Faster is Better: The Newest Innovations in Speedy Combat Casualty Care

by Mr. Ramin A. Khalili, U.S. Army Acquisition Support Center

Dr. Elliot Botvinick sits in his office on the campus of the University of California (UC), Irvine, holding a tiny device in the palm of his hand. It is smaller than a garage door opener, smaller than a standard business card even, and is so slight and inconspicuous that he might be able to stick one on a passing student without their noticing.

The Army believes the continuous lactate monitor could play a key role in future battlefield medicine. This prototype features a wearable, subcutaneous microsensor designed to detect critical illness and internal bleeding. Photos courtesy of UC Irvine

It also might be the future of battlefield medicine, according to the U.S. Army.

Minds like Botvinick’s may be exactly what’s needed to conquer approaching combat scenarios that experts predict will look starkly different than the current version, ones where the efficient use of targeted medical knowledge may be the single most important key to victory.

Botvinick’s handheld lactate monitor fits in perfectly then, as it features a wearable, subcutaneous microsensor designed to detect lactic acid levels, which rise in the body during episodes of critical illness and internal bleeding, both of which cause symptoms that aren’t always visible to the naked eye.

“We’re feeling pretty confident,” said Botvinick, a biomedical engineer. But while he is modestly optimistic, the Army expresses its faith in new medical technologies with a bullhorn.

To hasten the monitors’ delivery, the Army is looking to the Combat Casualty Care Research Program (CCCRP) of the U.S. Army Medical Research and Materiel Command (USAMRMC). “Our focus is squarely and specifically on the health and welfare of the warfighter,” said U.S. Air Force Col. Michael Davis, the newly installed CCCRP director.

Botvinick’s lactate monitor satisfies the Army’s desire for smaller, better technologies to operate in combat scenarios that will likely play out in denser, more urban areas, and in which prolonged field medical care will likely be the norm. Lactate is the chemical form of lactic acid that the body produces and uses.

“The vision [for the device] is something like a blister pack that you would peel open in the field and then a medic would just slap it on the body,” says Botvinick. “And in that simple act of slapping, an insertion needle would be guided just under the skin […] and then by pulling back on a sticker or tab, that needle would be removed and just a flexible fiber would remain.”

That tiny fiber would then interrogate the tissue around it, asking how much lactate exists in the area, according to Botvinick. From there, the assembled information would then be transmitted via Bluetooth technology to a wearable unit on the skin.

While measuring lactate is not currently the standard of care in the field (chiefly because current protocol requires blood samples to be drawn and then sent to a lab for study, a logistical nightmare in the field), Botvinick’s sensor measures lactate faster than the lactate level within the body can change, which makes it ideal for the fluidity of long-term transport situations, as well as transportation between levels of care.

This is just one example from a research program rich with potential solutions at UC Irvine, where the conversation grows subdued as it turns to treating burn injuries. While injuries thought to be fatal just a few years ago are no longer considered as such, burns are still complicated by infection and other variables. For Dr. Anthony Durkin, associate professor at the university and the adjoining Beckman Laser Institute and Medical Clinic, relief for burn victims is as much a matter of tissue as it is time.

SFDI surgical camera images show reconstruction skin flaps with normal circulation, upper left, and compromised circulation, upper right. SFDI images enable physicians to make early and accurate assessments of tissue viability for burn and wound management, reconstructive surgery and progressive monitoring of grafts and wound healing.

“Burns are psychologically difficult,” said Durkin, an investigator with the CCCRP’s photonics portfolio. “Someone who has a burn wants to know as soon as possible whether they’re going to need more surgery or not. Plus, the longer you wait to take action, the infection rate goes way up over a few days. The risk of scarring and all the nightmares that go along with scarring go up, too.” According to the current standard of care, it can take up to three days after a burn for laser Doppler imaging to be performed, which determines whether the injured tissue is structurally sound enough to be reconstructed. So Durkin’s team developed the cutting-edge spatial frequency domain imaging (SFDI) camera to assess the reconstructive potential of the tissue involved in burns and other wounds.

A clinician operates an SFDI unit, which is being developed and commercialized by California-based Modulated Imaging Inc. SFDI uses the principles of diffuse optical spectroscopy to determine whether burned tissue is suitable for reconstructive surgery.

The SFDI camera uses diffuse optical spectroscopy to take a snapshot of an affected burn area, with the resulting image providing an almost real-time visual map of parameters such as oxygen saturation, water content and total hemoglobin for each pixel. Clinicians can then evaluate tissue viability in wounded areas and determine whether that tissue is a suitable candidate for reconstructive surgery, all within just a few hours. “We think we can buy a couple of days that can dramatically decrease the risk of scars and infection,” Durkin said.

In addition to being a noninvasive technology, the SFDI can differentiate between superficial partial thickness burns and deep partial thickness burns, a relatively muddy area of wound designation within the medical community, according to Durkin. The SFDI, which is being developed and commercialized by California-based Modulated Imaging Inc., recently received a grant to perform a tissue viability analysis in a variety of wounds relevant to the military. As a result, Durkin’s team has received FDA approval for its technology for research purposes and began efforts to secure FDA clearance for a miniature version of the same device at the end of 2017.

The fruits of the CCCRP’s military medical mission often translate to the civilian world, and the lactate monitor is no exception. “The diabetes community has caught on to what I’m doing,” ­Botvinick said, “and they’re very interested in knowing if lactate can help them safely control sugar and exercise routines in diabetes patients.”

For as much effort and investment goes into the CCCRP’s litany of products and projects, so many of those same efforts—tourniquets, a balloon-tipped catheter that stops bleeding known as the REBOA and many knowledge products—have gone on to improve and save the lives of countless American citizens.

While that is not the stated priority of the CCCRP and its associated technologies, it is a substantial benefit to the taxpaying public. After all, if a resilient military can help develop a resilient population which, in turn, continues to fuel an even more resilient military—that’s the very definition of achievement.