Wednesday, April 28, 2004

By Karl Vick
The Washington Post

An orange screen atop the feet registered blood pressure and heart rate. The blue screen at the knees announced the level of postoperative pressure on the brain. On the stomach, a small gray readout recorded the level of medicine pumping into the body. And the slender plastic box atop the chest signaled that a respirator still breathed for the lungs under it.

At the door to the busiest hospital in Iraq, a wiry doctor bent over the worst-looking case, an Army gunner with coarse stitches holding his scalp together and a bolt protruding from the top of his head. Lt. Col. Jeff Poffenbarger checked a number on the blue screen, announced it dangerously high and quickly pushed a clear liquid through a syringe into the gunner's bloodstream. The number fell like a rock.

"We're just preparing for something a brain-injured person should not do two days out, which is travel to Germany," the neurologist said. He smiled grimly and started toward the UH-60 Black Hawk thwump-thwumping out on the helipad, waiting to spirit out of Iraq one more of the hundreds of Americans wounded here this month.

While attention remains riveted on the rising count of Americans killed in action — more than 100 so far in April — doctors at the main combat support hospital in Iraq are reeling from a stream of young soldiers with wounds so devastating that they probably would have been fatal in any previous war.

More and more in Iraq, combat surgeons say, the wounds involve severe damage to the head and eyes — injuries that leave soldiers brain-damaged or blind, or both, and the doctors who see them first struggling against despair.

For months the gravest wounds have been caused by roadside bombs — improvised explosives that negate the protection of Kevlar helmets by blowing shrapnel and dirt upward into the face. In addition, firefights with guerrillas have surged recently, causing a sharp rise in head wounds.

The neurosurgeons at the 31st Combat Support Hospital measure the damage in the number of skulls they open to get to the injured brain inside, a procedure known as a craniotomy. "We've done more in eight weeks than the previous neurosurgery team did in eight months," Poffenbarger said.

Numbers tell part of the story. So far in April, more than 900 soldiers and Marines have been wounded in Iraq, more than twice the number wounded in October, the previous high. With the tally still climbing, this month's injuries account for about a quarter of the 3,864 U.S. servicemen and women listed as wounded in action since the March 2003 invasion.

About half the wounded troops have suffered injuries light enough that they were able to return to duty after treatment, according to the Pentagon.

The others arrive on stretchers at the hospitals operated by the 31st CSH. "These injuries," said Lt. Col. Stephen Smith, executive officer of the Baghdad facility, "are horrific."

By design, the Baghdad hospital sees the worst. Unlike its sister hospital on a sprawling air base located in Balad, north of the capital, the staff of 300 in Baghdad includes the only ophthalmology and neurology surgical teams in Iraq, so if a victim has damage to the head, the medevac sets out for the facility here, located in the heavily fortified coalition headquarters known as the Green Zone.

Once there, doctors scramble. A patient might remain in the combat hospital for only six hours. The goal is lightning-swift, expert treatment, followed as quickly as possible by transfer to the military hospital in Landstuhl, Germany.

While waiting for the helicopters, the Baghdad medical staff studies photos of wounds they used to see once or twice in a military campaign but now treat every day. And they struggle with the implications of a system that can move a wounded soldier from a booby-trapped roadside to an operating room in less than an hour.

"We're saving more people than should be saved, probably," Lt. Col. Robert Carroll said. "We're saving severely injured people. Legs. Eyes. Part of the brain."

Carroll, an eye surgeon from Waynesville, Mo., sat at his desk during a rare slow night last Wednesday and called up a digital photo on his laptop computer. The image was of a brain opened for surgery earlier that day, the skull neatly lifted away, most of the organ healthy and pink. But a thumb-sized section behind the ear was gray.

"See all that dark stuff? That's dead brain," he said. "That ain't gonna regenerate. And that's not uncommon. ... We do craniotomies on average, lately, of one a day."

"We can save you," the surgeon said. "You might not be what you were."

Accurate statistics are not yet available on recovery from this new round of battlefield brain injuries, an obstacle that frustrates combat surgeons. But judging by medical literature and surgeons' experience with their own patients, "three or four months from now, 50 to 60 percent will be functional and doing things," said Maj. Richard Gullick.

"Functional," he said, means "up and around, but with pretty significant disabilities," including paralysis.

The remaining 40 percent to 50 percent of patients include those whom the surgeons send to Europe, and on to the United States, with no prospect of regaining consciousness. The practice, subject to review after gathering feedback from families, assumes that loved ones will find value in holding the soldier's hand before confronting the decision to remove life support.

"I'm actually glad I'm here and not at home, tending to all the social issues with all these broken soldiers," Carroll said.

But the toll on the combat medical staff is itself acute, and unrelenting.

In a comprehensive Army survey of troop morale across Iraq, taken in September, the unit with the lowest spirits was the one that ran the combat hospitals until the 31st arrived in late January. The three months since then have been substantially more intense.

"We've all reached our saturation for drama trauma," said Maj. Greg Kidwell, head nurse in the emergency room.

On April 4, the hospital received 36 wounded in four hours. A U.S. patrol in Baghdad's Sadr City slum was ambushed at dusk, and the battle for the Shiite Muslim neighborhood lasted most of the night. The event qualified as a "mass casualty," defined as more casualties than can be accommodated by the 10 trauma beds in the emergency room.

"I'd never really seen a 'mass cal' before April 4," said Lt. Col. John Xenos, an orthopedic surgeon from Fairfax, Va. "And it just kept coming and coming. I think that week we had three or four mass calls."

The ambush heralded a wave of attacks by a Shiite militia across southern Iraq. The next morning, another front erupted when Marines cordoned off Fallujah. The engagements there led to record casualties.

"Intellectually, you tell yourself you're prepared," said Gullick, from San Antonio. "You do the reading. You study the slides. But being here ... it's just the sheer volume."

In part, the surge in casualties reflects more frequent firefights after a year in which roadside bombings made up the bulk of attacks. At the same time, insurgents began planting improvised explosive devices (IEDs) in what one officer called "ridiculous numbers."

The improvised bombs are extraordinarily destructive. They're detonated by remote control and may be packed with such debris as broken glass, nails, sometimes even gravel.

To protect against the blasts, the U.S. military has wrapped many of its vehicles in armor. Troops wear armor as well, providing protection that Gullick called "orders of magnitude from what we've had before. But it just shifts the injury pattern from a lot of abdominal injuries to extremity and head and face wounds."

The skull of the Army gunner whom Poffenbarger was preparing for the flight to Germany had been pierced by shrapnel from four 155mm shells, rigged to detonate one after another in what soldiers call a "daisy chain." The shrapnel took a fortunate route through his brain, however, and "when all is said and done, he should be independent. ... He'll have speech, cognition, vision."

On a nearby stretcher, Staff Sgt. Rene Fernandez struggled to see from eyes bruised nearly shut.

"We were clearing the area and an IED went off," he said, describing an incident outside Ramadi where his unit was patrolling on foot.

The Houston native counted himself lucky, escaping with a concussion and facial wounds. Waiting for his own hop to the hospital plane headed north, he said what most soldiers tell surgeons: What he most wanted was to return to his unit.