COUNTERING MILITARY RECRUITMENT
Articles: Military Service: Casualties
The Heros The Healing: Military Medicine from the Frontlines to the Homefront
Neal Shea, National Georgraphic
Nov. 21 2006
Frontline medicine is always brutal, but for some U.S. troops injured in Iraq, the real fight begins when they come home.Part One: Front Lines
The war is on hold. The soldiers of Charlie 2-4 sprawl on battered chairs and couches in dust-lined rooms that stink of sweat and half-eaten meals. They stare at pirated DVDs, thumbing through gun magazines, car magazines, even copies of Glamour. Some wrestle like brothers cooped in a snowbound house, boots clomping past stacked rifles, insults riding over radio static. For 12 hours, nothing has happened. The men, crews of one of the busiest medevac helicopter units in Iraq, have fought only boredom. A feeling gathers that something is coming, that they're due. No one mentions it. That would break taboo.
Outside, a sea of stars spreads above the trailers and shipping containers that compose this base. The lights of Baghdad bloom on the horizon, making the place feel removed, safe, although insurgents have lately been lobbing mortars over the 20-foot (six-meter) walls. Elsewhere, infantry units roll out on patrols or return for midnight meals. Generators hum. Spring-armed doors clap shut as soldiers go to shower away the day's dust.
The men of Charlie 2-4 fly Black Hawks over a landscape too dangerous, too wrecked for road travel. They fly into the hot, violent cities, the mud-brick towns, the nowhere stretches of desert, picking up American and Iraqi soldiers, civilians, and, sometimes, enemy fighters. For medevac crews, there are missions, and the space in between. Earlier today, Charlie 2-4 rescued three Iraqi boys wounded in a bomb blast in a rural field. Blood and mud caked their bodies, stubs of straw clung to their bare backs like a pelt. The mission reset the clock, the psychic countdown. Now comes a rush of static and an anxious, tinny voice on the radio: Insurgents have attacked a U.S. Army patrol somewhere on a highway south of Baghdad. One of the soldiers is badly wounded.
A four-man crew sprints to the flight line, loose gear bouncing on shoulders. They stow their rifles, slip on sweat-greased helmets. The pilot and copilot spin up the Black Hawk's rotors and speed through the preflight checklists. A sweet, dizzying breath of fuel washes over them. David Mitchell, the flight medic, scans the cabin: litter pans for stretchers, four of them, jut from the sides of the helicopter like berths on a ship. Oxygen tanks, heart monitors, bandages, bags of saline, all of it ready, wedged into crooks, compartments.
The crew tenses, especially Mitchell. The tall, 29-year-old sergeant is earnest and usually quiet, a polite southern boy. Excited or nervous, his eyes widen and he curses more, a habit he's trying to curb. As he sorts the last of his gear, he swears, a single word, the sound of it lost in the clatter of rotor blades.
The helo slides loud and low over the desert. In the cockpit, the pilots scan for muzzle flashes, tracers, warning each other of low-hanging wires. In back, Mitchell thinks through scenarios. He decides where he will put the patient. He imagines what might go wrong, what he will do. Medics learn quickly to solve problems, or at least keep them from worsening. Much of their job comes down to plumbing: Plug the leaks, stop the bleeding. Speed is key. If medics hold fluids in, if the helicopter moves fast enough, the wounded win time.
Mitchell is from Waldo, Arkansas, population 1,600, in the southwest corner of the state. The Where's Waldo? jokes no longer amuse him. He is a father of four boys and was married on September 11, 2001. On every mission he carries three good-luck charms. One is a gift from his parents, a crucifix inscribed with the letters K.O.S.S.—Keep Our Son Safe. The others, a black rubber wrist bracelet and a single dog tag pressed with his nickname, Deucez, and those of two buddies, Skyzap and Spyder. It is only his first tour in Iraq—some of his colleagues have done three—but Mitchell has become a character in the superstition surrounding the unit's endless days. He is called a "mission magnet": Whenever he's on duty, something happens. Tonight the proof piles up.
It is near midnight when we arrive on the scene, circling while the pilots inspect what's below. Humvee headlights carve out a landing zone on an empty road. Soldiers aim their weapons into the blackness beyond, watching for an ambush. We bump down in a cloud of hot dust. The injured man has been laid on a litter and stripped to the waist. Four or five of his comrades run the litter to the helicopter and clumsily, frantically, shove him inside. He has no pulse. Mitchell begins CPR. The helo lifts off for Baghdad.
The soldier is perhaps 20. He is lanky, with knobby shoulders—a boy's shoulders. Green cabin lights wash across his chest, his right arm flops off the litter. Mitchell moves like a piston above him. "Come on, buddy," he says. "COME ON, BUDDY." Sweat pours off him in long beads. Even with the windows open, the helo racing 200 feet (60 meters) above the ground, it is well over a hundred degrees (38°C). The heat, the weight of his body armor, and the frantic pace drain him. He's exhausted, losing effectiveness. After ten minutes, crew chief Erik Burns makes Mitchell get out of the way. Then Burns waves me in, a fresh set of arms.
Medics must use any resource available to them, and tonight I am one. I shove down 15 compressions. The soldier's chest feels ready to crack. I sink all my weight into it, right over his heart, his ribs buckling beneath my hands. My head pounds. Mitchell slumps beside me. We're gonna save this kid, I think. I will it true. We fly on toward Baghdad, over the flat fields, the pinprick lights, the sleeping country. The last minutes to the hospital blur past, a manic, sweat-soaked dream.
We touch down on a landing pad outside Ibn Sina Hospital in Baghdad. A nurse and medic duck across the pad, their scrubs flapping in the rotor wash. They haul the soldier into the trauma room. Doctors and nurses swarm him. Someone continues CPR, others slide tubes down his throat, measure blood oxygen levels, check his pupils with a flashlight. Mitchell stands nearby, helmet tucked under his arm, downloading what he knows to a nurse. His bald head shines with sweat. Monitors beep, there is the gasp of breathing machines, the tear of bandages.
"I got blood coming out his ears!" a doctor is saying.
"Hey! I got a pulse!" another shouts. It's been five minutes since we arrived.
Mitchell grits his teeth in a tight smile and pumps his fist. Yes.
"I told you," he says, bouncing on his feet. "No one dies in my helicopter."
Then the mood shifts. Something is suddenly understood, it appears on the faces of the doctors. There is a pulse, nothing more. The soldier doesn't react to stimuli, shows no signs of life. There is a question about what to do. But Mitchell must leave, speed dictates, and we fly back to base to wait for the next call.
On the ground we learn the soldier's fate. Doctors discovered a metal fragment embedded deep in his brain. They decided an operation would be futile. The only hospital equipped to do that kind of brain surgery was too far away, in another part of Iraq. They pumped in pain meds, just in case, and waited for his heart to stop. For Mitchell, the flare of triumph dies. He looks at me blankly, then walks away, saying nothing. It doesn't always end like this. But these are the days the crews must get used to, the ones they never forget.
In Iraq, one massive U.S. military machine fights the war. Another cares for those injured in battle. The effort is enormous, unrivaled. Medical procedures and body armor have vastly improved since America's last comparable war, in Vietnam. Yet the techno-sheen given this war by smart bombs, night-vision goggles, and remote-controlled drones is misleading. It is not miracle technology that saves lives on the battlefield in Iraq. The most important tools are tourniquets, the most important methods timeworn.
Trauma care proceeds in stages. It begins on the battlefield, with medics pulling bandages from their backpacks, often under fire. Some wounded are then rushed to small field stations like the one at Al Taqaddum, where Navy surgeons operate on marines fresh from the urban hell of Ramadi.
Others are airlifted directly to larger hospitals such as Ibn Sina, a former Baathist facility, where the wounded arrive around the clock. When they are stable, patients are flown, IVs snaking from their bodies, nurses monitoring their vital signs, to a military hospital in Germany. Then, at last, they return to the United States for final procedures, recovery, family.
All this can happen in as few as 36 hours. The process rivals FedEx in complexity and tempo. Soldiers become warm packages, bundled and gently tended, hurtled across time zones in the bellies of cargo planes. Often they are drugged and remember little of the journey, waking in hospitals in Washington, D.C., or San Antonio, Texas, to find their worlds, their lives, have changed. For soldiers arriving in the "sandbox," as Iraq is often called, knowledge of this global lifeline boosts morale and relieves some of the stress that comes with heading into battle or patrolling roads clotted with bombs.
At Ibn Sina, the largest Army hospital in Iraq, staff boots tell stories of war. In calm hospital wings, boot tops are soft and clean. In the trauma room, they are splotched and matted with blood. The floor is a dump, often slick with red pools, littered with bandage wrappers, scissors, shreds of clothing, charred skin. Boots are necessary. At the nurses' station just inside the hospital entrance, all the boots have been baptized in blood.
It is lunchtime. Young medics and nurses cluster at the large wooden desk laughing and joking. Some wear surgical clamps clipped to their pants, always ready, just in case. Others tuck tape and syringes into their pockets. Nearby, Iraqi janitors swing mops lazily along marble floors that Baath Party elites, including Saddam Hussein and his family, once crossed on their way to receive privileged medical care. There is a faint odor of disinfectant and feces.
The staff at Ibn Sina is part of the Army's 10th Combat Support Hospital, or 10th CSH, pronounced "cash." Many of the war's worst casualties, from wounded coalition and Iraqi personnel to civilians and insurgents, are helped here by some of the best trauma teams in medicine. The hospital treats hundreds of patients each month. It does not mirror the sleek, high-tech civilian institutions in the U.S. or Europe. It is battle-ready and rough, the rooms cluttered with equipment, some of it aging. Occasionally, the electricity fails.
But then, war medicine is not civilian medicine. It's dirtier, faster. The wounds are worse, the patients at greater risk. Here medical teams cut, crack, and inject where their civilian counterparts might pause and worry about lawsuits. Ibn Sina is designed for life-saving procedures, not the long recoveries required by amputees or burn victims. The mission is simple: stabilize patients, ship them on to facilities equipped for longer term care.
"There are no litigious restrictions over here," a lieutenant colonel who is also a doctor tells me. "People play fearlessly, and when they play fearlessly, they make fewer mistakes. It's a dose of reality you'll never forget. The surgeons, nurses—never in the rest of their lives will they be who they are here."
The 10th arrived here in October 2005 to replace another CSH unit at the conclusion of a year-long tour. Few of the 10th's nurses or medics had ever seen the chaos of big trauma. Many are in their early or mid-20s; some had cared previously for cancer patients or the elderly. Iraq was immediate, terrifying immersion.
Lt. Col. John Groves, 42, head ER nurse, trained in some of America's busiest trauma centers, including Miami and Honolulu. He is a short, friendly man, a career soldier who, if prompted, can talk into the night about past cases and calamities, the mutilations of this war. He is a self-described steel-mill kid from Indiana, and on his desk lie photos of the 20 or so head of cattle he keeps on his new farm in Kansas, where he plans to retire.
Groves is a father figure to his young staff. He watches them carefully, knows their strengths, their weaknesses. He remembers thinking not all of them would last. "So many were timid, they didn't know what to do. It was a hard adjustment, and not everyone is cut out for this kind of medicine." Groves was ready to reassign several nurses to other wards. Lt. Riane Nelson was one of them.
She is 24, a tall round-faced blonde from San Diego with blue-green eyes that shift color depending on the scrubs she wears. From the time she was eight, she wanted to be a nurse. She lived then in Greece, where her parents worked as missionaries. After college, she joined the Army. She didn't have any trauma training before she arrived in Iraq.
Nelson grew up an athlete. She knew what it meant to work hard, play fast. But she struggled with the crushing pace of the trauma room, the weight of decisions made amid blood and fading lives. She forgot things, made mistakes. She began, she says, to crack. Then, slowly, the weeks of panic yielded to smoothness. She remembers when the conversion came.
Valentine's Day, 2006. Nelson hopes for a slow shift. But somewhere in Iraq, an Army convoy hits a roadside bomb and a medevac helicopter rushes in a seriously wounded soldier. The situation is going badly.
The soldier arrives medically dead. A tourniquet encircles the right leg. Below the tourniquet, the limb hangs by threads of flesh. The femoral artery is like a severed hose. There is the coppery smell of blood.
Nelson stands at the head of the bed, feeling for a pulse, giving directions. Medics slice away the remains of a uniform. Nelson realizes her patient is a woman. She has no pulse, she is drained of blood. Nelson orders someone to begin CPR, even though in her experience it has never saved anyone. A doctor calls for drugs: atropine, epinephrine. Nelson injects them into the woman's body. Finally, she feels the weak flutter of life. "After about five minutes of CPR, I felt a carotid pulse," Nelson later wrote in her journal. "We double- and triple-checked to make sure we weren't just so hyped up that we were feeling our own pulse in our fingers."
Nelson's team pumps blood into the woman; it runs out her shattered leg. To save the life, the limb must go. A surgeon slices. Someone loops another tourniquet around the stump. The team bandages the wound and preps the woman for the operating room, where surgeons will clamp off her artery, insert a chest tube, and clean shrapnel from her body.
After surgeons saved the woman's life, Nelson visits her upstairs in the intensive care ward. She finds the woman's husband at her bedside; the couple serve in the same unit.
"That was one of the more emotional cases I've had," Nelson says. "I think that's where I gained my confidence. With her, I felt I took charge. I felt I had peace of mind, I wasn't freaking out. And, on Valentine's Day, I didn't have to say, 'Your wife didn't make it.' "
Groves, her boss, noticed the change and kept her on. "Now she can do anything," he says, smiling. "She's brought people back from the dead. Our joke is if you come in dead, you want Nelson at the table."
After months in Iraq, Nelson and her colleagues have helped save hundreds of lives. They have seen more human wreckage than most of their stateside peers ever will. Their stained boots are badges of honor. In the late winter, it was common to hear young nurses and medics say, "I never want to leave." Older staffers shared the sense of purpose. Many said, "If it was a little safer and I could bring my family here, I'd stay." The work, the importance of it, was exhilarating.
By summer, past the halfway point in the 10th CSH's tour, those feelings have faded. A makeshift calendar hangs on the wall beside the nurses' station, each remaining day in Iraq marked on a slip of white paper. Home is not simply a place, it is a goal. Everyone yearns for a life less cloistered, closer to family and old routines, away from war.
Many have taken mid-tour leave. The two weeks' vacation either recharged them or intensified the desire to leave. "Before I went, I was not doing well," Nelson says. "I was starting to have dreams about patients, like, what could I have done differently." The break refreshed her, gave a boost she hopes will last till the tour is up. When I see John Groves again, after his leave, there is a new weariness, a heaviness in his face. "I'm ready," he says. "I think we all are."
The end will come soon enough, but heading home won't be simple. The memories will follow, and more. Groves worries that many of the young staff will be bored when they return to stateside jobs at base hospitals or troop clinics. "The medics and nurses here are doing things that only doctors do back in the States," he says. "I'm teaching 20-year-olds how to put in chest tubes. When they go back, they won't be able to do that stuff."
No one at Ibn Sina may ever feel as useful or needed as they do saving lives in Baghdad. It is not that the trauma crews hope for more wounded. It is not that they want the war to limp on forever. But they have an overwhelming desire to put their training into practice. The same can be said about medics like David Mitchell—about almost any soldier doing medicine here.
"We're like vultures, kinda," a nurse explains late one night as we sit waiting for the thump of incoming helicopters. "This is what we do. We're not out there stopping the fighting, so we're waiting to go to work."
For them trauma is exciting. A cloud descends, blocking out the rest of the world. There is only the work, the bright red immediacy of blood. In the trauma room, a simple truth rises above the gasp of breathing machines and the high, frantic voices: Life is everything; it is all that matters. The details come later.
Part Two: Home Front
Jason Welsh held the phone close and lied to his mother. He told her he'd been in a car wreck in Iraq, but he was fine. "I think I broke my jaw pretty good," he said, "but that's all." The lie made sense. Telling the truth, that he'd been blown up by a roadside bomb, his neck was broken, his face smashed, that three men died beside him, somehow didn't seem right. Welsh, 25, remembers thinking, If I don't tell her, it'll be OK. It'll be like it didn't happen.
Lynne Welsh, listening in Oklahoma, didn't believe him. Her mind spun. Fear flooded in. "I was so scared my voice got weak," she says. "I finally asked him, 'How are your arms and legs?' "
The question reveals the dread of every military parent, spouse, girlfriend, or boyfriend. The answer would shape the Welshes' future. Dreams would survive, or shatter. "My arms and legs are fine, Momma," Welsh said, and that, as far as it went, was the truth.
Some 20,000 American service members have been injured since the war in Iraq began in 2003. Medical technology and the sheer speed of rescue and treatment have increased soldiers' chances of surviving wounds that would have killed them in previous wars. But any notion that body armor and medicine have somehow made this war safe is unfounded. Stacking armor on troops and vehicles has only bred more accurate snipers, more devastating bombs. Medicine, while more advanced than in previous wars, cannot wipe out the brutality of the battlefield.
On American streets, amputees offer the most public and visually jarring testimony of war. The human eye, drawn to symmetry and startled by its absence, cannot help but scan voids where legs or arms once swung, while the mind wonders how it happened. But there are other injuries, some far worse than amputation.
Of the wounded, more than 20 percent have suffered traumatic brain injuries, called TBIs. As the roadside bomb, or improvised explosive device (IED), is the signature weapon of this war, the TBI has become its legacy, says Dr. George Zitnay, a neuropsychologist with some 40 years experience treating brain injuries. Zitnay, 67, has described brain injury as an "invisible epidemic," a plague the public knows little about or is unwilling to face. Zitnay believes this is because brain injuries carry heavy stigmas. "You get a brain injury in this country, you keep it quiet because here we value intellect so much," Zitnay says. "It's a very frightening thing to think about the psyche, to think about the mind. If you were brain injured, would you want people to know about it?"
After the Gulf War, Zitnay helped found the Defense and Veterans Brain Injury Center, now the military's premier brain injury program. The fate of Vietnam veterans pushed him to do it. Many of them, he says, returned with brain injuries that went undiagnosed and untreated. "They ended up in prisons and hospitals, on the street, undergoing divorces," Zitnay says. He sees some of the same things happening to Iraq vets today. "So many of these troops get redeployed so often. Their time in the war zone gets extended, their exposure to blast injuries is high. When they come back, we're not really screening them for concussions or other types of brain injuries. Often in people with mild or moderate concussion, it doesn't show up right away."
Mild brain injuries generally don't permanently impair a person's ability to function. More important, nothing is lost of the victims' essential nature—they remain who they were before injury. In more severe cases, the victims become violent, forgetful, manic. In the worst cases, the body returns from the war alive, but the victim does not. The old self is obliterated, fragmented, lost in furrows of gray matter that medical science does not fully understand and cannot repair.
Staff Sgt. Jason Welsh is slim and tall, his brown hair buzzed short, his face smooth and boyish. A black-ink tattoo spreads across his right forearm, a warrior angel he got while stationed in Germany. Another tattoo, a ring of flame, circles his left elbow. Both his parents served in the Army, and Welsh joined not long after high school. He wanted freedom, but with boundaries. "I didn't want to depend on anyone," he says. "I wanted to go out on my own, and the Army was the easy way to do it." He went to Iraq first in 2003 as a mechanic, found it disappointing. Afterward, he re-enlisted as an infantryman.
Welsh returned to Iraq in late 2005 with Bravo Company of the 2-6 Infantry, 1st Armored Division. The division deployed to Ramadi, the seething Sunni city wedged against the banks of the Euphrates River west of Baghdad. Welsh commanded two riflemen and a machine gunner. His unit patrolled garbage-lined streets renamed in desire and homesickness after young female celebrities, Route (Britney) Spears, Route (Jessica) Alba. The men skirted puddles of sewage, kicked in doors during raids, battled insurgents as temperatures needled toward summer. Once, he watched Iraqi soldiers throw down their weapons and flee under fire from insurgents. It was all an education. Welsh loved it.
The young sergeant had never been hit by fire. He was on patrol one night, steering his Humvee at the head of the column, his platoon leader, a translator, a roof gunner, and a 19-year-old medic named Nick Crombie riding with him. Crombie was an energetic kid, new to the unit, so eager to please he made mistakes in his excitement. But Welsh could work with that. He put Crombie in the back, had him sit where he could pass out Gatorades during the patrol. It was a Wednesday night in June, a night like any other. Then the truck burst.
An unarmored Humvee weighs about 5,200 pounds (2,360 kilograms). Many Humvees used on combat patrols in Iraq are augmented with steel plates and bullet-resistant glass that weigh an additional 3,000 pounds (1,360 kilograms) or more. The trucks are wheeled rhinoceroses, stout and tough. The blast that injured Welsh pulped his armored Humvee. It blew off the wheels, doors, the trunk, everything but the seating area. The platoon leader, the translator, and Crombie were killed, the roof gunner seriously wounded. Shrapnel carved them apart. But not Welsh. His injuries—the broken neck and face, a damaged knee—were caused by the blast concussion itself or from the force of it whipping his body against the truck. He doesn't know how he survived the flying metal. "It's as if I took a bowlful of Doritos and threw them at you, and somehow they all went around you and missed," he says.
By Thursday, the day after, Welsh was in the U.S. military hospital in Landstuhl, Germany. On Friday, he landed in Washington, D.C. He remembers blurry scenes from the journey, scraps of dialogue. "I woke up, and I was really violent," he says. "I was strapped down, and I didn't want to be. They stuck something in me, and I went down. I think I was on a plane." It may have been during his journey to Germany, or his way back to the States. Such experiences are not uncommon for seriously injured soldiers who've been drugged. Welsh's first coherent post-blast memories begin at Walter Reed.
Walter Reed Army Medical Center in Washington, D.C., is a sprawling collection of buildings, some of them nearly a hundred years old. The grounds are green and tree-lined, lending the feel of a college campus—except for the shotgun-slinging guards at the main gates. Walter Reed has treated U.S. wounded since World War I. It is not the sole military hospital in the nation; marines are often shipped to the National Naval Medical Center in Maryland, and some soldiers fly to Brooke Army Medical Center in San Antonio, Texas—but Walter Reed remains a critical hub for soldiers returning from Iraq.
Incoming wounded are sent to various hospital wards and intensive care units. From there, mildly wounded soldiers receive treatment and may be released, either back to their units or to hospitals run by the Department of Veterans Affairs. If they are medically discharged from the military, soldiers may also head home with family. Soldiers suffering more severe wounds, including amputations, recuperate at Walter Reed, where teams of doctors, nurses, and therapists monitor their recovery and battle the nagging details of post-wound care: persistent infections, bedsores, depression. Often patients stay at Walter Reed for months, their days organized around doctor consultations, surgeries, therapy—physical or occupational—or fittings for prosthetic legs and arms. The hospital encourages family visits. Some parents arrive before their sons or daughters, staying on campus, watching their children struggle into new lives.
Jason Welsh arrived at Walter Reed on a Friday in mid-June. His parents flew in the same day. In a photo taken shortly after their reunion, a black bruise curls under his right eye, cuts dot his forehead. His face is jaundiced, swollen, and he stares unsteadily at the camera like a drunk. He wears a neck brace. Welsh's neck was broken at the first cervical vertebra, or C1, the point where the spine meets the skull. It is one of the vertebrae that snapped in the late Christopher Reeve's neck when he was thrown from a horse in 1995. Reeve, famous for his role in Superman films, was paralyzed from the neck down. Welsh's spinal cord escaped damage, and doctors decided to let the wound heal without surgery. Soon after his arrival, he was released to Mologne House, a dormitory-style building on the Walter Reed campus where soldiers live during recovery.
Alone for the first time, Welsh woke confused, uncertain about where he was, what he was doing. It occurred to him that he should arrange his things and prepare to leave. "I was trying to get my stuff ready. I dumped all my stuff on the bed, but I couldn't figure out how to organize it," he says. "I would start doing something, and I'd forget what I was doing. I couldn't match items like socks. So I said 'screw this,' and I threw everything on the floor."
Welsh asked his Mologne House roommate for help. The man brought Welsh to the hospital and apparently left him alone. "I didn't know where I was. I didn't know how to figure out where to go. I was mindless." Eventually, a woman who had worked Welsh's case saw him. She asked why he'd missed his appointments. "I was like, 'Who are you and what appointments are you talking about?' " The woman recognized something was wrong. She brought Welsh to a neurologist. Doctors performed memory tests, gave him an MRI. They diagnosed him with TBI. At first Welsh couldn't believe it. But nothing made sense anymore, and he could barely string together words for an argument. "Imagine you can only know one thing in the world," he says, "and that one thing is that you don't know anything."
There had been other signs. Welsh's parents, Lynne and Earl, though relieved to see him alive, were worried. They tried to comfort their son and help him recover. He wouldn't have it. He cursed in fits. One day Welsh couldn't figure out how to put on his sweatpants. He exploded when his father offered to help. Then Welsh told them to leave, go home. Confused and frightened, they agreed. Shortly afterward, Welsh's younger brother Aaron came to visit. Welsh raged at Aaron, yelling and screaming. This was not the Jason his family remembered. It was as if someone else had come back from the desert.
American soldiers wear helmets that wrap their heads like tortoise shells in layers of ballistic fabric and resin. But they are not bulletproof. Snipers know this. The helmets also provide only limited protection against powerful blasts produced by IEDs, like the one that hit Jason Welsh.
Head injuries are divided into two categories, penetrating and closed. Bullets, shrapnel, rocks—anything that pierces the skull can wipe out brain matter or, by odd turns of physics, do little damage. Closed head injuries result from the force of a blast or a blow in which the skull remains intact but the brain, surrounded by fluid like an egg yolk, gets wrenched or slammed against the skull wall. Such sudden motion can squash brain cells and uproot axons, the rapid-fire, telephone wire-like tubes that connect brain cells. This effectively wrecks neural circuitry. Concussive forces may also rupture blood vessels in or around the brain, producing hematomas, or blood clots, that press on brain matter and, in some cases, kill it.
The physical destruction of brain matter or the disruption of brain cell communication can have profound effects. Injuries to the front of the brain are often worse, especially in closed head injuries. The back portion of the brain is better connected, more stable, than the frontal lobes. In the sudden shock of an IED blast, for example, the frontal lobes are more likely to be whipped against the skull, or rotate and tear axons. Because the frontal lobes control many aspects of memory, behavior, and motor function, severe damage can wipe out a patient's ability to solve problems, plan, speak, or control impulses.
One of the greatest challenges stemming from TBI manifests in what Dr. Warren Lux calls behavioral disregulation. Lux, a neurologist at Walter Reed, says cognitive problems—planning daily chores, pairing socks, solving problems—are often not as bad as the changes in emotional control and sexual behavior that occur. These shifts can scuttle marriages, alienate family, sever ties with former lives. In the worst cases, Lux says, TBI patients can become unpredictably violent.
Another major problem, Lux says, centers on self-awareness. Many brain-injured patients don't recognize that they're injured or that they have lost pieces of themselves. "Part of what you need your frontal lobes for is to figure out who you are, because you need that to plan your way in life. Your self-image is built in your frontal lobes. That means that people who have all the skills to do things in the world won't use them because they don't know that they have to."
In the most common, and simple, form of brain injury, called a concussion, the brain usually regains normal function quickly. When it cannot self-repair, the brain sometimes rewires, routing signals along new channels, across its backup networks of axons. There are limits to this. The brain contains a finite number of axons. Brain matter, if it regenerates at all, grows very slowly. Repair takes time, weeks or months or even longer. Rehabilitation seems to work best when it occurs almost simultaneously, spurring the brain to form new connections, and the injured to learn new ways of thinking, acting, living. If rehab doesn't follow soon after injury, recovery is less likely to succeed; it may even become impossible.
Soldiers diagnosed with TBI proceed along separate paths depending on the severity of injury: mild, moderate, or severe. Moderate and severe patients are transferred to one of four special hospitals run by the Department of Veterans Affairs. There they receive long-term care and therapy. Patients with mild TBI may be sent home, back to duty, or, if they need additional rehabilitation, to community-based centers that focus on rebuilding their mental abilities. After nearly a month at Walter Reed, Jason Welsh was sent to Virginia NeuroCare, a small, private clinic in the rich green hills of central Virginia.
It is a Thursday morning in early August, and the merciless wet heat of a Virginia summer hangs over Charlottesville. The city is peaceful, collegiate, home to the University of Virginia, and close to Thomas Jefferson's home at Monticello. In the tangled brush, the overgrown forests, and stubbled fields nearby, tens of thousands died in Civil War battles at Fredericksburg, the Wilderness, and Chancellorsville. To reach Sgt. Jason Welsh, you must steer past them all.
Welsh sits in a small office, still wearing a neck brace, and tries to write a grocery list. An occupational therapist named Joy Sandlin helps him. He chooses food for a week of meals. But Welsh has never lived alone or cooked much for himself. Since his arrival at Virginia NeuroCare, he has lived in a group home with other brain-injured patients, some of them soldiers. His TBI has reduced his ability to focus and remember.
"Jason's going to need to learn to shop for himself and eat healthily," says Sandlin, a petite young woman with long black hair. "One of the things is that he's a 25-year-old guy who moved directly from his mom's house to the Army. He's never had to do this before, and he doesn't necessarily care. But it's something an adult needs to do, and the skills go way beyond breakfast." The exercise is one of planning, navigation, memory, and execution. Eventually, he'll travel to the grocery store using public transportation, remember why he's there and what he needs, and then gather and buy it. Simple tasks requiring a thousand minute computations.
Sandlin scans the list—ramen noodles, peanut butter, Honey Nut Cheerios. She asks questions, forcing Welsh to concentrate, probing his memory. She taps the list with her pen and says, "What do you think you'll want to drink besides Coke and milk?"
Welsh's injury was relatively mild. The MRI revealed "diffuse axonal injury"—shearing and twisting of axons—mainly in the right lobe, and some in the left. After the injury, portions of his brain had difficulty communicating, signals were interrupted, the network damaged. He has had problems with memory, multitasking. He loses focus, and sometimes his temper flares erratically. He curses more, and his sense of smell and touch have weakened. Welsh also suffers survivor's guilt, especially about Crombie. "I let him down," Welsh says. "I didn't even know him long enough to learn anything about his personal life."
While talking, Welsh will pause, as if the current of thoughts had suddenly hit a dam. He searches for words. "Sometimes I have to stop and think. It's pretty embarrassing. I'm aware that it's not back yet. I can feel myself think slower, step by step, instead of just reacting. I hate it." Welsh spends hours each day working with therapists, developing ways to compensate for mental abilities that may take months to return, if they ever return at all. Still, through all of this, he has retained the major connections and patterns that form his personality.
Two months after his injury, Welsh is nearly ready to move into the clinic's independent apartment, where he will no longer be under 24-hour supervision. He has just been given a job at the nearby Judge Advocate General's Legal Center and School, which trains military lawyers. He'll wear his camouflage uniform, his sergeant's stripes. The job will help him practice social interaction and problem solving—some of the same skills the grocery shopping exercise focused on.
Welsh can't wait. He considers his injury a temporary setback. Returning to the infantry is all he wants, even if it means another tour in Iraq. "I feel like I've got a lot of leading left to do, a lot of teaching," he says. "Those guys in Iraq need experience, and I can give them that."
It's not clear yet whether the Army will allow Welsh to return to his old job. But his therapists have dedicated themselves to helping him progress as far as possible. One therapist describes Welsh as essentially normal, meaning he has regained, or developed compensations for, much of what he lost that night in Ramadi.
From the battlefield to the home front, Welsh has received the best medical care available anywhere, but his case reveals the limitations even of the massive military system. Early assessments missed his brain injury. And there are others like him. Many experts—including Dr. George Zitnay, who founded Virginia NeuroCare as well as Walter Reed's Defense and Veterans Brain Injury Center—have pressed the Department of Defense to screen returning veterans for brain injuries. The department has only recently begun limited screening.
Welsh's mother, Lynne, visits him for several days in Charlottesville to check on his recovery. One evening, over burgers and iced tea at a restaurant in a local strip mall, Lynne reminisces with Jason about his years as a headstrong kid with a mischievous streak and a disdain for authority. Her voice is raspy and midwestern. The pair joke and laugh, remembering. For Lynne Welsh, the fear is fading. She knows she's fortunate, watching the old Jason reemerge. She knows that many soldiers never do.
After dinner, mother and son sit together outside Welsh's room in the group home, a large, white house with a small yard and a wraparound front porch. Welsh burns to leave, but he can't yet. His neck hasn't healed, and last night he exploded when a staff member tried to order him to bed. He felt ashamed afterward, unsure why he did it. Maybe it was the sleeping pills, maybe the brain injury. He unfastens his neck brace, demonstrating how in anger he hurled it across the room. He catches a whiff of the sweat that had soaked it during the stifling summer days.
"God, I've gotta wash this thing," he says, a little embarrassed. He is less the sergeant in his mother's presence, more the kid who loved cars and used to ditch school and circle town in a big Chevy Blazer. Lynne Welsh looks him over.
"I'm just glad it's him," she says. "The important thing is that Jason is Jason."
Jason smiles, lines breaking at the corners of his eyes, dispelling for a moment the boyishness.
"For the most part," he says.
Part One: Front Lines
The war is on hold. The soldiers of Charlie 2-4 sprawl on battered chairs and couches in dust-lined rooms that stink of sweat and half-eaten meals. They stare at pirated DVDs, thumbing through gun magazines, car magazines, even copies of Glamour. Some wrestle like brothers cooped in a snowbound house, boots clomping past stacked rifles, insults riding over radio static. For 12 hours, nothing has happened. The men, crews of one of the busiest medevac helicopter units in Iraq, have fought only boredom. A feeling gathers that something is coming, that they're due. No one mentions it. That would break taboo.
Outside, a sea of stars spreads above the trailers and shipping containers that compose this base. The lights of Baghdad bloom on the horizon, making the place feel removed, safe, although insurgents have lately been lobbing mortars over the 20-foot (six-meter) walls. Elsewhere, infantry units roll out on patrols or return for midnight meals. Generators hum. Spring-armed doors clap shut as soldiers go to shower away the day's dust.
The men of Charlie 2-4 fly Black Hawks over a landscape too dangerous, too wrecked for road travel. They fly into the hot, violent cities, the mud-brick towns, the nowhere stretches of desert, picking up American and Iraqi soldiers, civilians, and, sometimes, enemy fighters. For medevac crews, there are missions, and the space in between. Earlier today, Charlie 2-4 rescued three Iraqi boys wounded in a bomb blast in a rural field. Blood and mud caked their bodies, stubs of straw clung to their bare backs like a pelt. The mission reset the clock, the psychic countdown. Now comes a rush of static and an anxious, tinny voice on the radio: Insurgents have attacked a U.S. Army patrol somewhere on a highway south of Baghdad. One of the soldiers is badly wounded.
A four-man crew sprints to the flight line, loose gear bouncing on shoulders. They stow their rifles, slip on sweat-greased helmets. The pilot and copilot spin up the Black Hawk's rotors and speed through the preflight checklists. A sweet, dizzying breath of fuel washes over them. David Mitchell, the flight medic, scans the cabin: litter pans for stretchers, four of them, jut from the sides of the helicopter like berths on a ship. Oxygen tanks, heart monitors, bandages, bags of saline, all of it ready, wedged into crooks, compartments.
The crew tenses, especially Mitchell. The tall, 29-year-old sergeant is earnest and usually quiet, a polite southern boy. Excited or nervous, his eyes widen and he curses more, a habit he's trying to curb. As he sorts the last of his gear, he swears, a single word, the sound of it lost in the clatter of rotor blades.
The helo slides loud and low over the desert. In the cockpit, the pilots scan for muzzle flashes, tracers, warning each other of low-hanging wires. In back, Mitchell thinks through scenarios. He decides where he will put the patient. He imagines what might go wrong, what he will do. Medics learn quickly to solve problems, or at least keep them from worsening. Much of their job comes down to plumbing: Plug the leaks, stop the bleeding. Speed is key. If medics hold fluids in, if the helicopter moves fast enough, the wounded win time.
Mitchell is from Waldo, Arkansas, population 1,600, in the southwest corner of the state. The Where's Waldo? jokes no longer amuse him. He is a father of four boys and was married on September 11, 2001. On every mission he carries three good-luck charms. One is a gift from his parents, a crucifix inscribed with the letters K.O.S.S.—Keep Our Son Safe. The others, a black rubber wrist bracelet and a single dog tag pressed with his nickname, Deucez, and those of two buddies, Skyzap and Spyder. It is only his first tour in Iraq—some of his colleagues have done three—but Mitchell has become a character in the superstition surrounding the unit's endless days. He is called a "mission magnet": Whenever he's on duty, something happens. Tonight the proof piles up.
It is near midnight when we arrive on the scene, circling while the pilots inspect what's below. Humvee headlights carve out a landing zone on an empty road. Soldiers aim their weapons into the blackness beyond, watching for an ambush. We bump down in a cloud of hot dust. The injured man has been laid on a litter and stripped to the waist. Four or five of his comrades run the litter to the helicopter and clumsily, frantically, shove him inside. He has no pulse. Mitchell begins CPR. The helo lifts off for Baghdad.
The soldier is perhaps 20. He is lanky, with knobby shoulders—a boy's shoulders. Green cabin lights wash across his chest, his right arm flops off the litter. Mitchell moves like a piston above him. "Come on, buddy," he says. "COME ON, BUDDY." Sweat pours off him in long beads. Even with the windows open, the helo racing 200 feet (60 meters) above the ground, it is well over a hundred degrees (38°C). The heat, the weight of his body armor, and the frantic pace drain him. He's exhausted, losing effectiveness. After ten minutes, crew chief Erik Burns makes Mitchell get out of the way. Then Burns waves me in, a fresh set of arms.
Medics must use any resource available to them, and tonight I am one. I shove down 15 compressions. The soldier's chest feels ready to crack. I sink all my weight into it, right over his heart, his ribs buckling beneath my hands. My head pounds. Mitchell slumps beside me. We're gonna save this kid, I think. I will it true. We fly on toward Baghdad, over the flat fields, the pinprick lights, the sleeping country. The last minutes to the hospital blur past, a manic, sweat-soaked dream.
We touch down on a landing pad outside Ibn Sina Hospital in Baghdad. A nurse and medic duck across the pad, their scrubs flapping in the rotor wash. They haul the soldier into the trauma room. Doctors and nurses swarm him. Someone continues CPR, others slide tubes down his throat, measure blood oxygen levels, check his pupils with a flashlight. Mitchell stands nearby, helmet tucked under his arm, downloading what he knows to a nurse. His bald head shines with sweat. Monitors beep, there is the gasp of breathing machines, the tear of bandages.
"I got blood coming out his ears!" a doctor is saying.
"Hey! I got a pulse!" another shouts. It's been five minutes since we arrived.
Mitchell grits his teeth in a tight smile and pumps his fist. Yes.
"I told you," he says, bouncing on his feet. "No one dies in my helicopter."
Then the mood shifts. Something is suddenly understood, it appears on the faces of the doctors. There is a pulse, nothing more. The soldier doesn't react to stimuli, shows no signs of life. There is a question about what to do. But Mitchell must leave, speed dictates, and we fly back to base to wait for the next call.
On the ground we learn the soldier's fate. Doctors discovered a metal fragment embedded deep in his brain. They decided an operation would be futile. The only hospital equipped to do that kind of brain surgery was too far away, in another part of Iraq. They pumped in pain meds, just in case, and waited for his heart to stop. For Mitchell, the flare of triumph dies. He looks at me blankly, then walks away, saying nothing. It doesn't always end like this. But these are the days the crews must get used to, the ones they never forget.
In Iraq, one massive U.S. military machine fights the war. Another cares for those injured in battle. The effort is enormous, unrivaled. Medical procedures and body armor have vastly improved since America's last comparable war, in Vietnam. Yet the techno-sheen given this war by smart bombs, night-vision goggles, and remote-controlled drones is misleading. It is not miracle technology that saves lives on the battlefield in Iraq. The most important tools are tourniquets, the most important methods timeworn.
Trauma care proceeds in stages. It begins on the battlefield, with medics pulling bandages from their backpacks, often under fire. Some wounded are then rushed to small field stations like the one at Al Taqaddum, where Navy surgeons operate on marines fresh from the urban hell of Ramadi.
Others are airlifted directly to larger hospitals such as Ibn Sina, a former Baathist facility, where the wounded arrive around the clock. When they are stable, patients are flown, IVs snaking from their bodies, nurses monitoring their vital signs, to a military hospital in Germany. Then, at last, they return to the United States for final procedures, recovery, family.
All this can happen in as few as 36 hours. The process rivals FedEx in complexity and tempo. Soldiers become warm packages, bundled and gently tended, hurtled across time zones in the bellies of cargo planes. Often they are drugged and remember little of the journey, waking in hospitals in Washington, D.C., or San Antonio, Texas, to find their worlds, their lives, have changed. For soldiers arriving in the "sandbox," as Iraq is often called, knowledge of this global lifeline boosts morale and relieves some of the stress that comes with heading into battle or patrolling roads clotted with bombs.
At Ibn Sina, the largest Army hospital in Iraq, staff boots tell stories of war. In calm hospital wings, boot tops are soft and clean. In the trauma room, they are splotched and matted with blood. The floor is a dump, often slick with red pools, littered with bandage wrappers, scissors, shreds of clothing, charred skin. Boots are necessary. At the nurses' station just inside the hospital entrance, all the boots have been baptized in blood.
It is lunchtime. Young medics and nurses cluster at the large wooden desk laughing and joking. Some wear surgical clamps clipped to their pants, always ready, just in case. Others tuck tape and syringes into their pockets. Nearby, Iraqi janitors swing mops lazily along marble floors that Baath Party elites, including Saddam Hussein and his family, once crossed on their way to receive privileged medical care. There is a faint odor of disinfectant and feces.
The staff at Ibn Sina is part of the Army's 10th Combat Support Hospital, or 10th CSH, pronounced "cash." Many of the war's worst casualties, from wounded coalition and Iraqi personnel to civilians and insurgents, are helped here by some of the best trauma teams in medicine. The hospital treats hundreds of patients each month. It does not mirror the sleek, high-tech civilian institutions in the U.S. or Europe. It is battle-ready and rough, the rooms cluttered with equipment, some of it aging. Occasionally, the electricity fails.
But then, war medicine is not civilian medicine. It's dirtier, faster. The wounds are worse, the patients at greater risk. Here medical teams cut, crack, and inject where their civilian counterparts might pause and worry about lawsuits. Ibn Sina is designed for life-saving procedures, not the long recoveries required by amputees or burn victims. The mission is simple: stabilize patients, ship them on to facilities equipped for longer term care.
"There are no litigious restrictions over here," a lieutenant colonel who is also a doctor tells me. "People play fearlessly, and when they play fearlessly, they make fewer mistakes. It's a dose of reality you'll never forget. The surgeons, nurses—never in the rest of their lives will they be who they are here."
The 10th arrived here in October 2005 to replace another CSH unit at the conclusion of a year-long tour. Few of the 10th's nurses or medics had ever seen the chaos of big trauma. Many are in their early or mid-20s; some had cared previously for cancer patients or the elderly. Iraq was immediate, terrifying immersion.
Lt. Col. John Groves, 42, head ER nurse, trained in some of America's busiest trauma centers, including Miami and Honolulu. He is a short, friendly man, a career soldier who, if prompted, can talk into the night about past cases and calamities, the mutilations of this war. He is a self-described steel-mill kid from Indiana, and on his desk lie photos of the 20 or so head of cattle he keeps on his new farm in Kansas, where he plans to retire.
Groves is a father figure to his young staff. He watches them carefully, knows their strengths, their weaknesses. He remembers thinking not all of them would last. "So many were timid, they didn't know what to do. It was a hard adjustment, and not everyone is cut out for this kind of medicine." Groves was ready to reassign several nurses to other wards. Lt. Riane Nelson was one of them.
She is 24, a tall round-faced blonde from San Diego with blue-green eyes that shift color depending on the scrubs she wears. From the time she was eight, she wanted to be a nurse. She lived then in Greece, where her parents worked as missionaries. After college, she joined the Army. She didn't have any trauma training before she arrived in Iraq.
Nelson grew up an athlete. She knew what it meant to work hard, play fast. But she struggled with the crushing pace of the trauma room, the weight of decisions made amid blood and fading lives. She forgot things, made mistakes. She began, she says, to crack. Then, slowly, the weeks of panic yielded to smoothness. She remembers when the conversion came.
Valentine's Day, 2006. Nelson hopes for a slow shift. But somewhere in Iraq, an Army convoy hits a roadside bomb and a medevac helicopter rushes in a seriously wounded soldier. The situation is going badly.
The soldier arrives medically dead. A tourniquet encircles the right leg. Below the tourniquet, the limb hangs by threads of flesh. The femoral artery is like a severed hose. There is the coppery smell of blood.
Nelson stands at the head of the bed, feeling for a pulse, giving directions. Medics slice away the remains of a uniform. Nelson realizes her patient is a woman. She has no pulse, she is drained of blood. Nelson orders someone to begin CPR, even though in her experience it has never saved anyone. A doctor calls for drugs: atropine, epinephrine. Nelson injects them into the woman's body. Finally, she feels the weak flutter of life. "After about five minutes of CPR, I felt a carotid pulse," Nelson later wrote in her journal. "We double- and triple-checked to make sure we weren't just so hyped up that we were feeling our own pulse in our fingers."
Nelson's team pumps blood into the woman; it runs out her shattered leg. To save the life, the limb must go. A surgeon slices. Someone loops another tourniquet around the stump. The team bandages the wound and preps the woman for the operating room, where surgeons will clamp off her artery, insert a chest tube, and clean shrapnel from her body.
After surgeons saved the woman's life, Nelson visits her upstairs in the intensive care ward. She finds the woman's husband at her bedside; the couple serve in the same unit.
"That was one of the more emotional cases I've had," Nelson says. "I think that's where I gained my confidence. With her, I felt I took charge. I felt I had peace of mind, I wasn't freaking out. And, on Valentine's Day, I didn't have to say, 'Your wife didn't make it.' "
Groves, her boss, noticed the change and kept her on. "Now she can do anything," he says, smiling. "She's brought people back from the dead. Our joke is if you come in dead, you want Nelson at the table."
After months in Iraq, Nelson and her colleagues have helped save hundreds of lives. They have seen more human wreckage than most of their stateside peers ever will. Their stained boots are badges of honor. In the late winter, it was common to hear young nurses and medics say, "I never want to leave." Older staffers shared the sense of purpose. Many said, "If it was a little safer and I could bring my family here, I'd stay." The work, the importance of it, was exhilarating.
By summer, past the halfway point in the 10th CSH's tour, those feelings have faded. A makeshift calendar hangs on the wall beside the nurses' station, each remaining day in Iraq marked on a slip of white paper. Home is not simply a place, it is a goal. Everyone yearns for a life less cloistered, closer to family and old routines, away from war.
Many have taken mid-tour leave. The two weeks' vacation either recharged them or intensified the desire to leave. "Before I went, I was not doing well," Nelson says. "I was starting to have dreams about patients, like, what could I have done differently." The break refreshed her, gave a boost she hopes will last till the tour is up. When I see John Groves again, after his leave, there is a new weariness, a heaviness in his face. "I'm ready," he says. "I think we all are."
The end will come soon enough, but heading home won't be simple. The memories will follow, and more. Groves worries that many of the young staff will be bored when they return to stateside jobs at base hospitals or troop clinics. "The medics and nurses here are doing things that only doctors do back in the States," he says. "I'm teaching 20-year-olds how to put in chest tubes. When they go back, they won't be able to do that stuff."
No one at Ibn Sina may ever feel as useful or needed as they do saving lives in Baghdad. It is not that the trauma crews hope for more wounded. It is not that they want the war to limp on forever. But they have an overwhelming desire to put their training into practice. The same can be said about medics like David Mitchell—about almost any soldier doing medicine here.
"We're like vultures, kinda," a nurse explains late one night as we sit waiting for the thump of incoming helicopters. "This is what we do. We're not out there stopping the fighting, so we're waiting to go to work."
For them trauma is exciting. A cloud descends, blocking out the rest of the world. There is only the work, the bright red immediacy of blood. In the trauma room, a simple truth rises above the gasp of breathing machines and the high, frantic voices: Life is everything; it is all that matters. The details come later.
Part Two: Home Front
Jason Welsh held the phone close and lied to his mother. He told her he'd been in a car wreck in Iraq, but he was fine. "I think I broke my jaw pretty good," he said, "but that's all." The lie made sense. Telling the truth, that he'd been blown up by a roadside bomb, his neck was broken, his face smashed, that three men died beside him, somehow didn't seem right. Welsh, 25, remembers thinking, If I don't tell her, it'll be OK. It'll be like it didn't happen.
Lynne Welsh, listening in Oklahoma, didn't believe him. Her mind spun. Fear flooded in. "I was so scared my voice got weak," she says. "I finally asked him, 'How are your arms and legs?' "
The question reveals the dread of every military parent, spouse, girlfriend, or boyfriend. The answer would shape the Welshes' future. Dreams would survive, or shatter. "My arms and legs are fine, Momma," Welsh said, and that, as far as it went, was the truth.
Some 20,000 American service members have been injured since the war in Iraq began in 2003. Medical technology and the sheer speed of rescue and treatment have increased soldiers' chances of surviving wounds that would have killed them in previous wars. But any notion that body armor and medicine have somehow made this war safe is unfounded. Stacking armor on troops and vehicles has only bred more accurate snipers, more devastating bombs. Medicine, while more advanced than in previous wars, cannot wipe out the brutality of the battlefield.
On American streets, amputees offer the most public and visually jarring testimony of war. The human eye, drawn to symmetry and startled by its absence, cannot help but scan voids where legs or arms once swung, while the mind wonders how it happened. But there are other injuries, some far worse than amputation.
Of the wounded, more than 20 percent have suffered traumatic brain injuries, called TBIs. As the roadside bomb, or improvised explosive device (IED), is the signature weapon of this war, the TBI has become its legacy, says Dr. George Zitnay, a neuropsychologist with some 40 years experience treating brain injuries. Zitnay, 67, has described brain injury as an "invisible epidemic," a plague the public knows little about or is unwilling to face. Zitnay believes this is because brain injuries carry heavy stigmas. "You get a brain injury in this country, you keep it quiet because here we value intellect so much," Zitnay says. "It's a very frightening thing to think about the psyche, to think about the mind. If you were brain injured, would you want people to know about it?"
After the Gulf War, Zitnay helped found the Defense and Veterans Brain Injury Center, now the military's premier brain injury program. The fate of Vietnam veterans pushed him to do it. Many of them, he says, returned with brain injuries that went undiagnosed and untreated. "They ended up in prisons and hospitals, on the street, undergoing divorces," Zitnay says. He sees some of the same things happening to Iraq vets today. "So many of these troops get redeployed so often. Their time in the war zone gets extended, their exposure to blast injuries is high. When they come back, we're not really screening them for concussions or other types of brain injuries. Often in people with mild or moderate concussion, it doesn't show up right away."
Mild brain injuries generally don't permanently impair a person's ability to function. More important, nothing is lost of the victims' essential nature—they remain who they were before injury. In more severe cases, the victims become violent, forgetful, manic. In the worst cases, the body returns from the war alive, but the victim does not. The old self is obliterated, fragmented, lost in furrows of gray matter that medical science does not fully understand and cannot repair.
Staff Sgt. Jason Welsh is slim and tall, his brown hair buzzed short, his face smooth and boyish. A black-ink tattoo spreads across his right forearm, a warrior angel he got while stationed in Germany. Another tattoo, a ring of flame, circles his left elbow. Both his parents served in the Army, and Welsh joined not long after high school. He wanted freedom, but with boundaries. "I didn't want to depend on anyone," he says. "I wanted to go out on my own, and the Army was the easy way to do it." He went to Iraq first in 2003 as a mechanic, found it disappointing. Afterward, he re-enlisted as an infantryman.
Welsh returned to Iraq in late 2005 with Bravo Company of the 2-6 Infantry, 1st Armored Division. The division deployed to Ramadi, the seething Sunni city wedged against the banks of the Euphrates River west of Baghdad. Welsh commanded two riflemen and a machine gunner. His unit patrolled garbage-lined streets renamed in desire and homesickness after young female celebrities, Route (Britney) Spears, Route (Jessica) Alba. The men skirted puddles of sewage, kicked in doors during raids, battled insurgents as temperatures needled toward summer. Once, he watched Iraqi soldiers throw down their weapons and flee under fire from insurgents. It was all an education. Welsh loved it.
The young sergeant had never been hit by fire. He was on patrol one night, steering his Humvee at the head of the column, his platoon leader, a translator, a roof gunner, and a 19-year-old medic named Nick Crombie riding with him. Crombie was an energetic kid, new to the unit, so eager to please he made mistakes in his excitement. But Welsh could work with that. He put Crombie in the back, had him sit where he could pass out Gatorades during the patrol. It was a Wednesday night in June, a night like any other. Then the truck burst.
An unarmored Humvee weighs about 5,200 pounds (2,360 kilograms). Many Humvees used on combat patrols in Iraq are augmented with steel plates and bullet-resistant glass that weigh an additional 3,000 pounds (1,360 kilograms) or more. The trucks are wheeled rhinoceroses, stout and tough. The blast that injured Welsh pulped his armored Humvee. It blew off the wheels, doors, the trunk, everything but the seating area. The platoon leader, the translator, and Crombie were killed, the roof gunner seriously wounded. Shrapnel carved them apart. But not Welsh. His injuries—the broken neck and face, a damaged knee—were caused by the blast concussion itself or from the force of it whipping his body against the truck. He doesn't know how he survived the flying metal. "It's as if I took a bowlful of Doritos and threw them at you, and somehow they all went around you and missed," he says.
By Thursday, the day after, Welsh was in the U.S. military hospital in Landstuhl, Germany. On Friday, he landed in Washington, D.C. He remembers blurry scenes from the journey, scraps of dialogue. "I woke up, and I was really violent," he says. "I was strapped down, and I didn't want to be. They stuck something in me, and I went down. I think I was on a plane." It may have been during his journey to Germany, or his way back to the States. Such experiences are not uncommon for seriously injured soldiers who've been drugged. Welsh's first coherent post-blast memories begin at Walter Reed.
Walter Reed Army Medical Center in Washington, D.C., is a sprawling collection of buildings, some of them nearly a hundred years old. The grounds are green and tree-lined, lending the feel of a college campus—except for the shotgun-slinging guards at the main gates. Walter Reed has treated U.S. wounded since World War I. It is not the sole military hospital in the nation; marines are often shipped to the National Naval Medical Center in Maryland, and some soldiers fly to Brooke Army Medical Center in San Antonio, Texas—but Walter Reed remains a critical hub for soldiers returning from Iraq.
Incoming wounded are sent to various hospital wards and intensive care units. From there, mildly wounded soldiers receive treatment and may be released, either back to their units or to hospitals run by the Department of Veterans Affairs. If they are medically discharged from the military, soldiers may also head home with family. Soldiers suffering more severe wounds, including amputations, recuperate at Walter Reed, where teams of doctors, nurses, and therapists monitor their recovery and battle the nagging details of post-wound care: persistent infections, bedsores, depression. Often patients stay at Walter Reed for months, their days organized around doctor consultations, surgeries, therapy—physical or occupational—or fittings for prosthetic legs and arms. The hospital encourages family visits. Some parents arrive before their sons or daughters, staying on campus, watching their children struggle into new lives.
Jason Welsh arrived at Walter Reed on a Friday in mid-June. His parents flew in the same day. In a photo taken shortly after their reunion, a black bruise curls under his right eye, cuts dot his forehead. His face is jaundiced, swollen, and he stares unsteadily at the camera like a drunk. He wears a neck brace. Welsh's neck was broken at the first cervical vertebra, or C1, the point where the spine meets the skull. It is one of the vertebrae that snapped in the late Christopher Reeve's neck when he was thrown from a horse in 1995. Reeve, famous for his role in Superman films, was paralyzed from the neck down. Welsh's spinal cord escaped damage, and doctors decided to let the wound heal without surgery. Soon after his arrival, he was released to Mologne House, a dormitory-style building on the Walter Reed campus where soldiers live during recovery.
Alone for the first time, Welsh woke confused, uncertain about where he was, what he was doing. It occurred to him that he should arrange his things and prepare to leave. "I was trying to get my stuff ready. I dumped all my stuff on the bed, but I couldn't figure out how to organize it," he says. "I would start doing something, and I'd forget what I was doing. I couldn't match items like socks. So I said 'screw this,' and I threw everything on the floor."
Welsh asked his Mologne House roommate for help. The man brought Welsh to the hospital and apparently left him alone. "I didn't know where I was. I didn't know how to figure out where to go. I was mindless." Eventually, a woman who had worked Welsh's case saw him. She asked why he'd missed his appointments. "I was like, 'Who are you and what appointments are you talking about?' " The woman recognized something was wrong. She brought Welsh to a neurologist. Doctors performed memory tests, gave him an MRI. They diagnosed him with TBI. At first Welsh couldn't believe it. But nothing made sense anymore, and he could barely string together words for an argument. "Imagine you can only know one thing in the world," he says, "and that one thing is that you don't know anything."
There had been other signs. Welsh's parents, Lynne and Earl, though relieved to see him alive, were worried. They tried to comfort their son and help him recover. He wouldn't have it. He cursed in fits. One day Welsh couldn't figure out how to put on his sweatpants. He exploded when his father offered to help. Then Welsh told them to leave, go home. Confused and frightened, they agreed. Shortly afterward, Welsh's younger brother Aaron came to visit. Welsh raged at Aaron, yelling and screaming. This was not the Jason his family remembered. It was as if someone else had come back from the desert.
American soldiers wear helmets that wrap their heads like tortoise shells in layers of ballistic fabric and resin. But they are not bulletproof. Snipers know this. The helmets also provide only limited protection against powerful blasts produced by IEDs, like the one that hit Jason Welsh.
Head injuries are divided into two categories, penetrating and closed. Bullets, shrapnel, rocks—anything that pierces the skull can wipe out brain matter or, by odd turns of physics, do little damage. Closed head injuries result from the force of a blast or a blow in which the skull remains intact but the brain, surrounded by fluid like an egg yolk, gets wrenched or slammed against the skull wall. Such sudden motion can squash brain cells and uproot axons, the rapid-fire, telephone wire-like tubes that connect brain cells. This effectively wrecks neural circuitry. Concussive forces may also rupture blood vessels in or around the brain, producing hematomas, or blood clots, that press on brain matter and, in some cases, kill it.
The physical destruction of brain matter or the disruption of brain cell communication can have profound effects. Injuries to the front of the brain are often worse, especially in closed head injuries. The back portion of the brain is better connected, more stable, than the frontal lobes. In the sudden shock of an IED blast, for example, the frontal lobes are more likely to be whipped against the skull, or rotate and tear axons. Because the frontal lobes control many aspects of memory, behavior, and motor function, severe damage can wipe out a patient's ability to solve problems, plan, speak, or control impulses.
One of the greatest challenges stemming from TBI manifests in what Dr. Warren Lux calls behavioral disregulation. Lux, a neurologist at Walter Reed, says cognitive problems—planning daily chores, pairing socks, solving problems—are often not as bad as the changes in emotional control and sexual behavior that occur. These shifts can scuttle marriages, alienate family, sever ties with former lives. In the worst cases, Lux says, TBI patients can become unpredictably violent.
Another major problem, Lux says, centers on self-awareness. Many brain-injured patients don't recognize that they're injured or that they have lost pieces of themselves. "Part of what you need your frontal lobes for is to figure out who you are, because you need that to plan your way in life. Your self-image is built in your frontal lobes. That means that people who have all the skills to do things in the world won't use them because they don't know that they have to."
In the most common, and simple, form of brain injury, called a concussion, the brain usually regains normal function quickly. When it cannot self-repair, the brain sometimes rewires, routing signals along new channels, across its backup networks of axons. There are limits to this. The brain contains a finite number of axons. Brain matter, if it regenerates at all, grows very slowly. Repair takes time, weeks or months or even longer. Rehabilitation seems to work best when it occurs almost simultaneously, spurring the brain to form new connections, and the injured to learn new ways of thinking, acting, living. If rehab doesn't follow soon after injury, recovery is less likely to succeed; it may even become impossible.
Soldiers diagnosed with TBI proceed along separate paths depending on the severity of injury: mild, moderate, or severe. Moderate and severe patients are transferred to one of four special hospitals run by the Department of Veterans Affairs. There they receive long-term care and therapy. Patients with mild TBI may be sent home, back to duty, or, if they need additional rehabilitation, to community-based centers that focus on rebuilding their mental abilities. After nearly a month at Walter Reed, Jason Welsh was sent to Virginia NeuroCare, a small, private clinic in the rich green hills of central Virginia.
It is a Thursday morning in early August, and the merciless wet heat of a Virginia summer hangs over Charlottesville. The city is peaceful, collegiate, home to the University of Virginia, and close to Thomas Jefferson's home at Monticello. In the tangled brush, the overgrown forests, and stubbled fields nearby, tens of thousands died in Civil War battles at Fredericksburg, the Wilderness, and Chancellorsville. To reach Sgt. Jason Welsh, you must steer past them all.
Welsh sits in a small office, still wearing a neck brace, and tries to write a grocery list. An occupational therapist named Joy Sandlin helps him. He chooses food for a week of meals. But Welsh has never lived alone or cooked much for himself. Since his arrival at Virginia NeuroCare, he has lived in a group home with other brain-injured patients, some of them soldiers. His TBI has reduced his ability to focus and remember.
"Jason's going to need to learn to shop for himself and eat healthily," says Sandlin, a petite young woman with long black hair. "One of the things is that he's a 25-year-old guy who moved directly from his mom's house to the Army. He's never had to do this before, and he doesn't necessarily care. But it's something an adult needs to do, and the skills go way beyond breakfast." The exercise is one of planning, navigation, memory, and execution. Eventually, he'll travel to the grocery store using public transportation, remember why he's there and what he needs, and then gather and buy it. Simple tasks requiring a thousand minute computations.
Sandlin scans the list—ramen noodles, peanut butter, Honey Nut Cheerios. She asks questions, forcing Welsh to concentrate, probing his memory. She taps the list with her pen and says, "What do you think you'll want to drink besides Coke and milk?"
Welsh's injury was relatively mild. The MRI revealed "diffuse axonal injury"—shearing and twisting of axons—mainly in the right lobe, and some in the left. After the injury, portions of his brain had difficulty communicating, signals were interrupted, the network damaged. He has had problems with memory, multitasking. He loses focus, and sometimes his temper flares erratically. He curses more, and his sense of smell and touch have weakened. Welsh also suffers survivor's guilt, especially about Crombie. "I let him down," Welsh says. "I didn't even know him long enough to learn anything about his personal life."
While talking, Welsh will pause, as if the current of thoughts had suddenly hit a dam. He searches for words. "Sometimes I have to stop and think. It's pretty embarrassing. I'm aware that it's not back yet. I can feel myself think slower, step by step, instead of just reacting. I hate it." Welsh spends hours each day working with therapists, developing ways to compensate for mental abilities that may take months to return, if they ever return at all. Still, through all of this, he has retained the major connections and patterns that form his personality.
Two months after his injury, Welsh is nearly ready to move into the clinic's independent apartment, where he will no longer be under 24-hour supervision. He has just been given a job at the nearby Judge Advocate General's Legal Center and School, which trains military lawyers. He'll wear his camouflage uniform, his sergeant's stripes. The job will help him practice social interaction and problem solving—some of the same skills the grocery shopping exercise focused on.
Welsh can't wait. He considers his injury a temporary setback. Returning to the infantry is all he wants, even if it means another tour in Iraq. "I feel like I've got a lot of leading left to do, a lot of teaching," he says. "Those guys in Iraq need experience, and I can give them that."
It's not clear yet whether the Army will allow Welsh to return to his old job. But his therapists have dedicated themselves to helping him progress as far as possible. One therapist describes Welsh as essentially normal, meaning he has regained, or developed compensations for, much of what he lost that night in Ramadi.
From the battlefield to the home front, Welsh has received the best medical care available anywhere, but his case reveals the limitations even of the massive military system. Early assessments missed his brain injury. And there are others like him. Many experts—including Dr. George Zitnay, who founded Virginia NeuroCare as well as Walter Reed's Defense and Veterans Brain Injury Center—have pressed the Department of Defense to screen returning veterans for brain injuries. The department has only recently begun limited screening.
Welsh's mother, Lynne, visits him for several days in Charlottesville to check on his recovery. One evening, over burgers and iced tea at a restaurant in a local strip mall, Lynne reminisces with Jason about his years as a headstrong kid with a mischievous streak and a disdain for authority. Her voice is raspy and midwestern. The pair joke and laugh, remembering. For Lynne Welsh, the fear is fading. She knows she's fortunate, watching the old Jason reemerge. She knows that many soldiers never do.
After dinner, mother and son sit together outside Welsh's room in the group home, a large, white house with a small yard and a wraparound front porch. Welsh burns to leave, but he can't yet. His neck hasn't healed, and last night he exploded when a staff member tried to order him to bed. He felt ashamed afterward, unsure why he did it. Maybe it was the sleeping pills, maybe the brain injury. He unfastens his neck brace, demonstrating how in anger he hurled it across the room. He catches a whiff of the sweat that had soaked it during the stifling summer days.
"God, I've gotta wash this thing," he says, a little embarrassed. He is less the sergeant in his mother's presence, more the kid who loved cars and used to ditch school and circle town in a big Chevy Blazer. Lynne Welsh looks him over.
"I'm just glad it's him," she says. "The important thing is that Jason is Jason."
Jason smiles, lines breaking at the corners of his eyes, dispelling for a moment the boyishness.
"For the most part," he says.
Part One: Front Lines
The war is on hold. The soldiers of Charlie 2-4 sprawl on battered chairs and couches in dust-lined rooms that stink of sweat and half-eaten meals. They stare at pirated DVDs, thumbing through gun magazines, car magazines, even copies of Glamour. Some wrestle like brothers cooped in a snowbound house, boots clomping past stacked rifles, insults riding over radio static. For 12 hours, nothing has happened. The men, crews of one of the busiest medevac helicopter units in Iraq, have fought only boredom. A feeling gathers that something is coming, that they're due. No one mentions it. That would break taboo.
Outside, a sea of stars spreads above the trailers and shipping containers that compose this base. The lights of Baghdad bloom on the horizon, making the place feel removed, safe, although insurgents have lately been lobbing mortars over the 20-foot (six-meter) walls. Elsewhere, infantry units roll out on patrols or return for midnight meals. Generators hum. Spring-armed doors clap shut as soldiers go to shower away the day's dust.
The men of Charlie 2-4 fly Black Hawks over a landscape too dangerous, too wrecked for road travel. They fly into the hot, violent cities, the mud-brick towns, the nowhere stretches of desert, picking up American and Iraqi soldiers, civilians, and, sometimes, enemy fighters. For medevac crews, there are missions, and the space in between. Earlier today, Charlie 2-4 rescued three Iraqi boys wounded in a bomb blast in a rural field. Blood and mud caked their bodies, stubs of straw clung to their bare backs like a pelt. The mission reset the clock, the psychic countdown. Now comes a rush of static and an anxious, tinny voice on the radio: Insurgents have attacked a U.S. Army patrol somewhere on a highway south of Baghdad. One of the soldiers is badly wounded.
A four-man crew sprints to the flight line, loose gear bouncing on shoulders. They stow their rifles, slip on sweat-greased helmets. The pilot and copilot spin up the Black Hawk's rotors and speed through the preflight checklists. A sweet, dizzying breath of fuel washes over them. David Mitchell, the flight medic, scans the cabin: litter pans for stretchers, four of them, jut from the sides of the helicopter like berths on a ship. Oxygen tanks, heart monitors, bandages, bags of saline, all of it ready, wedged into crooks, compartments.
The crew tenses, especially Mitchell. The tall, 29-year-old sergeant is earnest and usually quiet, a polite southern boy. Excited or nervous, his eyes widen and he curses more, a habit he's trying to curb. As he sorts the last of his gear, he swears, a single word, the sound of it lost in the clatter of rotor blades.
The helo slides loud and low over the desert. In the cockpit, the pilots scan for muzzle flashes, tracers, warning each other of low-hanging wires. In back, Mitchell thinks through scenarios. He decides where he will put the patient. He imagines what might go wrong, what he will do. Medics learn quickly to solve problems, or at least keep them from worsening. Much of their job comes down to plumbing: Plug the leaks, stop the bleeding. Speed is key. If medics hold fluids in, if the helicopter moves fast enough, the wounded win time.
Mitchell is from Waldo, Arkansas, population 1,600, in the southwest corner of the state. The Where's Waldo? jokes no longer amuse him. He is a father of four boys and was married on September 11, 2001. On every mission he carries three good-luck charms. One is a gift from his parents, a crucifix inscribed with the letters K.O.S.S.—Keep Our Son Safe. The others, a black rubber wrist bracelet and a single dog tag pressed with his nickname, Deucez, and those of two buddies, Skyzap and Spyder. It is only his first tour in Iraq—some of his colleagues have done three—but Mitchell has become a character in the superstition surrounding the unit's endless days. He is called a "mission magnet": Whenever he's on duty, something happens. Tonight the proof piles up.
It is near midnight when we arrive on the scene, circling while the pilots inspect what's below. Humvee headlights carve out a landing zone on an empty road. Soldiers aim their weapons into the blackness beyond, watching for an ambush. We bump down in a cloud of hot dust. The injured man has been laid on a litter and stripped to the waist. Four or five of his comrades run the litter to the helicopter and clumsily, frantically, shove him inside. He has no pulse. Mitchell begins CPR. The helo lifts off for Baghdad.
The soldier is perhaps 20. He is lanky, with knobby shoulders—a boy's shoulders. Green cabin lights wash across his chest, his right arm flops off the litter. Mitchell moves like a piston above him. "Come on, buddy," he says. "COME ON, BUDDY." Sweat pours off him in long beads. Even with the windows open, the helo racing 200 feet (60 meters) above the ground, it is well over a hundred degrees (38°C). The heat, the weight of his body armor, and the frantic pace drain him. He's exhausted, losing effectiveness. After ten minutes, crew chief Erik Burns makes Mitchell get out of the way. Then Burns waves me in, a fresh set of arms.
Medics must use any resource available to them, and tonight I am one. I shove down 15 compressions. The soldier's chest feels ready to crack. I sink all my weight into it, right over his heart, his ribs buckling beneath my hands. My head pounds. Mitchell slumps beside me. We're gonna save this kid, I think. I will it true. We fly on toward Baghdad, over the flat fields, the pinprick lights, the sleeping country. The last minutes to the hospital blur past, a manic, sweat-soaked dream.
We touch down on a landing pad outside Ibn Sina Hospital in Baghdad. A nurse and medic duck across the pad, their scrubs flapping in the rotor wash. They haul the soldier into the trauma room. Doctors and nurses swarm him. Someone continues CPR, others slide tubes down his throat, measure blood oxygen levels, check his pupils with a flashlight. Mitchell stands nearby, helmet tucked under his arm, downloading what he knows to a nurse. His bald head shines with sweat. Monitors beep, there is the gasp of breathing machines, the tear of bandages.
"I got blood coming out his ears!" a doctor is saying.
"Hey! I got a pulse!" another shouts. It's been five minutes since we arrived.
Mitchell grits his teeth in a tight smile and pumps his fist. Yes.
"I told you," he says, bouncing on his feet. "No one dies in my helicopter."
Then the mood shifts. Something is suddenly understood, it appears on the faces of the doctors. There is a pulse, nothing more. The soldier doesn't react to stimuli, shows no signs of life. There is a question about what to do. But Mitchell must leave, speed dictates, and we fly back to base to wait for the next call.
On the ground we learn the soldier's fate. Doctors discovered a metal fragment embedded deep in his brain. They decided an operation would be futile. The only hospital equipped to do that kind of brain surgery was too far away, in another part of Iraq. They pumped in pain meds, just in case, and waited for his heart to stop. For Mitchell, the flare of triumph dies. He looks at me blankly, then walks away, saying nothing. It doesn't always end like this. But these are the days the crews must get used to, the ones they never forget.
In Iraq, one massive U.S. military machine fights the war. Another cares for those injured in battle. The effort is enormous, unrivaled. Medical procedures and body armor have vastly improved since America's last comparable war, in Vietnam. Yet the techno-sheen given this war by smart bombs, night-vision goggles, and remote-controlled drones is misleading. It is not miracle technology that saves lives on the battlefield in Iraq. The most important tools are tourniquets, the most important methods timeworn.
Trauma care proceeds in stages. It begins on the battlefield, with medics pulling bandages from their backpacks, often under fire. Some wounded are then rushed to small field stations like the one at Al Taqaddum, where Navy surgeons operate on marines fresh from the urban hell of Ramadi.
Others are airlifted directly to larger hospitals such as Ibn Sina, a former Baathist facility, where the wounded arrive around the clock. When they are stable, patients are flown, IVs snaking from their bodies, nurses monitoring their vital signs, to a military hospital in Germany. Then, at last, they return to the United States for final procedures, recovery, family.
All this can happen in as few as 36 hours. The process rivals FedEx in complexity and tempo. Soldiers become warm packages, bundled and gently tended, hurtled across time zones in the bellies of cargo planes. Often they are drugged and remember little of the journey, waking in hospitals in Washington, D.C., or San Antonio, Texas, to find their worlds, their lives, have changed. For soldiers arriving in the "sandbox," as Iraq is often called, knowledge of this global lifeline boosts morale and relieves some of the stress that comes with heading into battle or patrolling roads clotted with bombs.
At Ibn Sina, the largest Army hospital in Iraq, staff boots tell stories of war. In calm hospital wings, boot tops are soft and clean. In the trauma room, they are splotched and matted with blood. The floor is a dump, often slick with red pools, littered with bandage wrappers, scissors, shreds of clothing, charred skin. Boots are necessary. At the nurses' station just inside the hospital entrance, all the boots have been baptized in blood.
It is lunchtime. Young medics and nurses cluster at the large wooden desk laughing and joking. Some wear surgical clamps clipped to their pants, always ready, just in case. Others tuck tape and syringes into their pockets. Nearby, Iraqi janitors swing mops lazily along marble floors that Baath Party elites, including Saddam Hussein and his family, once crossed on their way to receive privileged medical care. There is a faint odor of disinfectant and feces.
The staff at Ibn Sina is part of the Army's 10th Combat Support Hospital, or 10th CSH, pronounced "cash." Many of the war's worst casualties, from wounded coalition and Iraqi personnel to civilians and insurgents, are helped here by some of the best trauma teams in medicine. The hospital treats hundreds of patients each month. It does not mirror the sleek, high-tech civilian institutions in the U.S. or Europe. It is battle-ready and rough, the rooms cluttered with equipment, some of it aging. Occasionally, the electricity fails.
But then, war medicine is not civilian medicine. It's dirtier, faster. The wounds are worse, the patients at greater risk. Here medical teams cut, crack, and inject where their civilian counterparts might pause and worry about lawsuits. Ibn Sina is designed for life-saving procedures, not the long recoveries required by amputees or burn victims. The mission is simple: stabilize patients, ship them on to facilities equipped for longer term care.
"There are no litigious restrictions over here," a lieutenant colonel who is also a doctor tells me. "People play fearlessly, and when they play fearlessly, they make fewer mistakes. It's a dose of reality you'll never forget. The surgeons, nurses—never in the rest of their lives will they be who they are here."
The 10th arrived here in October 2005 to replace another CSH unit at the conclusion of a year-long tour. Few of the 10th's nurses or medics had ever seen the chaos of big trauma. Many are in their early or mid-20s; some had cared previously for cancer patients or the elderly. Iraq was immediate, terrifying immersion.
Lt. Col. John Groves, 42, head ER nurse, trained in some of America's busiest trauma centers, including Miami and Honolulu. He is a short, friendly man, a career soldier who, if prompted, can talk into the night about past cases and calamities, the mutilations of this war. He is a self-described steel-mill kid from Indiana, and on his desk lie photos of the 20 or so head of cattle he keeps on his new farm in Kansas, where he plans to retire.
Groves is a father figure to his young staff. He watches them carefully, knows their strengths, their weaknesses. He remembers thinking not all of them would last. "So many were timid, they didn't know what to do. It was a hard adjustment, and not everyone is cut out for this kind of medicine." Groves was ready to reassign several nurses to other wards. Lt. Riane Nelson was one of them.
She is 24, a tall round-faced blonde from San Diego with blue-green eyes that shift color depending on the scrubs she wears. From the time she was eight, she wanted to be a nurse. She lived then in Greece, where her parents worked as missionaries. After college, she joined the Army. She didn't have any trauma training before she arrived in Iraq.
Nelson grew up an athlete. She knew what it meant to work hard, play fast. But she struggled with the crushing pace of the trauma room, the weight of decisions made amid blood and fading lives. She forgot things, made mistakes. She began, she says, to crack. Then, slowly, the weeks of panic yielded to smoothness. She remembers when the conversion came.
Valentine's Day, 2006. Nelson hopes for a slow shift. But somewhere in Iraq, an Army convoy hits a roadside bomb and a medevac helicopter rushes in a seriously wounded soldier. The situation is going badly.
The soldier arrives medically dead. A tourniquet encircles the right leg. Below the tourniquet, the limb hangs by threads of flesh. The femoral artery is like a severed hose. There is the coppery smell of blood.
Nelson stands at the head of the bed, feeling for a pulse, giving directions. Medics slice away the remains of a uniform. Nelson realizes her patient is a woman. She has no pulse, she is drained of blood. Nelson orders someone to begin CPR, even though in her experience it has never saved anyone. A doctor calls for drugs: atropine, epinephrine. Nelson injects them into the woman's body. Finally, she feels the weak flutter of life. "After about five minutes of CPR, I felt a carotid pulse," Nelson later wrote in her journal. "We double- and triple-checked to make sure we weren't just so hyped up that we were feeling our own pulse in our fingers."
Nelson's team pumps blood into the woman; it runs out her shattered leg. To save the life, the limb must go. A surgeon slices. Someone loops another tourniquet around the stump. The team bandages the wound and preps the woman for the operating room, where surgeons will clamp off her artery, insert a chest tube, and clean shrapnel from her body.
After surgeons saved the woman's life, Nelson visits her upstairs in the intensive care ward. She finds the woman's husband at her bedside; the couple serve in the same unit.
"That was one of the more emotional cases I've had," Nelson says. "I think that's where I gained my confidence. With her, I felt I took charge. I felt I had peace of mind, I wasn't freaking out. And, on Valentine's Day, I didn't have to say, 'Your wife didn't make it.' "
Groves, her boss, noticed the change and kept her on. "Now she can do anything," he says, smiling. "She's brought people back from the dead. Our joke is if you come in dead, you want Nelson at the table."
After months in Iraq, Nelson and her colleagues have helped save hundreds of lives. They have seen more human wreckage than most of their stateside peers ever will. Their stained boots are badges of honor. In the late winter, it was common to hear young nurses and medics say, "I never want to leave." Older staffers shared the sense of purpose. Many said, "If it was a little safer and I could bring my family here, I'd stay." The work, the importance of it, was exhilarating.
By summer, past the halfway point in the 10th CSH's tour, those feelings have faded. A makeshift calendar hangs on the wall beside the nurses' station, each remaining day in Iraq marked on a slip of white paper. Home is not simply a place, it is a goal. Everyone yearns for a life less cloistered, closer to family and old routines, away from war.
Many have taken mid-tour leave. The two weeks' vacation either recharged them or intensified the desire to leave. "Before I went, I was not doing well," Nelson says. "I was starting to have dreams about patients, like, what could I have done differently." The break refreshed her, gave a boost she hopes will last till the tour is up. When I see John Groves again, after his leave, there is a new weariness, a heaviness in his face. "I'm ready," he says. "I think we all are."
The end will come soon enough, but heading home won't be simple. The memories will follow, and more. Groves worries that many of the young staff will be bored when they return to stateside jobs at base hospitals or troop clinics. "The medics and nurses here are doing things that only doctors do back in the States," he says. "I'm teaching 20-year-olds how to put in chest tubes. When they go back, they won't be able to do that stuff."
No one at Ibn Sina may ever feel as useful or needed as they do saving lives in Baghdad. It is not that the trauma crews hope for more wounded. It is not that they want the war to limp on forever. But they have an overwhelming desire to put their training into practice. The same can be said about medics like David Mitchell—about almost any soldier doing medicine here.
"We're like vultures, kinda," a nurse explains late one night as we sit waiting for the thump of incoming helicopters. "This is what we do. We're not out there stopping the fighting, so we're waiting to go to work."
For them trauma is exciting. A cloud descends, blocking out the rest of the world. There is only the work, the bright red immediacy of blood. In the trauma room, a simple truth rises above the gasp of breathing machines and the high, frantic voices: Life is everything; it is all that matters. The details come later.
Part Two: Home Front
Jason Welsh held the phone close and lied to his mother. He told her he'd been in a car wreck in Iraq, but he was fine. "I think I broke my jaw pretty good," he said, "but that's all." The lie made sense. Telling the truth, that he'd been blown up by a roadside bomb, his neck was broken, his face smashed, that three men died beside him, somehow didn't seem right. Welsh, 25, remembers thinking, If I don't tell her, it'll be OK. It'll be like it didn't happen.
Lynne Welsh, listening in Oklahoma, didn't believe him. Her mind spun. Fear flooded in. "I was so scared my voice got weak," she says. "I finally asked him, 'How are your arms and legs?' "
The question reveals the dread of every military parent, spouse, girlfriend, or boyfriend. The answer would shape the Welshes' future. Dreams would survive, or shatter. "My arms and legs are fine, Momma," Welsh said, and that, as far as it went, was the truth.
Some 20,000 American service members have been injured since the war in Iraq began in 2003. Medical technology and the sheer speed of rescue and treatment have increased soldiers' chances of surviving wounds that would have killed them in previous wars. But any notion that body armor and medicine have somehow made this war safe is unfounded. Stacking armor on troops and vehicles has only bred more accurate snipers, more devastating bombs. Medicine, while more advanced than in previous wars, cannot wipe out the brutality of the battlefield.
On American streets, amputees offer the most public and visually jarring testimony of war. The human eye, drawn to symmetry and startled by its absence, cannot help but scan voids where legs or arms once swung, while the mind wonders how it happened. But there are other injuries, some far worse than amputation.
Of the wounded, more than 20 percent have suffered traumatic brain injuries, called TBIs. As the roadside bomb, or improvised explosive device (IED), is the signature weapon of this war, the TBI has become its legacy, says Dr. George Zitnay, a neuropsychologist with some 40 years experience treating brain injuries. Zitnay, 67, has described brain injury as an "invisible epidemic," a plague the public knows little about or is unwilling to face. Zitnay believes this is because brain injuries carry heavy stigmas. "You get a brain injury in this country, you keep it quiet because here we value intellect so much," Zitnay says. "It's a very frightening thing to think about the psyche, to think about the mind. If you were brain injured, would you want people to know about it?"
After the Gulf War, Zitnay helped found the Defense and Veterans Brain Injury Center, now the military's premier brain injury program. The fate of Vietnam veterans pushed him to do it. Many of them, he says, returned with brain injuries that went undiagnosed and untreated. "They ended up in prisons and hospitals, on the street, undergoing divorces," Zitnay says. He sees some of the same things happening to Iraq vets today. "So many of these troops get redeployed so often. Their time in the war zone gets extended, their exposure to blast injuries is high. When they come back, we're not really screening them for concussions or other types of brain injuries. Often in people with mild or moderate concussion, it doesn't show up right away."
Mild brain injuries generally don't permanently impair a person's ability to function. More important, nothing is lost of the victims' essential nature—they remain who they were before injury. In more severe cases, the victims become violent, forgetful, manic. In the worst cases, the body returns from the war alive, but the victim does not. The old self is obliterated, fragmented, lost in furrows of gray matter that medical science does not fully understand and cannot repair.
Staff Sgt. Jason Welsh is slim and tall, his brown hair buzzed short, his face smooth and boyish. A black-ink tattoo spreads across his right forearm, a warrior angel he got while stationed in Germany. Another tattoo, a ring of flame, circles his left elbow. Both his parents served in the Army, and Welsh joined not long after high school. He wanted freedom, but with boundaries. "I didn't want to depend on anyone," he says. "I wanted to go out on my own, and the Army was the easy way to do it." He went to Iraq first in 2003 as a mechanic, found it disappointing. Afterward, he re-enlisted as an infantryman.
Welsh returned to Iraq in late 2005 with Bravo Company of the 2-6 Infantry, 1st Armored Division. The division deployed to Ramadi, the seething Sunni city wedged against the banks of the Euphrates River west of Baghdad. Welsh commanded two riflemen and a machine gunner. His unit patrolled garbage-lined streets renamed in desire and homesickness after young female celebrities, Route (Britney) Spears, Route (Jessica) Alba. The men skirted puddles of sewage, kicked in doors during raids, battled insurgents as temperatures needled toward summer. Once, he watched Iraqi soldiers throw down their weapons and flee under fire from insurgents. It was all an education. Welsh loved it.
The young sergeant had never been hit by fire. He was on patrol one night, steering his Humvee at the head of the column, his platoon leader, a translator, a roof gunner, and a 19-year-old medic named Nick Crombie riding with him. Crombie was an energetic kid, new to the unit, so eager to please he made mistakes in his excitement. But Welsh could work with that. He put Crombie in the back, had him sit where he could pass out Gatorades during the patrol. It was a Wednesday night in June, a night like any other. Then the truck burst.
An unarmored Humvee weighs about 5,200 pounds (2,360 kilograms). Many Humvees used on combat patrols in Iraq are augmented with steel plates and bullet-resistant glass that weigh an additional 3,000 pounds (1,360 kilograms) or more. The trucks are wheeled rhinoceroses, stout and tough. The blast that injured Welsh pulped his armored Humvee. It blew off the wheels, doors, the trunk, everything but the seating area. The platoon leader, the translator, and Crombie were killed, the roof gunner seriously wounded. Shrapnel carved them apart. But not Welsh. His injuries—the broken neck and face, a damaged knee—were caused by the blast concussion itself or from the force of it whipping his body against the truck. He doesn't know how he survived the flying metal. "It's as if I took a bowlful of Doritos and threw them at you, and somehow they all went around you and missed," he says.
By Thursday, the day after, Welsh was in the U.S. military hospital in Landstuhl, Germany. On Friday, he landed in Washington, D.C. He remembers blurry scenes from the journey, scraps of dialogue. "I woke up, and I was really violent," he says. "I was strapped down, and I didn't want to be. They stuck something in me, and I went down. I think I was on a plane." It may have been during his journey to Germany, or his way back to the States. Such experiences are not uncommon for seriously injured soldiers who've been drugged. Welsh's first coherent post-blast memories begin at Walter Reed.
Walter Reed Army Medical Center in Washington, D.C., is a sprawling collection of buildings, some of them nearly a hundred years old. The grounds are green and tree-lined, lending the feel of a college campus—except for the shotgun-slinging guards at the main gates. Walter Reed has treated U.S. wounded since World War I. It is not the sole military hospital in the nation; marines are often shipped to the National Naval Medical Center in Maryland, and some soldiers fly to Brooke Army Medical Center in San Antonio, Texas—but Walter Reed remains a critical hub for soldiers returning from Iraq.
Incoming wounded are sent to various hospital wards and intensive care units. From there, mildly wounded soldiers receive treatment and may be released, either back to their units or to hospitals run by the Department of Veterans Affairs. If they are medically discharged from the military, soldiers may also head home with family. Soldiers suffering more severe wounds, including amputations, recuperate at Walter Reed, where teams of doctors, nurses, and therapists monitor their recovery and battle the nagging details of post-wound care: persistent infections, bedsores, depression. Often patients stay at Walter Reed for months, their days organized around doctor consultations, surgeries, therapy—physical or occupational—or fittings for prosthetic legs and arms. The hospital encourages family visits. Some parents arrive before their sons or daughters, staying on campus, watching their children struggle into new lives.
Jason Welsh arrived at Walter Reed on a Friday in mid-June. His parents flew in the same day. In a photo taken shortly after their reunion, a black bruise curls under his right eye, cuts dot his forehead. His face is jaundiced, swollen, and he stares unsteadily at the camera like a drunk. He wears a neck brace. Welsh's neck was broken at the first cervical vertebra, or C1, the point where the spine meets the skull. It is one of the vertebrae that snapped in the late Christopher Reeve's neck when he was thrown from a horse in 1995. Reeve, famous for his role in Superman films, was paralyzed from the neck down. Welsh's spinal cord escaped damage, and doctors decided to let the wound heal without surgery. Soon after his arrival, he was released to Mologne House, a dormitory-style building on the Walter Reed campus where soldiers live during recovery.
Alone for the first time, Welsh woke confused, uncertain about where he was, what he was doing. It occurred to him that he should arrange his things and prepare to leave. "I was trying to get my stuff ready. I dumped all my stuff on the bed, but I couldn't figure out how to organize it," he says. "I would start doing something, and I'd forget what I was doing. I couldn't match items like socks. So I said 'screw this,' and I threw everything on the floor."
Welsh asked his Mologne House roommate for help. The man brought Welsh to the hospital and apparently left him alone. "I didn't know where I was. I didn't know how to figure out where to go. I was mindless." Eventually, a woman who had worked Welsh's case saw him. She asked why he'd missed his appointments. "I was like, 'Who are you and what appointments are you talking about?' " The woman recognized something was wrong. She brought Welsh to a neurologist. Doctors performed memory tests, gave him an MRI. They diagnosed him with TBI. At first Welsh couldn't believe it. But nothing made sense anymore, and he could barely string together words for an argument. "Imagine you can only know one thing in the world," he says, "and that one thing is that you don't know anything."
There had been other signs. Welsh's parents, Lynne and Earl, though relieved to see him alive, were worried. They tried to comfort their son and help him recover. He wouldn't have it. He cursed in fits. One day Welsh couldn't figure out how to put on his sweatpants. He exploded when his father offered to help. Then Welsh told them to leave, go home. Confused and frightened, they agreed. Shortly afterward, Welsh's younger brother Aaron came to visit. Welsh raged at Aaron, yelling and screaming. This was not the Jason his family remembered. It was as if someone else had come back from the desert.
American soldiers wear helmets that wrap their heads like tortoise shells in layers of ballistic fabric and resin. But they are not bulletproof. Snipers know this. The helmets also provide only limited protection against powerful blasts produced by IEDs, like the one that hit Jason Welsh.
Head injuries are divided into two categories, penetrating and closed. Bullets, shrapnel, rocks—anything that pierces the skull can wipe out brain matter or, by odd turns of physics, do little damage. Closed head injuries result from the force of a blast or a blow in which the skull remains intact but the brain, surrounded by fluid like an egg yolk, gets wrenched or slammed against the skull wall. Such sudden motion can squash brain cells and uproot axons, the rapid-fire, telephone wire-like tubes that connect brain cells. This effectively wrecks neural circuitry. Concussive forces may also rupture blood vessels in or around the brain, producing hematomas, or blood clots, that press on brain matter and, in some cases, kill it.
The physical destruction of brain matter or the disruption of brain cell communication can have profound effects. Injuries to the front of the brain are often worse, especially in closed head injuries. The back portion of the brain is better connected, more stable, than the frontal lobes. In the sudden shock of an IED blast, for example, the frontal lobes are more likely to be whipped against the skull, or rotate and tear axons. Because the frontal lobes control many aspects of memory, behavior, and motor function, severe damage can wipe out a patient's ability to solve problems, plan, speak, or control impulses.
One of the greatest challenges stemming from TBI manifests in what Dr. Warren Lux calls behavioral disregulation. Lux, a neurologist at Walter Reed, says cognitive problems—planning daily chores, pairing socks, solving problems—are often not as bad as the changes in emotional control and sexual behavior that occur. These shifts can scuttle marriages, alienate family, sever ties with former lives. In the worst cases, Lux says, TBI patients can become unpredictably violent.
Another major problem, Lux says, centers on self-awareness. Many brain-injured patients don't recognize that they're injured or that they have lost pieces of themselves. "Part of what you need your frontal lobes for is to figure out who you are, because you need that to plan your way in life. Your self-image is built in your frontal lobes. That means that people who have all the skills to do things in the world won't use them because they don't know that they have to."
In the most common, and simple, form of brain injury, called a concussion, the brain usually regains normal function quickly. When it cannot self-repair, the brain sometimes rewires, routing signals along new channels, across its backup networks of axons. There are limits to this. The brain contains a finite number of axons. Brain matter, if it regenerates at all, grows very slowly. Repair takes time, weeks or months or even longer. Rehabilitation seems to work best when it occurs almost simultaneously, spurring the brain to form new connections, and the injured to learn new ways of thinking, acting, living. If rehab doesn't follow soon after injury, recovery is less likely to succeed; it may even become impossible.
Soldiers diagnosed with TBI proceed along separate paths depending on the severity of injury: mild, moderate, or severe. Moderate and severe patients are transferred to one of four special hospitals run by the Department of Veterans Affairs. There they receive long-term care and therapy. Patients with mild TBI may be sent home, back to duty, or, if they need additional rehabilitation, to community-based centers that focus on rebuilding their mental abilities. After nearly a month at Walter Reed, Jason Welsh was sent to Virginia NeuroCare, a small, private clinic in the rich green hills of central Virginia.
It is a Thursday morning in early August, and the merciless wet heat of a Virginia summer hangs over Charlottesville. The city is peaceful, collegiate, home to the University of Virginia, and close to Thomas Jefferson's home at Monticello. In the tangled brush, the overgrown forests, and stubbled fields nearby, tens of thousands died in Civil War battles at Fredericksburg, the Wilderness, and Chancellorsville. To reach Sgt. Jason Welsh, you must steer past them all.
Welsh sits in a small office, still wearing a neck brace, and tries to write a grocery list. An occupational therapist named Joy Sandlin helps him. He chooses food for a week of meals. But Welsh has never lived alone or cooked much for himself. Since his arrival at Virginia NeuroCare, he has lived in a group home with other brain-injured patients, some of them soldiers. His TBI has reduced his ability to focus and remember.
"Jason's going to need to learn to shop for himself and eat healthily," says Sandlin, a petite young woman with long black hair. "One of the things is that he's a 25-year-old guy who moved directly from his mom's house to the Army. He's never had to do this before, and he doesn't necessarily care. But it's something an adult needs to do, and the skills go way beyond breakfast." The exercise is one of planning, navigation, memory, and execution. Eventually, he'll travel to the grocery store using public transportation, remember why he's there and what he needs, and then gather and buy it. Simple tasks requiring a thousand minute computations.
Sandlin scans the list—ramen noodles, peanut butter, Honey Nut Cheerios. She asks questions, forcing Welsh to concentrate, probing his memory. She taps the list with her pen and says, "What do you think you'll want to drink besides Coke and milk?"
Welsh's injury was relatively mild. The MRI revealed "diffuse axonal injury"—shearing and twisting of axons—mainly in the right lobe, and some in the left. After the injury, portions of his brain had difficulty communicating, signals were interrupted, the network damaged. He has had problems with memory, multitasking. He loses focus, and sometimes his temper flares erratically. He curses more, and his sense of smell and touch have weakened. Welsh also suffers survivor's guilt, especially about Crombie. "I let him down," Welsh says. "I didn't even know him long enough to learn anything about his personal life."
While talking, Welsh will pause, as if the current of thoughts had suddenly hit a dam. He searches for words. "Sometimes I have to stop and think. It's pretty embarrassing. I'm aware that it's not back yet. I can feel myself think slower, step by step, instead of just reacting. I hate it." Welsh spends hours each day working with therapists, developing ways to compensate for mental abilities that may take months to return, if they ever return at all. Still, through all of this, he has retained the major connections and patterns that form his personality.
Two months after his injury, Welsh is nearly ready to move into the clinic's independent apartment, where he will no longer be under 24-hour supervision. He has just been given a job at the nearby Judge Advocate General's Legal Center and School, which trains military lawyers. He'll wear his camouflage uniform, his sergeant's stripes. The job will help him practice social interaction and problem solving—some of the same skills the grocery shopping exercise focused on.
Welsh can't wait. He considers his injury a temporary setback. Returning to the infantry is all he wants, even if it means another tour in Iraq. "I feel like I've got a lot of leading left to do, a lot of teaching," he says. "Those guys in Iraq need experience, and I can give them that."
It's not clear yet whether the Army will allow Welsh to return to his old job. But his therapists have dedicated themselves to helping him progress as far as possible. One therapist describes Welsh as essentially normal, meaning he has regained, or developed compensations for, much of what he lost that night in Ramadi.
From the battlefield to the home front, Welsh has received the best medical care available anywhere, but his case reveals the limitations even of the massive military system. Early assessments missed his brain injury. And there are others like him. Many experts—including Dr. George Zitnay, who founded Virginia NeuroCare as well as Walter Reed's Defense and Veterans Brain Injury Center—have pressed the Department of Defense to screen returning veterans for brain injuries. The department has only recently begun limited screening.
Welsh's mother, Lynne, visits him for several days in Charlottesville to check on his recovery. One evening, over burgers and iced tea at a restaurant in a local strip mall, Lynne reminisces with Jason about his years as a headstrong kid with a mischievous streak and a disdain for authority. Her voice is raspy and midwestern. The pair joke and laugh, remembering. For Lynne Welsh, the fear is fading. She knows she's fortunate, watching the old Jason reemerge. She knows that many soldiers never do.
After dinner, mother and son sit together outside Welsh's room in the group home, a large, white house with a small yard and a wraparound front porch. Welsh burns to leave, but he can't yet. His neck hasn't healed, and last night he exploded when a staff member tried to order him to bed. He felt ashamed afterward, unsure why he did it. Maybe it was the sleeping pills, maybe the brain injury. He unfastens his neck brace, demonstrating how in anger he hurled it across the room. He catches a whiff of the sweat that had soaked it during the stifling summer days.
"God, I've gotta wash this thing," he says, a little embarrassed. He is less the sergeant in his mother's presence, more the kid who loved cars and used to ditch school and circle town in a big Chevy Blazer. Lynne Welsh looks him over.
"I'm just glad it's him," she says. "The important thing is that Jason is Jason."
Jason smiles, lines breaking at the corners of his eyes, dispelling for a moment the boyishness.
"For the most part," he says.
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