From Iraq—Back to Iraq: Modern combat orthopaedic care

From Iraq—Back to Iraq: Modern combat orthopaedic care

By Carolyn Rogers

At the “From Iraq—Back to Iraq” symposium on Friday, a panel of military traumatologists focused on the challenges and results being achieved with today’s modern orthopaedic techniques.

Improved treatments, but more severe injuries

Improvements in body armor and armored vehicles, intense training of U.S. military personnel and advances in medical care have given wounded soldiers a better-than-ever chance of survival.

The likelihood of surviving battlefield wounds was 69.7 percent during World War II, but had risen to 76.4 percent by the end of the Vietnam War. Today, the likelihood of survival for those wounded in the current Iraq War has increased to an astounding 90.4 percent.

Still, the extremity injuries coming out of Operation Iraqi Freedom and Operation Enduring Freedom have been devastating.

COL Roman A. Hayda, MD

Challenges unique to war trauma surgery

“Blast wounds and high-velocity missile wounds are very complex,” said Roman A. Hayda, MD, who served as moderator.

Approximately 70 percent of war wounds are musculoskeletal injuries; 55 percent are extremity wounds. Fractures account for 26 percent of injuries, and 82 percent of them are open fractures.

Tissue loss and a high degree of contamination are extremely common. Contamination and soft tissue injuries caused by improvised explosive devices (IEDs) require a more aggressive treatment approach than for most gunshot wounds.

Regardless of the magnitude of trauma, explosive injuries are qualitatively different from gunshot wounds, are associated with much greater loss of muscle and bone. The most mutilating wounds are caused by explosives—predominantly IEDs.

The fact that these injuries take place in an austere and dangerous environment, with limited resources, only adds to the challenge.

Injuries are being successfully treated using a specific protocol of treatments, reported the panel, including surgical debridement, leaving all wounds open, early fracture stabilization, broad-spectrum antibiotics, and rapid evacuation to higher levels of care.

Five echelons of care

Orderly and rapid evacuation from the war zone to definitive level of care is a critical component in providing state-of-the-art care to the wounded, said Dr. Hayda.

“Our ability to get these guys out of the field, cared for, and back home has dramatically improved with this war, which has been unlike any other conflict,” he said.

“Evacuations are very quick,” added James R. Fricke, MD. “We can get a patient back to the United States in 16 hours now.”

Wounded soldiers typically advance through the following five echelons of care:

  1. Battlefield care—“buddy aid” and combat medics
  2. A. Battalion aid station, where a physician provides resuscitative care or advanced trauma life support B. Forward surgical team, a highly mobile, austere surgical team that provides life and limb-saving care for injuries too severe to survive transport to the combat support hospital
  3. Combat support hospital—A theater-deployed mobile hospital with limited subspecialty and ICU care that prepares patients for long-distance transport
  4. Fixed facility at intermediate point of evacuation
  5. Definitive care facility—Military hospitals that are staffed and equipped to provide convalescent, restorative and state-of-art rehabilitative services (e.g, Walter Reed Army Medical Center)

Battlefield care: Damage control

Front-line hemorrhage control techniques include self-applied tourniquets, which are seen as effective and safe ways to prevent fatal limb exsanguinations on the battlefield.

“Twenty healthy volunteers from the U.S. Army Institute of Surgical Research tested seven different self-applied tourniquets. The study found that three tourniquets completely eliminated distal Doppler flow in both the upper and lower extremity,” said Michael T. Mazurek, MD.

Windlass or pneumatic compression is essential. In addition, battlefield care requires strict adherence to the principles of extremity damage control:

  • Stop the bleeding
  • Remove the contaminations
  • Restore the blood flow
  • Stabilize fractures
  • Don’t burn bridges for the next guy

“This is very rewarding work” said Romney Andersen, MD. “They’re true American heroes and they’re very motivated to rehabilitation. I don’t know how many times I’ve heard a soldier tell me he wants to get back because his buddies need him.”

“Extraordinary” amputee care

Military amputees often have additional conditions, including additional fractures, infections, nerve injuries and other soft-tissue injuries. Even so, says H. Michael Frisch, MD, “We’ve see extraordinary advances in amputee care treatment. Today’s prosthetic technology has helped countless patients return to independent living. Amputees are now able to run golf, ski, kayak, water ski, and participate in combat training as well as triathlons.”

To achieve such remarkable results, rehabilitation is vital. Outcomes are determined more by aggressive and comprehensive rehabilitation programs than by surgery. Quick evacuation can also help avoid circular amputations. Most importantly, noted the panelists, amputees should not be isolated. Rehabilitation teams are essential; with them, there is no limit to what amputees can accomplish.

Center for the Intrepid

Dedicated on Jan. 29, 2007, the Center for the Intrepid is “the most advanced rehabilitation facility in the military, and arguably in the world,” said Dr. Fricke. The Center for the Intrepid is a world-class state-of-the-art physical rehabilitation facility for wounded warriors at Brooke Army Medical Center in San Antonio, Texas. The four-story, 60,000 square foot center includes clinical space, a military performance lab with a gait lab and computer assisted rehabilitation environment, a pool, an indoor running track, a two-story climbing wall and prosthetic center. The center will provide amputees and those with severe extremity injuries the best opportunity to regain their ability to live and work productively.

“We’re most proud of the CAREN—the Computer Assisted Rehabilitation Environment,” Dr. Fricke said. “The CAREN is central to the research mission of the center.” CAREN is a 21-foot dome with a 300-degree screen upon which a variety of “virtual realities” may be displayed. This simulator is the first of its kind and holds much promise for the rehabilitation of patients.

Amputees: Back in action

“Amputation does not equal discharge,” said Dr. Frisch, who discussed current concepts in amputee care. Not that the amputees themselves want to be discharged. “These guys are sometimes hard to slow down,” he said.

About 60 military amputees have returned to active duty and 10 have actually been redeployed to the battlefield. The first amputee to return to the battlefield—Army Major David Rozelle—was present at the symposium and shared some of his experiences in Iraq, in rehab, and back to Iraq. “Our men were able to conduct these missions because they know if they’re injured they’ll be cared for by these great military surgeons sitting here at this table,” he said.

“It was a great honor to be first guy going back to the same battlefield where I was injured,” he said, but admits “it wasn’t easy” wearing a prosthetic leg in combat and dealing with the heat and sand. Maj. Rozelle, who commanded 150 men in combat, lost his right foot in an anti-tank mine explosion in Iraq.

Losing his leg made him more determined than ever to be the kind of leader that motivates soldiers by example.

“I’ve become a spokesperson for the recovery process,” he says. “I tell these guys that they need to ‘hit recovery hard’ and set goals for themselves.”

Maj. Rozelle set, and met, a number of goals for himself. Just one year after he lost his foot, he was declared “fit for duty” and returned to command. His next stop was back to Iraq. Within three years of his amputation, Rozelle qualified for the Iron Man Triathlon in Hawaii.

“People need to understand that neither the amputees nor the able-bodied soldiers are ready to quit just because they’ve been injured. They want to come back and join their units in combat—and in a combat role. With modern science, that’s a possibility,” said Maj. Rozelle.

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