Guest Editorial: The Wounds of War

    An article that recently appeared in Newsweek contained the following: “We can count the dead. We can see physical injuries. But in soldiers returning home, it’s hard to see the psychological damage among those who have witnessed the blood, heard the screaming, felt the shattering blast, and smelled the burning flesh.

Unless they make sense of what they saw and felt under fire, they’ll continue to relive the experiences of war. Fortunately, the human brain — which evolved in an environment of constant physical threat — is so resilient that horror is usually contained. Most soldiers do not require professional help. But when coping fails, so does recovery.”¹

    Unfortunately, it often takes a war to advance the science of acute injury. We must learn from the wounds of this war in Iraq and Afghanistan as we have from other experiences with wounds. Clearly, with advancing technology in the field, hemorrhage is less of a killer and limb loss can be decreased with shunts and earlier bypasses. We have improved transportation and communication. But what has the battlefield taught us about wound care?

    The military injury is an acute wound defined as “…a disruption in the integrity of the skin and underlying tissues that progress through the healing process in a timely and uncomplicated manner.”² New dressings and growth factors represent advances and potential benefits in wound treatment. Hemostasis achieved via impregnated dressings is another area with encouraging results. The bulk of war injuries are vascular and orthopedic. Because of the success of body armor, more lives may be saved but more limbs are lost, shifting the focus to vascular injuries and limb salvage — wounds must be left open or approximated gently for secondary healing. What is the most effective dressing for this type of wound?

    We are just probing the depth of vascular biology associated with wounds. We must address the role of acute wound fluid and compare it to chronic (eg, venous ulcers) wound fluid. Are we bathing venous ulcers treated with Unna boots in chronic wound fluid? What substances in chronic wound fluid suppress wound healing? Does this create a negative effect on cell division of the fibroblast? Does the Unna boot prolong exposure to other factors that delay wound healing?

    Yet, as stated earlier, it is not just the wound we can see, it is the wound we cannot see that we need to address. Although we tend to focus on the obvious wound, acute or chronic, it is the whole patient who is injured. I feel compelled to remind my healthcare provider colleagues — let us not forget the injury beyond the wound. Despite human resilience, the scars on the soul can be as devastating as the scars on the skin.
In this new year — this time for hope and renewal — let us strive to gain something positive from the tragedy of war. In helping soldiers “make sense” of their experiences, let us continue to learn and move forward, increasing our understanding and compassion for those with obvious and not-so-obvious wounds. As we continue to do research in the analysis of cellular, biochemical, and molecular components of acute wounds, we should remember the whole patient, the emotional as well as the physical component of wound care.

1. Shalev AY, Miller MC. To heal a shattered soul. Treatment for PTSD. Newsweek. December, 6, 2004.

2. Bates-Jensen BM, Wethe J. Acute surgical management. In: Sussman C, Bates-Jensen BM, eds. Wound Care: A Collaborative Practice Manual for Physical Therapists and Nurses. Gaithersburg, Md.: Aspen Pub., Inc.;1998.