The front lines of saving lives

By David Brown
Washington Post Staff Writer
Sunday, October 17, 2010; A1

AT FORWARD OPERATING BASE WILSON The first sign this isn't a routine pickup is the rhythmic right and left banking of the helicopter.

It's the kind of thing kids do on bikes to feel the thrill of heeling over. Only this is done to make the aircraft a less easy target.

At 6:09 p.m., Dustoff 57 has just left this base deep in Taliban-infiltrated Kandahar province, headed for a POI, or point of injury. On board are two pilots, a crew chief and a flight medic, as well as two litters for carrying the wounded and numerous black nylon bags stuffed with ultramodern medical gear and some of the oldest lifesaving tricks of the battlefield. That combination of new and old - of specially developed porcelain-powder gauze and old-fashioned tourniquets - is key to keeping gravely wounded soldiers alive in the minutes before they get to the hospital. It's also the basis of evolving front-line strategies that may eventually trickle down in modified form to civilian ambulances, emergency rooms and trauma centers in the United States.

Somewhere ahead of the aircraft is a soldier who minutes earlier stepped on an improvised explosive device, the signature weapon of the wars in Iraq and Afghanistan. All the helicopter crew knows is that he's "category A" - critical.

The sun is down but there is still a little pink in the western sky. Beneath the helicopter, the ground is made of what the troops call "moon dust." Fine-grained and dry, it is a color not as dark as dirt and not as light as sand.

The aircraft weaves over compounds enclosed by mud walls and surrounded by fields of grapes and vegetables. Farther away on the sere, unirrigated plain are the domed tents of herdsmen, their cooking fires glowing like terrestrial stars.

The trip out takes nine minutes.

The helicopter lands, stirring up a cloud of moon dust that nearly obscures six soldiers kneeling and standing around the wounded man, 50 feet from the aircraft. Their headlamps make tiny blue searchlights. The 28-year-old flight medic, Sgt. Cole Reece, runs toward them.

Cpl. Deanna Helfrich, 22, the crew chief, climbs out of her window and walks around the nose of the aircraft trailing a communication cable that allows her to talk to the rest of the crew. She stands near the open door where the wounded soldier will be brought, holding her rifle.

The weapon is a reminder: The crew is here to save lives, but Rule 1 of the Basic Management Plan for Care Under Fire is "Return fire and take cover."

There is no enemy fire this evening, but there is so much dust in the air and the rotors are spinning so fast that the leading edges of the blades light up like sparklers, flint on steel.

Fifteen minutes have now passed since the soldier was wounded. The details of how it happened don't matter to Reece. There are a limited number of things he can do between this nameless spot and the hospital at Kandahar Airfield, where they will soon be headed. What he needs to know he will see and feel for himself.

Speed, simplicity and priority have always been the hallmarks of emergency medicine. The new battlefield care that flight medics like Reece and others on the ground practice takes those attributes to the extreme.

Gone from their repertoire are difficult or time-consuming maneuvers, such as routinely hanging bags of intravenous fluids. On the ground, medics no longer carry stethoscopes or blood pressure cuffs. They are trained instead to evaluate a patient's status by observation and pulse, to tolerate abnormal vital signs such as low blood pressure, to let the patient position himself if he's having trouble breathing - and above all to have a heightened awareness that too much medicine can endanger the mission and still not save the patient.

Four people run to the helicopter with the stretcher holding the wounded soldier. He lies on his back partially wrapped in a foil blanket. His chest is bare. In the middle of it is an intraosseous device, a large-bore needle that has been punched into his breastbone by the medic on the ground. It's used to infuse fluids and drugs directly into the circulatory system when a vein can't be found. It's a no-nonsense technology, used occasionally in World War II, that fell out of favor when cheap and durable plastic tubing made IV catheters ubiquitous in the postwar years. Until they were revived for the Iraq and Afghanistan wars, intraosseous devices were used almost exclusively in infants whose veins were too small to find.

On each leg the soldier has a tourniquet, ratcheted down and locked to stop all bleeding below it. These ancient devices went out of military use more than half a century ago because of concern that they caused tissue damage. But research in the past 15 years has shown that they can be left on for two hours without causing permanent harm to limbs. Now every soldier carries a tourniquet and is instructed to put one on any severely bleeding limb and not think of taking it off.

Tourniquets have saved at least 1,000 lives, and possibly as many as 2,000, in the past eight years. This soldier is almost certainly one of them. They're a big part of why only about 10 percent of casualties in these wars have died, compared with 16 percent in Vietnam.

On the soldier's left leg, the tourniquet is above the knee. Both bones below his knee are broken, and the limb is bent unnaturally inward. The tourniquet on his right leg is lower, below the knee; how badly his foot is injured is hard to tell from the dressings. His left hand is splinted and bandaged, too.

Whether he will need an amputation is uncertain. The hospital where he's headed treated 16 patients in September who needed at least one limb amputated. Half were U.S. soldiers, and the monthly number has been climbing since March.

The man is covered in moon dust, and pale beneath it, but conscious and able to pay some attention to Reece. He's gotten 10 milligrams of morphine, not a lot.

First thing, the medic hooks a plastic tube to an oxygen tank and leans forward and puts a face mask on the soldier's head. He tells him over the din of the engine that he'll be okay, that they'll be at the hospital in 10 minutes.

After three minutes on the ground, the helicopter takes off.

Stanch the bleeding

The interior of the helicopter is lit by a single overhead light, headlamps and the glow of instruments. Reece tells Helfrich to check the tourniquets; things sometimes move in transit. He then pulls back the foil blanket and inspects. A tangle of dry grass lies directly over the soldier's navel.

The medic sees that a laceration in the soldier's left groin is still bleeding. This, too, is a signature wound of the two wars - a deep, dangerous injury just outside the protective veil of body armor and unable to be treated with a tourniquet. It's a wound from which a person can easily bleed to death. Death from blood loss has always been the greatest hazard of war wounds.

A recent analysis found that of soldiers deemed to have "potentially survivable" wounds, 80 percent died of bleeding. Usually the wound site was a part of the body where a tourniquet couldn't be applied.

The best option - not ideal - is to stuff the gash with Combat Gauze, a battlefield treatment new to the current wars. It's a bandage impregnated with a kind of powdered porcelain that stimulates clotting. The medic on the ground had already packed the wound with it. Reece unwraps some more, lays it across the injury and asks Helfrich to apply direct pressure.

He undoes the Velcro sleeve of a blood-pressure cuff and puts it on the soldier's right arm. He puts three stick-on EKG leads on the man's chest and abdomen, a right triangle. The man reaches up and touches his forehead, a self-confirming gesture. When he's done, the medic gently takes the hand and puts on the ring finger the toothless plastic jaws of a pulse oximeter - a device that measures the oxygen content of the blood through the skin. The soldier has lost a lot of blood. If his breathing falters and he can't oxygenate what's left, he will die.

The first blood pressure reading is 96/40. Normal is 120/80. The soldier's heart rate is way over 100, but the exact number is irrelevant. Nobody who's just had something blow up in front of him has a normal heart rate even if the blast has done nothing to him.

Every minute or so, Reece puts his right hand, which is in a black rubber glove, onto the soldier's head and rubs the center of his forehead. This is to stimulate him and gauge his level of consciousness. It may also reassure.

The pulse oximeter gives a reassuring reading. Several minutes into the trip the medic senses the soldier becoming drowsy and inserts a green plastic tube into his left nostril. This "nasopharyngeal airway" will make it easier, if the man becomes unconscious, for Reece to keep him alive.

While blood pressure somewhat below normal is considered all right - and even preferred - in severely injured patients, a diminishing level of consciousness is not a good sign.

Reece reaches for a 500-milliliter bag of Hextend - an intravenous fluid containing starch molecules that help boost blood pressure by preventing the watery part of blood from leaking out of vessels, as often happens in massive trauma. He squeezes the bag to make it run in more quickly through the device in the soldier's breast bone.

The soldier's next blood pressure reading is 116/71.

Just two minutes away, Reece leans forward and tells the patient they're almost there.

Communication glitch

Eleven minutes after lifting off from the POI, the helicopter lands at the so-called Role 3, or fully equipped, hospital at Kandahar Airfield, about 30 miles to the east of the also well-fortified Forward Operating Base Wilson. There, surgeons will take care of the injuries before transferring the patient, probably within two days, to the huge military hospital in Landstuhl, Germany, and there, after a week or so, to the United States.

But something has happened in the usually smooth communication between dispatch center, aircraft and hospital. No ambulance pulls up to the helicopter. Reece and Helfrich wait.

They wait.

The pilots radio the dispatcher that they've arrived with a critically injured soldier. Reece and Helfrich, helmeted and inaudible, gesture wildly to people outside the emergency room door to come over.

Two other patients have also recently arrived. But that's not the problem. There's an available ambulance 100 yards away. But it doesn't move.

Five minutes after touchdown, it finally drives up and the injured man is rushed into the back. Reece says later he was one minute from having the crew carry the patient to the emergency room themselves, even though running that distance with a trauma patient on a litter is just about the last thing you want to do.

It's been 28 minutes since the helicopter left Forward Operating Base Wilson. The ambulance, with Reece in it, disappears into a pool of greenish light at the hospital entrance.

In 10 minutes, the medic returns and the helicopter takes off to begin the refueling, restocking and cleaning that will make it ready, in less than an hour, for the next call.

It's for an Afghan man, described as a Taliban fighter, who has stepped on a land mine.

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