But then came Mogadishu in 1993 and Kosovo in 1999 and half a dozen other military interventions. The rules and decisions on committing our armed forces were also changing. To achieve its international goals, our government was becoming more predisposed toward military options than the use of diplomacy. U.S. presidents were growing increasingly more willing to send troops into all kinds of circumstances in every corner of the world, using smaller and more agile units to fight in ever more distant and difficult terrains. The majority of these actions were behind enemy lines or along very long and sparsely defended supply routes.
There was now little chance of the wounded being medevaced in a timely fashion. Medics would clearly have to learn a new trade. They would have to be able to keep casualties alive, without the possibility of evacuation, for up to seventy-two hours. A study by military physicians analyzing every serious injury and death that had occurred in Mogadishu following the battle documented what had gone wrong, along with what procedures and policies might have unwittingly led to all deaths.
The study showed that several of the casualties had bled to death from wounds where direct pressure to stop the bleeding could not be applied, such as wounds to the head and neck as well as the chest, abdomen, and groin. Many of the new recommendations were already in place within the military, but Somalia clearly accelerated the process. It was time to change from triage to intensive care.
The training period for the Combat Medical Specialty was increased from ten to sixteen weeks. The former 91B Military Occupational Specialty of Combat Medic was reclassified 91W as “Health Care Specialist.” All trainees were required to pass the civilian Emergency Medical Technician (EMT) test.
The additional weeks of training were devoted to developing the core skills necessary to keep the severely wounded alive where they were hit, with little chance for immediate evacuation. No more “patch ’em up and send them off.” This was to be big-time medicine, the city trauma unit brought to the battlefield.
The training added hands-on courses using high-tech patient simulators that could accurately mimic battlefield injuries, from respiratory failure to penetrating head wounds and transected spinal cords—in real time and under combat conditions. A “bleeding lab” set up to duplicate any number of hemorrhaging wounds became part of the program. The models used in the training actually would “bleed to death” if the blood loss was not stopped. The simulations are so real that the dummies really do “suffocate” if the chest tubes are not correctly placed or a tracheotomy performed within the required three minutes.
The military also incorporated the most recent and relevant advances in trauma surgery into the medical training. They moved to the evolving intensive-care treatment of hypotensive resuscitation, where blood, plasma, or IV fluids are given only in minimal amounts solely to keep the heart pumping, rather than the old World War II, Korean, and Vietnam method of resuscitation, where blood pressures were maintained at normal or elevated levels.
In a tragic and ironic way, these new medical and surgical procedures were found to work better for combat casualties than for civilian gunshot wounds, train, motorcycle, or car accidents. Combat troopers are basically healthy young men and women up until the time they are hit. In these patients, unlike civilian injuries where the patients might be older, likely out of shape, overweight with high blood pressure and diabetes, and often on three to five medications, you can sacrifice a little blood pressure to keep the life-saving blood clots from “popping loose” when blood pressures are raised too quickly or kept above normal levels for too long a time. Hypotensive resuscitation allows early clots to stay in place and new clots to form. It is always the bleeding that kills you on the battlefield.
But hypotensive blood and fluid replacement have an additional value. The large, cumbersome bottles and bags of plasma and IV fluids needed under the old techniques have been replaced by high-tech starch concentrate solutions, allowing medics to haul around fewer medical supplies while being able to care for more casualties over longer periods of time. Better-designed tourniquets, along with the hemostatic embedded dressings and stents, have also been introduced for better local hemorrhage control.
Medics are also taught a technique for evaluating a patient’s blood volume status that goes back to Hippocrates: by first looking at the patient, talking to them to establish their degree of consciousness, and taking a pulse. Patients in impending shock from blood loss experience mental confusion, while it is easy and immediate to characterize a pulse as “absent,” “weak,” or “normal.” Those with absent or weak pulses are given whole blood as quickly as possible. It is on such simple yet sophisticated assessments that modern life-saving decisions are made.
An early analysis of “potentially survivable” wounds in soldiers and marines in Iraq who died after reaching a hospital showed that over 80 percent died because of ongoing hemorrhage, 70 percent from continued or recurrent bleeding from what the military calls “non-tourniquetable” wound sites. A soldier or marine with a torn pelvic artery or a severed femoral artery that is too high up in the thigh to be clamped, or if the wound suddenly begins to re-bleed, will die within minutes.
With development and the use of what is called “combat gauze,” a surgical pack that contains a powder that causes clotting simply by being put into a wound, has proved effective in stopping bleeding from wounds that cannot be stopped with a tourniquet. There is a new medication called Nova 7, used by neurosurgeons to stop bleeding within the brain during surgical procedures. It is used when surgeons cannot tie off any major blood vessels without damaging the healthy parts of the brain needing an adequate blood supply to remain healthy and function properly. Nova 7, costing over a 1,000 dollars a gram, is a medication that will clot off bleeding blood vessels. It is given IV and is now being carried by medics. The problem with the use of any clotting medication is that the medication will also clot off undamaged and healthy vessels, a problem in the elderly and those whose clotting systems are already stressed or damaged. But our troops are basically young and healthy and can handle the medication without complications. The use of Nova 7 right there on the battlefield is a quantum leap in saving lives.
But now, the almost universal use of whole blood rather than the IV fluids and plasma used in World War II, Korea, and Vietnam to treat shock has made the greatest difference between our wounded living or dying.
Blood is basically a mixture of 45 percent circulating red blood cells that carry oxygen to all the organs of the body and 55 percent plasma that contains water, salts, sugars, fats, hormones, and the dozen circulating proteins that make up the body’s clotting factors. It is these clotting factors, working together in a complicated biochemical way, that causes blood to clot. Patients with hemophilia have a genetic absence of one of these factors, given the innocuous name of Factor 8, that can not only cause significant internal bleeding but can lead to the patient bleeding to death even from minor cuts or injuries, including tooth extractions. The problem is that any trauma patient will, if injured enough, consume their own circulating clotting factors and continue to bleed or re-bleed as these factors are not replaced. Unfortunately, if transfusions following a traumatic injury are made up mostly of oxygen-carrying red cells and stored plasma or IV fluids alone, simple bleeding can become a re-bleed that quickly cascades into a fatal hemorrhage. What works to keep soldiers and marines alive, even after massive traumatic injuries, is the use of whole blood or the infusions of the individual clotting factor proteins in a timely fashion. And that is what happens today in both Iraq and Afghanistan. Whole blood’s magical powers to save our newest trauma victims are now clearly understood and its use along with the other battlefield techniques of evaluation and wound treatments has made it more difficult to die than in any of our other wars at any other time in our country’s history.
In addition, today’s medics are taught to give antibiotics earlier and in much larger dosages than in the past. The deeper and more extensive the wounds, and that is mostl
y the case today in Afghanistan, the greater the risk of immediate or later infections. Medics also have begun to use the latest non-opioid painkillers that, unlike morphine, Demerol and oral codeine, do not depress respiration. Dying simply doesn’t happen as frequently as it has in the past. There is a new “normal” out there on our battlefields and it is that new normal that we are all going to have to deal with, as well as understand.
There is little doubt that today’s medics can keep casualties alive for days, until that chopper or overland relief finally arrives, and that the physicians, surgeons, and nurses all along the evac chain can now manage to hold off death itself.
But unfortunately our wars have clearly changed on us. There is no doubt that despite the pronouncements of “Mission Accomplished” the war in Iraq did not end with the defeat of Saddam’s army. The war turned into an insurgency and the combatants, aware of the well-publicized overwhelming firepower of the U.S. military, gave up direct military confrontations. They stepped up their use of IEDs, choosing support troops and supply convoys rather than the more heavily-armed, protected, and aggressive combat units.
When our military added more armor to the units moving through hostile areas, the insurgents switched to the more powerful car and roadside bombs, increasing the power and blast radius of their IEDs. Unlike all our other wars, today’s injuries, rather than coming from ahead and above, are coming from behind, below, and from the sides.
Regular Army combat units and National Guard and Reserve troops started losing arms and legs and suffering head injuries at unexpected and unanticipated rates. Overwhelmed by the increasing numbers of mangled limbs, eye injuries, penetrating head wounds, and closed head trauma, the upgraded medical training following Mogadishu began to lose its edge for the medical personnel.
Yet, despite the severity and grievousness of the new wounds, death rates have not increased. The explosive charges that now blow off arms and legs and lead to traumatic brain injuries (TBIs), would, in Vietnam, have killed those troops right there where the blasts occurred. The penetrating chest wounds, ruptured aortas, shattered livers and spleens, transected spinal cords and fractured kidneys, along with the collapsed lungs and the massive internal hemorrhages that had always gone along with severe extremity wounds and head injuries, had usually proved uniformly and quickly fatal. Those casualties with mangled or lost limbs, and those with brain and spinal cord injuries, rarely made it alive to the chopper, much less the nearest surgical or evac hospital. That is simply no longer the case.
Those military surgeons familiar with Vietnam spoke with amazement early in the war in Iraq, when they first removed the body armor from the newest med-evacs and could not find a scratch from chin to groin. Yet these casualties had arms and legs that were mangled along with head injuries that were horrific. But none of them bled to death. The body armor had spared the wounded shattered organs, and the unstoppable internal bleeding that uniformly led to a rapid, devastating, unstoppable blood loss followed quickly by death. You can live with half your brain gone as long as the deep centers keep you breathing and your intact heart remains pumping. And you can live if a limb is blown off and a tourniquet or vascular clamp is quickly placed to stop the bleeding.
As Clausewitz pointed out in his book, On War coining the memorable and accurate phrase “the Fog of War,” nothing in war is ever as simple or as straightforward as it first appears. And that applies to our troops surviving the terrible wounds of our present wars.
Survival is not solely the result of better body armor protecting the vital organs and major blood vessels in the chest and upper abdomen, nor is it the more effective and quick use of tourniquets, or the improved medical training for medics. Casualties survived because the whole military medical system has itself become both more mobile and more agile.
These new wars, under the current doctrine of “Faster, Lighter, Quicker,” places a limited number of boots—a so-called “light footprint,” on the ground. The need for widely dispersed units shuffling from border to border and town to town, along with the increasing severity of the peripheral body wounds, demanded a more sophisticated medical support that moved along with the different units. There was a need for an evacuation system that went beyond the post-Mogadishu “keep them alive for seventy-two hours” approach.
Out of both common sense as well as the need to support a faster and lighter military, the Army devised and instituted a new concept of frontline battlefield medical care: The Forward Surgical Teams, or FSTs.
These teams are in essence upgrades of the old MASH (Mobile Army Surgical Hospital) units of the Korean War era, only smaller and more nimble and in a strange way better equipped for their one specific task: survival. The typical team consists of fewer than twenty medical personnel: three general surgeons, one orthopedic surgeon, two nurse anesthetists, three nurses, and a few medics. Each FST travels in six Humvees. The transport vehicles carry three RATs (Rapid Assembly Tents) that can be set up in less than sixty minutes and attached to each other to form a 900-foot long surgical facility.
FSTs are decidedly lean affairs. There is no high-tech radiographic equipment. Surgeons detect fractures by feel, but there are operating tables, ultrasonic equipment, modern anesthesia packs, and high-tech ventilators.
These mobile units are not based on the major trauma centers that led to the EMT training of combat medics. The FSTs aim only for damage control. There is no effort at definitive repair. The surgeons seek to limit all operations to less than two hours, preferably to less than an hour. Abdomens are left open, bowels left unattached or connected to large drains, fractured livers simply packed to control bleeding, dirty wounds washed out, torn and useless bones and tissues quickly removed.
There are also the rapid evacuations back to the States. In Vietnam, the average time from the battlefield to the States was forty-five days; the average time now from Mosul or Nasharia to the hospital at Landstuhl, Germany is less than eighteen hours, and then on to Walter Reed or Bethesda Naval Hospital in the States within the next three days.
More importantly, even the number of those who do not survive after they reach a major surgical facility has decreased. But in military support hospitals in Iraq and Afghanistan, or in the neurosurgical ward at Landstuhl Regional Medical Center, the poly-trauma unit at Walter Reed or the orthopedic wards at Bethesda Naval Hospital, along with the Rehab and PTSD clinics in the Veteran Administration’s hospitals, survival no longer gives the entire picture of our newest wars, nor what have become the real and substantial risks that the majority of our wounded soldiers and marines actually do face.
Despite what you may have read about the dangers facing our troops fighting in Iraq and now in ever larger numbers in Afghanistan, the real truth is much closer to the comments of a nurse at the Twenty-fourth Combat Support Hospital in Baghdad:
We’re saving more people who shouldn’t be saved. We’re saving the really severely injured, legs gone, eyes blinded, deaf, parts of brains destroyed. You may get home, but you wouldn’t be the same as when you left.
And those that the nurse talks about now number into the tens of thousands.
Behind every fatality in Iraq and now Afghanistan there lies a hidden cost that few in the military seem to understand and even fewer among Washington’s policy makers seem to have fully grasped. Certainly the media, as well as political pundits, have refused to see the obvious.
Since September 2001, the Air Force’s Air Mobility Command, using the C-17 military transport aircraft that form the air ambulances that fly the wounded from Iraq and Afghanistan back to the Continental United States, landing mainly out of sight at restricted air bases, have flown some 30,000 aero-medical evacuation missions transporting over 150,000 patients. These evacuation flights have been cobbled together from various National Guard and Air Force Reserve units. Some of these squadrons have been routinely and constantly deployed, some a dozen or so times, six months of the year. This rapid evacuation back to the United States is part of the
new approach of military medicine. As one of the flight surgeons explained:
“We’ve adopted an entirely different vision of combat medical care than we had back in Vietnam. During that era, the military built huge hospitals in combat theaters, as close to the battlefield as practical to quickly care for the wounded. Now we are fighting multiple wars with very dispersed and fluid front lines, which means we don’t have the luxury of having huge hospitals near the action. So the psychology of medical care has changed to rapidly stabilizing the patients on the ground and then flying them back to the United States to receive definitive care as quickly as possible …”
But with all this, not everyone survives. Even with the newest technology, the effort and the speed, not everyone makes it. Some become brain dead during the first part of the flights home. More than one set of parents waiting in Germany to meet their sons and daughters have flown back to the States with the bodies, many to donate the soldier’s organs. Some of the docs and nurses working these flights have a more focused and more realistic view of their work than the rest of us:
We get these boys home so they can either get better, or we keep them alive long enough for their families to say goodbye.
James Kitfield, the Pentagon correspondent for the National Journal who made such a flight back to the States aptly wrote for the May 2010 issue of the Journal:
No matter how one feels about the conflicts in Iraq and Afghanistan, every American could benefit from spending time in the company of the wars’ wounded and maimed. Watching these young men and women clinging to life, at the mercy of machines that count their every breath and heart beat … a witness confronts an inescapable thought.
The same thought surely occurred to President Obama when he traveled last October to the tarmac at Dover Air Force Base in Delaware to meet the flag-draped caskets of fallen service members returning from Afghanistan in the middle of the night: This had better be worth it.
Broken Bodies, Shattered Minds: A Medical Odyssey From Vietnam to Afghanistan Page 7
