Iraq War 10 year anniversary: Survival rate of wounded soldiers better than previous wars
Lee Bowman, Scripps Howard News Service
12:00 PM, Mar 16, 2013
5:02 PM, Mar 15, 2013
When a suicide bomber detonated an explosive beside the vehicle in which Army Master Sgt. Todd Nelson was riding through Kabul, Afghanistan, in 2007, shrapnel struck his right side, and fire engulfed him.
Nearby troops pulled Nelson from the flaming wreckage of the Land Cruiser, and American medics and surgeons at the nearest base did what they could to stabilize him.
Nelson had a fractured skull and crushed facial bones. His nose, right eye and ear were gone. Burns covered more than 18 percent of his body. He was unconscious for six weeks, only a heartbeat showed he was alive.
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Now 40, he's sure the U.S. medical evacuation teams that flew him swiftly to Germany and on to Brooke Army Medical Center in San Antonio saved his life several times en route.
That Nelson didn't die from his grievous wounds is testament to the military medical advances that have given U.S. troops wounded in Iraq and Afghanistan a remarkable 90 percent chance of survival.
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Telling his story to a roomful of science reporters last month, Nelson recalled waking up in the hospital and looking at himself in the mirror for the first time, thinking "'I guess I can live with that.' Because I felt fortunate to be alive.''
Nelson is just one of more than 50,000 American troops who have suffered combat wounds in Afghanistan and Iraq. More than 5,200 have died. And every casualty has left a legacy of increased understanding about how to treat horrible wounds and save lives.
As the 10th anniversary of the start of the Iraq war approaches and American troops continue withdrawing from Afghanistan, military and civilian medical experts are taking stock of what the troops' shared sacrifice has meant in advancing the medical care of the wounded -- in uniform and out.
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The progress is evident in the remarkable survival statistic. In Vietnam and even the Persian Gulf War 20 years ago, just 76 percent of the wounded lived.
Insights gained from keeping severely wounded troops alive already are being put to work in civilian emergency departments and ambulances nationwide.
Many trauma experts believe lessons from military medicine in the past decade are a major reason why more civilians are surviving gunshot injuries in the U.S., even as the total number of shootings has been increasing, according to figures kept by the federal Centers for Disease Control and Prevention.
The casualties of Iraq and Afghanistan "are 50,000 case studies of traumatic amputations and gunshot wounds and brain injuries, all tracked and managed in the same military system,'' said Ken Koyle, former commander of an Army medical evacuation unit in Iraq and a military historian who now works at the National Library of Medicine.
"That drives very rapid changes in the way casualties are treated on the battlefield, and influences the way injuries are treated in the civilian world."
Every war fought by the American military has driven changes in medical practice that influence, and can advance, civilian medicine. The Civil War brought an Army-wide system of medical care, front line hospitals staffed by trained surgeons and ambulance corps that served as the model for the first civilian ambulance service in New York City.
World War I brought forward aid stations and pioneering use of blood transfusions. World War II sped the development of mass-produced penicillin that saved thousands of soldiers from deadly infections and quickly introduced antibiotics to civilian care after the war. Korea and Vietnam brought and refined helicopter evacuation and mobile surgical hospitals that laid the groundwork for much of the nation's paramedic and emergency trauma care today.
A decade of combat in Iraq and Afghanistan has accelerated care in similar fashion.
Dr. Howard Mell, Emergency Medical Services director for the Lake Health system of hospitals outside Cleveland, and chairman of the EMS Section of the American College of Emergency Physicians, sees the contributions to civilian care from the latest conflicts firsthand.
"Every time I share stuff we've learned out of the wars with our guys, I remind them that the information was unfortunately paid for at a very high price by a lot of families, and we have an obligation to use those lessons," Mell said.
Among the key medical advances:
-- Updated front-line first aid kits carried by medically trained soldiers and, now, civilian first responders alike. The kits include a tourniquet, bandages impregnated with clotting agents, and needles to re-inflate lungs collapsed by a sucking chest wound.
-- An evolving system to measure, diagnose and treat traumatic brain injuries ranging from mild concussions to open head wounds. Collaboration on care already has moved from the battlefield to the NFL and NCAA. And there is growing awareness of possible ties between concussions and post-traumatic stress disorder, with new strategies of early intervention for both.
-- Efforts to better serve more than 1,500 soldiers who have lost at least one major limb have accelerated advances in prosthetics. Dozens of soldiers have returned to active duty fitted with artificial limbs, including Army Ranger Sgt. Joseph Kapacziewski (leg); military war dog trainer Sgt. Chris Burrell (leg), and Col. Gregory Gadson, who lost both legs in Iraq and now commands Fort Belvoir, Va.
The wars have also changed how and where forward trauma care is performed, with an emphasis on rapidly getting the severely wounded to top military hospitals in Germany or the U.S. aboard flying intensive care units. Trauma doctors are less likely to pump saline solution into patients who've lost a lot of blood, and more likely to replace the loss with blood.
"There were no standard (battle) lines in Iraq or Afghanistan, so the echelons of care were compressed with the aim of getting patients stabilized and toward more specialized care up the system," said Alan Hawk, historical collections manager at the Defense Department's National Museum of Health and Medicine in Silver Spring, Md.
The busiest trauma operation in Iraq was the Air Force Joint Theater Hospital at Balad, about 40 miles north of Baghdad. Dozens of doctors, nurses and technicians treated some of the worst casualties of the war there for five years, and roughly 98 percent of those who reached the facility survived.
Trauma Bay II, where the most severely wounded usually went, was disassembled from canvas roof to disinfectant-stained concrete floor and shipped to the military's medical museum in 2008. "More people lived and died there than just about any other place in Iraq," Hawk said "Not a lot came through at one time. Choppers would bring in one or two at a time after most attacks."
The hours and days following the IED attack on Master Sgt. Nelson exemplify the benefit of rapid evacuation and advanced trauma care near the battlefield and in the U.S.
The 17-year Army veteran's progress and survival came from a combination of reconstructive surgery and skin grafts, using techniques first adopted decades ago but improved in recent years.
"I found out after 40-odd surgeries that some techniques we were using were invented in World War II," Nelson said.
Today, Nelson has a prosthetic blue eye, a prosthetic ear (complete with freckles to match his skin) held to his skull by magnets, and a nose built up from skin flaps, and relatively smooth facial skin taken from other parts of his body.
Although he closely follows the advances being made in skin repair and facial reconstruction, Nelson has called a halt to surgeries. "I'm just tired,'' he said. Only a proven method that would give him a full nose or a real ear might draw him back to an operating room.
But the outlook for those wounded in the future may be brighter.
Col. Robert Hale, who heads the head, face and jaw reconstruction branch of the Army Institute of Surgical Research in San Antonio, appearing with Nelson at a meeting of the American Association for the Advancement of Science last month, described advances he and others are working toward.
They include a "biomask" to help protect burn wounds; the regeneration of skin from a patient's own stem cells and body fat; and spray-on skin harvested from the patient's own skin cells.
Hale believes that the wars will be remembered for advances in regenerative medicine and that "within 20 years we'll be able to re-grow an entire face from the patient's own cells."
(Reach Scripps health and science writer Lee Bowman at firstname.lastname@example.org.)