CAMP ANACONDA, Iraq—First, the grievously wounded arrive for the flight on stretchers, some carried by volunteers who show up for special duty in the middle of the night after working on the base all day.
After the last stretcher is loaded aboard the military evacuation plane, the ambulatory patients prepare to ascend the ramp, one after the other.
Volunteers and staff from Camp Anaconda's tent hospital flank their path.
They clap vigorously and cheer loudly as the first patient appears, and they do this until the last one makes the climb, the circle closing, the salute echoing through the cavernous C-141 cargo plane.
This is the last sound the wounded American warriors hear in Iraq.
Speed, technology and advancements in armor have made the battlefield in Iraq one of the most survivable in the history of warfare:
_ A new blood-clotting powder for major bleeds has proved so effective that it's being issued for medical kits.
_ U.S. forces in the field are heavily populated with combat lifesavers, soldiers with training comparable to emergency paramedics back home.
_ A fleet of aircraft—including helicopters and cargo planes—is on call to rush casualties to medical care.
_ Physicians with advanced skills, such as neurosurgery and cardiology, practice in field hospitals.
_ In extreme cases, patients are flown to the storied military medical center in Landstuhl, Germany, within hours of their injuries, in airborne intensive-care units.
After two years, the U.S. death toll is rising toward 1,700, far lower than the 3,000-plus deaths estimated for the initial invasion.
Body armor saves lives, but explosions still leave hideous injuries.
Army Maj. Kendra Whyatt of Greenwood, Miss., sees the devastation of improvised bombs and blasts, the amputations of mangled limbs.
"We are a living, true testament that our soldiers are still in harm's way," said Whyatt, a veteran of Desert Storm, the 1991 U.S.-led offensive against Iraq. "The war is over but the battle continues."
"This kind of stuff is new to this war," Maj. Charles Campbell of San Antonio said of the medical advances. "The most significant improvement is the critical specialists close to the battlefield."
Campbell is an Air Force cardiologist who often practices his craft in the cold, noisy belly of a C-141 that's racing to Landstuhl from Camp Anaconda at two-thirds the speed of sound.
When fighting is fierce, helicopters hover over Anaconda's tent hospital, waiting to discharge their casualties, then hastening off for more.
"We're in the middle of 16 emergencies and our radiology equipment is busted," Lt. Col. Marilyn Arnold said by way of introduction. "It's a typical hospital."
Typical perhaps in its unpredictability, but atypical in most other respects.
Situated in this desert garrison of 23,000, about 60 miles north of Baghdad, Anaconda's hospital is 60,000 square feet of modern medical care dressed in tan canvas.
It has intensive care units, three operating rooms, two CT scanners, recovery wards and a chapel.
Specialties include neurosurgery, urology, psychiatry. A dozen operations a day is routine. A baby has even been delivered here.
Anaconda is also the main center for transfer to Germany. The staff here treats U.S. troops and contractors, Iraqi military and Iraqi citizens caught up in the nation's violent spiral.
"World-class medicine is being practiced here," Arnold said. "Just last night they hooked someone up to a machine that's not even approved for use in the U.S.
"He's still alive this morning."
The feet of the soldier—the victim of a bomb—already had been amputated, and he lay unconscious amid a retinue of specialists. The concussion bruised his lungs, which were bleeding into themselves, making respiration all but impossible.
As he was deemed too unstable to fly to Landstuhl, Landstuhl came to him.
A medical team flew in with a German invention called a Novalung, which takes blood from the leg artery, oxygenates it and returns it to the circulatory system, breathing for the patient without using the lungs.
"Thirty-six hours after he was injured, we were putting the lung in," said Lt. Col Mark Ivey of Grand Haven, Mich., a doctor with the Army National Guard.
The U.S. Food and Drug Administration has given Landstuhl physicians conditional permission to use the Novalung in acute cases. It's a landmark moment in American medical history. No matter how it ends, the soldier's case will be written in medical journals.
"If something like this happened in the States, we couldn't offer it," said Col. Bedford Boylston, an Army reservist from Ashland, Ky., who teaches at Marshall University in Huntington, W.Va.
It's only the second time the device has been tried. Weeks earlier, a Marine who'd been wounded by a roadside bomb was struggling to breathe at Anaconda. Doctors at Landstuhl rushed the Novalung, the size of a small suitcase, to the Air Force, which put it aboard a massive C-17 cargo plane and flew it to Anaconda.
That flight cost tens of thousands of dollars.
That Marine lived.
"We will use every tool in the box for these guys," said Air Force Col. Russ Turner of Florence, Ala.
The commander of the Anaconda hospital said its level of skill was comparable to such medical centers as Johns Hopkins or Massachusetts General.
Former patients won't argue, especially the soldier who arrived with a piece of shrapnel lodged behind his heart, one of the hardest places to operate.
"This would be a fatal case in most hospitals in the United States. This would be a fatal injury almost anywhere else," Turner said.
"But they got the shrapnel out. And the soldier went home."
Body armor, with its woven super-fibers and ceramic plates, is Turner's ally in the field.
"Before, it used to be shrapnel that killed people," he said. "Now it's all orthopedic extremity injury. The vests: a very good investment."
Speed of evacuation also distinguishes military medicine in Iraq.
"These young men and women will get injured in Fallujah one day and be in Germany two days later," Turner said. "We can take people critically injured and get them to care. It's just amazing."
"What we've changed is what we're comfortable flying with," said Air Force Lt. Col. Kirk Milhoan, explaining how advances in technology allow critically ill patients to be airlifted to specialty care. Ventilators and other critical equipment are now compact enough to fly.
"This allows them to get to a clean hospital outside a tent, usually in 36 to 48 hours."
Milhoan, a flight surgeon and specialist in pediatric cardiology from Wilford Hall Medical Center at Lackland Air Force Base in San Antonio, has served on Critical Care Air Transport units. They're composed of specialists who manage patients on the five-hour flight from Anaconda to Landstuhl.
CCAT patients are sedated to the verge of paralysis to manage the buffeting of the flight and to relax their respiratory systems so they won't fight the ventilators.
Intensive care is a vigorous, nursing-intensive specialty in ordinary circumstances, but aboard a cargo plane it becomes an endurance test.
Flight nurses, respiratory therapists and doctors must work in helmets and bulky protective vests when flying over Iraq, in a cold, noisy fuselage bathed only in red light so that no illumination escapes the windows.
It's too noisy to hear alarms, so nurses stand by patients constantly monitoring vital signs. In this stage of care, Milhoan said, the nurses are the front line. Physicians largely stand by, ready if needed.
Flying at night is agreeable to Air Force Capt. Todd Haifley of Kalamazoo, Mich.
"If they can't see you, they can't shoot you," said Haifley, a commercial pilot in civilian life whose Air Force Reserve unit, the 356 Airlift Squad, is based at Wright Patterson Air Force Base in Dayton, Ohio.
His venerable C-141 Starlifter is among the last in the Air Force, a cargo jet built in 1967 and scheduled for retirement this year.
Haifley's usual load is a dozen to 40 patients. But more than once, its four engines guzzling 12,000 pounds of fuel per hour, his Starlifter has carried a single patient with burns or some other critical injury. For cases like that, Haifley doesn't mind flying in daylight.
"We'll go back there and see some pretty messed-up guys," he said. "But they'll shake your hand and thank you for getting them home."
After the flight from Iraq, patients are loaded onto buses and driven to Landstuhl Regional Medical Center in Germany, a 150-bed hospital that's already seen 24,000 patients from Iraq and Afghanistan.
Some high-priority burn patients have reached Landstuhl within eight hours of injury on the battlefield. They've been treated, readied for another flight and reached the military burn unit at Brooke Army Medical Center in San Antonio 30 hours after their injuries.
Among the deadliest and most pervasive attacks on U.S. troops are improvised explosives and suicide bombers.
Army Spc. John Comito, 24, of Plano, Texas, was with his unit investigating sniper fire about 9:30 a.m. local time May 14 outside Mosul. He had 30 days left in his yearlong tour.
Soldiers were interviewing villagers when a suicide bomber aimed a car laden with explosives at Comito's patrol. It lurched to a halt about 10 paces from Comito, then exploded in a fiery burst of steel and glass.
Jagged metal tore into Comito's arm, shoulder and eye. The blast ripped through his boots, burning his feet.
His body armor shielded the vital organs in his chest. "I'm pretty sure it saved me," Comito said.
Within seconds, combat lifesavers were treating his bleeding and burns.
Within minutes, a medical evacuation helicopter touched down, and he was flown to the military hospital in Baghdad for follow-up.
By 12:30 p.m. local time, he was at Anaconda, getting more treatment and being prepared for evacuation to Germany.
He made the flight that night and was examined by specialists at Landstuhl the next morning, less than 24 hours after the blast.
"I'm still here and pretty happy to be here," said Comito, an Army reservist whose father served in Afghanistan in 2003.
"When you have a car bomb explode 20 feet in front of you, you shouldn't be able to walk away from it."
Modern lifesaving techniques have reduced mortality dramatically among U.S. troops in Iraq over previous wars.
WAR / KILLED IN ACTION / LETHALITY OF WOUNDS
Revolutionary War / 4,435 / 42 percent
Civil War (Union Force)(ASTERISK) / 140,414 / 33 percent
World War I / 53,402 / 21 percent
World War II / 291,557 / 30 percent
Korean War / 33,741 / 25 percent
Vietnam / 47,424 / 24 percent
Desert Storm / 147 / 24 percent
Operation Iraqi Freedom / 1,665(ASTERISK)(ASTERISK) / 10 percent
(ASTERISK)Authoritative statistics on Confederate forces aren't available.
(ASTERISK)(ASTERISK)As of June 1; comprises killed in action, natural and accidental deaths.
_Source: Department of Defense, New England Journal of Medicine
(c) 2005, Knight Ridder/Tribune Information Services.
PHOTOS (from KRT Photo Service, 202-383-6099): WARTRAUMA