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Iraq War Changes Face of Military Medicine

U.S. troop death rates are lower as surgeons face new challenges

THURSDAY, Dec. 9, 2004 (HealthDayNews) -- The unusual nature of the conflicts in Iraq and Afghanistan are drastically changing the way the military responds to injuries, say surgeons who have served there.

On one hand, highly mobile mini-hospitals are boosting the military's ability to scoop up the injured and give them lifesaving treatment, said Dr. Atul Gawande, a surgeon and staff writer for the New Yorker magazine. Bulletproof vests are also helping, and injured soldiers face a much lower risk of death than in any previous major American armed conflict.

But Gawande added that surgeons can't rely entirely on their previous experience on the battlefield. "Car bombs and land mines produce new kinds of injuries that change what they have to be able to deal with," he said.

Gawande, a surgeon at Brigham and Women's Hospital in Boston, visited Walter Reed Army Medical Center and reports on his findings about the state of military medicine in the Dec. 9 issue of the New England Journal of Medicine.

In an accompanying essay, Dr. George E. Peoples, chief of surgical oncology at Walter Reed Army Medical Center, presents photographs of emergency medical treatment in Iraq, where he served as a chief of surgery with the 274th forward surgical team of the U.S. Army.

The wide majority of injuries and deaths among coalition forces in Iraq -- excluding Iraqis -- have been among Americans. According to the U.S. Department of Defense, 10,369 military troops have been killed or injured in action in Afghanistan and Iraq since 2001; the death rate is 10 percent, or 1,004 people.

Death rates were much higher in previous military conflicts, from the Revolutionary War -- where 42 percent of 10,623 wounded soldiers died -- to the Vietnam and Korean wars, where the death rate was 24 percent.

In the total number of wounded and killed, the Iraq War has already surpassed the War of 1812, the Mexican War and the Spanish-American War, although the numbers are tiny compared to World War II (more than 963,000).

In previous wars, soldiers who lost three limbs were almost invariably doomed to death, Gawande said. But now, Kevlar vests are protecting vital organs in the chest and abdomen, allowing amputees to survive. Nearby medical care helps, too. "By moving the military surgical care right up to the battle, they're able to save these patients," he said.

Armed with mini-hospitals complete with miniature medical devices, medical teams follow closely on the heels of soldiers, setting up their tented facilities in hours, not days. "We've pushed our surgeons closer and closer to the front," Peoples said. "They can go with the fighters wherever they are, go into small spaces and provide lifesaving, limb-sparing procedures."

The mini-hospitals -- complete with about 20 surgeons, anesthesiologists, medics and nurses -- aren't designed to provide advanced care, however. The goal is to get the patients to a more traditional military hospital within four to six hours. At the first level, surgeons "only do what's required to preserve life and limb and eyesight," leaving the rest to the better-equipped facilities, Peoples said.

Later, the military tries to fly the injured to a hospital in another country -- such as Germany or the United States -- within just a few days. By contrast, it often took several weeks for injured Vietnam-era soldiers to land on U.S. soil.

And what of challenges? There are plenty. The Kevlar vests aren't immune to all shrapnel, and the cramped mini-hospitals have trouble meeting a variety of medical needs from X-rays to blood components. And the new prospect of survival for the most severely injured soldiers is raising new dilemmas. "Trying to figure out how to help someone like that lead a good life is beyond any question we've faced in medicine," Gawande said.

And despite the added protection on their bodies, many soldiers still feel they need more. After giving a pep talk to soldiers in Kuwait Wednesday, Secretary of Defense Donald Rumsfeld was peppered with some tough questions from the rank and file. One asked why they had to sift through scrap heaps to find metal to make their vehicles safer, a question that drew loud applause from the 2,300 troops on hand.

"You go to war with the Army you have," Rumsfeld replied. "You can have all the armor in the world on a tank and it can [still] be blown up."

More information

Learn more about military medicine from the Uniformed Services University.

SOURCES: Atul Gawande, M.D., M.P.H., surgeon, Brigham and Women's Hospital, and assistant professor, health policy and management, Harvard School of Public Health, Boston; George E. Peoples, M.D., chief, surgical oncology, Walter Reed Army Medical Center, and chief surgeon, 274th forward surgical team, U.S. Army, Washington, D.C.; Dec. 9, 2004, New England Journal of Medicine; photo courtesy Walter Reed Army Medical Center
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