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Blood Lessons 

A new book by the CEO of VCU Health System explores medical advances discovered on the battlefields of American wars.

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The military has been advancing American medicine since the founding of the country.

The first major leaps happened during the Civil War, when Union Major Jonathan Letterman transformed the Union army’s approach to combat casualty care. In Iraq and Afghanistan, early recognition that American servicemembers were dying on the battlefield from treatable wounds prompted rapid innovations that continued and even accelerated while the wars dragged on.

How the nation’s military healthcare system completely reshaped itself during Operation Enduring Freedom and Operation Iraqi Freedom is the topic of Dr. Art Kellermann’s new book, “Out of the Crucible: How the U.S. Military Transformed Combat Casualty Care in Iraq and Afghanistan” as well as an upcoming talk he’ll give on Thursday, June 9 at the Virginia Museum of History and Culture.

War has frequently driven rapid advances in military medical and surgical care, as evidenced by the Civil War, both world wars, Korea, Vietnam and now OEF and OIF. “In the civilian world, it takes 17 years on average for a new discovery to change medical practice,” explains Kellermann, senior vice president for Virginia Commonwealth University Health Sciences and CEO of VCU Health System. “In contrast, the U.S. military developed, fielded or expanded more than 27 major innovations in little more than a decade.”

Every bloody war produces innovations that eventually make their way to civilian trauma and emergency care. Horse-drawn ambulances came out of the Civil War; WWI led to use of intravenous fluids, blood transfusions and motorized ambulances; WWII produced antibiotics and fixed wing air emergency transport; Korea produced forward-deployed surgeons (MASH units) and helicopter evacuation of casualties; and Vietnam led to widespread use of medical helicopters, blood gas and blood chemistry measurement and designation of civilian trauma centers.

Over the course of Operation Enduring Freedom and Operation Iraqi Freedom, the innovations described in Kellermann’s book enabled America’s military health system to cut the death rate from severe battlefield wounds in half, the lowest level in the history of warfare. Thousands of service members who in earlier wars would have died are alive because of the advances. Tens of thousands more with severe injuries were able to recover substantial function and lead more complete lives as the result of the implementation of rapidly devised new techniques and technologies.

“For most of my career as a civilian ER doc, we believed that the first step in treating trauma patients in shock was to infuse large amounts of sterile saline –essentially salt water– to restore blood pressure,” Kellermann says. “Only when that didn’t work would we start blood transfusions. But we had it all wrong.”

click to enlarge Dr. Art Kellermann, senior vice president for Virginia Commonwealth University Health Sciences and CEO of VCU Health System.
  • Dr. Art Kellermann, senior vice president for Virginia Commonwealth University Health Sciences and CEO of VCU Health System.

During Operation Enduring Freedom and Operation Iraqi Freedom, the military demonstrated that immediate blood administration was a far better strategy. And rather than administering packed red blood cells alone, which was the standard in the U.S. at the time, military doctors began giving balanced amounts of red blood cells and plasma, which contain clotting factors to help the body stop bleeding. When available, platelets were given as well, while the best option of all was freshly donated blood matched to the same blood type as the victim. The concept of balanced resuscitation quickly caught on in U.S. trauma centers and is the standard of care today.

For Kellermann, the most gratifying part of compiling the book was working with the men and women who contributed the personal vignettes scattered through the book.

“Their relentless determination to save as many lives as possible and push past the limits of what was known at the time led to advances that continue to save lives every day and every night across the U.S. and around the world,” he says. “They didn’t go in harm’s way and serve alongside their patients to become rich or famous because even now, few of them are known outside of military circles. They did it out love of country and dedication to their fellow warriors and the families they left behind.”

That the number of discoveries and their rapid adoption by civilian centers reached a new peak with America’s wars in Iraq and Afghanistan was all the motivation Kellermann needed to document what had happened in book form.

“It’s one of the most remarkable achievements in the history of American medicine.”

“Out of the Crucible: How the U.S. Military Transformed Combat Casualty Care in Iraq and Afghanistan” lecture and reception with Dr. Art Kellermann will be held on Thursday, June 9 at 6 p.m. at the Virginia Museum of History and Culture, 428 N. Arthur Ashe Boulevard., Tickets required: virginiahistory.org

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