High Casualty Rate for Brief Period Seen

If war breaks out in the Persian Gulf, military medicine specialists are making the following predictions: As many as one out of every five soldiers seriously injured will die within several hours, and half of those who die will bleed to death.

Brain damage is likely to cause one-third of all the deaths. Burns are expected to make up more than 10% of injuries. One out of every three or four casualties will be psychiatric--soldiers unable to continue fighting because of combat fatigue.

“The expectations are for short, brief, intense combat, which produces high levels of casualties for a brief period,” said Dr. Robert Ursano, a retired Air Force colonel. “So exposure to the gross and the grotesque would be expected to be quite high.”

No one knows for certain how intense the fighting might be. Nor is it known how well the U.S. field hospital network will perform. But many experts in military medicine insist that the overall system is “first class.”

For example, wounded U.S. and allied soldiers who reach hospitals alive will have an excellent chance of survival: Fewer than 2% are expected to die. As Dr. John Constable, a burn care expert put it, the U.S. system of care begins “at a very elevated level.”

Even if chemical weapons and germ warfare are used, experts predict that the overall pattern of injuries is likely to resemble that of past wars. Any injuries from those weapons would be far outnumbered by injuries from guns, bombs, mortars and high explosives.

Specialists say experience in Vietnam and the Arab-Israeli wars has improved understanding of how best to treat medical and psychiatric casualties--making it possible to salvage many severely injured soldiers and perhaps to avert some long-term damage to mental health.

“The other countries (in the region) would be far, far below that even under the best of circumstances,” said Constable, of Massachusetts General Hospital in Boston.

Nevertheless, a Massachusetts-based physicians’ group issued a report last week raising doubts about whether military hospitals are adequately prepared, contending that many casualty estimates have been based on best-case, not worst-case, scenarios.

“In our judgment, the potential scale of the conflict in the Gulf could easily overwhelm not only U.S. military medical capability but the entire medical resources of the Gulf region,” the International Physicians for the Prevention of Nuclear War stated.

The key elements of both military and civilian trauma care are straightforward. The first hour after injury is crucial. The wounded must be stabilized, by stopping bleeding and providing intravenous fluids.

Next, they must be moved quickly to hospitals for blood, antibiotics and skilled surgical care. Later, they can be sent to hospitals far removed from the battlefield for more complex care and rehabilitation.

The approach is not unlike that used in a busy, inner-city hospital on a Saturday night.

“We are all singing from the same song sheet,” said Dr. Thomas Wachtel, who directs the trauma center at Sharp Memorial Hospital in San Diego and is a member of the Navy reserve. He described trauma care in the United States as “an export item from the Vietnam conflict” that is now being sent “back to the military.”

“The resources are different and the intensity is different (from that of urban trauma centers), but essentially all the other things are going to be very similar,” he said.

In Vietnam, the average delay between injury and hospital treatment was only about two hours, thanks to extensive use of helicopter evacuations. That record compares to average delays of five hours in the Korean War and 10 hours during World War II.

The ability to achieve a comparable record in the Persian Gulf will depend on air superiority and the ability to land helicopters on the battlefield, Wachtel said. The evacuation of the wounded from open desert areas may be risky and slow, and some fear that U.S. field hospitals may be vulnerable to missile attacks.

But even in the best of circumstances, there are limits to what can be accomplished.

“The casualty with a perforating wound of the head or heart, a transected aorta, a shattered liver . . . will not be especially helped by decreasing the evacuation time from four hours to two or even one hour,” Dr. Karl D. Bzik and Dr. Ronald F. Bellamy wrote in the journal Military Medicine in 1984. “These casualties are, as it were, the hard-core of those killed in action.”

Fortunately, lethal injuries are a minority of casualties. Typically, about half of war wounds involve the arms and legs, but fewer than 5% of such wounds tend to be lethal, according to Bellamy.

For most military personnel, the ability to survive until they reach hospitals will be far more important than their subsequent medical care in determining whether they live or die. In Vietnam, fewer than 2% of all casualties who reached hospitals alive died of their wounds, Bzik and Bellamy point out.

Improvements in medical care and surgical techniques will make a difference. Experts say more patients with massive burns will pull through, and more patients with ruptured arteries in their arms or legs will avoid amputations.

Similarly, American researchers are testing methods to apply high concentrations of antibiotics directly to wounds by packaging them in biodegradable polymers designed to release the drugs for days or weeks. This experimental therapy may help reduce the risk of infections and amputations.

On the other hand, severe head and brain injuries, uncontrollable bleeding and infections are likely to remain major causes of death.

Massive burns are also of great concern, with the threat of chemical warfare, extensive tank warfare and powerful Iraqi fuel-air explosives.

“The anticipation is with a fairly short-duration, high-intensity war, we will have a tremendous surge of burn patients early on,” Wachtel said.

Burns--from fuels, napalm, and phosphorus ammunition--are a fairly common combat injury, said Dr. Basil Pruitt, the director of the Army Institute of Surgical Research in San Antonio. But he estimated that only one in five burn victims would have serious burns covering more than 20% of their bodies.

Seriously burned soldiers are likely to go to U.S. military hospitals in Germany, then to the United States for further care, such as extensive skin grafts. If the supply of burn beds in military facilities is exhausted, military personnel may be sent to civilian hospitals.

As a general rule, burn patients require one day in the hospital for each percent of their body burned over 20%. Nine of 10 U.S. burn patients with burns on 40% or less of their bodies survive. But for more extensive burns, survival rates drop precipitously.

As many as one in every three or four casualties is expected to be psychiatric, based on experience in recent wars. These will range from minor bouts of combat fatigue, treatable with several days of rest, to cases of chronic depression and other long-term disorders.

Combat fatigue is the most common acute psychiatric problem. Soldiers become anxious and exhausted and are easily startled. Some have difficulty in eating and drinking and are unable to sleep or concentrate. They may become excessively fearful and emotionally numb.

Military psychiatrists say combat fatigue is best treated early and close to the front, or near the soldier’s unit, with several days of rest and respite. Soldiers are given rest, food and water, people to talk to, and the promise of an early return to their unit.

“It is said that if you can treat the person close to their unit and return them within three to 10 days, the chances that they will go on to develop (more serious disorders) are reduced by 50%,” said Alfonso Batres, a psychologist with the U.S. Department of Veterans Affairs.

The more serious psychiatric disorders that can be expected to develop in a war in the Persian Gulf range from long-term anxiety and depression to substance abuse and post-traumatic stress disorder, a condition that became widely known after Vietnam.

Post-traumatic stress disorder, which can occur in victims of other types of trauma such as rape, often involves recurrent memories or dreams of the painful event. Or it can entail a deliberate avoidance of thoughts that might evoke memories of the experience.

Therapists describe sufferers as being in a chronic state of emotional arousal. They also have many of the symptoms of battle fatigue. They may be excessively vigilant, easily startled, unable to sleep and quickly moved to anger.

Experts in military psychiatry say the kind of war being anticipated in the Persian Gulf offers advantages and disadvantages: Psychiatric casualties tend to be fewer in “intense, forward-moving” wars, but it is more difficult to treat casualties close to their units.

According to Ursano, now a psychiatry professor at the Uniformed Services University of the Health Sciences in Bethesda, Md., past wars suggest that rapid advance of troops “encourages cohesion and morale,” which helps protect against psychiatric casualties.

The threat of germ warfare and chemical weapons brings additional mental-health problems. The idea itself is a source of terror. And the suits used to protect against those weapons can have psychological consequences, breaking down communication within units.

The suits also can cause dehydration, which in itself can cause psychiatric symptoms, such as confusion. Similarly, the antidotes for some chemical weapons, such as the drug atropine, can cause anxiety at low doses and psychosis at very high doses.

In the end, the rate of psychiatric casualties will be influenced by many factors, including the nature of the combat, the expectations and attitudes toward the war among families and friends at home, and the availability of early, effective treatment.

“If you don’t deal with your psychiatric casualties, they will overwhelm all your other medical care because of their numbers,” said Ursano, the retired Air Force colonel.

COMBAT CASUALTIES

Combat casualty figures for U.S. Army personnel in three wars. This does not include casualties in other services.

WORLD WAR II KOREA VIETNAM *Killed in Action 192,220 19,353 25,342 *Died of Wounds 20,810 1,957 3,520 *Nonfatal Wounds Hospitalized 599,724 77,788 96,811 Not hospitalized 123,836 14,575 104,725

Source: U.S. Army statistics cited in Military Medicine.