Sarah’s Injuries

Sarah, our heroine, was in an IED blast while working in Iraq, leaving her scarred, bruised, broken, and in a coma before the play opens.

IEDs (improvised explosive devices) were common methods of violence during the Iraq War. A militant would often build and conceal the bomb at the side of a road or near a building and lie in wait for the military or military supporters. When the they got close enough, the device was detonated via cellphone or radio. (In a chilling twist, many bomb triggers in Iraq are made from children’s remote controlled toys.)

If at all possible, military bomb squads (the people who try to either disarm or detonate bombs at a safe distance from people) use robots to get the job done, but if that won’t work, a technician has to suit up in a huge armored outfit that makes them look like a deep sea diver had a baby with those sumo wrestling costumes from minor league baseball games. (Read more about Baghdad’s bomb squad in this fascinating article from Wired magazine.)

Let’s say the IED’s well hidden. Let’s say it goes off. What exactly happens? I’ll let one of my favorite technical blogs, “How Stuff Works”, take it from here:

  1. When the primary charge explodes, gases heat up and expand rapidly outward under pressure.
  2. The expansion creates shock waves or blast waves. The waves travel outward at about 1,600 feet per second (488 meters per second) over hundreds of yards or more depending upon the amount of explosive.
  3. The explosion fragments the container and sends pieces of shrapnel at high speeds outward. If the IED also contained other fragments such as ball bearings, nuts, bolts and pellets, then they also would be thrown outward.
  4. The heat from the explosion causes fire.
  5. The heat and fires from the explosion can cause secondary fires.
  6. The blast wave leaves a partial vacuum, which causes air to rush back in under high pressure. The inrushing air also pulls in debris and shrapnel.

So the two big things you have to contend with from an IED blast are the blast wave and the fires. Blast waves can send shrapnel and debris at victims. Body armor can protect against those kinds of wounds and fires can be put out but even a helmet can’t fully protect a victim from the traumatic brain injuries that concussive explosions can cause. (Some experts worry that IED related brain injuries may be causing the US military’s suicide crisis.)

IED Impact Symptoms

Many IED victims often describe a ringing in their ears as well as blurry vision. Victims can be burned or suffer broken bones or lacerations, so the usual treatments for those need to be done (grafting, setting bones, all that scary ER stuff.) The harder thing is traumatic brain injury caused by the impact of the blast wave or unfortunate shrapnel placement. (Flying shrapnel can result paralysis or loss of extremities.)

Traumatic brain injury patients can experience personality changes or PTSD (post traumatic stress disorder.) PTSD can cause the patient to believe they are once again in the war zone or can manifest as fear, anxiety, or irritability. Often both psychotropic drugs and talk therapy are used to treat these symptoms, but when a physical manifestation of the trauma can often be found, neurosurgery is a viable option.


A patient can have entered a coma as a result of her body’s trauma or her coma could have been induced medically using anesthesia. Some evolutionary biologists believe that comas are the body’s way of shutting down and “hibernating” while recovering from trauma. When doctors medically induce comas, this is the intention, to allow the body to focus on healing itself, basically conserving the brain’s blood flow to the areas that most need it (as in Sarah’s case.)

Contrary to what the movies show us, coma patients lose weight and color in their skin. In the short term, they can get nutrients through an IV but that is usually switched to a feeding tube if the coma persists. Muscles atrophy and patients are at risk for bed sores if they aren’t well washed, moved, and taken care of.

The sad truth is we actually know very little about treating comas. The first step of care is always to stabilize the patient’s signs and then to monitor their condition and responses to stimuli, usually beginning with pupillary response and moving onto responses from touch and sound. One of the methods of pulling a patient out of a coma is inducing hypothermia or implanting electrodes within the brain in a method called “deep brain stimulation.” Though it often makes families (and doctors) feel helpless, the most common treatment choice is to wait. People have woken from 19 year long comas with no warning. We just don’t know enough about the brain to explain why it happens.

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