US militqary medical data from Operations Iraqi and Enduring Freedom have revealed in detail the causes for medical evacuation of military personnel from the front line. Musculoskeletal and connective tissue disorders (24%) were the number one cause, followed by combat injuries (14%), nervous system disorders (10%) psychiatric disorders (9%) and spinal pain (7%). Furthermore, a variety of different factors influence the likelihood of returning to duty. The findings are reported in an Article published in this week's Conflict Special Issue of The Lancet—written by Dr Steven Cohen, Pain Management Division, Johns Hopkins School of Medicine, Baltimore, MD, USA, and colleagues.
Anticipation of the types of injuries that occur in modern warfare is essential to plan operations and maintain a healthy military. Former US Army Surgeon General, James Peake, called non-battle-related injuries "the hidden epidemic" plaguing modern armies, which suggests that prevention of such injuries, and control of associated pain, play a pivotal role in preservation of unit readiness. The authors say that this burden is not likely to decrease anytime soon. In this study, they aimed to identify the diagnoses that result in most medical evacuations, and identify the factors associated with return to duty.
Demographic and clinical data were recorded for US military personnel who had been medically evacuated from Operation Iraqi Freedom or Operation Enduring Freedom (January, 2004–December, 2007) to the main receiving hospital in Landstuhl, Germany. The primary endpoint of the study was return to duty within 2 weeks—the typical length of time before a decision is taken to either return to service member to Iraq/Afghanistan or evacuate them back home to the United States for further treatment.
More than 34,000 personnel were medically evacuated, of whom 89% were men, 91% were enlisted, 82% were in the army, and 86% sustained an injury in Iraq. The authors used as their baseline comparison an active duty male service member aged 29.8 years who is junior and enlisted in the army, on deployed for Operation Iraqi Freedlom, and has a battle-related injury with a diagnosis of a blood disorder. Compared with this, the factors associated with increased likelihood of return to duty were being a senior officer (2.0 times as likely); having a non-battle related injury or disease (3.2 times) ; presenting with chest or abdominal pain (2.5 times); a gastrointestinal disorder (non-surgical 2.3 times, surgical 2.5 times); or a genitourinary disorder (twice as likely). Women were also more than twice as likely to return to duty as men, though the authors note this could be indicative of the differences in their duties, and subsequently the nature of their injuries and illnesses.
Factors making a services member less likely to return to duty compared with the baseline above were serving in the navy or coast guard (41% less likely): being a marine (14% less); having a combat injury* (73% less); having a psychiatric disorder (72% less); a musculoskeletal or connective tissue disorder (54% less), spinal pain (59% less) or other non-defined wound (46% less).
The authors note that for the 4 years analysed, there was remarkable consistency in numbers of service members who were evacuated for each of the categorised medical disorders and who returned to duty. They say: "One exception to this finding was the sharp increase in the number of evacuated patients with psychiatric diagnoses. This rise occurred despite the introduction of mental health teams devoted to treating combat stress... Possible explanations for the incline in psychiatric illnesses necessitating evacuation are the cumulative psychological effect of repeated deployments, the increasing manpower burden borne by reserve and national guard units, a decreased threshold for evacuation, and a shift in public opinion regarding the war in Iraq."
The authors declare the main limitation of their study is that the data contain the frequency of return to duty in service members who had been medically evacuated out of the combat zone to a level IV centre in Germany, and do not include the numbers treated within the combat zone. Service members who are treated at the level IV regional medical centre in Germany for a psychiatric disorder have probably already failed several treatment attempts, since more than 80% of service members receiving treatment for combat stress remain with their units. Thus, these medically evacuated individuals might represent only a small percentage of the total number with a specific disorder (ie, those with the most severe pathology, intense symptoms, or least motivation). Interventions for these individuals are unlikely to be successful because they had already had previous treatments within the combat zone that were unsuccessful, had more motivation to leave their unit, or had commanders who did not want them to remain.
The findings of the study have several implications. First, non-battle-related injuries continue to be the leading cause of medical evacuation in modern warfare, and medical officers should be prepared for this burden in subsequent conflicts. To reduce the number of evacuees, preventive medicine programmes and educational initiatives need to target health-care providers, non-commissioned officers, and combat soldiers. Second, the burden of psychiatric illness will probably increase in correlation with the duration of the operation and increased reliance on reserve units. Third, although non-combat injuries are increasing, combat injuries are still a significant proportion of the total. As the wounded-in-action to killed-in-action ratio continues to increase, more of these service members will need long-term medical care and social support services.
The authors conclude: "As survival rates of combat injuries increase, and the burden of non-battle-related injuries and psychiatric disorders continues to soar, society must be prepared to deal with the aftermath of these injuries. Resources should be allocated, and civilian physicians trained to manage medical disorders that are commonplace in war veterans, such as PTSD, traumatic brain injury, pain after amputation, other chronic pain disorders, and combat-related disability. Additionally, the sequelae of war might also include adverse social consequences, such as substance abuse, divorce, homelessness, and increased rates of suicide, homicide, and other felonies."
In an accompanying Comment, Dr J Don Richardson, Consultant Psychiatrist for National Centre for Operational Stress Injuries (NCOSI), Veterans Affairs Canada, Montreal, Canada, Parkwood Hospital (St Joseph's Health Care), London, ON, Canada and University of Western Ontario, London, ON, Canada, and colleagues, say: "Today's study emphasises that, as survival rates of combat injuries increase, the medical community will need to prepare for increased rates of non-battle-related injuries, such as psychiatric morbidity, especially military related post-traumatic stress disorder. Resources dedicated to developing specific treatment for war veterans are needed, and they should focus not only on symptom reduction but also on rehabilitation and improving quality of life to help to mitigate combat-related disability."
Dr Steven Cohen, Pain Management Division, Johns Hopkins School of Medicine, Baltimore, MD, USA. T) +1 410-955-1818 E) scohen40@jhmi.edu
Dr J Don Richardson, Consultant Psychiatrist for National Centre for Operational Stress Injuries (NCOSI), Veterans Affairs Canada, Montreal, Canada, Parkwood Hospital (St Joseph's Health Care), London, ON, Canada and University of Western Ontario, London, ON, Canada. Please contact Anne Kay, Media Relations. T) +1 519-685-4292, ext. 42470 E) Don.Richardson@sjhc.london.on.ca / Anne.Kay@sjhc.london.on.ca
For full Article and Comment, see: http://press.thelancet.com/evacuation.pdf
Notes to editors: *Combat injuries included being shot or hit with an improvised explosive device/grenade shrapnel. A battle-related injury means only that the injury was caused or worsened during a combat mission. Many service members sustained musculoskeletal or spine injuries from motor vehicle accidents or road marches during combat missions. These are classified as battle-related in the data, but not combat. Thus battle or non-battle related was one category in the data, and then diagnosis was a separate category.
Journal
The Lancet