Research: 75% of nonmilitary group medically evacuated for nonbattle injuries did not return to field

After analyzing data on 2,155 private contractors, diplomats and other civilians supporting war efforts in Iraq and Afghanistan who were medically evacuated out of combat zones, researchers have found they are more likely to be evacuated for noncombat-related injuries, but more likely to return to work in-country after treatment for these conditions.

Still, the findings of the Johns Hopkins-led research team, published online in CMAJ, the journal of the Canadian Medical Association, note that 75 percent of the nonmilitary group medically evacuated from the war zones to Landstuhl Regional Medical Center in Germany between 2004 and 2007 did not return to the field.

"Everyone is understandably focused on the troops but wars have fundamentally changed. Today, roughly half of those deployed in Iraq and two-thirds in Afghanistan are not members of the military," says study leader Steven P. Cohen, M.D., an associate professor of anesthesiology and critical care medicine at the Johns Hopkins University School of Medicine and a colonel in the U.S. Army Reserves. "These individuals are increasingly an integral part of the mission but have been almost completely ignored in the medical literature. That needs to change so that we can develop better methods of injury and disease prevention."

Cohen suggests money may be one main reason that nonmilitary personnel return to work more often than those in the military. "Private contractors and other civilian workers tend to have significantly higher salaries than soldiers, and if they don't return to work on the ground in Iraq or Afghanistan, they don't get paid," he says. Soldiers, by contrast, will still get paid even if they are sent back home to the United States, losing only a small percentage of hazardous duty pay.

The study showed that combat injuries were not the leading cause of evacuation for either military personnel or civilians. Musculoskeletal injuries were the leading cause of medical evacuation in both groups, with a higher proportion of soldiers suffering those injuries than civilians. In modern warfare, the researchers note, injuries sustained in combat have never been the leading source of soldier attrition. Respiratory and infectious diseases were the main causes from World War I through the Korean War. By Vietnam, nonbattle injuries (e.g., back pain, fractures, overuse injuries) had become the leading source of loss of unit strength, where they have remained ever since.

Not surprisingly, Cohen and his colleagues found, military personnel were more likely to be evacuated for war-related injuries than civilians. The study considered combat, psychiatric, traumatic brain injury, and some musculoskeletal/spine injuries suffered during operational missions to be war-related. Civilians, who often work in security and transportation jobs, are less likely to be in the line of fire, and don't expect to be injured in combat, Cohen says. When they are, they are less likely to return to a war zone, with many concluding the job "isn't exactly what they signed up for."

The most prevalent diagnoses for civilians were musculoskeletal/spine injuries (19 percent), combat-related injuries (14 percent) and circulatory disorders (13 percent). Among members of the military, the most common diagnoses were musculoskeletal (31 percent — 6.4 percent considered war-related), combat (14 percent) and psychiatric (9 percent).

Cohen noted that civilians with psychiatric diagnoses were significantly more likely to return to duty (16 percent vs. 9 percent for soldiers). "Despite the military's emphasis on screening and early treatment for psychiatric disorders, they still take a much greater toll on military personnel than nonmilitary personnel," says Cohen, who is also director of chronic pain research at Walter Reed Army Medical Center.

The longer the wars continue, he adds, the worse this problem will be. "The more times a soldier is deployed, the more likely he is to experience a psychiatric problem," he says. "Instead of becoming more resistant, soldiers become more vulnerable."

According to the study, 16 percent of military personnel returned to duty compared to 22 percent of civilians after being evacuated for a routine musculoskeletal or spine injury. Soldiers' jobs tend to be more physically taxing than civilian jobs, Cohen says, making it harder, perhaps, for them to return to duty after such injuries. Civilian workers were more likely to be evacuated because of circulatory and heart problems, Cohen says, probably owing to their average older age (44.4 years compared to soldiers' 29.8 years) and accompanying age-related disorders.