Col. Shawn C. Nessen (center), commander of the 541st (Airborne) Forward Surgical Team in Afghanistan, works on a patient in the operating room while deployed in support of Operation Enduring Freedom. (Photo by Courtesy of Col. Shawn C. Nessen)
Col. Shawn C. Nessen, a trauma surgeon who served on the battlefields of Iraq in 2003 and Afghanistan from 2006 to 2008, credits three trauma care procedures as being among those responsible for saving the most lives.
All three have to do with hemorrhage control, said Nessen, who is commander of the U.S. Army Institute of Surgical Research, or USAISR, at Joint Base San Antonio-Fort Sam Houston.
Those procedures include greater use of tourniquets, improvements in transfusion therapy and hypothermia prevention.
Early on in the wars in Iraq and Afghanistan, tourniquets were not widely being used for wounds to the extremities, Nessen said.
In 2004, 28 people died of hemorrhage from extremity wounds in Iraq and Afghanistan. Nessen said he believes some would have survived had they had tourniquets applied.
Tourniquets were not used because of the mistaken belief that complications, including the need for amputations, could result from their use, he said. At the time, medics used pressure dressings instead.
In reality, a tourniquet that's on for around two hours won't result in complications or amputations, Nessen said. It takes five or six hours before a tourniquet can do serious damage -- but in those two hours, a tourniquet can save lives.
Once the use of tourniquets became widely accepted in 2004, the number who died from hemorrhage dropped to three in one year, he said.
Also, he noted that improvements in tourniquets in recent years have undoubtedly saved lives.
For instance, a Soldier can apply the Army's "Combat Application Tourniquet" to himself, with just one hand. Additionally, the Army also has available a "junctional tourniquet," which can be applied to the groin, waist, pelvis or armpit.
The military's greater use of tourniquets has had an impact on civilian trauma care as well, Nessen said.
In the aftermath of the Sutherland Springs church shooting in Texas in November, Nessen said that some of the victims that were cared for had tourniquets on and they survived as a result.
In 2003 when he was in Iraq, Nessen said he found that modern methods of blood storage -- the splitting of blood into components such as red blood cells, plasma and platelets -- caused some problems on the battlefield.
Combat support hospitals had the ability to keep frozen plasma and red blood cells on hand in sufficient quantities. But the requirements for storing platelets proved a challenge. As a result, platelets were not always available or were given in a smaller quantity than necessary to enable blood to coagulate.
During his next tour, in Afghanistan, an improved means of cold-storing platelets had been developed. Now, platelets could be stored longer. And when patients in combat zones needed all three components of blood at the same time, all three were available in sufficient amounts. As a result of that advancement, he said, lives were being saved.
Today, blood platelets can be stored for weeks at a time, he said, instead of only a few days.
Trauma patients are very susceptible to hypothermia. Cold weather contributes to coagulopathy, having frequently occurred to wounded Soldiers in the early war years in Afghanistan and Iraq. Nessen explained that coagulopathy means the blood's ability to coagulate is impaired, leading to excessive bleeding.
During Nessen's tour in Afghanistan, he said it got very cold in the eastern mountainous region where he was serving, and coagulopathy was a real issue.
Fortunately, around the 2004, a Hypothermia Prevention Management Kit, developed by the USAISR, began to be issued, he said.
The kit is basically a hat and chemical blanket that wraps around a Soldier. When exposed to air, the chemical is converted to heat, he explained. Use of the kit has kept Soldiers from dying, he said.
IMPORTANCE OF PEOPLE
Nessen said the trauma system starts with the medic, who administers aid at the point of injury.
While the importance of that medic cannot be underestimated, he or she can never replace a surgeon who has years of training to do incredibly difficult procedures, particularly in wounds to the stomach, chest and large blood vessels.
It's vitally important that battlefield trauma centers be fully staffed with surgeons, he added.
Lastly, Nessen said that "at the end of the day, it's like everybody else in the Army. We're only as good as our people. Technology enhances damage control surgery but it doesn't replace us."