IRVINE, Calif. -- Dr. Elliot Botvinick sits in his office on the campus of the University of California, Irvine, holding a tiny device in the palm of his hand. It is smaller than a garage door opener, smaller than a standard business card even, and is so slight and inconspicuous that he might be able to stick one on a passing student without their noticing.

It also might be the future of battlefield medicine, according to the U.S. Army.

Minds like Botvinick's may be exactly what's needed to conquer approaching combat scenarios that experts predict will look starkly different than the current version, ones where the efficient use of targeted medical knowledge may be the single most important key to victory.

Botvinick's handheld lactate monitor fits in perfectly then, as it features a wearable, subcutaneous microsensor designed to detect lactic acid levels, which rise in the body during episodes of critical illness and internal bleeding, both of which exhibit symptoms that aren't always visible to the naked eye.

"We're feeling pretty confident," said Botvinick, a biomedical engineer. But while he is modestly optimistic, the Army expresses its faith in new medical technologies with a bullhorn.

To hasten the monitors' delivery, the Army is looking to the Combat Casualty Care Research Program, known as CCCRP, of the U.S. Army Medical Research and Materiel Command. "Our focus is squarely and specifically on the health and welfare of the warfighter," said Col. Michael Davis, the newly installed CCCRP director.

In his role as an investigator with the CCCRP's portfolio for Photonics and Light-Based Innovation for Severe Injury, Botvinick's lactate monitor satisfies the Army's desire for smaller, better technologies to operate in combat scenarios that will likely play out in denser, more urban areas, and in which prolonged field medical care will likely be the norm.

"The vision [for the device] is something like a blister pack that you would peel open in the field and then a medic would just slap it on the body," says Botvinick. "And in that simple act of slapping, an insertion needle would be guided just under the skin […] and then by pulling back on a sticker or tab, that needle would be removed and just a flexible fiber would remain."

That tiny fiber would then interrogate the tissue around it, asking how much lactic acid exists in the area, according to Botvinick. From there, the assembled information would then be transmitted via Bluetooth technology to a wearable unit on the skin.

While measuring lactate is not currently the standard of care in the field (chiefly because current protocol requires blood samples to be drawn and then sent to a lab for study, a logistical nightmare in the field), Botvinick's sensor measures lactate faster than the lactate level within the body can change, which makes it ideal for the fluidity of long-term transport situations, as well as transportation between levels of care. As such, a number of prototype devices are being prepared for shipment to the U.S. Army Institute of Surgical Research in San Antonio for animal model testing.

This is just one example from a research program rich with potential solutions.

BATTLEFIELD MEDICINE

Based in a small building on the southern edge of Fort Detrick, Maryland, the CCCRP is the only federal entity specifically tasked with developing the tools and knowledge required to aid injured warfighters on the battlefield. It comprises four portfolio management areas: Hemorrhage and Resuscitation; Neurotrauma and Traumatic Brain Injury; Joint Forward Surgical En-Route Care; and the aforementioned photonics portfolio.

The Army is leaning on CCCRP to produce the next-generation tools it will need to conquer and secure the rather bleak battlefield projected for the 2025-2040 timeframe. Specifically, experts predict the U.S. will likely encounter far more sophisticated enemies in the future than in previous conflicts, as well as enemy forces with the capabilities to degrade and inhibit U.S. air, maritime, cyberspace and EMS access and superiority.

That puts the execution of prolonged field care in the spotlight. A recent Capability Needs Assessment commissioned by military leadership named prolonged field care as the No. 1 capability gap across the entire Army. Indeed, experts say future battlefields will require medical efforts to be more assertive at the point of injury as opposed to standard forward aid locations, a shift that also radically changes the concept of the "golden hour" standard of care, which relies on traditional medical transport to get service members treated within the first hour after injury.

LITERALLY, ON THE BATTLEFIELD

"We're going to need lighter, leaner, better capabilities than we currently have," said Col. Antoinette Shinn, manager of the CCCRP's joint Forward Surgical En-Route Care portfolio. "For instance, how are we going to maximize tele-health efforts in ways that will assist a far-forward medic, or maybe even no medic at all, in providing life-sustaining care for up to 72 hours?"

Shinn's portfolio is currently investing heavily in noninvasive hemorrhage detection capabilities for situations in which a warfighter sustains an injury but is neither overtly bleeding nor visibly symptomatic yet. The latter falls into the burgeoning area of "intelligent tasking," whereby physiology will ultimately determine a patient's medical needs.

A more fully realized version of the CCCRP's technological vision for the future is in the program's Neurotrauma and Traumatic Brain Injury portfolio, where a slew of recent investments have evolved into a variety of potential solutions, each with substantial benefits. With more than 370,000 cases of TBI across all military branches since 2000, progress in this discipline is a top priority.

"We've got a number of promising technologies, but it's not going to be just one of them that has all the answers for all environments," said portfolio manager Dr. Tammy Crowder. "It's not going to be like the chickenpox vaccine where everybody gets the shot and then we're all protected."

The portfolio's standout performer so far has been the I-Portal PAS tool, developed by Pennsylvania-based Neuro Kinetics Inc. The device uses a virtual-reality headset to assess possible brain injury by measuring a series of oculo-motor pathways, or, more simply, basic eye movement. The user completes more than two dozen tests over 25 minutes, after which a clinician analyzes eye movement and effective neuro-functional capability to determine if a TBI is present. Following initial feedback, NKI is in the process of reducing the exam time from 25 minutes to five while using the same battery of tests.

Crowder's team is looking for other technologies as well, including balance boards and additional virtual-reality devices that measure separate oculo-motor pathways.

"We're literally throwing the long ball with this one," said Crowder. "But these kinds of efforts will hopefully enable first responders to offer more complete care."

(Editor's Note: This is part one of a two-part series. This article will be published in the January -- March 2018 Army AL&T magazine.)