Better (7 page)

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F THE ANSWER
to how was not to be found in new technologies, it did not seem to reside in any special skills of military doctors, either. George Peoples is a forty-two-year-old surgical oncologist who was my chief resident when I was a surgical intern. In October 2001, after the September 11 attacks on the World Trade Center and the Pentagon, he led the first surgical team into Afghanistan. He returned after service there only to be sent to Iraq, in March 2003, with ground forces invading from Kuwait through the desert to Baghdad. He had gone to the U.S. Military Academy at West Point for college, Johns Hopkins Medical School in Baltimore, Brigham and Women's Hospital in Boston for surgical residency, and then M. D. Anderson Cancer Center in Houston for a cancer surgery fellowship. He owed the army eighteen years of service when he finally finished his training, and neither I nor anyone I know ever heard him bemoan that commitment. In 1998, he was assigned to Walter Reed, where he soon became chief of surgical oncology. Peoples was known in training for three things: his unflappability, his intellect (he had published seventeen papers on work toward a breast cancer vaccine before he finished his training), and the five children he and his wife had during his residency. He was not known, however, for any particular expertise in trauma surgery. Before being deployed, he hadn't seen a gunshot wound since residency, and even then, he never saw anything like the injuries he saw in Iraq. His practice at Walter Reed centered on breast surgery. Yet in Iraq, he and his team managed to save historic numbers of wounded.

"How is this possible?" I asked him. I asked his colleagues, too. I asked everyone I met who had worked on medical teams in the war. And what they described revealed an intriguing
effort to do something we in civilian medicine do spottily at best: to make a science of performance, to investigate and improve how well they use the knowledge and technologies they already have at hand. The doctors told me of simple, almost banal changes that produced enormous improvements.

One such change involved Kevlar vests, for example. There is nothing new about Kevlar. It has been around since the late 1970s. Urban police forces began using Kevlar vests in the early 1980s. American troops had them during the Persian Gulf War. A sixteen-pound Kevlar flak vest will protect a person's "body core"--the heart, the lungs, the abdominal organs--from blasts, blunt force trauma, and penetrating injuries. But researchers examining wound registries from the Persian Gulf War found that wounded soldiers had been coming in to medical facilities without their Kevlar on.
They hadn't been wearing their vests.
So orders were handed down holding commanders responsible for ensuring that their soldiers always wore the vests--however much they might complain about how hot or heavy or uncomfortable the vests were. Once the soldiers began wearing them more consistently, the percentage killed on the battlefield dropped instantly.

A second, key discovery came in much the same way, by looking more carefully at how the system was performing. Colonel Ronald Bellamy, a surgeon with the army's Borden Institute, examined the statistics of the Vietnam War and found that helicopter evacuation had reduced the transport time for injured soldiers to hospital care from an average of over eleven hours in World War II to under an hour. And once they got to surgical care, only 3 percent died. Yet 24 percent of wounded soldiers died in all, and that was because transport time to surgical
care under an hour still wasn't fast enough. Civilian surgeons talk of having a "Golden Hour" during which most trauma victims can be saved if treatment is started. But battlefield injuries are so much more severe--the blood loss in particular--that wounded soldiers have only a "Golden Five Minutes," Bellamy reported. Vests could extend those five minutes. But the recent emphasis on leaner, faster-moving military units moving much farther ahead of supply lines and medical facilities was only going to make evacuation to medical care more difficult and time-consuming. Outcomes for the wounded were in danger of getting worse rather than better.

The army therefore turned to an approach that had been used in isolated instances going back as far as World War II: something called Forward Surgical Teams (FSTs). These are small teams, consisting of just twenty people: three general surgeons, one orthopedic surgeon, two nurse anesthetists, three nurses, plus medics and other support personnel. In Iraq and Afghanistan, they travel in six Humvees directly behind the troops, right out onto the battlefield. They carry three lightweight, Deployable Rapid-Assembly Shelter ("drash") tents that attach to one another to form a nine-hundred-square-foot hospital facility. Supplies to immediately resuscitate and operate on the wounded are in five black nylon backpacks: an ICU pack, a surgical-technician pack, an anesthesia pack, a general-surgery pack, and an orthopedic pack. They hold sterile instruments, anesthesia equipment, medicines, drapes, gowns, catheters, and a handheld unit that allows clinicians to measure a complete blood count, electrolytes, or blood gases with a drop of blood. FSTs also carry a small ultrasound machine, portable monitors, transport
ventilators, an oxygen concentrator providing up to 50 percent pure oxygen, twenty units of packed red blood cells for transfusion, and six roll-up stretchers with litter stands. All of this is ordinary medical equipment. The teams must forgo many technologies normally available to a surgeon, such as angiography and radiography equipment. (Orthopedic surgeons, for example, have to detect fractures by feel.) But they can go from rolling to having a fully functioning hospital with two operating tables and four ventilator-equipped recovery beds in under sixty minutes.

Peoples led the 274th FST, which traveled 1,100 miles with troops during the invasion of Iraq. The team set up in Nasiriyah, Najaf, Karbala, and points along the way in the southern desert, then in Mosul in the north, and finally in Baghdad. According to its logs, the unit cared for 132 U.S. and 74 Iraqi casualties (22 of the Iraqis were combatants, 52 civilians) over those initial weeks. Some days were quiet, others overwhelming. On one day in Nasiriyah, the team received ten critically wounded soldiers, among them one with right-lower-extremity shrapnel injuries; one with gunshot wounds to the stomach, small bowel, and liver; another with gunshot wounds to the gallbladder, liver, and transverse colon; one with shrapnel in the neck, chest, and back; one with a gunshot wound through the rectum; and two with extremity gunshot wounds. The next day, fifteen more casualties arrived.

Peoples described to me how radically the new system changed the way he and his team took care of the wounded. On the arrival of the wounded, they carried out the standard Advanced Trauma Life Support protocols that all civilian trauma teams follow. However, because of the high
proportion of penetrating wounds--80 percent of casualties seen by the 274th FST had gunshot wounds, shrapnel injuries, or blast injuries--lifesaving operative management is required far more frequently than in civilian trauma centers. The FST's limited supplies provided only for a short period of operative care for a soldier and no more than six hours of postoperative intensive care. So the unit's members focused on damage control, not definitive repair. They packed off liver injuries with gauze pads to stop the bleeding, put temporary plastic tubes in bleeding arteries to shunt the blood past the laceration, stapled off perforated bowel, washed out dirty wounds--whatever was necessary to control contamination and stop hemorrhage. They sought to keep their operations under two hours in length. Then, having stabilized the injuries, they shipped the soldier off--often still anesthetized, on a ventilator, the abdominal wound packed with gauze and left open, bowel loops not yet connected, blood vessels still needing repair--to another team at the next level of care.

They had available to them two Combat Support Hospitals (or CSHs--"CaSHes"--as they call them) in four locations for that next level of care. These are 248-bed hospitals typically with six operating tables, some specialty surgery services, and radiology and laboratory facilities. Mobile hospitals as well, they arrive in modular units by air, tractor trailer, or ship and can be fully functional in twenty-four to forty-eight hours. Even at the CSH level, the goal is not necessarily definitive repair. The maximal length of stay is intended to be three days. Wounded American soldiers requiring longer care are transferred to what's called a level IV hospital--one was established in Kuwait and one in Rota, Spain, but the main one is in
Landstuhl, Germany. Those expected to require more than thirty days of treatment are transferred home, mainly to Walter Reed or to Brooke Army Medical Center in San Antonio, Texas. Iraqi prisoners and civilians, however, remain in the CSHs through recovery.

The system took some getting used to. Surgeons at every level initially tended to hold on to their patients, either believing that they could provide definitive care themselves or not trusting that the next level could do so. ("Trust no one" is the mantra we all learn to live by in surgical training.) According to statistics from Walter Reed, during the first few months of the war it took the most severely injured soldiers--those who clearly needed prolonged and extensive care--an average of eight days to go from the battlefield to a U.S. facility. Gradually, however, surgeons embraced the wisdom of the approach. The average time from battlefield to arrival in the United States is now less than four days. (In Vietnam, it was forty-five days.) And the system has worked.

One airman I met during my visit to Washington had experienced a mortar attack outside Balad on September 11, 2004, and ended up on a Walter Reed operating table just thirty-six hours later. In extremis from bilateral thigh injuries, abdominal wounds, shrapnel in the right hand, and facial injuries, he was taken from the field to the nearby 31st CSH in Balad. Bleeding was controlled, resuscitation with intravenous fluids and blood begun, a guillotine amputation at the thigh performed. He received exploratory abdominal surgery and, because a ruptured colon was found, a colostomy. His abdomen was left open, with a clear plastic covering sewn on. A note was taped to him explaining exactly what the surgeons
had done. He was then taken to Landstuhl by an air force critical care transport team. When he arrived in Germany, army surgeons determined that he would require more than thirty days of recovery, if he made it at all. Resuscitation was continued, a quick further washout performed, and then he was sent on to Walter Reed. There, after weeks in intensive care and multiple operations to complete the repairs, he survived. This sequence of care is unprecedented, and so is the result. Injuries like his were unsurvivable in previous wars.

But if mortality is low, the human cost remains high. The airman lost one leg above the knee, the other at the hip, his right hand, and part of his face. How he and others like him will be able to live and function remains an open question. His abdominal injuries prevented him from being able to lift himself out of bed or into a wheelchair. With only one hand, he could not manage his colostomy. We have never faced having to rehabilitate people with such extensive wounds. We are only beginning to learn what to do to make a life worth living possible for them.

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PRIL 4, 2004,
after four private military contractors were killed and their bodies mutilated in Fallujah, just to the west of Baghdad, three marine battalions launched an attack to take control of the city from the fifteen to twenty thousand insurgents operating there. Five days later, after intense fighting and protests from Iraqi authorities, the White House ordered the troops to retreat. The marines staged a second attack seven months afterward, on November 9. Four marine battalions and two army mechanized infantry battalions with some
twelve thousand troops in all fought street-to-street against snipers and groups of insurgents hiding among the two hundred mosques and fifty thousand buildings of the city. The city was recaptured in about a week, although fighting continued for weeks afterward. During the two battles for Fallujah, American forces suffered more than 1,100 casualties in all, the insurgents a still-untold number. To care for the wounded, fewer than twenty trauma surgeons were in the vicinity; just two neurosurgeons were available in the entire country. Marine and army forward surgical teams received some of the wounded but were quickly overwhelmed. Others were transported by two-hundred-mile-per-hour Blackhawk medevac helicopters directly to combat support hospitals, about half of them to the 31st CSH in Baghdad.

Another of the surgeons I had trained with in Boston, Michael Murphy, was a reservist on duty there at the time. A North Carolina vascular surgeon, he had signed up with the army reserves in June 2004. In October, he got a call from central command. "I left Durham on a Sunday, and a week later I was in a convoy going down the Irish Road in Iraq with an M9 pistol in my hand, wondering what I had gotten myself into," he later told me.

The moment he arrived at the 31st CSH--he still had his bags in his hands--Murphy was sent to the operating room to help with a soldier who had shrapnel injuries to the abdomen, both legs missing, and a spouting arterial injury in one arm. It was the worst injury Murphy had ever seen. The physicians, nurses, and medics took him in like a wet pup. They worked together as more of a team than he'd ever experienced. "In two weeks, I went from a guy who was scared to death about
whether I was going to cut it to the point where I was the most comfortable I had ever felt as a surgeon," he says.