National Defence Committee on March 27th, 2013

[The Chair, Conservative, James Bezan]

Thank you.

Monsieur Larose, s'il vous plaît.

[Jean-François Larose, NDP, Repentigny, QC]

Thank you, Mr. Chair.

Being a Star Trek fan myself, I remember Dr. McCoy saying that we were butchers in our era. Hopefully technology can come quickly so we stop being such people.

[Tarik Brahmi, NDP, Saint-Jean, QC]

That's off the record.

[Jean-François Larose, NDP, Repentigny, QC]

Colonel Tien, congratulations on being appointed Major Banting Military Trauma Research Chair, in June 2012.

What do you hope to achieve as Major Banting Military Trauma Research Chair?

[Col Homer Tien]

I'm hoping to promote military trauma research. In the terms of reference for the chair, it would be to stimulate research, to conduct the research myself, and to develop collaboration with other Canadian academic centres and with our allies in conducting research important to the care of the injured in the military.

[Jean-François Larose, NDP, Repentigny, QC]

What are the main issues you would like to address? What are the most urgent problems?

[Col Homer Tien]

Because of my background in general surgery and trauma, I know the leading cause of preventable death on the battlefield remains bleeding. My personal research interests lie in how we best treat massive bleeding, how we resuscitate, and how we stop that.

[Jean-François Larose, NDP, Repentigny, QC]

What do you think are the advantages of a military trauma research chair?

[Col Homer Tien]

For example, if you look at civilian funding, CIHR funding in Canada, the big pillars tend to be things like cardiovascular health and cancer. Mostly because this is what kills Canadians. There's no separate pillar at CIHR in terms of trauma care or care to the injured. Because trauma is a disease that affects young people—and thank goodness, as a relative proportion of causes of death in Canada, it's not in the top three leading causes of death—it is the leading cause of young people dying.

The advantage of a military chair is that I can spend my time focusing on what injures and kills Canadian Forces members in conflict, and that justifiably is not a big priority for CIHR because that's not what kills the majority of Canadians, but for the military, trauma is what kills most soldiers.

[Jean-François Larose, NDP, Repentigny, QC]

Exactly.

In what specific way do you think your research will be implemented in the Canadian Forces?

[Col Homer Tien]

There are two types of work that I do. I do database research and I do clinical trials. We're now actually doing a study in collaboration with the U.S. It's called the PROPPR trial. We're looking at how we can best transfuse patients who are massively bleeding. There are a lot of different ideas on the best way to transfuse patients, so we're studying those in a clinical trial.

From database research you can ask different questions, and there are lots of different databases we can use to help answer military-related questions, including the Joint Theatre Trauma Registry, and so forth.

[Jean-François Larose, NDP, Repentigny, QC]

I am down to my last question. Earlier, you were asked if the programs in place were adequate when it came to trauma. I think you said that they were. Could certain programs be abolished if cuts were made in the Department of National Defence? I am talking about areas that are doing okay now but could not handle any additional cuts.

[Col Homer Tien]

In terms of budget cuts, it's hard for me to answer because I don't have an overview. What I will say is that during the war years, so 2006 and so forth.... It's very expensive to care for acutely injured patients. We did a study on how much it costs to look after injured Canadian soldiers in the field. It was probably threefold what it costs to treat an injured Canadian civilian here. There are budgetary savings in switching from a combat role, where we have lots of casualties, to a system now where we're really dealing with the aftermath of the war. I would assume there are some budgetary savings in terms of the money we used to spend on providing care, which was very expensive for the battlefield injured.

[The Chair, Conservative, James Bezan]

Thank you very much. Your time is up.

Mr. Strahl.

[Mark Strahl, Conservative, Chilliwack—Fraser Canyon, BC]

Thank you, Mr. Chair.

I read a couple of books, thanks to John. He brought us Dr. Ray Wiss' FOB Doc and A Line in the Sand. It's my first exposure, really, to the challenges faced by foreign operating bases, and how they would transfer patients to the Role 3.

He mentioned in his book as well, and maybe you can just expand on it a bit if it's your research, that in the first rotation he went through, when there was blood loss there was a powder that was applied to stop the bleeding that caused a lot of damage to the skin and muscle. Then there was a major change in how that was done. Maybe you could just walk us through how that happened.

It's medical research. I've been on the health committee before as well. These things take years to develop. Maybe you can just describe how that problem was identified and how you were able to come up with a better solution in such a short period of time.

[Col Homer Tien]

In fact as a disclaimer, it wasn't my research. I wish it were, but it wasn't. This was a product that was developed by the U.S. military called QuikClot. When tactical combat casualty care came about there was the development of tourniquets. If you had a traumatic injury to an extremity, to a leg or an arm, you would put on a tourniquet that would stop the blood loss. However, as you got closer to the body, to the torso, it became harder and harder to apply a tourniquet to that. So what we had was a good solution for amputations to the hand, or to the foot, or to the lower leg, but we didn't have a good solution to proximal amputations because you couldn't get a tourniquet on that. So the U.S. Army Institute for Surgical Research came up with this product called QuikClot. If you apply it to proximal bleeding where you can't put a tourniquet on, it promotes clotting.

This product was put out with the Canadian Forces as well as a method for dealing with bleeding that you couldn't stop with a tourniquet because it was too close to the body. But then problems were identified with it. When you applied it you would put it in water and it would give off heat and it would cause some mild skin burns. As a surgeon who had to clean it out I didn't find it a big problem, and personally I was much happier that a patient came in with an amputation that stopped bleeding than I was worried about a few superficial skin burns. It's always about trying to improve care to the next level. Then the next generation of product that came out was called—I forget the trade name—but it was based on a shellfish product that you would put on and it would stop bleeding as well.

The problem with that is the way it was designed: if you were bleeding a lot the product would wash out. So then a lot of U.S. companies focused a lot of effort on coming up with products that would work that would try to deal with these problems.

Obviously, because it's the U.S. military there was a huge financial incentive for these companies to do the research because if it was adopted by the U.S. Army they would order millions of these things. So there was quite a lot of progression in terms of the development of hemostatic dressings. In my role as national practice leader for trauma, we would often be asked to evaluate the product in terms of reading the studies and seeing whether we should adopt them for Canadian Forces soldiers. I wasn't involved in the actual research, in their development.

[Mark Strahl, Conservative, Chilliwack—Fraser Canyon, BC]

Obviously, the almighty dollar was the motivator, it sounds like, there for private companies to make that improvement.

The other thing that the doctor talked about in his book was the use of ultrasound. Has that become more common? In the ten years we were in combat mission there, did it become something that was given to the medics so that they were able to diagnose? He said there were cases where someone might look like they were the most injured, but an ultrasound would reveal they were going to be okay for a half hour whereas this other guy was bleeding out internally.

Were those upgrades made throughout the course of the mission in Afghanistan?

[Col Homer Tien]

They weren't. The ultrasound was given to physicians and Dr. Wiss, who I know well, is an expert and a teacher of trauma ultrasound. The reason it's not given to medics at the moment is that it requires a fair amount of training and exposure to real patients with different pathology. You can imagine the problems if someone is not familiar and they read it as having blood and there's not blood. Then it actually causes more problems. Or if you read it as a false negative when it was a positive it causes more problems. Hence, that's one of the reasons why Downsview is trying to develop an automated diagnosis program for the finding of blood.

So it was never deployed in the field for medics because of the training burden that it would imply for the med techs.

[The Chair, Conservative, James Bezan]

Thank you, time has expired.

Just so members know, we did extend an invitation to Dr. Wiss to come and appear before committee. Unfortunately his wife passed away in December so he needs to make child care arrangements for his two kids if he's going to visit us and talk about his experience. Most of us have read FOB Doc and A Line in the Sand that he wrote while in Afghanistan.

We have time for one more question.

Monsieur Brahmi, s'il vous plaît.

[Tarik Brahmi, NDP, Saint-Jean, QC]

Thank you, Mr. Chair.

Colonel Tien, thank you for your testimony. I have a question that's somewhat similar to the one my colleague asked about nurses. Nurses have to provide such assistance to injured soldiers on a daily basis. I am wondering the same thing about surgeons. You are a surgeon. I assume that, in a civilian hospital, you don't have to deal with any cases similar to those following a bomb explosion in Afghanistan.

As part of continued training for surgeons, are you sent to any other theatres of operation where Canada is not involved, but where you may come across similar types of injuries? Are there any joint programs with the American army, for instance, that would allow surgeons to come in contact with similar injuries?

[Col Homer Tien]

I wrote a paper with the U.S. and the British on how you prepare a surgeon for war. We surveyed what our allies were doing with regard to preparation for surgeons. It's very difficult to send surgeons, for training purposes, to conflicts that we're not involved in.

With regard to all of our allies, we have arrangements with civilian trauma centres. The U.S. has arrangements with Baltimore, Miami, and L.A. County. We have arrangements with various trauma centres in Canada where we work.

You're absolutely right, in that there are some differences in how you treat blast versus how you treat car accident, but the principles of some of the trauma management—how you have to stop the bleeding, how you resuscitate—are very similar.

In that same context, all the major trials that the military are interested in with regard to trauma resuscitation are actually carried out in the civilian setting. We realize that it's impossible to do these things in the military setting. The principles of bleeding and bleeding control are still the same.

[Tarik Brahmi, NDP, Saint-Jean, QC]

If my understanding is correct, that would cause problems. If Canadian surgeons were sent to a country where Canada was not involved, a problem of a diplomatic, rather than medical, nature would arise .

[Col Homer Tien]

Yes, I would believe so.

[Tarik Brahmi, NDP, Saint-Jean, QC]

Thank you.

Let's talk about the fact that some physicians are leaving the armed forces. You said that you were bound to serve out a three-year term. Your contract obligates you to stay with Canadian Forces for three years following your training. I have done some research, and I know that, for instance, a specialist has to stay in the French army for 12 months.

How does Canada compare with other countries?

[Col Homer Tien]

The three years actually wasn't for surgery. That was just after my medical school, as a general duty medical officer. My obligatory service for general surgery was five years.

I'm not aware of what the obligation is for different countries. We can find out for you and get back to you on that.