Miracles We Have Seen

by Harley Rotbart

  Among the GIs in the 16th General Hospital was a twenty-year-old high school dropout serving as a private in the Medical Corps, doing the grunt work needed to keep a “M*A*S*H” military field hospital running. So moved was this young man that he regarded the surgeons working to save the thousands of wounded with religious awe, and what they achieved as miracles.

  Following the war a changed young man finished high school, and the GI Bill allowed a college and medical school education to follow, leading to a civilian career on the surgical faculty of a major university medical center.

  That young man was my dad. Could he have foreseen the future, and what his experience in that miserable winter would lead to?

  * * *

  Sixty-nine years later, a twenty-one-year-old soldier, far from his home in Tennessee, stepped on an IED (improvised explosive device) in Helmand Province of Afghanistan. America was back at war, and once again U.S. soldiers were taking casualties. Germany was again at the heart of the treatment of battlefield wounded.

  The soldier collapsed, blood streaming from his legs, exposed bones and muscle dangling. He is one of hundreds, even thousands. These so-called improvised devices are actually very sophisticated. They have radio controlled triggers, pressure triggers like a land mine, or wire-controlled triggers; these are major explosive devices that have destroyed many vehicles.

  A field paramedic embedded in the soldier’s unit provides first aid. The soldier is promptly evacuated to the nearest Forward Operating Base, where emergency surgery is done. Dead tissue is removed, which unfortunately includes most of his left leg. There’s dead tissue in the right leg as well, but notwithstanding multiple broken bones, it appears that limb is salvageable. Hemorrhage is stopped. Bolts are drilled through broken bones, and an external “erector set” is used to manipulate the bones into position to allow heal-ing to begin. Infection is addressed with antibiotics, and most importantly through aggressive surgical removal of dead tissue.

  The patient is transfused with blood, and soon thereafter is flown by helicopter to a combat surgical hospital. Again, he undergoes surgery. More unhealthy tissue is removed. Sterile fluids and antibiotics are used to flush out foreign material from the wounds: grit and grime, fragments of clothing, fragments of weapons. Sophisticated suction dressings are applied. Fluids and antibiotics are administered. The patient is carefully evaluated for associated injuries to his brain, eardrums, lungs, heart, kidneys, and other vital structures.

  A giant C-17 Globemaster Air Force transport plane lowers a huge trapdoor under its tail. An ambulance bus nearly drives up this ramp, but it stops and its rear doors are opened. Injured soldiers from the Combat Surgical Hospital are carried aboard by hand stretchers. The belly of this plane is not filled with rows of seats, although there are seats around the walls, facing the center of the airliner. In the center are layered racks for stretchers, accompanied by equipment to allow artificial breathing, transfusions, intravenous fluid administration, cardiac support, and other services consistent with an intensive care unit (ICU). From the back of the ambulance bus our injured soldier is one of those carried aboard the Globemaster by uniformed personnel. His lower body is covered in bandages and adorned by the metallic orthopedic devices that have been drilled through the bones of his remaining leg to repair the shattered bones. His stretcher is fastened into one of the racks, and the plane lifts off, accompanied by nurses and physicians specially trained for the challenges of intensive patient care at 30,000 feet.

  Seven hours and thousands of miles later, at Ramstein Air Base in Germany, the scene is repeated in reverse. The stretchers come off the Globemaster, and are loaded into the ambulance buses that are backed up to the rear ramp of the plane. The “walking wounded” follow down the ramp, and all are transported to Landstuhl Regional Medical Center. This is America’s largest overseas hospital and serves military and State Department personnel sta-

  tioned throughout Europe, Asia, and Africa. Since the beginning of Operation Enduring Freedom in Afghanistan, and throughout related operations in Iraq, Landstuhl has been the primary site of treatment of major injuries arising in these war zones. American soldiers and their comrades from coal-

  ition countries have been arriving there daily.

  The hospital is staffed by full-time military physicians on active duty, reservists called up to active duty, as well as by civilian volunteer physicians giving their time and skills to allow the Army to send additional uniformed active-duty physicians “down-range” into the war zone.

  As I—the son of that Army private who saw the miracles, and tragedies, of combat medicine in the cold winter of 1944—stand among my fellow surgeons awaiting the injured soldier from Tennessee, I reflect on how powerfully and proudly my father’s experience has been passed to another generation.

  We at Landstuhl know what to expect. It is surely not the first time. The flight plan from Bagram Airbase in Afghanistan has been transmitted to the ICU at Landstuhl; arrival time is precisely known. The patient’s records fly through the electronic ether and the details of physician reports and care provided at each step of the way flash on to the computer screen of the ICU in Germany hours before the patient’s arrival. The next steps in his care are planned. Appropriate personnel are ready and waiting as the young man is lifted off the ambulance bus at the Landstuhl emergency entrance.

  The young soldier is wheeled into the ICU. We examine him and compare our findings with the information transmitted from down-range. Large wounds, both legs, and one leg missing. Genital wounds, the blast from below. They’re open, bones exposed, but the wounds have been well cared for en route to us. There is no active bleeding, yet inevitably some debris still accumulated in the depths of the wounds.

  Back to the operating room. The remaining debris, Afghani soil, and metallic fragments are removed. All living tissue is left in place. Detailed protocols have been developed by the Army Institute for Surgical Research for care of these injuries, based on careful analysis of thousands of such victims. The pattern of wounds in each soldier is electronically recorded, as is the treatment and outcome to find the most effective paradigm to treat each constellation of injuries. Newly enlisted active-duty physicians, reservists called up, and we volunteer surgeons all have access to the same best practice protocols; nobody needs to reinvent the wheel.

  We administer antibiotics and vaccines for infections we don’t see in the West; this, too, has been driven by detailed analysis of years of experience with such complex medical and surgical cases. Pain medication, psychological support, physical therapy, and attentive nursing care all working together for each soldier as an individual.

  Our Tennessee soldier gets stronger each day, less pain medicine, cleaner wounds. Plans for reconstruction and rehabilitation are being made, and thoughts turn to home. Thousands of miles farther must be traveled. It’s back to the C-17 Globemaster, with its four large jet engines on a wing over the fuselage, lifting the giant belly of the plane—a belly full of stretchers surrounded by specialists, and the “walking wounded” in the seats with their backs to the outside walls. Another seven or eight hours, this time to Andrews Air Force Base and Walter Reed Medical Center. Then they will be closer to home where a family from Tennessee can visit, and further efforts can be made in reconstructing wounds, supporting families, and rebuilding lives.

  By the time soldiers reach Germany, most know they’re going to survive. Miraculously, and a true tribute to the infrastructure of military medicine, 98 percent of those who make it off the battlefield to the nearest Forward Operating Base alive will survive. If the soldier is not killed on the battlefield, his or her chances of survival are now overwhelmingly good.

  The young private in Germany decades earlier who witnessed surgeons working battlefield miracles would have loved to see this new day. During his time, in World War II, only about 20 percent of those who were injured on the battlefield survived, and that was a great improve
ment from the first World War thanks to the introduction of antibiotics.

  Ours is a world in seemingly perpetual conflict. Thankfully, since my dad’s days in that World War II military field hospital, the odds for soldiers have improved with each conflict. By the Korean War, surgeons were mastering the repair of major blood vessel injuries (which became the basis for heart bypass surgery throughout the world soon afterward). Many advances grew out of the Vietnam experience, among which was the recognition of Da Nang lung, a lethal fluid buildup in the lungs that follows injury or infection. Since that time, the treatment of this problem, now known as adult respiratory distress syndrome (ARDS), has become a key part of ICU care of patients throughout the world. ARDS affects hundreds of thousands of patients every year who have never been on a battlefield or in a war—yet it was on the battlefield where we learned to recognize and treat that condition. The current level of care our soldiers—and, for that matter, our civilians—receive is built on the shoulders of past soldiers and their battlefield caregivers.

  Before flying home to his family, the young soldier from Tennessee expresses profound gratitude to those of us caring for him. I share with him the stories of battlefield miracles performed by generations of physicians and nurses before me—miracles that paved the way for what we can accomplish today. For me, these stories began years before I was born, with the experi-

  ences of a young soldier from an earlier generation, a private on the German front in the bitter winter of ’44.

  Date of event: 1973

  Safe to Sleep

  Henry Sondheimer, MD

  It was a dark and rainy night. . . . Well, it really was a dark and rainy night, and in Northern Arizona where it only rains seven or eight inches a year, that was pretty unusual. I was working at a small, thirty-eight bed hospital on the Hopi Reservation about 250 miles from Phoenix and 80 miles from Winslow, Arizona, where we bought our groceries. We had seven doctors, all Anglo, and about forty nurses, almost all Hopi and Navajo. Our group of doctors had been there for seven months by the time this January night came around so the nurses were familiar with all of us and, probably more importantly, we had the sense that they liked and respected our group of outsiders on their homeland—or at least we hoped they did.

  Probably the best strategic decision our group of doctors made was that we would have the on-call doctor sleep in the hospital. This had been a major bone of contention among the group that preceded us. In the end, they had slept at their houses in the government compound two miles away and the nurses didn’t like that. The hospital wasn’t extremely busy at night, but there was a delivery almost every night and the small ER on the ground floor always had some action: a sick child, a car accident, or just an adult wanting to refill medications. The seven of us were all very young, no one being more than two years out of medical school. Most of the group had done a year of family medicine training, one guy had done two years of internal medicine, and my wife and I had each done two years of pediatrics. No one had formal training in obstetrics and gynecology, surgery, or orthopedics, although we had 250 deliveries each year, fractures, and other orthopedic events regularly. The occasional need for a surgeon always meant an ambulance ride for the patient to the bigger Indian Health Service hospitals seventy miles east and west of us. Over time, we each picked up the skills of at least one of the required specialties that we knew our patients needed but for which we had no formal training: diabetes clinic, TB clinic, field outreach health delivery, etc. I became a regular at prenatal and postpartum clinics.

  So that brings us to January. I was on call, had gone home to the compound for dinner, returned in time to see two adults in the ER and deliver a baby, and was finally tucked away into our call room on the second floor of the hospital. I know I was asleep because, when the pediatric nurse called me, I was a little disoriented and didn’t at first understand what she was concerned about: “The baby doesn’t look good.”

  What did that mean, “ . . . doesn’t look good”? Back in residency at the university hospital last summer I would have expected a lot more detail from the nurse. The baby’s temperature, heart rate, and blood pressure. Has he urinated, had bowel movements? But in Hopiland less talk was more. I knew she wouldn’t have woken me if she hadn’t been concerned, so I held my tongue from all those questions I might have asked six months earlier and jumped out of bed.

  And she was right, the baby didn’t look good. He was three months old, Navajo, cute as a button. One of my partners had admitted him early the previous morning for pneumonia. Coughing, a few crackles in the chest, and an X-ray that was suggestive of pneumonia, but not overly concerning. He had appropriately sent the baby upstairs to the pediatrics unit. It was probably a viral pneumonia, my partner had written, and he was probably right. It was winter and respiratory viruses were rampant on the reservation. So why didn’t the baby look good? I wasn’t sure. His temperature was just 100 degrees Fahrenheit, not very high at all. But his color was pale. His blood pressure was good and his heart rate was 104, a little slow but he was sleeping, so probably okay. I listened to his lungs. I kept listening to his lungs. I couldn’t hear any signs of pneumonia—and then it struck me. I couldn’t hear anything at all—because he wasn’t breathing. He wasn’t breathing!

  I turned to the nurse, “Is he breathing?” At first she thought so. I was awake now, adrenaline-fueled. I looked at my watch, at the second hand. I decided I wasn’t going to panic. So I watched him, watched him for one full minute. Sixty seconds is a long time when you don’t know what’s going on. He breathed only twice. Normal babies breathe twenty-four to thirty times a minute, babies with pneumonia are supposed to breathe even faster. I stimulated him, pushed a little on his breast bone, he breathed three or four times in response, but then he slowed back down again. We didn’t have the standard heart rate and breathing monitors every hospital off the reservation had. I asked the nurse to recheck his pulse. Still good. It was just his breathing, or lack thereof, that was failing.

  I then realized I was looking at a case of impending sudden infant death syndrome, or SIDS, or “crib death.” Babies who die silently in their sleep, in their cribs. Tragically, these cases are almost always discovered too late, after a baby has already completely stopped breathing for too long to resuscitate. A parent’s worst nightmare. This child was on his way to stopping breathing completely, and then to being a crib death. But here he was in front of me, and I certainly wasn’t going to let him die. Of course we also didn’t have an infant ventilator (breathing machine), so there would be no use putting a tube down his throat to breathe for him the way I learned to during my training. My guess is that even if we had a ventilator we probably wouldn’t have had a tube the right size anyway. This wasn’t University Hospital.

  So there we were, the nurse and I. It was 2:00 am, very dark and rainy outside, and it’s just the two of us and this baby who was trying to become a statistic. And then the nurse turned around, went to the work station, and brought me a nine-inch length of twine. She put it around the baby’s ankle, tied a slip knot, and passed it to me. I was catching on by now, so I knotted the metal end of my reflex hammer to the end of the rope. I pulled on the ankle, gently, and the child breathed. I did that every ten seconds or so for about an hour and a half. I wasn’t sleepy at all. Every few minutes the nurse would come in and I’d stop stimulating the baby, and we would count his respira-

  tions. Slowly they came back up, maybe six or eight per minute at first, but a lusty thirty after ninety minutes. And then he was fine, coughing and acting like he had viral pneumonia, which he did, now with a 101 degrees Fahrenheit temperature. Infections can trigger SIDS. He had passed the crucial moments when his breathing would have stopped entirely. He went on to a full recovery from his pneumonia with no further interruptions of breathing.

  I’ve thought about this night for many years now. It was my miracle that I got to save a child who I am sure would have died of SIDS. And
it was the nurse’s miracle that she recognized there was something wrong with this baby and stayed by my side through the night. And it was a miracle for the baby and his parents, as well. In recent times, babies like this with “near SIDS,” those with slowed breathing or dangerously long gaps between breaths, are sent home from emergency rooms or hospital nurseries with apnea monitors. Apnea means lack of breathing, and such monitors can be managed by families of at-risk babies at home. There were no home monitors in 1973. We didn’t even have a monitor in the hospital for our patient; yet his breathing came back to normal and he was able to go home shortly thereafter without further problems.

  But that’s not the end of the story. SIDS wasn’t even recognized as a distinct medical entity until 1969. In 1974, a year after our little miracle baby, Congress passed the Sudden Infant Death Syndrome Act, recognizing SIDS as a public health threat and directing funds for research. At that time, no one knew the causes or risk factors for SIDS. The first true breakthroughs didn’t happen for another decade when epidemiologists, scientists who study large populations of people, discovered an association between a baby’s sleep position and the risk of SIDS. They discovered that putting a baby to sleep on his back dramatically reduced the risk of SIDS compared with babies who slept on their tummies. A hard sleeping surface was also shown to be protective. In 1994, the Surgeon General of the United States issued a policy statement recommending babies sleep on their backs or sides. This became the “Back to Sleep” public education campaign. (Subsequently, side sleeping has also been shown to be associated with a risk for SIDS, making back sleeping the only recommended position.)

  In retrospect, the Navajo parents on our Indian reservation may have been well ahead of their time, and well ahead of other Indian Health Service locations. We had no cases of SIDS occurring in Navajo homes that I can recall or ever heard about (notwithstanding the near-SIDS case I just described). It has since dawned on me that every Navajo baby, probably for hundreds of years, has slept on a board, on his or her back, beginning the day they are born. Back to Sleep. In contrast, other Native American cultures, and other reservations, had very high rates of SIDS. In 2002 and 2003, the National Institutes of Health began educational programs directed specifically at high-risk Native American communities.