I thought I knew the costs of war. They had fueled my outrage over the arrogance, the ignorance, and the folly of the Iraq War, a rage that had begun to corrode my most treasured relationships. It had already begun to sap the life from my perceived calling to invite urban eighth graders to savor the wonders of algebra and geometry. It wasn’t just my imagination, I feared, that when my friends saw me coming, they ducked through the nearest open door to avoid my too‐familiar litany of criticism, mourning, and helplessness.
News that the nearby Naval Medical Center in San Diego (NMCSD) would become the third center in the United States to provide rehabilitation for amputees from Iraq and Afghanistan helped to focus this query for me. It drove me to admit that carrying a sign by the side of the road, reading aloud with others the names of slain U.S. service members, and flying a flag at my house day and night at half‐mast wasn’t enough. There was nothing I could do about an estimated half‐million Iraqis killed. But perhaps here was a chance to rechannel some of my rage.
Is being an enraged critic all you’ve got? How can you be an engaged doer?
Just how much do you know about the damage and destruction you despise?
You have all your faculties; you’re in good health; why are you claiming a helpless state?
If you say that you are the wrong age to reach out to 20‐year‐olds, just what is the right age?
If you were to work with amputees and were criticized for helping the war effort, what makes you think that getting a Department of Defense parking sticker to enter a military base to assist in binding up wounds is cooperating?
I became a volunteer through the Armed Services YMCA on the NMCSD base, coordinating response to the wounded that arrived by Medevac at a nearby Marine Corps air station. Family members of the wounded began to arrive from all over the western United States. Their distress over the wounds of a young family member (70 percent of the casualties are 19 to 23 years old) was compounded by bewildered attempts to cope with both military and hospital regulations as well as limited means to travel or set up housing in a city far from home.
Under the guidance of an envisioned Comprehensive Combat Casualty Critical Care (C5) program at NMCSD, we trained volunteers, greeted the wounded, and helped guide family members through the labyrinthine bureaucracies. I have met weekly with the two dozen medical professionals who consider the broad needs of these patients one by one every week. I have grown respectful of the dedicated, caring, and capable care by providers who combine their talents to deal with patients and their families.
I was struck by the number of invisible wounds the C5 team considered each week. My memory brought forth a portal of entry to this new world I was now struggling to enter. I recalled memories of my father, who was a World War I veteran. In the age of radio of my childhood, we would listen to some radio drama in which we heard the firing of artillery shells, followed by their explosions. Those were the only times when I was growing up that I saw my father weep. Adults, I learned later, called it “shell shock.” All I knew was that it didn’t subside until we changed the station. But his eyes remained wet—and distant—for a long time, each time. I was almost 50 when he died, and had enjoyed 50 years of his relentless determination to raise a family and support it well. During that time I never once heard that he had slept entirely through the night. We never knew the horrors of his nights, but we did know we never saw him rested in the morning.
We didn’t have the concepts yet—much less the words—for Post Traumatic Stress Disorder (PTSD). The term in use then was “shell shock.” My father’s was mild. There were many more cases, far more severe. It was, all agreed, a price to be paid after the fear, the stench, the suffering of trench warfare spent enduring shelling in the slime of mud and on the bodies of those who had been killed—with medical attention scant and distant. Shell shock? You dealt with it. Families adapted. A grateful nation could do little more than say “Tsk‐tsk.” Children wondered, but never inquired. At least your loved one had survived.
As life has changed, so has war for combat infantry, Marines, Navy medics—and for their families. Gone are adversaries defined by uniforms; gender or age is not an identifier. Bullets are not the biggest danger; 70 percent of the complex multi‐causal wounds from Iraq and Afghanistan are caused by the detonations of Improvised Explosive Devices (IEDs). Often hidden in everyday materials and detonated remotely from unknown sources, they cause far more injuries than the ubiquitous rounds of AK‐47s or the bullets of snipers.
With no whistling warning of approach, the sudden blasts of the IEDs gouge craters large enough to hold several automobiles, rip off limbs, shred spinal cords, and riddle bodies not only with shrapnel but also with infectious debris and contaminants from the soil that had once filled those craters. And that’s only the visible part.
Yes, there is ceramic armor, but sharpshooters have learned to aim for its edges and seams, both of which are vulnerable to blast‐impelled shrapnel. Designed to deter bullets, armor offers little protection against the blasts of Rocket Propelled Grenades (RPGs), IEDs, or land mines. The bottoms of Humvees, often lightly armored, are as vulnerable to IED blasts as the seams of body armor.
The rotor blades of Medevac helicopters are already turning, ready and waiting to be called, when Marines leave for patrol. This symbolizes the speed with which the reduction of time from battlefield to hospital has been dramatically shortened with improved resuscitation, evacuation, protection, surgery, and antibiotics. The ratio of casualties to deaths has thus risen sharply in Iraq to an astounding high of 16 survivors to every death. It does not follow that planned use of resources was sufficient to cope with this. Nor does it follow that families realize what awaits the return of the loved one who comes back. It does follow that aftercare for battle wounded—now survivors as never before—has ballooned. And it may extend far, far beyond hospital time.
The Navy medic who accompanies every Marine patrol and who is nearby to respond to an IED or RPG casualty, tries to clear airways, maintain breathing, and assure circulation in the face of multiple wounds, only a portion of which are visible. Medics themselves, always in the battle arena, are frequently among the wounded, and the damage to them is often initially as invisible as for those in combat.
Within minutes a helicopter arrives to pluck out the patient for transport to a nearby base hospital. Once stabilized, the wounded warrior is on the way to a major medical center. It sometimes takes less than 48 hours to get from the scene of a combat wound to a full‐service hospital in another country. However, even with the most intensive and advanced medical care, wounds so incurred may have to stay open for six to eight weeks until infection is controlled. Surgeries must wait. The agony is prolonged not only for patients but also for surgeons, who must wait to determine whether it is possible to save a limb or if it is necessary to amputate.
Among the complex multiple injuries, not all of which surface immediately, is Traumatic Brain Injury (TBI)—what medical professionals call the signature injury of the Iraq War. These closed head injuries, not as immediately visible as penetrating head wounds, are often the result of blasts, not bullets—and blast injuries have afflicted about two out of three of those wounded in action in Iraq and Afghanistan.
Severe cases of traumatic brain injury may be obvious, but those that are mild, commonly called concussions, are not. Recovery from concussions, or mild brain injuries, is sometimes uncomplicated and complete, but not always. Some individuals continue to experience cognitive or mood difficulties. There also may be a delay in the symptoms becoming apparent. Measurements vary in several locales but often show that about one out of ten of the combat wounded treated showed some evidence of TBI.
With a total of one and a half million individuals having served in regular, reserve, and National Guard units in Iraq and Afghanistan, whatever the actual proportion, the number of those with TBI is large. It is no wonder that the Veterans Administration reports that requests for mental health aid have risen dramatically in the past 15 months.
It is often difficult to distinguish between the effects of concussions (TBI) and the aftereffects of combat stress (PTSD). A commonly used list of the widely varying emotional, physical, mental, and behavioral reactions to combat stress fills a single typewritten page with 30 column‐inches of newspaper‐size print. These emotional aftershocks can be the result of simply witnessing as well as being involved in life‐threatening circumstances.
Perhaps even more difficult is that the stress reactions may not appear until months after the trigger event, perhaps at the very time that the recovering wounded have reunited with their families and are supposedly past the period in which they received treatment. These reactions vary from lack of coping skills, profound grief, or guilt over one’s own survival to anxiety that saps resiliency and varied forms of anger, agitation, and irritability—forming a list far too long to enumerate here.
Among the amputees at the military hospital where I have been the past year, the determination of patients who have lost one leg or both to match the physical therapist’s goals to get them to run again is thrilling to see. Coupled with the demonstrations of courage, loyalty, and honor one so frequently sees in the wounded patients, this grit, this drive despite the horrors of war and the battlefield is a reminder of the strengths of youth that we often fail to acknowledge.
Even professional care providers face compassion fatigue and must labor to avoid giving a patient the impression that he or she is damaged for good and undermining the will to keep the healing process moving. One cannot overstate the stress on some families as they try to welcome back those so changed by their war experience.
Unpalatable truths may appear for us as heartbreaking questions in the night: wouldn’t it be easier to handle death than disabling disfigurement, diminished capacity, or lifelong care of wounds? But what may appear as an “unpalatable truth” may simply be unpalatable, and not a truth. For example, criticism aimed at a Quaker for “cooperating” with the military effort. Look at the unholy basis for this criticism. What Amos and Jeremiah called “false gods,” Jesus called “demons,” Paul called “principalities and powers,” and Shakespeare called “instruments of darkness,” we call “absolute principles.” Truth triumphs over them every time.
Other unpalatable truths can still be digested; there are things you can do no matter how old you are. No major hospital can function without volunteers. Wounds may take a lifetime of healing and require more than only patient and doctor. “Helpless” doesn’t mean lack of power, it means lack of vision. There isn’t a “right” time; the time is now.