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Combat Research: 1 in 5 Suffer Head and Neck Wounds

Finding points to need for more specialty surgeons in Iraq, Afghanistan

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HealthDay Reporter

FRIDAY, Sept. 24, 2004 (HealthDayNews) -- A significant percentage of U.S. soldiers wounded in Iraq and Afghanistan are suffering potentially lethal wounds to the head and neck, areas not covered by today's improved body armor.

A unique report on combat injuries found that, in a 14-month period, one of every five soldiers injured in battle and airlifted to an American military hospital in Germany suffered from this type of injury.

The finding, presented this week by a U.S. military surgeon at a conference in New York City, led the research team to urge that more head-and-neck specialists be deployed closer to the front, advice that the U.S. Air Force has just begun following.

"I think that any time you can bring the surgeons that definitively treat those types of injuries closer to the patient, seeing them in a more timely manner, it's always better for the patient," said study co-author Lt. Col. Michael S. Xydakis, an ear-nose-and-throat specialist and head-and-neck surgeon with the U.S. Air Force medical corps.

Xydakis, 40, spent the first year of the Iraqi conflict working with incoming wounded at the U.S. military's Landstuhl Regional Medical Center, part of Ramstein Air Force Base in southwestern Germany. Landstuhl is the facility receiving the majority of casualties from combat in Iraq and Afghanistan.

Working with two information specialists and Dr. John Casler, chief of head and neck surgery at Walter Reed Army Medical Center in Washington, Xydakis used a computerized patient tracking system to categorize the nature of injuries to more than 11,000 wounded soldiers who were admitted to Landstuhl between Jan. 1, 2003, and March 19, 2004.

"This operation we have ongoing right now in Iraq is the first sustained use of ground combat since Vietnam," Xydakis said. Keeping in mind changes in armor and tactics, his team sought to determine patterns of injury in troops today, and whether medical personnel were being properly deployed to respond to the types and numbers of casualties.

"What the military really cares about is 'Is the stuff that we're providing our troops really effective?" he explained.

Xydakis' team of researchers report that 16 percent of all the 11,287 soldiers airlifted from Iraq or Afghanistan and cared for at Landstuhl in that 14-month period were treated for injuries to the face, neck and throat below the helmet line. But when the researchers focused on troops classified as having suffered "battle injuries," the number of patients with at least one type of head and neck trauma rose to 21 percent.

The study ended in March, but Xydakis suspects injury patterns may have changed somewhat since then, due to the evolving nature of the Iraqi resistance. "My sense is that you're going to see more blast injuries and less penetrating injuries," he said.

He presented the findings Sept. 20 at the annual meeting of the American Academy of Otolaryngology -- Head and Neck Surgery.

Before the advent of a super-tough synthetic fiber called Kevlar, most combat deaths and injuries stemmed from wounds to the chest or skull, Xydakis said. However, lightweight Kevlar resists penetration by nearly all high-velocity bullets and shrapnel. It is now the main component of all chest, back armor and helmets worn by American troops today.

Xydakis said he's not sure if enemy combatants are aiming for these areas in the knowledge that the chest and upper head are nearly invulnerable due to armor. However, he said, "you have a lot of emerging tactics now, because they know that it is very hard to put down an American soldier because of what they are wearing." Furthermore, "if a soldier is crouched down in the shooting position, that's the only exposed area."

Whatever the enemy's intent, even nonfatal injuries in this vulnerable area can have devastating results, including shattered jaws, impaired breathing, brain damage and blindness, Xydakis noted.

He said head and neck injuries occurring on the battlefield are generally more severe than those he encountered in civilian patients during his residency in Minnesota. "The weapons are so much more powerful, blast injuries aren't common in the civilian world -- it's clearly different," he said. "There's a spectrum -- you've got massive, mutilating injuries."

The relative youth of patients and the extent of their injuries can be tough to deal with, even for a military surgeon with a long experience of caring for wounded. "It tugs on the heartstrings," Xydakis said. "It works at many levels."

Right now, he explained, most American troops injured in the face and neck first receive Level 1 care, consisting of first aid and other stopgap measures provided by a combat medic in their fighting unit. They are then quickly transported to what's known as Level 2 or 3 care -- either a small, mobile medical staff following the unit, or a larger field hospital.

If more care is needed, the patient is airlifted to Landstuhl, the military's only Level 4 center outside the United States. These patients are sometimes accompanied by a surgeon, nurse and anesthesiologist in a journey that takes an average of 18 hours.

Given the increased incidence of head and neck injuries, Xydakis and his colleagues are urging all branches of the U.S. military to move specialized surgeons closer to the front.

The Air Force is already heeding his advice, Xydakis added: "There will be a rotation all the time now for one [Air Force ENT/head and neck surgeon] into the theater. I think they are picking up on this, now that we've got the data coming out."

The first Air Force ENT/head-and-neck surgeon is already working in Iraq, Xydakis added, "but it's my idea that we need to get all of the services to do the same."

Xydakis noted that he was speaking purely as a surgeon and researcher. "All I can do is present the data," he said.

Lt. Col. Guillermo Tellez, chief of the ENT/head and neck department at Landstuhl Medical Center, said Xydakis' work is part of an ongoing "feedback mechanism" between surgeons at the medical center and health-care teams closer to the front.

Landstuhl surgeons "are able, on a continuous basis, to reach the troops and trauma teams [in Iraq] to improve care, based on what we are seeing here with our casualties," Tellez said. "It brings light to all of the processes. What our goal is here is to continue to provide state-of-the-art care across all specialties."

Xydakis added that moving surgeons into the combat theater would also cut back on airlifts to Germany. That would serve the interests of many troops, he said, because a majority of young soldiers wish to return to their units as soon as they recover.

"Especially in the Special Operations troops, and the Army and Marine units, the esprit de corps is such that they don't want to leave their battle buddies," he said. "It's really noble. They don't want to leave their units."

More information

Learn about what the U.S. Defense Department is doing for soldiers at the Pentagon.

SOURCES: Lt. Col. Michael S. Xydakis, M.D., U.S.A.F., formerly of Landstuhl Regional Medical Center, Ramstein Air Force Base, Germany; Lt. Col. Guillermo Tellez, M.D., chief, ENT/head and neck department, Landstuhl Regional Medical Center, Ramstein Air Force Base, Germany; Sept. 20, 2004, presentation, American Academy of Otolaryngology Head and Neck Surgery annual meeting, New York City

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