Wednesday, December 08, 2004

We Don't Know What We've Bought, But Here's What It Cost 

Courtesy of correspondent Douglas O'Heir at Altercation: The New England Journal of Medicine has kindly made available to non-subscribers "Casualties of War," a new article by Atul Gawande, whose recent New Yorker essay "The Bell Curve" attracted much attention for its focus on concealed disparities in the quality of American healthcare. The new piece has to do with medical treatment for soldiers wounded in Iraq and Afghanistan:
When U.S. combat deaths in Iraq reached the 1000 mark in September, the event captured worldwide attention. Combat deaths are seen as a measure of the magnitude and dangerousness of war, just as murder rates are seen as a measure of the magnitude and dangerousness of violence in our communities. Both, however, are weak proxies. Little recognized is how fundamentally important the medical system is — and not just the enemy's weaponry — in determining whether or not someone dies. U.S. homicide rates, for example, have dropped in recent years to levels unseen since the mid-1960s. Yet aggravated assaults, particularly with firearms, have more than tripled during that period.2 The difference appears to be our trauma care system: mortality from gun assaults has fallen from 16 percent in 1964 to 5 percent today.

We have seen a similar evolution in war. Though firepower has increased, lethality has decreased. In World War II, 30 percent of the Americans injured in combat died.3 In Vietnam, the proportion dropped to 24 percent. In the war in Iraq and Afghanistan, about 10 percent of those injured have died. At least as many U.S. soldiers have been injured in combat in this war as in the Revolutionary War, the War of 1812, or the first five years of the Vietnam conflict, from 1961 through 1965 (see table). This can no longer be described as a small or contained conflict. But a far larger proportion of soldiers are surviving their injuries . . . .

On the arrival of the wounded, teams carry out the standard Advanced Trauma Life Support protocols that civilian trauma teams follow. However, because of the high incidence of penetrating wounds — 80 percent of casualties seen by the 274th FST had gunshot wounds, shrapnel injuries, or blast injuries — lifesaving operative management is required far more frequently than in civilian trauma centers. Today, military surgical strategy aims for damage control, not definitive repair, unless it can be done quickly. Teams pack off liver injuries, staple off perforated bowel, wash out dirty wounds — whatever is necessary to stop bleeding and control contamination without allowing the patient to lose body temperature or become coagulopathic. Surgeons seek to limit surgery to two hours or less, and then ship the patient off to a Combat Support Hospital (CSH), the next level of care. Abdomens can be left open, laparotomy pads left in, bowel unanastomosed, the patient paralyzed, sedated, and ventilated. For this approach to be successful, however, control of air space and major roadways and establishment of the next-level hospital (achieved early in Iraq but delayed in Afghanistan) are essential.

Two CSHs with four sites now exist in Iraq. These are 248-bed hospitals with six operating tables, some specialty surgery services, and radiology and laboratory facilities. Mobile hospitals, too, they arrive in modular units by air, tractor-trailer, or ship and can be fully functional in 24 to 48 hours. Even at the CSH level, the goal is not necessarily definitive repair. The maximal length of stay is intended to be three days. The policy is to transfer any American soldier who requires more to a level IV hospital — one was established in Kuwait, one in Rota, Spain, and one in Landstuhl, Germany. If expected to require more than 30 days of treatment, wounded soldiers are to be transferred home, mainly to Walter Reed or to Brooke Army Medical Center in San Antonio, Texas. (Iraqi prisoners and civilians, on the other hand, receive all their care in Iraq.)

It is a system that took some getting used to. Surgeons at every level initially tended to hold on to their patients, either believing that they could provide definitive care themselves or not trusting that the next level could do so. According to statistics from Walter Reed, during the first few months of the war, it took an injured soldier an average of eight days to go from the battlefield to a U.S. facility. Gradually, however, surgeons have embraced the wisdom of the system. The average time from battlefield to arrival in the United States is now less than four days. (In Vietnam, it was 45 days.)

One airman with devastating injuries from a mortar attack outside Balad on September 11, 2004, was on an operating table at Walter Reed just 36 hours later. In extremis from bilateral thigh injuries, abdominal wounds, shrapnel in the right hand, and facial injuries, he was taken from the field to the nearby 31st CSH in Balad. Bleeding was controlled, volume resuscitation begun, a guillotine amputation at the thigh performed. He underwent a laparotomy with diverting colostomy. His abdomen was left open, with a clear plastic bag as covering. He was then taken to Landstuhl by an Air Force Critical Care Transport team. When he arrived in Germany, Army surgeons determined that he would require more than 30 days' recovery, if he made it at all. Therefore, although resuscitation was continued and a further washout performed, he was sent on to Walter Reed. There, after weeks in intensive care and multiple operations, he did survive. This is itself remarkable. Injuries like his were unsurvivable in previous wars. The cost, however, can be high. The airman lost one leg above the knee, the other in a hip disarticulation, his right hand, and part of his face. How he and others like him will be able to live and function remains an open question . . . .

Late complications have emerged as a substantial difficulty as well. Surgeons are seeing startling rates of pulmonary embolism and deep venous thrombosis, for example, perhaps because of the severity of the extremity injuries and reliance on long-distance transport in management. Initial data show that 5 percent of the wounded at Walter Reed have had a pulmonary embolism, resulting in two deaths. The solution is not obvious. Using anticoagulants in patients with fresh wounds and in need of multiple procedures would seem unwise. On the other hand, there is no facility or expertise in Iraq for the routine placement of inferior vena cava filters.

Injured soldiers from Iraq have also brought an epidemic of multidrug-resistant Acinetobacter baumanii infection to military hospitals. It is not known how this has occurred. No such epidemic appeared among soldiers from Afghanistan, and whether the drug resistance is being produced by antibiotic use or is already carried by the strains colonizing troops is still being debated. Regardless, data from 442 medical evacuees seen at Walter Reed showed that 37 (8.4 percent) were culture-positive for acinetobacter — a rate far higher than any previously experienced. The organism has infected wounds and prostheses and caused catheter-related sepsis in soldiers and, through nosocomial spread, in at least three other hospital patients. Medical evacuees from Iraq are now routinely isolated on arrival and screened for the bacteria.

These are just the medical challenges. Perhaps the most pressing difficulties arise from the changing conditions of the war. Medical teams were designed and outfitted for lightning-quick, highly mobile military operations. The war, however, has proved to be slow-moving and protracted. To adapt, CSHs have had to be converted into fixed facilities. In Baghdad, for example, the 28th CSH took over and moved into an Iraqi hospital in the Green Zone. This shift has brought increasing numbers of Iraqi civilians seeking care, and there is no overall policy about providing it. Some hospitals refuse to treat civilians for fear that some may be concealing bombs. Others are treating Iraqis but find themselves overwhelmed, particularly by pediatric patients, for whom they have limited personnel and few supplies.
The NEJM has also made available a photo essay by Doctors George Peoples, James R. Jezior, and Craig D. Shriver, "Caring for the Wounded in Iraq" (see below). You may read a New Yorker interview with Atul Gawande by clicking here.

A common type of injury associated with roadside improvised explosive device run over by a Humvee.

Damage-control laparotomy with temporary abdominal closure — serially closed at WRAMC to prevent long-term ventral hernia and need for skin grafting.

UPDATE (via Another Dark Little Corner): Charlie Stross on the Pentagon's admission to CBS that over 15,000 troops with so-called 'non-battle' injuries and diseases have been evacuated from Iraq, in addition to the 9300 wounded in actual combat:
So the total US casualty count so far is over 25,000, with over 9,000 permanently out of combat (dead or crippled). As 300,000 troops have been rotated through Iraq, that makes for a total casualty rate of around 9%. To draw an analogy to another insurgency in which a western nation got pinned down in street fighting over a period of years, the average rate of attrition is roughly ten times the peak sustained by the British Army during the Northern Ireland Troubles at their worst (circa 1972-74) -- but as the rate of attacks on US personnel is increasing rapidly, I suspect it's much worse than these figures suggest.
UPDATE II: On the Merceresque principle that you got to ac-cen-tchu-ate the positive, e-lim-i-nate the negative, latch on to the affirmative, and don't mess with Mr. In-Between, Ceci Connolly summarizes Gawande's harrowing NEJM article in tomorrow's Washington Post under the happy-go-lucky headline "U.S. Combat Fatality Rate Lowest Ever: Technology and Surgical Care at the Front Lines Is Credited With Saving Lives."

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