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Management of War Wounds in Iraq
Abstract and Commentary
By Dean L. Winslow, MD, FACP, FIDSA, Chief, Division of AIDS Medicine, Santa Clara Valley Medical Center; Clinical Professor, Stanford University, School of Medicine, Section Editor, HIV, is Associate Editor for Infectious Disease Alert.
Synopsis: Sixty-eight patients whose war wounds were treated by the Plastic Surgery Department at Naval Medical Center San Diego between April 2003 and December 2005 were reviewed. Extremities were the site of injury in 91.2% of patients. Limb salvage rate was 93.6%, and was attributed to aggressive surgical management, use of wound vacuum-assisted closure, and appropriate antibiotic use.
Source: Geiger S, et al. War wounds: lessons learned from Operation Iraqi Freedom. Plastic and Reconstructive Surgery. 2008; 122:146-153.
A retrospective review of one major continental United States (CONUS) tertiary care medical center's plastic surgery department's experience in the management of combat wounds was performed and included all cases seen between April 2003 and December 2005. Of the 68 patients treated, 16.2% sustained injuries to the head/face/neck, 61.8% had lower extremity injuries, 29.4% had upper extremity injuries, 15.6% had both upper and lower extremity injuries, and 35.9% had multiple sites of injuries. All patients underwent debridement within 24 hours of arrival. Almost all had wound vacuum-assisted closure dressings as part of this initial procedure. The average number of surgical procedures (mainly repeated aggressive wound debridement) was five prior to definitive closure, which was generally accomplished with a flap procedure of some type. Antibiotic-impregnated beads were used when bony defects were present and were used until delayed bone grafting was performed. Microvascular techniques were used in 27 patients. Acute osteomyelitis occurred in 24.2% of patients but, as of September 2006, only one patient had been diagnosed with chronic osteomyelitis. Bacterial contamination of the wounds by time-of-arrival at San Diego Naval Hospital was common. Organisms isolated from initial bone cultures in patients with acute osteomyelitis included Acinetobacter baumannii in nine, Enterobacter species in five, coagulase-negative Staph in four, Enterococcus in three, MRSA in two, and Bacillus species and Klebsiella isolated in one patient each.
During World War II, more than 25% of wounded American servicemen died of their wounds. Due to the advent of helicopter MedEvac and the use of ICUs, the mortality rate fell to less than 20% during the Vietnam War. During Operation Iraqi Freedom, the mortality rate from war wounds has been less than 10%. Factors responsible for this dramatic reduction in mortality include the routine wear of Kevlar helmets, protecting the upper cranium, and individual body armor (IBA), incorporating ceramic plates capable of stopping even assault rifle rounds, protecting much of the torso. Additionally, a wounded American soldier, airman, or marine (often suffering from a severe extremity wound as a result of either a high velocity gunshot wound or improvised explosive device detonation) receives immediate life-saving care and initial resuscitation in the field by either a combat medic or fellow soldier who has completed rigorous training as a combat life-saver. Following this, the wounded individual is generally no more than 10 minutes by helicopter MedEvac from a Forward Surgical Team (FST), Combat Support Hospital (CSH), an Air Force EMEDS, or even the tertiary care Air Force Theater Hospital (AFTH) in Balad. At any one of these facilities, the wounded individual undergoes immediate life-/limb-saving surgery, and is then generally transported within 48 hours by fixed wing aerovac to Landstuhl Regional Medical Center in Germany, where more definitive surgery, debridement, and washout of wounds is performed. Generally, within 4-7 days, the individual is back at one of the major CONUS military medical centers for definitive care and rehabilitation.
During my own four tours of duty as an Air Force physician in Iraq since March 2003, I saw a steady evolution in the standardization of surgical techniques and confidence shown by US military surgeons in their management of horrific injuries both in theater, at Landstuhl, and at CONUS medical centers. This case series report from the plastic surgery service at San Diego Naval Hospital provides a good review of some of the important lessons learned from this experience. While caring for these brave young people with such devastating injuries is often a heart-breaking experience, it is gratifying to see so many of them survive and be able to eventually return to some type of life with good quality. Fortunately, many of these medical and surgical "lessons learned" from the wars in Iraq and Afghanistan are being transferred to the management of trauma in the civilian world.