March 16, 2003 How to Save a Soldier By SEAN FLYNN
No matter how efficient the mechanics of warfare become, no matter how smart the bombs or how accurate the bullets, the process of dying remains grimly constant. An artery, after all, will hemorrhage just as violently whether it is severed by a musket ball or Scud shrapnel. Soldiers, the medical instructors at Fort Sam Houston in San Antonio like to say, have been dying the same way for centuries. But perhaps not as often anymore. ''For years and years,'' says Col. David A. Rubenstein, who commands the Army's Landstuhl Regional Medical Center in Germany, ''if a soldier arrived at a field hospital alive, the odds were greatly in his favor of him staying alive. The problem has always been getting the patient from the point of injury to the field hospital.'' From the instant a man is injured, a clock starts ticking, sweeping through what is called the golden hour. This is the time when most lives are saved or lost, and the Army has been working hard to get better at shepherding wounded men through these critical moments. Compared with even a few years ago, today soldiers are better prepared, better trained and better equipped to survive a combat wound. They carry innovative bandages and tourniquets that can seal off wounds that might have bled them to death in years past. They're evacuated in faster armored ambulances. Most important, they're treated in the field by medics whose training has been revolutionized in just the past 18 months. Indeed, before they're dispatched to their units, young medics will have dealt with dozens of realistic wounds on high-tech mannequins, practice that was impossible when their only patients were fellow soldiers. The 142 human patient simulators at Fort Sam Houston, life-size and about as heavy as a trim infantryman, can be squeezed with tourniquets and jabbed with needles and fitted with airway tubes and IV's and catheters. The wrists and necks and groins throb with an artificial pulse, and mechanized lungs rise and fall, rasp and wheeze. Fake blood squirts from blown-off limbs, mucous and tears stream from chemically burned faces, plastic bones jut from compound fractures. Six of the mannequins even give make-believe birth (important in an era when a lot of the work American soldiers do is humanitarian). Each $37,000 dummy is wired to a laptop computer that monitors vital signs, changes them, collapses a lung, drops blood pressure, skips the electronic heartbeat into one of 2,500 rhythms. It records every time the medic touches the body, what procedure was performed and what effect it had. Sometimes -- most of the time in the early days of training -- the simulators die, which is O.K. Killing a dummy in the classroom is good practice for keeping real soldiers alive. Away from the chaos of battle, in the combat hospitals about 12 miles off the front lines and on the sprawling bases in Europe and the United States, doctors are quite adept at putting maimed soldiers back together. But that doesn't matter in the fleeting golden hour, when a soldier is bleeding through his fatigues and screaming for a medic. ''If they don't save him,'' says Col. James A. Morgan, who's in charge of medic training, ''it doesn't matter how good the care is farther back.'' here's a simulated soldier down, crumpled in the dust in a spread of scrubby woods and stubby hills outside Fort Sam. He has two wounds, bullet holes in his chest and right thigh; his uniform is wet with bottled blood. Pvt. Kaleb Twilligear is the first medic to reach him. He's been out with his platoon searching for mock casualties on a make-believe battlefield, his last day of field exercises. Twilligear and the rest of his class, 317 recruits in all, have been in training for four months, one of six classes rotating through Fort Sam Houston simultaneously. Every two weeks, 400 or so new soldiers arrive from boot camp to train as 91W's -- combat medics in civilian terms, 91 Whiskeys in Army dialect. They're a self-selected group, soldiers who signed up for the job when they enlisted and whose general aptitude tests said they could handle it. Ask any of them why, and you'll get a clipped and curious Army answer: ''To save lives, sir,'' a phrase that can almost never be used to explain a military job. The first thing Twilligear and the rest learned was how to be emergency medical technicians, following the six-week course-work and certification standards from the civilian world. The Army teaches that well: Colonel Morgan, who expanded the glorified first-aid course of the Army's old medic training into the 91W program in 2001, says that 98 percent of his students pass the E.M.T. test. (They get three chances, and if they fail, they'll be reassigned as truck drivers or cooks, which gives them a mighty incentive.) The next thing they learned is that battlefield medicine isn't nearly the same as domestic trauma care. The main difference: civilian E.M.T.'s generally aren't being shot at. The battlefield forces priorities to be reordered, basic protocols to be adapted. That's what Twilligear and his platoon are practicing now, combat conditions. Their immediate task, coming across a hemorraghing soldier in a small clearing, is to secure the perimeter, which is why 17 men flopped onto their bellies in the brush. There are buildings at Fort Sam named for medics who were cut down while tending to comrades, which is heroic but not particularly effective. ''Sometimes,'' says a 91W instructor, ''the best medical care you can give someone in the field is laying down a good line of suppressive fire.'' If the enemy can't be shut down, the wounded man has to be lugged out of the line of fire. This is not done with the gentle rhythm of a domestic paramedic packing up a crash victim. Leaving cover to fetch a buddy is so risky that the Army plans to equip each soldier with a retrieval rope, a synthetic cord with 1,100 pounds of tensile strength that clips to his fatigues. A man who goes down within throwing distance of shelter, assuming he's still conscious, can pitch the loose end to rescuers, then get dragged to safety. The next order of the medic's business, in most cases, is to stop the bleeding. This is different in combat, too. A civilian E.M.T. will almost never use a tourniquet to tie off a hemorraghing arm. In combat, where 67 percent of the wounds are to the limbs, and where a man can linger for hours or days before being evacuated, they are now routine. It has been a hard lesson learned: more than 2,500 soldiers bled to death in Vietnam from injuries to the arms and legs that they could have survived if only they'd had a rag to squeeze off the bleeding. A one-handed tourniquet, in fact, is becoming part of every soldier's standard gear. It's a nylon strap threaded through a clasp in such a way that it can be tightened by tugging on one end, allowing a G.I. to use it on himself. In a firefight, it will not only stop the bleeding; it will also allow the soldier to keep shooting. The mock casualty in the woods near Fort Sam is too badly injured for a tourniquet to do much good. Four medics are pulling at his fatigues, stripping back the damp fabric, searching for the damage. Twilligear and Pvt. Shay McArthur find a pencil-size puncture in the soldier's chest, just below his left clavicle. McArthur lifts the shoulder, reaches under, feels a gaping crater behind the lung. ''I've got the exit wound,'' he says. Pvt. Quinn Grooms yanks down the trousers. He finds the second gunshot wound, the tunnel blown through the thigh. Grooms clamps a hand over the inside of the soldier's groin, trying to squeeze it shut, hold back the blood that's leaking through his fingers. ''I need a dressing,'' he says. The platoon is using standard-issue Army pressure dressings, gauze taped down with an Ace bandage. They're generally effective, but for a wound like this -- an arterial hemorrhage -- won't hold for long. In actual combat, a medic would more likely use one of the new hemostatic bandages: spongy squares about the size of a bathroom tile and made from chitosan, a chemical extracted from the ground-up shells of shrimp and lobsters. They aren't cheap, $90 apiece, but pressed over a wound, they bind like superglue, the chitosan sealing it shut. On an ideal battlefield, a casualty will be evacuated immediately, as soon as he's been pulled from the line of fire and wrapped in bandages. There is no such ideal, of course. Contemporary warfare, with its emphasis on small teams venturing deep inside hostile territory, can make extraction exceedingly difficult. Rescue can be hours or even days away. An article in The Lancet, the British medical journal, recently examined the treatment of American soliders in Somalia, where Special Forces units endured the most ferocious firefight since Vietnam. Some wounded soldiers were trapped for more than 15 hours. From that experience, some basic tenets of combat medicine were rethought. Standard trauma care included pumping intravenous fluids into the bleeding patients, keeping them hydrated and their blood pressure up. But medics carry only about six liters of fluid -- precious little if they're dealing with a half-dozen casualties for a half-day or longer. As it turns out, not every bloodied man needs an IV, and even if he does, he can get by with limited amounts of fluid, as long as his blood pressure doesn't fall enough to drop him into shock. Somalia also demonstrated how rapidly infection can take root. Every G.I. will soon be issued two tablets of gatifloxacin, a general-duty antibiotic that will tide him over for 48 hours, and medics carry intravenous drugs to treat any unconscious casualties. A wide-open battlefield, like the one on which the United States last fought in Iraq, makes ferrying casualties back from the front lines easier. But the last Iraq experience also exposed a drawback -- the ambulances were too slow, lagging almost two hours behind the ground forces. The new Stryker M.E.V. -- medical evacuation vehicle, one of 10 configurations of an entire new class of light armor vehicles -- is designed to keep up. It's unarmed, save for the smoke grenades to provide obscuring cover, and nimble, able to race over rough terrain at highway speeds, and it has a satellite communications system that links it to the combat forces. Only a dozen were scheduled to be in active service by the end of March, equipping the First Brigade, but eventually it will be deployed throughout the Army. A Stryker can take four men out on stretchers, six if they're able to sit up, and it's equipped with enough critical-care gear to stablize a man until he gets to a forward support medical team. It might be tailing a combat unit up to the front lines, grabbing wounded men straight from the field, or it might shuttle between the rear units and the battalion aid station, which is just behind the actual shooting -- ''tailgate medicine,'' one medic says, a way station where soldiers are either patched up and sent back to fight or evacuated to a hospital in the rear. Care gets more sophisticated as wounded soldiers are moved away from the front. The forward surgical teams have five doctors, three nurses and a dozen or so medics. Behind that is the combat-support hospital, the upgraded version of the MASH unit of yore, a sprawling complex of sturdy modular buildings that can go up in a matter of hours yet can handle most battlefield traumas. They're staffed with general surgeons and some specialists -- radiologists, orthopedic surgeons, ophthamologists -- and have enough nurses and support staff to keep up to 297 patients resting comfortably on their last stop in the combat theater. After that, badly wounded soldiers would be transported to a hospital ship or to Europe and, eventually, to the States. Critical patients can be airlifted to Germany via a Nightingale jet, essentially a flying intensive-care unit. The speed with which the modern military can move a wounded man from the field to the safety and advanced care of a European or an American installation is dizzying. Lieut. Gen. James B. Peake, the Army's surgeon general, tells the story of a soldier wounded during Operation Anaconda, a raid on Taliban and Qaeda forces a year ago that dragged on for two vicious weeks. Early in the attack in a remote Afghan valley, a Special Forces soldier was blown out of his helicopter by a rocket-propelled grenade, then shot after he hit the ground. That happened on a Monday morning. A medic patched him until another copter flew him to a combat hospital for emergency surgery. Then he was flown to Incirlik Air Base in Turkey for more treatment, after which he was airlifted to Landstuhl Regional Medical Center in Germany, the pinch-point for the sick and wounded extracted from the European theater (which includes the Middle East and parts of Asia). By Sunday morning, six days and three surgeries after he was hit, the soldier was recuperating comfortably at Walter Reed Army Medical Center in Washington. Private grooms is pressing on the mannequin's pelvis, stanching the blood flow, while Pvt. Caleb Latiolais opens a field dressing. Privates Twilligear and McArthur have patched the chest wound. The four medics have followed the proper A-B-C procedure: they made sure the soldier had an open airway, confirmed that he was breathing, then turned their attention to circulation, that is, where he was bleeding. It's counterintuitive: the reflex is to treat the obvious injuries first, go right to the wet red spots, forget that a man who can't breathe will suffocate before he bleeds to death. But Sim Man has a chest wound, a bullet hole through his left lung. Maj. Daniel St. Armand, who's in charge of medic field exercises, tells the privates to check the breathing again, see if anything else is wrong. McArthur presses his ear to the plastic skin just to the right of the breastplate. There's a faint rasp, and he can feel a slight rise and fall. He shifts to the left side, listens, back to the right, then left again. There's no sound on the left. Sim Man's mechanical lung has collapsed, just as a real soldier's would have. ''I need a needle,'' McArthur says. He has to ventilate the chest, let off some of the pressure building up inside. Latiolais hands him a large-bore needle with a small valve on the end. McArthur cocks his arm and stabs downward, and the steel slips through the skin, right between where two ribs should be. Eighteen months ago, before the Army started using simulators, no medic could have practiced that move: the mock casualties were generally fellow soldiers whose chest walls couldn't be needlessly pierced. Indeed, there was only a patina of realism washed over the training -- fatigues, the concussion of dummy fire, painted-on wounds. Yet no matter how ably a soldier could moan or how limply he could feign unconsciousness, he couldn't fake an erratic heartbeat, say, or a missing limb. ''With the simulator,'' says Major St. Armand, ''I can cut his arm off and have it spurting blood all over the place. Believe it or not, it makes an incredible difference.'' They do that back at Fort Sam. On the second floor of a converted barracks, two shower rooms are stage set as battalion aid stations. Camouflage netting is draped over the tiled walls, the fluorescent lights are dimmed with dark paper, stretchers are positioned over the drains. The mannequin in one has a bullet hole in his right thigh, and most of his left leg is missing. With a few computer strokes, fake blood squirts from both wounds. When the instructors start flashing the lights on and off and crank up the gunfire soundtrack from ''Saving Private Ryan,'' it's as close an approximation to battlefield conditions as anything this side of Kandahar. ''The first time you see that in real life,'' says General Peake, ''the adrenaline flows and you spaz. This gets them over that.'' Most of the 142 simulators aren't in battlefield settings. They're lined up on cots in laboratories, each programmed with different vital stats and injuries. Students work on them round robin, moving from one to the next. Some need breathing tubes inserted, others need tourniquets tightly knotted, others need needles slipped into veins -- all procedures that can't be accurately or easily performed on a live volunteer. As part of their training, medics rotate through Brooke Army Medical Center at Fort Sam for two days, taking pulses and blood pressure and the like, but they certainly never practice a cricothyroidotomy -- puncturing the throat to open an airway -- on anyone. At the battalion aid station, a new crew of four medics is working on the dummy brought in from the field. They're scrambling, disorganized, three of them tying one bandage, no one paying attention to his collapsed lung. On the laptop cabled to his body, the vital signs are dropping. The sergeant monitoring the simulator's laptop computer gives St. Armand a look, raises one eyebrow. ''You want to kill him?'' St. Armand watches for another moment. His jaw is set in a slight grimace. He wants his medics to practice techniques, but he also wants them to learn how real bodies will respond. In actual combat, at a genuine battalion aid station, Sim Man would already be dead. St. Armand nods to the sergeant. ''Kill him,'' he whispers. The sergeant taps the keyboard. The artificial heart stops beating, the mechanical lungs stop rasping. Two medics start CPR, one pressing on the dummy's chest, the other squeezing air through a bag-valve mask. St. Armand lets them work for half a minute, then calls them off. ''Soldier medics,'' he barks, ''that's enough. You've lost him.'' It happens all the time in Texas, dummies dying. ''But that's all right,'' says Maj. Allen Whitford, a 91W instructor. ''They'll kill one of these guys here and get embarrassed. But when they get out there, they'll be ready.'' Sean Flynn is the author of ''3,000 Degrees: The True Story of a Deadly Fire and the Men Who Fought It.'' http://www.nytimes.com/2003/03/16/magazine/16BATTLE.html?ei=5070&en=a211eb8cd79f1b10&ex=1054526400&pagewanted=print&position=top __________________________________ Do you Yahoo!? Yahoo! Calendar - Free online calendar with sync to Outlook(TM). http://calendar.yahoo.com --- SMU-L Vous connaissez quelqu'un desirant devenir membre de la liste du prehospitalier? Demandez-lui d'envoyer un courriel a l'adresse de la liste ([EMAIL PROTECTED]) avec, comme sujet, le mot abonnement et son nom dans le corps du message.
