Attrition: The Bright Side Of Tragedy


August 27, 2010: The fighting in Iraq and Afghanistan has produced another few hundred highly experienced surgeons, a phenomena that has repeated itself for centuries. Wars provide a large number of casualties, troops who can often only been saved by some daring surgery. All this changed dramatically during World War II, when the introduction of antibiotics not only greatly reduced the deaths from infections, but allowed surgeons to attempt surgery more often, not just when it was either that, or the patient would die. The problem with surgery had always been the risk of infection, but antibiotics like penicillin, changed all that. After World War II, surgery was revolutionized, as the combat experienced surgeons, now possessing skills they could never have acquired in civilian practice, or would have required decades to do so, developed many new procedures.

The current crop of combat surgeons arrived despite the fact that there were far fewer combat casualties than in past wars. The most notable change was the sharp drop in the number of American combat dead. The combat death rate in Iraq was a third of what it was in Vietnam and World War II. With the dramatic drop in combat deaths, came another big shift. In World War II, a third casualties were fatal. In Iraq and Afghanistan, only 12 percent of the casualties were fatal.

But there were still a lot of troops being hospitalized. Like most of the wars in the last century, only a small percentage of the casualties in Iraq and Afghanistan were directly by combat. Most casualties were from non-combat causes. During the peak period of combat (2004-7) in Iraq, 34,000 American troops were evacuated out to obtain more advanced care elsewhere (U.S. military hospitals in Europe and the United States). That was about six percent of the troops who were there during that period. Most of those who were sick or wounded were not evacuated (minor injuries were treated and the patient returned to duty), meaning that nearly 15 percent of the troops were sick, injured or wounded while in the combat zone.

Those evacuated had the most serious conditions, and the most common (24 percent) was muscular problems (including back pain and repetitive stress). Next came combat injuries (14 percent). Then came neurological problems (10 percent), psychiatric problems (9 percent) and spinal pain (7 percent). The rest (36 percent) consisted of a wide variety of problems (infections, respiratory problems, gastrointestinal, pregnancy, tumors, and hormonal problems.)

A lot of the illness related problems had to do with the different mixture of microbes in the region. This produces the same array of problems tourists encounter when they visit someplace quite different from home. A major source of injuries was traffic accidents, and the stress of carrying heavy weights (usually by the infantry, but supply troops and engineers also suffer from this).

Those troops who were injured in combat, tended to come in bunches, which is where the surgeons and their staffs got all that experience. Many of the injuries were similar to what surgeons encountered in an emergency room (car accidents, falls, burns). But roadside bombs presented unique injures that surgeons rarely see. Same with many other combat injuries. Emergency room doctors often see gunshot wounds, but not multiple gunshot wounds, plus injuries from explosions. Dealing with this is where new treatments are developed, often on the spot, in response to a unique (for civilian medicine) situations.

The war has also led to improved treatments for stress related problems. During this period, for every soldier killed in combat, at least one was sent back to the United States because of severe PTSD (post-traumatic stress disorder), and several others are treated in the combat zone for less severe cases. During World War II, PTSD was an even more serious problem. In the European Theater, 25 percent of all casualties were serious PTSD cases, compared to about 20 percent today. In the Pacific Theater, the rate varied widely, depending on the campaign. In some of the most intense fighting, like Okinawa in 1945, PTSD accounted for over a third of all wounded. In Iraq, less than ten percent of the wounded are PTSD, but the more troops serve in a combat zone, in combat jobs, the more likely they are to develop PTSD. This has been known for over a century.

The last decade has also demonstrated how important it is to provide treatment to the seriously injured quickly. So about one in ten troops outside the wire (outside a base) is trained and equipped to deal with massive bleeding, which was a major cause of death in past wars. New tools and treatments enabled these troops, who were often not trained medics (although they were trained) to provide treatments only doctors or nurses could handle two decades ago.




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