Military medicine has historically led the way. Much of what we know about nutrition and exercise comes from the concerns on how to get and keeps troops healthy. The military also led the way in infectious disease control because when you assemble an army the last thing you want is for them to get sick or drop dead from disease. Food safety was a big problem in this nation but only after it became clear that more troops died from food poisoning than combat in the Mexican-American war did the powers that be get around to creating the USDA and clean up the food supply.

A long time ago the standard treatment for wounds was to sear the wounds with boiling 'wound oil'. Imagine walking into an ER and finding hot irons and boiling oil. That was the state of the art. During one battle the number of wounded was so great that they ran out of oil. So the surgeon told the orderlies to clean the wounds with clean water and to apply wet compresses. When he returned the surgeon was surprised to find this treatment was more effective than boiling oil, shocking.

The first X-ray machines were used in the Boer war. Before then they used long metal rods to find slugs and shrapnel. A good number of wounded died from probes puncturing vital organs and the process was often very painful and traumatic.

I used to see a doctor who got his training in Vietnam. He said it changes his life and was the best education available. In normal life, a time before trauma centers, a doctor might only see a major trauma case every year or so. He operated on several a day for a year. He saw and did more in one year than most doctors did in their entire career.

Soldiers also make good study subjects. They are young, healthy and their histories are well documented. When a treatment program is decided upon the treatments are fairly uniform, surgical teams can do the same procedure the same way many times, and patient compliance is high.

Yes, soldiers do get used, to some extent, as guinea pigs. But they both suffer from and benefit from being experimental subjects. For better and worse soldiers which were considered 'basket cases' in earlier times are routinely saved.

10-4 Pete, we're tracking.

The complaining about the effectiveness of tools like HemCon, QuickClot and more usually leaves out the 2 most important factors: context and training.

Context is important because these tools don't reveal their full value with wounds that respond reliably to gauze, direct pressure and tourniquets. Using these advanced tools on such wounds is like using a Cray supercomputer for a boat anchor: it works but performs no better than a hunk of steel. The headlines would read "Billons in computer research funds wasted; Cray anchor no more effective than steel anchors!". It's when that hot little AK47 round sneaks deeply into the groin, too high for a tourniquet, that the hemostatics begin to shine. Sure, you follow it with Kerlix but the hemostatic makes a real difference.

Training is important because if you don't use the tool properly, it doesn't do the job. Early on, soldiers would just dump QuikClot onto the surface of a deep arterial bleed. They wouldn't get it down to the bleeder, and they wouldn't back it up with direct pressure via Kerlix packing and pressure bandages. So the story was "QuikClot a failure!". Wrong.

Bottom line, the article is written by a journalist who doesn't really understand the world he's writing about. Many journalists (especially the activist types) are just louder versions of know-nothing people who want things both ways: full, thorough reviews of new procedures, but have it done yesterday... and for free. They love to gin up suspicion and mistrust. And many adhere to Rahm Emmanuel's advice to "never let a good crisis go to waste".

I spent some time this weekend talking with an 18D instructor and heard from the horse's mouth how the trauma care developed by the military over the last few years has saved many, many lives. And when I say "horse's mouth", I mean a warfighter who was there doing the deed (both delivering and treating trauma), not a disgruntled Army surgeon with wounded pride.

I'm not saying the military is perfect and blameless. But I suspect that if the military followed the review procedure quoted by the author ("The same process at the Department of Veterans Affairs involves up to 19 steps, including multiple reviews by independent committees"), the headline would instead be "Military drags feet on lifesaving procedures, lets soldiers die needlessly!".

What about the authors of the studies that found HemCon no more effective than gauze? Did they not know what they were talking about, either?

What about the study author who rejected a negative result with HemCon as an outlier without disclosing it?

We're not talking about rejecting clotting agents in general, we're talking about the effectiveness of HemCon specifically.

The finding of the HemCon as being no more beneficial than the use of standard gauze does not address if the conditions (trauma wounds) of the test subjects is similar to what is seen with battlefield trauma. It is one thing to lacerate with a scalpel and control hemorrhage of a major artery/vein of a test subject and another to control hemorrhage of a gunshot, shrapnel or traumatic amputation seen on the battlefield.



Having been involved with animal studies for over 32 years, I can tell you it is not uncommon to eliminate certain study animals from the final study for a number of valid reasons. Many animal studies rely upon the common genotype (genetic makeup) and phenotype (the physical characteristics) of a group of animals. For the most part the variables of genotype and phenotype are minimized in mice and rats, where either through genetic selection (in-breeding) or through the use genetic modifying techniques (transgenic, knockout selection, etc.) populations of these species can be highly regulated. Now with larger species, including pigs, there has been some use of genetic modifying techniques, but the genetic and phenotype variation of these species is much greater the with mice and rats.

The elimination of the outlier may have been due to many factors, which may have been legitimate in nature or not, but the article does not cite the reason why the investigator(s) chose to eliminate this animal, so immediately it must be due some nefarious reason.



Whether or not HemCom is a valid medical device or not, is really not the issue. The issue is, if the same parameters of testing medical devices, medicines and techniques before implementation in battlefield conditions can be fairly equated with the evaluation process used in civilian medicine. My humble opinion, and experience is no. Ask a medical instructor, a general practice physician, an emergency medical physician and a field EMT or Paramedic the same questions regarding the effectiveness of a medical device or technique and most likely you will get very different answers. Teaching medicine, medical practice in a hospital and “street” medicine all provide a very different prospective of what works and what doesn’t. All have value in their respective environments.

Medical devices, medicines and techniques will always be evolving as information regarding their effectiveness or lack thereof is gleaned through use. A good example of this in EMS was the use of Military Anti-Shock Trousers (MASTs). When I first became an EMT back in 1978, MASTs were touted as the greatest thing for traumatic shock. Use during the Viet Nam War and subsequent transfer to civilian EMS providers seemed to provide a tool for use in treating traumatic shock. All types of SOPs were established and MASTs became widely distributed in EMS. The idea of MASTs is they would auto-transfuse blood from the lower extremities into the truck and stem both internal and external hemorrhaging of the lower extremities and pelvis. After years of use, the statistical benefit vs. risk factors led to the disuse of MASTs in most situations and many/most jurisdictions have removed them from use. I doubt whether or not a new EMT or Paramedic would even know what a MASTs is or the SOPs for use.

Pete

Correct, but my point is that this is not a case of the journalist not understanding the conditions. We'd be talking about the study authors not understanding the conditions.

But of course, we blame the journalist, rather than blaming the Army doctors who performed the studies in question. And we're doing that without actually seeing the studies in question.



I understand that. But failing to disclose that the outlier was discarded, or to give reasons for doing so, casts doubt on the results.

This doesn't mean the reasons were nefarious, as you put it, but there can be legitimate disagreement as to their validity. Particularly if followup studies give different results.



Well, I guess we agree and disagree.

I agree that the military context is not the same. I agree that the editorial slant adopted in this article, suggesting that the military callously uses soldiers as test subjects, is unfair.

But that is not the issue. The only thing that need concern us, in my view, is whether HemCon is effective -- because whether the US military uses fair evaluation processes is far beyond my control, and frankly, isn't my concern. My concern is what works.

The post I responded to talked about hemostatic agents in general, and mentioned Quick Clot. The article doesn't talk about hemostatic agents in general, or Quick Clot -- it talks about specific agents that have had questionable results.

So while we can quibble about the specifics of the article, the major takeaway lesson -- that we should look to Quick Clot or Celox before HemCon and Wound Stat -- seems to be valid.

(Although frankly, from my reading, I'm not sure any of these belong in your backcountry hiker's first aid kit.)

I would say, it is not so much the investigators not understanding the conditions of the battlefield and perhaps more to do with how research studies in general are designed and how well or poorly they translate into patient care. Animal studies in and of themselves can lead to erroneous conclusions, when the study moves into human field trials or even bedside/battlefield treatment, the positive outcome based upon animal studies does not always come out as anticipated. Humans are much more diverse in their genetic and phenotype makeup, their response to various treatments can vary significantly and occasionally, with disastrous results.



I both agree and disagree. In a perfect world where one can objectively look at data and discount outlying points, disclosing the existence of the outlier point should be disclosed. The problem is the subjective importance placed upon the outlier and the doubt it raises in the validity of the results, which why many types of research discount without disclosure of outlying data points.

Here is an example:

If one were to check the accuracy/precisian of a weapons system, fire 10 rounds at a target and find that 9 of the rounds struck within 1mm of each other, within the center of target and 1 round was outside the target area completely. You could include that round in the analysis and find the average of the 10 rounds to be skewed by that aberrant data point or discount that data point entirely, it is entirely up to you as the one setting the conditions. Researchers can do the same thing; aberrant data points are often discarded least they significantly skew the results.

Not knowing why the 1 pig was discarded, one can only conjecture as to why. The size of the pig itself, the health condition, the induction of the wound (depth, length, location, etc.) or a host of other factors may or may not have had an influence on the elimination of the pig from the study. Non-disclosure does not invalidate the analysis of the remaining study animals.







We may never truly know that answer, since it is almost impossible to objectively analysis success or failure of the product, since each use may have been influenced by the condition of the patient, the ancillary treatments and the prejudices (for or against) of the evaluator. My personal view is to listen to field reports of combat and civilian medics/EMTs, as whether or not they thought there was any benefit of any particular product. Here is why and arguably purely speculative, several studies have shown that asking a medic/EMT to provide a gut instinct assessment, treatment regime and potential outcome of any particular patient was often closer to the actual diagnosis and outcome than adherence to strict protocols. While we might want empirical studies to validate a particular conclusion, gut instinct is often a better indicator of outcome. If one wanted to spend the money and stock one or more blood clotting products, I say go for it. Personally, I think most bleeding can be controlled with standard techniques, but sure as shooting, someone will come along with a story on how only the use of product “X” worked. Depending upon whom that person is and their experience, it may determine my decision on whether or not to purchase a particular product. If Matt and/or a few others on these forums said they used and felt a particular medical product was of value, I would likely be first in line to make a purchase.

Pete

My biggest interest would be how the Baltimore Sun reporters had such indepth investigation into ARMY Medicine. Most reportes cant find a story unless the AP publishes it. Sources or the lack there of are the journlist biggest claim.
But not withstanding Military medicine has been some of the most cutting, pun intened, since the civil war. Okay they may make mistakes but it is science and is self correctiong and learning. I know a lot of the plasma treatments are still in clinical triles and the Army is a major advocate of a lot of them. Why to save lives.
Journalist are not scientist nor very good investigators just rumor mongers

cheers

Actually Andrew, we are talking about the journalist's work and not the medical facts about this product or that product. The thread moved away from a purely medical issue as soon as someone posted "Seriously, it sounds like these wounded service members really were just unwitting guinea pigs", which received a lot of followup.

There are 1,001 threads on the 'net debating the medical efficacy of various hemostatics. But that really wasn't the direction of the thread, and while your interest in the actual effectiveness of HemCon is quite valid, it is also off-topic.

There is one great assumption that I have to question here.

I really wonder if injuries are that much different between the military and the civilian population.
I especially question it when I am looking at industrial accidents.

And before anybody gets jumpy, yes, I know bombs and bullets are terrible things but so are explosions in refineries, flour mills or steam plants, and so are cables bolts and tension rods when they fail.

Edit: I thought Art's comment, "In normal life, a time before trauma centers, a doctor might only see a major trauma case every year or so. He operated on several a day for a year. He saw and did more in one year than most doctors did in their entire career." was worth repeating.

We have developed trauma into a civilian medical specialty now.
We have surgeons who work steady on amputated limbs, or severe burns, or whatever.
Any large city supplies more than enough serious accident cases to keep those specialists busy.
You can add to that the steady stream of shooting, stabbing and beating victims they get to see on a regular basis too.

I would think that what a medic or surgeon sees in combat is rather different from what even busy civilian trauma surgeons and EMS see on a regular basis. At a very high level, an explosion is an explosion and a penetrating wound is a penetrating but that's probably where the similarity ends. First, obviously, the causes of wounds are typically very different. The forces involved with high explosives, weapons versus just accidents, high velocity ammunition, jagged shrapnel versus a smooth blade or prison shank, how often multiple types of injuries occur together, they're all rather different. Then again, many military doctors do get experience at civilian hospitals like County-USC Med Center here in Southern California.

Also, don't forget that it's not just the wound itself that is different. On the battlefield, you are severely constrained as far as supplies and equipment goes, and there may be quite a long delay until definitive medical care can be reached. Actually, that's apparently the main impetus for the combat lifesaver training and the high premium put on developing effective hemostatics, both internal and external. On today's highly dispersed battlefield, the nearest combat medic could be quite far away and the combat lifesaver is supposed to help bridge that gap. And once the medic reaches you, it could still be quite a while until the patient receives definitive medical care, whether due to distance, transportation delays, or just surgical capacity. The Army's doctrine of continuous operations can put huge burdens on surgical resources as the wounded continue to keep flowing in and the most severely wounded continually get triaged to the head of the line.

That said, I've been thinking about this topic for the past week, considering the other comments, and also doing some more reading on the topic. I have softened in my reaction to the article, although I do maintain that these soldiers are still basically guinea pigs since the Army is basically seeing what works as they go, not necessarily having any prior clinical research to build on. For someone trained for civilian research and a strong believer in "evidence based medicine", it's hard not to instinctively cringe at what was in the news article, so my first post reflected that initial gut reaction.

I wouldn't consider this acceptable practice in civilian medicine or even military medicine in peacetime, however, I suppose that the great celestial balance between the Ethics/Patient Welfare and Potential Benefits shifts when these soldiers are already in harm's way--very grave harm. I never doubted that exciting advances could be made this way, but it's hard to instinctively avoid thinking of an "ends justifies the means" argument against such relatively fast and loose development and that is always a danger to look out for.

I agree with Glock-a-Roo that there's been a lot of new developments in combat trauma care very recently, some of which I had heard about but a lot of it totally new to me until I read about them recently. Pretty crazy stuff, actually, particularly for any EMS folks out there. I suspect that the 18D instructor that Glock-a-Roo spoke with could show an EMT or paramedic a lot of new stuff that would be really different. Not just different, but maybe even seem wrong. Like the comeback of frequent tourniquet use. Or low fluid volume resuscitation, including permitting hypotension.

I thought that was pretty wild when I first read about it this weekend. On the battlefield, the medic is limited in how much they can carry, so they don't have bags and bags of IV fluid with them. There is also the problem of delayed transport, so the problem of a clot coming lose and restarting bleeding is a major concern. Low volume resuscitation means less fluid is necessary, and permitting the patient's blood pressure to remain low will minimize the risk of the clot being popped off from a higher blood pressure or vigorous resuscitation. There is a logic to it, but it's quite different from anything that civilian folks are accustomed to since hypotension is generally something to be vigorously corrected. Particularly if a head injury is involved, even brief episodes of hypotension is associated with worse outcomes. Anyway, those are just two new things which go against the grain.

Some of these things may translate into civilian EMS and medicine, but like Pete's example of MAST, some don't. Or, like in the news article, Shock Trauma's research (one of the top civilian trauma centers) that showed no difference between using blood components and whole blood transfusions. But other developments, like hemostatic agents for external bleeding have apparently made the transition, and some things may become wildnerness medicine staples. Only time, and experience, will tell.