Extended Interview: Dr. Mark Bagg
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SUSAN DENTZER: Let’s start by talking about the circumstances of Operation Iraqi Freedom. One of the aspects of this is the urban warfare setting and the sort of random attacks. How is that manifesting itself in terms of the wounds that the soldiers are experiencing?
DR. MARK BAGG: With all these types of wounds they are very devastating wounds. They’re close-up wounds. The proximity of the actual attack to the injured person is very close. So we’re seeing a significant number of very devastating, particularly extremity wounds. The characteristics are severe, open wounds with severe fragmentation of the bone, what we call combination. There is disruption of nerves, in many situations tendons, and then the muscles themselves are severely injured. Sometimes blood vessels can be disrupted, and because of that they need to be put back together again at the — what we call the forward surgical team level, which is the surgical team that’s closest to the battlefield, if you will.
We’ve seen a significant number of injuries to the elbow from riding in Humvees, elbows out the side. So there’s been some very, very significant upper extremity injuries as well as lower extremity injuries.
I think the use of the body armor has prevented some of the devastating injuries to the torso but has left us with patients that have very severe injuries to the extremities and they’re surviving these injuries because they haven’t had the injuries to the chest or torso.
SUSAN DENTZER: Apparently also because of the nature of the current urban warfare you’re getting lots of homemade bombs that tend to inflict very severe injuries but not kill people. Is that so?
DR. MARK BAGG: That may be. A lot of these wounds are in some ways very similar. I mean, they’re very high energy, particularly when they’re close up and they impart a tremendous amount of energy to the tissues, cause a lot of destruction to like bone, muscle, nerves. And so all these different structures need to be considered for reconstruction later on down the road when they receive their definitive care.
As far as definitive care, the definitive care can only be done when they’ve received initial prompt good care, excellent care in the theater, and that’s being done, and that’s probably one of the greatest things right now. We’ve got surgeons that are very well trained right up at the front line. We’ve had folks there from the 28th Combat Support Hospital, the 21st Combat Support Hospital that are doing the lion’s share of the work of stabilizing these injuries, these very, very devastating injuries, washing them out. We call that irrigation and debridement, and getting them evacuated very quickly back to the medical centers either at Landstuhl and then on to either Walter Reed or Brooke Army Medical Center.
SUSAN DENTZER: You said that one of the possible impacts of this [body armor] is that we’re going to see fewer injuries to the spine. Some people have said fewer paraplegics coming out of this war, more amputees. Is it possible to say that at this point?
DR. MARK BAGG: It’s hard to say it just yet. I mean, just from discussions with the surgeons that are in the theater, the body armor they feel appears to be working. One of the things we tried to specifically address was behind body armor injuries. That is, blunt trauma as a result of a fragmentation that was blocked by the body armor. And we’ve asked the surgeons [if they have noticed] any hematomas, which are basically bruises that might give the indication that this perhaps would have been a penetrating trauma that was stopped from the use of the body armor.
But it’s really hard to say right now. What we’re going to have to do is probably look back retrospectively to identify whether or not there really was a decrease in the rate of deaths as a result of battle injuries to really assess the effectiveness of the body armor.
What I was going to say was that we think that we’re seeing a higher percentage of extremity trauma because our soldiers are surviving their injuries as a result of the use of the body armor, particularly with the fragmentation wounds where you have multiple fragments going out. The fragments are being stopped by the body armor, but they’re catching the extremities.
SUSAN DENTZER: But you’re saying in effect that the ability to save limbs is much greater than ever before also.
DR. MARK BAGG: I think so. There’s been, since the Vietnam War there’s been advances in medical science both on the civilian and the military side, particularly in microvascular surgery. [That means] doing reconstructive procedures to try to save limbs, putting blood vessels back together again, providing definitive wound coverage of severe open wounds to get vital structures which is bone, nerves, tendons covered. So we’re taking tissue from one part of the body and moving it to another part of the body, sewing in little blood vessels with the use of a microscope, and that allows us to get these severe open contaminated wounds that have been washed out, cleaned up, debrided, and then covered with some type of definitive coverage.
So those are some of the advances that have been made over the last 10, 20 years that we’re now applying to some of these wounds, and I think we have been able to provide, or at least save some of the extremities that perhaps would have been amputated in previous conflicts.
SUSAN DENTZER: Let’s talk about what happens to people who are wounded. As you know, we’ve been speaking with B.J. Jackson, who is in effect, for our purposes, a case in point. He was severely injured, a combination of homemade land mine rocket-propelled grenade attacks, sniper fire, etc., severely burned on his arms as well as his legs, and it was in fact apparently the burns that necessitated the amputation.
He was taken to Kuwait to a field hospital. Is that a typical pattern?
DR. MARK BAGG: Yes. In most situations, if there’s a burn along with the orthopedic trauma, there may be amputating more soon than if there weren’t a burn. But it’s not uncommon to get … the initial management in theater, getting the initial washout. Washout is an irrigation where they use approximately nine to ten liters of fluid, just basically irrigating the wound copiously and removing all devitalized tissue, along with any gross contamination. There’s going to be microscopic contamination, and that’s the reason why we have to continually take patients back through the evacuation chain repeatedly to go and continue to wash the wounds out, continue to debride the wounds because at the first washout or the first debridement you’re not going to get everything removed. Some of the tissue initially may look like it’s viable, living, and then the second time you go back you’ll find that now that tissue has really declared itself as not viable. And so you have to remove it in order to prevent infection.
So that’s one of the principles of managing these wounds is rapid transport to a site for stabilization of the fraction, irrigation and debridement, and then repeated trips back to the operating room through the evacuation chain to remove again dead, devitalized tissue and removal of contaminated contaminants.
SUSAN DENTZER: Now, we understand in B.J.’s case, after this amputation was done, the wounds in effect were left open.
DR. MARK BAGG: Yes. When we leave wounds open, that’s just how we do business, and it perhaps needs some explanation. We never do definitive management, as I mentioned, in the theater. We always leave wounds open so that we don’t trap bacteria underneath the skin flaps which would cause a much more devastating infection, maybe requiring a more proximal amputation. [That means] an amputation that’s done further up the leg or the arm, maybe having to sacrifice the knee at that point because of an infection. The surgeons throughout the evacuation chain know you don’t close wounds. We learned that from many conflicts prior to this one. We always leave wounds open. The closure is done back at the definitive site, and that’s done through a combination of either just secondary closure of the wound, bringing the skin edges together if there’s enough skin, or rotating what we call flaps to cover the ends of bones, or bringing in tissue from some other part of the body. That’s called a free tissue transfer, where you take a muscle and move it to another area of the body and tie in little blood vessels.
SUSAN DENTZER: How is it that most patients become aware of the fact that they’ve lost limbs? Everybody remembers the famous scene from the Ronald Reagan movie, the character wakes up and says, “Where’s the rest of me?” Is that the way it happened?
DR. MARK BAGG: Normally it doesn’t. I mean, in most situations when you have a devastating injury and the patient is brought back to a definitive site for management, Walter Reed, Brooke Army Medical Center. We have to make a decision — can you save the limb through a limb salvage type of procedure, operation, or many operations, or is it in the patient’s best interest to perform an amputation. And in most situations, the decision is made in conjunction with the patient based on his own personal desires after he’s had a chance to consider the pros and cons of both, because just because you salvage an extremity doesn’t mean it’s going to work perfectly, and there may be multiple operations that he has to go to to make this a function extremity, and in some situations, and I remember as a resident myself at Walter Reed during the first Gulf War, in particular a patient or soldier who is injured with devastating below knee, open tibia fracture. Happened to be a farmer, and he did not want to go through multiple operations, and he wanted one procedure. And so, in his case, it was appropriate to go with a below knee amputation.
So that’s usually the scenario. You know, someone comes back here at least with a devastating injury. They haven’t done the amputation theater. A discussion is had with the patient, and decisions made at that point.
SUSAN DENTZER: How do you tell a patient that it looks as if a limb is going to have to be amputated? What do you say?
DR. MARK BAGG: Well, the first thing I do is I present what danger is, and then what structures have been injured. And then I go through what the options are. What can we do. Because ultimately it’s the patient’s decision. It’s his decision on how he wants to proceed, if we can save it. Sometimes, I mean, if there is an infection that’s set up and it’s clear that he needs an amputation, we’re going to tell him that, relay that. That’s the best way to go. But we present the options to the patient, and then tell them with option number one, limb salvage, you’re going to have to probably go through multiple operations. It may take, you know, a year, maybe two, and in some situations, because of the devastation, you still may have an amputation later on down the road.
And we do know that when you have an amputation as a result of an injury that happened two years ago, it never works quite as well as if you had it at the time of the injury. So we have to guide them along in the decision making process. But we try to include them in the decision.
SUSAN DENTZER: Let’s move on and talk a bit about phantom limb syndrome and the sensations that many people report. Do we know what causes that, and what happens to that set of feelings over time?
DR. MARK BAGG: The phantom limb is a pain sensation, is well known with any kind of major limb type of amputation. The nerve that supplies sensation to the limb has been severed; however, the connection of that nerve to the brain still remains. And so there is still the sensation they get as a result, the connection between the brain and the nerve that was severed, and those can be very uncomfortable. Sometimes it’s just a sensation, and the way the sensation or pain is manifested is different in different people, but eventually it does go away. Or at least it is, if it doesn’t go away, they learn to cope with it and understand it so that it doesn’t become as bothersome. But initially it can be very bothersome.
SUSAN DENTZER: Let’s talk a bit about, in overall terms, how the care of these types of serious injuries to the arms and legs in particular, how the treatment compares to the treatment that people similarly injured in Vietnam, for example, or even Desert Storm would have been treated. What’s the difference between now and then?
DR. MARK BAGG: Actually, it’s in many ways very similar. We continue to have to relearn the lessons of previous conflicts. As you know, the conflicts happen in general terms maybe every 20 years, which is the life cycle of a military surgeon. And so we’re always continually having to relearn some of the lessons that physicians have learned in previous conflicts. It just so happens this conflict happened 10 years after the last one, so there are many of us that are still in uniform, that understand the importance of irrigation, debridement, stabilization, rapid transport.
I think some of the things that have changed is that we do have probably a quicker evacuation. We have air superiority, and we’re able to get patients back to [the continental United States] or back to a definitive management site sooner than perhaps we were able to do in some of the previous conflicts…
SUSAN DENTZER: Let’s talk a bit about innovations in prosthetics. Again, then versus now, what characterizes today’s prosthetics? It’s different from what would have been the case for Vietnam veterans…
DR. MARK BAGG: Well, there are just a tremendous amount of advances that are being made in prosthetics — lighter designs, computer enhanced, knees, hydraulics that are — that are smaller, that allow again more lightweight designs. There are microprocessors that enhance the computer design of these prosthetics. And it’s a specialty within itself, if you will. It’s just unbelievable the advances that are made which sometimes makes it difficult for those of us that do a lot of limp salvage to say well, we’re going to be able to make you better than a prosthetic. And in some centers the prosthesis actually may be better than trying to save the limb, and that’s something that has to go into the discussion with the injured soldier.
SUSAN DENTZER: So you actually could get one of these titanium and graphite and microprocessor driven hands that’s better than a salvaged hand that doesn’t work very well?
DR. MARK BAGG: When I talk about upper versus lower extremity, there’s probably a difference. And the lower extremity prosthesis have really been worked out and they’re tremendous. We still, in my opinion, have a ways to go with the upper extremity, and I think whenever we can salvage the upper extremity, we’re better off if we can. Some people might argue with me, but the lower extremity prostheses right now, those prostheses are really good, and very well advanced.
The myoelectric prosthesis for the upper extremity, when there has been an amputation, we’ve made significant improvements in the design of these prostheses. They’re lighter weight. Again, they’re supposed to be body powered, which in some situations is actually better because you can use the body power ones in a lot more different, you know, environments than the myoelectric. But the myoelectric prostheses allow a lot more control in some situations, and better usage.
SUSAN DENTZER: How excited should we get about these whiz bang new technologies? Are they everything they’re cracked up to be?
DR. MARK BAGG: Well, I think with anything, and new technologies that come out, there’s generally an initial excitement. There’s an initial excitement in this field, and then you start seeing some of the down sides of the newer technology.
I think really the most important thing besides all the new technology is how badly folks that have these types of injuries want to get back to doing what they were doing, what kind of motivation they have. Those are the types of things that really we can’t quantitate, but they probably have a much larger impact on whether or not they wear body powered versus a myoelectric prosthesis.
Certainly, though, I think if you can provide, you know, both prostheses to a given patient, there are times when they’re probably going to want to use the body powered versus there are probably other times they’re going to use the myoelectric, and we’re trying to give our soldiers the options of both.
SUSAN DENTZER: What lessons do you think people will take away from this conflict in terms of the nature of the wounded, how they were treated, what worked, what didn’t work, what needs improvement?
DR. MARK BAGG: I think the way we’re organized medically, there have been some things that have definitely worked, and that’s during the conflict phase of this war, the maneuvering phase, having forward surgical teams embedded with the combat units really did what it was supposed to do, and that provided far forward expert surgical treatment to injured soldiers. That’s been good.
One of the problems now is what to do with the forward surgical teams once the maneuvering phase of the war has ended, and that has been somewhat problematic. We don’t want our surgeons sitting around. Most of the wounded are now being flown to the combat support hospitals, and they’re bypassing the forward surgical teams because our theater has matured and we’ve got very robust combat support hospitals that aren’t easily maneuverable during a 300-mile fast paced hike up to Baghdad. But once you’re up there, and those combat support hospitals then become developed most of the injured now are going straight to those combat support hospitals…
I have to be careful about what I say here because there’s obviously some things here that we’re still learning how we position our medical assets, and have the command and control of those medical assets. That’s a difficult topic.
But that’s really one of the things that really is key here, and it’s how we manage mainly getting right there in the fight, right there behind the injured soldier, close proximity, getting the wounds cleaned out, getting them stabilized, and a rapid evacuation. That’s what’s come out of this conflict.
And I’ve seen several soldiers that have come through here and I know at Walter Reed that have had that expert care done in the theater and have had their extremities perhaps salvaged as a result of it.