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.
A Normal Life
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.
Learning to Shave — Again
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."
The Memory Book
Each patient is given a "memory book," which outlines that day's schedule and other vital information. Warren's book even tells him how he got here.
"I had a head injury from an explosion in Iraq on June 14, 2004," he said, reading from the book. Warren adds that without his memory book, he would not know what happened to him. In physical therapy, he exercises his muscles and brain at the same time. While cycling, Warren is asked to count by twos backward from 100.
He responds: "100, 99, 88, 84 ..."
The Scavenger Hunt
In a kitchen specially built for TBI patients, he learns how to whip up a hamburger dish. But the real challenge is a scavenger hunt, aimed at reintegrating him into the community. Even the simplest task — such as finding an item on a list — is daunting to these patients.
"They may be able to focus on one task, but external stimuli or even internal stimuli can cause them to lose concentration and be easily distracted like something beeping in the background or somebody walking by," said Karen Parecki, an occupational therapist.
Warren finds the items on his scavenger hunt check list, but struggles at the checkout counter. He tries to calculate his change on a piece of paper. But he still gets it wrong.
A Daily Struggle
This daily struggle to relearn the simplest things can be frustrating and exhausting, no matter how much encouragement he gets. No wonder Warren's favorite activity is sleeping. "No one bothers me," he said.
This is not just a psychological reaction. TBI patients are easily tired, and prone to mood swings. "If you have a domino effect of frustration, like I've had, it leads to a very bad day, and you just want to give up," said Giess.
When asked if it gets a little depressing, Giess said, "Oh yes, yes it does. You have to realize that you aren't the same person you were. And then once you start realizing that you aren't the same person, you can start rebuilding."
This former building contractor knows something about starting from scratch. Some days are especially frustrating. Like the time he went home to attend his daughter's middle school graduation. "I made sure I got there early, got everything ready, and then I forgot what time it was, what time the graduation was," said Giess.
He was late. And he was devastated. But his anger at himself never spills over into anger at the war. "No regrets. I'd go back over right now if I was able."
Proud to Serve His Country
Warren is also proud of his service, proud of the Purple Heart he received. But he questions the war that did this to him.
"I had lot of pride for my country and they shipped me to Iraq. With me having no say-so. I mean, look at me now, missing the top part of my head," he said.
Both men struggle to accept the reality of their situation. As do the families of TBI patients.
"They have this expectation, 'Oh, they're in a rehab unit, they'll be perfectly fine, they'll be the same as before.' And there's no way they can ever be the same as before," said Alvarez.
For everyone involved, that's a tough prognosis.
A Warm Welcome Home
When Warren went home to Los Angeles for a visit, the welcome from his family and girlfriend washed over him like a tonic.
"The doctors said it would be a good part of his rehab, you know, to help him in the recovery long term, and we definitely see that," said his mother, Cynthia Piccione.
Even Warren recognizes the change. Asked to name something he could now do that was impossible earlier, he said, "Have a normal conversation with somebody who's here."
At the same time, Warren knows he has a long way to go. Taking a shower by himself, for example, is difficult.
He still cannot be left alone. So his mother and girlfriend take turns staying home with him, even though they both have full-time jobs.
"He can concentrate on one thing at a time, he's easily distracted by the TV or other things," said his girlfriend, Vanessa Vargas. "Processing information, you know, he can tell he's a little slower." On a recent visit, they manage to get to a swimming pool, where Warren swam a few laps. This is real progress for a young man who wasn't walking three months ago.
Many Veterans Are Undiagnosed
Even so, he still needs 24-hour supervision. In some ways, veterans with traumatic brain injury are like toddlers again, something of a sad irony.
"The majority of them join the military because they want to leave the parents or they want to leave home," said Alvarez. "And to be independent. And now they're back to square one and it's sad to see that."
Not all veterans with TBI have the kind of support Warren and Giess enjoy waiting at home. In fact, many veterans with this "invisible wound" are going undiagnosed, their families misunderstanding their behavior.
Warren, at least, has started on the road to recovery. "My hopes are very good, very good," he said.
But there are still times when he feels sorry for himself. How does he deal with that? "I just cry."