Massive bleeding from the torso. Penetrating head trauma. Profuse bleeding from the neck or an extremity. Electrocution. A burn over more than 80 percent of body surface.
That's pretty much what it takes to be killed during the current wars. In remarkable and unprecedented numbers, soldiers in Iraq are surviving blast, fragmentation, gunshot, crush, and burn injuries. In the Revolutionary War, 42 percent of war wounds were lethal; by the Civil War, 33 percent of severe wounds were fatal, dropping to 25 percent of those from the Korean, Vietnam, and first Gulf War. In the present conflicts, only 10 percent have lost their lives to serious war wounds. Here we find the rarest thing of all: something that has gone well in Bush's Iraq Adventure.
Oddly, the crack and heroin epidemics in the 1990s can be thanked for the drop in deaths. From the running turf battles of drug traffickers, a generation of trauma doctors learned many new tricks: get people to expert care in less than an hour, concentrate on the severely injured, have at least one highly experienced doctor on the team, focus the expert teams at one or two regional centers, use packed red-blood cells rather than crystalloids for resuscitation, try new genetically engineered clotting factors after transfusing six units of blood, and minimize hypothermia by heating up operating rooms. In combination, these ideas turned good old-fashioned, American-style urban homicides into attempted homicides, sending murder rates plummeting and making a Giuliani presidential run possible.
By the time the Afghanistan and Iraq wars rolled around, the military had incorporated these ideas into something deemed a Surgical Shock Trauma Platoon, comprising two operative teams, an X-ray technician, an administrative team, a triage, and a critical-care team. This highly focused group could be set up within an hour and handle 18 major operations within a 48-hour period without relief or resupply. Body bags were modified to allow transportation by helicopter of patients with open chests or abdomens to more capable, but distant, hospitals. It all worked and has brought home hundreds of soldiers who otherwise would have perished. While a typical unit predominantly treats American soldiers, a significant number of Iraqi civilians, military, and even insurgents have benefited from care as well.
This success creates a new problem. Many of the service members—surviving injures that otherwise would have been fatal—face a very long recovery period and profound disability. Largely unanswered is how to best care for these people who have lost limbs, parts of major organ systems, or suffered significant brain traumas. The Department of Veterans Affairs, the government agency tasked with this problem, has had its budget repeatedly threatened by the Bush administration. Putting aside the issue of cost, there is no clear idea or plan for how to care for these survivors. The record in the civilian world hasn't been the greatest, as the recent Walter Reed scandal has shown. In the midst of discussions of surges and nonbinding resolutions, it would be wise to at least consider the best course for those who truly have sacrificed for all of us.