Between Flesh and Steel

by Richard A. Gabriel

  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.”43 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.44 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.45 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.46

  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.47

  The Iraq and Afghanistan Wars have become notorious for the number of soldiers suffering brain damage from explosive devices. Fully 20 percent of the wounded have suffered some form of brain trauma.48 If the full spectrum of brain injuries are considered, thousands of soldiers may be suffering from brain injuries who have gone undiagnosed. Brig. Gen. Stephen Xenakis, a psychiatrist with the Psychiatric Institute in Washington, D.C., has observed that beyond the thousand or so cases of major brain trauma (fractured skulls, penetration, etc.), thousands of soldiers have suffered concussions, some temporary loss of consciousness, memory, hearing, and so on, from blasts that would produce mild brain injury. “But you also have literally hundreds of thousands of troops who’ve been exposed to blast, maybe repeatedly. We don’t know the long-term effect on these soldiers. That’s the big worry.”49

  Of great concern are the 30 percent of the soldiers who have developed Post-Traumatic Stress Disorder (PTSD) within a few months of returning home from the combat theaters. The symptoms of PTSD are remarkably similar to those associated with mild brain injury: confusion, depression, irritability, rage, and fatigue. When PTSD was first diagnosed during World War I, doctors called it “shell shock” and thought it was caused by explosive concussion that produced micro-bleeding in the brain. Russian and German neurologists performed dozens of autopsies in search of the physical evidence of micro-damage with little success. As a consequence, American and British military psychiatrists rejected the biological explanations of the Russians and Germans, opting for then popular Freudian psychological explanations. Now, it turns out the Russians and Germans might have been right all along.

  To explain the high rates of PTSD among American soldiers, psychiatrists have turned to a new theory regarding its cause that bears a strong resemblance to the original shell shock explanations of World War I. The new theory suggests that the overpressure from an explosive shock wave traveling thousands of feet per second creates microscopic gas bubbles in the brain that then pop, leaving tiny cavities that never heal. The result is minor brain damage that produces PTSD’s symptoms and is similar to the minor brain damage acquired through other causes.50 The great fear is that these injuries may have affected tens of thousands or hundreds of thousands of soldiers who were exposed to blasts but were never counted among the wounded because they did not show any immediate symptoms of injury. Prior to the Afghanistan and Iraq Wars, the Pentagon had greatly reduced its research funding for brain injury by almost 50 percent. In 2007, however, the military reversed its decision and once more began to budget money for brain research. In addition, all returning soldiers are screened after three to six months for previously unnoticed brain injury.51 In 2002, 200,000 American soldiers sought mental health counseling for post-traumatic stress–related disorders. In 2011, the number of soldiers who actually received treatment or counseling from behavioral health specialists increased to 280,000.52

  Beyond the advances in treating brain injuries, the U.S. military has made great strides in developing prosthetic limbs for amputees and has greatly funded surgical trials to deal with the facial disfigurement that explosive devices often cause. In many cases, surgeons can now repair or replace entire faces. Most recently, surgeons have succeeded in transplanting forearms and hands. Once more the terrible human costs of war have produced significant medical advances from which the larger population may benefit.

  NOTES

  1. Stephen Tanner, Afghanistan: A Military History from Alexander the Great to the War against
the Taliban (New York: Da Capo Press, 2009), 228.

  2. Ibid.

  3. Ibid., 248.

  4. Ibid., 255.

  5. Lester W. Grau and William A. Jorgensen, “Handling the Wounded in a Counter-Guerrilla War: The Soviet-Russian Experience in Afghanistan and Chechnya,” Army Medical Department Journal, January–February 1998, 2, citing official Russian statistics in G. F. Krivosheev, “The Secret Seal Is Removed,” Voyenizdat, 1993, 401–5.

  6. Grau and Jorgensen, “Handling the Wounded,” 2, citing Soviet source: E. A. Nechaev, A. K. Tutokhel, A. I. Gritsanov, and I. D. Kosachev, “Medical Support of the 40th Army: Facts and Figures,” Military Medical Journal, August 1991, 4.

  7. Soviet Studies Research Center, The Sustainability of the Soviet Army in Battle (The Hague: SHAPE Technical Center: September, 1986): 286–96.

  8. Department of the U.S. Army, FM-100-2-2: The Soviet Army Specialized Warfare and Rear Area Support (Washington, DC: U.S. Government Printing Office, 1984), 13–21.

  9. V. D. Kurvshinskiy, “Technical Service and Repair of Medical Equipment in the Course of Military Activity,” Military Medical Journal, 1992, 42–44.

  10. I. M. Chizh and N. I. Makarov, “The Experience of Medical Support to Local Wars and the Problems of Air Evacuation of the Sick and Wounded,” Military Medical Journal, January 1993, 23.

  11. Ibid.

  12. Grau and Jorgensen, “Handling the Wounded,” 8.

  13. Ibid.

  14. Yuri Nemytin, “Special Medical Aid to the Wounded in Afghanistan,” Military Medical Journal, January 1991, 17.

  15. Grau and Jorgensen, “Handling the Wounded,” 8.

  16. Ibid.

  17. Ibid., 2.

  18. Lester W. Grau and William A. Jorgensen, “Medical Support in a Counter-Guerrilla War: Epidemiological Lessons Learned in the Soviet-Afghan War,” U. S. Army Medical Department Journal, May–June 1998, 2.

  19. Ibid.

  20. I. V. Sinopal’nikov, “Medical Losses of Soviet Troops during the War in Afghanistan: Medical Losses from Infectious Diseases,” Military Medical Journal, September 2000), 4–11.

  21. Grau and Jorgensen, “Medical Support,” 3, citing E. A. Nechaev, “Medical Rehabilitation of Veterans of Wars and Local Conflicts,” Military Medical Journal, February 1994, 5.

  22. Ibid., 7.

  23. Yuri Nemytin and V. V. Boldyrev, “Rehabilitation Management of Infectious Patients in Overcrowded Hospitals,” Military Medical Journal, April–May 1992, 38–39.

  24. Lester W. Grau and William A. Jorgensen, “Viral Hepatitis and the Russian War in Chechnya,” U S. Army Medical Department Journal, May–June 1997, 2.

  25. The Russian Weekly, February 21, 2003, 1.

  26. N. N. Novichkov et al., The Russian Armed Forces in the Chechnyan Conflict (Moscow: Holweg-Infoglobe-Trivola, 1995), 133.

  27. Ibid., 18.

  28. Grau and Jorgensen, “Viral Hepatitis,” 1–5, for a good overview of the health problems confronting the Russian Army there.

  29. Ibid., 2.

  30. Casualty figures are up to date as of June 2011.

  31. L. G. Stansbury et al., “Amputations in U.S. Military Personnel in Afghanistan and Iraq,” Journal of Orthopedic Trauma 22, no. 1 (2008): 43–46.

  32. Owen Dyer, “The Iraq War and the Military Medicine Sea Change,” National Review of Medicine 4, no. 8 (April 2007).

  33. David Brown, “U.S. Military Medics Use Old and New Techniques to Save Wounded in Afghanistan,” Washington Post, November 1, 2010.

  34. Lester W. Grau and William A. Jorgensen, “Beaten by the Bugs: The Soviet-Afghan War Experience,” Military Review 77, no. 6 (November–December 1997): 5.

  35. Ibid.

  36. Frank K. Butler Jr., “Tactical Combat Casualty Care 2007: Evolving Concepts and Battlefield Experience,” Military Medicine 172 (November 2007): 11.

  37. Dyer, “The Iraq War and Military Medicine,” 1.

  38. Brown, “U.S. Military Medics.”

  39. Ibid.

  40. Ibid.

  41. Ibid.

  42. Ibid.

  43. Gawande, “Casualties of War.”

  44. Ibid.

  45. Ibid.

  46. Ibid.

  47. Ibid.

  48. Deborah White, “Iraq War Facts: Results and Statistics as of April 26, 2011,” Ask.com.

  49. Dyer, “Iraq War and Military Medicine,” 1.

  50. Ibid.

  51. Ibid.

  52. Greg Jaffe, “Departing General Favors Ending Ban on Women in Battle,” Boston Globe, February 5, 2012.

  8

  SOME THOUGHTS ON WAR

  Not a single major military establishment in the world is without a military medical service. The connection between civilian and military medical establishments in highly industrialized societies is now symbiotic, with advances in one being quickly adopted by the other. The paralysis once engendered by the separation of the civilian and military establishments, closely paralleled in the tension between the physician and surgeon, is gone. Gone, too, is the dependence upon the brilliance of a few people, often military doctors, for medical advances. The search for new medical technologies is so highly organized and requires so many organizational resources that individual genius is unlikely to be productive unless linked with large research facilities. Even then, it is more likely that medical advances will be the product of research teams than of brilliant individuals.

  The impact of military medicine on casualty survival rates has been dramatic. It is noteworthy that almost 65 percent of the wounded receive only minor injuries and 20 percent of soldiers struck by enemy weapons are killed outright; thus, only 35 percent of the wounded require medical attention to survive. Undoubtedly battlefield medicine has had an enormous impact on survival rates and on the fighting ability of modern armies.

  It is wise to remember, however, that the military surgeon’s role has not changed much since he first appeared in ancient Sumer. His task is still to rescue as many salvageable bodies as possible from the carnage, treat them quickly, and return them to the battlefield so that the carnage may continue until, finally, one side’s will gives way. To accomplish this task, some practical realities remain historical constants. The first is that only 35 percent of the wounded in any given battle require serious medical attention to survive their wounds. As body armor recently has become a normal item of military equipment for the first time in almost five hundred years, the number of wounded requiring serious medical intervention to survive has declined by yet another 6 percent. The second constant is that regardless of the increasing destructiveness of modern weapons, the ratio of dead to wounded has remained almost unchanged for five hundred years. Third, although disease causes far fewer deaths than it used to, disease-related infirmities still account for the highest percentage of temporary manpower loss in campaigns. Together, the challenges confronting the military physician have remained remarkably similar throughout history.

  What has changed, of course, are the conditions under which the military physician must apply his or her skill. Three factors have altered these conditions: the dispersion of combat forces over far greater areas, the increased rates of destruction of locally engaged forces made possible by increases in the rates of fire and lethality of modern weaponry, and the greatly increased vulnerability of combat medical assets on the high-mobility battlefield. While the challenges to the military physician have remained essentially unchanged, the nature of modern war has greatly transformed the medical practitioner’s ability to meet them.

  The increased ability of weapons to acquire targets at longer ranges and to destroy them with greater certainty has necessarily dispersed combat forces. In World War II, the probability of a tank round hitting another tank on the first attempt was less than 10 percent, and then only if the tank was shooting from a stationary position. Today, the probability of a moving tank getting a first-round hit is almost 98 percent. Smart bombs and other precision-guided munitions, including guided artillery rounds
, have made the modern battlefield a terribly lethal place. The tactician’s only solution when facing exponential increases in firepower, accuracy, and lethality is to disperse forces over wider areas and rely upon increased mobility to avoid being killed.

  One consequence of dispersion is that troops spread over very wide areas make it almost impossible to locate casualties. Unlike earlier wars of fixed lines and relatively shallow zones of operation, the modern conventional battlefield vastly complicates military medical teams’ efforts to determine the location, number, and severity of casualties and to react in time. The dispersion of casualties, first brought about by the introduction of gunpowder weapons and then by the adoption of linear tactics, has reached far greater proportions than anyone imagined even twenty years ago. In future wars, it may take much longer to locate and reach casualties for treatment. Despite the best efforts of medical teams, wounded men will remain untreated for many hours and even days. Many who would have been saved in earlier wars are likely to die. Those who survive until medical help reaches them are likely to present with infected wounds that will greatly complicate treatment and recovery.

  Increased firepower and lethality of modern weapons cause very high rates of destruction and wounding when employed in compact battle areas. Dispersion, after all, only works so long as one is avoiding contact or moving toward the battle engagement. At some point the forces must concentrate at the schwerpunkt (focal point) and the battle against contending forces joined. The loss of life and equipment in these engagements will probably be quite high for both attacker and defender, with kill and wound rates rising past 60 percent. It is unlikely that any medical service will be able to handle the sudden flood of the casualty stream under these conditions. In the case of a successful attack, the victor might be able to move rear area medical assets to the battlefield in time to treat some of the wounded. In the defender’s case, however, once his battle area is penetrated and the attack continued to his rear, his available medical assets are likely to be destroyed or crippled in a battle of annihilation. Iraqi forces faced this scenario in the Gulf War in 1991 and again in 2003. A defeated enemy, furthermore, can expect little in the way of medical help from a victor already overburdened by its own casualties.