Free Better by Atul Gawande

directed to wear eye protection, but they evidently found the issued goggles too ugly. As one soldier put it, "They look like something a Florida senior citizen would wear." So the military bowed to fashion and switched to cooler-looking Wiley-brand ballistic eyewear. The rate of eye injuries decreased markedly.
    Military doctors also found that blast injuries from suicide bombs, land mines, and other IEDs were increasing and were proving particularly difficult to manage. IEDs often produce a combination of penetrating, blunt, and burn injuries. The shrapnel include not only nails, bolts, and the like but also dirt, clothing, even bone from assailants. Victims of IED attacks can exsanguinate from multiple seemingly small wounds. The military therefore updated first aid kits to include emergency bandages that go on like a tourniquet over a wound and can be cinched down with one hand by the soldiers themselves. A newer bandage impregnated with a material that can clot blood more quickly was distributed. The surgical teams that receive blast injury victims learned to pack all the bleeding sites with gauze before starting abdominal surgery or other interventions. And they began to routinely perform serial operative washouts of wounds to ensure adequate removal of infectious debris.
    This is not to say military physicians always found solutions. The logs have revealed many problems for which they do not yet have good answers. Early in the war in Iraq, for example, Kevlar vests proved dramatically effective in preventing torso injuries. Surgeons, however, found that IEDs were causingblast injuries that extended upward under the armor and inward through underarm vents. Blast injuries also produced an unprecedented number of what orthopedists term "mangled extremities"--limbs with severe soft-tissue, bone, and often vascular injuries. These can be devastating, potentially mortal injuries, and whether to amputate is one of the most difficult decisions in orthopedic surgery. Military surgeons used to rely on civilian trauma criteria to guide their choices. Examination of their outcomes, however, revealed that those criteria were not reliable in this war. Possibly because the limb injuries were more extreme or more often combined with injuries to other organs, attempts to salvage limbs by following the criteria frequently failed, resulting in life-threatening blood loss, gangrene, and sepsis.
    Late complications emerged as a substantial difficulty, as well. Surgeons began to see startling rates of pulmonary embolism and lower-extremity blood clots (deep venous thrombosis), for example, perhaps because of the severity of the extremity injuries and reliance on long-distance transportation of the wounded. Initial data showed that 5 percent of the wounded arriving at Walter Reed developed pulmonary emboli, resulting in two deaths. There was no obvious solution. Using anticoagulants--blood thinners--in patients with fresh wounds and in need of multiple procedures seemed unwise.
    Mysteriously, injured soldiers from Iraq also brought an epidemic of infections from a multidrug-resistant bacteria called Acinetobacter baumanii . No such epidemic appeared among soldiers from Afghanistan, and whether the drug resistance was produced by antibiotic use or was already carried in the strains that had colonized troops in Iraq is unknown. Regardless,data from 442 medical evacuees seen at Walter Reed in 2004 showed that thirty-seven (8.4 percent) were culture-positive for Acinetobacter --a rate far higher than any previously experienced. The organism infected wounds, prostheses, and catheters in soldiers and spread to at least three other hospital patients. Later, medical evacuees from Iraq were routinely isolated on arrival and screened for the bacteria. Walter Reed, too, had to launch an effort to get health care personnel to be better about washing hands.
    These were just the medical challenges. Other, equally pressing difficulties arose from the