10 March 2011

Report shows steep increase in amputations in 2010

SOURCE: Landstuhl Regional Medical Center | The Washington Post - March 6, 2011.

Data assembled by John B. Holcomb, a trauma surgeon and retired Army colonel, and two physicians at Landstuhl Regional Medical Center was presented Tuesday to the Defense Health Board, a committee of experts that advises the Defense Department on medical matters. The report showed a sharp increase in amputations, and particularly multiple-limb amputations, in 2010 versus prior years. The steepest increase occurred over the last four months of the year.

Doctors and nurses treating soldiers injured in Afghanistan have begun speaking of a new "signature wound" - two legs blown off at the knee or higher, accompanied by damage to the genitals and pelvic injuries requiring at least a temporary colostomy.

Twice as many U.S. soldiers wounded in battle last year required limb amputations than in either of the two previous years. Three times as many lost more than one limb, and nearly three times as many suffered severe wounds to their genitals. In most cases, the limbs are severed in the field when a soldier steps on a buried mine.

The increase in both rate and number of such wounds is most likely a result of the troop surge in Afghanistan that began last spring, combined with a counterinsurgency strategy that emphasizes foot patrols in villages and on farm compounds. It was noticed by military surgeons in Afghanistan last fall and quantified in late December by a team of surgeons at Landstuhl Regional Medical Center in Germany, where virtually every evacuated soldier stops en route to the United States.

"I've seen these types of injuries before. What I haven't seen is them coming in over and over and over again," said John B. Holcomb, a trauma surgeon at the University of Texas at Houston and retired Army colonel who helped identify the trend.

The report prepared by Holcomb and two surgeons at Landstuhl has circulated at the highest levels of civilian and military command in the past two months. An abbreviated version was provided to The Washington Post with Pentagon permission.

It shows that from 2009 to 2010, the proportion of war casualties arriving at Landstuhl who had had a limb amputated rose to 11 percent from 7 percent - a 60 percent increase. The fraction suffering genitourinary (GU) injuries increased to 9.1 percent from 4.8 percent - a 90 percent increase.

The actual number of patients with the injuries increased even more drastically.

In 2009, 75 soldiers underwent amputation and 21 lost more than one limb. In 2010, 171 soldiers had amputations and 65 lost more than one limb. GU injuries increased from 52 to 142 over the same period.

In mid-October, a Washington Post reporter attended a weekly videoconference in which military medical personnel from around the world discuss the previous week's severe trauma cases. Of the 13 patients on the agenda, many had lost limbs, and three had lost both legs and both testicles.

Medical staff at Landstuhl also noticed a rise in severe genital injuries last fall.

"In my 21/2 years here, it's just started," intensive-care unit nurse Kathryn Gillespie said in late October.

Most critically injured soldiers arrive at Landstuhl unconscious or heavily sedated. Some regain consciousness for the first time since the battlefield during their two- or three-day stay. Gillespie described a typical awakening.

"The first thing we let them know is they're in Germany. We tell them, 'You're hurt, but you're okay.' Then they want to do a scan of their body. They ask, 'Is my junk all together?' They want to check their 'package.' Then they check their arms and legs. This all happens probably within 15 minutes of being off sedation."

Many patients, minds clouded by illness and medication, "discover" their injuries more than once during the stay. Each time, they ask nurses and doctors to explain what happened and what lies ahead.

From a related article:
Holcomb, who spent two weeks at Landstuhl in December and is a former head of the U.S. Army Institute of Surgical Research, said he had heard of "unwritten pacts among young Marines that if they get their legs and genitals blown off they won't put tourniquets on but will let each other die on the battlefield."

Richard H. Carmona, who was U.S. surgeon general from 2002 to 2006 and is now on the board, said the information was "very disturbing."

Why amputation-requiring injuries increased so much in recent months isn't entirely understood. It is partly a function of tactics that emphasize more foot patrols in rural areas. Some people have speculated the mines may be constructed specifically to cause the devastating wounds.

The two Washington Post articles can be found here and here.

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