|Doctor Louis-Philippe Palerme, right, from Gatineau, Quebec, is getting assistance from a Danish doctor, Captain Sacha Soelbeck, during a surgery at the Role 3 Multinational Medical Unit in Afghanistan. (Sgt. Paz Quille / Department of National Defence)|
"Tourniquets were once completely out of style, absolutely," he says.
One of the arguments against their use was that when tourniquets are tightened around a damaged limb, they cause tissue below to die. So doctors and hospitals discouraged their use. But Tien says battlefield surgery is very different from surgery in a city, where many of the decisions on such things are often made.
"Battlefield injuries are usually not puncture wounds, like the gunshot wounds and stabbings you'd see in a city," he says.
The wait for medical help is also not nearly as long in the city as it might be for a soldier injured in a hard-to-reach outpost in Afghanistan. And in the case of a limb amputation from an IED, the biggest worry is that the soldier will bleed to death while he waits for medical help.
So in recent years, there's been a revival of tourniquets.
"They made a comeback for Canadians around 2004-2005. And by the time we got to Kandahar [in 2006], it was part of the kit we gave to medics," Tien says.
Today's tourniquets are not what they once were. Now, they look like short belts made of nylon webbing that can be wrapped around a limb and tightened off with one hand. Every soldier is issued one and instructed on how to use them as part of their pre-deployment training. Soldiers report that some comrades even strap their tourniquets on each leg every morning before setting out on a patrol, just in case.
Tien calls tourniquets "a 90 per cent solution to the bleeding issues that come up in the field." But in cases where a tourniquet won't help, such as an abdominal wound or shoulder injury, other new and effective tools called "hemostatic agents" are being put to use.
Hemostatic agents limit blood loss
One of them is called QuikClot. It was originally a powder that every soldier carried in their packs. The powder was made of a mineral called zeolite that was poured directly on wounds to stop bleeding. While it was effective in stopping bleeding, it created a great deal of heat and often caused chemical burns that made repairing the wound more difficult. So it was discontinued.
QuikClot's manufacturer then switched approaches and created a gauze containing kaolin, a mineral found in clay. Kaolin activates a key clotting factor in the blood, allowing blood under the gauze to clot and block off broken vessels.
The gauze is now part of the kit carried by Canadian medics, as are HemCon bandages, a kind of bandage that works much the same way as QuikClot.
HemCon bandages actually made from crushed shrimp and crab shells. The shells contain chitin, which attracts the blood's platelets and red blood cells and causes them to form a gel-like clot that seals a bleeding vessel.
The bandages and gauze offer medics one more tool to minimize blood loss when a tourniquet won't work. They're also being tested for use in civilian hospital settings and among first responders, such as paramedics. The manufacturers of both products are marketing their products to consumers as well, though it seems just through their websites for now.
More intense training for soldiers, medics
Training on how to use hemostatic agents is just one component of a new type of first aid training that all soldiers now undergo, called "tactical combat casualty care." Tien says TCCC is another development that is having a big impact on saving lives in the field, by ensuring that more injured soldier and civilians make it to the hospital quickly.
The Canadian military adopted TCCC after the devastating "friendly fire" incident in 2002, in which four Canadian soldiers died. All Canadian combat soldiers now undergo two weeks of TCCC training that focuses on teaching them how to suppress enemy action first, so that they can quickly evacuate injured comrades.
Once they can tend to the wounded, the soldiers put to use their training on how to stop bleeding quickly, when to use tourniquets and when not to, and how to quickly treat collapsed lungs.
Tien says another key advancement he's witnessed in the field in Afghanistan is the better training of medics, who are a critical link in treating injured soldiers and civilians.
"I was in Yugoslavia in the mid-90s and the way we train our medics is just completely different. They're so much better prepared now," he says.
Medics are now trained to deal with multiple traumas, even while still under fire, tending to multiple patients at once if needed. They, too, focus on quickly stopping bleeding and stabilizing the injured to prepare them for evacuations.
While these small changes to first aid approaches may seem modest, they can make a big difference, since 90 per cent of soldier deaths occur in the field and the most common reason for trauma deaths in war is massive blood loss.