"I can't stop. I don't have any legs."

"He literally said that," White recalled, adding that the Humvee came to a halt only after it rammed into a store....

The explosion drilled a hole the size of a softball in the driver's door, he said. The red-hot shrapnel severed the driver's legs while the Humvee was still moving.

"He probably would have bled out except the shaped charge made [the metal] so hot it actually cauterized his legs as it cut his legs off," White said.

One minor grisly detail from a recent Washington Post story on IEDs and 2,000 gone.

The Humvee driver in that case survived as an unintended byproduct of insurgent innovation with IEDs. Many others survive because of innovations in battlefield medicine. As this article from the New England Journal of Medicine makes clear, we're getting better at saving soldiers' lives. In WWII, 30 percent of those injured in combat died. In Vietnam--and even in the Gulf War--it was 24 percent. Now it's 10 percent. That is unquestionably a positive development. But it also means that a great many of those we save are horribly maimed.

One airman with devastating injuries from a mortar attack outside Balad on September 11, 2004, was on an operating table at Walter Reed just 36 hours later. In extremis from bilateral thigh injuries, abdominal wounds, shrapnel in the right hand, and facial injuries, he was taken from the field to the nearby 31st CSH in Balad. Bleeding was controlled, volume resuscitation begun, a guillotine amputation at the thigh performed. He underwent a laparotomy with diverting colostomy. His abdomen was left open, with a clear plastic bag as covering. He was then taken to Landstuhl by an Air Force Critical Care Transport team. When he arrived in Germany, Army surgeons determined that he would require more than 30 days' recovery, if he made it at all. Therefore, although resuscitation was continued and a further washout performed, he was sent on to Walter Reed. There, after weeks in intensive care and multiple operations, he did survive. This is itself remarkable. Injuries like his were unsurvivable in previous wars. The cost, however, can be high. The airman lost one leg above the knee, the other in a hip disarticulation, his right hand, and part of his face. How he and others like him will be able to live and function remains an open question....

Still, for many new problems, the answers remain unclear. Early in the war, for example, Kevlar vests proved dramatically effective in preventing torso injuries. Surgeons, however, now find that IEDs are causing blast injuries that extend upward under the armor and inward through axillary vents. Blast injuries are also producing an unprecedented burden of what orthopedists term"mangled extremities" — limbs with severe soft-tissue, bone, and often vascular injuries. These can be devastating, potentially mortal injuries, and whether to amputate is one of the most difficult decisions in orthopedic surgery. Military surgeons have relied on civilian trauma criteria to guide their choices, but those criteria have not proved reliable in this war. Possibly because the limb injuries are more extreme or more often combined with injuries to other organs, attempts to salvage limbs following the criteria have frequently failed, with life-threatening blood loss, ischemia, and sepsis.

Every other Thursday, surgeons at Walter Reed hold War Rounds by telephone conference with surgeons in Baghdad to review the American casualties received in Washington during the previous two weeks. The case list from October 21 provides a picture of the extent of the injuries. There was one gunshot wound, one antitank-mine injury, one grenade injury, three rocket-propelled–grenade injuries, four mortar injuries, eight IED injuries, and seven patients with no cause of injury noted. The least seriously wounded of these patients was a 19-year-old who had sustained soft-tissue injuries to the face and neck from a mine and required an exploration of the left side of the neck. Other cases involved a partial hand amputation; a hip disarticulation on the right, through-knee amputation on the left, and open pelvic débridement; a left nephrectomy and colostomy; an axillary artery and vein reconstruction; and a splenectomy, with repair of a degloving scalp laceration and through-and-through tongue laceration. None of the soldiers were more than 25 years of age.