While the first rule of medicine might be, “Do no harm, ” it is quickly followed in importance by, “Stop the bleeding.” All our fancy 21st-century technology and innovative medical techniques are of no use if the loss of blood cannot be stopped.
Few people understand this better than military physicians who work in combat situations. A 2011 article from the Journal of the American Medical Association stated that “approximately 90 percent of combat-related deaths occur prior to a casualty reaching a medical treatment facility.” So injured soldiers have an excellent chance of survival, provided they can be kept alive until reaching a facility.
The problem is many combat wounds occur in areas of the body where it is extremely difficult to stop the bleeding. This is particularly an issue where the limbs meet the torso, such as the groin, pelvis and armpit. Traditional tourniquets that can be wrapped around arms and legs simply cannot be applied tightly and securely enough in those areas without causing potentially life-threatening pressure damage to the body.
Birmingham resident Dr. John Croushorn knows this all too well. He first began contemplating the issue in 2004 while working as a flight surgeon with the U.S. Army in Iraq during Operation Desert Storm. He said a wounded solider often could be picked up and helicoptered to a medical facility in less than 20 minutes, but that still might not be quickly enough when dealing with an injury to a high-bleed area such as the pelvis.
“There were very few things that medics had in their box to be able to treat those wounds and keep somebody alive long enough to get them to a hospital where they can have surgery, ” Croushorn says. “So we began to work on a solution for this problem.”
The result is the Abdominal Aortic & Junctional Tourniquet (AAJT), which Croushorn developed along with Dr. Richard Schwartz — a Georgia physician who was with a combat unit in Iraq — and now markets through his company Compression Works LLC. The AAJT looks similar to a blood-pressure cuff, cutting off the flow of blood to the aorta before it reaches the wound but doing so without causing damage to the body or internal organs. The device was named one of the top inventions of 2012 by Popular Science.
“(The military is) always trying to create solutions for problems, but they do it from a specific point of view. It’s called requirements-based development, ” says Croushorn, who currently works as an emergency room physician at Princeton Baptist Medical Center. “So it’s not a bunch of scientists coming up with an idea. Instead, we’ll debrief and a medic will say, ‘I couldn’t save him, but if I had something that would do X, I could have.’ OK, let’s go find a way to make X.”
Croushorn and Schwartz literally sketched out the initial idea for the AAJT on dinner napkins while attending a medical conference in 2006. They determined that the key was to create a bladder-shaped device that would apply pressure over a larger area.
“Other types of tourniquets cause more focal pressure and tend to create local injury from the pressure, because the pressure is focused on one spot. Whereas the bladder we use is much larger and distributes the pressure over a larger area, ” says Schwartz, chairman and professor at the Medical College of Georgia in Augusta. “The larger bladder also makes it easier to place it, so you don’t have to have as exact of a placement over the blood vessel that is bleeding.”
The bladder is attached to a belt with a base plate to hold it in place, and the device is strapped around the body near the wound. It is then inflated by hand the way blood-pressure cuffs are inflated. A gauge pops up when the device has reached proper inflation, insuring that it remains tight during changes of altitude pressure (which is important if the injured person is being airlifted to a medical facility). Croushorn says the entire process of attaching and inflating the device takes about 45 seconds.
After nearly five years of research and experimentation — partially funded by the U.S. Department of Defense — Croushorn and Schwartz finally had a design they thought would work. The DoD was so convinced of the device’s life-saving potential that it expedited the approval process with the U.S. Food and Drug Administration.
“We were approved in eight days, ” Croushorn says. “The Army immediately put in their first order, but we didn’t even have a manufacturer yet.”
Production of the AAJT began in May 2012, and by June the device was being sent overseas. Croushorn says a British military unit in Afghanistan was the first to use the AAJT on the battlefield. Croushorn himself used the device twice in 2013 on gunshot victims at Princeton Baptist, successfully stopping bleeding for wounds in the arm and groin.
“We’re just now starting to launch more heavily into the EMS (Emergency Medical Services) market, ” Croushorn says. “This was designed for the military, but there is far more blunt trauma in the civilian world. Bleeding from pelvic fractures is the most common injury in motor vehicular accidents, and those injuries have a significant rate of death. My contention is no one should ever die from a pelvic fracture bleed again.
“So the device has kind of taken on a new life. What started as a solution to battlefield injuries has now evolved into a tool that may fill capability gaps in a number of places. The American Heart Association has studied the device, looking at its ability to increase coronary profusion pressures in CPR, making CPR more effective.
“We think it will also increase the concentration of cardio-effective medications in the heart during resuscitation. It could even help traumatic brain injury patients. Research shows that if the top blood pressure number drops below 90 even once, it triples their chance of dying. So if we put this device on, it can prevent hypotension and a drop in blood pressure.”
Croushorn says he currently is working on another product for the military that applies pressure to the torso to stop bleeding in the liver or kidney. He says manufacturing of that product could begin next year.
“I love the inventive process, ” says Croushorn. “It’s also very satisfying to know we’re creating something that will save lives. The day the Brits used the device the first time, I got a call telling me it had worked. They said, ‘This guy is going to make it. He’ll get to go home to his family.’ That’s why I’m going to keep doing this.”
Cary Estes and Cary Norton are freelance contributors to Business Alabama. Both are based in Birmingham.
Text By cary estes // Photo by cary norton