The “Golden Hour” in Afghanistan

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Read this fascinating and rather frightening dialogue published by ABC News (Australia) on The Golden Hour

MAJOR MATT HUEMAN: The golden hour is when the person has an injury . . .within the first two to five minutes there’s a certain number of people who will die that are not saveable. The next hour is where a lot of people, if they don’t get to a place that has surgical capability and the full gamut of taking care of them, will die as well. So the golden hour really reflects those people that are saveable if you’re able to get them to a place like a forward surgical team.

MAJOR BRYAN HELSEL: We provide 21st century intensive care, critical care for patients that would otherwise die. I mean there’s no way around, some of these people would have died.

CORCORAN: Too many soldiers wounded on Afghanistan’s remote battlefields were bleeding to death before reaching surgery at the big military hospitals. So last year, army surgical teams were moved much closer to the fight, to beat the golden hour.  For those who make it here alive, often with horrific injuries, there’s now a 98% chance of survival. A young female solider pulled from the wreckage of the MRAP has multiple fractures. For her comrade, Sgt. Adam Sandifer, hit by the massive concussive blast, the injuries are less clear.

MAJOR MATT HUEMAN: We try and get the chest and pelvis within the first ten minutes with all the other things that we do like checking the airway, making sure that they’re breathing, making sure they have a pulse, getting an IV in, doing an ultrasound making sure that they don’t have blood in their abdomen.

CORCORAN: Matt Hueman and Bryan Helsel both served in Iraq. They’re well practised in treating IED victims – but this is a different war, with different injuries.

(TO HUEMAN) So even if they are travelling in the new armoured MRAP’s they still can suffer severe injuries?

MAJOR MATT HUEMAN: They can, and it’s deceptive because it tends to be internal injuries so you know in my last deployment, we would see amputations, significant like above the knee amputations with the Hummvees. In this deployment the leg still appears to be functionally intact, but it’s still a significant injury inside so it’s actually sometimes a little bit harder to figure out.

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Medics Improvise to save lives on killing fields of Afghanistan

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In a compelling story published today by the Washington Post, “Military medics combine ultramodern and time-honored methods to save lives on the battlefield” of Afghanistan.

Key Highlights:

  • At 6:09 p.m., Dustoff 57 has just left this base deep in Taliban-infiltrated Kandahar province, headed for a POI, or point of injury. Somewhere ahead of the aircraft is a soldier who minutes earlier stepped on an improvised explosive device, the signature weapon of the wars in Iraq and Afghanistan. All the helicopter crew knows is that he’s “category A” – critical.  The trip out takes nine minutes.  Fifteen minutes have now passed since the soldier was wounded. Speed, simplicity and priority have always been the hallmarks of emergency medicine. The new battlefield care that flight medics and others on the ground practice takes those attributes to the extreme.
  • Four people run to the helicopter with the stretcher holding the wounded soldier. He lies on his back partially wrapped in a foil blanket. His chest is bare. In the middle of it is an “intraosseous device,” a large-bore needle that has been punched into his breastbone by the medic on the ground. It’s used to infuse fluids and drugs directly into the circulatory system when a vein can’t be found. It’s a no-nonsense technology, used occasionally in World War II, that fell out of favor when cheap and durable plastic tubing made IV catheters ubiquitous in the postwar years. Until they were revived for the Iraq and Afghanistan wars, intraosseus devices were used almost exclusively in infants whose veins were too small to find. On each leg the soldier has a tourniquet, ratcheted down and locked to stop all bleeding below it. These ancient devices went out of military use more than half a century ago because of concern that they caused tissue damage. Now every soldier carries a tourniquet and is instructed to put one on any severely bleeding limb and not think of taking it off.
  • Tourniquets have saved at least 1,000 lives, and possibly as many as 2,000, in the past eight years. This soldier is almost certainly one of them. They’re a big part of why only about 10 percent of casualties in these wars have died, compared with 16 percent in Vietnam.  On the soldier’s left leg, the tourniquet is above the knee. The tourniquet on his right leg is lower, below the knee; how badly his foot is injured is hard to tell from the dressings. His left hand is splinted and bandaged, too. Whether he will need an amputation is uncertain. The hospital where he’s headed treated 16 patients in September who needed at least one limb amputated. Half were U.S. soldiers, and the monthly number has been climbing since March.
  • After three minutes on the ground, the helicopter takes off.  Eleven minutes after lifting off from the POI, the helicopter lands at the so-called Role 3, or fully equipped, hospital at Kandahar Airfield, about 30 miles to the east of the also well-fortified Forward Operating Base Wilson. There, surgeons will take care of the injuries before transferring the patient, probably within two days, to the huge military hospital in Landstuhl, Germany, and there, after a week or so, to the United States. It’s been 28 minutes since the helicopter left Forward Operating Base Wilson.

SFTT Analysis:

  • Before every Grunt leaves the wire, they want to know if air or artillery support is readily available and more importantly, if required, will an aerial medevac be responsive – in Joe speak “Time on Target for Air and Arty and a quick Nine-line medevac request . . . how quick will the angels of mercy get here?”.   Quick means quick, the sooner the better obviously, since every minute counts.  Secretary Gates figured this out when he began his battlefield circulation tours in Afghanistan when he became Secretary of Defense and quickly realized that the “Golden Hour”, that period in time that is the standard from time of request for a medevac to arrival at the point of injury and back to medical care on a base, was not being met in Afghanistan due to lack of medevac resources and the distant out-posts that troopers were operating from.  Secretary Gates made it a personal mission to close the gap and ensure that troopers were supported by the “Golden Hour” standard and personally kept the pressure on logistics planners to increase medevac resources and establish medical unit facilities in support of all forward deployed personnel.   The only question SFTT raises regarding this issue is why did it take the Secretary of Defense to correct this situation?  
  • The Washinton Post online article provides a remarkable photo gallery,  – of note is:
    • the destructive nature of an IED that targeted a Mine Resistant Ambush Protected (MRAP).  The simplicity of a pressure plate device loaded with hundreds of pounds of fertilizer (and other components) can defeat US “resistant” vehicles.  More telling is that a device of this size takes time and local support to emplace;
    • grunts not wearing all of their protective gear – no throat, deltoid, or groin protectors – obviously a commanders call, but is the decision not to wear the complete armor suite because of weight and comfort?;
    • the chinstrap for the Advanced Combat Helmet is a flimsy strap of material – no chin pads are provided and the harness is simply used to hold the “brain bucket” in place.  At least the trooper is being medevaced for treatment of a possible TBI.
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Military News you may have missed – Oct 22, 2010

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Policy – General Sees Progress in Counter-IED Fight

Key Highlights:

  •  Despite an increase in incidents that tracks with the build-up of forces in Afghanistan, Oates said, “my assessment is we’re making progress” in the fight against IEDs. The growing number of forces in the country and increased fighting caused the number of roadside-bomb incidents in Afghanistan to spike to 8,994 in 2009 -– from 2,677 in 2007 — and to nearly 10,500 so far this year.
  • Officials hope to model their strategy to counter the deadly devices in Afghanistan on successes in Iraq, where the downward trend of incidents illustrates the success of the strategy there, Oates said. In 2007, Iraq reported nearly 24,000 incidents; so far in 2010, the number is just over 1,100.

Analysis:        

 

Making progress?  Road-side incidents in Afghanistan = 2.6K in 2007, 8.9K in 2009, 10.5K so far in 2010.  That’s an increase General Oates.  Progress?  Clearly countering the IED threat is a complex and resource intensive process and any gains made, and the efforts behind them are noteworthy, but to claim “progress” when the data says the opposite doesn’t square. 

In 2007, at the height of the surge in Iraq, there were 24K reported incidents.  Thus far in 2010 there has only been 1.1K reported incidents in Afghanistan.  The question someone should have asked General Oates is “What tactics, techniques, and procedures were being used in Iraq to get Iraqi’s to report 24,000 incidents that could be applied to Afghanistan?”  “And if you are applying them, then why are they not obviously working?   Instead, the briefing ended up detailing how the IED task force would simply throw billions of more dollars at the problem and deploy a battalions worth of analysts to study the problem.  Hey, General Oates, the US is downsizing it’s footprint in Afghanistan starting in July 2011 in case you haven’t heard.  Well, at least that is what everyone has told the troops.  So, maybe the General might want to reconsider his plan – sadly, it might be a little too late.

 

Policy – Are We Starting To Win? New weapon systems—and, even more, improved intelligence—may be giving Americans an edge in Afghanistan.

 

Key Highlights:

  • It’s the intelligence that’s changed in recent months—and it has changed dramatically.  Along with the surge of troops and the shift toward much more aggressive attacks on insurgency strongholds, Petraeus, has intensified intelligence-gathering operations to a still greater (though less-reported) extent.
  • The air over Afghanistan’s heavy fighting spots is jammed with intelligence, surveillance, and reconnaissance devices—drones, towers, even blimps filled with various sensors. (Number of blimps has soared from eight to 64 just in the last month.)
  • All this information is collected and interpreted by a growing number of imaging and intelligence analysts. Still more important, it’s coordinated with information gathered on the ground by special-operations officers and—increasingly—by Afghan security forces, who are better able to gain the trust of local Afghans who dislike the Taliban.

Analysis

The NYT reports success one day attributed to precision strikes from MLRS’ and so it must be true.

 

Policy – ‘Wolfpack Wall’ Designed To Push Insurgents Into Open Terrain

 Highlights:

  • The Wolfpack Wall, a mile-long Hesco barrier, follows the bank of a wadi, or dry stream bed, and cuts across a strip of marijuana and poppy fields in Maiwand district, Kandahar province. Hesco containers are large, wire mesh boxes, shipped flat, which are assembled and have a plastic bag inserted and filled with dirt. Alongside the barrier, erected by U.S. Navy Seabees late last month, there’s a trench dug as an extra obstacle.  The wall is designed to force insurgents into open desert, where soldiers monitoring the area from strategically placed outposts or cameras on unmanned aircraft hovering overhead can spot them.
  • The motor pool at Combat Outpost Terminator, just north of the wadi, was a graveyard of damaged military vehicles, including an MRAP that had been cut in half by one bomb.  “Every one of those vehicles, you look at them and say: ‘How did anyone live?’ ” Redick said. “It just blows my mind.”

Analysis

Can you imagine a mile-long HESCO wall with ditches and wire?  Should work right?  What does the enemy do?  Employs women and children to emplace bombs to defeat your efforts.  What do the bombs do?  Split MRAP’s in half.  What happens to the troopers inside the MRAP?  They live.  What happens next?  WolfPack builds more walls and hopelessly watch more women and children plant more bombs, and General Oates briefs that “the strategy is working.”  A vicious cycle with no end in sight.

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Bloody Sunday: 16 (US Troop Casualties) vs. 6 (NFL Player Casualties)

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 I follow football.  High School, College, Professional – all levels, all kinds. It’s a blood sport.  So there was no way I could ignore the blaring RSS feed headlines on Monday morning announcing that this past weekend’s games will be forever known as “Bloody Sunday.” Sports Illustrated football analyst Peter King reported that “Last Sunday could go down as a seminal moment in NFL history,” because of the injuries sustained on the playing field and the impact on future play, rules and equipment.  The Vice President of Operations for the NFL, Ray Anderson, said that “We’ve got to protect players from themselves” as a result of the violent day.

I also follow the war and the troops.  You know, the ones who allow us to watch sports on weekends without having to worry about some mushroom cloud or Mumbai-style attack here on American soil.  The ones out there protecting that freedom thing, right? 

But, “Bloody Sunday” in the NFL?  Six vicious and violent hits?  Four concussions?  A couple of broken bones?  Oh, my . . . especially compared to how “Bloody” it was in Afghanistan last week.  And compare the changes the NFL is making for head injuries sustained by players, to DOD’s lack of concern for frontline troops.

Since January 2010, on average, 15 troops have been wounded in Afghanistan every single day.  Every. Single. Day. Period.  Simply put, that’s a lot of bloody days.  This past Sunday, there were 15 wounded troopers, and sadly, one killed in action; that equals 16 casualties.  Bloody indeed!  But maybe last Sunday in Afghanistan was simply a bad day, so for some perspective, let’s add up all the casualties from last week.  On average, there were over 100 troopers wounded in action, and 18 US service members paid the ultimate sacrifice and were killed in action.  15 deaths resulted from IED strikes, and 3 deaths resulted from hostile fire.  Of the 15 deaths resulting from IED strikes, 4 were killed in one vehicle, 3 were killed in another, and 2 were sharing another vehicle when they were killed by IED’s.[1]  Statistics that detail the type and extent of the more than 100 wounds suffered are not available (or accurate).  However, we can pretty safely assume that the troopers that survived IED blasts in Mine Resistant Ambush Protected (MRAP) vehicles suffered some type of mild-to-severe brain injury—or at the least were concussed—and  that these injuries clearly outpaced those suffered by football players last week. 

I’m comparing head trauma in football and combat, because everyone involved is wearing a helmet.  And if on a given Sunday, the spike in head trauma injuries prompts immediate change in policy and a new commitment to equipment upgrades by the NFL—but not the Department of Defense—then it seems to me that we should all take notice.

So what actions did the NFL take? The concern from head injuries and concussions forced the NFL to impose huge fines on three players this Tuesday for dangerous and flagrant hits and warned the league that violent conduct will be cause for suspension.  It only took the NFL 48-flipping-hours!  And I guarantee that helmets, padding, chinstraps, buckles, screws and straps for every single NFL football helmet is being inspected by equipment maintenance personnel and will be carefully repaired, replaced or some new whiz-bang safety component will be added.  I also guarantee that any and all big-contract players who suffered the slightest head injury have received top-shelf medical care and will most likely be forced to sit out a game or two to protect their team’s “investment.”

So what was the response from the Pentagon after last week’s bloody fray in Afghanistan?  Not a peep except to update the casualty data base and keep issuing sub-standard Advanced Combat Helmets to troops.   From what the troops report to SFTT, some troops obviously get Medevac’ed out of theater due to the severity of their injuries; but some don’t.  And for those who weren’t, maybe the mission profile will allow them to take a one-day or two-day respite from being outside the wire.  But probably not, in line with the old adage, “Every man strengthen the north wall.”  Most ludicrous is the appalling fact that no comparison can be made between frontline troops and NFL players regarding the quality of available medical care, the amount of investment in science and technology to improve the equipment and the commitment to provide long term treatment for traumatic brain injuries.  Must be nice to play in the NFL, and that is the bloody truth!


[1] Department of Defense and icasualties.org data.

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