For war buffs, military enthusiasts, and lots of other people it is a fascinating read. The photoessay, however, is hard to look at. Very explicit. Very sad. Not for the faint of heart. Has to be seen in all its full color glory to be truly appreciated.
Some selected quotes from the essay by Dr. Gawande:
Combat deaths are seen as a measure of the magnitude and dangerousness of war, just as murder rates are seen as a measure of the magnitude and dangerousness of violence in our communities....[snip]....U.S. homicide rates, for example, have droppe din recent years to levels unseen since the mid-1960s. Yet aggravated assaults, particularly with fireamrs, have more than tripled during that period. The difference appears to be our trauma care system: mortality from gun assaults has fallen from 16 percent in 1964 to 5 percent today.
We have seen a similar evoluation in war. Though firepower has increased, lethality has decreased. In World War II, 30 percent of hte Americans injured in combat died. In Vietnam, the proportion dropped to 24 percent. In the war in Iraq and Afghanistan, about 10 percent of those injured have died. At least as many U.S. soldiers have been injured in combat in this war as in the Revolutionary War, the War of 1812, or the first five years of the Vietnam conflict, from 1961 through 1965...snip... But a far larger proporition of soldiers are surviving their injuries.
He goes on to to describe the Forward Surgical Teams (FST)- portable trauma centers than fit into six hummvees, including all suppleis and personnel.The Army is estimated to have only 120 general surgeons on active duty and a similar number in the reserves. It has therefore sought to keep no more than 30 to 50 general surgeons, and 10 to 15 orthopedic surgeons in Iraq
Each FST is equipped to move directly behind troops and establish a functioning hospital with four ventilator-equipped beds and two operating tables within a difficult-to-fathom 60 minutes.
This, by the way, is a 900 square foot facility that goes up in 60 minutes, ready for the wounded and surgery. They carry enough supplies to treat 30 soldiers on the spot. Some of the choices they make to enable this are interesting - they don't carry oxygen with them, they carry and "oxygen concentrator" that can supply an air mix of 50% oxygen as long as it has power. They don't carry x-ray equipment - the orthopedic surgeons feel out bone breaks. OK, after you look at the photoessay you realize that in many cases you don't have to find broken bones by touch, or by x-ray - in fact, they're easily identified by the layperson since they're hanging out in the open air. The equipment is chosen with the idea they will be treating healthy young people with broken bodies, not looking for heart disease in overweight, middle-aged corporate managers.
He goes on at some length about the 274th FST, which traveled 1100 miles in four months and treated 132 US soldiers and 74 Iraqis (22 Iraqi combatants, 52 civilians)
When the wounded arrive, the receive the same sort of initial screenings used in civilian trauma cases, but the pattern of injuries is a little different. 80% of casulaties seen by the 274th have gunshot wounds, shrapnel wounds, blast injuries, or all of the above.
The main mission of the FST is damage control - stablize the wounded enough for transport to a Combat Support Hospital (CSH). The goal is to have a wounded soldier transported within 2 hours to more advanced facilities. "Repairs" are done only if they can be done quickly. Otherwise, it's a liberal use of staple guns and wound packing to control bleeding, and washing out dirty/contaminated wounds - pretty much all of them. In the case of abdominal wounds (those of you who checked in on the "gutshot and kneecap thread awhile back might be interested) that might mean washing out the pelvic cavity, stapling shut the cut ends of the bowel, taking care of bleeding blood vessels, packing the wound - the shipping the poor guy off with his belly still open to the next level of care while still sedated, anesthetized, and ventilated. It's rather like stopping surgery in the middle of an operation and sending the patient off to another hospital across town. It took some retraining to get the doctors used to working this way.
Two CSHs are now in Iraq. These are 248 bed hospitals with six operating tables plus some other services (they have x-rays here, as well as some laboratories). They are mobile, and are fully functional in 24-48 hours after being parked in a location. The maximum length of stay is intended to be three days - if you need more than that you go elsewhere - to facilties in Kuwait, Rota in Spain, or Landstuhl, Germany. If more than 30 days of care are expected the soldiers are transferred to the US, iether Walter Reed or Brooke Army Medical Center in Texas. The average time from the battlefield to the US for the severely wounded is less than four days - compared to Vietnam, when the same trip was about 45 days.
One airman wounded in a mortar attack in Iraq made the trip to Walter Reed in just 36 hours. He survived. Which Dr. Gawande uses to illustrate some of the aftermath of war - in no prior war would this man with his injuries have survived. He wound have died at the front, and quickly. Now he will live - after losing both legs, his right hand, some of his intestines, and part of his face. He will live the rest of his life crippled and mutilated, and you have to wonder about things like "quality of life". One certainly can have a long, wonderful life even if maimed in war... but it's harder to achieve that than if you were intact and whole.
The war has gone on far longer than planned, the volume of wounded soldiers has increased, and the nature of the injuries has changed. Blast injuries from suicide bombs and land mines - improvised explosive devices (IEDs) in military lingo - have increased substantially and have proved particularly difficult to manage. They often combine penetrating, blunt, and burn injries. The shrapnel include not only nails, bolts, and the like, but also dirt, clothing, even bone from assaillants.
Surgeons also discovered a dismayingly high incidence of blinding injuries. Soldiers had been directed to wear eye protection, but they evidently found the issued goggles too ugly. As some soldiers put it "They look like something a Florida senior citizen would wear". So the military bowed to fashion and switched to cooler-looking Wiley-brand ballistic eyewear. The rate of eye injuries has since descreased markedly.
Speaking of blast injuries from IEDs, the photoessay also includes a picture of what a Humvee occupant's feet look like after the Humvee drives over an IED. They are not pretty. You can't even really describe them as feet anymore, although some of the toes are still recognizable as toes.Kevlar vests proved dramatically effective in preventing torso injuries. Surgeons, however, now find that IEDs are causing blast injuries that extend upward under the armor
That means amputations. LOTS of amputations. They are not having much success "salvaging" these "extremeties".Blast injuries are also producing an unprecedented burden of what orthopedists term "managled extremeties" - limbs with sever soft-tissue, bone, and often vascular injuries.
There have also been lots of complications - the rates of pulmonary embolism and deep venous thrombosis (DVT) are very high - possibly due to transporting the wounded by air so much (guess we have to find a new name other than "economy class syndrome" for the DVT blood clot problem). It's a problem. Using anti-coagulants - the civilian treatment for this - in wounded soliders with multiple punctions could kill them through uncontrolled bleeding. Failure to transport them to more advanced facilities could kill them. Moving them could kill them. OK, you're the doctor - you have to make a decision right now - what's best for the patient? If you're wrong, he could die. Hell, even if you're right he could die.
37% of the wounded retunring have this microbe in their system. It has spread several times to non-combatant patients at the military medical facilities. Now, wounded from Iraq are isolated on arrival and screened for the bacteria.Injured soliders from Iraq have also brought an epidemic of multidrug-resistant Acinetobacter baumanii infection to military hospitals. It is not known how this occurred.
Don't forget that all the hideous wounds suffered by our soldiers are also being suffered by civilians caught in the crossfire or who are also victims of IED's - young children, women, the old, the sick, the pregnant...so it's not just our young men having their limbs blown off.In Baghdad... the 28th CSH took over and moved into an Iraqi hospital in the Green Zone. This shift has brought increasing numbers of Iraqi civilians seeking care, and there is no overall policy about providing it. Some hospitals refuse to treat civilians for fear that some may be concealing bombs. Others are treating Iraqis, but find themselves overwhelmed, particularly by pediatric patients, for whom they have limited personnel and few supplies
Requests have been made for additional staff members and resources at all levels. As the medical needs facing the military have increased, however, the supply of medical personnel has gotten tighter. Many surgeons have been on second deployment or an extended deployment, and even this has not been sufficient. As a result, military urologists, plastic surgeons, and cardiothoracic surgeons have been tasked to fill some general surgeon positions. Planners are having to contemplate pressing surgeons into yet a third deployment.
Compounding hte difficulties, none of these realities has made it appealing to sign up as a military surgeon. Interest in joining the reserves has dropped precipitously. President George W. Bush has flatly declared that there will be no draft. However, the Selective Service, the U.S. agnency that maintains draft preparations in case of a national emergency, has recently update a plan to allow the rapid resitration of 3.4 million health care workers 18 to 44 years of age.
The full article and photoessay is in the December 9, 2004 New England Journal of Medicine, citation is N ENGL J MED 351:24, pp 2471-2480. We get this one at work, not sure where you'd get it otherwise - I'd start with a library. I pretty sure on-line access requires a subscription.The nation's military surgical teams... have saved the lives of an unprecedented 90 percent of the soliders wounded in battle
