Lessons from Afghanistan and Iraq: The Costly Benefits from the Battlefield for Emergency Medicine

Abstract

Whatever the geopolitical implications of the Iraq and Afghanistan wars may be, and despite their horrific costs in lives, limbs and dollars, the conflicts hold 2 undeniable and positive truths for emergency physicians: Emergency medicine has benefited from the American war effort, and the victims of those war-torn regions have benefited from emergency medicine. The lethality of war wounds in both Iraq and Afghanistan stands starkly lower than any other conflict in US history, and that is due at least in part to improved emergency medical care. At the same time, a new generation of emergency physicians and trauma surgeons has gained valuable experience with severe trauma, learned lessons that will improve civilian care, and gathered casualty data that will assess the value of new medical treatments and devices. “It has made me a better physician, no question,” said Dr. Brad Younggren, an emergency physician who worked as a Squadron Surgeon with Stryker team in Iraq from September 2004 to September 2005. “You see such a large volume of penetrating trauma. When you’re a resident, the vast majority of trauma is blunt trauma. We see gunshot wounds, penetrating shrapnel, and the sheer volume improves your skills in that regard.” Emergency medicine and war have had a symbiotic relationship for more than half a century. During World War II advances in front line trauma care— such as blood transfusions, resuscitation and rapid transport of injured soldiers to field hospitals—were lessons brought back to nascent US emergency departments. Despite these advances, according to the Department of Defense, 30% of the wounded died—more than any conflict since the Civil War. Such was the price of one of the first truly mechanized wars. Immediately after World War II in 1946, Congress passed the Hill-Burton Act. It provided federal funding for hospitals with a number of restrictions, one of which was that any facility built with the federal money must include an emergency department. In part because of the advent of helicopter evacuations, the lethality of war wounds in Korea and Vietnam fell to about 25%. This innovation was partially translated into civilian medicine, with the creation of modern emergency medical THE RISE OF EMERGENCY MEDICINE Since the Vietnam War, emergency medicine has become a full-fledged academic discipline, with significant advances in care for patients with severe trauma. It is perhaps no coincidence, then, that the lethality of war wounds in Iraq and Afghanistan has fallen to 10%. “The presence of emergency physicians and other physicians in the field has dramatically changed survival rates,” said Dr. Linda Lawrence, a colonel in the United States Air Force and the Chief of Medical Staff at Travis Air Force Base in California. “In all military services, significant revamping of the operational medical mission has resulted in the presence of life-saving treatment being readily available for all troops even at the front of the battlefield. Add the advanced treatment options available and sophisticated critical care air transport, and the outcomes are remarkable. Many valuable lessons can be learned from military emergency medical care that can hopefully be adapted for use in the civilian community.” Emergency physicians in Iraq and Afghanistan have had ample learning opportunities. As a squadron surgeon, Younggren supported between 400 and 800 troops, spending much of his time at aid stations and combat support hospitals in northern Iraq. Though his days varied, they almost always included sick calls for US troops and Iraqis. Often he would join soldiers in his squadron to support their missions. “We took fire, there were the IEDs, all that kind of stuff,” said Younggren, a Major. “Providing care under fire is definitely a whole other way to practice medicine. But with that being said, a majority of time the casualties were being brought to us.” There frequently were mass casualty events. Younggren recalled an event during early April 2005, in Tall Afar, a violent city of 250,000 about 40 miles from the Syrian border. A large bomb exploded near a bus carrying Iraqi soldiers who were returning from a week’s leave. The insurgency’s bomb killed at least 3 and wounded nearly 4 dozen soldiers. Such events—requiring rapid decisions in large triage areas with 40 to 50 injured soldiers—are simply not seen in civilian care, he said. Who should MEDEVAC first from the aid station to a combat support hospital? Which of the bloodied patients could wait? Decisions must be made in minutes, often without the benefit of consulting a colleague.