Journey of the war's wounded

When Tammy Duckworth woke up Nov. 20 at Walter Reed Medical Center in Washington, D.C., she had no idea of the journey she had taken the previous eight days.

She had no idea that she was missing almost all of her right leg up to her hipbone or that her left leg was gone just below the knee. The 36-year-old Army National Guard pilot could feel the bandage over her broken right arm but didn't realize she might lose it if doctors couldn't restore its blood supply.

And Duckworth, who was plucked from her crippled Blackhawk helicopter after a rocket-propelled grenade tore through her cockpit as she was flying across Iraq, wouldn't understand until the haze of medication lifted that she was one of the lucky ones.

If it had happened during World War II, Vietnam or even the Gulf War, doctors believe Duckworth, who lost nearly half of her blood from the assault, would have died. But a revamped emergency medical system rushed her to battlefield surgeons, saving her life. It has been the same for thousands of other injured soldiers, Marines and airmen whose bodies have been mangled, burned and shattered in attacks since the war in Iraq began March 19, 2003. In any other combat, at any other time, doctors say they would have died.

Chances of surviving have increased with every war of any duration the United States has fought. During World War II, roughly one in three injured troops died. In the Korean, Vietnam and Gulf wars, it was about one in four.

Today, it's down to one in eight.

Military leaders point to three changes behind a higher survival rate in the Iraq war: They gave troops better body armor, put surgeons into field hospitals closer to combat and created an air evacuation plan to get the wounded to surgical care within an hour.

Undoubtedly, one other contributing factor is the advances in the first aid carried by medics traveling with the troops. One such advance is QuikClot, a mineral powder that adheres to exposed tissue and helps blood clot. Bleeding is a primary reason so many wounded die.

Fellow troop members and medics provide initial treatment and prepare the wounded for the air or land transport to whichever is nearer: a 20-person forward surgical team, called an FST, that operates out of six Humvees and can fashion a tent-draped hospital in minutes, or one of the larger combat area support hospitals, known as CASH, that operate out of tents on former Iraqi airbases. A CASH typically has at least 15 surgeons and equipment such as X-ray machines.

The wounded cannot stay in either spot for long. There is no room. The higher survival rate means that a higher volume of wounded is flowing through the medical system.

The goals are to keep the patient alive and with as many body parts as possible and to whisk him or her out of harm's way in Iraq to the Landstuhl Regional Medical Center in Germany, the largest U.S. hospital in Europe.

Helping get them to Landstuhl is the newest, and what some call the most important, leg of the medical journey: a ride on a Critical Care Air Transport helicopter.

These "flying ICUs" are the workstations for doctors and nurses who tend to patients during the eight-hour flight. Landstuhl is the last, albeit usually brief, stop for the wounded before they return to their units or come to the United States for more surgery or rehabilitation.

Nearly 6,000 wounded troops (at least 250 from Arizona) have gone in and out of Landstuhl since the start of Operation Iraqi Freedom. But more than 1,500 troops (including 44 from Arizona) have died, most before getting to Landstuhl. In Vietnam, most of the 58,000 deaths happened before the wounded could ever reach a surgeon, a wait of several hours or more. During the Gulf War, field hospitals were put closer to the action, but there was still a delay in transporting the wounded to intensive care.

For the war in Iraq, military officials knew they would need a larger number of mobile medical teams that were closer to combat and could get to the wounded by air or land within the "golden hour," that daunting 60-minute window before a battered body begins to shut down. Even in the Gulf War, it could take several hours.

Suicide car bombs, improvised explosive devices and RPGs have ripped into bodies with such trauma that immediate treatment is necessary to prevent shock or death from loss of blood.

The RPG that struck Capt. Tammy Duckworth shredded one leg, crushed the other and badly damaged her right forearm, breaking it in three places. She had seen a fireball hit below her feet and thought the helicopter engine had been taken out. Communications inside the aircraft were gone, so Duckworth couldn't speak to the pilot, Chief Warrant Officer Dan Milberg, who was observing her flying that day. They both tried to land the chopper as Duckworth was fading in and out. The last thing she saw before she blacked out and fell forward was grass coming through the floor bubble. Milberg had managed to set the chopper down in a date grove.

It was then that he turned to Duckworth and could see her massive injuries. He thought she was dead.

Flying behind them, another pilot had already radioed for a medical evacuation helicopter, and troops on the ground rushed to do what they could, giving "Buddy Care," the basic first-aid training all troops are taught before they're deployed.

In cases like Duckworth's, it's a life-or-death battle to stop the bleeding. Medics traveling with troops can rip open and apply a packet of QuikClot powder, one of the newest medical weapons. Every soldier carries a plastic ring tourniquet that, with just one hand, can be slipped above a wound and pulled tight with a hand or mouth.

Duckworth's femoral artery was severed when her right leg was torn off. She could bleed out within five minutes. The wound was so jagged and so near her hip that getting a tourniquet on was nearly impossible. Medics couldn't stop the blood flow, but they pressed on the wound and slowed it down.

A helicopter flew Duckworth to a CASH in Baghdad where surgeons amputated her right leg a few inches below her hip bone and cut off her left leg just below the knee. They reset the bones in her arm and stitched the cuts.

A stretcher carried her out to a Critical Care Air Transport helicopter, and Duckworth was bound for the 350-bed Landstuhl hospital. But it was just a pit stop. She was in and out within hours, finally arriving at 10 p.m. Nov. 14 at Walter Reed. Not even 60 hours had passed since the RPG exploded into her legs.

During Vietnam, if the soldier had lived, it could have taken a month to 45 days to get to a stateside military hospital.

Landstuhl

Not everyone gets to leave Landstuhl as quickly as Duckworth. About 15 percent are too sick or too unstable to move and may stay for weeks.

At Landstuhl, the goal is to clean wounds, do more surgery, if necessary, and attack any infection. So that the wounds can be easily cleaned to fight bacteria, most aren't sewn up until the patient reaches a medical center in the United States.

Doctors at Landstuhl also look for small shrapnel that medical staff before them might not have had time to find. Some soldiers come in with 10,000 or more microscopic pieces in their skin.

Col. Eric Holmstrom, a chaplain and chief of the department of pastoral services at Landstuhl, tries to minister to the emotional needs of the wounded.

He and the other six chaplains in the hospital listen as the wounded talk about their best buddies who were killed, the units and friends they left behind and their guilt for being removed from the fight.

Holmstrom tries to make a connection in the often-brief time before a wounded soldier moves on and another takes his or her place.

The Walter Reed Army Institute of Research estimates that 15.6 percent to 17.1 percent of U.S. troops suffer from a mental disorder, including post-traumatic stress syndrome, the modern term for shell shock. PTSD is the primary or secondary ailment afflicting a number of the nearly 6,000 wounded.

Maj. Timothy Woods, a trauma surgeon at Landstuhl, likens the hospital to a turnstile, with so many wounded coming and going.

He wishes they had more time to help with the mending. He wonders how they will make out, whether they will lose another limb, lose a battle to infection. He'd like to keep them around for just a few more days before the long flight to the States.

But as soon as they come in, he already is filling out the paperwork to ship them on.

Walter Reed

When Tammy Duckworth woke up that November day at Walter Reed, she was in pain. Her legs ached.

Her husband, Capt. Bryan Bowlsbey, was at her side. He knew he had to break the news that what she was feeling was just phantom pain. So he told her what he had to say: Her right leg was gone, and there was nothing below her left knee.

He kept talking, and she quietly took it all in: that she wasn't the only one having to go through this and, like the other amputees in the ward, she would get better.

She didn't cry and didn't ask why it had happened to her. Instead, she said she wanted to get on with it and do whatever was necessary. She told her husband that she loved him but that, hey, after six days by her side, he really needed a shower.

He was relieved. Her can-do spirit and humor were still very much intact.

But it was hardly easy going the next few weeks.

Duckworth's right arm was in jeopardy and needed repair. For stretches during November and December, she was having surgery every other day to improve the blood flow and to fight a stubborn infection.

For Duckworth, who hails from a Chicago suburb, and other patients, it is a frustrating time, waiting for the body to heal enough so they can begin rehabilitation. There is little within the patient's control. Limbs swell. Shrapnel no one ever knew was there suddenly breaks through skin and must be removed. Patients have to decipher what doctors are telling them. Every day can mean visits by new teams of doctors. The Physical Medicine and Rehabilitation Service team. The Infectious Disease team.

Finally, the day comes when, barring the unforeseen, the surgeries are over and the OK is given for physical therapy. It's a chance for dormant muscles to awaken and the patients to regain a little control over their bodies, to see what works and what doesn't. It's time to rebuild.

Rehabilitation

On a cold morning in late January, bright light floods the physical therapy room on the third floor of Walter Reed. Duckworth is stretching her muscles on a padded table. She pauses to watch a fellow soldier attempt the parallel bars as he tries out the two prostheses attached to his legs. She returns his smile when he takes a break, breathless from the journey of a few inches.

Some in the room are where she was a month ago. And some, like this young man, are where she'll be, in time.

It gives her hope.

Most of the people in the physical therapy room have lost a limb. Since the war started, at least 283 people have lost one arm or leg. Duckworth is among the 34 to have lost all or part of two limbs. Four have lost three. If there is someone who has lost both arms and both legs, Chuck Scoville, who manages the Walter Reed amputee patient care program and tracks such statistics, hasn't heard.

Duckworth's daily visits to therapy have elevated her spirits. She takes heart in seeing the familiar faces that share the same struggles.

Like Lonnie Moore, an Army captain from Wichita, Kan.

He has been attacking the rehab equipment for several months, and it shows in his broad upper body. He is doing chin-ups on this January morning, the muscles in his arms tightening as he dangles from a bar, pulling his body up and down.

His medical odyssey from Iraq to the United States began on April 6, 2004, when the Bradley fighting vehicle he was commanding was ambushed just outside Ramadi in central Iraq en route to help Marines under attack. A rocket-propelled grenade sheared off his gunner's right hand and went through Moore's right leg above the knee. He saw that the gunner's hand was missing but had been cauterized by the RPG and, therefore, wasn't bleeding. Moore, who was knocked down by the blast, thought he had missed being hit until the gunner told him he'd better look again.

Moore, 29, had pretty much bled out and barely had a pulse by the time he got to medical help. "I lost my leg, didn't I?" he asked his doctor, waking up after surgery in a CASH.

On a bench near Duckworth and Moore, Joseph Bozik, 26, an Army sergeant from Wilmington, N.C., grimaces as he raises and lowers what remains of his left leg.

He is one of the more severely injured to have come to Walter Reed. He lost a portion of his right arm (from the forearm down) and both legs: the right leg above the knee; the left, below.

Bozik regained consciousness at Walter Reed, thinking he had only been shot.

On Oct. 29, his Humvee went over an anti-tank mine. The airborne soldier, who had been stationed with the 118th Military Police Company at Fort Bragg, was unconscious for three days.

Bozik, who has lost count of his surgeries, is grateful to be alive. He doesn't want to look back. He only wants to move forward, he says quietly.

The wounded soldiers don't chat much as they exercise. But they're closely monitoring each other's progress. When someone gets a new piece of equipment, the others shout and cheer him on.

No one follows the same path, even those sharing the same injury. Healing can be slow, and there can be setbacks. Sometimes more of a limb has to be amputated.

Here, at Walter Reed and other surgical and rehab hospitals that the wounded go to stateside, progress is made by the slightest of measures.

The patients look forward to the day when changing a bandage won't reveal a wound glossy with blood. Or the day that they can raise their stumps another half-inch above the workout bench.

They look forward to the day when someone will make casts of their limbs for prostheses. Those who have lost a leg above the knee will be fitted for a state-of-the-art "C-Leg," which has a computer microprocessor in the knee-shin area, capable of sensing a person's gait.

Vietnam-era amputees had to settle for plastic legs or for metal legs with limited hydraulics. Hydraulics are still used in prosthetic legs today, but the materials are stronger, the movements smoother.

Before Duckworth can be fitted for her prostheses, she has to continue to work at being completely upright. After weeks in bed or in a wheelchair, a vertical position makes her light-headed.

Today, she will make her fourth effort at staying upright. The goal is to better her time. Therapists move her onto a table and place straps across her body. They then levitate the table to a full standing position while her right leg rests on padding and her left inside a temporary prosthesis. (Temporaries are used until the sizes of patients' stumps are stable.)

Duckworth's husband is there to cheer her on. "You aren't turning all white this time," Bowlsbey jokes.

Duckworth grins and nods.

The world beyond

The question is always around them: What are they going to do when they get out of here? It's a topic that dominates thoughts and conversation from their early days at Walter Reed.

Should they push to stay in the service? Should they ask for a discharge and seek disability benefits? Making the decision is often highly stressful. One reason is the decision is not solely theirs to make. A medical review board has the final say.

Moore, who has been in the Army for nine years and grew up the son of an Army father, isn't sure whether he should strive to stay on active duty or retire. He has an appointment coming up with the medical review board.

Bozik has already made his choice. He will request a discharge but isn't sure where he'll settle. Even though he is still in a military hospital, he already feels like an outsider.

He feels like he has aged 50 years in a matter of months.

His family has been his rock, but he is worried that his mother has gone through too much. He worries that people in their hometown are asking her over and over again to tell his story.

But there is a new chapter to share. Bozik and Jayme, his fiancee, moved up their plans and got married on New Year's Eve. It was at the hospital, and Bozik even got to wear a tuxedo.

He had planned to be a federal law enforcement officer, but he doesn't want to be assigned to just a desk job. So he is thinking of working with the disabled.

He wants to help others find their way back into life.

Duckworth, who was promoted to major not long after getting to Walter Reed, feels she is lucky in that, at 36, she had a lot of years to enjoy her two legs. The 20-year-olds she sees in the room who are barely beyond their high school football days got a much worse deal, she says.

She gets through the physical therapy by focusing on her dream to fly again. If not for the military, then for a private company.

And she thinks about that day when the RPG hit and how she could have died. She calls the pilot her hero as she talks about those last seconds before the helicopter set down.

During those particularly hard days in therapy, she clings to her memory that she, too, was trying to get the helicopter down.

It speaks to who she is and how she will tackle the challenges ahead.

"I was still trying," she says, her voice breaking. "I was still trying to do my job."

Connie Cone Sexton The Arizona Republic
Mar. 13, 2005 12:00 AM
photo caption and credit: Michael Chow/ The Arizona Republic

Army Sgt. Joseph Bozik of North Carolina rests during a physical therapy session in January at the Walter Reed Army Medical Center in Washington D.C. His Humvee was struck by an anti-tank bomb south of Baghdad.
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