This report originally appeared in the December 2009 issue of DOTmed Business News

Tang drink mix was not actually invented for astronauts - it was a bit of savvy marketing to let moms nationwide know that NASA did, in fact, deem it of high enough quality to fly with America's space-bound heroes. Teflon, on the other hand, was used by the U.S. military long before it coated the world's frying pans. It was used by the Manhattan Project to coat valves and seals in the process of enriching uranium to develop the atomic bomb. Much later, due to its exceptional flexibility and bio-compatibility, it was utilized in artificial joint replacements and in grafts used to bypass stenotic arteries in the treatment of peripheral vascular disease.

When ingenuity is applied to cases of urgent necessity, as is so often the case in the field of medicine during periods of war, both hot and cold, inventions flourish that spill over into conventional use, replacing treatments that were less effective and more costly. And frequently solutions emerge that so radically alter the way we look at a problem, that they change the course of medical history.

Fast-Clotting Bandages

Blood loss emerges as the leading killer in war, historically accounting for more than half of all deaths. In just the past decade, strides have been made to lessen the damage in the very midst of the danger. New tools for dressing open flesh wounds have emerged as simple but effective lifesavers. For more than a decade, Col. John Holcomb, head of the Army's Institute of Surgical Research in San Antonio, Texas, has led research on a new type of bandage that first saw use early in the Iraq War. When this bandage, coated with fibrinogen and thrombin, is applied to a wound, the factors combine to form fibrin, the major component of a blood clot. Another bandage, developed at the Oregon Medical Laser Center in Portland, Ore., achieves a similar result by different means. Chitosan (key-toe-san), a substance with varied commercial applications that in its natural state binds the outer shells of shrimp and other crustaceans, when refined, helps to promote the formation of blood clots. When positively charged chitosan molecules are fixed to a bandage, they attract negatively charged red blood cells, causing them to clump together into a solid clot. The HemCon (for "hemorrhage control") bandage works in 90% of cases and stops bleeding in as little as 30 seconds. Since getting fast-track approval from the FDA, the bandage has become not just standard-issue in the armed forces, but since 2006, has also been distributed to civilian medical personnel, including ambulance drivers and emergency room doctors.




While these bandages can save lives on the battlefield and at home, they don't come cheaply. Fibrin bandages cost close to $1000 each. At just $85 each, the chitosan solution seems like a bargain. But there is another fast-clotting technology that costs less than $20 for a 3½-ounce packet. QuikClot was developed by Z-Medica LLC of Wallingford, Conn., and works by activating the natural coagulation cascade, advancing the clotting process at the site of the wound to begin natural healing immediately. The active ingredient in the battle-tested gauze product is kaolin, an inert, non-allergenic substance, that reacts upon contact with water. A slightly different formulation of QuikClot, marketed under the product name QuikClot 1st Response, has become a standby for environmental health and safety teams, industrial nurses, and civilian first-responders everywhere. Z-Medica's kaolin-based Combat Gauze, after extensive comparison-testing of the available products, has succeeded HemCon in use by the military.

Battle-Strength Antibiotics

Severe wounds, including compound fractures and torn muscles, resulting from improvised explosive devices often make the introduction of antibiotics by intravenous injection infeasible. The medical benefits simply can't reach the devastated site because the local vasculature has been destroyed. Osteomyelitis is a bone infection which usually occurs in severe fractures when bone is exposed to open air. It can create an atmosphere for further infection and potentially necessitate amputation. For years, physicians in conventional hospitals have worked to prevent it by packing common bone cement with dosages of standard broad-spectrum antibiotics. The shortcomings of this practice encountered by the military in Iraq were threefold. First, in a conventional hospital, a setting treatment is continuous and constantly monitored, with supplemental antibiotics administered as needed - a luxury not available on the battlefield. Second, while the bacterium Acinetobacter baumannii, a major cause of osteomyelitis, is rare in the United States, it's prevalent in the Middle East. It tends to make the injury more vulnerable to methicillin-resistant Staphylococcus aureus (MRSA), regarded as the most deadly pathogen in the United States. Finally, the bone cement solution is inconsistent, and varies with the practitioner. Mixing and manipulation of the materials in the open air only invites further risk.

A Minnesota company that has become a leader in both medical coatings and drug delivery systems, SurModics, is said to be developing preformed plastic beads layered with antibiotics for use in battlefield hospitals [a company representative declined to comment on the development in conversation with DOTmed news, while trial testing is being deliberated by the FDA]. The beads, infused with specific antibiotics, resemble a pearl necklace, and can be placed inside wounds in the first hours after an injury to slowly release antibiotics into damaged tissues. The 7mm beads purportedly provide up to 72 hours of antibiotic treatment. The SurModics solution is said to eliminate the mixing stage, and standardize the dosing rates for the inserted matrix. SurModics' patented antibiotic beads can be forced into a wound straight from the package, slowing or stopping the spread of infection until the patient can be moved to a more secure operating stage, thereby greatly reducing the number of amputations resulting from infections. If it proves successful on the battlefield, the innovations represented by the SurModics beads may add a new chapter to ER procedures everywhere in the very near future.




A Knee with a Brain

There are times when the best efforts of physicians in the field are not enough to save a limb. That is where the company Otto Bock comes in. The company's work focuses on improving the quality of life for amputees. To do so, it developed the C-Leg Prosthesis System, a replacement limb that puts a microprocessor in the main operating joint to mediate footfall pressure, angle of ascent, speed and balance. The microprocessor feeds back information about the terrain the leg encounters 50 times per minute. The result is a more natural gait and safer, smoother walking and even running. It also enables better coordination between the limbs, so the user can engage in sports and other activities that require syncopated physical movements. This smart limb is going a long way toward getting fallen soldiers literally on their feet. Of course, the technology is likely to be of interest to the civilian population as well.

Not Just New Technologies, New Techniques

At the start of the Iraq war in 2003 a group of eight American neurologists and neurosurgeons took a bold new approach to the emergency treatment of traumatic brain injuries (TBIs) sustained by soldiers in the field. Previous conflicts have shown that fewer than 10% of soldiers survived serious TBIs. Of those, less than 5% were able to resume a life without assistance. The prevalent use of IEDs by the insurgents in Iraq and Afghanistan has made the treatment of TBIs one of military medicine's most daunting challenges. Dr. Rocco Armondo was the commander of the Army's 207th Neurosurgery Team, the team that operated out of the 28th Combat Support Hospital near Fallujah. Dr. Armondo and his team developed a technique whereby they opened the skull to allow for the normal swelling of the brain to fully take its course (thus their macabre sobriquet "Skull Crackers").

They had determined that it was the increased pressure exerted by the traumatized and swollen brain tissue that ultimately resulted in the greatest incidence of coma and the most serious and long-term effects. After opening the skull, balloon stents are strategically administered to keep vessels open that have been constricted by swelling of the tissue, a treatment similar to that performed on stroke victims. After a period of recovery that may last as long as six months, the open skull is fitted with an acrylic plate and closed permanently. Today, the number of severely brain-injured soldiers successfully rescued using these techniques has risen to about 50%, with a third of these soldiers returning to unassisted lifestyles. With almost 1.5 million Americans sustaining TBIs each year, the techniques mastered on the battlefield have migrated into the conventional regimens applied in stateside hospitals. Dr. Armondo, a West Point graduate and Army colonel, serves as director of cerebrovascular surgery and interventional neuroradiology at the Walter Reed Army Medical Center and the Bethesda National Naval Medical Center, and also has a private practice. Among his best-known patients is ABC news reporter Bob Woodruff, who in January of 2006 was injured by an IED in Iraq while reporting on the war. In Lee Woodruff's published account of her husband's catastrophic injury, the reporter's all-but-impossible return not only to normal functioning but to his former profession is largely credited to Dr. Armondo's pioneering techniques.

Preparing for Tomorrow's Battles

Founded in 2002 with a $50 million grant from the federal government, the Institute for Soldier Nanotechnologies at the Massachusetts Institute of Technology is dedicated to a single, powerful mission: To develop and exploit nanotechnology to improve the survival rate of wounded soldiers. Nanotechnology utilizes the advantages of miniaturization, which offers the dual benefits of making the essential tools a soldier must carry on his or her shoulders a negligible burden, yet providing greater accessibility in emergencies; and expanding processing power. For soldiers in war, miniaturization is a necessity, but it takes very little to imagine how, in the luxury of peacetime, miniaturization can enhance ease, efficiency and medical security in everyday settings. For instance, the Institute's overarching project is the development of a nanotechnology-based battle suit. The suit would be extremely lightweight, thin and comfortable, but would be capable of containing communications and health-monitoring circuitry, easing injury, detecting and reacting to chemical and biological agents, and even resisting bullets. Though few of us face such dangers, who wouldn't benefit from "smart clothing" that allows us to speak with others without removing a device from our pocket, dials 911 before we even realize we're having a heart attack or stroke, and uploads our entire medical history when the ambulance arrives, in case we're unable to speak?

To date, none of the Institute's inventions has been deployed to the battlefield, but expect this research to produce ancillary innovations in a variety of areas key to health care and human services. Among the Institute's most promising (and thoroughly developed) projects is the "blood lab on a chip," a fully-portable miniaturized device that can segregate a single drop of bodily fluid, sluice it through numerous divisions 10 microns wide, then pump the resulting samples across different electronic pathways to be tested for the presence of specific molecules, all in the form of a handheld gauge. Innovations like this may keep combat troops alive today, and do the same for whole populations in underdeveloped parts of the world tomorrow.

To date, the wars in Afghanistan and Iraq have taken the lives of over 5280 American soldiers and left at least 32,000 wounded. Though the medical profession needs no further motivation than that knowledge, it can still be heartened to consider that in serving those serving our country, we'll continue to help those most in need in their critical hour, for generations to come.