Veterans care

Trauma Transit: U.S. Strategy for Treating Critically Wounded Troops

Posted Dec. 01, 2010, at 4:31 p.m.
Last modified Dec. 01, 2010, at 4:49 p.m.

BAGRAM AIR BASE, Afghanistan _ Only the head and feet of Sgt. Diego Solorzano are visible outside his camouflage blanket and below the skyline of medical devices keeping him alive.

Clamped to his litter is an over-the-legs shelf. On it are three vacuum canisters putting gentle suction on wounds in Solorzano’s thighs and abdomen, two IV pumps delivering drugs to his veins, a ventilator breathing for him, and a monitor recording his pulse, EKG rhythm and blood pressure.

In the intensive care unit of the military hospital here, Solorzano – “Sgt. Solo” to the members of Able Company, 1st Battalion, 506th Infantry – has a nurse at his bedside and a doctor never far away. He’s been to the operating room three times in the previous 24 hours. He’s hemorrhaged his entire blood volume five times and had it replaced. He’s unconscious and might not survive.

In any U.S. hospital, Solorzano would be considered too sick to put on an elevator and take to the CT-scan suite. Now he’s about to fly across half of Asia and most of Europe.

An Air Force chaplain puts a folded blue-and-white plaid blanket over Solorzano’s feet. A few minutes later, Maj. Michael Gonzalez, the doctor who’s just taken over his care, says, “Okay, I think we’re ready to go.”

Six people wheel him out of the ICU, down a hall and out a door to a loading zone. They put him and three other critical patients on a specially fitted bus that will drive several hundred yards onto a runway. There, a hulking C-17 jet waits, its tail ramp down, spilling light in the pre-dawn darkness.

If the soldier’s condition worsens during the flight, Gonzalez and the nurse and respiratory therapist helping him will have to count on having the knowledge, tests, drugs and equipment to “advance his care” just as they would in the ICU he’s leaving.

The U.S. military’s ability – not to mention its willingness – to take a critically ill soldier on the equivalent of a seven-hour elevator ride epitomizes an essential feature of the doctrine for treating war wounds in the 21st century:

Keep the patient moving.

In the civilian world, victims of car accidents and gunshots hope to get to a hospital that can save their life – and then stay there. The military strategy is pretty much the opposite – and is, paradoxically, part of the reason the care of soldiers wounded in the Iraq and Afghanistan wars has been so successful.

In both those theaters, the military has placed a few extremely sophisticated hospitals very close to the battlefield. Within a few hours of being wounded, casualties can reach neurosurgeons, maxillofacial surgeons, interventional radiologists, ophthalmologists and intensivists – specialists that previously were farther “up-range” and days away.

Advanced care so close to the fight is feasible only if casualties don’t fill up the hospitals and prevent new ones from coming in. To keep that from happening, patients are moved within hours of being treated.

Typically, seriously wounded soldiers move from the “point of injury” to a combat support hospital and then to one of the sophisticated “Role 3″ hospitals (of which Bagram is one of four in Afghanistan). If they’re hurt badly enough that they won’t be able to recover quickly in-country, they’re brought to Bagram, if they’re not already here.

This all takes place within two or three days of the wounding, with the patient getting surgery and resuscitation at each stop.

Five nights a week, evacuation flights leave the airfield here for Ramstein Air Base in southwestern Germany, where there’s been a U.S. military air base since World War II. They are then taken to a giant hospital in nearby Landstuhl for a few more days of treatment before flying home across the Atlantic. Many soldiers are back in the United States within five or six days of being wounded.

This strategy was devised after the 1983 Beirut Marine barracks bombing, in which some of the wounded had to wait more than 12 hours to get surgery and aircrews did not have the expertise to care for them in transit. It works only if transport doesn’t alter or diminish the care soldiers are getting.

“The flight is squeezed in between surgeries, not the other way around,” said Col. Christian R. Benjamin, an Air Force physician and commander of the hospital in Bagram. “Continuity of care is not interrupted by pesky little things like moving the patients 10,000 miles.”

For evacuations from Bagram, last summer was the busiest in eight years. The number of critical patients evacuated reached a new peak in July, when 100 were transported. But October proved even more dangerous. By the end of the month, 144 critical patients had been flown out of Afghanistan, up from 60 the previous October and 25 in October 2008.

More than 4,000 critical patients have been evacuated to Europe from Iraq and Afghanistan since 2001. Fewer than 10 have died en route.

In Afghanistan

In the early afternoon of Oct. 27, Solorzano was shot several times in his thighs while on patrol near Yahya Kel, in central Afghanistan about 15o miles southwest of Kabul. The bullets broke his right femur and severed his femoral arteries, which supply blood to the legs.

“We were told it was impossible to get him out of the firefight quickly,” Col. Jay A. Johannigman, one of the surgeons who had worked on Solorzano, said as he watched Gonzalez and his team package the patient for the flight to Germany.

Nothing more was known about the circumstances of Solorzano’s wounding. Damaged bodies travel up-range faster than details about how they got that way. But a buddy who came with him, Sgt. Shawn Allen, did mention this: It was Solorzano’s 24th birthday.

At the hospital at Forward Operating Base Sharana, surgeons tried to get the bleeding under control, without complete success. Solorzano required 30 units of blood, or about 2 1/2 times the body’s normal capacity. He received CPR for 65 minutes and suffered unknown damage to the brain. He slowly slipped into the “coagulopathy of trauma,” in which the finely tuned clotting system goes haywire from the consequences of low blood pressure, falling temperature and rising acidity in the blood.

He was then flown to Bagram. Ten minutes after his arrival, Johannigman and Maj. Mark Kromer, a 34-year-old Air Force surgeon, took him to the operating room to try to control his bleeding once more. They were there four hours. For two of those hours, Johannigman squeezed the aorta shut inside Solorzano’s abdomen, effectively cutting the size of his circulatory system in half so the blood that remained would go to Solorzano’s heart and brain.

Three hours after leaving surgery, Solorzano became increasingly unstable and was probably still bleeding. He was taken back to the operating room for 90 more minutes. About 3 a.m., the hospital was running low on blood of his type and activated the “walking blood bank.”

Someone began calling volunteers from a list of pre-screened A-positive donors. Allen, Solorzano’s buddy, went out into the chilly night, doing his own search.

“I knocked on doors,” he said. “I was pulling people off buses. I saw soldiers and said, ‘Anybody A-positive? Please rally to the hospital.’ ”

More than 50 people showed up. Thirty-five units of whole blood were collected. Solorzano got 21 units still warm from the donors, the state in which it’s almost a miracle drug. Finally, long after the sun was up, his body pulled out of the dive and leveled off.

In all, he’d gotten about 65 units of blood; required a drug, vasopressin, to support his blood pressure; and was in a coma. But he was alive, a fact Johannigman attributed as much to the patient as to the doctors.

“We’re privileged by the soldiers we’re taking care of,” he said. “They’re specimens of health. We can leverage the physiology of these young soldiers.”

Whether he would survive, or for how long, was uncertain. The staff nevertheless decided to send him to Landstuhl.

“We used to say we wouldn’t send someone unless they were stable. Now we say they have to be ‘stabilizing,’ ” said Maj. David Zonies, Bagram’s “trauma czar.” “We have pushed our comfort zone considerably.”

Johannigman said, “Just like the soldiers never leave anyone behind, the doctors want to get everyone home.”

Solorzano’s parents were contacted in Huntington Park, Calif., and advised to fly to Germany as soon as possible.

In flight

Solorzano’s litter was the last one carried into the brightly lit belly of the airplane, so it would be the first one taken off in Germany – evidence of the grave condition of its occupant. But Solorzano wasn’t the only object of the Critical Care Aeromedical Transport (CCAT) team’s attentions.

There were three other critical patients, 18 more patients who were carried on but not critically ill, and 15 who walked on.

The patients, the aircrew and a few passengers occupied the forward two-thirds of the jet’s cavernous interior. At the forward end were containerized toilets. Toward the aft end was a 10-foot-high cargo box. Beyond it, in an area dark and 15 degrees colder, the retracted ramp sloped upward, piled with pallets of cargo.

A single row of seats lined the walls of the plane. Toward the center of the fuselage, the litters were clamped to hangers suspended from the ceiling. On these triple-decker bunks were patients whose wounds did not require constant vigilance. They lay under brightly colored quilts, handmade by nameless American volunteers and given to them, along with candies and crayoned thank-you cards from schoolchildren, as part of the “repatriation package.”

A profusion of tattooed elbow webs, biceps amulets, skulls and slogans adorned the arms resting on the sleeping men’s chests and stomachs.

At the aft end of the aircraft were the four critical patients. The sickest other than Solorzano was a soldier who had lost both legs and had his pelvis blown open by a homemade bomb. Near him was a man who had been shot in the left side of the head. The bullet damaged the Broca’s area of the brain, where language expression resides. The soldier can follow directions but can’t speak.

“He may never regain that,” Gonzalez said grimly as he reviewed a clipboard of data.

Only one of the critical patients could engage the CCAT team in conversation: Hiram Provorse, a red-haired, 34-year-old sergeant and mechanic who had been wounded in a mortar attack in Logar province a few days before he was scheduled to leave.

At the foot of his bed, a one-page summary cataloged his wounds: all three bones in his left leg broken, torn arteries in both legs repaired with bypasses, and a shrapnel fragment nestled against his third neck vertebra. His eyelids were heavy with morphine, which he delivered to himself with an orange controller in his hand.

“The secret to these flights is preparation,” said Gonzalez, whose regular job is heading the emergency room at Landstuhl.

This is his third deployment. He’s been running CCAT missions for seven years.

“We try to imagine what could go wrong,” he said. “We do that with every single patient every single flight. If something goes wrong that we can’t handle, it’s a failure of the imagination.”

As a practical matter, that means drawing up drugs in syringes and IV bags, ready to use if a patient spikes a fever, throws a blood clot, starts to bleed, has an allergic reaction, or can’t breathe and needs to be put on a ventilator.

On this flight, all the patients were stable except Solorzano.

Damaged by shock and the molecular trauma of repeated resuscitation, the cells lining his miles of blood vessels were already starting to leak before the soldier was put on the airplane. As water moved out of the bloodstream into surrounding tissue, his blood pressure fell. His arteries clamped down to compensate but couldn’t keep his systolic (or top) blood pressure from dwindling down below 100. As it did, the amount of urine made by his kidneys – a gauge of healthy “perfusion” of his organs – fell, too.

Two and a half hours into the flight, Gonzalez conferred with Capt. Julia Kiss, the nurse giving one-on-one care to Solorzano. Normally a CCAT team has one nurse; Kiss was an extra lent by the Bagram ICU because the unconscious soldier needed so much attention. The two talked through a closed-circuit headset, the only way to converse easily over the engine noise.

They decided to give him a “bolus” of IV fluid to see if that would boost his urine output. It did. But not for long.

Elsewhere in the plane, Maj. Marilyn E. Thomas, the regular ICU nurse on the team, and Master Sgt. Alfonso L. Betiong, the respiratory therapist, tended to the other patients, testing their blood, monitoring the machines and logging data in tiny boxes on record sheets. Provorse asked for drink, and Thomas watched him hawklike as he sipped from a 6-ounce can.

As morning came, the patients on the bunks stirred. Three got down and hobbled to the bathrooms, a member of the aircrew on each arm. Many produced iPods from under their quilts. On one top bunk, a soldier read a paperback, “Hitler’s Lair.”

Four hours out, Solorzano’s blood pressure had dropped below 90. The IV bag with norepinephrine, a neurotransmitter used to treat shock, was set up, and Gonzalez ordered it started.

“He’s basically in multi-organ failure now,” the doctor said.

Six hours out, as the airplane passed over Budapest, Gonzalez added phenylephrine, a last-ditch drug to raise blood pressure.

The plane landed at Ramstein Air Base at 10:19 a.m. German time, six hours and 42 minutes after leaving Afghanistan. The day was cloudless and cool. An ambulance pulled up to the lowered ramp. Members of the ground crew in brown flight suits helped unclip Solorzono’s litter and carry him to a waiting ambulance.

His blood pressure was 60/30, and his urine output was zero.

The ambulance had room for a half-dozen patients, but it left for the 12-minute trip to Landstuhl with only Solorzano aboard, sirens blaring as soon as it hit the highway. Afterward, Gonzalez said it was the first time he’d ever seen that happen.

In Landstuhl

Landstuhl Regional Medical Center, built in the early 1950s, has three miles of corridors and 3,000 employees. About 65,000 soldiers from the Iraq and Afghanistan wars have passed through it since October 2001. Its peacetime allotment of chaplains is two. After the wars started, that increased to four. Since 2005, there have been six.

The average battlefield casualty stays in the hospital for 3 1/2 days before being discharged to outpatient care or, more likely, sent on to Walter Reed Army Medical Center in Washington, the National Naval Medical Center in Bethesda, Md., or Brooke Army Medical Center in San Antonio.

Many of the most seriously injured patients – those who have lost multiple limbs or suffered serious head trauma – are not aware of their injuries until they are back in the United States.

A few are never aware, and never make it home.

Diego Solorzano died at 9:45 p.m. German time the day he arrived, never regaining consciousness. His parents arrived the next morning at 5:15.

It was a Sunday. They had spent most of the morning with a chaplain. They had not yet seen their son’s body. They agreed to speak briefly about him. They were brought to the pediatric clinic, which was quiet except for a doctor catching up on paperwork with his daughter, in pigtails, who was exploring the empty rooms.

Solorzano’s mother, Patricia Valdovinos, is a 41-year-old clothing designer. She was originally from Mexico. His stepfather, Cesar Muralles, is a 53-year-old truck driver from Guatemala. Theirs is a blended family of six children, ranging from age 12 to 30. Diego was the second-oldest.

Valdovinos held a framed picture of them. She was composed, but her lower eyelids were swollen. Her husband sat next to her, holding her hand.

She said: “The last time I talked to him on the phone, he said, ‘I’m a sheepdog, protecting the sheeps.’ He didn’t care for his own safety if he had to protect somebody else.”

His stepfather said: “We were proud of him. I want to say that he never got into trouble with the kids who want to become gang members. He chooses to be an Army guy. His platoon called to say he was a hero. And we believe so.”

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