Thankfully, most Americans don’t live in a world of armored Humvees and improvised explosive devices (IEDs). But those who do…those who wake up in a compound or tent every morning in Iraq and Afghanistan and head out to do battle deserve the finest musculoskeletal care that the United States can provide. Lieutenant Colonel Philip Belmont, Jr., M.D. is one of the dedicated military orthopedists who is trying to ensure that this happens. Dr. Belmont: “We have a solemn covenant, not only to conserve the fighting strength of the U.S. military, but also to provide the best possible musculoskeletal surgical care to our soldiers.”
And to know how to improve, one must get a lay of the land. To this end, Dr. Belmont and his colleagues undertook the first prospective, longitudinal analysis of a large combat-deployed unit in which musculoskeletal combat casualty care incidence rates could be accurately calculated.
Describing the origins of this work Dr. Belmont states, “The most significant impetus for our study was the fact that more than half of all injured soldiers in Iraq and Afghanistan reported extremity wounds.”
While there is now widespread use of body armor and vehicular armor, as well as a highly integrated trauma system, we are still seeing massive extremity injuries due to the enemy’s use of deadly IEDs. My colleagues and I decided to study one unit from beginning to end so that we could examine the full spectrum of injuries with a known denominator…this enabled us to determine the incidence of each type of injury as well as the mechanisms of injury.
“We studied this group of soldiers for 15 months, and hopefully captured information that sheds light on the impact of the evolving nature of conflict on U.S. troops.”
Creating the Data Base
True surgeon-researchers, Dr. Belmont and his team knew that they needed a full understanding of the nuances of the data collection and analysis—no small task given that there were 4, 122 soldiers deployed with the brigade combat team. He states, “We created a casualty database, used electronic medical records, and utilized an existing combat casualty roster of the unit. The military’s Joint Theater Trauma Registry (JTTR), a prospective database, was also helpful as it contains information on each injured soldier who goes to a hospital or is treated by a surgical team. There have been more than 40, 000 trauma cases entered within the JTTR database and data collection now occurs over a period of days instead of months. The JTTR has been used to assess the epidemiology of combat injuries and musculoskeletal combat injuries to the extremities as well as to evaluate the effectiveness of treatment modalities on combat casualty outcomes. By using all of these resources we were able to capture nearly 100% of musculoskeletal combat injuries.”
But how exactly is musculoskeletal combat casualty defined? “Musculoskeletal combat casualty definitions can significantly affect casualty analysis results, ” indicates Dr. Belmont. “The inclusion of soldiers killed in action, those returned to duty, and those with non battle injuries in any cohort analyzed will affect the distribution of musculoskeletal wounds and mechanism of injury. Similarly, inclusion of only the primary or dominant wound, without taking into account secondary wounds, can also lead to altered data. As a result, the reporting of musculoskeletal combat wounds from previous wars may be biased toward more severe injuries, with less severe wounds being overlooked. In contrast, the data presented here includes all musculoskeletal combat wounds sustained by soldiers wounded in action.”
With an eye toward improving on past attempts to capture this data, Dr. Belmont states, “Previous studies of musculoskeletal combat casualties were compiled from hospitals or surgical treatment facilities and generally excluded soldiers evaluated and treated in an ambulatory setting. The result is that you have an underestimation of the magnitude and nature of orthopedic combat casualties.”
Spc. Henry/Wikimedia Commons
Primary Findings
So what are the details on that unfortunate news? “Our primary findings were twofold. First, we can see how the enemy has changed, i.e., their increasing reliance on explosive devices and the fact that these devices are especially deadly. In our study, we found that 36.4% of all soldiers who sustained musculoskeletal combat injuries were lost from the theater of operations…something that is attributable to the effectiveness of the enemy weaponry and tactics. The good news, however, is that our military medical system has not only become more advanced, but it is better integrated and can thus provide level one trauma care within an hour of an injury—the standard goal now. When a soldier gets injured, the first combat lifesaver is their buddy or the medic. This person will perform first aid, may apply a field tourniquet, and will give the soldier pain medication. At that point they call in for an evacuation (usually by helicopter).”
“The next phase of treatment is when the injured soldier goes to a level two or three center. Level two is a forward surgical team, which is normally comprised of 20 people, including one orthopedic surgeon. This team, which focuses on stabilizing life threatening injuries, is with the unit, but is contained away from the fighting. Level three care is at a combat support hospital (usually located in one of the larger military bases). And of course, the military does its best to protect soldiers with body armor, Kevlar helmets, as well as armored vehicles. Think about the difference, say, between the Korean War and how things are today…now, a soldier can sustain direct fire to the head or torso in some cases with little or no injury. That is progress.”
Costs and Benefits
And the cost of this progress? “Many more severely injured soldiers are surviving their wounds, in part because the Department of Defense has made it a priority to improve armored tactical vehicles and thereby increase crew protection by initiating the Mine Resistant Ambush Protected (MRAP) vehicle program. Casualty figures suggest that the quick pace of the development of MRAP vehicles with ‘V’ shaped hulls has helped to reduce U.S. military fatalities from IED attacks. Figures compiled on the website icasualties.org reveal that in 2009, the percentage of U.S. military service members who were killed in IED attacks decreased to 40% compared to 50% in 2008. All of this is great news…but it does mean that the volume of surviving soldiers requiring extensive, often long-term treatment, has increased significantly. In fact, the estimated initial hospitalization and projected disability benefits for soldiers sustaining combat extremity wounds in Iraq and Afghanistan between October 2001 and December 2005 is $1.66 billion dollars.”
From the site of battle, all the way to U.S. military facilities such as Walter Reed, there is always a bill that must be paid. And generally speaking, the payment involves a substantial amount of fracture care, soft tissue treatment, and amputations. Dr. Belmont notes, “Of the 242 soldiers in our study who experienced musculoskeletal injuries, 24% had fractures and 36% had soft tissue wounds; approximately 9% of those injured in this study sustained major amputations. In the future we need to closely examine our outcomes with regard to complex limb salvage, spine treatment, and long bone fractures. Walter Reed and Brooke Army Hospital are leading the way and following patients longitudinally.”
Regarding the issue of how to handle the threat of IEDs and other deadly munitions, Dr. Belmont leaves that to the military brass. “I feel that it is not necessarily my place to suggest how to change things but instead I would like to focus on how to best treat the musculoskeletal combat casualties of the all-volunteer force. All military orthopedic surgeons fully understand not only their role in providing optimal treatment to musculoskeletal combat casualties in order to conserve the fighting strength of the military but also the solemn covenant of providing the best possible musculoskeletal surgical care to those brave United States military service members who defend our nation. The all-volunteer force’s exceptional performance coupled with the sacrifice of its human treasure upon the battlefields of Iraq and Afghanistan should continually remind us all that service in the defense of the country is a fundamental responsibility of citizenship.”
Next Steps
The Combat Musculoskeletal Injury Study has resulted in ground gained for the U.S. military. To make even more progress, states Dr. Belmont, there is no getting around further research. “While our study has allowed us to determine exactly how many soldiers are at risk of injury and enables the calculation of musculoskeletal combat casualty care statistics, only a large, prospective, and scientifically rigorous study of all soldiers wounded in Iraq and Afghanistan can truly characterize musculoskeletal injury patterns in the present conflicts. We hope that this study may serve as an initial benchmark, to which future investigations on this topic can be compared.”
