The following is an excerpt from Ann Jones' new book, They Were Soldiers: How the Wounded Return from America's Wars—The Untold Story (Haymarket Books / Dispatch Books, 2013). Jones' new book takes us on a powerful journey from the devastating moment an American soldier is first wounded in rural Afghanistan to his return home for recovery. This excerpt picks up at Ann Jones' visit to Craig Hospital, a Level III Trauma Center at Bagram Airforce Base in Afghanistan. Craig Hospital is often the first serious medical stop on the "medevac pathway" that sends critically wounded soldiers to Landstuhl Regional Medical Center in Germany and the US for further extensive treatment.
At Bagram the three orthopedic surgeons work 14-hour days at a minimum with one night on call, the next night on backup, and the third night, if they’re lucky, asleep. When I talked with them in 2011 they were riding a long wave of wounds, and it was still spring. The winter when fighting falls off was just passing, and in summer they knew everything would be worse.
The catastrophic blasts brought other surgical specialties to Bagram. The explosions seemed to everyone only to get more powerful and the wounds more extensive. Blasts now regularly rose into the perineal area, where the two legs meet, to smash genitals and into the pelvic cavity to pulverize soft tissue and sever intricate bodily systems. In response to a surge of such catastrophic injuries, the army dispatched a urological surgeon from Walter Reed to Bagram in 2010. Six months later, in March 2011, a navy commander stepped into that position. It was his first deployment to a war zone, but after his residency at a level one trauma center and seven years of work as a Naval surgeon at hospitals in the States and Japan, he thought he knew what he was in for. After two months at Bagram, he told me, “Nothing in my experience prepared me for the catastrophic nature of these injuries.”
His first surgical patient, three days after he arrived at Bagram, was a young soldier who had stepped on an IED, triggering an upward blast that destroyed his legs and left his pelvic cavity “hollowed out.” His urinary system was in shreds. His testicles were destroyed. His penis was attached to his body by only “a little thread of skin.” That first surgery, the doctor said, was “emotional” for everyone on the surgical team. “The others hadn’t seen anything like these injuries for a while,” he said, “and I had never seen anything like it. To have to amputate that boy’s penis and watch it go into the surgical waste container—it was emotional.”
In two months at Bagram, the urological surgeon had done 20 similar surgeries, though that was the worst. Injuries confined mainly to the testicles are “easier,” he says, but for the soldiers they are brutally serious. Most soldiers who survive blasts that require high-level amputations of their legs also suffer severe injury to the scrotum and ruptured testicles. Surgeons can debride and clean the scrotum, and in many cases salvage at least part of one testicle and put it back. Keeping even part of his genitals is a psychological break for the soldier, but since the testicles produce testosterone, he still faces the inevitable ill effects of a deficient supply—a long and imperfectly understood list headed by osteoporosis, metabolic syndrome, cardiovascular problems including coronary artery disease and atherosclerosis, erectile dysfunction with its attendant psychological difficulties, low sperm count impairing fertility, obesity, depression, and a lifetime seesaw of hormonal treatment.
Yet it’s the penile injuries that are most devastating. How bad the injury is determines how much of the penis a soldier gets to keep. “Sometimes we can leave some,” the surgeon says. He has done such partial amputations. But even if the penis is intact, the urinary tract may be damaged within the organ or the perineum. If the damage is slight, the surgeon may be able to repair the urinary tract and expect his patient to have an “unremarkable urological life,” but if it is severe, he knows then, in that first surgery, that the soldier’s urological system will never again function normally. In the worst cases, the doctor realigns things as best he can and puts them together with a catheter, but often dirt and bacteria blown into the perineum have already spawned infections that may not be cleared for weeks or months.
The urological surgeon is the only surgeon in explosive Afghanistan who tells me he also worries about gunshots. A shot to the gut can demolish internal structures as effectively as a bomb. All this generalized damage to essential systems drops penile injuries well down the list of non-life-threatening problems not immediately fixable. The devastated legs and arms and internal organs, the amputations and infections and necrotizing tissues mean it may be months before anyone but the soldier can give primary attention to what’s left of his genitals. Doctors know the soldier pays a psychological price waiting to have his “junk” dealt with last, but even when surgeons would like to put that junk back in place, there may be nothing left to attach it to.
For years, no one mentioned these genital injuries. Then it was said that the number of soldiers who have lost all or part of their genitalia is “small.” It has been reported that in the year or so after President Obama took office in 2009, only about a dozen soldiers lost their penises and testicles to IEDs or subsequent amputations, while about 50 lost part of the penis and another 150 lost one or both testicles. But the numbers have rarely been presented straight up.
In April 2012, USA Today reported that “more than 1,440” soldiers had lost limbs in Afghanistan or Iraq, and in Afghanistan “nearly three in four troops who lost legs to bomb blasts also suffered genital injuries from February 2010 to February 2011.” That’s the way the numbers are reported—like one of those narrative math puzzles on the College Boards. The urological surgeon at Bagram told me he had done “only” 20 such surgeries in two months, but at that rate he might tally 120 all by himself within a year. In fact, the numbers in Afghanistan have risen steadily since 2005, and dramatically with the Obama “surge” of 2010.
By early 2012, 3,000 soldiers had been killed by IEDs in Iraq and Afghanistan, and 31,394 wounded. Among the wounded were more than 1,800 soldiers with severe damage to their genitals.17 Asking the Department of Defense for an update on the statistics in July 2013, I was told I would have to file a formal request under the Freedom of Information Act. Evidently the new numbers are high enough to be made hard to get. It’s safe to say they can no longer convincingly be described as “small.”
“It’s not a huge number of people,” the urological surgeon says, speaking of the surgeries he has performed himself, “but the severity of the injuries, and the possibility of complications down the road—that weighs heavily. The kind of injuries—you don’t have any idea of the devastation until you see it up close. This has been eye opening. It’s given me a new understanding of the costs of armed conflict. Even being in the military, I didn’t know.”18 An ER nurse, an Army major on her second deployment at Bagram, tells me that catastrophic cases pass through the ER four days out of seven, and quadruple amputees “often.” She says, “I’ve taken care of twenty or thirty of them myself.”19 She has lost count. I ask how she would describe the typical case she sees in the ER. She replies, “Amputees up to the waist. No arms. No legs. No genitals. Age 21 or 22. We cry.”
At midnight the drill starts all over again. The choppers, the litters borne through the doors, the doctors huddled over the patients— three Americans this time, their uniforms already cut away, their wounds field dressed, their legs and arms apparently intact. No catastrophic injuries here. Or none that I can see. But that offers no reassurance. An invisible wound is another signature of this war, as it was in Iraq—the traumatic brain injury, or TBI. Current military medical protocol calls for every wounded soldier to be screened for TBI within 72 hours of being injured by a blast or fall or blow to the head, but that means asking the soldier himself what happened.
If he is conscious and can answer, he may not remember, or he may not remember accurately. Or he may “suck it up,” as he has been trained to do, and say nothing. If he is unconscious and intubated during treatment for more urgent and bloody physical wounds, he can’t answer at all. Even the terminology of TBI suggests the complexity of the diagnostic problem: if the wound is invisible, how can you spot it? How can you know how bad it is? And if you can’t ask the soldier, what then? For the soldier badly wounded in an explosion, his brain may become like his damaged penis—the last item on the doctors’ list of priorities. The exigencies of modern life-saving surgery rank legs and arms before genitalia and far ahead of the brain.
In the emergency room, the staff neurologist, an Army major, is talking to one of the newly delivered soldiers who is conscious and seems to mumble in reply. The dustoff medics reported that these three soldiers were in the vicinity of an explosion, and the neurologist believes that a blast affecting the brain must be diagnosed and treated right away. Concussion has been a problem in all modern wars—think of “shell shock” in World War I—and the prescribed treatment has always been the same: rest. But until he talks to the soldiers and observes them, the neurologist doesn’t know whether he is looking at a simple concussion, which the military labels “mTBI” (mild traumatic brain injury), or a far more serious brain injury.
Unlike the Bagram surgeons who read the cause of injury in the wounds themselves, the neurologist wants to know exactly what happened. It’s the history, and not the all-too-common symptoms— headache, nausea, memory loss, and so on—that will tell him whether or not the soldier is a candidate for the little rest home he runs on the base. There, a concussed soldier can sleep and eat well, play diagnostic board games with the doctor’s good-natured assistant, and maybe even get to hang out with Timmy, a golden retriever who exudes an incomparable kind of canine comfort.
I had visited that barracks a few days earlier to talk with three recuperating young soldiers. Two of them told me terrible sad stories of blasts that vaporized friends nearby and then moved on, like a tornado cutting a swathe across a prairie, to level those walking some distance away. The third soldier had been blown out of the passenger seat of an armored personnel carrier when an IED ex ploded beneath the driver. The neurologist said, “Seeing a concussion a day or two after it happens is completely different from seeing it even a couple of weeks later. By then, it’s a different animal.”
Visiting his resting soldiers I can see for myself. Edgy and brittle, they slump in armchairs looking pale and exhausted. They seem startled to have a civilian visitor. They are willing to talk with me, but our conversations take place as if on tiptoe. They are nervous and tentative. The youngest soldier, only 18, who came in just the day before, is still tightly wound in anticipation of the next blast. Timmy, the therapy dog, crosses the room to sit beside him, and the boy reaches out to touch him.
All three of the soldiers are contending not only with concussion, but also with the psychological shock of having been brushed by death as it ripped into their friends. Here they can rest, and nobody can send them back into combat until the doctor releases them. They are the “lucky” ones, yet their confusion is palpable. Others just like them will be put back to work, and perhaps six months or a year later, when they show up at a VA hospital complaining vaguely of headaches or an inability to sleep or remember things, they will pose insoluble diagnostic problems. VA counselors screening soldiers for TBI long after the fact know that the results will be imprecise, if not meaningless. Even in cases of serious structural damage to the brain, a CT scan may be perfectly normal. So when counselors diagnose a soldier with PTSD, just to be on the safe side, they write down TBI, too. They might be right. Or not. They are fudging the nearly indistinguishable line between physical and psychological impairment because at that point they can’t see the line at all.
In the emergency room, the neurologist bends over the second of the newly blasted soldiers. He lies on his back, staring into space so blankly that it is impossible to tell whether he hears the doctor or not. Knowing these men have been exposed to a blast, the doctor is determined to learn more, whether or not they can tell him themselves. These two soldiers will spend the night in intensive care, where they will be screened for visible wounds, but perhaps tomorrow they will be lucky enough to make it to the neurologist’s rest barracks and have a chance to recover, although nobody really knows the optimal length of time it takes for such a “recovery.” Three days? A week? Six months? Can the soldier really rest in the barracks, or should he be farther away from the combat zone? Maybe in Germany or back home? Such seemingly simple questions have been answered differently in different modern wars by different militaries and medical experts, apparently with few lasting lessons learned.
Doctors and the military command often find themselves at cross purposes because doctors want to save lives, not patch people up for demolition in the next battle, while the generals want their soldiers back. Doctors who are themselves military officers embody the contradiction. The military command, always on the lookout for malingerers, also worries about treating soldiers too well. Give some soldier a diagnosis and a break, and others will soon present themselves with similar symptoms—or so the classic argument goes—and the next thing you know, they will all be applying for disability benefits. So how much rest is the soldier to be allowed? And what is “rest”? A furlough? Sleep? An insulin-induced coma? All have been prescribed at times. Who determines when the soldier has recovered enough to return to duty? Who is to say if the look of recovery is anything like recovery itself? Who knows if the appearance of being “back to normal” would look anything like “normal” to a soldier’s mom and dad?
These questions don’t arise when a soldier has visible physical wounds: when his legs are gone or his face has been melted by fire. Nor will they arise now in the case of the third soldier lying unconscious in the ER. He was exposed to the same blast as his two companions and may have a terrible brain injury for all anyone can tell, but it’s the gaping hole in his belly that commands attention and sends him swiftly away to surgery.
Reprinted with permission from Haymarket Books/ Dispatch Books -- Copyright 2013. From "They Were Soldiers: How the Wounded Return from America's Wars—The Untold Story" by Ann Jones