Battle Field Angels (37 page)

Yet psychological casualties remained one of the least likely to be treated on the battlefield. Many soldiers were hesitant to acknowledge PTSD or related symptoms in the war zone. Two thirds feared they would be perceived as weak or would be treated differently by other soldiers. A majority feared a loss of confidence by their fellow soldiers, and about 40 percent simply were too embarrassed to seek treatment.

The psychological impact of multiple deployments also affected the Navy’s ability to supply the Marines with field corpsmen. Navy corpsman reenlistment rates declined 5 percent to less than 60 percent in 2006 among those who were six- to ten-year veterans. In 2008, the Navy reduced the reenlistment bonus for some basic corpsmen ratings and increased the bonus for more experienced corpsmen. It came at a time when the Navy needed approximately 2,500 new corpsmen annually to meet personnel needs, in part to supply the 4,500 corpsmen who were assigned to the Marines. Although the corpsman rating has been one of the most highly decorated in the Navy, it has not been recognized as a fast track to promotion. In addition, other nonmedical specialties offering higher reenlistment bonuses and better postmilitary service compensation prompted some corpsmen to apply for transfers.

Some psychological casualties became fatalities before a soldier returned home. Between 2001 and 2008, nearly six hundred active-duty Army soldiers committed suicide, the equivalent of a battalion. The Army active-duty suicide rate rose from 12.4 per 100,000 in 2003 to 18.1 in 2007, an increase of nearly 50 percent. In late 2008, the Army suicide rate was on pace to exceed that of 2007. Suicide was the fourth most common cause of death in the war zone, behind enemy fire, accidents, and disease. In early 2008, Veterans Administration officials acknowledged that 12,000 of the veterans seen at VA facilities attempted suicide annually, approximately one attempt every forty-two minutes.

Unlike other battle wounds, psychological casualties can take months or even years to identify. A 2004 study revealed a PTSD incidence rate of 6.2 percent among soldiers three months after they were sent to Afghanistan or Iraq. It increased to 16.6 percent one year after their deployment.
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Today, the military conducts multiple postdeployment assessments to monitor their soldiers’ mental health, and the reported incidence of PTSD has increased significantly.

In 2008, RAND Corporation released a study estimating that 300,000 of the 1.6 million men and women who served in Afghanistan and Iraq to that point suffered from PTSD, major depression, or related mental health issues. The one-in-five incidence rate increased to one in three when mental and emotional damage inflicted by traumatic brain injury was included. This 33 percent incidence rate was consistent with the findings of long-term studies of PTSD among Vietnam veterans.

The RAND study estimated the cost of treatment to be more than $6.2 billion in the near term, but that figure could be much higher due to associated unemployment, drug abuse, violence, and suicide if veterans did not receive care. Although veterans make up approximately 11 percent of the population, they account for 25 percent of America’s homeless.

The physical, mental, and emotional casualties suffered in combat in Afghanistan and Iraq, coupled with veterans’ long-term disabilities, threatened to overwhelm the VA. Veterans seeking VA services faced a gauntlet of bureaucratic approvals. In 2007, some veterans were required to complete as many as twenty-two documents to obtain care. An audit of the VA revealed sixteen information systems, many of which did not communicate with each other.

The Army’s showcase medical facility, Walter Reed Army Medical Center, became a symbol of military medicine’s struggle to adapt to the evolving needs of war’s casualties. The facility provides state-of-the-art, life-saving surgical and medical care for thousands of critically wounded soldiers. It treats about 25 percent of all soldiers wounded in Afghanistan and Iraq, but has been ill equipped to meet the needs of outpatients. In 2007, there were seventeen outpatients for every hospital patient. Walter Reed’s inadequate outpatient facilities and services became a national shame. Many of its five outpatient buildings were riddled with cockroaches, rats, mice, and mold. Wounded soldiers who had supervisory duties were responsible for as many as two hundred rooms. Basic services, such as hot water, were unreliable in facilities in which the average outpatient stay was ten months but could be as long as two years. The medical center’s commanding officer acknowledged a reluctance to promptly discharge some outpatients who might leave the armed services at a time when some branches of the military were under pressure to meet recruitment quotas.

That same year, Congress appropriated $900 million to fund stress-related research projects, psychological health programs, and traumatic brain injury initiatives. The funding was made available within months of reports by a Department of Defense task force and the President’s Commission on Care for America’s Returning Wounded Warriors, which outlined shortcomings in the military’s mental health care and the need for significantly increased research, diagnosis, and treatment programs.

Researchers across the country evaluated new techniques of treating PTSD and related mental disorders suffered by veterans. In 2008, the Army made $4 million available for clinical, evidence-based research projects that focused on alternative treatments for PTSD. Possible therapies included massage, art, dance/movement, acupuncture, and yoga.

Treatment programs involving virtual reality appear to hold significant promise. One simulation program, called “Virtual Iraq,” was created by Albert Rizzo, a clinical psychologist at the University of Southern California. He modified an existing computer game, “Full Spectrum Warrior,” to create two scenarios: an Iraqi market square and a military convoy of Humvees on a rural road. Rizzo’s prototype program received a lukewarm response in 2004 when he sought funding for trials. That year, the first mental-health assessment of troops returning from Afghanistan and Iraq was published in the
New England Journal of Medicine
. The study concluded that 17 percent of Iraq veterans and 11 percent of Afghanistan veterans were suffering from PTSD and related disorders. The magnitude of the problem surprised the military, and soon thereafter the Office of Naval Research offered to fund clinical trials using Rizzo’s simulation program.

Four years later, the Veterans Administration and American Psychiatric Association endorsed two principal types of virtual reality use in continuing clinical trials. Using realistic computer simulations, head-mounted displays, sophisticated surround-sound systems, and vibrating platforms, they placed veterans suffering from PTSD in a realistic war environment. The therapy immersed the patient in conditions similar to what had triggered PTSD.

Long-exposure therapy utilized virtual reality sessions repeatedly until a patient learned to master his emotional response to what he had experienced. Cognitive-processing therapy also employed virtual reality simulations as therapists helped patients think through their experience and put it in the proper perspective. One approach was based on re-experiencing the traumatic event, while another helped patients analyze the event. Some researchers also used an old tuberculosis drug, D-cycloserine, which was found to inhibit the fear response in laboratory animals.

By the end of 2008, increasingly sophisticated virtual reality simulations enabled therapists to control the level of intensity by adjusting the sound, adding bomb blasts and gunfire, and incorporating the smell of sweat and smoke while monitoring their patients’ vital signs. Virtual Iraq was being tested by the Department of Defense in six locations, including Naval Medical Center San Diego, one of the Navy’s foremost medical treatment and research facilities. Navy psychologists reported that some veterans recovered in less than two months of virtual reality-based treatments that addressed their fundamental fears, tendencies to avoid associated personal issues, and pervasive anxiety.

Overall, clinical trials using prolonged virtual-reality treatments reduced PTSD symptoms in veterans in 65 percent of the cases, compared to a 40 percent success rate for behavioral therapy and 20 percent for patients using antidepressants.

Widespread recognition of the prevalence of psychiatric casualties not only led to new research, it spawned changes in how the military trained personnel for combat. Soldiers and medical personnel were instructed on what to expect in battle. They learned that experiencing tunnel vision, a temporary loss of hearing, and other involuntary reactions was not unusual. In some cases, virtual reality was incorporated into corpsman training, better preparing them for the battlefield.

In late 2008, Congress authorized a $41 billion annual budget for VA health programs, which were expected to serve 5.8 million veterans. The appropriation included $3.8 billion for mental health services, twice the funding level in 2001, and $584 million for substance abuse programs. Several veterans’ organizations believed the funding levels for both were inadequate to meet growing demand. Congress also appropriated $5 billion for VA hospitals, a 14 percent increase over the previous year.

Meanwhile, the Navy took steps in 2008 to increase psychiatric care on the battlefield. Officials announced a plan to increase its deployable psychiatric teams from seven to twenty-three, one for each Marine Corps regimental combat team. A social worker was to be added to the existing four-person teams comprised of a psychiatrist or psychologist and three psychiatric technician corpsmen. The plan reflected the recognition that psychiatric specialists in the war zone would be able to build the relationships and trust necessary for more effective treatment and would eliminate soldiers’ guilt over leaving their comrades to seek mental health treatment in the rear. The teams were expected to be fully deployed in 2011.

The Navy also established the Naval Center for Combat and Operational Stress Control, its first comprehensive program to include stress training during both pre- and postdeployment. The center’s goals are to become a principal hub of data management, act as a catalyst of diverse stress research projects, and lead community outreach efforts within the military to reduce the stigma attached to PTSD and related disorders.

For more than two hundred years, America’s military medical corps has raced to keep pace with the evolving realities of war, both on and off the battlefield. In the twenty-first century, the American way of war is premised upon mobility, speed, technology, precision, and warrior empowerment. We may never be completely without war, but for as long as men and women in uniform serve our nation’s causes, equally heroic corpsmen and medics will carry on the proud tradition of risking their lives to save those who fall wounded on the battlefield.

E
ight generations of Americans have confronted war. More than 1 million have died on battlefields that over two centuries have been transformed by industrialization, science, and technology.

As America has gone to war more frequently in our recent history, war’s lethality has accelerated as well. Nearly ninety years passed between the Revolutionary War and the Civil War. Weapons evolved in size and speed and grew more deadly, but it was not until America entered World War I more than fifty years later that industrialization produced massive, mechanized weaponry capable of killing thousands in a day and hundreds of thousands in a single battle. World War II, the Korean War, and the Vietnam War each resulted in widespread death, increasingly complicated injuries, and new challenges for America’s military medical corps.

Military medicine adapted to the unique realities of the battlefield in each war and pioneered medical advances that frequently redefined civilian health care. The modern ambulance system was developed during the Civil War when Union and Confederate armies and their doctors faced thousands of casualties for the first time in battle. The pavilion design adopted by hospitals for nearly a century was conceived by Civil War doctors who sought to improve the sanitary conditions in military hospitals in the mid-nineteenth century.

At the outset of World War I, military surgeons sewed a wounded soldier’s basilic vein at the elbow to a donor’s radial artery at the wrist for direct, unmatched blood transfer. The failure rate demonstrated the need to match donor and recipient blood types, which served as an impetus to the creation of a viable blood bank. Although at the time they lacked the technology to preserve blood, the military medical corps demonstrated the enormous potential of blood transfusions and blood banks. They also refined the practice of triage, the immediate assessment and staged treatment of injuries, which was originated by French doctors.

During World War II, corpsmen and medics helped establish antibiotics as a cornerstone of modern medicine. They were the first to use sulfa drugs on a widescale basis to control infections. By the end of the war, they also proved that the new drug penicillin was even more effective. That validation on the battlefield served as a harbinger of the development of dozens of other antibiotics in the postwar years.