Aug 5, 2008
To Heal the Wounded

The pictures show shredded limbs, burned faces, profusely bleeding wounds. The subjects are mostly American G.I.’s, but they include Iraqis and Afghans, some of them young children.

They appear in a new book, “War Surgery in Afghanistan and Iraq: A Series of Cases, 2003-2007,” quietly issued by the United States Army — the first guidebook of new techniques for American battlefield surgeons to be published while the wars it analyzes are still being fought.

Its 83 case descriptions from 53 battlefield doctors are clinical and bone dry, but the gruesome photographs illustrate the grim nature of today’s wars, in which more are hurt by explosions than by bullets, and body armor leaves many alive but maimed.

And the cases detail important advances in treating blast amputations, massive bleeding, bomb concussions and other front-line trauma.

Though it is expensively produced and includes a foreword by the ABC correspondent Bob Woodruff, who was severely injured by a roadside bomb in 2006, “War Surgery” is not easy to find. There were strenuous efforts within the Army over the last year to censor the book and keep it out of civilian hands.

Paradoxically, the book is being issued as news photographers complain that they are being ejected from combat areas for depicting dead and wounded Americans.

But efforts to censor the book were overruled by successive Army surgeons general. It can be ordered from the Government Printing Office for $71; lists it as out of stock, but the Borden Institute, the Army medical office that published it, said thousands more copies would be printed.

“I’m ashamed to say that there were folks even in the medical department who said, Over my dead body will American civilians see this,” said Dr. David E. Lounsbury, one of the book’s three authors. Dr. Lounsbury, 58, an internist and retired colonel, took part in the 1991 and 2003 invasions of Iraq and was the editor of military medicine textbooks at Walter Reed Army Medical Center.

“The average Joe Surgeon, civilian or military, has never seen this stuff,” Dr. Lounsbury said. “Yeah, they’ve seen guys shot in the chest. But the kind of ferocious blast, burn and penetrating trauma that’s part of the modern I.E.D. wound is like nothing they’ve seen, even in a Manhattan emergency room. It’s a shocking, heart-stopping, eye-opening kind of thing. And they need to see this on the plane before they get there, because there’s a learning curve to this.”

The pictures of wounded children include some of a 5-year-old shot in a vehicle trying to run through a checkpoint. Other pictures show wounds riddled with dirt, genitals severed by a roadside bomb, a rib — presumably that of a suicide bomber — driven deep into a soldier’s body, and the tail of an unexploded rocket protruding from a soldier’s hip.

There are moments that reflect the desperation in the invaded country: an Afghan in the jaw-locked rictus of tetanus after home-treating a foot blown off by a landmine. And moments that reflect the modern American army: a soldier with unexplained pelvic pain that turns out to be a life-threatening ectopic pregnancy.

The book was created to teach techniques that surgeons adopted, abandoning old habits.

For example, they no longer pump saline into a patient with massive trauma to try to get the blood pressure back up to 120. “You do that, you end up with a highly diluted, cold patient with no clotting factors, and the high pressure restarts bleeding,” Dr. Lounsbury said. Instead, they try to bring it up to just 80 or 90 with red cells and extra platelets, which encourage clotting.

Also, initial surgery even on a severely wounded patient may be brief — just enough to control hemorrhaging and prevent contamination by a torn bowel. Then the patient is returned to intensive care to warm up, raise the blood pressure and restore the electrolyte balance. The next operation is usually just enough to stabilize the patient for transport to a more sophisticated hospital, perhaps in Baghdad or Kabul, in Germany or the United States.

The book describes a surgeon who erred fatally by trying to do too much — a four-hour operation on a soldier who had lost a leg to a roadside bomb. The effort drained the forward hospital’s blood bank, and the patient died on the helicopter to the next hospital.

Also, neurosurgeons treating a blast victim now quickly remove a large section of the skull to relieve pressure, even if no shrapnel has penetrated. Such patients are sometimes able to walk and talk after a blast but then collapse and die as their brain swells.

The procedure is described by the surgeon who saved Mr. Woodruff’s life that way.

Amputations have also changed. Dr. Lounsbury’s brother lost both legs and an arm in Vietnam, and in those days clean “guillotine” amputations were done as high as possible. Now surgeons try to preserve as much bone and flesh as they can, even if the stump is unsightly. Modern prosthetics are molded to it.

Doctors have also become quicker to diagnose “compartment syndrome” even in patients too sedated to feel pain; swelling in an injured muscle can cut off the blood supply, leading to gangrene and amputation. Surgeons now “fillet” the muscles to relieve the pressure, often even before it builds, since restitching healthy tissue is better than losing a limb.

And when morphine is not enough, nerve blocks — internal drips of local anesthetic, often given by a small pump held by the patient — have become common in pain control.

Dr. Ramanathan Raju, chief medical officer for the New York City Health and Hospitals Corporation and a former trauma surgeon, viewed the book and said it would be “extremely useful” to civilian surgeons because of what it teaches about blast injuries and when a surgeon should stop to let a patient recover.

“The Army should be very happy about this,” Dr. Raju said. “In the past, people said, Oh, Army surgeons are like butchers, they’re not research oriented. This shows how skillful they are.”

One of the book’s most powerful aspects is its juxtaposition of operating room photographs with those of the war outside the tent. It is filled with random shots — burning vehicles, explosions, a medic carrying a child, another in a Santa Claus hat. It also has portraits of soldiers, often dazed and exhausted; one even has tears on his cheek.

Many are by David Leeson of The Dallas Morning News, who was embedded with the Third Infantry Division during the Iraq invasion and won a Pulitzer Prize for his coverage.

Even more humanizing are photos of recovered patients: an Iraqi whose jaw was destroyed shown with it rebuilt, a soldier who lost half of his skull smiling at a ceremonial dinner with his wife, a soldier whose face was pulverized by a blast looking scarred but handsome a year later.

Military censors suggested numerous changes, including removing photos showing burning vehicles and the faces of any American wounded. They also wanted to excise references to branches of service and how injuries occurred.

For example, according to unclassified e-mail provided by the authors, one suggested removing this description: “A helmeted soldier suffered a forehead injury during the explosion of an improvised explosive device. He was a front seat passenger” in a Humvee. The censor suggested: “A 22-year-old male was hurt in a blast.”

Two in the chain of command who raised such objections — one civilian and one officer — said they did so only out of concern for patients’ privacy and for security reasons. For example, they said, mentions of wound patterns might tell the enemy that helmets and Humvees were vulnerable.

But the authors argued that it was crucial for surgeons to expect wounds behind armor and absurd to conceal that they occurred.

“The enemy knows that,” said Dr. Stephen P. Hetz, a retired colonel and co-author.

They also argued that the book was dedicated to soldiers and marines and that the wounded were proud to be identified as such. All whose faces were fully shown, whether American, Iraqi or Afghan, had given written permission, they said. If it was not obtained, patients’ eyes were covered with black bars. The random war photos, they argued, were as much as five years old and some had been in newspapers, so they would give enemies no useful information.

Censors also tried to prevent the book from getting a copyright and the international standard book number letting it be sold commercially, Dr. Lounsbury said.

Ultimately, they were overruled.

Kevin C. Kiley, a retired lieutenant general who was the Army’s surgeon general when the book was being prepared, said some higher-ups in the military had been worried that the pictures “could be spun politically to show the horrors of war.”

“The counter-argument to that, which I concurred with,” Dr. Kiley said, “was that this is a medical textbook that could save lives.”

He said it “absolutely” ought to be available to civilians, particularly to surgeons.

Dr. Hetz said that as a West Point graduate and onetime infantry officer — and as a former aide to two surgeons general, to whom he could appeal directly — he always had more faith than Dr. Lounsbury that the book would ultimately not be suppressed.

“There was never any doubt in my mind that the Army would publish this,” he said. “It was just a matter of getting around the nitwits.”