This is an excerpt from reporter Scott Johnson's blog, which focuses on the effects of violence and trauma on the community.

Doctors have gotten a lot better over the years at keeping their patients alive. During the Civil War, for instance, mortality -- the proportion of deaths to population -- was around 56 percent. Soldiers would die from basic wounds -- getting shot in the arm, or getting cow dung in a leg wound, what doctors call "necrotizing infections." The simplest things were often deadly.

As medical practices have improved, so too has our ability to save lives. During the first and second World Wars, the mortality rate dropped down to mid-30 percent as medical practices improved, and by the time American soldiers were fighting in Korea and later in Vietnam it had descended all the way down to the teens, even though 58,000 Americans still died during Vietnam, a shockingly high number by today's standards. Perhaps ironically, the medical advances that helped save lives also arrived as weapons technology improved. Our ability to kill improved proportionally to our ability to keep people alive.

These days a lot of killing is done remotely. American pilots sitting in air-conditioned bases in Nevada thousands of miles from their targets fly remote controlled drones and kill without fear of any retaliation -- none that is immediate anyway.


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Soldiers who do go to war (the real physical thing, not the simulacrum of drone warfare) in places like Iraq or Afghanistan benefit from vastly improved medical services. As a result, mortality has continued to drop, hovering around 5 or 6 percent today, roughly 10 times lower than what it was during the three days of the battle of Gettysburg in July 1863, when more than 10,000 people were killed, and another 40,000 or so were wounded, went missing or got captured.

The flip side of this picture is that while fewer people are dying in wars, accidents, urban violence, conflict of all stripes, a lot more people are surviving with injuries of one sort or another. "Now we have conflicts and a lot more people are coming back with traumatic brain injuries, amputations, other injuries," says Suresh Agarwal, chief of Critical Care Medicine at the Boston University's School of Medicine, "Now with motor vehicle crashes, improvised explosive devices (IED's), gunshot wounds, more people are surviving, but with many injuries, and these would have killed them in the past."

Another development is that as the ability to merely save lives has improved, doctors have shifted their priorities. Whereas in the past trauma surgeons and their colleagues may have focused exclusively on preventing death, the focus is now shifting to what happens to their patients after doctors have saved their lives.

"Everything we do is aimed toward making patients have better outcomes," Agarwal told me, "Before, our main outcome was looking at mortality, now we're looking at other things -- how well they're getting off ventilator, or out of the hospital, the significance of their brain injuries, and we're realizing that the initial and early management of these patients have a significant impact on how well they do in the long term."

Many trauma centers will also look much more deeply at victims of inner city violence and take more appropriate, trauma-centered treatment options. As awareness about the high prevalence of PTSD among victims of inner city violence grows, so too do the treatment options available -- psychiatric evaluations, screening for anxiety and depression. "A lot of people think you can only get PTSD from being in a conflict," says Agarwal, "But the reality is that anybody who has had a traumatic event can get symptoms, so we're trying to not miss that component of trauma care."

As the science around trauma care improves, so too does public awareness of just how complicated and complex different sorts of trauma can be. Many of the most damaged people look perfectly fine from the outside -- but their insides are roiling with a kind of neuronal chaos. Gone, for the most part anyway, are the days when you could die easily from an infection -- antibiotics have helped see to that. But the walking wounded -- from wars, from American gun violence, car crashes, abuse and all the other pathologies of our age -- are among us still, and their care still calls for improvement.

Contact Scott Johnson at 510-208-6429 or scjohnson@bayareanewsgroup.com.