AP) — More than 800 of them have lost an arm, a leg, fingers or toes. More than 100 are blind. Dozens need tubes and machines to keep them alive. Hundreds are disfigured by burns, and thousands have brain injuries and mangled minds.

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Marine Cpl. Joshua Pitcher, 22, is recovering
from a brain injury and shrapnel wounds from
a grenade blast in February.

These are America’s war wounded, a toll that has received less attention than the 3,500 troops killed in Iraq. Depending on how you count them, they number between 35,000 and 53,000.

More of them are coming home, with injuries of a scope and magnitude the government did not predict and is now struggling to treat.

“If we left Iraq tomorrow, we would have the legacy of all these people for many years to come,” said Dr. Jeffrey Drazen, editor-in-chief of the New England Journal of Medicine and an adviser to the U.S. Department of Veterans Affairs. “The military simply wasn’t prepared for its own success” at keeping severely wounded soldiers alive, he said.

Survival rates today are even higher than the record levels set early in the war, thanks to body armor and better care. For every American soldier or Marine killed in Iraq, 15 others have survived illness or injury there.

Unlike previous wars, few of them have been shot. The signature weapon of this war — the improvised explosive device, or IED — has left a signature wound: traumatic brain injury.

Soldiers hit in the head or knocked out by blasts — “getting your bell rung” is the military euphemism — sometimes have no visible wounds but a fog of war in their minds. They can be addled, irritable, depressed and unaware they are impaired.
Invisible injury

An estimated 2,000 cases of brain injury have been treated, but doctors think many less obvious cases have gone undetected. One small study found that more than half of one group of wounded troops arriving at Walter Reed Army Medical Center had brain injuries. Around the nation, a new effort is under way to check every returning man and woman for this possibility.

Some of those on active duty may have subtle brain damage that was missed when they were treated for more visible wounds. Half of those wounded in action returned to duty within 72 hours — before some brain injuries may have been apparent. The military just adopted new procedures to spot these cases, too.

Back home, concerns grow about care. The Walter Reed hospital scandal and problems with some VA nursing homes have led Republicans and Democrats to call for better care for this new crop of veterans.

Mental health problems loom large. More than a third of troops received psychological counseling shortly after returning from Iraq, and in a third of those a problem was diagnosed, a recent Pentagon study found. The government plans to add 200 psychologists and social workers to help treat post-traumatic stress disorder and other issues.

No one knows what the ultimate cost will be. Harvard University economist Linda Bilmes estimates the lifetime health-care tab for these troops will be $250 billion to $650 billion — a wide range but a huge sum no matter how you slice it.
Numbers at issue

Counting the wounded can be contentious. Earlier this year, the Department of Defense changed how it tallies war-related injuries and illness, dropping those not needing air transport to a military hospital from the bottom-line total.

Bilmes, the economist, thinks this is disingenuous.

“An accident that happens while they’re there is a cost of war, particularly when you factor in the length of deployment” and injury-inducing conditions like very hot weather, carrying heavy packs, and more vehicle accidents because it is not safe to walk anywhere, she said.

As of June 2, 25,830 troops had been wounded in action. Of these, 7,675 needed airlifts to military hospitals and the rest were treated and remained in Iraq.

Of the half-million troops who have left active duty and are eligible for VA health care, about one-third have sought it. The most complicated cases end up at one of the four polytrauma centers, in Tampa, Florida.; Richmond, Virginia.; Palo Alto, California; and Minneapolis, Minnesota.

These were formed after doctors realized they were missing problems — amputees who were confused and unable to put on their prosthetics because of undiagnosed brain injuries, and guys who could remember their therapy dog’s name but not their doctor’s, or who could carry on a conversation but not recall what they had for breakfast. Most of these injuries are caused by IED blasts, which send a pressurized air wave through delicate tissues like the brain, sometimes send it smacking against the inside of the skull and shearing fragile nerve connections that control speech, vision, reasoning, memory and other functions. Lungs, eardrums, spinal cords — virtually anything — can be damaged by the pressure wave. Injuries also come from collapsing buildings, flying debris, heat, burns or inhaled gases and vapors.

Much needs to be learned about how to treat these injuries, Kilpatrick said, but credited the military medical staff for having the chance.

“It’s just amazing to me every day when I look at these numbers,” he said. “The good news is that the majority of these people who become ill or injured … are going to survive and are going to be able to return either to the military or to civilian life and be productive.”

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