In a very real way every generation deserves the wounds they get …
—military surgeon, 2010
There is a new normal in medicine today and that new normal has worked its way into military medicine and definitely has become the norm for battlefield care. It is no longer expertise in medicine or surgery that is expected, that much, for better or worse, is simply assumed. It is technology. X-rays once read exclusively on the view boxes of radiology departments in every hospital in America were always connected to a patient as well as a name and possible diagnosis. But when these images became digitalized as data points and could be sent through phone lines and satellite connections anywhere in the world at almost the speed of light, the patient was lost. It is true that today many of the X-rays, flat plates of the abdomen, CT scans, and MRIs taken at night in your hospital are sent to India to be read, the results texted back within minutes, eliminating the need and the expense of the hospital to have to pay for a radiologist on call twenty-four hours a day, seven days a week.
The use of the newly-developed robotic surgery allows surgeons in New York, using a “slave machine,” to operate in real time on a patient in an operating room in Iowa. In reality, you no longer need to have a physician physically present to see or even examine a patient. A moveable robot with its own camera as a videocam, a motorized tread connected to a two-way microphone, and voice-box operated with a joy stick by an expert in, say neurology, at some remote location, can with the help of a trained surrogate, ask the important neurological questions and actually perform a credible physical examination.
It used to be that you knew the physicians who diagnosed and took care of your heart attack or the surgeon who did your coronary by-pass. Now the cardiologist who puts in the stent to unplug your coronary artery an hour after you have your chest pain is someone you never saw before, someone you never knew, and someone who most likely you will never see again. It is the same with the gastroenterologist who does your colonoscopy, and after removing the polyp in your colon tells you that you will need another colonoscopy in five years even as he leaves the examination room. The new paradigm of medicine lies in the technology and it is only to be expected that the benefits and the downside of this kind of anonymous medical and surgical care has been brought to the battlefield. And why not? It works.
Medicine is always easier when it is only the technical aspects that are in play. In referral hospitals across the country over 80 percent of all pacemakers are put into patients well over eighty-five years of age. If you are only discussing the functions of the heart and not the whole patient, then these numbers might make sense. What no one knows, because it is not asked, is how many of these patients over eighty-five have dementia or other disabling and untreatable chronic conditions. The cardiologist simply becomes the technician, or the more accepted term “provider.” And apparently they do provide.
Once a week, the physicians, nurses, and surgeons at all the combat hospitals in Afghanistan, in Europe, and in the United States, linked by telephones and videocams, meet over a secure internet connection to discuss those patients wounded during the preceding week. It is all business, with experts in all the fields of medicine and surgery from orthopedics to neurosurgery to infectious diseases, as well as occupational therapists, medical and surgical nurses and nurse practitioners taking part, even if they have never talked to each other before and are in rooms more then 16,000 miles apart. The focus is only on the injuries and not the patient. There is no time for ethics or moral decisions here. There are little or no personal conversations. The majority of physicians and surgeons in the conferences have never met one another. Indeed, the participants are not referred to by name since no one really knows anyone else and so the discussions are called out by location, “Ballad,” “Kandahar,” “Landstuhl,” “Fort Sam Houston,” “Walter Reed.”
These last years of changing wounds in Iraq, and now throughout Afghanistan, have taken battlefield medicine well past rapid med-evacs and even Forward Surgical Teams. The Mash Unit and even the Evac hospitals with wounded staying hours and hours, if not days or weeks, are things of the past. There is no need now for lengthy hospitalizations at any one facility along the evac chain. There is certainly no longer the need for a Camp Zama in some distant country, nor is there time for long individual discussions or thoughtful contemplative postures. Today, in civilian hospitals and certainly military hospitals, with the fragmentation of medicine itself into its different specialties, there is the need for an abundance of different medical and surgical personnel to take care of the multiple needs of soldiers and marines who are blown up while, at the same time, being exposed to enormous shock waves of these IED blasts. Few if any military physicians will see the wounded longer than a few hours or a few days, before the patients are moved on to what has become transcontinental care, with survival being the single goal.
The truth is that with the new kinds of battlefield injuries, this is precisely the kind of care that is needed because it is efficient, technically sound, and, more importantly, it can now be done. With the new understanding of wounds, injuries, and the new technologies, and the fact that the wounded are usually young and fit, there is no one to “hang the crepe” unless the shroud is ready. After all, this isn’t cancer or strokes, these are accidents—immediate and complicated, but still accidents, and that is precisely how they are viewed and how they are treated.
All of this, taken together, is called “Damage Control Surgery” which began in Iraq but is being perfected, out of necessity, in Afghanistan. The point, obvious to everyone involved with military medicine and those on the weekly telecommunication calls, is that because of the new type of hyper-technical divided expert care, the vast majority of these patients are not what they had always been in every one of our other wars, dead within hours, if not days, of being hit. It is hard to ignore the virtue in all that.
The fact that today’s wounds are now attended to in stages is not genius but the fact that years of experience within civil trauma centers has shown that the more severe and complicated trauma patients survive if their various injuries are treated incrementally in a well-organized step-wise fashion. And that is exactly the types of wounds we are getting in Afghanistan and in ever increasing numbers.
As one of the Navy surgeons deployed to Kandahar Air Field recently explained:
“Twenty years ago, if you left the operating room without fixing everything, you weren’t a good surgeon. We don’t believe that anymore.”
But the reason for no longer practicing that kind of trauma surgery is because our troops are no longer being shot at; they are being blown up. They suffer from multiple wounds, terrible and contaminated by projectiles and the dirt and dust set into motion by the explosions. Unlike simple bullet wounds that can be dealt with quickly and usually with one surgery, these wounds, because of their various body locations and differing severities, along with the multiple types of contamination, have to be treated by stages with as little done at each surgery as possible.
This type of limited surgery is a medical requirement because, initially, no one knows or can determine with any accuracy the exact extent of the wounds. The nature of blast injuries is such that the extent of the injuries only becomes obvious over time. Often it is one surgery per hospital at a time, and the patient is passed on down the line to the next and more sophisticated group of surgeons and physicians, until finally reaching one of the giant medical centers in the States.
The term Improvised Explosive Device or IED is clearly a misnomer. There is nothing improvised about these blasts and what are now being called “Dismounted IED Injuries” to designate wounds caused by a bomb that injures a soldier or marine outside of a vehicle. These weapons blowing up soldiers, outside or under or beside a vehicle, explode with deadly force resulting in such widespread and extensive injuries that no one surgery can fix all the injuries, much less the patient, at any one time or with any one procedure.
IEDs break bones and blow off limbs and drive dirt deep into the opened wounds while the shock waves kill cells and damage tissues. It may take hours or even days to become evident. In the new damage-control surgery, these wounds are washed out, the obvious dead tissue removed often under repeated anesthesia, the increasingly dead tissues removed bit by bit even if the removals necessitate ever wider and more extensive surgeries, and repeated amputations over days or weeks.
It is the same with abdominal wounds. With any penetrating chest or abdomen wound, the chests and abdomens of these kids are explored and re-explored, the surgeons looking for additional organ damage and any newly leaking blood vessels or veins that might have been missed during previous explorations and surgeries. It is here that the advances of vascular surgery, including the placement of patches and grafts developed to treat the wounds of Vietnam, become so important.
In Afghanistan the pelvic blast injuries are particularly massive and difficult to treat. It is the common in-between-the-leg blasts set off by soldiers on patrol that routinely take off both legs as well as the genitals while causing massive internal injuries to the bladder, colon, and pelvic bones. New wars—new weapons—new injuries—new treatments and procedures—a new kind of suffering.
The new techniques of battlefield medicine have become one long and desperate surgery that may go on for weeks and months and even years. Maybe those who sent our troops into Iraq and Afghanistan, and keep sending them there, should have known all this would happen. They could argue they didn’t know and couldn’t have known. But they know now.
It is probably true that none of these kids would, with similar injuries, survive out in the civilian world, or that they could have been saved in either Iraq or Afghanistan just five years ago. But that isn’t the issue. It is almost counter-intuitive, but as a physician or surgeon it is always a bit easier, if that is the word for it, to give up on a desperately ill or damaged patient if you know them and if you know the family, and have a sense of what survival will actually mean in the long term to both the patient and their loved ones.
When you talk to military surgeons about what they do, they will tell you that they don’t feel their efforts are futile even in the face of treating a 90 percent burn victim, or a patient with all four limbs amputated, or those who need a respirator to breathe. But this new type of “Damage Control Surgery” is a kind of shift work where everyone does their own thing and the big picture is lost in the effort, or left up to someone else down the line to deal with, which in the final analysis will be the family. Today’s battlefield physicians save lives. It is what they do because they can do it. But if you push them, they admit that they try not to withdraw care in the combat theater, but then admit that, every now and then, they will stop all cares. But that is usually with the severe head injuries where the wounded would likely die in transport. Then they make sure that those soldiers die where they are, with other troops by the bedside. “It just affords them that last little bit of dignity.” And when they admit that much, their voices usually crack and their eyes fill with tears—