Dec

5

2021

Talking About Blood: Perspectives From the Battlefield

By Helen Osborne

John Bradley Holcomb received his M.D. from the University of Arkansas Medical School in 1985. John entered the U.S. Army in 1985 and completed his general surgery training in 1991. Dr. Holcomb then deployed with the Joint Special Operations Command for the next decade. From 2002 to 2008, Colonel Holcomb was the Commander of the U.S. Army Institute of Surgical Research and Trauma Consultant for the Army Surgeon General. Over the years, he has deployed in multiple combat deployments. He is a three-time recipient of the Army’s Greatest Invention award. COL Holcomb retired from active duty in 2008 and received the Lifetime Achievement Award in Trauma Resuscitation Science from the American Heart Association, the United States Special Operations Command Medal, and the Service award from the American College of Surgery. He has been a member of the Committee on Tactical Combat Casualty Care since 2001. From 2008-2019 Dr. Holcomb worked at UT Health, Houston, as a Professor of Surgery. In 2016, he received the Major Jonathan Letterman Medical Excellence Award from the National Museum of Civil War Medicine. In 2019, he joined the University of Alabama, Birmingham, as a Professor of Surgery. Dr. Holcomb is actively involved in clinical medicine, education, research, entrepreneurship and is a founder of a health IT company. He reviews papers for more than 35 journals, has published over 600 peer reviewed articles and serves on multiple boards.

From New York Times cover story on Holcomb. Caption: CRITICAL CARE Col. John Holcomb, a top trauma surgeon in the Army. Credit: Erich Schlegel for The New York Times.

In this podcast, John Holcomb talks with Helen Osborne about:

  • Experience as a trauma surgeon in the Iraq war
  • The history of fluid resuscitation
  • The importance of blood donation

Music by Skilsel from Pixabay.

Producer and audio editor: James Aird

Transcript:

HELEN: Welcome to talking about blood. I’m Helen Osborne, host of this podcast series and a member of the advisory board for The Blood Project. I also produce and host my own podcast series, Health Literacy Out Loud.” Today, I’m talking with Dr. John Holcomb, who is Professor of Surgery at the university of Alabama. He was a much decorated colonel in the U. S. army working for many years as a trauma surgeon in Iraq and other conflict areas. Building on his experience and battlefield trauma and resuscitation, Dr. Holcomb now is actively involved in clinical medicine, education, research entrepreneurship and health IT. Welcome to Talking about Blood. 

JOHN: Helen, thank you very much. Good morning.  

HELEN: Good morning. So, I am sure our listeners of this podcast, who include trainees or those who want to become doctors, those who are practicing physicians and others on medical teams and also people just interested in all aspects of blood. I’m sure we all, as I do, want to know a little more about the experiences – some of your experiences – as a trauma surgeon on the battlefield. I’m hoping we can also talk about what are some lessons that you’ve learned from those experiences and how that applies to medical care in the civilian world. 

JOHN: Yep, I’m looking for looking forward to it. 

HELEN: Okay, taking it from the start. Give us a picture of what it is like as the trauma surgeon on the battlefield. 

JOHN: You know, a lot of the time, Helen, it’s boring – there’s nothing going on. Which of course is fabulous, right? Because nobody’s getting hurt. So, interspersed, then, with times of I wouldn’t say chaos but lots of activity and the team working really well together, focused on saving lives and usually multiple lives at the same time. Doctors, nurses and medics all working together as a team. 

HELEN: You know, it’s really interesting that you say it’s really boring because all I know is what I’ve seen on the news and all the news it’s not boring at all. 

JOHN: Yeah, you know, of course the news only shows that exciting part, and the drama part because that makes good news. If you talk to folks and we have now deployed literally millions of Americans to the battlefield in this war, there are periods, long periods of time with nothing going on, and I would reiterate: that’s a really good thing because nobody’s getting hurt 

HELEN: Of course, of course but when something is going on, it is profound and a matter truly of life and death. Can you explain from your perspective as a surgeon in this situation when an incident happens – not even sure I have the right word if “incident” is the right word – but when something happens and all of a sudden there’s one or more patients with you, what’s it like as a trauma surgeon and specifically what are the aspects about blood because that’s what we’re talking about is about the blood part? 

JOHN: You know, the casualty events or incidents – as you said – are, are, they are dramatic and they are emotional and they are gut wrenching, and they are lifelong lasting, but I guess I would go back to that team effort of everybody working together. People talk about the surgeon. You know, the surgeon can’t do anything without the technician putting the instruments in his or her hands. 

HELEN: Okay. 

JOHN: The nurses taking care of the patient and ultimately, given the point of our podcast, Helen, delivering blood from the blood bank or from a walking blood bank and hanging the blood on the patient.  

HELEN: So, you’re the person kind of who’s getting a lot of the attention because you’re the surgeon, but it takes the whole team to do it. So, somebody has been her horrifically injured and now there, you know, in surgery. Tell us more about that part about the blood. What happens, and you also use the term of a walking blood bank, so tell us more about that. 

JOHN: You know this really is a history of blood, which I think is really interesting. People have been getting injured of course for millennia – for thousands and thousands of years – the causes of injuries have changed obviously with gunpowder and bullets and bombs and mines and that sort of thing on the battlefield compared to previous years. But the human body hasn’t changed much in thousands of years and the response to injury hasn’t changed much despite the different wounding agents. What is interesting is blood has only been used for resuscitation of casualties and resuscitation of patients who have lost you know twenty, thirty, forty, fifty percent of their blood volume  

HELEN: Okay, I just want to clarify for those of us like me who are not physicians, when you say resuscitation, I think of CPR or something. Are you using that in the broader term that kind of keeps someone alive? 

JOHN: Right, thank you. Helen, if you get shot while we’re talking on the phone – horrible – and you fall down and you’re bleeding, you’re bleeding out, and you lose twenty, thirty, forty percent of the blood that’s inside your blood vessels because of damage to major blood vessels and the medical show up -911 gets called – and they will resuscitate you with blood. They will put an IV in and start putting blood back into your blood vessels to bring your blood pressure back up. At the same time, they’re going to try to stop the bleeding, right? So to give blood and stop bleeding at the same time. And that really that summarizes, you know, what the whole team does. It’s actually pretty simple. 

HELEN: It does sound clear and it reminds me of what I’ve read about the history of blood and blood letting and leeches and all kinds of things that happened hundreds of years ago probably even longer than that. Is it pretty straightforward like that? Just give people blood and stop the bleeding or is there more to it for all our listeners – kind of want to know – how this is applied to civilian medical care? 

JOHN: Yep, so I am a student of history and specifically military history and then focusing actually on blood transfusion. In World War One and World War Two and Korea it was just as simple as that. You got injured we had to – the medics, the whole team, the medics, nurses, docs – worked to stop bleeding and we gave blood back. In Vietnam and in the civilian world at the same time in the 70’s we got a little distracted. We got a little confused for about thirty years with different kinds of fluids to resuscitate instead of blood but I would say in the last decade last fifteen years really coming from that experience on the battlefield and then translating that experience into the civilian world, blood has resumed its proper place as the primary resuscitation fluid. 

HELEN: That’s interesting. It’s interesting to me too that it was kind of out of practice for several decades there and has come back. What, John, from all your perspectives because you’re still a practicing physician in surgery and you bring all these important experiences on the battlefield, what would you want listeners of this podcast to know 

JOHN: I think it and I think the and this obviously comes from a viewpoint of practicing medicine now for thirty five forty years, know why you’re doing something… know why you’re doing something. I practiced medicine for many years, I was taught by my fellow residents and faculty and I really didn’t dive into why I was doing what I had been taught.  

HELEN: Can you give an example please? 

JOHN: Sure well I gave we this resuscitation for second I gave a lot of the clear fluid you know the clear bags of fluid that are really good for people who have diarrhea or dehydration or heat stroke but I didn’t give blood to patients who were bleeding to death. And I did what I did for many many years because I was taught to do that and I didn’t ask why I was doing that. It was just what was done. And then and then we went to the battlefield and in multiple places and you start seeing these patients who do better with more blood and they do worse with the standard way we’ve been taught to resuscitate patients with the clear fluid. You collect the data and do the research and analyze the results and it becomes very clear and that experience by  a lot of people on the battlefield has changed practice not only on the battlefield and this is the world not just in the US but around the world  

HELEN: So what I’m hearing you started well know why you’re doing something and also seems to be question why you were doing something there’s been in practice and then you talked about trying something else collecting the data and analyzing the results. Maybe that somebody new to practice can do that. What would be your advice for someone who’s been doing this for decades and it’s always been done this way. What would you want to see there? 

JOHN: You know when we sit and talk about these kind of things in the academic setting where we teach residents and medical students every day. What we tell folks who look around you and think about why you’re doing what you’re doing and question tradition, respectfully and put, try a to put good data and results driven, outcome driven next to these questions. Question everything. Question everything  

HELEN: I wonder how hard it is for someone who’s been doing this and it just got in the groove of doing this for a while but it is something that people have to consider and I think hearing from you is very important. How bout for the lay public. What would you want all of us to know about blood, trauma and resuscitation that maybe we can just as an interesting fact that we can learn or maybe we can share with somebody else?

JOHN: So number one – donate blood. Go donate. There is a nationwide shortage of blood right now, well publicized, well known. Go donate blood. Number two. Talk to your local EMS agency the medics who ride in the ambulances. Every community has an EMS agency. Find out if they carry blood products. If they don’t, ask why they don’t. The sooner you give blood to a patient who needs it. End of statement.

HELEN: And it’s not common practice everywhere

JOHN: It’s not common practice everywhere. It’s changing, it’s changing. But you know what’s the hardest thing to change, Helen? Tradition. Tradition says give the clear fluid and the data says give the blood.

HELEN: And is this interwoven with issues of cost and accessibility? There’s not enough blood out there or blood costs more maybe than the clear fluids?

JOHN: Yeah always, always always right? Money is always a part of this equation. You know but the whole medical system right exist to improve outcome and save lives. And it is really clear that in patients who need it and it’s a small percentage of patients but patients who need, who are and hemorrhagic shock who’ve lost all that blood that we talked about earlier out of their blood vessels, and it’s minutes. As soon as they get blood back into their blood vessels, the higher their survival rate. And it is a matter truly a matter of minutes.

HELEN: Thank you. Thank you for 

having questioned why practice was the way it was. For trying something else, looking at the data and measuring it and sharing with all of us about what we can do because what we all have in common we all share this interest and dedication to saving lives and improving the human condition. And John, I thank you so much for also sharing that with listeners of Talking about Blood 

JOHN: my pleasure Helen. Great talking to you. 

HELEN: As we just heard from doctor John Holcomb, our work is all about saving lives and having good outcomes. But sometimes what we’ve learned by tradition and habit is not always the most effective.

To learn more about The Blood Project and explore its many resources for professionals, trainees, patients, and the lay public, please go to https://www.thebloodproject.com.

I invite you to also listen to my podcast series about health communication called Health Literacy Out Loud at https://www.healthliteracyoutloud.com. Please help spread the word about this podcast series and The Blood Project. I thank you for listening. Until next time, I’m Helen Osborne.