Lasting head injuries on rise in Iraq
BY KARL VICK: The Washington Post;; April 28, 2004
MORE AND MORE, combat surgeons say, soldiers have been left
brain-damaged or blind, or both, largely the result of makeshift
roadside bombs and firefights. Beleaguered neurosurgeons and
ophthalmologists, who see the worst of the casualties, struggle to save
many patients who will never regain consciousness. As the numbers
climb, the toll on the medical staff is itself acute, and unrelenting.
BAGHDAD, Iraq - The soldiers were lifted into the helicopters
under a moonless sky, their bandaged heads grossly swollen by trauma,
their forms silhouetted by the glow from the row of medical monitors
laid out across their bodies, from ankle to neck.
An orange screen atop the feet registered blood pressure and
heart rate. The blue screen at the knees announced the level of
postoperative pressure on the brain. On the stomach, a small gray
readout recorded the level of medicine pumping into the body. And the
slender plastic box atop the chest signaled that a respirator
still breathed for the lungs under it.
At the door to the busiest hospital in Iraq, a wiry doctor bent
over the worst-looking case, an Army gunner with coarse stitches
holding his scalp together and a bolt protruding from the top of his
head. Lt. Col. Jeff Poffenbarger checked a number on the blue screen,
announced it dangerously high and quickly pushed a clear liquid through
a syringe into the gunner's bloodstream. The number fell like a rock.
"We're just preparing for something a brain-injured person
should not do two days out, which is travel, to Germany," the
neurologist said. He smiled grimly and started toward the UH-60 Black
Hawk thwump-thwumpmg out on the helipad, waiting to spirit out of Iraq
one more of the hundreds of Americans wounded here this month.
While attention remains
riveted on the rising count of Americans killed in action - more
than 100 so far in April - doctors at the main combat
support hospital in Iraq are reeling from a stream of young soldiers
with wounds so devastating that they probably would have been fatal in
any previous war.
More and more
in Iraq, combat surgeons say, the wounds involve severe damage to the
head and eyes - injuries that leave soldiers brain--damaged or blind,
or both, and the doctors who see them first struggling against despair.
For months the gravest wounds have been caused by roadside bombs
- improvised explosives that negate the protection of Kevlar helmets by
blowing shrapnel and dirt upward into the face. In addition, firefights
with guerrillas have surged recently, causing a sharp rise in head
'Intellectually, you tell
yourself you're prepared.
You do the reading. You
study the slides. But being
here ... it's just the sheer volume.'
MAJ. Richard Gullick
The neurosurgeons at the 31st Combat Support Hospital measure
the damage in the number of skulls they open to get to the injured
brain inside, a procedure known as a craniotomy. "We've done more in
eight weeks than the previous neurosurgery team did in eight months,"
Numbers tell part of the story. So far in April, more than 900
soldiers and Marines have been wounded in Iraq, more than twice the
number wounded in October, the previous high. With the tally still
climbing, this month's injuries account for about a quarter of the
3,864 U.S. servicemen and women listed as wounded in action since the
March 2003 invasion.
About half the wounded troops have suffered injuries light
enough that they were able to return to duty after treatment, according
to the Pentagon.
The others arrive on stretchers at the hospitals operated by the
31st CSH. "These injuries," said Lt. Col. Stephen Smith, executive
officer of the Baghdad facility, "are horrific."
By design, the Baghdad hospital sees the worst. Unlike its
sister hospital on a sprawling air base located in Balad, north of the
capital, the staff of 300 in Baghdad includes the only ophthalmology
and neurology surgical, teams in Iraq, so if a victim has damage to the
head, the medevac sets out for the facility here, located in the
heavily fortified coalition headquarters known as the Green Zone.
Once there, doctors scramble. A patient might remain in the
combat hospital for only six hours. The goal is lightning-swift, expert
treatment, followed as quickly as possible by transfer to the military
hospital in Landstuhl, Germany.
While waiting for the helicopters, the Baghdad medical staff
studies photos of wounds they used to see once or twice in a military
campaign but now treat every day. And they struggle with the
implications of a system that can move a wounded soldier from a
booby-trapped roadside to an operating room in less than an hour.
"We're saving more people
than should be saved, probably," Lt. Col. Robert Carroll said. "We're saving severely injured people.
Legs. Eyes. Part of the brain."
Carroll, an eye surgeon from Waynesville, Mo., sat at his desk
during a rare slow night last Wednesday and called up a digital photo
on his laptop computer. The image was of a brain opened for surgery
earlier that day, the skull neatly lifted away, most of the organ
healthy and pink. But a thumbsized section behind the ear was gray.
"See all that dark stuff
That's dead brain," he said. "That ain't gonna regenerate. And that's
not uncommon. We do craniotoimes on average, lately, of one a day."
"We can save
you," the surgeon said. "You might not be what you
Accurate statistics are not yet available on recovery from this
new round of battlefield brain injuries, an obstacle that frustrates
combat surgeons. But judging by medical literature and surgeons'
experience with their own patients, "three or four months from now, 50 to
60 percent will be functional and doing things," said Maj.
he said, means "up
and around, but with pretty significant disabilities," including
40 percent to 50 percent of patients include those whom the surgeons
send to Europe, and on to the United States, with no prospect of
regaining consciousness. The practice, subject to review after
gathering feedback from families, assumes that loved ones will find
value in holding the soldier's hand before confronting the decision to
remove life support.
"I'm actually glad I'm here and not at home, tending to all the
social issues with all these broken soldiers," Carroll said.
But the toll on the combat medical staff is itself acute, and
In a comprehensive Army survey of troop morale across Iraq,
taken in September, the unit with the lowest spirits was the one that
ran the combat hospitals until the 31st arrived in late January. The
three months since then have been substantially more intense.
"We've all reached our saturation for drama trauma," said Maj.
Greg Kidwell, head nurse in the emergency room.
On April 4, the hospital received 36 wounded in four hours. A
U.S. patrol in Baghdad's Sadr City slum was ambushed at dusk, and the
battle for the Shiite Muslim neighborhood lasted most of the night. The
event qualified as a “mass casualty,” defined as more casualties than
can be accommodated by the 10 trauma beds in the emergency room.
"I'd never really seen a 'mass cal' before April 4," said Lt.
Col. John Xenos, an orthopedic surgeon from Fairfax, Va. "And it just
kept coming and coming. I think that week we had three or four mass
The ambush heralded a wave of attacks by a Shiite militia across
southern Iraq. The next morning, another front erupted when Marines
cordoned off Fallujah. The engagements there led to record casualties.
"Intellectually, you tell yourself you're prepared," said
Gullick, from San Antonio. "You do the reading. You study the slides.
But being here ... it's just the sheer volume."
In part, the surge in casualties reflects more frequent
firefights after a year in which roadside bombings made up the bulk of
attacks. At the same time, insurgents began planting improvised
explosive devices (IEDs) in what one officer called "ridiculous
The improvised bombs are extraordinarily destructive. They're
detonated by remote control and may be packed with such debris as
broken glass, nails, sometimes even gravel.
To protect against the blasts, the U.S. military has wrapped
many of its vehicles in armor. Troops wear armor as well, providing
protection that Gullick called "orders of magnitude from what we've had
before. But it just shifts the injury pattern from a lot of abdominal
injuries to extremity and head and face wounds."
The skull of the Army gunner whom Poffenbarger was preparing for
the flight to Germany had been pierced by shrapnel from four 155mm
shells, rigged to detonate one after another in what soldiers call a
“daisy chain.” The shrapnel took a fortunate route, through his brain,
however, and "when all is said and done, he should be independent. ...
He’ll have speech, cognition, vision."
On a nearby stretcher, Staff Sgt. Rene Fernandez struggled to
see from eyes bruised nearly shut.
"We were clearing the area and an IED went off," he said,
describing an incident outside Ramadi where his unit was patrolling on
The Houston native counted himself lucky, escaping with a
concussion and facial wounds. Waiting for his own hop to the hospital
plane headed north, he said what most soldiers tell surgeons: What he
most wanted was to return to his unit.