Between Flesh and Steel

by Richard A. Gabriel

  Soviet positions were often marked by an accumulation of refuse that were rife with rats and disease. Stagnant pools of water in discarded ration cans served as breeding grounds for malaria-carrying mosquitos. The Soviet soldier was entitled to three sets of underwear that were supposed to be changed weekly; however, in practice, the soldier often received only one set that he wore for months at a time. This unhygienic practice and the failure to wash bedding regularly led to an infestation of lice. The resulting epidemics of typhus crippled the combat units’ ability to fight.

  The lack of a professional career noncommissioned officer (NCO) corps also contributed to the Soviets’ failure to control infectious diseases. The Soviet NCO was a conscript who first attended a six-month training course to serve as an NCO; however, these conscript NCOs had no effective practical or moral authority over their fellow conscripts with whom they identified and sympathized. As with the average Soviet conscript, the NCO looked forward to being released from service as soon as possible. Soviet NCOs were little help to their platoon leaders in enforcing discipline and military standards, and complete responsibility fell upon the young lieutenant commanding the unit. Thus, in addition to his primary responsibilities for training, maintenance, and combat duty, the platoon leader personally had to ensure that his troops were free of lice, washed their hands, drank clean water, disposed of their trash properly, and dug and used latrines. Without professional NCOs to help him, the Soviet platoon leader often failed to perform all of his duties adequately. One result was a breakdown in field sanitation.

  The Soviet military medical system in Afghanistan functioned relatively well when it came to dealing with the wounded, but it became overwhelmed when handling large numbers of diseased and sick soldiers. Apparently the Soviets grossly underestimated the amount of medical support their army would require to treat casualties and disease simultaneously. The Soviet solution was to evacuate large numbers of sick and wounded to military hospitals in the Soviet Union and Warsaw Pact countries to relieve overcrowded hospitals in-country. In Afghanistan, meanwhile, the Soviets’ infectious disease hospitals and rehabilitation center for recovering disease patients were constantly filled with patients, and evacuating the sick out of the country became the norm.23 The army constantly shipped replacements into the theater of operations to compensate for the large amount of manpower lost to disease. After the war, media reports indicated that significant numbers of Soviet troops who had fought in Afghanistan also had acquired an addiction to the cheap opiates available there. Soviet officials, however, have not released any statistics on drug abuse by Soviet troops, and no evidence suggests that it affected the fighting ability of the Soviet Army as a whole.

  POST-USSR RUSSIAN OPERATIONS

  An analysis of Soviet military operations since the Afghanistan war suggests that the Russian ground forces made few reforms to their medical support system after their experience in Afghanistan. In 1988, the Soviet Army was sent to Armenia to provide earthquake relief. Their lack of a good diet, field sanitation, and clean clothing resulted in high rates of disease and illness; consequently, the rescuers had to be rescued themselves. In 1989, a Soviet air assault regiment, an airborne regiment, and a motorized rifle regiment were sent to Tbilisi, Georgia, to put down rioting. The troops deployed with only a single change of underwear.

  In 1992, the Russian Fourteenth Army engaged in combat in Tiraspol, Moldova. The lack of clean water and an abundance of disease-contaminated cooks once again led to an outbreak of disease. Only the brevity of the deployment kept events from getting medically out of hand. In 1992, the Russian 201st Motorized Rifle Division deployed to the border region between Afghanistan and Tajikistan to help guard the newly independent republic’s border against mujahideen infiltration. Once again the Russian medical establishment failed to provide sanitary mess halls, field messes, and adequate clean water for drinking. Within weeks, viral hepatitis, intestinal infections, and malaria had rendered the division combat ineffective as hospital wards filled with sick soldiers.24

  The Russian medical experience in Chechnya (1994–1996) was not much different than it had been in Afghanistan or in its other post-Afghanistan military operations. In two years, the Russians suffered 4,739 dead and 13,108 wounded.25 The Chechnya war was primarily a conflict fought in urban zones and produced different types of casualties than those suffered in Afghanistan. The majority of Soviets killed in Chechnya were victims of sniper fire and had been hit in the head or upper chest. While the normal ratio of wounded to dead is roughly three or four to one, this ratio was reversed in the Chechnya fighting, which saw three killed for every one wounded.26 This type of combat confronted the Soviet medical system with new challenges. Snipers and the willingness of Chechnya insurgents to shoot down medical evacuation helicopters forced the Russians to rely on armored personnel carriers (BTR-80) as ambulances and other ground transport to reach and transport their casualties. The Russians seem to have anticipated the unique nature of the urban combat they would face in Chechnya, and weeks before the invasion they established and trained special emergency medical treatment detachments that deployed with the army.27 In addition, each maneuver company was reinforced with a physician’s assistant, and each maneuver battalion received an additional doctor and ambulance section. On balance, the Russian medical system performed about as well as it had in Afghanistan when dealing with combat casualties.

  The Russians’ medical performance in dealing with infectious disease, however, was as dismal as it had been in Afghanistan.28 The same causes that had plagued the Russians in Afghanistan—a nutritionally inadequate diet; a lack of clean drinking water, clean clothing, and bathing facilities; poor hygiene among unit cooks; and generally poor field hygiene by the troops—plagued them again in Chechnya. Acute viral hepatitis and cholera were epidemic among Russian troops, and units were frequently rendered combat ineffective during outbreaks of disease. Throughout the war, the Russian Ministry of Defense could barely maintain its combat field units in Chechnya at 60 percent because of disease.29

  THE U.S. WARS IN IRAQ AND AFGHANISTAN

  The American military has been engaged almost continually in combat operations from 1990 to 2012. During this period, the United States conducted combat operations in Iraq (1990–1991), Somalia (1992–1993), Iraq again (2003–2012), and Afghanistan (2001–2012). American casualties in all of these conflicts were light by historical standards. In the Gulf War (1990–1991), 382 soldiers died, but only 147 of them, or 38.5 percent, were killed in combat. In Somalia, 31 American soldiers were killed and less than 200 wounded. Nine years of insurgency warfare in Iraq has cost 3,480 deaths by hostile fire and 31,931 wounded; 928 soldiers died in accidents or by disease. During ten years of war in Afghanistan, U.S. forces have suffered 1,227 dead, 11,411 wounded, and 253 dead due to disease and nonhostile causes.30 Of the 5,684 soldiers in Iraq and Afghanistan who suffered major limb injuries, 862 underwent amputation. The injured-to-amputation rate for both wars was 7.4 percent, or approximately the same as in Vietnam (8.3 percent).31 The traumatic limb injuries that casualties in Iraq and Afghanistan have suffered often were far worse than those seen in Vietnam, however, as they combine penetrating, blunt, and burn injuries with contamination by shrapnel, dirt, clothing, and even bone.32

  From a medical perspective, U.S. casualties have been generally light, and in only a few battles, such as Mogadishu (1993) and Fallujah (2003), was the immediate casualty stream even moderately heavy. Field medical facilities have never been overwhelmed by the volume of casualties similar to those that occurred occasionally during Vietnam and commonly in Korea and World War II. In World War II, 22.8 percent of the wounded died; in Vietnam the figure was 16.5 percent. Taking the Iraq and Afghanistan Wars together, 8.8 percent of the wounded died.33 The performance of the medical disease control teams and the troops’ general field hygiene were excellent in all wars. In Somalia, for example, where the endemic disease and contagion profiles are high, the health of American troops r
emained excellent. The weekly disease and non-battle injury rate was approximately 11.5 percent, with only 0.5 percent requiring hospitalization.34 Only seventy-two cases of malaria were recorded, and problems with diarrhea and heat stroke were minimal.35 Excellent diet, field hygiene, clean water, mosquito and rat control, and a program of disease surveillance were responsible for these outcomes.

  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.36 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.37 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.38

  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.39

  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.40 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 cas
ualties 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.41 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.42

  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.