Broken Bodies, Shattered Minds: A Medical Odyssey From Vietnam to Afghanistan

by Ronald Glasser M. D.

  There is even a growing sense within the military’s own corps of mental health specialists that the more serious TBIs, those accompanied with unconsciousness, may actually protect against the eventual development of PTSD by leading to an amnesia that protects against recalled memories and frightening experiences that could easily trigger the early, as well as the late, symptoms of PTSD.

  What was becoming clear in Iraq, and even clearer now in Afghanistan, is that the brain’s exposure to blast waves may be the most frequent and the most lasting of wounds. No one really knows the best way to accurately diagnose these wounds, or the best way to treat or prevent them. In the wars that had once been full of bullets, exploding artillery shells, rocket-propelled grenades, machine guns, chest and abdominal wounds, transected spinal cords, shattered livers, and fractured spleens there is something new. It is what Marilyn Lash and her colleagues, seeing the obvious, and refusing to look away, are calling our “Invisible Wounds.”

  13.

  THE BLEEDING WARS

  In its view, the “bleeding wars” offer the best opportunity to defeat the United States. Enlarging the war in Afghanistan is exactly what Al Qaeda wants, just as it wants the conflict in Iraq to continue …

  —The Search For Al Qaeda/Its Leadership, Ideology and Future,

  Brookings Institutional Press (2009)

  There was clearly no thought on the part of those who launched the attack in Afghanistan in 2001 and on Iraq in April of 2003 of our being bled to death, or that the Army and Marines would be stretched to the breaking point, and our National Guard pushed to the very edge of the cliff.

  Iraq was to be a war waged on the cheap. As for Afghanistan, well, we did succeed in destroying the Taliban once and forced Al Qaeda out of the country, somewhat evening up the score for 9/11. If necessary, we could always go back and fix whatever was left to fix. Some ten years later, we still have over 50,000 troops in Iraq, with sectarian violence once again increasing throughout the major cities even as we begin to send more troops back into Afghanistan. Over the last ten years, the Taliban have returned to the mountains and plains of Afghanistan and hold more than half of that country, while the leadership of Al Qaeda remains intact in the mountainous tribal areas that border an uncooperative Pakistan. What is clear today is that “Mission Accomplished” was no more than a snappy slogan.

  Military histories written in the midst of the conflicts are notoriously incomplete compared to the less emotional, betterresearched, and more-documented later efforts. But you don’t have to wait to understand what went so wrong in Iraq and Afghanistan. Beginning after World War II, the military implemented what are called “After Action Reports” or AARs. These are the immediate and for the most part on-site interviews with the combatants and commanding officers following a battle in order to evaluate in a strictly tactical sense, leaving aside egos and politics, the conduct of a battle in terms of both the immediate successes and obvious failures.

  AARs may be long or short, depending on the length and importance of the battle, but they are always informative. They act as a post-mortem, hopefully to serve as a future template to fix what went wrong and improve on what was done right. They are basically the authentic, unadorned, unrevised, and unedited history of what actually did happen.

  Recently, a number of monographs based on AARs involving both Iraq and Afghanistan have been published in the military and foreign policy press. The most direct, learned, and unblinking of these evaluations were published in the Journal of Foreign Policy in the Fall 2008, under the bland and rather innocuous title, “Learning From Contemporary Conflicts to Prepare for Future War.”

  It was written by Brigadier General H.R. McMaster, who in the fall of 2008, as the Regimental Commander of the 3rd Armored Cavalry, finally retook the Iraqi town of Tal Afar, near the Syrian border, from Al Qaeda after three years of occupation by the terrorists. Looked at realistically, the twenty-five page monograph is not only a review of AARs covering the previous eight years of our two current wars, but its tone, as well as McMaster’s position, is very close to the comments of the British military historian, Sir Michael Howard.

  In his book, Abuse and Use of Military Power, Howard wrote, “While everything changes with the first shot, the key to any chance of success is not to be so far off the mark that it becomes impossible to set things right.” Based on the AARs of the battles in Iraq and Afghanistan from 2001, the monograph is a professional attempt to begin to “set things right.” While McMaster does not predict ultimate success, he does at least offer the way to keep us from fooling ourselves.

  Here is the opening paragraph:

  Flushed with the ease of the military victory over Saddam’s forces in the 1991 Gulf War and aware of the rapid advance of communications, information, and precision munitions technology, many argued that U.S. competitive advantages in these technologies had brought about a Revolution in Military Affairs. Many argued that if these technologies were pursued aggressively, military forces could “skip a generation” of conflict and achieve “full-spectrum dominance” over potential adversaries well into the future. It was assumed that, based on the military technological advantages the United States already enjoyed, there would be “no peer competitor” of U.S. military forces until at least 2020. In the near future, it was assumed that U.S. forces would achieve “dominant battle space knowledge.” Military concepts based on this assumption promised rapid, low-cost victory in future war.

  These were the assumptions in place when the Iraq War began in April of 2003. It was the basis of the whole “Shock and Awe” approach that was to defeat the Iraqi military within weeks. As it turned out, the surprises were also on our side. But as McMaster points out, the battles a year earlier in Afghanistan should have made the administration, the Pentagon, and the country, suspicious of these new assumptions.

  McMaster goes on to say:

  At Tora Bora, for example, surveillance of the difficult terrain could not compensate for a lack of ground forces to cover exfiltration routes. After a 16-day battle, many Al Qaeda forces, including Osama bin Laden, escaped across the Pakistan border.

  And later, when U.S. intelligence detected a concentration of Taliban forces in the Shah-i-Kot valley, commanders deliberately planned an attack that would include two American Infantry battalions reinforced with Afghan and other Allied troops. Intelligence prepared for the operation spanned two weeks. U.S. forces focused every available surveillance and target acquisition capability, including satellite imagery, unmanned aerial vehicles, and communications and signal intelligence assets, on a 10X10 km box that defined the battleground. Enemy countermeasures to the sensors, however, were effective, and the fight was characterized by a high degree of uncertainty.

  As the fight developed, it became apparent that more than half of the enemy positions and at least 350 Al Qaeda fighters had gone undetected. The enemy’s reaction to the attack also was unexpected. American commanders had expected Al Qaeda forces to withdraw upon contact with the superior force rather than defend as they did from fortified positions. The unit had deployed with no artillery, assuming that surveillance combined with precision fires from the air would be adequate.

  However, even the most precise bombs proved ineffective against small, elusive groups of enemy infantry. In fact, soldiers (without artillery support) had to rely on small mortars. A combination of small unit skills, soldier initiative, and determined leadership permitted American forces to shake off the effects of tactical surprise, defeat Al Qaeda attacks on the landing zones, and then mount an offensive.

  During these early battles the advanced surveillance and information technologies failed to deliver the promised “dominant battlefield knowledge” as enemy forces employed traditional old-fashioned countermeasures to these high-tech capabilities, such as dispersion, concealment, deception, and intermingling with civilian populations.

  The Third Infantry Division, in crossing the Euphrates River, ran into an undetected Iraqi armored brigade that
counterattacked in a failed attempt to regain control of crossing sites along the river. There were a large and unexpected number of casualties.

  What is clear from a review of AARs is that these were not the wars, much less the kinds of battles, that had been planned for nor expected. The 1st Cavalry Division was actually sent to Iraq without its armor. As bizarre as it now seems, the Division off-ramped in Iraq with no tanks. But with casualties mounting within the Division and its units bogged down fighting insurgents within Iraq’s towns and cities, those same tanks had to be airlifted into Iraq from the States, one at a time, aboard C-5As.

  It is a fundamental military doctrine that without tanks any firefight becomes basically light infantry against light infantry. In those battles, the forces in control of the terrain, whether in cities or towns or along mountain passes, have the advantage of making the fight where they want and on their terms. In reality, if you have to go around kicking in doors or patrolling along narrow mountain paths, those behind the doors or using the rocks for cover always have the tactical advantage. That makes going on street patrols and setting up temporary road blocks in the midst of enemy forces while having to decide within seconds who to shoot and who to let go, at the same time that you are worrying about being shot or blown up yourself, is not only frightening but exhausting work. Do that every day and it quickly becomes impossible. And that is exactly what has happened and continues to happen to the majority of our troops.

  The AARs dealing with the initial run up from Nasiriyah to Baghdad at the very beginning of the Iraq War point out that even back then the initial lack of troops was the cause for the ever-increasing numbers of casualties.

  Troop strength compelled [our] dispersed forces to move continuously along routes that they were unable to secure, which, one could argue with confidence, was the principal cause of the large number of casualties from roadside bombs.

  This kind of war, with not enough troops on the ground— leading to small unit firefights, ambushes of supply columns, the use of IEDs along with suicide bombers—has not only led to a startling number of amputations and traumatic brain injuries, but to a new kind of PTSD where deployed personnel returning home have flashbacks and anxiety attacks simply driving a car down a highway, and nightmares about going to a movie or walking down a crowded street. We can’t do this without more of a national commitment and we can’t do this without a lot more troops or we shouldn’t even try to do it at all.

  As McMaster points out:

  In war, we have to reject the notions that lightness, ease of deployment and quickness are virtues in and of themselves. Forces must also have staying power and survivability if they are to succeed.

  What unit commanders need to know most about enemy forces, such as degree of competence and motivation, lay completely beyond the reaches of technology. And military units, whether a squad, platoon, company, battalion, or brigade, have to be able to survive as well as fight. Out on the battlefield, back-ups do count and redundancies do matter. And that cannot be done on the cheap.

  What McMaster documents is that our reliance—to the exclusion of virtually everything else—on technology and sophisticated weapons systems to control the battlefield is a flaw in both our strategic as well as our tactical thinking. It is an approach to warfare and the battlefield that can best be described as “Gadgetry Replacing Strategy.” It puts every soldier and marine at risk.

  Sir Rupurt Smit, a general in the British Army who won praise from American generals as commander of the 1st Armored Division in the First Gulf War, has offered much the same assessment, though in the less dramatic and decidedly more understated British way.

  “Frequently we can see that our opponents deliberately operate below the threshold of the utility of our weapons and organization as we would wish to use them … We have equated technology with the use of force … but force can be achieved by throwing rocks … When a terrorist can detonate a bomb with a mobile phone our battalions are useless.”

  Yet, the real message in Learning from Contemporary Conflicts to Prepare for Future Wars is in the final summation. The ending is more than a cautionary tale and more than the difference between winning and losing. It is the difference between coming home intact or in a box, or with your arms or legs blown off, having a traumatic brain injury or a diagnosis of PTSD.

  Wars cannot be waged efficiently. In both Afghanistan and Iraq, the United States’ planned troop reductions assumed a linear progression toward stability. As a result, units shifted areas of operation to compensate for troop shortages and unit deployments were accelerated, as it became clear that “off ramp” plans were unrealistic. Moreover, a short-term approach to long-term problems generates multiple short-term plans that confuse activity with progress.

  But perhaps Gladstone, the Prime Minister of England during the reign of Queen Victoria, who presided over the failure of the British invasions of Afghanistan, explained it best when, at the end of his career, he was asked by a reporter what was the most difficult part of being Prime Minister. Gladstone did not hesitate, “Why reality, my dear boy—reality!”

  14.

  IEDS/BLASTS THAT KILL AND MAIM

  Every war has its own signature wounds. At Agincourt and Crecy in the Fifteenth Century, it was the puncture wounds inflicted on the French knights by flights of arrows from English longbows. The beginnings of gunpowder-propelled projectiles, the muskets of the Sixteenth Century, led to chest and abdominal wounds never before seen on a battlefield, while the cannon balls with their explosive charges led to multiple as well as massively contaminated wounds that inevitably proved fatal.

  In our own Civil War, it was high-velocity bullets fired with astonishing accuracy from weapons with rifled barrels that caused the new types of deeply penetrating and tissue-shattering wounds. The bullets hit with such impact that they routinely broke bones, leading to the thousands of amputations that became the hallmark of the major battles of the war, from Harper’s Ferry to Shiloh, Spotsylvania, Antietam, and Gettysburg.

  The Civil War was the first major war following the Industrial Revolution and the slaughter was on an industrial scale. By the end of the war, well over a third of all the men in the State of Mississippi had become amputees. And the carnage has simply increased with each new decade and each new war.

  During the First World War, it was machine gun fire that caused multiple head, torso, and abdominal injuries. The majority of those wounded bled to death from punctured lungs, shattered livers and spleens, blown-away abdominal aortas, torn iliac arteries, and fractured kidneys. There was a reason that 20,000 soldiers died on the first day of the Battle of the Somme.

  In the Second World War, it was multiple shrapnel wounds from barrages of artillery, as well as burns from exploding tanks, trucks, and torpedoed ships leaking tons of flammable fuel oil easily ignited, that were the major causes of both deaths and disabilities. The real lifesavers during those years of fighting in the fields of Europe and the jungles of the Pacific was the availability, beginning in 1941, of the newly discovered sulfur antibiotics, along with the use of plasma and other blood substitutes, as well as better and more effective wound care.

  In Vietnam it was vascular injuries caused by booby traps and close-up machine gun and small-arms fire, exploding satchel charges, and shrapnel from rocket-propelled grenades. Those who lived survived because of rapid med-evacs to a surgical or evac hospital, the increasing skills of the surgeons, and the development of grafting techniques to reconstruct damaged arteries and veins.

  Today, in Iraq and increasingly in Afghanistan, it is poly-trauma and traumatic brain injuries from the blasts and shock waves of car, roadside bombs, and suicide bombers that have become the major cause of casualties and death leading to what are these war’s signature wounds—amputated and destroyed limbs and traumatic brain injuries.

  The sad truth is that there is little “improvised” in an explosion that can turn over a 70-ton M1A1 tank, blow the windows out of every building within a four
-block radius, or rattle the brains of any soldier or marine within a dozen meters of even the smallest blasts.

  In Iraq and Afghanistan, it is the powerful blast waves even more then the heat and projectiles from the explosions that does the most damage to internal organs, rupturing bladders and stomachs, causing air to leak from the lungs leading to asphyxia and sudden death, as well as injuries to the brain itself. Of all the organs of the body, the brain is the most susceptible to damage from rapid and dramatic shifts in atmospheric pressures, in short, from the shock waves generated by detonated IEDs.

  What nature gives, nature often takes away. Placing the brain within the protective shell of the skull, while having clear evolutionary advantages, can be a real problem if the brain is set into motion from the head being hit with a hammer, a fall in the bathroom, or the passing pressure wave front of an exploding IED. Even thirty or forty meters out from the center of a large explosive charge, brain tissues can be significantly, and in some cases permanently, damaged.

  The Pentagon’s own data on IEDs is scary at best and terrifying at worst. Wire together three 155-mm artillery shells, put them in the ground and cover them with a few pounds of Centex, then put some canisters of butane gas on top of the explosives and the temperature at the center of the explosion will reach between 6,000 and 7,000 degrees. The blast wave moves at 1,000 feet per second with a pressure gradient of 400 pounds per square inch, or over a 1,000 times atmospheric pressure.

  The blast waves of high pressure spread out in all directions, followed closely by what is called a “secondary wind,” the result of the huge volume of displaced air flooding back into the area of low pressure generated in the wake of the original blast front.