Otolaryngology is not just another specialty in the wars of the twenty-first century. It is one of—if not the—most crucial subspecialties in the care of the injured. In Iraq one out of six troops wounded in combat needs to see an otolaryngologist. Today’s effective body armor means that most serious injuries are to the extremities—which are rarely fatal—and to the head and neck, where they can be grave indeed.
Insurgents and terrorists specifically target the major means of human communication, including the ears and the nasopharyngeal complex. For example, many attacks attempt to maximize noise, because a deafening blast disorients and confuses, as well as injures. Bombs aimed at soldiers and civilians are “super-sized” with shrapnel and toxins. They are meant to kill, but if they fail to kill, they are intended to cause maximum panic, pain, and disfigurement.
In the course of the conflicts in Iraq and Afghanistan, the US military has deployed increasing numbers of otolaryngologists, and moved them closer to the battlefield. In Israel, an otolaryngologist was stationed 24/7 at the trauma hub to which military and civilian wounded were evacuated during the 2006 war with Hizbollah. Wherever terror strikes, from Bali to Britain, otolaryngologists have become indispensable.
There are still snipers, precision-propelled grenades, heavy machine guns, and shoulder-fired rockets in the field, but the greatest number of injuries is caused by improvised explosive devices (IEDs). IEDs cause a disproportionate number of ear, nose, and throat injuries, even in civilians without body armor, because the shrapnel tends to spray upward. Moreover, the propelled shards can be minute, causing occult injuries that take time and medical sophistication to detect.
Otolaryngologic Injuries in War
In an Air Force study, Colonel Joseph Brennan, MD, one of the US military’s most seasoned otolaryngologists, found the most common otolaryngologic procedures performed in Iraq to be complex facial laceration repair, tracheotomy, and neck exploration for penetrating neck trauma.
Tympanic puncture is very common, as it is in everyday practice. But even if most heal spontaneously, the conditions of war make intervention imperative. In the bombing of the US embassy in Kenya, a study showed, five of 14 untreated membranes failed to heal, while all of those that were treated did heal.
Sensorineural hearing loss and the resultant balance disorder are more problematic, says Commander Michael E. Hoffer, MD, of the Naval Medical Center in San Diego. “Neurocognitive dysfunction—temporary or permanent—is almost universally present, and it’s not as obvious as other injuries.”
Although the US services issue earplugs to troops, they are not as effective as they should be, he says. Dr. Hoffer would like to see the type of hearing protection afforded industrial workers. But there is always a tradeoff between hearing protection and communication, which is so vital in wartime.
Rear Admiral Henry Falk, MD, MPH, of the US Centers for Disease Control and Prevention, who was involved in aiding victims of the 9/11 attacks, says the injured sometimes can’t hear questions and instructions from first responders. “Unlike those with previous hearing impairment, they don’t know how to deal with their communication problems,” he observed.
Injuries from Terror Attacks
Terror attacks in closed spaces result in injuries different from those seen on the battlefield. Avishay Golz, MD, head of otolaryngology and a member of the Trauma Unit at Rambam Medical Center in Haifa, Israel, has treated victims of blasts in restaurants and buses. “The pressure waves were tremendous; 95 percent required ear treatment,” he noted.
G. Richard Holt, MD (see sidebar, p. 13), who was deployed to Gulf War I as an otolaryngologist and to Iraq recently as a combat aviation brigade surgeon, has seen the dire results of blasts and overpressure exceeding 200 dB, including permanent inner ear damage and fractured ossicles. “Even how the head is turned can make a difference in injury to the facial nerve at the cheek,” he said.
Another problem is inhalation injury. The US Navy first reported on it as a major cause of mortality/ morbidity in the bombing of the USS Cole. The recent use of chlorine gas in Iraq has raised popular alarm. Chlorine is meant mainly to terrorize; it was ineffective as a weapon even when first used in World War I. Although chlorine can cause burns, and even fatal airway edema, it is easily detectable, and, being water-soluble, can be neutralized by as little as a wet handkerchief held to the face. (Deaths and serious injuries in recent attacks involving chlorine gas were caused by the blasts of IEDs.)
Among the most serious wounds of battle and terror are those to the neck. When breathing is compromised by tracheal perforation, edema, or aspiration of foreign material, tracheotomy must be performed as soon as possible, because prolonged intubation causes additional trauma. “All my residents can do trachs with one hand tied behind their backs,” said Dr. Golz.
Major Charles J. Fox, MD, of Walter Reed Army Medical Center, a vascular surgeon who works closely with otolaryngologists, has studied combat-related neck trauma in American soldiers. He noted that the preponderance of cervical injuries caused by blasts, 79%—compared with 21% by high-velocity gunshot—means that few wounds are likely to be “clean.” Of course the first priority is to stabilize the airway and/or hemorrhaging, but it is crucial to explore for occult damage caused by blast fragments, and the sooner scans and arteriograms can be done, the better, Dr. Fox said.
Triage and Screening
It is important for the right people to do the right screening. In the Cole bombing, initial triage showed nine of 39 patients with head and neck injuries. But when otolaryngologists conducted the screening, they found that 23 of the patients had those injuries.
Dr. Golz is another advocate of early exploration. He finds that once injuries are ruled out, some fragments can be left alone, avoiding further trauma.
After an attack most hearing loss is temporary and most perforated eardrums will heal spontaneously, but emotional distress should not be ignored, said Dr. Golz. His unit received the victims of the rocket attacks on northern Israel, as well as evacuated soldiers from Lebanon, in last summer’s war. “All of the injured, especially children, need TLC,” he said.
Otolaryngologists in combat remind us that this is not your father’s war or your father’s otolaryngology. The “meatball” surgery of Korean War-era MASH units is long gone. Even the first Gulf war was very different from the current one. Dr. Holt, who served in both, recalls that in the first Gulf war, troops were prepared for chemical and biological attack, but faced a conventional army. “In this one we’ve been learning on the fly. It’s urban, guerrilla warfare. There’s nothing clean or gentlemanly about it,” he observed.
Access to Treatment
In war, as in peacetime medicine, treatments have improved dramatically, but it is now their access that has become a major challenge. The Marines deploy Forward Resuscitative Surgery System teams, with a median time to treatment of one hour. Thanks to Dr. Brennan, special head-and-neck teams now include an otolaryngologist, as well as a neurosurgeon, an ophthalmologist, and an oral surgeon. Delivered by the famed Critical Care Aeromedical Transport (CCAT) jets—essentially, flying ICUs—a team can reach any soldier in Iraq within 45 minutes. (The US military uses a “buddy system” for the services, pairing the Navy with the Marines and the Army with the Air Force.) Quick access to subspecialists, Dr. Brennan emphasizes, has helped send the percentage of surviving wounded from 70 to 75% in Vietnam, to more than 90% in Iraq.
The steep hills of Lebanon impeded medevac helicopters from lifting Israeli wounded, so “tankbulances” were deployed. Merkava Mark IV tanks, which can withstand heavy direct fire and climb 70-degree inclines, are outfitted with full operating theaters. They can transport up to 12 wounded, plus crew. The downside is that tankbulances are not covered by Geneva protections. However, when conventional ambulances are targets of fire, there is little to lose.
The US military employs a four-tier triage system. At the first level, the casualty is treated by a buddy or medic. At Level II the patient is examined by the medical company of the brigade or division. Level III is treatment in a theater-deployed hospital. In Iraq that means Balad, a large complex 30 miles north of Baghdad. It is a state-of-the-art trauma facility, equal to any in the United States, according to physicians who have worked there. The most serious cases are flown to a Level IV facility. Stateside that is usually either the Walter Reed Army or Bethesda Naval medical centers. However, when the patient cannot tolerate a long flight, he or she is transported to Landstuhl, Germany, the only Level IV facility outside the United States.
Standard of Care
Air Force Lieutenant Colonel Michael S. Xydakis, MD, an otolaryngologist who served in Landstuhl for four years, is impressed by the level of care. “Information from Balad was relayed to us by secure electronics and contact was maintained with air transport,” so that everything was ready before the patient landed. Once in Germany “all the king’s horses and all the king’s men” were pulled out for the troops. Dr. Xydakis says it is fortunate that Landstuhl is situated in Germany, which, he believes, has the best medical care in Europe. With unusually specialized cases, German colleagues could always be called upon to lend enthusiastic assistance. He once turned to surgeons from Hamburg University with a complicated laryngeal fracture, and they did a noteworthy job, he said.
Recent reports have brought attention to facility and bureaucratic inadequacies at the Walter Reed medical complex and at the loci for the wounded in Israel’s summer war. But every otolaryngologist interviewed for this report professed extraordinary devotion to the care of his patients. They rate all their health care colleagues as nothing less than heroic on the battlefield, and insist that once their charges have stabilized, they will continue to receive cutting-edge care. Dr. Hoffer believes those injured in battle may be good candidates for cochlear implants. Dr. Holt has seen those with disfiguring wounds that will require facial reconstructive surgery, and those with injuries to the mouth and throat will likely require extensive swallowing and speech therapy. Over and over, otolaryngologists said that “nothing is too good for our young men and women.”
Exceptional Ethics, High Morale
What about the other wounded? American and Israeli doctors find no conflict between their military orders and their medical ethics: they must and do treat soldier or civilian, friend or foe, equally. Dr. Fox recalls operating on an enemy combatant in Iraq who needed 70 units of blood. The entire staff of the field hospital was cross-matched for transfusion, but this patient was AB negative. Two of the surgeons scrubbed out to donate their own blood.
In some cases this ethical policy can win the hearts and minds of the enemy. Journalist Brigitte Gabriel was raised as an Arab to see all Israelis as monsters. But after her mother was wounded in the first Lebanon war, and received superior treatment in Israeli hospitals, Ms. Gabriel became an outspoken advocate of Israel.
The horrors of war can bring out the best in human beings—and that is what leaves the deepest impression on the doctors who have served at the front lines. Above all political differences, these physicians have an overwhelming admiration for the bravery of the “muddy boots” soldiers, and consider it a privilege to care for them.
“They’re doing a great job, and their morale is excellent. It’s especially inspiring to see how they take care of their fellow soldiers,” said Dr. Brennan.
“Their self-sacrifice and courage make me feel good about the youth of today,” said Dr. Holt.
Colleagues are also singled out for praise. During Israel’s summer war, Dr. Golz’s hospital itself was bombed. “A rocket hit meters from my own house,” he said. “Our staff’s families were living in bomb shelters. Nurseries and children’s facilities were closed. But not one person missed work—in fact, I had to ‘triage’ them so they wouldn’t wear themselves out.”
“Besides our troops,” said Dr. Xydakis, “the people I admire most are the reservists. They are among the finest doctors in the world, and they leave their remunerative practices to put themselves in harm’s way. They are true patriots.”
Look for the Unusual
Otolaryngologists on or near a battlefield or terror attack expect to see a wide range of pathology—but hepatitis B? That is what presented to the team at Hillel Yaffe Medical Center in Hadera, a city in central Israel, following a suicide bombing in 2002.
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.
Throughout the Korean and Vietnam conflicts experiments were made using woven steel, fiberglass, synthetic cloth fibers, and ceramics. The watershed occurred in the 1970s when the DuPont Corporation introduced Kevlar, a light, flexible material five times stronger than steel. Kevlar vests and helmets have also proved comfortable enough to wear routinely. Comfort and ease of movement are not perks; protection is only as good as compliance. Every physician interviewed for this article agrees that the new vests have saved thousands of lives.
Material scientists in Israel and the United States are currently creating artificial spider silk, an even stronger and lighter material than Kevlar. Armor containing this component is set to be field-tested in 2007.
Experts are less enthusiastic about the helmets. Although compressed Kevlar helmets are light and comfortable, their design doesn’t protect enough of the face and neck, says Dr. G. Richard Holt. Dr. Holt, who has testified before Congress on this matter, proposes helmets designed like those worn by professional football players, which protect most of the face and neck, as well as the head.
Until such innovations are realized, there is a collar attachment to the Kevlar vest that protects part of the neck. If only Franz Ferdinand had had one.
©2007 The Triological Society