1. Salcido, Richard MD

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Whether you support or oppose the current armed conflicts in the Middle East-Operation Iraqi Freedom and Enduring Freedom in Afghanistan (OIF-EFA)-I believe we can all agree that the common denominator of war is loss of life and limb. At the time of this writing, the US Department of Defense (DOD) reported a total of 3649 deaths since the beginning of the war,1 and another 26,588 military personnel as wounded.2

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A well-documented fact about our country's advances in military medicine is the enhanced survivability of those wounded in combat. In modern warfare when a soldier sustains a wound, combat lifesavers immediately administer resuscitation, stabilize the wound, and relieve pain. Simultaneously, the wounded soldier is triaged and medical evacuation takes place. Through a sophisticated and well-orchestrated medical evacuation system, the wounded soldier, marine, seaman, airman, coast guardsman, and even civilians can be in a tertiary medical treatment facility within hours to a few days.


Sequentially, each of the various conflicts, from World War II, Korea, Vietnam, and the Gulf War, has improved the survivability of our troops. Our recent experience in OIF-EFA underscores the chance of survival for a soldier wounded on the battlefield. Today, 1 in 8 soldiers die because of their wounds, in contrast to the 1 in 4 lives lost during the Vietnam War.


Enhanced battlefield survival is partially attributed to the recent advances in body armor. It is now possible for an individual to survive multiple complex injuries (MCI) because the characteristics of the wounds in this current conflict are changing. We are seeing patients with more wounds to the limbs, head, and neck, but with fewer to the chest and abdomen, because of increased protection to the torso from body armor; however, the axillae and the brachial plexus remain vulnerable.3


The mechanisms of the injury are different, as well. Roadside bombs or improvised explosive devices (IEDs) are inflicting multiple wounds to the head, neck, and limbs, resulting in long-term functional deficits, such as large wounds, amputations, and a phenomenon known as polytrauma or MCI; most of these wounds are managed in stages by delayed primary closure or by tertiary intension.4


Polytrauma often results from blast injuries sustained by IEDs, or from being hit with a rocket-propelled grenade (RPG). In fact, IED blasts, landmines, and explosive fragments account for 65% of combat injuries. The combination of high-pressure waves, explosive fragments, and falling debris may produce multiple injuries, including brain injury (TBI), loss of limbs, burns, fractures, blindness, and hearing loss, with 60% of those with MCI having an associated TBI with significant risk for psychosocial impairment and posttraumatic stress disorder (PTSD). Paradoxically, the emergence of polytrauma is not all attributed to the types of injuries, but to the advances in combat medical management and lifesaving. With more survivors and now more combat-disabled veterans, the obstacle now is how to provide systems-based practices and benchmarks that enhance "hassle-free" access to rehabilitation services, thus improving the psychosocial function of those with polytrauma TBI, MCI, and PTSD, and their families.4,5


The DOD, the Veterans Administration (VA), and private charitable organizations, such as the Wounded Warriors program, are working to alleviate the short term and enduring consequences of polytrauma.4-6 As a veteran of the Vietnam War, and now as a physician, it was my honor to serve on a National Advisory Committee reporting directly to the Secretary of Veterans Affairs, (who at that time was Anthony J. Principi), on Prosthetics, Orthotics, and Special Disabilities, including the effects of polytrauma on our returning veterans. I saw first-hand the importance the VA is placing on increasing our capability as a nation to care for our wounded. Our committee had the humbling experience of visiting our troops at Walter Reed Army Medical Center in Washington, DC, and witness their drive and determination and loyalty to their fellow soldiers. I met a Special Forces soldier who was hit by an RPG. He stated that his only regret was having to leave his comrades; we owe these soldiers a lot. More recently, President Bush has appointed a commission to give recommendations for the care of our returning wounded warriors.4,5 Subsequently, the VA is relentlessly expanding resources for patients with MCIs. To meet the need for specialized medical care for returning combat veterans, the VA has expanded its 4 polytrauma centers, located in Minneapolis, MN;Palo Alto, CA; Richmond, VA; and Tampa, FL, to encompass additional specialties to treat patients for MCIs. This effort is being expanded to 21 polytrauma network sites and clinic support teams around the country that can provide state-of-the-art treatment closer to injured veterans' homes.4,5


In addition to the DOD and the VA, the individual care for the resultant chronic wounds related to this war will be provided by thousands of wound care practitioners, nurses, nursing assistants, physical and occupational therapists, social workers, physicians, and psychologists. Orthotists and prosthetists also play a critical role, especially for amputees and those with neurologic and motor dysfunction. Family caregivers and those in the private sector also have a significant role in the burden of care for our wounded warriors.


Without the manufacturers of wound care products, we would not have the advanced lifesaving and wound healing products available in the combat theater. For example, Hem-Con, Inc, Portland, OR, maker of the "shrimp bandage" was recognized as one of the Army's Top 10 Greatest Inventions of 2004.7 They received the award for Hem-Con Bandages, which are manufactured from a natural product called chitosan-a substance found in the shells of shrimp, crab, and other crustaceans. The positively charged chitosan material bonds with red blood cells and forms a clot that stops hemorrhaging. The Hem-Con bandage has now evolved into the standard treatment for severe hemorrhaging and is included in the recommended guidelines for all 3 casualty management phases of Tactical Combat Casualty Care.7 The US Army has reportedly issued a shrimp bandage to each soldier in the combat zone. Negative pressure wound therapy is also appearing in the scientific literature as an adjunct for delayed primary closure in combat-related wounds for both US Military and Wounded Iraqi citizens.8 MIST ultrasound therapy is another modality being used in military hospitals.8 In addition, Hartmann International, Heidenhaim, Germany, provides wound dressings and operating supplies to the military.9


I know this list should include more manufacturers who are contributing to the war effort. The National Library of Medicine search, however, is representative of the literature in peer-reviewed articles. I encourage wound care practitioners or product manufacturers to alert me of any war-related projects that I may have missed.


In conclusion, I think the simple but powerful words of Abraham Lincoln capture the essence of the duty to caring for our wounded.10 "Let us strive on to finish the work we are in; to bind up the nation's wounds; to care for him who shall have borne the battle and for his widow and his orphan; to do all which may achieve and cherish a just and lasting peace among ourselves, and with all nations."10


Richard "Sal" Salcido, MD

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1. US Casualties Confirmed by the Department of Defense. Available at: Accessed on August 1, 2007. [Context Link]


2. Iraq Coalition Casualty Count. Available at: Accessed on August 1, 2007. [Context Link]


3. Peake JB. Beyond the purple heart-continuity of care for the wounded in Iraq. N Engl J Med 2005;352:219-22. [Context Link]


4. Polytrauma Rehabilitation Procedure VHA Handbook 1172.1 Transmittal Sheet. September 22, 2005. Department of Veterans Affairs, Veterans Health Administration, Washington, DC. [Context Link]


5. Fact Sheet: Taking Care of America's Returning Wounded Warriors President Bush Names Bob Dole and Donna Shalala to Serve on the President's Commission on Care for America's Returning Wounded Warriors. Office of the Press Secretary, March 6, 2007. Available at: Accessed on August 7, 2007. [Context Link]


6. Wounded Warrior Project. Available at: Accessed on August 7, 2007. [Context Link]


7. Hem-Con Medical Technologies, Inc, press release. Available at:[Context Link]


8. Leininger BE, Rasmussen TE, Smith DL, Jenkins DH, Coppola C. Experience with wound VAC and delayed primary closure of contaminated soft tissue injuries in Iraq. J Trauma 2006;61:1207-11. [Context Link]


9. Hartmann International. Available at: Accessed on August 7, 2007. [Context Link]


10. Brown CR. Lincoln, the Greatest Man of the Nineteenth Century. New York, NY: Macmillan, 1922. [Context Link]

Suggested Readings


Brandes SB. Experience with wound VAC and delayed primary closure of contaminated soft tissue injuries in Iraq. Int Braz J Urol 2006;32:730.


Ingari JV, Powell E. Civilian and detainee orthopaedic surgical care at an Air Force theater hospital. Tech Hand Up Extrem Surg. 2007;11:130-4.


Swan KG. Comment on "Experience with wound VAC and delayed primary closure of contaminated soft tissue injuries in Iraq." J Trauma 2007;63:248-9; author reply 249.