Beyond the Purple Heart — Continuity of Care for the Wounded in Iraq
http://www.100md.com
《新英格兰医药杂志》
You can hear the usual hum of the emergency room, and all the familiar beeps of monitors in the operating room provide a backdrop for medical teams boasting the usual collection of skills and following the typical team approach to injured patients. But beyond the generic hospital buzz, the background noises are unusual. The whoosh and explosion of incoming mortars and the loud whine of the turbo engines of Blackhawk helicopters bringing patients, often directly from the point of wounding, distinguish the military combat support hospitals and forward surgical teams in Iraq from the ERs and ORs back home. Different also are the spectrum of patients seen here and the frequency of major penetrating traumas. Many of these patients are U.S. soldiers who have sustained devastating injuries from high-velocity gunshots or fragments from explosions. Thus far, during the war in Iraq, the Army has awarded more than 5000 Purple Hearts for injuries sustained in combat.
(Figure)
Members of the 212th Mobile Army Surgical Hospital Establishing Their Position in Iraq.
My perspective on Operation Iraqi Freedom comes from talking with patients who are recovering at Walter Reed Army Medical Center (Washington, D.C.), Brooke Army Medical Center (San Antonio, Texas), and Landstuhl Regional Medical Center in Germany; from visits with health care providers in Iraq; from e-mail messages sent by those in the field; and from a bird's-eye view of the complex health care system that supports the U.S. military and coalition forces in the war in Iraq.
To be accurate, the perspective must be broader than the ER and OR, for the battlefield is linked with the Landstuhl center (staffed by the Army and the Air Force) and with the medical system in the United States. These linkages are multifaceted and rely on electronic media along with the use of common protocols at all echelons of care. Many physicians have taken and passed special courses, in which they learn not only guidelines for the care of burns or extremity injuries but also what will occur at the next level of care and how to set the stage for ultimate success by performing minimal yet optimal work at the first surgical intervention.
(Figure)
Caring for a Burned Child at a Combat Support Hospital.
Since many U.S. surgeons do not see substantial trauma routinely in their practices, each military service has rotated surgical teams through civilian high-volume trauma centers to refresh the relevant skills. The Air Force's strategic evacuation system is highly responsive and has added hands-on in-flight care by Critical Care Air Transport Teams. A new medical doctrine of "essential care in theater" has been made possible by these teams and the technology that supports them. We do not have the convalescence centers in the theater of war that we had in Vietnam or the 44 hospitals that we had in place for Desert Shield and Desert Storm. The casualties who cannot return to their units within seven days are transported to Germany within 8 to 72 hours.
Carving a health care system out of the desert is a challenge. Everything that supports such an enterprise — from basics such as food, water, and shelter for the care providers to communications equipment to the technology of modern medicine — is tied to a logistic tail that reaches back to the United States. Attaining an initial foothold meant battling not only enemies but also the elements.
Since the troops began the march to Baghdad, more than 17,000 have been evacuated from the area of operations in Iraq to Germany. Of the soldiers who were so transported, 2302 (14 percent) returned to their units in Iraq for further duty. The others were reevaluated, their condition was stabilized, and after receiving the next stage of care, they were sent back to facilities in the United States. The graph shows the frequency of various causes of battle injuries. In addition, since the first days of the war, Iraqi patients (military and civilian) have accounted for more than 55 percent of the hospital days in our facilities in Iraq.
Percent of Injuries from Various Causes in U.S. Soldiers in Iraq, March 19, 2003, through September 30, 2004.
Data are from the U.S. Armed Forces Medical Examiner, the Department of Defense Transcom, and the U.S. Army Health Research Center.
Many of the stories told by wounded soldiers have a similar refrain — appreciation for the medical care that brought them back. They describe the continuum of care as a blur, but a blur punctuated by shining examples of competence, compassion, and heroism. "I was lucky that day . . . I was riding with my medic!" said an air assault trooper with a below-the-knee amputation of the right leg, extensive soft-tissue injury in the left leg, and an external fixator orthopedic device on the left arm. "His" medic, he said, had ruptured eardrums from the blast of a land mine, yet he extracted the trooper from his vehicle, stopped his bleeding, carried him to another vehicle, and drove him to the combat support hospital. Before the transport, they continued to be peppered by small-arms fire, but, he added, a second medic came forward, laid his body in front of them, and returned fire.
During the rush to Baghdad from March to May 2003, many wounds were from small-arms fire. As the insurgents increased their resistance, small arms and rocket-propelled grenades gave way to "improvised explosive devices" and "vehicular-borne improvised explosive devices" targeting vehicles, convoys, and groups of soldiers traveling along regular routes. In response to the enhancement of vehicles' armor, the insurgents elevated their explosive devices off the ground and placed them along the sides of roadways. Explosions causing fragment wounds and multisite injuries became commonplace.
Because of the use of body armor, soldiers with upper-body wounds have been surviving, but at the expense of severe injuries to the proximal upper extremities. Twenty-six above-elbow amputations, including three shoulder disarticulations, have been performed. Furthermore, even with the torso-protecting body armor, the axilla remains vulnerable, and the armor has not entirely eliminated deaths from thoracic injuries. Recognizing this pattern, a physician assistant and a surgeon from a forward surgical team have invented a device to cover the axilla and upper arm; 50,000 of these devices have been sent into Iraq.
As of early November 2004, before the battle for Fallujah, 203 U.S. soldiers had undergone major amputations in Iraq or Afghanistan. This number continues to increase. The medical philosophy of the U.S. military has been to stress the continuity of care and doing whatever is necessary to return each soldier to the highest possible level of function. This approach includes far more than the use of computer-assisted prostheses, custom-built hip sockets, and multiple types of limbs (see video, available with the full text of this article at www.nejm.org). An amputee registry has been created to track and manage the care of these patients, whose needs differ greatly from those of patients, typically elderly, who have lost limbs to vascular disease. A specialized center for amputees has been established at Walter Reed, built around a multidisciplinary team of surgeons, physical therapists, orthotists, prosthetists, case managers, social workers, and mental health professionals — all focusing on long-term functionality.
(Figure)
Soldier Walking on Short Prostheses (Left) before Progressing to Full-Length Computer-Assisted Prostheses (Right).
For soldiers who have sustained serious burns, the U.S. Army Institute for Surgical Research at Brooke Army Medical Center has been reengineered to serve as the primary center for patients with burns as well as multisystem trauma. Clinicians at Brooke follow the same protocols for amputees that are used at Walter Reed, while addressing the unique aspects of burn physiology and wound care.
Many of these severely injured soldiers will return for repeated inpatient stays and outpatient visits over a period of many months, for care ranging from adjustment of prostheses to stump revision to reconstructive plastic surgery. Patients may return to their home station for interim care or may be placed under the coordinated care of a Veterans Administration (VA) facility near their home. More than 50 VA managers have been assigned to Army hospitals to facilitate such transfers and to help with planning for long-term care and with the adjudication of benefits when a soldier leaves active duty.
The goal is more than just the physical healing of the soldiers. The emotional effects of war and wounds must be tended to as well, so the behavioral health component of care is key. In addition to the patients themselves, the families of patients receive help from the military medical center. They, too, come from long distances, often the same night as their soldier arrives, and require support as they begin to participate in rehabilitation. Ultimately, the goal of all the coordination, from the forward surgical team to the VA and beyond, is to enable these young men and women to reenter society and lead full lives. In many cases, new life skills and new vocational skills must be taught. In addition to the integration with the VA system to facilitate follow-up care, a Disabled Soldier Support System has been put into place as a clearinghouse for financial, administrative, medical, vocational, and other services.
Although the continuum of care has never been stronger, we have learned and will continue to learn from this war, as we have from previous wars. In the end, the success of rehabilitation will boil down to the people involved — the medical personnel of the military whose competence and compassion make all the difference.(James B. Peake, M.D.)
(Figure)
Members of the 212th Mobile Army Surgical Hospital Establishing Their Position in Iraq.
My perspective on Operation Iraqi Freedom comes from talking with patients who are recovering at Walter Reed Army Medical Center (Washington, D.C.), Brooke Army Medical Center (San Antonio, Texas), and Landstuhl Regional Medical Center in Germany; from visits with health care providers in Iraq; from e-mail messages sent by those in the field; and from a bird's-eye view of the complex health care system that supports the U.S. military and coalition forces in the war in Iraq.
To be accurate, the perspective must be broader than the ER and OR, for the battlefield is linked with the Landstuhl center (staffed by the Army and the Air Force) and with the medical system in the United States. These linkages are multifaceted and rely on electronic media along with the use of common protocols at all echelons of care. Many physicians have taken and passed special courses, in which they learn not only guidelines for the care of burns or extremity injuries but also what will occur at the next level of care and how to set the stage for ultimate success by performing minimal yet optimal work at the first surgical intervention.
(Figure)
Caring for a Burned Child at a Combat Support Hospital.
Since many U.S. surgeons do not see substantial trauma routinely in their practices, each military service has rotated surgical teams through civilian high-volume trauma centers to refresh the relevant skills. The Air Force's strategic evacuation system is highly responsive and has added hands-on in-flight care by Critical Care Air Transport Teams. A new medical doctrine of "essential care in theater" has been made possible by these teams and the technology that supports them. We do not have the convalescence centers in the theater of war that we had in Vietnam or the 44 hospitals that we had in place for Desert Shield and Desert Storm. The casualties who cannot return to their units within seven days are transported to Germany within 8 to 72 hours.
Carving a health care system out of the desert is a challenge. Everything that supports such an enterprise — from basics such as food, water, and shelter for the care providers to communications equipment to the technology of modern medicine — is tied to a logistic tail that reaches back to the United States. Attaining an initial foothold meant battling not only enemies but also the elements.
Since the troops began the march to Baghdad, more than 17,000 have been evacuated from the area of operations in Iraq to Germany. Of the soldiers who were so transported, 2302 (14 percent) returned to their units in Iraq for further duty. The others were reevaluated, their condition was stabilized, and after receiving the next stage of care, they were sent back to facilities in the United States. The graph shows the frequency of various causes of battle injuries. In addition, since the first days of the war, Iraqi patients (military and civilian) have accounted for more than 55 percent of the hospital days in our facilities in Iraq.
Percent of Injuries from Various Causes in U.S. Soldiers in Iraq, March 19, 2003, through September 30, 2004.
Data are from the U.S. Armed Forces Medical Examiner, the Department of Defense Transcom, and the U.S. Army Health Research Center.
Many of the stories told by wounded soldiers have a similar refrain — appreciation for the medical care that brought them back. They describe the continuum of care as a blur, but a blur punctuated by shining examples of competence, compassion, and heroism. "I was lucky that day . . . I was riding with my medic!" said an air assault trooper with a below-the-knee amputation of the right leg, extensive soft-tissue injury in the left leg, and an external fixator orthopedic device on the left arm. "His" medic, he said, had ruptured eardrums from the blast of a land mine, yet he extracted the trooper from his vehicle, stopped his bleeding, carried him to another vehicle, and drove him to the combat support hospital. Before the transport, they continued to be peppered by small-arms fire, but, he added, a second medic came forward, laid his body in front of them, and returned fire.
During the rush to Baghdad from March to May 2003, many wounds were from small-arms fire. As the insurgents increased their resistance, small arms and rocket-propelled grenades gave way to "improvised explosive devices" and "vehicular-borne improvised explosive devices" targeting vehicles, convoys, and groups of soldiers traveling along regular routes. In response to the enhancement of vehicles' armor, the insurgents elevated their explosive devices off the ground and placed them along the sides of roadways. Explosions causing fragment wounds and multisite injuries became commonplace.
Because of the use of body armor, soldiers with upper-body wounds have been surviving, but at the expense of severe injuries to the proximal upper extremities. Twenty-six above-elbow amputations, including three shoulder disarticulations, have been performed. Furthermore, even with the torso-protecting body armor, the axilla remains vulnerable, and the armor has not entirely eliminated deaths from thoracic injuries. Recognizing this pattern, a physician assistant and a surgeon from a forward surgical team have invented a device to cover the axilla and upper arm; 50,000 of these devices have been sent into Iraq.
As of early November 2004, before the battle for Fallujah, 203 U.S. soldiers had undergone major amputations in Iraq or Afghanistan. This number continues to increase. The medical philosophy of the U.S. military has been to stress the continuity of care and doing whatever is necessary to return each soldier to the highest possible level of function. This approach includes far more than the use of computer-assisted prostheses, custom-built hip sockets, and multiple types of limbs (see video, available with the full text of this article at www.nejm.org). An amputee registry has been created to track and manage the care of these patients, whose needs differ greatly from those of patients, typically elderly, who have lost limbs to vascular disease. A specialized center for amputees has been established at Walter Reed, built around a multidisciplinary team of surgeons, physical therapists, orthotists, prosthetists, case managers, social workers, and mental health professionals — all focusing on long-term functionality.
(Figure)
Soldier Walking on Short Prostheses (Left) before Progressing to Full-Length Computer-Assisted Prostheses (Right).
For soldiers who have sustained serious burns, the U.S. Army Institute for Surgical Research at Brooke Army Medical Center has been reengineered to serve as the primary center for patients with burns as well as multisystem trauma. Clinicians at Brooke follow the same protocols for amputees that are used at Walter Reed, while addressing the unique aspects of burn physiology and wound care.
Many of these severely injured soldiers will return for repeated inpatient stays and outpatient visits over a period of many months, for care ranging from adjustment of prostheses to stump revision to reconstructive plastic surgery. Patients may return to their home station for interim care or may be placed under the coordinated care of a Veterans Administration (VA) facility near their home. More than 50 VA managers have been assigned to Army hospitals to facilitate such transfers and to help with planning for long-term care and with the adjudication of benefits when a soldier leaves active duty.
The goal is more than just the physical healing of the soldiers. The emotional effects of war and wounds must be tended to as well, so the behavioral health component of care is key. In addition to the patients themselves, the families of patients receive help from the military medical center. They, too, come from long distances, often the same night as their soldier arrives, and require support as they begin to participate in rehabilitation. Ultimately, the goal of all the coordination, from the forward surgical team to the VA and beyond, is to enable these young men and women to reenter society and lead full lives. In many cases, new life skills and new vocational skills must be taught. In addition to the integration with the VA system to facilitate follow-up care, a Disabled Soldier Support System has been put into place as a clearinghouse for financial, administrative, medical, vocational, and other services.
Although the continuum of care has never been stronger, we have learned and will continue to learn from this war, as we have from previous wars. In the end, the success of rehabilitation will boil down to the people involved — the medical personnel of the military whose competence and compassion make all the difference.(James B. Peake, M.D.)