Army Teams Face Surgeon Shortage

Esther Schrader
LA Times
8 December 2004

WASHINGTON _ A severe shortage of surgeons in Iraq has left U.S. Army medical teams in the country scrambling to handle the largest number of casualties since the Vietnam War, the New England Journal of Medicine will report Thursday.

Despite the numbers _ the Army has fewer than 50 general surgeons and 15 orthopedic surgeons in Iraq at any one time _ advances in battlefield surgical techniques and care mean a greater percentage of soldiers wounded in Iraq and Afghanistan are surviving their injuries than in any previous American conflict.

The article by Atul Gawande, an assistant professor at the Harvard School of Public Health and a former senior health advisor to the Clinton White House, paints a picture of a military medical system that has made fundamental changes since the Persian Gulf War in 1991. But that system is nonetheless overwhelmed by the scope and severity of injuries among troops in Iraq.

Blast injuries from suicide bombs and land mines are up substantially in recent months and have proved particularly difficult to treat without risking infection, Gawande writes. Eye injuries have caused blindness among a dismaying number of soldiers. And Kevlar body armor, which early in the war proved dramatically effective in preventing torso injuries, provides inadequate protection against bomb blasts.

Soldiers who survive the initial blasts and field treatment are suffering at high rates from later complications, including pulmonary embolisms and deep venous thrombosis, the article states. Some of those soldiers have died of the complications. According to the article, 5% of the wounded being treated at Walter Reed Army Medical Center in Washington have had pulmonary embolisms, a condition in which a blood clot travels to the lungs. Of those, two have died.

Army medical teams are also worried about what Gawande calls an epidemic of multi-drug-resistant bacterial infection in military hospitals. Among 442 medical evacuees seen at Walter Reed, 8.4% tested positive for the infection _ a far higher rate than ever seen among wounded troops. "Just as the rest of the military structure was unprepared for the length of the war and the evolution in the nature of the war, so has the military medical establishment been understandably unprepared for that," Gawande said in an interview.

"What is striking is that they have been able to adapt in ways that allow them to keep a high rate of survival for the soldiers," he said. "But there are costs, and what you see is a potential problem on the horizon."

Dr. Michael Kilpatrick, deputy director of deployment health support with the Pentagon's office of health affairs, acknowledged that Army surgeons working in Iraq have had to improvise in some cases, and work outside their specialties in others. But he said that the relatively few number of combat deaths proves the system is working. "There are certainly going to be times in any location where the workload is going to exceed the personnel present. There are going to be some extremely long hours at times," Kilpatrick said. But, he added, "the fact that they have responded as well as they have speaks to the fact that they were well prepared. You can't anticipate every eventuality. I think the training and preparation that people had has stood them in good stead."

With just 120 general surgeons on active duty, the Army has been forced to use urologists, plastic surgeons and cardiothoracic surgeons to conduct general surgery on soldiers in Iraq. Many surgeons have been deployed for more than two years in Iraq, and military planners are contemplating pressing some to return again, Gawande writes. The doctors work in difficult circumstances. In many cases, the military has taken over Iraqi hospitals, and the facilities are flooded with a surge of civilian patients that doctors are unable to treat.

With no clear directive from the Pentagon on treating civilians, some doctors refuse to help even pediatric patients, for fear the children could be booby-trapped with bombs, Gawande writes. Despite the challenges, Gawande also credits nurses, anesthetists, helicopter pilots, other transport staff and an entire rethinking of the combat medicine system for soldiers' survival.

The system focuses on damage control, not definitive repair, Gawande writes. Field doctors carry "mini-hospitals" in Humvees and field operating kits in backpacks so they can move with troops and do surgery on the spot. They limit surgery to two hours or less, often leaving temporary closures and even plastic bags over wounds, and send soldiers to one of several combat support hospitals in Iraq with services like labs and X-rays.

The strategy seems to be working. Although at least as many U.S. troops have been wounded in combat in the Iraq war as in the Revolutionary War, the War of 1812 or the first five years of Vietnam, 90% are surviving their injuries, compared to 76% in Vietnam. In that war, almost all of the wounded who died did so before they could reach MASH units-military surgery facilities _ some distance from the fighting.

But the survivors today often have injuries so severe and maiming that their prospects are uncertain, Gawande writes. Gawande writes about the case of an airman who lost both legs, his right hand and part of his face. "How he and others like him will be able to live and function remains an open question," Gawande writes.

Citation: Esther Schrader, "Army Teams Face Surgeon Shortage," LA Times, 8 December 2004.