November 18, 2003 Features

Caring for Our Soldiers

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.

cite as: Newman, L. A. , Battiata, L. , Gurevich, J. , Powell, K.  & Walsh, K. (2003, November 18). Caring for Our Soldiers. The ASHA Leader.

2003 Walter Reed Army Medical Center War Data

Cases Treated by Walter Reed Army Medical Center in 2003

Total Cases for Operation Enduring Freedom and Operation Iraqi Freedom at Walter Reed: 1501

Inpatient: 544

Outpatient: 957

(Of the total, 288 are battle injuries.)

Cases from Operation Iraqi Freedom Treated by WRAMC in 2003

Total Casualties for Operation Iraqi Freedom: 1366

Battle Injuries: 265

Non-Battle Injuries: 589

Disease: 492

Undetermined: 20



Five Months in Iraq

by Laura Battiata and Katherine Walsh

Sgt. 1st Class David Arabinko does not remember his time in Iraq.

After being deployed in March 2003, he spent five months in northern Iraq as an 18 Delta—also known as a Special Forces medical technician. He was admitted to Walter Reed Army Medical Center on Sept. 1, 2003, exactly one month before he was scheduled to return home to his wife and three-year-old son in Colorado. On August 28, David was traveling in a military vehicle that came under enemy fire. He sustained a superficial gunshot wound to the head, and his vehicle, which was going in excess of 90 mph, rolled over and burst into flames. As a result of being thrown through the windshield, he suffered severe head and neck trauma.

David joined the Army in 1986, one year after his twin brother enlisted. He grew up in a military family; his grandfather served as an army medic in WWII and his father spent time in the Navy. He spent four years in infantry and was selected in 1990 to train for the Special Forces. As a Special Forces medical technician, he had expertise in advanced trauma and life support and was trained to stabilize a victim in the field for up to four days. The responsibility of his unit was to land in friendly or enemy territory by any means necessary to rescue victims. To execute this mission, he was trained as a paratrooper. His current hospitalization is not the first time he has required extensive rehabilitation for serious injuries.

Sitting next to her husband’s hospital bed, his wife recalls his first days at Walter Reed, when he was unable to talk, move, or breathe on his own. David arrived on full ventilator support and was minimally responsive. An MRI of his brain revealed cerebral and midbrain contusions as well as diffuse axonal injury. He had a Glasgow Coma Scale of 11 and no movement of the right side of his body. Upon admission, David was evaluated by the Traumatic Brain Injury service, speech-language pathology, occupational therapy, and physical therapy. Through medical care, intensive rehabilitation, and strong family support, David progressed rapidly. After 16 days and two modified barium swallow studies, he was able to begin an oral diet.

David’s future with the Army is unknown. Like many injured soldiers, David wants to return to his previous duties and continue serving his country. He would like to continue as a free-fall instructor and hopes to return to college and become a physician’s assistant. He has served his country in the Army for 17 years. His medical condition will dictate whether he will remain as an enlisted soldier or will be forced into medical retirement. At the present time, David’s largest barriers to functional independence are his continued right hemiplegia and his severe memory loss. He struggles to remember his home, his employment responsibilities, and most details of the last 13 years. Although David feels ready to go home now, he will need to go to a VA hospital to continue rehabilitation. His length of stay and need for rehabilitative services have not been determined.

The most memorable experience for David was a visit from President George Bush and the first lady. The president asked the Arabinkos’ three-year-old son, Ulysses Shelby Arabinko (named so his initials would be USA) about his father. He described his father perfectly, saying “My daddy is broke.”



  

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