"Beyond the Battlefield" is a 10-part series exploring the challenges that severely wounded veterans of Iraq and Afghanistan face after they return home, as well as what those struggles mean for those close to them. Other stories in the series can be found here.
July 4, 2010, was a bad day for Tyler Southern. He dreamed he was with his older brothers, playing sandlot football, running and laughing, horsing around just like they used to when they were together as kids in Jacksonville, Fla.
In his dream, he was whole again.
Then he awoke in his hospital bed at the Walter Reed National Military Medical Center in Bethesda, Md., and reality came flooding back. Both of his legs and his right arm were gone, blown off in Afghanistan two months earlier by an improvised explosive device so powerful that only bits of his legs and boots were ever found. The explosion left one remaining limb, his left arm, broken and mangled.
Southern began to hyperventilate. His mother Patti, at his bedside, reached out to calm him. Mom, something's coming on, he cried. Breathe with me, she murmured. Breathe with me. She gathered him in her arms and held his head tight against her chest as sweat beaded over his body and his heart pounded wildly. He gulped lungfuls of air, his mother rocking him in her arms.
Breathe with me.
Suddenly Southern vomited. Patti rocked him gently in her arms until he was calm.
"My last big, bad day,” he recalled recently. "Everybody has 'em," he added, speaking of the other patients he knows who are struggling with severe wounds.
A 22-year-old Marine Corps corporal, Southern is just one of a growing number of young Americans -- 16,000 or more, so far, out of 2.3 million American troops sent overseas -- who volunteered for Iraq or Afghanistan and came back alive but catastrophically wounded.
Those numbers are small but significant, because they indicate an alarming new trend in warfare. Despite untold billions of dollars spent over the past 10 years to defeat Afghan insurgents, the enemy's ability to severely wound Americans in battle is growing, according to U.S. military data and analysis.
Proportionately fewer American troops are being killed outright on the battlefield, thanks in part to better protective equipment and improved medical care. "We are stealing some people from death," Army Brig. Gen. Joseph Caravalho, a senior Army medical officer, told me at the Pentagon.
Still, more Americans are being wounded in combat. And their wounds are more severe and complex, raising difficult issues for military medicine and for the nation on which disabled soldiers will depend for a lifetime of care.
The Defense Department uses a measure called the Military Injury Severity Score to categorize wounds. In Afghanistan, the severity scores have increased steadily since 2006, the Army reported in June.
The number of American soldiers who lost at least one limb in combat doubled from 86 in 2009 to 187 last year, while the number with multiple limb loss tripled, from 23 in 2009 to 72 last year. Those in need of blood transfusions of 10 units of blood or more (the human body holds a total of 10 units of blood) rose during that 12-month period from 91 to 165.
And triple amputees like Tyler Southern are becoming more common. Their ranks have nearly doubled this year from the total of all triple amputees seen over the past eight years of war, the Army said in its report, "Dismounted Complex Blast Injury."
"These complex blast injuries are not only complex for the person to live with for the rest of their life, but they're also difficult for the entire medical health care system because of the resources they take," said Army Col. James Ficke, chief orthopedic surgeon at the Brooke Army Medical Center in San Antonio, Texas.
THE DEVASTATION OF THE IED
Most of the severely wounded are victims of a deadly new form of explosives perfected by insurgents in Iraq and Afghanistan, classified as improvised explosive devices. A seven-year, $20 billion Pentagon campaign has been unable to defeat the IED and its deadly cousin, the suicide bomb. Over the past year, American troops have become more vulnerable to IEDs because they are walking more foot patrols, in keeping with the U.S. counterinsurgency doctrine of working closely with local Afghan villagers.
The survivors' wounds are often horrific. In Afghanistan, an IED is typically made of a plastic bucket of ammonium nitrate buried beneath layers of sand and dirt. It explodes with a lethal pressure wave strong enough to knock down concrete walls and bend metal, followed by a fireball as hot as 2,700 degrees that can burn away eyelids and fingers.
The blast severs limbs, ears and noses; tears off faces; crushes bones and teeth; bruises the brain; strips away skin and muscle; and ruptures eyeballs, eardrums, lungs, bowels and other internal organs. As the blast erupts upward, it drives sand, dirt, pebbles, bone fragments and barnyard filth deep into vulnerable soft tissue.
In recent months, trauma surgeons have seen a sharp rise in the war's most disturbing wound: the traumatic loss of both legs and the genitals.
The upward blast of an IED often rips off lower limbs as high as the hip, as well as the genitals. It shatters the pelvis and often takes off the arm the victim is using to hold out his weapon. In some cases the perineum, the seam at the bottom of the torso, is ripped open and the intestines and other organs spill out, a Navy combat corpsman told me.
One out of five Americans whom the Army medically evacuated from Afghanistan last October suffered such wounds, which the military calls genitourinary, or “GU,” wounds.
These GU injuries have become so widespread that the Army has begun training surgeons in genital repair and reconstruction in its urology residency training programs.
Among the troops serving in Afghanistan, though, the response has been more direct: They would rather be dead than castrated. According to the Army task force report on severe IED wounds, a number have developed "do not resuscitate" pacts in case they suffer traumatic genital amputation.
This month, the Army begins shipping tens of thousands of pairs of armored overgarments -- in effect, diapers -- to try to protect soldiers’ genitals from blasts. The devices, made with layers of Kevlar, is strapped on over clothing, passing between the legs and snapping at the waist, and provides front and rear shielding.
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According to Army Col. William Cole, the procurement officer, the garments will only be issued to soldiers at risk of encountering IEDs, such as those who operate with route-clearance teams.
An informal accounting of GU wounds by doctors at the U.S. military hospital in Landstuhl, Germany, where the wounded first arrive from Iraq or Afghanistan, described a threefold increase in genital wounds, from 45 in 2008 to 142 last year. Through July of this year, Landstuhl's surgeons have seen 90 GU cases, most of them involving the loss of genitals.
"It's the first thing they ask" when patients wake up, said Dr. Steven Davis, a psychiatrist at Walter Reed. "Are they still there?"