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Second Chances at Life

The untold revolution in combat medicine.

By 3.23.06

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This article first ran in The American Spectator's February 2006 issue. To subscribe, please click here.

LOOK AT THE FRONT PAGE of any major U.S. newspaper or the evening news on cable and network television and you'd think Iraq really was another Vietnam. All you hear about are kidnappings, beheadings, and suicide bombings. Every death in Iraq -- be it U.S., Coalition, or civilian -- is reported as if it were the assassination of Lincoln or Kennedy.

Of course, while every combat death is an individual tragedy, the U.S. is making slow but steady progress in Iraq. We're training Iraqi forces to police their own country and hunt down terrorists who continue to kill and maim innocent citizens. Our Army Corps of Engineers, Navy Seabees, and others are helping to rebuild vital infrastructure either destroyed by the terrorists or never deemed important by Saddam Hussein. And we're helping to foster democracy among a people who were brutalized by an unflinching dictator for more than three decades.

But the truly remarkable untold story of Iraq is that of combat medicine. Put succinctly, there are soldiers coming home today maimed or wounded who ten years ago would have been killed. And while some of the wounded will take years to fully recover, their second chance at life is made possible by some incredible advances in combat medicine that are receiving scant attention from the mainstream media.

"Soldiers are walking on prostheses that wouldn't have lived before," said Lieutenant Colonel Clark Searle, an Army orthopedic surgeon who served in Iraq in 2003 with the 86th and 21st Combat Support Hospitals. "People are keeping limbs that ten years ago they would have lost."

One reason is that the U.S. military has started giving basic first-aid instruction to as many soldiers as possible -- not just medics and corpsmen -- through a program called Combat Lifesavers.

"We've made great strides in teaching a lot of soldiers first-aid skills," said Lieutenant Colonel Mike Place, deputy commander at Blanchfield Army Community Hospital at Fort Campbell, Kentucky. He was a division surgeon with the 101st Airborne in Iraq in 2003 and 2004.

"That training is one of the reasons why more soldiers are surviving after being wounded," he said.

Indeed, bleeding is the number one preventable cause of death in combat. If your buddy next to you knows what to do if you're hit, your chances of survival go way up. As a result, combat medicine used to refer to "the golden hour" to describe the all-important initial care that a soldier receives after being wounded. Today, thanks to Combat Lifesavers and some of the new medical technology, the talk is about "the platinum five minutes."

"A major arterial bleed will cause you to die within five minutes," said Major Lisa Maxwell, a general surgeon who deployed to Iraq in 2005 with the 86th Combat Support Hospital. "What we're trying to do is focus more on point-of-injury care to stop the initial bleeding, and then use transportation to get them to a hospital."

BECAUSE SOLDIERS ARE USUALLY no more than 20 minutes away from a Combat Support Hospital, or CASH, the Combat Lifesavers can use a new one-hand tourniquet designed to stop severe bleeding.

"Tourniquets were really frowned on before because of the time it took from when they were applied to when a wounded soldier first saw a doctor or other trained medical professional," Colonel Place said. "But because the transportation time has been drastically reduced, we don't admonish anyone from putting on a tourniquet."

Another advancement in combat medicine is a bandage made of chitosan, a biodegradable carbohydrate found in shrimp and lobster shells that bonds with blood cells and helps form a clot. There's another bandage that contains fibrinogen and thrombin, clotting proteins that can reduce blood loss by up to 85 percent.

"Both products have been highly effective and there are many reports from the field where they have been able to stop bleeding that normal bandages have not been able to control," according to Army literature.

Advances in body armor have saved a lot of lives as well.

"One of the reasons we have people alive today is body armor," Colonel Place said. "It works."

Primarily because it protects the torso, which if damaged by shrapnel can result in wounds that not even the best surgeons can close fast enough.

"Body armor prevents a number of traumatic injuries to the torso," Colonel Place said. "It allows people who would otherwise die to have only severe extremity trauma."

In addition to training and technology, transportation plays an important role in assuring that our soldiers get the best care possible, as soon as possible. For instance, because the U.S. has been able to improve infrastructure in Iraq and assure that there's a steady, reliable supply of electricity at most bases, hospitals have been able to import blood from the U.S.

"Those blood supplies are saving lives," Major Maxwell said. "A good safe supply of blood from the U.S. is key."

In late 2005 U.S. military hospitals in Iraq acquired the ability to make platelets, which are also vital to stopping bleeding in trauma patients.

"Blood was pretty readily available from the start of the conflict," Major Maxwell said in a November 2005 interview. "It's the more complicated blood products that have become available more recently."

And because platelets expire in a week from the time they're drawn from the donor, it's important to have the infrastructure to both harvest them and store them.

"That requires a pretty sophisticated supply line," Major Maxwell said. "Just look at Napoleon's march through Russia. The lesson there was don't outrun your supply lines."

WHILE SOME CRITICS WOULD ARGUE that we've made the lives of Iraqis worse, not better, the doctors clearly don't see it that way. That's because the U.S. military has taken on the added responsibility of treating Iraqi civilians -- be they wounded by a suicide bomber or suffering from more common ailments.

"The military medical facilities take care of three groups," Colonel Place said. "Coalition forces, Iraqi civilians, and Iraqi detainees."
It is U.S. policy that Iraqi civilians stay in U.S. military hospitals until they're ready to be released or can be transferred to an Iraqi civilian hospital that can adequately care for them. Afghanistan is much the same way.

"Coalition hospitals are often all that's available," Colonel Place said.

Indeed, many of the doctors who served in Iraq or Afghanistan said that upwards of half the patients in U.S. hospitals were civilians. Colonel Searle worked regularly with Iraqi doctors, most of whom were Western trained and educated, but who suffered from a lack of trained nurses and equipment.

"They knew our treatment, our literature," he said. "They just didn't have our equipment."

In addition to treating Iraqi civilian trauma patients, the U.S. and its allies have also set up local medical clinics where Iraqis can go to get treatment for everyday maladies.

"We've set up literally hundreds of public health clinics over there," Colonel Searle said. "It's a great story."

Not only do our soldiers and Iraqi civilians get cutting-edge trauma treatment when they first come into U.S. medical facilities, they also receive great long-term care.

"Once we developed a fixed facility, we had ICUs, some very high-tech ventilators that saved a lot of lives, and we had intensive care physicians on the ground," Major Maxwell said. "Once we get past the golden hour, we have personnel to make sure they survive the next 24 hours.

"To have an ICU in a Third World country is amazing," she said.

The U.S. also has some of the most advanced equipment and techniques for evacuating soldiers who need treatment at our base hospitals in Germany or the U.S. This is the specialty of the Air Force, which has Critical Care Air Transport Teams (CCT) that transport soldiers on C-17 cargo planes that are converted into flying ICUs. For instance, because of the assets available to U.S. medical teams, when two U.S. helicopters collided over Mosul in November 2003, killing 17 soldiers, one of the critically injured survivors was in the burn unit at Fort Sam Houston in San Antonio, Texas, within 48 hours.

"The CCTs are staffed by intensive care nurses and doctors and have everything you'd expect in an ICU, except they're at 10,000 feet," Major Maxwell said.

WHAT'S MOST AMAZING is that all of this operates relatively smoothly in an intense combat environment with shifting lines of engagement against terrorists who are increasingly innovative at hitting U.S. and Coalition forces. But like much in the military, it succeeds because of teamwork and selfless dedication.

"It's an entire team," said Colonel Place. "It's a seamless chain that starts with a Combat Lifesaver treating a soldier on the Syrian border, to the medic, the doctor, the medevac crew, the CASH and the surgeon and support staff. Because of all them, the soldier lives. Twenty years ago, we would have been writing letters to his parents."

And while all of this is de rigueur for the Army medical staff, they still sometimes stand back and marvel at how well it all works.

"I saw soldiers who were victims of IED explosions that were entirely peppered with shrapnel, including in and around their eyes, face, and chest," Colonel Place said. "I've seen amputations, the whole gamut. Yet it's remarkable to see that kind of carnage and to know that all of them that get to you [at a CASH] are going to survive."

"The most rewarding thing that I experienced over there was the teamwork," Major Maxwell said. "I saw people brought in and the entire CASH was focused on that patient. We had a personnel officer helping to ventilate patients. It was amazing to see how everyone came together."

Captain Charles Blake is an Army physical therapist who was deployed in Iraq with the 86th Combat Support Hospital for most of 2005. In Iraq, physical therapists perform triage and treat non�life threatening injuries.

"I saw neuro musculo skeletal injuries and determined if they could stay in theater and undergo treatment or had to go stateside," Captain Blake said. "If it was a mass casualty, if you were walking wounded and not in immediate need to see a doctor, I was the one seeing you."

He also noted that while much of the military medical community is focused on combat injuries, there are still the everyday injuries associated with just being a soldier.

"Just walking with a rucksack and weapon on patrol is going to result in twisted ankles, wrenched knees, and other injuries," he said. "When you dive to the ground because an IED went off nearby, even if you're not hit by shrapnel you're going to have dislocated shoulders."

And, of course, once a soldier recovers from his wounds he'll often begin a long rehabilitation process. That's where Captain Blake and Colonel Searle return to their more traditional roles of physical therapist and orthopedic surgeon, as do so many of their colleagues in stateside military and Veterans Affairs hospitals across the country.

"Because of advances in combat medicine, people are keeping extremities that they wouldn't have kept 10 or 15 years ago," Colonel Searle said. "They're surviving injuries they didn't used to survive. Injuries that were automatic amputations 10 years ago aren't so anymore."

"What I love about Army rehab is that every soldier who wants to come back is expected to be running through the woods and shooting his weapon like every other soldier," Captain Blake said. "At IBM, it's all about getting back behind a desk and maybe doing some recreational sports. In the Army, there's the full expectation that they'll run two miles on a prosthetic limb for the Army's annual PT test."

"The prosthetics are phenomenal," Captain Blake said. "There's nothing that can compare to it on the civilian side."

Army doctors aren't stopping there. The Army Medical Corps continues to seek out new technologies that will help them save even more lives on the battlefield.

For instance, the U.S. military is working with the Israelis to adopt recombinant activated Factor VII (rFVIIa), used to stem severe surgical bleeding in trauma patients.

"rFVIIa stops bleeding in trauma patients when their own clotting mechanisms are not working properly," according to Army literature. "As a result of this collaboration, rFVIIa is now being used in major trauma centers throughout the world and has been used on over 400 wounded patients in Iraq."

Army medics call rFVIIA "a remarkable, life-saving drug."

FRANKLY, I THINK THAT ALL OF THEM are remarkable, in everything they do. Too bad the war on terror has divided us so that we all can't put our political differences aside and acknowledge what truly remarkable work these doctors, nurses, and physical therapists are doing to treat our soldiers, both in Iraq and here in the U.S. But that's clearly not the case.

An anti-war group called Code Pink has regularly gathered outside the gates at Walter Reed Army Medical Center in suburban Washington. The purpose? To heckle amputees going out for dinner and a movie.

Indeed, on November 11, Veterans Day, they gathered for a candlelight vigil, holding signs that read, "Why isn't war a war crime" and "Support Our Troops: Bring Them Home Now." On other occasions, the group was seen holding signs that read, "Maimed for a lie."

I wonder if any of them know the work that Drs. Maxwell, Place, and Searle and other Army Medical Corps are doing in Iraq and elsewhere. I wonder if they even care.

Mark Yost is associate editorial page editor of the St. Paul Pioneer Press. His father, Captain George F. Yost, was a thoracic surgeon in a MASH unit in Korea and worked for the Veterans Administration for 20 years. This article first ran in The American Spectator's February 2006 issue. To subscribe, please click here.

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Mark Yost is associate editorial page editor of the St. Paul Pioneer Press.