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The Lasting Wounds of War

"Intellectually, you tell yourself you're prepared," said Gullick, from San Antonio. "You do the reading. You study the slides. But being here . . . ." His voice trailed off.

"It's just the sheer volume."

Staff at the 31st Combat Support Hospital in Baghdad, the Iraqi capital, move a patient into position for a CT scan. (Dana Smillie For The Washington Post)

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In part, the surge in casualties reflects more frequent firefights after a year in which roadside bombings made up the bulk of attacks on U.S. forces. At the same time, insurgents began planting improvised explosive devices (IEDs) in what one officer called "ridiculous numbers."

The improvised bombs are extraordinarily destructive. Typically fashioned from artillery shells, they may be packed with such debris as broken glass, nails, sometimes even gravel. They're detonated by remote control as a Humvee or truck passes by, and they explode upward.

To protect against the blasts, the U.S. military has wrapped many of its vehicles in armor. When Xenos, the orthopedist, treats limbs shredded by an IED blast, it is usually "an elbow stuck out of a window, or an arm."

Troops wear armor as well, providing protection that Gullick called "orders of magnitude from what we've had before. But it just shifts the injury pattern from a lot of abdominal injuries to extremity and head and face wounds."

The Army gunner whom Poffenbarger was preparing for the flight to Germany had his skull pierced by four 155mm shells, rigged to detonate one after another in what soldiers call a "daisy chain." The shrapnel took a fortunate route through his brain, however, and "when all is said and done, he should be independent. . . . He'll have speech, cognition, vision."

On a nearby stretcher, Staff Sgt. Rene Fernandez struggled to see from eyes bruised nearly shut.

"We were clearing the area and an IED went off," he said, describing an incident outside the western city of Ramadi where his unit was patrolling on foot.

The Houston native counted himself lucky, escaping with a concussion and the temporary damage to his open, friendly face. Waiting for his own hop to the hospital plane headed north, he said what most soldiers tell surgeons: What he most wanted was to return to his unit.

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