Wall Street Journal

19 September 2014

U.S. News

Are U.S. Soldiers Dying From Survivable Wounds? Despite Advances in Care, the
Military Failed to Save Some Troops in Iraq and Afghanistan From 'Potentially
Survivable' Wounds

By
Michael M. Phillips

A U.S. Army soldier receives medical assistance after being injured by an explosive in
Afghanistan in 2012. Agence France-Presse/Getty Images
In an unassuming building in suburban Washington, a team of military medical specialists
spent six months poring over autopsies of 4,016 men and women who had died on the
battlefields of Iraq and Afghanistan.

They read reports from the morgue at Dover Air Force Base, where bodies arrived in flag-
draped coffins. They examined toxicology reports. They winced at gruesome photos of
bullet wounds and shredded limbs. In each case, the doctors pieced together the evidence
to determine the exact cause of death.
Their conclusion would roil U.S. military medicine: Nearly a quarter of Americans killed
in action over 10 yearsalmost 1,000 men and womendied of wounds they could
potentially have survived. In nine out of 10 cases, troops bled to death from wounds that
might have been stanched. In 8%, soldiers succumbed to airway damage that better care
might have controlled. "Obviously one death or one bad outcome is too many, but there
are a lot of them," said one of the researchers, John Holcomb, a former commander of the
U.S. Army Institute of Surgical Research.

How Enemy's Tactics Can Alter Fatality Rate

The findings appeared in the Journal of Trauma and Acute Care Surgery in 2012 to
almost no public attention. But in military medical circles, they have fueled a behind-the-
scenes controversy that rages to this day over whether American men and women are
dying needlesslyand whether the Pentagon is doing enough to keep them alive.
Indeed, a new internal report concluded that the military still hasn't fully adopted
battlefield aid techniques that could have kept many wounded men alive in Afghanistan.
Some of those techniques have been used to great effectand with little extra costby
elite commando units, such as the Army Rangers, for more than a decade, say active-duty
and retired military trauma specialists.

In response, the Defense Department points to steps it has takenincluding putting

nurses and blood-transfusion equipment on medical-evacuation helicopters. "I would
argue that particularly the primary lifesaving components" of the latest casualty-care
guidelines "are readily implemented across the theater," said David Smith, deputy
assistant secretary of Defense for force health protection and readiness.

But Dr. Smith did say that the wider military hasn't uniformly implemented the lessons
learned from elite units and that the Pentagon was working "to remove that variation." He
said the agency was still examining the internal casualty-care report from Afghanistan.
The report, completed in May but not widely circulated outside the military, was
conducted by a medical-research team that visited 26 front-line clinicsand found that
only one had fully implemented the latest guidelines.
Lt. Col. David Marcozzi, a trauma doctor, left, shows a flight medic where to insert a
chest-decompression needle during a training session at Bagram Airfield in Afghanistan.
Michael M. Phillips/The Wall Street Journal

According to the report, for instance, though tranexamic acid is approved by the military
as an anti-bleeding agent, more than 90% of aid stations in Afghanistan reported they
didn't put it in medics' kits. Only two-thirds possessed junctional tourniquets, new tools
used to stop hemorrhaging for injuries too close to the victim's trunk for normal
tourniquets. Just 12% of medics carried ketamine, the painkiller now recommended
because, unlike morphine, it doesn't cause a drop in blood pressure or breathing.
Shortcomings in battlefield care among regular troops may cause "the increased killed-in-
action, case fatality rate, and preventable deaths seen in conventional forces when
compared with special-operations forces," the report concluded.

Military doctors say bureaucratic issues have stalled efforts to fully implement the most
successful battlefield care techniques. The Pentagon has generals in charge of dentistry,
nursing and veterinary care, but no single general is in charge of care for wounded
soldiers before they reach a surgeon's table. In fact, front-line first respondersmostly
Army medics and Navy corpsmentake orders from combat commanders who are likely
to be infantry, tank or artillery officers, not from the military's top doctors.
"Right now there is nobody in charge of pre-hospital medicine in the U.S. military, so
there's not one person that can make the decisions that can effect change in the military as
whole," said Army Col. Russ Kotwal, a special-operations doctor.
Military officials say they are working to fix the situation and cite examples of their
efforts to improve battlefield medicine. As early as 2005, military doctors urged soldiers
to apply tourniquets immediately to a serious bleed in an arm or leg, reversing a previous
policy, which recommended their use as a last resort. The shift is believed to have saved
as many as 2,000 lives.

In 2006, Central Command, which oversees U.S. forces in Afghanistan and the Middle
East, incorporated updated casualty-care practices in its guidance for training battlefield
first responders. The Navy says all of its corpsmen, who treat wounded Marines in
combat, are required to be trained on the latest techniques. But a Navy spokesman said
the service doesn't track compliance with the requirement.

In November last year, U.S. Marine Gen. Joseph Dunford, then-commander of allied
forces in Afghanistan, ordered use of the junctional tourniquets. In February, he ordered
that nasal ketamine replace morphine as the primary battlefield pain killer. In March,
Gen. Dunford ordered medical personnel in the war zone to "maintain proficiency" in the
latest battlefield-care techniques.

"We certainly have room to improve, and we're pursuing those improvements right now,"
said Col. Mark Mavity, command surgeon for Central Command. He said his staff is
seeking ways to "decrease the variance in compliance" with the latest casualty-care
guidelines.

Trauma doctors say many of the military's efforts have come too late. Thirteen years after
the Sept. 11 attacks, the latest drugs, gear and techniques are still used inconsistently by
medics in the field, and by doctors at lower-level aid stations. "There is frustration from a
lot of us in military medicine," said Brian Eastridge, an Army colonel who specializes in
trauma care and who headed up the research team for the 2012 study on deaths from
survivable wounds.

The uproar over battlefield medicine dates to 1993, when two Black Hawk helicopters
were shot down during a botched U.S. special-operations raid in Mogadishu, Somalia.
Robert Mabry, then an Army Delta Force medic, landed at the site of one of the downed
helicopters and worked under intense fire to rescue two surviving crewmen. One bullet
went through his pants pocket; another grazed his fingers.

At the time, military medics employed civilian techniques. Dr. Mabry, now a lieutenant
colonel specializing in trauma care, realized that "taking civilian first aid based on car
wrecks and trying to apply them to a gunfight was not really smart." Army medics, for
instance, were taught to put braces and spinal boards on patients with suspected neck
injuries, even as bullets were flying.

The Battle of Mogadishu left 18 Americans dead, including six Army Rangers, and
served as a wake-up call for Dr. Mabry and a generation of special-operations doctors.
Led by former Navy SEAL Frank Butler, they developed the first wartime Tactical
Combat Casualty Care guidelines in the mid-1990s. The guidelines are regularly updated.
The Civil War was the first American war in which the military set up an entire tiered
medical system. National Archives

In the late 1990s, former Gen. Stanley McChrystal, at the time a colonel and commander
of the 75th Ranger Regiment, ordered his men to adopt the new techniques. The Rangers
put them to the test in Afghanistan and Iraq. On more than 8,000 missions between 2001
and 2010, the Rangers lost 28 men on the battlefield, but not one had a wound he could
have survived under any circumstances, according to a 2011 paper by Dr. Kotwal.

It was an achievement unmatched in the history of major wars, doctors say, and brought
battlefield medicine into closer alignment with the military's success in treating troops at
surgical hospitals behind the front lines. There, it has recorded a survival rate of greater
than 95%, according to military data. That outcome is a combination of medical success
and the likelihood that many of the worst injured died before they reached a surgeon.
The Rangers' story suggested to Dr. Eastridge and others that the military could save lives
by focusing on the minutes immediately after an injury takes place.

Dr. Eastridge knew the research itself would be hard going. Several colleagues who had
previously performed autopsy reviews declined to participate; they knew the pictures
would be too graphic. "Many of those images lie in wait and present as the stuff of my
nightmares to this day," said Dr. Eastridge.

The team spent months debating whether the wounded could have pulled through had
they received better treatment or whether they were doomed from the moment they were
hit.

The doctors chose a liberal definition of survivability, categorizing an injury as

"potentially survivable" if it had taken place close to a major U.S. trauma center. The
researchers knew they would be counting some injuries as survivable when, in fact, the
soldier could well have been too isolated, or in a situation too dangerous, to receive
lifesaving care.

"Maybe somebody bled out because they didn't get a tourniquet, but the reason might
have been he was lying out on the battlefield while there was a firefight going on and they
couldn't get to him," said Staff Sgt. Michael Smith, a combat medic and member of the
team that produced the new report on trauma care in Afghanistan.
Dr. Eastridge's researchers deemed 76% of the battlefield injuries non-survivable; most
were catastrophic head wounds, dismemberments or heart injuries. Another 24%, though,
were potentially survivable, the researchers found. The study set off alarm bells. It was,
doctors said, the most extensive look into the actual causes of death in war. And it
suggested conventional forces aren't consistently applying the latest techniques for
controlling bleeding and clearing airways.

In part, the problem reflects decades of military focus on big stateside hospitals, which
tend to the ordinary health needs of troops and their families at home. When a crisis
occurs, the military pulls family practitioners, obstetricians and pediatricians, among
others, from these hospitals to serve at the front lines, rather than trauma specialists, who
are generally posted to surgical hospitals further back.

"We hadn't really focused attention in the pre-hospital arena"the front lines"as much
as we focused our attention on the hospital levels of care," said Col. Mavity, the Central
Command surgeon.

Rapid change, military doctors say, would require orders from the very top of the
Pentagon. The precedent many cite is then-Defense Secretary Robert Gates, who in 2009
ordered that all wounded in Afghanistan be evacuated to a hospital within one hour of
their injuries. The military shifted doctors and helicopters to make that happen, and now
air evacuations usually take less than 45 minutes.

"The leadership is not engaged to solve the problem" of potentially preventable combat
deaths, said Dr. Holcomb, one of the researchers, who served in Somalia and Iraq before
leaving the military in 2008.

Dr. Smith, at the Defense Department, disputed that, and the May report detailing care in
Afghanistan did praise some steps commanders have taken: The military has equipped
medevac helicopter crews with blood-transfusion capabilities and has approved use of the
bleeding-control agent, tranexamic acid. The Army now puts critical-care nurses aboard
medevac flights, a move that has reduced deaths in flight by two-thirds, according to
researchers.

If an autopsy review were conducted today, Dr. Smith "is confident the number of
potentially survivable deaths would be lower due to the dramatic learning that has
occurred on the battlefield since 2001," the Pentagon said in a written response to
questions about the military's performance in battlefield care.

Still, trauma doctors worry the military will return to managing domestic hospitals and
forget what it has learned about battlefield medicine, especially once with U.S. leaves
Afghanistan.

President Barack Obama has announced that, should the next president of Afghanistan
agree, he will reduce the U.S. troop presence to 9,800 at the end of the year, down from
some 100,000 at war's peak.

Frontline care, doctors say, will be vital when the U.S. finds itself sending smaller units
into smaller conflicts, where it won't have the extensive evacuation and hospital networks
it maintains in Afghanistan and once had in Iraq. On those scattered battlefields, a
wounded man will likely have to wait longer before reaching a surgeon. What the medic
does when he is injured may determine whether he lives long enough to do so.

"We're putting people back in Iraq," said Dr. Holcomb, referring to Mr. Obama's recent
decision to insert American special-operations troops to advise Baghdad in its campaign
against radical Islamists. "We've got people in Africa. This fight is just changing theaters
and perspectives. In some sense it may be harder now than in Iraq and Afghanistan."