Amputations and genital injuries increase sharply among soldiers in Afghanistan
By David Brown
Washington Post Staff Writer
Friday, March 4, 2011; 8:56 PM
Doctors and nurses treating soldiers injured in Afghanistan have begun speaking of a new "signature wound" - two legs blown off at the knee or higher, accompanied by damage to the genitals and pelvic injuries requiring at least a temporary colostomy.
Twice as many U.S. soldiers wounded in battle last year required limb amputations than in either of the two previous years. Three times as many lost more than one limb, and nearly three times as many suffered severe wounds to their genitals. In most cases, the limbs are severed in the field when a soldier steps on a buried mine.
The increase in both rate and number of such wounds is most likely a result of the troop surge in Afghanistan that began last spring, combined with a counterinsurgency strategy that emphasizes foot patrols in villages and on farm compounds. It was noticed by military surgeons in Afghanistan last fall and quantified in late December by a team of surgeons at Landstuhl Regional Medical Center in Germany, where virtually every evacuated soldier stops en route to the United States.
"I've seen these types of injuries before. What I haven't seen is them coming in over and over and over again," said John B. Holcomb, a trauma surgeon at the University of Texas at Houston and retired Army colonel who helped identify the trend.
The report prepared by Holcomb and two surgeons at Landstuhl has circulated at the highest levels of civilian and military command in the past two months. An abbreviated version was provided to The Washington Post with Pentagon permission.
It shows that from 2009 to 2010, the proportion of war casualties arriving at Landstuhl who had had a limb amputated rose to 11 percent from 7 percent - a 60 percent increase. The fraction suffering genitourinary (GU) injuries increased to 9.1 percent from 4.8 percent - a 90 percent increase.
The actual number of patients with the injuries increased even more drastically.
In 2009, 75 soldiers underwent amputation and 21 lost more than one limb. In 2010, 171 soldiers had amputations and 65 lost more than one limb. GU injuries increased from 52 to 142 over the same period.
Month-by-month totals were not provided, but numerous people who have seen the full report say that multiple-limb amputations rose especially steeply starting in September. Lt. Col. Paul Pasquina, a physician who heads the amputee program at Walter Reed Army Medical Center, recently confirmed that those injuries had "gone up a lot." Also on the increase are patients requiring "hip disarticulation" - the removal of the entire thigh bone, which makes fitting and using a prosthesis more difficult.
Injuries to the genitals
Of the 142 soldiers with genitourinary wounds who arrived at Landstuhl last year, 40 percent - 58 men in all - suffered injury to the testicles. Of that group, 47 had injury to one testicle, and 21 men lost a testicle. Eleven soldiers had injuries to both testicles, and eight lost both testicles.
Body armor, which has greatly reduced fatalities, usually includes a triangular flap that protects the groin from projectiles coming from the front. It does not protect the area between the legs from an upward blast. Various laboratories are reportedly working on shielding that would provide such protection.
Although the U.S. Army Medical Command released the data on genital injuries, military officials are reluctant to discuss these wounds further.
"While these types of injuries are a reality of the combat we now face, detailed discussion . . . can potentially provide insights to our enemies into the effectiveness of their improvised explosive devices and other weapons they use," said Maj. Gen. Stephen R. Lanza, chief of Army public affairs.
A recent medical journal article that reviewed more than 800 GU injuries suffered from 2001 to 2008 (mostly in Iraq, not Afghanistan) reported that 9 percent involved damage to the testicles. That suggests the proportion of GU injuries involving the testicles is growing. The review provided no data on the on soldiers who had lost both testicles, so it is unclear whether that number is rising.
Anecdotal evidence, however, suggests it is.
In mid-October, a Washington Post reporter attended a weekly videoconference in which military medical personnel from around the world discuss the previous week's severe trauma cases. Of the 13 patients on the agenda, many had lost limbs, and three had lost both legs and both testicles.
Medical staff at Landstuhl also noticed a rise in severe genital injuries last fall.
"In my 21/2 years here, it's just started," intensive-care unit nurse Kathryn Gillespie said in late October.
Most critically injured soldiers arrive at Landstuhl unconscious or heavily sedated. Some regain consciousness for the first time since the battlefield during their two- or three-day stay. Gillespie described a typical awakening.
"The first thing we let them know is they're in Germany. We tell them, 'You're hurt, but you're okay.' Then they want to do a scan of their body. They ask, 'Is my junk all together?' They want to check their 'package.' Then they check their arms and legs. This all happens probably within 15 minutes of being off sedation."
Many patients, minds clouded by illness and medication, "discover" their injuries more than once during the stay. Each time, they ask nurses and doctors to explain what happened and what lies ahead.
"It sickens us. It's devastating," said Gillespie, who has twin sons who served in the military in Iraq.
The long-term prospects for the recent double-amputees are a mixture of the known and unknown.
A study published last year compared 73 Vietnam War veterans and 61 Iraq or Afghanistan veterans who had lost two or more limbs.
Of the Vietnam group, 76 percent reported being married or cohabitating, and 85 percent reported having children. Of the more recent veterans, 61 percent were married and 46 percent had children. Thirty-nine percent of the Vietnam veterans rated their health as "very good" or better, while 61 percent of Iraq and Afghanistan veterans said so.
About 70 percent of each group experienced phantom pain in their lost limbs. An increased risk for cardiovascular disease is well-recognized in amputees, even in those who are fit: One in six of the Vietnam veterans, whose average age was 61, had suffered heart attacks.
Soldiers who have lost two limbs and their testicles, however, are a new category of survivor.
They will require testosterone supplementation for life. While infertile, some might be able to have sexual intercourse. A search of the medical literature found no articles about their long-term care, quality of life or psychological adjustment.
An Army spokeswoman, Cynthia Vaughan, said this week that a "severe and complex injury task force" had been formed to look into what constitutes optimal care and support.
"I don't think anybody has really explored these issues in depth," said Allen D. Seftel, a urologist and former editor of the International Journal of Impotence Research who worked in the Veterans Affairs medical system for 17 years before joining Cooper University Hospital in Camden, N.J. "We owe it to our veterans, and to the medical community, to understand what the effects of these injuries are."
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