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Ninety percent of U.S. wounded survive

In Iraq, firepower increases, deaths decrease

By William J. Cromie
Harvard News Office

Better, faster medical care has reduced deaths from the more than 10,000 war injuries in Iraq and Afghanistan to the lowest percentage of any war in American history. In World War II, 30 percent of U.S. soldiers died from wounds received in combat; in Vietnam, 24 percent of the wounded died. In Iraq and Afghanistan, despite the horrific increase in the destructibility of weapons, mortality has dropped to 10 percent.

Surgeon and writer Atul Gawande's investigation of wounds in Iraq and Afghanistan shows the lowest death rate of any war in U.S. history, but, he says, it has its price. (Staff file photo Rose Lincoln/Harvard News Office)

But that's not entirely good news for the survivors. Injuries from suicide bombs and land mines often leave lifetime disabilities. Surgeons report a depressingly high incidence of blindness. Amputations, seen almost weekly on television, raise distressing questions about how survivors and their families will adapt and function.

Both sides of the story are told in an article in the Dec. 9 issue of the New England Journal of Medicine written by Atul Gawande, an assistant professor at Harvard Medical School and a surgeon at Brigham and Women's Hospital in Boston who gathered data on casualties and talked with surgical teams that served near the front lines. He concludes that the "military medical system has made fundamental - and apparently effective - changes in the strategies and systems of battle care, even since the Persian Gulf War." In that 1990-91 conflict, 24 percent of the wounded died, or more than twice the rate in Iraq and Afghanistan since 2001.

Forward force

The reduced death toll has occurred despite the limited number of medical personnel available. Gawande says that the shortage means that the Army keeps "no more than 30 to 50 general surgeons and 10 to 15 orthopedic surgeons in Iraq." This relatively small cadre attends a fighting force growing to 150,000 troops.

The surgeons are deployed in small teams of 20 people called Forward Surgical Teams (FST). "Each FST is equipped to move directly behind troops and establish a functioning hospital with four ventilator-equipped beds and two operating tables within a difficult-to-fathom 60 minutes," Gawande explains.

He describes the activities of the 274th FST led by 42-year-old George Peoples, who was Gawande's chief resident when he was a surgical intern at Brigham and Women's Hospital. In 2001, Peoples, then at Walter Reed Army Medical Center in Washington, D.C., put in one tour of duty in Afghanistan. He was called upon again to serve in Iraq in 2003.

While with the 274th FST, Peoples' logs show he traveled 1,100 miles over four months. He and his team cared for 132 U.S. and 74 Iraq casualties, 52 of whom were civilians. On a single day in Nasiriyah, the team treated 10 critically wounded patients. The next day, 14 more patients arrived. Eighty percent of casualties seen by the 274th had gunshot wounds, shrapnel penetrations, or blast injuries.

Gawande says that Peoples is known for his "unflappability" and intellect: "A West Point graduate, he owed the Army 18 years of service when he finally finished his training, and neither I or anyone I know ever heard him bemoan that commitment."

The medical journal article is accompanied by five pages of color photographs of Peoples' Iraq tour, most of which should not be viewed by the timid.

Getting home

The Forward Surgical Teams stabilize patients and seek to limit surgery to two hours. Patients are then shipped to a Combat Support Hospital (CSH), the next level of care. "Two CSHs with four sites now exist in Iraq," Gawande says. They are 248-bed hospitals with six operating tables. Maximum stays at such units are intended to be three days. Those who require further care may go to larger hospitals in Kuwait, Spain, or Landstuhl, Germany. If physicians expect treatment to require more than 30 days, soldiers are usually transferred to Walter Reed or Brooke Army Medical Center in San Antonio, Texas.

Gawande quotes statistics from Walter Reed - "during the first few months of the war, it took an injured solder an average of eight days to go from the battlefield to a facility in the U.S. The average time from battlefield to arrival in the U.S. is now less than four days." In the Vietnam War of 1961-1972, when 200,727 soldiers were wounded or killed in action, transit time was 45 days.

Gawande cites the case of an airman who suffered devastating injuries from a mortar attack on Sept. 11, 2004. He was on an operating table at Walter Reed 36 hours later. After weeks of intensive care and multiple operations, he survived.

"This in itself is remarkable," Gawande comments. "Injuries like his were unsurvivable in previous wars." But the airman lost both legs, his right hand and part of his face, leading Gawande to raise the key question in the lethality versus survival question: How the airman and others like him will be able to live and function in the future.

Shortage of help

Finding enough medical personnel to keep up the unprecedented achievement of saving 90 percent of the wounded continues to be a problem. The supply is so tight many surgeons have been pressed into a second deployment. Gawande says that planners have begun to consider third deployments. Compounding that is the understandable difficulty of recruiting new people. "Interest in joining the Reserves has dropped precipitously," Gawande says.

The article points out that President Bush insists that no draft will take place. However, the article notes, "the Selective Service, the U.S. agency that maintains draft preparations in case of a national emergency, has recently updated a plan to allow the rapid registration of 3.4 million health care workers, 18 to 44 years of age."

The Department of Defense indicates that it will raise the pay of medical professionals, but it would hardly match civilian compensation. Then there's the necessity of leaving home - and the danger.

Gawande describes the case of one Mark Taylor, 41, a surgeon who began his Army service in 2001. In fulfilling the terms of a military scholarship to attend medical school, he was deployed twice to Iraq. On March 20, 2004, four days from returning home, Taylor was hit by a rocket-propelled grenade while making a telephone call outside his barracks.

He did not survive.

Copyright 2007 by the President and Fellows of Harvard College