US troops injured in Iraq are being airlifted to Germany for medical treatment within hours. As a result, many lives are being saved and surgeons are learning techniques that will save many more beyond the theatre of war. Tom Clonan was given access to the US battle trauma treatment centre.
An hour's drive south of Frankfurt, the A6 autobahn crosses the Rhine and enters the picturesque German Rhine-Pfalz region. Minutes later, south of Kaiserslauten, the pretty picture-postcard town of Landstuhl comes into view - nestled among hills lined with snow-covered firs and spruces.
Landstuhl, with its myriad church steeples, red-tiled roofs and quaint central square - complete with its own Irish bar, the Blarney Stone on Hauptstrasse - is like any other German town except that it is home to the US military's Landstuhl Regional Medical Centre.
Perched on top of Landstuhl's Kirchberg Hill, the hospital was built in the immediate aftermath of the second World War amid the ruins of the infamous Landstuhl Adolf Hitler School - a leadership academy for top Nazis.
Throughout the Cold War, Landstuhl serviced the needs of the 50,000 or so US troops stationed in Germany. It still does so today and has evolved into a state-of-the-art hospital specialising across all the major medical disciplines from obstetrics and gynaecology to general surgery and, of late, trauma surgery and critical care.
In addition to the 1,000 or so US citizens that are born in Landstuhl's maternity ward each year, the hospital's trauma centre annually treats up to 10,000 battle injuries sustained by US forces stationed in Iraq and Afghanistan.
Just five hours by air from the heat and dust of Baghdad, the rural idyll of Landstuhl has recently found itself on the front line in the war in Iraq. Located just six kilometres from neighbouring Ramstein US air force base, Landstuhl has become the key central stepping stone in the air evacuation route from Iraq. This is an air-bridge consisting of combat helicopters and C-17 jet aircraft that stretches from the remotest US marine corps forward-operating posts in Iraq to Andrews US air force base just outside Washington DC in the United States.
As I approach the hospital, security is very tight and the perimeter fences and environs of the hospital are patrolled by armed German security personnel along with US military police units.
Once inside the base I am introduced to Col John Sweeney, the medical head of the Deployed Warrior Medical Management Centre. Col Sweeney, whose family come from Donegal, began his military career with combat experience in a helicopter unit in Vietnam in the late 1960s. He later qualified as a physician and specialises in psychiatry.
He is responsible for co-ordinating the care of the daily plane-loads of critically injured soldiers arriving directly from the battlefield in Iraq. Col Sweeney's office in Landstuhl ensures continuity of care for US soldiers - from the site of injury in Iraq through to the trauma and intensive care unit in Landstuhl and on to the final destination of the wounded in the US naval hospital in Bethesda, Maryland, or at the Walter Reed army hospital in Washington DC.
Col Sweeney produces a box of Barry's tea bags and, over a cup for his Irish guest, explains the unique manner in which the war in Iraq is producing injuries of a type not previously survived in combat.
Unlike the war in Vietnam, where only 3 per cent of casualties were caused by bomb and blast injuries, approximately 75 per cent to 80 per cent of the injured arriving at Landstuhl are wounded by the blast effect and shrapnel from improvised explosive devices (IEDs) - essentially home-made bombs, the weapon of choice in Iraq.
This has led to a situation where wounded US troops are not presenting at Landstuhl with simple gunshot wounds but with complex blast and burn injuries combined with profound brain and spinal injuries. These IEDs or home-made bombs have killed almost 1,200 US troops in Iraq.
Troops that survive insurgent attacks are taken to Landstuhl with what the US military call polytrauma. Polytrauma consists of multiple serious injuries caused by blast and shrapnel to those parts of the body least protected by body armour, such as the head, and can include brain and spinal injuries.
These are usually combined with penetrating and rupturing injuries to internal organs, along with substantial injuries to arms and legs. In previous wars, troops wounded in this way would not have survived. According to Col Sweeney: "The enemy is getting very good at these IEDs and the blast injuries are getting more serious. But we've got some very serious surgeons 'down range' [ ie in combat] who do the initial life-saving surgeries in the combat-support hospitals. Then they send them to here where we can do what's necessary, surgically, for them to survive the 9½-hour flight from Landstuhl to the US."
According to Col Sweeney, a soldier wounded in Iraq can be repatriated to a hospital in the US in less than 72 hours. As a consequence, death rates among the wounded have decreased. To put the US military's current medical air evacuation route into perspective, during the second World War it took an average of 120 days to get a US soldier from the place where he was wounded - whether it was in Europe, Africa or Asia - to a hospital in the US. Approximately one-third of US soldiers wounded in such circumstances died of their injuries.
During the 1960s, it took an average of 45 days to evacuate a wounded US soldier from Vietnam to a hospital in the US. Approximately one quarter of these troops died of their injuries during this period.
In Iraq and Afghanistan today, the mortality rate among wounded US troops has fallen dramatically to around 10 per cent of the total wounded. Landstuhl is seen as crucial to the survival of these critically wounded troops.
According to Col Sweeney: "These kids just couldn't withstand the 14½-hour flight direct from Baghdad to Washington. So we fly them here and its saving hundreds if not thousands of lives."
So much so that there is a saying among US troops serving in Iraq to the effect that when injured, "if you make it to Landstuhl, you're good to go" - meaning that safe arrival at Landstuhl is almost a guarantee of survival.
Shortly after I arrive at Landstuhl, a C-17 jet lands at Ramstein. Along with Col Sweeney's team of trauma surgeons and nurses, I await the arrival of 14 wounded US troops to the hospital.
They arrive within minutes aboard a large converted bus. Of the 14, nine are borne from the coach on stretchers. As they are gently lowered from the vehicle, a team of US military chaplains whisper gentle words of encouragement to each one.
The chaplains carry dog-eared copies of the US army field manual 16-100, The Unit Ministry Team Handbook. I ask to look at it. It opens to a marked page headed "Words to a Dying Soldier".
For the dying Christian soldier it recommends Psalm 23. For the dying Jewish soldier, the manual recommends the Shema, the Jewish prayer for the dying. For the dying Muslim soldier, it recommends the prayer to Allah, the Shahada.
All of the injured are very young men and women. Many are still wearing the combat fatigues they had on when they were injured - in some cases only hours earlier.
The first soldier to be stretchered into the hospital has shrapnel injuries all over his face. His throat, cheeks and forehead are peppered with black marks from the blast and his face has swollen to the extent that one eye is squeezed tightly shut. The other eye is obscured by a dressing. He is completely immobile. I notice his combat boots are still caked with the dust of Iraq.
The second patient is very young and very pale. He appears disoriented, perhaps partially sedated. One of his legs appears to have been shattered by a blast and a large sponge-like bandage is seeping blood from under his right ankle.
The next patient is equally young and has a nasal tube inserted. He stares silently at the nurses and clutches a colostomy bag to his abdomen.
The remaining soldiers - black, white, Hispanic, male and female and all very young - are stretchered by in a blur.
Four of the soldiers are walking wounded and make their own way into the hospital. They are still wearing their flak jackets and one carries his helmet. They shiver from the cold of this near-freezing morning in Landstuhl. They glance anxiously around the room - scanning the phalanx of medical specialists and nurses for a familiar or friendly face as they enter.
One of the injured arrives in a separate ambulance and is brought directly to the intensive-care unit. I later learn of a case of a young female soldier with "catastrophic facial injuries and the loss of one eye".
One of the chaplains, Maj David Bowermann, explains that at this point, the soldiers are very anxious to retell their stories and anxiously inquire about other soldiers killed or injured in the same incident. The chaplain also explains that the soldiers are often quite "conflicted" in speaking about traumatic incidents, particularly if they have killed an enemy combatant.
Maj Bowermann explains that the chaplaincy deal directly with the question of killing in combat and the manner in which they reconcile that with the Fifth Commandment - thou shalt not kill. He is at pains to point out that US troops do not receive any simplistic answers to this ethical dilemma and that each soldier has to work out their own, individual route to salvation or inner reconciliation from the savagery of combat in the context of a "forgiving God".
I follow the wounded troops through to the emergency room and on to the trauma surgery centre and the intensive-care unit. Here I meet trauma surgeon Dr Tim Woods, a graduate of Notre Dame University, whose alumni are "known as the Fighting Irish", he tells me with a grin.
Dr Woods has been working for over 36 hours. The previous night, the trauma team lost the battle to save the life of a critically injured soldier.
Despite his fatigue, Dr Woods is upbeat about the work of the trauma team in Landstuhl. "There's no doubt that this war is going to teach us a lot about how we treat injuries in the civilian world," he says.
He refers specifically to brain injuries.
"We are continuing to learn about brain injury," he says. "One thing we are doing is deploying neurosurgeons to the front line. When troops sustain a brain injury, we immediately remove the skull, often near the scene, to allow the brain to swell. That way you don't get compression of the vessels and further damage. This has saved significant numbers of lives and has allowed significant improvements in the recovery prospects of wounded soldiers."
Dr Woods goes on to describe the manner in which surgeons treat leg injuries to avoid amputation. He describes the significant swelling associated with blast injuries to the leg that can cause compression and loss of further tissue and muscle mass, which can often require amputation of the limb. According to Dr Woods, US army surgeons are now "routinely cutting through the fascia or binding tissue of the leg to allow the injured muscle mass and tissue to swell unhindered during the recovery phase, thus saving the limb".
He also describes how abdominal injuries are being treated. In the past, penetrating injuries from shrapnel or bullets usually proved fatal. Now, according to Dr Woods, "we're actually leaving the abdominal injuries open. That allows them to swell as the body needs. At a later date we can close the abdomen. So we can allow a patient to go through the significant injury phase in a sterile environment such as here and they survive to recover fully."
Dr Woods also notes that surgeons are seeing fewer injuries to the genitalia, due to the simple addition of a groin plate to body armour.
Despite these advances and the various high-tech and low-tech responses to the conflict, there are still a large number of amputees processed through Landstuhl. Approximately 400 amputees have passed through the facility. Almost a quarter of these are double and triple amputees.
I meet Sgt Frank Cuevas (27) in the recovery ward. He agrees to do an interview, despite his injuries. At the beginning of our conversation, it is clear that he is in pain and slightly disoriented. With some gentle prompting, he tells his story.
He describes being on a search operation in Ramadi. As he and his colleagues dismounted from their vehicle, their patrol was fired upon by a sniper.
Frank describes what happened: "A shot rang out and one of the guys to my rear was hit in the buttocks area. I got out of the truck to run around and try to drag him back and then another shot rang out. It hit me in the leg and went through and hit my intestines and my colon. It just didn't hurt at first.
"I just crawled up under the axle of the vehicle and waited for them to come get me. They airlifted me to Camp Ramadi and they did surgery and then they got me to here."
Sustaining wounds that in recent conflicts might have proved fatal, Sgt Cuevas is confident he will return to the US and recover fully.
At the only point in the interview when Sgt Cuevas manages to smile, he mentions Shannon airport. "On our way to Iraq, we stopped at Shannon. We got out and we were allowed to walk around the airport. It was pretty much the last time we were not actually locked down in combat - the last transition stage. I was wondering about the castles around there. When I'm back on my feet I'll go back there."
Lieut Parker Hahn, the trauma nurse in charge of the ward, also mentions Shannon. After a discussion in which he describes "removing the femur of a suicide bomber from the chest cavity of a guy in Iraq", he goes on to describe the stopover in Shannon.
"They let us off the plane to stretch our legs which was great. I remember it being very foggy and I think even rainy - go figure! It was different . . . before, you were always worried about mortars and rockets and someone shooting at you. To get off a plane and walk into a terminal building without any of your weapons and gear was nice. To be just able to breathe."
Lieut Hahn, who has no Irish connections, then went on to say how the Shannon experience had prompted him to return to Ireland as a tourist, where he found the driving to be "a nerve-wracking experience, even compared to Iraq, but the best country I've ever been in. The people and the countryside are beautiful".
As I leave Landstuhl, John Sweeney tells me that the strain of dealing with so many critically injured young troops can take its toll on his surgical staff.
He talks of the phenomenon of "empathy fatigue" among doctors and nurses at the facility. He introduces me to Landstuhl's nursing manager, Ethna McElrath, a native of Donegal.
She speaks of the effect working there has had on her. "I get to have the pleasure of meeting all of these soldiers that come in here, male and female. I see them on the ward, trying to walk on crutches. Really, they make you want to help them because actually they're my heroes."
Col Sweeney reminds me before I leave that the US medical staff at Landstuhl treat not just US troops but soldiers and civilians from 37 different countries. He also tells me that he is responsible for the medical evacuation and care in Landstuhl of all of the Irish Defence Forces personnel that are serving with the Kfor Nato battle group in Kosovo and the Irish troops serving in Afghanistan with the International Security Assistance Force (ISAF).
The links between Landstuhl and Ireland range from the coincidental and casual to formal referral arrangements for Irish troops serving in Nato missions abroad.
In time, the lessons learned at Landstuhl from the treatment of polytrauma among US troops will benefit a far wider group of people. Doctors are making huge leaps in the treatment of brain and spinal injuries, the sort of injuries that can also occur in road crashes and all of the other catastrophes of civilian life.
Tom Clonan is The Irish Times security analyst