The New Veteran

Anyone who has watched the news in the past year has seen the “human interest” stories regarding veterans who return from Iraq. Many of you may wonder, as I have, what this will mean for the type of patients we see during our VA rotations.  I read with great interest two recent articles published in the New England Journal of Medicine. I also had the opportunity to speak with our residency coordinator who is also a colonel in the Kansas Army National Guard, and who currently is deployed to active duty.

As of February 9, 2005, a total of 12,314 service members have suffered war injuries. Of this number, 1,448 died, 1,110 were killed in action, 5,681 were wounded in action and unable to return to duty, and 5,190 suffered less severe injuries and were able to return to duty within 72 hours. These figures represent the greatest burden of casualties our military medical personnel have seen since the Vietnam War.

The true story of this war, from a medical perspective, is the survival rate of our soldiers and the changes that have occurred within the military’s medical system that allows a greater survival.  In World War II, 30 percent of Americans injured in combat died. In Vietnam, the number decreased to 24 percent, and in the Iraqi war 10 percent have died.

The survival rates have changed in large part due to how the military medical system has adapted to the mobile and agile needs of ground troops. Initial triage is provided by Forward Surgical Teams (FSTs), which consist of 20 people who are equipped to move directly behind troops with the ability to establish a functioning hospital (that includes four ventilator-equipped beds and two operating tables) within 60 minutes.  The teams have sufficient supplies to evaluate and perform surgery on as many as 30 wounded soldiers. Surgeons plan for two hours or less of surgical time per patient prior to shipping the patient to a Combat Support Hospital (CSH). These hospitals are also modular units and can be fully functional within 24-48 hours. The maximum length of stay at a CSH is intended to be three days. Soldiers who require additional care are sent to a Level IV hospital (the primary Level IV location is in Landstuhl, Germany).  If the soldier requires more than 30 days of treatment, they usually are transferred to Walter Reed Army Medical Center or Brooke Army Medical Center.  Soldiers then are referred to the Community Based Health Care Operation (CBHCO), where they are connected with a case manager and a physician administrator. This program allows soldiers to return home and live with their families, but remain on active duty with work accommodations for their injuries. The soldiers then are cared for within an HMO-type system, and are assigned to a primary care physician who provides needed referrals.

There is no doubt that this system has had a great impact on survival. The average time from battlefield to arrival in the US is now less than four days. In Vietnam, it was 45 days. This means that soldiers are rapidly transitioned to state-of-the-art medical facilities to receive the best care available. Survival has also been greatly enhanced by the use of body armor. However, with the protection of body armor, a soldier survives what would have been a fatal wound, only to be faced with severely mangled extremities.

As of November 2004, 203 US soldiers had undergone major amputations in Iraq or Afghanistan. These soldiers are receiving state-of-the-art prosthetics including prototypes not yet available commercially. Upon transition to the VA system, they can expect the same level of expertise and care.

Perhaps an even bigger impact will be the number of musculoskeletal problems that will require physiatric input and management. Large numbers of active duty soldiers are from the Army Reserve and National Guard. These are soldiers who went from training one weekend per month and two weeks during the year to full-time active duty, carrying heavy packs and equipment under difficult conditions. These soldiers are a prime target for degenerative arthritis, soft tissue trauma, and various musculoskeletal injuries.

Physiatric expertise will undoubtedly play an important role in the continuum of care once these soldiers return from the war. Many of these men and women will be affected by their injuries on a physical and emotional level for years, if not for the rest of their lives. For those of us who have observed the war on television, treating these men and women will make the war painfully real. Our measure of success will be the ability to help them return as productive and fully functioning members of society. 

Linda Ladesich, MD, MS

University of Kansas Medical Center

lladesich@kumc.edu

Gawande A. Notes of a Surgeon:  Casualties of War – Military Care for the Wounded from Iraq and Afghanistan. New England Journal of Medicine. 2004;351:2471–2475.

Peake JB. Beyond the Purple Heart – Continuity of Care for the Wounded in Iraq. New England Journal of Medicine. 2005;352:219–222.