Shortly after midnight on this frigid night, Capt. Nicholas Ingham arrived at this massive air base, in the belly of an Air Force C-130. As the back door swung open, flooding the cabin with light, the heavily sedated Marine, strapped onto a stretcher, blinked away a tear. A black-and-white American flag tattooed on his chest rose and fell gently as a ventilator pumped air into his collapsed lung.
A team of doctors, nurses and medical technicians assigned to the trauma center here gently offloaded Ingham and a handful of other injured troops with mechanical precision, the first stop on their journey home.
It would be the same journey thousands of wounded warriors had made before them.
These days, 12 years after the start of America's longest war, far fewer U.S. troops are being killed or wounded in Afghanistan. The military's drawdown has picked up pace, and Afghans have begun to shoulder the brunt of the fighting. But the war continues to churn out American casualties by the dozen each week. Their injuries rarely make headlines.
Still, military health-care experts say those wounded in battle are coming home more severely injured than at any time since 2006, a sobering sign of the strength of the insurgency at the twilight of the war. Many of the injured arrive on the medical evacuation flights that land twice a week at Joint Base Andrews in Maryland physically intact but mentally wrecked, struggling with the demons of multiple deployments over the past decade.
Their caretakers, part of a massive wartime medical evacuation system that is being wound down, have a rare and often grim vantage on the final chapter of the Afghan war -- a conflict that is increasingly being endured, rather than fought, largely out of sight.
"Are you feeling any pain?" Maj. Scott Zakaluzny, a surgeon at Bagram's hospital, asked Ingham as his colleagues inspected the gashes torn into his back, arms and legs by shrapnel from a suicide bombing. Looking miserable, Ingham, 27, opened his eyes slightly and shook his head.
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In Washington, among policymakers, the Afghan war is increasingly discussed with exasperation, like a curse. It is the type of warfare the United States must avoid at all cost, President Barack Obama argued during his State of the Union address.
"We must fight the battles that need to be fought," Obama told those in attendance, among them a soldier disfigured by a roadside bomb in Afghanistan. "Not those that terrorists prefer from us -- large-scale deployments that drain our strength and may ultimately feed extremism."
Also in the House chamber that night was Rep. Adam Kinzinger, R-Ill., a former Air Force pilot who flew intelligence and medevac missions in Iraq and Afghanistan.
"I think there is a sense in the military that Americans are not paying attention anymore," he had told a reporter a few weeks earlier, shortly after returning from a visit to Kabul. "I think they're right, to be honest. There is a sense that it's over, but it's not."
There are currently roughly 33,700 U.S. troops in Afghanistan, down from a peak of more than 100,000 in the spring of 2011.
Those who have been wounded here have had a better chance at survival than in any previous U.S. war -- a result of stunning achievements in battlefield care.
But in some ways, combat medics say, the work in Afghanistan has become more challenging. The injury severity score, a measure that takes into account the extent of a patient's wounds, has gone up gradually in Afghanistan since 2006, according to data compiled by the military.
Col. Kirby Gross, a physician who studies trauma care for wounded troops and who is deployed at Bagram, struggled to find the right words to explain how insurgents have become so proficient at killing and maiming American service members.
"They're nimble," was as much of a compliment as he was willing to pay.
Medical professionals say the combat evacuation system that sprang up at the height of the Iraq war to care for the wounded is being pared down. In December, Bagram became the only base in Afghanistan with a top-tier trauma center, which means that patients across the battlefield in need of specialized care face longer journeys. As the footprint becomes smaller in coming months, the margin of error will widen, said Lt. Col. Mary Danko, the chief Air Force flight nurse in Bagram.
"Right now, it's a great process we have," she said. "But you worry about the one life you won't be able to save because of the lack of resources."
At the U.S. military hospital in Landstuhl, Germany, the three miles of hallways that were once brimming with war victims are now largely empty. Air Force Lt. Col. David Zonies, the chief of trauma and critical care at Landstuhl, expressed longer-term concerns on this morning, noting that when his tour is up, he won't be replaced. The same goes for his partner.
"There's a very serious concern that we will potentially not learn the lessons of this war for the next one," he said. "After Korea and Vietnam, the money ran out, the resources ran out, skills started to wane. Are we going to make the same mistake after this conflict?"
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Ingham had deployed twice before to Afghanistan during periods when U.S. troops battled insurgents every day. His last wartime assignment was to lead a group of Georgian soldiers tasked with preventing militants from firing rockets into a sprawling NATO base in Helmand province, in southwestern Afghanistan.
Early in the afternoon of Dec. 14, a lone driver in a blue sedan steered his vehicle toward a patrol he was leading. The Georgian soldiers appeared edgy, and Ingham worried that if they overreacted, he could have a civilian casualty incident on his watch. So he walked toward the driver, alone, hoping to wave him off.
"Civilian casualties in Afghanistan are a particularly touchy subject," he would say later. "I was trying to prevent something that could have turned into a very bad event."
As Ingham moved toward the car, the driver pressed on toward him. The lanky captain raised his rifle in a final effort to get him to back off. By then, he was close enough to hear the man at the wheel utter "Allahu akbar," or "God is great," words that could have meant only one thing in that context. Ingham opened fire, pumping 18 bullets into the driver, whose vehicle continued to inch toward him.
"I turned around and got a step and a half and it exploded," Ingham said, comparing the fury of the blast to a massive wave that thrusts you from behind. The explosion sent the car's engine flying 100 meters and dug out a massive crater in the ground. As he limped away from the plume of smoke toward his men, Ingham took a breath and realized he had been badly hurt.
"I felt my lung bubbling," he said, recounting the attack and its aftermath weeks later at Walter Reed National Military Medical Center in Bethesda, Md. "I knew something had gone through my chest."
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Ingham's doctors expect he will make a full recovery and could soon lead Marines in combat again. But as he spoke on this morning, he was surrounded by service members who won't. One, Lance Cpl. Paul Shupert, who had been deployed in the same province as Ingham, had arrived at Walter Reed a few weeks before, missing part of his right leg.
"It's a shame you guys are coming home hurt," Ingham told the 22-year-old Marine, shaking his head.
"We know what we signed up for," Shupert replied quietly, his legs draped by a heavy black blanket with leopard-print edges.
There was no sense talking Shupert out of following in his father's footsteps when, at 17, he persuaded his parents in Jefferson City, Tenn., to sign a waiver allowing him to join the Marines. When he deployed to Afghanistan for the first time last summer, his mother was paralyzed by fear.
"Everyone was thinking I was taking it too hard," Tonya Shupert said. "They think the war's over."
Tonya Shupert is nothing if not a patriot, often donning "Marine Corps Mom" T-shirts. But like many in military families, she struggled to understand why men such as her son were still being sent to Afghanistan.
"I think there are some things we shouldn't be involved in," she said one evening while doing laundry at the patient living quarters. "Some of those people have been fighting for years and years, and us going there is not going to change that."
The war changed her son permanently the afternoon of Nov. 25, after he had volunteered to help explosive ordnance disposal experts search a compound.
Shupert had carefully followed the footsteps of the Marine in front of him, mindful that the compound could be surrounded by land mines.
"I guess I must have missed a spot," he would say later. "I did back flips through the air and remember landing on my back and looking at my legs. My pants were blown off, and I saw it had taken off the foot."
Shupert has not allowed himself a moment of self-pity since that day, arguing that dwelling on his loss will not make the limb grow back. When he first saw his family at Walter Reed after being evacuated, they were comforted that he had not lost his sense of humor. The ordeal was a perfect excuse for a new tattoo, Shupert told them. He would ink the words "Part A" on his thigh and label his prosthetic leg "Part B."
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After each flight arrives at Andrews, Army Col. Michael Worth writes a report with tiny narratives about each wounded warrior he has debriefed.
A few are bizarre, for instance the ordeal of a female lieutenant nurse who was accidentally shot in the foot by her boss.
"She doesn't know precisely what her boss was doing to cause the discharge," wrote Worth, who is tasked with making sure patients get to the right final destination for additional care.
Some of the narratives are haunting. Only after failing to get a young soldier to talk after one flight did Worth realize that the Army Ranger had sustained serious wounds to his genitals.
But it is perhaps the mental wounds that trouble the colonel the most. He had recently welcomed home an Army couple. The wife, a staff sergeant assigned to a transportation unit who had been deployed seven times, had shot herself in the abdomen in an apparent suicide attempt. Her husband was relieved to be home but ashen as he escorted his unconscious spouse off the plane.
Like most military officers, Worth tries to focus on the mission and not dwell on the politics of war.
"We execute the lawful orders of the president," he said. "What I see on the airplane is a consequence of that, and I'm here to help them and deal with them. Any thoughts I have as a private citizen will have to wait until I leave."
And so there was stoic silence among the military personnel awaiting Shupert's flight on a cold, windy evening in early December. As the plane turned on its landing lights and tipped its nose down, it was commanded to turn back skyward and circle overhead for more than 30 minutes. Vice President Biden's team was ready to take off for a trip to Asia, so authorities at Andrews froze all other movement on the airfield.
On the ground, some in the medical team awaiting Shupert shivered, but they kept their thoughts to themselves. The Marine never knew the flight was diverted. Told about it later, his only reaction was: "Oh."
By Ernesto Londoño
The Washington Post