Preparing for Casualties

'Bringing Good Medicine to Bad Places'

By David Abel  |  Globe Staff  |  10/23/2001

They were there, ironically, to provide medical support for Army Rangers making a nighttime assault on a Taliban-held airport in southern Afghanistan. But when the dust cleared from the Black Hawk helicopter crash, two men were dead and three injured. In addition, two Rangers were hurt parachuting to the attack site - reminders of the human cost of ground combat.

Still, the Black Hawk's presence in the night sky over Pakistan last week vividly illustrates the US approach to casualties in the coming ground war: Get them help fast and get them out fast.

The helicopters are flying ambulances, carrying everything from bandages that speed clotting to defibrillators that can spark hearts back to life. They can reach wounded soldiers and evacuate them at speeds of up to 150 miles per hour.

In modern field medicine, speed is paramount. The faster a wounded soldier gets to a hospital, the better his chance of survival.

As military planners prepare for the first large-scale US ground combat since 1991, they must contend with the harsh reality of battlefield medicine: Despite experienced doctors and years of progress in medical science, the Army's ability to save lives on the battlefield itself hasn't improved much since the battle of Gettysburg in 1863.

"It's really sad to say, but almost all of the medical advances have come from after the soldier reaches the doctor," said Col. Robert Vandre, director of Combat Casualty Care Research at the Army Medical Research and Materiel Command.
"The reason is bleeding," said Dr. Robert Mosebar, a retired Army colonel who has witnessed both the advances and intractable problems in battlefield medicine since World War II.

About 50 percent of those wounded in battle die of blood loss from a severed major artery or an internal hemorrhage that failed to clot in the critical time of about 30 minutes, explained Mosebar, a former World War II medic who went on to help plan combat medical operations at the Army Medical Command.

"We are looking at a lot of things, but I don't think we have really answered the problem," he said.

Although hospitals' abilities to heal soldiers has improved steadily since World War I, about 20 percent of those wounded in battle during the Vietnam and Gulf wars died before reaching a doctor - roughly the same rate as during the Civil War, according to doctors at the Army Medical Command in San Antonio.

To improve the survival rate, the research wing of the military, called the Defense Advanced Research Projects Agency, envisions a future in which soldiers would wear monitors that track their vital signs - and signal the nearest medic when they're hurt - while medics of the future would carry stretchers with built-in intensive-care units.

But those ideas remain in development. For now, the military has been focusing on sending in the best-equipped staff it can - especially for special-forces operations like the one being mounted in Afghanistan. The Army Rangers and other commandos in that country's hostile landscape will be supported by special-operations medics who have more training than their counterparts elsewhere in the military.

While today's average Army medic carries a set of equipment similar to the 40-pound rucksack soldiers hauled in World War II and has only about 10 weeks of first-aid training, medics in the special-operations squads now likely in Afghanistan have more than a year's worth of intensive medical training and carry the latest life-saving medical gear.

An Army Ranger, for example, now carries a Palm Pilot device storing reams of basic medical information, a satellite phone to consult doctors, GPS devices to monitor their life signs, advanced antibiotics such as Cipro and a variety of other medications, immobilization equipment, centrifuges to test blood, and surgical kits to remove shrapnel and suture wounds.

"The biggest difference now in capabilities is the training," said Col. Kevin Keenan, dean of the Joint Special Operations Medical Training Center at Fort Bragg, N.C., explaining how since 1996 special forces medics have trained with paramedics at hospitals in New York City and Tampa. "But our ability to intervene in casualties in the first hour is perhaps no different than before."

For all their knowledge and equipment, the military medics' most important job may remain what it was back in the Korean War - calling in choppers.
The helicopter, more than any other development since World War II, reduced the time it took to evacuate casualties, allowing soldiers to survive wounds that previously would have killed them.

"For the first time in Korea, but much more so in Vietnam, a soldier could be picked up at the point of wounding and be evacuated in the middle of a firefight," said Dr. Robert J.T. Joy, a former Army colonel and the retired chairman of the medical history department at the Uniformed Services University of the Health Sciences in Maryland. "That made a huge difference."

In Vietnam, medical personnel took helicopter medicine to a new plateau, largely because the huge number of casualties - 200,000 killed or wounded - fostered a strong system of field hospitals and helicopter rescue units.

Now, with larger, faster, and more sophisticated helicopters, the United States can get people off the battlefield even more rapidly. Today's Black Hawk is like a Corvette compared to the Chevette-like Huey from the Vietnam era.

But a fast helicopter helps only if it can reach the wounded soldier, something that is tough to do in irregular combat of the type American troops are expected to face in Afghanistan. In the chaos of the failed 1993 peacekeeping mission in Somalia, one soldier died from a groin injury when he couldn't be evacuated and medics couldn't stop the bleeding for more than two hours.

"The benefits of a speedy evacuation has a limit," Joy said. "Now the challenge is bringing better treatment to the battlefield."

At the Uniformed Services University, officials refer to that task as "bringing good medicine to bad places." And it has a long and valiant, if bloody, history. During the Revolutionary War, a medic attending to wounded soldiers had little more than a tourniquet to control bleeding and an axe to chop off an infected limb.

By World War I, wounded soldiers received blood transfusions at hospitals close to the front lines. Doctors there practiced advanced forms of trauma surgery and could treat infection and shock.

Medical advances since then - primarily penicillin and other antibiotics - have also significantly improved a soldier's chance of surviving serious wounds by reducing the number of infections. The rate of those who died after making it alive to a doctor has steadily improved, from 8 percent of all wounded in action in World War I to little more than 2 percent in Vietnam, according to the Army Medical Research and Materiel Command in Maryland.

Unfortunately, military medical officials say, the ability to treat patients on the battlefield has reached a plateau.

Military planners are keenly aware of the need for first-rate medical support. A report by the General Accounting Office in 1995 rapped the Pentagon for fielding "inadequate" medical teams to the Persian Gulf in 1991 and said the military didn't have the expertise or resources to treat a large number of casualties.

Now, small but sophisticated teams of about 20 medical personnel follow every brigade in what the Army today calls "Forward Surgical Teams," a successor to the more stationary MASH units in Korea. Behind each division is a larger field hospital. And today regular soldiers get far more medical training than they ever did.

In recent years, some military doctors have worked at urban hospitals that get large numbers of trauma victims, while Black Hawk pilots honed their skills by responding to accidents in remote locations in California.

Howard Champion, senior advisor on trauma at the Uniformed Services University, seemed to foreshadow the pressure on medical personnel at a military health care conference in Washington last January, when he described their role in the next ground war. "They've got to do it right the first time, because CNN is over there - and they are going to get increasingly critical."

Some military medical officials see remarkable promise in new blood-clotting technologies, some of which may now be carried by soldiers in Afghanistan.
One device being tested in the field is a special "hemostatic" bandage that uses fibrin to speed clotting. Another piece of equipment coming into use is portable ultrasound monitors, enabling medics to locate internal bleeding and fractures.

More high-tech solutions may be in store down the road. Although it may take years before they would work on the battlefield, surgical robots are being designed to carry out commands by doctors a continent away.

"These devices don't make sense in today's battlefield, especially in rough or urban terrain," said Dr. Richard Satava, a professor of surgery at Yale who recently ran the advanced biomedical technologies program at the Pentagon's Defense Advanced Research Projects Agency. "But telemedicine is here. It works. And it's just a question of whether and when we want to use it."

As important as technology is to saving soldiers, 77-year-old Dr. Mosebar, who was brought back from retirement recently to help the Army Medical Command at Fort Sam Houston in San Antonio plan for the future, said nothing will ever replace a well-trained medic. "When the going gets rough, and the blood starts flowing, the medics are dear to everyone's hearts. The combat medic will always be a little god to soldiers wounded in battle."

David Abel can be reached at