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New technologies can extend the golden hour of combat injuries

Military medicine can help win wars. Treating and then returning military personnel to duty — which has always been a primary mission of any military medical corps — maintains force strength. Moreover, knowing that they will be cared for and have a high chance of survival if injured boosts service members’ morale and will to fight.


The advances in military medicine has enhanced survival rates of Soldiers ,  the best in the history of warfare, but, of those who don’t make it, 90% die on the battlefield before reaching hospital. When a Service member suffers a traumatic injury or acute infection, the time from event to first medical treatment is usually the single most significant factor in determining the outcome between saving a life or not. First responders must act as quickly as possible, first to ensure a patient’s sheer survival and then to prevent permanent disability.


The Department of Defense refers to this critical, initial window of time as the “golden hour,” but in many cases the opportunity to successfully intervene may extend much less than sixty minutes, which is why the military invests so heavily in moving casualties as rapidly as possible from the battlefield to suitable medical facilities.


In the wars in Iraq and Afghanistan, the U.S. military medicine achieved the highest rate of survival from battlefield injuries in history. The wounded-to-killed ratio has more than doubled, from 4:1 during last century’s world wars, to 10:1 today. Substantial credit for this achievement goes to a tireless focus on getting wounded warfighters lifesaving care within 60 minutes of injury — a timespan that is referred to as the “golden hour.”


The military’s ability to deliver golden hour care was developed in the recent low-level counter-insurgencies and counter-terrorism wars of the early 21st century. With the shift away from global unipolarity, however, the United States may be more likely to fight conventional wars against peer or near-peer adversaries in the future. This shift requires the military to reassess existing approaches and innovate new ones for extending golden hour care in a different kind of war. Potential challenges include larger numbers of casualties, injuries from new types of weaponry (e.g. directed energy, thermobaric, nuclear), and degraded ability to promptly locate, treat, and evacuate patients.

Golden hour Technologies

A variety of developing technologies will improve resuscitative care at the front lines. New tools may allow medics working near the point of injury to autonomously establish entry inside the large arteries and veins of the torso. Linked to small catheters that can work inside the vessels, these tools could allow medics to stop bleeding, restore blood volume, and control the circulatory system. New endovascular devices (that is, devices operating inside vessels) could also be coupled with automated drug and fluid delivery tools to provide pain control, anesthesia, and organ support. While this network of technologies is complex, all the elements exist in some form today. The remaining challenges are to miniaturize and integrate them, make them battery-powered, and test them in the lab and in field conditions.


Wearable biosensors and advanced vital signs monitors, which could serve the dual purpose of remotely locating and triaging injured troops, are also on the horizon. Collecting and analyzing large amounts of real-time patient data (a.k.a. predictive analytics) from these monitors could help inform and build automated devices such as ventilators, organ support machines, and infusion pumps. Decision support and automated devices would expand the medic or corpsman’s ability to provide golden hour care to a greater number of injured at any one time.


In situations where MEDEVAC and other life-saving measures are not available, telemedicine will also expand the capability of point-of-injury providers to perform some types of surgeries such as wound debridement, extremity fasciotomy, or amputation. Subsequent prolonged field care delivered by medics and corpsmen could then include treatment of large wounds, intra-abdominal injuries, and mangled extremities — injuries managed inside of a hospital operating room today. Although the science is less advanced in these areas, the military is investing in research on antimicrobial dressing systems and self-expanding foams able to be injected into the abdomen to stabilize bleeding and contamination until definitive surgery can occur.


Managing traumatic brain injury during the new golden hour will be challenging. In addition to more comprehensive study of new and wearable blast gauge technologies and improved protection measures to avoid blast exposure, research is focusing on devices to diagnose concussive traumatic brain injury and limit severe brain injury. Brain-wave and eye-tracking devices and rapid blood tests may soon be available to diagnose concussions on the battlefield. Innovations such as small devices that use light sources and software algorithms to look inside the skull to diagnose bleeding and then drill a hole to evacuate blood and relieve pressure could help treat more severe forms of traumatic brain injury.


US Army

The guiding concept for battle in the 2025-2050 time frame is multidomain operations. It describes how the U.S. Army, as part of a joint force, can counter and defeat near-peer adversaries in the 2025-2050 time frame across the operational environment: air, land, sea, cyberspace and space. With that in mind, DOD continually explores game-changing concepts, technologies, equipment and protocols that bolster the medical prospects for injured warfighters. For example, DOD envisions that many future military engagements may require small, mobile, expeditionary forces capable of self-sustainment for significant periods in deep areas far removed from U.S. military or medical support. That means elevating prolonged field care to new heights to overcome a host of battlefield challenges, such as severe bleeding, airway compromise, burns, crushing injuries, and traumatic brain injuries.


The U.S. Army Medical Research and Development Command (MRDC) is pursuing a number of promising innovative medical and knowledge products that will enable warfighters to survive bleeding emergencies and other injuries, empowering them to return to battle amid the chaos of war. MRDC, based at Fort Detrick, Maryland, continually investigates medical solutions for the evolving battlefield in various areas of biomedical research, including military infectious diseases, combat casualty care, military operational medicine, medical chemical and biological defense, and clinical and rehabilitative medicine.


The Combat Casualty Care Research Program (CCCRP), as part of MRDC, collaborates with the U.S. Food and Drug Administration (FDA) to find novel approaches for extending the shelf life of blood products and, as a result, preserving the lives of warfighters. Research funded by the Army and conducted by the Army’s Institute of Surgical Research and industry partners indicates that freeze dried plasma and cold stored platelets can provide game-changing advances in the treatment of massive bleeding.


Blood loss leads to decreases in circulating volume, oxygen-carrying capacity, clotting factors and platelets. This, in turn, results in shock and ultimately death if not addressed promptly. The primary advantage of using freeze-dried blood plasma is that it is a stable, dry product that remains effective at room temperature for up to two years, until it is reconstituted with sterile water when ready for use by medical personnel. Unlike fresh frozen plasma, which requires refrigeration at all times, freeze-dried plasma can be stored practically anywhere and transported in backpacks to treat wounded warfighters in the field. Platelets, one of four components found in blood, play a pivotal role in the clotting process by gathering at the site of an injury and sticking to the lining of the injured blood vessel. Cold stored platelets are typically refrigerated between 1 to 6 degrees Celsius, essentially extending the shelf-life beyond the typical 72-hours of platelets stored at room temperature.


Recently, the FDA approved a license request submitted through a collaboration of the Army and the South Texas Blood and Tissue Center in San Antonio, permitting the manufacture and distribution of cold stored platelets (up to 14 days) for use in actively bleeding patients when conventional platelet products are unavailable or impractical.


In May 2021 it was reported, Army Combat Capabilities Development Command’s Army Research Laboratory (ARL) is using a mature small business innovative research contract to expand its work on StatBond, a product created by Vanderbilt University and Hybrid Plastics. StatBond is a gel that can be secreted onto hard-to-reach or hard-to-treat areas like the neck, groin and internal organs.


“A wound on your leg or in your arm, you can obviously put the tourniquet upstream of that location and cut off or reduce blood flow areas and try to induce clotting. That’s not the case in these areas of the body,” Robert Mantz, a chemistry branch chief at ARL, told Federal News Network. “Even in those situations, if an artery has been ruptured, it’s particularly challenging to stop that blood flow, partially because they tend to be at higher pressure.” Hemorrhaging is the leading cause of death among soldiers in combat.


“The material is made of polyhedral oligomeric silsesquioxanes, which form a robust barrier, but not one that hardens, and is able to basically help the body to form a clot and to shut down bleeding,” Mantz said. “Oftentimes you see some products where they want to have something that goes in there and hardens and then that becomes very difficult for the surgeons down the road to be able to remove that material without causing further injury.”


StatBond can be wiped away, and the rest can be absorbed by the body. So far, the product has been used on pigs and rats. Mantz said Hybrid Plastics is now entering into a phase two enhancement small business innovative research contract to expand that work.



Indian defence lab develops combat drugs to reduce casualties in Pulwama type attacks, warfare

With 90 per cent of gravely wounded security personnel succumbing to injuries within a few hours, DRDO’s medical laboratory has come up with a range of ‘combat casualty drugs’ that can extend the golden hour till the trooper is shifted to hospital. The spectrum includes bleeding wound sealants, super absorptive dressings and glycerated salines, all of which can save lives in the event of warfare in jungle and high altitude areas as well as in terror attacks, scientists said.

Scientists at INMAS, entrusted with research and development in a number of areas concerning the defence sector, said the main battlefield emergencies are excess bleeding, sepsis, shock, hypovolemia (decreased blood volume) and pain. DRDO’s indigenously made medicines will be a boon for paramilitary and defence personnel during warfare, said A K Singh, director general of life sciences at the organisation.These medicines will ensure that our brave soldiers do not suffer from unwanted blood loss while being taken to a better healthcare from war zones, he told PTI.


Citing the February 14 terror attack in Pulwama where 40 CRPF soldiers were killed, they said the medicines could have brought down the death toll. According to developers of the drugs at the Institute of Nuclear Medicine and Allied Sciences, a laboratory of the Defence Research and Development Organisation, chances of survival and minimum disability are highest when effective first aid care is given within the golden hour.


The challenges are many. There is only one medical person and limited equipment to take care of soldiers during combat in most cases. This is compounded by battlefield conditions such as forests, hilly terrain and inaccessibility of vehicles, experts said. Among the drugs developed is glycerated saline, a battlefield intravenous fluid that does not freeze till -18 degrees Celsius and is useful in handling trauma cases in high altitude areas.


According to Manju Bala Popli, senior scientist at INMAS, glycerated saline, unlike normal saline, reduces inflammation. The drug can be life saving, particularly if the traumatic edema, collection of fluid in tissues and cavities of the body, is in the brain or lungs. Glycerated saline has life saving capacities as it gives more time to the medical personnel to shift the wounded patient to a higher care facility, Popli said.


INMAS has also developed a special medicated dressing material which is 200 times more absorptive than normal dressings during bleeding wounds. Amit Tyagi, another senior scientist at INMAS and part of the team behind developing the drug, said the cellulose fibre-based dressings are more effective in stopping bleeding and keeping the wound clean.


Additionally, antiseptics, antibiotics and curcumin can be impregnated in the dressing which acts as a slow drug release system, said a note prepared by INMAS on the medicines developed by it. Normal cotton dressing used for bleeding wounds has sub optimal absorptive capacity and is soiled after sometime. In heavily bleeding wounds, putting a normal dressing can actually enhance the bleeding by sucking out the blood,” said INMAS scientist Gaurav Mittal.


“It is safer and more effective to put in a long stuffed absorptive strip rather than individual gauge pieces. It has four-five times higher capacity to absorb blood, he said. Then there is Chitosan gel, which helps in preventing blood loss by forming a film over the wound. Coupled with platelets and red blood cells aggregation, it stops the bleeding. Its antibacterial and wound health properties are of added benefit.


Chitosan gel is suitable for sealing wounds by twin action: haemostasis by chemical action and filing action. It can be used for wounds on the limbs and also cavities such as abdomen and thorax, INMAS Director Tarun Sekhri told PTI. The gel is poured onto the wound and held with physical pressure for few minutes till the bleeding stops, he said.


It is topped by Chitosan wound cover. If the wound is deep, filters like silk and cellulose granules may be used after Chitosan gel, he explained. The products developed for jungle warfare are at the stage of implementation, said Aseem Bhatnagar, additional director of the institute. The Ministry of Home Affairs has recommended the cost-effective drugs to be inducted into their paramilitary forces while efforts are on with other forces for induction,” he said.


Part of the range is hypocholorous acid (HOCL), a disinfectant for troopers involved in jungle warfare. It is helpful in treating necrotising fascitis, a rapidly progressing bacterial infection of soft tissues. Bacterial toxins cause local tissue damage and necrosis, as well as blunt immune system responses. In such cases, pure 0.01 per cent HoCL has both broad-spectrum antimicrobial activity and can rapidly neutralise bacterial toxins. Bhatnagar said jungle warfare wounds have significant infection risk. The standard approach is to treat them with antibiotics. However, overuse and misuse of antibiotics often leads to breeding resistant strains of superbugs


Fresh whole blood transfusion in battlefield

In March 2017, the U.S. Army Materiel Command recognized the 75th Ranger Regiment’s Ranger O Low Titer (ROLO) Whole Blood Program as the individual military winner of the annual Army’s Greatest Innovation Award. Three years later, as a result of an accelerated military approval process, ROLO is saving lives on the battlefield.


The program tests all members of a unit or fighting force to determine whether their blood is O-. Donors with type O- blood have the unique power to help anyone in need of a blood transfusion, regardless of the recipient’s blood type. Red blood cells from O- donors can be transfused to anyone, which is especially important in battlefield settings when medics need to quickly administer blood transfusions before blood-typing a casualty for an exact match. In conjunction with more precise methods of screening donor blood, the ROLO program represents a marked improvement in blood donor programs compared with those in place during World War II, the Korean War and the Vietnam War.


Lightweight medical backpacks. DOD is working with several academic research institutions to develop self-contained trauma care systems that fit into a medic bag or rucksack and make it possible to stabilize and transport injured warfighters in remote locations.


Thermal packaging containers

The patented Golden Hour technology was invented by Peli BioThermal in 2003 in response to the US Army’s request for a reliable temperature controlled container that medics could use to transport blood and platelets to the battlefield during the life or death first hour after injury, or the Golden Hour. The technology won the US Army’s Greatest Invention Award the same year and serves as the foundation for other Peli BioThermal products, including Crēdo Cube, Crēdo ProMed and bulk shippers like the Crēdo Cargo.Golden Hour One joins a family of Golden Hour products, including the original Golden Hour Mobile and Golden Hour Medic.


Golden Hour One keeps blood cool without the use of external energy for 18 hours under extreme conditions and over 36 hours under optimal conditions. The technology, composed of a TIC coolant and vacuum insulation, prevents temperature excursions with a tight, protective thermal seal that eliminates possible hot or cold pockets or the need for ice, dry ice, or gel packs. The two versions differ in form factor, which offers flexibility for inclusion in the combat pack-out. Both the rectangular and cylinder versions have built in data loggers to track temperature information and protect the safety of the blood product payload.


Golden Hour Mobile transports four units of whole blood and maintains temperature control for 72 hours or more. Golden Hour Medic holds up to two units of whole blood and keeps blood cool for 24 hours under extreme conditions and 48+ hours under optimal conditions. Recently, an increasing number of UK air ambulance charities have been deploying ProMed, produced by Peli BioThermal. The ProMed transport bag is being used to transport blood products by HEMS first responders in Europe and globally. Being able to give a pre-hospital transfusion at the scene of an incident can sometimes be a lifesaving intervention.


Cellular reprogramming, which could allow wounds to heal up to five times faster

AFRL’s Air Force Office of Scientific Research has been funding efforts to research cellular reprogramming, which could allow wounds to heal up to five times faster than the human body would heal naturally. University of Michigan researcher Indika Rajapakse is now working with the Air Force in researching the ways that could allow for a person’s own cells to be reprogrammed to heal wounds faster. Rajapakse secured funding from the military branch to purchase a special live cell imaging microscope and improve an elaborate algorithm to advance the research.


“There are amazing opportunities in the United States, that you don’t see in the rest of the world, to humanize science and meet critical needs in medicine,” Rajapakse said. “We have the resources to do this, and it is our obligation to take full advantage of them. Thanks to the Air Force’s help, I was able to acquire the tools I need to advance my research into cellular reprogramming and wound healing.” The funding was made possible by collaboration between AFRL’s 711th Human Performance Wing and the Air Force Futures.


“The impact of this research effort can be far reaching,” said Dr. Rajesh Naik, 711th Human Performance Wing chief scientist. “The convergence of biosciences with mathematical models can truly provide an inflection point to advance the development of wound healing. Dr. Rajapakse’s research can result in innovative solutions for addressing our needs in the aeromedical operations and in future space environments.”


Big data

Multidisciplinary teams representing medicine, surgery and critical care endeavor to provide real-world data and medical algorithms for roboticists and computer scientists to incorporate in the creation of automated technologies capable of stabilizing medical treatments such as organ support, resuscitation and the administration of pharmaceuticals.


AI based Battlefield robotic surgical systems

AI is changing the face of the modern battlefield: AI is and will continue to be used not only for offensive measures, but also is playing a significant role in defensive measures, including saving lives on the front line. Artificial intelligence (AI) can reduce serious injury and death on the field of battle and can bolster battlefield healthcare.


Reserchers are now working to employ Autonomous  unmanned ground vehicles (UGVs) to implement and provide aid in on-site surgery. Even though currently there still must be a human doctor to oversee a robot-performed procedure, the systems can be helpful in places where highly skilled medical resources and doctors are not available to perform complex surgeries, such as on the battlefield and in isolated enclaves. Remote surgical systems – while still in the developing phase – could change the whole scenario of battlefield healthcare.


Situational awareness

the Army Futures Command’s modernization efforts are helping the medical community to provide better care to wounded Soldiers in medical evacuations from the battlefield. A key component of improving patient care is a program known as Medical Hands-Free Unified Broadcast (MEDHUB), which allows providers better situational awareness within the battlespace. It relies on Nett Warrior, which is an integrated dismounted leader situational awareness system used during combat operations.


MEDHUB connects to multiple wireless patient monitors housed in a medevac vehicle or helicopter, transmitting the person’s condition, injury and vital signs (updated every two minutes) to the receiving medical facility—and inevitably reducing potential human error in a chaotic battlefield environment. Awaiting medical facilities can now use a dashboard running on a Mounted Family of Computer Systems to update patient information in real time. CCCRP researchers believe that MEDHUB vastly accelerates the process of accurately communicating a patient’s medical condition throughout the evacuation and transfer process.


Unmanned technology

Unmanned technology could also enable a new golden hour paradigm. Drones or unmanned ground vehicles could preposition — or deliver in real time — supplies such as battlefield medicines and  blood for different tactical situations, a strategy already employed for humanitarian aid in Africa.  Additionally, the military is researching whether and how unmanned MEDEVAC might augment patient evacuation. By creating teams of combat developers, medics, scientists and engineers to work on these initiatives, the military is trying to make sure that new technologies are not merely “cool,” but that they are actually necessary and will be effective in the golden hour of future wars.


Battlefield casualty-extraction robots

Battlefield casualty-extraction robots – designed especially for retrieval of injured soldiers – can wend through rough or uneven terrain while carrying the weight of a human. Metal-bodied remote-control UGVs currently have a top speed of 10 km per hour (6.2 miles per hour) and can easily lift weights up to 227 kg (500 pounds).


“Porter” UGVs and RGPs

Soldiers who must carry loads on and off the battlefield have some of the most dangerous tasks, as often they are encumbererd and may not be able to defend themselves. AI seeks to change this scenario by determining how and where to deploy UGVs and robotic ground platforms (RGPs) to carry heavy loads over long distances and rough terrain. Such platforms can also guard soldiers – by conducting surveillance and gathering intelligence – on both operational and logistical missions. Some of these platforms have already been developed and can work up to 72 hours without refueling.




At Fort Benning, Georgia, a new standardized way to train combat troops of all services in battlefield casualty care is underway. Tier 2, which will replace what is currently known as Combat Lifesaver training, draws on the most medically up-to-date lessons learned during the nearly two decades of post-9/11 combat in places like Iraq and Afghanistan, said Lt. Col. Ethan Miles, chairman of the Tier 2/Combat Lifesaver Working Group and medical lead for Fort Benning’s Maneuver Center of Excellence. “One of the many things that the Global War on Terrorism has taught us is that one of the most important things you can do in saving lives is training nonmedical people,” Miles emphasized. Tier 2 is one of four parts of what the military calls Tactical Combat Casualty Care.


Tactical Combat Casualty Care, based on a March 2018 DOD directive that a new tactical combat casualty care curriculum be developed for all the armed forces, consists of four levels of skill, all geared to training service members in the best methods for giving medical care to the wounded in the first critical minutes before they can be taken to a hospital. Those skill levels are:

  • Knowledge or overview of combat casualty care.
  • Ability to assess the severity of casualties.
  • Ability to assess and mitigate massive external hemorrhage.
  • Ability to assess airway blockages and clear them.



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