Iraq

The trauma of war: Daily life at a U.S. hospital unit in Iraq
by John Camp
January 14, 2008

The beat of the choppers, big dark 65-foot-long Blackhawks, was audible down the hospital hallways, and came almost simultaneously with the trauma alert. Nurses and orderlies started running for the door and outside and through an archway with a huge American flag used as a canopy, to the helipad. By the time they were through the arch, the first of the Blackhawks was settling onto the pad at the Air Force Theater Hospital (AFTH), and a second was coming in behind.
There were two separate gurney crews, one for each helicopter, one for each casualty; they hustled out to each of the choppers, the casualties were bundled out, and back came all the nurses and orderlies and helicopter medics, in a hurry, pushing the gurneys down the helipad, under the flag canopy, into the emergency room, where the injured men were swarmed by doctors and more nurses: plugged into tubes, evaluated.
If the problems were bad enough — and they often are, because of the nature of this hospital — they can be through emergency and into a full-bore operating room in eight minutes. If the injuries are not quite that bad, they can be routed through two nearby CAT scan units, for a good look at the injuries, before they're moved to the waiting ORs.
One of the doctors working around the two injured men was Lt. Col. Jeff Bailey, an Air National Guard surgeon from St. Louis, Mo.: in this hospital, he is known as the "Trauma Czar." A few minutes earlier, on Friday afternoon, he'd been sitting in a lounge area, talking about the problems of war wounds.
At the St. Louis University Hospital, he said, they often see terrible injuries, but they are, taken as a whole, essentially different from those seen in Iraq.
"The wounding mechanisms are different. In St. Louis you'd see multiple blunt injuries [on the same patient], from car accidents, or multiple penetrating injuries from gunshot wounds, which basically punch holes in people. Multiple injuries, but the same mechanism. Here, though, you have multiple injuries from multiple mechanisms. You can have burns, blunt injuries and multiple penetrating injuries, all on the same guy. The severity of the wounds tends to be much greater."
Even though his St. Louis hospital is a full-blown Level 1 trauma center, he said that patients were often patched up and sent home. That doesn't happen at the AFTH: When trauma victims come through the emergency room doors, they are usually badly hurt. Another major difference: "At home, we get one patient at a time. Here, we often get multiple patients at a time," as in suicide bombings, where the bomber tries to get as many people as possible. While major American trauma centers practice and drill for mass casualties, they rarely see them. In Iraq, "Mass casualties are not a 'what if' situation, it happens regularly," he said.
AFTH may see 1,500 trauma patients in three months, he added. In U.S. hospitals, 1,500 trauma patients in a year would be a big load. Surgeon S.P. Bowers, a lieutenant colonel from San Antonio and an old friend of Bailey's, said that during the battle for Fallujah, "We had 30 major trauma patients a day for 10 straight days. Major trauma."
Probably the most-famous patient so far was ABC network anchor Bob Woodruff , badly wounded at Taji during a reporting trip. He suffered multiple penetrating injuries of the head and neck, and blast injuries. He probably arrived within an hour of the attack, the surgeons said, was evaluated in the emergency room where he was resuscitated and various intravenous lines put in, and then was rushed through to the operating room where he underwent several operations. "He did well," Bowers said. "He got excellent care, quick."
Bailey emphasized the importance of the "quick." The longer people go without treatment, the more complications ensue — not just as a matter of survival, but in all the downstream recovery stages. Delays of even a few minutes can mean more damage, longer recovery periods, less complete recoveries.
In one case, he said, "We had a kid who had a piece of shrapnel penetrate his heart." The surgeons did an excellent job in repairing the heart, he said, but the real hero was a front-line doc who evaluated a series of blast injuries, recognized the urgency of the boy's problem, put him on a chopper and got him to AFTH in time to be saved. Hesitation, he said, would have been fatal.

Injuries evolve over time

Minnesotan Eric Nelson, a lieutenant colonel and orthopedic surgeon currently stationed in Colorado Springs, Colo., sees the same violence in the wounds he treats. In civilian practice, most bone fractures are "closed" — there is no external bleeding, and the skin is unbroken. In Iraq, "Most of them are open fractures. Of the 450 surgeries I've done in the last four months, I can probably count on the fingers of one hand the number where the skin was intact."
The AFTH is a sophisticated trauma center, but is really meant to treat trauma, rather than perform long-term care or rehabilitation. Patients are stabilized, and then shipped either to Germany or to the United States for further treatment. "We clean out the wounds and then apply an external fixation device, and then send them to [Landstuhl Army Hospital] in Germany," Nelson said. Asked about differences he sees between injuries in a U.S. emergency room and those in Iraq, he says the causes of the injuries — like the blast from an explosive — will have a longer-term effect than most American non-war injuries.
"A blast injury tends to evolve over time," Nelson said. "You clean up a wound, and you see some muscle that you think looks good. In the U.S., you're usually right. Here, you come back 24 hours later, and often the muscle will have died because of effects from the blast."
Nelson, who grew up in Plymouth, is married with two children; tours in Iraq, for surgeons, last four months in most cases, and Nelson is near the end of his. He may also be at the end of his Air Force career. "I'm ready to go home and see Kirsten," he said. He and his wife, who is from Glenwood, Minn., and their two children, Karina and Zachary, may move to Alexandria, where Nelson hopes to join an orthopedic surgery practice.

Wounded children

In addition to being the main hospital for U.S. war casualties, AFTH also cares for badly wounded Iraqis, including, at times, insurgents. One surgeon said that he's operated on an insurgent while an armed guard stood in the corner of the OR as a precautionary measure.
Among the frequent Iraqi patients, unfortunately, are children. On Thursday afternoon, Lt. Col. Christopher Coppola, a pediatric surgeon, said "about 18 percent of the blown-up people I see" are children. He suggests that the pattern of mass woundings are changing — that the Iraqi insurgents, unable to directly face U.S. formations, are being forced to go after softer targets. As a result, more children are hurt.
On Thursday, Coppola was working over a 4-year-old Iraqi who'd been in a car accident after an IED exploded next to it. As he and another surgeon, a surgical tech, an anesthetist and a nurse hovered over the operating table, all that could be seen of the patient was a small, thin chest, moving slowly up and down with each breath. His major wound was a skull fracture, and he'd had surgery to pull a depressed area of the skull back out. Coppola had hopes that he'd substantially recover: for the moment, though, he was in a coma. Coppola, wrapped in a blue surgical gown with a full transparent face shield, opened both the child's throat to insert a breathing tube, and his belly to insert a feeding tube, since the boy couldn't eat on his own.
"I think we should know what's going to happen, the shape of it, in six weeks or so," he said. "With children with this kind of injury, there's often a good chance for a complete recovery. But you can't tell ahead of time. You wait and see."
Nelson, the Minnesota doctor, told of an Iraqi who'd been brought in with a nearly severed foot, "cut 270 degrees around," the foot dangling from "an artery, a vein, a nerve and a couple of tendons. We said, 'Well, do we try to fix it?'"
They did. "The foot had a blood supply, so that was good," he said, but one of the leg bones had been smashed just above the ankle. To make it work with the other bone, they had to shorten the second one.
They operated, the leg was repaired, and six weeks later, the Iraqi came back for a post-operative check.
"The guy asked, 'Is my leg shorter than it was?' We said, 'Yeah, we had to shorten it. We figured a short leg was better than no leg.' He was inclined to agree."

Traumatic injury rate declining

The AFTH is run by Col. Patrick R. Storms, a gastroenterologist. He is an unabashed cheerleader for the place, and for its staff. "If you get into this place alive, you've got a 98.8 percent chance of getting out alive," he said. One of his staff members, somewhat tongue-in-cheek, suggested that the 98.8 percent may be somewhat overblown, since, "If you get out of here alive, and die in Germany, well ...you're not on our stats." But the same staff member said the treatment level at AFTH "is absolutely as good as anything you can get anywhere. I don't think there's any place on earth that could match us for trauma care."
Storms had a pile of statistics, and one group was of particular interest. While the media tend to look closely at the American death rate, another index of what's going on is the traumatic injury rate. The death rate, which is generally much lower than the injury rate, can be sharply changed by a few deaths. Since there are many more non-fatal trauma injuries, those numbers may be more representative of the combat intensity in the country.
Storms' numbers showed that in 2007, the AFTH treated 169 U.S. trauma injuries in March, the most of any month of the year, although May was close behind, with 162. By August, September and October, the numbers were 126, 128 and 125, respectively. In November, the number was 110. In December, 89. Whether the trend is sustainable is a matter of debate, and for experience: we'll see. Purely on the basis of the current numbers, however, the trend is clear, and sharply downward.
(For the full year, the numbers are: January, 138; February, 155; March, 169; April, 133; May, 162; June, 149; July, 104; August, 126; September, 128; October, 125; November, 110; and December, 89.)
The numbers of Iraqi nationals treated, however, show no such trend, with the most trauma treatments of the year, 183, occurring in January 2007, the least, 135, occurring in May; and with 164 in December.
In addition to numbers, Storms provided an explanation for the giant U.S. flag beneath which wounded soldiers are carried between the helipad and the emergency room. It is not decoration, he said: It's functional. Many times, he said, when soldiers are badly wounded, they are intensely disoriented and don't really know what is going on around them. Often, they first begin to think coherently as they are being removed from the medivac helicopters. They don't know faces, they don't know medical language, there's a lot going on; but when they are taken out of the plane, "That flag may be literally the first thing they recognize, and it tells them that they're in American hands, and that they are safe."

'I love this place'

When the two Blackhawks came in Friday afternoon, one of the people in the hospital was Air National Guard technical Sgt. Dan Clare, 31, of Grant County, Ky., who said, during a previous visit, "I love this place."
Clare's job in Iraq is to keep an eye on visiting media. Back in Kentucky, he works for the Disabled American Veterans organization as associate national director of communications. As part of that job, he spends quite a bit of time with younger men recently back from Iraq, who are in different stages of recovery from their injuries. The AFTH provides some insight on what happens to these soldiers right at the time that they're wounded, he said; right from the first moments of a serious, and perhaps lifelong, recovery process.
Clare has no interest in a medical career himself. "When I lived in California, I was in advertising; now, all this — it seems like a more purposeful life."
Still, "I love this place," sounded a little unusual. Pressed about it — maybe teased a little — he said, "All the time, you see people coming in here who shouldn't survive, but they do. You see this team get this guy, and he should die, but now he's going to make it."
He said, "Listen: There's lots of miracles here. They happen all the time."