Amputees double in rate

Amputation rate for U.S. troops twice that of past wars

By Raja Mishra
Boston Globe

U.S. troops injured in Iraq have required limb amputations at twice the rate of past wars, and as many as 20 percent have suffered head and neck injuries that may require a lifetime of care, according to new data giving the clearest picture yet of the severity of battlefield wounds.

The data are the grisly flip side of improvements in battlefield medicine that have saved many combatants who would have died in the past: Only 1 in 10 U.S. troops injured in Iraq has died, the lowest rate of any war in U.S. history.

But those who survive have much more grievous wounds. Bulletproof Kevlar vests protect soldiers' bodies but not their limbs, as insurgent snipers and makeshift bombs tear off arms and legs and rip into faces and necks. More than half of those injured sustain wounds so serious they cannot return to duty, according to Pentagon statistics.

Much attention has focused on the 1,000-plus soldiers killed in Iraq, but the Pentagon has released little information on the 9,765 soldiers injured as of this week.

"The death rate isn't great compared to Vietnam, Korea, and World War II. But these soldiers are coming back to their communities and people are seeing just how high the price is that these young people are paying," said Dr. G. Richard Holt, a head and neck surgeon at the University of Texas Health Science Center in San Antonio and a retired U.S. Army surgeon who served as a civilian adviser in Iraq earlier this year.

Responding to the large number of amputations, scientists at Brown University in Providence and the Massachusetts Institute of Technology Wednesday announced a $7.2 million research program to design more functional prosthetic limbs. The U.S. Department of Veterans Affairs is paying for the work.

Data compiled by the U.S. Senate, and included in the 2005 defense appropriations bill in support of a request for increased funding for the care of amputees at Walter Reed Army Medical Center, reveal that 6 percent of those wounded in Iraq have required amputations, compared with a rate of 3 percent for past wars.

According to Brown Medical School's Dr. Roy Aaron, the current VA medical system "literally cannot handle the load" of amputees.

Aaron is heading up the Brown-MIT effort, which will also include the Providence VA Medical Center.

"Amputee research has never been a high priority because it's not . . . fashionable," said Aaron. "Iraq has changed that."

Stephan Fihn, acting VA chief research and development officer, said that military officials were concerned about the expected flood of amputees but that the system would "absolutely, without a doubt" be able to handle them.

"Returning veterans from Iraq and Afghanistan are our highest priority now," he said.

The new Brown-MIT effort, funded for five years by the VA, will research methods to build better titanium prosthetic limbs, extend bone stumps for tighter attachment of prosthetics, and use computer technology to develop prosthetic devices that can be controlled by brain sensors implanted in patients. However, the advances will not be ready for years, and many Iraq veterans will not immediately benefit, said Aaron.

In Thursday's New England Journal of Medicine, journalist and Harvard surgeon Dr. Atul Gawande, writes: "The nation's military surgical teams are under tremendous pressure, but they have performed remarkably in this war. They have transformed the strategy for the treatment of war casualties."

In World War II, about 30 percent of those wounded died, and in Vietnam the figure was 24 percent. In Iraq and Afghanistan, the mortality rate has been 10 percent.

Gawande and others credited improvements made after Vietnam, when medics noted that most soldiers who made it to surgical facilities survived. In Iraq, military field surgical teams work just behind front lines, with four surgeons and a nursing team able to erect a four-bed surgical unit in one hour. In the current conflict, the average time it takes a wounded soldier to go from the battlefield to front-line care and on to full-service military hospitals in Germany, Kuwait, and Spain has been about four days, compared with weeks in previous wars.

In addition to amputations, many soldiers making this journey have head and neck injuries, frequently injured by improvised explosive devices, or IEDs, essentially remote-controlled bombs planted in the ground.

"The angle of the force of these IEDs is right for the neck and face. That's been devastating to folks over there," said Holt, explaining that Kevlar helmets do not protect the underside of heads and necks, where crucial nerves and blood vessels lie.

Lieutenant Colonel Michael S. Xydakis, a military surgeon, released a little-noticed study in September at a medical conference of head and neck surgeons. He found that over a 14-month period, about 1 in 5 US soldiers treated at Landstuhl Regional Medical Center in Germany, which handles most Iraq casualties, had head or neck injuries.

These injuries, surgeons said, have long-term implications, with many involving irreversible brain damage, breathing and eating impairments, blindness, or severe disfiguration. The study prompted the military to add a full-time head and neck surgeon to a Baghdad field hospital.

"These folks are just starting to come back, and they may require care for a long, long time," said Holt.

© 2004 Times Argus