Teleconferencing from the war zone improves treatment for wounded soldiers

By David Brown
Saturday, October 30, 2010; 2:45 AM

BAGRAM AIR FIELD, AFGHANISTAN -- It's a heart-stopping and heartbreaking catalogue of the mayhem, heroics and human toll of modern war.

Every Thursday afternoon doctors, nurses and medics gather in a conference room at the military hospital here, linked by telephone or videocam to colleagues at all the combat hospitals in Afghanistan, and at military hospitals in Europe and the United States. Over two hours, this virtual assembly of about 80 people reviews the care of every U.S. service member critically injured in Afghanistan in the previous week.

Among the 13 discussed at one recent meeting, nine will have permanent disabilities: Two lost one leg; two lost a leg and a foot; two lost both legs; two lost both legs and a hand; and one was paralyzed from the waist down. Three of the nine also lost their genitals.

The conference helps ensure no injuries are overlooked in patients who often have a dozen wounds or more. It's a way of double-checking innumerable pieces of information that have been entered into a database and will be studied to help improve practice. It's also a way of gently monitoring everyone's performance.

Lots of people take care of these patients, but few see them for more than the 36 hours before they are flown out of Afghanistan. The weekly conference assembles, for everyone's benefit, the chapters of a narrative whose only common character is the broken body of the soldier himself.

Treatment and transport

These transcontinental medical rounds reflect a revolution in the care of battlefield casualties.

No longer are grievously injured soldiers kept in one place until they're stable and have had their wounds fully addressed. Instead they're moved in a seamless process that combines treatment and transport from the battlefield to a combat hospital, to Bagram, to a military hospital in Landstuhl, Germany, and then to one of the giant medical centers in Washington, Bethesda or San Antonio.

The system is based on an approach called "damage control surgery," imported from civilian medicine but perfected in the past nine years in the Iraq and Afghanistan wars. Wounds are addressed in stages. Surgery is kept as short as possible. Most soldiers with critical injuries get two operations in two hospitals in the first 24 hours.

Experience has shown that fewer trauma victims die if you treat them in step-wise fashion. But most Afghanistan trauma is caused by make-shift bombs or IEDs that inflict such extensive damage that fixing the body in two or three operations is impossible anyway.

"Twenty years ago, if you left the operating room without fixing everything, you weren't a good surgeon," said Rodd Benfield, a 39-year-old Navy surgeon from San Diego deployed to Kandahar Air Field in southern Afghanistan. "We don't believe that anymore."

IEDs not only blow limbs off the body, they drive dirt deep into flesh and often peel skin back a foot or more above the bone's jagged end. The shock wave kills tissue that initially looks normal and takes days to "declare" its true condition. With damage-control surgery, these wounds are washed out, and dead tissue removed, under general anesthesia every day for a week or more.

Similarly, abdominal cavities are explored and re-explored, as surgeons look for wounds overlooked in the first operation, or that have developed since. Pelvic injuries, often massive because of between-the-legs IED blasts triggered by soldiers on foot patrol, are left open, protected with bandages and repaired step by step.

Inevitably, inhabiting this near-death state for a prolonged period results in hard-to-avoid complications - pneumonia, collapsed lungs, blood clots - that require their own procedures.

"It's like one long operation," said Eric Elster, a 41-year-old transplant surgeon at the naval hospital in Bethesda who's now at Kandahar.

Five deployments

The conference is run by Col. Brian Eastridge, a 47-year-old trauma surgeon with 23 years in the Army. He grew up in Damascus, Md., graduated from Virginia Tech and the University of Maryland School of Medicine. He now heads the Joint Theater Trauma System, which organizes trauma care in both wars.

Over five deployments, Eastridge has seen the entire arc of worsening wounds and increasing survival that has marked trauma care during the Iraq and Afghan wars.

Dressed in brown camouflage battle dress, he sits halfway around a large U made of wooden tables. Around him on the walls are idealized scenes of Afghan life painted by a local artist - a girl leading a caravan of camels, children being taught arithmetic at the base of a tree, kids flying kites. Eastridge runs the conference with somber efficiency, offers comments sparingly and addresses his listeners mostly by location-"Kandahar," "Landstuhl," "Walter Reed."

The rapid-fire reports are dense with medical jargon and anatomical description. It's a narration of one disaster after another, and of how things were kept from getting worse, and made better, by skill, speed and attention. It's the aural equivalent of watching a dozen high-wire acts in which some people are rescued mid-fall.

Here's just one.

"Dismounted IED" injury is jargon for wounds caused by a bomb or mine that are suffered outside a vehicle. The soldier had tourniquets placed for partial amputation of both legs. One liter of a special IV fluid was given in the helicopter, and the patient arrived at the Kandahar hospital in and out of consciousness and in shock.

In the operating room, surgeons temporarily tied off the arteries going to the legs and repaired a tear in a major vein. There was massive damage to the area between the legs. One leg was amputated at the knee. In a second operation the next day his wounds were rewashed and a finger, broken in the explosion, was fixed with external hardware.

That same day the soldier was evacuated to Bagram, where his wounds were washed out and the pelvic region was re-explored. A "foreign body"- the speaker didn't say whether it was dirt, metal or something else - not seen in the first operation was removed. He suffered a collapsed lung after surgery, which was fixed.

He stayed there two days before flying by critical care air transport to Landstuhl.

There the process was repeated.

Seven days after suffering his wounds the soldier arrived at a hospital in the United States. He had another collapsed lung, and pneumonia. His right foot, initially thought to be salvageable, wasn't healing and the surgeons planned to amputate it at the ankle. He had further surgery to his abdomen and numerous operations to start repairing the missing floor of his pelvis.

"This was one of the biggest pelvic injuries I've ever seen," said one of the surgeons in the United States. Eastridge later said he hears that a lot from surgeons in the United States who haven't been deployed yet.

This was not an uncommon case.

'Tremendous saves'

After a litany of such descriptions, the group filed out. "None of these kids would have survived in the civilian world," said Jay Johannigman, one of the surgeons. "And we never would have saved them five years ago."

The last thing Eastridge said before ringing off was: "Another busy week. There was a bunch of tremendous saves. There are several really tremendous saves that are going to be coming up next week, too."

But do the doctors sometimes wonder if the lives they've saved will be worth living?

It's an extremely delicate question and not one anyone asks in the heat of the moment. But sometimes, afterward, they do.

"The efforts we take are not futile at all," said Elster, the Navy surgeon at Kandahar. "We've seen a few of these guys move through Bethesda and recover. This is not in vain. Between prosthetics and rehabilitation, these folks can go on to lead a very productive life."

Eastridge would not disagree with any of that. Nevertheless, he wonders how he would feel if he had the disabilities of some of his patients.

"A lot of my colleagues have similar questions," he said the next day, after staying up all night operating. "We talk about it amongst ourselves. Did we do the right thing by saving that 90 percent burn patient, or the casualty who has all four extremities amputated?"

He continues: "But there are so many stories of people who have gone on to be functional and appreciative that they had the chance to live the rest of their lives. We definitely struggle with the ones that are out there that don't feel that way."

The surgeons here have a fierce dedication to saving every life. Only in mass casualty events must some patients be put aside and treated "expectantly," the euphemism for the assumption they will die. Even getting someone alive to Landstuhl, where their family can see them before they die, counts as a victory.

"We try not to withdraw care here in theater," Eastridge said.

But every once in a while it happens. It's usually someone with brain injuries so severe they're likely to die during transport. They're allowed to die here, with troops at the bedside. "That just affords them that last little bit of dignity," he said.

He stopped, and his eyes filled with tears.

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