Military medics combine ultramodern and time-honored

methods to save lives on the battlefield

http://www.washingtonpost.com/wp-dyn/content/article/2010/10/16/AR201010
1602974.html?wpisrc=nl_cuzhead.

By David Brown
Washington Post Staff Writer
Sunday, October 17, 2010; 1:14 AM

FORWARD OPERATING BASE WILSON The first sign this isn't a routine pickup
is the rhythmic right and left banking of the helicopter.

It's the kind of thing kids do on bikes to feel the thrill of heeling
over. Only this is done to make the aircraft a less easy target.

At 6:09 p.m., Dustoff 57 has just left this base deep in

Taliban-infiltrated Kandahar province, headed for a POI, or point of
injury. On board are two pilots, a crew chief and a flight medic, as
well as two litters for carrying the wounded and numerous black nylon
bags stuffed with ultramodern medical gear and some of the oldest
lifesaving tricks of the battlefield. That combination of new and old -
of specially developed porcelain-powder gauze and old-fashioned
tourniquets - is key to keeping gravely wounded soldiers alive in the
minutes before they get to the hospital. It's also the basis of evolving
frontline strategies that may eventually trickle down in modified form
to civilian ambulances, emergency rooms and trauma centers in the United
States.

Somewhere ahead of the aircraft is a soldier who minutes earlier stepped

on an improvised explosive device, the signature weapon of the wars in
Iraq and Afghanistan. All the helicopter crew knows is that he's
"category A" - critical.

The sun is down but there is still a little pink in the western sky.
Beneath the helicopter, the ground is made of what the troops call "moon
dust." Fine-grained and dry, it is a color not as dark as dirt and not
as light as sand.

The aircraft weaves over compounds enclosed by mud walls and surrounded
by fields of grapes and vegetables. Farther away on the sere,
unirrigated plain are the domed tents of herdsmen, their cooking fires
glowing like terrestrial stars.

The trip out takes nine minutes.

The helicopter lands, stirring up a cloud of moon dust that nearly
obscures six soldiers kneeling and standing around the wounded man, 50
feet from the aircraft. Their headlamps make tiny blue searchlights. The
28-year-old flight medic, Sgt. Cole Reece, runs toward them.

Cpl. Deanna Helfrich, 22, the crew chief, climbs out of her window and
walks around the nose of the aircraft trailing a communication cable
that allows her to talk to the rest of the crew. She stands near the
open door where the wounded soldier will be brought, holding her rifle.

The weapon is a reminder: The crew is here to save lives, but Rule 1 of
the Basic Management Plan for Care Under Fire is: "Return fire and take
cover."

There is no enemy fire this evening, but there is so much dust in the
air and the rotors are spinning so fast that the leading edges of the
blades light up like sparklers, flint on steel.

Fifteen minutes have now passed since the soldier was wounded. The
details of how it happened don't matter to Reece. There are a limited
number of things he can do between this nameless spot and the hospital
at Kandahar Airfield, where they will soon be headed. What he needs to
know he will see and feel for himself.

Speed, simplicity and priority have always been the hallmarks of

emergency medicine. The new battlefield care that flight medics like
Reece and others on the ground practice takes those attributes to the
extreme.

Gone from their repertoire are difficult or time-consuming maneuvers,

such as routinely hanging bags of intravenous fluids. On the ground,
medics no longer carry stethoscopes or blood pressure cuffs. They are
trained instead to evaluate a patient's status by observation and pulse,
to tolerate abnormal vital signs such as low blood pressure, to let the
patient position himself if he's having trouble breathing - and above
all to have a heightened awareness that too much medicine can endanger
the mission and still not save the patient.

Four people run to the helicopter with the stretcher holding the wounded
soldier. He lies on his back partially wrapped in a foil blanket. His
chest is bare. In the middle of it is an "intraosseous device," a
large-bore needle that has been punched into his breastbone by the medic
on the ground. It's used to infuse fluids and drugs directly into the
circulatory system when a vein can't be found. It's a no-nonsense
technology, used occasionally in World War II, that fell out of favor
when cheap and durable plastic tubing made IV catheters ubiquitous in
the postwar years. Until they were revived for the Iraq and Afghanistan
wars, intraosseus devices were used almost exclusively in infants whose
veins were too small to find.

On each leg the soldier has a tourniquet, ratcheted down and locked to
stop all bleeding below it. These ancient devices went out of military
use more than half a century ago because of concern that they caused
tissue damage. But research in the past 15 years has shown that they can
be left on for two hours without causing permanent harm to limbs. Now
every soldier carries a tourniquet and is instructed to put one on any
severely bleeding limb and not think of taking it off.

Tourniquets have saved at least 1,000 lives, and possibly as many as

2,000, in the past eight years. This soldier is almost certainly one of
them. They're a big part of why only about 10 percent of casualties in
these wars have died, compared with 16 percent in Vietnam.

On the soldier's left leg, the tourniquet is above the knee. Both bones
below his knee are broken, and the limb is bent unnaturally inward. The
tourniquet on his right leg is lower, below the knee; how badly his foot
is injured is hard to tell from the dressings. His left hand is splinted
and bandaged, too.

Whether he will need an amputation is uncertain. The hospital where he's

headed treated 16 patients in September who needed at least one limb
amputated. Half were U.S. soldiers, and the monthly number has been
climbing since March.

The man is covered in moon dust, and pale beneath it, but conscious and
able to pay some attention to Reece. He's gotten 10 mg of morphine, not
a lot.

First thing, the medic hooks a plastic tube to an oxygen tank and leans
forward and puts a face mask on the soldier's head. He tells him over
the din of the engine that he'll be okay, that they'll be at the
hospital in 10 minutes.

After three minutes on the ground, the helicopter takes off.

Staunching the blood

The interior of the helicopter is lit by a single overhead light,

headlamps and the glow of instruments. Reece tells Helfrich to check the
tourniquets; things sometimes move in transit. He then pulls back the
foil blanket and inspects. A tangle of dry grass lies directly over the
soldier's navel.

The medic sees that a laceration in the soldier's left groin is still
bleeding. This, too, is a signature wound of the two wars - a deep,
dangerous injury just outside the protective veil of body armor and
unable to be treated with a tourniquet. It's a wound from which a person
can easily bleed to death. Death from blood loss has always been the
greatest hazard of war wounds.

A recent analysis found that of soldiers deemed to have "potentially

survivable" wounds, 80 percent died of bleeding. Usually the wound site
was a part of the body where a tourniquet couldn't be applied.

The best option - not ideal - is to stuff the gash with Combat Gauze, a
battlefield treatment new to the current wars. It's a bandage
impregnated with a kind of powdered porcelain that stimulates clotting.
The medic on the ground had already packed the wound with it. Reece
unwraps some more, lays it across the injury and asks Helfrich to apply
direct pressure.

He undoes the Velcro sleeve of a blood-pressure cuff and puts it on the

soldier's right arm. He puts three stick-on EKG leads on the man's chest
and abdomen, a right triangle. The man reaches up and touches his
forehead, a self-confirming gesture. When he's done, the medic gently
takes the hand and puts on the ring finger the toothless plastic jaws of
a pulse oximeter - a device that measures the oxygen content of the
blood through the skin. The soldier has lost a lot of blood. If his
breathing falters and he can't oxygenate what's left, he will die.

The first blood pressure reading is 96/40. Normal is 120/80. The

soldier's heart rate is way over 100, but the exact number is
irrelevant. Nobody who's just had something blow up in front of him has
a normal heart rate even if the blast has done nothing to him.

Every minute or so, Reece puts his right hand, which is in a black
rubber glove, onto the soldier's head and rubs the center of his
forehead. This is to stimulate him and gauge his level of consciousness.
It may also reassure.

The pulse oximeter gives a reassuring reading. Several minutes into the
trip the medic senses the soldier becoming drowsy and inserts a green
plastic tube into his left nostril. This "nasopharyngeal airway" will
make it easier, if the man becomes unconscious, for Reece to keep him
alive.

While blood pressure somewhat below normal is considered all right - and
even preferred - in severely injured patients, a diminishing level of
consciousness is not a good sign.

Reece reaches for a 500-milliliter bag of Hextend - an intravenous fluid

containing starch molecules that help boost blood pressure by preventing
the watery part of blood from leaking out of vessels, as often happens
in massive trauma. He squeezes the bag to make it run in more quickly
through the device in the soldier's breast bone.

The soldier's next blood pressure reading is 116/71.

Just two minutes away, Reece leans forward and tells the patient they're
almost there.

Communication glitch

Eleven minutes after lifting off from the POI, the helicopter lands at
the so-called Role 3, or fully equipped, hospital at Kandahar Airfield,
about 30 miles to the east of the also well-fortified Forward Operating
Base Wilson. There, surgeons will take care of the injuries before
transferring the patient, probably within two days, to the huge military
hospital in Landstuhl, Germany, and there, after a week or so, to the
United States.

But something has happened in the usually smooth communication between

dispatch center, aircraft and hospital. No ambulance pulls up to the
helicopter. Reece and Helfrich wait.

They wait.

The pilots radio the dispatcher that they've arrived with a critically
injured soldier. Reece and Helfrich, helmeted and inaudible, gesture
wildly to people outside the emergency room door to come over.

Two other patients have also recently arrived. But that's not the
problem. There's an available ambulance 100 yards away. But it doesn't
move.

Five minutes after touchdown, it finally drives up and the injured man
is rushed into the back. Reece says later he was one minute from having
the crew carry the patient to the emergency room themselves, even though
running that distance with a trauma patient on a litter is just about
the last thing you want to do.

It's been 28 minutes since the helicopter left Forward Operating Base
Wilson. The ambulance, with Reece in it, disappears into a pool of
greenish light at the hospital entrance.

In 10 minutes, the medic returns and the helicopter takes off to begin
the refueling, restocking and cleaning that will make it ready, in less
than an hour, for the next call.

It's for an Afghan man, described as a Taliban fighter, who has stepped
on a land mine.