Veteran Medics Help Reduce Iraq Fatalities

For all their horror, wars are learning laboratories for trauma medicine. The knowledge that U.S. military doctors have gained in Iraq is helping them save the lives of more combat wounded than ever before.

A critically injured Army sergeant who arrived recently at Ibn Sina Hospital in Baghdad’s Green Zone was a case in point. A sniper’s bullet had entered his back and clipped off the side wall of a vein just above the liver that returns blood from the lower body to the heart. Had he arrived at virtually any other hospital in the world, the sergeant probably would have bled to death.

But Army Col. Richard Briggs, a veteran of several wars, had the combat zone experience and the state-of-the-art tools to stabilize the patient after a two-hour operation.

“It was a terrible, terrible, terrible wound,” said Briggs, 53, a cardio-thoracic surgeon and reservist from Knoxville, Tenn. “But it looks like he’s going to make it.”

Quicker medical evacuations, improved emergency room instruments and new surgical approaches mean fewer injured service members are dying. The mortality rate among those wounded in Iraq is about 10%, compared with 20% in the 1991 Persian Gulf War, 24% in Vietnam and 30% in World War II, according to a recent issue of the New England Journal of Medicine.

The higher survival rate raises other issues, the Journal noted, such as the quality of life for the increased number of troops with multiple amputations and disfiguring wounds. Still, doctors such as Briggs are getting better at their profession’s essential goal, keeping patients alive.

The heavy body armor worn by U.S. troops also has been a factor in reducing fatalities. About two-thirds of all trauma injuries are the result of shrapnel from powerful roadside or suicide bombings, Briggs said. The rest are gunshot wounds. The armor is being modified in response to a Pentagon study that found side plates could have saved many American lives in Iraq.

“The typical gunshot wound you see in an emergency room back home is what we call a ‘recreational wound’ compared with what we see here, which is the damage caused by high-caliber bullets, rocket-propelled grenades and flying metal shrapnel this big across,” Briggs said, holding his thumb and forefinger 6 inches apart.

The case of the wounded sergeant, whom the military declined to identify, is an example of advances in the treatment of trauma victims. He was taken by helicopter to the Ibn Sina emergency room within an hour of being shot, quickly enough to receive treatment within what medics call the “golden hour.”

Briggs and other doctors were able to quickly replace the blood the sergeant had lost with a new instrument called a Belmont rapid infuser that can inject a unit of blood into the body in 30 seconds, compared with the drip method that takes as long as 15 minutes. The instrument was first used in military medical hospitals in 2003. The sergeant ended up receiving 30 units of blood during surgery.

He was kept warm, an important element in reducing risk of hypothermia and infection, with a Bair Hugger blanket, a molded air mattress filled with warm air.

But as much as anything, the soldier benefited from Briggs’ 25 years of practice in trauma surgery, and his more recent experience in the field. In the United States, Briggs might never see a wound like the sergeant’s, but at Ibn Sina, he had treated two in one week. He and other members of his surgical team regularly rehearse and review the procedures because they are under enormous pressure when the injured come in.

In the sergeant’s case, the difficulty was in exposing the vein amid massive bleeding. Briggs and his team were able to isolate the damaged section with shunts to temporarily block the blood flow.

Military surgeons have generally changed their approach to critical trauma injuries by opting when possible for “damage control surgery” rather than immediate major chest or abdominal intervention. The primary goals are to stop bleeding, clean wounds to fight infection and treat the patient for shock. Then surgeons wait to perform major procedures.

Experience has shown that a 24-hour period to recuperate from the severe shock of a gunshot or bomb wound improves a patient’s chance of survival, Briggs said.

But some cases, like that of the wounded sergeant, won’t wait.

Ranked by the number of trauma patients treated, the Ibn Sina emergency room is the third-busiest in the world after Cook County Hospital in Chicago and Ben Taub General Hospital in Houston, Briggs said.

The work pace is brutal. Briggs and the other surgeons average 17 major trauma surgeries a day. Although theoretically they work in three shifts, “you are always on,” Briggs said. “You are dealing with human tragedy constantly. All these are young people in the prime of their lives.”

Gen. George W. Casey, the top military commander in Iraq, acknowledged in late January that the U.S. military overall was stretched thin, and no military specialty is under more stress than medical reserve nurses, psychologists and doctors. Many have been repeatedly deployed since the Sept. 11 terrorist attacks.

Briggs says his medical practice suffers whenever he is activated. During his four-month deployments, the general practitioners or cardiologists who refer patients to him get used to giving the business to other surgeons.

Since the invasion of Afghanistan, the military has tried to accommodate its medical reservists by reducing deployments to a maximum of four months, an improvement over Desert Storm, when Briggs and other doctors were activated for six months at a time.

But Briggs emphasizes that he is in Iraq by choice, because he knows his experience is of value to the troops. He also served in military trauma rooms in Somalia in 1993, a special operations mission in Ecuador in 1997 and in Afghanistan in 2004 before reporting to Iraq in November.

In his private practice in Knoxville, Briggs is often called on to perform emergency surgery, applying techniques learned on the battlefield.

Baghdad’s Green Zone, the fortified area where most U.S. and Iraqi government and top military officials are stationed, is not exempt from risk. Insurgents regularly lob mortar rounds into the zone, and on Jan. 27, demolition experts detonated a bomb-laden car in front of Ibn Sina.

“If you tell people you want to be in a combat zone, they look at you like you’re crazy. But if I’m going to be mobilized, I want to be where the troops are. The last place I want to be is Walter Reed,” Briggs said, referring to the army’s giant medical center in Bethesda, Md.

“It’s not completely altruistic. It’s an honor to be with our armed forces. I always go home with a sense of what’s important, and of feeling so proud of these young people,” he said.

Returning to Knoxville after a tour in the war zone is “rejuvenating and cathartic,” Briggs said, because “you realize that the petty things that once bothered you are just that, petty things, and not worth worrying about.”

“The important things are happening here.”