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US wounded in the shadows
By David Isenberg

On July 2, President George W Bush, in referring to combat operations in Iraq, said, "Bring them on." And bring it on they have. As everyone knows, coalition forces, primarily American, are being killed and wounded on a regular basis - 357 US and British fatalities to date. But while the US dead, whether in combat operations or from other causes, are reported publicly, the wounded have almost disappeared from public view. And their numbers are growing, and providing appropriate care is an increasing burden for the military and civilian health systems.

How many wounded and injured are there? Nobody really knows for sure. Understandably, it is difficult to be precise when more casualties are being created on a near daily basis. But gathering data is difficult for other reasons.

Casualties are first triaged "in country" and then sent to the Landstuhl Regional Medical Center (LRMC) in Germany. The LRMC processes every patient from Operation Iraqi Freedom and Operation Enduring Freedom, the military campaign in Afghanistan. It is the largest military medical center outside the United States, and remains at its 322-bed capacity, nearly twice the number of pre-war beds. As of September 16, Landstuhl had treated approximately 6,000 service members from Operation Iraqi Freedom.

From LRMC, the wounded go on to facilities in the US, such as the Army's Walter Reed Army Medical Center in Washington, DC. From there they are sent as soon as possible throughout the country - first to base hospitals where their unit is or to local Veterans' Administration and hometown hospitals. This makes it next to impossible to collect data on the total number of injured, types of injuries and dispensation of the injured. To make a true database, one would have to poll nearly every hospital in the country on a weekly basis to garner real-time information on these patients.

As was recently evidenced in the recovery of well-known former US prisoner of war Jessica Lynch, hospital employees are told not to talk about numbers or types of injuries. The Health Insurance Portability and Accountability Act of 1996, which went into effect last October, states health care personnel can go to prison and/or be fined astronomical amounts for even talking to other health professionals or family members about the condition and/or treatment of anyone in health care in the US at this time.

The Washington Post reported on September 3 that the number of those wounded in action has grown so large and attacks have become so commonplace that US Central Command usually issues press releases listing injuries only when the attacks also kill one or more personnel. The result is that many injuries go unreported.

According to the Post article, C-17 transport jets arrive virtually every night at Andrews Air Force Base, outside Washington, on medical evacuation missions. Since the war began, more than 6,000 service members have been flown back to the United States. Aside from the wounded in action, and those with non-hostile injuries, the figure includes the mentally ill.

Interestingly enough, while the US Central Command website does post casualty reports, and even allows one to search back in time by day or month, there is no such feature on DefenseLink, the Pentagon's public website. It only lists fatalities.

According to Central Command figures, as of September 28, a total of 1,358 US people have been reported wounded in action, or an average of 7.07 a day since March 20, when Saddam Hussein's statue was toppled in Baghdad. Plus another 327, or 1.7 per day, wounded in non-hostile incidents. That is a total of 1,685, or 8.7 US military wounded per day. The numbers of course fluctuate day-to-day and don't appear to take in non-combat injuries (given the 6,000 plus figure mentioned as treated above) or are understated.

Fortunately for the soldiers, the percentage of those who die from their wounds is less than in past wars. The Boston Globe reported in August that roughly one in seven soldiers wounded in combat in Iraq has died. In previous conflicts dating to World War II, one in every three or four soldiers died after incurring combat wounds.

In World War II, 30.3 percent of soldiers wounded in combat died. That percentage fell during the Korean War to 24.1 percent, and held steady through the Vietnam War (23.6 percent) and the Gulf War of 1991(23.9 percent). But the number has declined sharply in Iraq, with 13.8 percent of battlefield wounds being fatal.

The types of wounds being seen in Iraq include gunshot wounds, shrapnel wounds from rocket-propelled grenades (RPGs) and mortars, burn injuries, motor vehicle accidents and many other injuries. Many of the wounded have required amputations.

According to Major Gene Delaune, a US Air Force reserve physician interviewed by Minnesota Public Radio, since arriving in Baghdad July 16, virtually every injured soldier he has seen had been hurt seriously enough to require transport out.

"We see a lot of amputations," Delaune said. "Initially I was probably seeing one or two amputations a day. Now we're down to maybe one every two or three days," said Delaune. "The limbs just get damaged to a point where they can't be salvaged, and in the field hospitals where they're initially treated, an amputation is performed. We see a lot of eye injuries as well."

While the issue of emotional or psychological disorders has received almost no public attention, it is very much on the minds of the medical community. One publication, prepared for clinics treating returned Iraq war veterans, stated, "Post-traumatic stress disorder is one of many different ways a veteran can manifest chronic post-war adjustment difficulties. Veterans are also at risk for depression, substance abuse, aggressive behavior problems, and the spectrum of severe mental illnesses precipitated by the stress of war."

According to a report in the July 9 Christian Science Monitor, the US military took unprecedented steps to prepare for the inevitable psychological problems among returning troops. It reported, "Early intervention, officials hope, will lessen the amount and severity of post traumatic stress, depression, substance abuse, as well as domestic violence and marital breakdowns."

Caring for the wounded has become more difficult due to lack of space. In August it was reported that Walter Reed Army Medical Center was referring some outpatients to nearby hotels because casualties from operations in Afghanistan and Iraq have overloaded the hospital's convalescence facility. At that time they were referring about 20 patients or their relatives to hotels each day. Walter Reed has been at maximum capacity since Operation Enduring Freedom began in Afghanistan in 2001.

The hospital staff is working 70- or 80-hour weeks, and Walter Reed is so full that it has taken over beds normally reserved for cancer patients to handle the influx.

Sometimes the lack of needed items borders on the surreal. Back in July, the Chaplain's Office at LRMC sent out an appeal for useable clothing for male soldiers injured in Iraq. Many of these soldiers were airlifted to the hospital in medical dressing gowns and had no access to clothes for onward transportation.

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Oct 2, 2003



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