One of the most heralded innovations of modern military medicine—hemostatic dressings designed to stop the kind of bleeding that has killed combatants for centuries—has also created an inter-service rivalry, with Army and Navy surgeons at odds over which branch's dressing is saving lives and which might be costing lives.
Every Marine in combat today carries a package of QuikClot, an inorganic, sand-like substance developed by Connecticut-based Z-Medica Corp. with assistance from Navy scientists. Doctors who have poured it into combat wounds say QuikClot can stop bleeding in cases where tourniquets cannot, saving lives from injuries that were often fatal in the past.
Among QuikClot's proponents is Captain Peter M. Rhee, U.S. Navy, director of the Navy Trauma Training Center, who became a devotee three years ago after pouring some into a civilian gunshot victim as a last resort.
"I was sure he was going to bleed to death," Rhee said. "So I ran to my office and got some QuikClot, scrubbed up and poured it in, and that guy walked out of here."
But QuikClot does have its shortcomings, chief among them its tendency to generate heat. The fine granules can also blow around in the wind, or be displaced by spurting blood. One of the earliest field reports from Iraq said Marines experienced difficulty keeping QuikClot inside a wound long enough for it to work.
And so the U.S. Army supports an alternative, called HemCon, developed by a Portland, Oregon, company with help from the Army's Institute of Surgical Research. Made from a shrimp-shell derivative called chitosan, HemCon resembles a foam pad and is pressed onto a wound more like a traditional bandage. Its main supporter is Col. John B. Holcomb, the Army's top trauma advisor.
"It has no known side effects, the performance is amazing in every study we've developed and the reports from people who actually use the product have been positive." said Holcomh. "There's no reason to field an alternative that has known complications."
There is little disagreement within the medical and scientific communities about which dressing stops bleeding the best: QuikClot. Doctors who have used it say QuikClot can form a stable clot even on arterial wounds, apparently by absorbing moisture from the blood and leaving behind a concentration of clotting factors. HemCon's blood-stopping quality is less profound, and doctors who have used it say the dressing seems to work primarily by forming a super-adhesive patch over a wound.
There also is near-unanimity about which dressing is the safest: HemCon, which is no more problematic than gauze. QuikClot. conversely, must be flushed out by surgeons and has been compared to pouring dirt into a wound. And a recent Navy report from Iraq describes a Marine burned by QuikClot who required a skin graft, though the report also credited the material with saving his life.
It is in these debates over safety and efficacy that the Army and Navy disagree the most, almost to the point of absurdity. In nearly identical bench-top laboratory tests, for instance, in which QuikClot was mixed with water. Army researchers recorded temperatures high enough to melt plastic, while researchers working for the Navy recorded temperatures no hotter than a cup of coffee.
The Committee on Tactical Combat Casualty Care, a multi-service panel of doctors and first-responders that writes the military's guidelines for pre-hospital trauma care, promotes a somewhat awkward compromise, recommending the use QuikClot if HemCon fails. The services largely ignore the recommendation, however, since individual soldiers, airmen and Marines are unlikely to carry both dressings.
In the field, many combatants throughout the armed forces seem to have decided that QuikClot's potential for burns is outweighed by its effectiveness. The U.S. Air Force recently chose to field QuikClot after conducting its own studies, and many Army soldiers have reached a similar conclusion. QuikClot introduced a teabag-like product last year called the Advanced Clotting Sponge, in which the granules are applied from inside a gauze-like pouch, and the 101st Airborne has bought more than 14,000 for use in Iraq. The services continue to tout their preferred products, but initial case studies from Iraq suggest both are keeping Americans alive.
"Both products can be lifesaving." Rhee said in a recent e-mail from Ar Ramadi, Iraq, where he was serving as Officer in Charge of a surgical detachment. "In the last three weeks I have seen QuikClot used in a Marine who was injured by an IED, and it was highly effective and possibly life saving. I also used five packages of HemCon on a patient, in and on the liver and all the other wounds. I use both."
Mr. Little is the national correspondent for the Baltimore Sun.