Before the war in Afghanistan started in 2001, battlefield medical care had evolved little since Vietnam, and few Army surgeons had experience in combat trauma.
And so Army leaders, eager for innovative treatments to manage mounting casualties from Afghanistan and Iraq, enlisted a team of medical researchers in San Antonio, Texas, to recommend and implement new ideas. Headed by veteran trauma surgeon Col. John Holcomb, head of the Army's Institute for Surgical Research, the group was given almost complete authority to issue treatment guidelines throughout the war zones and analyze combat data to determine whether the treatments were working, according to Army documents obtained through the Freedom of Information Act and from published accounts in medical journals.
They also bypassed checks and balances common in civilian medicine. For instance, implementing a new treatment in Iraq required just four steps: writing it, submitting it to Holcomb and a handful of senior physicians, circulating it "for informational purpose only," and publishing it.
The same process at the Department of Veterans Affairs involves up to 19 steps, including multiple reviews by independent committees.
According to interviews with dozens of Army physicians and scientists, many of whom spoke to The Sun on the condition of anonymity because they said publicity would imperil their careers, the group sometimes moved so aggressively to implement unproven medicines and techniques that some doctors felt pressured to defy their own judgment.
Doctors who challenged the use of a blood-clotting drug said they were berated by senior physicians from the San Antonio laboratory.
At one point in 2006 military leaders proposed to measure a physician's use of the Army's guidelines as a measurement of the quality of treatment - meeting with a backlash from clinicians in the combat zone, three doctors told The Sun.
Dr. Arthur Caplan, a professor of bioethics at the University of Pennsylvania, said a system that allows medical researchers to establish treatment protocols should have concerned the Pentagon.
"Certainly there is a need for the military to try to learn from the tragic opportunity that war presents," said Caplan. "But if you're going to try novel things, you owe it to the people who are your subjects to have as many eyeballs on it as you can. The potential for someone to pursue and promote their own biases is too great."
A report issued in December 2007 cleared Holcomb and his institute of complaints about his command style and alleged inattention to research, but the stress of the investigation pushed him to retire from the military last July, according to a transcript of his interview with investigators.
Holcomb declined to comment for this article. But in numerous interviews with The Sun the past four years he has defended the Army's aggressive push for new treatments as necessary. Greater risks are acceptable, he said, given the devastating nature of today's combat injuries.
"These guys don't have the luxury of waiting," for more scientific data, he said in one interview in Baghdad in 2006.
He is still revered by many Army doctors - and decried by others.
In interviews with investigators, transcribed in a 453-page report obtained by The Sun, an Army officer who worked at the Institute for Surgical Research referred to Holcomb, in the same sentence, as "arrogant, obnoxious, overbearing" and "exactly the type of leader the ISR needed."
Much of the Army's system of testing and implementing medical treatments in combat has been restructured over the last year. Practice guidelines must be reviewed by an advisory panel before being implemented, for instance.
"I won't argue with you that early on it may have appeared unsophisticated and less than optimal in its alignment with direct data being derived from theater, because we lacked some of the fidelity of data that we needed," Schoomaker said. "But we now have evolved. We've evolved while in the fight."
Here are The Sun's findings:
Finding: An $89 bandage distributed to combat soldiers and honored as one of the service's greatest inventions was deployed despite two unpublished studies from the Army's research lab showing that the dressing was no more effective than plain gauze. After mixed reports from the battlefield, it was recalled and replaced.
The bandage, called HemCon, made from a substance derived from shrimp shells, was approved by the Pentagon's advisory committee on combat medicine in 2003 as the preferred dressing for combat. The committee based its recommendation on animal tests conducted by San Antonio researchers showing HemCon to be significantly more effective than plain gauze, according to committee members. The Army named the bandage one of its "greatest inventions" in 2005, eventually distributing it to every soldier in the combat zones.
Army medicine: Untested in battle
New procedures were rushed into theaters of war without rigorous review
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