BAGHDAD, Iraq – For every American soldier 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, some young soldiers and Marines have had faces, arms and legs blown off and are now returning home badly maimed.
But they have survived thanks, in part, to armor-like vests and fast treatment from doctors on the move with surgical kits in backpacks.
"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 Thursday's New England Journal of Medicine (search).
The journal also published a five-page spread of 21 military photographs that graphically depict the horrific injuries and conditions under which these modern-day MASH surgeons operate.
"We thought a lot about it," said the journal's editor, Dr. Jeffrey Drazen, and ultimately decided the pictures told an important story.
"This war is producing unique injuries — less lethal but more traumatic," he said.
In one traumatic case, Gawande tells of an airman who lost both legs, 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," Gawande writes.
Kevlar helmets and vests are one reason for the high survival rate.
"The critical core, your chest and your abdomen, are protected," said Dr. George Peoples, a Walter Reed Army Medical Center (search) surgeon who served in Iraq and Afghanistan. "Parodixically, 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 roughly 90 percent. In the Vietnam War, one in four wounded died, virtually all of them before they could reach MASH units some distance from the fighting.
Today in Iraq, real-life Hawkeyes and B.J. Hunnicuts have stripped trauma surgery to its most basic level, carrying "mini-hospitals" in six Humvees and field operating kits in five backpacks so they can move with troops and do surgery on the spot.
"Within an hour, we drop the tents and set up the OR tables, and we can pretty much start operating immediately," said Peoples, whose photographs are in the medical journal.
He's now at Walter Reed in Washington which has treated 150 amputees from the Iraq war. American military hospitals collectively have had 200 amputees from Iraq and Afghanistan, three of them triple amputees.
The record survival rates in Iraq have been achieved with an astonishingly small number of general surgeons. The entire Army has only 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, Gawande reports.
That's fewer than the 80 general and orthopedic surgeons on staff at two Boston hospitals — Brigham and Massachusetts General.
"It's a very tight supply," Gawande said of the surgeons in Iraq. "They're now also burdened with civilian Iraqis seeking their help because the U.S. has taken over many Iraqi hospitals."
Virginia Stephanakis, a spokeswoman for the Army Surgeon General's Office, said Gawande had done excellent research and that his figures on casualties jibe with those on Department of Defense Web sites, though she wouldn't confirm the number of surgeons in Iraq.
Gawande and others also credit nurses, anesthetists, helicopter pilots, other transport staff and an entire rethinking of the combat medicine system for soldiers' 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 soldiers to one of several combat support hospitals in Iraq with services like 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 the injury is not going to be salvageable, we do a rapid amputation, and there have been a fair number of those."
If soldiers are shipped to a combat support hospital, the maximum stay is three days. If more advanced care is needed, they're sent to hospitals in Landstuhl, Germany, or Kuwait or Spain. If care will be needed for a month or more, they're whisked directly to Walter Reed 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," Gawande writes.
John Greenwood, a historian with the Army Surgeon General's office, said the new strategy has made a big difference in survival.
"Historically, the key change has been the ability to move the wounded man to definitive surgical care," he said.
Field surgeons moving with troops is the first step. Peoples traveled 1,100 miles throughout southern Iraq and into Baghdad, doing only what was absolutely necessary to save a life and shipping patients out.
He said he tried to ignore personal danger, like the time his medical team was sent to an evacuated air base in southern Iraq.
"At least, we thought it was evacuated," he said. In fact, Iraqi soldiers were still being routed out. The medical team was told to pick any of the bombed-out buildings to use as a makeshift hospital. After finishing one surgery, he walked outside and noticed big red X's on all the other buildings warning against entry.
By sheer luck, he said, "we had chosen the only one that hadn't been booby-trapped."
As for the soldiers he took pictures of, he had this to say:
"Every person depicted in those photos survived."