by Atul Gawande
ON APRIL 4, 2004, after four private military contractors were killed and their bodies mutilated in Fallujah, just to the west of Baghdad, three marine battalions launched an attack to take control of the city from the fifteen to twenty thousand insurgents operating there. Five days later, after intense fighting and protests from Iraqi authorities, the White House ordered the troops to retreat. The marines staged a second attack seven months afterward, on November 9. Four marine battalions and two army mechanized infantry battalions with some twelve thousand troops in all fought street-to-street against snipers and groups of insurgents hiding among the two hundred mosques and fifty thousand buildings of the city. The city was recaptured in about a week, although fighting continued for weeks afterward. During the two battles for Fallujah, American forces suffered more than 1,100 casualties in all, the insurgents a still-untold number. To care for the wounded, fewer than twenty trauma surgeons were in the vicinity; just two neurosurgeons were available in the entire country. Marine and army forward surgical teams received some of the wounded but were quickly overwhelmed. Others were transported by two-hundred-mile-per-hour Blackhawk medevac helicopters directly to combat support hospitals, about half of them to the 31st CSH in Baghdad.
Another of the surgeons I had trained with in Boston, Michael Murphy, was a reservist on duty there at the time. A North Carolina vascular surgeon, he had signed up with the army reserves in June 2004. In October, he got a call from central command. "I left Durham on a Sunday, and a week later I was in a convoy going down the Irish Road in Iraq with an M9 pistol in my hand, wondering what I had gotten myself into," he later told me.
The moment he arrived at the 31st CSH--he still had his bags in his hands--Murphy was sent to the operating room to help with a soldier who had shrapnel injuries to the abdomen, both legs missing, and a spouting arterial injury in one arm. It was the worst injury Murphy had ever seen. The physicians, nurses, and medics took him in like a wet pup. They worked together as more of a team than he'd ever experienced. "In two weeks, I went from a guy who was scared to death about whether I was going to cut it to the point where I was the most comfortable I had ever felt as a surgeon," he says.
With Operation Phantom Fury, as the military called the November battle for Fallujah, the CSH was strained almost to the breaking point. "The wounded came in waves of five, ten, fifteen every two hours," Murphy says. The CSH had twenty-five beds in the ER, five operating tables, and one critical care team, and that did not seem nearly enough. But they made do. Surgeons and emergency physicians saw the worst casualties as they came in. Family physicians, pediatricians, and even ophthalmologists--whoever was available--stabilized the less seriously injured. The surgical teams up in the operating rooms stuck to damage control surgery to keep the soldiers moving off the operating tables. Once stabilized, the American wounded were evacuated to Landstuhl. One-third of the patients were Iraqi wounded, and they had to stay until beds in Iraqi hospitals were found, if they were civilians or security forces, or until they were recovered enough to go to prison facilities, if they were insurgents. In the thick of it, Murphy says, he and his colleagues worked for forty-eight hours with little more than half-hour breaks here and there, grabbed some sleep, then worked for forty-eight hours more.
Six hundred and nine American soldiers were wounded in the first six days of the November battle. Nonetheless, the military teams managed to keep the overall death rate at just 10 percent. Of 1,100 American soldiers wounded during the twin battles for Fallujah, the teams saved all but 104--a stunning accomplishment. And it was only possible through a kind of resolute diligence that is difficult to imagine. Think, for example, about the fact that we even know the statistics of what happened to the wounded in Fallujah. It is only because the medical teams took the time, despite the chaos and their fatigue, to fill out their logs describing the injuries and their outcomes. At the 31st CSH, three senior physicians took charge of collecting the data; they input more than seventy-five different pieces of information on every casualty--all so they could later analyze the patterns in what had happened to the soldiers and how effective the treatments had been. "We had a little doctors' room with two computers," Murphy recalls. "I remember I'd see those guys late at night, sometimes in the early hours of the morning, putting the data in."
We do little tracking like this here at home. Ask a typical American hospital what its death and complications rates for surgery were during the last six months and it cannot tell you. Few institutions ask their doctors to collect this information. Doctors don't have time, I am tempted to say. But then I remember those surgeons in Baghdad in the dark hours at their PCs. Knowing their results was so important to them that they skipped sleep to gather the data. They understood that such vigilance over the details of their own performance--the same kind of vigilance practiced by WHO physicians working to eradicate polio from the world and the Pittsburgh VA hospital units seeking to eliminate hospital infections--offered the only chance to do better.
AS THE WAR continued, medical teams were forced to confront numerous unanticipated circumstances. The war went on far longer than planned, the volume of wounded soldiers increased, and the nature of the injuries changed. The data, however, proved to be of crucial importance. Surgeons following the trauma logs began to see, for example, a dismayingly high incidence of blinding injuries. Soldiers had been directed to wear eye protection, but they evidently found the issued goggles too ugly. As one soldier put it, "They look like something a Florida senior citizen would wear." So the military bowed to fashion and switched to cooler-looking Wiley-brand ballistic eyewear. The rate of eye injuries decreased markedly.
Military doctors also found that blast injuries from suicide bombs, land mines, and other IEDs were increasing and were proving particularly difficult to manage. IEDs often produce a combination of penetrating, blunt, and burn injuries. The shrapnel include not only nails, bolts, and the like but also dirt, clothing, even bone from assailants. Victims of IED attacks can exsanguinate from multiple seemingly small wounds. The military therefore updated first aid kits to include emergency bandages that go on like a tourniquet over a wound and can be cinched down with one hand by the soldiers themselves. A newer bandage impregnated with a material that can clot blood more quickly was distributed. The surgical teams that receive blast injury victims learned to pack all the bleeding sites with gauze before starting abdominal surgery or other interventions. And they began to routinely perform serial operative washouts of wounds to ensure adequate removal of infectious debris.
This is not to say military physicians always found solutions. The logs have revealed many problems for which they do not yet have good answers. Early in the war in Iraq, for example, Kevlar vests proved dramatically effective in preventing torso injuries. Surgeons, however, found that IEDs were causing blast injuries that extended upward under the armor and inward through underarm vents. Blast injuries also produced an unprecedented number of what orthopedists term "mangled extremities"--limbs with severe soft-tissue, bone, and often vascular injuries. These can be devastating, potentially mortal injuries, and whether to amputate is one of the most difficult decisions in orthopedic surgery. Military surgeons used to rely on civilian trauma criteria to guide their choices. Examination of their outcomes, however, revealed that those criteria were not reliable in this war. Possibly because the limb injuries were more extreme or more often combined with injuries to other organs, attempts to salvage limbs by following the criteria frequently failed, resulting in life-threatening blood loss, gangrene, and sepsis.
Late complications emerged as a substantial difficulty, as well. Surgeons began to see startling rates of pulmonary embolism and lower-extremity blood clots (deep venous thrombosis), for example, perhaps because of the severity of the extremity injuries and reliance on long-distance transportation of the wounded. Initial data showed that 5 percent of the wounded arriving at Walter Reed developed pulmonary emboli, resulting in two deaths. There was no obvious solution. Using anticoa
gulants--blood thinners--in patients with fresh wounds and in need of multiple procedures seemed unwise.
Mysteriously, injured soldiers from Iraq also brought an epidemic of infections from a multidrug-resistant bacteria called Acinetobacter baumanii. No such epidemic appeared among soldiers from Afghanistan, and whether the drug resistance was produced by antibiotic use or was already carried in the strains that had colonized troops in Iraq is unknown. Regardless, data from 442 medical evacuees seen at Walter Reed in 2004 showed that thirty-seven (8.4 percent) were culture-positive for Acinetobacter--a rate far higher than any previously experienced. The organism infected wounds, prostheses, and catheters in soldiers and spread to at least three other hospital patients. Later, medical evacuees from Iraq were routinely isolated on arrival and screened for the bacteria. Walter Reed, too, had to launch an effort to get health care personnel to be better about washing hands.
These were just the medical challenges. Other, equally pressing difficulties arose from the changing conditions of war. As the war converted from lightning-quick, highly mobile military operations to a more protracted, garrison effort, the CSHs had to adapt by converting to fixed facilities. In Baghdad, for example, medical personnel moved into the Ibn Sina hospital in the Green Zone. This shift brought increasing numbers of Iraqi civilians seeking care, and there was no overall policy about providing it. Some hospitals refused to treat civilians for fear of suicide bombers hiding among them in order to reach an American target. Others treated Iraqis but found themselves overwhelmed, particularly by pediatric patients, for whom they had limited personnel and few supplies.
Requests were made for additional staff members and resources at all levels. As the medical needs facing the military increased, however, the supply of medical personnel got tighter. Interest in signing up for military duty dropped precipitously. In 2004, according to the army, only fourteen other surgeons besides Murphy joined the reserves. Many surgeons were put on a second or extended deployment. But the numbers were not sufficient. Military urologists, plastic surgeons, and cardiothoracic surgeons were then tasked to fill some general surgeon positions. Planners began to contemplate ordering surgeons to take yet a third deployment. The Department of Defense announced that it would rely on improved financial incentives to attract more medical professionals. But the strategy did not succeed. The pay had never been competitive, and joined with the near certainty of leaving one's family for duty overseas and the dangerous nature of the work, it was not enough to encourage interest in entering military service. By the middle of 2005, the wars in Iraq and Afghanistan had stretched longer than American involvement in World War II--or in any war without a draft. In the absence of a draft, it has been extremely difficult for the nation's military surgical teams to maintain their remarkable performance.
Nonetheless, they have, at least thus far. At the end of 2006, medical teams were still saving an unbelievable 90 percent of soldiers wounded in battle. Military doctors continued to transform their strategies for the treatment of war casualties. They did so through a commitment to making a science of performance, rather than waiting for new discoveries. And they did it under extraordinarily demanding conditions and with heroic personal sacrifices.
One surgeon deserves particular recognition. Mark Taylor began his army service in 2001 as general surgeon at Fort Bragg's Womack Army Medical Center, in North Carolina, to fulfill the terms of the military scholarship that had allowed him to attend George Washington University Medical School several years before. He, like many others, was twice deployed to Iraq--first from February through May 2003 and then from August 2003 through winter the next year, as a member of the 782nd Forward Surgical Team. On March 20, 2004, outside Fallujah, four days from returning home, the forty-one-year-old surgeon was hit in a rocket-propelled-grenade attack while trying to make a phone call outside his barracks. Despite his team's efforts, he could not be revived. No doctor has paid a greater price.
PART II
Doing Right
Naked
There is an exquisite and fascinating scene in Kandahar, the 2001 movie set in Afghanistan under the Taliban regime, in which a male physician is asked to examine a female patient. They are separated by a dark blanketlike screen hung between them. Behind it, the woman is covered from head to foot by her burka. The two do not talk directly to each other. The patient's young son--he looks to be about six years old--serves as the go-between. She has a stomachache, he says.
"Does she throw up her food?" the doctor asks.
"Do you throw up your food?" the boy asks.
"No," the woman says, perfectly audibly, but the doctor waits as if he has not heard.
"No," the boy tells him.
For the purposes of examination, there is a two-inch circle cut in the screen. "Tell her to come closer," the doctor says. The boy does. She brings her mouth to the opening, and through it he looks inside. "Have her bring her eye to the hole," he says. And so the exam goes. Such, apparently, can be the demands of decency.
When I started in my surgical practice, I was not at all clear what my etiquette of examination should be. There are no clear standards in the United States, expectations are murky, and the topic can be fraught with hazards. Physical examination is deeply intimate, and the way a doctor deals with the naked body--particularly when the doctor is male and the patient female--inevitably raises questions of propriety and trust.
No one seems to have discovered the ideal approach. An Iraqi surgeon told me about the customs of physical examination in his home country. He said he feels no hesitation about examining female patients completely when necessary, but because a doctor and a patient of opposite sex cannot be alone together without eyebrows being raised, a family member will always accompany them for the exam. Women do not remove their clothes or change into a gown. Instead, only a small portion of the body is uncovered at any one time. A nurse, he said, is rarely asked to chaperone: if the doctor is female, it is not necessary, and if male, the family is there to ensure that nothing unseemly occurs.
In Caracas, according to a Venezuelan doctor I met, female patients virtually always have a chaperone for a breast or pelvic exam, whether the physician is male or female. "That way there are no mixed messages," the doctor said. The chaperone, however, must be a medical professional. So the family is sent out of the examination room, and a female nurse brought in. If a chaperone is unavailable or the patient refuses to allow one, the exam is not done.
A Ukrainian internist from Kiev told me that she has not heard of doctors there using a chaperone. I had to explain to her what a chaperone was. If a family member is present at an office visit, she said, he or she will be asked to leave. Both patient and doctor wear their uniforms--the patient a white examining gown, the doctor a white coat. Last names are always used. There is no effort at informality to muddy the occasion. These practices, she believes, are enough to solidify trust and preclude misinterpretation of the conduct of care.
A doctor, it appears, has a range of options.
In October 2003, I posted my clinic hours, and soon my first patients arrived to see me. For the first time, I realized, I was genuinely alone with patients. No attending physician supervising in the room or getting ready to come in; no bustle of emergency room personnel on the other side of a curtain. Just a patient and me. We'd sit down. We'd talk. I'd ask about whatever had occasioned the visit, about past medical problems, medications, the family and social history. Then the time would come to have a look.
There were, I will admit, some inelegant moments. I had an instinctive aversion to examination gowns. At our clinic they are made of either thin, ill-fitting cloth or thin, ill-fitting paper. They seem designed to leave patients exposed and cold. I decided to examine my patients while they were in their street clothes, for the sake of dignity. If a patient with gallstones wore a shirt she could untuck for the abdominal exam, this worked fine. But then I'd encounter a patient in tights and a dress, and the next thing I knew, I had her dress bunched up
around her neck, her tights around her knees, and both of us wondering what the hell was going on. An exam for a breast lump one could manage, in theory: the woman could unhook her brassiere and lift or unbutton her shirt. But in practice, it just seemed weird. Even checking pulses could be a problem. Pant legs could not be pushed up high enough to check a femoral pulse. (The femoral artery is felt at the crease of the groin.) Try pulling them down over shoes, however, and . . . forget it. I finally began to have patients change into the damn gowns. (I haven't, however, asked men to do so nearly as often as women. I asked a female urologist friend of mine whether she had her male patients change into a gown for a genital or rectal examination. No, she said. Both of us just have them unzip and drop.)
As for having a chaperone present with female patients, I hadn't settled on a firm policy. I found that I always asked a medical assistant to come in for pelvic exams and generally didn't for breast exams. I was completely inconsistent about rectal exams.
I surveyed my colleagues about what they do and received a variety of answers. Many said they bring in a chaperone for all pelvic and rectal exams--"anything below the waist"--but only rarely for breast exams. Others have a chaperone for breast and pelvic exams but not for rectal exams. Some do not have a chaperone at all. Indeed, an obstetrician-gynecologist I talked to estimated that about half the male physicians in his department do not routinely use a chaperone. He himself detests the word chaperone because it implies that mistrust is warranted, but he offers to bring in an "assistant" for pelvic and breast exams. Few of his patients, however, find the presence of the assistant necessary after the first exam, he said. If the patient prefers to have her sister, boyfriend, or mother stay for the exam, he does not object--but he is under no illusion that a family chaperone offers protection against an accusation of misconduct. Instead, he relies on his reading of a patient to determine whether bringing in a nurse witness would be wise.
