The most lasting wounds are hard to measure
by Roger Boyes
LANDSTUHL: The front line is only a few hours away, and there is still sand stuck to their desert boots as the wounded are lowered on to the waiting trolleys.
"OK, next one is coming out feet first," shouts a nursing sister as yet another US soldier is rolled out of a Blue Bird ambulance bus. The chaplain glances at his clipboard, leans forward and says: "You're safe now, Billy – you're in Landstuhl."
A liaison officer places a "wounded warrior's pack" next to the man's feet, sees that one of his legs is missing and places it a bit higher.
Billy does not look well, but then none of today's deliveries from Iraq are in good shape…
It has been a five-hour flight from Iraq to the Ramstein airbase, then an ambulance drive to the biggest US military hospital in Europe. Many of the casualties were hit only 24 hours earlier, the C-17 transporter is the equivalent of the bumpy World War I field ambulance, and the wounded are drained and dazed.
The figures are contested, but at least 3300 US troops have been killed and almost 25,000 wounded in Iraq. Those wounded in Iraq and in the Afghanistan conflict have to come through Landstuhl, a sprawling compound in Germany close to the French border that was designed as a Hitler Youth campus.
Landstuhl is the chokepoint of a controversial war. Every day, the US wounded are wheeled in – 23 on the first day we were there, 39 the next – and always there is the same nervous buzz among the waiting medical staff.
Even the lowliest orderly understands that the treatment of the wounded is one way a country measures its performance in war. When poor standards at the Walter Reed military hospital in Washington were exposed recently, there was an immediate impact on the troops, and it also stirred public distaste.
But what if the most lasting wounds are invisible and therefore immeasurable? All the signs are that the sustained war is creating a mental health problem in the US military – the modern equivalent of shell shock, a combination of post-traumatic stress disorder, which induces a continuing state of anxiety, and traumatic brain injury that may have several physical symptoms.
"Six hundred of the soldiers who came here from Iraq last year had mental health conditions," says Lieutenant-Colonel Gary Southwell, Landstuhl's chief psychologist. "And 20 per cent of them were suffering from post-traumatic stress syndrome – flashbacks, hyper-vigilance, memory loss. "One of the major reasons people are being sent home is self-destructiveness and suicidal thoughts."
Lance Corporal Yahiel Sanchez drove over a booby-trap bomb on Friday the 13th, and the nurses are telling the 19-year-old Puerto Rican he was lucky. "I was blown out of our gun-truck," he says. "I hit the ground, and a friend dragged me to the cover of a cleared house."
While the battle with the insurgents raged on, Corporal Sanchez had his clothes ripped off, his broken leg was splinted, and when a medical squad arrived they smashed down a door to make a stretcher. It was an exemplary case of field medicine. Yet the young US marine's answers are fuzzy, his eyes unfocused – his memory of the incident is precise but everything else around him seems to be in a fog.
"We can spot some TBI sufferers straight away," says Lieutenant-Colonel Stephen Flaherty, the chief surgeon who has helped to pioneer a brain-screening system. "They can't find their way to the dining facilities. Weeks on, they could be still reading maps upside down."
Since last May, the physically injured passing through Landstuhl have been given a brain scan: moderate and severe TBI can be spotted, but the mild variation does not show. So a nurse waits patiently to see Corporal Sanchez and asks him to recite the months of the year backwards or recall the first fivewords of their conversation.
"We have developed a points system that has been tried out on contact sport athletes, football players mainly, who have suffered concussion," says Colonel Flaherty. About 60 per cent of the troops who survive bomb blasts – the top cause of death – could have brain injury.
In the wards and the corridors of the huge military hospital, we meet people whose injuries are little different from those suffered in the trenches of World War I. The face of Sergeant Derek Whittaker creases in pain as his physiotherapist persuades him to stand up for the first time since his vehicle was blown up. As he rises from the bed, he leaves a sheet that has turned magenta from lost blood. A big chunk of bone is missing from his leg.
"I can't do it," he gasps, blenched by the effort, and shamed by the admission of defeat. He is 28, nine months in Iraq with an army transport unit, an old man in a young man's war. Conceding failure comes hard. Lying down again, he covers his face. "Headache?" asks his doctor. He grunts. A waiting nurse ticks her TBI question box.
There is no collective memory in the US, as there is in other armies, of troop experience in previous wars: of trench warfare in 1915, of desert campaigning in World War II. The US textbooks are written by Vietnam veterans. But mental health experts have been mugging up on World WarI: the overlapping symptoms of TBI and post-traumatic stress disorder resemble the shell shock suffered, sometimes for decades, by survivors of the Somme. The combination of noise, fear and pain overloads the brain.
"Above all, the problem is fatigue," says Colonel Southwell. He has just returned from a year in Iraq and knows 12 months active service is a real psychological steam. "Six months would be optimal, but that is not possible in this war."
Now, as part of the US surge, combat service is to be extended to 15 months. Colonel Southwell hesitates before saying: "We do worry about this."
So how modern is this war? Post-traumatic stress disorder was a condition diagnosed after returning Vietnam veterans went off the rails. Gulf War syndrome has been used to explain the extraordinary physical and mental symptoms of often distraught soldiers. But TBI has been defined amid a counter-insurgent war, and as a result it carries little of the stigma attached to the shell-shocked, locked away in asylums in the 1920s.
"We have regular conferring – audio with Iraq and Afghanistan, video with Walter Reed – to track the development of a TBI case," says Colonel Flaherty.
The Congressional Research Service estimates twice as many US soldiers are being treated for brain injuries as for amputations.
"If this country cannot serve severely injured men and women coming back from this conflict, we need to look at ourselves," says John Melia, executive director of the Wounded Warrior Project.
"Unfortunately, to this point we have failed."
That stamps the Iraq mission as a modern war, not a rehash of Vietnam or the Somme.
It can be measured in the number of soldiers who want to return to combat after horrific injuries. Lance Corporal Kimani Boyea, 19, had most of the left side of his face ripped out while serving as a gunner. Now, with more than 100 stitches holding his face together, he is on his way back to his unit.
"My mother cussed me out. She said, 'Like, why are you going out there again?'," he says. "But this is my decision." Psychiatrists say soldiers feel guilty about leaving comrades behind.
Troops at the front can phone home regularly to discuss their child's schooling or the kitchen renovation. This can be a double-edged benefit, bringing tensions from home "down-range", as the US forces describe Iraq.
To be 19, to have been brought up on video game warfare and Tarantino films, to go to war in a strange land, be blown up and want to return – that requires courage, but also a suspension of normal fears and anxieties. It is the numbing down of war.
But the gritty reality of war returns in the Intensive Care Unit.
"One night a soldier called for me and said, 'I'm going straight to hell'," says chaplain Erik Harp. The soldier told him he had killed 37 Iraqis. "They killed my buddies, I killed them and I found joy in it." The chaplain told the dying man God's grace was infinite. The man continued to scream: "I'm going to hell."
"Is war ugly?" asks the Mormon minister. "It is."
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