http://www.wsj.com/articles/are-u-s-soldiers-dying-from-survivable-wounds-1411145160
Are U.S. Soldiers Dying From Survivable Wounds?
Despite Advances in Care, the Military Failed to Save Some Troops in Iraq and Afghanistan From 'Potentially Survivable' Wounds
ENLARGE
A U.S. Army soldier receives medical assistance after being injured by an explosive in Afghanistan in 2012. AGENCE FRANCE-PRESSE/GETTY IMAGES
By
MICHAEL M. PHILLIPS
Updated Sept. 19, 2014 5:47 p.m. ET
122 COMMENTS
In an unassuming building in suburban Washington, a team of military medical specialists spent six months poring over autopsies of 4,016 men and women who had died on the battlefields of Iraq and Afghanistan.
They read reports from the morgue at Dover Air Force Base, where bodies arrived in flag-draped coffins. They examined toxicology reports. They winced at gruesome photos of bullet wounds and shredded limbs. In each case, the doctors pieced together the evidence to determine the exact cause of death.
Their conclusion would roil U.S. military medicine: Nearly a quarter of Americans killed in action over 10 years—almost 1,000 men and women—died of wounds they could potentially have survived. In nine out of 10 cases, troops bled to death from wounds that might have been stanched. In 8%, soldiers succumbed to airway damage that better care might have controlled. "Obviously one death or one bad outcome is too many, but there are a lot of them," said one of the researchers, John Holcomb, a former commander of the U.S. Army Institute of Surgical Research.
The findings appeared in the Journal of Trauma and Acute Care Surgery in 2012 to almost no public attention. But in military medical circles, they have fueled a behind-the-scenes controversy that rages to this day over whether American men and women are dying needlessly—and whether the Pentagon is doing enough to keep them alive.
Indeed, a new internal report concluded that the military still hasn't fully adopted battlefield aid techniques that could have kept many wounded men alive in Afghanistan. Some of those techniques have been used to great effect—often with little extra cost—by elite commando units, such as the Army Rangers, for more than a decade, say active-duty and retired military trauma specialists.
WOUNDED IN BATTLE: A HISTORY OF TREATMENTS
The Civil War was the first American war in which the military set up an entire tiered medical system. NATIONAL ARCHIVES
In response, the Defense Department points to steps it has taken—including putting nurses and blood-transfusion equipment on medical-evacuation helicopters. "I would argue that particularly the primary lifesaving components" of the latest casualty-care guidelines "are readily implemented across the theater," said David Smith, deputy assistant secretary of defense for force health protection and readiness.
But Dr. Smith did say that the wider military hasn't uniformly implemented the lessons learned from elite units and that the Pentagon was working "to remove that variation." He said the agency was still examining the internal casualty-care report from Afghanistan. The report, completed in May but not widely circulated outside the military, was written by a medical-research team that visited 26 front-line clinics—and found that only one had fully implemented the latest guidelines.
According to the report, for instance, though tranexamic acid is approved by the military as an anti-bleeding agent, more than 90% of aid stations in Afghanistan reported they didn't put it in medics' kits. Only two-thirds possessed junctional tourniquets, new tools used to stop hemorrhaging for injuries too close to the victim's trunk for normal tourniquets. Just 12% of medics carried ketamine, the painkiller now recommended because, unlike morphine, it doesn't cause a drop in blood pressure or breathing.
Shortcomings in battlefield care among regular troops may cause "the increased killed-in-action, case fatality rate, and preventable deaths seen in conventional forces when compared with special-operations forces," the report concluded.
Military doctors say bureaucratic issues have stalled efforts to fully implement the most successful techniques. The Pentagon has generals in charge of dentistry, nursing and veterinary care, but no single general is in charge of care for wounded soldiers before they reach a surgeon's table. In fact, front line first responders—mostly Army medics and Navy corpsmen—take orders from combat commanders who are likely to be infantry, tank or artillery officers, not from the military's top doctors.
"Right now there is nobody in charge of pre-hospital medicine in the U.S. military, so there's not one person that can make the decisions that can effect change in the military as whole," said Army Col. Russ Kotwal, a special-operations doctor.
ENLARGE
Lt. Col. David Marcozzi, a trauma doctor, left, shows a flight medic where to insert a chest-decompression needle during a training session at Bagram Airfield in Afghanistan. MICHAEL M. PHILLIPS/THE WALL STREET JOURNAL
Military officials say they are working to fix the situation and cite examples of their efforts to improve battlefield medicine. As early as 2005, military doctors urged soldiers to apply tourniquets immediately to a serious bleed in an arm or leg, reversing a previous policy, which recommended their use as a last resort. The shift is believed to have saved as many as 2,000 lives.
In 2006, Central Command, which oversees U.S. forces in Afghanistan and the Middle East, incorporated updated casualty-care practices in its guidance for training battlefield first responders. The Navy says all of its corpsmen, who treat wounded Marines in combat, are required to be trained on the latest techniques. But a Navy spokesman said the service doesn't track compliance with the requirement.
In November last year, U.S. Marine Gen. Joseph Dunford, then-commander of allied forces in Afghanistan, ordered use of the junctional tourniquets. In February, he ordered that nasal ketamine replace morphine as the primary battlefield pain killer. In March, Gen. Dunford ordered medical personnel in the war zone to "maintain proficiency" in the latest battlefield-care techniques. "We certainly have room to improve, and we're pursuing those improvements right now," said Col. Mark Mavity, command surgeon for Central Command.
Trauma doctors say many of the military's efforts have come too late. The latest drugs, gear and techniques are still used inconsistently by medics in the field, and by doctors at lower-level aid stations. "There is frustration from a lot of us in military medicine," said Brian Eastridge, an Army colonel who specializes in trauma care and who headed up the research team for the 2012 study on deaths from survivable wounds.
The cost of providing medics with the most updated battlefield first-aid equipment and medications is negligible, according to military doctors. For instance, a dose of nasal ketamine, the pain killer, costs about $1, the same as the morphine it would replace. The price tag for training medical personnel to use the latest techniques, however, is more daunting. By 2017, in one example, the military expects to have trained some 1,200 flight medics to the higher level of critical-care paramedics, at a cost of about $70 million, according to a doctor involved in the program.
The uproar over battlefield medicine dates to 1993, when two Black Hawk helicopters were shot down during a botched U.S. special-operations raid in Mogadishu, Somalia. Robert Mabry, then an Army Delta Force medic, landed at the site of one of the downed helicopters and worked under intense fire to rescue two surviving crewmen. One bullet went through his pants pocket; another grazed his fingers.
At the time, military medics employed civilian techniques. Dr. Mabry, now a lieutenant colonel specializing in trauma care, realized that "taking civilian first aid based on car wrecks and trying to apply them to a gunfight was not really smart." Army medics, for instance, were taught to put braces and spinal boards on patients with suspected neck injuries, even as bullets flew.
MORE ON BATTLEFIELD MEDICINE
The Battle of Mogadishu left 18 Americans dead, including six Army Rangers, and served as a wake-up call for Dr. Mabry and a generation of special-operations doctors. Led by former Navy SEAL Frank Butler, they developed the first wartime Tactical Combat Casualty Care guidelines in the mid-1990s. The guidelines are regularly updated.
In the late 1990s, former Gen.
Stanley McChrystal , then a colonel and commander of the 75th Ranger Regiment, ordered his men to adopt the new techniques. The Rangers put them to the test in Afghanistan and Iraq. On more than 8,000 missions between 2001 and 2010, the Rangers lost 28 men on the battlefield, but none had survivable wounds, according to a 2011 paper by Dr. Kotwal.
It was an achievement unmatched in the history of major wars, doctors say, and brought battlefield medicine into closer alignment with the military's success in treating troops at surgical hospitals behind the front lines. There, it has recorded a survival rate of greater than 95%, according to military data. That outcome is a combination of medical success and the likelihood that many of the worst injured died before they reached a surgeon.
The Rangers' story suggested to Dr. Eastridge and others that the military could save lives by focusing on the minutes immediately after an injury.
Dr. Eastridge knew the research itself would be hard going. Several colleagues who had previously performed autopsy reviews declined to participate; they knew the pictures would be too graphic. "Many of those images lie in wait and present as the stuff of my nightmares to this day," said Dr. Eastridge.
The team spent months debating whether the wounded could have pulled through had they received better treatment or whether they were doomed from the moment they were hit.
The doctors chose a liberal definition of survivability, categorizing an injury as "potentially survivable" if it had taken place close to a major U.S. trauma center. The researchers knew they would be counting some injuries as survivable when, in fact, the soldier could well have been too isolated, or in a situation too dangerous, to receive lifesaving care.
"Maybe somebody bled out because they didn't get a tourniquet, but the reason might have been he was lying out on the battlefield while there was a firefight going on and they couldn't get to him," said Staff Sgt. Michael Smith, a combat medic and member of the team that produced the new report on trauma care in Afghanistan.
Dr. Eastridge's researchers deemed 76% of the battlefield injuries non-survivable; most were catastrophic head wounds, dismemberments or heart injuries. Another 24%, though, were potentially survivable, the researchers found. The study set off alarm bells. It was, doctors said, the most extensive look into the actual causes of death in war. And it suggested conventional forces aren't consistently applying the latest techniques for controlling bleeding and clearing airways.
In part, the problem reflects decades of military focus on big stateside hospitals, which tend to the ordinary health needs of troops and their families at home. When a crisis occurs, the military pulls family practitioners, obstetricians and pediatricians, among others, from these hospitals to serve at the front lines, rather than trauma specialists, who are generally posted to surgical hospitals further back.
"We hadn't really focused attention in the pre-hospital arena"—the front lines—"as much as we focused our attention on the hospital levels of care," said Col. Mavity, the Central Command surgeon.
ENLARGE
Rapid change, military doctors say, would require orders from the very top of the Pentagon. The precedent many cite is then-Defense Secretary Robert Gates, who in 2009 ordered that all wounded in Afghanistan be evacuated to a hospital within one hour of their injuries. The military shifted doctors and helicopters to make that happen, and now air evacuations usually take less than 45 minutes.
"The leadership is not engaged to solve the problem" of potentially preventable combat deaths, said Dr. Holcomb, one of the researchers, who served in Somalia and Iraq before leaving the military in 2008.
Dr. Smith, at the Defense Department, disputed that, and the May report detailing care in Afghanistan did praise some steps commanders have taken: The military has equipped medevac helicopter crews with blood-transfusion capabilities and has approved use of the bleeding-control agent, tranexamic acid. The Army now puts critical-care nurses aboard medevac flights, a move that has reduced deaths in flight by two-thirds, according to researchers.
If an autopsy review were conducted today, the Pentagon "is confident" the number of potentially survivable deaths would be lower.
Still, trauma doctors worry the military will return to managing domestic hospitals and forget what it has learned about battlefield medicine, especially once the U.S. leaves Afghanistan.
President
Barack Obama has announced that, should the next president of Afghanistan agree, he will reduce the U.S. troop presence to 9,800 at the end of the year, down from some 100,000 at war's peak.
Front-line care, doctors say, will be vital when the U.S. finds itself sending smaller units into smaller conflicts, where it won't have the extensive evacuation and hospital networks it maintains in Afghanistan and once had in Iraq. On those scattered battlefields, a wounded man will likely have to wait longer before reaching a surgeon. What the medic does when he is injured may determine whether he lives long enough to do so.
"We're putting people back in Iraq," said Dr. Holcomb, referring to Mr. Obama's recent decision to insert American special-operations troops to advise Baghdad in its campaign against radical Islamists. "We've got people in Africa. This fight is just changing theaters and perspectives. In some sense it may be harder now."
