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Combat wounds proving less deadly

WASHINGTON -- American soldiers in Iraq are surviving combat-related injuries at a markedly higher rate than in past wars, according to a review of casualty figures from Iraq and other recent US conflicts.

Roughly one in seven soldiers wounded in combat in Iraq has died, according to figures released by US Central Command. In previous conflicts dating to World War II, one in every three or four soldiers died after combat wounds.

Widespread use of lightweight body armor, improved battlefield medicine, and the lack of Iraqi artillery use have all contributed to the US survival rate, according to medical authorities and military specialists.

But that survival rate also may disguise the day-to-day danger level that coalition forces face in Iraq. Since most attention focuses on deaths, particularly those from ambushes and other combat, the higher numbers of wounded in Iraq have drawn relatively little attention. Since President Bush declared major combat operations over on May 1, a US soldier has been killed roughly every other day. During the same time period, an average of 4.5 troops have been wounded in combat each day.

According to US Central Command, 1,111 US personnel have been wounded in action since the start of hostilities, including 561 since May 1. Over the same period, 178 have been killed in action, 66 since May 1. According to coalition officials in Baghdad, allied forces are attacked on average a dozen times a day.

"Body armor and helmets have been the very big winner on the battlefield this last go-round," said Robert Kinney, who heads the individual protection division at the US Army Soldier Systems Center in Natick, Mass. He added the Iraq war marks the first time the military used ceramic body armor -- lightweight plates inserted into the front and back of a soldier's combat vest -- on a mass scale.

That protection has translated into fewer immediately fatal injuries.

"We are seeing very few chest wounds and very few head wounds," said Colonel David W. Polly, chief of the Department of Orthopedic Surgery and Rehabilitation at the Walter Reed Army Medical Center in Washington. Polly estimated about 80 percent of the wounds he and his staff have treated have been to arms and legs. He said the expected range in combat is between 60 and 80 percent.

"Patterns of injury were very different in Iraqi versus US soldiers," Major General Kenneth L. Farmer Jr., US Army deputy surgeon general, told Military Medical Technology magazine in June. "Iraqi soldiers experienced the whole spectrum of injuries: upper and lower extremities, chest, abdomen, and back. US soldiers have had predominantly upper and lower extremity injuries."

Troops also have benefited from decades' worth of improvements in combat medicine, not simply improved equipment but also better training. For example, Polly said, during the buildup to the war, the Army put its doctors through a course emphasizing techniques for saving arms and legs. "They tried to get every doctor going overseas to get that course before going," Polly said.

In Iraq the Army also made more widespread use of Forward Surgical Teams, -- small, mobile units that can move with troops, cutting down on the time between injury and treatment. Military doctors focus on the first hour after an injury, the so-called golden hour, as the critical time when treatment can make the difference between survival and death. Whereas in Vietnam helicopters carried wounded soldiers to medical bases far behind the front lines, Forward Surgical Teams can move more quickly to the troops.

Military physicians also deploy more modern medicine, including antibiotic beads that secrete highly concentrated medicine into wounds and genetically engineered bone morphogenetic proteins, which help heal bones without the need for bone grafts.

US forces also have benefited from the fact that most Iraqi attacks have involved small-arms fire, or at worst rocket-propelled grenades, rather than artillery, which has historically been the greatest cause of battlefield injuries.

"If your adversary's mainly using small arms . . . there's just a limited number of lethal pieces of metal that are coming at you," said John Pike, from GlobalSecurity.org, a think tank based in Alexandria, Va.

While attention has focused on the number of US deaths, critics of the war suggested the larger issue of total casualties is gaining urgency. Jamal Simmons, a spokesman for the presidential campaign of Senator Bob Graham, Democrat of Florida, said that in his campaign appearances Graham has been putting greater emphasis on the issue of US casualties because he increasingly gets asked about it.

Barry Posen, from the Security Studies program at the Massachusetts Institute of Technology, said that despite the relatively low death rate, the ongoing incidence of casualties will become a problem because of the "morbidity version of the `six degrees of separation' hypothesis," which argues that any two people in the world are connected by no more than six levels of acquaintances. In this case, Posen said, people could increasingly hear about friends of friends getting wounded in Iraq.

In World War II, 30.3 percent of soldiers wounded in combat died. That percentage fell during the Korean War to 24.1 percent, and held steady through the Vietnam War (23.6 percent) and the Persian Gulf War (23.9 percent). But the number has declined sharply in Iraq, with 13.8 percent of battlefield wounds being fatal.

For American soldiers in Baghdad, the continuing attacks are no surprise -- they do not consider themselves to be in a postwar environment. The troops' uniforms still carry a backwards US flag patch, an indication of continuing conflict.

"You really have to be on your toes. No matter how hot it gets, no matter how tired you are," said Specialist Tristan Byars, 23, of San Diego. "When you get complacent, it's like putting a bull's-eye on your chest."

One soldier, Byars recalled, survived one attack and was sent back to his unit, only to be hit with a rocket-propelled grenade that took off both of his legs and an arm.

Daily, soldiers receive reports of deaths and injuries among colleagues, and many wonder whether they will be next, said Sergeant Nestor Rodriguez, 33, of Puerto Rico. "There are days some of us flip out and say, `I'm not going to make it here; we're going to die.' You just have to calm them down."

Susan Milligan of the Globe staff contributed to this report from Baghdad; Robert Schlesinger can be reached at schlesinger@globe.com.

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