New York Times
January 7, 2011
In Wider War in Afghanistan, Survival Rate of Wounded Rises
By C. J. CHIVERS
KHAKREZ DISTRICT, Afghanistan — Intensified fighting and a larger troop presence in Afghanistan in 2010 led to the highest American combat casualties yet in the war, as the number of troops wounded by bullets, shrapnel and bombs approached that of the bloodiest periods of the war in Iraq.
But the available data points to advances in the treatment of the fallen, as the rate at which wounded soldiers who died reached a wartime low.
More than 430 American service members died from hostile action in Afghanistan last year through Dec. 21, according to official data released by the Pentagon last week at the request of The New York Times.
This was a small fraction of those struck. Nearly 5,500 American troops were wounded in action — more than double the total of 2,415 in 2009, and almost six times the number wounded in 2008.
In all, fewer than 7.9 percent of the Americans wounded in 2010 died, down from more than 11 percent the previous year and 14.3 percent in 2008.
The fatality rate declined even though many more troops patrolled on foot, exposing the force to greater dangers than in years past. Several doctors said the improvements came not from a single breakthrough but through a series of lessons learned over nearly a decade of fighting two wars, such as placing medevac helicopters closer to the fighting and the more extensive use of tourniquets.
Although fatality rates for wounded Afghan troops are not similarly available, doctors involved in their care said hospital records showed that they trail those of Western troops by a few percentage points, but have also fallen.
Several soldiers and those who care for them framed the improved survival rates as the grimmest sort of success. Many more troops — some missing multiple limbs or their genitals, or suffering brain damage — are being rescued from near death. But their wounds will be exceptionally difficult to overcome later as they try to resume work, and social and family lives.
Along with interviews with medics and military doctors, and a month spent by two journalists from The Times observing the collection and immediate treatment of troops suffering from a wide range of trauma, the data shows the results, in broad terms, of an evolving contest for wounded soldiers’ fates.
The contest pits a multilayered and expensive effort to keep troops alive against the sharply increased rate at which they suffer grievous injuries, some beyond what any medical system can heal.
A clear decline was evident: In 2005, 19.8 percent of wounded American soldiers died from their injuries. For the past five years in Afghanistan and Iraq, the fatality rates for wounded Americans have otherwise fluctuated between 9.4 and 14.3 percent.
(The data draws from a sample running into the tens of thousands; in 2006 in Iraq, for example, nearly 7,200 American troops were wounded by hostile action, more than 700 of them fatally.)
The statistics further served to reinforce consistent trends in the battlefield’s array of lethal hazards, and offered glimpses of wars within the war.
More soldiers in Afghanistan in 2010 were wounded by explosive devices (at least 3,615, compared to 828 troops reported to suffer gunshot wounds). But the higher fatality rates from gunshot wounds (12.9 percent versus 7.3 percent for wounds caused by bombs) made rifles and machine guns the most statistically deadly weapons.
Rocket-propelled grenades, for all their ferocious reputation, proved less of a threat. They wounded 373 American soldiers, of whom 13 — 3.5 percent — died.
No matter the improved odds, the data, like the field observations, illuminated that even the most determined efforts to cheat death could still be desperate — like the case of an Afghan soldier wounded on Dec. 9.
He was a disoriented young man on a stretcher with his uniform cut away, revealing wounds caused by a makeshift bomb.
His face was mashed. A tourniquet was cinched to his left leg, high by the hip. His abdomen swelled slightly from the bleeding within. From his torso rose the odor of burned flesh and hair.
The man worked with an American Special Forces team. Medics labored over him as the helicopter lifted from the dust, counting minutes in a race against time.
Medical workers attributed his improved chances to several factors, among them changes in training for soldiers who administer first aid, swifter movement of victims to hospitals made possible by more helicopters in the war, and shifts in procedures in operating rooms.
Equipment has also been a factor, including heavier armored vehicles more resistant to explosives and fire-retardant uniforms and gloves — two factors doctors and soldiers say seem to have led to a decline in the frequency and severity of burns.
“We have seen fewer burn injuries over all,” said Col. Evan M. Renz, director of the Army Burn Center in Texas, “even as the number of troops in Afghanistan has climbed sharply.”
Doctors said a change in attitude about tourniquets also prevented many deaths. Until a few years ago, they said, tourniquets were often regarded as a measure of last resort, not always applied swiftly to those with severe extremity wounds.
Every soldier now carries at least one tourniquet — some carry several — in their first-aid kits or visibly on their flak jackets. Fellow soldiers apply them immediately. “The liberal use of tourniquets has clearly been a lifesaver,” said Dr. Eric Elster, a Navy commander and director of surgical services at the NATO hospital at Kandahar Air Field.
One doctor, deployed in an area of fighting along the Arghandab River, said medics on patrols had become more proficient at other lifesaving techniques, too.
These include opening airways via tracheotomies, using needles to decompress swollen chest cavities that can collapse a wounded soldiers’ lungs and applying pressure dressing and bandages with clotting agents to areas — the groin, neck or armpits — where tourniquets have little effect
“This is just basic techniques, trained well,” said Lt. Col. Michael Wirt, brigade surgeon for Task Force Strike, a unit of the 101st Airborne Division.
Confidence in the ability to mitigate trauma — including legs shattered or amputated by bombs — has led to a sometimes visible practice that most units discourage: troops who pre-emptively apply tourniquets loosely to their thighs or upper arms before patrols.
“I think potentially that’s a negative,” Dr. Wirt said, adding that it could be read to suggest nervousness, or that such soldiers are too focused on being wounded. “Our command has not endorsed that.”
Part of the willingness to use tourniquets, doctors and medics said, has been related to the speed with which wounded soldiers reach hospitals.
Afghanistan’s harsh climate, combined with a relative dearth of helicopters in years past, often restricted the reach of medevac crews.
With the increased troop presence in 2010, there are now three Army combat aviation brigades in the country, and detachments of medevac helicopters have been moved to small outposts near the fighting — minutes away from many firefights or bomb blasts.
Within a half-hour of being wounded, a large fraction of troops now are en route to hospitals and being tended by flight medics. On repeated flights flown by the two journalists in May, June and December, some wounded soldiers were retrieved within 20 minutes of their injuries. None waited an hour.
The case of the wounded Afghan soldier showed the risks from wounds that battlefield first aid can barely help, and for whom speed might not be enough.
The man lifted his head and gazed down at his ruined body. Blood ran from his rectum. He had little time.
He frantically waved his burned arms, which were so damaged and sensitive that the medics hesitated to start an IV.
Instead, Sgt. Patrick Shultz lifted a small electric drill and cut through the bone below the man’s right knee, creating access into the marrow to administer drugs.
The hospital was not much farther ahead. But it was too late — 30 minutes after arriving, this man was dead.
For patients who reach NATO-run trauma centers, the overall survival rates have approached levels unseen in past wars. The staff said this was in part a result of the accumulated experience of surgical teams in Afghanistan and Iraq, as well as shifts in how patients were treated.
For one example, Dr. Elster and Dr. Wirt said the military had dropped administering saline solutions to patients in favor of what they called “massive transfusion protocols” — giving enormous quantities of blood.
High-volume transfusions aid in clotting and carrying oxygen, and have prevented more patients from dying in the hours after suffering severe wounds, they said.
“It is not unusual for us to give a patient 50 or 100 units of blood in the first 24 to 48 hours,” Dr. Elster said.
At the military hospital in Kandahar, 98 percent of Western troops that arrived alive last year did not die, the staff said.
For Afghans the survival rate was several percentage points lower.
Doctors said there were many reasons, including that most Afghans had not been issued fire-retardant clothing and often traveled in pickup trucks. Unlike vehicles used by American forces, pickup trucks stop neither bullets nor most shrapnel, and are easily blown apart by roadside bombs.
Moreover, Afghan soldiers are often loath to wear protective equipment, including helmets and bulletproof vests.
http://www.nytimes.com/2011/01/08/world/asia/08wounded.html?_r=1&hp
