Indeed.
8.
TELECONFERENCING/MORE THAN SIX DEGREES OF SEPARATION
In a very real way every generation deserves the wounds they get …
—military surgeon, 2010
There is a new normal in medicine today and that new normal has worked its way into military medicine and definitely has become the norm for battlefield care. It is no longer expertise in medicine or surgery that is expected, that much, for better or worse, is simply assumed. It is technology. X-rays once read exclusively on the view boxes of radiology departments in every hospital in America were always connected to a patient as well as a name and possible diagnosis. But when these images became digitalized as data points and could be sent through phone lines and satellite connections anywhere in the world at almost the speed of light, the patient was lost. It is true that today many of the X-rays, flat plates of the abdomen, CT scans, and MRIs taken at night in your hospital are sent to India to be read, the results texted back within minutes, eliminating the need and the expense of the hospital to have to pay for a radiologist on call twenty-four hours a day, seven days a week.
The use of the newly-developed robotic surgery allows surgeons in New York, using a “slave machine,” to operate in real time on a patient in an operating room in Iowa. In reality, you no longer need to have a physician physically present to see or even examine a patient. A moveable robot with its own camera as a videocam, a motorized tread connected to a two-way microphone, and voice-box operated with a joy stick by an expert in, say neurology, at some remote location, can with the help of a trained surrogate, ask the important neurological questions and actually perform a credible physical examination.
It used to be that you knew the physicians who diagnosed and took care of your heart attack or the surgeon who did your coronary by-pass. Now the cardiologist who puts in the stent to unplug your coronary artery an hour after you have your chest pain is someone you never saw before, someone you never knew, and someone who most likely you will never see again. It is the same with the gastroenterologist who does your colonoscopy, and after removing the polyp in your colon tells you that you will need another colonoscopy in five years even as he leaves the examination room. The new paradigm of medicine lies in the technology and it is only to be expected that the benefits and the downside of this kind of anonymous medical and surgical care has been brought to the battlefield. And why not? It works.
Medicine is always easier when it is only the technical aspects that are in play. In referral hospitals across the country over 80 percent of all pacemakers are put into patients well over eighty-five years of age. If you are only discussing the functions of the heart and not the whole patient, then these numbers might make sense. What no one knows, because it is not asked, is how many of these patients over eighty-five have dementia or other disabling and untreatable chronic conditions. The cardiologist simply becomes the technician, or the more accepted term “provider.” And apparently they do provide.
Once a week, the physicians, nurses, and surgeons at all the combat hospitals in Afghanistan, in Europe, and in the United States, linked by telephones and videocams, meet over a secure internet connection to discuss those patients wounded during the preceding week. It is all business, with experts in all the fields of medicine and surgery from orthopedics to neurosurgery to infectious diseases, as well as occupational therapists, medical and surgical nurses and nurse practitioners taking part, even if they have never talked to each other before and are in rooms more then 16,000 miles apart. The focus is only on the injuries and not the patient. There is no time for ethics or moral decisions here. There are little or no personal conversations. The majority of physicians and surgeons in the conferences have never met one another. Indeed, the participants are not referred to by name since no one really knows anyone else and so the discussions are called out by location, “Ballad,” “Kandahar,” “Landstuhl,” “Fort Sam Houston,” “Walter Reed.”
These last years of changing wounds in Iraq, and now throughout Afghanistan, have taken battlefield medicine well past rapid med-evacs and even Forward Surgical Teams. The Mash Unit and even the Evac hospitals with wounded staying hours and hours, if not days or weeks, are things of the past. There is no need now for lengthy hospitalizations at any one facility along the evac chain. There is certainly no longer the need for a Camp Zama in some distant country, nor is there time for long individual discussions or thoughtful contemplative postures. Today, in civilian hospitals and certainly military hospitals, with the fragmentation of medicine itself into its different specialties, there is the need for an abundance of different medical and surgical personnel to take care of the multiple needs of soldiers and marines who are blown up while, at the same time, being exposed to enormous shock waves of these IED blasts. Few if any military physicians will see the wounded longer than a few hours or a few days, before the patients are moved on to what has become transcontinental care, with survival being the single goal.
The truth is that with the new kinds of battlefield injuries, this is precisely the kind of care that is needed because it is efficient, technically sound, and, more importantly, it can now be done. With the new understanding of wounds, injuries, and the new technologies, and the fact that the wounded are usually young and fit, there is no one to “hang the crepe” unless the shroud is ready. After all, this isn’t cancer or strokes, these are accidents—immediate and complicated, but still accidents, and that is precisely how they are viewed and how they are treated.
All of this, taken together, is called “Damage Control Surgery” which began in Iraq but is being perfected, out of necessity, in Afghanistan. The point, obvious to everyone involved with military medicine and those on the weekly telecommunication calls, is that because of the new type of hyper-technical divided expert care, the vast majority of these patients are not what they had always been in every one of our other wars, dead within hours, if not days, of being hit. It is hard to ignore the virtue in all that.
The fact that today’s wounds are now attended to in stages is not genius but the fact that years of experience within civil trauma centers has shown that the more severe and complicated trauma patients survive if their various injuries are treated incrementally in a well-organized step-wise fashion. And that is exactly the types of wounds we are getting in Afghanistan and in ever increasing numbers.
As one of the Navy surgeons deployed to Kandahar Air Field recently explained:
“Twenty years ago, if you left the operating room without fixing everything, you weren’t a good surgeon. We don’t believe that anymore.”
But the reason for no longer practicing that kind of trauma surgery is because our troops are no longer being shot at; they are being blown up. They suffer from multiple wounds, terrible and contaminated by projectiles and the dirt and dust set into motion by the explosions. Unlike simple bullet wounds that can be dealt with quickly and usually with one surgery, these wounds, because of their various body locations and differing severities, along with the multiple types of contamination, have to be treated by stages with as little done at each surgery as possible.
This type of limited surgery is a medical requirement because, initially, no one knows or can determine with any accuracy the exact extent of the wounds. The nature of blast injuries is such that the extent of the injuries only becomes obvious over time. Often it is one surgery per hospital at a time, and the patient is passed on down the line to the next and more sophisticated group of surgeons and physicians, until finally reaching one of the giant medical centers in the States.
The term Improvised Explosive Device or IED is clearly a misnomer. There is nothing improvised about these blasts and what are now being called “Dismounted IED Injuries” to designate wounds caused by a bomb that injures a soldier or marine outside of a vehicle. These weapons blowing up soldiers, outside or under or beside a vehicle, explode with deadly force resulting in such widespread and extensive injuries that no one surgery can fix all the
injuries, much less the patient, at any one time or with any one procedure.
IEDs break bones and blow off limbs and drive dirt deep into the opened wounds while the shock waves kill cells and damage tissues. It may take hours or even days to become evident. In the new damage-control surgery, these wounds are washed out, the obvious dead tissue removed often under repeated anesthesia, the increasingly dead tissues removed bit by bit even if the removals necessitate ever wider and more extensive surgeries, and repeated amputations over days or weeks.
It is the same with abdominal wounds. With any penetrating chest or abdomen wound, the chests and abdomens of these kids are explored and re-explored, the surgeons looking for additional organ damage and any newly leaking blood vessels or veins that might have been missed during previous explorations and surgeries. It is here that the advances of vascular surgery, including the placement of patches and grafts developed to treat the wounds of Vietnam, become so important.
In Afghanistan the pelvic blast injuries are particularly massive and difficult to treat. It is the common in-between-the-leg blasts set off by soldiers on patrol that routinely take off both legs as well as the genitals while causing massive internal injuries to the bladder, colon, and pelvic bones. New wars—new weapons—new injuries—new treatments and procedures—a new kind of suffering.
The new techniques of battlefield medicine have become one long and desperate surgery that may go on for weeks and months and even years. Maybe those who sent our troops into Iraq and Afghanistan, and keep sending them there, should have known all this would happen. They could argue they didn’t know and couldn’t have known. But they know now.
It is probably true that none of these kids would, with similar injuries, survive out in the civilian world, or that they could have been saved in either Iraq or Afghanistan just five years ago. But that isn’t the issue. It is almost counter-intuitive, but as a physician or surgeon it is always a bit easier, if that is the word for it, to give up on a desperately ill or damaged patient if you know them and if you know the family, and have a sense of what survival will actually mean in the long term to both the patient and their loved ones.
When you talk to military surgeons about what they do, they will tell you that they don’t feel their efforts are futile even in the face of treating a 90 percent burn victim, or a patient with all four limbs amputated, or those who need a respirator to breathe. But this new type of “Damage Control Surgery” is a kind of shift work where everyone does their own thing and the big picture is lost in the effort, or left up to someone else down the line to deal with, which in the final analysis will be the family. Today’s battlefield physicians save lives. It is what they do because they can do it. But if you push them, they admit that they try not to withdraw care in the combat theater, but then admit that, every now and then, they will stop all cares. But that is usually with the severe head injuries where the wounded would likely die in transport. Then they make sure that those soldiers die where they are, with other troops by the bedside. “It just affords them that last little bit of dignity.” And when they admit that much, their voices usually crack and their eyes fill with tears—
9.
ALL THE TOMS/IRAQ/2004
We have a volunteer army and have had one since the late 1970s. There is no draft. Yet of all the three services, the Marines, except for Vietnam, have never needed one. Organized in 1775 to fight on both sea and land before the founding of the Republic, the Marines have always been a volunteer force. It was only the enormous casualties of the early years of the Vietnam War, fought in a country of mountains and jungles, a landscape set up for war, that forced sergeants in induction centers across the country, beginning in early 1968, to walk down the lines of newly arrived draftees tapping each third young man on the shoulder as an unceremonious induction into the Marines.
Those young men knew, if they knew nothing else, it might well be that fateful tap. Marines were being killed platoon by platoon in the elephant grass of the Central Highlands and along the Laotian border. A joke had begun going around the Marine Corps early in the Vietnam War that the reason there were so few captains in charge of companies was that they had all been killed as second lieutenants. Lieutenants, captains, majors, and noncommissioned officers were being killed and wounded alongside enlisted personnel in numbers that, at times, made filling all the empty slots difficult, if not impossible.
When units of the First Air Cav replaced the Marines following the three-month siege of Khe Sanh—a Marine outpost in Northern Quang Tri Province—in late 1967, the Cav troopers were astonished to find that the Marines—despite the hourly mortar and rocket attacks, had never dug in and were walking around the hill tops of the siege area in flack vests and helmets. The officers of the First Cav asked the Marine officers why they hadn’t built more defensive positions. The official, as well as unofficial, answer was “ You can’t kill ‘em if you’re in a bunker.”
Being drafted to go to ’Nam was one thing, being sent as a marine was quite another. Karl Marlente captures it perfectly in his novel Matterhorn. In the late 1960s and early 70s you didn’t have to read a book about Vietnam to understand what was happening. Everyone in America, unlike today, knew about their war. They knew that their country had sent over half a million troops to make the fight. They knew about Khe Sanh and the Tet Offensive and they knew about the casualties. Our battles, as well as the number of deaths and casualties, were constantly on the evening news and written about daily in the newspapers.
We now have a military, rather than a country, at war and we have a volunteer army and a constantly deployed National Guard rather than a draft to supply our military with enough troops to make a fight. But those who still chose to go into the Marines, like the marines themselves, haven’t changed. They are still a bit different from the rest of the military and the rest of us.
The gangs in East Los Angeles, if not the rest of us, understand that much about our wars, as well the dangers faced by our marines. The LA police will tell you that it is a well-understood fact that you cannot get out of these gangs once you become a member. Being in a gang is a lifetime commitment, unless you go into the Marines. If you finish the four-year commitment and get safely back home you can decide if you want to go back into the gang or simply walk away. It is an agreement of sorts that indeed, the Marines are different. The gangs understand that there are no short cuts where survival is due either to luck or the ability to kill someone before they kill you. In either case, you deserve admiration and at the very minimum, respect. That clearly seems to be something missing from the rest of the country, or at least most of it. But not all—
There are still other volunteers. It doesn’t happen all that often. But when it does happen, it usually happens like this. A bright eighteen-year-old kid decides that college is not for him and that a job flipping hamburgers at McDonald’s or Burger King is not all that appealing. He asks around and somehow finds out that the Marines have a deferred enlistment program available at the end of the senior year of high school that allows recruits their choice of any of the three Military Occupational Specialties: Artillery, Tanks, or Low Level Anti-aircraft. Always interested in cars and trucks, and realizing the advantage of choosing the type of duty he wants, or at least fancies, the eighteen-year-old chooses to be a tanker and decides to enlist at the beginning of his senior year. Whatever else happens, at least he will not have to walk into battle.
The parents are not happy and take their son aside to caution him that this should not be a frivolous or casual decision and that there are real, grown-up consequences to joining the military, including being killed or being wounded. But “Tom” will have none of it, insisting that he will be careful. The parents, understanding that their child is a bit lost, and that the military is better than sitting around not really doing anything, reluctantly agree. The military will give him the chance to grow up. Besides, what other options are there? For many if not most, the volunteer Army or Marines is as much a way out, a
s it is a way up.
You don’t need much to sign up, just be free of drugs, pass a normal physical examination, and not have a criminal record. The Marines will take care of the rest. And so, with his parents unwilling, but unable to stop or dissuade him, Tom is in the Marines a month after high school graduation.
Two weeks later, he is on his way to thirteen weeks of basic training. He is strangely pleased and oddly comforted that basic training in the Marines is the longest and most demanding of all the armed forces. He even appreciates that the Marines separate the female from the male recruits during basic training. It wasn’t sexism, he simply viewed the women as probably slowing the rest of them down.
And there was talk from the very beginning of basic about the “Crucible,” the three days of hell to get through at the end of basic that would not only separate the men from the boys, but the winners from the losers. Tom might be young, but he is no fool. He knew he’d make it through the Crucible. He understood that if you wanted to be the best, you had to know how to be the best. And he was willing to learn.
Tom never wavered once, not even during the Crucible, which he found to be the most difficult thing, physically and mentally, he’d ever done in his life. Pushed to the limit while testing his own perseverance and teamwork, he was amazed that he’d actually gotten through the three days without giving up or quitting. It was heady stuff. The core values of being a Marine were no longer what had been presented that first day of basic— Duty, Honor, Country—but had morphed into Commitment, Courage, and Responsibility, and simply deciding not to fail. And he had done it without failing and without complaining. He finally understood what someone told him that a climber had said about why he’d wanted to climb Everest, “Because It Is There.” That is what becomes so life changing, at eighteen or at sixty-five.
Broken Bodies, Shattered Minds: A Medical Odyssey From Vietnam to Afghanistan Page 8
