For every American soldier killed in Iraq, nine others have been wounded and survived -- the highest rate of any war in U.S. history.
It isn't that their injuries were less serious, a new report says. In fact, some young soldiers and Marines have had faces, arms and legs blown off and are now returning home badly maimed. But they have survived thanks, in part, to armor-like vests and fast treatment from doctors on the move with surgical kits in backpacks.
"This is unprecedented. People who lose not just one but two or three extremities are people who just have not survived in the past," said Dr. Atul Gawande, a surgeon at Brigham and Women's Hospital in Boston who researched military medicine and wrote about it in today's New England Journal of Medicine.
The journal also published a five-page spread of 21 military photographs that graphically depict the horrific injuries and conditions under which these modern-day MASH surgeons operate.
"We thought a lot about it," said the journal's editor, Dr. Jeffrey Drazen, and ultimately decided the pictures told an important story.
"This war is producing unique injuries -- less lethal but more traumatic," he said.
In one traumatic case, Gawande tells of an airman who lost both legs, his right hand and part of his face. "How he and others like him will be able to live and function remains an open question," Gawande writes.
Kevlar helmets and vests are one reason for the high survival rate.
"The critical core, your chest and your abdomen, are protected," said Dr. George Peoples, a Walter Reed Army Medical Center surgeon who served in Iraq and Afghanistan. "Parodixically, what we've seen is devastating extremity injuries because people are surviving wounds they otherwise wouldn't have."
By mid-November, 10,369 American troops had been wounded in battle in Afghanistan or Iraq, and 1,004 had died -- a survival rate of roughly 90 percent. In the Vietnam War, one in four wounded died, virtually all of them before they could reach MASH units some distance from the fighting.
Today in Iraq, real-life Hawkeye Pierces and B.J. Hunnicuts have stripped trauma surgery to its most basic level, carrying "mini-hospitals" in six Humvees and field operating kits in five backpacks so they can move with troops and do surgery on the spot.
"Within an hour, we drop the tents and set up the OR tables, and we can pretty much start operating immediately," said Peoples, whose photographs are in the medical journal.
He's now at Walter Reed in Washington, which has treated 150 amputees from the Iraq war. American military hospitals collectively have had 200 amputees from Iraq and Afghanistan, three of them triple amputees.
The record survival rates in Iraq have been achieved with an astonishingly small number of general surgeons. The entire Army has only about 120 on active duty and a similar number in the reserves. Of these, only 30 to 50 are in Iraq, plus 10 to 15 orthopedic surgeons, to care for 130,000 to 150,000 troops, Gawande reports.
That's fewer than the 80 general and orthopedic surgeons on staff at two Boston hospitals -- Brigham and Massachusetts General.
"It's a very tight supply," Gawande said of the surgeons in Iraq. "They're now also burdened with civilian Iraqis seeking their help because the U.S. has taken over many Iraqi hospitals."
Virginia Stephanakis, a spokeswoman for the Army Surgeon General's Office, said Gawande had done excellent research and that his figures on casualties jibe with those on Department of Defense Web sites, though she wouldn't confirm the number of surgeons in Iraq.
Gawande and others also credit nurses, anesthetists, helicopter pilots, other transport staff and an entire rethinking of the combat medicine system for soldiers' survival.