Health & Medicine / Mental Health

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.

Dr. Gerald Grant, a neurosurgeon at Balad Air Force Theater Hospital (Courtesy of Lt. Col. Gerald Grant)

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 where up 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 cardiothoracic surgeon 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.'"

Name Address 1 Address 2 City

State Zip Code

Email

If you live outside of the US & Canada,