Combat Medicine’s ‘Golden Hour’

WASHINGTON — While the news swells this week with sad and angry retrospectives on the war in Iraq, it is worth noting that the tremendous human costs of that war would have been much greater, were it not for breakthroughs in combat medicine deployed for the first time on a broad scale in Iraq.

4,486 American men and women were killed in the Iraq war. This represents approximately 14 percent of the 32,221 wounded in action — versus the 19 percent killed in Vietnam, or 27 percent killed in World War II. These statistics are cold comfort for those whose lives were derailed and families tormented in the process, and they are a clarion call to re-double all our efforts to help those who survived.

But these statistics do offer some small succor for a war a large majority of Americans believe should never have been fought.

The jump in the survival rate of servicemen and women wounded in Iraq partially explains two other phenomena initiated with the war in Iraq and accelerated by the war in Afghanistan: the seemingly outsized number of veterans suffering from obvious physical disability — and the seemingly unprecedented profusion of psychiatric illness, mostly in the form of post-traumatic stress disorder, among wounded veterans.

Both phenomena are, paradoxically, the result of good medical news — of our military’s long, steady improvements in combat medicine.

The Iraq war was the first in which military medical units were able to mobilize, on a major scale, a set of aggressive medical and surgical practices all focused on one idea: “the golden hour.” The survival chances for anyone seriously wounded in action escalate dramatically with how quickly he or she is stabilized, medically and even surgically, often on the spot.

Two critical treatment components in the golden hour involve the immediate infusion of drugs: antibiotics to prevent systemic infection from wounds caused by bullets, shrapnel, or fragments from explosives, and steroids to minimize damage to the spinal cord. Research on these drug protocols in normal emergency medical situations in the years leading up to the start of the Iraq war inspired the application of these practices to war zones.

A third component of aggressive treatment inside the golden hour involves the movement of actual surgical teams as close to the action as operationally and humanly possible. The enduring symbol of the Korean war — burned into our national consciousness by the TV show M*A*S*H, really more a harsh critique of the war in Vietnam — was the medical evacuation helicopter, airlifting the wounded to hospitals several miles from the front. By the start of the Iraq war, even these evacuations were too slow, the hospital too far away, the golden hour slipping by.

The result was an expansion of the capabilities of medics in the field, and the movement of actual surgical teams closer to the fire, some actually embedding with advance units. Surgical interventions, practically in the line of fire, may not save limbs, but they do save lives, as we discovered in Iraq.

Literally operating under fire requires unimaginable courage, but in the case of the Iraq war, we do not have to imagine.

On Call in Hell is the harrowing 2007 Iraq war memoir of Navy surgeon, Cdr. Richard Jadick, who received the Bronze Star for Combat Valor for actions detailed in his you-are-there, de facto textbook for placing surgical teams at the bloody edge of combat. Dr. Jadick’s book is one of the few documents of redemption we may ever get from a war fought at great human cost. In it, he draws from his remarkable combat surgical experiences to make several important recommendations about how we select, train and mobilize our nation’s military medical personnel.

While we engage this week in a collective mea culpa about the Iraq war, it is good to remember that from our biggest mistakes — as with individuals, so too with nations — we can learn important lessons.

Yes, 4,486 American sons and daughters were lost in Iraq. But more than 32,000 came home. And as with so many other spheres of medicine in America — like premature birth, organ failure, heart disease, cancer — our systems for taking care of those who survived have become overwhelmed by the task.

This may be a good problem to have — because we were able to save these courageous people – but it is a problem we must solve.

Independent of those mea culpae, and regardless of the final accounting on the purpose, outcome and cost of the Iraq war, we owe these veterans nothing less than full modernization of all systems in place to care for them — as we do for the veterans of the ongoing war in Afghanistan. The reduction of mortality ratio — from 27 percent in World War II, to 19 percent in Vietnam, to 14 percent in Iraq — would constitute a major victory, if we were talking about insured Americans with heart disease or cancer, and we would find billions of dollars in incremental spending to achieve it.

And yet, another statistic about what happens to survivors of combat in Iraq and Afghanistan has become drearily familiar: the fates of too many with traumatic brain injury and untreated or undertreated psychiatric disorders. It is to our great national shame that far more veterans of the wars in Iraq and Afghanistan die from suicide than combat.

In recognition of this tenth anniversary of the start of the Iraq war, it is time to get serious about the diagnosis and treatment of traumatic brain injury and post-traumatic stress disorder in veterans. TBI and PTSD have always been real — but thanks to progress in combat medicine like the golden hour, we now have enough survivors to recognize the problem as the post-war equivalent of an epidemic.

In that same spirit, it is also time to immunize the Veterans Health Administration and all related programs against current political squabbles over federal spending. These programs are not handing out “entitlements” — they are attempting to deliver benefits earned with tears and blood. Our wounded veterans and their families are not takers. We are, from them.

We have always figured out how to send our young off to war, and we are getting better at figuring out how to bring most of them back. We are long overdue at figuring out how to minimize their continued suffering.

J.D. Kleinke is a pioneering health care information entrepreneur, medical economist, author, policy expert, and business strategist.

8 replies »

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  2. Ummm, why is the guy in the operating theatre not wearing a mask? He just contaminated the room!

  3. I hear you, man. Everything about medical care is a blessing and a curse, so why should combat medicine escape this cruel irony?

    We tame heart disease and cancer – so we can discover Alzheimer’s. Progress is a bittersweet pill.

    The best medicine of all is prevention. My prescription: NO MORE WAR.

  4. Had we had Vietnam War era MASH capability, my late dad would likely not have left a leg behind in Europe during WWII.

    Had we had today’s FOB triage Evac/MASH capability during the Vietnam war, we’d have orders of magnitude more vets living today with multiple serious lifelong injuries, with a much lower Vietnam battlefield death rate.

    Dunno, man. The ironies.

    Watch “Restrepo” and read “Outpost.” Years down the line we’ll have even more intractable chronic damage (a lot of it Psych) to deal with — or not.

    My boss is a retired special forces medic. We talk about this stuff a lot.

  5. Worthy of a book, John, not just one essay. This is one more example of how good we are at waging war – and now how good at mobilizing acute care in the warzone – but at how lousy we are at planning for the fallout, be it the occupation of “nations” that are really amalgamations of tribes or the honoring those who make immense sacrifices. The typical VA hospital – a gleaming deployment of high tech medicine and the best EMR out there – is fantastic, but the benefits systems for vets a disgrace. Sound like the rest of the system, times 10, or what?

  6. Nice post JD.

    This is a story I’ve been trying to draw attention to for years.

    But I fear you’ve barely scratched the surface of the story here. Let’s have a follow up looking at the situation at the VA. From what I hear – and I hear a lot – the system is rapidly being overwhelmed by the influx of a new generation of veterans from the wars in Afghanistan and Iraq.

    Throw in the fact that many Vets have the kind of problems we aren’t very good at dealing with – chronic pain, PTSD and other conflict related psych issues, brain injuries caused by roadside bombs and IEDs, way downplayed drug and alcohol dependency problems (different than Vietnam, worse in some ways) and you have a huge huge huge problem that nobody wants to talk about because everybody got tired of talking about these wars about five news cycles ago.

  7. Very good points here; I fully agree. There should be 100% coverage for all veterans health care and cost of war-related health expenses for our nation’s finest. The current realities undermine our nation’s strength by causing doubt about the assurance of care for veterans. You are correct that veterans’ health care is not an ‘entitlement’; it is part of our very identity of being Americans; an intuitive and inherent right of these people. One possible move forward I believe which should be explored: offer veterans parity with mainstream health care by allowing them – should they so choose – to use the non-VA health care system in the private world through an alternative insurance program, with heavy subsidization. This would serve to further incentivize improvements in the VA through competition, and would ensure that veterans never are treated as a subclass.