More injured troops survive

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ASSOCIATED PRESS

For every American service member killed in Iraq, nine others have been wounded and survived -- the highest rate of any war in U.S. history.

It isn't that their injuries were less serious, a new report says. In fact, many young soldiers have had their faces, arms and legs blown off and are returning home severely maimed. They have survived because of armorlike vests and fast treatment from doctors on the move with the troops.

"This is unprecedented. People who lose not just one but two or three extremities are people who just have not survived in the past," said Dr. Atul Gawande, a surgeon at Brigham and Women's Hospital in Boston who researched military medicine and wrote about it in today's New England Journal of Medicine.

The journal also published a five-page spread of 21 military photographs that graphically depict the injuries and conditions under which the military surgeons operate.

"We thought a lot about it," said the journal's editor, Dr. Jeffrey Drazen , and ultimately decided that the pictures told an important story.

"This war is producing unique injuries -- less lethal but more traumatic," he said.

Kevlar helmets and vests are one reason.

"The critical core, your chest and your abdomen, are protected," said Dr. George Peoples , a Walter Reed Army Medical Center surgeon who served in Iraq and Afghanistan. "Paradoxically, what we've seen is devastating extremity injuries because people are surviving wounds they otherwise wouldn't have."

By mid-November, 10,369 American troops had been wounded in battle in Afghanistan or Iraq, and 1,004 had died -- a survival rate of about 90 percent. In the Vietnam War, one in four wounded died, nearly all of them before they could reach surgical units.

In Iraq, military surgeons have stripped the process to its most basic level so they can move with troops and do surgery on the spot.

"Within an hour, we drop the tents and set up the [operating] tables, and we can pretty much start operating immediately," said Dr. Peoples, whose photographs are in the medical journal.

The record survival rates in Iraq have been achieved with an astonishingly small number of general surgeons. The military has about 120 on active duty and a similar number in the reserves. Of these, only 30 to 50 are in Iraq, plus 10 to 15 orthopedic surgeons, to care for 130,000 to 150,000 troops, Dr. Gawande reports.

"It's a very tight supply," he said. "They're now also burdened with civilian Iraqis seeking their help because the U.S. has taken over many Iraqi hospitals."

Dr. Gawande and others also credit nurses, anesthetists, helicopter pilots, other transport staff and an entire rethinking of the combat medicine system for the troops' survival.

The strategy is damage control, not definitive repair. Field doctors limit surgery to two hours or less, often leaving temporary closures and even plastic bags over wounds, and send injured troops to one of several combat-support hospitals in Iraq that have services such as labs and X-rays.

"We basically work to save life over limb," said Navy Capt. Kenneth Kelleher, chief of the surgical company at the chief U.S. Marine base near Fallujah. "No frills, nothing complicated."

If troops are shipped to a combat-support hospital, the maximum stay is three days. If more advanced care is needed, they are sent to hospitals in Landstuhl, Germany, or Kuwait or Spain. If care will be needed for a month or more, they are whisked directly to Walter Reed in Washington or Brooke Army Medical Center in San Antonio.

"The average time from battlefield to arrival in the United States is now less than four days. In Vietnam, it was 45 days," Dr. Gawande writes.