The Costs of War

With 103 American fatalities, October was the fourth-bloodiest month since the beginning of the Iraq War. But the focus on the number of battle deaths may understate the true costs of the war for the American soldier. Due to innovations in battlefield medicine, we’re getting much better at saving soldiers’ lives. In WWII, 30 percent of those injured in combat died. In Vietnam–and even in the Gulf War–it was 24 percent. Now it’s around 10 percent. That is unquestionably a positive development. But it also means that many of those we save are horribly maimed. As this article from the New England Journal of Medicine describes:

One airman with devastating injuries from a mortar attack outside Balad on September 11, 2004, was on an operating table at Walter Reed just 36 hours later. In extremis from bilateral thigh injuries, abdominal wounds, shrapnel in the right hand, and facial injuries, he was taken from the field to the nearby 31st CSH in Balad. Bleeding was controlled, volume resuscitation begun, a guillotine amputation at the thigh performed. He underwent a laparotomy with diverting colostomy. His abdomen was left open, with a clear plastic bag as covering. He was then taken to Landstuhl by an Air Force Critical Care Transport team. When he arrived in Germany, Army surgeons determined that he would require more than 30 days’ recovery, if he made it at all. Therefore, although resuscitation was continued and a further washout performed, he was sent on to Walter Reed. There, after weeks in intensive care and multiple operations, he did survive. This is itself remarkable. Injuries like his were unsurvivable in previous wars. The cost, however, can be high. The airman lost one leg above the knee, the other in a hip disarticulation, his right hand, and part of his face. How he and others like him will be able to live and function remains an open question….

[F]or many new problems, the answers remain unclear. Early in the war, for example, Kevlar vests proved dramatically effective in preventing torso injuries. Surgeons, however, now find that IEDs are causing blast injuries that extend upward under the armor and inward through axillary vents. Blast injuries are also producing an unprecedented burden of what orthopedists term “mangled extremities” — limbs with severe soft-tissue, bone, and often vascular injuries. These can be devastating, potentially mortal injuries, and whether to amputate is one of the most difficult decisions in orthopedic surgery. Military surgeons have relied on civilian trauma criteria to guide their choices, but those criteria have not proved reliable in this war. Possibly because the limb injuries are more extreme or more often combined with injuries to other organs, attempts to salvage limbs following the criteria have frequently failed, with life-threatening blood loss, ischemia, and sepsis.

Even with all the efforts made to save limbs, “the amputation rate in Iraq is double that of previous wars,” as the LA Times reported earlier this year, in its three-part series on wounded American soldiers. 

That war is a bloody business is hardly a novel point.  And, of course, it is not by itself an argument against any particular war. If these men incurred similar injuries charging Al Qaeda positions at Tora Bora, that would have been terrible, but far easier to justify.  However, it is becoming increasingly hard to justify the costs of our open-ended commitment in Iraq, where our mission becomes ever murkier, and victory, however defined, continues to recede over the horizon.