Otolaryngologists on the Front Lines

Among the victims was a 31-year-old woman examined by otolaryngologists for facial burns and lacerations and bilateral traumatic tympanic membrane perforations. Itzhak Braverman, MD, Chief of Otolaryngology, removed a number of impacted blast fragments. The patient’s other wounds were extensive and led to surgery and prolonged hospitalization, so Dr. Braverman took the opportunity to send the excised fragments for thorough forensic analysis. By 2002 suicide bombers had begun using novel materials to magnify the impact of the primary blast: nail heads, ball bearings, even rat poison, so an investigation was imperative.

The lab showed the excised fragments to be human bone. Several tests were conducted. Thankfully, the fragments were free of HIV—but positive for HbsAg (hepatitis B), for which the patient was successfully treated.

The lesson for all front-line physicians—and the front line today includes not only war zones in the Middle East, but public places everywhere—is to be ready for absolutely anything. Suicide bombers in particular are often marginal members of their societies. Sometimes they are recruited with a promise to cleanse a perceived stain to the family’s honor through “martyrdom.” In the past bombers have included the mentally retarded, infertile women, and people accused of sexual misbehavior. They could be, as in the Hadera case, infected with disease.

A Short History of Body Armor

Helmets and body armor have been around almost as long as war itself. One cannot imagine Roman centurions or Spanish conquistadors without their characteristic defensive wear. But by the US Civil War metal armor was no match for enhanced firepower and the old shields were considered nothing but a nuisance.

In 1881 an Arizona physician, George Goodfellow, recorded the case of a man who had been shot in the heart and survived, thanks to the folded silk handkerchief in his breast pocket, which had deflected the bullet. The strength, flexibility, and light weight of silk made it a good material for the composition of the first “bulletproof” vests. Silk was precious, too. A century ago the vests cost the equivalent of $15,000 each.

Expense was no object to heads of state, and the Archduke Franz Ferdinand was wearing one on the fateful day in 1914 when he was assassinated by Gavrilo Princip, with the shot that sparked World War I. Unfortunately, the Archduke was hit above the vest, in the jugular vein.

The first World War brought innovation in the soldier’s personal defense. Steel helmets came into wide use, but experiments with body armor proved largely ineffective. During World War II steel helmets were virtually universal for combat troops, but body armor was still considered too bulky, heavy, and ineffective for standard issue. The most important innovation of the time was the flak jacket. These nylon vests were used only by air crews. “Flak,” non-direct fire, caused 75% of battlefield injuries during World War II, and ever more through the years. In Iraq and Afghanistan it causes more than 95% of injuries to American troops.