Dire Medical Threats on the Non-Linear Battlefield must be solved

By Dr. Jonathan Sullivan MD and Mike Sparks

IRAQ

13 March 2004

Dan Rather Interview with CNN's Larry King: blast thru HMMWV windshield: doctors can't save the men

www.cnn.com/TRANSCRIPTS/0403/12/lkl.00.html

"Let me say that yesterday, Larry, on the road, just west of Baghdad, we saw the medevac team in action. We were on the road where, just ahead of us, a roadside bomb went off against an 82nd U.S. Army convoy. And just as we rolled up, the medevac helicopter was arriving; we saw them carrying away three Soldiers on three stretchers.

But the medevac people were tending to the Soldiers on two of those stretchers. They weren't attending to the Soldier on the third. And I said to myself as we saw that, 'I hope I'm wrong, but it probably means that at least one of those Soldiers is dead.' And indeed it did.

One was killed almost instantly. Another died if not on the medevac itself, just as they arrived at the hospital. And the third 82nd Airborne Paratrooper is still in serious condition.

I mention it because we had done the piece on the medevac people earlier in the week. And it's so much in my mind. And it was just a coincidence, but it was a sobering one, to see the people that we had done the story on earlier in the week actually do their job.

They got there very, very quickly. This was a case of -- I think this is typical of the way some of the injuries and deaths among the well over 500 Americans who have been killed here happens. The 82nd Airborne, Larry, as you know, is beginning to hand off their responsibilities in part of the Sunni Triangle -- in this case, just west of Baghdad -- to the 1st U.S. marine Division. And the 82nd Airborne Soldiers were on a mission to help a U.S. marine convoy.

And it was on that mission they made a stop at a certain place in the road. And when they did, what appeared to me to be a command-detonated mine at the side of the road. I'm not sure that's what it was, which is to say, somebody off in the distance by wire set this thing off.

And it was at just the right level. If it had been one foot lower or one foot higher, it probably wouldn't have blown through the window of that Humvee. But it was a combination of a sophisticated bit of good planning and some luck on the part of the people who put the bomb there that was placed just in the right place. They set it off at just the right time, with those tragic results."

29 December 2004

"I am writing now from Kuwait, awaiting the final orders whether to proceed home or back to Iraq. I am tentatively escorting home the body of my XXXXXXXXXX and friend, Captain Ernesto Blanco, who was killed before my eyes in Quryat Ash Shahabi, Iraq, on Sunday, 28 December 2003 at 1245 HRS, approximately 3 hours after my last email to you. We were returning from a 'routine' vehicle recovery mission when an IED went off right next to his Humvee. He took the force of the blast in his face. He had lost so much blood there was nothing we could do, though we sped as quickly as possible to the Medical Detachment at the nearest base camp. He was still hanging on, but soon thereafter the docs were performing CPR. After about 30 minutes, it was over.

What makes me angry is we saw the little Haji bastards who did it; they couldn't have been older than 10. They were 400 meters away and running right to left at an oblique, and so they escaped. Our rounds missed them. Old enough to pull the trigger, old enough to pay the price, I say, but they got away to do it again some other day. Ernie Blanco was an upstanding Christian man, one of the best officers I have ever had the privelidge of working with. He was a friend I could confide in "off line." He will be sorely missed.

We have contracted for more steel hardening of the HMMWVs. CPT Blanco was hit in the face, above the armor plating. The rest of his body was unscathed. There is only so much one can do. We are still trying to contract for the LMTV armor, but it is in the works. Like I keep saying, they have checked-the-block and that is all they will do until someone else dies and makes another block-to-check". 1

05 March 2004 from Baghdad a Report by CA Soldier:

"I had an interesting chat with a lady captain named Beverly who was down from one of the more hostile areas north of Baghdad today. She's from the Army's Civil Affairs outfit. These are U.S. Army units who have the job of building clinics, keeping hospitals supplied (the NGOs having left) and generally getting up and out every day to make life a bit better for the workaday, Iraqi folks in their areas.

She'd had a couple of rough weeks as she and her people are constantly on those dangerous roads up north, where IEDs and ambushes are common. She's young and very pretty, but there's lines creeping in around her eyes and they're not from the sun. 'We were in a regular convoy, going off to drop antibiotics at a local health clinic when the IED went off,' she said. 'The fifth vehicle in our convoy was hit by an artillery shell rigged to go off on command. It flipped the vehicle over and the driver was killed immediately. Everyone else is in Walter Reed.'

Well, it was a little more than that. She went on to tell me that the driver that was killed was a little girl only 19yrs old, just out of high school. The device had gone off right next to her side of the vehicle. I won't go into detail, but this girl was more than just killed. If you have any idea what happens to someone in close proximity to an exploding artillery shell, you know what I am talking about. At least it was mercifully quick. The rest of the team was so busted up it's unsure if they'll ever make it back to duty at all and one young man has probably lost his sight.

Oddly enough, Beverly isn't bitter about that. She's a senior Soldier and has reconciled herself that these things happen in war. Their Humvee was a regular, soft skin vehicle that had been modified by local contractors with steel plate, known to the troops as a 'Hadji Hardshell.' You see a lot of them around, with boiler plate bolted or welded on in a hodge-podge of different styles and configurations. All of them emergency field modifications concocted as things turned hostile over the last year. The protection they provide is dubious at best and in some cases it is obvious that the additional plate would only make things worse in an explosion of any force, adding to the shrapnel involved. Steel plate for armor is a special composition and hardness. It is made especially for the task. Boiler plate from an Iraqi contractor's yard doesn't cut it.

For example, I talked to some MPs who for kicks and curiosity 'tested' their 'Hadji Hardshell' against an AK-47 they had captured. The rounds went right through. So then they pushed a bayonet through it with a little help from a ball peen hammer. They are now some very, very worried MPs. Their "Armor" wouldn't stop a knife. This is the type of Humvee that most Civil Affairs Soldiers ride around in.

To truly understand this, you need to know that there is a new barometer that the troops measure their relative risks in Iraq by. It's called 'Road-time' and if you get lots of road-time, you're bucking the odds against the IEDs. You don't get much road-time, you're sitting on a base, behind walls and wire. With most of the heavy stuff being pulled back to base camps, road-time also means Humvees. 'Road-time' doesn't apply to some guy in a tank.

CA gets lots of road-time. They have to, as on any given day they're responsible for supporting the workings of everything from clinics to water treatment plants to the sanitary conditions in a local market. For every stop on their schedule it means 'road-time' and that means driving past about 10,000 different places where someone could rig up a bomb.

I spoke to one CA doctor who has put 3,000 miles on his Humvee and he's been here since January. This is probably the only place in the world where regular Army MPs, National Guard truck drivers and Army Reserve CAs tip their hats to each other. Both are at top of the "road-time" food chain.

But here's the real kicker; an emergency order of armored Humvees from factories in the US is due to start arriving sometime soon. Scuttlebutt has it, however, that Civil Affairs is somewhere near the bottom of the list to receive them. 'I have an area that stretches from Kirkuk almost down to the outskirts of Baghdad,' Beverly said with a sigh. 'And now I've got five less people to cover it with because we can't seem to get up-armored Humvees.' What she didn't mention was that those five less people aren't your average Joe with an M-16 pulling guard at Camp Victory. They're public health nurses, infectious disease doctors, veterinarians and civil infrastructure engineers. They're a little hard to replace. They come from a demographic that isn't exactly lining up to join the army.

But incredibly, Civil Affairs is apparently below tank drivers who have traded in their M1s for an armored Humvee and who drive around for an hour or two on 'Patrols' but rarely, if ever, stop and interact with the Iraqis whose country we're trying to rehabilitate. To be fair, such patrols are necessary to show a visible, Coalition presence and those boys need decent vehicles as well.

But it boils down to a question of return for time and effort invested and a bunch of guys speeding past on a presence patrol doesn't stack up against a load of unobtainable cancer medication delivered to a children's hospital. The priorities seem to be fouled up and until someone takes notice of it, ladies like Beverly are going to keep racking up 'road-time' in death traps."2

Just a statistic?

www.militarycity.com/valor/2651826.html

Army PFC. Nichole M. Frye

Army PFC. Nichole M. Frye, 19, of Lena, Wis.; assigned to Company A, 415th Civil Affairs Battalion, U.S. Army Reserve, Kalamazoo, Mich.; died Feb. 16 when an improvised explosive device struck her convoy in Baqubah, Iraq.

Killed: February 16, 2004

--------------------------------------------------------------------------------

Wake held for Wisconsin Soldier killed in Iraq

Associated Press

LENA, Wis. Dozens of people gathered at Lena High School at the funeral Thursday for a 19-year-old woman killed while serving with the Army Reserve in Iraq.

A U.S. flag was draped over the casket of Pfc. Nichole Frye during the service.

Bishop David Zubik of the Roman Catholic Diocese of Green Bay joined the mourners and at one point kissed the casket of the fallen Soldier.

The civil affairs specialist died Feb. 16. when a roadside bomb exploded near her convoy in Baqouba, Iraq, according to the Department of Defense.

She belonged to the 432nd Civil Affairs Battalion based in Ashwaubenon, but had been deployed with the Michigan-based 415th Civil Affairs Battalion.

Among those who went to the wake was Village Sweet Shop owner Jean Soukup.

"It affects the whole community," she said. "No ones immune from the war.

Mandi Fonder, 17, of Oconto, said she was a friend of Fryes fiancé, Jeremy Stumpf. She described the Soldier as sweet and understanding.

"Its hard to believe she went there (to Iraq) to make a difference somebody thats this close to everybody here and just didnt come back," Fonder said.

Retired dairy farmer Ruth Loberger said it "such a waste of a young life."

*************************************************************************************

EXCLUSIVE!

WHY TRUCKS ARE NOT COMBAT VEHICLES:

To show a little of the lethal firepower possible today, we have this video gun camera footage from Iraq of a 224th Attack Aviation Battalion AH-64 Apache lighting up some Iraqi terrorists in soft-skin wheeled trucks using the M230 30mm autocannon. The point is, watch what these large, exploding bullets do to human bodies and thin-skinned trucks. THIS IS WHY THE MINIMUM TRANSPORTATION STANDARD ON THE BATTLEFIELD MUST BE A LIGHT TRACKED ARMORED FIGHTING VEHICLE NOT A WHEELED TRUCK.

30mm Chain Gun in action (MPA) file

WHAT HAPPENS WHEN TRUCKS ARE HIT:

U.S. ARMY REPORT: Anatomy of an Iraqi Command-Detonated Land Mine (current buzz word: "IED") Ambush

HOW UNPROTECTED OUR TRUCKS ARE:

PREVENTABLE CASUALTIES: Iraqi Coalition Deaths by Cause using imperfectly revealed data (rough work in progress)

789 confirmed coalition deaths, 686 Americans in the Iraqi war as of April 15th, 2004

What CENTCOM admits: 686 U.S. dead, 2,132 wounded and did not return to duty

Sources:

http://lunaville.org/warcasualties/Summary.aspx
www.cnn.com/SPECIALS/2003/iraq/forces/casualties/
www.pigstye.net/iraq/wd.php?sort=state&page=6
www.worldmessenger.20m.com/uscasualties.html

Small Arms Fire/Grenades 200 deaths/789 = 25.34% of all deaths or 1/4th of all deaths

Land Mines/Improvised Explosive Devices 142 deaths/789 = 18% of all deaths or about 1/5th of all deaths

Vehicular and other Accidents: 109 deaths out of 789 = 13.81% or 1/8th

Rocket-Propelled Grenades: 48 deaths/789 = 6.08% or less than 1/10th of all deaths

Mortars/Large rocket bombardments: 25 deaths out of 789 = 3.16% or 1/33 of all deaths

1/5th of all our dead is by Land mines/IEDs and RPG attacks...another 1/4th killed by small arms fire, hand grenades, mortars and large rockets....over 50% of all our war dead. We must ask some hard questions:

1. How many would be alive today if instead of driving around in unarmored HMMWV and FMTV trucks they were in M113 Gavin light tracked AFVs with gunshields, belly armor, peel 'n stick composite tiles, spaced applique' armor?

2. How many would be alive today if they properly sandbagged their albeit inadequate wheeled vehicles?

ANSWER: Potentially 130 people alive instead of dead from land mines/IEDs. Another 48 from RPGs if they had been in M113 Gavins with RPG resistant applique' armor.

Another 2 alive if their M113s had belly armor.

Plus a Soldier put in for the Congressional Medal of Honor might be a living hero had he been behind a modern TC's gunshield like the IDF uses on his M113 Gavin.

Basically 189 people would be alive today if we had upgraded M113s and used them more extensively than HMMWVs, FMTVs and other unarmored trucks in Iraq. But during the 4 years of the General Shinseki era (1990-2003) we ignored the entire M113 Gavin fleet and did not up-armor them, install belly armor or gunshields etc even though cost estimates are just $78,000 per vehicle to make them RPG and highly bomb-resistant. Instead, we wasted $9 BILLION on 600 inferior Stryker armored cars at $3.3 million each which haven't done anything in Iraq; the hard fighting was and is being done by some well-equipped troops using M113s, M2/M3s and M1s (what the Shinsekiites used to call the "legacy" force) but the majority of our 134,000 troops in Iraq struggle on foot and in 10,000 HMMWV trucks at a horrible human cost.

3. 225 Soldiers have been killed by small arms fire, grenades, rockets and mortar attacks while on foot or in un or poorly armored vehicles, 1/4 of all the dead.

How many of them would be alive today had we upgraded the thousands of war-stock M113 Gavins and supplied them to use to protect themselves from garden-variety AKM bullets?

4. How many of them did not have rifle-caliber Interceptor Body Armor (IBA) on because we squandered billions on Stryker armored cars?

5. How about a small gunshield on the end of their individual weapons?

www.geocities.com/combatreform.com/gunshield.htm

ANSWER: Adding these 225 potential lives saved, 414 people could have been saved and alive heroes today had we been better prepared for the non-linear battlefield---52.47% or over HALF OF OUR WAR DEAD COULD HAVE BEEN PREVENTED.

6. How many wounded and maimed could have been avoided?

ANSWER: potentially thousands, we don't have the specifics on how all our wounded/maimed were injured.

7. How many of the 109 people who have died in vehicle and other accidents could have lived had they gotten adequate sleep if we were in a more realistic adult military that actually discovers lessons and learns from them instead of the current dumb macho PC yes-man culture where everyone is afraid to tell the emperor he is naked?

www.geocities.com/equipmentshop/sleeplessarmy.htm

ANSWER: 13.81% or another 1/8th of all our war dead. Add that in to the preventable deaths above and you have 523 lives that could have been saved or about 70% of all our war dead.


The U.S. Army has lost over 686 Soldiers killed and 10,000 wounded so far in Iraq; however, DoD will not own up to how many of the latter are maimed for life and missing limbs.3 To meet world operational tempo needs the Army is increasing in quantity by expanding from 33 brigades to 43-48 new mini-brigade units of action by making more light infantry Soldiers which walk on foot or in HMMWV trucks.4 However, without dramatically improving the quality of the Army's "lightfighter" units so they are better protected on the increasingly lethal non-linear battlefield (NLB) we will suffer even more casualties. The HMMWV's wheeled SUV configuration has windows, doors and windshield that can never be protected enough and lacks an unified armored body for all-around protection. The Army's recent message to units on vehicle self-help armoring says vehicles need hard steel to stop bullets and soft steel to stop blasts; HMMWVs limited to just a 1.25 ton payload can't even be fully covered by one thin steel layer let alone the two layers needed and can then only carry two troops inside. SOLDIERS ARE DYING AND BEING MAIMED IN IRAQ WAITING FOR FACTORY-MADE ARMORED HMMWV "SALVATION" THAT WILL NEVER COME, WHILE BETTER PROTECTED M113 Gavin LIGHT TRACKS SIT IN STORAGE. The National Guard 30th and 81st Brigades left over 235 M113-type light tracked AFVs back in their motor pools before going to Iraq. Details:

www.geocities.com/paratroop2000/armoredstrykershmmwvsfail.htm 5

Better Army Medical Ethos: combat tactics must factor in medical threats

Traditionally Army Medicine stays-in-its-lane and does its best to save lives and heal wounded Soldiers but its time we protest the Army's unsound tactical course of action of placing troops in wheeled trucks on the non-linear battlefield. We are going to reveal here a shocking medical reality that needs to be understood by everyone in the Army: some wounds are fatal no matter what you do: the point is you must not get wounded in the first place. This was tragically shown in the death of Captain Ernesto Blanco. What we are saying is that some wounds even if you could teletransport the Soldier instantly into the worlds best trauma room will still kill Soldiers. This means improved medical care technology will NOT, repeat NOT ever solve the problem completely. We are trying to solve the problem when its deteriorated too far along and its taking our Soldiers to early graves. We need a better medical ethos that weighs in on TACTICAL matters since "an ounce prevention beats a pound of cure". The Light infantry mentality particularly with its can-do hubris especially does not understand the dire medical consequences of being wounded on the NLB, and assumes that some sort of "super combat medicine"; a medical form of can-do hubris can fix most if not all wounds if given some mythical exotic technology. The current Army lightfighter plan of having troops ride around in vulnerable so-called "up-armored HMMWV trucks" is dangerous and must be changed. Army Medicine is seeing thousands of Soldiers flooding our facilities missing limbs and scarred for life and its high time we stop suffering these preventable human tragedies in silence and ACT as Army leaders and human beings.

How People Die In Ground Combat 6

KIA 31% Penetrating Head Trauma

KIA 25% Surgically Uncorrectable Torso Trauma

KIA 10% Potentially Correctable Surgical Trauma

KIA 9% Exsanguination from Extremeity Wounds

KIA 7% Mutilating Blast Trauma

KIA 5% Tension Pneumothorax

KIA 1% Airway problems

DOW 12% (Mostly infections and complications of shock).

 

90% Die Before Making it to a treatment Facility

U.S. marines pray over a fallen comrade at a first aid point after he died from wounds suffered in fighting in Fallujah, Iraq (news - web sites), Thursday, April 8, 2004. Hundreds of U.S. marines have been fighting insurgents in several neighborhoods in the western Iraqi city of Fallujah in order to regain control of the city. (AP Photo/Murad Sezer)

Consider that 90% of our Soldiers that die, die before reaching a treatment facility. 7 This means their wounds are so severe they die even before a doctor can even try to save them. If you look above that 88% are wounded in the face, neck, head or torso areas that are not protected adequately when riding in a HMMWV truck with a large windshield, 4 windows and doors rolling on 4 air-filled tires or arms/legs at all when on foot. The 7% of Soldiers that die by mutilating blast trauma are so torn apart NO AMOUNT OF MEDICAL CARE WOULD HAVE SAVED THEM. Now turn to the 12% of our lost Soldiers who died of wounds (DOW). These are the Soldiers who made it to a treatment facility only to die. Senior Army leaders need to be made aware of Disseminated Intravascular Coagulation (DIC same as CID); a condition where your body stops clotting blood. You have sewn up the Soldiers wounds. Then suddenly, every hole in his body including your stitches starts to bleed. Then bleeding through all the body's mucous membranes. Dr. Mary A Furlong, MD, Fellow, Soft Tissue Pathology, Armed Forces Institute of Pathology writes: "In the setting of major trauma, the presence of DIC approximately doubles the mortality rate." 8

Consider sepsis or infection alone. The battlefield is very dirty, germs are everywhere. You get sewn up then your body burns out with fever trying to kill all those germs that got sewn into your wounds. Then there is Acute Respiratory Distress Syndrome (ARDS) and renal shock when your kidneys stop working because the Soldier was in shock too long...or a part of the bowel simply dies.9 Senior Army leaders who are tacticians not doctors lack a coup d'oeil (understanding of everything at once) of this medical reality --- and many don't think its important to factor in these realities into tactical plans because they think as senior in rank the "details are dirty" and only concerns of enlisted and lower ranking Soldiers. Others think 10% casualties in combat are somehow "acceptable" ie; the status quo is AOK. The status quo is NOT OK in a 4GW media-driven world where the center of gravity is earning the support of the people themselves. If the people "in the middle" see Americans easily killed they will not believe we can protect them and could turn to the enemy. Callously thinking preventable casualties while accomplishing the mission are somehow "ok" is a dangerous myth and must be corrected with a bottom-to-top understanding by everyone in the Army which is the goal of this paper.

The Army transportation standard on the Non-Linear Battlefield Must be a Light Tracked AFV not a wheeled truck

The wheeled Army truck is an invention based on the battlefield totally under U.S. linear control where large areas are safe of enemy. Its the cheapest way to move people from A to B as long as no one is shooting at you and the terrain is paved or hard and flat. Zero population growth America in 2004 cannot field 100 divisions of troops like it did in 1944 to clear the enemy for trucks to operate safely. If the areas were indeed safe enough for trucks to be operated there would be no need for Army troops to maintain security. Today friend and foe are intermingled and attacks can occur at any time in any direction--the battlefield is non-linear. This means the minimum standard Army transportation vehicle must be a thick, armored body without windows/doors rolling on tracks that are light enough to not damage roads yet are inexpensive to operate: the amazing 11-ton M113 Gavin light tracked armored fighting vehicle (TAFV) is widely available by the thousands in the U.S. Army. TAFVs are 28% more weight/space efficient than wheeled vehicles and this potential for 28% better armor protection cannot be squandered away by trying to slap armor onto wheeled vehicles. TAFVs roll on solid metal roadwheels and steel tracks far more able to keep operating if hit by enemy fire; rubber tires are easily shredded and set on fire. Once a vehicle is immobilized, its easy for the enemy to pour fire into it and finish off anyone still alive inside. You have to keep moving to survive on the NLB, and you need EVERY advantage possible to include the 28% greater efficiency of TAFVs. The outward size of roughly a HMMWV truck and the weight of a 5-ton cargo truck, M113 Gavins cost only $3-a-mile to operate and tip-toe at a light 8 psi ground pressure over any terrains. M113 Gavin constitute 50% of an Army heavy division yet thousands of them sit in storage while the other 50% of a heavy division and 100% of a light division drive in trucks or walk on foot. The IDF moves its troops around in up-armored M113s and does not lose a man a day like we are in Iraq. 10 The Army must be able to fight anywhere in the world at any time, wheeled vehicles burdened with inadequate armor are notoriously prone to getting stuck in mud; an Army restricted to roads and trails is easily ambushed by the enemy. We have been lucky that the Iraqi resistance has been inept; against a more capable foe fighting for a cause they believe in and not money the Army rolling inside trucks could be a military and medical disaster beyond any amount of rescue.

Having our troops ride in M113 Gavin TAFVs peering out behind gunshields would eliminate a huge amount of the 31% penetrating head trauma deaths. Having their lower bodies and chests inside the M113 Gavin troop compartment would eliminate the 25% surgically uncorrectable torso trauma injuries from even happening. The 10% of potentially correctable surgical traumas, 9% exsanguinations from extremity wounds and unsolvable 7% mutilating blast traumas would be reduced. What we are saying is the Army medical community needs to blow the whistle on the Armyís plans to field lightfighters in trucks and insist that 88% of our Army battle deaths be prevented by a non-linear battlefield force structure that moves by M113 Gavin light tracked AFVs. Doing this will keep 90% of our Soldier we are now losing alive long enough and intact so medical care can save them.

Better Combat Medical Care must be Non-linear in method

The Civil War Jonathan Letterman fatalism of "triage" where you write off Soldiers condemning them to die is not only morally repugnant its unnecessary. Its a linear construct where the Soldiers who are deemed worth saving are passed around to different half-baked care providers instead of solving their problems immediately. As the wounded Soldiers are "evaced" their bodies are kept in damaging states of shock resulting in the horrific 12% DOW category. Again, we must not have our Soldiers get wounded in the first place as our first form of medical care via sound light tracked AFV mobility means that fully protects our Soldiers. But it also means we need to stop wasting time shuttling Soldiers when their wounds must be treated and their bodies taken out of shock. The problem is our treatment methods are linear.

In the Fall 2003 Journal of Special Operations Medicine, the Tactical Combat Casualty Care (TCCC) folks offer a 3-step linear process which is light/special operations infantry centric, but a typical, narrow-minded military construct that wastes time and unintentionally kills our troops.

Stages of care in TCCC

1. Care under fire

Return fire to suppress enemy, you are limited to only the medical gear you have on your back, do just life saving steps to keep victim from dying right then and there

2. Tactical field care

Get victim out of enemy fire, stabilize his condition for transport

3. Combat casualty evacuation care

Transport victim to care facility where he can be completely surgically repaired and healed

However, If you examine this 3-step process you see that it is oblivious to the fact that a light tracked AFV like the M113 Gavin can contribute to the combat medical process simultaneously in all 3 of their steps, and in ways not even recognized by their light/special operations can only be foot-infantry mindset. Other countries use TAFVs in special operations without their egos being threatened. On almost any battlefield situation, M113 Gavin TAFVs could be there during the battle moving Soldiers with armor protection so they don't even get injured in the first place. That's a moot point. However, let's say the troops dismount to fight on foot to fan out and influence a large area simultaneously with the vehicle in overwatch. Suppose some troops get injured. The M113 Gavin can zoom in and place itself between the enemy fire and the troops acting as a shield. The TCCC protocol doesn't even address the concept of using a vehicle as a moving shield and the egocentric elite unit mentality always seems to be anti-vehicle until it finds itself in a desperate jam. In Somalia, Rangers and Delta Force were trapped and only then did they request TAFVs to come in and bust them out when they could have been in on the mission from the get-go and prevented encirclement in the first place. 11 LAPD cops when outgunned by two assault rifle and body armor clad Bank of America robbers realized they needed something more than returning fire to get their wounded; a brave cop jumped into a patrol car, zoomed in and threw casualties in, then backed out in reverse to save their lives. 12 Why must we wait for people to die before being humble enough to ask for vehicular help?

Furthermore, the M113 Gavin can have almost every lifesaving medical care device known to man inside so as soon as the victim is inside its armored hull, he can be getting more than just a tourniquet, he could be clamped and even surgically repaired without ANY of the hours and hours of time of their bodies in shock which results in 12% dying of wounds later despite being patched up obviously too little, too late.

Certainly, the TCCC people mean well and are full of important contributions to improve military medicine. However, not only does their linear mantra neglect the armored vehicle's possible contributions to medical care, its care content lacks other non-vehicular tactics, techniques and procedures (TTP) like using smoke to screen victims from enemy fire. Let's propose another construct.

Non-Linear Combat First Aid Mantra: 6 simultaneous tasks you chose mix 'n match as situation dictates

suppress--mask--move--mend--fix--heal

 

Suppress

The TTC mantra offers return fire to suppress which is fairly obvious. What is not is its linear construction offers it as the first COA when there simply may not be anyone to shoot at as when a bomb goes off without a small arms fire ambush. Instead we offer SUPPRESS as just one COA not the first and let the Soldier mix as needed or use as appropriate.

Mask

*Armored vehicle like a M113 Gavin moves in to shield by driving right up to victim

* ballistic protection blanket throw over

* smoke grenade throw

Move

* Place victim in a M113 Gavin armored vehicle

* Kosmo MOUT lifeline line drag 13

* Load Bearing Equipment drag

* Darby ATACS 14

* SKEDCO drag

Mend

All of the TCCC procedures now in their Step 1 are done here

Combat LifeSavers (CLSers) and 91W Aidmen ("Medic") do this

We must fight the conventional Army to change their medical training instructs Soldiers to use tourniquets to stop serious bleeding on arm/legs while under fire. We must change the Army's Common Task training (CTT) manual. The civilian medical non-sense that you will lose a limb if you use a tourniquet so use direct pressure first must be refuted.

When under fire go straight to tourniquet to arm/legs; doctors can let off pressure and limbs will not be lost.

Fix

The TCCC directives under step 2 are done here.

The 9% of Soldiers that die due to exsanguination from extremity wounds is widely discussed in the TCC 21 February 2003 draft paper. The bottom line is don't over-use IVs. A M113 Gavin with a telelink to a doctor can show patient vital signs so a determination can be made; such heavy electronics gear is not easily carried on a Soldier's back and the TAFV provides a way for this capability to be brought to the battlefield without adding another burden to the Soldiers' load.

However, bleeding blood vessels can be found and clamped within minutes while inside M113 Gavin TAFV. Actual surgical repair is even possible if the vehicle is properly sized, equipped and staffed by competent physicians assistants and doctors. TAFVs offer more than just a casevac means.

Heal

The TCC protocol step 3 items go under this category which obviously implies moving the patient to somewhere where he can be completely healed.

Near simultaneous implementation is goal of the above 6 life saving steps to immediately reverse the act of physical cellular damage to the Soldier's body and eliminate the lingering post care complications from sending our Soldiers to early graves.

What is the protection "floor", minimum transportation standard on the NLB? When "Perfect" becomes the enemy of "Good Enough"

What is going on is that you have some defeatist types in the Army who say if what you do isn't PERFECT (invincible) we will do NOTHING---not even do the improvements to make our vehicles MORE VINCIBLE. Their real agenda is to do the MINIMAL thing, which is NOTHING; troop protection be damned. These are primarily All Volunteer Force (AVF) egotists who do not have the humility or love of their nation and other Soldiers to study war honestly. They are in the AVF as a personal ego trip. War is a STRUGGLE and these types lack the will to win and do EVERYTHING in our power to win, which implies a STRUGGLE; being chalant and pulling your sleeves up and working with people and using their ideas. You cannot be an egomaniac, narcissistic snob and work-together in a co-operative STRUGGLE. It takes HUMILITY. Humility to respect the enemy and what he can do with C4, RPGs and 155mm artillery shells as a cunning human being made in God's image but with an evil nature like you: a "Killer Angel". Humility to admit your human body is NOT invincible if you are a Special Forces/Airborne/light infantry egotist. No amount of physical fitness will enable you to avoid all battlefield weaponry and will not save you if you are hit; "PT" will not save you from "TNT". You have to be lucky all the time if you are vulnerable; the enemy only has to be lucky once. The solution is to have humility and admit you can be hit, and have "PLAN B" armor protection in this case to withstand the enemy's actions. At the strategic and operational levels of war good generalship seeks to collapse the will of the enemy so he resists us less so we have less shots to avoid and withstand, but this is not always possible or should be counted on when we design our force structures. Our easy victories in Grenada, Panama and the first Gulf War where the enemy will collapsed after a few days of fighting have lulled us into the illusion that we don't need robustness to overcome an enemy fighting back like he is in Iraq.

You will have to at some point ride in a motor vehicle to cover the great distances on our still very large planet earth, and when doing so if you are in an unarmored, wheeled truck, you are a target that can be easily killed regardless if you are a SEAL physical fitness "stud" or a National Guard "couch potato" called to active duty. Consider the tragedy of former SEAL Scott Helventson who was one of the Blackwater civilian contractors who was killed in a gasoline-powered SUV truck in Iraq and then pulled out of his burning wheeled vehicle beaten, and dragged through the street by an angry Iraqi mob:

www.yahoo.com/_ylh=X3oDMTB1M2EzYWFoBF9TAzI3MTYxNDkEdGVzdAMwBHRtcGwDaWUtYmV0YQ--/s/171126

Middle East - AP

Fitness Guru Among Four Killed in Iraq

Fri Apr 2, 9:59 AM ET

By MASON STOCKSTILL, Associated Press Writer

LOS ANGELES - After serving 12 years in the Navy, Scott Helvenston started a career as a fitness instructor and worked as trainer and stunt man for such movies as "Face/Off" and "G.I. Jane."

He helped prepare actress Demi Moore for her role as the first woman to join the Navy SEALs in "G.I. Jane," and appeared on two reality series: "Man vs. Beast" and "Combat Missions."

But after years out of the service, friends said they weren't surprised to learn the former SEAL had left the comfort of his life in California behind him and headed for Iraq (news - web sites).

"That's what, in a time of need, true American warriors like Scott would do," "Combat Missions" producer Mark Burnett said Thursday.

Helvenston, 38, was among four American civilian contractors killed in Fallujah, Iraq, in an ambush on Wednesday, their charred bodies mutilated and dragged through the streets. The contractors were working for Blackwater Security Consulting when their vehicle was hit by rocket-propelled grenades.

Two of the other victims have been identified as Jerko "Jerry" Zovko, 32, and Michael Teague, 38.

Zovko always wanted to save the world, his mother said. He joined the Army at 19 and spoke five languages fluently English, Croatian, Spanish, Russian and Arabic.

"Jerry was a man with a principle, an idea," his mother, Danica "Donna" Zovko said in Willoughby, Ohio. "He loved people. He wanted the world to be without borders, for everybody to be free and safe."

Mrs. Zovko said she and her husband, Jozo, suspected their son was one of the dead late Wednesday evening because he had been working in Iraq. Their fears were confirmed early Thursday.

"He was the most self-motivated person," Zovko's brother Tom told ABC's "Good Morning America. "He grew up a skinny, little guy but wanted to be big, and he become big. He had desire and motivation and never gave up."

Teague was a 12-year Army veteran who served in Afghanistan (news - web sites), Panama and Grenada, said his wife, Rhonda Teague. She said he received a bronze star for his service in Afghanistan.

Rhonda Teague called her husband a "proud father, soldier and American."

"I, his son Brandon and his friends and family will miss him without

measure," her statement said.

Teague, of Clarksville, Tenn., had worked in the security business since he left the Army six years ago, and joined Blackwater Security two months ago, WTVF-TV of Nashville reported.

A friend, Sgt. John Ratliff, told CBS' "The Early Show" that Teague "told me to promise to take care of his wife and his son ... He knew it was rough over there."

"In my opinion, Mike was caught in a situation to where he couldn't do anything for himself or his counterparts," Ratliff said. He said he knew his friend "would have done anything in his power" to save himself and the other three if it had been possible.

Helvenston's fitness company, Amphibian Athletics, promised to bring a Navy SEAL-style workout to his customers. His wife, Tricia, appeared in some of the company's workout videos.

Fred Atkinson, a neighbor of Helvenston's in Oceanside, said he was a devoted father to his children, Kyle and Kelsey, and often took them camping or surfing.

The identity of the fourth victim was not immediately known. The names of the victims were not officially released because all family members had yet to be notified, U.S. officials said Thursday.

Blackwater Security, based in Moyock, N.C., provides security training and guard services to customers around the world. President Gary Jackson and two other company leaders are former Navy SEAL commandos.

A statement on the company's Web site said officials were grieving for the employees.

"Our tasks are dangerous, and while we feel sadness for our fallen colleagues, we also feel pride and satisfaction that we are making a difference for the people of Iraq."

___

On the Net:

Blackwater USA: http://blackwatersecurity.com

Furthermore, some injuries are so devastating to the human body, NO AMOUNT of medical care can save you. So you had best NOT GET INJURED IN THE FIRST PLACE.

Here is the vehicle protection reality:

MOST PROTECTED

Rolls on steel tracks with rubber pads...

Heavy Tanks (70 ton M1 Abrams tanks)

Medium Tanks (33-ton M2 Bradleys)

M113 Gavins with extra armor

M113 Gavins with sandbags

Light Tanks (11-ton M113 Gavins)

----------------------------------dividing line-------------------------------

Rolls on air-filled rubber tires that burn....

Heavy armored cars (do not exist, not practical)

Medium armored cars (19-ton Strykers)

Light armored cars (4-6 ton armored HMMWVs)

unarmored cars/trucks with sand bags

unarmored cars/trucks (3 ton HMMWV SUVs)

troops on foot

LEAST PROTECTED

What the Army is doing by having the majority of its troops ride in wheeled trucks is BELOW the line or "floor" of what will protect our troops on the lethal non-linear battlefield.

However, we need an EXISTING VEHICLE IN LARGE QUANTITIES that can be upgraded to make our Army combat ready N-O-W WITHOUT $3-10 MILLION EACH NEW SINGLE PLATFORM PURCHASES. There are really only two candidates for this:

HMMWV 3-ton trucks

M113 Gavin light 10.5 ton tracks

That's it.

Clearly, we can get more troop protection and combat capabilities for $500,000 with one 3.5 mpg M113 Gavin light track than a pair of HMMWV $250,000 trucks (5 mpg) that have 4 windows, 4 doors, a windshield and roll on air-filled rubber tires that can neither swim, be RPG resistant or go cross-country at will. The MINIMUM TRANSPORTATION STANDARD ON THE NON-LINEAR BATTLEFIELD MUST BE A LIGHT TRACKED AFV not a wheeled truck.

What we're saying is EVERYONE that is not in a medium or heavy track be in a LIGHT TRACK unless they are in a wheeled cargo hauling truck because we do not have cargo hauling tracks fielded en masse. Scott Miller wants to fix this with XM1108 Gavin variants with PLS flat racks:

www.geocities.com/dominantlogistics

Fuel economy, affordability, pavement damage and 3D transportability issues dictate that the best en masse level of protected troop transport feasible is a LIGHT TRACKED AFV.

NLB Air-Mech-Strike Forward Surgical repair Teams: fix Soldiers immediately within Light Tracked Armored Fighting Vehicles not pass-the-buck

"In World War II, neurosurgeons learned that by moving closer to the front lines -- where they could see patients within hours of their injury instead of days -- they could dramatically lower infection and fatality rates. Even though front-line surgeons were operating in far-more-primitive conditions, infection rates for patients dropped to less than 5% when the doctors were closer to the front, from 33% when they were positioned further back"

--Lieutenant Colonel Jeff Poffenbarger, Chief of Neurosurgery at Brooke Army Medical Center in San Antonio now in combat in Iraq as quoted in a recent article in the Wall Street Journal (see reference 17 below for full article)

Currently the Army has Forward Surgical Teams (FSTs) that deploy into static tents a good distance to the rear of the battlefield. However, on the NLB there is no guarantee that wounded Soldiers will be able to even be evaced back to the FSTs at all let alone in time. In Somalia, it took 15 hours to get wounded men back to doctors and 18 died because of it. What we need are Air-Mech-Strike (AMS) FSTs to be in light TAFVs that can be less than 1,000 meters back from the battlefield with robust self-protection so we don't have to wait until we are winning the battle to get our wounded men mended.

An AMS FST would consist of 6 physicians which would include 2 trained general surgeons, 1 orthopedic surgeon, 1 anesthesiologist , and 2 MOS 62A emergency medicine physicians, 6 nurses and 12 track commanders/drivers.

On the NLB, the only safe area is where we have made it safe. The TAFV would be an armored M1068A4 variant of the M113 Gavin with a higher roof and stretched MTVL hull. 15 Extra RPG-resistant armor and gunshields would be fitted. The entire vehicle could be hybrid-electric powered with band tracks to be stealthy quiet eliminating that typical knee-jerk objections of light infantry/special operations to using light TAFVs. Light TAFVs are HMMWV-sized and are more cross-country mobile to include amphibious swimming capability across rivers, lakes and with waterjets oceans that HMMWV trucks cannot do. 16

The M1068A4 NLB Medical Gavin TAFV would feature a full trauma unit ambulance suite of life-saving devices:

* On board oxygen

* Refrigeration for whole blood and packed red blood cells (PBCs)

* Heart restart paddles

* Portable diagnostic equipment such as the Sonosite portable ultrasound device and electronic monitoring equipment

* Equipment/supplies to do surgical repairs of gunshot/shrapnel wounds

* Telelink to other doctors to monitor vital signs render extra advice

* Air-conditioned, sanitary internal environment

DETAILS OF PROPOSED ARMY ARMORED MEDICAL VEHICLES:

AMEV

http://globalsecurity.org/military/systems/ground/amev.htm

M113A4 MTVL

http://globalsecurity.org/military/systems/ground/m113a4-esv.htm

The point is AMS FSTs in TAFVs can find/clamp better than 91W Medic in the dirt with only the medical gear carried on his back. There would be no passing-the-buck, Letterman triage style time wasting that kills our Soldiers.

We propose 3 AMS FSTs be stood up in every new "Brigade Unit of Action" (BUA) to mirror each maneuver infantry battalion and provide them at least 1 AMS FST to be assigned to support them directly with instant forward surgical care.

At every physical training session there should be an AMS FST in a TAFV nearby so if Soldiers collapse they can be revived. The following story has happened too many times.

http://home.hamptonroads.com/stories/story.cfm?story=69062&ran=53364

Virginia Soldier drops dead in Iraq during physical training

Associated Press© April 16, 2004 | Last updated 10:03 AM Apr. 16

RICHMOND A Soldier from Virginia died in Iraq after collapsing during physical training, the Department of Defense said today. Spc. Frank K. Rivers Jr., 23, of Woodbridge, died Wednesday in Mosul in northern Iraq. Officials were trying to determine the cause of death. Rivers was assigned to the Army's 3rd Brigade, 2nd Infantry Division based at Fort Lewis, Wash. The 3rd Brigade is also know as the Stryker Brigade Combat Team because it uses high-tech fighting vehicles known as Strykers, an eight-wheeled vehicle with onboard computers.

As said before, the NLB is so lethal, some wounds are fatal no matter what you do: so don't get wounded by moving whenever possible in a TAFV. Army medicine could lead the way for the rest of the Army by providing AMS FSTs to EVERY Army BUA regardless of whether its "light" or not. This idea that light TAFVs cannot be employed by Army light/special operations units must be ended once and for all, even if it must start with life-saving Army doctors insisting on it. When the Vietnam war began there were plenty of senior officers who absurdly thought tracked armored vehicles couldn't operate in the closed terrain there. Once TAFVs began showing their worth by doing, it became patently obvious to everyone involved that TAFV forces were the most powerful units there. 62As need to be on every mission.

Not enough doc officers able to provide emergency medicine to the U.S. Army?

Some may complain that the AMS FST proposal will not work because we cannot get enough doctors. Well, if Army leaders continue to have their Soldiers ride around in HMMWVs no amount of doctors will be able to save them. If you want more doctors we better treat them right. Let's be brutally honest here; intelligent people donít like being treated like feces with the typical Army blue-collar egomaniacsí garrison antics nor like to freeze the night in sleeping bags. Doctors can make more money in civilian medical practice than in the Army uniform. If you took a cross-section of Army doctors this is what you would find:

Patriotic driven 25%

Economic co-dependants 50%

Incompetents who cant make it in civilian life 25%

Therefore, what we need to do is expand the top two types of doctors.

Massive U.S. NG/RC civil-military Combat Doctor program

First off, we need to offer doctors hooah! schools to "sweeten the pot" for them to be Army doctors, and to show them being a mud Soldier can be fun. Every doctor that wants to go to Airborne, Air Assault, Light leaders, or Ranger schools should be given a change to go.

Next, we need to stop having round peg in square hole situations where doctors fulfil tasks they are not trained to do which makes them situationally incompetent.

The BN surgeon who works at the aid station is a different position than the AMS FST doctors. However, ALL BN Surgeons should be 62A who have completed a residency in Emergency Medicine. This training would include the internship. The AMS FST docs would need to be residency trained in general surgery, orthopedics, anesthesiology, emergency medicine.

We need to change this by making every BN surgeon a MOS 62A emergency medicine residency trained doctor by joining with civilian hospitals to create civil-military training programs on a large scale. The goal is to after 3-4 years become medical emergency medicine board certified. While a difficult path; the Army would provide for free an Army doctor for 2 years to pay back the civilian hospital for taking on this task, the 10 major most violent U.S. cities should be where the Army trains its crop of combat doctors. The goal would be to create each year, 100 MOS 62A and the other AMS FST specialty doctors to man the Army's BUAs in a 3 year cycle. Every 3 years we would have 300 new combat doctors to add to the 18 doctor FSTs in all 43-48 of the Army's BUAs. 774-874 would be the total numbers of doctors needed.

The AMS FSTs would be manned by the doctor doing 3 years on active duty and one last 3 year NG/RC commitment for complete repayment of ALL MEDICAL schooling costs. Instead of the current partial repayment. 2 years of the active duty time would be in residence in a top 10 violent American city learning how to actually treat wounds of violence followed by 1 year in the field in a FST. Then the next 3 years one weekend-a-month with the Guard/Reserve in an AMS FST.

If the combat doctor is deployed for 1 year the roughly $20,000 officer pay will not pay for the typical $200,000 of civilian practice bills to break even and could result in the collapse of his practice. Instead, the Army should pay whatever the documented difference is for the doctor's time during deployment.

The typical cost to train a pilot is $1 million. Why not spend a fraction of this on doctors who save lives and can for their lifetime benefit the entire nation? The cost to produce a combat doctor from commissioning to 3/3 service commitment worse-case scenario of being deployed for all 3 years while in the guard/reserve would still be under $1 million. The annual cost of the civil-military doctor program would be about $100 million or less than a V-22 Osprey tilt-rotor aircraft which in an instant could crash and be lost.

Summary/Conclusion

Army medical leaders need to fight for and insist that light TAFVs be the NLB mission transportation standard for the entire U.S. Army because its too late to save Soldiers after their faces have been blown off in a bomb blast. Its high time Army medicine speak up and instruct the rest of the Army that we have reached the limits of what emergency medicine can do if we let our Soldiers get torn apart by today's lethal weaponry. The plan proposed above would reverse this trend by Army medicine embedding into each Army BUA at least a dozen light tracked AFV medical care vehicles with fully trained doctors and nurses to render near instantaneous surgical repair capabilities. The proposal above outlines how America's violent cities could get an infusion of Army know-how to save lives now as internal cultural conflicts rack our nation with violent crime. The authors call upon the American Congress to enact this plan immediately.

 

Notes

1. email to Mike Sparks from friend in 82nd Airborne in Iraq at the time

2. email to Mike Sparks from friend in Civil Affairs in Iraq at the time

3. "Pentagon hiding reality of toll from war in Iraq", Palm Beach Post Editorial Sunday, February 1, 2004

www.palmbeachpost.com/opinion/content/auto/epaper/editions/sunday/opinion_04a18dbd454ca0b51081.html

Sen. Chuck Hagel, R-Neb., a Vietnam veteran and senior member of the Senate Foreign Relations Committee, tried asking Secretary of Defense Donald Rumsfeld about U.S. troops who have been wounded in Iraq.

He wanted to know the number of battlefield casualties, how the Pentagon was defining "wounded in action," the procedure for releasing information on wounded and how many Americans had received the Purple Heart. Sen. Hagel told National Public Radio that it took six weeks to get a response. A letter from the Pentagon said: "At this time, we were unfortunately lacking in information, and we didn't have the information that you requested." Sen. Hagel found the non-answers "astounding" and criticized a widening credibility gap between the government and the American people over a complete accounting of the war's toll.

The nation reached a sad milestone this month with the 500th death in Iraq. But the numbers of wounded continue to be lost beneath the headlines, as does the severity of the wounds. If Sen. Hagel can't get answers, what chance does the public have? Military records suggest that about 9,000 U.S. troops have been evacuated from Iraq for a wide spectrum of reasons, including combat wounds, accident injuries, psychological problems, infections and illness. At least 21 have committed suicide. About 3,000 U.S. soldiers are counted among the group wounded in battle or injured in accidents since the invasion.

The ratio of wounded to dead -- about 6-to-1 -- is the encouraging news. In the Korean War, for example, it was 3-to-1, and in the Civil War 2-to-1. The improvement comes from the protective body armor modern Soldiers wear, the efforts of field commanders to minimize casualties and great advances in battlefield hospital care. Soldiers who would have bled to death in Korea routinely are saved.

The discouraging news is that a higher percentage of those surviving wounds will live out their days with severe disfigurements or disabilities. The nature of warfare in Iraq -- especially vehicle bombings and guerrilla attacks -- have produced large numbers of horrific burns and amputations that cannot be repaired. Unseen damage such as post-traumatic stress disorder or toxic poisoning also can leave lifetime scars. The Pentagon's numbers that show high percentages of survivors do not capture the scope of the losses. The word wounded too often passes for undamaged.

The government still fails to deal with all the casualties of past wars. Vietnam vets await treatment for Agent Orange poisoning, and veterans of the Gulf War complain of neurological problems that the Pentagon won't acknowledge. The Department of Veterans Affairs has 2.7 million clients and a budget that doesn't keep up with the demand for disability benefits, medical care and pensions. President Bush says it's worth spending close to $1 trillion to send a man to Mars at a time when many vets can't make it into a doctor's waiting room. Hundreds of veterans are coming home from Iraq with wounds that will require long rehabilitation and expensive treatment. It will be years before the full cost is counted.

The numbers Americans are able to get do not reflect the war's toll in human suffering. The real numbers are something that Americans deserve to know.

4. Detailed report by the 1st Tactical Studies Group (Airborne) on the Army's current Transformation plans

www.geocities.com/pentomicarmyagain

5. Detailed report by the 1st Tactical Studies Group (Airborne) on why wheeled vehicles are tactically unsound on the modern, non-linear battlefield

www.geocities.com/paratroop2000/armoredstrykershmmwvsfail.htm

6. "Tactical Medicine Training for SEAL Mission Commanders", CPT Frank Butler MC USN, Director of Biomedical Research, Naval Special Warfare Command, July 12, 2000 page 16

7. 86% of all the Soldiers who die do so within the first 30 minutes after being wounded according to the Combat Casualty Care Research Program web site

www.usaccc.org/aboutccc.jsp

8. "Disseminated Intravascular Coagulation" by Mary A Furlong, MD

www.emedicine.com/emerg/topic150.htm

Author: Mary A Furlong, MD, Fellow, Soft Tissue Pathology, Armed Forces Institute of Pathology

Coauthor(s): Brendan R Furlong, MD, Associate Medical Director, MedSTAR Transport, Department of Emergency Medicine, Washington Hospital Center

Editor(s): Steven A Conrad, MD, PhD, Chief, Department of Emergency Medicine; Chief, Multidisciplinary Critical Care Service, Professor, Department of Emergency and Internal Medicine, Louisiana State University Health Sciences Center; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, Pharmacy, eMedicine; Jeffrey L Arnold, MD, FACEP, FAAEM, Assistant Clinical Professor, Department of Emergency Medicine, Baystate Medical Center; John Halamka, MD, Chief Information Officer, CareGroup Healthcare System, Assistant Professor of Medicine, Department of Emergency Medicine, Beth Israel Deaconess Medical Center; Assistant Professor of Medicine, Harvard Medical School; and Barry Brenner, MD, PhD, Chairman, Department of Emergency Medicine, Professor, Departments of Emergency Medicine and Internal Medicine, University of Arkansas for Medical Sciences

INTRODUCTION Section 2 of 10

Author Information Introduction Clinical Differentials Workup Treatment Medication Follow-up Miscellaneous Bibliography

Background: Disseminated intravascular coagulation (DIC) is a complex and controversial systemic thrombohemorrhagic disorder involving the generation of intravascular fibrin and the consumption of procoagulants and platelets.

DIC is seen in association with a number of well-defined clinical situations, including sepsis, major trauma, and abruptio placenta, and with laboratory evidence of the following:

Procoagulant activation

Fibrinolytic activation

Inhibitor consumption

Biochemical evidence of end-organ damage or failure

DIC is a pathophysiologic term describing a continuum of events that occur in the coagulation pathway in association with a variety of disease states. DIC occurs in acute and chronic forms.

Consider DIC in patients with one of the underlying disorders listed above, with evidence of decreased or decreasing platelet counts, and with any of the laboratory findings listed above.

As the sequelae of DIC can be devastating, early clinical suspicion and laboratory diagnosis are essential. This chapter provides essential guidelines for the appropriate diagnosis and clinical management of patients with DIC.

Pathophysiology: The pathophysiology of DIC involves initiation of coagulation via endothelial injury or tissue injury and subsequent release of procoagulant material in the form of cytokines and tissue factors. Interleukin-6 and tumor necrosis factor may be the most influential cytokines involved in coagulation activation.

Two proteolytic enzymes, thrombin and plasmin, are activated and circulate systemically. Their balance determines a bleeding or thrombotic tendency. Thrombin cleaves fibrinogen to form fibrin monomers. It ultimately potentiates the coagulation cascade and leads to small and large vessel thrombosis, with resultant organ ischemia and organ failure. Plasmin, a component of the fibrinolytic system, is capable of degrading fibrin into measurable degradation products. Plasmin also activates complement. Plasmin and thrombin induce qualitative and quantitative platelet abnormalities.

Acute DIC is characterized by generalized bleeding, which ranges from petechiae to exsanguinating hemorrhage, or microcirculatory and macrocirculatory thrombosis. This leads to hypoperfusion, infarction, and end-organ damage. In severe cases, patients may develop fever and a shocklike picture with tachycardia, tachypnea, and hypotension. Chronic DIC is characterized by subacute bleeding and diffuse thrombosis. Localized DIC is characterized by bleeding or thrombosis confined to a specific anatomic location. It has been associated with aortic aneurysms, giant hemangiomas, and hyperacute renal allograft rejection.

Frequency:

In the US: Approximately 18,000 cases of DIC occurred in 1994. DIC may occur in 30-50% of patients with sepsis.

Mortality/Morbidity: Morbidity and mortality depend on both the underlying disease and the severity of coagulopathy. Assigning a numerical figure for DIC-specific morbidity and mortality is difficult. Below are examples of mortality rates in diseases complicated by DIC:

Idiopathic purpura fulminans associated with DIC has a mortality rate of 18%.

Septic abortion with clostridial infection and shock associated with severe DIC has a mortality rate of 50%.

In the setting of major trauma, the presence of DIC approximately doubles the mortality rate.

Sex: Incidence is equal in males and females.

Age: No age predilection is known. CLINICAL Section 3 of 10

Author Information Introduction Clinical Differentials Workup Treatment Medication Follow-up Miscellaneous Bibliography

History: In addition to the symptoms related to the underlying disease process, ascertain history of blood loss and hypovolemia, such as gastrointestinal bleeding. Look for symptoms and signs of thrombosis in large vessels, such as deep venous thrombosis (DVT), and of microvascular thrombosis, such as renal failure.

Epistaxis

Gingival bleeding

Mucosal bleeding

Cough

Dyspnea

Confusion, disorientation

Fever

Physical:

Circulation

Signs of spontaneous and life-threatening hemorrhage

Signs of subacute bleeding

Signs of diffuse or localized thrombosis

Central nervous system

Nonspecific altered consciousness/stupor

Focal deficits not usually present

Cardiovascular system

Hypotension

Tachycardia

Circulatory collapse

Respiratory system

Pleural friction rub

Signs of adult respiratory distress syndrome (ARDS)

Gastrointestinal system

Hematemesis

Hematochezia

Genitourinary system

Signs of azotemia and renal failure

Hematuria

Oliguria

Metrorrhagia

Uterine hemorrhage

Dermatologic system

Petechiae

Purpura

Hemorrhagic bullae

Acral cyanosis

Skin necrosis of lower limbs (purpura fulminans)

Localized infarction and gangrene

Wound bleeding and deep subcutaneous hematomas

Thrombosis

Causes: Causes of DIC can be classified as acute or chronic, systemic or localized. DIC may be the result of a single or multiple conditions.

Acute DIC

Infectious

Bacterial (eg, gram-negative sepsis, gram-positive infections, rickettsial)

Viral (eg, HIV, cytomegalovirus [CMV], varicella, hepatitis)

Fungal (eg, histoplasma)

Parasitic (eg, malaria)

Malignancy

Hematologic (eg, acute myelocytic leukemias)

Metastatic (eg, mucin-secreting adenocarcinomas)

Obstetric

Placental abruption

Amniotic fluid embolism

Acute fatty liver of pregnancy

Eclampsia

Trauma

Burns

Motor vehicle accidents (MVAs)

Snake envenomation

Transfusion

Hemolytic reactions

Massive transfusion

Liver disease - Acute hepatic failure

Prosthetic devices

Shunts (Denver, LeVeen)

Ventricular assist devices

Chronic DIC

Malignancies

Solid tumors

Leukemia

Obstetric

Retained dead fetus syndrome

Retained products of conception

Hematologic

Myeloproliferative syndromes

Paroxysmal nocturnal hemoglobinuria

Vascular

Rheumatoid arthritis

Raynaud disease

Cardiovascular - Myocardial infarction

Inflammatory

Ulcerative colitis

Crohn disease

Sarcoidosis

Localized DIC

Aortic aneursyms

Giant hemangiomas (Kasabach-Merritt syndrome)

Acute renal allograft rejection

Hemolytic uremic syndrome

DIFFERENTIALS Section 4 of 10

Author Information Introduction Clinical Differentials Workup Treatment Medication Follow-up Miscellaneous Bibliography

Hemolytic Uremic Syndrome

Thrombocytopenic Purpura

Other Problems to be Considered:

Severe liver failure (most common differential disorder)

Idiopathic purpura fulminans

Primary fibrinolysis

Vitamin K deficiency

Hemolysis, elevated liver function, and low platelets (HELLP) syndrome in pregnancy

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Clinical

Differentials

Workup

Treatment

Medication

Follow-up

Miscellaneous

Bibliography

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WORKUP Section 5 of 10

Author Information Introduction Clinical Differentials Workup Treatment Medication Follow-up Miscellaneous Bibliography

Lab Studies:

D-dimer test

D-dimer is a fibrin degradation product generated by plasmin lysis of cross-linked fibrin clots.

The presence of this fragment documents the presence of thrombin (cross-linking) and plasmin (fibrinolysis).

This monoclonal antibody test has the greatest specificity and is a highly reliable test for diagnosis of DIC.

Antithrombin III level

Functional antithrombin III levels decrease in DIC.

This synthetic substrate assay is a reliable and useful test for diagnosis and therapeutic monitoring.

Fibrinogen and fibrin degradation products

Latex particle agglutination test is used to detect fibrinogen and fibrin degradation products (FDPs).

Degradation products increase as plasmin biodegrades fibrinogen (ie, fibrinolytic activity).

This test is not diagnostic of DIC, yet levels are elevated in 85-100% of patients.

Fibrinopeptide A

Enzyme-linked immunosorbent assay (ELISA) or radioimmunoassay is used to measure fibrinopeptide A (FPA).

FPA is a breakdown product of fibrinogen, indicative of thrombin activity.

Levels are elevated in DIC.

Platelet count

Platelet counts are invariably decreased. This is usually evident in the peripheral smear.

Functional deficits in platelets are often present and further studies are not indicated.

Fibrinogen

Thrombin-time based assay is used to measure fibrinogen levels.

Levels usually are decreased in DIC.

Fibrinogen is an acute phase reactant and initially may be elevated secondary to the primary disease.

Prothrombin time

Prothrombin time (PT) tests the extrinsic and common pathways.

PT may be normal, prolonged, or shortened in DIC.

It is generally an unreliable test for diagnosis of DIC, and 50-75% of patients will have prolonged values.

Activated partial thromboplastin time

Activated partial thromboplastin time (aPTT) tests the intrinsic and common pathways.

Values are unpredictable in DIC.

It is an unreliable test for diagnosis of DIC, and 50-60% of patients will have prolonged values.

Thrombin time

Thrombin time measures the conversion of fibrinogen to fibrin.

It should be prolonged in DIC.

Protamine test

The protamine test is a paracoagulation test that detects fibrin monomers in plasma.

Fibrin web formation indicates a positive result.

This test should be positive in patients with DIC.

Anemia

Schizocytosis

Decreased coagulation factors

V

VIII

X

XIII

Protein C

Hemoglobinuria

Hematuria

Hematochezia

No single diagnostic test exists for DIC. DIC is initially suggested by the following combination: a clinical condition consistent with DIC, thrombocytopenia (< 100 x 109/L), prolonged PT and aPTT, and presence of FDP/D-dimer. Other tests listed here also may help to exclude DIC.

PF 1+2 assay: This ELISA assay, which quantitates levels of PF 1+2 in the circulation, provides evidence of factor Xa generation. (Levels are abnormal in more than 90% of patients with DIC.)

Imaging Studies:

Base diagnostic imaging on the underlying pathologic process as well as suspicion for areas of thrombosis and hemorrhage.

Perform a bilateral perihilar soft density chest x-ray if pulmonary injury is present.

Other Tests:

Base other tests on the underlying pathologic process as well as suspicion for areas of thrombosis and hemorrhage.

Procedures:

Base procedures on the underlying pathologic process as well as suspicion for areas of thrombosis and hemorrhage.

Conduct invasive procedures with care because of bleeding complications. Procedures should follow administration of clotting factor and platelet repletion.

TREATMENT Section 6 of 10

Author Information Introduction Clinical Differentials Workup Treatment Medication Follow-up Miscellaneous Bibliography

Prehospital Care: Monitor vital signs, assess and document extent of hemorrhage and thrombosis, correct hypovolemia, and administer basic hemostatic procedures when indicated.

Emergency Department Care: The cornerstone of DIC management is treatment of the underlying disorder. The following supportive measures are essential:

Continue prehospital measures.

Attend to life-threatening issues such as airway compromise or severe hemorrhage.

Determine the underlying cause of the patient's DIC and initiate therapy. Obtain appropriate imaging studies if necessary.

Draw specimens for appropriate coagulation studies and other diagnostic laboratory tests.

Begin anticoagulant therapy if indicated (see Medication section for indications).

Replace blood products as indicated (see Medication section).

RBC transfusion (ie, packed RBCs [PRBCs])

Platelet concentrates

Fresh frozen plasma (FFP)

Cryoprecipitate

Antithrombin III concentrate

Consultations:

Consult hematology for assistance with diagnosis and management.

Consult transfusion medicine or blood bank; determine the availability of general and specialized blood products that may be necessary for the acute management of fulminant DIC.

Consult critical care medicine if multiple organ failure is present.

Early consultation is indicated for this complicated, life-threatening condition. Obtain other subspecialty consultations as indicated by the patient's primary diagnosis.

MEDICATION Section 7 of 10

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Therapy should be based on etiology and aimed at eliminating the underlying disease. Therapy should be appropriately aggressive for the patientís age, disease, and the severity and location of hemorrhage/thrombosis. Treatment for acute DIC includes anticoagulants, blood components, and antifibrinolytics.

Hemostatic and coagulation parameters should be monitored continuously during treatment. Base therapeutic decisions on clinical and laboratory evaluation of hemostasis. In cases of low-grade DIC, therapy other than supportive care may not be warranted or may include antiplatelet agents or subcutaneous heparin; treatment decisions should be based on clinical and laboratory evaluation of hemostasis.

Drug Category: Anticoagulant agents -- These agents are used in the treatment of clinically evident intravascular thrombosis when the patient continues to bleed or clot 4-6 h after initiation of primary and supportive therapy. Thrombosis can present as purpura fulminans or acral ischemia. Take special precaution in obstetric emergencies or massive liver failure. The anti-inflammatory properties of antithrombin III may be particularly useful in DIC secondary to sepsis.

Drug Name

Heparin (Hep-Lock) -- Use and dose of heparin is based on severity of DIC, underlying cause, and extent of thrombosis. Monitoring results of therapy is mandatory. Heparin augments antithrombin III activity and prevents conversion of fibrinogen to fibrin. Does not actively lyse but inhibits further thrombogenesis. Prevents reaccumulation of a clot after spontaneous fibrinolysis.

Adult Dose 80-100 U/kg SC q4-6h or 20,000-30,000 U IV qd continuous infusion

Pediatric Dose Not established

Contraindications Documented hypersensitivity; subacute bacterial endocarditis; active bleeding; history of heparin-induced thrombocytopenia

Interactions Digoxin, nicotine, tetracycline, and antihistamines may decrease effects; NSAIDs, aspirin, dextran, dipyridamole, and hydroxychloroquine may increase toxicity

Pregnancy C - Safety for use during pregnancy has not been established.

Precautions Monitor for localized bleeding or hematoma; may aggravate hemorrhage; in neonates, preservative-free heparin is recommended to avoid possible toxicity (gasping syndrome) by benzyl alcohol, which is used as preservative; caution in severe hypotension and shock

Drug Name

Antithrombin III (ATnativ, Thrombate III) -- Used for moderately severe to severe DIC or when levels are depressed markedly. Alpha 2-globulin that inactivates thrombin, plasmin, and other serine proteases of coagulation, including factors IXa, Xa, XIa, XIIa, and VIIa. These effects inhibit coagulation.

Adult Dose Total units = (desired level - initial level) (0.6 x total body weight kg) IV q8h with a desired level >125% or loading dose of 100 U/kg IV over 3 h; followed by continuous infusion of 100 U/kg/d

Pediatric Dose Not established

Contraindications Documented hypersensitivity

Interactions Increases anticoagulation effects of heparin

Pregnancy C - Safety for use during pregnancy has not been established.

Precautions Caution in hypotension; despite measures taken to delete infectious agents from human product, potentially still can transmit disease or contain unknown infectious agents

Drug Category: Blood components -- Blood components are used to correct abnormal hemostatic parameters. These products should be considered only after initial supportive and anticoagulant therapy. Washed PRBCs and platelet concentrates are considered safe in uncontrolled DIC. Specialized blood components (cryoprecipitate, FFP) may interfere with or improve DIC.

Drug Name

PRBCs (washed) -- Preferred to whole blood since they limit volume, immune, and storage complications. Obtain PRBCs after centrifugation of whole blood. Use washed or frozen PRBCs in individuals with hypersensitivity transfusion reactions.

Adult Dose 1 unit of PRBCs should raise hemoglobin by 1 g/dL or raise hematocrit by 3%.

Pediatric Dose Not established

Contraindications Competent adult or legal guardian may refuse blood product; immediate consultation with hospital ethical and legal staff is mandated

Interactions None reported

Pregnancy A - Safe in pregnancy

Precautions Use CMV-negative units or filtered ones; transfusion reactions and transmission of blood-borne pathogens are a concern; benefits should outweigh risks associated with such products

Drug Name

Platelet concentrates (random or single donor, pheresis units) -- Considered safe for use in acute DIC.

Adult Dose Based on platelet count and clinical situation

Pediatric Dose Not established

Contraindications Competent adult or legal guardian may refuse blood product; immediate consultation with hospital ethical and legal staff mandated

Interactions None reported

Pregnancy A - Safe in pregnancy

Precautions Platelets should be CMV-negative or the pheresis units from single donors filtered; benefits should outweigh risks associated with such products

Drug Name

Cryoprecipitate -- Not commonly recommended except when fibrinogen is needed.

Adult Dose Each bag contains 80-100 U of factor VIII; base administration on fibrinogen levels, antithrombin III levels, and coagulation parameters

Pediatric Dose Not established

Contraindications Documented hypersensitivity; uncontrolled DIC with abnormal antithrombin III levels

Interactions None reported

Pregnancy A - Safe in pregnancy

Precautions Benefits should outweigh risks associated with transfusion therapy; viral contamination and infection are remotely possible although unlikely because of prescreening

Drug Category: Antifibrinolytic agents -- These agents are used only after all other therapeutic modalities have been tried and deemed unsuccessful. Increase in circulating plasmin and laboratory evidence of decreased plasminogen should be documented. Antifibrinolytics may be useful in cases of DIC secondary to hyperfibrinolysis associated with acute promyelocytic leukemia and other forms of cancer.Drug Name

Aminocaproic acid (Amicar) -- Inhibits fibrinolysis via inhibition of plasminogen activator substances and, to a lesser degree, through antiplasmin activity. Main problem is that thrombi that form during treatment are not lysed, and clinical significance of reducing bleeding is uncertain.

Adult Dose Load 5-10 g IV slowly; followed by 2-4 g/h IV; not to exceed 30 g/d

Pediatric Dose Not established

Contraindications Documented hypersensitivity; evidence of active intravascular clotting process; since aminocaproic acid can be fatal in patients with DIC, important to differentiate between hyperfibrinolysis and DIC

Interactions Estrogens may cause increase in clotting factors, leading to hypercoagulable state

Pregnancy C - Safety for use during pregnancy has not been established.

Precautions Do not administer unless definite diagnosis of hyperfibrinolysis has been made; caution in cardiac, hepatic, or renal disease

Drug Name

Tranexamic acid (Cyklokapron) -- Used as alternative to aminocaproic acid. Inhibits fibrinolysis by displacing plasminogen from fibrin.

Adult Dose Nonstandardized dosing: 25 mg/kg PO tid/qid; 1-2 g IV q8-12h

Pediatric Dose Not established

Contraindications Documented hypersensitivity; ongoing DIC and CNS involvement

Interactions None reported

Pregnancy B - Usually safe but benefits must outweigh the risks.

Precautions Adverse effects include gastrointestinal and visual disturbances and hypotension; caution in renal impairment

FOLLOW-UP Section 8 of 10

Author Information Introduction Clinical Differentials Workup Treatment Medication Follow-up Miscellaneous Bibliography

Further Inpatient Care:

Most patients with acute DIC require critical care management appropriate for the primary diagnosis, occasionally including emergent surgery.

Assessment of severity of DIC (DIC score)

A DIC scoring system has been proposed by Bick to assess the severity of the coagulopathy as well as the effectiveness of therapeutic modalities.

Clinical and laboratory parameters are measured with regularity (every 8 h).

Further Outpatient Care:

Patients who recover from acute DIC should follow up with their primary physician or a hematologist.

Patients with low-grade or chronic DIC may be managed by a hematologist on an outpatient basis after initial assessment and stabilization.

In/Out Patient Meds:

Outpatient medications may include antiplatelet agents for those with low-grade DIC and/or antibiotics appropriate to the primary diagnosis.

Transfer:

Patients who are stable enough for transfer should be referred expeditiously to centers with appropriate critical care and subspecialty expertise, such as hematology, blood bank, or surgical centers.

Complications:

Acute renal failure

Life-threatening thrombosis and hemorrhage (in patients with moderately severe to severe DIC)

Cardiac tamponade

Hemothorax

Intracerebral hematoma

Gangrene and loss of digits

Death

Prognosis:

The prognosis is influenced most by the underlying condition that led to DIC and the severity of the DIC.

MISCELLANEOUS Section 9 of 10

Author Information Introduction Clinical Differentials Workup Treatment Medication Follow-up Miscellaneous Bibliography

Medical/Legal Pitfalls:

Failure to have early clinical suspicion and make a laboratory diagnosis, as the sequelae of DIC can be devastating

Failure to focus on treating the underlying cause of DIC when the thromboembolic and bleeding complications of the process seem to be dominating the clinical picture

BIBLIOGRAPHY Section 10 of 10

Author Information Introduction Clinical Differentials Workup Treatment Medication Follow-up Miscellaneous Bibliography

Bick RL: Disseminated intravascular coagulation: objective clinical and laboratory diagnosis, treatment, and assessment of therapeutic response. Semin Thromb Hemost 1996; 22(1): 69-88[Medline].

Bick RL: Disseminated intravascular coagulation: objective criteria for diagnosis and management. Med Clin North Am 1994; 78: 511-543[Medline].

Bick RL: Disseminated intravascular coagulation: pathophysiological mechanisms and manifestations. Semin Thromb Hemost 1998; 24(1): 3-18[Medline].

Bick RL: Syndromes of disseminated intravascular coagulation in obstetrics, pregnancy, and gynecology. Objective criteria for diagnosis and management. Hematol Oncol Clin North Am 2000 Oct; 14(5): 999-1044[Medline].

Carr JM, McKinney M, McDonagh J: Diagnosis of disseminated intravascular coagulation. Role of D-dimer. Am J Clin Pathol 1989 Mar; 91(3): 280-7[Medline].

Fourrier F, Chopin C, Huart JJ, et al: Double-blind, placebo-controlled trial of antithrombin III concentrates in septic shock with disseminated intravascular coagulation. Chest 1993 Sep; 104(3): 882-8[Medline].

Hamilton GC: Disorders of hemostasis and polycythemia. In: Rosen P, ed. Emergency Medicine: Concepts and Clinical Practice. 3rd ed. Mosby-Year Book; 1992:1695-710.

Levi M, Ten Cate H: Disseminated intravascular coagulation. N Engl J Med 1999 Aug 19; 341(8): 586-92[Medline].

Levi M, de Jonge E, van der Poll T, ten Cate H: Novel approaches to the management of disseminated intravascular coagulation. Crit Care Med 2000; 28(Suppl): S20-S24.

Mammen EF: Antithrombin: its physiological importance and role in DIC. Semin Thromb Hemost 1998; 24(1): 19-25[Medline].

Marder VJ, et al: Consumptive thrombohemorrhagic disorders. In: Hemostasis and Thrombosis, Basic Principles and Clinical Practice, 3rd ed. Lippincott, Williams & Wilkins; 1994: 1023-63.

Nur S, Anwar M, Saleem M: Disseminated intravascular coagulation in acute leukaemias at first diagnosis. Eur J Haematol 1995 Aug; 55(2): 78-82[Medline].

Rodgers G: Acquired coagulation disorders. In: Kjeldsberg CR, ed. Practical Diagnosis of Hematologic Disorders, 2nd ed. Amer Society of Clinical; 1995: 697-713.

NOTE:

Medicine is a constantly changing science and not all therapies are clearly established. New research changes drug and treatment therapies daily. The authors, editors, and publisher of this journal have used their best efforts to provide information that is up-to-date and accurate and is generally accepted within medical standards at the time of publication. However, as medical science is constantly changing and human error is always possible, the authors, editors, and publisher or any other party involved with the publication of this article do not warrant the information in this article is accurate or complete, nor are they responsible for omissions or errors in the article or for the results of using this information. The reader should confirm the information in this article from other sources prior to use. In particular, all drug doses, indications, and contraindications should be confirmed in the package insert. FULL DISCLAIMER

Disseminated Intravascular Coagulation excerpt

9. "Acute Respiratory Distress Syndrome" by Dr. Todd Rothenhaus, MD, Assistant Residency Program Director, Director of Medical Informatics, Assistant Professor, Department of Emergency Medicine, Boston University School of Medicine, Boston Medical Center

www.emedicine.com/emerg/topic15.htm

Acute Respiratory Distress Syndrome
Last Updated: May 16, 2003 Rate this Article
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Synonyms and related keywords: ARDS, adult respiratory distress syndrome, severe respiratory failure, pulmonary infiltrates, severe acute respiratory syndrome, SARS

AUTHOR INFORMATION Section 1 of 9
Author Information Introduction Clinical Differentials Workup Treatment Follow-up Miscellaneous Bibliography

Author: Todd Rothenhaus, MD, Assistant Residency Program Director, Director of Medical Informatics, Assistant Professor, Department of Emergency Medicine, Boston University School of Medicine, Boston Medical Center

Todd Rothenhaus, MD, is a member of the following medical societies: Alpha Omega Alpha, American College of Emergency Physicians, and American Medical Informatics Association

Editor(s): William Lober, MD, Instructor, Department of Medical Education, Division of Biomedical and Health Informatics, University of Washington School of Medicine; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, Pharmacy, eMedicine; Paul Blackburn, DO, Program Director, Department of Emergency Medicine, Maricopa Medical Center; Assistant Professor, Department of Surgery, University of Arizona; John Halamka, MD, Chief Information Officer, CareGroup Healthcare System, Assistant Professor of Medicine, Department of Emergency Medicine, Beth Israel Deaconess Medical Center; Assistant Professor of Medicine, Harvard Medical School; and Jonathan Adler, MD, Instructor, Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School
INTRODUCTION Section 2 of 9
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Background: In 1967, Ashbaugh first described adult or acute respiratory distress syndrome (ARDS) as a syndrome of severe respiratory failure associated with pulmonary infiltrates similar to infant hyaline membrane disease.

ARDS is defined as the presence of bilateral pulmonary infiltrates on chest radiograph, impaired oxygenation resulting in a PaO2 to fraction of inspired oxygen (FIO2) ratio of less than 200, and absence of elevated pulmonary arterial occlusion pressure (PAOP) or left atrial pressure. Stated another way, ARDS is the presence of pulmonary edema in the absence of volume overload or depressed left ventricular function.

ARDS occurs in children as well as adults. The condition originates from a number of insults involving damage to the alveolocapillary membrane with subsequent fluid accumulation within the airspaces of the lung. Histologically, these changes have been termed diffuse alveolar damage.

Pathophysiology: Noncardiogenic pulmonary edema results from the loss of integrity of the alveolar-capillary membrane, resulting in increased permeability to plasma. Fluid enters the alveolar space and disrupts the function of pulmonary surfactant, resulting in microatelectasis and impaired gas exchange. Ultimately, regional variations in pulmonary perfusion, ventilation/perfusion (V/Q) mismatch with shunting of blood through unventilated alveoli, and increased alveolar-arterial oxygen gradient occur.

Mortality/Morbidity: Mortality remains as high as 40-60% despite years of research. CLINICAL Section 3 of 9

Author Information Introduction Clinical Differentials Workup Treatment Follow-up Miscellaneous Bibliography

History:

Patients may present early in the course of the disease without symptoms or signs.
Mild tachypnea may be the only manifestation.
Severe respiratory distress eventually ensues.

Physical:

Rales most often are heard with auscultation of the lungs, although, surprisingly, findings usually are minimal compared to chest radiographic findings.
Signs of volume overload, such as a third heart sound (S3) on auscultation of the heart or jugular venous distention, should be noticeably absent.

Causes:

A number of clinical conditions are associated with development of ARDS.
Sepsis and the systemic inflammatory response syndrome (SIRS) are the most common predisposing factors associated with development of ARDS. These conditions may result from the indirect toxic effects of neutrophil-derived inflammatory mediators in the lungs.

Severe traumatic injury (especially multiple fractures), severe head injury, and pulmonary contusion are strongly associated with development of ARDS. Long bone fractures may give rise to ARDS through fat embolism. In association with head injury, ARDS is thought to ensue from a sudden discharge of the sympathetic nervous system, resulting in acute pulmonary hypertension and injury to the pulmonary capillary bed. Pulmonary contusions cause ARDS through direct trauma to the lung.

Multiple transfusions are another important risk factor for ARDS, independent of the reason for transfusion or the coexistence of trauma. The incidence of ARDS increases with the number of units transfused. Preexisting liver disease or coagulation abnormalities further contribute to this risk.

Patients who have nearly drowned can develop ARDS. Development of ARDS is slightly more common with salt-water aspiration than with fresh-water aspiration. Infiltrates and hypoxia develop within 12-24 hours of the initial accident. Patients who are symptomatic after 6 hours of observation generally do well. Aspiration is particularly damaging to lung tissue, leading to an osmotic gradient that favors movement of water into airspaces of the lung. Aspiration may be visible with chest radiography, although the chest radiograph may be normal early in the course of the disease.

Smoke inhalation causes lung tissue damage from direct heat, toxic chemicals, and particulate matter carried into the lower lung. Patients with smoke inhalation initially may be asymptomatic. Patients with airway burns and/or exposure to carbon monoxide or toxic fumes should be monitored closely for development of ARDS, even if symptoms initially are absent.

Overdoses of narcotics (eg, heroin), salicylates, tricyclic antidepressants, and other sedatives have been associated with development of ARDS. (Overdoses of tricyclic antidepressants are the most common.) This risk is independent of the risk from concurrent aspiration. Other implicated toxins and drugs include tocolytic agents, hydrochlorothiazide, protamine, and interleukin-2 (IL-2).

DIFFERENTIALS Section 4 of 9
Author Information Introduction Clinical Differentials Workup Treatment Follow-up Miscellaneous Bibliography

Altitude Illness - Pulmonary Syndromes
Congestive Heart Failure and Pulmonary Edema
Pneumonia, Aspiration
Pneumonia, Bacterial
Pneumonia, Immunocompromised
Pneumonia, Mycoplasma

Other Problems to be Considered:

Irritant gas inhalation
Severe acute respiratory syndrome (SARS)

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WORKUP Section 5 of 9
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Lab Studies:

ABG usually reveals hypoxia. Respiratory alkalosis may be present early in the course of the disease; hypercarbia and respiratory acidosis develop as the disease progresses.

Obtain complete blood count (CBC), serum electrolytes, blood urea nitrogen (BUN), and creatinine. Obtain appropriate cultures in cases of severe ARDS without discernible cause, as sepsis is by far the most common etiology.
Imaging Studies:

The chest radiograph most often depicts bilateral diffuse infiltrates, normal-sized cardiac silhouette, and absence of vascular redistribution (eg, cephalization).
Chest radiographic findings may be normal early in the course of the disease but may rapidly progress to complete whiteout of both lung fields.

TREATMENT Section 6 of 9
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Prehospital Care:

Patients rarely develop ARDS quickly enough to require intervention when being transported from the scene, but patients undergoing interhospital transfer may require consideration prior to transport. High levels of positive end-expiratory pressure (PEEP), high inspiratory flow rates, and hemodynamic instability portend a high incidence of complications.

Administration of 100% oxygen is recommended, since regional differences in V/Q mismatch suddenly may provoke a higher degree of hypoxia with movement and repositioning of the patient. Intubation prior to transfer may be warranted.
High peak pressures (ie, >50 cm of water) should prompt consideration of bilateral chest tube placement.

Emergency Department Care: Treatment of the patient in the ED is largely supportive. Intensive ventilatory support and hemodynamic monitoring are essential.

Apply a cardiac monitor, a pulse-oximeter, and a time-cycled noninvasive BP cuff. Start an IV line and administer fluids to hypotensive patients. As volume overload in the presence of ARDS may significantly worsen pulmonary edema, volume status must be reassessed continually.

Place patients on sufficient supplemental oxygen to keep the oxygen saturation above 90%. Perform endotracheal intubation if the oxygen saturation drops or if the patient develops fatigue or hypercarbia.

Ventilator settings for patients with ARDS should aim to maintain oxygenation and ventilation, while minimizing the effects of barotrauma on the lung.

If oxygen saturation cannot be kept above 90% after institution of mechanical ventilation, add PEEP in small increments (ie, 2-3 cm of water). Take care to monitor the patient's hemodynamic status and peak airway pressures because higher airway pressures may decrease venous return and lead to hypotension.

Routine or prophylactic use of antibiotics or corticosteroids is not beneficial. Administration of antibiotics to patients with ARDS may lead to development of multiple drug-resistant infections.

Consultations:

Consultation with an intensivist is mandatory for all patients requiring high inspired-oxygen concentrations.

FOLLOW-UP Section 7 of 9
Author Information Introduction Clinical Differentials Workup Treatment Follow-up Miscellaneous Bibliography

Further Inpatient Care:

Admit and closely observe all patients with significant risk factors for the development of ARDS. Possible exceptions to this rule are patients who have mild near-drowning experiences with no symptoms after a 4- to 6-hour period of observation.

Admit to a monitored setting any patient with risk factors for ARDS and dyspnea or tachypnea.
ICU admission is mandatory for patients with respiratory alkalosis, hypoxia, or abnormal chest radiographic findings.

MISCELLANEOUS Section 8 of 9
Author Information Introduction Clinical Differentials Workup Treatment Follow-up Miscellaneous Bibliography

Medical/Legal Pitfalls:

Failure to identify patients with impending ARDS may lead to discharge or improper triage to a noncritical care unit.

Failure to identify progressive hypoxia and incipient respiratory failure may lead to delayed endotracheal intubation and mechanical ventilation, with eventual cardiopulmonary arrest.

BIBLIOGRAPHY Section 9 of 9
Author Information Introduction Clinical Differentials Workup Treatment Follow-up Miscellaneous Bibliography

Ashbaugh DG, Bigelow DB, Petty TL, Levine BE: Acute respiratory distress in adults. Lancet 1967 Aug 12; 2(7511): 319-23[Medline].
Bernard GR, Artigas A, Brigham KL, et al: The American-European Consensus Conference on ARDS. Definitions, mechanisms, relevant outcomes, and clinical trial coordination. Am J Respir Crit Care Med 1994 Mar; 149(3 Pt 1): 818-24[Medline].
Hudson LD, Milberg JA, Anardi D, Maunder RJ: Clinical risks for development of the acute respiratory distress syndrome. Am J Respir Crit Care Med 1995 Feb; 151(2 Pt 1): 293-301[Medline].
Kollef MH, Schuster DP: The acute respiratory distress syndrome. N Engl J Med 1995 Jan 5; 332(1): 27-37[Medline].
Reed CR, Glauser FL: Drug-induced noncardiogenic pulmonary edema. Chest 1991 Oct; 100(4): 1120-4[Medline].

NOTE:
Medicine is a constantly changing science and not all therapies are clearly established. New research changes drug and treatment therapies daily. The authors, editors, and publisher of this journal have used their best efforts to provide information that is up-to-date and accurate and is generally accepted within medical standards at the time of publication. However, as medical science is constantly changing and human error is always possible, the authors, editors, and publisher or any other party involved with the publication of this article do not warrant the information in this article is accurate or complete, nor are they responsible for omissions or errors in the article or for the results of using this information. The reader should confirm the information in this article from other sources prior to use. In particular, all drug doses, indications, and contraindications should be confirmed in the package insert. FULL DISCLAIMER

Acute Respiratory Distress Syndrome excerpt

10. Detailed report by the 1st Tactical Studies Group (Airborne) on why M113 Gavin light tracked AFVs are vitally needed on the modern, non-linear battlefield

www.geocities.com/equipmentshop/m113combat.htm

11. "Blackhawk Down!" Mark Bowden

12. "Officers Face Barrage of Bullets to Take Comrades Out of Line of Fire"
by Beth Shuster and James Rainey, Times Staff Writers

www.pulitzer.org/year/1998/breaking-news-reporting/works/barrage.html

A fallen policeman sat in a parking lot in a pool of his own blood. Bullets from a brazen gunman whirred and crackled across asphalt, glass and earth. Police officers, with their small sidearms, seemed hopelessly outmatched and unable to rescue their colleague.

But in a moment of raw bravery and studied precision, the Los Angeles Police Department rode to the rescue of one of its own, in just one of the many dramatic televised images of a botched bank robbery Friday morning.

The carload of police sped into an unprotected parking lot across the street from the bank, threw open their doors and pulled the injured plainclothes officer to safety. Then, under constant fire, the police car lurched into reverse and sped out of the parking lot--to safety and a waiting ambulance.


Time and again in a morning of extreme violence, policemen and policewomen stepped from behind cover with their light sidearms to face the suspected bank robbers, who launched a blazing gun battle that ranged across several blocks of a North Hollywood neighborhood.

''The thin blue line is made out of the men and women who are out there who put themselves in harm's way every day,'' Police Chief Willie L. Williams said later in the day, as police continued to search for suspects. ''It's these brave men and women who allow us to go about our daily lives.''
Ten officers were wounded or injured, including six by gunfire, but as the long day drew to a close, it seemed miraculous that the only fatalities were two riflemen in ski masks. Most of the gallery of heroes remained anonymous. Only shaky television images--taped from above by news helicopters--were testament to their actions.

Among those who faced down the gunmen or protected their colleagues in blue were a young female detective from the North Hollywood Division who helped push her wounded partner into a patrol car; another detective nearing retirement, wounded in the ankle, who compared the shootout to his duty in Vietnam; and a rookie cop whose own bullet wound didn't stop him from trying to save his partner.

Less than half an hour after the shooting, Det. Tracey Angeles was still gripping her police radio so tightly that her knuckles were white. Her royal blue jacket and black skirt were spattered with her partner's blood, her nylons were shredded and one black tennis shoe was missing.

An ashen Angeles, 29, told how she had been working that morning in the field, in plainclothes, when the call went out: ''Officers under fire.''

That message sent a rocket of adrenaline through the seven-year veteran and her colleagues. And although many were without their body armor or heavy weapons, they sped to the Bank of America on Laurel Canyon Boulevard where the robbery was coming violently unhinged.

Angeles and a colleague stopped in a parking lot across the street from the bank and quickly found themselves under fire. They dove first behind a car, then a key-making kiosk, but found that the AK-47 fire had little respect for such flimsy cover.

Uniformed officers with bulletproof vests then arrived to rescue the rescuers. One officer threw himself over Angeles to shield her from the fusillade. Later she wondered who her protector had been, hoping she could thank him.
Said Angeles: ''We were taking too much fire. We couldn't stay where we were. We ran a short distance. That's when the officer got shot.''

The downed policeman then became the preoccupation of his colleagues. He lay completely exposed in the parking lot. ''It came to the point where, do you leave him to die or do you go in and get him?'' said Det. Gordon Hagge.

Angeles said her wounded partner ''unbelievably had the presence of mind to broadcast his location. A black and white unit came. They were still firing the whole time,'' she said. ''We were able to get him in the car and get him out of there. We all helped.'' Hagge, an auto theft detective in North Hollywood, said the police found their weapons of little use against the body armor of the robbers. ''They're waving AK-47s and I have a 9-millimeter,'' Hagge said. ''I'm in the wrong place with the wrong gun.

''We had nothing that would go through their vests. Nothing,'' he said. ''It was nuts.''

For the Los Angeles Police Department, the unforgiving eye of the video camera has not always been kind. There are the unforgettable images of a prone Rodney G. King being beaten and of officers surrendering the intersection of Florence and Normandie avenues to a violent mob.

But on this day, the images were of swift and decisive police. Just minutes after the pictures of the parking lot rescue were broadcast, a home television audience saw two unidentified officers step out from behind a car and a tree and, without any cover, shoot and kill one of the gunmen who was walking slowly away from the bank.

When another of the masked men tried to abandon his crippled getaway car and take over a pickup truck, SWAT officers roared straight at the gunman in their squad car, seemingly ignoring the high-powered rifle and the clip of 100 rounds that he toted. The officers crept to within feet of the man. Withstanding a barrage of heavy gunfire, the officers shot and killed him.

Cmdr. Tim McBride, the Police Department's chief spokesman, said the SWAT officers were free in such a situation to use deadly force without direction from superiors.

''It was their call to make,'' McBride said. ''It is a dangerous situation. You don't want to let these guys get away, so you have got to engage them. If you let them get away, who knows how many other people they are going to hurt.''

Back at the parking lot where the daring rescues had occurred, other officers also coped with the fusillade. Two of them--a rookie patrolman and a detective looking forward to retirement--thought they had found refuge behind a van when armor-piercing bullets came slamming right through the vehicle.

The two officers lunged for the closest doorway and scrambled up a flight of stairs, where they found Dr. Jorge Montes, a dentist.

Over the next several minutes, Montes, 42, treated the officers' wounds. In the adrenaline-charged moment, Montes never bothered to learn their names. One, who had been on the force just three months, had a bullet rip into his buttocks. The other, the veteran detective who had done a tour in Vietnam, took a bullet or debris in his ankle, Montes said.

Although the rookie cop had a wound 6 inches long and 2 inches wide, he was preoccupied with his injured partner, who remained in the street with a leg wound.

''He wanted to go back down there in the street and make sure his partner was out of harm's way,'' Montes said. ''I don't think he realized how seriously hurt he was.''

The veteran officer told the dentist that he had not seen such a firefight since Vietnam. The detective persuaded the rookie that his partner would be safe below after they radioed for backup. ''Even though they were the ones who were injured, they were concerned with their fellow officers,'' Montes said. ''They were very concerned with the public and helping each other, and they did all this to keep us safe. I was very, very impressed.''

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15. UDLP MTVL Medical variant possibilities

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16. Detailed report by the 1st Tactical Studies Group (Airborne) on how M113 Gavin light tracked AFVs can be made to swim in oceans with ARIS SPA waterjet kits

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17. http://online.wsj.com/article/0,,SB109338845641600227,00.html?mod=home%5Fpage%5Fone%5Fus

Battlefield Debate: An Army Surgeon Says New Helmet Doesn't Fit Iraq

Stronger, Lighter and Smaller, But Does It Cover Enough?
Military: 'Good Trade-Off'
Studying Shrapnel's Entry Point

By GREG JAFFE
Staff Reporter of THE WALL STREET JOURNAL

August 25, 2004; Page A1

BAGHDAD, Iraq -- Earlier this year, with the insurgency in Iraq building and U.S. casualties mounting, Lt. Col. Jeff Poffenbarger, the Army's senior neurosurgeon here, became convinced the Army was making a mistake that could lead to American deaths.

The Army had begun issuing a new helmet, dubbed the Advanced Combat Helmet. Made of a new type of Kevlar, the helmet is stronger and lighter than its predecessor. But the new helmet has a critical flaw, Col. Poffenbarger contends: It is about 8% smaller than the old helmet, offering less protection on the back and side of the head.

In past wars, this might not have been a big problem. In infantry-style combat, Soldiers typically are struck in the front of the head as they charge toward the enemy. But in Iraq, where the deadliest threat is remote-detonated roadside bombs, many Soldiers are getting blasted on the sides and back of the head, says Col. Poffenbarger. In other words, they are getting hit in areas where the new helmet offers less coverage.

"I've become convinced that for this type of guerrilla fight, we are giving away coverage that we need to save lives," says Col. Poffenbarger, a 42-year-old former Green Beret.

This summer, he briefed Gen. George Casey, the top American general in Iraq, as well as a senior Army official in the Pentagon about his concerns regarding the helmet. Gen. Casey declined to comment on the matter. However, a senior defense official said the colonel's observations are raising questions about whether the Army should move forward with a helmet that may not be suited for the kind of hit-and-run insurgency it is fighting in Iraq. The marine corps has already decided not to issue the helmet to the vast majority of its forces.

Broader Struggle

The questions surrounding the new helmet reflect the broader struggle facing the Army as it tries to transform from a force built to fight traditional armies into one capable of waging guerrilla warfare. Already, the Army is retraining more than 100,000 troops, in specialties such as artillery and air defense, to work as military police, engineers and civil-affairs troops, concentrating on reconstruction. All are considered more effective in battling insurgencies.

Col. Poffenbarger isn't the only one with doubts about use of the new Army helmet. The marines have developed their own new helmet, made of the same stronger Kevlar as the Army's. The marines decided not to alter the shape, so their new helmet will continue to cover portions of the side and back of the head.

The marines say their helmet provides protection against mortars, remote-detonated roadside bombs and rocket-propelled grenades -- three of the biggest killers of U.S. troops in Iraq. "We felt like the extra coverage was needed to protect against those indirect fire threats," says Lt. Col. Gabe Patricio, the marine corps' project manager for infantry equipment.

Col. Poffenbarger's observations are by no means a comprehensive study. His research is based on about 160 head-trauma patients who have passed through the 31st Combat Support Hospital in Baghdad, where he works. Because the hospital houses the only American neurosurgeons in Iraq, virtually every serious head-trauma patient is treated by him or his partner. "If you get shot in the head in Iraq, I see you," he says.

He has gone through the records of all the hospital's head-trauma patients, documenting the exact entry point at which the shrapnel or bullet entered the brain and the type of helmet the Soldier or marine was wearing. Extrapolating from this, Col. Poffenbarger estimates the new helmet might result in a 30% increase in serious head traumas if distributed throughout the entire force in Iraq.

Because of his research, some senior commanders of new units arriving in Iraq have been given the choice of keeping their old helmets or using the new ones, one defense official says. Tens of thousands of Soldiers are already wearing the new helmet in Iraq and Afghanistan.

For now, the Army is committed to issuing the helmet to all 840,000 Soldiers in the force by 2007, says Col. John Norwood, the Army's project manager for Soldier equipment.

There's a good reason that the new helmet is slightly smaller, Col. Norwood says. For years, Soldiers have complained that when they are lying on their stomachs firing rifles, their body armor rides up -- tipping their helmet over their eyes. The new helmet was designed to address that problem. "We think it is a good trade-off or we wouldn't be fielding it," he says.

The new helmets -- which cost $300 each, compared with about $100 for the old ones -- are made to the Army's specifications by MSA Corp., based in Pittsburgh; Specialty Defense Systems of Dunmore, Pa.; and Gentex Corp., of Carbondale, Pa. Like the Army, the manufacturers say the new helmet allows Soldiers to see and hear better than its predecessor. A spokesman for MSA says Soldiers are likely to wear the new helmet longer because it is more comfortable.

The marine corps has bought about 40,000 of its new helmet, which is larger than the Army's and is also made by Gentex. The marines plan to buy about 140,000 more over the next two years, at a cost of about $200 each. The marines also plan on purchasing about 1,000 of the new Army helmets for Force Reconnaissance Soldiers, who typically charge out in front of the larger marine force and are less exposed to shrapnel from artillery and mortars.

Col. Poffenbarger, whose father was an Army physician in Vietnam and whose mother was a geneticist, says that for infantrymen charging into conventional battle, a smaller helmet makes sense. "The best way to be safe in combat is to be more lethal than the enemy," he says. The new helmet, which allows Soldiers to see better while lying on their stomach shooting, should make them more effective in that situation, he says.

The old Army helmet (left) provides more protection to the back and sides of the head than the new helmet (right), which is lighter and allows greater mobility. Both include chin straps.

But for the majority of Soldiers in Iraq, who aren't aiming at the enemy head-on, he contends the new helmet will lead to more injuries and deaths.

The doctor concedes his research has at least two shortcomings. If a Soldier is shot or struck by fragment in the head -- but is protected by the helmet and avoids serious injury -- Col. Poffenbarger is unlikely to see him. "My conclusions could be slightly slanted to the negative because I don't see the success stories," he says.

He also hasn't been able to get data on Soldiers who are struck in the head and die before reaching the hospital. Col. Poffenbarger estimates there have been 300 such cases since the war began. He has asked the military morgue at Dover Air Force base in Delaware for copies of those autopsy reports but says that so far, officials there have denied his requests to e-mail him the data.

A senior defense official said Col. Poffenbarger could review the autopsy data when he returns from Iraq. This official said the request to e-mail data was denied because of concerns the information could circulate and compromise patients' rights to privacy. "There has been no attempt to keep him from doing research. In fact, we welcome it," this official said.

The Army's smaller helmet was developed as part of the service's Rapid Fielding Initiative, which seeks to push new equipment to Soldiers in the field. Usually, it takes months or years to develop new military gear. Under the Rapid Fielding Initiative, the Army says it can speed new equipment to Soldiers in weeks.

The rapid-fielding program kicked off in early 2002, in an effort to address complaints from Soldiers in Afghanistan that their equipment wasn't holding up in the rocky terrain. So far, more than 50 items, such as improved ammunition packs, better radios, shoulder pads and weapon sights, have been sent to troops under the initiative, which typically looks to commercially available products.

In the case of the Advanced Combat Helmet, the Army used a preexisting contract the U.S. Special Operations Command had to develop a new helmet for its troops.

The biggest appeal of the new Army helmet is that it is made of a stronger Kevlar, able to stop a bullet from a 9mm pistol at close range. The old helmet can't stop such a round, says the Army's Col. Norwood. The new helmet is also lighter, weighing three pounds compared with the older four-pound helmet. "The extra pound makes a big difference to the Soldier in Iraq," Col. Norwood says.

Soldiers in Iraq say the new Army helmet, which is padded on the inside, is more comfortable. "It doesn't shift around on your head as much as the old helmet. That's important when you are using night-vision goggles," says an Army sergeant who leads regular convoys between Ramadi and Khalidiyah. Night-vision goggles usually are bolted to the helmet. The sergeant says he also noticed the new helmet doesn't cover as much of his head. "It seems the area around my ears is a lot more exposed," he says.

At about the same time the Army was starting to field its new helmet in Iraq, Col. Poffenbarger was trying to persuade the Army to send him off to war.

In the U.S., Col. Poffenbarger serves as Chief of Neurosurgery at Brooke Army Medical Center in San Antonio. Generally, hospital chiefs are deemed too senior to send to war zones. Col. Poffenbarger, a married father of four, says he volunteered for duty in Iraq, in part because he believed the nature of combat might help spur medical innovation, as it has in past wars. He wanted to be a part of that innovation.

In World War II, neurosurgeons learned that by moving closer to the front lines -- where they could see patients within hours of their injury instead of days -- they could dramatically lower infection and fatality rates. Even though front-line surgeons were operating in far-more-primitive conditions, infection rates for patients dropped to less than 5% when the doctors were closer to the front, from 33% when they were positioned further back, Col. Poffenbarger says.

Before the Vietnam War, military neurosurgeons went out of their way to ensure that every bit of shrapnel and dirt was removed from Soldiers' skulls during surgery. Often that meant operating as many as five times. By the end of the Vietnam War, surgeons had discovered they could leave a small amount of shrapnel or dirt behind without increasing the patient's risk of seizures. Fewer surgeries meant more patients survived longer.

Because he had worn a helmet as an enlisted and Special Forces Soldier, Col. Poffenbarger was particularly interested in how that piece of equipment could be improved. In his more than 20 years as an Airborne Soldier, he estimates he made more than 100 jumps. "I know what it is like to jump from an airplane in a helmet and body armor," he says.

Upon his arrival in Iraq in January, Col. Poffenbarger volunteered for flight duty, boarding helicopters that fly out to the scene of attacks to evacuate the wounded, as well as for duty with his old special-operations unit. "He's got serious thrill issues," says Maj. Rich Gullick, Col. Poffenbarger's assistant in Iraq.

The colonel also began plotting on a spreadsheet the entry point at which shrapnel penetrated the skulls of his patients. He noted whether they were wearing the old helmet or the new one. After logging in the first 50 or so patients, he noticed a disturbing trend. Soldiers wearing the Army's new combat helmet were suffering repeated blows to exposed portions of the skull. In about a third of the cases, the shrapnel was penetrating the skull in areas that he figured would have been covered by the old helmet.

When struck on the side of the head, the Soldiers often suffered serious injury requiring surgery, he says. When struck on the back of the head near the neck, a part of the skull that houses the cerebellum, patients frequently died. "Even moderate injury to the cerebellum causes swelling which crushes the brain stem," he says. The brain stem regulates breathing and heart rate.

Col. Poffenbarger's day usually begins with a 7:30 a.m. staff meeting, followed by two hours of hospital rounds and a three-mile jog in what has lately been up to 115-degree heat. He and Maj. Gullick refer to the time between 3 p.m. and 3 a.m. as the "witching hours," when most of the head-trauma cases come into the hospital. In one 48-hour period last week, he and his partner did six back-to-back craniotomies, or surgical openings of the skull, before they had a chance for a few hours of sleep.

In his small office in Baghdad, Col. Poffenbarger keeps the helmets of a half a dozen Soldiers he has operated on in the last year. So far, he has personally seen only one case in which a patient was struck by shrapnel in his Kevlar helmet and died. In that instance, a giant piece of shrapnel from a massive artillery shell placed by the side of the road exploded.

The shrapnel didn't penetrate the Kevlar. But it hit the Soldier's head with such force that it caused a massive concussion, which killed him. "This is the only documented failure I have seen in eight months in Iraq," he says. "The message is that when struck, Kevlar helmets work."

--Nicholas Zamiska contributed to this article.

Light Infantry Narcissists don't want to be reminded they are not bulletproof

...and that they need M113 Gavin light tracked tanks to protect them....

Washington Post
May 17, 2006
Pg. C1

Strategic Retreat?

HBO Says Army Brass Initially Rallied Around 'Baghdad ER,' But Soldiers Are Mostly MIA at Screening in Washington

By Paul Farhi, Washington Post Staff Writer

It's not who attended Monday's screening of the war documentary "Baghdad ER" that disappointed the film's producers, but rather who didn't. The National Museum of American History's theater was mostly full -- of civilians.

Only a few rows were filled by men and women dressed in the crisp, olive-drab uniforms of the U.S. Army. And that was a huge disappointment and a potent symbol for HBO, the network that produced the film -- a harrowing look at a combat support hospital in Iraq -- which will debut Sunday.

HBO executives say that top Army officials expressed enthusiasm for the documentary in March, but that the Pentagon's support has waned. They believe the military is troubled by the film's unflinching look at the consequences of the war on American Soldiers, and that it might diminish public support.

The documentary, shot over 2 1/2 months in mid-2005, contains graphic and disturbing footage of Soldiers reeling from their wounds -- in some cases, dying of them -- as Army medical personnel try to save them. The film illustrates the compassion and dedication of the staff of the 86th Combat Support Hospital in Baghdad. But it also has many gruesome images, such as shots of Soldiers' amputated limbs being dumped into trash bags, and pools of blood and viscera being mopped from a busy operating room floor. At one point, an Army chaplain, reciting last rites for a Soldier, calls all the violence "senseless."

"Maybe people [at the Pentagon] feel the truth will discourage people" from backing the war, Sheila Nevins, president of HBO's documentary unit, said after the invitation-only screening. "The film certainly tells you what could happen in a war, but it's also about the heroism, courage and dedication of our troops.

"I can't quite figure out their reaction. I was hoping this audience would be covered in green."

Pentagon spokesman Paul Boyce said the Army went to great lengths to support the HBO project, including giving filmmakers prolonged and intimate access to the hospital. It also made the Soldiers featured in the film available for media interviews and hosted screenings on 22 military installations.

"We believe [the film] is a very thorough representation of the professionalism of the military medical community, and reflects the ethos of our Soldiers," said Boyce, who attended Monday's screening. "Although we're grateful to work with people who accurately portray the role of U.S. Army, we can't endorse every project to the level and desire of some of the groups we work with."

The network screened the film in mid-March for senior Army officials, including Secretary of the Army Francis J. Harvey, and received an enthusiastic response, said Richard Plepler, HBO's executive vice president. One retired general, whom Plepler did not identify, told him the film " 'captured the soul of the U.S. Army,' " the executive recalled. Said Plepler: "We were obviously very proud to have received that embrace, and we were looking forward to working with the Army in the coming months."

Thereafter, Plepler said, the Army's support began to evaporate. The network's offer to co-sponsor a screening of the film this week at Fort Campbell, Ky., the home of the 86th, was turned down by the Pentagon without explanation. The Army wasn't an official sponsor of Monday's screening, and none of the service's highest-ranking officers or senior medical personnel attended, despite HBO's invitation.

Several of the medical specialists featured in the documentary, including Col. Casper P. Jones III, the commander of the 86th CSH, attended this week's screening and were accorded a prolonged standing ovation at the film's conclusion.

The Army's Surgeon General, Lt. Gen. Kevin Kiley, sent out a memo to Army medical personnel last week, alerting them to the film and asking them to remain vigilant about any adverse reactions to it.

Boyce downplayed the absence of the Army's top brass from the screening, saying: "The heroes of [the] documentary don't have stars on their shoulders. The stars are the wounded Soldiers, doctors, nurses and chaplains who are there supporting those Soldiers on the battlefront. This is not about a particular general." Nevertheless, he said, there were four colonels among the 40 or so Soldiers at the screening.

Among the guests in attendance was Paula Zwillinger, whose son, marine Lance Cpl. Robert Mininger, 21, died in Iraq from injuries from a roadside bomb. Zwillinger said in an interview that she didn't know exactly how her son died until the film's producers -- Joseph Feury, Jon Alpert and Matthew O'Neill -- contacted her as they were editing the film. Mininger's death is chronicled in a prolonged sequence at the end of "Baghdad ER."

She called the film a gift. "It gave me peace. At least I know he was with someone, and didn't die alone," she said.

Despite the grim subject matter, Zwillinger said: "I am positive about this film. It needs to be shown. I want the world to know this is reality. War is graphic, war is raw, war hurts. And we need more support for our troops, no matter what we think of the war."



About the authors

Dr. Jonathan Sullivan MD is the pen name of an U.S. Army 62A Emergency medicine doctor with the rank of captain. Mike Sparks is a former infantry marine enlisted NCO and officer now in the Army reserves. He is the co-author of the book, "Air-Mech-Strike: Asymmetric Maneuver warfare for the 21st century" which outlines a new force structure design for Army transformation maximizing TAFVs.

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