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SCOTT SIMON, host:

U.S. combat deaths in Iraq are at their lowest point since the war started, but at least 30,000 U.S. soldiers have been wounded in action. The use of IEDs and other explosives have changed the nature of war injuries. More soldiers survive because of improved medical knowledge and technology, but more are also left with devastating wounds of the kind that most surgeons never see.

Now we want to alert you that we'll be discussing some graphic war injuries and surgical procedures for a few minutes if you're inclined to tune away. The U.S. army recently released a new textbook called, "War Surgery in Afghanistan and Iraq: A series of cases, 2003-2007." Dr. Stephen Hetz is co-editor of the book. He was deployed to Iraq twice where he worked as a surgeon at Balad Air Base. He joins from the studios of member station KTEP in El Paso, Texas. Doctor Hetz, thanks very much for being with us.

Dr. STEPHEN HETZ (Co-editor, "War Surgery in Afghanistan and Iraq: A series of cases, 2003-2007"): My pleasure.

SIMON: And give us some idea of the kind of new injuries and challenges that military surgeons are facing in field hospitals in Iraq and Afghanistan.

Dr. HETZ: Well, I don't think the injuries are really new. It's just the volume of these massive blast injuries with these very large explosions that really cause such devastating extremity injuries. You know, one of the things that has definitely improved survival is also the protective equipment our soldiers carry, both helmets and the body armor. And as a result, truncal injuries that would have caused death in the past are avoided with the body armor that surrounds the chest and abdomen, but the extremities, of course, are exposed to this horrific blast and as a result, they come in severely wounded, whereas perhaps in wars past they would not have survived such an injury.

SIMON: We've warned our listeners that this might be graphic, so maybe I can get you to describe one or two cases that particularly figure in mind.

Dr. HETZ: Sure. There was, about a mile from us was a - Air Force compound. A mortar round hit very close to an airman there and you know, that airman was transported to us almost immediately, and initially, when he entered our trauma bay, he'd essentially lost both of his legs and one of his hands was blown off. When he arrived, he probably was - had hemorrhaged at least half of his blood volume if not more. That airman was rapidly resuscitated and then evacuated back to Walter Reed with continued ongoing resuscitation. He eventually underwent rehabilitation and I believe today is somewhere studying architecture.

SIMON: Well, God bless. Good for him. Because some of these surgeries are so extraordinary and deploy such technology and I gather sometimes take so much time, are there more complications sometimes, too?

Dr. HETZ: Well, I think that's a pretty tough question to answer. I mean, the worse the injury, obviously, the more risks there are for complications - infection, bleeding, et cetera. As you probably know, there have been some pretty virulent bacteria and organisms that have stuck with soldiers that have been brought back to the United States, and those sometimes end up doing additional damage and even have taken some soldiers' lives once they've returned because of the difficulty there has been in eradicating such infections.

SIMON: Surgeons who were working on a soldier or a civilian, for that matter, who has been severely wounded and confronting massive trauma, they must be concerned about what kind of life the person who is in their care is going to have after the surgery is completed.

Dr. HETZ: Oh, yeah. Sure. I think it does cross your mind. I must admit - I'll give you an example. Early on in the war, when I went over as the consultant in 2003, I visited a hospital in Tikrit area. A soldier came in that had suffered a 50-caliber gunshot wound to his lower extremity. Fifty caliber, you know, that's half an inch-sized bullet. I'm not talking about length. I'm talking about the thickness of the bullet. And as we washed that out and looked at what we had, he still had some sensation in his foot and some motion. The question came up, should we just amputate this or should we try to preserve it? Now, of course, we always want to preserve it but if you have a useless extremity because of the devastating injury, preserving it doesn't make any sense. It ends up being a very difficult problem.

But after we discussed it, we put an external fixture on it. We saved the lower extremity, sent him back to one of the medical centers back in the United States, and the orthopedic surgeons there assured us that we had done the right thing.

And after a year of misery and difficulty and inability to be able to ambulate because of the useless nature of the extremity, he eventually was amputated. And once he was amputated, he was able to get up and around and get moving again. So, you know, ultimately I'm going to do what I can to preserve life, limb and function as best as I know how, and then it's up to the other physicians back in the States and/or that patient. They have to make that decision for themselves at some point.

SIMON: Stephen Hetz is director of medical education at William Beaumont Army Medical Center in El Paso, Texas and an editor of the new book, "War Surgery in Afghanistan and Iraq: A Series of Cases, 2003-2007." Thank you, doctor.

Dr. HETZ: Thank you.

SIMON: And photographs and excerpts from the book are on our Web site, npr.org. Once again, we caution that the photographs are extremely graphic and obviously may be somewhat upsetting to some of our listeners.

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