Accessibility and affordability of extra-durable alloys conceived over the past several decades have change warfare, and the pattern of injuries we see in war. Flak jackets and Kevlar helmets are relatively impenetrable to small arms fire or small fragments from IEDs. High velocity rounds will go right through a Kevlar helmet, and we have seen a patient with an AK-47 round lodged in the middle of her brain - and it will likely stay there for the rest of her life. Likewise, direct hits from explosive devices of nearly any kind are mostly fatal from despite these protections.
In general, there are more survivors, or rather, survivors per servicemember attacked, then there were in conflicts as recent at Vietnam. This is largely due to improved protective devices (eg, armored vehicles, kevlar helmets, flak vests) quick access to medical care. Tactical superiority plays a role, but in Iraq and Afghanistan, the guerrilla warfare and use of suicide bombings have negated much of the conventional military advantage. Unfortunately, explosions which would have killed servicemen in the past now leave many with amputations, and many more with traumatic brain injury (TBI) and secondary, or coexistent post-traumatic stress disorder (PTSD). The DoD has made large investments in medical personnel and research in this area, but the treatment of TBI is still underdeveloped.
We have several patients in the hospital at any one time with TBI. Usually, this is from proximity to an explosion, but can be vehicular accidents, falls, or brawls. We are largely not equipped to handle these patients here, and they are sometimes the toughest patients to properly classify. For example, while it is quite clear that patients who have brain surgery for a concussive injury and subsequent brain swelling are to be stabilized, and then sent home, and patients with mild/distant exposure to explosives who do not suffer concussions and pass a TBI screening test should be able to stay in theater; it is difficult, however, to discern how to triage those in the middle. There are always soldiers who have a concussion and clear post-concussive anxiety who plead to stay here with their squad. And for each of these, there is another with no concussion who seems fine and pleads to leave (this includes malingerers, and there are some of those too). It is not an easy judgment call; determining who should be sent home for priority medical care, and who is fit to return to duty.
The other night, I think that we saw the results of one who slipped through the cracks. This gentleman was 40 feet from a rocket blast, and though he had no clear injuries (behind the wall), he was shaking like a leaf and had a massive headache. His CT was normal, and brain was not bruised, but it turns out that he has a history of PTSD, and related headaches, from exposure to another explosion in an earlier deployment. After years of behavioral therapy he somehow garnered approval to return to theater, and then he gets hit again. His nerves were fried, and one could see months and years of work unraveling.
He insisted on returning to his unit. He wasn't my patient, so it wasn't my decision - though it never really is the doctor's decision, as the commanding officer makes the final call - but I do wonder if something else is going to happen to him, or that he'll go unhinged if/when it does. We have to do better with this here, and when he returns to the US, and is expected to hold down an honest job, and get along with others in a world surreal to his own.