Combat injuries: A matter of life and death

Orthopaedic surgeons play a crucial role in the care of active duty military personnel according to a Forum article in the April 2009 issue of The Journal of Bone and Joint Surgery (JBJS).

Surgical teams are providing treatment as soon as possible after injury, thereby saving lives and helping injured personnel obtain optimal function.

Author Capt. (Dr.) Dana C. Covey, orthopaedic surgeon from Naval Medical Center San Diego, says, "Most military personnel who die from combat trauma do so because they bleed to death. If they live through that first golden 15 minutes, they often gain another two or three critical hours. Consequently we try and get patients to our forward surgical teams as soon as possible."

"Many medical advances have been made during wartime, because it stimulates research and experimentation with new ideas. These advances play a role in survival and optimal function in people who are injured." For instance, the basis for the U.S. regional trauma center system came out of the Vietnam War. "Many advances in orthopaedics have evolved because orthopaedic surgeons are integrally involved in the treatment of those personnel with war wounds," noted Dr. Covey.

Orthopaedic surgeons are highly skilled at repairing the limb injuries that comprise approximately 70 percent of combat injuries. Those injuries are typically caused by high-energy weapons and are highly damaging to bone and soft-tissue. Injuries caused by explosive devices are common in Iraq and often combine penetrating, blunt, and burn injuries.

In Iraq, nine out of 10 wounded service members survive. This highest survival rate in history is probably the result of multiple factors including:

• Rapid medical evacuation
• Improved training of corpsmen, medics and other frontline personnel
• Close proximity of highly trained medical teams in far-forward field hospitals
• Improved body armor with ceramic plates
• Improved vehicle armor
• Devices to detect explosives

Small, highly mobile surgical units are being placed far forward on the battlefield to provide expedient treatment known as tactical surgical intervention. Surgical and intensive care advances have centered on improvements in the ability to stop bleeding and decrease infection. The following medical factors are helping the armed services treat wounded personnel:

• Recombinant factor 7, a genetically engineered blood clotting factor.
• Tourniquets are issued to all Marines, soldiers, airmen, and sailors on patrol, so they can be rapidly applied to injuries.
• Damage control surgery techniques to stabilize severely injured patients.
• Improved training of corpsmen and medics in treating traumatic injuries.

Another military innovation is the practice of moving casualties through a string of medical facilities with increasing expertise. Damage control orthopaedics, such as rapid amputation and fracture stabilization, is being done at the far-forward field hospital before the wounded service member is transported for systemic stabilization with blood and fluids to an ICU-equipped facility. A service member is transported from the field to a more advanced facility for additional surgery in Germany within 12 to 48 hours and eventually to the United States for rehabilitation. During the Vietnam War, this transport took an average of 45 days.

"In addition, the rapid helicopter transport that began in Korea and improved in Vietnam allowed for much greater success in the earlier repair of extremity vascular injuries compared with the methods of World War II," concluded Dr. Covey.