Over there

I sometimes wonder if this blog should devote itself exclusively to the writings of surgeon Atul Gawande. The big concern is that I wouldn't be able to keep up (I already missed the boat covering his latest New Yorker piece).

In last week's NEJM, Gawande wrote on combat medicine, providing some blockbuster statistics in his usual understated, enlightening manner:

When U.S. combat deaths in Iraq reached the 1000 mark in September, the event captured worldwide attention. Combat deaths are seen as a measure of the magnitude and dangerousness of war, just as murder rates are seen as a measure of the magnitude and dangerousness of violence in our communities. Both, however, are weak proxies. Little recognized is how fundamentally important the medical system is — and not just the enemy's weaponry — in determining whether or not someone dies. U.S. homicide rates, for example, have dropped in recent years to levels unseen since the mid-1960s. Yet aggravated assaults, particularly with firearms, have more than tripled during that period.2 The difference appears to be our trauma care system: mortality from gun assaults has fallen from 16 percent in 1964 to 5 percent today.

We have seen a similar evolution in war. Though firepower has increased, lethality has decreased. In World War II, 30 percent of the Americans injured in combat died.3 In Vietnam, the proportion dropped to 24 percent. In the war in Iraq and Afghanistan, about 10 percent of those injured have died. At least as many U.S. soldiers have been injured in combat in this war as in the Revolutionary War, the War of 1812, or the first five years of the Vietnam conflict, from 1961 through 1965 (see table). This can no longer be described as a small or contained conflict. But a far larger proportion of soldiers are surviving their injuries.

He goes on to discuss the transformation of front-line trauma care since Vietnam, and some of the remarkable people behind it. One comes away with a greater appreciation of what the tiny number of army physicians and surgeons have accomplished in Iraq. There are implications for our civilian trauma management, as well (lengthy stabilization in the field or community hospital may not be in the patient's best interest).

I understand there was some controversy over how his article was presented, because he's not a trauma surgeon and is not involved with the war. But to me, his points are so clear and salient, I can't see how readers are disserviced. Plus, as becomes obvious from his reporting, the doctors in Iraq don't currently have the time to write.