Iraq War Already Lost on Unacknowledged Shock Wave of Brain Injuries

                       By Ronald Glasser, pediatric nephrologist and author of Wounded: Vietnam to Iraq, from the Washington Post

   This is the new physics of war.  Three 155mm shells, linked together and combined with 50kg of Semtex plastic explosive, covered by barrels of petrol, can upend a 70-tonne tank, destroy a Humvee or blow an engine block through the hood of a truck.  Those deadly ingredients form the signature weapon of the war in Iraq: improvised explosive devices, known by anybody who watches the news as IEDs. [The pentagon, the world's greatest organization at using language to obfuscate reality, uses "improvised" and its implication of amateurish and ad hoc, to leave the impression of benign, when the reality is a violence of unprecedented proportions ("shock and awe").]

   Some of the impact of these roadside bombs is brutally clear.  Troops are maimed by projectiles, poisoned by clouds of bacteria-laced debris and burned by post-blast flames.  But the IEDs have added an extra dimension to battlefield injuries: wounds and even deaths among troops who have no external signs of trauma but whose brains have been severely damaged.  Iraq has brought back one of the worst afflictions of first world war trench warfare - shell shock.  The brain of a soldier exposed to a roadside bomb is shocked, truly.

   About 1,800 US troops, according to the Department of Veterans Affairs, are suffering from traumatic brain injuries (TBIs) caused by penetrating wounds.  But neurologists worry that hundreds of thousands more - at least 30% of the troops who have engaged in active combat for four months or longer in Iraq and Afghanistan - are at risk of potentially disabling neurological disorders from the blast waves of IEDs and mortars, all without suffering a scratch. For the first time the US military is treating more head injuries than chest or abdominal wounds, and it is ill-equipped to do so.  According to a July 2005 estimate from Walter Reed Army Medical Center, two-thirds [7,000 as of 4/28/07] of all soldiers wounded in Iraq who don't immediately return to duty have traumatic brain injuries. [And let's not forget the Iraqi people who are also being exposed to these weapons.]

   Here's why IEDs carry such hidden danger.  The detonation of any powerful explosive generates a blast wave of high pressure that spreads out at 500m per second from the point of explosion and travels hundreds of meters.  The lethal blast wave is a two-part assault that rattles the brain against the skull.  The initial shock wave of very high pressure is followed closely by the "secondary wind": a huge volume of displaced air flooding back into the area, again under high pressure.  No helmet or armor can defend against such a huge wave front.

   These sudden differences in pressures - routinely 1,000 times greater than atmospheric pressure - lead to significant neurological injury.  Blast waves cause severe concussions, resulting in loss of consciousness and obvious nerological deficits such as blindness, deafness, and developmental disabilities.  Blast waves causing TBIs can leave a 19-year-old private who could easily run a six-minute mile unable to stand or even to think.

   Another problem is that these blast-related brain injuries differ from other severe head traumas and the complexity of treating returning troops with "closed-head" injuries is taxing an overburdened military healthcare system.  The standard care involves using calcium channel blockers to protect damaged nerve cells against further injury, intravenous diuretics to control brain swelling and, if the swelling becomes too great, removal of the top of the skull to allow the brain to swell.

   All this works with common types of severe head injuries, but it does not work with brains damaged by shock waves.  Despite the usual interventions and treatments, most blast-injury patients who have neurological damage do not fully recover.  There is a growing understanding within the neurosurgical community that blast injuries are different from those caused by penetrating or skull-fracture trauma.  It is thought that shock waves damage the brain at a microscopic, sub-cellular level.  That's why surgeons who can reconstruct the skull of a motorcycle crash victim struggle to come up with treatment and rehabilitation techniques for the explosion-damaged brains of troops.

   "TBIs from Iraq are different," said P. Steven Macedo, a neurologist and former doctor at the veterans administration.  Concussions from motorcycle accidents injure the brain by stretching or tearing it.  But in Iraq something else is going on. "When the sound wave moves through the brain, it seems to cause little gas bubbles to form," he said. "When they pop, it leaves a cavity.  So you are littering people's brains with these little holes."

   Almost as daunting as treating TBI is the volume of such injuries coming out of Iraq.  Macedo cited the estimates, gleaned at seminars with veterans affairs doctors, that as many as one-third of all combat forces are at risk of TBI.  Military physicians have learned that significant neurological injuries should be suspected in any troops exposed to a blast, even if they were far from the explosion.  Soldiers walking away from IED blasts have discovered that they often suffer from memory loss, short attention spans, muddled reasoning, headaches, confusion, anxiety, depression and irritability.

   The unseen damage can be long-lasting.  Most of the families of the wounded that I have interviewed months, if not years, after the injury say the same thing: "Someone should have told us that with these closed-head injuries, things would not really get all that much better."

   The Iraq conflict is not a war of death for US troops nearly so much as it is a war of disabilities.  The symbol of this battle is not the cemetery but the orthopedic ward and the neuro-surgical unit.  The men and women inside those units have come home alive but missing arms and legs, many unable to see or hear or remember who they were before being hit by a roadside bomb.  Survival clearly represents as much of a revolution in military medicine as does the dominance of the suicide bomber and the roadside bomb.  But the medical profession and the US are left to play a terrible game of catch-up.

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