A8
EZ SU THE FRONT LINES OF SAVING LIVES
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SUNDAY, OCTOBER 17, 2010
PHOTOS BY LINDA DAVIDSON/THE WASHINGTON POST U.S. soldiers carry a wounded colleague with a tourniquet onto a medical helicopter.Acombination of ultramodern and time-honored techniques keep the wounded alive in the minutes before they reach a hospital.
On the battlefield, extreme emergency medicine 6
medevac from A1 The helicopter lands, stirring
upa cloudofmoondust thatnear- ly obscures six soldiers kneeling and standing around the wound- ed man, 50 feet from the aircraft. Their headlamps make tiny blue searchlights. The 28-year-old flightmedic, Sgt. ColeReece, runs towardthem. Cpl. Deanna Helfrich, 22, the
crew chief, climbs out of her win- dowandwalks around the nose of the aircraft trailing a communica- tioncable thatallowsher totalkto the rest of the crew. She stands near the open door where the wounded soldier will be brought, holdingher rifle. Theweapon is a reminder: The
crewisheretosavelives,butRule1 of the BasicManagement Plan for Care Under Fire is “Return fire andtake cover.” There is no enemy fire this eve-
ning, but there is somuch dust in the air andthe rotors are spinning sofast that theleadingedgesof the blades light up like sparklers, flint onsteel. Fifteen minutes have now
passed since the soldier was wounded. The details of how it happened don’t matter to Reece. There are a limited number of things he can do between this nameless spot and the hospital at Kandahar Airfield, where they will soon be headed. What he needs to knowhewill see and feel forhimself. Speed, simplicity and priority
have always beenthehallmarks of emergency medicine. The new battlefield care that flight medics like Reece and others on the ground practice takes those attri- butes to the extreme. Gone from their repertoire are
difficult or time-consuming ma- neuvers, such as routinely hang- ing bags of intravenous fluids. On the ground,medics no longer car- ry stethoscopes or blood pressure cuffs. They are trained instead to evaluate a patient’s status by ob- servation and pulse, to tolerate abnormal vital signs such as low blood pressure, to let the patient position himself if he’s having trouble breathing—and above all to have a heightened awareness that too much medicine can en- danger the mission and still not save thepatient. Four people run to the helicop-
ter with the stretcher holding the wounded soldier. He lies on his back partially wrapped in a foil blanket. His chest is bare. In the middle of it is an intraosseous device, a large-bore needle that has been punched into his breast- bone by themedic on the ground. It’s used to infuse fluids and drugs directly into the circulatory sys- temwhenaveincan’tbefound. It’s a no-nonsense technology, used occasionally inWorldWar II, that fell out of favor when cheap and durable plastic tubing made IV catheters ubiquitous in the post- war years.Until theywere revived for the IraqandAfghanistanwars, intraosseousdeviceswereusedal- most exclusively in infants whose
on
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severely injuredpatients, adimin- ishinglevelofconsciousness isnot a goodsign. Reece reaches for a 500-millili-
ter bag of Hextend — an intrave- nous fluidcontainingstarchmole- cules that help boost blood pres- surebypreventingthewaterypart of blood from leaking out of ves- sels, as often happens in massive trauma. He squeezes the bag to make it run in more quickly through the device in the soldier’s breast bone. The soldier’s next blood pres-
sure reading is 116/71. Just two minutes away, Reece
leans forwardandtells thepatient they’re almost there.
Communication glitch Eleven minutes after lifting off
Sgt. Cole Reece runs through Afghan “moon dust” to reach soldiers wounded by an improvised explosive device in Kandahar province.
veinswere too small to find. On each leg the soldier has a
tourniquet, ratcheted down and locked to stop all bleeding below it. These ancient deviceswent out of military use more than half a century ago because of concern that they caused tissue damage. But research in the past 15 years has shown that they can be left on for twohourswithoutcausingper- manent harmto limbs.Nowevery soldier carries a tourniquet and is instructed to put one on any se- verelybleedinglimbandnot think of taking it off. Tourniquets have saved at least
1,000 lives, and possibly as many as 2,000, in the past eight years. This soldier is almost certainly one of them. They’re a big part of whyonly about 10percentof casu- alties in these wars have died, comparedwith 16 percent inViet- nam. On the soldier’s left leg, the
tourniquet is above theknee.Both bones below his knee are broken, and the limb is bent unnaturally inward. The tourniquet on his right leg is lower, below the knee; how badly his foot is injured is hardtotell fromthedressings.His left hand is splinted and ban- daged, too. Whether hewill need an ampu-
tation is uncertain. The hospital where he’s headed treated 16 pa- tientsinSeptemberwhoneededat least one limb amputated. Half wereU.S. soldiers, andthemonth- lynumberhasbeenclimbingsince March. The man is covered in moon
dust, and pale beneath it, but con- scious and able to pay some atten- tion to Reece.He’s gotten 10milli-
An Afghan boy, wounded by shrapnel in a mortar fight betweenU.S. and Taliban forces, rests as a medical evacuation helicopter carries him to a hospital. The boy’s brother was killed in the battle.
grams ofmorphine,not a lot. First thing, the medic hooks a
plastic tube to anoxygentank and leans forward and puts a face mask on the soldier’s head. He tellshimover thedinof the engine that he’ll be okay, that they’ll be at thehospital in10minutes. After three minutes on the ground, thehelicopter takes off.
Stanch the bleeding The interior of the helicopter is
litbyasingleoverheadlight,head- lamps and the glow of instru- ments. Reece tells Helfrich to check the tourniquets; things sometimes move in transit. He then pulls back the foil blanket and inspects.Atangle of dry grass lies directly over the soldier’s na- vel.
Themedicsees thatalaceration
in the soldier’s left groin is still bleeding. This, too, is a signature
wound of the two wars — a deep, dangerous injury just outside the protective veil of body armor and unable to be treatedwitha tourni- quet. It’s a wound from which a person can easily bleed to death. Death fromblood loss has always been the greatest hazard of war wounds. A recent analysis found that of
soldiers deemed to have “poten- tially survivable” wounds, 80 per- cent died of bleeding. Usually the wound site was a part of the body where a tourniquet couldn’t be applied. Thebestoption—not ideal—is
to stuff the gash with Combat Gauze,abattlefieldtreatmentnew to the currentwars. It’s a bandage impregnated with a kind of pow- dered porcelain that stimulates clotting.Themedic on the ground had already packed the wound with it. Reece unwraps some
more, lays it across the injury and asksHelfrich to apply direct pres- sure. Heundoes theVelcrosleeveof a
blood-pressure cuff and puts it on the soldier’s right arm. He puts three stick-on EKG leads on the man’s chest and abdomen, a right triangle. Theman reaches up and touches his forehead, a self-con- firming gesture. When he’s done, the medic gently takes the hand and puts on the ring finger the toothless plastic jaws of a pulse oximeter—adevicethatmeasures the oxygen content of the blood through the skin. The soldier has lost a lot of blood. If his breathing falters and he can’t oxygenate what’s left,hewilldie. The first blood pressure read-
ingis96/40.Normal is120/80.The soldier’sheart rateiswayover 100, but theexactnumber is irrelevant. Nobodywho’s just had something blow up in front of him has a normal heart rate even if the blast hasdonenothing tohim. Everyminute or so, Reece puts
his right hand,which is in a black rubber glove, onto the soldier’s head and rubs the center of his forehead. This is to stimulate him and gauge his level of conscious- ness. Itmay also reassure. Thepulseoximeter gives a reas-
suring reading. Several minutes into the trip themedic senses the soldier becoming drowsy and in- serts a green plastic tube into his left nostril. This “nasopharyngeal airway” will make it easier, if the man becomes unconscious, for Reece to keephimalive. While blood pressure some-
what below normal is considered all right—andevenpreferred—in
fromthe POI, the helicopter lands at the so-called Role 3, or fully equipped, hospital at Kandahar Airfield, about 30miles to the east of the also well-fortified Forward Operating Base Wilson. There, surgeonswill take care of the inju- ries before transferring the pa- tient,probablywithintwodays, to the huge military hospital in Landstuhl, Germany, and there, after a week or so, to the United States. But somethinghashappenedin
the usually smooth communica- tion between dispatch center, air- craft and hospital. No ambulance pulls up to the helicopter. Reece andHelfrichwait. Theywait. The pilots radio the dispatcher
that they’vearrivedwithacritical- ly injured soldier. Reece and Hel- frich, helmeted and inaudible, gesture wildly to people outside the emergency roomdoor to come over. Two other patients have also
recently arrived.But that’snot the problem. There’s an available am- bulance 100 yards away. But it doesn’tmove. Five minutes after touchdown,
it finally drives up and the injured manis rushedintotheback.Reece says later hewas oneminute from having the crew carry the patient to the emergency room them- selves, even though running that distancewith a trauma patient on a litter is just about the last thing youwant todo. It’s been 28 minutes since the
helicopter left ForwardOperating BaseWilson.Theambulance,with Reece in it, disappears into a pool of greenish light at the hospital entrance. In 10 minutes, the medic re-
turns and the helicopter takes off to begin the refueling, restocking and cleaning that will make it ready, in less than an hour, for the next call. It’s for an Afghan man, de-
scribed as a Taliban fighter, who has steppedona landmine.
browndm@washpost.com
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