"Beyond the Battlefield" is a 10-part series exploring the challenges that severely wounded veterans of Iraq and Afghanistan face after they return home, as well as what those struggles mean for those close to them. Other stories in the series can be found here.
Stepping carefully through the blinding sun and heat and dust of southern Afghanistan with Lance Cpl. Tyler Southern and several squads of sweating Marines was a brand-new Navy corpsman, James Stoddard. He had never treated a real-life battle casualty. He was 19 years old.
Yet when an IED blew off Southern's legs and right arm, leaving him bleeding to death in the smoking crater, Stoddard's reaction was quick and simple: "You see a missing limb, you throw on a tourniquet."
Stoddard had already strapped tourniquets on simulated bleeding limbs hundreds of times, maybe thousands. During four months of medical school, two months of field training and then relentless drilling with the Marines, he'd practiced slamming that tourniquet on and yanking it tight over and over. By feel, blindfolded, in the rain, in the heat and while a sergeant bawled him out, Stoddard’s fingertips learned to quickly trace out the slick of fake blood on a volunteer and, one-handed, slip that tourniquet up and strap it down hard.
That training helped Stoddard to power through the shock of seeing his buddy blasted into pieces. Southern's life now depended on him. What did that moment feel like? "I have no idea," Stoddard says. "I literally don't remember. Muscle memory took over."
That begins to explain why Tyler Southern didn't die that day, May 5, 2010. Thanks to Stoddard, Southern came home -- badly wounded, but alive.
Stoddard is part of a long and noble tradition. Battlefield medics have saved countless lives since the Civil War and techniques have improved steadily since then, in small and large ways (at the Battle of Manassas in 1862, for example, it took a week to get the wounded off the field; today that usually happens almost immediately, most often by medevac helicopter with a trauma specialist aboard).
Razor-sharp training, battle-tested new medical procedures and new technology -- and the heroic work of medics like Stoddard -- are rescuing and revivifying a new generation of severely wounded survivors.
Combat has always produced gruesome wounds, and until recently many were fatal. During the Vietnam war, out of every 10 who died on the battlefield, nine would have died even if a trauma surgeon was standing next to them -- there simply wasn’t the medical technology or know-how to keep them alive.
"We've changed that nine of 10 to five or six out of 10," says Dale Smith, a medical historian at the Uniformed Services University of the Health Sciences in Bethesda, Md., a Defense Department medical school. "That's a huge difference. We've had 43,000 wounded in 10 years of war, and only 6,000 died. That's 13 percent, as low a number as we've ever had."
I interviewed Smith last summer, and since then those numbers have risen to 46,300 wounded and 6,232 dead, roughly the same 13 percent.
Since March 2005, every troop headed into combat is certified with advanced trauma care training as a Combat Life Saver and carries at least two tourniquets and an airway tube. Those devices have dramatically cut the primary causes of previous combat deaths: choking and bleeding to death. A combat life saver medical kit also carries a needle and catheter for relieving pressure caused by a chest wound.
Other innovations include rapidly infusing patients in the operating room with a combination of whole blood, plasma and platelets to stem bleeding, rather the previous practice of using crystelloids or saline solution; rapid medical evacuation from the war zone aboard aircraft that are essentially flying intensive care units; and "smart" powered artificial limbs and experimental use of regenerated bone and spray-on skin.
"There's been more innovation in this war than in any other," said Dr. Robert Hale, a surgeon at the Armed Forces Institute of Surgical Research in San Antonio, where a number of clinical trials are about to get underway. "Much still has to be proven in the lab."
Tyler Southern, thanks to James Stoddard, is one of the saved.
In a previous war, he likely would have lived only minutes after an IED exploded beneath him, as all the blood in his body drained into the dust. Until recently, medics and corpsmen didn't use tourniquets. Official military medical practice was to pump IV saline solution into the patient and then try to stem the bleeding with bandages. The result: more than half of all those struck down in battle died of acute hemorrhage.
Tourniquets had long spooked military medical experts because in civilian practice, a tightly-bound limb could become damaged from lack of blood and require amputation. But by the early years of the Afghanistan and Iraq wars, the death rates in battle were so dismaying that combat trauma medics and doctors began reconsidering the tourniquet. In combat, they figured, better to risk the potential loss of a limb than to risk the loss of the patient. To embrace that strategy, the military turned on a dime: it supplied medics with redesigned tourniquets that could be applied and tightened with one hand.
The tourniquets proved so effective that in 2005 the military began issuing two to every combat troop, along with extensive instruction and training on how to use them on themselves and on buddies.
The tourniquet is only one innovation that is now saving lives. Another is the Combat Life Saver, a designation for a soldier or Marine who has been taught advanced trauma lifesaving skills.
The idea of extending battlefield medical expertise beyond medics came from the Israeli army's experience during the Lebanon war in 1982. Trained non-medical soldiers were saving lives by providing immediate treatment, usually tourniquets to stop the bleeding, before medics could arrive.
U.S. Army medical officers pushed the idea, which was met with resistance by the generals, according to Army medical historian Lewis Barger. Yet a few combat units at Fort Bragg tested the practice anyway, and such training proved invaluable during the invasion of Panama in 1989.
Today, nearly all soldiers and Marines have had CLS training. Even in basic training, soldiers are required to master skills that go well beyond Boy Scout first aid, including controlling bleeding, inserting a breathing tube through the nostrils, decompressing a chest wound with a needle, mouth-to-mouth resuscitation, cardiopulmonary resuscitation (CPR) and calling in a medevac helicopter.
"Okay, gunshot wound to the chest, you want to seal that off, tape down all four sides," Army Spc. Steven Zimmerman told troopers of the 2nd Battalion, 30th Infantry last fall, before they deployed to Afghanistan.
The soldiers were sprawled beneath the longleaf pines of Fort Polk, La. Zimmerman was their medic, but he and the older ones had learned from previous deployments that everyone these days had to be a lifesaver. In a firefight, he was saying, a lot of guys might be hit. He'd be busy with the worst casualties. Self-aid and buddy aid would be critical until he could get to everybody. Got it?
With their deployment to Afghanistan only days away, some soldiers were taking notes. All listened intently.
"Always check for the exit wound. Don't try to clean 'em up, just get 'em on the chopper," Zimmerman said, talking quickly. "The heat from an explosion will cauterize a wound and it'll fuse clothing to the skin. Don't try to peel it off, that is his skin now. Just get 'em on the chopper."
Medics, of course, get far more sophisticated training, and senior medics get what many consider the most effective preparation for combat trauma: live tissue training. In that course, a medic or corpsman is given a short time to save a pig or goat that's been anesthetized and has gunshot wounds and partial amputations.
That training, long hidden due to concerns about protests by animal rights groups, "best simulates the challenges and stress inherent in stopping actual bleeding,” the Army's former surgeon general, Maj. Gen. Gale Pollack, told a congressional committee in 2007. It is "essential to properly train corpsmen for combat casualty response," according to a Marine Corps briefing.
Tough and realistic training, constant drilling and the widespread use of tourniquets has helped change the face of battlefield trauma medicine. Now, the military is saving people "who are literally within a minute of dying," Smith said.
Other improvements have come thick and fast in the heat of battle. Early in the Iraq war, soldiers were suffering penetrating chest wounds from gunshots and shrapnel; the Army designed body armor with ceramic plates that have virtually eliminated those wounds. Advanced helmets, eye protection and flameproof coveralls and gloves also cut the rate of serious wounds. The first of many versions of QuickClot, a powder or powder-impregnated gauze that helps stop bleeding, came in 2004. It's now routinely carried by all combat troops.
To control pain -- a major contributor to the later development of post-traumatic stress disorder -- combat medics found that fentanyl, a powerful pain reliever, was faster and more effective than morphine, especially when administered through the mouth. Some battlefield medics tape a fentanyl lozenge to the fingertip of the patient and stick it in his or her mouth; when the drug takes effect and the patient falls asleep, his or her finger drops out.
Medics also found that even in the intense heat of Iraq and Afghanistan, the severely wounded get cold -- hypothermic -- which accelerates blood loss. Now they are given warming blankets.
The Army is adding critical care flight paramedics aboard the helicopters that transport the wounded from battlefield to hospital to provide in-flight CPR and other life-saving interventions. A new, high-tech litter for patients medevac'ed by helicopter enables these paramedics to monitor patients' vital signs as well as administer oxygen and fresh blood in the minutes before the helicopter touches down at a Forward Surgical Hospital.
These field hospitals, manned by Forward Surgical Teams, or FSTs, are typically housed in large, air-conditioned and sterile tents close to combat action. Medevac helicopters bring the most seriously injured patients there for immediate resuscitation.
Equipped like a civilian hospital emergency room, they typically have two trauma surgeons, operating room technicians, a nurse-anesthesiologist and several nurses. FSTs are meant to stabilize critically wounded patients -- providing blood transfusions and tying off blood vessels and intestines -- before they are flown to a major hospital and on to the United States.
For some of those treating severely wounded soldiers, their work has become the stuff of high-end handiwork, albeit of the most probing sort.
At a Forward Surgical Hospital in Kandahar, Afghanistan in 2008, Navy Lt. Cmdr. Tom Vanhook, a trauma surgeon, described his work this way: "Basically, it's plumbing."
Their work relies heavily on such innovations as computerized tomography, or CT scans, to trace the often invisible paths that shrapnel and other fragments take as they slice through soft tissue and internal organs. Such deep, internal wounds can be fatal if untreated, said Army Staff Sgt. Bethany Moser, 27, a medic, who served with an FST in Ramadi, western Iraq.
"You have to track the path to find out what's been damaged," she explained at Fort Bragg, N.C., where she serves in the 82nd Airborne.
In another innovation, Navy doctors have figured out a way to move an operating room itself into the middle of a battle.
Frustrated by delays in treating severely wounded Marines, they invented a combat "doc-in-a-box" by mounting a small medical facility on the back of a truck and riding into battle. Predictably, their first effort attracted a fusillade of bullets from insurgents. Chastened, they went back and replaced it with a stoutly armored box. Today, these Mobile Trauma Bays accompany Marines across southern Afghanistan, where a team of surgeons, trauma specialists and senior medics can drive into firefights too intense for a medevac helicopter to land.
"The idea was to get trauma care to Marines closest to the point of injury," says Navy Cmdr. Sean Barbabella, the 2nd Marine Division (Forward) surgeon, in a phone interview from Camp Leatherneck in southern Afghanistan. "We can go in there and begin pretty sophisticated treatment, and keep it going while we're driving [back] out to a field hospital."
All of this, of course, rides on the back of basic research and the willingness of taxpayers to have their funds used this way.
"The trauma system is in pretty good shape. We got em forward, they can be saved, we stabilize them, get them back quickly to a good hospital and then we rehabilitate them," said Dale Smith, the medical historian. "Each of those pieces grew over 30 to 50 years, not over 10 years. But they all became militarily useful between the first Gulf war and Operation Enduring Freedom [Afghanistan]."
"It's important to understand that," he added, because at budget-cutting time "we are prone to wonder what some of our public expenditure on basic research is worth."
Combat medical practitioners like Barbabella and Stoddard talk about their work in crisp, clinical tones that mask the emotional burden of battlefield trauma care. It is only later that they can let down.
"When you see these guys, it breaks your heart that anybody has to be wounded like this," says Navy Cmdr. Lisa A. Osborne. "They're often in a state of confusion, frantically looking around wondering where they are,” she says. ‘I'm the last person they see" before they are sedated for surgery, "so whatever I say to them may be the last thing they hear for a really long time."
"I'm always hesitant to tell somebody they're going to be okay, because that's not always going to be true," she says. "We don't save every single person -- some of their injuries are not compatible with life, is the grim reality."
UNTIL THE BIRD ARRIVED
James Stoddard never told Tyler Southern he'd be okay, either. He knew better. After the medevac bird swooped in and carried Southern away, Stoddard had about a minute before the combat patrol resumed.
"I took a knee for a moment," he recalls, using military jargon for a pause to relax. Then he went around cleaning up bloody bandages and wrappings and stuffed them in his pockets.
He and another Marine picked up the bits of Southern's legs and arm that they could find. "It was one of the worst scenarios I've been in," he says.
But there was no time to absorb it. "I had to check all my guys for psychological issues. I went to each one, put my hand on his shoulder and said, 'Are you okay to push, you need anything?"
Back at their base that evening, Stoddard sat down with the Marine squad and platoon leaders and explained what had happened, and what he had done for Southern. He did not say Southern would be okay. "I just said I had done everything I could for him and sat with him until the bird arrived.”
Stoddard's deployment, or course, was not over. He treated 10 more casualties. In one 45-minute attack, Stoddard suffered a concussion and perforated eardrums from an explosion, but went on to save a Marine who'd lost three limbs, a Marine who'd lost two limbs and a Marine with shrapnel wounds on his face.
"I remember the initial blast and coming to, and I was putting on the tourniquets when I came to," Stoddard says.
Where did this teenager find all that strength?
A decade earlier, Stoddard was a Cub Scout when he heard a short lecture on first aid. Make sure the victim's airway and mouth are clear, he was told. Keep the victim warm, elevate his legs, and then go for help.
A few weeks after that, he and his younger brother Robert were playing on an abandoned railway bridge when Robert toppled off and was knocked unconscious. Stoddard ran to his side, checked that his brother's mouth and airway were clear, made sure he was warm, elevated his legs and ran for help.
At the hospital hours later, where his brother was diagnosed with a mild concussion, a doctor told Stoddard: You saved your brother's life by clearing his airway. He's going to be okay. You saved Robert's life.
At that moment, Stoddard’s work was set.
In Afghanistan, Stoddard heard that Southern had been airlifted to Germany, that he had flatlined twice and had been resuscitated each time. It wasn't until Stoddard's Marine battalion returned home to Camp Lejeune, N.C., that he and Southern were reunited.
Here came Stoddard, stepping off the bus, and there was Southern, grinning up from his wheelchair, the stumps of his legs and arm wrapped in bandages. They embraced.
Unfortunately, not everyone gets a James Stoddard. NEXT: Marine Cpl. Jimmy Cleveland Kinsey, 25, dies sick and alone in a hotel room, four long, difficult years after he was injured in an IED blast in Iraq.