March 1, 2013  

Medicine and the GWOT

edicine is the only victor in war,” said Dr. William Mayo, and the recent wars in Iraq and Afghanistan are no exceptions. It is time to view through a health-care perspective the advances and terrible human cost of the conflict known as the Global War on Terror and to begin grappling with the immense, decades-long burden of caring for those who have borne the battle.

The Good

Like previous conflicts, the GWOT has fostered improvements in training, systems, evacuation, resuscitation, wound care and surgery techniques. Many advances have been adopted into civilian practice.

First responders are key to survival in those first minutes after wounding, and medics and corpsmen are better trained than ever. (So are individual warriors, in self-care and buddy care.) Using tourniquets to stop bleeding, which was recommended against in civilian trauma courses in previous years, is now recognized as a major lifesaver. New battlefield gear has also helped, including self-applicable tourniquets and hemostatic dressings, which have shown effectiveness in controlling hemorrhage. Patients with devastating wounds who in previous conflicts might have bled to death can be stabilized long enough to reach definitive care. Quadruple amputees have survived due to rapid and precise tourniquet placement.

Time, distance and weather have historically prevented definitive lifesaving surgery for casualties during the “golden hour,” the 60 minutes after trauma when getting a patient to the operating room can make a huge difference. Surgery has been moved to the edge of battle with mobile forward surgical units. This brings definitive care near or in actual combat to save those who would otherwise perish, despite personal risk to medical staff.

We have changed the way we approach care for multiply injured patients. Previously, they might have undergone long and definitive procedures in the operating room to fix every problem. But these marathon sessions often saw such patients become progressively hypothermic (cold body core temperature), acidotic (buildup of lactic acid due to low perfusion of oxygen) and coagulopathic (blood does not clot) — a triad that can spiral downward to death.

Now life- and limb-saving “damage control procedures” for massively injured patients are the norm. The patient undergoes abbreviated surgery — quick fixes to get them off the operating table so that metabolic and coagulation needs can be corrected. Such procedures control hemorrhage, limit contamination and use temporary wound closure. This allows resuscitation with transfusion of blood, clotting factors and warming to improve physiologic stability. Further operative treatment or onward movement of an injured casualty to a higher level of care can then take place. The next surgeon will evaluate for stability, then proceed to completion of deferred repairs and wound closure.

Battlefield observations, combined with research at civilian trauma centers, have changed our approach to treating blood loss. Trauma courses had prescribed that injured patients be infused with at least two liters of saline-based fluid to restore the circulating volume and raise the blood pressure. But researchers found decreased survival in hypotensive patients suffering from injuries given saline in large amounts. Further studies on the battlefield confirmed that large volumes of fluid that raise blood pressure can cause dilution, worsen coagulation and result in more bleeding. Permissive hypotension is tolerated: first stop bleeding, allowing blood pressure to slip in certain patients. To restore circulating blood volume, we have learned that the best results are given not by the customary saline or starch-based volume expanders, or even banked blood alone (which can lack adequate clotting factors and platelets), but by fresh whole blood or packed cell transfusion augmented by fresh frozen plasma and platelets.

We have improved our ability to transport the most grievously wounded to a higher level of care at Landstuhl Regional Medical Center, Germany, or facilities in the U.S., thanks to the creation of Critical Care Air Transport Teams. Each CCATT has a critical-care physician, critical-care nurse and respiratory therapist along with the supplies and equipment to operate a portable intensive-care unit within a cargo aircraft, and can care for six low-acuity patients or three high-acuity patients. These teams have worked out protocols for even the most complex intensive care — extracorporeal membrane oxygenation for cardiac and respiratory support to patients whose heart and lungs are so severely damaged that they can no longer serve their function of delivering oxygen to the tissues, previously done only in specialized intensive-care units.

Information technology has improved so that records of care and images taken during treatment are shared with medical professionals along the evacuation and treatment chain. Every week, each critical patient is discussed on a video teleconference that spans nine time zones on three continents. Attendees include representatives from forward surgical teams, combat support hospitals, Landstuhl, NATO colleagues, and the Air Force Aeromedical Evacuation service — and may include participants at the Walter Reed National Military Medical Center in Maryland, Brooke Army Medical and Burn Center in Texas, and the Veterans Health Administration. Sharing information and exchanging feedback with providers along the chain of care and evacuation improves performance and patient care.

Better training, tools and techniques augment the professionalism, selflessness and devotion to duty of the young medical staff. First responder and field care, forward surgical units, CCATTs and others have helped save lives. Each of these developments was worked out by young medical professionals in uniform observing, studying and pushing the envelope. The validation of their observations and results with civilian hospital studies has led to incorporation of many of these advances into the care of casualties around the world.

The Bad

The hallmark injury of this conflict is the massive blast injury: penetrating fragment wounds, burns, toxic inhalation, blast overpressure and kinetic collision with stationary objects involving multiple anatomic sites. The patients can have multiple open amputations, head and spinal injuries, and complex torso wounds. (Thanks to the advances noted above, however, I have seen patients with all of these injuries survive to reach definitive care.)

Another signature finding is traumatic brain injury. TBI can be a major penetrating wound, a fracture or a brief loss of consciousness. It can be subtle, inapparent on physical examination nor seen by CT scans or other imagery. But its effects can be profound, including headache, confusion, behavioral changes, memory loss, concentration and attention deficits. TBI patients have problems with higher-level executive functions, such as planning and organizing, and early dementia and Parkinson-like syndromes may result. Based on self-reporting data, about 15 percent of troops engaged in active combat in Afghanistan and Iraq may have suffered a mild TBI. Other reports indicate that at Walter Reed, one-third of patients with combat-related injuries and three-fifths of the patients with blast-related injuries have sustained a TBI. Many have sustained more than one TBI, and there is evidence that repeated mild TBIs are cumulative in causing problems.

Casualties can also have other invisible wounds: psychological injuries, which can be equally difficult, complex and resource-intensive to treat properly. Post-traumatic stress disorder is an anxiety disorder that is a result of an overwhelming or dangerous event. It can lead to flashbacks, emotional numbness, depression, difficulty in sleeping or angry outbursts.

One recent study found that PTSD sufferers, compared with a control group, are twice as likely to be diagnosed with an unrelated medical disease within five years of returning from deployment. Another study found that veterans with PTSD used nonmental health care services — primary care, ancillary services, diagnostic tests and procedures, emergency services and hospitalizations — at a rate 71 to 170 percent higher.

Through March 2011, DoD clinicians had diagnosed PTSD in about 75,000 active-duty service members. In the same period, the Veterans Health Administration treated about 187,000 patients — 27 percent of the total — who had been diagnosed with PTSD. Many had suffered a TBI as well. Recent studies have shown that TBI, often overlapping with PTSD, places sufferers at higher risk for lifelong medical problems, such as seizures, heart disease, dementia and other chronic diseases. TBI and PTSD patients have trouble completing school, holding a job, keeping the family together, and often become homeless. Risk-taking behaviors — smoking, drug abuse, overeating, unprotected sex, fighting and drunk driving — occur in high numbers in TBI and PTSD patients.

Suicide has become epidemic. The past year has seen an 18 percent rise in suicide among active-duty military members; one suicide a day now occurs in the serving military. The number of service members who took their lives this year has at times surpassed the number killed in combat. Suicide represents 7 percent of deaths among men in the general population ages 17 to 60, but 20 percent of deaths among men of this age in the military. The only good news is that efforts are being stepped up to recognize warning signs and prevent suicides.

Large numbers of troops are using psychotropic medications, a monumental change in military culture and military medicine. A June 2010 report from the Department of Defense Pharmacoeconomic Center at Fort Sam Houston in San Antonio showed that 213,972, or 20 percent, of the 1.1 million active-duty troops surveyed were taking some form of psychotropic drug: antidepressants, antipsychotics, sedative hypnotics or other controlled substances. Psychotropic medicine use, especially on the battlefield, is an enigma to me when these medications can have severe side effects such as insomnia, suicidal thoughts or hallucinations. This psychotropic use will interweave with and complicate treatment for TBI, PTSD, depression, suicide and other health problems, and is likely to complicate medical and mental health problems after discharge.

The Ugly

The current drawdown of troops from Afghanistan may soon end hostilities but is by no means the end of escalating medical care and mental health costs for veterans, contractors, their families and others touched by this conflict. It will burden and potentially overwhelm emergency departments, health care providers, social services, jails and society. It is a looming public health crisis whose cost, while difficult to predict, appears to be set to peak 30 to 40 years or longer after the conflict.

Ultimately, the visible and invisible injuries of war involve such large numbers that it will surpass anything we have seen in my lifetime in terms of difficulty, complexity and cost. Compared with prior wars, the costs of care are likely to escalate exponentially for a variety of reasons: more casualties survived with devastating injuries not seen in previous conflicts; better health care has resulted in longer life spans; and diagnostic and therapeutic tools, treatments and prosthetics have gotten better and more expensive. The large number of veterans with complex injuries will require considerable resources. Many will require more restorative procedures and extensive rehabilitation as they progress. Care will be done in military facilities initially, but will ultimately during the years or even decades of rehabilitation shift to the VHA and private-sector care.

GWOT returnees are using veterans’ medical services and applying for disability at higher rates than in previous conflicts. As of December 2010, more than 2.2 million U.S. troops had served in the GWOT; 1.25 million have been discharged. Some 654,000 have been treated at VA hospitals and medical facilities. About 552,000 have filed claims for compensation in connection with their service disabilities. Experts have estimated that 50 percent of GWOT veterans will eventually present to a health care provider with one or more problems such as PTSD, TBI, depression, suicide attempt and/or substance abuse.

The direct costs of treatment are only a fraction of the total costs related to mental health and cognitive conditions. Far higher are the long-term individual and societal costs stemming from lost productivity, reduced quality of life, homelessness, impaired health, substance abuse, reckless behavior and suicide. These conditions can impair relationships, disrupt marriages, aggravate the difficulties of parenting and cause problems in children that may extend the consequences of combat trauma across generations.

There is no metric I know of for the disastrous effect of these wars on families and children. The spouses and children of those on long deployments, whose family members have been wounded or killed, or that have been torn by domestic violence, divorce or substance abuse, will be forever damaged by this conflict. The DoD and VHA do not measure this “collateral damage.” It is another future cost to society that will be huge but is neither predictable nor quantifiable.

I need to insert a note here about contractors, the several hundred thousand civilians used to sustain the war effort and lower the number of active-duty troops being deployed. These contractors have suffered from the same kinds of injuries and problems as troops in uniform. During the 18-month period from fiscal 2007 through the first half of 2008, the U.S. spent $34 billion on almost 57,000 contingency contracts for construction, capacity building, security and support services for U.S. forces in Iraq and Afghanistan. There were about 200,000 contractor personnel working on these activities; and during this period there were at least 455 contractors killed and 15,787 injured, according to Government Accountability Office reports. The government does not track contractors killed and wounded, so these numbers are based on reports to the Department of Labor (which provides insurance) and may be underestimated. It is a group with no ties or access to the military or veterans’ health care services, but whose service and injuries will impose both direct budgetary costs through federal subsidies to worker compensation and insurance companies, and projected higher costs to Medicare, along with social burdens.

Ugliest of All

I learned a key economic concept in business class: opportunity cost. This is the value of any activity measured in terms of the best alternatives not chosen. This war’s cost and the ballooning expenditures for the future could have gone toward fixing the U.S. economy, reducing the national debt, repairing infrastructure, creating a functional health care system, improving education, advancing homeland security, conducting research or influencing hearts and minds around the world.

The projected cost data above are from earlier studies. We have since accrued more casualties, PTSD, TBI and much higher costs as the fiasco of the GWOT grinds onward. Nobel Prize-winning economist Joseph Stiglitz, co-author with Harvard professor Linda Bilmes of “The Three Trillion Dollar War” said, “This is the first time that, at the time we went into war, we actually cut taxes, rather than raised taxes. … So that means this war has been totally financed by deficit.” They calculated (in 2008) that medical care and disability will be the second-largest expense of the war, coming to $700 billion and making up the primary long-term expense of the conflict. The butcher’s bill has now run another couple of years.

What to Do

Our society must prepare for the coming public health crisis. Those of us who practice medicine will see our clinics and emergency rooms more heavily affected by veterans, their family members and those hired contractors no one has on their radar.

Doctors and others in health care and involved in social services need to ask about “prior military service and/or combat zone deployment” as risks to health.

VHA and DoD need to invest now to ease the approaching problems caused by the health issues of GWOT veterans and the anticipated ballooning expense as they age. Health care and mental health services must be easily accessible, and the paperwork — which can take a year for a claim — needs to be simplified and acted on in a timely manner. Delivering effective care now and restoring veterans to better mental and physical health can reduce these longer-term costs. We need to press our elected representatives to step up and be vocal and active for the veterans, and all of us need to participate in local veteran support activities.

The president needs to establish a commission to act on veterans’ future needs and coordinate resource issues. History tells us that when conflicts end, resources become scarce and are often diverted, national resolve can shift or wane, and media and public interest become focused elsewhere. Even today, while we have troops in battle in a foreign land, there is little mention of the GWOT in the news.

There needs to be a comprehensive national strategy for veterans, with a long-term plan that includes health care, psychological services, education and career transition, and family support. The plan should have a vision for the future and a timeline with benchmarks and a definition of roles, responsibilities and coordination of individuals, communities, volunteer groups, government and private-sector corporations.

Ultimately, as in all prior conflicts, we will have to take care of each other. I doubt that the federal government can be visionary, the VA can get proactive, that politicians can do the right thing or that Joe Average will give a damn — or a dollar. There are those who have started their own local, regional and national programs to help the injured vet. New organizations such as “Purple Heart Homes,” which builds homes for disabled vets; “The Mission Continues,” which links wounded vets to public services; “Hire Heroes USA;” and similar programs are reaching out to help their less fortunate brothers and sisters. The people in these efforts are my heroes. Those who have worn the cloth of this country — every one of us — is bound together.