Fog of war

One soldier's struggle with the Iraq war's trademark injury

By RUTHANN RICHTER

Brett Miller was just 6 feet from the roadside bomb when it exploded amid a flash of light, a hail of dirt and splintering glass. A 31-year-old U.S. Army sergeant, he’d been speeding in his Humvee down a debris-strewn road in Iraq, a stretch between Mosul and Kirkuk that is notorious for its roadside bombs. Miller had been hit there several times before but never with the kind of head-splitting force that roared through on Aug. 11, 2005.

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This time he wouldn’t walk away. Instead he would become captive to a brain injury that would go unrecognized for more than a year. Today, after many months of therapy, he can express what that initial feeling was like — of literally losing his mind.

“You can’t communicate. You have no physical reactions. You have no feelings. It’s as if you’re duct-taped, blindfolded and tied,” says Miller, now in a brain injury rehabilitation unit at the Veterans Affairs Palo Alto Health Care System.

These hidden, often debilitating, traumatic brain injuries have become the trademark of the Iraq war. Kevlar-armored soldiers who would have previously died in combat are surviving blasts, vehicle collisions and other assaults, only to walk away with injuries to the brain that might not be immediately apparent.

Nearly 1,900 of the more than 24,000 soldiers wounded in Iraq and Afghanistan have been treated for traumatic brain injuries at the eight Defense and Veterans Brain Injury Centers, of which the Palo Alto-VA is one. Eighty-eight percent suffered “closed head” injuries — those that are buried in the brain and are often missed, especially when there are other obvious problems, such as an amputation, that need urgent attention, according to VA figures.

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In addition, there are believed to be many others — at least 8,000 to 10,000 based on U.S. Army estimates — who have been discharged home or are still in combat situations who might have head injuries and don’t know it, says Harriet Zeiner, PhD, a neuropsychologist with the Palo Alto-VA program.

“When people are very injured, that’s obvious, but what about the person who’s not bleeding, not unconscious on the scene?” asks Zeiner, who counsels brain injury patients and their families. “After the pressure wave [from a blast] has gone through, they may be dazed, but by the time all the hysteria drops down and the chaos ends, they pick up the gun and they’re moving again. But something’s changed. From that moment, they may have the effects of a brain injury. And the problem is, they don’t know it.”

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Brett Miller is an example of the soldier who fell through the system’s cracks, trying to function with a serious injury that wasn’t initially recognized. Miller was at the top of his game when, as a member of the Oregon National Guard, he headed to Iraq in late 2004. He had dreamed of becoming a firefighter since the age of 14, when he watched his family home near Sacramento, Calif., burn to the ground. He later earned a master’s degree in fire science, teaching firefighting at a community college in Oregon and spending summers commanding a squadron of 200, battling forest fires for the National Guard.

That would all crash to a halt on the road to Kirkuk, when Miller’s Humvee ran afoul of an improvised explosive device, an IED: “Bam! It was like a flash of light and a wall of dirt. Everything turned brown,” he recalls. He was briefly knocked unconscious and was airlifted to Balad, the major military hospital in Iraq. He suffered one of the classic injuries of the Iraq war, in which a pressure wave from a blast sends the brain ricocheting off the skull, causing brain damage similar to shaken baby syndrome. He lost hearing and sight on his right side and suffered a big crack in his right knee. His left side was weakened by the brain injury, which was so diffuse a CT scan failed to show it.

Miller would follow the usual soldier’s road to treatment, with stops at Landstuhl hospital in Germany and Walter Reed Army Medical Center in Bethesda, Md., this winter the subject of widely publicized complaints over allegedly poor conditions. Miller says he spent three weeks on a gurney in a hallway there, mostly staring at the ceiling. In October 2005 he was transferred to Fort Lewis in Washington, where he reported to duty every day and was treated for his obvious physical injuries at Madigan Army Medical Center on base. But he found himself incapable of performing his designated job as a computer instructor.

“Once my physical injuries started to recover and my mobility returned, there were a lot of things I was cloudy about — memory and talking, speech, things like that,” he says. “I don’t think the screening process is all that effective. If they can see it, they can fix it.”

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Brett Miller

But he noticed many disquieting symptoms. He couldn’t add and subtract or read a page of a book. He would forget what he was doing in the middle of a task. He couldn’t dial a phone number because the digits would dissolve in his head before he could finish. He jokes that he’d make a poor Jeopardy contestant because he’d get the answer an hour later. Finally, at his case manager’s urging, he made a list of all of his problems and stepped out of rank to walk into the office of a neurosurgeon.

For the first time he was formally recognized as a victim of brain injury.

Miller said his real road to recovery began in Palo Alto when he arrived at the VA in October 2006. He describes himself at that time as a “babbling idiot,” unable to form a full sentence. With speech therapy, he’s regained the ability to express himself — so well, in fact, that it’s easy to miss the serious cognitive deficits and psychosocial problems, including post-traumatic stress disorder, that dog him to this day.

 On first meeting, he looks the part of the battle-ready soldier, with his U.S. Army flap jacket, mirrored sunglasses and baseball cap over his gray-flecked hair, a wartime souvenir. But beneath the manicured exterior is a diminished man who has lost his sense of identity, for, as he notes, the brain defines who you are. Sadly, he says he wishes he’d lost his legs, instead of his mind.

“People run without their legs but you can’t think without your mind,” he says. “The essence of a person is in their mind. If you take that away, you’re less of a person. You can run and swim and do everything with prosthetic legs. There’s no such thing as a prosthetic mind.”

Miller remains close to his family, but it’s not the same, he says. His father lives in Lake Tahoe. He also has an ex-wife and an 8-year-old daughter in Oregon. During family get-togethers, he says, he doesn’t reminisce about the past, because his is fuzzy.

“There’s still a distance there because those memories are lost,” he says. “Those are the things that shape and mold a family. It might be like a foster family. In actuality, it’s almost like it was another person.”

Miller now spends his days in an intensive rehabilitation program, in which he gets individualized attention from neuropsychologists, speech therapists, occupational therapists, physical therapists and recreational therapists, among other caregivers. He attends a memory group, a computer group, a group on basic living skills and a stress management program. He also receives counseling for PTSD.

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Tim Jeffers

These therapy programs capitalize on new research in the last decade that has debunked the notion of the brain as an immutable organ, and shown it to be a highly flexible one, capable of repairing itself. Contrary to long-held dogma, new studies have shown that brain-injured patients like Miller have the ability to make new, functional neurons and to retrain one region of the brain to take over jobs once performed by another damaged region, a concept known as neuroplasticity. The window of opportunity for this physiological retraining is up to about 24 months after injury, neuropsychologist Zeiner says, though patients might continue to make progress based on new learning and experiences, she says.

One of Miller’s fellow patients at the VA, 23-year-old Tim Jeffers, offers stunning proof of the brain’s uncanny ability to recover from severe trauma. A corporal in the U.S. Marine Corps, he made the near-fatal mistake of looking down the hole of a discarded car muffler, a cleverly disguised IED, while on patrol in Iraq on May 18, 2006. The blast sheared off part of his skull and his right eye and blew off one of his legs and a finger. He was in a coma for two weeks. Ultimately both legs had to be amputated above the knee.

When Jeffers arrived two months later at the Palo Alto-VA, he was still so weak he could hardly sit up in bed. But one of his first requests was for prosthetic legs so that he could walk again.

“I’m going to pick myself up,” Jeffers, sitting in his wheelchair, says between therapy sessions at the VA. “I’m not going to let the turd who planted the IED win. I don’t know if he was watching. He’s probably thinking he messed up my life. But I’m still alive.”

Elaine Date, MD,  director of the Palo Alto-VA’s Polytrauma Rehabilitation Center, calls Jeffers “one of the bravest men I know.”

He’s also a lucky man — given his terrible injuries. Zeiner says he’ll be able to go to college and do pretty much anything, except for activities limited by his physical, non-brain, injuries.

Just how much patients recover depends on what part of the brain was affected and the severity of the injury, as well as how soon they receive appropriate rehabilitation therapy, Zeiner says. Social support can also make a difference in a patient’s ability to regain normal functions, she says.

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Palo Alto-VA center is a leader in care for brain injuries

More than 60 percent of the soldiers wounded in Iraq have suffered injuries from blasts, often caused by improvised explosive devices, according to the Office of the Surgeon General of the Army. These blasts typically arrive in an overpowering wave of force that can rock the brain and cause serious, though often invisible, injury.

The Defense and Veterans Brain Injury Center provides screening and care for these injuries, conducts research and educates the public about them. Founded in 1992, the DVBIC operates at eight military, VA and civilian sites, including the Veterans Affairs Palo Alto Health Care System.. One of the goals of these centers is to increase public awareness of this hidden injury. Nearly 1,900 soldiers wounded in Iraq have been treated for brain injury at these medical facilities.

 

But even with the best of care, symptoms of brain injury might persist over time. In a 2006 study published in the Journal of Rehabilitation Research and Development, Henry Lew, MD, PhD, clinical associate professor of physical medicine and rehabilitation at Stanford, followed the progress of 168 brain-injured patients in his VA clinic. He found that while their physical wounds usually healed, 94 percent still had cognitive difficulties and 84 percent had persistent emotional problems after two years. Lew says those with head injuries might continue to suffer social handicaps that impair their ability to relate to family and friends or to hold down a job.

“This invisible wound is hurting them more than their visible wound because it affects them in so many ways — their jobs and their relationships,” Lew says. Fortunately, he says that with treatment these patients still can learn strategies to compensate for their residual cognitive and emotional problems.

Concerned about the impact of brain injury on its personnel, the military now is screening all returning soldiers for possible head trauma so they can be referred for appropriate treatment, if needed, says Deborah Warden, MD, national director for Defense and Veterans Brain Injury Centers. The military also has developed a screening tool — a series of simple, neuropsychological tests — to detect brain injury early, out in the field, Date says. Moreover, any patient who walks into a VA facility today, even if it’s for a dental exam or prostate test, is routinely asked four basic questions: Have you ever been in a blast? Have you ever been in combat? Have you ever seen stars? Did you ever get confused? If patients answer yes to any of those questions, they receive a battery of tests to detect possible head injury.

“People are discharged home, and they may have a brain injury that is impacting them and their entire family,” Zeiner says. “Then it becomes a health-care problem for the American public.” Because many Iraq returnees seek care at non-military facilities, it’s important for community physicians to be attuned to the issue, she says.

 “This is really an American health-care problem, not just a VA problem,” she says.

The cost of treatment and long-term care for these brain-injured soldiers could be staggering — as much as $14 billion over the next 20 years, according to a 2006 report by Linda Bilmes of Harvard’s Kennedy School of Government and Joseph Stiglitz, PhD, of Columbia University.

Though Brett Miller has made significant progress as a result of his treatment in Palo Alto, he recognizes it will only take him so far. He’s had to come to grips with the fact that he’ll never return to his former life. “The hardest thing for me to realize is it’s not going to come back — the memory, the cognitive speed. Ten years down the road, I’m not going to be the same person. That’s the hardest thing for me to wrap my brain around,” he says.

He plans to go into a PTSD treatment program at the Menlo Park-VA and then enter a VA-sponsored vocational rehabilitation program that will help him decide his next step in life. He’s found a passion in competitive mountain bike racing, his form of mental and physical therapy, and he says he’ll always be the “weekend warrior” of the biking world. But as for the rest, it’s a leap into the unknown.

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