The Global War on Terrorism (GWOT) was an executive initiative signed by President George W. Bush following the attacks of Sept. 11, 2001 on American soil. GWOT is an international coalition against terrorism comprising over 136 countries and 46 multilateral organizations. As a result of the initiative, hundreds of thousands of U.S. troops have been deployed throughout the world. Since the United States has embarked on Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF), there have been hundreds of American and foreign military and civilian personnel killed and injured.
Military casualties—those patients whose wounds are results of enemy action—are initially treated by the 75 military hospitals around the world. Walter Reed Army Medical Center (WRAMC), established in 1909 and located in Washington, DC, is the flagship Army hospital caring for all branches of the active duty military, retirees, and their families. It was named for Maj. Walter Reed, the physician and researcher who identified the mosquito as the sole transmission source for yellow fever. The Army Audiology and Speech Center (AASC) at WRAMC was established in 1946 to “evaluate hearing and speech, rehabilitate patients with impairments, and conduct basic research in hearing and speech.” It is presently the most active, comprehensive center for evaluation, treatment, and research of communication disorders in the Depart ment of Defense.
New Technology, New Injuries
The number of troops wounded in Iraq is more than twice that of the Persian Gulf War of 1991. The types of injuries may differ from those of previous conflicts because of technological advances in weapons, protective gear, and medical care. According to Col. David Chandler, PhD, Medical Service, director of AASC, the Army has undergone a transformation in recent years to become more responsive, lethal, and versatile, while ensuring that soldiers have the protective equipment such as the Kevlar helmets and body armor that keeps them survivable and sustainable in their duty performance. This equipment provides an effective defense against weapons rounds (up to 7.62 mm), as well as insulating soldiers from projectiles and shrapnel from mines, grenades, mortar shells and artillery fire. Although the reduction in head and thoracic injuries means that injured soldiers have a better chance of survival than ever before, there are more extenuating wounds to the periphery, limbs, and head and neck area not covered by the helmet.
The retired Col. Robert Mosebar, MD, a veteran of three wars (WWII, Korea, and Vietnam), consultant to the United States Army, and a renowned expert in military medicine, reports that there are several changes in the delivery of medical care during this current conflict. The greatest change is “hypotensive resuscitation.” When injured, the body produces blood clots where bleeding occurs. Previously, the standard of care was to return the soldier's blood pressure to normal, which increased the chance of dislodging the clot. Presently, resuscitation in the field attempts to get blood pressure to a hypotensive state, just enough to maintain minimum metabolism (e.g., kidneys, heart, and brain) thus reducing the chance of dislodged clots and increasing survival.
Mosebar notes that the conflict in Afghanistan is unique in requiring soldiers to wage battle in the mountains. Blood is being moved further forward into combat operations in Afghanistan using newer ice chests to keep blood products colder for longer periods of time.
Another major difference is the use of minimal medical facilities to take care of casualties at the front. During previous conflicts, MASH units were used to provide medical care. During GWOT, the goal of the medical facility at the front line is to “resuscitate, stabilize, and evacuate to the major military medical centers in the United States.” Frequently, casualties are medically evacuated (or medevac'ed) to regional military medical centers before coming to the United States. The goal of the distribution of medical services is to allow casualties to receive the multitude of sophisticated services that are best provided in a major medical center.
Role of the Speech-Language Pathologist
As the result of technological and medical changes, soldiers and civilians with severe injuries are surviving and those wounded in this conflict are receiving speech-language pathology services sooner than in any previous conflict. If casualties reach a medical facility alive, Mosebar says, they have a 99% chance of survival. At the same time, our profession has expanded as a result of technological changes and research. Our scope of practice now incorporates such areas as swallowing, the medically fragile patient, and traumatic brain injury. The SLP treating casualties is treating a different type of patient than in past conflicts.
According to the Patient Administration Office of North Atlantic Regional Medical Command, 1,501 patients from OEF and OIF have been treated at WRAMC. The spectrum of care for patients is listed in the sidebar and was current as of September 2003. The total number of patients for OEF was 133 with 1,368 patients for OIF. The breakdown of patient care for Operation Iraqi Freedom can be seen in the sidebar. Interestingly, battle injuries are only 19% of total casualties. Other cases are the result of diseases and accidents.
Of the 1,501 cases treated at WRAMC, 47 were referred for speech-language pathology services. Forty-four of the casualties occurred during OIF and three during OEF. Two of the patients were outpatients and both were treated for voice-related disorders; one patient suffered laryngeal injuries related to a burning oil well and the other required surgery for a vocal fold polyp. The 45 hospitalized patients were 8.3% of the hospitalized casualties. The mean and median ages were 31.98 and 31 years respectively (s.d. = 10.12 years) with a range of 19 to 57 years. Three of the patients were female.
The types of injuries suffered by the casualties included blast (13), motor vehicle accident (9), gunshot wound (8), helicopter crash (3), CVA (3), chemical-burning oil well (1), GuillainBarre (1), heat stroke/seizure (1), laryngeal polyp (1), and vocal cord dysfunction (1).
Similar to the statistics for all cases at Walter Reed, a good number of patients referred to our unit were non-battle related cases and included various disease processes and accidents. The most frequent speech-language pathology service was evaluation and treatment of swallowing difficulties (31 out of 47, or 61%). The number of patients with traumatic brain injury was 24, or 51% of the 47 casualties. Twenty-eight (60%) had some type of cognitive, language, or speech deficit that required treatment. Fourteen (30%) of the patients had a tracheotomy and of those, 10 (22%) received a speaking valve. Fourteen of the patients were also ventilator-dependent at the time of the referral. Clearly, many of these patients were referred while still in the Intensive Care Unit (ICU).
Many of these patients are still hospitalized. Of the 31 who were discharged, only one patient has been reassigned and one returned to Iraq. Twenty patients (65%) required continued treatment at other facilities including VA hospitals, other army hospitals, rehabilitation hospitals, and TBI facilities. Eight patients (26%) were discharged on convalescent leave, some of whom will receive outpatient treatment.
GWOT does not appear to be ending soon. Advances in technology and changes in the delivery of medical services have resulted in increased survival of the injured and speech-language pathology services being requested as soon as a casualty can be evacuated to a major medical center. Surprisingly, the patients from OEF and OIF were not just battle-related but included accidents, diseases, heat effects, psychological reactions, and undetermined etiologies. In this sample, 8.3% of the hospitalized inpatients were referred for speech-language pathology services. Many patients were referred while still in the ICU and were most frequently referred for diagnosis and treatment of swallowing-related disorders. In addition, patients with tracheostomies and speaking valves required our services. Traumatic brain injury and speech/language/cognitive deficits were present in over half of these cases and will require additional treatment at other facilities.
Speech-language pathology services begin in the ICU, and in the long term, our services will be required to help these men and women live, function, and communicate as civilians. As a profession, we must be prepared to treat this increasing population of men and women who have sacrificed so much in the service of our country.