Sgt. Joshua Echtinaw's hands wouldn't work.
The 21-year-old Omahan had successfully pulled the tourniquet from his shoulder pocket just as they taught over and over in training.
But this was no drill. It was June 18, a firefight raged on this makeshift base deep within Taliban country, and the explosion had just blown Echtinaw off his feet.
He had felt the telltale pop of shrapnel slicing into skin. He could see the left pants leg of his Army uniform darkening with blood.
But he couldn't get the tourniquet tightened around his leg, couldn't get the bleeding stanched, couldn't keep from feeling fuzzy and starting to fade and ...
“He's been hit!” yelled one of Echtinaw's Army buddies, who had happened to peer into the temporary barracks where Echtinaw had fallen. “Get the medic!”
He took his own tourniquet — one of two that's now standard issue on every U.S. Army combat uniform — and easily stanched the bleeding that might have killed Echtinaw had he been a soldier in World War II or Korea.
With that, Echtinaw, a 2008 graduate of Omaha's Burke High School, became one of nearly 50,000 American troops who have been wounded in Iraq or Afghanistan. Hidden largely from public view, that wounded total is now about half the number hurt during the brutal fighting of the Korean War.
“It's not like you can turn on CNN and see ‘Soldier wounded in Afghanistan' scroll across the bottom,” Echtinaw said during an interview last week after arriving in Omaha to begin his recovery process.
In one sense, the nearly 50,000 wounded-in-action can actually be viewed as a positive thing — it isn't death, said military and VA doctors.
Today, thanks to leaps in battlefield medicine, evacuation speed and even helmet design, nine out of every 10 service members wounded in battle survive to receive their Purple Hearts, just like the one that Echtinaw was given as he lay in a Bagram Air Base hospital bed in late June. Compare that survival rate with the 75 percent who survived in Korea and 86 percent who survived wounds in Vietnam, according to government records.
But having survived, many of these young wounded Americans will still bear the scars from Iraq and Afghanistan long after the wars have faded into the history books.
Click on the image below for a closer look at statistics on soldiers who were killed in battle or wounded but survived in American wars.
Tens of thousands of service members have suffered severe brain injuries, which can cause long-term cognitive problems for some and seemingly intractable psychological problems for more, doctors say.
And nearly 1,500 Americans have had at least one or more limbs amputated. That number will likely go up in the next decade, even after the wars end, as veterans grow tired of the multiple surgeries and painful rehabilitation meant to help them save damaged arms and legs.
The frequent culprit of this long-term pain: improvised explosive devices, commonly known as IEDs.
Soldiers such as Echtinaw fear IEDs. Doctors say they often lead to months and even years of medical care.
“With a bomb, you don't have to be too precise,” said Maj. Steve Chen, a surgeon with the 55th Aerospace Medicine Squadron based at Bellevue's Offutt Air Force Base. “You could get the entire victim. Your whole body sustains trauma.”
Echtinaw had his first operation mere hours after shrapnel from a 25 mm anti-tank round pierced his calf.
He had smoked a cigarette after the medic shot him full of painkillers.
He had been placed on a litter and swiftly evacuated by a medevac helicopter that's outfitted like a high-tech flying ambulance.
He had passed out on the chopper and been taken into emergency surgery at a hospital in Sharana, Afghanistan. His lungs, shaken by the explosion, had filled with fluid. Doctors, concerned about his condition, had kept sedated as he was flown to Kabul.
He awoke, groggy, in a hospital bed at Bagram Air Base. He dialed the cellphone number of his mother, Master Sgt. Danye Echtinaw, herself an Army veteran of the dangerous major supply roads in Iraq.
I'm in the hospital, Mom, he said, but don't worry. I'm going to be OK.
Echtinaw's optimistic prognosis is in large part due to medical and military advances made since the Vietnam War.
Start with the tourniquet, said James Rose, a physician assistant with the Omaha VA Medical Center and a longtime Nebraska National Guardsman.
In Vietnam, tourniquets were viewed with fear: Only medics had them, and often evacuation would take so long that the tourniquet would cut off circulation to the limb and lead to an amputation.
Now every service member knows how to use a tourniquet, and often apply them properly before a medic can even reach the scene.
Death from arm and leg injuries has virtually disappeared during the Iraq and Afghan Wars, Rose said. The quick tourniquet use is also greatly lowering the number of amputations that take place.
“I taught the (tourniquet use) course for the National Guard for a while, and it was very, very gratifying, because a couple soldiers I trained got a valor medal for providing limb-saving care for their buddies,” he said.
What's also saving limbs — and lives — is an evacuation system that's stunningly better than anything the United States military has mustered in previous wars, Chen thinks.
Often a seriously wounded soldier or Marine is jumped from Level 1 to Level 3 care — basic medical attention, to a small hospital, to a larger and advanced hospital such as Bagram — within several hours. In Vietnam, that process would have taken days or even weeks.
“Really sick patients, they actually receive ICU care as they are flying back in the United States,” Chen said. “It's just a really outstanding trauma system we have now in theater.”
Echtinaw got a quick tourniquet, a speedy chopper to two hospitals and then a flight.
Two days after he was laid out on the ground in eastern Afghanistan — a border area rife with insurgents and danger — he found himself safe and sound at Landstuhl Regional Medical Center in Germany. There, doctors prepped him for his second surgery to clean and begin to close his wound.
After surgery, Echtinaw talked on the phone with several worried soldiers from his unit, who were overjoyed to hear that the youngest sergeant in the platoon was doing well.
But he also made new friends. Ten National Guard soldiers had been attacked in Afghanistan just hours after the firefight that wounded Echtinaw.
One had lost an eye. Another had lost both testicles. A third had shrapnel in his chest.
“It happens,” Echtinaw said. “It happens on a daily basis.”
Doctors say this daily drumbeat of injury will have serious long-term consequences both for the wounded soldiers and the medical apparatus set up to care for them.
Traumatic brain injury, often caused when the head is jarred by a roadside bomb blast, is one such vexing medical problem, they say.
Nearly one out of five local vets shows at least some sign of a potential brain injury, according to screening done by the Omaha VA. The vast majority of those TBIs are extremely mild, the war equivalent of getting your bell rung on a football field, doctors say.
But as many as 23,000 military members nationally have more serious TBIs, according to the Department of Defense, and deal with symptoms such as chronic headaches, severe memory loss and even personality changes.
In a cruel twist, veterans with serious TBIs almost always suffer from post-traumatic stress disorder, creating a potent combination that makes successful psychological and medical treatment much harder.
“This is the great unrecognized signature injury of this war,” Mark Showers, occupational therapist at the Omaha VA's Polytrauma Clinic, said last year. “I don't know what the final number of these injuries is going to be, but it's going to be really, really high.”
And doctors also foresee long-term and repeated medical care for those who are injured in IED blasts.
A study done by a Marine medical battalion that served two tours of duty in Iraq shows that more than half of the wounded those doctors cared for had been injured either by shrapnel fragments or debris from explosions. Most of those explosions were from IEDs, Rose said.
No body armor, no matter how advanced, can protect you if your Humvee rolls over a 250-pound bomb hidden in the dirt of an Afghan road, Echtinaw said.
And though a quick evacuation may save those wounded by IEDs, it doesn't change the reality that their rehabilitation will often be long, painful and ultimately incomplete.
“Everything from the skin to the muscle to the blood vessels to the nerves are injured,” said Maj. Chen, the Air Force surgeon. “Often you will have burns to 80 percent of your body. ... That's intensive care, skin grafts on big burns and many, many surgeries.”
How many surgeries?
“Twenty or thirty surgeries,” he said.
Four local veterans treated by the VA have lost limbs during the Iraq or Afghan Wars, said Adam Jacobsen, a VA prosthetist. Several more are considering prosthetics, Jacobsen said, though medical advancements have made keeping the natural limb more likely with continued surgeries and rehabilitation.
“Guys missing legs — we'll be seeing them for quite a while,” he said.
It's in this context that Echtinaw said he feels lucky.
He has made it through his third and final surgery and is now back in Omaha for several weeks before he returns to his Army unit based in Alaska.
The shrapnel that entered his calf veered left, exiting and missing the big bones and large muscles that could've put him in a wheelchair or on crutches for the rest of 2012.
Yes, he has three to six months of intense physical therapy; and yes, he has a mild TBI and a little hearing loss and a sudden need for glasses.
But doctors have told him he will likely make a full recovery by the summer of 2013.
And no one needs to tell Echtinaw how close he came to being much worse off.
Right before the blast, he said, he turned and ran three steps. If he had frozen where he was, or if he had turned in the other direction ...
“I'm pretty sure I'd be dead.”
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