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Army textbook on war surgery. Go Army!

Robert F. Smith rfsmithmd at comcast.net
Tue Aug 5 11:44:39 BST 2008


NB I was going to edit out some of the "non-medical" stuff but I found the
censorship part pretty interesting so I left it alone.


To Heal the Wounded 

neil/index.html?inline=nyt-per>  Jr. NYTimes today.

The pictures show shredded limbs, burned faces, profusely bleeding
e=nyt-classifier>  wounds. The subjects are mostly American G.I.'s, but they
include Iraqis and Afghans, some of them young children.

They appear in a new book, "War Surgery in Afghanistan
ghanistan/index.html?inline=nyt-geo>  and Iraq
aq/index.html?inline=nyt-geo> : A Series of Cases, 2003-2007," quietly
issued by the United States Army
/index.html?inline=nyt-org>  - the first guidebook of new techniques for
American battlefield surgeons to be published while the wars it analyzes are
still being fought.

Its 83 case descriptions from 53 battlefield doctors are clinical and bone
dry, but the gruesome photographs illustrate the grim nature of today's
wars, in which more are hurt by explosions than by bullets, and body armor
leaves many alive but maimed. 

And the cases detail important advances in treating blast amputations,
massive bleeding, bomb concussions
line=nyt-classifier>  and other front-line trauma.

Though it is expensively produced and includes a foreword by the ABC
correspondent Bob Woodruff
ndex.html?inline=nyt-per> , who was severely injured by a roadside bomb in
2006, "War Surgery" is not easy to find. There were strenuous efforts within
the Army over the last year to censor the book and keep it out of civilian

Paradoxically, the book is being issued as news photographers complain that
they are being ejected from combat areas for depicting dead and wounded

But efforts to censor the book were overruled by successive Army surgeons
general. It can be ordered from the Government Printing Office for $71;
Amazon.com lists it as out of stock, but the Borden Institute, the Army
medical office that published it, said thousands more copies would be

"I'm ashamed to say that there were folks even in the medical department who
said, Over my dead body will American civilians see this," said Dr. David E.
Lounsbury, one of the book's three authors. Dr. Lounsbury, 58, an internist
and retired colonel, took part in the 1991 and 2003 invasions of Iraq and
was the editor of military medicine textbooks at Walter Reed Army
lter_army_medical_center/index.html?inline=nyt-org>  Medical Center. 

"The average Joe Surgeon, civilian or military, has never seen this stuff,"
Dr. Lounsbury said. "Yeah, they've seen guys shot in the chest. But the kind
of ferocious blast, burn and penetrating trauma that's part of the modern
I.E.D. wound is like nothing they've seen, even in a Manhattan emergency
room. It's a shocking, heart-stopping, eye-opening kind of thing. And they
need to see this on the plane before they get there, because there's a
learning curve to this."

The pictures of wounded children include some of a 5-year-old shot in a
vehicle trying to run through a checkpoint. Other pictures show wounds
riddled with dirt, genitals severed by a roadside bomb, a rib - presumably
that of a suicide bomber - driven deep into a soldier's body, and the tail
of an unexploded rocket protruding from a soldier's hip.

There are moments that reflect the desperation in the invaded country: an
Afghan in the jaw-locked rictus of tetanus
e=nyt-classifier>  after home-treating a foot blown off by a landmine. And
moments that reflect the modern American army: a soldier with unexplained
pelvic pain that turns out to be a life-threatening ectopic
html?inline=nyt-classifier>  pregnancy. 

The book was created to teach techniques that surgeons adopted, abandoning
old habits. 

For example, they no longer pump saline into a patient with massive trauma
to try to get the blood
nline=nyt-classifier>  pressure back up to 120. "You do that, you end up
with a highly diluted, cold patient with no clotting factors, and the high
pressure restarts bleeding," Dr. Lounsbury said. Instead, they try to bring
it up to just 80 or 90 with red cells and extra platelets, which encourage

Also, initial surgery even on a severely wounded patient may be brief - just
enough to control hemorrhaging and prevent contamination by a torn bowel.
Then the patient is returned to intensive care to warm up, raise the blood
pressure and restore the electrolyte balance. The next operation is usually
just enough to stabilize the patient for transport to a more sophisticated
hospital, perhaps in Baghdad or Kabul, in Germany or the United States. 

The book describes a surgeon who erred fatally by trying to do too much - a
four-hour operation on a soldier who had lost a leg to a roadside bomb. The
effort drained the forward hospital's blood bank, and the patient died on
the helicopter to the next hospital.

Also, neurosurgeons treating a blast victim now quickly remove a large
section of the skull to relieve pressure, even if no shrapnel has
penetrated. Such patients are sometimes able to walk and talk after a blast
but then collapse and die as their brain swells.

The procedure is described by the surgeon who saved Mr. Woodruff's life that

Amputations have also changed. Dr. Lounsbury's brother lost both legs and an
arm in Vietnam, and in those days clean "guillotine" amputations were done
as high as possible. Now surgeons try to preserve as much bone and flesh as
they can, even if the stump is unsightly. Modern prosthetics are molded to

Doctors have also become quicker to diagnose "compartment
ew.html?inline=nyt-classifier>  syndrome" even in patients too sedated to
feel pain; swelling
ine=nyt-classifier>  in an injured muscle can cut off the blood supply,
leading to gangrene
inline=nyt-classifier>  and amputation. Surgeons now "fillet" the muscles to
relieve the pressure, often even before it builds, since restitching healthy
tissue is better than losing a limb.

And when morphine is not enough, nerve blocks - internal drips of local
anesthetic, often given by a small pump held by the patient - have become
common in pain control.

Dr. Ramanathan Raju, chief medical officer for the New York City Health and
Hospitals Corporation and a former trauma surgeon, viewed the book and said
it would be "extremely useful" to civilian surgeons because of what it
teaches about blast injuries and when a surgeon should stop to let a patient

"The Army should be very happy about this," Dr. Raju said. "In the past,
people said, Oh, Army surgeons are like butchers, they're not research
oriented. This shows how skillful they are."

One of the book's most powerful aspects is its juxtaposition of operating
room photographs with those of the war outside the tent. It is filled with
random shots - burning vehicles, explosions, a medic carrying a child,
another in a Santa Claus hat. It also has portraits of soldiers, often dazed
and exhausted; one even has tears on his cheek. 

Many are by David Leeson of The Dallas Morning News, who was embedded with
the Third Infantry Division during the Iraq invasion and won a Pulitzer
zes/index.html?inline=nyt-classifier>  for his coverage. 

Even more humanizing are photos of recovered patients: an Iraqi whose jaw
was destroyed shown with it rebuilt, a soldier who lost half of his skull
smiling at a ceremonial dinner with his wife, a soldier whose face was
pulverized by a blast looking scarred but handsome a year later.

Military censors suggested numerous changes, including removing photos
showing burning vehicles and the faces of any American wounded. They also
wanted to excise references to branches of service and how injuries

For example, according to unclassified e-mail provided by the authors, one
suggested removing this description: "A helmeted soldier suffered a forehead
injury during the explosion of an improvised explosive device. He was a
front seat passenger" in a Humvee. The censor suggested: "A 22-year-old male
was hurt in a blast."

Two in the chain of command who raised such objections - one civilian and
one officer - said they did so only out of concern for patients' privacy and
for security reasons. For example, they said, mentions of wound patterns
might tell the enemy that helmets and Humvees were vulnerable. 

But the authors argued that it was crucial for surgeons to expect wounds
behind armor and absurd to conceal that they occurred.

"The enemy knows that," said Dr. Stephen P. Hetz, a retired colonel and

They also argued that the book was dedicated to soldiers and marines and
that the wounded were proud to be identified as such. All whose faces were
fully shown, whether American, Iraqi or Afghan, had given written
permission, they said. If it was not obtained, patients' eyes were covered
with black bars. The random war photos, they argued, were as much as five
years old and some had been in newspapers, so they would give enemies no
useful information.

Censors also tried to prevent the book from getting a copyright and the
international standard book number letting it be sold commercially, Dr.
Lounsbury said.

Ultimately, they were overruled.

Kevin C. Kiley, a retired lieutenant general who was the Army's surgeon
general when the book was being prepared, said some higher-ups in the
military had been worried that the pictures "could be spun politically to
show the horrors of war." 

"The counter-argument to that, which I concurred with," Dr. Kiley said, "was
that this is a medical textbook that could save lives."

He said it "absolutely" ought to be available to civilians, particularly to

Dr. Hetz said that as a West Point
states_military_academy/index.html?inline=nyt-org>  graduate and onetime
infantry officer - and as a former aide to two surgeons general, to whom he
could appeal directly - he always had more faith than Dr. Lounsbury that the
book would ultimately not be suppressed.

"There was never any doubt in my mind that the Army would publish this," he
said. "It was just a matter of getting around the nitwits."


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