Speaker 1: You are listening to Your Practice Made Perfect, support, protection and advice for practicing medical professionals. Brought to you by SVMIC.

J. Baugh: Hello everyone, and welcome to this week's episode of Your Practice Made Perfect. My name is J. Baugh and I'll be your host for this episode. Today, we're going to continue our discussion about military medicine with Dr. Melissa Givens. Dr Givens, welcome to the show.

Dr. Givens: Thank you very much. It's a pleasure to be here. Excited to talk about this topic.

J. Baugh: It's good to have you here today. Before we get started, could you give us a brief summary of your background in military medicine?

Dr. Givens: Sure. I'm currently a colonel in the United States Army. I would say I'm a product 100% of education by Uncle Sam. I'm a Military Academy graduate and then I went to the Uniformed Services University of the Health Sciences, which is the Department of Defense's military medical school, and I'm emergency medicine board certified and then also sub-specialty trained in toxicology and sports medicine. And I've been kind of all over the place in my military career. I've done some academic stuff as a residency director, I've deployed in combat zones and into non-combat zones for kind of NGO type work, and also just been a straight clinician with a couple different specialties. So kind of have had a myriad of experiences within the military. So I really love to talk about it because it's been good to me and it's nice to share our story.

J. Baugh: Well, that's great. We're really looking forward to our discussion today. Before we get started, I would like to remind our listeners that this is Part Two of a two-part series. You may want to go ahead and listen to Part One, and then you can come back and listen to the rest of this podcast. So, having said that, we'll just dive right into this week's topic. So Doctor Givens, what prehospital innovations have evolved during war time that will influence civilian prehospital care?

Dr. Givens: Well, I think there's actually several. I'm gonna hit on a couple, and I'm going to stay kind of in my lane of emergency medicine. There's many things that fall inside some other specialty lanes, but I'm going to kind of stick with what I know and know well, and so we're going to talk about tactical emergency casualty care and some prehospital resuscitation and prehospital pain management. The first one that has really been probably the most remarkable thing that's come out of the conflicts that have been going on for greater than 15 years now, is the concept of tactical combat casualty care. We call it T-Triple C. This is a process that gives anybody responding to a casualty an algorithm to go through that will address interventions that can actually save a life in an order of what the most likely life threatening injury is.

We looked at a lot of wartime data and realized people are dying for a couple of reasons. They're dying because they bled to death or they're dying because they were having some sort of airway or ventilation issue. And so T-Triple C was developed as a process, much like ATLS or our CPR algorithms to say, hey, this is what you need to do first, second, third and fourth to address the most likely things. T-Triple C has now been translated into a civilian algorithm that's called Tactical Emergency Casualty Care and it's being used by EMS services, by tactical SWAT teams, right at the point of injury where they're engaging, and then we're actually kind of teaching it across the board for anybody that responds to somebody with some sort of traumatic event, because it really kind of keeps you focused and in line for that.

So, I think that's probably the biggest win. We were able to show that out of preventable deaths on the battlefield, we could reduce them almost to zero when this is fully applied as it's intended. So that's really amazing when you're looking at, we had battlefield deaths that were upwards of 25 to 30% with preventable injuries, to take that down to almost zero. It's really a success story when it comes to teaching an algorithm approach to patient care.

J. Baugh: Yeah. That really is an amazing statistic.

Dr. Givens: It is. So that was done by the Ranger Regiment, which, if you've ever met a U.S. Military Ranger, they're very driven by, hey, I'm going to do exactly as I'm told when I'm told to do it. Very by the rule book kind of folks, and smart too. And so when applied with support from leadership and good training, they were able to take their preventable deaths down to zero. So just an amazing success story. Two, that's one of kind-of the big ways that we've influenced prehospital care. The other thing has been we've really been pushing the envelope for resuscitation products forward at the hospital. Just this year we did our first walking transfusion right at the point of injury, to folks that were ... Right where somebody got shot or blown up, we're able to draw blood off another person type and cross it appropriately and then transfuse it into that casualty right there on the scene so that they were resuscitated before even getting in the helicopter to go back to the hospital.

This has been an evolution. When I first deployed over 10 years ago, we were still in that kind of mindset of give two liters of crystalloid and then some packed red cells and then maybe something else, so folks weren't getting resuscitated until far into their course in the emergency department, and now we're putting blood out with our medics that are way forward of the hospital, to be able to resuscitate injuries outside of the hospital setting. Now will that directly translate into the civilian world? Probably not in places where you can quickly get to a hospital where there's blood products, but in remote areas it might be reasonable to have some sort of blood products that can be pushed forward to these areas. The other one that we've really had success with is freeze-dried plasma. We did an investigational new drug protocol because freeze-dried plasma isn't available in the U.S. and you use French freeze-dried plasma and forward deployed it into the Middle East and we're able to use it as a resuscitation alternative.

The beauty of this is, it doesn't need to be refrigerated. You don't have to type and cross for it and it just provides better outcomes than just resuscitation with crystalloid in that far forward setting. It's just kind of been remarkable to see that evolution of where we've come in 10 years and knowing how to get the right product on board for the patient as close to their time getting injured as possible. And then the other one I want to touch on is just prehospital pain management, which has been really aggressive at getting after managing injured people's pain because we know that their initial pain experience can play into their lifelong feelings of pain, like whether or not they might become addicted to opiates or they might have some PTSD or things like that. So getting after the pain problem way far forward has been important, but you also have to recognize that pain meds can be risky. So trying to find safe alternatives.

So we've really kind of pioneered prehospital use of Ketamine, putting it in the hands of our medics, training them safely for that. And then one of the other ones that we came up with that came out of the cancer world was Fentanyl lollipops. This wasn't something typically used in an emergency setting for pain, but we could take those lollipops, tape them to the finger of an injured person, put them in their mouth, and when they got too sedated from the medication, a lollipop would fall out of their mouth and it would eliminate their chance of overdosing or being too sedated. So it was really kind of this ingenious thing that actually some really good friends of mine came up with when they were in some really, really hostile situations. And we're like, how are we going to make this work? Don't have enough hands to do everything, but really kind of get after that. Wow, I can control pain far forward of the hospital in a very safe manner. So, those are just some examples. There's a lot more, but those are the big ones.

J. Baugh: Now, I'm pretty sure that when we started today I didn't think I would hear the phrase "Fentanyl lollipop." But that's a pretty interesting innovation that you have, and I like hearing the stories about ways that we can get medical care and medical services and products to patients as quickly as possible. Very interesting information there. Let me ask you this question. What are some of the specific technological advances that have been gained by the military?

Dr. Givens: Again, I'm going to kind-of focus on the prehospital in emergency setting, but wow, there's just been amazing advances in things, and I'll touch on things like prosthetics and robotics and all those kind of things that are way outside of my lane as an emergency medicine physician. The things that I'm really passionate about have truly impacted my life in the civilian ERs back here, when I show up for work at a civilian hospital. There's some things that we now use that didn't exist 15 years ago. One of those is hemostatic dressings.

Normally when there's a wound that's bleeding, you put a bandage on it and you hope it stops bleeding. Well, that's not always the case in some of these wounds. And so the military invested in technology in which they embedded these dressings with different age limits that will facilitate the clotting process. Whether it be a kaolin or there's some chitosan based products, but embedded these dressings so that when we used them to pack the wound, they would facilitate the clotting process and they'll stop bleeding. And I have to say as somebody that's worked in a civilian ER, there's so many times where you have people on anticoagulants that's really challenging to control their bleeding with wounds that these can be really, really helpful.

The other kind of ... And this is what I call low-tech technology advancement, tourniquets. Tourniquets are something that I was always trained when I was young physician are horrible, you should never put one on somebody, but we showed during the wars that tourniquets save lives and can be used safely. But now what we've done is there's a Stop the Bleed campaign that's been led up here out of DC and is a nationwide campaign to teach laypeople how to use tourniquets. And so, we've evolved these tourniquets to be so user friendly for somebody that's never seen one before. So literally making them color coded so that you can pick one up and figure out while somebody is bleeding to death, okay, I can get this on and get it done right. Because we've kind of worked through having a lot of untrained people put these tourniquets on, hey, this is how you can do it to make it easy and to do it safely and effectively.

So that's another big win. Bolster the knowledge about tourniquets, but then being able to put it in the hands of non-medical people so it can save lives where injury is occurring. And then some of the other ones, they're a little less sexy, but they're really important. We're always in the military trying to figure out how to take products and make them lighter and easier to use and more durable and be able to take them in the middle of nowhere and have them function without some of the niceties of being inside a hospital building. And we've really kind of made it the ancillary equipment across the board and making it incredibly useful in austere environments. And so, for our civilian colleagues out there that might be doing search and rescue in ski areas or hiking areas, or for EMS crews that have to go into very rural, remote areas, the ability for them to have products that are packaged appropriately that will survive in the environment and be easy to pack in and pack out, it's just a great advance.

I love my equipment now. You're often frustrated with it as you work outside a hospital environment, but we've really gotten to the point where we've evolved equipment to suit our specific needs outside of the hospital. Again, like I said, those are all kind of within that emergency medicine lane, but I think there's a lot of applications for that within the civilian hospital system.

J. Baugh: I know that in both parts of this podcast we've talked about how military medicine would affect civilian medicine and vice versa, but I hadn't thought about the fact that the advances that are being made in military medicine could also be helpful for people who are not trained in the medical field, to be able to use these basic medical devices that you're talking about in a way that would be easy for a layperson to understand. So, there's more than just the synergies between medical medicine and civilian medicine, but you also have the effects of medicine on those who are not trained to practice medicine. That's very interesting.

Dr. Givens: Yeah. We're a living laboratory of untrained medical people that are forced to care for patients, because there's obviously not doctors and nurses and medics right there where these people are getting shot and blown up. And so it's their friends and their coworkers who are responding to them. And I think that translates into some of the things we've learned in some of the horrific events that have gone here in the U.S., whether it's been shootings or accidents or whatever, it takes a while for a medical to respond. And so, having an educated public with equipment that's appropriate to their level of ability to apply those interventions is really a big win.

J. Baugh: Absolutely. So, what has the military learned about medication and resuscitation of severely injured patients that can influence civilian trauma care?

Dr. Givens: Well, I really think we've become masters at resuscitation of severely injured patients. The catastrophic type injury that we see in wartime isn't always reproduced in civilian care, but we can take some of those lessons and apply them to the trauma patients that are severely injured or even some of the other medical patients that might have massive volume loss due to bleeding, whether it be a GI bleed or something similar as that. We've learned how do we restore volume in these patients in an effective way that influences outcomes? And it's really been an evolution. And like I mentioned earlier, I was initially trained, you know, anybody that's bleeding gets two liters of crystalloid, and then after that they get some packed cells, and then after that start considering maybe some platelets. And that was what I knew the day I stepped on a plane to go to war in Iraq, and I can tell you the day I arrived in Iraq, somebody told me, "No, you don't give any IV fluid, you give blood products."

And I gave more blood products in my year deployment than I have in my entire career, 20 years of practicing emergency medicine here in the United States. So, we really pushed to get blood product on board because we recognized that's what was saving people's lives. Giving them this fluid made them hypothermic. It made them coagulopathic. And they were dying in the ICU despite having their injuries addressed surgically, they just were not resuscitated appropriately. So we worked with the products we had. We started out with packed cells and then we kind of figured out, hey, fresh whole blood is better if we can get it, that's even better.

Now we're kind of doing a mix of packed red cells with plasma and with platelets with a very aggressive mix of almost one-to-one of those. If we can get fresh whole blood, we'll use it. We have in many circumstances we'll use cold whole blood and then warm it onsite, and so we've developed warmers that can be used outside of the hospital system so you can infuse blood on a patient that's not in the hospital, which that's quite a tricky thing to do, and we've perfected that system. So all of these things could influence patient outcomes in civilian circumstances where a patient might not be able to be transported to a hospital. There's been a couple studies that have come out, I'll just mention one that probably proved it in the civilian model, it was the Prompt study that was published in 2013, and it looked at balanced resuscitation giving red blood cells with plasma and platelets early on for patients that required more than three units in the first 24 hours. And it was able to show a significant reduction in mortality in civilian trauma patients. So we kind of said, yeah, hey it does translate across the board. TXA, so Tranexamic Acid is an old, old drug that's been around for a long time, but I never learned about it in training. We started using it in the military and were able to publish in the Matters trial that it significantly reduced mortality in patients who had hemorrhagic blood loss. And so it's become part of that T-Triple C protocol that we were talking about earlier. We're giving that TXA very early in the injury process, teaching our medics to give it so they're able to give it prehospital, and it has significantly reduced mortality in severely injured patients. These findings have been reproduced in civilian trials. There was a crash trial is what it was called, so there's both crash one and two that showed that early use of TXA influences outcomes in patients with volume loss due to hemorrhage. And so, like I said, it's an old drug, but it's a good drug in these settings and I'm glad that somebody thought of it and brought it off the shelf.

So, those are the big money winners, but there's so many other things. Like I said, lots of things that are outside the emergency medicine scope in terms of pain care in ICUs and post surgically when we're talking about prosthetics and recovery for service members, but I really kind-of wanted to highlight the ones that I'm intimately familiar with and can speak about.

J. Baugh: Well, Dr. Givens, that's very interesting information that you've given to us today, and very fascinating advancements in military medicine that will affect so many people for years to come. As we wrap things up today, do you have any final thoughts or comments that you'd like to make?

Dr. Givens: I always say this. I have to thank my colleagues and I always give a shout out to my medics, too. And I think this applies to the prehospital folks out there, anybody that's trying to medicine forward of a hospital is really doing a hard job. They're trying to do what most of us do inside a hospital and do it to a quality that we provide inside of hospitals. So I always have to give that shout out to my medics. They do wonderful work. But I think the message I want to leave with is there are so many lessons learned in the military that we could share with the civilian community, but we definitely depend on the civilian community to be a resource for us because we sometimes have deterioration of some skills that we might not see as much in wartime. And so we need to reach the civilian community to balance out our knowledge base and our skill set. So those partnerships are critically important, so that we all can become better providers in whatever our environment is.

And so I really appreciate an opportunity like this to speak about it because then folks are kind of aware, hey, there's this great relationship that can be had out there between the military medical community and the civilian medical community, and talks like this just give a chance to open those doors.

J. Baugh: Dr. Givens, we want to thank you, not only for your service to our country, but we also want to thank you for spending the time that you spent with us today to get us up to speed on all the advancements going on in military medicine. Thank you very much.

Dr. Givens: Thank you. I really appreciate the opportunity.

Speaker 1: Thank you for listening to this episode of Your Practice Made Perfect with your host J. Baugh. Listen to more episodes, subscribe to the podcast, and find show notes at SVMIC.com/podcast. 


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