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more surgery and war

Andy Brainard trauma-list@trauma.org
Mon, 31 Mar 2003 16:22:37 -0700


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The New York Times <http://www.starbucks.com/default.asp?ci=3D1012>
<http://www.starbucks.com/default.asp?ci=3D1012> Sponsored by Starbucks
<http://www.starbucks.com/default.asp?ci=3D1012>=20


  _____ =20


March 30, 2003


Armed With New Tools, Doctors Head to Battle


By GINA KOLATA





=20

>From redesigned first-aid kits to a radically new kind of surgery on the
front lines, battlefield medicine has changed markedly and, as a result,
doctors in the war in Iraq hope to significantly reduce the death rate =
from
battlefield wounds - a rate that has not budged for 150 years.

Since the Civil War, experts in military medicine say, one of five =
wounded
soldiers has died, half from profuse bleeding. Pentagon doctors hope to
change that, and have mobilized an array of innovations.

Some, like putting pressure bandages in first-aid kits, are drugstore =
cheap.
Others, like a new anticlotting drug for internal bleeding, are =
high-tech
expensive, about $7,000 per dose. And some, like sending radically
redesigned surgical teams to operate at the front lines, involve tactics =
and
equipment that simply were not available in the last gulf war. These =
special
surgery units were tested in Afghanistan, where they reduced the
died-of-wounds rate, the death rate for those who survived long enough =
for a
surgeon to operate, to a fraction of a percent. For the past =
half-century,
it has hovered around 2 percent.

Doctors said it was hard to overestimate the difference.

There was little change from Vietnam to the first gulf war in doctors'
instruments, drugs, techniques or tactics. Except for some in the Army,
which put surgeons in the front lines in Desert Storm, wounded soldiers
received first aid from medics but no surgical care until they were
evacuated to a larger hospital.

Now, all the services have small mobile surgical teams scattered =
throughout
the battlefield, where they operate on the most severely wounded as =
close to
the front as possible. They do the minimum operation to stabilize =
patients
for evacuation to a larger hospital. There, they may have another =
operation
to further stabilize them for evacuation to a hospital in Europe.=20

"Never before in modern warfare have we done things so differently," =
said
Lt. Col. Donald Jenkins, a surgeon who is chief of trauma at Wilford =
Hall
Air Force Medical Center in San Antonio.=20

Many of the patients treated have been Iraqis. "By Geneva Convention and
NATO standards, casualties are taken care of in order of priority, based =
on
injury and illness, not based on uniform," Dr. Jenkins said. "That's =
been
the policy back to our own Civil War at least."=20

Col. John Holcomb, a surgeon who directs the Army Institute of Surgical
Research in San Antonio, said some of the innovations came from =
after-action
reviews in which doctors analyzed data on why soldiers died, where they
died, and how.=20

Each branch of the service makes its own decisions about which =
innovations
to adopt. For example, the Marine Corps has added a new product, =
QuikClot,
to every marine's first-aid kit, said Lt. Cmdr. Joe DaCorta, who is in
charge of expeditionary medicine at the Marine Corps Warfighting Lab in
Quantico, Va.

The substance was tested for battlefield use by Dr. Hasan Alam, a trauma
surgeon at the Uniformed Services University of the Health Sciences in
Bethesda, Md. Dr. Alam said he was haunted by troops who bled to death =
in
Somalia before surgeons could help them.

For Dr. Alam, it meant that "your buddy has to stop the bleeding, not =
the
medic, not the surgeon."=20

So he turned to QuikClot, a product made of the mineral zeolite and sold
over the counter by Z-Medica. It looks like cat litter but, sprinkled on =
a
wound, it absorbs water from blood, concentrating the body's own =
clotting
factors and speeding up the formation of a clot.

Z-Medica has supplied 50,000 doses to the military.=20

Dr. Alam and his colleagues tested the substance on 36 Yorkshire swine,
which are close to a person's size. The results have not been published, =
but
Dr. Alam said QuikClot converted wounds that were 100 percent fatal into
wounds that were 100 percent nonfatal - clots formed and none of the =
animals
died.

Although the Marine Corps plans to use it, other branches of the =
military
are not yet convinced. The question is whether to use it, and at what =
dose.
One concern is that heat is generated when QuikClot is poured on a =
wound,
and the fear is that it might burn tissue. "We don't have a huge amount =
of
data," Dr. Alam said. "We've done two studies."=20

Also, the troops must be trained in how to use it and surgeons must be
trained about what to expect.=20

Meanwhile, the Army and the Special Operations forces are taking an
additional approach to clotting, Colonel Holcomb said. They will use =
coated
bandages to stop bleeding. One bandage, developed by the Red Cross, used =
two
clotting proteins, fibrin and thrombin, to speed clot formation. The =
other,
made by HemCon of Oregon, uses chitosan, a clot-promoting protein in =
shrimp
shells.=20

Remaining problems include what to do about severe injuries to the =
abdomen
or pelvis, which may cause rapid and uncontrolled internal bleeding, or
bleeding in the brain from a head injury.=20

"What about an intravenous drug that could accelerate the =
hemorrhage-control
process?" Dr. Holcomb asked. The Army, he said, is considering using =
factor
VIIa, a clotting drug recently approved for treating hemophilia. Animal
studies, he said, indicate that it can work, and trauma centers often =
use
it. The Defense Department and the company hope to conduct a clinical =
trial.

Military medical experts said the hope, with all of these new products, =
is
that they will keep the wounded alive until they can see a surgeon.

Surgeons will be using a method pioneered a decade ago in trauma centers =
in
cities reeling from an epidemic of drug-fueled violence.

One of its leading innovators was Dr. C. William Schwab, a trauma =
surgeon at
the University of Pennsylvania, who was troubled by the number of =
patients
treated there who died later.

"We started to see that even though we would get the injury controlled =
and
fixed, even though we put them back together, they would die," Dr. =
Schwab
said. Patients would go into shock, their temperatures would drop, their
blood would become acidic and coagulate, forming fatal clots.

Dr. Schwab decided to try doing the absolute minimum surgically to stop =
the
bleeding, so doctors could turn their attention to stabilizing the =
patients.
Later, he reasoned, surgeons would complete their repair.

Dr. Schwab named the method damage control, a Navy term he recalled from =
the
10 years he spent on an aircraft carrier in Vietnam. When a ship was =
hit, he
recalled, the idea was to patch it up and keep it afloat, doing the =
major
repairs later.=20

He tried it with trauma victims. "We would control bleeding and any
contamination from the GI tract," he said. "Then we would continue to
resuscitate them and bring them back in two or three days and do =
definite
surgery."=20

To assess the method, he compared patients treated with damage control =
with
similar, seriously injured patients who had had traditional surgery. =
With
damage control, 75 percent survived. With traditional surgery, almost =
every
patient died. A decade later, after further refining of the technique, =
90
percent are surviving, Dr. Schwab said.=20

As the approach spread in trauma centers across the country, military
surgeons started showing up at Dr. Schwab's hospital for training.=20

"What I learned from Bill Schwab was absolutely indispensable," said Dr.
Jenkins, who spent two years there. "I took care of people who for sure =
in
my training we would have looked at them and said, `There is no way this
person could survive.' " Yet survive they did.=20

But to bring the technique to the battlefield, the military had to make
major changes. First, it had to put the surgeons with the frontline =
troops,
so they could do damage control surgery immediately.

The new idea was to keep a small surgical team on the front line, using =
a
portable operating room that is set up in an hour for damage control
surgery. From there, patients are stabilized and taken to hospitals for
additional surgery days later.

It required making what once was bulky equipment light and portable, =
said
Dr. Paul K. Carlton Jr., the recently retired surgeon general of the Air
Force who now directs the Integrative Center for Homeland Security at =
Texas
A & M. Today, Dr. Carlton said, surgeons can carry the equipment they =
need
in a backpack.

For example, frontline units are equipped with sonogram machines the =
size of
cassette recorders, and devices the size of a PDA that can do a complete
laboratory analysis on a drop of blood.

Another piece of the plan is to train surgeons and support staff, and =
once
again military doctors turned to urban trauma center. "They have too =
many
patients," Colonel Holcomb said. "We need patients."

In Miami, Dr. Tom Knuth, who directs the Army Trauma Training Center at
Ryder Trauma Center, is training military general surgeons, plastic =
surgeons
and other specialists and technicians and medics.

"They integrate with the civil staff to manage whatever patients come
through the door - bad motor vehicle crashes, gunshot wounds," Dr. Knuth
said. "And they get to work together as a team." With the war, the =
training
regimen has been compressed from a month to 10 days.

Dr. Carlton said the war in Afghanistan showed what is possible. Of 250
seriously injured patients, only one died. "It was the lowest =
died-of-wounds
rate in the history of war," he said.

One man suffered a catastrophic wound to his rectum, prostate, anus and
bladder. The ghastly injury plunged him into shock immediately, but one =
of
the backpack surgical teams got to him right away and did a damage =
control
surgery. Then, he was put on an airplane equipped as a critical care =
unit
and flown a few thousand miles to another hospital for another surgery =
to
stabilize him. Then he was flown to Germany for reconstructive surgery.

"He's home with his family now," Dr. Carlton said. In any other war, he
added, "he would have been dead."=20

=20

 <http://www.nytimes.com/ref/membercenter/help/copyright.html> Copyright
2003 The New York Times Company <http://www.nytco.com/>  | Privacy
<http://www.nytimes.com/ref/membercenter/help/privacy.html>  Policy=20

=20

[AB]=20


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<table class=3DMsoNormalTable border=3D0 cellspacing=3D0 cellpadding=3D0 =
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 <tr>
  <td valign=3Dtop style=3D'padding:0in 0in 0in 0in'>
  <p class=3DMsoNormal><img width=3D199 height=3D47
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  border=3D0><font size=3D3 face=3D"Times New Roman" =
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clear=3Dall>
  </p>
  <div class=3DMsoNormal><font size=3D3 face=3D"Times New Roman"><span
  style=3D'font-size:12.0pt'>
  <hr size=3D1 width=3D"100%" align=3Dleft>
  </span></font></div>
  <h5><b><font size=3D2 face=3D"Times New Roman"><span =
style=3D'font-size:10.0pt'>March
   30, 2003</span></font></b></h5>
  <NYT_HEADLINE type=3D" " version=3D"1.0">
  <h2><b><font size=3D5 face=3D"Times New Roman"><span =
style=3D'font-size:18.0pt'>Armed
  With New Tools, Doctors Head to </span></font></b>Battle</h2>
  </NYT_HEADLINE><NYT_BYLINE  type=3D" " version=3D"1.0">
  <p class=3DMsoNormal><strong><b><font size=3D2 face=3D"Times New =
Roman"><span
  style=3D'font-size:10.0pt'>By GINA =
KOLATA</span></font></b></strong><br>
  <br>
  <br>
  </p>
  </NYT_BYLINE>
  <table class=3DMsoNormalTable border=3D0 cellspacing=3D0 =
cellpadding=3D0 align=3Dright>
   <tr>
    <td style=3D'padding:0in 0in 0in 0in'>
    <p class=3DMsoNormal><font size=3D3 face=3D"Times New Roman"><span
    style=3D'font-size:12.0pt'>&nbsp;</span></font></p>
    </td>
   </tr>
  </table>
  <p><img width=3D25 height=3D33 =
src=3D"cid:image003.gif@01C2F7A1.BD7F7F40"
  align=3Dleft alt=3DF border=3D0><font size=3D3 face=3D"Times New =
Roman"><span
  style=3D'font-size:12.0pt'><NYT_TEXT></span>rom redesigned first-aid =
kits to a
  radically new kind of surgery on the front lines, battlefield medicine =
has
  changed markedly and, as a result, doctors in the war in Iraq hope to
  significantly reduce the death rate from battlefield wounds &#8212; a =
rate
  that has not budged for 150 years.</font></p>
  <p><font size=3D3 face=3D"Times New Roman"><span =
style=3D'font-size:12.0pt'>Since
  the Civil War, experts in military medicine say, one of five wounded =
soldiers
  has died, half from profuse bleeding. Pentagon doctors hope to change =
that,
  and have mobilized an array of innovations.</span></font></p>
  <p><font size=3D3 face=3D"Times New Roman"><span =
style=3D'font-size:12.0pt'>Some,
  like putting pressure bandages in first-aid kits, are drugstore cheap.
  Others, like a new anticlotting drug for internal bleeding, are =
high-tech
  expensive, about $7,000 per dose. And some, like sending radically =
redesigned
  surgical teams to operate at the front lines, involve tactics and =
equipment
  that simply were not available in the last gulf war. These special =
surgery
  units were tested in </span></font>Afghanistan, where they reduced the
  died-of-wounds rate, the death rate for those who survived long enough =
for a
  surgeon to operate, to a fraction of a percent. For the past =
half-century, it
  has hovered around 2 percent.</p>
  <p><font size=3D3 face=3D"Times New Roman"><span =
style=3D'font-size:12.0pt'>Doctors
  said it was hard to overestimate the difference.</span></font></p>
  <p><font size=3D3 face=3D"Times New Roman"><span =
style=3D'font-size:12.0pt'>There
  was little change from </span></font>Vietnam to the first gulf war in
  doctors' instruments, drugs, techniques or tactics. Except for some in =
the
  Army, which put surgeons in the front lines in Desert Storm, wounded =
soldiers
  received first aid from medics but no surgical care until they were =
evacuated
  to a larger hospital.</p>
  <p><font size=3D3 face=3D"Times New Roman"><span =
style=3D'font-size:12.0pt'>Now,
  all the services have small mobile surgical teams scattered throughout =
the
  battlefield, where they operate on the most severely wounded as close =
to the front
  as possible. They do the minimum operation to stabilize patients for
  evacuation to a larger hospital. There, they may have another =
operation to
  further stabilize them for evacuation to a hospital in =
</span></font>Europe. </p>
  <p><font size=3D3 face=3D"Times New Roman"><span =
style=3D'font-size:12.0pt'>&quot;Never
  before in modern warfare have we done things so differently,&quot; =
said Lt.
  Col. Donald Jenkins, a surgeon who is chief of trauma at Wilford Hall =
Air
  Force Medical Center in </span></font>San Antonio. </p>
  <p><font size=3D3 face=3D"Times New Roman"><span =
style=3D'font-size:12.0pt'>Many of
  the patients treated have been Iraqis. &quot;By Geneva Convention and =
NATO
  standards, casualties are taken care of in order of priority, based on =
injury
  and illness, not based on uniform,&quot; Dr. Jenkins said. =
&quot;That's been
  the policy back to our own Civil War at least.&quot; =
</span></font></p>
  <p><font size=3D3 face=3D"Times New Roman"><span =
style=3D'font-size:12.0pt'>Col.
  John Holcomb, a surgeon who directs the Army Institute of Surgical =
Research
  in San Antonio, said some of the innovations came from after-action =
reviews
  in which doctors analyzed data on why soldiers died, where they died, =
and
  how. </span></font></p>
  <p><font size=3D3 face=3D"Times New Roman"><span =
style=3D'font-size:12.0pt'>Each
  branch of the service makes its own decisions about which innovations =
to
  adopt. For example, the Marine Corps has added a new product, =
QuikClot, to
  every marine's first-aid kit, said Lt. Cmdr. Joe DaCorta, who is in =
charge of
  expeditionary medicine at the Marine Corps Warfighting Lab in =
</span></font>Quantico,
   Va.</p>
  <p><font size=3D3 face=3D"Times New Roman"><span =
style=3D'font-size:12.0pt'>The
  substance was tested for battlefield use by Dr. Hasan Alam, a trauma =
surgeon
  at the </span></font>Uniformed Services University of the Health =
Sciences in Bethesda,
   Md. Dr. Alam said he was haunted by troops who bled to death in =
Somalia
  before surgeons could help them.</p>
  <p><font size=3D3 face=3D"Times New Roman"><span =
style=3D'font-size:12.0pt'>For Dr.
  Alam, it meant that &quot;your buddy has to stop the bleeding, not the =
medic,
  not the surgeon.&quot; </span></font></p>
  <p><font size=3D3 face=3D"Times New Roman"><span =
style=3D'font-size:12.0pt'>So he
  turned to QuikClot, a product made of the mineral zeolite and sold =
over the
  counter by Z-Medica. It looks like cat litter but, sprinkled on a =
wound, it
  absorbs water from blood, concentrating the body's own clotting =
factors and
  speeding up the formation of a clot.</span></font></p>
  <p><font size=3D3 face=3D"Times New Roman"><span =
style=3D'font-size:12.0pt'>Z-Medica
  has supplied 50,000 doses to the military. </span></font></p>
  <p><font size=3D3 face=3D"Times New Roman"><span =
style=3D'font-size:12.0pt'>Dr. Alam
  and his colleagues tested the substance on 36 </span></font>Yorkshire =
swine,
  which are close to a person's size. The results have not been =
published, but
  Dr. Alam said QuikClot converted wounds that were 100 percent fatal =
into
  wounds that were 100 percent nonfatal &#8212; clots formed and none of =
the
  animals died.</p>
  <p><font size=3D3 face=3D"Times New Roman"><span =
style=3D'font-size:12.0pt'>Although
  the Marine Corps plans to use it, other branches of the military are =
not yet
  convinced. The question is whether to use it, and at what dose. One =
concern
  is that heat is generated when QuikClot is poured on a wound, and the =
fear is
  that it might burn tissue. &quot;We don't have a huge amount of =
data,&quot;
  Dr. Alam said. &quot;We've done two studies.&quot; </span></font></p>
  <p><font size=3D3 face=3D"Times New Roman"><span =
style=3D'font-size:12.0pt'>Also,
  the troops must be trained in how to use it and surgeons must be =
trained
  about what to expect. </span></font></p>
  <p><font size=3D3 face=3D"Times New Roman"><span =
style=3D'font-size:12.0pt'>Meanwhile,
  the Army and the Special Operations forces are taking an additional =
approach
  to clotting, Colonel Holcomb said. They will use coated bandages to =
stop
  bleeding. One bandage, developed by the Red Cross, used two clotting
  proteins, fibrin and thrombin, to speed clot formation. The other, =
made by HemCon
  of Oregon, uses chitosan, a clot-promoting protein in shrimp shells. =
</span></font></p>
  <p><font size=3D3 face=3D"Times New Roman"><span =
style=3D'font-size:12.0pt'>Remaining
  problems include what to do about severe injuries to the abdomen or =
pelvis,
  which may cause rapid and uncontrolled internal bleeding, or bleeding =
in the
  brain from a head injury. </span></font></p>
  <p><font size=3D3 face=3D"Times New Roman"><span =
style=3D'font-size:12.0pt'>&quot;What
  about an intravenous drug that could accelerate the hemorrhage-control
  process?&quot; Dr. Holcomb asked. The Army, he said, is considering =
using
  factor VIIa, a clotting drug recently approved for treating =
hemophilia.
  Animal studies, he said, indicate that it can work, and trauma centers =
often
  use it. The Defense Department and the company hope to conduct a =
clinical
  trial.</span></font></p>
  <p><font size=3D3 face=3D"Times New Roman"><span =
style=3D'font-size:12.0pt'>Military
  medical experts said the hope, with all of these new products, is that =
they
  will keep the wounded alive until they can see a =
surgeon.</span></font></p>
  <p><font size=3D3 face=3D"Times New Roman"><span =
style=3D'font-size:12.0pt'>Surgeons
  will be using a method pioneered a decade ago in trauma centers in =
cities
  reeling from an epidemic of drug-fueled violence.</span></font></p>
  <p><font size=3D3 face=3D"Times New Roman"><span =
style=3D'font-size:12.0pt'>One of
  its leading innovators was Dr. C. William Schwab, a trauma surgeon at =
the </span></font>University
   of Pennsylvania, who was troubled by the number of patients treated =
there
  who died later.</p>
  <p><font size=3D3 face=3D"Times New Roman"><span =
style=3D'font-size:12.0pt'>&quot;We
  started to see that even though we would get the injury controlled and =
fixed,
  even though we put them back together, they would die,&quot; Dr. =
Schwab said.
  Patients would go into shock, their temperatures would drop, their =
blood
  would become acidic and coagulate, forming fatal =
clots.</span></font></p>
  <p><font size=3D3 face=3D"Times New Roman"><span =
style=3D'font-size:12.0pt'>Dr. Schwab
  decided to try doing the absolute minimum surgically to stop the =
bleeding, so
  doctors could turn their attention to stabilizing the patients. Later, =
he
  reasoned, surgeons would complete their repair.</span></font></p>
  <p><font size=3D3 face=3D"Times New Roman"><span =
style=3D'font-size:12.0pt'>Dr.
  Schwab named the method damage control, a Navy term he recalled from =
the 10
  years he spent on an aircraft carrier in </span></font>Vietnam. When a =
ship
  was hit, he recalled, the idea was to patch it up and keep it afloat, =
doing
  the major repairs later. </p>
  <p><font size=3D3 face=3D"Times New Roman"><span =
style=3D'font-size:12.0pt'>He
  tried it with trauma victims. &quot;We would control bleeding and any
  contamination from the GI tract,&quot; he said. &quot;Then we would =
continue
  to resuscitate them and bring them back in two or three days and do =
definite
  surgery.&quot; </span></font></p>
  <p><font size=3D3 face=3D"Times New Roman"><span =
style=3D'font-size:12.0pt'>To
  assess the method, he compared patients treated with damage control =
with
  similar, seriously injured patients who had had traditional surgery. =
With
  damage control, 75 percent survived. With traditional surgery, almost =
every
  patient died. A decade later, after further refining of the technique, =
90
  percent are surviving, Dr. Schwab said. </span></font></p>
  <p><font size=3D3 face=3D"Times New Roman"><span =
style=3D'font-size:12.0pt'>As the
  approach spread in trauma centers across the country, military =
surgeons
  started showing up at Dr. Schwab's hospital for training. =
</span></font></p>
  <p><font size=3D3 face=3D"Times New Roman"><span =
style=3D'font-size:12.0pt'>&quot;What
  I learned from Bill Schwab was absolutely indispensable,&quot; said =
Dr.
  Jenkins, who spent two years there. &quot;I took care of people who =
for sure
  in my training we would have looked at them and said, `There is no way =
this
  person could survive.' &quot; Yet survive they did. </span></font></p>
  <p><font size=3D3 face=3D"Times New Roman"><span =
style=3D'font-size:12.0pt'>But to
  bring the technique to the battlefield, the military had to make major
  changes. First, it had to put the surgeons with the frontline troops, =
so they
  could do damage control surgery immediately.</span></font></p>
  <p><font size=3D3 face=3D"Times New Roman"><span =
style=3D'font-size:12.0pt'>The new
  idea was to keep a small surgical team on the front line, using a =
portable
  operating room that is set up in an hour for damage control surgery. =
From
  there, patients are stabilized and taken to hospitals for additional =
surgery
  days later.</span></font></p>
  <p><font size=3D3 face=3D"Times New Roman"><span =
style=3D'font-size:12.0pt'>It
  required making what once was bulky equipment light and portable, said =
Dr.
  Paul K. Carlton Jr., the recently retired surgeon general of the Air =
Force
  who now directs the </span></font>Integrative Center for Homeland =
Security at
  Texas A &amp; M. Today, Dr. Carlton said, surgeons can carry the =
equipment
  they need in a backpack.</p>
  <p><font size=3D3 face=3D"Times New Roman"><span =
style=3D'font-size:12.0pt'>For
  example, frontline units are equipped with sonogram machines the size =
of
  cassette recorders, and devices the size of a PDA that can do a =
complete
  laboratory analysis on a drop of blood.</span></font></p>
  <p><font size=3D3 face=3D"Times New Roman"><span =
style=3D'font-size:12.0pt'>Another
  piece of the plan is to train surgeons and support staff, and once =
again
  military doctors turned to urban trauma center. &quot;They have too =
many patients,&quot;
  Colonel Holcomb said. &quot;We need patients.&quot;</span></font></p>
  <p><font size=3D3 face=3D"Times New Roman"><span =
style=3D'font-size:12.0pt'>In </span></font>Miami,
  Dr. Tom Knuth, who directs the Army Trauma Training Center at Ryder =
Trauma Center,
  is training military general surgeons, plastic surgeons and other =
specialists
  and technicians and medics.</p>
  <p><font size=3D3 face=3D"Times New Roman"><span =
style=3D'font-size:12.0pt'>&quot;They
  integrate with the civil staff to manage whatever patients come =
through the
  door &#8212; bad motor vehicle crashes, gunshot wounds,&quot; Dr. =
Knuth said.
  &quot;And they get to work together as a team.&quot; With the war, the
  training regimen has been compressed from a month to 10 =
days.</span></font></p>
  <p><font size=3D3 face=3D"Times New Roman"><span =
style=3D'font-size:12.0pt'>Dr.
  Carlton said the war in </span></font>Afghanistan showed what is =
possible. Of
  250 seriously injured patients, only one died. &quot;It was the lowest
  died-of-wounds rate in the history of war,&quot; he said.</p>
  <p><font size=3D3 face=3D"Times New Roman"><span =
style=3D'font-size:12.0pt'>One man
  suffered a catastrophic wound to his rectum, prostate, anus and =
bladder. The
  ghastly injury plunged him into shock immediately, but one of the =
backpack
  surgical teams got to him right away and did a damage control surgery. =
Then,
  he was put on an airplane equipped as a critical care unit and flown a =
few thousand
  miles to another hospital for another surgery to stabilize him. Then =
he was
  flown to </span></font>Germany for reconstructive surgery.</p>
  <p><font size=3D3 face=3D"Times New Roman"><span =
style=3D'font-size:12.0pt'>&quot;He's
  home with his family now,&quot; Dr. Carlton said. In any other war, he =
added,
  &quot;he would have been dead.&quot; </span></font></p>
  </NYT_TEXT>
  <p class=3DMsoNormal><font size=3D3 face=3D"Times New Roman"><span
  style=3D'font-size:12.0pt'>&nbsp;</span></font></p>
  <p class=3DMsoNormal align=3Dcenter style=3D'text-align:center'><font =
size=3D1
  color=3D"#000099" face=3DArial><span =
style=3D'font-size:7.5pt;font-family:Arial;
  color:#000099'><a
  =
href=http://www.trauma.org/index.php/community/list/url/http:list.ftech.net/pipermail/trauma-list/2003-April/3D"http://www.nytimes.com/ref/membercenter/help/copyright.html"><NYT=
_COPYRIGHT>Copyright
  2003</a>&nbsp;<a href=http://www.trauma.org/index.php/community/list/url/http:list.ftech.net/pipermail/trauma-list/2003-April/3D"http://www.nytco.com/">The New York Times =
Company</a></span></font><font
  size=3D2 color=3D"#000099" face=3DArial><span =
style=3D'font-size:10.0pt;font-family:
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  face=3DArial><span =
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  =
href=http://www.trauma.org/index.php/community/list/url/http:list.ftech.net/pipermail/trauma-list/2003-April/3D"http://www.nytimes.com/ref/membercenter/help/privacy.html">Privac=
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 </tr>
 </NYT_COPYRIGHT>
</table>

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