Refinements in medical care help more war wounded survive
January 3, 2006
LANDSTUHL, Germany — The number of troops dying as a result of battlefield injuries in the Iraq war is half of what it was during the Vietnam War, critical care and trauma surgery experts at Landstuhl Regional Medical Center say.
Medically speaking, today’s mortality rate among wounded troops is 50 percent less than it was roughly 35 years ago.
The lower mortality rate among today’s wounded troops has been achieved not so much by innovations but rather refinements to U.S. military medical care, doctors said.
“I think it’s the refinement of techniques that has really changed the outcomes of our multitrauma patients,” said Air Force Dr. (Lt. Col.) Guillermo J. Tellez, chief of Landstuhl Regional Medical Center’s surgery division. “It’s everybody putting their lessons learned toward refining techniques.”
Those refinements have saved thousands of lives since the beginning of the wars in Iraq and Afghanistan.
“There would have been an additional 2,200 people that would have died without the things that we’ve done,” said Air Force Dr. (Lt. Col.) Warren Dorlac, chief of critical care and trauma surgery at Landstuhl.
Those include: damage-control surgery, limb and abdomen incisions, external fixators, critical care air transport, formal trauma systems and concurrent process improvement.
Damage-control surgery has had as much as an effect of saving lives of troops from Iraq and Afghanistan as anything else, Dorlac said. Nowhere were the benefits of damage-control surgery more apparent than in Fallujah, Iraq, during November 2004. The Navy Forward Surgical Team there performed damage-control surgery on casualties, Dorlac said.
“They had huge numbers of patients and managed all those guys with perfect damage-control principles,” he said. “By doing that, for their Marines, I think they had a zero-mortality rate in theater.”
In damage-control surgery, surgeons treat only a patient’s most critical problems and get that patient out of surgery so he or she can receive additional treatment at a medical facility with more assets.
“We’re operating on patients and getting them out of the operating room before they develop a physiologic crisis,” Dorlac said. “If we operated in the old mode of surgery — this is even 15 years ago — you would start the case and operate until you finished the case. And if the guy died, the guy died, but you didn’t walk out of the operating room until you had done basically everything. Now we just go in and stop the hemorrhage. We stop the contamination. We leave the abdomen open. We cover it with a piece of plastic, and we get the guy out.”
Specific surgical procedures being used on wounded troops are refinements of tried-and-true techniques. Instead of making two incisions to relieve pressure inside limbs damaged by roadside bomb blasts, surgeons at Landstuhl are making four cuts to the limbs. Landstuhl surgeons also will open patients’ abdomens sooner than they would have in the past. Surgeons cut open the abdomen to release internal pressure, promote blood flow and allow internal organs to swell.
“We now know that by relieving some of the internal abdominal pressure that we are able to save a lot of the bowel, the liver, kidneys,” Tellez said. “That has been very helpful.”
Once swelling subsides, doctors at Landstuhl or even in the States can close the patients’ abdomens.
Only in the past few years have doctors been able to determine when it’s best to close wounds that have been left open to prevent infection.
“We’ve known since the Civil War that keeping wounds open — dirty wounds — is very important, but what we’ve done is that we’re able to fine tune when the right time is to reconstruct some of these wounds,” Tellez said.
The use of external fixators offers doctors a way to stabilize fractures without covering open wounds subject to swelling. Among their benefits, external fixators help bone and soft tissue heal, and the devices also allow open fractures to be treated.
“It decreases further movement and hopefully decreases further loss of bone and tissue,” Tellez said. “It decreases infection rates too.”
The critical care air transport allows wounded patients to be evacuated from downrange to Landstuhl, where doctors can provide more comprehensive treatment. From July 2004 to July 2005, 690 critically injured patients were transported to Landstuhl via critical care air transport. The air transport capability allows U.S. military medical providers to have a smaller presence downrange.
Until very recently, the military lacked a formal trauma system that linked what doctors were doing to patients across its continuum of care — from downrange to Landstuhl and on to Walter Reed Army Medical Center in Washington, D.C.
“You can’t just have all these pieces working by themselves,” Dorlac said. “You’ve got to pull them all together. We (Landstuhl surgeons) were doing surgery, and our patients were going to Walter Reed. We had no idea if what we were doing was right or not.”
Now that the system is in place, doctors have made wide-ranging policies that have been able to prevent fatal problems such as pulmonary embolisms. At one time, pulmonary embolism — basically, a blood clot in the lungs — was the top preventable mortality at Landstuhl.
“In the first year and a half of the war, we had a number of patients die from pulmonary embolisms here, and Walter Reed had a number of patients die there from pulmonary embolisms,” Dorlac said. “When we instituted a theaterwide policy, our No. 1 preventable thing went to zero.”
With concurrent process improvement, military medical providers have been able to examine data and make treatment changes just weeks later — something that has never been done in prior U.S. conflicts.
“It has been done on a large scale before, so at the end of one or two years in World War II someone says, ‘Hey, we’ve had a lot of complications with this,’” Dorlac said. “They pull all the records up, look at it and say, ‘We are having some problems. Yeah, let’s change that.’ We’re making decisions now after a month of data.”
From Baghdad to Walter Reed, military traumatic care doctors have the goal of decreasing morbidity — ill effects of injuries — and mortality — deaths — Dorlac said.
“We’re attacking that from hundreds of different directions,” he said.