The small holes in the man's neck look harmless enough, but U.S. Air Force Col. Dr. Joseph Brennan knows better. He and other hospital staff can also see that the soldier is bleeding from the mouth.
Brennan, an otolaryngologist/head-and-neck surgeon, spent most of last fall and early winter caring for cases like this at Air Force Theater Hospital in Balad, located 50 miles north of Baghdad in the fractious Sunni Triangle.
"Roadside bombs carried in vehicles, or 'improvised explosive devices,' are the cause of the majority of injuries that we're seeing," he said. "They generally pepper the patients with shrapnel; they'll be hit everywhere. But often you'll only see just these tiny specks, like shaving nicks."
These "nicks" mark the entry points for shrapnel just millimeters thick. But the high velocity at which these fragments enter the head or neck means "they're often equated with severe, life-threatening injuries," Brennan said.
That means that incoming patients bearing these wounds are automatically CT-scanned and sent to exploratory surgery, if necessary -- even if they appear perfectly fine to the untrained eye.
In the sergeant's case, Brennan's team quickly examined him, then went to work opening his airway and locating the source of the bleeding -- an artery torn by a piece of metal just 1 millimeter wide. Surgeons then repaired the artery to stop the bleeding, saving the soldier's life.
For these types of casualties, this delicate and highly specialized work is best performed by an otolaryngology team deployed as close to the front as possible, Brennan said.
The surgeon -- now back at Lackland Air Force Base, Texas -- will present an overview of the work done by his team in Iraq at the American Academy of Otolaryngology/Head and Neck Surgery annual meeting, which starts Sept. 25 in Los Angeles.
Although the Iraqi conflict began in March 2003, the U.S. Air Force didn't order that a dedicated team of head-and-neck specialists be stationed at Balad until last September. Statistics released last year revealed that one in every five wounded soldiers in the Iraqi conflict was suffering head and neck injuries -- a much higher number than in previous conflicts. So, why did the Air Force wait so long to deploy a team of otolaryngology specialists to Iraq?
"Good question," Brennan said. "I can't answer that. But we're there now."
And they're busy.
According to Brennan, in the 26 weeks covered by his report -- from early September 2004 to late January 2005 -- the Balad hospital had 159 patients who underwent 257 operative procedures. His team also treated 525 outpatient cases. Allied personnel accounted for about half the patients treated, with the other half made up of Iraqi civilians and combatants.
Some days were relatively calm for his team, Brennan said -- four or five outpatients to see in the clinic, and maybe just one or two surgical procedures.
"Then there were certain times that we'd be very busy," he added. The busiest period occurred in mid-November 2004, during the "Fallujah Offensive." During that 10-day offensive, the Balad hospital admitted 381 injured combat personnel, including 52 on just one day, Nov. 9.
Brennan said that while many of the procedures his team knows best can also be performed by non-specialists, in many cases the right training makes all the difference.
"First of all, we're the ultimate 'airway experts,' " he said. "If someone comes in injured and you don't get an airway working, it doesn't matter what else they have because they've only got four or five minutes to live." In fact, Brennan lists three cases in his report where his team successfully intubated patients "after failed attempts by other services."
And because so many injuries occur from bomb shrapnel flying upward into soldiers' throats and faces, a detailed knowledge of neck anatomy is key. "There's literally no more complex area in the human body," Brennan said. "Pretty much every vital structure goes through the neck."
The work of specialist teams, in conjunction with improved body armor and the dedicated work of other emergency and health workers in the field, means the death rate for injured U.S. soldiers has fallen to just 10 percent in the Iraqi conflict -- down from 30 percent in World War II and 24 percent in the Korean and Vietnam wars, Brennan said.
The Balad hospital, which he described as "an interconnected tent complex," is also state-of-the-art, with everything a large trauma center in the United States has, including CT scans and other imaging technologies.
"As far as the head and neck region, I think they have everything right there to get these folks fixed up and kept alive," said Dr. G. Richard Holt, a professor of otolaryngology/head and neck surgery at the University of Texas Science Center in San Antonio.
Holt, who is also a colonel in the Texas Army National Guard and served as a surgeon in the first Gulf War, said many of the less-severely wounded recover and return to their units. Those with tougher injuries are usually evacuated after their initial treatment to either Germany or the United States for further evaluation and care.
Soldiers with facial wounds may require follow-up plastic and reconstructive surgeries, while others may require therapy to help restore impaired swallowing or speech due to throat wounds, Holt said. Many others can suffer long-term hearing loss due to eardrum punctures suffered in high-decibel blasts.
Holt has been back to Baghdad himself recently, but this time as a civilian member of a group called the Medical Alliance for Iraq. "We went there to teach and to help Iraqi doctors to be able to start handling a lot of these things for themselves," he explained.
Brennan said he sees his work caring for Iraqis, both civilians and soldiers, as a vital part of his mission, too. While the unit's priority is trauma care, his team often treated Iraqis needing other types of urgent care -- like the time he helped remove a tumor from a 9-year-old Iraqi girl's cheek that was threatening her sight.
"We saved a lot of Iraqi lives -- obviously, they prefer to come to our hospital if they can, and we saw a lot of them," said Brennan, who is set to return to Balad late next spring or early summer for another tour of duty.
"Hopefully in the future, if things calm down a little bit, we'll be able to have a greater impact on the civilian populace for this type of routine care," he said. "And that's a great morale builder."
More information
Find out more at the Air Force Medical Service.
