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 by the 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.
 |
|
The truck in which marine Samuel Reyes Jr. was riding when a suicide |
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.
 |
|
Courtesy of Michael Mason |
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.
