Stephen Ginn: Military medicine

Stephen GinnWar may not be good for much, but it has proved to be an effective incubator for innovation. I’m not just talking about the Slinky: the development of nylon, polythene, and aerosol sprays also benefitted from conflict.

The urgency of war has also lead to many of the most important innovations in medicine. It was the battlefield surgeon Ambroise Paré who in the 16th century introduced the ligature of arteries (instead of cauterization) during amputation. An effective treatment for leukaemia emerged from nitrogen mustard’s use as a poisonous gas and Dwight Harken operated on wounded D-Day soldiers and demonstrated that shrapnel could successfully be removed via open surgery to the heart. 

A recent Royal College of Surgeon’s event, “Disability and the military,” discussed medical progress emerging from more recent conflicts. Most notably the chance of surviving an injury during combat is now much improved. During the Second World War wounded soldiers had a one in three chance of dying. Today this figure in Afghanistan is less than one in ten. 

Speaking at the event orthopaedic registrar Major Arul Ramasamy attributes this improvement to a variety of factors. Body armour plays an important role, as have improved helmets and ocular protection. The “continuum of care” is also vital. Treatment now starts the moment an injury is sustained, as all deployed troops are trained in battlefield first aid and carry tourniquets and haemostatic dressings. “We’re bringing some of the stuff that was always left to the hospital out to the battlefield,” said Major Ramasamy. 

The injured are evacuated quickly and soldiers receive medical attention, including blood transfusions, on the evacuation helicopter. On arrival at Camp Bastion the team aim for rapid surgical decision making. “The fastest time I’ve seen from a patient arriving to them being operated on is 45 seconds” said Major Ramasamy. To a psychiatrist like me, even thinking about this sort of speed makes my head swim. 

Soldiers are now living with injuries that five years ago were considered unsurvivable, such as the loss of two or even three limbs. This brings its own challenges and physically surviving such injuries is only the beginning of a long period of recovery. 

David Richmond, an army colonel wounded in Afghanistan, also spoke at the event about his own recovery and that faced by others. The majority of the injured are very young and “under different circumstances they would be in the 6th form at school” he said. “To have your life tipped upside down at that point of your life when you haven’t really worked out who you are in the first place is much more a battle of mind than it is a battle against injury.” 

Much of the provision for long term rehabilitation comes from the charitable sector with the Royal British Legion and Help for Heroes providing facilities such as Tedworth House. Colonel Richmond was keen to stress that injured soldiers are capable of much, including outdoor activities, and that one of the challenges of rehabilitation is persuading them of this. 

It remains to be seen how far the advances in treating battlefield injuries will translate into improved civilian trauma treatment as the advanced continuum of care the military can offer is unlikely to be replicable on civvy street.  Few civilian casualties, for instance, find themselves injured whilst standing next to friend trained in first aid.

Stephen Ginn is the BMJ editorial registrar.

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