everyone I met who had worked on medical teams in the war. And what they described revealed an intriguingeffort to do something we in civilian medicine do spottily at best: to make a science of performance, to investigate and improve how well they use the knowledge and technologies they already have at hand. The doctors told me of simple, almost banal changes that produced enormous improvements.
One such change involved Kevlar vests, for example. There is nothing new about Kevlar. It has been around since the late 1970s. Urban police forces began using Kevlar vests in the early 1980s. American troops had them during the Persian Gulf War. A sixteen-pound Kevlar flak vest will protect a person's "body core"--the heart, the lungs, the abdominal organs--from blasts, blunt force trauma, and penetrating injuries. But researchers examining wound registries from the Persian Gulf War found that wounded soldiers had been coming in to medical facilities without their Kevlar on. They hadn't been wearing their vests. So orders were handed down holding commanders responsible for ensuring that their soldiers always wore the vests--however much they might complain about how hot or heavy or uncomfortable the vests were. Once the soldiers began wearing them more consistently, the percentage killed on the battlefield dropped instantly.
A second, key discovery came in much the same way, by looking more carefully at how the system was performing. Colonel Ronald Bellamy, a surgeon with the army's Borden Institute, examined the statistics of the Vietnam War and found that helicopter evacuation had reduced the transport time for injured soldiers to hospital care from an average of over eleven hours in World War II to under an hour. And once they got to surgical care, only 3 percent died. Yet 24 percent of wounded soldiers died in all, and that was because transport time to surgicalcare under an hour still wasn't fast enough. Civilian surgeons talk of having a "Golden Hour" during which most trauma victims can be saved if treatment is started. But battlefield injuries are so much more severe--the blood loss in particular--that wounded soldiers have only a "Golden Five Minutes," Bellamy reported. Vests could extend those five minutes. But the recent emphasis on leaner, faster-moving military units moving much farther ahead of supply lines and medical facilities was only going to make evacuation to medical care more difficult and time-consuming. Outcomes for the wounded were in danger of getting worse rather than better.
The army therefore turned to an approach that had been used in isolated instances going back as far as World War II: something called Forward Surgical Teams (FSTs). These are small teams, consisting of just twenty people: three general surgeons, one orthopedic surgeon, two nurse anesthetists, three nurses, plus medics and other support personnel. In Iraq and Afghanistan, they travel in six Humvees directly behind the troops, right out onto the battlefield. They carry three lightweight, Deployable Rapid-Assembly Shelter ("drash") tents that attach to one another to form a nine-hundred-square-foot hospital facility. Supplies to immediately resuscitate and operate on the wounded are in five black nylon 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 that allows clinicians to measure a complete blood count, electrolytes, or blood gases with a drop of blood. FSTs also carry a small ultrasound machine, portable monitors, transportventilators, an oxygen concentrator providing up to 50 percent pure oxygen, twenty units of packed red blood cells for transfusion, and six roll-up stretchers with litter stands. All of this is ordinary medical equipment. The teams must forgo many technologies normally available to a surgeon, such as angiography and radiography
One such change involved Kevlar vests, for example. There is nothing new about Kevlar. It has been around since the late 1970s. Urban police forces began using Kevlar vests in the early 1980s. American troops had them during the Persian Gulf War. A sixteen-pound Kevlar flak vest will protect a person's "body core"--the heart, the lungs, the abdominal organs--from blasts, blunt force trauma, and penetrating injuries. But researchers examining wound registries from the Persian Gulf War found that wounded soldiers had been coming in to medical facilities without their Kevlar on. They hadn't been wearing their vests. So orders were handed down holding commanders responsible for ensuring that their soldiers always wore the vests--however much they might complain about how hot or heavy or uncomfortable the vests were. Once the soldiers began wearing them more consistently, the percentage killed on the battlefield dropped instantly.
A second, key discovery came in much the same way, by looking more carefully at how the system was performing. Colonel Ronald Bellamy, a surgeon with the army's Borden Institute, examined the statistics of the Vietnam War and found that helicopter evacuation had reduced the transport time for injured soldiers to hospital care from an average of over eleven hours in World War II to under an hour. And once they got to surgical care, only 3 percent died. Yet 24 percent of wounded soldiers died in all, and that was because transport time to surgicalcare under an hour still wasn't fast enough. Civilian surgeons talk of having a "Golden Hour" during which most trauma victims can be saved if treatment is started. But battlefield injuries are so much more severe--the blood loss in particular--that wounded soldiers have only a "Golden Five Minutes," Bellamy reported. Vests could extend those five minutes. But the recent emphasis on leaner, faster-moving military units moving much farther ahead of supply lines and medical facilities was only going to make evacuation to medical care more difficult and time-consuming. Outcomes for the wounded were in danger of getting worse rather than better.
The army therefore turned to an approach that had been used in isolated instances going back as far as World War II: something called Forward Surgical Teams (FSTs). These are small teams, consisting of just twenty people: three general surgeons, one orthopedic surgeon, two nurse anesthetists, three nurses, plus medics and other support personnel. In Iraq and Afghanistan, they travel in six Humvees directly behind the troops, right out onto the battlefield. They carry three lightweight, Deployable Rapid-Assembly Shelter ("drash") tents that attach to one another to form a nine-hundred-square-foot hospital facility. Supplies to immediately resuscitate and operate on the wounded are in five black nylon 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 that allows clinicians to measure a complete blood count, electrolytes, or blood gases with a drop of blood. FSTs also carry a small ultrasound machine, portable monitors, transportventilators, an oxygen concentrator providing up to 50 percent pure oxygen, twenty units of packed red blood cells for transfusion, and six roll-up stretchers with litter stands. All of this is ordinary medical equipment. The teams must forgo many technologies normally available to a surgeon, such as angiography and radiography
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