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Iraq War 10th Anniversary Highlights EMS Lessons

As the 10th anniversary of the start of the war in Iraq approaches, emergency medicine in the United States has already learned many lessons from the battlefield care of troops wounded in combat there and in Afghanistan.

Dr. Dave Ross is certain that civilians and law enforcement officers who have been shot or hurt in accidents are benefitting.

``The ambulances have been re-equipped with all these things that have gotten popularized in military settings, and trauma systems have long used the military-style approach in handling patients,'' said Ross, medical director to more than 50 emergency medical services and a physician at Penrose-St. Francis Health Services in Colorado Springs.

The first aid kits used by paramedics include a new generation of ratchet-like tourniquets, a piece of equipment that exemplifies how treating combat wounds can influence stateside medicine.

JEMS: Return of Tourniquets (Kalish, MD and Burke, MD)

"First aid training had relegated (tourniquets) to a last resort, to save the patient but trading that for a loss of the limb," said Ken Koyle, former commander of an Army medical evacuation unit in Iraq and a military historian who now works at the National Library of Medicine.

Generations of Americans received first aid training that included winding a handkerchief or cloth around an arm or leg above a severely bleeding wound and tightening it with a stick to stop the flow of blood, loosening it every so often to maintain some circulation.

The practice had fallen into disfavor largely due to concern that cutting off circulation for a protracted period could damage nerves and muscle, requiring amputation.

"Now, the pendulum has swung back with awareness that surgeons can now fix most vascular damage that might occur," Koyle said. The new emergency tourniquets more resemble nylon belts with a built-in winding device simple enough to be applied one-handed.

The military tracked what happened after tourniquets were used on more than 450 wounds in Iraq. It found that 87 percent of the soldiers who got them lived, and none lost a limb from their use. Now, there's even a clamp-like tourniquet approved for use on groin wounds.

JEMS: Civilian EMS Should Consider Tourniquets (Risk, MD, MPH, FACEP and Augustine, MD, FACEP)

"They showed they were not losing limbs left and right, and now tourniquets are showing up on ambulances here in the States,'' said Dr. David Tan, head of the EMS section in the division of emergency medicine at Washington University School of Medicine in St. Louis.

Dr. Howard Mell, EMS director for the Lake Health system of hospitals outside Cleveland and chairman of the EMS Section of the American College of Emergency Physicians, sees the contributions to civilian care from the latest conflicts firsthand.

He noted that improvements in trauma dressings, tourniquets and methods to keep a patient breathing "are actually helping civilians, particularly in mass trauma events. Some were used at the scene of the shootings involving Rep. (Gabrielle) Giffords in Arizona, for instance."

Koyle said the lessons of the wars largely "comes down to polytrauma care -- people who get shot, blown up, suffer multiple injuries.

"When I flew MedEvac missions, if we did our job well, it made the surgeons' jobs that much harder. Soldiers who would once have died on the battlefield are being kept alive. But many of them can only recover to some extent and are being thrust back into society and have to make their way as best they can."



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