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Treating the trauma of war

In Iraq, the devastating wounds suffered by soldiers stun even the most experienced doctors.

By SUSAN ASCHOFF
Published June 23, 2005

TAMPA - A week after he arrived in Iraq, trauma surgeon Donald Jenkins was introduced to the devastation only war can wreak on a human body.

A mortar hit 3 feet in front of a 20-year-old airman on his way to the restroom. The capricious direction of the blast left the man untouched above his waist and below his knees. His thighs and right hand were "pulverized."

"He's dying," thought Jenkins, a lieutenant colonel in the Air Force, when the patient arrived at Air Force Theater Hospital at Balad Air Base, about 40 miles north of Baghdad.

He lived. Three amputations and 12 hours later, the airman was on a plane to the military hospital in Landstuhl, Germany.

Jenkins spent six months in Iraq in late 2004 and early 2005. None of his extensive emergency room experience at home in Texas could prepare him for the savagery of war's assaults.

"As a surgeon, you cannot imagine the amount of tissue destruction a soldier or Marine can sustain and arrive alive," he says.

Mangled limbs. Missing jaws. Blinded eyes. Vaporized bone.

The difficulty of Jenkins' surgical cases is testament to the high survival rate in Iraq and Afghanistan. The ratio of wounded to killed is about 7.5 to 1 - higher than in any other major war. Officials credit body armor, swift evacuation of the injured and advances in battlefield medicine. From blood-clotting powder to C-141s transformed into flying intensive care units, medical care in the war is the equal of a level one trauma center at a major city hospital.

Jenkins is chief of trauma services at Wilford Hall Medical Center at Lackland Air Force Base in Texas. He recently spent a morning with resident medical students at Tampa General Hospital, and also spoke on lessons in trauma care learned through his military experience for the dean's lecture series at the University of South Florida.

Originally slated for a specialty in urological surgery, Jenkins was sent on the invasion of Panama in December 1989 and tasked with triage. Trauma surgery, he decided then, was the "ultimate military physician's job."

"I went from gentlemanly duty taking care of senior officers' prostates to bullet wounds."

Within two weeks of the 9/11 attacks, Jenkins traveled with a mobile, 10-bed hospital dispatched to an unidentified country to care for troops invading Afghanistan. "We spent two months in a black box," he says. There was no communication with family. The team set up a tent and took care of all casualties until additional personnel arrived.

At Balad Air Base, the hospital consists of about 30 tents with 325 staffers and departments mirroring a bricks-and-mortar facility: operating rooms, intensive care, lab, X-ray, pharmacy and evacuation station for transporting patients. It is part of a 15-square-mile "city" called Camp Anaconda, the largest Army supply center in Iraq. Within its perimeter are more than 20,000 military and civilian personnel, four dining halls, two swimming pools, a movie theater and a Burger King.

Those with a darker sense of humor call their home "Mortaritaville." On average, 10 hit the base every day.

When new medical personnel arrive, those they are replacing stay on for a five- to seven-day "handover" on how wartime medicine is practiced.

"We leave our egos at the door," Jenkins says.

Even the most experienced surgeon is unprepared for wartime injuries. "When we compare photos (of injuries) in Vietnam to Iraq, Vietnam looks like World War II." Vietnam is the conflict a generation of military doctors studied before Operation Desert Storm almost 15 years ago and now Operation Iraqi Freedom.

"We knew what it was supposed to be like," Jenkins says. "We didn't know what it was like."

More than 500,000 troops were deployed to Kuwait and the Middle East for Desert Storm in 1991 in the United States' first major conflict in more than 20 years. The rapid movement of people and equipment, officials feared, would leave medical care behind. In Iraq, the invasion launched in March 2003 was also characterized by a rapid push to Baghdad.

Surgeons would have to travel light and fast as well. A "hospital" may arrive in a trailer pulled behind a Humvee and loaded with 5,000 pounds of medical supplies, from operating tables to ventilators. Set up in a 16- by 32-foot tent, the operating room can take patients within hours.

Mobile surgery, Jenkins says, is part of a continuum of care, from the medic on the battlefield to occupational therapy and counseling in the United States. Each branch of the military has its own version of that continuum.

In addition to speedy, sophisticated medical care, Jenkins and others give much of the credit for an estimated 25 percent decline in combat death over the past 50 years to body armor: Kevlar helmets and vests with ceramic plates which protect the brain and vital organs from shrapnel and some bullets.

"The only U.S. guys we saw who weren't wearing it were in the shower," he says.

In Iraq and Afghanistan, researchers have learned that although helmets protect against penetration, the concussive power of blasts may be causing brain injury. Neck injuries suffered from shrapnel prompted work on a helmet extension that would hang from the back for further protection. Kevlar vests have proved effective, but when a gunner's arms are raised atop a vehicle, his chest is exposed through the armholes. An additional piece similar to football shoulder pads has been devised that raises with the arms.

Before each surgical team finishes its stint at Balad, it builds on the quality of care, Jenkins says. "We came up with 17 things we wanted to do differently for infection control." Airplane hangar paint was applied to bare concrete floors and plastic coverings devised for canvas tent walls so surfaces can be scrubbed and disinfected. "Every day's a dust storm," Jenkins says, so they put a filtering system on the operating room air-conditioning system.

With their Army colleagues, they experimented with wound vacuum machines, used to prevent infection before skin grafting. When patients arrive, tissue too damaged to survive is excised as well as "the dirt, clothing fragments, flak" from an explosion, Jenkins says. Typically wounds are not closed because of the threat of infection. With a new vacuum protocol, he says, wounds could be sutured. There was only one infection in 400 patients.

Surgeons, he admits, are notorious for poor bedside manners. They focus on the problem, Jenkins says, not the person. He operated on 1,300 patients while he was in Iraq. About half of them were Iraqis: security workers, members of the Iraqi National Guard, citizens the local hospitals were not capable of treating. The hospital had translators, but communication in an emergency is universal, Jenkins says. A squeeze of the hand, a reassuring nod.

Soldiers would look into his face, seeking the confidence that could save them. That was enough.

The airman who lost both legs and his right hand, who unknowingly introduced Jenkins to the battlefront, is walking on protheses, goes skiing and has married.

"Almost everybody has a strong will to live," Jenkins says, "particularly if you're 20 years old."

- Susan Aschoff can be reached at 727 892-2293 or aschoff@sptimes.com

[Last modified June 22, 2005, 09:06:02]