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.