Better
Page 5
On the second day of the mop-up, we reached Upparahalla, the village where the Karnataka outbreak had started. The first, index case of polio was now a fourteen-month-old boy with a healthy, almost muscular thickness about his upper body; after the first few days of his infection, his breathing had returned to normal. But when his mother put him down on his stomach you could see that his legs were withered. With the exercises the nurses had taught her to do with him, he had regained enough movement in his left leg to be able to crawl, but his right leg dragged limply behind him.
Making our way around the open sewage in Upparahalla, the mud-covered pigs, the cows resting curled up like cats with their heads on their hooves, we found the neighbor girl who had come down with polio after the boy. She was eighteen months old, with a big, worried face, perfect white teeth, and short, spiky hair. She was wearing small gold earrings and a yellow-and-brown checked dress. She squirmed in her mother's arms, but her legs only dangled beneath her dress. Her mother wore an impassive expression as she stood before us in the sun, holding her paralyzed child. Pankaj gently asked her if the girl had ever received polio drops--perhaps she'd got the vaccine but it had not taken. The mother said that a health worker had come around with polio drops a few weeks before her daughter became sick. But she had heard from other villagers that children were getting fevers from the drops. So she refused the vaccination. A look of profound sadness now swept over her. She had not understood, she said, staring down at the ground.
Eventually, Pankaj continued onward, checking on the vaccinators going door to door. Then, when he was finished, we left. The road heading out of the village was a red dirt track and we rattled over it with our wheels in the ruts that the bullock carts had made.
"What will you do when polio is finally gone?" I asked Pankaj.
"Well, there is always measles," he said.
Casualties of War
Each Tuesday, the U.S. Department of Defense provides an online update of American military casualties from the wars in Iraq and Afghanistan. According to this update, as of December 8, 2006, a total of 26,547 service members had suffered battle injuries. Of these, 2,662 died; 10,839 lived but could not return to duty; and 13,085 were less severely wounded and returned to duty within seventy-two hours. These figures represent, by a considerable margin, the largest burden of casualties our military medical personnel have had to cope with since the Vietnam War.
When U.S. combat deaths in Iraq reached the two-thousand mark in September 2005, the event captured worldwide attention. Combat deaths are seen as a measure of the magnitude and dangerousness of war, just as murder rates are seen as a measure of the magnitude and dangerousness of violence in our communities. Both, however, are weak proxies. Little recognized is how fundamentally important the medical system is--and not just the enemy's weaponry--in determining whether or not someone dies. U.S. homicide rates, for example, have dropped in recent years to levels unseen since the mid-1960s. Yet aggravated assaults, particularly with firearms, have more than tripled during that period. A key mitigating factor appears to be the trauma care provided: more people may be getting shot, but doctors are saving even more of them. Mortality from gun assaults has fallen from 16 percent in 1964 to 5 percent today.
We have seen a similar evolution in war. Though firepower has increased, lethality has decreased. In the Revolutionary War, American soldiers faced bayonets and single-shot rifles, and 42 percent of the battle wounded died. In World War II, American soldiers were hit with grenades, bombs, shells, and machine guns, yet only 30 percent of the wounded died. By the Korean War, the weaponry was certainly no less terrible, but the mortality rate for combat-injured soldiers fell to 25 percent.
Over the next half century, we saw little further progress. Through the Vietnam War (with its 153,303 combat wounded and 47,424 combat dead) and even the 1990-91 Persian Gulf War (with its 467 wounded and 147 dead), mortality rates for the battle injured remained at 24 percent. Our technology to save the wounded seemed to have barely kept up with the technology inflicting the wounds.
The military wanted desperately to find ways to do better. The most promising approach was to focus on discovering new treatments and technologies. In the previous century, that was where progress had been found--in the discovery of new anesthetic agents and vascular surgery techniques for World War I soldiers, in the development of better burn treatments, blood transfusion methods, and penicillin for World War II soldiers, in the availability of a broad range of antibiotics for Korean War soldiers. The United States accordingly invested hundreds of millions of dollars in numerous new possibilities: the development of blood substitutes and freeze-dried plasma (for infusion when fresh blood is not available), gene therapies for traumatic wounds, medications to halt lung injury, miniaturized systems to monitor and transmit the vital signs of soldiers in the field.
Few if any of these have yet come to fruition, however, and none were responsible for what we have seen in the current wars in Iraq and Afghanistan: a marked, indeed historic, reduction in the lethality of battle wounds. Although more U.S. soldiers have been wounded in combat in the current war than in the Revolutionary War, the War of 1812, and the Spanish-American War combined, and more than in the first four years of military involvement in Vietnam, we have had substantially fewer deaths. Just 10 percent of wounded American soldiers have died.
How military medical teams have achieved this is important to think about. They have done it despite having no fundamentally new technologies or treatments since the Persian Gulf War. And they have done it despite difficulties with the supply of medical personnel. For its entire worldwide mission, the army had only about 120 general surgeons available on active duty and two hundred in the reserves in 2005. To support the 130,000 to 150,000 troops fighting in Iraq, it has been able to put no more than thirty to fifty general surgeons and ten to fifteen orthopedic surgeons on the ground. And these surgeons and their teams have been up against devastating injuries.
I got a sense of the extent of the injuries during a visit to Walter Reed Army Medical Center in Washington, D.C., in the fall of 2004, when I was invited to sit in on what the doctors call their "War Rounds." Every Thursday, the Walter Reed surgeons hold a telephone conference with army surgeons in Baghdad to review the American casualties received in Washington. The case list for discussion the day I visited included one gunshot wound, one antitank-mine injury, one grenade injury, three rocket-propelled-grenade injuries, four mortar injuries, eight improvised explosive device (IED) injuries, and seven with no cause of injury noted. None of these soldiers was more than twenty-five years of age. The least seriously wounded was a nineteen-year-old who had sustained extensive blast and penetrating injuries to his face and neck from a mine. Other cases included a soldier with a partial hand amputation; one with a massive blast injury that amputated his right leg at the hip, a through-knee amputation of his left leg, and an open pelvic wound; one with bullet wounds to his left kidney and colon; one with bullet wounds under his arm requiring axillary artery and vein reconstruction; and one with a shattered spleen, a degloving scalp laceration, and a through-and-through tongue laceration. These are terrible and formidable injuries. Nonetheless, all were saved.
IF THE ANSWER to how was not to be found in new technologies, it did not seem to reside in any special skills of military doctors, either. George Peoples is a forty-two-year-old surgical oncologist who was my chief resident when I was a surgical intern. In October 2001, after the September 11 attacks on the World Trade Center and the Pentagon, he led the first surgical team into Afghanistan. He returned after service there only to be sent to Iraq, in March 2003, with ground forces invading from Kuwait through the desert to Baghdad. He had gone to the U.S. Military Academy at West Point for college, Johns Hopkins Medical School in Baltimore, Brigham and Women's Hospital in Boston for surgical residency, and then M. D. Anderson Cancer Center in Houston for a cancer surgery fellowship. He owed the army eighteen years of service when he finally finished his tra
ining, and neither I nor anyone I know ever heard him bemoan that commitment. In 1998, he was assigned to Walter Reed, where he soon became chief of surgical oncology. Peoples was known in training for three things: his unflappability, his intellect (he had published seventeen papers on work toward a breast cancer vaccine before he finished his training), and the five children he and his wife had during his residency. He was not known, however, for any particular expertise in trauma surgery. Before being deployed, he hadn't seen a gunshot wound since residency, and even then, he never saw anything like the injuries he saw in Iraq. His practice at Walter Reed centered on breast surgery. Yet in Iraq, he and his team managed to save historic numbers of wounded.
"How is this possible?" I asked him. I asked his colleagues, too. I asked everyone I met who had worked on medical teams in the war. And what they described revealed an intriguing effort to do something we in civilian medicine do spottily at best: to make a science of performance, to investigate and improve how well they use the knowledge and technologies they already have at hand. The doctors told me of simple, almost banal changes that produced enormous improvements.
One such change involved Kevlar vests, for example. There is nothing new about Kevlar. It has been around since the late 1970s. Urban police forces began using Kevlar vests in the early 1980s. American troops had them during the Persian Gulf War. A sixteen-pound Kevlar flak vest will protect a person's "body core"--the heart, the lungs, the abdominal organs--from blasts, blunt force trauma, and penetrating injuries. But researchers examining wound registries from the Persian Gulf War found that wounded soldiers had been coming in to medical facilities without their Kevlar on. They hadn't been wearing their vests. So orders were handed down holding commanders responsible for ensuring that their soldiers always wore the vests--however much they might complain about how hot or heavy or uncomfortable the vests were. Once the soldiers began wearing them more consistently, the percentage killed on the battlefield dropped instantly.
A second, key discovery came in much the same way, by looking more carefully at how the system was performing. Colonel Ronald Bellamy, a surgeon with the army's Borden Institute, examined the statistics of the Vietnam War and found that helicopter evacuation had reduced the transport time for injured soldiers to hospital care from an average of over eleven hours in World War II to under an hour. And once they got to surgical care, only 3 percent died. Yet 24 percent of wounded soldiers died in all, and that was because transport time to surgical care under an hour still wasn't fast enough. Civilian surgeons talk of having a "Golden Hour" during which most trauma victims can be saved if treatment is started. But battlefield injuries are so much more severe--the blood loss in particular--that wounded soldiers have only a "Golden Five Minutes," Bellamy reported. Vests could extend those five minutes. But the recent emphasis on leaner, faster-moving military units moving much farther ahead of supply lines and medical facilities was only going to make evacuation to medical care more difficult and time-consuming. Outcomes for the wounded were in danger of getting worse rather than better.
The army therefore turned to an approach that had been used in isolated instances going back as far as World War II: something called Forward Surgical Teams (FSTs). These are small teams, consisting of just twenty people: three general surgeons, one orthopedic surgeon, two nurse anesthetists, three nurses, plus medics and other support personnel. In Iraq and Afghanistan, they travel in six Humvees directly behind the troops, right out onto the battlefield. They carry three lightweight, Deployable Rapid-Assembly Shelter ("drash") tents that attach to one another to form a nine-hundred-square-foot hospital facility. Supplies to immediately resuscitate and operate on the wounded are in five black nylon backpacks: an ICU pack, a surgical-technician pack, an anesthesia pack, a general-surgery pack, and an orthopedic pack. They hold sterile instruments, anesthesia equipment, medicines, drapes, gowns, catheters, and a handheld unit that allows clinicians to measure a complete blood count, electrolytes, or blood gases with a drop of blood. FSTs also carry a small ultrasound machine, portable monitors, transport ventilators, an oxygen concentrator providing up to 50 percent pure oxygen, twenty units of packed red blood cells for transfusion, and six roll-up stretchers with litter stands. All of this is ordinary medical equipment. The teams must forgo many technologies normally available to a surgeon, such as angiography and radiography equipment. (Orthopedic surgeons, for example, have to detect fractures by feel.) But they can go from rolling to having a fully functioning hospital with two operating tables and four ventilator-equipped recovery beds in under sixty minutes.
Peoples led the 274th FST, which traveled 1,100 miles with troops during the invasion of Iraq. The team set up in Nasiriyah, Najaf, Karbala, and points along the way in the southern desert, then in Mosul in the north, and finally in Baghdad. According to its logs, the unit cared for 132 U.S. and 74 Iraqi casualties (22 of the Iraqis were combatants, 52 civilians) over those initial weeks. Some days were quiet, others overwhelming. On one day in Nasiriyah, the team received ten critically wounded soldiers, among them one with right-lower-extremity shrapnel injuries; one with gunshot wounds to the stomach, small bowel, and liver; another with gunshot wounds to the gallbladder, liver, and transverse colon; one with shrapnel in the neck, chest, and back; one with a gunshot wound through the rectum; and two with extremity gunshot wounds. The next day, fifteen more casualties arrived.
Peoples described to me how radically the new system changed the way he and his team took care of the wounded. On the arrival of the wounded, they carried out the standard Advanced Trauma Life Support protocols that all civilian trauma teams follow. However, because of the high proportion of penetrating wounds--80 percent of casualties seen by the 274th FST had gunshot wounds, shrapnel injuries, or blast injuries--lifesaving operative management is required far more frequently than in civilian trauma centers. The FST's limited supplies provided only for a short period of operative care for a soldier and no more than six hours of postoperative intensive care. So the unit's members focused on damage control, not definitive repair. They packed off liver injuries with gauze pads to stop the bleeding, put temporary plastic tubes in bleeding arteries to shunt the blood past the laceration, stapled off perforated bowel, washed out dirty wounds--whatever was necessary to control contamination and stop hemorrhage. They sought to keep their operations under two hours in length. Then, having stabilized the injuries, they shipped the soldier off--often still anesthetized, on a ventilator, the abdominal wound packed with gauze and left open, bowel loops not yet connected, blood vessels still needing repair--to another team at the next level of care.
They had available to them two Combat Support Hospitals (or CSHs--"CaSHes"--as they call them) in four locations for that next level of care. These are 248-bed hospitals typically with six operating tables, some specialty surgery services, and radiology and laboratory facilities. Mobile hospitals as well, they arrive in modular units by air, tractor trailer, or ship and can be fully functional in twenty-four to forty-eight hours. Even at the CSH level, the goal is not necessarily definitive repair. The maximal length of stay is intended to be three days. Wounded American soldiers requiring longer care are transferred to what's called a level IV hospital--one was established in Kuwait and one in Rota, Spain, but the main one is in Landstuhl, Germany. Those expected to require more than thirty days of treatment are transferred home, mainly to Walter Reed or to Brooke Army Medical Center in San Antonio, Texas. Iraqi prisoners and civilians, however, remain in the CSHs through recovery.
The system took some getting used to. Surgeons at every level initially tended to hold on to their patients, either believing that they could provide definitive care themselves or not trusting that the next level could do so. ("Trust no one" is the mantra we all learn to live by in surgical training.) According to statistics from Walter Reed, during the first few months of the war it took the most severely injured soldiers--those who clearly needed prolonged and extensive care--an average of eight days to go from th
e battlefield to a U.S. facility. Gradually, however, surgeons embraced the wisdom of the approach. The average time from battlefield to arrival in the United States is now less than four days. (In Vietnam, it was forty-five days.) And the system has worked.
One airman I met during my visit to Washington had experienced a mortar attack outside Balad on September 11, 2004, and ended up on a Walter Reed operating table just thirty-six hours later. In extremis from bilateral thigh injuries, abdominal wounds, shrapnel in the right hand, and facial injuries, he was taken from the field to the nearby 31st CSH in Balad. Bleeding was controlled, resuscitation with intravenous fluids and blood begun, a guillotine amputation at the thigh performed. He received exploratory abdominal surgery and, because a ruptured colon was found, a colostomy. His abdomen was left open, with a clear plastic covering sewn on. A note was taped to him explaining exactly what the surgeons had done. He was then taken to Landstuhl by an air force critical care transport team. When he arrived in Germany, army surgeons determined that he would require more than thirty days of recovery, if he made it at all. Resuscitation was continued, a quick further washout performed, and then he was sent on to Walter Reed. There, after weeks in intensive care and multiple operations to complete the repairs, he survived. This sequence of care is unprecedented, and so is the result. Injuries like his were unsurvivable in previous wars.
But if mortality is low, the human cost remains high. The airman lost one leg above the knee, the other at the hip, his right hand, and part of his face. How he and others like him will be able to live and function remains an open question. His abdominal injuries prevented him from being able to lift himself out of bed or into a wheelchair. With only one hand, he could not manage his colostomy. We have never faced having to rehabilitate people with such extensive wounds. We are only beginning to learn what to do to make a life worth living possible for them.