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Wed Aug 6 04:17:08 BST 2008

Well the article talked a lot about attempted censorship on the book. I
thought it was great that the authors persevered and presented what should
be a vitally important contribution.

Rob Smith

-----Original Message-----
From: trauma-list-bounces at trauma.org [mailto:trauma-list-bounces at trauma.org]
On Behalf Of McSwain, Norman E Jr.
Sent: Tuesday, August 05, 2008 5:11 PM
To: Trauma &amp; Critical Care mailing list
Subject: RE: Army textbook on war surgery. Go Army!

Not sure I  understand the "censorship" thing that you mentioned. I went
to the US Gov't Printing Office website, found it immediately and
ordered a copy. I encountered no problems. Military friends seem to know
about it.

Norman

Norman McSwain MD

Professor, Tulane School of Medicine

Trauma Director, Charity Hospital Trauma Center

norman.mcswain at tulane.edu <mailto:norman.mcswain at tulane.edu> 

504 988 5111

From: trauma-list-bounces at trauma.org
[mailto:trauma-list-bounces at trauma.org] On Behalf Of Robert F. Smith
Sent: Tuesday, August 05, 2008 5:45 AM
To: 'Trauma &amp; Critical Care mailing list'
Subject: Army textbook on war surgery. Go Army!

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 

By DONALD G. McNEIL
<http://topics.nytimes.com/top/reference/timestopics/people/m/donald_g_j
r_mcneil/index.html?inline=nyt-per>  Jr. NYTimes today.

The pictures show shredded limbs, burned faces, profusely bleeding
<http://health.nytimes.com/health/guides/injury/bleeding/overview.html?i
nline=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
<http://topics.nytimes.com/top/news/international/countriesandterritorie
s/afghanistan/index.html?inline=nyt-geo>  and Iraq
<http://topics.nytimes.com/top/news/international/countriesandterritorie
s/iraq/index.html?inline=nyt-geo> : A Series of Cases, 2003-2007,"
quietly issued by the United States Army
<http://topics.nytimes.com/top/reference/timestopics/organizations/a/us_
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
<http://health.nytimes.com/health/guides/disease/concussion/overview.htm
l?inline=nyt-classifier>  and other front-line trauma.

Though it is expensively produced and includes a foreword by the ABC
correspondent Bob Woodruff
<http://topics.nytimes.com/top/reference/timestopics/people/w/bob_woodru
ff/index.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 hands.

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

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 printed.

"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 Medical Center
<http://topics.nytimes.com/top/reference/timestopics/organizations/r/ree
d_walter_army_medical_center/index.html?inline=nyt-org> . 

"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
<http://health.nytimes.com/health/guides/disease/tetanus/overview.html?i
nline=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 pregnancy
<http://health.nytimes.com/health/guides/disease/ectopic-pregnancy/overv
iew.html?inline=nyt-classifier> . 

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 pressure
<http://health.nytimes.com/health/guides/test/blood-pressure/overview.ht
ml?inline=nyt-classifier>  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 clotting.

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 way. 

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 it. 

Doctors have also become quicker to diagnose "compartment syndrome
<http://health.nytimes.com/health/guides/disease/compartment-syndrome/ov
erview.html?inline=nyt-classifier> " even in patients too sedated to
feel pain; swelling
<http://health.nytimes.com/health/guides/symptoms/swelling/overview.html
?inline=nyt-classifier>  in an injured muscle can cut off the blood
supply, leading to gangrene
<http://health.nytimes.com/health/guides/disease/gas-gangrene/overview.h
tml?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 recover.

"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 Prize
<http://topics.nytimes.com/top/reference/timestopics/subjects/p/pulitzer
_prizes/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
occurred.

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
co-author.

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 surgeons. 

Dr. Hetz said that as a West Point
<http://topics.nytimes.com/top/reference/timestopics/organizations/u/uni
ted_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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Army textbook on war surgery. Go Army!