[Paleopsych] SW: On the Casualties of War

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Mon May 23 19:47:11 UTC 2005

Public Health: On the Casualties of War

    The following points are made by Atul Gawande (New Engl. J. Med. 2004
    1) Each Tuesday, the US Department of Defense provides an online
    update of American military casualties (the number of wounded or dead)
    from Operation Iraqi Freedom and Operation Enduring Freedom.[1]
    According to this update, as of November 16, 2004, a total of 10,726
    service members had suffered war injuries. Of these, 1361 died, 1004
    of them killed in action; 5174 were wounded in action and could not
    return to duty; and 4191 were less severely wounded and returned to
    duty within 72 hours. No reliable estimates of the number of Iraqis,
    Afghanis, or American civilians injured are available. Nonetheless,
    these figures represent, by a considerable margin, the largest burden
    of casualties our military medical personnel have had to cope with
    since the Vietnam War.
    2) When U.S. combat deaths in Iraq reached the 1000 mark in September,
    the event captured worldwide attention. Combat deaths are seen as a
    measure of the magnitude and dangerousness of war, just as murder
    rates are seen as a measure of the magnitude and dangerousness of
    violence in our communities. Both, however, are weak proxies. Little
    recognized is how fundamentally important the medical system is -- and
    not just the enemy's weaponry -- in determining whether or not someone
    dies. US homicide rates, for example, have dropped in recent years to
    levels unseen since the mid-1960s. Yet aggravated assaults,
    particularly with firearms, have more than tripled during that
    period.[2] The difference appears to be our trauma care system:
    mortality from gun assaults has fallen from 16 percent in 1964 to 5
    percent today.
    3) We have seen a similar evolution in war. Though firepower has
    increased, lethality has decreased. In World War II, 30 percent of the
    Americans injured in combat died.[3] In Vietnam, the proportion
    dropped to 24 percent. In the war in Iraq and Afghanistan, about 10
    percent of those injured have died. At least as many US soldiers have
    been injured in combat in this war as in the Revolutionary War, the
    War of 1812, or the first five years of the Vietnam conflict from 1961
    through 1965. This can no longer be described as a small or contained
    conflict. But a far larger proportion of soldiers are surviving their
    4) It is too early to make a definitive pronouncement that medical
    care is responsible for this difference. With the war ongoing and
    still intense, data on the severity of injuries, the care provided,
    and the outcomes are necessarily fragmentary. One key constraint for
    planners has been the limited number of medical personnel available in
    a voluntary force to support the 130,000 to 150,000 troops fighting in
    Iraq. The Army is estimated to have only 120 general surgeons on
    active duty and a similar number in the reserves. It has therefore
    sought to keep no more than 30 to 50 general surgeons and 10 to 15
    orthopedic surgeons in Iraq. Most have served in Forward Surgical
    Teams (FSTs) --small teams, consisting of just 20 people: 3 general
    surgeons, 1 orthopedic surgeon, 2 nurse anesthetists, 3 nurses, plus
    medics and other support personnel. In Vietnam, only 2.6 percent of
    the wounded soldiers who arrived at a surgical field hospital died,
    which meant that, despite helicopter evacuation, most deaths occurred
    before the injured made it to surgical care.[4] The recent emphasis on
    leaner, faster-moving military units added to the imperative to push
    surgical teams farther forward, closer to battle. So they, too, were
    made leaner and more mobile -- and that is their fundamental departure
    from previous wars.
    5) Each FST is equipped to move directly behind troops and establish a
    functioning hospital with four ventilator-equipped beds and two
    operating tables within a difficult-to-fathom 60 minutes. The team
    travels in six Humvees. They carry three lightweight, Deployable Rapid
    Assembly Shelter ("drash") tents that can be attached to one another
    to form a 900-square-foot facility. Supplies to immediately
    resuscitate and operate on the wounded arrive in five backpacks: an
    ICU pack, a surgical-technician pack, an anesthesia pack, a
    general-surgery pack, and an orthopedic pack. They hold sterile
    instruments, anesthesia equipment, medicines, drapes, gowns,
    catheters, and a handheld unit allowing clinicians to obtain a
    hemogram and measure electrolytes or blood gases with a drop of blood.
    FSTs also carry a small ultrasound machine, portable monitors,
    transport ventilators, an oxygen concentrator providing up to 50
    percent oxygen, 20 units of packed red cells, and six roll-up
    stretchers with their litter stands. Teams have forgone angiography
    and radiography equipment. (Orthopedic surgeons detect fractures by
    feel and apply external fixators.) But they have sufficient supplies
    to evaluate and perform surgery on as many as 30 wounded soldiers.
    They are not equipped, however, for more than six hours of
    postoperative intensive care.[5]
    1. U.S. casualty status. Washington, D.C.: Department of Defense,
    2004. Accessed November 17, 2004, at
    2. Harris AR, Thomas SH, Fisher GA, Hirsch DJ. Murder and medicine:
    the lethality of criminal assault 1960-1999. Homicide Stud
    3. Principal wars in which the United States participated: U.S.
    military personnel serving and casualties. Washington, D.C.:
    Department of Defense, 2004. Accessed November 17, 2004, at
    4. Whelan TJ Jr. Surgical lessons learned and relearned in Vietnam.
    Surg Annu 1975;7:1-23
    5. Pear R. U.S. has contingency plans for a draft of medical workers.
    New York Times. October 19, 2004:A22
    New Engl. J. Med. http://www.nejm.org

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