In a flash, the blast incinerates air, sprays metal,burns flesh. Milliseconds after an improvised explosive device (IED) detonates, a blink after a mortar shell blows, an overpressurization wave engulfs the human body, and just as quickly, an underpressure wave follows and vanishes. Eardrums burst, bubbles appear in the bloodstream, the heart slows. A soldier—or a civilian—can survive the blast without a single penetrating wound and still receive the worst diagnosis: traumatic brain injury, or TBI, the signature injury of the Iraq War.
But in the same instant that the blast unleashes chaos, it also activates the most organized and sophisticated trauma care in history. Within a matter of hours, a soldier can be medevaced to a state-of-the-art field hospital, placed on a flying intensive care unit, and receive continuous critical care a sea away. (During Vietnam, it took an average of 15 days to receive that level of treatment. Today the military can deliver it in 13 hours.) Heroic measures may be yielding unprecedented survival rates, but they also carry a grim consequence: No other war has created so many seriously disabled veterans. Soldiers are surviving some brain injuries with only their brain stems unimpaired.
While the Pentagon has yet to release hard numbers on brain-injured troops, citing security issues, brain-injury professionals express concern about the range of numbers reported from other military-related sources like the Defense and Veterans Brain Injury Center, the Department of Defense, and the Department of Veterans Affairs (VA). One expert from the VA estimates the number of undiagnosed TBIs at over 7,500. Nearly 2,000 brain-injured soldiers have already received some level of care, but the TBIs—human beings reduced to an abbreviation—keep coming.
"We would get about 300 helicopters landing a month, all having some level of trauma," says Dr. Elisha Powell, an orthopedic surgeon who served as commander of the U.S. Air Force Theater Hospital in Balad, Iraq, a facility described as "MASH on steroids," where most of the severely brain injured are treated.
A soldier treated at Balad Air Base stands a 96 percent chance of surviving; several hundred come through every month. I ask Dr. Gerald Grant, who served as one of the few neurotrauma surgeons in Iraq, how the hospital managed to keep patients alive.
"It's complex in that it's not only medical advances," he tells me. "This war is different in that the aerovac system is superb. The ability to get someone into your care facility with many forward surgeons and subspecialists so close to the front line, very quickly, is a novel concept in this theater."
The moment an injured soldier hits the helipad at Balad, he's swept into a whirlwind of critical care. It's the one ER in the world whereup to 10 surgical specialists are hell-bent on saving a life. Patients get lined up with IVs and catheters, undergo CT scans and X-rays, and then hit the operating table—the hospital's best time is 18 minutes. The head-and-neck team tackles their trauma while a cardiothoracicsurgeon and a vascular surgeon go to work on the chest. They're shoulder to shoulder with the urologist, who's brushing against the chief trauma surgeon, who's coordinating everything over the buzz of orthopedic surgeons drilling external fixators into bone. It's crowded. It's hot.
Amid the cramped bustle, doctors are pushing the boundaries of medicine. They're going through crates of the hemophilia drug Factor VII, yet to be approved for trauma but a wonder drug in stopping bleed-outs. At $3,000 a vial, two vials per dose, the price is a drop in the bucket compared with the expenses incurred during the critical phase of recovery, which can easily exceed a million dollars in the coming weeks. The lifetime cost of care for brain-injured troops could reach $35 billion, according to a Nobel Prize–winning economist and a Harvard University budget expert.
If the diagnostics come up positive for blast-related brain trauma,the neurosurgeon takes action based on observable signs of trauma. Depending on whether the brain was pulled, pushed, twisted, or punctured in the blast, the neurosurgeon could elect major surgery.
"Our expression is 'Go big or go home,' " Grant says. "We really want to do the definitive operation that we know will be OK for them."
In a matter of minutes, a surgeon will saw the skull in half and discard the damaged portion. There will be a plastic replacement waiting farther down the line. Shrapnel is excised, cerebral tissue swells, and the scalp is pulled taut and sewn back over a ballooning brain. Thanks to the wealth of surgical resources, a procedure that takes several hours in any general hospital in the United States might take Balad surgeons 30 minutes. "The secret to our hospital's ability is throughput," Powell says. "We have to keep churning. Things that would overwhelm a major hospital would not overwhelm us. During the worst incident, we had 35 people come to us in 90 minutes, all by helicopter, landing with just horrible injuries."
"There are soft tissue traumas where we have no scalp, no eye, and no skull base left," Grant says. "And we have to somehow treat that acutely in one surgery setting."
Many of the soldiers treated at Balad won't remember being there. After leaving the frontline hospital, they're loaded onto a massive C-17 cargo plane that has been retrofitted to hold an entire intensive care unit—up to 8 critical care patients and 27 noncritical litter patients. It's basically a flying warehouse abuzz with armor-clad clinicians and portable life-support units. Known as a critical care air transport team, each consists of a critical care physician, a critical care nurse, and a respiratory therapist. There are 249 of these teams in the Air Force, catering to all branches of the armed forces.
Five hours later, the C-17 lands at Ramstein Air Base in Germany. Having been prepped through a satellite tracking system, doctors at Landstuhl Regional Medical Center (just across the autobahn from Ramstein) already have a strong grasp of any patient's treatment needs. In Balad, surgeons don't have the time to check medical records or advance directives, so every life is saved at any cost. But that's not the case in Landstuhl. In addition to being a transitional facility, Landstuhl also happens to be the place where the family has a voice in their loved one's fate.
"You can look at someone and see they will not survive," says Dr. Gene Bolles, former chief of neurosurgery at Landstuhl. "When you see that, you are up front with the families. But so often, you don't know enough. When you are in the military, you don't question, you just save life. When I was there, our modus operandi was to maintain them and keep them alive to get them to the States."
"It is very rare for us to have family contact in Iraq because the communication is so difficult," Grant explains. "The family can meet the patient in Germany. They are there to make decisions for them, and they can withdraw care there, whether the patient has an advance directive or not."
When one veteran's wife, Michele Reid, spoke with a doctor at Landstuhl about her husband, Pete, she was surprised to learn that he had survived an attack on May 2, 2004. She had feared him dead after receiving funeral notices for some of the friends he served with. A Navy Seabee, Pete Reid was one of the three severely injured servicemen hit by a barrage of mortar shells in Ramadi, Iraq. Thirty people were injured, six were killed.
"First they told me he lost his eye and that his brain was bleeding," she says. "But then they said that they didn't think he was going to make it."
Michele asked for the phone to be placed next to Pete's ear, and she told him to hang on, that she wanted to see him get better. Later that day, Pete emerged from his coma, opened his eyes, and asked a nurse when he could see his wife. The team immediately flew him back to the States to see Michele.
The aggressive level of care continues once the troops return to either Walter Reed Army Medical Center in Washington, D.C., or the National Naval Medical Center in Bethesda, Maryland. At Walter Reed, troops undergo intensive therapies aimed at helping them regain their independence. Reid was transferred to Bethesda, where Michele was waiting for him.
"When they let me see him, I lost it," she says. "I could see his open wounds when they pulled back the sheet. He didn't say anything—he just squeezed my hand."
While in the intensive care unit at Bethesda, doctors told Michele that her husband had a 1 percent chance of recovery, and if he survived, he would be vegetative.
"I cried, I prayed, I cussed, and I screamed," Michele says. "After a few days, Pete turned his head toward me and said, 'Enough already. I'm going to be OK.'"
From Walter Reed, soldiers are then triaged to one of the nation's VA polytrauma centers, where the hard work begins. (There are only 4 polytrauma centers and 21 designated polytrauma rehabilitation sites, a painfully small number to deal with the great many injured troops.) Weeks ago, a staff sergeant might have been conducting complex tactical operations; on the polytrauma unit, his biggest challenge might involve lifting his head off the pillow. Another soldier experiencing sequencing problems might try his hand at disassembling a carburetor in one of the rehab rooms. That same soldier could then be taken to physical therapy to work on his balance. Because of the brain's complexity, each injury manifests its own unique set of challenges.
"All the polytrauma centers offer patients highly individualized care," says Dr. Rose Collins, a psychologist with the Minneapolis polytrauma center. "One of my roles is to decrease the barriers that get in the way of your participating in rehabilitation." Soldiers are not the only ones whose issues get addressed at the center. "Part of my job is to help their families," she says. "How do you make positive meaning out of this? How do you grieve ambiguous losses? On some level, family members prepare for the possibility of death, but they don't prepare for the possibility of severe disability. Who, outside in the real world, thinks about the lifetime impairments of a traumatic brain injury?"
At the polytrauma center in Tampa, Florida, Michele had a better idea of what condition her husband was in. He arrived at the center with a hundred stitches along his scalp and a missing eye. Surgeons had removed some of his stomach muscles along with portions of his hip bone and transplanted them to his right leg. Michele could come to terms with his physical injuries, but the personality changes brought on bythe TBI made her feel as though her husband was a different man altogether. The injuries to Pete's right frontal lobe caused severe impulse control and reasoning problems.
"Near the beginning, Pete threw his urinal and grabbed people by the throat," Michele says. "He thought he was still in Iraq, and he even tried to stab out his one good eye with a pen. He could never be left alone, ever."
Inside the Minneapolis VA's polytrauma unit, military insignias adorn the walls, and the milieu is preternaturally calm—a necessity in brain-injury treatment centers. Color-coded floor tiles in front of entryways help soldiers who can no longer read room numbers. Halls and doorways are extra wide, all the furniture is movable, and even the bathroom fixtures are amputee-friendly. The unit was recently redesigned to be completely focused on treatment. Like Balad, Landstuhl, and Walter Reed, the polytrauma center represents the culmination of research and resources, a level of care to which many private hospitals aspire. The patients on the unit represent some of the most complicated treatment challenges in the world.
While there, I met a young soldier who had received the military's full battery of services. He had been blown apart and put back together, but not entirely, not yet. The upper left quadrant of his head was missing, pending a new skull plate, and the remainder was dappled with tufts of dark hair and notches left by shrapnel. In place of two limbs, he had prosthetics—one arm, one leg. The visible parts of his body were replete with fresh skin grafts, giving him an uneven, patched-together appearance. In some respects, he didn't look quite possible, but because he could talk and interact and function, he was a success story. The guy parked in the foyer's corner, whom I didn't meet, wasn't faring as well. He was wrapped head to toe in heavy white blankets, with only his mouth and a single gray hand exposed. A plastic tube ran from his lips back behind the chair; he never moved for the duration of my visit. From a far room, the angry wailings of another brain-injured patient broke the calm. As I passed that soldier's room, I could see him sitting on the edge of his bed, swiping an arm at the nurse who was trying to help him. Behavioral outbursts, particularly those driven by agitation, are a common side effect of brain injury.
What looks otherworldly to us now will be commonplace in a matter of years. Projections based on a recent VA report suggest that 400,000 veterans deployed in the global war on terrorism will file for disability. Can such a number be adequately treated? With the lifetime costs of civilian brain injuries escalating, are local communities prepared for the complex treatment measures many veterans will require?
In high heels and a business suit, Marilyn Price Spivack makes an unlikely rock star, but in the world of brain-injury experts, that's exactly the image she conjures up. She is innately tenacious, bold, and energetic. The availability of cognitive, neurobehavioral, and mental health services is sorely lacking, Spivack explains. Men and women in the military will receive excellent care for a time, but eventually, they are going back to their communities.
"The military is doing an extraordinary job in saving young soldiers and treating them through the acute rehabilitation phase," says Spivack, who works with the brain-injured population at Spaulding Rehabilitation Hospital in Boston. In the early 1980s she founded the Brain Injury Association, today the foremost advocacy organization for TBI survivors.
"Now the government must make a commitment to help them in their recovery, but where are the resources going to come from? As brain-injury professionals, we know that TBI services aren't available in many places across the country, and we are aware of huge holes in the system," she says. "Frankly, I'm frustrated and angry about the government's refusal to give the TBI population the support it desperately needs."
Spivack is not being glib; the giant holes are glaringly apparent. Many states do not have a single brain-injury rehabilitation center, and of the states that do offer some level of TBI treatment, few actually provide enough assistance to acquire even the most basic level of specialized care. At rates that can exceed a thousand dollars a day for postacute TBI rehabilitation, there aren't many American families that can afford a month's worth of treatment, much less the recommended minimum of 90 days.
As recently as mid-July 2006, the VA Office of the Inspector General admitted that patients and families were dealing with major inadequacies. The reality is that a fundamental level of care is simply absent in most states.
The military did not anticipate the magnitude of the problem, and now they are scrambling to add new brain-injury programs and services. Problems experienced by patients and families include inadequate or absent communication with case managers, lack of follow-up care, and being forced to pay out-of-pocket for necessary treatments and medication.
An evaluation of TBI programs and services conducted by the Institute of Medicine reads like a list of indictments. It concludes that "finding needed services is, far too often, an overwhelming logistical, financial, and psychological challenge...the quality and coordination of postacute TBI service systems remains inadequate."
Samuel Reyes Jr. had never heard the term "traumatic brain injury" before he enlisted in the Marines. As a machine gunner who patrolled Route Mobile near Fallujah, he was well aware of the loss of limb and life. He regularly saw the unspeakable, and then he lived it.
On September 6, 2004, Reyes rode in the back of a seven-ton supply truck with his patrol buddies and members of the Iraqi National Guard. A suicide bomber pulled up next to the truck and detonated its payload of C-4 explosive and 250-millimeter shells. The blast reduced the truck to little more than a chewed-up driveshaft. Only Reyes and four other marines survived the attack.
Reyes's body sustained a range of trauma in the attack. The impact of the blast cleaved his tongue in two and tore open his abdomen from rib cage to navel. It slammed both his knees into a metal barrier and peppered his back with shrapnel. His left arm was blown open to the bone.
"I remember waking up, being on the street, being hot like I was on fire," Reyes recalls. "People were talking to me, asking questions I couldn't understand. Someone told me I got hit by an IED [improvised explosive device], and I got scared because I knew what it meant."
Reyes could not have guessed what had happened inside his skull.
Blast-related brain injuries like those sustained by Reyes can deliver multiple TBIs. First there is barotrauma, in which the body suffers the same magnitude of pressure felt deep underwater. It's theorized that portions of the brain swell and decompress almost instantly during this stage, causing a host of cellular defects throughout the brain. Objects like shrapnel and gravel penetrate the skull, ping-ponging within the cranium walls. The force of the blast then blows an individual against an object, like a wall or a roof, causing blunt trauma to the head. Finally, in response to these injuries, the brain releases a metabolic cascade of neurochemicals that have a toxic effect on brain tissue. Reyes had no penetrating fragments; he experienced three of the four blast insults.
Reyes's ride through the military's medical system wasn't as clean as most. The medevac helicopters never arrived, so he was trucked to an ER. His heart stopped on the way to Baghdad—twice. Reyes awoke in a blur of bandages, surrounded by other wounded soldiers. Later that day,his platoon commander appeared from out of the haze and told him seven of his friends had died in the blast. The accompanying Iraqi soldiers had all died as well, he said.
"I had already lost a lot of friends before that, and this was another really big kick," Reyes says. "It's really bad to feel it, to hear it, and to know it."
The lieutenant left Reyes alone with his grief, and eventually Reyes's mind wandered to his own well-being. "It was all really going downhill then," Reyes says. "I was wondering what was going to happen to my military career, or if I could ever have a career at all anywhere else. It was hard to think of all that."
At the time of his injury, Reyes had only two more weeks of duty remaining before his tour was over. A natural-born athlete, he had planned to try out for Marine Recon, a component of special operational forces, and then move on to Officer Cadet School. He dreamed of someday leading his own platoon, then working his way up the chain of command until retirement. His entire future began to crumble away as he lay helpless among the damaged.
In less than a day, Reyes was transported to Balad, where a critical care air transport team accompanied him to Landstuhl. There he regained enough strength to make it to the National Naval Medical Center in Bethesda, Maryland.
"I was just waiting at Bethesda," Reyes explains. "By then, I was walking a bit better, but I still had a lot of headaches, a lot of pain, and vision blurs." Prior to his injury, Reyes had perfect eyesight; now he wears glasses in order to drive.
After a couple of days as an inpatient, Reyes was discharged to Camp Pendleton, near San Diego, where his father saw him for the first time since his injury.
"I was just happy to see he was alive and walking, but I knew something was different," Reyes Sr. tells me. "I could tell by the expression on his face that he didn't know me at first."
Reyes accompanied his father home for a three-week medical leave. During his entire journey through the military's most elite treatment centers, nobody mentioned anything about a traumatic brain injury to him—the most that was discussed was the likelihood of a mild concussion. Meanwhile, Reyes's concentration was shot, his tolerance was low, and he still could not shake the terrible headaches. He figured he was just a little shaken up and that his head would clear in a short time.
During his convalescence at home, Reyes didn't tell his family or friends about his memory gaps. Initially, he recognized no one. Reyes's father grew increasingly concerned.
"I had to keep explaining things to him," Reyes Sr. says. "He would ask me how everyone was, and I would have to tell him who they were and how he was related to them."
Reyes smiled and shook the hands of high school buddies and cousins, trusting that his memory would be jogged, but other problems began to creep in. Once, he drove an old girlfriend to work and then lost his sense of direction. When he dropped her off, he had a full tank of gas. He pulled into his driveway hours later with less than a quarter of a tank. Reyes also began drinking heavily; it was the only thing that soothed the searing pain in his head.
When he returned to Camp Pendleton that October, Reyes complained and complained, but the Marines put him back to work training new recruits. He misidentified guns; he forgot to include details about special combat procedures. It took the Marines a month to realize that Reyes wasn't the same, but instead of looking deeper, he says they simply allowed him to whittle his time away playing video games in the barracks while the rest of his friends prepared for another tour in Iraq. Finally, in June 2005, out of concern for Reyes's unrelenting headaches, a civilian doctor tested him for neurological problems. It was the first time Reyes heard the term "brain injury."
"I didn't know what a brain injury was, how it was caused, what it did, or what it was going to do to me," Reyes says. "It was just another term. They told me I would have to deal with these problems my whole life and that I needed to work with it and to find ways to live with it."
The military sent Reyes straight to the polytrauma center in Palo Alto. "They told me that his mild concussion wasn't as mild as they thought it was," Reyes Sr. says, recalling his first meeting with the Palo Alto treatment team. The team told both father and son that the memory damage might be permanent but that the son could still benefit from rigorous rehabilitation.
At Palo Alto, Reyes spent more than a year learning to learn again.The rehab team gave him a handheld organizer that beeps when he has appointments. They taught him meditation in hopes of relieving his anger. They educated him about brain injury and warned him that it would probably be tough on his social life.
Reyes is currently stationed back at Camp Pendleton. His primary duty involves chauffeuring a sergeant major around the base, a job he feels comfortable doing. As he grows more aware of his limitations, he is beginning to draw connections between his injury and its effect on his life.
"I don't really tell people about my injury," he says. "I don't like to go out at all. I stay inside and do things with people I know. I don't talk to my friends as much. When I get really upset, I forget how to calm myself."
Reyes's injury may be fresh, but his challenges mirror the complaints I hear from other survivors many years after the injury. Isolation, addiction, agitation—they are all quintessential characteristics of a serious TBI. When I ask officials in the VA system if they knew about the long-term outcomes faced by blast-injury survivors, I am met with shoulder shrugs. The injury is too new, the research is ongoing, the book is still being written.
I ask Reyes's father if he has any advice for other families dealing with the effects of a blast injury. "There ain't no really easy way to get through this," Reyes Sr. says. "You got to hope like hell someone is there to help you."
After five months of multiple transports between VA hospitals in Bethesda and Tampa, Seabee Pete Reid was finally cleared to return home. He still struggles with frequent nightmares, and sometimes he asks for the car keys, thinking he can still drive. His behavioral outbursts occur only every few days now.
"When someone dies, you go through all the steps of grieving," says his wife, Michele. "When someone goes through what we have, you grieve over and over because the TBI never goes away. This has ripped our family apart emotionally, physically, and financially. He was once the strong one who kept our lives together, and now our roles have changed drastically."
Pete Reid has a good sense of what he has lost, and what remains. "My biggest problem right now is staying focused," he says. "But I also miss being able to drive and do things around the house. It's frustrating to be taken care of, to not be able to wash myself and use the toilet on my own."
Reid knows he won't return to the service, but he still carries a strong sense of duty. I ask him what he sees himself doing 10 years from now, and he doesn't hesitate a moment in his answer. "I hope to help other vets so they don't have to go through what my wife has had to deal with," he says. "To me it seems like we had a lot of paperwork and mess to deal with. If they're going through the trouble of fixing me up, then they ought to help walk us through the red tape."
In its ambitious efforts to save lives, the military did not expect the dire circumstances that await surviving soldiers. With most other kinds of injuries and disorders, there are a wealth of services in place. Any heart patient can find affordable treatment within city limits, and any kidney patient can get dialysis within state lines. But brain-injury patients are stranded in their communities, isolated without basic services. Why have we devoted such tremendous effort to sustaining life while investing so little to support and nurture it? How did we become so shortsighted about such a serious problem?
Spivack agrees that the equation is unbalanced. "Our government will spend whatever it takes in pharmacology and technology to save people, and if they don't die, it's OK," she says. "Prevent fatality. They speak to caring, but meanwhile services are being cut and access is an issue. When we first began this effort, everybody talked about the quality of life, maximizing functionality. It costs money, and a lifetime of commitment."
Today Samuel Reyes Jr. perseveres despite the realities of his impairments. He plans to enroll in college and pursue a career in business management. "I expect school to be really hard, but I just want to try," he says.
Behind the impairments, you can still sense the soldier. Reyes's determination is rivaled only by his loyalty to the Marines. He believes they'll take care of him, Semper Fi. I want to believe Reyes, but I know there are obvious problems with service delivery. What happens when he and others are taken off active duty? In my eyes, he's the future. He's one of the thousands of veterans who will be in routine contact with brain-injury centers, asking for advice and help. Bolles points out that the actual number of troops wounded in Iraq is likely to be twice as many as reported. Will local VA hospitals have brain-injury clinicians ready to deal with a plague of psychological and social issues? Can communities already overburdened with brain-injury patients sustain the new influx of veterans?
The military has done a spectacular job repairing bodies, but it has not yet learned how to put lives back together. "More lives are being saved," says Bolles. "At the same time, those that are being saved are the more critically injured. There's a higher incidence of permanently disabled people." America isn't prepared for the injured's medical demands. After the dream-team care is finished, soldiers are finding themselves trapped in a nightmare.