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Lifesaving knowledge, innovation emerge from war’s deadly violence
By GREGG ZOROYA
USA TODAY
AD DULUIYAH, Iraq — Even with 10 milligrams of morphine, Army Sgt. Robert Mundo lay in agony after a sniper’s bullet pierced his thigh and blasted through his groin.
Mundo gripped the hand of another GI as medic Bridgett Joseph surveyed the bloody damage. Then Joseph reached into her bag for a bandage no other war has seen.
Made with an extract from shrimp cells, the HemCon bandage created a tight bond that stopped the bleeding almost instantly. Seconds later, Mundo, 24 — a widower from Colorado Springs and the father of two young girls — was airlifted to the Air Force Theater Hospital in Balad, 10 miles away. He got there in five minutes.
New ways of healing are as much a product of war as are new ways of killing. To save lives on the battlefield, medical innovations are born in days rather than in years, military and civilian doctors say. And as with wars past, the new ways of treating the injured and sick in Iraq and Afghanistan — soldiers such as Mundo — could have benefits beyond the battlefield.
Civilian emergency care experts such as Thomas Judge say medical technicians in the USA are beginning to use the HemCon bandage and new battlefield tourniquets to treat trauma patients. A portable heart-lung machine developed in Germany and not yet approved for use by U.S. doctors is helping wounded soldiers breathe. It is small — not much larger than a laptop computer — and connects to blood vessels in the groin to filter out poisonous carbon dioxide while filtering in oxygen. Military doctors in Balad also are using an expensive clotting drug, licensed for use on hemophiliacs, to help stem massive hemorrhaging in troops torn apart by roadside bombs.
Not all advances come easily. Civilian doctors complain that the military sometimes fails to share information on the success of a new drug or technology. Military doctors disagree over the effectiveness of some new products. The Army, for instance, favors the HemCon bandage even though Navy and Marine doctors question whether it works as well as a cheaper bandage developed by the Navy.
Some innovations, such as the HemCon, result from government-sponsored research. Others come from the ingenuity of battlefield doctors who seek new ways to use existing medicines, or try untested technology when all else fails.
“The military has to try things that nobody has tried before,” said Judge, immediate past president of the Association of Air Medical Services, an air ambulance trade group. “Some of the greatest advancements of medicine only come about from war.”
Controlled chaos
When Mundo arrived at Balad at 11:45 a.m. on March 5, a rickshaw-like gurney carried him from the helipad into the controlled chaos of the Air Force Theater Hospital emergency room. Nurses, medical technicians and doctors — some of them with 9mm pistols slung from shoulder holsters — swarmed over each patient wheeled inside. (They’re under orders to carry weapons, even during surgery.)
As patients arrive, doctors and nurses poke, prod and inspect; they cut away clothing, shout out blood pressure readings, insert oxygen tubes and wheel up portable X-ray machines. Helicopter medics, helmets under their arms, squeeze into the scrum to recite how each soldier fell on the battlefield.
Bloody linens and body fluids collect on the floor. The clatter of arriving or departing helicopters, beating against the hospital tents, muffles conversation.
“You got kids?” Air Force Lt. Col. Jay Bishoff, a urologist, asked Mundo. “I have kids,” Mundo answered apprehensively. “But if I get home, I may want more.”
“Well,” Bishoff replied, “you’ll be able to have a lot more.”
About 20 minutes after entering the ER, Mundo was wheeled into one of three operating rooms. There, Bishoff began knitting the soldier back together. “We’ll rebuild everything,” Bishoff said through his surgical mask. “We’re going to reconstruct it. Save it.”
Simple, effective design
The Air Force hospital in Balad is one of the two largest military hospitals in Iraq. The other is an Army facility in Baghdad. The 300 staff members at Balad treat about 9,000 patients a year: Americans, coalition troops, Iraqis, even captured insurgents. The caseload rivals any major trauma center in the USA, said Air Force Col. Tyler Putnam, chief of intensive care.
Its 37,000 square feet lie under a series of tents, and surgeons here are particularly proud of the hospital’s simple design. Combat casualties pass from emergency room to CT scan and into surgery.
“It’s this 100 yards from the ER doors to the operating room. It’s just a straight shot. There are no corners, no turns — you just go straight down the hallway,” said Air Force Lt. Col. Jeffrey Bailey, 49, of St. Louis, the chief of trauma here.
Because a major airbase sits within the Balad installation, almost all sick and wounded Americans from across Iraq flow through the hospital on their way home.
American casualties here fall into two categories. Those with mild ailments — kidney stones, for example — are treated and recuperate here, then return to their units.
The severely wounded undergo surgery, then are quickly placed aboard aircraft for flights to the Army’s Landstuhl Regional Medical Center in Germany. Mundo would join this river of casualties soon.
After Mundo underwent almost two hours of surgery, his battalion and company commanders and other soldiers visited to wish him well. They joked about his bravely “taking one for the team.” A Purple Heart and a Combat Infantryman Badge were pinned to his pillow.
Bishoff, 44, of San Antonio, said it was the 16th groin injury he has repaired since arriving in Iraq more than a month ago.
“Every time I do it, I get better, I get faster, I learn more,” he said. “In prior wars, he would have likely lost both of his testicles.”
Doctors have learned about the extent of damage caused by high-velocity bullets and bomb blasts. They have taught themselves how to better identify dead tissue and reconnect what can be saved.
Applying the lessons
The lessons from treating complex battle wounds can form the basis for seminars and published papers to educate doctors at home.
Almost every war has given rise to medical achievements. After yellow fever killed soldiers during the Spanish-American War, military doctors were the first to prove that mosquitoes carried the disease. Among those doctors: Maj. Walter Reed, namesake of the famous Army hospital in Washington, D.C.
Large-scale blood transfusions began during World War I. And medical evacuations by helicopter originated during the Korean War and became common in Vietnam.
Today, the Pentagon is asking civilian researchers to develop dehydrated blood products that can be stored up to two years; a portable battlefield device that stops internal bleeding with ultrasound; a non-addictive painkiller as powerful as morphine, and prosthetics that respond to brain waves.
“Many, if not all, of these will have civilian uses,” said Brett Giroir, a deputy director at the Defense Advanced Research Projects Agency, which does research and development for the Pentagon.
Even more important, doctors say, are further advances in trauma care, the long-term process of saving, healing and rehabilitating the wounded and injured. Traumatic injuries remain the No. 1 killer of Americans under age 45. The speed and efficiency of trauma care, improved upon recently by civilian medicine, are being pushed even further in Iraq and Afghanistan.
“Things come from civilian medicine, and then we take it into the cauldron of the war and focus it, test it and evaluate it, and then use it many, many, many more times than the civilians have. And then whatever spits out in the end is better,” said Army Col. John Holcomb, commander of the U.S. Army Institute of Surgical Research.
At the Balad hospital, Air Force Maj. Paul “Chip” Gleason, 35, of Springboro, Ohio, heads orthopedic surgery. Advances in body armor protect the abdomen and upper chest of soldiers. But the legs, arms, faces and lower abdomens remain vulnerable to bullets and explosions. Orthopedic surgeons stay busy. In surgery, Gleason uses a small digital camera to record images for future lessons. A key task is recognizing and removing dying tissue eviscerated by bullets or shrapnel. Dead tissue can cause infection.
Because of endless opportunities to examine torn flesh, “I’ve noticed a steady progression in my ability to judge what’s viable, what’s living and what’s been too damaged,” Gleason said.
Back in the USA, experts such as Andrew Pollak, an associate professor of orthopedics at the University of Maryland School of Medicine, said the knowledge gained in Iraq will prove priceless.
“If you see these injuries in numbers of one and two, you never gain any experience,” Pollak said. “When you do a high volume ... you can teach people what works and what didn’t work.”
Air Force Lt. Col. David Powers, 42, of Louisville, is a facial surgeon at Balad. He already has helped publish a guide based on his experience treating the wounded. One lesson: Hold off on surgery until three-dimensional models of the face can help guide doctors on what lies beneath the damage.
A medical journey
From the moment the sniper shot Mundo in a market in Ad Duluiyah, his world changed rapidly. After the five-minute helicopter ride to Balad and almost two hours in surgery, he was recuperating.
By 5 a.m. the next day, he was strapped to a litter and loaded onto a C-17 aircraft headed for Germany.
The Air Force’s system of using specially configured aircraft to move thousands of casualties from war zones almost daily is another crucial innovation. The technology didn’t exist during Vietnam, the last war in which large numbers of casualties were routinely evacuated to the USA. In those days, doctors typically waited up to six weeks for patients to become stable enough to complete the trip home, said Dale Smith, a professor of medical history at the Uniformed Services University of the Health Sciences in Bethesda, Md.
Now, because of new treatment methods and technology on the aircraft, the most critically injured patients can make the trip in a few days. “They’ve really thought about this very carefully, no wasted moments, no wasted movements,” Judge said of the military. “It’s very, very focused.”
He and others say the long-distance air evacuation process -- with its speed and flying care centers -- would prove invaluable should a terrorist attack or natural disaster overwhelm local medical facilities, as happened with Hurricane Katrina last year. After Katrina, hundreds of patients from flooded hospitals were moved to other cities by Air Force medical crews. The White House investigation into the hurricane recommended that disaster response plans better integrate military air evacuations.
Rather than try to re-create in Iraq or Afghanistan sophisticated hospitals such as Landstuhl, the military has built smaller field hospitals where patients are treated and stabilized. Doctors in Iraq now leave many wounds open and vacuum-sealed with plastic. That also was not possible in Vietnam. “Now the sickest of sick patients can get on that airplane,” said Air Force Maj. Timothy Woods, a general surgeon at Landstuhl.
A hospital in the sky
On a recent C-17 medical evacuation flight from Balad to Landstuhl, 32 patients rested comfortably, many of them in litters stacked three high on aluminum racks. Among them: burn patients; an amputee; soldiers with broken bones, a shoulder sprain and back injuries; one with a blood disorder; two psychiatric cases; and a servicemember stricken with lung cancer. Two in critical condition were hooked to ventilators.
Like flight attendants, the nurses, medical technicians and doctors circulated throughout the plane, offering water, oxygen and medication to relieve the pain. They also kept a close eye on monitors.
“The civilians are always amazed at how we do this,” said Air Force Reserve Maj. Ken Winslow, 49, a flight nurse from Issaquah, Wash.
About 65 hours after he was shot — and after a stop in Germany — Mundo arrived at Andrews Air Force Base near Washington. From there, he headed to Walter Reed.
“It was great because I didn’t really feel like I needed to be that far away from home. I wanted to get here to Walter Reed and start doing my rehab,” he said.
Within eight days of his return, Mundo had been reunited with his daughters, JoLyne, 3, and Shania, 1, and flew home to Colorado. The two girls had lost their mother, Rachel, to lupus in November, just days before their father shipped out for Iraq. In his absence, Mundo’s sister-in-law, Jessie Mundo, cared for them.
The children were thrilled to see him and curious about his wound.
“I didn’t want to tell them about the sniper or anything,” Mundo said. “As far as they know, it was just a nice little doctor’s shot.”
Contributing: Paul Overberg, Robert Davis, Liz Szabo in McLean, Va.