BALAD, Iraq – Australian Army Corporal Jake Morcom works with U.S. Air Force medical staff to stabalize a patient in the emergency room of the theater hospital at Balad Air Base, Iraq, Dec. 3. The hospital sees approximately 400 patients a month—most of whom are trauma patients. (U.S. Army photo by Sgt. Dallas Walker)

AAOS Now

Published 3/1/2007
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Carolyn Rogers

From Iraq—Back to Iraq: Modern combat orthopaedic care

At the “From Iraq—Back to Iraq” symposium, a tri-service panel of military traumatologists provided insight on the current treatment of highly complex war injuries.

Advances in medical care, improvements in body armor and armored vehicles, and intense training of U.S. military personnel give today’s wounded soldiers a better-than-ever chance of survival.

The downside of that encouraging news is that the soldiers are surviving with far more serious injuries than in any previous war. The extremity injuries coming out of Operation Iraqi Freedom and Operation Enduring Freedom have been devastating, reported a panel of military orthopaedists during the 2007 AAOS Annual Meeting.

Challenges unique to war trauma surgery
As noted in the accompanying article, “A brief background of combat injuries,” (page 34) blast wounds and high-velocity missile wounds are complex injuries that are associated with a high degree of contamination and much greater loss of muscle tissue and bone than gunshot wounds.

Fortunately, most of these injuries are being successfully cared for using a specific protocol of treatments, including surgical débridement, leaving all wounds open, early fracture stabilization, broad-spectrum antibiotics, and rapid evacuation to higher levels of care.

Battlefield care: Damage control
In the past, battlefield medical teams usually attempted to address every possible aspect of a wounded soldier’s injuries, resulting in many hours on the operating table and extreme stress to the patient’s condition.

In the 1990s, the approach to battlefield care began to shift toward damage-control orthopaedics (DCO), according to Lt. Cmdr. Michael T. Mazurek, MD, of the Naval Medical Center in San Diego.

“DCO shifts the focus to the essential care that a patient needs for optimized outcome,” he said.

That does not mean doing the absolute minimum on the battlefield, Dr. Mazurek emphasized. Rather, the patient’s needs are assessed and treatment is handled in a manner likely to produce the highest quality outcome.

Battlefield care requires strict adherence to the following principles of extremity damage control:

  • Stop the bleeding: Front-line hemorrhage control techniques include self-applied tourniquets, which are seen as effective and safe ways to prevent fatal limb exsanguinations on the battlefield. Windlass or pneumatic compression is essential.
  • Remove the contamination: Multiple irrigation and débridement of wounds occur at every level, from the far-forward surgical teams to the combat support hospitals. Aggressive, far-forward use of antibiotic beads and vacuum-assisted closure devices accelerate wound healing and decrease the need for skin grafting.
  • Restore the blood flow.
  • Stabilize fractures: External fixation devices for improved stability of injuries are used as far forward on the battlefield as the tactical situation permits.
  • Don’t burn bridges for the next guy.

Five echelons of care
Orderly and rapid evacuation from the war zone to definitive level of care is a critical component in providing state-of-the-art care to the wounded, said Col. Roman A. Hayda, Brooke Army Medical Center (BAMC), San Antonio. “Our ability to get these guys out of the field, cared for, and back home has dramatically improved with this war, which has been unlike any other conflict,” he said.

“We can get a patient back to the United States in 16 hours now,” added Col. James R. Ficke, MD, also of BAMC.

Wounded soldiers typically advance through the following five echelons of care:

  • Battlefield care, provided by combat medics and “buddy aid”
  • aid station, where a physician provides resuscitative care or advanced trauma life support
  • surgical team, a highly mobile, austere surgical team that provides life- and limb-saving care for injuries too severe to survive transport to the combat support hospital
  • Combat support hospital, a theater-deployed mobile hospital with limited subspecialty and Intensive Care Unit treatment that prepares patients for long-distance transport
  • Fixed facility at intermediate point of evacuation
  • Definitive care facility, a military hospital such as BAMC or Walter Reed Army Medical Center (WRAMC) staffed and equipped to provide convalescent, restorative, and state-of-art rehabilitative services

“Extraordinary” amputee care
Approximately 70 percent of war wounds today are musculoskeletal injuries; 55 percent are extremity wounds. Fractures account for 26 percent of injuries, and 82 percent are open fractures.

According to the Pentagon, about 6 percent of the casualties in the conflicts in Afghanistan and Iraq have returned home with one or more limbs amputated. Military amputees often have concomitant conditions, including additional fractures, infections, nerve injuries, and other soft-tissue injuries.

“Fortunately, we’ve seen extraordinary advances in amputee care treatment,” reported WRAMC’s Lt. Cmdr. H. Michael Frisch, MD.

Quick evacuation can help avoid circular amputations, and advanced prosthetic technology has helped countless patients return to independent living, Dr. Frisch said. “Amputees are now able to run, golf, ski, kayak, water ski, and participate in combat training as well as triathlons.”

To achieve such remarkable results, rehabilitation is vital.

In fact, the panelists agreed that outcomes are determined more by aggressive and comprehensive rehabilitation programs than by surgery.

“Rehabilitation teams are essential; with them, there is no limit to what amputees can accomplish,” Dr. Frisch said.

Up to and including return to combat.

Amputees: Back in action
“Amputation does not equal discharge,” Dr. Frisch said.

Not that the amputees themselves are seeking to be discharged. “These guys are sometimes hard to slow down,” he said.

In fact, about 60 military amputees have returned to active duty and 10 have actually been redeployed to the battlefield.

The first amputee to return to the battlefield—Army Maj. David Rozelle—was present at the symposium and shared some of his experiences in Iraq, in rehab, and after his return to Iraq.

Maj. Rozelle, who commanded 150 men in combat, lost his right foot in an anti-tank mine explosion in Iraq. Just one year later, he was declared “fit for duty” and returned to command. His next stop was back to Iraq.

“It was a great honor to be the first guy going back to the same battlefield where I was injured,” he said, although he admitted “it wasn’t easy” wearing a prosthetic leg in combat and dealing with the heat and sand.

“People need to understand that neither the amputees nor the able-bodied soldiers are ready to quit just because they’ve been injured,” he said. “They want to come back and join their units in combat—and in a combat role. With modern science, that’s a possibility.”