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Rise in Survival Rate
GRASSAU, Germany -- The survival rate for U.S. service members wounded in Iraq has reached 90 percent, higher than in any previous war, and 10 points higher than in the 1991 Persian Gulf War.
The major reason, says the general in charge of Army medical training, is improved trauma care being delivered moments after injury by medics and a growing number of soldiers trained as combat lifesavers.
Maj. Gen. George W. Weightman, commander of the Army Medical Department’s Center and School at Fort Sam Houston in San Antonio, traveled here in early November to discuss lessons learned from the Iraq war at a conference of medical service officers assigned to Europe.
Better body armor, forward-deployed surgical teams and swift medical evacuations are factors that have raised the survival rate. But the most significant change, Weightman said, has been the performance of medics and combat lifesavers in applying trauma care techniques.
A few years ago the Army created the Joint Theater Trauma Registry, a tool to track what occurs for severely wounded patients, from injury through arrival at a stateside medical center. The data confirmed what some trauma experts had been preaching: that the greatest potential for saving more lives was better, more immediate point-of-injury care.
That meant enhancing the skills and responsibilities of combat medics, and teaching many other soldiers lifesaving techniques offered through a new Tactical Combat Casualty Course. The improved training, now being used to great effect in Iraq and Afghanistan, was largely the vision of retired Lt. Gen. James Peake when he had Weightman's job in the late 1990s and during his tour as Army surgeon general from 2000 through 2004.
"He understood that we'd already polished the apple as much as we could on combat support hospitals and surgical capability. We'd already started working on the forward surgical team that [moved] surgery a lot closer to the point of injury," said Weightman. "He realized that any other impact we were going to make on survivability…would have to be…at point of injury" and performed by medics and other troops, not doctors.
The Army no longer teaches that the critical period for a trauma patient is the first "golden hour’’ after injury, Weightman said in an interview here for this column. Far more important are the "platinum 10 minutes."
"If we can keep them alive for that first 10 minutes then, by and large, we've got a little more time -- an hour-and-a-half to two hours -- before they have to have definitive surgery," Weightman said.
It’s no small thing for doctors to give battlefield medics more trauma care responsibility.
"That was a giant leap of faith for us because, in the medical profession, we tend to guard our skills because we don't want to do any harm," said Weightman. In most situations, having less-skilled personnel do a procedure raises the risk to patients. But the greater risk here is delay.
By medics and combat lifesavers "the additional skills, and focusing on several very specific circumstances, you can have an immense change to the morbidity result."
"Medic" refers to a specific Army job specialty, requiring 16 weeks of training. Combat lifesavers are soldiers in other specialties who complete a combat casualty course. Its length is being extended from 24 to 40 hours of instruction. With Iraqi insurgents using bigger improvised explosive devices (IEDs), combat commanders are sending a lot of soldiers through the course.
"Some units in Iraq have put it for everybody," Weightman said.
The three great threats to body-armored soldiers who receive traumatic wounds are blood loss from damaged limbs, sucking chest wounds and obstructed airways, Weightman said.
Until recently, medics trying to stop hemorrhaging from limbs were to try four or five different techniques before resorting to a tourniquet. The belief was that a tourniquet, once applied, made amputation necessary.
"As a result," Weightman said, "we lost many patients because they bleed to death.’’
More recent experiences and studies show tourniquets don't cause as much harm as was believed. "Conversely, it really saves a lot of lives," Weightman said
A second major trauma threat is sucking chest wounds, a condition depicted graphically in the movie Three Kings. Each breath sends a rush of air into the chest cavity through the bullet or shrapnel hole. Because the wound acts as a one-way valve, pressure builds and lungs can’t inflate. The solution is to plunge a 14-gauge needle into the thorax to allow air to escape. This technique was added to combat lifesaving training this past summer.
Weightman said the needle "looks like a harpoon" to soldiers who haven’t received the training so, even as the Army improves its first-aid kits, the needle will only be provided in kits for medics and combat lifesavers.
A third common condition that affects trauma victims is an obstructed airway. It can occur when shock sets in, muscles relax and the tongue rolls back to block the throat. A soft rubber tube must be inserted in the nose and pushed past the back of the tongue so that air reaches the lungs. The Army has trained medics to do this for the last few years, Weightman said. But only last summer did it become part of combat lifesaver training.
Six percent of U.S. wounded in the Iraq War have lost a limb, which is double the amputation rate of past wars. One reason is the improved body armor, said Weightman. It can save lives during an IED or other type of attack but more survivors lose arms or legs.