Disability

Background

Since the late 19th century, military physicians and scientists have made great strides toward limiting the numbers of troops either killed or permanently disabled because of wartime injury and illness. In World War I, advances in battlefield evacuation and emergency trauma care saved the lives and limbs of countless wounded men. In World War II, the introduction of penicillin and sulfa drugs reduced death rates even further, allowing war-injured combatants to fight off infections that would have been fatal only a few years earlier. In the Korean and Vietnam Wars, the use of evacuation helicopters and Mobile Army Surgical Hospitals dramatically decreased the transit time between a combatant’s point of injury and the site of definitive care—a key step in the reduction of permanent disability. Today, the Department of Defense (DOD) and the VA, working alongside civilian contractors and nonprofit organizations, have developed a wide range of assistive technologies and social programs to minimize the long-term effects of physical and psychological trauma. Despite such efforts, however, the era of disability-free warfare— predicted by military scientists as far back as the late 19th century—remains a distant fantasy. Since the start of the Global War on Terrorism in 2001, more than 30,000 U.S. troops have been wounded in combat, more than half of them requiring immediate medical transport back to the United States. To add insult to injury, the latest generation of disabled veterans continues to face many of the same [Page 478]bureaucratic and institutional barriers that plagued their 20th-century counterparts.

Treatment and Recovery

For U.S. forces fighting in Afghanistan and Iraq, traumatic injury—both physical and mental— remains a constant hazard. To the surprise of military planners in Washington, both Operation Enduring Freedom and Operation Iraqi Freedom quickly devolved from mobile wars of maneuver into grinding antiguerrilla campaigns characterized by the use of “irregular” tactics on all sides. Unable or unwilling to wage war by conventional means, Afghan and Iraqi insurgents increasingly turned to homemade bombs and other improvised explosive devices—known in military jargon as IEDs— to shred the bodies of the American occupiers. In addition to extensive soft tissue damage, IED victims frequently suffer fourth degree burns, internal bleeding, and traumatic brain injury—sometimes referred to as the “signature wound” of the Global War on Terrorism. Some 50% of IED casualties exhibit prolonged headaches, memory loss, cognitive problems, and other symptoms of traumatic brain injury. Moreover, because the destructive force of IEDs is focused largely on their victims’ extremities, more than 500 Americans have returned from Afghanistan and Iraq as amputees, their bodies forever marked by wartime trauma.

Against this backdrop, the U.S. Military Health System has implemented a two-phase campaign to minimize the number of combat personnel permanently disabled through military service. The first phase focuses on saving the lives of U.S. casualties and optimizing their chances of functional recovery. It begins on the battlefield, with combat lifesavers or field medics providing U.S. casualties with immediate medical treatment. Once evacuated from the line of fire, wounded combatants move through additional levels or “echelons” of care, depending on the severity of their injuries. The first stop is usually a nearby aid station, where a small forward surgical team stabilizes the patient for further travel. From there, wounded service members are transferred to an army combat support hospital, a navy hospital, or an air force theater hospital, where military surgeons administer further treatment—such as reconstructive surgery and transfusion—before shipping them out of the combat theater. En route to the United States, most injured Operation Enduring Freedom/Operation Iraqi Freedom troops make a brief stop at Landstuhl Regional Medical Center in Germany, the U.S. military’s largest overseas medical facility. Thanks to improvements in transportation, communications, and organization, the medevac process is remarkably efficient. During the Vietnam War, U.S. casualties typically waited 2 weeks or longer to receive definitive, off-continent care. Today, the same level of treatment is available in less than 13 hours.

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