Between Flesh and Steel (48 page)

Until after the Gulf War, the U.S. Army was medically configured to deal with casualties that were expected to occur in a conventional large-scale conflict. The emphasis on conventional conflict was evident in the training and equipment of American troops in the Gulf War for operations in the chemical and biological environments that U.S. commanders believed they would face. They issued troops were chemical suits and gave them atropine syringes for use in reversing the effects of some chemical weapons. Medical teams were outfitted with chemical suits, and decontamination facilities were placed near medical service points. All of these practices had been developed earlier during the Cold War when the United States expected to fight a conventional war against the Soviets in Europe.

In 1998, the U.S. military undertook a study and reevaluated its military medical practices, taking into consideration its experience in its most recent conflicts. In 2007 it resulted in the Tactical Combat Casualty Care program, which instituted a number of changes in the medical structure and practices for treating casualties in
the tactical environment of guerrilla war. Casualty statistics revealed that the most common killers of the wounded were shock and bleeding, as they had been since time immemorial. Renewed emphasis was placed on stopping bleeding quickly and reversing blood loss, and the guidelines called for improving the training and equipment of combat medics to accomplish these goals. The military also recognized that some individuals who are not medics should be trained in additional medical skills beyond those that all soldiers were trained to have. The military instituted the Combat Lifesaver Program in which selected soldiers were trained in four basic skills to keep a wounded man alive: conducting a needle thoracostomy (an operation in which a responder makes an incision in the chest wall and maintains the opening for drainage of fluid or abnormal accumulation of air; heretofore performed only by surgeons but now by field medics), starting an intravenous (IV) line, performing fluid resuscitation, and using traction splinting.
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American soldiers were issued improved first aid kits that contained combat gauze, a tourniquet, and a nasopharyngeal airway for stopping hemorrhage and inadequate airway difficulties, both of which are frequent causes of death on the battlefield.

The initial stimulus for reexamining field medical practices came from the American experience in the Battle of Mogadishu. That engagement involved 170 soldiers in a fifteen-hour urban battle with guerrillas in which 100 American troops were wounded and 14 died on the battlefield. Another 4 died later in hospital. Experience in Iraq and Afghanistan also showed that besides producing more serious injuries than did previous wars, these wars were wounding more soldiers relative to the number killed in action. Paradoxically, although the overall casualty rates were low, the number of wounded that required medical attention was relatively high compared to other wars. In World War II, the U.S. military suffered 1.6 wounded for every man killed; in Vietnam, 2.8 wounded for each man killed; and in Iraq and Afghanistan, 16 servicepeople wounded for each soldier killed.
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These experiences led to major changes in U.S. military medical practice and the incorporation of new medical technologies for treating the wounded. Among the most important new practices was the extensive use of the tourniquet.

American armies have used the tourniquet since at least the Civil War and did so extensively in World War I. However, it acquired a reputation as being dangerous when misuse (overtightening) caused tissue damage or when the time lapse between initial application and the casualty reaching a medical facility where the tourniquet could be safely removed was too long to prevent necrosis of the limb. The tourniquet
consequently fell out of use. Nonetheless, the tourniquet was especially critical for blast injuries where damage to the extremities caused massive bleeding. A severed femoral artery, for example, will cause a person to bleed to death in seven minutes. At the start of the Gulf War, U.S. combat medics had no longer been trained in the use of the tourniquet and did not carry them in their medical kits.

The experience in Mogadishu led to the rediscovery of the tourniquet as in important life-saving device. The tourniquet stops bleeding quickly before shock can set in, and it helps stabilize the casualty for further treatment or evacuation. Newly designed tourniquets equalize the force distributed across the pressure strap to prevent tissue damage. The new models used in Iraq and Afghanistan can be tightened with one hand to prevent overtightening, and even the wounded soldier can apply it with only one hand. Equally important, the ability to reach and transport casualties quickly to nearby medical facilities where the tourniquet can be removed has done much to reduce necrotic damage to injured limbs, an important factor in saving the limb from amputation. Today every American soldier carries a tourniquet in his or her medical pack before going out on a dangerous mission, and medics carry a half dozen for immediate use. Soldiers have also come to appreciate the value of the device and commonly place tourniquets loosely around their arms and legs for quick use in the event that they are wounded. The military is also experimenting with incorporating gas-powered tourniquets into battle uniforms that inflate automatically when the soldier is wounded. Using the tourniquet in Iraq and Afghanistan has saved an estimated two thousand lives.
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The focus on preventing shock has also led to changes in the medical assessment of casualties. Since World War II, medics had been trained to keep the casualty's blood pressure up and to administer intravenous fluids to prevent shock. The IV bottle hung from a pole became part of the standard tableau of military medical treatment through Vietnam. This procedure continued to be recommended even though the medical community had recognized during the war that raising blood pressure was dangerous and caused clots to dislodge and start bleeding again. Medics in Iraq and Afghanistan are now trained to assess the casualty's blood pressure by pulse and not to worry about low blood pressure, because a wounded soldier can tolerate lower blood pressure with beneficial results. Gone, too, is the IV bottle. Medics now carry a capped catheter that can be used to push fluids into a vein if the soldier goes into severe shock.
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The widespread use of the Kevlar flak jacket has greatly reduced bullet wounds to the chest and thorax, and many of the casualties now present with wounds to the
neck, groin, and abdomen, locations were the tourniquet cannot be used. An army study of “potentially survivable” wounded in Iraq who reached medical help showed that 80 percent died of hemorrhage, 70 percent of the time from wounds in locations where the tourniquet could not be used to stop bleeding.
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The army searched for effective hemostatic agents to treat these wounds, and in 2007 approved the use of two such agents, QuikClot and HemCon, to be carried by combat medics. Since then, a new technology called Combat Gauze has come into use. Combat Gauze is a fabric bandage impregnated with kaolin, a powdered clay that stimulates blood-clotting. It has proved more effective than other clot-forming powders and granules, which often blew away or were washed away by the bleeding. Combat Gauze has a shelf life of thirty-six months, making it easy to store and transport.

The almost magical power of whole blood to revive trauma patients had been recognized as early as World War I, but once scientists learned to separate blood's components—red cells, plasma, and platelets—which were easier to store and had a longer shelf life than whole blood, the use of whole blood for transfusions fell out of use. Instead, physicians used IV fluid mixed with red blood cells, but in many cases this led to more extensive bleeding. During the second battle of Fallujah, Iraq (2004), no blood bank was available, and dozens of casualties were treated on the battlefield with whole blood drawn from fellow troops. All of the transfused casualties survived to be evacuated. This experience led the army to conduct a study in the Baghdad hospital and found that casualties who received whole blood had a survival rate nearly nine times greater than those who had been transfused with red blood cells and IV fluid.
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In addition to restoring clotting, whole blood reduces the risk of acute respiratory failure, a condition first recognized in the Korean War and treated in Vietnam as “Da Nang lung,” as well as multiple organ failure. Standard practice is now to transfuse whole blood to the wounded whenever possible and to use blood that is less than twenty-one days old, before its components decay.
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The Tactical Combat Casualty Care program also recommended the use of prophylactic antibiotics and that medics be equipped to apply broad-spectrum antibiotics immediately to the wounded. In Mogadishu, the delayed evacuation of casualties often resulted in rapid infection of battle wounds due to contamination by dirt, shrapnel, clothing, and the general bacteria in the area. Infected wounds also became a problem in Iraq. Casualties evacuated to stateside hospitals from Iraq often presented with wounds infected by a multidrug-resistant
Acinetobacter baumannii
infection.

Combat medics also are now equipped with more effective pain-controlling analgesics for battlefield use. Morphine and fentanyl, the traditional analgesics, are cardiorespiratory
depressants and potentially dangerous. New drugs, such as intranasal or IV ketamine, that don't depress one's breathing or heart beat are now in use.

Both the Afghanistan and Iraq Wars initially produced high rates of blinding injuries. Soldiers had been issued eye protection goggles but refused to wear them because soldiers thought “they look like something a Florida senior citizen would wear.”
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The military bowed to fashion and issued new Wiley-brand ballistic eye wear, and the rate of eye injuries decreased markedly in both operational theaters.

In both theaters, the military evacuated casualties from the battlefield mostly via medevac helicopters whose onboard medical teams were trained to prevent shock, stop bleeding, and stabilize the soldier being transported to a medical facility. In Vietnam, only 2.4 percent of the wounded who were alive when they reached a field hospital died of their wounds. This statistic indicated that most deaths occurred before the wounded soldier made it to surgical care; thus, experience emphasizes reducing bleeding and shock to keep the soldier alive on the battlefield and in the transport helicopter. In a fundamental departure from U.S. medical practice in previous wars, another innovation was to move surgical teams and facilities closer to the battle area and make them more mobile to shorten the time between the soldier's being wounded and his receiving surgical care.
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The result has been that a medevac helicopter and medic reached most wounded in Iraq and Afghanistan within forty minutes of their being wounded.

It is estimated that the U.S. Army has only 120 general surgeons on active duty and a similar number in the reserves.
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The army has strived to keep thirty to fifty general surgeons and ten to fifteen orthopedic surgeons in each theater of war. Most of the surgeons serve in forward surgical teams (FSTs) consisting of twenty people: three general surgeons, one orthopedic surgeon, two nurse anesthetists, three nurses, and a collection of medics and other support personnel. Each FST is equipped to move directly behind the troops and can set up a functioning surgical hospital with four ventilator-equipped beds and two operating tables within an hour. The team travels in six of its own Humvees and carries three lightweight deployable rapid assembly shelters (known as a DRASH) that can be attached to one another to form a medical facility of nine hundred square feet. Supplies to resuscitate and operate on the wounded come in five backpacks: an intensive care unit pack, a surgical-technician pack, an anesthesia pack, a general surgery pack, and an orthopedic pack. These packs contain sterile instruments, anesthesia equipment, medicines, drapes, gowns, catheters, and a handheld unit that allows clinicians to obtain a hemogram
and measure electrolytes or blood gases using only a single drop of blood. The FST also carries a small ultrasound machine, portable monitors, transport ventilators, an oxygen concentrator, twenty units of packed red cells, and six roll-up stretchers with litter stands. The FST has sufficient supplies to perform surgery on as many as thirty wounded soldiers. They are not equipped, however, for providing more than six hours of postoperative intensive care.
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The surgical strategy of the FST is to stabilize and control the patient's damage and not to undertake definitive repair unless it can be done quickly. The goal is to stop bleeding, prevent shock, and control contamination without allowing the patient to lose body temperature or become coalgulopathic, a condition in which the blood's ability to clot is impaired. The surgeons try to limit surgery to two hours or less, and then the unit ships the patient to a combat support hospital (CSH), the next level of care. For this approach to be successful, however, the military must have control of the airspace and major roadways and have established the next level hospital.

The CSH is equipped with 248 beds, six operating tables, some specialty surgical services, and radiology and laboratory facilities. These hospitals are mobile and arrive in modular units by air, tractor trailer, or ship. They can be set up to function fully within twenty-four to forty-eight hours. Even at the CHS, the goal is not definitive repair except, again, when it can be done quickly. The maximum stay is intended to be no longer than three days. Any soldier who requires more care is transferred to a level-four hospital. There again, if treatment is expected to take more than thirty days, the wounded soldier is transferred to a medical facility in the United States. The system required some retraining of the surgeons who, instead of transferring their patients, had the caregiver's tendency to keep them at whatever level they were being treated. In the early days of the Iraq War, it took an average of eight days for a wounded soldier to move from the battlefield to a stateside hospital. The travel time is now less than four days. During the Vietnam War, it took a wounded soldier forty-five days to make the journey home.
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