How civilians have benefited from battlefield medical care

BY JIM HOWE

MANY ADVANCES IN MEDICINE have come from the military, where medical teams seek new ways to help wounded warriors, from the battlefield to the operating room to the research laboratory.

Wartime necessity spurred the expanded use of tourniquets, penicillin and many practices in modern emergency care.

Some of these improvements were outlined by Patrick Basile, MD, in a fall 2018 lecture at Upstate, where he was honored with the Outstanding Young Alumnus award. Basile, a 2003 graduate of Upstate’s College of Medicine, cared for the wounded while serving in the Navy. He took part in the first double arm transplant at Johns Hopkins and also participated in U.S. military missions abroad to repair cleft lips and other deformities. He currently practices plastic and reconstructive surgery in Florida.

Basile worked at what is now called the Walter Reed National Military Medical Center, in Bethesda, Md., the largest military medical center in the world, where he saw many blast injuries from the Iraq War.

Among the innovations he noted:

Today, antibiotics are taken for granted, but less than a century ago, war wounds could easily become infected and deadly.

Penicillin, one of the first antibiotic drugs, existed chiefly in research labs before World War II. A crash Anglo-American program during the war led to wide use of the drug and greatly improved combat survival rates. Sulfa drugs, which also fought infections, were available to the public shortly before WWII but also saw widely expanded use in that war and were even carried into battle in first-aid kits. Penicillin and sulfa drugs have been widely available to the general public since then and are still widely used, although they are less effective today due to drug-resistant bacteria.

These emergency devices cut off circulation to an arm or leg to stop heavy bleeding. They have existed for centuries and been used widely on battlefield injuries since the Civil War. In this century, U.S. military personnel in Afghanistan and Iraq have sometimes gone into the field equipped with loose tourniquets that can be quickly tightened if needed. Tourniquets are generally used “to save a life vs. lose a limb,” Basile says. Tourniquets, which have come into and fallen out of favor over the years, have also seen widespread use in civilian emergency care and surgery.

The name stands for military (or medical) anti-shock trousers – a pressurized garment to stop massive bleeding. “You slip these pants on and increase the pressure, and it shunts the blood to the core and the brain,” Basile says. A pressurized suit based on this principle was used in WWII to prevent blackout in pilots. MAST came into wide use during the Vietnam War, when the garment allowed injured soldiers – who would have likely died otherwise — to survive a helicopter ride to a hospital. Civilian use followed, and although studies have questioned MAST’s value, they are still used in many circumstances.

Ships have been used for evacuating and/or treating the wartime wounded for centuries, with the idea of floating hospitals coming into use on a massive scale during World Wars I and II. Today, the U.S. Navy has two hospital ships, the USNS Mercy for the Pacific Fleet and USNS Comfort for the Atlantic Fleet, which Basile says are “an amazing tool — basically floating trauma centers.” While their primary mission is to provide emergency care for combat forces, they can also go anywhere in the world on short notice and anchor offshore to provide disaster relief or humanitarian work, such as after the 2010 Haitian earthquake. The ships have also undertaken missions to perform surgery on congenital deformities and other problems in countries lacking such resources. Nowadays, there are also non-military, privately run hospital ships that perform charitable work around the world.

Basile describes a sailor with a sciatic nerve damaged by a gunshot wound who was in danger of never walking again. The sciatic nerve runs from each side of the lower spine down to the foot and connects to leg and foot muscles. Surgeons at Walter Reed used a piece of nerve from a cadaver as a graft — like an extension cord — to reconnect the torn nerve. “We got him able to walk at two years, and to run at three years,” he says. Nerve grafts are usually taken from elsewhere on the patient’s own body and are known as autografts. Surgery to implant a specially treated cadaver nerve segment, or allograft, is seeing more widespread use to repair damaged or severed nerves and is an example of the military’s constant study of how to repair traumatic injuries.

“In the Vietnam era, if you had a wounded leg that looked like it couldn’t be salvaged, you got an abovethe-knee amputation,” Basile says. Such amputations make it harder to walk when later fitted with a prosthetic leg than would a below-the-knee amputation. “Now, if the knee joint is intact, we work to preserve the knee joint. That’s something that’s much different now than even in the late 1900s.”

The system of sorting which patients should receive care first originated in Napoleon’s army, evolved and spread, reaching U.S. civilian health care by the early 20th century. Triage, in some form, is widely used in wartime, as well as in emergency rooms and civilian disasters, to evaluate patients quickly, then treat the most serious patients first.

This practice was rare and dangerous for centuries, but advances took place just before and during World War I that greatly expanded its use: identifying blood types; discovering anticoagulants to prevent clotting; and storing blood in advance, rather than doing patient-to-patient transfusions. These practices took years to catch on in civilian medical care, but transfusions continued to improve and greatly reduced battlefield deaths in World War II and since then.

Basile predicts the military will contribute to the field of regenerative medicine. “When you need a kidney or another organ or tissue fixed from a burn or whatever, you’ll be able to harvest your own tissue and grow your own organs and tissue that are specific to you,” he says. “Regenerative medicine, and learning from other animals that can regenerate organs and figuring out how they do it and seeing how we can do it to some degree. Some organs regenerate to some degree on their own. A fetus has an innate ability to heal wounds without a scar in utero that we lose as adults,” he said, noting that researchers are trying to figure out why a fetus can be operated on in the womb and heal without a scar. ●