Updated May 26, 2015
 |
Combat is dirty business. Whether it happens in a far-off land or here at home, it means open wounds and the risk of severe infection. You already know how to defend yourself against the bad guys, but you should also know how to fight off the infections that can kill you afterward.
Antibiotics are a relatively recent development in medicine, but their utility for the soldier was recognized very early. Sulfa compounds discovered in the early 1930s were incorporated into the World War II medic’s bag in the form of powder sprinkled directly into the wound. We have learned a lot since then, and the primary lesson is that early use of antibiotics is key to reducing infection and saving lives.
Combat wound infections
One publication[1] discussing some of the hard research done on this topic states that a well-known military medicine researcher (Mabry, et al 2000) reported that 16 of 58 wounded in the Battle of Mogadishu had very significant wound infections. Evacuation for some was delayed for 15 hours, and the medics did not carry antibiotics. Compare this to another instance (Tarpey, et al 2005) years later in Operation Iraqi Freedom, with the researcher reporting that none of the 32 casualties with open wounds had infection when antibiotics were readily available and given in the field. Another described one casualty scenario where 19 special operations personnel and 30 Iraqis were wounded and antibiotics were given. He reported a “negligible” rate of wound infection (Butler, et al 2006).
Where do these infections come from? Bacteria and other infective agents, often collectively referred to by medical professionals as “bugs,” come from many sources. They could come from dirt and dust blowing in the wind, especially in environments where sewerage is in the open air and sun-baked particles mix into the wind. Or they could come from the murky and parasite-infested ponds and streams to which a wound may be exposed. Large, sub-sonic rounds such as the .45 caliber will, for only a brief but effective fraction of a second, pull air and the bugs it may contain into an entry wound. These and many more are sources of the infectious bugs that can disable or ultimately kill you and your teammates.
Even though a great deal of thought has been dedicated to the role of antibiotics in the military venue in recent years, there still seems to be some debate regarding which are the best to use. However, there seems to be no debate about their general value. Tactical Combat Casualty Care (TCCC) has been a leader on this topic, and has published some recommendations.
Combat pill packs
Quick and easy are the packets of oral medications often issued to military personnel and sometimes referred to as “Combat Pill Packs” or “Ranger Pill Packs.” These packs contain different individual medications depending on the time they were issued, the branch of the service issuing them, and other variables. While the particular drugs will vary, the pattern continues of including antibiotics and non-sedating pain medications. The current TCCC recommendation for oral antibiotics is Moxifloxacin 400 mg or Levofloxacin 500 mg, both of which are drugs that can kill a very broad range of infective bugs.
If you have medics in your tactical unit, you may want to augment the pill packs and consider carrying intramuscularly (IM) injectable or intravenously (IV) infused drugs in your inventory. The current TCCC recommendations are cefotetan (brand name Cefotan), 2 grams given by IV or IM once every 12 hours, or ertapenam (brand name Invanz ),1 gram given by IV or IM once every 24 hours. Both are long-acting drugs and potently cover a very broad spectrum of the bugs one might encounter.
The logistics of administering these medications needs some consideration and planning. Pill packs are outstanding for their ease of use without medical personnel and the potential for early administration as long as the casualty is conscious enough, and without severe facial injuries, to safely ingest them on his own. The downside is the inability to ingest them, and that oral antibiotics generally don’t pack the wallop that IM or IV drugs do.
IM injected drugs are far more potent than their oral counterparts, but require some limited medical equipment and knowledge. They typically come in a glass vial in powdered form, and require reconstitution with some sterile water or saline. You now draw up the mixed solution with a needle and syringe and inject it into the casualty or yourself. IM injection technique is an easily-learned skill and is routinely taught to non-medical personnel in the military and other venues.
The IV administration of antibiotics is the most powerful route, but also requires the most medical knowledge, equipment, and time. The powdered medication is mixed into a solution, then injected into a bag of intravenous fluid. That bag of fluid is infused over a period of 30 to 60 minutes depending on the drug. While the potency of this method is excellent, the need to start an IV, to manage a constantly-infusing IV solution bag, the amount of time needed for preparation and administration, and the ability to carry all of the necessary equipment may be operationally unmanageable.
Incorporating antibiotic therapy into your tactical team’s arsenal is very good medicine. It will require a bit of planning and training, but it will have a wonderfully beneficial impact on your team’s morbidity and mortality in the event of open wound injuries.
References
1. Journal of Special Operations Medicine - Fall 2008 Training Supplement
