Trauma doctors are learning battlefield techniques. And they're saving victims of mass shootings.

Amid America’s grim epidemic of gun violence, doctors are learning new ways to save gunshot victims’ lives.

According to the latest reports on the survivors of the mass shooting in Orlando, of the 44 wounded who made it to the Orlando Regional Medical Center, nine died on arrival. All of the 35 remaining were still alive, and as of Tuesday, only 27 remained in hospital (with six in critical condition).

"All patients since arrival to the hospital are still with us," Dr. Michael Cheatham, the chief surgical quality officer at Orlando Regional Medical Center, said in a press briefing today. "And they are steadily improving." (Other surviving victims were sent to Florida Hospital in Orlando.)

Doctors who specialize in trauma care — treating people with disabling or life-threatening injuries that resulted from things like gun violence or car crashes — say they expect relatively good outcomes for all of these patients. "I am certain those that made it to the hospital [in Orlando], unless they had devastating injuries, will survive," said M. Margaret Knudson, a professor of surgery at the University of California San Francisco.

One surprising reason for hope: a new approach to trauma care honed by military doctors on the battlefields of Iraq and Afghanistan that's been translated for wounded civilians here.

"During the height of the wars, we were treating injury patterns at a rate that was 10 to 100 times [that which] you would treat in any given city," said Col. Todd Rasmussen, a medical doctor and professor of surgery who served in both wars.

That unprecedented burden of injury and the instructive medical research it generated, researchers say, may even be helping gun fatalities stabilize in this country — while the rate of gunshot injuries has increased.

Rasmussen calls this "once-in-a-generation burden of injury" on the battlefields one of the few "silver linings of the wars." Or, as he put it in a recent paper, "the only beneficiary of war is medicine."

Here are a few of the recent advances learned on battlefields for responding to life-threatening violence that are helping victims like those in Orlando.

1) Stop the bleeding

The most common reason people die at the scene of a mass casualty event like Orlando is bleeding. (The second most common cause of death at these events is massive brain injury.)

Before the Iraq and Afghanistan wars, the use of tourniquets in medicine had fallen out of favor. "Tourniquets to control extremity bleeding were not used, and best practice was that they shouldn't be used," said Rasmussen. But new evidence changed the practice: Military health professionals saw early on that patients on whom tourniquets were used were more likely to survive their injuries.

This change in practice is why the Department of Homeland Security launched the Stop the Bleed campaign in 2015, encouraging bystanders in violent attacks to compress the wounds of victims if health professionals haven’t yet arrived at the scene.

"In the last 15 years of war," Knudson added, "those techniques have saved many lives on the battlefield." They also may have saved lives in Orlando, where some of the nightclub goers and bystanders made makeshift tourniquets out of T-shirts, bandanas, or belts to stop the bleeding from the injured around them, according to news reports.

2) Small, stopgap surgeries

Some gunshot victims need immediate surgery.

But doing all the necessary surgeries immediately in a mass casualty event is usually impossible. So doctors now do smaller and quicker surgeries first, with one key goal: saving lives. This type of care was perfected in Iraq and Afghanistan, and it’s called "damage control surgery."

For example, for a patient with a more minor blood vessel injury on the leg, doctors may put a small piece of plastic in place (called a "shunt") to keep the blood flowing. That can allow them to move on to do other, more critical surgeries on the same patient or help other patients in a more critical state. Later, the doctors can go back and do a more definitive surgery to repair the broken blood vessel.

"We do these abbreviated surgeries whenever we can," and they help save lives, said Knudson.

3) Help clotting by giving blood plasma and platelets first

Patients wounded by gunshot typically have lost a lot of blood. If they need surgery, they’ll also probably need blood transfusions.

Blood transfusions oftentimes involve supplementing patients with specific blood components (also known as products) — like blood plasma, including red blood cells, which carry oxygen, or platelets, which are essential for making blood clot.

In the past, doctors would first respond by giving patients saline solutions (mixtures of sodium chloride in water) in addition to or followed by blood products. But in the recent wars, military doctors started to notice that patients actually fared better when they got the blood products immediately.

"When someone loses 20 to 30 percent of their blood volume from a gunshot wound," said Rasmussen, "we don't give them ... saline solutions. We try to give plasma, platelets, and packed red blood cells right away."

Studies conducted during the wars also helped doctors refine the ratios and amounts of blood products to give to the injured. "We learned from military experience that it’s really important to give clotting factors almost first, and in a better ratio," Knudson said.

That definitely decreased mortality in military wounds, and it’s dramatically changing the way we care for patients in the civilian world. "Not only does it save some of the blood by using products judiciously but it also allows you to [better] direct what you give," said Knudson.

Despite these advancements in trauma care, there’s still a lot to learn

Angel Colon, one of the surviving victims of the Pulse nightclub shooting, at the Orlando Regional Medical Center Tuesday in Orlando. (AP Photo/John Raoux)

As part of their preparedness plans, all trauma centers have been trained to handle terror attacks and mass shootings. Yet the mass tragedies in the US in recent years still present these facilities with unforeseen hurdles.

The tragedy in Orlando — the largest mass shooting in recent US history — turned the hospital there into "a war scene" where "patient after patient after patient" overwhelmed the hospital’s capacity, doctors said at a Tuesday press briefing.

The doctors also were faced with less familiar injuries that are challenging to treat. Joseph Ibrahim, the trauma medical director at Orlando Regional Medical Center, told reporters, "We saw the gamut of wounds — from wounds to the extremities, the chest, abdomen, and pelvis area — as if they were shot from below ... something we’re not used to seeing." (Recent evidence from at least one hospital suggests the types of injuries doctors have seen in recent years are indeed more severe and potentially deadly.)

These moments remind us of the urgent need to translate even more lessons from the battlefields back home, said Boston Medical Center vascular surgeon Jeffrey Kalish, who treated victims of the Boston Marathon bombings.

At that time in 2013, Kalish said he looked to the military for expertise about how to care for the victims "from day one," applying their experience on treating wounds from an improvised explosive device and related complications — such as ear trauma from the blast and infection.

"We have an amazing wealth of knowledge with the military," he said, "I’m trying to bridge the gap between military and civilian worlds."

Others in the scientific community see the opportunity, too. The National Academies of Sciences released a report on Friday detailing "how military advances can be sustained and translated to the civilian sector."

According to the report, the leading cause of death for Americans under the age of 46 is trauma — and with a national trauma care strategy, focused on bringing medical knowhow from war zones to hospitals across the US — an estimated 20 percent of those deaths could be prevented.

Kalish added: "Something like Boston or Orlando, I can almost guarantee it’s going to happen again." Applying the best evidence from war can save lives when the battlefield moves closer to home.

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