For over a century, one in five wounded soldiers has died from battlefield wounds, and half of the deaths are related to excessive bleeding. Now, doctors in the Iraq war are hoping to reduce this death rate by applying a number of new innovations.

While some of the measures are inexpensive, such as adding pressure bandages to first-aid kits, others are costly, such as an anti-clotting drug for internal bleeding that costs about $7,000 per dose. Other measures, like sending redesigned surgical teams to the front lines, involve equipment that has not been available in the past.

When these new surgery units were tested in Afghanistan, they reduced the death rate of soldiers who survived long enough to receive surgery, known as the died-of-wounds rate, from two percent, where it has remained for the last 50 years, to a fraction of a percent.

In the past, wounded soldiers received medical care from medics but could not receive surgical care until they were transported to a larger hospital.

Now, mobile surgical teams are available at the battlefield site. They perform operations to stabilize the most severely wounded soldiers until they can be evacuated to a larger hospital. Soldiers with the most severe injuries are taken care of first, regardless of whose side they are on, and many of the patients treated in the Iraq war have been Iraqis.

Each branch of service decides which innovations it will adopt. The Marines Corps, for instance, has added QuikClot, a product to help prevent soldiers from bleeding to death, to their first-aid kits.

QuikClot, made from the mineral zeolite, works by absorbing water from the blood. When the product, which resembles cat litter, is sprinkled on a wound, it speeds up the formation of a clot.

Researchers tested QuikClot on 36 Yorkshire swine and found that wounds that would have been fatal were converted into nonfatal wounds 100 percent of the time.

However, other branches of the military remain skeptical about whether to use the product and at what dose. Heat is generated when QuikClot is put on a wound, and some are concerned that it could burn tissue. Additionally, soldiers must be taught how to use the product and surgeons have to know what to expect from its use.

Other branches, including the Army, are using coated bandages to promote clotting and stop bleeding. One bandage uses the clotting proteins fibrin and thrombin to speed clotting, while another uses chitosan, a protein in shrimp shells that promotes clotting.

For internal bleeding, which can result from injuries to the abdomen and pelvis, or bleeding in the brain from a head injury, the Army is considering using an intravenous clotting drug. They hope to conduct a clinical trial of clotting drug VIIa, which is used to treat hemophilia.

The purpose of the new products aimed at blood clotting is to keep wounded soldiers alive long enough to see a surgeon, according to military medical experts, and are part of a method, known as damage control.

The method involves controlling bleeding with the least surgery possible and stabilizing the patient. The major surgery can then be conducted later, even two or three days later. According to a study, 75 percent of patients survived with the damage control method, while nearly every patient died using traditional surgery. After being refined for a decade, the method yields a 90 percent survival rate, according to investigators.

Damage control is particularly useful on the battlefield, where patients can be stabilized in portable operating rooms and then taken to hospitals for other surgeries days later. To coordinate this effort, the military had to put surgeons on the frontlines and make changes to the previously bulky equipment.

Frontline surgeons can now carry the equipment they need in a backpack. They have sonogram machines that are no bigger than cassette recorders and devices the size of a PDA that provide laboratory analysis from a drop of blood.

Military surgeons and support staff are also being trained at urban trauma centers. They work along with the civil staff to complete the training regimen, which has been cut down from a month to 10 days because of the war.

According to investigators, the damage control method tested in Afghanistan yielded the lowest died-of-wounds rate in the history of war. Out of 250 seriously injured patients, only one death occurred.

New York Times March 30, 2003