The Washington Post, October 3, 2010
Traumatic brain injury leaves an often-invisible, life-altering wound
In some cases, even apparently mild brain injuries can leave a soldier disqualified for service or require lifelong care that critics say the Department of Veterans Affairs isn't equipped to handle
By Christian Davenport
The doctor begins with an apology because the questions are rudimentary, almost insultingly so. But Robert Warren, fresh off the battlefield in Afghanistan and a surgeon's table, doesn't seem to mind.
Yes, he knows how old he is: 20. He knows his Army rank: specialist. He knows that it's Thursday, that it's June, that the year is 1020. Quickly, he corrects the small stumble: "It's 2010." He knows that his wife is Brittanie, that she's due with their first child any day now, and that they "got married two to three weeks before I went to that country."
Stumble No. 2: "That country."
David Williamson doesn't let it slide. "Which country?"
"Whatever country it was that I got blown up in," Warren says.
In a conference room at the National Naval Medical Center in Bethesda, he purses his lips, and as he searches for the word "Afghanistan," he slides his hand over the left side of his head, which is cratered, like an apple with a bite taken out of it.
"Crap, I can't remember," he says finally.
Warren has trouble remembering a lot of things. Which isn't surprising, considering that several pieces of shrapnel tore through his skull after insurgents outside Kandahar blew up his truck with a rocket-propelled grenade in May. One piece came to rest in the center of Warren's brain - two millimeters from his carotid artery - where it remains, suspended like a piece of fruit in a gelatin mold, too dangerous to extract.
"I'm going to say three words and then have you say them back to me, okay?" says Williamson, a neuropsychiatrist who runs Bethesda's traumatic brain injury unit. "Apple. Desk. Rainbow."
Warren doesn't hesitate: "Apple. Desk. Rainbow."
He seems satisfied to have answered a question correctly. But repeating the words immediately isn't the point of the exercise; it's being able to repeat them in 10 minutes or so, after some other tests. A person with normal cognitive function will probably remember all three words. Patients with mild Alzheimer's might recall two. People with advanced dementia might remember only one, or none at all.
At the Bethesda hospital, the flow of brain-injured patients is constant. For nearly a decade, the United States has been fighting wars in which soldiers are routinely exposed to brain-rattling blasts that can send ripples of compressed air hurtling through the atmosphere at 1,600 feet per second. Now, the military is struggling to come to terms with an often-invisible wound.
The military brass are discovering that what used to be shrugged off as "getting your bell rung" can lead to serious consequences. In some cases, even apparently mild brain injuries can leave a soldier disqualified for service or require lifelong care that critics say the Department of Veterans Affairs isn't equipped to handle.
Since 2000, traumatic brain injury, or TBI, has been diagnosed in about 180,000 service members, the Pentagon says. But some advocates for patients say hundreds, if not thousands, more have suffered undiagnosed brain injuries. A Rand study in 2008 estimated the total number of service members with TBI to be about 320,000.
A small percentage of those injuries are as serious as Warren's. To let his brain swell and keep the blood flowing, thereby preventing the damage from worsening, doctors removed virtually the entire left side of his skull, a procedure known as a craniectomy.
Warren's physical wounds will heal, but three weeks after he was hit, military doctors are still discovering the extent of the damage.
Williamson plows ahead with other tests, revealing that Warren doesn't know where he is. "This is the U.S.A.?" he says. Warren cannot subtract seven from 135, but he can spell "world" - though not backward. He can recite the days of the week but can't come up with the words for necktie or button.
Finally, Williamson asks whether he can remember those three words he had to repeat. Sixteen minutes and 19 seconds have passed.
"Which words?" Warren says.
The patients on 7 East
No two traumatic brain injuries - signature wounds of the wars in Iraq and Afghanistan - are the same, but the patients on 7 East, Williamson's TBI unit, demonstrate what life is like when the organ that turns a body into a person is damaged.
There's the Marine whose injury robbed him of the ability to understand speech even though he could still read, another who could no longer laugh, one who could see out of both eyes but only to the left, and one soldier who became dangerously impulsive and started spending thousands of dollars on junk he didn't need.
Although their injuries might not be as visible as a severed limb, TBI victims' damaged neurons and altered brain chemistry can cause all sorts of behavioral problems. Those injuries are about much more than a lump of tissue sitting between the temples. "It's about who they are," Williamson says. "How they see the world. How they process different experiences. It's about how their personality changes. It's about their humanity."
Many patients on 7 East suffer from little more than the general haziness that comes from having been too close to an explosion. Those concussions, often referred to as mild TBI, are the most common brain injuries in wars in which the enemies' weapon of choice is the makeshift bomb.
Severe TBI, such as Warren's, can lead to wholesale personality changes. But doctors now know that even mild TBI can have serious consequences. A blast "causes a change in how your brain functions," said Vice Adm. Adam M. Robinson Jr., the Navy surgeon general. "People have been very, very slow to come to that conclusion, but it's true."
Established after trauma surgeons realized their brain-injured patients needed additional help, 7 East, one of the few units dedicated exclusively to TBI, is less than two years old. Patients usually land in the hospital's trauma unit first, but if they show any sign of cognitive impairment there - can't remember where you went to high school? - Williamson has authority to transfer them to his unit.
Veterans Affairs Secretary Eric K. Shinseki said in August that the military and the VA "simply cannot afford to be less than aggressive in our effort to identify, treat and rehabilitate TBI victims."
Williamson's unit, which can handle six patients, is a first, but insufficient, step. Next month, a $65 million medical center devoted to TBI, post-traumatic stress disorder and other psychological problems will open its doors at Bethesda; it will eventually treat about 20 patients.
But the military's awakening on the severity of traumatic brain injury comes nine years after the flow of victims began. Critics such as Cheryl Lynch, founder of American Veterans With Brain Injuries, say the delayed response is nothing short of a dereliction that has left severely injured veterans suffering for years. Her son, Chris Lynch, a former Army private who hit his head after falling 26 feet in a training exercise 10 years ago, was in and out of hospitals for years before getting treated at 7 East in the spring.
"The only appropriate place I know to send families for brain injury treatment is to Dr. Williamson," Cheryl Lynch said. "That's sad."
Every morning, Williamson gathers his team - nurses, doctors, social workers, therapists - to discuss their patients. Tall and genial, Williamson gives his patients his cellphone number and is known to reply to text messages at 5:30 a.m. He has close-cropped gray hair and a Scottish lilt that has faded a touch since he came to the United States to study at Johns Hopkins University 24 years ago.
At one recent meeting, the staff is especially concerned about Chris Lynch, who had been seen running down the hallway naked. "BIMs" - Lynch's term for brain injury moments such as this one - are no excuse for bad behavior, Williamson tells his team. Even though Lynch has a serious brain injury, "he still has the capacity to learn. Part of our job is to retrain him behaviorally."
The doctor tells his team to help the patient by treating him as they would a misbehaving child. "We want to cultivate guilt," he says. "Appeal to his sense of ethics."
Behavioral therapy is only part of the treatment. Much of Williamson's work is finding the right mix of medications - not always an easy task with patients whose brain chemistry is already altered. Ever since his injury in 2000, Lynch has shown signs of manic behavior, swinging wildly from elation to depression and back again. Now, for the first time after years of shuffling in and out of hospitals, Lynch is getting what his mother thinks is the correct diagnosis: bipolar disorder.
The good news, Williamson says, is that there are drugs to treat it.
A rose is a telephone
After seeing Williamson in the morning, Robert Warren has an afternoon session with his speech therapist, who proudly tells him he's "come a long way" - quite an understatement considering Warren arrived in Bethesda on a ventilator and in a coma from which he didn't emerge for five days.
But now, just three weeks after he was hit, he denies any problems with speech or memory: "I say everything just like I did before I was in that country."
He still can't recall the word "Afghanistan," but he does know he's at the Bethesda naval hospital. Answering the therapist's rapid-fire questions, Warren demonstrates that he also knows that the door is closed, that the light is on, that paper burns, that he's not wearing red pajamas. But soon his concentration fades, and he slips.
"Do you eat a banana before you peel it?" she asks.
"Does it typically snow in July?"
Then the therapist shows him a rose and asks what it is.
"This would be a telephone," he says.
It hurts his family to see him like this, but they're mainly happy he's alive. When she first got word that Robert had been wounded, Brittanie, then eight months pregnant, collapsed. Her father took the phone and was told that the only thing they knew about Robert was that they didn't know whether he would live.
Now, amazingly, Warren, speaking with his same Arkansas drawl, shows flashes of his old self. When Brittanie tells him he's "full of it," he smiles, tickles the top of her head and says, "Yeah, full of Southern pride."
Warren, who dropped out of school and worked at Jiffy Lube and a poultry plant, finally got his GED diploma so he could enlist in the Arkansas National Guard.
Brittanie got pregnant, they married, and then an insurgent's blast sent several fragments, at least one as big as a pencil eraser, into his head.
When Warren holds his daughter for the first time at the naval hospital, his father-in-law asks what it feels like to be a dad. It's a simple question, but given the situation, a loaded one: Will Robert be able to care for the bundle in his arms? What will life be like when there are no more nurses and doctors tending to him around the clock?
"I don't know yet," he responds.
Everyday life as therapy
"How was your day?" John Barnes's mother asks as he walks in the door.
John Barnes incurred a traumatic brain injury in Iraq when shrapnel entered his brain from an enemy attack on March 14, 2006. (Whitney Shefte/TWP)
"Pretty good," he says, dropping his camouflage backpack in the foyer of their home in Tampa.
And it was. He woke up and showered. Shaved. Took his meds. Then he spent the day with his "life skills" coach, who was proud of his behavior except for a few off-color comments.
But Valerie Wallace is worried. Not just because she found a bowl of half-eaten egg noodles that her son left behind this morning in the shower - such surprises are normal when you live with someone as brain-damaged as Barnes - but because she also found a Benadryl in his shorts pocket and another one on the floor of his room.
A couple of years ago, a few loose pills would not have bothered her. Her son had made an amazing recovery from a 12-day coma after a piece of shrapnel pierced his brain near Baghdad in 2006. He vowed he would be walking again by the time his unit returned from Iraq, and he was, even though that meant ditching the wheelchair and dragging himself down the hospital hallway using the handrail.
After intensive therapy, he got so much better that when he was discharged from the hospital, VA doctors said he was well enough to live on his own. His mother imagined that he would have something of a normal life again. It seemed like total victory.
But once he got home, the problems really started. Barnes started drinking, then smoking pot and then inhaling gas from compressed-air canisters. He crashed his car four times.
Once he gets going, he can't stop, which is why his mother is so worried about the Benadryl, the only drug he can easily get his hands on now. One pill turns to two, then 12. Wallace, a labor and delivery nurse, wishes her son could realize that his actions have consequences; that driving under the influence leads to car crashes; that saying the first hateful thing that comes to mind alienates people, at best.
But Barnes can't think about consequences. The mortar round sent shrapnel tearing through his frontal lobe, the region in charge of decision making, reason and morality. As a result, Barnes is impulsive, always in the moment, like an especially reckless 13-year-old. He's 26 but needs round-the-clock supervision.
Finally, after Barnes had nearly killed himself several times with his reckless behavior, Wallace heard about Williamson's unit in Bethesda and had her son admitted. After a series of stays on 7 East, he emerged clean and sober, with new medications. Barnes went home with a plan that started with the basics: shower and shave every day, no illegal drugs, do your physical therapy, take your meds, go to all your appointments.
At home, each task Barnes completes earns him a check mark on a dry-erase board that Wallace has posted in the kitchen. The more check marks, the better his score. The better his score, the more allowance she gives him. Today, she's worried about the no-illicit-substances column, but for the moment lets it pass, asking again about his day.
He beat his life skills coach in bowling, 96-71, Barnes says proudly. But that wasn't his best moment - at least not in the eyes of Josh Shannon, the VA contractor who has worked with Barnes three days a week since he came home from Bethesda three months ago.
The best moment came as Barnes was checking out video games at Wal-Mart. Just then, an overweight African American woman walked by. And Barnes, who is white, said nothing. None of the impulsive, loud comments about her behind or her race that have gotten him in trouble since his injury. Just a once-up-and-down glance and a smirk. Then, only after she was out of earshot, he uttered one quick comment: "Two sacks of potatoes. No, 2.75 sacks."
Shannon celebrated Barnes's success: "Did you see that?" he said proudly.
Barnes had adhered to the 10-foot rule Shannon had been drilling into him - waiting until a person is out of earshot before saying anything derogatory. And Barnes had used their code word: One sack of potatoes is someone who is "merely overweight," Barnes explained. "Two point seven five and you have an ass like a . . ."
"John!" Shannon snapped. "Inappropriate!"
The life skills coach is a human prosthetic, a replacement not for a missing arm or leg but for a damaged frontal lobe. In his constant nitpicking - Barnes can't so much as toss a cigarette butt in Shannon's presence without a reprimand - Shannon does what Barnes's brain used to do. He corrects socially unacceptable behavior and mutes Barnes's impulses. Over time, Shannon thinks, Barnes's brain can be retrained so that he more closely resembles the person he used to be.
Before he was injured, Barnes led a fairly successful life. He had enlisted and been promoted to sergeant in the 101st Airborne. He was a husband and a father. But since the injury, his marriage dissolved; his wife now lives in Indiana with their 5-year-old son. And he developed a very bad habit of saying despicable things about people. In public. Loudly.
That's why Shannon takes him out into what he calls the "G.P." - the general public. It's everyday life as therapy. A few times a week, mostly in a diverse area north of Tampa, they circulate at the Wal-Mart, the bowling alley, among all sorts of people who used to trigger his derogatory and sometimes racist remarks. Wallace says her son was not a racist before the injury - something Shannon finds hard to believe.
Four years after his injury, Barnes is making progress. Still, without constant supervision, Wallace says, her son would "be dead within three months." With it, there are still signs of trouble.
Like the Benadryl.
He had a stash hidden in the well of his luggage where the retractable handle rests. But does he have more pills stashed elsewhere? She has other worries, too, about his impulsiveness, his erratic behavior and the fact that he always seems one bad decision from yet another crash.
He needs more help than one person can provide. Wallace has accepted that the burden is hers; she must care for her son for the rest of her life. But that leads to her scariest thought of all:
"What will happen to him if something happens to me?"
'The real test'
One month after getting hit, Warren remembers the word "Afghanistan." He remembers Kandahar. He remembers the moments before the rocket blew up his truck.
"I've seen tremendous improvement," his mother, Susan Bryant, tells Williamson during a meeting at the hospital.
"You really are doing very well," Williamson agrees.
But memory, language and the ability to think clearly - up to now the focus of his rehab - are not the only problems Warren might encounter. "There's one other area that's on my radar," Williamson tells Warren and his family. The area of the brain that's injured "is also involved in emotional regulation."
"In severe cases, we have some patients who get manic-depressive mood swings or they get profound depression or they have temper outbursts," the doctor warns.
In other words, Warren could start acting like John Barnes, requiring round-the-clock supervision. There's no way to tell. Some erratic behaviors might not show up for months or years, Williamson says. Warren and his family must wait and see how he does at home, where he'll face everyday challenges: getting a job, soothing a crying baby, remembering appointments, managing money.
"The real test," Williamson says, "is real life."
This article is part of year-long series on the impact of the Iraq and Afghanistan wars back home. A blog with firsthand accounts is at voices.washingtonpost.com/impact-of-war.
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