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I've just finished reading "Better: A Surgeon's Notes On Performance" by Atul Gawande, and as the title suggests, it’s a clear look at ways in which doctors can do better. Gawande looks at everything from eradicating polio to handling malpractice – and treating of the injured in Iraq and Afghanistan. The chapter on how combat medicine has reduced mortality for the first time in decades is illuminating.
Rapid casualty evacuation by helicopter can only do so much. When the MASH units of the Korean War were working, mortality for combat injured was 25%. This figure remained unchanged right the way through to the first Gulf War. Doctors had to get to the casualties even quicker. The answer was Forward Surgical Teams (FST or 'Fast').
*These are small teams, composed of just twenty people: three general surgeons, one orthopoedic 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 and form a nine-hundred-foot square hospital facility. *
Supplies to immediately resuscicate and operate on the wounded are in give black nylon backpacks: an ICU pack, a surgical-technical pack, an anesthesia pack, a general-surgery pack and an orthopedic pack.
The mobile teams carry out Advanced Trauma Life Support, the lifesaving measures that are needed to stabilise the injured. Because they're ont he spot, they can often do this within the vital first few minutes. A few hours later the casualties are shipped off, in many cases still anesthetised and on a ventilator, to the next level of care, the Combat Support Hospitals. These perform the next level of treatment and the wounded are sent on to final care in the US – on average within four days, compared to 45 days in Vietnam.
Just 10 per cent of the wounded now die - down from the previous 24%, so less than half as many now die on the battlefield. This is a huge reduction, and a testimony to the effectiveness of the system and the skill of dedication of military medical teams.
Gawande also sounds a cautionary note. The improved care means that many are now surviving who would otherwise have died, including some with multiple amputations, major organ damage and other extreme injuries.
*We have never faced having to rehabilitate people with such extensive wounds. We are only beginning to learn what to do to make a life worth living for them. *
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Saving lives on the battlefield is vital. But it is only the start of the process for wounded soldiers, not the end.
