Cheating grim death
Lightning-fast treatment is the key to success
LANDSTUHL, GERMANY--"Mom, is that you? I'm alive."
When Pat Coleman heard those words in a midnight phone call, she knew her son had been wounded in Iraq.
David Coleman, a 20-year-old Marine lance corporal, was calling home on a satellite phone to Butte, Mont., from a hospital in Baghdad. He didn't know how badly he was injured. Only later would he learn that he'd nearly bled to death, that the improvised explosive device that ripped open his armored humvee on September 23 had shattered both his legs, and that he had only a fifty-fifty shot at not having his right leg amputated. At that point, the young marine knew only that he was about to be evacuated to the Landstuhl Regional Medical Center in Germany and that everyone said if you made it to Landstuhl, you were going to be OK.
"I remember everything, like a movie," Coleman said from his bed at Landstuhl four days later, his eyes wide and black from anesthesia three hours after surgery to clean his wounds. "Boom! There was dust. There was smoke. People were screaming, 'I'm hit! I'm hit!' " Blood was pouring out of his boot. Coleman remembers hearing someone say, "He's got 10 minutes before the shock kills him" and realizing that the guy was talking about him . "There was blood everywhere." Less wounded buddies carried Coleman to another humvee for the drive to a medevac helicopter and a short flight to a forward surgical team. Surgeons stopped the bleeding; then Coleman was ferried to a combat support hospital at Asad Airfield, where doctors performed emergency surgery to stabilize his legs. After spending the night in Baghdad, Coleman was strapped to a litter and loaded onto a C-141 transport plane to Germany. He arrived barely 36 hours after the IED shredded his humvee and had been in Iraq just 10 days. "I'm the first soldier from Montana to be injured," he said, with a dazed smile. "I wanted to be a part of Marine Corps history. And now I am."
Better stats. Landstuhl is the first step in the long journey home for David Coleman and the nearly 9,500 other soldiers who have been wounded in Iraq and Afghanistan. Unbeknown to them, they are part of a great experiment in military medicine. Soldiers today are far more likely to survive battle than in any other war in American history. In World War II, 1 in 3 casualties died. Even in the relatively bloodless 1991 Gulf War, 147 were killed in battle, 467 wounded in action. In Iraq and Afghanistan, however, 98 percent of those wounded have survived. "Mortality is down about 22 percent" compared with the first Gulf War, says Dale Smith, chairman of medical history at the Uniformed Services University of the Health Sciences. He credits better protection for soldiers, as well as improved medical care. "It's phenomenal progress, at phenomenal expense."
As more soldiers come home with physical injuries and mental health problems, it becomes increasingly clear that survival has other, greater costs. The nation's healthcare system for veterans is already overburdened, and federal officials and veterans groups fear the country won't fulfill its promise to care for its wounded soldiers for the rest of their lives.
During the Vietnam War, it could take a wounded soldier a month to make it home for treatment. Iraq is different, partly because it's an urban battlefield and partly because the military has radically retooled its system of treatment and evacuation. "We have to provide fast, flexible medical care," says Lt. Col. Slobodan Jazarevic, a vascular surgeon at Landstuhl who is returning to Iraq to head the 44th Medical Command. "There are no lines of battle. The battle is fought everywhere."
Badly wounded patients like Coleman are quickly flown to Landstuhl and spend three to five days there before being shipped to the States. The very ill move even faster. "The biggest change in military medicine in the past 10 years has been the CCAT s [critical care air transports]--flying ICU s," says Air Force Col. Kory Cornum, an orthopedic surgeon who commands the 86th Medical Squadron at Landstuhl. Cornum recently operated on a patient who was in the intensive care unit at Walter Reed Army Medical Center in Washington, D.C., just 36 hours after being badly wounded in Iraq. "Our country's the only country that can do that," Cornum says. "Not the only country that can but the only country that will."
At Landstuhl, a hospital that had become a snoozy Cold War relic is back in full war mode; more than 20,000 patients have arrived from Iraq and Afghanistan since the wars began. After the battle in Fallujah began, on November 8, the hospital took in 455 patients in a week. When the call goes out on the hospital PA system that a plane from downrange is "wheels down" at nearby Ramstein Air Base, staff members start lining up gurneys outside the emergency room door. The critically ill arrive first, by ambulance; their CCAT teams wheel them directly to intensive care or an operating room.
24-7. More-stable patients like Coleman are carried off buses on litters. Those with bad backs and other less pressing health problems--the "disease nonbattle injury" cases, which make up the bulk of troop loss in any war, far more than from enemy fire--walk off the bus themselves and are handed a list of their doctor appointments and a phone card so they can call home. The traffic is choreographed in the Deployed Warrior Medical Management Center, a fancy name for a handful of modular offices in the parking lot outside the ER. There, doctors, nurses, and dispatchers work 24-7, monitoring an online database where their counterparts in the Middle East list the incoming wounded--multiple trauma from a vehicle rollover, abdominal pain, amputations. Says Capt. Monabell Vamvas, a triage nurse and reservist from Glendale, Calif.: "I know every person on that flight."
If the rapid evacuations are one of the big medical success stories of this war, another is improved body armor, which physicians credit with much of the reduced death rate. Flak jackets have been used for decades, but even in the 1991 Gulf War, they weren't capable of stopping high-velocity rifle rounds. Now they do. "It is also different because soldiers wear it," says Army Col. David Burris, a trauma surgeon and interim chairman of surgery at the Uniformed Services University of the Health Sciences. "It's thrilling. I'd much rather prevent an injury than fix it."
But the vests don't prevent all injuries. Because arms and legs aren't protected, extremity injuries like Coleman's now account for some 70 percent of battlefield wounds. Surgeons say the damage is comparable to a catastrophic machinery accident back home. At least 152 soldiers have had limbs amputated; the number of traumatic brain injuries is also up. But it's as yet impossible to tell if those injury rates have increased, partly because the number of survivors has risen, skewing the statistics, and because the Army is compiling its trauma registry from paper records. One wounded soldier could have records at three or four places in Iraq and could arrive at Landstuhl with medical records and X-rays on his Army blanket or with no records at all.
Simple solutions. Surgeons say the use of new fast-clot bandages and better tourniquets and access to fresh whole blood are helping to keep severely wounded patients from bleeding to death. The fact that trauma teams trained together at civilian trauma centers back home helps, too, according to Col. John Holcomb, commander of the Army Institute of Surgical Research. But sometimes even a simple solution can help. Soldiers were suffering devastating eye injuries from shrapnel, but doctors realized such injuries could be prevented if the soldiers wore sunglasses with shatterproof polycarbonate lenses, such as WileyXs. "Most of the injuries were from people who got sweaty and took their glasses off for one second," says James Burden, one of four ophthalmologists at Landstuhl. Once the Army distributed posters with gruesome injury photos, the sunglasses stayed on. Says Burden: "We've seen injuries drop dramatically."
The patients are also changing battlefield medicine. Forty percent of the troops in Iraq are National Guard and Reserve, who are older than active-duty soldiers and more likely to have heart problems or back trouble. "A fair number of reservists and National Guard were activated with cataracts," says Burden. "Once they go into theater with the bright sunshine, they started complaining of problems. We fix them up and send them back."
For seriously wounded soldiers like Coleman, the next step on the journey home is a military hospital stateside. Because he's a marine, Coleman wound up in the National Naval Medical Center in Bethesda, Md. His parents took unpaid leave from their jobs to be at his bedside. Coleman spent the fall undergoing surgery and fighting off a staph infection, making the slow progression from hospital bed to wheelchair to, finally, a walker. "I can wiggle my toes!" he exclaimed last week, two months after shrapnel from the IED tore into his legs. His right leg is no longer in peril. His new calf, which surgeons built out of muscle grafts from his abdomen and skin grafts from his flank, flexes as if it had always been there. But he still has a long way to go; at least one more surgery for bone and nerve grafts, then lengthy physical therapy. On his bedside table, on top of his laptop, lies an application for veterans' disability benefits. "I'm torn right now," he says of the decision ahead--to try to stay in the Marine Corps or seek a medical discharge and use his benefits to go to film school. "If I can do the job I came into the Marine Corps to do, then I want to go back. I'll have to see what they say."
The path from military medicine to the Department of Veterans Affairs, which is charged with providing care to the nation's 24.7 million veterans, is, all too often, no simple stroll down easy street. The Defense Department and the VA have separate medical systems and separate medical boards that determine soldiers' eligibility for benefits. Efforts are underway to remove some of the roadblocks. The VA now has representatives at 136 military installations, including Landstuhl and Bethesda. The Pentagon has a new program, the Disabled Soldier Support System, with 10 counselors around the country. The VA and the Pentagon are working on a two-way electronic medical records system, which VA Secretary Anthony Principi says will be in place next year. Since 1998, the departments also have been trying to establish one-stop medical exams that would work for both military discharge and veterans benefits. Just this month, the Government Accountability Office reported that four of eight single-exam programs touted by the VA didn't exist and that the military often diverted funds for the project to healthcare for active-duty soldiers.
Returnees from Iraq and Afghanistan are guaranteed two years' free healthcare by the VA. Veterans groups give the VA high marks for quality of care; over the past decade it has pioneered patient-safety programs like computerized prescription entry, considered vital for reducing medical errors. But the system faces increased demand. Enrollment has risen from 4.8 million to 7.6 million since 2001. "The VA is not ready for an influx of new veterans," says Rep. Lane Evans, ranking Democrat on the House Veterans Affairs Committee. "It is managing by rationing healthcare services."
Last year, in an effort to stretch the dollars, the VA eliminated healthcare benefits for vets who make more than about $30,000 a year; the agency has also proposed increasing user fees. And although the VA has cut the wait for an initial primary-care visit down to 30 days for most patients, it can take months to see an eye doctor or oncologist. "Often the appointment to see a specialist is 10 months to a year," says Cathy Wiblemo, deputy director for healthcare for the American Legion. Principi says it may take six months to see an orthopedist for a hip replacement, "but I'm not sure that's that much different than the private sector."
When his long convalescence is over, David Coleman isn't sure where he will be headed. But last week he got some great news: The Marine Corps decided he'd be better off recuperating at home in Montana for 30 days before his next surgery. As soon as the paperwork is done, Coleman will be headed for the airport. He says: "I will be home for Thanksgiving."
Battle wounds
Causes of injuries to Army troops wounded in action and evacuated to military hospitals.
Iraq
Improvised explosive devices 31.6 pct.
Shrapnel 18.9 pct.
Gunshot 15.5 pct.
Other 34 pct.
Afghanistan
Gunshot 25.5 pct.
Blast 20.4 pct.
Land mines 14.3 pct.
Other 39.8 pct.
Source: U.S. Army Medical Department
USN&WR
With Elizabeth Querna, Susan Brink, Angie Cannon, Marianne Szegedy-Maszak, Daniel Gilgoff, Carol Susan Hook, Jennifer L. Jack, Nancy L. Bentrup, Allegra Moothart, Ann M. Wakefield, Jill Konieczko and Monica M. Ekman
This story appears in the November 29, 2004 print edition of U.S. News & World Report.