Dr. H. Theodore Harcke, forensic radiologist with the Armed Forces Medical Examiner System at Dover Air Force Base, examines CT scans. All U.S. service members killed in Afghanistan and Iraq have undergone a complete autopsy. (Suchat Pederson / The News Journal)
DOVER AIR FORCE BASE — Combat medics were perplexed. They’d been applying the standard treatment to U.S. troops in Iraq who’d suffered a collapsed lung — piercing the chest with a special needle-thin catheter to release trapped air and relieve pressure. But troops who might have survived were dying.
In 2007, doctors with the Armed Forces Medical Examiner System at Dover Air Force Base began studying the CT scans of troops autopsied at the base the previous year and made an astounding discovery: In close to half of the 100 troops studied, the standard 5-centimeter angiocatheter in medics’ aid kits hadn’t completely penetrated the chest wall.
“Our guys today are big,” explained Air Force Col. Scott Russi, a veteran trauma surgeon at Travis Air Force Base, Calif., who until December was deputy director for clinical surgeries at Craig Joint Theater Hospital in Bagram, Afghanistan. “They lift weights, they use supplements, they’re benchin’ 250, 300 pounds.”
After studying the results, the Army changed the length of the angiocatheters from 5 to 8 centimeters.
It was a signature finding by the personnel at AFMES, one of many that are deeply appreciated by caregivers in the field.
AFMES studies the dead. But the goal, in the words of director of scientific investigation Navy Capt. Edward Reedy, is “trying to save lives.”
“Dover has a huge role in improving combat casualty care,” said Air Force Col. Raymond Fang, a trauma surgeon who succeeded Russi at Bagram but has returned to direct the U.S. Air Force Center for Sustainment of Trauma & Readiness Skills in Baltimore. “By knowing what killed the soldier, we can say, ‘How can we prevent this? How do we improve body armor? How do we improve resuscitation?’ ”
At Dover, AFMES stands adjacent to the Dover Port Mortuary, where casualties are transferred after autopsy for burial preparation. Behind the front office suites, AFMES exudes a cold sterility.
Near the back entrance, where the transfer cases flown from overseas are brought inside, signs for barcoding, photography, fingerprinting and dental mark the walls. At the opposite end of the corridor stands a radiology suite; the farthest room contains a long, wide table and CT scanner. Other walkways are dotted with autopsy rooms, labeled “restricted” and sealed by huge, sliding metal doors.
Every one of the 6,745 U.S. service members killed in the wars in Afghanistan and Iraq as of Monday has passed through these halls.
Each of them has undergone a complete autopsy, the first time in history that’s been done, said Army Col. Ladd Tremaine, a forensic pathologist and the AFMES director. The process includes full-body X-rays and, beginning in 2004, extensive CT scans that provide a three-dimensional view of the torso. To ensure that AFMES has the clearest sense of what happened, the deceased service member’s body is sent to Dover as it was at the moment of death, whether on the battlefield or in a medical setting.
“Any medical-legal investigation, you want to evaluate that deceased individual exactly how they were when they died,” said Air Force Lt. Col. Edward Mazuchowski, a forensic pathologist who directs one of AFMES’ four divisions. “So any medical intervention, you want to keep that on so we can document what they had and what was done.”
A closer look
The effort has its roots in the decision, at the start of post-9/11 conflict, to study and document every combat death to develop a better and broader understanding of the sorts of injuries being caused by irregular warfare and how they could be most effectively treated — an effort that quickly evolved in terms of sophistication. Increased use of technology dramatically improved what could be seen.
In late 2004, AFMES began running fallen service members through CT scans as well as X-rays — a process termed “CT-assisted autopsy.” The CT scans were launched, Tremaine said, with a grant from the Defense Advanced Research Projects Agency.
“We realized there were several categories of information that we could achieve from the CT scans,” said Ted Harcke, an AFMES forensic radiologist who was part of the investigation that produced the longer angiocatheters.
Seated before a bank of monitors, Harcke pointed to a conventional radiograph. “Here, I can’t tell where it is,” he said. Harcke then moved a cursor through an adjacent CT scan image. “When I get up here to the sternum, bing.” A white line clearly marks the needle’s presence.
That’s a huge advantage for the medical examiner doing the autopsy, Mazuchowski said. “It’s in the sternum, I know it is, I can verify right here that it is ... without doing a more labor-intensive [procedure], which would be cutting through that bone to verify it.”
The intensive examinations are an effort to provide “full accountability” to family members — to ensure, Tremaine said, that “we don’t ever again in history have a Tomb of the Unknown Soldier, or somebody who’s unaccounted for.”
Full accountability also includes cause and manner of death. As Tremaine noted, not every death in theater is combat-related. An accident investigation board wants to know exactly what injuries occurred, with the hope of preventing the same in the future. If the death is a non-combat homicide, forensic evidence must be preserved. If the death is related to sickness, public health officials must be notified.
Many remains, torn by roadside bombs, in aircraft crashes and sometimes co-mingled, can be identified only by their DNA, he said. “We separate everything out,” Tremaine said, adding that the AFMES DNA lab, which takes up the building’s entire second floor, can produce results in less than eight hours. The lab also identifies remains from past conflicts.
“We have the best DNA identification lab in the world,” he said.
The angiocatheter improvement was an early success in the more intensive study of combat deaths. Officials wanted to advance and better coordinate in-theater trauma care, streamline the movement of patients and improve outcomes.
The result was the Army’s Joint Theater Trauma System — which quickly became a joint service entity — and its backbone, an in-theater Joint Trauma Registry, a compilation of data on the care provided to all U.S. casualties.
The initiatives mirrored civilian medical programs that had improved trauma outcomes, according to Army Col. Kirby Gross, a trauma surgeon with the stateside Joint Trauma System, which grew out of the initial effort, as did a larger stateside Joint Trauma Registry.
AFMES is a key player in this ongoing exchange of data, sending autopsy observations to the war theater that it calls “Feedback to the Field,” and sharing what it’s learned more formally through monthly teleconferences with Joint Trauma System analysts, based in San Antonio, and other military caregivers.
“They present what they saw on the battlefield, in the hospital in Germany,” said Navy Lt. Cmdr. Pete Seguin, chief of AFMES’ Medical Mortality Surveillance Division, “and then we present what we found on autopsy.”
“It’s a true clinical pathologic correlation,” Reedy said. “We’ve tried to bring that back into combat casualty care.”
One of the collaborations produced a 2012 paper published in the Journal of Trauma that looked at 10 years of U.S. casualties from Iraq and Afghanistan. It found that although most troops died of their injuries before reaching a surgeon, 24 percent were determined to be “potentially survivable” but, largely, bled to death. The conclusion: strategies are needed to stop hemorrhage and improve airway management, as well as to get casualties to a surgeon more quickly.
Such conclusions are being continually absorbed in the military medical community. “The data that we collect and pass forward, or backward, it’s already shown improvements,” Reedy said.