February 14, 2020: On January 8^th, 2020 Iran fired fifteen ballistic missiles at three American bases in Iraq. While several missiles failed about ten landed in or near the American bases. The U.S. troops had advance warning and all were in bomb shelters when the missiles arrived. The early announcement was that no troops were injured. But after a few weeks, it was revealed that over 60 troops had some degree of blast concussion injury. None of those injuries were visible and so far most of the troops went back to work. But others would have to be monitored for years to see if there were any long-term effects. It also took some time to discover all who had suffered a concussion. The effects are not always immediate or obvious. It often takes an MRI scan or other tests to sort this out and even then many victims deny that they are hurt. This is why the number of concussion victims grew week by week. That is not unusual at all. 

This form of injury, first described as “shell shock” during World War I (1914-18), later became concussion injury during World War II (1939-45) and was considered a normally mild disability that could be cured with a few days of rest in a hospital or base camp. That attitude changed after 2003 when there were a lot more concussion victims and better tools to detect and measure the damage. By 2013 American troops in Iraq and Afghanistan U.S. troops had suffered 57,090 conventional casualties (dead and wounded) during the previous twelve years. But because of better diagnostic tools and techniques, many other combat zone injuries could now be measured as well. These included 253,330 cases of traumatic brain injury (more commonly called concussion) and 103,792 cases of PTSD (Post Traumatic Stress Disorder). In the past, these conditions were not considered “wounds” in the same sense as something that broke a bone or caused bleeding. This was despite the fact that many soldiers were put out of action temporarily, and a few permanently, because of concussion and PTSD. By 2019 the American military had detected over 400,000 troops who had served in combat since 2001 and suffered some degree of concussion injury.

There are far more concussion patients among the general population and it has always been that way. Nearly two million Americans a year suffer traumatic brain injury. Throughout the 20^th century, the military recognized this as a real, if bloodless, injury. Whether to consider a concussion a wound eligible for a Purple Heart medal had, for generations, been unsettled. Combat commanders, veteran NCOs and combat zone physicians all agreed that many concussions could be as obviously debilitating as broken bones or wounds that drew blood. Many of those minor but bloody wounds earned a Purple Heart even though the patient was often back at work in days, if not sooner, and their commanders saw them as fit for duty. In contrast, many severe concussion victims were ordered back to the field hospital by combat commanders and physicians who had found the victims much disoriented and very unfit for duty, especially in a combat unit. There were really no medications for concussion and the best cure was bed rest until the patience “came around” to his normal self. Doctors were careful about releasing concussion victims because they if their commander found these former patients unable to do their job, they would complain up the chain-of-command. The most dangerous situations were combat troops (army or marine) who believed they had recovered from a concussion but the doctor had to point out that this “recovery” could be deceptive and it was a medical decision when it came to who was released from the hospital. The troops, many of them eager to rejoin their fellow combat veterans, often accepted this advice because they knew of troops who caused problems because of mental disorientation. Then there was the fact that there were so many concussion victims in peacetime among the civilian population that most troops had heard about or witnessed how concussion and dangerous debilitation worked.

By 2011 the U.S. military felt they had new concussion damage detection tools that military doctors could state how badly a concussion victim was hurt. This was still not an exact science but it was much more precise than in the past. With this new information, the military established guidelines for which concussion victims were eligible for a Purple Heart and which were not. In reality, most combat troops had long since adopted their own criteria and many would refuse Purple Hearts for light wounds or combat injuries. That said, even combat veterans recognized that some concussion injuries could be as debilitating as losing a limb, eyesight or the disfigurement of severe burns. Severe concussion was recognized as a serious injury because, in the days before seatbelts and airbags, a familiar sight with automobile accidents was cracked glass in front of where the driver or someone next to him sat. This meant a collision threw the front seat passengers against the glass with such force that they were killed or suffered very serious and often permanent mental disorientation.

Physical injuries to the brain can now be detected with more precise instruments like MRI and can often be treated. In the last decade, it has become clear that there are several sources of PTSD (post-traumatic stress disorder) and concussions from explosions were more of a factor than previously thought. Many troops, because of exposure to roadside bombs and battlefield explosions in general, developed minor concussions that, like sports injuries, could turn into long term medical problems. Often these concussions were accompanied by some PTSD. Examining medical histories of World War II, Korea, and Vietnam War vets showed a pattern of later medical problems among many concussion victims. The same pattern has been found among athletes and accident victims who suffered concussions. Medical experts concluded that pulling troops out of combat after being exposed to three explosions would have long term benefits, in that it would prevent most permanent brain injuries and PTSD, including cases that could require a soldier or marine to be retired early on medical disability.

Combat commanders, and many of the troops pulled out of combat this way, were opposed to the policy. Commanders felt that sending units into action with fewer troops made it more likely that they will suffer still more casualties. Infantrymen tend to be reluctant to leave their buddies in the lurch, unless physically unable to continue fighting. The military sought to convince troops that, like boxers, hockey, or football players, too many concussions will lead to serious problems down the line or even sooner.

Another problem with this proposal is that roadside bombs are only one of several sources of concussions. But the military medicine experts believe that roadside bombs were by far the biggest source of these concussions and the resulting brain injuries. The "three bombs and you're out" (of combat) rule tended to not pull more than one or two percent of troops out of action and commanders considered it a prudent rule. But this had a higher impact on combat units, which always suffer most of the casualties. Thus infantry units could lose another 5-10 percent of their troops because of the “three bomb” rule.

After 2001 the U.S. Army eventually began conducting long-term studies to identify and measure the impact of combat zone stress and concussions on soldiers. This began with a random selection of 55,000 soldiers who were interviewed to obtain additional data on their experiences in the military. That will be periodically updated for the lives of the study subjects. Over the decades the army will learn more and more about military and combat stress and be better able to develop policies to avoid it and create treatments for harmful aftereffects.

This is one of a growing number of efforts to deal with an unprecedented number of troops who have spent a lot (more than any other war) of time in a combat zone. The result of this is that over the last decade more and more combat NCOs and junior officers have been found to be suffering from debilitating PTSD. Studies so far have found that at least 20 percent of troops sent into a combat zone suffer some form of mental distress. That's over 400,000 troops (out of two million who have served in Iraq or Afghanistan). Not all these are actually diagnosed, often because the victim is unaware that they have PTSD.

Taking the recent victims and adding in the many Vietnam veterans who have been treated for PTSD and studied, the army has already found some useful data. For example, troops are more prone to serious PTSD effects (including suicide) if there are genetic factors that are often, but not always, revealed by a family history of psychiatric problems. Even traumatic childhood events and insufficient support and treatment after traumatic battlefield events can cause problems. For centuries it's been accepted that some men are prone to "break" under the stress of combat. It was understood, even without any knowledge of genetics, that a soldier with a family history of mental instability would be less able to handle combat. Now the army can more precisely measure the risk and more accurately screen out those who will be most at risk.

The major problem is that most people eventually get PTSD if they are in combat long enough. This has been confirmed by nearly a century of energetic efforts to diagnose and treat PTSD, including much more recent attention to civilian victims, via accidents, sports injuries or criminal assault. During World War II it was found that, on average, 200 days of combat would bring on a case of PTSD. After World War II methods were found to delay the onset of PTSD. These included more breaks from combat, better living conditions in the combat zone and prompt treatment when PTSD was detected. Military historians note that successful, and often popular, commanders throughout history have paid attention to the physical well-being of the troops, all in the name of "maintaining morale." These measures also delayed the onset of combat fatigue.

That's why combat troops in Iraq and Afghanistan often slept in air-conditioned quarters, had Internet access, lots of amenities, and a two-week vacation (anywhere) in the middle of their combat tour. This extended their useful time in combat before PTSD (or "bad morale") sets in. No one is yet sure what the new combat days average is, and the new screening methods are an attempt to find out. The army and marines are now confronting the fact that, for a large number of their combat NCOs, the limits are being reached. It's a lot more than 200 days in combat but the army and marines have the majority of their most able and experienced NCOs approaching that limit.

This was not unexpected. The army knew that they had a large, and growing, percentage of its combat troops with over 200 days of combat. Some have three or four times that. For a while, treatments (counseling and medications, for the most part) worked. But these are not cures. A major reason for army generals talking about the army "needing a break" (from combat) was the looming loss of many combat experienced NCOs to PTSD. The army won't give out exact figures, partly because they don't have much in the way of exact figures. But over the next few years the army will get a clearer picture of how well they have coped with PTSD among troops who have, individually, seen far more combat than their predecessors in Vietnam, Korea, or World War II.

The problem is mainly among combat NCOs. Most of the troops are in for one enlistment (usually four years) and then leave. Junior officers get promoted out of jobs involving close combat, and officers, in general, are rotated between leadership and staff jobs. NCOs spend all their time with the troops, except those few who get promoted to Sergeant Major (a largely staff job as advisor to senior commanders). The Sergeants Major were among the first to note the stress problems with career NCOs (squad and platoon leaders, as well as company 1st Sergeants).

The only acceptable solution for the problem is to transfer the worst hit combat NCOs to non-combat jobs. This is a common sort of thing in the army and marines, where it's long been common for NCOs with physical conditions and injuries (resulting from the rigors of peace or wartime infantry service) to be offered transfers and retraining. Severe cases may also be offered a medical discharge (and disability pay). The loss of these skilled and experienced NCOs from combat units results in more troops getting killed or wounded in combat. But that can happen anyway if you leave a stressed-out NCO in action for too long.

Then there's the problem of what to call this new situation. Many troops wish everyone would revert to the older term, Combat Fatigue. What's in a word? For the troops, PTSD is just another injury and not a disorder. It's something you deal with. Like debilitating physical injuries (bad backs or knee/ foot problems), trying to cope often leads to sinking morale and a lot of people leaving the military.

The army and marines are dealing with PTSD head-on, believing that what happened in Iraq and Afghanistan will happen again and now is the time to get ready. Experience so far has shown that PTSD can be delayed, perhaps for a long time. When a soldier does come down with it, PTSD can often be treated and its effects reversed. But not always. This has large ramifications for non-military medicine as many civilians suffer from PTSD. That's because military recruits are screened for their ability to handle stress and resist PTSD. In the civilian community, there are far more people who can acquire PTSD after exposure to much less stress. What many troops wish the brass would understand is that, as recruits, they learned that stress was a major part of the job and understood it more than the mental health mafia is willing to admit.