By Carina Storrs
Independent journalist
If the audience wasn't fully awake yet for the Saturday morning session entitled "Lessons of war: Advances in medical science and technique," the pictures of soldiers' blast injuries-one of them extending from the back to the front of a leg-should have captured their attention.
The man showing the pictures, and the first speaker in the session, was Michael S. Weingarten, M.D., M.B.A., F.A.C.S., professor of surgery and chief of vascular surgery at Drexel University College of Medicine in Philadelphia. Weingarten has done two rotations at Landstuhl Regional Medical Center in Germany, where he treated soldiers and civilian contractors injured in Iraq and Afghanistan. The patients arrive in Germany on CCATT (Critical Care Air Transport Team) flights – essentially mobile ICUs in which the soldiers are stabilized.
But Weingarten was sure to point out that "stabilized" does not necessarily mean "stable." He marveled at the fact that patients are flown across continents in this condition, whereas in his civilian hospital back home, he worries about moving a patient downstairs a few flights.
Transporting these "true emergencies"- head injuries and ventilator-required pneumonia to name a couple – is just the way it must be because, as Weingarten said, "the (U.S.) military didn't want big hospitals in Iraq and Afghanistan because they're obviously terrorist targets."
There is a lesson in all of this for trauma care in the U.S. Only about 10 percent of Americans in rural areas live within 45 minutes of a trauma center. And nationwide, hospitals are dealing with surgeon shortages. "The problem will be exacerbated," Weingarten said. By 2015, it is estimated that there will be only 21.6 surgeons per 100,000 people by 2015.
Given these numbers, it seems likely that transporting civilian "true emergencies" – people injured in a car accident for example – will become more common. The current mode of transport is by medevac, rather than CCATT. Weingarten does not expect CCATTs for civilians anytime soon: Flights cost $45,000 an hour, mostly for the medical care, and getting insurance companies to cover that bill would be difficult.
Still, there are strategies for streamlining care that can be adopted in civilian care. One example Weingarten mentioned is the Special Medical Emergency Evacuation Device (SMEED), a metal shelf that fits around a gurney and holds medical devices. Rather than attaching them to the transported patient, as is traditionally done, equipment like ventilators and oxygen cylinders, are attached to the SMEED, making them easier for the medical team to handle.
In addition to transportation, another area of civilian health care that could benefit from advances in military trauma care is diagnosis. In particular, the diagnosis of traumatic brain injury (TBI).
Most injuries and fatalities in Iraq and Afghanistan are due to improvised explosive devices (IEDs) and the blast force they create. (Although Weingarten said that IEDs are now being packed with HIV-tainted needles, he said that there has not been any evidence of HIV transmission through explosions. The virus probably does not survive the blast, though he said it is a very effective terrorism tool.)
D. Kacy Cullen, Ph.D., the second speaker in the session and a research assistant professor at the University of Pennsylvania Center for Brain Injury and Repair, said, "Upwards of 20 percent of all the soldiers rotated through Iraq and Afghanistan may have been exposed to IEDs at levels that would induce mild TBI (mTBI)."
There is a "critical need to measure [mTBIs] at the source," Cullen said. A soldier might notice relatively few symptoms immediately after experiencing an mTBI, then develop cognitive and psychological problems months later. Diagnosis at that point is difficult because there are no markers or imaging tests to detect mTBI.
Cullen and his collaborators are developing a lightweight chip, called a dosimeter, that can be worn in the helmet or uniform of soldiers. It is based on nanomaterial that changes optical properties specifically in response to the frequency and magnitude of blast shock waves, going for example from green to white.
"The best analogy is to a rad badge," which indicates radiation exposure, Cullen said. "It'll never diagnose TBI, it'll just define the population that need a more through workup."
The dosimeter has proved its mettle in lab blast simulations, and is now being tested in rodents.
In response to a question by Pieter Droppert of Biotech Strategy Blog, Cullen said a similar type of dosimeter, but with a different type of nanomaterial, could makes its way into pee wee football helmets.
Also on the horizon for diagnosing TBI, Cullen gave a nod to the work of Robert Siman, also at U Penn. Siman is developing a panel of protein biomarkers for TBI to diagnose and track the progression of the disease. Currently being validated, the panel should be in use in five to 10 years, Cullen said.
Of course not all IED-related injuries are difficult to detect. Many soldiers lose limbs, and despite intense research into making the most seamless prosthetic limb, there is still much room for improvement.
Cullen described work in his research group toward developing a biohybridized neural interface. Unlike electrode-based prosthetics, the system relies on living neural tissue, specifically lab-grown axons, that get connected at one end to the severed nerve endings in the body. At the other end is an electrode array. Although the research is still in the rodent phase, and at least five to 10 years away from human implementation, according to Cullen, it could offer patients who have lost a limb, as well as stroke victims and possibly even victims of neurodegenerative diseases, an easier way to regain function.
Of course many groups are working on improving prosthetics, and Cullen pointed to the "fantastic" work of Todd Kuiken, M.D., Ph.D., in Chicago.
There are a number of resources to learn more about the field of military medicine and health care, and the third speaker, Jay M. Uomoto, Ph.D., interim deputy director of the Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury in the U.S. Department of Veterans Affairs, mentioned some.
For example, Defense and Veterans Brain Injury Center (DVBIC, pronounced "div-bik") provides Department of Defense numbers of TBIs by year and severity of TBI, and gives the guidelines for treating people "in theater" with a concussion or known mTBI.
The Polytrauma System of Care treats US veterans for TBI along with other comorbidities. "By the time they're a vet, there can be some cumulative effects," Uomoto said. He added that depression and chronic pain are often seen in people with TBI, both in civilian and military health care.
Uomoto said he is now working with the DOD on instructions for responding in the line of command. "One distinguishing feature [of collaborations between the VA and DOD] is that we don't wait for symptom report problems before someone must take a knee. If blast occurs within a HUMV, everyone in HUMV must take a knee and only after they are cleared later by medical can they return to duty."
