Better by Atul Gawande: Chapter 3

To continue the chapter-by-chapter discussion of Better by Atul Gawande, here's a quick overview of Chapter 3: Casualties of War. It covers the efforts of battlefield surgeons in Iraq and Afghanistan to save as many wounded in the wars as possible.




This chapter blew my mind continually. Some statistics:
- Mortality rates for those wounded in World War 2 were 30%, in Vietnam it was 24%, in the Gulf War it was 24%, and in Iraq it has so far been 10% (in the Revolutionary War it was 50%, which is astounding to me... maybe as a function of infections probably taking a lot of lives of the wounded?)
- A Forward Surgical Team (FST) that travels into combat zones and sets up basic surgical tents carries backpacks with all their necessary equipment and can set up in less than 60 minutes
- The travel time of a seriously wounded soldier from the frontlines back to the US averages 4 days; in Vietnam, it occurred in an average of 45 days

These three stats are related because they all point to the focus of medical care in modern day wars - quick and basic emergency treatment followed up by longer care treatment away from the frontlines. The focus of the FSTs is "damage control, not definitive repair." The wounded is then sent on to a temp treatment facility immediately; if their injuries are serious they are then sent back to the US within a few days. The goal is for each level of treatment to give the patient the best chance for survival and then trust the next step in the chain to do its part to carry on the treatment.

So far it's working, as the 10% mortality rate shows. Gawande relates the incredible story of one individual with blast injuries who was opened up at the FST, received life-saving surgery and had arteries tied off, then was cleaned out, packed with ice, and sent on an air evac - still left open from surgery with a note taped to him explaining what was done - to the nearest combat hospital and a new surgical team. This is apparently the typical flow of battlefield treatment.

This technique was developed by meticulously analyzing the data of battlefield treatment. The key was assessing the patterns of injuries and examining the results of existing treatments. Just like civilian trauma cases, it was determined that fast responses for "damage control, not definitive repair" were the most important life-saving component of treatment. Hence the implementation of the FST and the chain of treatment described above.

By analyzing the patterns of injuries and treatment, other basic life-saving measures were implemented. Soldiers coming into treatment were found to be without their kevlar; orders were issued that kevlar was to be taken seriously, it was, and these injuries became less severe. Blindness was occurring with heightened regularity because soldiers weren't wearing their goggles; soldiers told command that the goggles were too ugly, more fashionable goggles were commissioned, and increased usage reduced the blindness injuries.

Gawande goes to great pains to make one image stand out in this chapter - that of a battlefield surgeon at his computer, working long into the early morning, entering data from each and every injury and treatment he worked on. Gawande's point is that reporting is vital to diligence - just as it was for the WHO supervisor fighting malaria - so these doctors recorded the details and results of each case. They understand, as Gawande writes, that "vigilance over the details of their own performance offered the only chance to do better." It is that very vigilance which led to the incredible treatment processes described above and has resulted in 90% survival of all those injured as of 2006, when Better was written.