War injuries in Iraq are usually obvious — from shrapnel wounds to lost limbs. But one type of wound is not so obvious. In fact, it often goes undetected.
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Consider the case of Army Sgt. Alec Giess, now recovering at a Veterans Affairs hospital in Palo Alto, Calif.
Giess served in an engineering unit that built housing for Iraqis. He was riding in a truck when the driver swerved to miss an explosive device.
Giess was pinned underneath the vehicle. When they dug him out, he had lost consciousness, but not his cigar.
"The cigar was blown up in my face and I was gritting it between my teeth," he said.
Giess, 45, soon healed from his obvious injuries, including several cracked vertebrae and a broken collarbone. But when he went home to Oregon on leave, his wife noticed dramatic changes in his behavior. He would erupt in anger and fail to complete the simplest tasks.
"She couldn't understand, actually, what was going on," said Giess. "She was afraid of me. I thought I was all right, and my behavior was not all right. Not the way I was when I left."
Giess was finally diagnosed with TBI — traumatic brain injury. It is sometimes called "the invisible handicap." Symptoms include irritability, poor memory, lack of inhibition, anxiety, confusion, unusual fatigue and persistent headaches. These problems are often dismissed as postwar stress reactions.
While an estimated 20 percent of injured veterans in past wars suffered from TBI, doctors say more than 60 percent of injured troops returning from Iraq may be afflicted. The reason: Troops have new body armor that saves lives by protecting the torso, but not the brain.
Marine Lance Cpl. Raymond Warren took shrapnel to his legs, to his stomach, to his arms and to his head, which made the TBI diagnosis easy. He lost much of his memory, and must wear a protective helmet until his skull heals. Warren could neither walk nor talk when he arrived at the Palo Alto facility in July. Now he can do both. But he has dreams of much more. "Get back to running, drive a car, stuff like that," he said. "Just the normal life of Raymond Warren."
But a "normal life" is a long way off — and may look very different than his "normal life" of the past.
Warren is one of more than 350 veterans from Iraq and Afghanistan now being treated for traumatic brain injury at a handful of VA facilities. But as wounded veterans return, the need for more beds is enormous.
"We're getting more and more every day, and it's very frustrating because we don't know when it will end," said Stephanie Alvarez, nurse manager at the Palo Alto VA hospital.
The rehabilitation requires months of work with a skilled team. It also requires a great deal of patience. Warren, for example, needed to relearn basic tasks, from brushing his teeth to shaving. A chart reminds him what to do and when to do it.
"The majority of them, they're incontinent, both bowel and bladder, so we have to retrain them when to use the toilet, how to use the toilet," said Alvarez.
In all TBI patients, the frontal lobe — an area of the brain that governs impulse control — is affected. These patients often have trouble focusing if there are any distractions in the room.
"I'm a little frustrated," said Warren. "Too much going on right now. [It] boggles my mind sometimes."