Frontline medicine
In combat hospitals in Iraq, despite 'incredible chaos,' all patients are equal; speed and innovative care save 96% of the wounded
MOSUL, Iraq -- The explosion sprayed white-hot shrapnel across the road, ripping the two Iraqi police officers' thighs open like meat on a butcher's block.
But the insurgents who detonated the bomb were not finished. As the officers lay on the ground, writhing in agony, gunmen stepped from the shadows of this, Iraq's third-largest city, and shot them in the groin.
''If they just wanted them to die, they would have shot them in the head," said US Army Captain Chris Washack, standing near the operating table where surgeons at the 47th Combat Support Hospital worked feverishly to save the two officers. ''They wanted them to suffer."
As Washack spoke last month, one of the surgeons, Colonel David Watts, used forceps to pick a piece of metal from one of the police officer's legs, held it up briefly to examine it, then placed it aside.
The two Iraqi police officers survived, as do 96 percent of the seriously wounded trauma patients who make it to this 164-bed hospital and three others like it in other parts of Iraq, according to American military officials.
Lieutenant Colonel David Meissner, who is in charge of the emergency room at the 47th, said it is the quality of care, and especially the speed of the evacuations -- from the battlefield to the combat support hospitals, then on to the Landstuhl Regional Medical Center in Germany -- that has dramatically improved the mortality rate in this war compared with previous ones. Meissner said the emergency room can handle nine major traumas at once.
''It's incredible chaos," he said. ''But organized chaos."
Colonel W. Bryan Gamble, a surgeon and commander at Landstuhl, said that during the Vietnam War, it typically took about 45 days to get wounded soldiers from the battlefield back to the United States for long-term recovery. Now, with soldiers being stabilized at the combat support hospital within hours, then flown to Landstuhl, that process is down to 48 to 72 hours, Gamble said.
Beyond the emphasis on speed, there have been medical innovations -- including some adopted during the current conflict -- that have shrunk mortality rates, according to Colonel Philip C. Corcoran, chief of cardiothoracic surgery at Walter Reed Army Medical Center in Washington, D.C., who recently spent a 90-day stint with the 47th. For example, Corcoran said, doctors here have taken to using pediatric instead of adult scopes when they work inside the chests of patients because the tinier, more flexible pediatric scopes can go more places faster and less invasively.
Doctors here have also created what Corcoran called a ''walking, living, fresh blood bank," in which many of the 270 hospital staff are regular, real-time donors.
When a patient comes in with a major trauma, Corcoran explained, prescreened hospital employees with a similar blood type quickly make donations.
''The blood isn't processed, or cooled. It is warm and more likely to coagulate," which means the patient will stop bleeding faster, Corcoran said. The process ''has implications for our force readiness. We have nurses coming off duty to give blood. But it's saved lives."
Standing in the intensive care unit where the two Iraqi police officers would soon be recovering from surgery, Colonel James Polo, commander of the 47th, said there is no hierarchy of patients here. Soldiers wounded by bombs sometimes lie in beds next to the insurgents who planted them. Polo recently had the commander of a US Army combat unit in his face, complaining that some of his wounded men had to wait while the 47th's surgeons tended first to a wounded insurgent.
''The insurgent was in worse shape than our guys," Polo said. ''Medically, we have an ethical standard to treat people in the order of the seriousness of the injuries. Sometimes that leads to confrontations, it's something we've got to explain, but we stand our ground."
The Hippocratic oath must co-exist with military guidelines, though, which sometimes leaves the doctors with hard choices. The 47th, like other combat support hospitals, is supposed to treat coalition forces and their Iraqi military and police allies as well as any civilians who are wounded by coalition fire.
''This hospital doesn't exist to do goodwill," Polo said.
But sometimes the rules are stretched on humanitarian grounds.
In the middle of the open ward, 12-year-old Samah Arajy, a girl with dark hair and haunting eyes, is clearly the darling of the 47th. Two months earlier, her father flagged down a US patrol, asking for a balm to treat the girl's infection. After getting caught in a crossfire, the care she got at a civilian hospital in Mosul was poor, and an infection had eaten away at her leg. Doctors at the 47th have performed several corrective surgeries.
''If I said, 'No, we can't see this kid,' it would have been a reasonable response," Polo said, smiling at the girl as her father sat at her bedside. ''But we didn't say no."
The 47th is housed in what was a former Iraqi Air Force hospital, a one-story cement block building that for all its state-of-the-art equipment is pretty scruffy. It is surrounded by 15-foot cement blast walls to ward off the impact of the mortar rounds that are regularly lobbed in. Polo said that about 80 percent of the patients treated here in recent months are Iraqi, many of them Iraqi soldiers and police officers, who are increasingly taking on the role of providing security on the street.
While Iraqis are stitched up here, the follow-up care is on the outside, and it is often substandard and sometimes nonexistent.
''A couple of months ago, we had a 9-year-old girl caught in a crossfire. She's a paraplegic," said Polo, a child psychiatrist. ''Our soldiers went into the house. She had bed sores. Large, gaping holes on her back. The family didn't have a vehicle. Our soldiers brought her here. We did what we could, but she's back with her family. This little girl will die. She won't make it past adolescence."
Because they save so many, the loss of any patient here is a body blow. Washack, the company commander, remembers the hospital revving into motion when two badly injured aviators were brought in after their helicopter went down under hostile fire Jan. 13.
''This place was humming," he said. The anticipation and adrenaline, he said, was palpable.
But the first aviator was pronounced dead on arrival despite herculean efforts to keep him alive while he was transported to the hospital in a heavily armored vehicle called a Stryker. Staff worked on the second aviator for 20 more minutes before he, too, was pronounced dead.
The 35 medical personnel who had been mobilized stood in stunned silence, frustrated that the men died before they could be resuscitated for surgery.
''The air just sort of drained from the room," Washack said.
Still, morale here is high, as is job satisfaction.
As dawn broke one morning last month, about a dozen soldiers in combat fatigues clambered onto the hospital's roof to watch three comrades reenlist. The roof provided a sweeping view of the sprawling city of 2 million that surrounds the hospital -- not to mention a clear shot for anybody who was predisposed to taking one. In an unusual coupling of medical dedication and warrior bravado, the small reenlistment ceremony was a reminder that while the people here are medics, doctors, and nurses, they are also soldiers.
Mauree Staley, 33, a nurse, was finishing up a three-year hitch; she signed up for four more. Sergeant Jesse Warren, 25, a medic, signed up for five more years. And with 14 years already in, Staff Sergeant Stephan Pandarvis, 34, figured he'd sign up for life.
''I'd be lying if I didn't say there's a bonus involved," said Staley as she was congratulated by other soldiers. But money isn't what it's about. She, like the others, could make more money in healthcare outside the military.
''I enjoy my work. I know if sounds like a cliche, but I make a difference here," she said, then, glancing around the roof, she added, ''We make a difference."
On the ground below, soldiers jumped out of an armored vehicle and loaded a wounded comrade onto a stretcher, then moved him into the ER.
The newly re-upped soldiers and their comrades climbed down a narrow metal ladder, and some of them ran into the hospital.
There was work to do.