It would seem there is no difficult or horrifying sight that Col. (ret.) Dr. John McManus hasn't seen. McManus, who served as a trauma and emergency medicine expert in the U.S. military, spent three years in Afghanistan and Iraq treating American casualties of terror attacks. He also served as a doctor with NATO forces in Bosnia after the Serbs ethnically cleansed the Muslims in 1995, participated in a special rescue mission following Hurricane Katrina in 2005, and treated victims of the devastating earthquake in Haiti in 2010.
"Of all the things I've seen, one sight was particularly difficult and horrible," says McManus, making a possibly surprising selection. He is not referring to the hundreds of soldiers who died in his arms under heartbreaking circumstances in Iraq and Afghanistan, nor is he referring to the children who were left orphaned and penniless in Haiti. "In Bosnia I saw something I had never before encountered, and I hope I never will again. Simply genocide. The Serbs slaughtered the Muslims in a horrible way. I came in with NATO forces right after U.N. forces withdrew from the area. We saw mass graves, endless rows of bodies and body parts strewn in pits on the ground. There was evidence of criminal abuse, hate and inhuman acts. The only thing reminiscent of those images is the Nazi crimes during World War II."
McManus has been awarded a plethora of medals and decorations for his diverse work as an emergency doctor in the American military, for his developments in combat medicine and as a surgeon and hospital director who treated trauma patients and fighters who were physically and emotionally crippled by war. In addition to all his other achievements, he also led a number of research projects on medical treatment on the battlefield. He was awarded the U.S. Army Surgeon-General's Physician Recognition Award in 2006, was inducted to the Order of Military Medical Merit in 2007, and was given a lifetime achievement award for Excellence in Emergency Medicine in 2011.
McManus lives in San Antonio, Texas. During his service he was forced to travel thousands of miles from home for long stretches, leaving behind a wife and two children. Until recently, he oversaw 120 American doctors at a hospital for combat soldiers – his last position outside the U.S. – until the withdrawal from Iraq in 2011. While he served in Iraq and Afghanistan, McManus' main focus took him outside the hospital to disasters in the field and emergency medicine.
"I definitely carry the scars of various traumas. I would be lying if I said I didn't," he says, recalling another event that left him scarred: "Last November, just before the pullout, I happened to treat the last American soldier to be killed in Iraq, David Hickman. He was hit with an IED that crushed him. I remember David well, the way he looked and how much his friends loved and admired him. Last Memorial Day I wrote a letter to his family. It is definitely a stressful situation. You lose soldiers. You in Israel are very familiar with these situations.
"There is one thing that is more difficult than losing a soldier and that is meeting their families afterward, and telling them and explaining to them what happened. Trying to console them without really succeeding."
McManus is a composed guy. His sentences are terse and to the point. He doesn't use descriptive or elevated language. He avoids flowery phrases. From time to time he responds with a joke. In his state, he needs a bit of humor to cope. I wonder how a man who saw hundreds of soldiers die in his arms is able to hold on and remain sane.
"I hate to say it, but you get used to the horrible sights, but you have to be able to handle it. The one thing that is crucial is good teamwork. We doctors have to act as a unit, share with one another and talk about whatever is happening, make sure everyone is alright, that we tried our best and that no one is to blame. We try to move forward and improve," he says.
What is the most important character trait for a doctor in the field?
"When you are in a disaster area, you have to recognize your limitations. Even the best training won't necessarily prepare you for this situation in an optimal way. You have to learn from others who have been in these types of situations, who know how to behave."
Appreciation for the IDF
Currently the director of the emergency medicine residency program at a U.S. Army hospital in San Antonio, McManus also instructs and guides future doctors at military hospitals and devotes much of his time to emergency medicine research. This week he landed in Israel for the first time to take part in the Rambam Summit, an annual conference that brings together medical experts in different fields from Israel and around the world. He is here to give a talk on his field of expertise.
"I am thrilled to be here, because the U.S. Army and Rambam Medical Center often collaborate on experiments in the field of emergency medicine, treating trauma patients and resuscitation," McManus says. "Many of the lessons we Americans have learned, especially in regard to mass disasters, can be applied to Israel due to the dangers that exist here. That is the purpose of the conference."
McManus’ talk focused on a new invention he developed for treatment in the battlefield. His experience on the front lines led him to realize that the leading cause of death in the battlefield, especially from improvised explosives as in Iraq, is loss of blood from injured limbs. On the one hand, the bleeding needs to be stopped and first aid must be administered. On the other hand, it is unwise to perform too many procedures in the field as this may hasten death. The doctor has to find the ideal middle point that will stabilize a patient quickly and efficiently and enable him or her to survive the trip to a hospital, where access to full equipment can hopefully save lives. Thanks to this realization, McManus and his colleagues invented an advanced tourniquet that constitutes a true revolution in battlefield medicine.
Training in the battlefield
McManus speaks very humbly of his many achievements and takes little credit for himself. He claims that his success is the product of intense teamwork and cooperation with other doctors, including his collaboration with Israel.
"With Israeli doctors, we tested and examined different tourniquets and we developed all kinds of advances. Today we have lots of tourniquets and advanced bandages," he says.
"The number one cause of death from explosions is loss of blood. External bleeding. We realized that we needed better tourniquets. The Israelis developed all kinds of bandages in the beginning of the 2000s, but with new technologies we learned how to create a better tourniquet. It is a sort of round rubber hose, a type of ring that tightens and locks onto the injured area. It is simple mechanics that closes off the limb. The secret of the success of this tourniquet is its ability to be horizontal and still apply pressure around the limb. This development actually changed the mortality rate in the field and the tourniquet is currently in wide use in the U.S. There are even IDF units that use it."
Can you give me numbers?
"According to the statistics, we have reached a point where if a casualty arrives at the hospital alive, the mortality rate is only 6 percent. We had a lot of casualties that we didn't think would survive, but they did. This statistic is pretty similar to the statistics in Israel today."
When you hear the retired colonel talk about relations between Israel and the U.S. Army, you understand how deep the ties between Israel and the U.S. run, built on joint military and technological research. McManus voices a lot of appreciation for Israel in general, and for the IDF specifically. He especially admires the advances in the field of military medicine and the teamwork among Israeli doctors.
"First of all, we have joint funding, joint research projects or parallel research projects that build on each other's findings," he says. "We invite Israeli doctors and researchers to describe their experiences and the Israelis invite us here, so there is wonderful reciprocation and mutual inspiration by way of sharing information."
Another issue that occupies McManus these days is the training of new doctors in the U.S. Army to perform emergency medicine. "The IDF trains at a much higher level than we do," he says.
"We, in the U.S. Army, are trying to imitate that. Today our training methods are very similar and approaching the same level. But you have to remember that in the U.S. Army there are 49,000 doctors and it is harder to train them all at the same level. In Israel there are maybe 3,000 doctors serving in the military.
"In any case, special forces from Israel come to our conferences and help us learn some of these things. The Israelis are very famous for battlefield resuscitation. In the 1970s and 1980s, Israel was a world leader, trailblazing in resuscitation treatment in disaster victims. You knew how to cut to the chase in the battlefield and quickly treat the affected areas. The Americans had to learn a lot from you. Today, the Israeli army and the American army train their doctors much better than other armies and our treatment of casualties is among the best in the world."
What is unique about Israel in its medical preparedness?
"Israel is a small country that understands the importance of blood donation. In the U.S. it is different. When there was an earthquake in Haiti, or during Hurricane Katrina, we weren't ready. We learned how to operate from you. We realized that we needed a system of donated blood and to strike agreements so that the blood would reach areas affected by disaster.
"Look, the system in the U.S. is complex and tough. There are 50 states with different laws and separate systems. There is, for example, a problem with licenses. If there is a disaster in Louisiana and I want to bring in a doctor from Texas, for example, he can't work in Louisiana as a doctor because he is not licensed there. We had to learn from that and improve our bureaucracy. We learned a lot from those situations."
The next big thing in medicine
Within the framework of his research projects, McManus puts an emphasis on technological advances in medicine. These advances are moving forward at great speed and pose a challenge to doctors, who must constantly keep themselves up to date with the latest developments. "We conduct research, and if we find a solution to a certain problem we start using it immediately in the battlefield," McManus says. "We don't wait for final results of experiments, thinking that we can use the new tool next time. We implement these advances in real time."
What is your next step in the technological avenue?
"Sensors. We want to develop better monitors that would give us more accurate readings on whether a patient is deteriorating, requiring resuscitation or defibrillation. Another thing is the issue of autologous blood donation that we are currently looking at together with Israeli doctors. The idea is that with a proper circulation system we will be able to transfuse the patient's own blood back into his body, obviating the need for blood donations from someone else."
McManus adds that "there are additional areas in technology – methods of stopping internal bleeding rapidly, treatment of traumatic brain injuries, resuscitation of tissue and rehabilitation of limbs. And of course the field of advanced prosthetic limbs, that technology has propelled forward in an amazing way. Today people run faster on prosthetic legs than on human legs."
Are there unusual cases?
"There are many people whom we released from the hospital without limbs, but alive. We asked them after they lost their arm or leg if they were happy to be alive. It must be said that not too long ago a large portion of them would not have survived, but technology helps a lot in the battlefield and in rehabilitation.
"There are wonderful cases of people who fully recover. Take for example the winner of ‘Dancing With the Stars’ two years ago [J.R. Martinez]. He was burned very badly all over his body in the battlefield, and thanks to today's technology he survived and can fully function."
During his talk at the Rambam Summit, McManus stressed the importance of teamwork. "It is important that every member of the team knows what his function is and understands what it is that he is doing. In addition, it is important that every member of the team is capable of stepping in for another member should the need arise. It is essential to know how to use the equipment, and the supervising doctor should know how to manage a team. The secret to good medicine is good teamwork."