is remarkably different from its competitors. One has a mineral base, another is derived from algae, another from lava rock, and yet another from the thrombin in cow’s blood. One is granular, one is a powder, another looks like a bandage. All are supposed to work in seconds. But the question is, do they really work? And it’s not easily answered because unlike synthetic drugs that require years of FDA testing prior to approval, the manufacturers of biologics like hemostatic agents don’t have to do extensive research to back up their claims.

Tell it to the Marines

QuikClot, derived from lava rock, absorbs water molecules in blood and facilitates clotting.

For obvious reasons, the Marines have taken great interest in researching the efficacy of hemostatic products. In 2000 the Marine Corps Warfighting Lab undertook a study funded by the Office of Naval Research. The goal was to find a product that worked on the battlefield. The following three products were tested:

Rapid Deployment Hemostat Bandage (RDH) is made by Marine Polymer Technologies in Danvers, Mass., and derived from single-cell algae found in the ocean. For the test, Marine Polymer supplied a 3.5-inch poly-N-acetylglucosamine disk backed by a 4-inch by 4-inch square of gauze. According to the company, the RDH bandage placed on a wound will attract plateaccelerate clotting.

QuikClot, from Z-Medica in Newington, Conn., looks like cat litter, and is a granular zeolite derived from lava rock that absorbs water. When poured into a wound, it absorbs the water molecules in the blood, creating a high platelet concentration to facilitate clotting. It also produces heat, through an exothermic reaction, if the product comes in contact with water. Because of this, the user is instructed to remove all water from the wound area prior to use. The material can later be removed by aspiration or irrigation.

TraumaDEX, manufactured by Minneapolis-based Medafor Inc., is a plant-based material that consists of bioinert microporous particles that dehydrate the blood. TraumaDEX is made from a specific type of potato starch and comes in powder form, and when applied to a wound it promotes clotting by producing a gelling action. It does not have to be removed later because, according to the company, it is absorbed by the body within hours.

The Marine Corps study involved tests on six groups of animals (three control and three experimental). One group received no treatment at all for a complex extremity wound; a second group received the standard treatment of a gauze bandage and pressure to the wound; a third experimental group received standard treatment and aggressive resuscitation with fluids; the fourth group received standard treatment and limited resuscitation (which is the standard type of medical response in this country). The remaining two groups received treatment with the various hemostatic products.

When the RDH was used, the survival rate was 33 percent. When TraumaDEX was used, the survival rate was 67 percent, which duplicated the results from the group that received the standard treatment of pressure and a dressing. When QuikClot was applied to the wound, the survival rate was 100 percent, with a significant reduction in blood loss. According to the study, “The RDH bandage and TraumaDEX, which have shown promising results in less severe models, failed to offer any advantage in our study. QuikClot, a relatively unknown agent, proved to be remarkably effective and significantly improved the short-term outcome.”

The Lab currently is conducting a follow-up test, comparing a reformulated version of QuikClot that does not produce an exothermic reaction; an increased dosage of TraumaDEX from the 10 grams used in the first test to 30 grams; the HemCon Bandage, which is a shrimp-based product that uses chitosan as its active ingredient; Urgent QR, manufactured by Biolife, which is composed of a non-toxic mixture of a hydrophilic polymer and a potassium salt; and a form of bovine thrombin-based material, which has been used for many years to stop bleeding in surgical procedures.

“We started doing these studies because the Marine Corps wanted to re-engineer its individual first-aid kits and the question was, ‘Is there a good hemostatic product out there?’ This is an item we’re going to put in an unskilled, non-medical person’s hand, and we want to be triple darned sure it’s not going to hurt anyone. We also want to find a product that we can put in the hands of trained, medical personnel. We’re looking at new technologies—glues, foams, fibrins, even focused laser ultrasound waves—to stop bleeding,” DaCorta says.

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