In the second, insurgent phase of the war, injuries have been more severe, transport times longer, more injuries have occurred per individual and more soldiers have been killed in action or died of their wounds.

"Operation Iraqi Freedom is an ongoing conflict that has changed dramatically since the initial invasion," the authors write as background information in the article. "Following the maneuver warfare that resulted in the capture of Baghdad, Iraq, in April 2003, firm U.S. military bases have been established throughout the country to support the Iraqi government and to fight insurgencies."

During the first phase of warfare (March and April 2003), the Forward Resuscitative Surgery System-a small mobile surgery team of eight personnel that treated soldiers' injuries -moved 11 times as the battlefield changed. In the second phase of the war, from March 2004 to February 2005, medical support for U.S. forces has remained stationary.

Stacy A. Brethauer, M.D., of Cleveland Clinic, and colleagues analyzed records from combat trauma databases for 338 casualties treated during the first phase of the war (maneuver) and 895 treated in the second phase (insurgency). When comparing those injured in phase II with those injured in phase I, the authors found that:

- More major injuries occurred per patient (2.4 vs. 1.6)

- More individuals sustained fragment wounds (61 percent vs. 48 percent) but fewer were injured by gunshots (33 percent vs. 43 percent)

- Critically injured U.S. casualties took longer to reach the surgical unit (a median or midpoint time of 59 minutes vs. 30 minutes)

- The percentage of individuals killed in action before reaching the surgical unit increased (20.2 percent from 13.5 percent)

- The percentage of patients who died of their wounds after evaluation by a physician also increased, from 0.88 percent to 5.5 percent

In the second phase of the war, the use of improvised explosive devices by insurgents has resulted in more fragment wounds and a higher percentage of critically injured patients arriving to the surgical unit.

"A higher percentage of patients arriving at the Forward Resuscitative Surgery System are undergoing surgery, and these patients have more injuries and undergo more procedures than casualties during Operation Iraqi Freedom I," the authors write.

The higher percentage of surgeries is due to an increase in the number of wounds per patient, the severity of these wounds and the stationary nature of the surgical unit, they note.

"The nature of the current conflict in Iraq should influence the way that casualties are managed and entered into the medical system," the authors conclude. "Only with continued data collection and careful attention to the many variables involved will we be able to make definitive statements regarding optimal trauma care in Iraq."

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